drug benefit list

DRUG BENEFIT LIST 2010

NON-INSURED HEALTH BENEFITS

First Nations and Inuit Health Branch

The Non-Insured Health Benefits (NIHB) Program provides supplementary health benefits, including prescription and non-prescription drugs, for registered First nations and recognized Inuit throughout Canada.

Visit our Web site at: www.healthcanada.gc.ca/nihb

Health Canada Non-Insured Health Benefits

INTRODUCTION Drug Benefit List

Effective 2010

Introduction to NIHB Drug Benefit List Effective 2010

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Table of Contents 1. Background on NIHB Program ................................................................................................iii 2. Purpose of the NIHB Drug Benefit List ....................................................................................iii 3. Drug Review Process ...............................................................................................................iii 4. Benefit Criteria ......................................................................................................................... v

A. Drug Benefit Listings .................................................................................................... v B. Deletion Criteria .......................................................................................................... .vi C. Open Benefits……………….………………………………………………………………..vii D. Limited Use Benefits....................................................................................................vii E. Exception Criteria ........................................................................................................vii F. Exclusions...................................................................................................................viii

5. Policies....................................................................................................................................viii A. Best Price Alternative and Interchangeability .............................................................viii B. “No Substitution” Claims ............................................................................................viii C. Prescription Quantities ............................................................................................... ix D. Short Term Dispensing ……………………………………………………………………...ix

6. Special Formulary for Chronic Renal Failure Patients .............................................................. x 7. Palliative Care Formulary.......................................................................................................... x 8. Drug Utilization Evaluation........................................................................................................ x 9. General Information ................................................................................................................. xi

10. NIHB Privacy Code ................................................................................................................. xi 11. Pharmacologic-Therapeutic Classification of Drugs................................................................ xi

Legend.....................................................................................................................................xii Drug Benefit List

04:00 Antihistamine Drugs ................................................................................................ 1 08:00 Anti-Infective Agents ............................................................................................... 2 10:00 Antineoplastic Agents............................................................................................ 13 12:00 Autonomic Drugs................................................................................................... 16 20:00 Blood Formation and Coagulation......................................................................... 22 24:00 Cardiovascular Drugs............................................................................................ 25 28:00 Central Nervous System Agents ........................................................................... 42 32:00 Contraceptives (Non-Oral) .................................................................................... 70 36:00 Diagnostic Agents ................................................................................................. 71 40:00 Electrolytic, Caloric and Water Balance ................................................................ 73 48:00 Respiratory Tract Agents ...................................................................................... 76 52:00 Eye, Ear, Nose and Throat Preparations .............................................................. 77 56:00 Gastrointestinal Drugs........................................................................................... 83 60:00 Gold Compounds .................................................................................................. 91 64:00 Heavy Metal Antagonists ...................................................................................... 92 68:00 Hormones and Synthetic Substitutes .................................................................... 93 80:00 Serums, Toxoids and Vaccines........................................................................... 101 84:00 Skin and Mucous Membrane Agents .................................................................. 102 86:00 Smooth Muscle Relaxants .................................................................................. 110 88:00 Vitamins .............................................................................................................. 111 92:00 Unclassified Therapeutic Agents......................................................................... 114 94:00 Devices ............................................................................................................... 119 96:00 Pharmaceutical Aids ........................................................................................... 124

Appendix A (Limited Use Benefits and Criteria)........................................................................ A-1 Appendix B (Special Formulary for Chronic Renal Failure Patients) ........................................ B-1 Appendix C (Palliative Care Formulary).................................................................................... C-1 Appendix D (List of Drug Manufacturers).................................................................................. D-1 Appendix E (List of Exclusions) ............................................................................................... E-1 Alphabetical Index of drug products............................................................................................I-1


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1. BACKGROUND ON NIHB PROGRAM The Non-Insured Health Benefits (NIHB) Program of Health Canada provides coverage for approximately 816,000 eligible registered First Nations and recognized Inuit with a limited range of medically necessary health-related goods and services not provided through private or provincial/territorial health insurance plans. These benefits complement provincial and territorial health care programs, such as physician and hospital care, as well as other First Nations and Inuit community-based programs and services. Benefits include drugs, medical transportation, dental care, medical supplies and equipment, crisis intervention counselling and vision care. The authority for the NIHB Program is based on the 1979 Indian Health Policy which describes the responsibility for the health of First Nations as shared amongst various levels of government, the private sector and First Nations communities. As a result of this shared responsibility, when a benefit is covered under another plan, the federal government requires the coordination of benefits to ensure that the other plan meets its obligations. 2. PURPOSE OF THE NIHB DRUG BENEFIT LIST The Drug Benefit List is a listing of the drugs provided as benefits by the Non-Insured Health Benefits (NIHB) Program. The DBL is updated regularly and published annually. The listed drugs are those primarily used in a home or ambulatory setting. A prescription from a licensed practitioner is required for any listed drug to be processed as a benefit. Practitioners are those people authorized to prescribe drugs within the scope of practice in their province or territory. The DBL is a tool for physicians and pharmacists that encourages the selection of optimal, cost-effective drug therapy 3. DRUG REVIEW PROCESS

The review process for drug products that are considered for inclusion as a benefit under the NIHB Program varies depending on the type of drug submitted.

3.1 New Chemical Entities / New Combination Drug Products/ Existing Chemical Entities with New Indication Submissions for new chemical entities, new combination drug products and existing chemical entities with new indications, must be sent to the Canadian Agency for Drugs and Technologies in Health (CADTH). Clinical and pharmacoeconomic reviews are coordinated by the Common Drug Review (CDR) Directorate and forwarded to the Canadian Expert Drug Advisory Committee (CEDAC) for recommendations on formulary listing. These recommendations are forwarded to participating drug plans, including the NIHB Program, for consideration. The NIHB Program and other drug plans make listing decisions based on CEDAC recommendations and other specific relevant factors, such as mandate, priorities and resources.

Please refer to the Canadian Agency for Drugs and Technologies in Health (CADTH) for a list of requirements for manufacturers’ submissions and a summary of procedures for the Common Drug Review Process. Inquiries should be directed to:

Common Drug Review (CDR) Canadian Agency for Drugs and Technologies in Health 865 Carling Avenue, Suite 600 Ottawa, Ontario K1S 5S8 Telephone: (613) 226-2553 Website: www.cadth.ca

Please ensure a copy of the complete CDR submission is also sent to NIHB either electronically to [email protected] or on CD ROM to the mailing address indicated in section 3.2.2.4 3.2 Line Extensions, Generics and All Other Submissions Submissions for line extensions, generics and all other submissions are reviewed internally or by the Federal Pharmacy and Therapeutics Committee. Generic drug products are considered for inclusion on the formulary based on provincial interchangeability lists and other relevant factors.

http://www.cadth.ca/


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3.2.1 Federal Pharmacy and Therapeutics Committee The Federal Pharmacy and Therapeutics (FP&T) Committee provides formulary listing recommendations for drug products to participating federal drug plans, including the NIHB Program. The NIHB Program and other federal drug plans make listing decisions based on FP&T Committee recommendations and other specific relevant factors, such as mandate, priorities and resources. The Federal Pharmacy and Therapeutics (FP&T) Committee is an advisory body of health professionals established to provide evidence based pharmacy and medical advice to the drug benefit plans of the six federal departments (Health Canada, Veterans Affairs Canada, Royal Canadian Mounted Police, Correctional Services Canada, Department of National Defense and Citizenship and Immigration Canada). 3.2.2 Submission Requirements All submissions for drug products that are line extensions, generics and all other submissions must be submitted to the NIHB Program. Only drug products with a Health Canada Notice of Compliance will be considered for provision as a benefit.

3.2.2.1 Letter of Authorization The manufacturer will provide a letter authorizing the NIHB Program to gain access to all information with respect to the product in the possession of Health Canada or of the government of any provinces or territory in Canada, Patented Medicine Prices Review Board (PMPRB) or Canadian Agency for Drugs and Technologies in Health (CADTH). 3.2.2.2 Justification for Consideration of Listing The manufacturer will provide a statement indicating the rationale and evidence to justify the provision of the new product. 3.2.2.3 General Information Additional information should include: • Evidence of approval by Health Canada, such as a Notice of Compliance (NOC) and Drug

Identification Number (DIN).and • Two therapeutic Classifications:

- American Hospital Formulary Service (AHFS) Pharmacologic Therapeutic Classification and;

- The World Health Organization’s Anatomical Therapeutic Chemical (ATC) Classification 3.2.2.4 Pricing and Marketing Information The manufacturer must submit current price information for the drug product. Manufacturers are required to notify the NIHB Program of any significant change to listed drug products. Significant changes include changes in DIN, product name, manufacturer or distributor, indication, product monograph, packaging, formulation, manufacturing specifications or discontinuation of a product. Notification of changes should be provided electronically to the NIHB Program. All submissions for drug products, to be reviewed for inclusion on the NIHB Drug Benefit List (DBL), must be sent to the NIHB Program electronically. Please send all drug submissions to the following email address: [email protected]. Submissions will also be accepted on CD ROM when mailed to the following address:

c/o Manager of Pharmacy, Benefit Management Non-Insured Health Benefits First Nations and Inuit Health Branch, Health Canada Room 503, Suite 550, Address Locator 4005A 55 Metcalfe Street, Ottawa, Ontario K1A 0K9


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Only ONE copy of the submission is required. Receipt of submission will be acknowledged electronically.

4. BENEFIT CRITERIA The following criteria are the framework for the Non-Insured Health Benefits Program Drug Benefit List (DBL). The criteria provide the basis for decisions about drugs on the formulary relating to:

A. Listings B. Deletions C. Open Benefit D. Limited Use E. Exceptions F. Exclusions

All drugs that are to be either considered for listing or currently listed as program benefits must, as a minimum:

1. be legally available for sale in Canada with a Notice of Compliance;

2. be sold in Canada (proof may include a copy of the completed notification form issued under the Food and Drug Regulations or listing on a provincial drug benefit formulary);

3. be administered in a home setting or in other ambulatory care settings;

4. not be provided in a provincially/territorially covered setting (hospital/institution) or provided through provincially/territorial covered programs or clinics according to provincial/territorial legislation; and

5. be in accordance with NIHB Program mandate and policies.

A. Drug Benefit Listings The Non-Insured Health Benefits (NIHB) Program, with assistance from the Canadian Expert Drug Advisory Committee (CEDAC) and the Federal Pharmacy and Therapeutics (FP&T) Committee, balances a number of factors in making listing decisions about changes to the Drug Benefit List, such as:

• The needs of First Nations and Inuit recipients;

• Accumulated scientific and clinical research on currently-listed drugs;

• Cost-benefit analysis;

• Availability of alternatives;

• Current health practices; and • Policies and listings in provincial drug formularies.

New formulations and new strengths of listed products may be added or may replace previously approved products. Generic products are added according to provincial interchangeability lists and other relevant factors. Combination products are considered for listing if:

1. each component of the combination makes a contribution to the claimed effect;

2. a pharmacological or pharmaceutical rationale exists for the combination;


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3. the dosage of each component (amount, frequency, duration) is safe and effective for a significant proportion of the patient population requiring such concurrent therapy as defined in the labeling of the drug; and,

4. the cost is reduced, or scientific evidence indicates that the advantages outweigh any additional cost; or

5. an improvement in compliance, resulting in an increase in clinical effectiveness, is demonstrated.

Sustained Release Products may be listed when:

1. clinical studies have demonstrated the safety and efficacy of the active ingredient when administered in the sustained released form; and,

2. a therapeutic advantage is demonstrated in the treatment of the disease entity for which the product is indicated (therapeutic advantage is defined as: improved efficacy relative to the conventional dosage with no increase in toxicity; or less toxicity with improved or similar efficacy); or,

3. there is demonstrated improvement in compliance resulting in an increase in clinical effectiveness, or,

4. there is evidence that the sustained release product is at least as cost-effective as the best price alternative in the conventional form that is currently covered; or,

5. there is no suitable conventional dosage form(s) of the drug listed that is readily available.

Injectable Drug Products will be considered if they are:

1. self-administered in a home or other ambulatory setting;

2. not part of a physician’s standard office supply; 3. not provided in a provincially/territorially covered hospital or institution; or, 4. not provided through provincially/territorial covered programs or clinics according to

provincial/territorial legislation. B. Deletion Criteria The following deletion criteria guide the removal or delisting of a drug product from the NIHB drug benefit list. Drugs are deleted:

1. when a product is discontinued from the Canadian market;

2. when new products possessing clearly demonstrated therapeutic and safety advantages or improvements have been listed;

3. when new toxicity data shift the risk/benefit ratio to make the continued listing of the product inappropriate;

4. when new information demonstrates that the product does not have the anticipated therapeutic benefit;

5. when the purchase cost is disproportionate to the benefits provided; or

6. when the drug has a high potential for misuse or abuse.


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NOTE: Drugs may also be removed at the discretion of the Director General, NIHB Program when there are undesirable financial, supply or administrative implications to the continued listing of a product. C. Open Benefits Open benefits are the drugs listed in the NIHB DBL which do not have established criteria or prior approval requirements. D. Limited Use Benefits Limited use drugs are drug products listed on the NIHB DBL that may be inappropriate for general listing, but have value in specific circumstances. These products will have specific criteria for provision as a benefit under the NIHB Program. A product will be designated for limited use when:

1. it has the potential for widespread use outside the indications for which benefit has been demonstrated;

2. it has proven effectiveness, but is associated with predictable severe adverse effects;

3. it is usually a second or third line choice for treatment and is required because of allergies, intolerance, treatment failure or noncompliance with a first line alternative; or

4. it is very costly and a therapeutically effective alternative is available as a benefit.

There are three types of limited use benefits:

1. Limited use benefits which do not require prior approval. These include: • Multivitamins (which are benefits for children up to 6 years of age); and • Prenatal and postnatal vitamins (which are benefits for women of childbearing

age (12 to 50 years).

2. Benefits which have a quantity and frequency limit. A maximum quantity of drug is allowed within a specified period of time. No prior approval is required for the recipient to obtain the allowable quantity of drug within the specified period. Drugs with a quantity and frequency limit include smoking cessation products. Recipients are eligible to receive a 3-month supply of smoking cessation products over a one year period which is renewable 12-months from the day the initial prescription was filled.

3. Limited use benefits which require prior approval (using the “Limited Use Drugs

Request Form”). Limited use benefits and the criteria for their coverage are identified in the Drug Benefit List and also in Appendix A. The criteria are also listed on the forms faxed to prescribers for completion.

E. Exceptions Exception drugs are drug products which are not listed in the DBL. These drug products may be approved in special circumstances upon receipt of a completed “Exception Drugs Request Form” from the attending licensed practitioner.

• when the prescription is for a recognized clinical indication and dose which is supported by published evidence or authoritative opinion; and

• when there is significant evidence that the requested drug is superior to drugs already listed as program benefits; or,

• when a patient has experienced an adverse reaction with a best- price alternative drug, and a higher cost alternative is requested by the prescriber; or

• when there is supporting evidence that available alternatives are ineffective, toxic, or contraindicated (personal preference alone does not justify an exception).


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F. Exclusions Exclusions are items not listed as benefits on the DBL and are not available through the exception or appeal processes. These include certain drug therapies for particular conditions which fall outside of the NIHB mandate and are not provided as benefits under the NIHB Program. These products are not considered for coverage under the NIHB Program:

• Anti-obesity drugs; • Household products (regular soaps and shampoos); • Cosmetics; • Alternative therapies, including glucosamine and evening primrose oil; • Megavitamins; • Drugs with investigational/experimental status; • Vaccinations for travel indications; • Hair growth stimulants; • Fertility agents and impotence drugs; • Selected over-the-counter products; • Codeine containing cough preparations; • Stadol TM NS and generics (butorphanol tartrate nasal spray); and • Darvon® and 642® (propoxyphene); • Fiorinal®, Fiorinal® C ¼, Fiorinal® C ½ and generics (Butalbital containing analgesics with and

without codeine); • Dalmane®, Somnol® and generics (flurazepam); • Librium®, Solium®, Medilium® and generics (chlordiazepoxide); • Tranxene® and generics (clorazepate).

5. POLICIES

A. Best Price Alternative and Interchangeability The Non-Insured Health Benefits (NIHB) program will reimburse only the best price (lowest cost) alternative product in a group of interchangeable drug products. Pharmacists must follow their provincial/territorial pharmacy legislation/policies to identify interchangeable products and to select the lowest-priced brand. (NIHB may not necessarily reimburse at the cost listed in the provincial drug plan formulary). If a recipient selects a higher cost equivalent, he/she will be responsible for any incremental costs above the cost of the best price equivalent drugs. B. “No Substitution” Claims NIHB will consider reimbursement for a higher-cost interchangeable product when a patient has experienced an adverse reaction with a lower-cost alternative. In such circumstances, the prescriber must provide the pharmacist with: 1. a completed and signed Health Canada form: ‘Report of suspected adverse reaction due to drug

products marketed in Canada’ and, 2. the prescription with “No Substitution” or “No Sub” handwritten. Upon receipt, the pharmacist will forward a copy of the form and the prescription to NIHB for review. A copy of the form will be forwarded to the Adverse Drug Reaction Monitoring Program of Health Canada. Forms can be obtained by calling Health Canada at 1-866-234-2345 or by downloading a copy from Health Canada website at http://www.hc-sc.gc.ca/dhp-mps/medeff/report-declaration/ar-ei_form-eng.php or by photocopying a


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copy from the Compendium of Pharmaceuticals and Specialties. NOTE: The report of Adverse Reaction form will not need to be resubmitted for renewals or new prescriptions of the same drug for the patient, although “No Sub” will still have to be written on the prescription. C. Prescription Quantities The normal quantity dispensed shall be the entire quantity of the drug prescribed. A maximum 100-day supply should be considered for those circumstances where the patient has been stabilized on a medication and the prescriber feels that further adjustment during the prescribed period is unlikely. The physician may continue to prescribe a smaller quantity with repeats at certain intervals when it is in the patient’s best interest. D. Short Term Dispensing Policy It is the Program’s expectation that certain medications required for long-term maintenance therapy should be prescribed and dispensed in up to 100 days supplies. For refills for medications requiring short-term dispensing for a shorter time than 28 days due to compliance concerns, the Program will only reimburse a total of one dispensing fee per 28 days, except: a. Refills for intermittent treatment of a chronic disorder (e.g. dosage change) b. Refills for drugs prescribed for as required use (e.g. PRN) c. Refills of methadone d. Others as identified by the NIHB Program Minimum 28 day supply NIHB will consider compensation for no more than one dispensing fee every 28 days for chronically used oral medication. These medications include (but are not limited to) drugs in the following categories: Alpha-adrenoreceptor Antagonists Anti-dementia Drugs Anti-gout Drugs Anti-Parkinsonian Drugs Anti-platelet aggregation Drugs BPH Drugs Cardiovascular Drugs Enzyme Preparations Drugs for Diabetes Drugs for Treatment of Bone Diseases GI Anti-inflammatory Drugs Thyroid Therapy Proton Pump Inhibitors Urinary Anti-Spasmotics H2-Receptor Antagonists OTCs (including vitamins) Other Drugs for Peptic Ulcer and Gastro-esophageal Reflux Disease (GERD) Note: this list may be amended as required and changes will be communicated through the quarterly drug bulletin and as on-line updates to the Drug Benefit List. Medications on the Short term Dispensing list are identified in the DBL using the symbol ST beside the medication strength and dosage form. Compensation The compensation will be the lesser of the usual and customary fee up to the maximum negotiated NIHB regional dispensing fee for each 28 days supplied. NIHB will continue to audit and recover in instances where quantity reduction occurs. Less than 28 Day Supply For certain “high-risk” drugs where safety, risk of diversion and compliance are of concern, a less than 28 day supply will be compensated. The drug categories for which less than a 28 day supply will be compensated are: antidepressants anti-psychotics opioids benzodiazepines Through provider audit, special attention will be given to these drug categories to ensure the appropriateness of short-term dispensing in all cases.


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Implementation - When filling a new prescription for a chronic use drug, the Program will pay a full dispensing fee regardless of the days supply. A new prescription may include a dosage change or an intermittent treatment, based on an assessment by a prescriber. - When refilling a prescription for a chronic use drug that is for less than a 28 day supply or when a need for compliance packaging is identified by the prescriber, the Program will pay no more than one full dispensing fee per 28 day period. - A refill is defined as the second and all subsequent fills for a given strength and dosage of a drug.

6. SPECIAL FORMULARY FOR CHRONIC RENAL FAILURE PATIENTS Recipients with chronic renal failure are eligible to receive a list of supplemental benefits that are not included in the NIHB Drug Benefit List but which are required on a long-term basis. Some supplemental benefits include: darbepoetin alfa products (except in provinces where NIHB recipients are eligible to receive darbepoetin alfa through the provincial programs), calcium products, multivitamins formulated for renal patients and select nutritional supplements formulated for renal patients. New patients requiring drugs on the special formulary will be identified for coverage through the usual prior approval process. Once the patient is confirmed as eligible, coverage will automatically be extended to all drugs in the special formulary for as long as needed. 7. PALLIATIVE CARE FORMULARY Recipients diagnosed with a terminal illness and are near the end of life will be eligible to receive a list of supplemental benefits that are not included in the NIHB Drug Benefit List. The Palliative Care Formulary includes medications used to provide comfort to those near the end of life. Requests for any of the DINs on the Palliative Care Formulary will generate a Palliative Care Application Form, faxed to the prescribing physician. Once completed and submitted, the recipient will be eligible for all medications on the Palliative Care Formulary if the following criteria are met: The recipient: 1. is not receiving care in a provincially covered hospital or provincially covered long-term care facility and 2. has been diagnosed with a terminal illness or disease which is expected to be the primary cause of death

within six months or less Once approved, the recipient will be eligible for all medications on the Palliative Care Formulary for six months without the need for further prior approval. If coverage is required beyond the initial six months, an additional six months may be granted upon receipt of another completed Palliative Care Application Form. Please note: During the six month coverage period, a maximum 30 day supply will be reimbursed at any one time. 8. DRUG UTILIZATION EVALUATION A drug utilization evaluation, which is part of the point-of-service or on-line adjudication system, provides an analysis of both previous claims data and current claims data to identify potential drug-related problems. Messages are returned to pharmacists to alert them of the potential problems. These messages are intended to enhance pharmacy practice with additional information. Currently, the system monitors for:

- potential drug/drug interactions - duplicate drugs - duplicate therapy

The NIHB Drug Use Evaluation Advisory Committee was established in Fall 2003 to provide advice to the NIHB Drug Use Evaluation (DUE) Program, to promote effective, efficient and optimal drug therapy to First Nations and Inuit recipients.


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9. GENERAL INFORMATION Sources of information about the NIHB Program include:

• The NIHB Internet site which provides background information on the program and a copy of the Drug Benefit List. It can be found at: http://www.hc-sc.gc.ca/fniah-spnia/nihb-ssna/provide-fournir/pharma-prod/med-list/index-eng.php

• The NIHB Drug Bulletin which is available to pharmacists and to medical practitioners through the

Health Canada’s website. Bulletins can be found at: http://www.hc-sc.gc.ca/fniah-spnia/pubs/nihb-ssna/index-eng.php#drug-med

Information about the NIHB Program can also be obtained by contacting: Director, Benefit Management Non-Insured Health Benefits First Nations and Inuit Health Branch Room 504, Suite 550 Address Locator 4005A 55 Metcalfe Street Ottawa, Ontario K1A 0K9 10. 10. NIHB PRIVACY CODE The NIHB Program of Health Canada is committed to protecting an individual’s privacy and safeguarding the personal information in its possession. When a benefit request is received, the NIHB Program collects, uses, discloses and retains an individual’s personal information according to the applicable federal privacy legislation. The information collected is limited to only that information required for the NIHB Program to administer and verify benefits. As a program of the federal government, the NIHB Program must comply with the Privacy Act, the Canadian Charter of Rights and Freedoms, the Access to Information Act, the Treasury Board of Canada Privacy and Data Protection Policies, the Government Security Policy, and Health Canada’s Security Policy. 11. PHARMACOLOGIC-THERAPEUTIC CLASSIFICATION OF DRUGS The drugs in the Non-Insured Health Benefits (NIHB) Drug Benefit List are classified according to the AHFS Pharmacologic-Therapeutic classification developed by the American Society of Health-System Pharmacists for the purposes of the AHFS Drug Information. Permission to use this system has been granted by the American Society of Health-System Pharmacists. The Society is not responsible for the accuracy of transpositions from the original context. Drugs are listed alphabetically within each therapeutic classification according to their chemical names. Under each drug, acceptable products are listed.

http://www.hc-sc.gc.ca/fniah-spnia/nihb-ssna/provide-fournir/pharma-prod/med-list/index-eng.php

http://www.hc-sc.gc.ca/fniah-spnia/nihb-ssna/provide-fournir/pharma-prod/med-list/index-eng.php


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LEGEND

1. Pharmacologic-Therapeutic classification

2. Pharmacologic-Therapeutic sub-classification 3. Nonproprietary or generic name of the drug 4. Drug strength and dosage form. ST indicates the drug is identified as a

chronic medication under the Short-Term Dispensing Policy. 5. Drug Identification Number (DIN), assigned by the Therapeutic Products

Directorate of Health Canada, to uniquely identify the drug product as to its manufacturer, name and strength of active ingredients, route of administration and pharmaceutical dosage form

6. Brand name of the drug 7. List of all active ingredients in a combination product 8. Strengths of active ingredients in a combination product, listed in the same

order as the ingredients 9. List of available brands of drugs. Provincial or territorial drug plan

formularies should be consulted to determine interchangeable products and to identify best price (lowest cost) alternatives

10. Three letter identification code assigned to manufacturer 11. An asterisk (*) to the right of the manufacturer code indicates that the

product is not available in all regions


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1 04:00 ANTIHISTAMINE DRUGS 2 04.00.00 ANTIHISTAMINE DRUGS 3 CETIRIZINE HCL 4 ST 10mg Tablet 5 02231603 APO-CETIRIZINE APX 6 7 28:08.08 ACETAMINOPHEN, CAFFEINE, CODEINE PHOSPHATE 8 300mg & 15mg & 15mg Tablet 00706515 PMS-ACET 2 PMS 00653241 RATIO-LENOLTEC NO.2 RPH 02163934 TYLENOL WITH CODEINE NO.2 JNO 9 300mg & 15mg & 30mg Tablet 00653276 RATIO-LENOLTEC NO.3 RPH 02163926 TYLENOL WITH CODEINE NO.3 JNO 10 36:00 DIAGNOSTIC AGENTS 36:26.00 DX – DIABETES MELLITUS GLUCOSE OXIDASE, PEROXIDASE Freestyle Strip 00901388 FREESTYLE THS * 00905500 FREESTYLE THS 00950907 FREESTYLE THS * 09857141 FREESTYLE THS 44123028 FREESTYLE THS 97799829 FRESSTYLE THS 99004704 FREESTYLE THS * 99401062 FREESTYLE THS 11

DRUG BENEFIT LIST

Non-Insured Health BenefitsHealth Canada

04:00 ANTIHISTAMINE DRUGS04:00.00 ANTIHISTAMINE DRUGS

BROMPHENIRAMINE MALEATE, PHENYLEPHRINE HCL

Oral Liquid02243980 DIMETAPP COLD WRI

CETIRIZINE HCL1mg/mL SyrupST

02238337 REACTINE JNO10mg Tablet

02315955 ALLERGY RELIEF ES PED02231603 APO-CETIRIZINE APX02223554 REACTINE JNO

20mg TabletST

02315963 PMS-CETIRIZINE PMS01900978 REACTINE JNO

CHLORPHENIRAMINE MALEATE12mg Sustained Release TabletST

00738964 CHLOR-TRIPOLON SCH4mg TabletST

00738972 CHLOR-TRIPOLON SCH00021288 NOVOPHENIRAM NOP

DIPHENHYDRAMINE HCL25mg Capsule

00757683 PMS-DIPHENHYDRAMINE PMS50mg Capsule

02019671 BENADRYL WLA00757691 PMS-DIPHENHYDRAMINE PMS

2.5mg/mL Elixir00804193 ALLERNIX RPH02019736 BENADRYL WLA00833266 DIPHENHYDRAMINE HCL TAN00792705 PMS-DIPHENHYDRAMINE PMS

50mg/mL Injection00596612 DIPHENHYDRAMINE SDZ00878200 PMS-DIPHENHYDRAMINE PMS

1.25mg/mL Liquid02019698 BENADRYL CHILD WLA

12.5MG/5ML Liquid02298503 JAMP-DIPHENHYDRAMINE JMP02298503 JAMP-DIPHENHYDRAMINE JMP

25mg Tablet02176483 ALLER-AIDE RPH01949454 ALLERGY TAN02229492 ALLERGY FORMULA SDR02097583 ALLERNIX RPH02017849 BENADRYL WLA02257548 JAMP-DIPHENHYDRAMINE JMP02239029 NADRYL RIV

50mg Tablet02097575 ALLERNIX PLUS RPH02230398 DIPHENHYDRAMINE HCL TAN02257556 JAMP-DIPHENHYDRAMINE JMP

04:00.00 ANTIHISTAMINE DRUGSFEXOFENADINE HCL

60mg TabletST

02231462 ALLEGRA AVT

KETOTIFEN FUMARATE0.2mg/mL SyrupST

02221330 APO-KETOTIFEN APX02176084 NOVO-KETOTIFEN NOP02218305 NU-KETOTIFEN NXP02231679 PMS-KETOTIFEN PMS

1mg TabletST

02230730 NOVO-KETOTIFEN NOP02231680 PMS-KETOTIFEN PMS00577308 ZADITEN NVR

LORATADINE1mg/mL SyrupST

02019973 CLARITIN SCH02241523 CLARITIN KIDS SCH

10mg TabletST

00782696 CLARITIN SCH02244692 LORATADINE VTH02280159 LORATADINE VTH

LORATADINE, PSEUDOEPHEDRINE SULFATE5mg & 120mg Sustained Release TabletST

01970399 CHLOR-TRIPOLON ND SCH01945157 CLARITIN EXTRA SCH

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08:00 ANTI-INFECTIVE AGENTS08:08.00 ANTHELMINTICS

MEBENDAZOLE100mg Tablet

00556734 VERMOX JNO

PYRANTEL PAMOATE50mg/mL Suspension

01944355 COMBANTRIN PFI125mg Tablet

01944363 COMBANTRIN PFI

08:12.06 CEPHALOSPORINSCEFACLOR

250mg Capsule02230263 APO-CEFACLOR APX00465186 CECLOR PHH02177633 DOM-CEFACLOR DPC02231432 NU-CEFACLOR NXP02238200 PDL-CEFACLOR PDL02237729 SCHEIN-CEFACLOR SCN

500mg Capsule02230264 APO-CEFACLOR APX00465194 CECLOR PHH02177641 DOM-CEFACLOR DPC02231433 NU-CEFACLOR NXP02238201 PDL-CEFACLOR PDL02237730 SCHEIN-CEFACLOR SCN

25mg/mL Suspension00465208 CECLOR PHH02177668 DOM-CEFACLOR DPC02238202 PDL-CEFACLOR PDL

50mg/mL Suspension00465216 CECLOR PHH02177676 DOM-CEFACLOR DPC02238203 PDL-CEFACLOR PDL

75mg/mL Suspension02237502 APO-CEFACLOR APX00832804 CECLOR BID PHH02177684 DOM-CEFACLOR DPC02238204 PDL-CEFACLOR PDL

CEFADROXIL500mg Capsule

02240774 APO-CEFADROXIL APX02235134 NOVO-CEFADROXIL NOP02311062 PRO-CEFADROXIL PDL

CEFIXIME20mg/mL Suspension

00868965 SUPRAX SAC400mg Tablet

00868981 SUPRAX SAC

08:12.06 CEPHALOSPORINSCEFPROZIL

25mg/mL Suspension02293943 APO-CEFPROZIL APX02163675 CEFZIL BMS02303426 SANDOZ CEFPROZIL SDZ

50mg/mL Suspension02293951 APO-CEFPROZIL APX02163683 CEFZIL BMS02293579 RAN-CEFPROZIL RBY02303434 SANDOZ CEFPROZIL SDZ

250mg Tablet02292998 APO-CEFPROZIL APX02163659 CEFZIL BMS02293528 RAN-CEFPROZIL RBY02302179 SANDOZ CEFPROZIL SDZ

500mg Tablet02293005 APO-CEFPROZIL APX02163667 CEFZIL BMS02293536 RAN-CEFPROZIL RBY02302187 SANDOZ CEFPROZIL SDZ

CEFPROZIL MONOHYDRATE125MG/5ML Oral Liquid

02329204 RAN-CEFPROZIL RBY02329204 RAN-CEFPROZIL RBY

CEFUROXIME AXETIL25mg/mL Suspension

02212307 CEFTIN GSK250mg Tablet

02244393 APO-CEFUROXIME APX02212277 CEFTIN GSK02242656 RATIO-CEFUROXIME RPH

500mg Tablet02244394 APO-CEFUROXIME APX02212285 CEFTIN GSK02311453 PRO-CEFUROXIME PDL02242657 RATIO-CEFUROXIME RPH

CEPHALEXIN250mg Capsule

00342084 NOVO-LEXIN NOP500mg Capsule

00342114 NOVO-LEXIN NOP25mg/mL Suspension

02177862 DOM-CEPHALEXIN DPC00342106 NOVO-LEXIN NOP

50mg/mL Suspension02177870 DOM-CEPHALEXIN DPC00342092 NOVO-LEXIN NOP

Page 2 of 1242010


08:12.06 CEPHALOSPORINSCEPHALEXIN

250mg Tablet00768723 APO-CEPHALEX APX02177846 DOM-CEPHALEXIN DPC00583413 NOVO-LEXIN NOP00865877 NU-CEPHALEX NXP00828858 PDL-CEPHALEXIN PDL02177781 PMS-CEPHALEXIN PMS

500mg Tablet00768715 APO-CEPHALEX APX02177854 DOM-CEPHALEXIN DPC00583421 NOVO-LEXIN NOP00865885 NU-CEPHALEX NXP00828866 PDL-CEPHALEXIN PDL02177803 PMS-CEPHALEXIN PMS

08:12.12 MACROLIDESAZITHROMYCIN

100MG/5ML Oral Liquid02332388 SANDOZ-AZITHROMYCIN SDZ

200MG/5ML Oral Liquid02332396 SANDOZ-AZITHROMYCIN SDZ

20mg/mL Suspension02315157 NOVO-AZITHROMYCIN NOP02274388 PMS-AZITHROMYCIN PMS02223716 ZITHROMAX PFI

40mg/mL Suspension02315165 NOVO-AZITHROMYCIN NOP02274396 PMS-AZITHROMYCIN PMS02223724 ZITHROMAX PFI

250mg Tablet02247423 APO-AZITHROMYCIN APX02255340 CO AZITHROMYCIN COB02278359 GEN-AZITHROMYCIN GEN02267845 NOVO-AZITHROMYCIN NOP02278588 PHL-AZITHROMYCIN PMI02261634 PMS-AZITHROMYCIN PMS02310600 PRO-AZITHROMYCIN PDL02275287 RATIO-AZITHROMYCIN RPH02275309 RIVA-AZITHROMYCIN RIV02265826 SANDOZ-AZITHROMYCIN SDZ02212021 ZITHROMAX PFI

600mg Tablet02256088 CO AZITHROMYCIN COB02261642 PMS-AZITHROMYCIN PMS02275317 RIVA-AZITHROMYCIN RIV02231143 ZITHROMAX PFI

CLARITHROMYCIN500mg Extended Release Tablet

02244756 BIAXIN XL ABB

08:12.12 MACROLIDESCLARITHROMYCIN

250mg Film Coated Tablet02274744 APO-CLARITHROMYCIN APX01984853 BIAXIN ABB02248856 GEN-CLARITHROMYCIN GEN02247573 PMS-CLARITHROMYCIN PMS02247818 RATIO-CLARITHROMYCIN RPH02266539 SANDOZ-CLARITHROMYCIN RHO

500mg Film Coated Tablet02266547 SANDOZ-CLARITHROMYCIN RHO

500mg Film Coated Tablet02274752 APO-CLARITHROMYCIN APX02126710 BIAXIN ABB02248857 GEN-CLARITHROMYCIN GEN02247574 PMS-CLARITHROMYCIN PMS02247819 RATIO-CLARITHROMYCIN RPH

25mg/mL Suspension02146908 BIAXIN ABB

50mg/mL Suspension02244641 BIAXIN ABB

ERYTHROMYCIN250mg Enteric Coated Capsule

00726672 APO-ERYTHRO APX00607142 ERYC PFI

333mg Enteric Coated Capsule01925938 APO-ERYTHRO APX

333mg Enteric Coated Tablet00873454 ERYC PFI

250mg Tablet00682020 APO-ERYTHRO BASE APX

ERYTHROMYCIN ESTOLATE50mg/mL Suspension

00262595 NOVO-RYTHRO ESTOLATE NOP

ERYTHROMYCIN ETHYLSUCCINATE40mg/mL Suspension

00605859 NOVO-RYTHRO ETHYLSUCCINATE

NOP

80mg/mL Suspension00652318 NOVO-RYTHRO

ETHYLSUCCINATENOP

600mg Tablet00637416 APO-ERYTHRO-S APX00583782 EES-600 ABB00704377 ERYTHRO-ES PDL

ERYTHROMYCIN STEARATE250mg Tablet

00545678 APO-ERYTHRO-S APX00563854 ERYTHROMYCIN PDL02051850 NU-ERYTHROMYCIN S NXP

500mg Tablet00688568 APO-ERYTHRO S APX00704393 ERYTHRO PDL

Page 3 of 1242010


08:12.16 PENICILLINSAMOXICILLIN

250mg Capsule00628115 APO-AMOXI APX02238171 GEN-AMOXICILLIN GEN02239761 MED-AMOXICILLIN MEC00406724 NOVAMOXIN NOP00865567 NU-AMOXI NXP02229584 PENTA-AMOXICILLIN PEN02230243 PMS-AMOXICILLIN PMS00644307 PRO-AMOX PDL02241826 SCHEIN-AMOXICILLIN SCN

500mg Capsule00628123 APO-AMOXI APX02238172 GEN-AMOXICILLIN GEN02239762 MED-AMOXICILLIN MEC00406716 NOVAMOXIN NOP00865575 NU-AMOXI NXP02233017 PENTA-AMOXICILLIN PEN02230244 PMS-AMOXICILLIN PMS00644315 PRO-AMOX PDL02241827 SCHEIN-AMOXICILLIN SCN

125mg Chewable Tablet02036347 NOVAMOXIN NOP

250mg Chewable Tablet02036355 NOVAMOXIN NOP

25mg/mL Suspension00628131 APO-AMOXI APX00452149 NOVAMOXIN NOP01934171 NOVAMOXIN SUGAR

REDUCEDNOP

00865540 NU-AMOXI NXP02229582 PENTA-AMOXICILLIN PEN02230245 PMS-AMOXICILLIN PMS00644323 PRO-AMOX PDL

50mg/mL Suspension00628158 APO-AMOXI APX00452130 NOVAMOXIN NOP01934163 NOVAMOXIN SUGAR

REDUCEDNOP

00865559 NU-AMOXI NXP02229583 PENTA-AMOXICILLIN PEN02230246 PMS-AMOXICILLIN PMS00644331 PRO-AMOX PDL

AMOXICILLIN, CLAVULANIC ACID25mg & 6.25mg/mL Suspension

02243986 APO-AMOXI CLAV APX01916882 CLAVULIN-F 125 GSK

40mg & 5.7mg/mL Suspension02288559 APO-AMOXI CLAV APX02238831 CLAVULIN 200 GSK

50mg & 12.5mg/mL Suspension02243987 APO-AMOXI CLAV APX01916874 CLAVULIN-F 250 GSK

80mg & 11.4mg/mL Suspension02238830 CLAVULIN 400 GSK

08:12.16 PENICILLINSAMOXICILLIN, CLAVULANIC ACID

250mg & 125mg Tablet02243350 APO-AMOXI CLAV APX

500mg & 125mg Tablet02243351 APO-AMOXI CLAV APX01916858 CLAVULIN-F GSK02243771 RATIO-ACLAVULANATE RPH

875mg & 125mg Tablet02245623 APO-AMOXI CLAV APX02238829 CLAVULIN GSK02248138 NOVO-CLAVAMOXIN NOP02247021 RATIO-ACLAVULANATE RPH

AMPICILLIN250mg Capsule

00020877 NOVO-AMPICILLIN NOP500mg Capsule

00020885 NOVO-AMPICILLIN NOP25mg/mL Suspension

00603260 APO-AMPICILLIN APX00717495 NU-AMPI NXP

50mg/mL Suspension00603287 APO-AMPICILLIN APX00717649 NU-AMPI NXP02043203 PENBRITIN WAY

CLOXACILLIN250mg Capsule

00618292 APO-CLOXI APX02069660 CLOXACILLINE PRO00337765 NOVO-CLOXIN NOP00717584 NU-CLOXI NXP

500mg Capsule00618284 APO-CLOXI APX02069679 CLOXACILLINE PRO00337773 NOVO-CLOXIN NOP00717592 NU-CLOXI NXP

25mg/mL Suspension00644633 APO-CLOXI APX00337757 NOVO-CLOXIN NOP00717630 NU-CLOXI NXP

PENICILLIN V BENZATHINE36mg/mL Suspension

02229618 PEN VEE PED60mg/mL Suspension

02229617 PEN VEE PED

PENICILLIN V POTASSIUM25mg/mL Suspension

00642223 APO-PEN VK APX60mg/mL Suspension

00642231 APO-PEN VK APX00391603 NOVO-PEN VK NOP

Page 4 of 1242010


08:12.16 PENICILLINSPENICILLIN V POTASSIUM

300mg Tablet00642215 APO-PEN VK APX00021202 NOVO-PEN VK NOP00717568 NU-PEN VK NXP00468029 PENICILLINE V PDL

PIVMECILLINAM HCL200mg Tablet

00657212 SELEXID LEO

08:12.18 QUINOLONESCIPROFLOXACIN HCL

250mg Tablet02229521 APO-CIPROFLOX APX02155958 CIPRO BAY02251752 CIPROFLOXCIN PDL02247339 CO CIPROFLOXACIN COB02251272 DOM-CIPROFLOXACIN DPC02245647 GEN-CIPROFLOXACIN GEN02317427 MINT-CIPROFLOXACIN MIN02161737 NOVO-CIPROFLOXACIN NOP02249634 NU-CIPROFLOXACIN NXP02251310 PHL-CIPROFLOXACIN PHH02248437 PMS-CIPROFLOXACIN PMS02249960 PREM-CIPROFLOXACIN PRE02317796 PRO-CIPROFLOXACIN PDL02303728 RAN-CIPROFLOX RBY02267934 RAN-CIPROFLOXACIN RBY02246825 RATIO-CIPROFLOXACIN RPH02251221 RIVA-CIPROFLOXACIN RIV02248756 SANDOZ-CIPROFLOXACIN SDZ02266962 TARO-CIPROFLOXACIN TAR

500mg Tablet02229522 APO-CIPROFLOX APX02155966 CIPRO BAY02251760 CIPROFLOXACIN PDL02247340 CO CIPROFLOXACIN COB02251280 DOM-CIPROFLOXACIN DPC02245648 GEN-CIPROFLOXACIN GEN02317435 MINT-CIPROFLOXACIN MIN02161745 NOVO-CIPROFLOXACIN NOP02249642 NU-CIPROFLOXACIN NXP02251329 PHL-CIPROFLOXACIN PHH02248438 PMS-CIPROFLOXACIN PMS02249979 PREM-CIPROFLOXACIN PRE02317818 PRO-CIPROFLOXACIN PDL02303736 RAN-CIPROFLOX RBY02267942 RAN-CIPROFLOXACIN RBY02246826 RATIO-CIPROFLOXACIN RPH02248757 RHOXAL-CIPROFLOXACIN RHO02251248 RIVA-CIPROFLOXACIN RIV02266970 TARO-CIPROFLOXACIN TAR

08:12.18 QUINOLONESCIPROFLOXACIN HCL

750mg Tablet02229523 APO-CIPROFLOX APX02155974 CIPRO BAY02251779 CIPROFLOXACIN PDL02247341 CO CIPROFLOXACIN COB02251299 DOM-CIPROFLOXACIN DPC02245649 GEN-CIPROFLOXACIN GEN02317443 MINT-CIPROFLOXACIN MIN02161753 NOVO-CIPROFLOXACIN NOP02249650 NU-CIPROFLOXACIN NXP02251337 PHL-CIPROFLOXACIN PHH02248439 PMS-CIPROFLOXACIN PMS02249987 PREM-CIPROFLOXACIN PRE02303744 RAN-CIPROFLOX RBY02267950 RAN-CIPROFLOXACIN RBY02246827 RATIO-CIPROFLOXACIN RPH02248758 RHOXAL-CIPROFLOXACIN RHO02251256 RIVA-CIPROFLOXACIN RIV

LEVOFLOXACINLimited use benefit (prior approval not required).

Coverage will be limited to a maximum of 14 days.250mg Tablet

02284707 APO-LEVOFLOXACIN APX02315424 CO-LEVOFLOXACIN CBT02286920 DOM-LEVOFLOXACIN DOM02313979 GEN-LEVOFLOXACIN GEN02236841 LEVAQUIN JNO02307200 LEVOFLOXACIN SOR02248262 NOVO-LEVOFLOXACIN NOP02286947 PHL-LEVOFLOXACIN PMI02284677 PMS-LEVOFLOXACIN PMS02298635 SANDOZ LEVOFLOXACIN SDZ

500mg Tablet02284715 APO-LEVOFLOXACIN APX02315432 CO-LEVOFLOXACIN CBT02286939 DOM-LEVOFLOXACIN DOM02313987 GEN-LEVOFLOXACIN GEN02236842 LEVAQUIN JNO02307219 LEVOFLOXACIN SOR02248263 NOVO-LEVOFLOXACIN NOP02286955 PHL-LEVOFLOXACIN PMI02284685 PMS-LEVOFLOXACIN PMS02298643 SANDOZ LEVOFLOXACIN SDZ

NORFLOXACIN400mg Tablet

02229524 APO-NORFLOX APX02269627 CO NORFLOXACIN COB02237682 NOVO-NORFLOXACIN NOP02239670 PDL-NORFLOXACINE PDL02246596 PMS-NORFLOXACIN PMS02241483 RIVA-NORFLOXACIN RIV02301504 RIVA-NORFLOXACIN RIV

Page 5 of 1242010


08:12.18 QUINOLONESOFLOXACIN

200mg Tablet02231529 APO-OFLOX APX

300mg Tablet02231531 APO-OFLOX APX02243475 NOVO-OFLOXACIN NOP

400mg Tablet02231532 APO-OFLOX APX

08:12.20 SULFONAMIDESSULFAMETHOXAZOLE

500mg Tablet00421480 APO-SULFAMETHOXAZOLE APX

SULFAMETHOXAZOLE, TRIMETHOPRIM40mg & 8mg/mL Suspension

00726540 NOVO-TRIMEL NOP100mg & 20mg Tablet

00445266 APO-SULFATRIM PED APX400mg & 80mg Tablet

00445274 APO-SULFATRIM APX00510637 NOVO-TRIMEL NOP00865710 NU-COTRIMOX NXP00512516 PROTRIN PDL

800mg & 160mg Tablet00445282 APO-SULFATRIM DS APX00510645 NOVO-TRIMEL DS NOP00865729 NU-COTRIMOX DS NXP00512524 PROTRIN DF PRO

SULFASALAZINE500mg Enteric Coated Tablet

00598488 PMS-SULFASALAZINE PMS02064472 SALAZOPYRIN PFI

500mg Tablet00598461 PMS-SULFASALAZINE PMS02064480 SALAZOPYRIN PFI

08:12.24 TETRACYCLINESDOXYCYCLINE

100mg Capsule00740713 APO-DOXY APX00817120 DOXYCIN RIV00742562 DOXYCYCLINE PDL00725250 NOVO-DOXYLIN NOP02044668 NU-DOXYCYCLINE NXP02289539 PMS-DOXYCYCLINE PMS02093103 RATIO-DOXYCYCLINE RPH

100mg Tablet00874256 APO-DOXY APX00860751 DOXYCIN RIV00887064 DOXYTAB PDL02158574 NOVO-DOXYLIN NOP02044676 NU-DOXYCYCLINE NXP02289466 PMS-DOXYCYCLINE PMS02091232 RATIO-DOXYCYCLINE RPH

08:12.24 TETRACYCLINESMINOCYCLINE HCLLimited use benefit (prior approval required).

For:a. - patients who cannot tolerate other tetracyclines.b. - patients with severe widespread acne who have failed on tetracycline.

50mg Capsule02084090 APO-MINOCYCLINE APX02239667 DOM-MINOCYCLINE DPC02237875 MED-MINOCYCLINE MEC02173514 MINOCIN STI02108143 NOVO-MINOCYCLINE NOP02153394 PDL-MINOCYCLINE PDL02239238 PMS-MINOCYCLINE PMS02294419 PMS-MINOCYCLINE PMS01914138 RATIO-MINOCYCLINE RPH02242080 RIVA-MINOCYCLINE RIV02237313 SANDOZ-MINOCYCLINE SDZ

100mg Capsule02084104 APO-MINOCYCLINE APX02239668 DOM-MINOCYCLINE DPC02237876 MED-MINOCYCLINE MEC02173506 MINOCIN STI02239982 MINOCYCLINE IVX02108151 NOVO-MINOCYCLINE NOP02154366 PDL-MINOCYCLINE PDL02294427 PMS-MINOCYCLINE PMS02239239 PMS-MONOCYCLINE PMS01914146 RATIO-MINOCYCLINE RPH02242081 RIVA-MINOCYCLINE RIV02237314 SANDOZ-MINOCYCLINE SDZ

TETRACYCLINE HCL250mg Capsule

00580929 APO-TETRA APX00156744 TETRACYCLINE PRO

250mg Tablet00717606 NU-TETRA NXP

08:12.28 MISCELLANEOUS ANTIBIOTICSCLINDAMYCIN HCL

150mg Capsule02245232 APO-CLINDAMYCIN APX02248525 CLINDAMYCINE PDL00030570 DALACIN C PFI02258331 GEN-CLINDAMYCIN GEN02241709 NOVO-CLINDAMYCIN NOP02242409 RIVA-CLINDAMYCIN RIV

300mg Capsule02245233 APO-CLINDAMYCIN APX02248526 CLINDAMYCINE PDL02182866 DALACIN C PFI02258358 GEN-CLINDAMYCIN GEN02241710 NOVO-CLINDAMYCIN NOP02242410 RIVA-CLINDAMYCIN RIV

Page 6 of 1242010


08:12.28 MISCELLANEOUS ANTIBIOTICSCLINDAMYCIN PALMITATE HCL

15mg/mL Solution00225851 DALACIN C PFI

FUSIDATE SODIUM250mg Tablet

01934252 FUCIDIN FC LEO

LINEZOLIDLimited use benefit (prior approval required).

Tablets:

For treatment of proven vancomycin-resistant enterococci (VRE) infections when other antibiotics are not available, and for the treatment of proven Methicillin-Resistant Staphylococcus aureus (MRSA) infections in patients who cannot tolerate or who had an idiosyncratic reaction with Vancomycin.

I.V. solution:

When linezolid cannot be administered orally in the above mentioned situations.

2mg/mL Injection02243685 ZYVOXAM PFI

600mg Tablet02243684 ZYVOXAM PFI

08:14.04 ALLYLAMINESTERBINAFINE HCL

250mg Tablet02239893 APO-TERBINAFINE APX02254727 CO TERBINAFINE COB02242503 GEN-TERBINAFINE GEN02031116 LAMISIL NVR02240346 NOVO-TERBINAFINE NOP02248845 NU-TERBINAFINE NXP02240807 PMS-TERBINAFINE PMS02294273 PMS-TERBINAFINE PMS02262924 RIVA-TERBINAFINE RIV02262177 SANDOZ-TERBINAFINE SDZ

08:14.08 AZOLESFLUCONAZOLE

150mg Capsule02241895 APO-FLUCONAZOLE APX02311690 CANESORAL BAY02323419 CO FLUCONAZOLE CBT02141442 DIFLUCAN PFI02245697 GEN-FLUCONAZOLE GEN02243645 NOVO-FLUCONAZOLE NOP02246620 PMS-FLUCONAZOLE PMS02282348 PMS-FLUCONAZOLE PMS02310694 PRO-FLUCONAZOLE PDL02255510 RIVA-FLUCONAZOLE RIV

10mg/mL Suspension02024152 DIFLUCAN PFI

08:14.08 AZOLESFLUCONAZOLE

50mg Tablet02237370 APO-FLUCONAZOLE APX00891800 DIFLUCAN PFI02245292 GEN-FLUCONAZOLE GEN02236978 NOVO-FLUCONAZOLE NOP02245643 PMS-FLUCONAZOLE PMS02249294 TARO-FLUCONAZOLE TAR

100mg Tablet02237371 APO-FLUCONAZOLE APX02281279 CO FLUCONAZOLE CBT02245293 GEN-FLUCONAZOLE GEN02236979 NOVO-FLUCONAZOLE NOP02245644 PMS-FLUCONAZOLE PMS02310686 PRO-FLUCONAZOLE PDL02271516 RIVA-FLUCONAZOLE RIV02249308 TAR0-FLUCONAZOLE TAR

ITRACONAZOLE100mg Capsule

02047454 SPORANOX JNO10mg/mL Solution

02231347 SPORANOX JNO

KETOCONAZOLE200mg Tablet

02237235 APO-KETOCONAZOLE APX02231061 NOVO-KETOCONAZOLE NOP02122197 NU-KETOCON NXP

VORICONAZOLELimited use benefit (prior approval required).

For the treatment of:a. - patients with invasive aspergillosis.b. - culture proven invasive candidiasis with documented resistance to fluconazole.

50mg Tablet02256460 VFEND PFI


08:14.28 POLYENESNYSTATIN

100,000U/mL Suspension02125145 DOM-NYSTATIN DPC00792667 PMS-NYSTATIN PMS02194201 RATIO-NYSTATIN RPH

500,000U Tablet02194198 RATIO-NYSTATIN RPH

08:16.04 ANTITUBERCULOSIS AGENTSETHAMBUTOL HCL

100mg Tablet00247960 ETIBI VAE

400mg Tablet00247979 ETIBI VAE

Page 7 of 1242010


08:16.04 ANTITUBERCULOSIS AGENTSISONIAZID

10mg/mL Syrup00265500 ISOTAMINE VAE00577812 PMS-ISONIAZID PMS

50mg Tablet00577782 PMS-ISONIAZID PMS

300mg Tablet00272655 ISOTAMINE VAE00577804 PMS-ISONIAZID PMS

PYRAZINAMIDE500mg Tablet

00618810 PMS-PYRAZINAMIDE PMS00283991 TEBRAZID VAE

RIFABUTIN150mg Capsule

02063786 MYCOBUTIN PFI

RIFAMPIN150mg Capsule

02091887 RIFADIN SAC00393444 ROFACT VAE

300mg Capsule02092808 RIFADIN SAC00210463 RIMACTANE NVR00343617 ROFACT VAE

08:18.04 ADAMANTANESAMANTADINE HCL

100mg Capsule02130963 DOM-AMANTADINE DPC02139200 GEN-AMANTADINE GEN02199289 MED-AMANTADINE MEC01990403 PMS-AMANTADINE PMS

10mg/mL Syrup02130971 DOM-AMANTADINE DPC02022826 PMS-AMANTADINE PMS01913999 SYMMETREL BMS

08:18.08 ANTIRETROVIRALSABACAVIR

20mg/mL Oral Liquid02240358 ZIAGEN GSK

300mg Tablet02240357 ZIAGEN GSK

ABACAVIR, LAMIVUDINE600mg & 300mg Tablet

02269341 KIVEXA GSK

ABACAVIR, LAMIVUDINE, ZIDOVUDINE300mg & 150mg & 300mg Tablet

02244757 TRIZIVIR GSK

08:18.08 ANTIRETROVIRALSATAZANAVIR SULFATE

150mg Capsule02248610 REYATAZ BMS



DARUNAVIRLimited use benefit (prior approval required).

For the management of HIV in patients who failed or have experienced adverse events to three or more listed protease inhibitors.

300mg Tablet02284057 PREZISTA JNO



DIDANOSINE125mg Capsule

02244596 VIDEX EC BMS200mg Capsule



02244599 VIDEX EC BMS

EFAVIRENZ50mg Capsule

02239886 SUSTIVA BMS200mg Capsule

02239888 SUSTIVA BMS600mg Tablet

02246045 SUSTIVA BMS

EFAVIRENZ, EMTRICITABINE, TENOFOVIR DISOPROXIL FUMARATELimited use benefit (prior approval required).

For the treatment of HIV-1 infection adults where the virus is susceptible to each of tenofovir, emtricitabine and efavirenz, and:a. - Atripla is used to replace existing therapy with its component drugs, orb. - the patient is treatment naïve, orc. - the patient has established viral suppression but requires antiretroviral therapy modification due to intolerance or adverse effects.

Note: Criteria will be confirmed against medication history.600mg & 200mg & 300mg Tablet

02300699 ATRIPLA BMS

Page 8 of 1242010


08:18.08 ANTIRETROVIRALSEMTRICITABINE, TENOFOVIR DISOPROXIL FUMARATELimited use benefit (prior approval required).

For the treatment of patients with HIV infection where the virus is susceptible to both emtricitabine and tenofovir AND where the triple-entity antiretroviral agent (tenofovir/ emtricitabine/efavirenz) is not indicated due to one of the following:a. - efavirenz resistance b. - adverse effects secondary to efavirenz

200mg/300mg Tablet02274906 TRUVADA GIL

ETRAVIRINELimited use benefit (prior approval required).

For use in combination with other antiretroviral agents for treatment-experienced patients with HIV-1 infection who:a.- have failed prior antiretroviral therapy; andb. - have HIV-1 strains resistant to multiple antiretroviral agents, including NNRTIs

100mg Tablet02306778 INTELENCE JNO

FOSAMPRENAVIR CALCIUM50mg/mL Oral Suspension

02261553 TELZIR GSK700mg Tablet

02261545 TELZIR GSK

INDINAVIR SULFATE200mg Capsule

02229161 CRIXIVAN FRS400mg Capsule

02229196 CRIXIVAN FRS

LAMIVUDINE10mg/mL Solution

02192691 3TC GSK100mg Tablet

02239193 HEPTOVIR GSK150mg Tablet

02192683 3TC GSK300mg Tablet

02247825 3TC GSK

LAMIVUDINE, ZIDOVUDINE150mg & 300mg Tablet

02239213 COMBIVIR GSK

LOPINAVIR, RITONAVIR80mg & 20mg/mL Oral Solution

02243644 KALETRA ABB100mg & 25mg Tablet

02312301 KALETRA ABB200mg & 50mg Tablet

02285533 KALETRA ABB

08:18.08 ANTIRETROVIRALSMARAVIROCLimited use benefit (prior approval required).

For the treatment of HIV-1 infection, given in combination with other antiretroviral agents, in patients who have:a. - CR5 tropic viruses; andb. - documented resistance to at least one agent from each of the three major classes of antiretroviral agents (nucleoside reverse transcriptase inhibitors, non-nucleoside reverse transcriptase inhibitors, and protease inhibitors)

150mg Tablet02299844 CELSENTRI VII


NELFINAVIR MESYLATE50mg/g Powder for Suspension

02238618 VIRACEPT PFI250mg Tablet

02238617 VIRACEPT PFI625mg Tablet

02248761 VIRACEPT PFI

NEVIRAPINE200mg Tablet

02238748 VIRAMUNE BOE

RALTEGRAVIRLimited use benefit (prior approval required).

For the treatment of HIV infection in patients who are antiretroviral experienced and have virologic failure due to resistance to at least one agent from each of the three major classes of antiretroviral agents, nucleoside/tide reverse transcriptase inhibitors, non-nucleoside reverse transcriptase inhibitors and protease inhibitors.

400mg Tablet02301881 ISENTRESS FRS

RITONAVIR100mg Capsule

02241480 NORVIR SEC ABB80mg/mL Liquid

02229145 NORVIR ABB

SAQUINAVIR MESYLATE200mg Capsule

02216965 INVIRASE HLR500mg Tablet

02279320 INVIRASE HLR

STAVUDINE15mg Capsule

02216086 ZERIT BMS20mg Capsule

02216094 ZERIT BMS30mg Capsule

02216108 ZERIT BMS

Page 9 of 1242010


08:18.08 ANTIRETROVIRALSSTAVUDINE

40mg Capsule02216116 ZERIT BMS

TENOFOVIR DISOPROXIL FUMARATELimited use benefit (prior approval required).

For the management of HIV disease in patients who have failed or have experienced adverse events to an alternative nucleoside reverse transcriptase inhibitor.

245mg Tablet02247128 VIREAD GIL

TIPRANAVIRLimited use benefit (prior approval required).

For the management of HIV disease in patients a. - who have failed all currently listed protease inhibitorsb. - intolerant to all currently listed protease inhibitors

250mg Capsule02273322 APTIVUS BOE

ZIDOVUDINE100mg Capsule

01946323 APO-ZIDOVUDINE APX01902660 RETROVIR GSK

10mg/mL Syrup01902652 RETROVIR GSK

08:18.20 INTERFERONSPEGINTERFERON ALFA-2ALimited use benefit (prior approval required).

For the treatment of chronic hepatitis C in patients who are treatment naïve, upon the written request of a hepatologist or other specialist in this area.

a. - For genotypes 1, 4, 5 and 6, an initial 24 week supply will be approved. A further 24 week supply may be approved if patient has a viral reduction of at least 2 logs or HCV is undetectable at 12 weeks (48 weeks total).

b. - For genotypes 2 or 3, initial coverage for a maximum of 24 weeks will be approved. Renewals will not be covered

180mcg/0.5mL Injection02248077 PEGASYS HLR

180mcg/1mL Injection02248078 PEGASYS HLR

08:18.20 INTERFERONSPEGINTERFERON ALFA-2A, RIBAVIRINLimited use benefit (prior approval required).




180mcg/0.5mL & 200mg Injection & Tablet02253429 PEGASYS RBV HLR

180mcg/1mL & 200mg Injection & Tablet02253410 PEGASYS RBV HLR

PEGINTERFERON ALFA-2BLimited use benefit (prior approval required).



b. - For genotypes 2 or 3, initial coverage for a maximum of 24 weeks will be approved. Renewals will not be covered.

74mcg/Vial Injection02242966 UNITRON PEG SCH

118.4mcg/Vial Injection02242967 UNITRON PEG SCH



PEGINTERFERON ALFA-2B, RIBAVIRINLimited use benefit (prior approval required).




50mcg/0.5mL & 200mg Injection & Capsule02246026 PEGETRON SCH02254573 PEGETRON REDIPEN SCH


Page 10 of 1242010


08:18.20 INTERFERONSPEGINTERFERON ALFA-2B, RIBAVIRINLimited use benefit (prior approval required).







08:18.32 NUCLEOSIDES AND NUCLEOTIDES

ACYCLOVIR40mg/mL Suspension

00886157 ZOVIRAX GSK200mg Tablet

02207621 APO-ACYCLOVIR APX02242784 GEN-ACYCLOVIR GEN02285959 NOVO-ACYCLOVIR NOP02197405 NU-ACYCLOVIR NXP02237541 PDL-ACYCLOVIR PDL02078627 RATIO-ACYCLOVIR RPH00634506 ZOVIRAX GSK

400mg Tablet02207648 APO-ACYCLOVIR APX02242463 GEN-ACYCLOVIR GEN02285967 NOVO-ACYCLOVIR NOP02197413 NU-ACYCLOVIR NXP02237542 PDL-ACYCLOVIR PDL02078635 RATIO-ACYCLOVIR RPH01911627 ZOVIRAX GSK

800mg Tablet02207656 APO-ACYCLOVIR APX02242464 GEN-ACYCLOVIR GEN02285975 NOVO-ACYCLOVIR NOP02197421 NU-ACYCLOVIR NXP02237543 PDL-ACYCLOVIR PDL02078651 RATIO-ACYCLOVIR RPH01911635 ZOVIRAX GSK

08:18.32 NUCLEOSIDES AND NUCLEOTIDES

ADEFOVIR DIPIVOXILLimited use benefit (prior approval required).

For the treatment of chronic hepatitis B infection when used in combination with lamivudine in patients who have developed failure to lamivudine, as defined by an increase in HBV DNA of ≥ 1 log10 IU/mL above the nadir, measured on two separate occasions within an interval of at least one month, after the first three months of lamivudine therapy, and when failure to lamivudine is not due to poor adherence to therapy.

10mg Tablet02247823 HEPSERA GIL

ENTECAVIRLimited use benefit (prior approval required).

For the treatment of chronic hepatitis B infection in patients with cirrhosis documented on radiologic or histologic grounds and a HBV DNA concentration above 2000IU/mL.

0.5mg Tablet02282224 BARACLUDE BMS

FAMCICLOVIR125mg Tablet

02292025 APO-FAMCICLOVIR APX02305682 CO FAMCICLOVIR COB02229110 FAMVIR NVR02278081 PMS-FAMCICLOVIR PMS02278634 SANDOZ-FAMCICLOVIR SDZ

250mg Tablet02292041 APO-FAMCICLOVIR APX02305690 CO FAMCICLOVIR COB02229129 FAMVIR NVR02278103 PMS-FAMCICLOVIR PMS02278642 SANDOZ-FAMCICLOVIR SDZ

500mg Tablet02292068 APO-FAMCICLOVIR APX02305704 CO FAMCICLOVIR COB02177102 FAMVIR NVR02278111 PMS-FAMCICLOVIR PMS02278650 SANDOZ-FAMCICLOVIR SDZ

GANCICLOVIR SODIUM500mg Injection

02162695 CYTOVENE HLR

VALACYCLOVIR HCL500mg Tablet

02295822 APO-VALACYCLOVIR APX02298457 PMS-VALACYCLOVIR PMS02316447 RIVA-VALACYCLOVIR RIV02219492 VALTREX GSK

500mg Tablet02315173 PRO-VALACYCLOVIR PDL

VALGANCICLOVIR HCL450mg Tablet

02245777 VALCYTE HLR

Page 11 of 1242010


08:30.04 AMEBICIDESDIIODOHYDROXYQUIN

210mg Tablet01997769 DIODOQUIN GLE

650mg Tablet01997750 DIODOQUIN GLE

PAROMOMYCIN SULFATE250mg Capsule

02078759 HUMATIN ERF

08:30.08 ANTIMALARIALSCHLOROQUINE PHOSPHATE

250mg Tablet00021261 NOVO-CHLOROQUINE NOP

HYDROXYCHLOROQUINE SULFATE200mg Tablet

02246691 APO-HYDROXYQUINE APX02252600 GEN-HYDROXYCHLOROQUINE GEN02017709 PLAQUENIL SAC02311011 PRO-HYDROXYQUINE PDL

PRIMAQUINE PHOSPHATE26.3mg Tablet

02017776 PRIMAQUINE SAC

PYRIMETHAMINE25mg Tablet

00004774 DARAPRIM GSK

08:30.92 MISCELLANEOUS ANTIPROTOZOALS

ATOVAQUONE150mg/mL Suspension

02217422 MEPRON GSK

METRONIDAZOLE500mg Capsule

02248562 APO-METRONIDAZOLE APX250mg Tablet

00545066 APO-METRONIDAZOLE APX00420409 METRONIDAZOLE PDL

PENTAMIDINE ISETHIONATE300mg/Vial Injection

02183080 PENTAMIDINE MAY

08:36.00 URINARY ANTI-INFECTIVESNITROFURANTOIN

50mg Capsule01997637 MACRODANTIN PGP02231015 NOVO-FURANTOIN NOP

100mg Capsule02063662 MACROBID PGP02231016 NOVO-FURANTOIN NOP

50mg Tablet00319511 APO-NITROFURANTOIN APX

08:36.00 URINARY ANTI-INFECTIVESNITROFURANTOIN

100mg Tablet00312738 APO-NITROFURANTOIN APX

TRIMETHOPRIM100mg Tablet

02243116 APO-TRIMETHOPRIM APX200mg Tablet

02243117 APO-TRIMETHOPRIM APX

Page 12 of 1242010


10:00 ANTINEOPLASTIC AGENTS10:00.00 ANTINEOPLASTIC AGENTS

ALTRETAMINE50mg Capsule

02126230 HEXALEN LIL

ANASTROZOLE1mg Tablet

02224135 ARIMIDEX AZC

BICALUTAMIDE50mg Tablet

02296063 APO-BICALUTAMIDE APX02184478 CASODEX AZC02274337 CO BICALUTAMIDE COB02302403 GEN-BICALUTAMIDE GEN02270226 NOVO-BICALUTAMIDE NOP02275589 PMS-BICALUTAMIDE PMS02311038 PRO-BICALUTAMIDE PDL02277700 RATIO-BICALUTAMIDE RPH02276089 SANDOZ-BICALUTAMIDE SDZ

BUSERELIN ACETATE1mg/mL Injection

02225166 SUPREFACT SAC1mg/mL Nasal Solution

02225158 SUPREFACT SAC6.3mg/Implant Subcutaneous Injection

02228955 SUPREFACT DEPOT 2 MONTHS

SAC

9.45mg/Implant Subcutaneous Injection02240749 SUPREFACT DEPOT 3

MONTHSSAC

BUSULFAN2mg Tablet

00004618 MYLERAN GSK

CAPECITABINE150mg Tablet

02238453 XELODA HLR500mg Tablet

02238454 XELODA HLR

CHLORAMBUCIL2mg Tablet

00004626 LEUKERAN GSK

CYCLOPHOSPHAMIDE25mg Tablet

02241795 PROCYTOX BAT50mg Tablet

00344885 CYTOXAN BMS02241796 PROCYTOX BAT

10:00.00 ANTINEOPLASTIC AGENTSCYPROTERONE ACETATE

50mg Tablet00704431 ANDROCUR BEX02245898 APO-CYPROTERONE APX02229723 GEN-CYPROTERONE GEN

ERLOTINIB HYDROCLORIDELimited use benefit (prior approval required).

Treatment of non-small cell lung cancer (NSCLC) after failure of at least one prior chemotherapy regimen, and whose EGFR expression status is positive or unknown.

100mg Tablet02269015 TARCEVA HLR


ETOPOSIDE50mg Capsule

00616192 VEPESID BMS

EXEMESTANE25mg Tablet

02242705 AROMASIN PFI

FLUDARABINE PHOSPHATE10mg Tablet

02246226 FLUDARA BEX

FLUTAMIDE250mg Tablet

02238560 APO-FLUTAMIDE APX00637726 EUFLEX SCH02230089 NOVO-FLUTAMIDE NOP02239388 PDL-FLUTAMIDE PDL02230104 PMS-FLUTAMIDE PMS

GOSERELIN ACETATE3.6mg/Depot Injection

02049325 ZOLADEX AZC10.8mg/Depot Injection

02225905 ZOLADEX LA AZC

HYDROXYUREA500mg Capsule

02247937 APO-HYDROXYUREA APX02242920 GEN-HYDROXYUREA GEN

500mg Tablet00465283 HYDREA BMS

Page 13 of 1242010


10:00.00 ANTINEOPLASTIC AGENTSIMATINIB MESYLATELimited use benefit (prior approval required).

a.- For the treatment of patients with chronic myeloid leukemia in blast crisis, accelerated phase, or in chronic phase after failure of interferon-alpha therapy.b.- For the treatment of patients with gastrointestinal stromal tumour.c.- For newly diagnosed adult patients with Philadelphia chromosome-positive chronic myeloid leukemia (CML).

100mg Tablet02253275 GLEEVEC NVR

400mg Tablet02253283 GLEEVEC NOV

INTERFERON ALFA-2B6,000,000IU/mL Injection

02238674 INTRON A SCH10,000,000IU/mL Injection

02238675 INTRON A SCH10,000,000IU/Vial Injection


02240693 INTRON A SCH18,000,000IU/Vial Injection



02240695 INTRON A SCH

LETROZOLE2.5mg Tablet

02231384 FEMARA NVR02348969 LETROZOLE CBT02309114 PMS-LETROZOLE PMS02344815 SANDOZ LETROZOLE SDZ

LEUPROLIDE ACETATE3.75mg/Vial Injection

00884502 LUPRON DEPOT ABB7.5mg/Vial Injection



02248240 ELIGARD SAC02230248 LUPRON DEPOT ABB

30mg/Vial Injection02248999 ELIGARD SAC02239833 LUPRON DEPOT ABB

45mg/Vial Injection02268892 ELIGARD SAC

LOMUSTINE10mg Capsule

00360430 CEENU BMS

10:00.00 ANTINEOPLASTIC AGENTSLOMUSTINE

40mg Capsule00360422 CEENU BMS

100mg Capsule00360414 CEENU BMS

MEGESTROL ACETATE40mg/mL Suspension

02168979 MEGACE BMS40mg Tablet

02195917 APO-MEGESTROL APX02223104 MEGESTROL PDL02185415 NU-MEGESTROL NXP

160mg Tablet02195925 APO-MEGESTROL APX00731323 MEGACE BMS02223112 MEGESTROL PDL02185423 NU-MEGESTROL NXP

MELPHALAN2mg Tablet

00004715 ALKERAN GSK

MERCAPTOPURINE50mg Tablet

00004723 PURINETHOL NOP

METHOTREXATE SODIUM10mg/mL Injection

02182947 METHOTREXATE MAY25mg/mL Injection

02182777 METHOTREXATE MAY02182955 METHOTREXATE MAY02099705 NOVO-METHOTREXATE NOP

2.5mg Tablet02182963 APO-METHOTREXATE APX02170698 METHOTREXATE WAY02244798 RATIO-METHOTREXATE RPH

10mg Tablet02182750 METHOTREXATE MAY

MITOTANE500mg Tablet

00463221 LYSODREN BMS

NILUTAMIDE50mg Tablet

02221861 ANANDRON SAC

PROCARBAZINE HCL50mg Capsule

00012750 NATULAN SIG

Page 14 of 1242010


10:00.00 ANTINEOPLASTIC AGENTSRITUXIMABLimited use benefit (prior approval required).

Prescribed by a rheumatologist for treatment of adult patients with severely active rheumatoid arthritis who have failed to respond to a trial of an anti-TNF agent. Treatment should be combined with methotrexate. Rituximab should not be used in combination with anti-TNF agents.

Treatment beyond six months will only be considered for patients who have achieved a response. (Please refer to Appendix A).

10mg/mL Injection02241927 RITUXAN HLR

SUNITINIB MALATELimited use benefit (Prior approval required)

Criteria for initial six month coverage of Sutent:For patients with histologically proven unresectable or recurrent/metastatic GIST who have failed or are unable to tolerate imatinib therapy. Sunitinib will not be funded concomitantly with imatinib.

Criteria for assessment at every six months:There is no objective evidence of disease progression.

12.5mg Capsule02280795 SUTENT PFI

25mg Capsule02280809 SUTENT PFI


TAMOXIFEN CITRATE10mg Tablet

00812404 APO-TAMOX APX02088428 GEN-TAMOXIFEN GEN00851965 NOVO-TAMOXIFEN NOP02237459 PMS-TAMOXIFEN PMS01926624 TAMOFEN SAC02296721 TAMOXIFEN PDL

20mg Tablet00812390 APO-TAMOX APX02089858 GEN-TAMOXIFEN GEN02048485 NOLVADEX D AZC00851973 NOVO-TAMOXIFEN NOP02237460 PMS-TAMOXIFEN PMS01926632 TAMOFEN SAC02296748 TAMOXIFEN PDL

10:00.00 ANTINEOPLASTIC AGENTSTEMOZOLOMIDELimited use benefit (prior approval required).

For: a. - treatment of adult patients with glioblastoma multiforme or anaplastic astrocytoma, and documented evidence of recurrence or progression after standard therapy (resection, radiotherapy, and chemotherapy).b. - treatment of adult patients with newly diagnosed glioblastoma multiforme concomitantly with radiotherapy and then as maintenance treatment.

5mg Capsule02241093 TEMODAL SCH




THIOGUANINE40mg Tablet

00282081 LANVIS GSK

TRETINOIN10mg Capsule

02145839 VESANOID HLR

TRIPTORELIN PAMOATE3.75mg/Vial Injection

02240000 TRELSTAR WAT11.25mg/Vial Injection

02243856 TRELSTAR LA WAT

VINCRISTINE SULFATE1mg/mL Injection

02143305 VINCRISTINE SULFATE NOP02183013 VINCRISTINE SULFATE MAY

Page 15 of 1242010


12:00 AUTONOMIC DRUGS12:04.00 PARASYMPATHOMIMETIC

AGENTSBETHANECHOL CHLORIDE

10mg Tablet01947958 DUVOID SHI01985671 MYOTONACHOL GLE

25mg Tablet01947931 DUVOID SHI01985558 MYOTONACHOL GLE

50mg Tablet01947923 DUVOID SHI

DONEPEZIL HCLLimited use benefit (prior approval required).

Initial six month coverage for cholinesterase inhibitors:•Diagnosis of mild to moderate Alzheimer’s disease; AND•Mini Mental State Exam (MMSE) score of 10-26, established within the last 60 days; AND•Global Deterioration Scale (GDS) score between 4 to 6, established within the last 60 days•Continued coverage beyond 6 months will be based on improvement or stabilization of cognition, function or behaviour.

Criteria for coverage at every six month interval:•Diagnosis is still mild to moderate Alzheimer’s disease; AND•MMSE score > 10; AND•GDS score between 4 to 6; AND•Improvement or stabilization in at least one of the following domains(please indicate improved, worsened, or no change)1.Memory, reasoning and perception (e.g., names, tasks, MMSE)2.Instrumental activities of daily living (IADLs: e.g., telephone, shopping, meal preparation)3.Basic activities of daily living (e.g., bathing, dressing, hygiene, toileting)4.Neuropsychiatric symptoms (e.g., agitation, delusions, hallucination, apathy)

5mg Tablet02232043 ARICEPT PFI


12:04.00 PARASYMPATHOMIMETIC AGENTS

GALANTAMINELimited use benefit (prior approval required).



8mg Extended Release Capsule02266717 REMINYL ER JNO



NEOSTIGMINE BROMIDE15mg Tablet

00869945 PROSTIGMIN VAE

PYRIDOSTIGMINE BROMIDE180mg Sustained Release Tablet

00869953 MESTINON-SR VAE60mg Tablet

00869961 MESTINON VAE

Page 16 of 1242010


12:04.00 PARASYMPATHOMIMETIC AGENTS

RIVASTIGMINELimited use benefit (prior approval required).



1.5mg Capsule02242115 EXELON NOV02332809 MYLAN-RIVASTIGMINE MYL02305984 NOVO-RIVASTIGMINE NOP02306034 PMS-RIVASTIGMINE PMS02311283 RATIO-RIVASTIGMINE RPH02324563 SANDOZ RIVASTIGMINE SDZ

3mg Capsule02242116 EXELON NOV02332817 MYLAN-RIVASTIGMINE MYL02305992 NOVO-RIVASTIGMINE NOP02306042 PMS-RIVASTIGMINE PMS02311291 RATIO-RIVASTIGMINE RPH02324571 SANDOZ RIVASTIGMINE SDZ

4.5mg Capsule02242117 EXELON NOV02332825 MYLAN-RIVASTIGMINE MYL02306018 NOVO-RIVASTIGMINE NOP02306050 PMS-RIVASTIGMINE PMS02311305 RATIO-RIVASTIGMINE RPH02324598 SANDOZ RIVASTIGMINE SDZ

6mg Capsule02242118 EXELON NOV02332833 MYLAN-RIVASTIGMINE MYL02306026 NOVO-RIVASTIGMINE NOP02306069 PMS-RIVASTIGMINE PMS02311313 RATIO-RIVASTIGMINE RPH02324601 SANDOZ RIVASTIGMINE SDZ

2mg/mL Oral Liquid02245240 EXELON NOV

12:08.08 ANTIMUSCARINICS / ANTISPASMODICS

IPRATROPIUM BROMIDE250mcg/mL Inhalation Solution (Multi-Dose)

02126222 APO-IPRAVENT APX02239131 GEN-IPRATROPIUM GEN02210479 NOVO-IPRAMIDE NOP02231136 PMS-IPRATROPIUM PMS

125mcg/mL Inhalation Solution (Unit Dose)02231135 PMS-IPRATROPIUM UDV PMS02097176 RATIO-IPRATROPIUM UDV RPH

250mcg/mL Inhalation Solution (Unit Dose)02216221 GEN-IPRATROPIUM UDV GEN02231785 NU-IPRATROPIUM UDV NXP02231244 PMS-IPRATROPIUM UDV PMS02231245 PMS-IPRATROPIUM UDV PMS02097168 RATIO-IPRATROPIUM UDV RPH99001446 RATIO-IPRATROPIUM UDV RPH

20mcg/Inhalation Inhaler02247686 ATROVENT HFA BOE

0.03% Nasal Spray02246083 APO-IPRAVENT APX02240508 DOM-IPRATROPIUM DPC02239627 PMS-IPRATROPIUM PMS

0.06% Nasal Spray02246084 APO-IPRAVENT APX

IPRATROPIUM BROMIDE, SALBUTAMOL0.2mg & 1mg/mL Inhalation Solution (Unit Dose)

02231675 COMBIVENT BOE02272695 GEN-COMBO GEN02243789 RATIO-IPRA SAL RPH

SCOPOLAMINE BUTYLBROMIDE10mg Tablet

00363812 BUSCOPAN BOE

TIOTROPIUM BROMIDE MONOHYDRATELimited use benefit (prior approval required).

For the treatment of moderate* to severe* chronic obstructive pulmonary disease (COPD), in patients who continue to be symptomatic after an adequate trial (3 months) of ipatropium, at a dose of 8-12 puffs daily.

*Canadian Thoracic Society COPD Classification by Symptoms/Disability and Lung FunctionModerate: shortness of breath from COPD causing the patient to stop after walking about 100 meters (after a few minutes) on level ground (MRC 3 to 4); 50% ≤ FEV1 < 80% predicted, FEV1/FVC <0.7

Severe: shortness of breath from COPD leaving the patient too breathless to leave the house or breathless after undressing (MRC 5), or in the presence of chronic respiratory failure or clinical signs of right heart failure; 30% ≤ FEV1 < 50% predicted, FEV1/FVC <0.7

18mcg Powder for Inhalation (Capsule)02246793 SPIRIVA BOE

Page 17 of 1242010


12:12.04 ALPHA ADRENERGIC AGONISTSMIDODRINE HCL

2.5mg Tablet01934392 AMATINE SHI

5mg Tablet01934406 AMATINE SHI

12:12.08 BETA ADRENERGIC AGONISTSFORMOTEROL FUMARATELimited use benefit (prior approval required).For the treatment of asthma in patients who are using optimal corticosteroid therapy and experiencing breakthrough symptoms requiring regular use of a rapid onset, short duration bronchodilator. Oxeze is not intended for the relief of acute asthma symptoms: patients must have access to an inhaled fast-acting bronchodilator (beta-2 agonist) for symptomatic relief.

12mcg/Capsule Powder for Inhalation02230898 FORADIL NVR

FORMOTEROL FUMARATE DIHYDRATE6mcg/Dose Dry Powder Inhaler

02237225 OXEZE TURBUHALER AZC12mcg/Dose Dry Powder Inhaler

02237224 OXEZE TURBUHALER AZC

FORMOTEROL FUMARATE DIHYDRATE, BUDESONIDELimited use benefit (prior approval required).

For the treatment of reversible obstructive airway disease in patients who are not adequately controlled on medium doses of inhaled corticosteroids ( e.g. fluticasone 250 - 500 mcg daily, or the equivalent) as the sole agent and require addition of a long- acting beta agonist. Patients using this combination product must also have access to a short-acting bronchodilator for symptomatic relief.

6mcg & 100mcg/Inhalation Inhaler02245385 SYMBICORT 100

TURBUHALERAZC

6mcg & 200mcg/Inhalation Inhaler02245386 SYMBICORT 200

TURBUHALERAZC

ORCIPRENALINE SULFATE2mg/mL Syrup

02236783 APO-ORCIPRENALINE APX02192675 TANTA-ORCIPRENALINE TAN

SALBUTAMOL5mg/mL Inhalation Solution (Multi-Dose)

02139324 DOM-SALBUTAMOL DPC02232987 GEN-SALBUTAMOL GEN02069571 PMS-SALBUTAMOL PMS00860808 RATIO-SALBUTAMOL RPH02154412 SANDOZ-SALBUTAMOL SDZ02213486 VENTOLIN GSK

0.5mg/mL Inhalation Solution (Unit Dose)02208245 PMS-SALBUTAMOL PMS02239365 RATIO-SALBUTAMOL RPH

12:12.08 BETA ADRENERGIC AGONISTSSALBUTAMOL

1mg/mL Inhalation Solution (Unit Dose)02216949 DOM-SALBUTAMOL DPC01926934 GEN-SALBUTAMOL GEN02084333 MED-SALBUTAMOL MEC02231783 NU-SALBUTAMOL NXP02208229 PMS-SALBUTAMOL PMS01986864 RATIO-SALBUTAMOL RPH02213419 VENTOLIN PF GSK

2mg/mL Inhalation Solution (Unit Dose)02173360 GEN-SALBUTAMOL PF GEN02231784 NU-SALBUTAMOL NXP02208237 PMS-SALBUTAMOL PMS02239366 RATIO-SALBUTAMOL RPH02213427 VENTOLIN PF GSK

100mcg/Inhalation Inhaler02232570 AIROMIR MMH02245669 APO-SALVENT CFC FREE APX02326450 NOVO-SALBUTAMOL HFA NOP02244914 RATIO-SALBUTAMOL HFA RPH02241497 VENTOLIN HFA GSK

0.4mg/mL Oral Liquid02212390 VENTOLIN GSK

400mcg Powder for Inhalation (Capsule)00895415 VENTOLIN ROTACAPS GSK

200mcg Powder for Inhalation (Disk)99000369 VENTODISK & DISKHALER GSK

400mcg Powder for Inhalation (Disk)99000377 VENTODISK GSK

2mg Tablet02146843 APO-SALVENT APX

4mg Tablet02146851 APO-SALVENT APX02165376 NU-SALBUTAMOL NXP

SALMETEROL XINAFOATELimited use benefit (prior approval required).

a. - For the treatment of asthma in patients who are using optimal corticosteroid therapy and experiencing breakthrough symptoms requiring regular use of a rapid onset, short duration bronchodilator. Serevent is not intended for the relief of acute asthma symptoms: patients must have access to an inhaled fast-acting bronchodilator (beta-2 agonist) for symptomatic relief.b. - For the treatment of Chronic Obstructive Pulmonary Disease (COPD) in patients not adequately controlled with ipratropium.

50mcg/inhalation Powder Diskus02231129 SEREVENT DISKUS GSK

50mcg/Inhalation Powder for Inhalation02214261 SEREVENT DISKHALER GSK

Page 18 of 1242010


12:12.08 BETA ADRENERGIC AGONISTSSALMETEROL XINAFOATE, FLUTICASONE PROPIONATELimited use benefit (prior approval required).

For treatment of reversible obstructive airway disease in patients who are not adequately controlled on medium doses of inhaled corticosteroids (e.g., fluticasone 250-500mcg daily, or the equivalent) as a sole agent and require addition of a long-acting beta agonist. Patients using this combination product must also have access to a short-acting bronchodilator for symptomatic relief.

For the treatment of moderate* to severe* chronic obstructive pulmonary disease (COPD), in patients who continue to be symptomatic after an adequate trial (2-4 months) of ipatropium, at a dose of 12 puffs daily.

*Canadian Thoracic Society COPD Classification by Symptoms/DisabilityModerate: shortness of breath from COPD causing the patient to stop after walking about 100 meters (after a few minutes) on the level

Severe: shortness of breath from COPD leaving the patient too breathless to leave the house or breathless after undressing, or in the presence of chronic respiratory failure or clinical signs of right heart failure.

By Symptom/Disability:Moderate: shortness of breath from COPD causing the patient to stop after walking approximately 100 meters (or after a few minutes) on the level.Severe: shortness of breath from COPD resulting in the patient being too breathless to leave the house or breathless after undressing, or the presence of chronic respiratory failure or clinical signs of right heart failure.

25mcg & 125mcg Inhaler02245126 ADVAIR GSK


50mcg & 100mcg Inhaler02240835 ADVAIR DISKUS 100 GSK



TERBUTALINE SULFATE500mcg/Inhalation Powder for Inhalation

00786616 BRICANYL TURBUHALER AZC

12:12.12 ALPHA AND BETA ADRENERGIC AGONISTS

EPINEPHRINE0.15mg/0.15mL Injection

02268205 TWINJECT PAL0.5mg/mL Injection

00578657 EPIPEN JR AXL

12:12.12 ALPHA AND BETA ADRENERGIC AGONISTS

EPINEPHRINE1mg/mL Injection

00155357 ADRENALIN ERF00721891 EPINEPHRINE ABB00509558 EPIPEN AXL02247310 TWINJECT PAL

1mg/mL Topical Solution00155365 ADRENALIN ERF

PSEUDOEPHEDRINE HCL, TRIPROLIDINE HCL60mg & 2.5mg Tablet

02238302 ACTIFED PFI

12:16.00 SYMPATHOLYTIC AGENTSDIHYDROERGOTAMINE MESYLATE

1mg/mL Injection00027243 DIHYDROERGOTAMINE STE02241163 DIHYDROERGOTAMINE SDZ

4mg/mL Nasal Spray02228947 MIGRANAL STE

ERGOTAMINE TARTRATE, CAFFEINE1mg & 100mg Tablet

00176095 CAFERGOT NVR

METHYSERGIDE MALEATE2mg Tablet

00027499 SANSERT NVR

12:20.04 CENTRALL ACTING SKELETAL MUSCLE RELAXANTS

CYCLOBENZAPRINE HCLLimited use benefit (prior approval is not required).

For relief of muscle spasm associated with acute, painful musculoskeletal conditions. Coverage is limited to 60mg per day for three (3) weeks, renewable every two (2) months.

10mg Tablet02177145 APO-CYCLOBENZAPRINE APX02220644 CYCLOBENZAPRINE PDL02238633 DOM-CYCLOBENZAPRINE DPC02231353 GEN-CYCLOPRINE GEN02080052 NOVO-CYCLOPRINE NOP02171848 NU-CYCLOBENZAPRINE NXP02249359 PHL-CYCLOBENZAPRINE PHH02212048 PMS-CYCLOBENZAPRINE PMS02236506 RATIO-CYCLOBENZAPRINE RPH02242079 RIVA-CYCLOBENZAPRINE RIV

Page 19 of 1242010


12:20.04 CENTRALL ACTING SKELETAL MUSCLE RELAXANTS

TIZANIDINE HCLLimited use benefit (prior approval required).

For treatment of spasticity in patients with multiple sclerosis, who have failed therapy with or are intolerant to baclofen.

4mg Tablet02259893 APO-TIZANIDINE APX02272059 GEN-TIZANIDINE GEN02239170 ZANAFLEX ELN

12:20.08 DIRECT-ACTING SKELETAL MUSCLE RELAXANTS

DANTROLENE SODIUM25mg Capsule

01997602 DANTRIUM PGP100mg Capsule

01997653 DANTRIUM PGP

12:20.12 GABA-DERIVATIVE SKELETAL MUSCLE RELAXANTS

BACLOFEN10mg Tablet

02139332 APO-BACLOFEN APX02152584 BACLOFEN PDL02138271 DOM-BACLOFEN DPC02088398 GEN-BACLOFEN GEN00455881 LIORESAL NVR02084449 MED-BACLOFEN MEC02136090 NU-BACLO NXP02236963 PHL-BACLOFEN PHH02063735 PMS-BACLOFEN PMS02236507 RATIO-BACLOFEN RPH02242150 RIVA-BACLOFEN RIV

20mg Tablet02139391 APO-BACLOFEN APX02152592 BACLOFEN PDL02138298 DOM-BACLOFEN DPC02088401 GEN-BACLOFEN GEN00636576 LIORESAL DS NVR02084457 MED-BACLOFEN MEC02136104 NU-BACLO NXP02236964 PHL-BACLOFEN PHH02063743 PMS-BACLOFEN PMS02236508 RATIO-BACLOFEN RPH02242151 RIVA-BACLOFEN RIV

12:92.00 MISCELLANEOUS AUTONOMIC DRUGS

NICOTINE (GUM)Limited use benefit with quantity and frequency limits (prior approval is not required).

For smoking cessation:Coverage is limited to 945 pieces during a one-year period. The year starts on the date the first prescription is filled. Once this quantity has been reached, the client is eligible again for coverage for nicotine gum when one year has elapsed from the day the initial prescription was filled.

2mg Gum02091933 NICORETTE JNO

4mg Gum02091941 NICORETTE PLUS PMJ

NICOTINE (PATCH)Limited use benefit with quantity and frequency limits (prior approval is not required).

For smoking cessation: Coverage will be provided for up to the allowable number of patches for one of the following products, during a one-year period. The year starts on the date the first prescription is filled. The number of patches covered in the one-year period is: Habitrol 84 patches or Nicoderm 70 patches or Nicotrol 70 patches

Once this quantity has been reached, the client is eligible again for coverage for nicotine patches when one year has elapsed from the day the initial prescription was filled.

7mg Patch (Habitrol)01943057 HABITROL NVC



36mg Patch (Nicoderm)02093111 NICODERM PMJ



8.3mg/10cm2 Patch (Nicotrol)02065738 NICOTROL TRANSDERMAL JNO



Page 20 of 1242010


12:92.00 MISCELLANEOUS AUTONOMIC DRUGS

VARENICLINELimited use benefit with quantity and frequency limits (prior approval is not required).

Coverage will be limited to 165 tablets during a one-year period. The year starts on the date the first prescription is filled. Once this quantity has been reached, the client is eligible again for coverage for varenicline (Champix®) when one year has elapsed from the day the initial prescription was filled.

0.5mg Tablet02291177 CHAMPIX PFI

0.5mg & 1mg Tablet02298309 CHAMPIX STARTER PACK PFI

1mg Tablet02291185 CHAMPIX PFI

Page 21 of 1242010


20:00 BLOOD FORMATION COAGULATION AND THROMBOSIS

20:04.04 IRON PREPARATIONSFERROUS FUMARATE

300mg CapsuleST

02237556 EURO-FER EUR00482064 NEO FER NEO01923420 PALAFER GSK

300mg/5mL Oral LiquidST

02246590 FERRATE O/L EUR60mg/mL SuspensionST

01923439 PALAFER GSK200mg TabletST

02138751 FERROUS FUMARATE VTH300mg TabletST

00031089 FERROUS FUMARATE PED

FERROUS GLUCONATE300mg TabletST

00545031 APO-FERROUS GLUCONATE APX00031097 FERROUS GLUCONATE PED00041157 FERROUS GLUCONATE PMS00021458 NOVO-FERROGLUC NOP80000435 NOVO-FERROGLUC NOP

324mg TabletST

00582727 FERROUS GLUCONATE VTH

FERROUS SULFATE15mg/mL DropST

02237385 FERODAN ODN02232202 PEDIAFER EUR02222574 PMS-FERROUS SULFATE PMS

75mg/mL DropST

00762954 FER-IN-SOL MJO80008309 JAMP SULFATE FERREUX JMP

6mg/mL SyrupST

00017884 FER-IN-SOL MJO02242863 PEDIAFER EUR

30mg/mL SyrupST

00758469 FERODAN ODN80008295 JAMP SULFATE FERREUX JMP00792675 PMS-FERROUS SULFATE PMS

300mg TabletST

01912518 APO-FERROUS SULFATE FC APX02246733 EURO-FERROUS SULFATE EUR02248699 FERODAN ODN00031100 FERROUS SULFATE PED00179655 FERROUS SULFATE SDR00346918 FERROUS SULFATE PMT00782114 FERROUS SULFATE VTH02125471 FERROUS SULFATE PDL00586323 PMS-FERROUS SULFATE PMS

20:04.04 IRON PREPARATIONSIRON DEXTRAN

50mg/mL Injection02205963 DEXIRON GEN02221780 INFUFER SDZ

20:12.04 ANTICOAGULANTSDALTEPARIN SODIUM

7,500IU/0.3mL Injection99100159 FRAGMIN PFI

10,000IU/0.4mL Injection09853790 FRAGMIN PMJ99004143 FRAGMIN PMJ

10,000IU/mL Injection02132664 FRAGMIN PMJ

12,500IU/0.5mL Injection99004151 FRAGMIN PMJ



25,000IU/mL Injection (Multi-Dose)02231171 FRAGMIN PMJ

2,500IU/0.2mL Injection (Pre-filled Syringe)02132621 FRAGMIN PMJ

5,000IU/0.2mL Injection (Pre-filled Syringe)02132648 FRAGMIN PMJ

ENOXAPARIN SODIUM30mg/0.3mL Injection

02012472 LOVENOX SAC40mg/0.4mL Injection

02236883 LOVENOX SAC60mg/0.6mL Injection

99002965 LOVENOX AVT80mg/0.8mL Injection



99004941 LEVENOX HP AVT150mg/1.0mL Injection

02242692 LEVONEX HP SAC300mg/3mL Injection

02236564 LOVENOX SAC

HEPARIN SODIUM1,000 U/mL Injection

00740519 HEPALEAN ORG10,000 U/mL Injection

00740497 HEPALEAN ORG10U/mL Lock Flush

00725323 HEPARIN LOCK FLUSH ABB

Page 22 of 1242010


20:12.04 ANTICOAGULANTSHEPARIN SODIUM

100U/mL Lock Flush00740578 HEPALEAN LOK ORG00727520 HEPARIN LEO LEO00725315 HEPARIN LOCK FLUSH HOS

NADROPARIN CALCIUM9,500IU/mL Injection

02236913 FRAXIPARINE GSK19,000IU/mL Injection

02240114 FRAXIPARINE FORTE GSK

NICOUMALONE1mg Tablet

00010383 SINTROM PED4mg Tablet

00010391 SINTROM PED

RIVAROXABANLimited use benefit (prior approval not required).

For the prevention of venous thromboembolism following total knee replacement or total hip replacement surgery, for up to two weeks.

10mg Tablet02316986 XARELTO BAY

TINZAPARIN SODIUM10,000IU/mL Injection

02167840 INNOHEP LEO14,000IU/mL Injection

99002612 INNOHEP LEO20,000IU/mL Injection

02229515 INNOHEP LEO20,000IU/mL Injection (Graduated Syringe)

02231478 INNOHEP LEO10,000IU/mL Injection (Pre-filled Syringe)

02229755 INNOHEP LEO09853898 INNOHEP LEO

20,000IU/mL Injection (Pre-filled Syringe)09853901 INNOHEP LEO09853928 INNOHEP LEO99002620 INNOHEP LEO

WARFARIN SODIUM1mg Tablet

02242924 APO-WARFARIN APX01918311 COUMADIN BMS02244462 GEN-WARFARIN GEN02265273 NOVO-WARFARIN NOP02242680 TARO-WARFARIN TAR

2mg Tablet02242925 APO-WARFARIN APX01918338 COUMADIN BMS02244463 GEN-WARFARIN GEN02265281 NOVO-WARFARIN NOP02242681 TARO-WARFARIN TAR

20:12.04 ANTICOAGULANTSWARFARIN SODIUM

2.5mg Tablet02242926 APO-WARFARIN APX01918346 COUMADIN BMS02244464 GEN-WARFARIN GEN02265303 NOVO-WARFARIN NOP02242682 TARO-WARFARIN TAR




6mg Tablet02287501 GEN-WARFARIN GEN02242686 TARO-WARFARIN TAR

7.5mg Tablet02287528 GEN-WARFARIN GEN02242697 TARO-WARFARIN TAR

10mg Tablet02242929 APO-WARFARIN APX01918362 COUMADIN BMS02244467 GEN-WARFARIN GEN02242687 TARO-WARFARIN TAR

20:12.18 PLATELET AGGREGATION INHIBITORS

ANAGRELIDE HCL0.5mg CapsuleST

02236859 AGRYLIN SHI02253054 GEN-ANAGRELIDE GEN02274949 PMS-ANAGRELIDE PMS02260107 RHOXAL-ANAGRELIDE RHO

CLOPIDOGREL BISULFATELimited use benefit (one-year duration, prior approval required).

a. - Patients with intra-coronary stent implantation following insertion.b. - Patients with acute coronary syndrome (ACS) (unstable angina or non-ST-segment elevation MI), in combination with ASA.

75mg TabletST

02238682 PLAVIX SAC

Page 23 of 1242010


20:12.18 PLATELET AGGREGATION INHIBITORS

TICLOPIDINE HCL250mg TabletST

02237701 APO-TICLOPIDINE APX02239744 GEN-TICLOPIDINE GEN02236848 NOVO-TICLOPIDINE NOP02237560 NU-TICLOPIDINE NXP02238208 PDL-TICLOPIDINE PDL02243587 SANDOZ-TICLOPIDINE SDZ

20:16.00 HEMATOPOIETIC AGENTSFILGRASTIM

300mcg/mL Injection01968017 NEUPOGEN AMG99001454 NEUPOGEN AMG

480mcg/1.6mL Injection09853464 NEUPOGEN AMG

PEGFILGRASTIMLimited use benefit (prior approval required).

a. - To decrease the incidence of infection, as manifested by febrile neutropenia, in patients with non-myeloid malignancies receiving myelosuppressive antineoplastic drugs with curative intent.andb. - Where access to a health care facility is problematic.

10mg/mL Injection02249790 NEULASTA AMG

20:24.00 HEMORRHEOLOGIC AGENTSPENTOXIFYLLINE

400mg Sustained Release TabletST

02230090 APO-PENTOXIFYL APX02230401 NU-PENTOXIFYL NXP01968432 RATIO-PENTOXIFYLLINE RPH02221977 TRENTAL SAC

20:28.16 HEMOSTATICSTRANEXAMIC ACID

500mg Tablet02064405 CYKLOKAPRON PFI

Page 24 of 1242010


24:00 CARDIOVASCULAR DRUGS24:04.04 ANTIARRHYTHMIC AGENTS

AMIODARONE HCL100mg TabletST

02292173 PMS-AMIODARONE PMS200mg TabletST

02246194 APO-AMIODARONE APX02036282 CORDARONE WAY02240604 GEN-AMIODARONE GEN02239835 NOVO-AMIODARONE NOP02242472 PMS-AMIODARONE PMS02309661 PRO-AMIODARONE PDL02240071 RATIO-AMIODARONE RPH02245781 RIVA-AMIODARONE PHH02247217 RIVA-AMIODARONE RIV02243836 SANDOZ-AMIODARONE SDZ

DISOPYRAMIDE100mg CapsuleST

02224801 RYTHMODAN SAC150mg CapsuleST

02224828 RYTHMODAN SAC250mg TabletST

02224836 RYTHMODAN LA SAC

FLECAINIDE ACETATE50mg TabletST

02275538 APO-FLECAINIDE APX01966197 TAMBOCOR MMH

100mg TabletST

02275546 APO-FLECAINIDE APX01966200 TAMBOCOR MMH

MEXILETINE HCL100mg CapsuleST

02230359 NOVO-MEXILETINE NOP200mg CapsuleST

02230360 NOVO-MEXILETINE NOP

PROCAINAMIDE HCL250mg Sustained Release TabletST

00638692 PROCAN SR PFI500mg Sustained Release TabletST

00638676 PROCAN SR PFI750mg Sustained Release TabletST

00638684 PROCAN SR PFI

PROPAFENONE HYDROCHLORIDE150mg TabletST

02243324 APO-PROPAFENONE APX02245372 GEN-PROPAFENONE GEN02249480 NU-PROPAFENONE NXP02243727 PMS-PROPAFENONE PMS02294559 PMS-PROPAFENONE PMS02243783 PROPAFENONE PDL00603708 RYTHMOL ABB

24:04.04 ANTIARRHYTHMIC AGENTSPROPAFENONE HYDROCHLORIDE

300mg TabletST

02243325 APO-PROPAFENONE APX02245373 GEN-PROPAFENONE GEN02243728 PMS-PROPAFENONE PMS02294575 PMS-PROPAFENONE PMS00603716 RYTHMOL ABB

24:04.08 CARDIOTONIC AGENTSDIGOXIN

0.05mg/mL Elixir02242320 LANOXIN VIR

0.0625mg Tablet02335700 TOLOXIN MTH



24:06.04 BILE ACID SEQUESTRANTSCHOLESTYRAMINE RESIN

4g PowderST

00999968 NOVO-CHOLAMINE NOP00999967 NOVO-CHOLAMINE LIGHT NOP00890960 PMS-CHOLESTYRAMINE

LIGHTPMS

02210320 PMS-CHOLESTYRAMINE REGULAR

PMS

COLESTIPOL HCL5g GranulesST

00642975 COLESTID PFI02132699 COLESTID ORANGE PFI

1g TabletST

02132680 COLESTID PFI

24:06.05 CHOLESTEROL ABSORPTION INHIBITORS

EZETIMIBELimited use benefit (prior approval required).

a.- 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 “statin” doses.

b.- For use as monotherapy in the management of hypercholesterolemia in patients intolerant to HMG-CoA reductase inhibitors.

10mg TabletST

02247521 EZETROL MSP

24:06.06 FIBRIC ACID DERIVATIVESBEZAFIBRATE


02083523 BEZALIP SR HLR

Page 25 of 1242010


24:06.06 FIBRIC ACID DERIVATIVESBEZAFIBRATE

200mg TabletST

02240331 PMS-BEZAFIBRATE PMS

FENOFIBRATE67mg CapsuleST

02243180 APO-FENO-MICRO APX02243551 NOVO-FENOFIBRATE NOP

100mg CapsuleST

02225980 APO-FENOFIBRATE APX02223600 NU-FENOFIBRATE NXP

160mg CapsuleST

02250004 FENOMAX CIP200mg CapsuleST

02239864 APO-FENO-MICRO APX02240360 FENO-MICRO PDL02240210 GEN-FENOFIBRATE GEN02146959 LIPIDIL MICRO FOU02243552 NOVO-FENOFIBRATE NOP02249715 NU-FENO-MICRO NXP02273551 PMS-FENOFIBRATE MICRO PMS02250039 RATIO-FENOFIBRATE RPH02247306 RIVA-FENOFIBRATE MICRO RIV

48mg TabletST

02269074 LIPIDIL EZ FOU100mg TabletST

02246859 APO-FENO-SUPER APX02241601 LIPIDIL SUPRA FOU02289083 NOVO-FENOFIBRATE-S NOP02310228 PRO-FENO-SUPER PDL02288044 SANDOZ FENOFIBRATE S SDZ

145mg TabletST

02269082 LIPIDIL EZ FOU160mg TabletST

02246860 APO-FENO-SUPER APX02241602 LIPIDIL SUPRA FOU02289091 NOVO-FENOFIBRATE-S NOP02310236 PRO-FENO-SUPER PDL02288052 SANDOZ FENOFIBRATE S SDZ

GEMFIBROZIL300mg CapsuleST

01979574 APO-GEMFIBROZIL APX02241608 DOM-GEMFIBROZIL DPC02136031 GEMFIBROZIL PDL02185407 GEN-FIBRO GEN00599026 LOPID PFI02241704 NOVO-GEMFIBROZIL NOP02058456 NU-GEMFIBROZIL NXP02239951 PMS-GEMFIBROZIL PMS

24:06.06 FIBRIC ACID DERIVATIVESGEMFIBROZIL

600mg TabletST

01979582 APO-GEMFIBROZIL APX02230580 DOM-GEMFIBROZIL DPC02136058 GEMFIBROZIL PDL02230476 GEN-GEMFIBROZIL GEN00659606 LOPID PFI02237292 MED-GEMFIBROZIL MEC02142074 NOVO-GEMFIBROZIL NOP02058464 NU-GEMFIBROZIL NXP02229604 PENTA-GEMFIBROZIL PEN02230183 PMS-GEMFIBROZIL PMS02242126 RIVA-GEMFIBROZIL RIV

24:06.08 HMG-COA REDUCTASE INHIBITORS

ATORVASTATIN CALCIUM10mg TabletST

02295261 APO-ATORVASTATIN APX02310899 CO ATORVASTATIN CBT02288346 GD-ATORVASTATIN PFI02230711 LIPITOR PFI02302675 NOVO-ATORVASTATIN NOP02313448 PMS-ATORVASTATIN PMS02313707 RAN-ATORVASTATIN RBY02350297 RATIO-ATORVASTATIN RPH

20mg TabletST


40mg TabletST


80mg TabletST


Page 26 of 1242010



FLUVASTATIN SODIUM20mg CapsuleST

02061562 LESCOL NVR40mg CapsuleST

02061570 LESCOL NVR80mg Extended Release TabletST

02250527 LESCOL XL NOV

LOVASTATIN20mg TabletST

02220172 APO-LOVASTATIN APX02248572 CO LOVASTATIN COB02243127 GEN-LOVASTATIN GEN00795860 MEVACOR FRS02246542 NOVO-LOVASTATIN NOP02231434 NU-LOVASTATIN NXP02246013 PMS-LOVASTATIN PMS02312670 PRO-LOVASTATIN PDL02267969 RAN-LOVASTATIN RBY02245822 RATIO-LOVASTATIN RPH02272288 RIVA-LOVASTATIN RIV02247056 SANDOZ-LOVASTATIN SDZ

40mg TabletST

02220180 APO-LOVASTATIN APX02248573 CO LOVASTATIN COB02243129 GEN-LOVASTATIN GEN00795852 MEVACOR FRS02246543 NOVO-LOVASTATIN NOP02246014 PMS-LOVASTATIN PMS02312689 PRO-LOVASTATIN PDL02267977 RAN-LOVASTATIN RBY02245823 RATIO-LOVASTATIN RPH02272296 RIVA-LOVASTATIN RIV02247057 SANDOZ-LOVASTATIN SDZ

PRAVASTATIN SODIUM10mg TabletST

02243506 APO-PRAVASTATIN APX02265613 BCI-PRAVASTATIN BAK02248182 CO PRAVASTATIN COB02249723 DOM-PRAVASTATIN DPC02257092 GEN-PRAVASTATIN GEN02330954 JAMP-PRAVASTATIN JMP02317451 MINT-PRAVASTATIN MIN02247008 NOVO-PRAVASTATIN NOP02244350 NU-PRAVASTATIN NXP02249766 PHL-PRAVASTATIN PHH02247655 PMS-PRAVASTATIN PMS00893749 PRAVACHOL BMS02243824 PRAVASTATIN-10 PDL02284421 RAN-PRAVASTATIN RBY02246930 RATIO-PRAVASTATIN RPH02247856 RHOXAL-PRAVASTATIN RHO02270234 RIVA-PRAVASTATIN RIV02301792 ZYM-PRAVASTATIN ZYM


PRAVASTATIN SODIUM20mg TabletST


40mg TabletST


ROSUVASTATIN CALCIUM5mg TabletST

02265540 CRESTOR AZC10mg TabletST



02247164 CRESTOR AZC

Page 27 of 1242010



SIMVASTATIN5mg TabletST

02247011 APO-SIMVASTATIN APX02265656 BCI-SIMVASTATIN BAK02248103 CO SIMVASTATIN COB02253747 DOM-SIMVASTATIN DPC02281619 DOM-SIMVASTATIN DPC02246582 GEN-SIMVASTATIN GEN02331020 JAMP-SIMVASTATIN JMP02250144 NOVO-SIMVASTATIN NOP02247072 NU-SIMVASTATIN NXP02281546 PHL-SIMVASTATIN PMI02252619 PMS-SIMVASTATIN PMS02269252 PMS-SIMVASTATIN PMS02329131 RAN-SIMVASTATIN RBY02247067 RATIO-SIMVASTATIN RPH02247827 RHOXAL-SIMVASTATIN RHO02247297 RIVA-SIMVASTATIN RIV00884324 ZOCOR FRS02300907 ZYM-SIMVASTATIN ZYM

10mg TabletST

02247012 APO-SIMVASTATIN APX02265664 BCI-SIMVASTATIN BAK02248104 CO SIMVASTATIN COB02253755 DOM-SIMVASTATIN DPC02281627 DOM-SIMVASTATIN DPC02246583 GEN-SIMVASTATIN GEN02331039 JAMP-SIMVASTATIN JMP02250152 NOVO-SIMVASTATIN NOP02247075 NU-SIMVASTATIN NXP02281554 PHL-SIMVASTATIN PMI02252635 PMS-SIMVASTATIN PMS02269260 PMS-SIMVASTATIN PMS02329158 RAN-SIMVASTATIN RBY02247068 RATIO-SIMVASTATIN RPH02247298 RIVA-SIMVASTATIN RIV02247828 SANDOZ-SIMVASTATIN SDZ02247221 SIMVASTATIN-10 PDL02265885 TARO-SIMVASTATIN TAR00884332 ZOCOR FRS02300915 ZYM-SIMVASTATIN ZYM




40mg TabletST


Page 28 of 1242010




02247015 APO-SIMVASTATIN APX02265699 BCI-SIMVASTATIN BAK02248107 CO SIMVASTATIN COB02253798 DOM-SIMVASTATIN DPC02281651 DOM-SIMVASTATIN DPC02246585 GEN-SIMVASTATIN GEN02331063 JAMP-SIMVASTATIN JMP02250187 NOVO-SIMVASTATIN NOP02247078 NU-SIMVASTATIN NXP02281589 PHL-SIMVASTATIN PMI02252678 PMS-SIMVASTATIN PMS02269295 PMS-SIMVASTATIN PMS02329182 RAN-SIMVASTATIN RBY02247071 RATIO-SIMVASTATIN RPH02247301 RIVA-SIMVASTATIN RIV02247833 SANDOZ-SIMVASTATIN SDZ02240332 ZOCOR FRS02300974 ZYM-SIMVASTATIN ZYM

24:08.16 CENTRAL ALPHA-AGONISTSCLONIDINE HCL

0.025mg TabletST

02248732 APO-CLONIDINE APX00519251 DIXARIT BOE02304163 NOVO-CLONIDINE NOP

0.1mg TabletST

00868949 APO-CLONIDINE APX00259527 CATAPRES BOE01910396 CLONIDINE PRO02046121 NOVO-CLONIDINE NOP01913786 NU-CLONIDINE NXP

0.2mg TabletST

00868957 APO-CLONIDINE APX00291889 CATAPRES BOE01908162 CLONIDINE PRO02046148 NOVO-CLONIDINE NOP01913220 NU-CLONIDINE NXP

METHYLDOPA125mg TabletST

00360252 APO-METHYLDOPA APX00456365 METHYLDOPA PDL

250mg TabletST


500mg TabletST


METHYLDOPA, HYDROCHLOROTHIAZIDE250mg & 15mg TabletST

00441708 APO-METHAZIDE-15 APX

24:08.16 CENTRAL ALPHA-AGONISTSMETHYLDOPA, HYDROCHLOROTHIAZIDE

250mg & 25mg TabletST

00441716 APO-METHAZIDE-25 APX

24:08.20 DIRECT VASODILATORSDIAZOXIDE

100mg CapsuleST

00503347 PROGLYCEM SCH

HYDRALAZINE HCL10mg TabletST

00441619 APO-HYDRALAZINE APX01913638 HYDRALAZINE PDL00759465 NOVO-HYLAZIN NOP01913204 NU-HYDRAL NXP

25mg TabletST


50mg TabletST


MINOXIDIL2.5mg TabletST

00514497 LONITEN PFI10mg TabletST

00514500 LONITEN PFI

24:12.08 NITRATES AND NITRITESISOSORBIDE DINITRATE

5mg Sublingual TabletST

00670944 APO-ISDN APX00658812 ISOSORBIDE PDL

10mg TabletST

00441686 APO-ISDN APX00584266 ISOSORBIDE PDL00786667 PMS-ISOSORBIDE PMS

30mg TabletST

00441694 APO-ISDN APX00584258 PDL-ISOSORBIDE PDL

ISOSORBIDE-5-MONONITRATE60mg TabletST

02272830 APO-ISMN APX02126559 IMDUR AZE02301288 PMS-ISMN PMS02311321 PRO-ISMN PDL

NITROGLYCERIN2% Ointment

01926454 NITROL SQU

Page 29 of 1242010


24:12.08 NITRATES AND NITRITESNITROGLYCERIN

0.2mg PatchST

02162806 MINITRAN MMH01911910 NITRO-DUR KEY00584223 TRANSDERM-NITRO NVR02230732 TRINIPATCH TRT

0.4mg PatchST


0.6mg PatchST


0.8mg PatchST

02011271 NITRO-DUR KEY0.4mg Spray

02243588 GEN-NITRO GEN02231441 NITROLINGUAL PUMPSPRAY SAC02238998 RHO-NITRO PUMPSPRAY SAC

0.3mg Sublingual Tablet00037613 NITROSTAT PFI

0.6mg Sublingual Tablet00037621 NITROSTAT PFI

24:12.92 MISCELLANEOUS VASODILATING AGENTS

DIPYRIDAMOLE25mg TabletST

00895644 APO-DIPYRIDAMOLE APX02229396 PDL-DIPYRIDAMOLE PDL

50mg TabletST

00571245 APO-DIPYRIDAMOLE APX00895652 APO-DIPYRIDAMOLE APX02229397 PDL-DIPYRIDAMOLE PDL00067393 PERSANTINE BOE

75mg TabletST

00601845 APO-DIPYRIDAMOLE APX00895660 APO-DIPYRIDAMOLE APX02229398 PDL-DIPYRIDAMOLE PDL00452092 PERSANTINE BOE

DIPYRIDAMOLE, ACETYLSALICYLIC ACIDLimited use benefit (prior approval required).

For secondary prevention of stroke or transient ischemic attacks (TIAs) in patients who have failed therapy with ASA alone.

200mg & 25mg CapsuleST

02242119 AGGRENOX BOE

NIMODIPINE30mg CapsuleST

02155923 NIMOTOP BAY

24:20.00 ALPHA ADRENERGIC BLOCKING AGENTS

DOXAZOSIN MESYLATE1mg TabletST

02240588 APO-DOXAZOSIN APX01958100 CARDURA 1 PFI02240978 DOXAZOSIN PDL02240498 GEN-DOXAZOSIN GEN02242728 NOVO-DOXAZOSIN NOP02244527 PMS-DOXAZOSIN PMS

2mg TabletST


4mg TabletST


PRAZOSIN HCL1mg TabletST

00882801 APO-PRAZO APX00560952 MINIPRESS ERF01934198 NOVO-PRAZIN NOP01913794 NU-PRAZO NXP01907158 PRAZOSIN PDL

2mg TabletST


5mg TabletST


TERAZOSIN HCL1mg TabletST

02234502 APO-TERAZOSIN APX02243746 DOM-TERAZOSIN DPC00818658 HYTRIN ABB02230805 NOVO-TERAZOSIN NOP02233047 NU-TERAZOSIN NXP02237476 PDL-TERAZOSIN PDL02243518 PMS-TERAZOSIN PMS02218941 RATIO-TERAZOSIN RPH

Page 30 of 1242010


24:20.00 ALPHA ADRENERGIC BLOCKING AGENTS

TERAZOSIN HCL2mg TabletST


5mg TabletST


10mg TabletST


24:24.00 BETA ADRENERGIC BLOCKING AGENTS

ACEBUTOLOL HCL100mg TabletST

02164396 ACEBUTOLOL PDL02147602 APO-ACEBUTOLOL APX02237721 GEN-ACEBUTOLOL GEN02237885 GEN-ACEBUTOLOL (TYPE S) GEN02239758 MED-ACEBUTOLOL MEC02239754 MED-ACEBUTOLOL (TYPE S) MEC02204517 NOVO-ACEBUTOLOL NOP02165546 NU-ACEBUTOLOL NXP02231251 PENTA-ACEBUTOLOL PEN01910140 RHOTRAL SAC02257599 SANDOZ-ACEBUTOLOL SDZ01926543 SECTRAL SAC


ACEBUTOLOL HCL200mg TabletST


400mg TabletST


ATENOLOL25mg TabletST

02303647 GEN-ATENOLOL GEN02266660 NOVO-ATENOL NOP02247182 PHL-ATENOLOL PMI02246581 PMS-ATENOLOL PMS02277379 RIVA-ATENOLOL RIV

50mg TabletST

00773689 APO-ATENOL APX00828807 ATENOLOL PDL02257629 BCI-ATENOLOL BAK02255545 CO ATENOLOL COB02229467 DOM-ATENOLOL DPC02146894 GEN-ATENOLOL GEN02188961 MED-ATENOLOL MEC01912062 NOVO-ATENOL NOP00886114 NU-ATENOL NXP02229585 PENTA-ATENOLOL PEN02238316 PHL-ATENOLOL PHH02237600 PMS-ATENOLOL PMS02267985 RAN-ATENOLOL RBY02171791 RATIO-ATENOLOL RPH02242094 RIVA-ATENOLOL RIV02231731 SANDOZ-ATENOLOL SDZ02039532 TENORMIN AZC

Page 31 of 1242010



ATENOLOL100mg TabletST

00773697 APO-ATENOL APX00828793 ATENOLOL PDL02257637 BCI-ATENOLOL BAK02255553 CO ATENOLOL COB02229468 DOM-ATENOLOL DPC02147432 GEN-ATENOLOL GEN02188988 MED-ATENOLOL MEC01912054 NOVO-ATENOL NOP00886122 NU-ATENOL NXP02229586 PENTA-ATENOLOL PEN02238318 PHL-ATENOLOL PHH02237601 PMS-ATENOLOL PMS02267993 RAN-ATENOLOL RBY02171805 RATIO-ATENOLOL RPH02242093 RIVA-ATENOLOL RIV02231733 SANDOZ-ATENOLOL SDZ02039540 TENORMIN AZC

ATENOLOL, CHLORTHALIDONE50mg & 25mg TabletST

02248763 APO-ATENIDONE APX02302918 NOVO-ATENOLTHALIDONE NOP02049961 TENORETIC AZC


02248764 APO-ATENIDONE APX02302926 NOVO-ATENOLTHALIDONE NOP02049988 TENORETIC AZC

BISOPROLOL FUMARATE5mg TabletST

02256134 APO-BISOPROLOL APX02241148 MONOCOR BPC02267470 NOVO-BIPOPROLOL NOP02302632 PMS-BISOPROLOL PMS02306999 PRO-BISOPROLOL PDL02247439 SANDOZ-BISOPROLOL SDZ02321556 ZYM-BISOPROLOL ZYM

10mg TabletST

02256177 APO-BISOPROLOL APX02267489 NOVO-BIPOPROLOL NOP02302640 PMS-BISOPROLOL PMS02307006 PRO-BISOPROLOL PDL02247440 SANDOZ-BISOPROLOL SDZ02321572 ZYM-BISOPROLOL ZYM


CARVEDILOL3.125mg TabletST

02247933 APO-CARVEDILOL APX02248748 DOM-CARVEDILOL DPC02347512 MYLAN-CARVEDILOL MYL02248752 PHL-CARVEDILOL PMI02245914 PMS-CARVEDILOL PMS02268027 RAN-CARVEDILOL RBY02252309 RATIO-CARVEDILOL RPH02338068 ZYM-CARVEDILOL ZYM

6.25mg TabletST


12.5mg TabletST


25mg TabletST


LABETALOL HCL100mg TabletST

02106272 TRANDATE SHI200mg TabletST

02106280 TRANDATE SHI

METOPROLOL TARTRATE100mg Sustained Release TabletST

02285169 APO-METOPROLOL SR APX00658855 LOPRESOR SR NVR02303396 SANDOZ-METOPROLOL SR SDZ


02285177 APO-METOPROLOL SR APX00534560 LOPRESOR SR NVR02303418 SANDOZ-METOPROLOL SR SDZ

Page 32 of 1242010



METOPROLOL TARTRATE25mg TabletST

02246010 APO-METOPROLOL APX02252252 DOM-METOPROLOL-L DPC02302055 GEN-METOPROLOL (TYPE L) GEN02296713 METOPROLOL PDL02261898 NOVO-METOPROL CT NOP02248855 PMS-METOPROLOL-L PMS02315300 RIVA-METOPROLOL L RIV02315106 ZYM-METOPROLOL-L ZYM

50mg TabletST

00618632 APO-METOPROLOL APX00749354 APO-METOPROLOL-L APX02172550 DOM-METOPROLOL-B DPC02231121 DOM-METOPROLOL-L DPC02230448 GEN-METOPROLOL GEN02174545 GEN-METOPROLOL-L GEN00397423 LOPRESOR NVR02239771 MED-METOPROLOL MEC00648019 METOPROLOL PDL00648035 NOVO-METOPROL NOP00842648 NOVO-METOPROL NOP00865605 NU-METOP NXP02232546 PENTA-METOPROLOL PEN02145413 PMS-METOPROLOL-B PMS02230803 PMS-METOPROLOL-L PMS02315319 RIVA-METOPROLOL L RIV02247875 SANDOZ-METOPROLOL-L SDZ02315114 ZYM-METOPROLOL-L ZYM

100mg TabletST

00618640 APO-METOPROLOL APX00751170 APO-METOPROLOL-L APX02172569 DOM-METOPROLOL-B DPC02231122 DOM-METOPROLOL-L DPC02230449 GEN-METOPROLOL GEN02174553 GEN-METOPROLOL-L GEN00397431 LOPRESOR NVR02239772 MED-METOPROLOL MEC00648027 METOPROLOL PDL00648043 NOVO-METOPROL NOP00842656 NOVO-METOPROL-B NOP00865613 NU-METOP NXP02232547 PENTA-METOPROLOL PEN02145421 PMS-METOPROLOL-B PMS02230804 PMS-METOPROLOL-L PMS02315327 RIVA-METOPROLOL L RIV02247876 SANDOZ-METOPROLOL-L SDZ02315122 ZYM-METOPROLOL-L ZYM

NADOLOL40mg TabletST

00782505 APO-NADOL APX00828815 NADOLOL PDL02126753 NOVO-NADOLOL NOP


NADOLOL80mg TabletST

00782467 APO-NADOL APX00818704 NADOLOL PDL02126761 NOVO-NADOLOL NOP

160mg TabletST

00782475 APO-NADOL APX

OXPRENOLOL HCL80mg TabletST

00402583 TRASICOR NVR

PINDOLOL5mg TabletST

00755877 APO-PINDOL APX02231650 DOM-PINDOLOL DPC02057808 GEN-PINDOLOL GEN02084376 MED-PINDOLOL MEC00869007 NOVO-PINDOL NOP00886149 NU-PINDOL NXP00828416 PINDOLOL PDL02231536 PMS-PINDOLOL PMS02261782 SANDOZ-PINDOLOL SDZ00417270 VISKEN NVR

10mg TabletST


15mg TabletST


PINDOLOL, HYDROCHLOROTHIAZIDE10mg & 25mg TabletST

00568627 VISKAZIDE NVR10mg & 50mg TabletST

00568635 VISKAZIDE NVR

PROPRANOLOL HCL60mg Long Acting CapsuleST

02042231 INDERAL LA WAY

Page 33 of 1242010



PROPRANOLOL HCL80mg Long Acting CapsuleST

02042258 INDERAL LA WAY120mg Long Acting CapsuleST

02042266 INDERAL LA WAY160mg Long Acting CapsuleST

02042274 INDERAL LA WAY10mg TabletST

00402788 APO-PROPRANOLOL APX02137313 DOM-PROPRANOLOL DPC00496480 NOVO-PRANOL NOP00512575 PROPRANOLOL PDL

20mg TabletST

00663719 APO-PROPRANOLOL APX00740675 NOVO-PRANOL NOP02044692 NU-PROPRANOLOL NXP00667072 PROPRANOLOL PDL

40mg TabletST

00402753 APO-PROPRANOLOL APX02137321 DOM-PROPRANOLOL DPC00496499 NOVO-PRANOL NOP02044706 NU-PROPRANOLOL NXP00512532 PROPRANOLOL PDL

80mg TabletST

00402761 APO-PROPRANOLOL APX02137348 DOM-PROPRANOLOL DPC00496502 NOVO-PRANOL NOP00582271 PMS-PROPRANOLOL PMS00512540 PROPRANOLOL PDL

120mg TabletST

00504335 APO-PROPRANOLOL APX00582298 PMS-PROPRANOLOL PMS00667064 PROPRANOLOL PDL

SOTALOL HCL80mg TabletST

02210428 APO-SOTALOL APX02270625 CO SOTALOL COB02238634 DOM-SOTALOL DPC02229778 GEN-SOTALOL GEN02237269 MED-SOTALOL MEC02231181 NOVO-SOTALOL NOP02200996 NU-SOTALOL NXP02238768 PHL-SOTALOL PHH02238326 PMS-SOTALOL PMS02316528 PRO-SOTALOL PDL02084228 RATIO-SOTALOL RPH02234008 RHOXAL-SOTALOL RHO02242156 RIVA-SOTALOL RIV02257831 SANDOZ-SOTALOL SDZ02222019 SOTALOL PDL


SOTALOL HCL160mg TabletST

02167794 APO-SOTALOL APX02270633 CO SOTALOL COB02238635 DOM-SOTALOL DPC02229779 GEN-SOTALOL GEN02237270 MED-SOTALOL MEC02231182 NOVO-SOTALOL NOP02163772 NU-SOTALOL NXP02238769 PHL-SOTALOL PHH02238327 PMS-SOTALOL PMS02316536 PRO-SOTALOL PDL02084236 RATIO-SOTALOL RPH02257858 RHOXAL-SOTALOL RHO02242157 RIVA-SOTALOL RIV02234013 SANDOZ-SOTALOL SDZ02222027 SOTALOL PDL

240mg TabletST

02229780 GEN-SOTALOL GEN

TIMOLOL MALEATE5mg TabletST

00755842 APO-TIMOL APX01947796 NOVO-TIMOL NOP02044609 NU-TIMOLOL NXP00812455 TIMOLOL PDL

10mg TabletST

00755850 APO-TIMOL APX01947818 NOVO-TIMOL NOP02044617 NU-TIMOLOL NXP00812447 TIMOLOL PDL

20mg TabletST

00755869 APO-TIMOL APX01947826 NOVO-TIMOL NOP00812439 TIMOLOL PDL

24:28.08 DIHYDROPYRIDINESAMLODIPINE

2.5mg TabletST

02326825 DOM-AMLODIPINE DOM02280124 GD-AMLODIPINE PFI02326760 PHL-AMLODIPINE PMI02295148 PMS-AMLODIPINE PMS02331489 RIVA-AMLODIPINE RIV02330474 SANDOZ-AMLODIPINE SDZ02326795 ZYM-AMLODIPINE ZYM

Page 34 of 1242010


24:28.08 DIHYDROPYRIDINESAMLODIPINE

5mg TabletST

02273373 APO-AMLODIPINE APX02297485 CO AMLODIPINE CBT02326833 DOM-AMLODIPINE DOM02280132 GD-AMLODIPINE PFI02272113 GEN-AMLODIPINE GEN02331071 JAMP-AMLODIPINE JMP00878928 NORVASC PFI02250497 NOVO-AMLODIPINE NOP02326779 PHL-AMLODIPINE PMI02284065 PMS-AMLODIPINE PMS02321858 RAN-AMLODIPINE RBY02259605 RATIO-AMLODIPINE RPH02331497 RIVA-AMLODIPINE RIV02284383 SANDOZ-AMLODIPINE SDZ02326809 ZYM-AMLODIPINE ZYM02342790 ZYM-AMLODIPINE ZYM

10mg TabletST

02273381 APO-AMLODIPINE APX02297493 CO AMLODIPINE CBT02326841 DOM-AMLODIPINE DOM02280140 GD-AMLODIPINE PFI02272121 GEN-AMLODIPINE GEN02331098 JAMP-AMLODIPINE JMP00878936 NORVASC PFI02250500 NOVO-AMLODIPINE NOP02326787 PHL-AMLODIPINE PMI02284073 PMS-AMLODIPINE PMS02321866 RAN-AMLODIPINE RBY02259613 RATIO-AMLODIPINE RPH02331500 RIVA-AMLODIPINE RIV02284391 SANDOZ-AMLODIPINE SDZ02326817 ZYM-AMLODIPINE ZYM02342804 ZYM-AMLODIPINE ZYM

AMLODIPINE, ATORVASTATIN5mg & 10mg TabletST

02273233 CADUET PFI5mg & 20mg TabletST







02273314 CADUET PFI

24:28.08 DIHYDROPYRIDINESFELODIPINE

2.5mg Extended Release TabletST

02057778 PLENDIL AZC02221985 RENEDIL SAC

5mg Extended Release TabletST

00851779 PLENDIL AZC02221993 RENEDIL SAC02280264 SANDOZ-FELODIPINE SDZ09857203 SANDOZ-FELODIPINE SDZ


00851787 PLENDIL AZC02222000 RENEDIL SAC02280272 SANDOZ-FELODIPINE SDZ09857204 SANDOZ-FELODIPINE SDZ

NIFEDIPINE5mg CapsuleST

00725110 APO-NIFED APX02235897 PMS-NIFEDIPINE PMS

10mg CapsuleST

00755907 APO-NIFED APX02236758 DOM-NIFEDIPINE DPC00865591 NU-NIFED NXP02235898 PMS-NIFEDIPINE PMS


02237618 ADALAT XL BAY30mg Extended Release TabletST

02155907 ADALAT XL BAY02349167 MYLAN-NIFEDIPINE ER MYL


02155990 ADALAT XL BAY02321149 GEN-NIFEDIPINE XL GEN


02197448 APO-NIFED PA APX02211092 NIFEDIPINE PA PDL02212102 NU-NIFEDIPINE PA NXP


02181525 APO-NIFED PA APX02211106 NIFEDIPINE PA PDL02200937 NU-NIFEDIPINE PA NXP

24:28.92 MISCELLANEOUS CALCIUM-CHANNEL BLOCKING AGENTS

DILTIAZEM HCL120mg Controlled Delivery CapsuleST

02230997 APO-DILTIAZ CD APX02097249 CARDIZEM CD BPC02231472 DILTIAZEM CD PDL02254808 GEN-DILTIAZEM GEN02242538 NOVO-DILTAZEM CD NOP02231052 NU-DILTIAZ CD NXP02229781 RATIO-DILTIAZEM CD RPH02243338 SANDOZ-DILTIAZEM CD SDZ

Page 35 of 1242010



DILTIAZEM HCL180mg Controlled Delivery CapsuleST

02230998 APO-DILTIAZ CD APX02097257 CARDIZEM CD BPC02231474 DILTIAZEM CD PDL02242539 NOVO-DILTAZEM CD NOP02231053 NU-DILTIAZ CD NXP02229782 RATIO-DILTIAZEM CD RPH02243339 SANDOZ-DILTIAZEM CD SDZ

240mg Controlled Delivery CapsuleST

02230999 APO-DILTIAZ CD APX02097265 CARDIZEM CD BPC02231475 DILTIAZEM CD PDL02242540 NOVO-DILTAZEM CD NOP02231054 NU-DILTIAZ CD NXP02229783 RATIO-DILTIAZEM CD RPH02243340 SANDOZ-DILTIAZEM CD SDZ

300mg Controlled Delivery CapsuleST

02229526 APO-DILTIAZ CD APX02097273 CARDIZEM CD BPC02231057 DILTIAZEM CD PDL02254832 GEN-DILTIAZEM GEN02242541 NOVO-DILTAZEM CD NOP02229784 RATIO-DILTIAZEM CD RPH02243341 SANDOZ-DILTIAZEM CD SDZ

120mg Extended Release CapsuleST

02291037 APO-DILTIAZ TZ APX02231150 TIAZAC BPC










02256738 TIAZAC XC BPC180mg Extended Release TabletST




02256770 TIAZAC XC BPC60mg Sustained Release CapsuleST

02222957 APO-DILTIAZ SR APX


DILTIAZEM HCL90mg Sustained Release CapsuleST

02222965 APO-DILTIAZ SR APX120mg Sustained Release CapsuleST

02222973 APO-DILTIAZ SR APX02271605 NOVO-DILTIAZEM ER NOP02245918 SANDOZ-DILTIAZEM T SDZ

180mg Sustained Release CapsuleST

02271613 NOVO-DILTIAZEM ER NOP02245919 SANDOZ-DILTIAZEM T SDZ







30mg TabletST

00771376 APO-DILTIAZ APX00828785 DILTIAZEM PDL02189038 MED-DILTIAZEM MEC00862924 NOVO-DILTIAZEM NOP00886068 NU-DILTIAZ NXP02229593 PENTA-DILTIAZEM PEN

60mg TabletST

00771384 APO-DILTIAZ APX00828777 DILTIAZEM PDL02189046 MED-DILTIAZEM MEC00862932 NOVO-DILTIAZEM NOP00886076 NU-DILTIAZ NXP02229594 PENTA-DILTIAZEM PEN

VERAPAMIL HCL180mg Extended Release TabletST

02231676 COVERA-HS PFI240mg Extended Release TabletST

02231677 COVERA-HS PFI120mg Sustained Release TabletST

02246893 APO-VERAP SR APX02210347 GEN-VERAPAMIL SR GEN01907123 ISOPTIN SR ABB


02246894 APO-VERAP SR APX02210355 GEN-VERAPAMIL SR GEN01934317 ISOPTIN SR ABB

Page 36 of 1242010



VERAPAMIL HCL240mg Sustained Release TabletST

02246895 APO-VERAP SR APX02240321 DOM-VERAPAMIL SR DPC02210363 GEN-VERAPAMIL SR GEN00742554 ISOPTIN SR ABB02211920 NOVO-VERAMIL SR NOP02249812 NU-VERAP SR NXP02237791 PMS-VERAPAMIL SR PMS02238276 RIVA-VERAPAMIL PHH02248082 RIVA-VERAPAMIL SR RIV

80mg TabletST

00782483 APO-VERAP APX02237921 GEN-VERAPAMIL GEN02239769 MED-VERAPAMIL MEC00812331 NOVO-VERAMIL NOP00886033 NU-VERAP NXP00871028 VERAPAMIL PDL

120mg TabletST

00782491 APO-VERAP APX02237922 GEN-VERAPAMIL GEN02239770 MED-VERAPAMIL MEC00812358 NOVO-VERAMIL NOP00886041 NU-VERAP NXP00871036 VERAPAMIL PDL

24:32.04 ANGIOTENSIN-CONVERTING ENZYME INHIBITORS

BENAZEPRIL HCL5mg TabletST

02290332 APO-BENAZEPRIL APX00885835 LOTENSIN NVR

10mg TabletST


20mg TabletST


CAPTOPRIL6.25mg TabletST

01999559 APO-CAPTO APX12.5mg TabletST

00893595 APO-CAPTO APX00695661 CAPOTEN BMS01910329 CAPTOPRIL PDL02242788 CAPTOPRIL ZYM02238551 DOM-CAPTOPRIL DPC02163551 GEN-CAPTOPRIL GEN02188929 MED-CAPTOPRIL MEC01942964 NOVO-CAPTORIL NOP01913824 NU-CAPTO NXP02234254 PENTA-CAPTOPRIL PEN02230203 PMS-CAPTOPRIL PMS


CAPTOPRIL25mg TabletST


50mg TabletST


100mg TabletST

00893625 APO-CAPTO APX02242791 CAPTOPRIL ZYM02238554 DOM-CAPTOPRIL DPC02163594 GEN-CAPTOPRIL GEN02188953 MED-CAPTOPRIL MEC01942999 NOVO-CAPTORIL NOP01913859 NU-CAPTO NXP02234257 PENTA-CAPTOPRIL PEN02230206 PMS-CAPTOPRIL PMS

CILAZAPRIL1mg TabletST

02291134 APO-CILAZAPRIL APX02283778 GEN-CILAZAPRIL GEN01911465 INHIBACE HLR02266350 NOVO-CILAZAPRIL NOP02280442 PMS-CILAZAPRIL PMS

2.5mg TabletST

02291142 APO-CILAZAPRIL APX02285215 CO CILAZAPRIL COB02283786 GEN-CILAZAPRIL GEN01911473 INHIBACE HLR02266369 NOVO-CILAZAPRIL NOP02280450 PMS-CILAZAPRIL PMS

Page 37 of 1242010



CILAZAPRIL5mg TabletST

02291150 APO-CILAZAPRIL APX02285223 CO CILAZAPRIL COB02283794 GEN-CILAZAPRIL GEN01911481 INHIBACE HLR02266377 NOVO-CILAZAPRIL NOP02280469 PMS-CILAZAPRIL PMS

CILAZAPRIL, HYDROCHLOROTHIAZIDE5mg & 12.5mg TabletST

02284987 APO-CILAZAPRIL HCTZ APX02181479 INHIBACE PLUS HLR

5mg/12.5mg TabletST

02313731 NOVO-CILAZAPRIL/HCTZ NOP

ENALAPRIL MALEATE2.5mg TabletST

02020025 APO ENALAPRIL APX02291878 CO ENALAPRIL COB02300036 GEN-ENALAPRIL GEN02300680 NOVO-ENALAPRIL NOP02300079 PMS-ENALAPRIL PMS02299984 RATIO-ENALAPRIL RPH02300796 RIVA-ENALAPRIL RIV02299933 SANDOZ ENALAPRIL SDZ02323478 SIG-ENALAPRIL SIG02300117 TARO-ENALAPRIL TAR00851795 VASOTEC FRS

5mg TabletST


10mg TabletST



ENALAPRIL MALEATE20mg TabletST


40mg TabletST

02330601 NOVO-ENALAPRIL NOP

ENALAPRIL MALEATE, HYDROCHLOROTHIAZIDE

5mg & 12.5mg TabletST

02300222 NOVO-ENALAPRIL/HCTZ NOP10mg & 25mg TabletST

02300230 NOVO-ENALAPRIL/HCTZ NOP00657298 VASERETIC FRS

FOSINOPRIL SODIUM10mg TabletST

02266008 APO-FOSINOPRIL APX02332566 FOSINOPRIL RBY02262401 GEN-FOSINOPRIL GEN02331004 JAMP-FOSINOPRIL JMP01907107 MONOPRIL BMS02247802 NOVO-FOSINOPRIL NOP02303000 PDL-FOSINOPRIL PDL02255944 PMS-FOSINOPRIL PMS02294524 RAN-FOSINOPRIL RBY02275252 RATIO-FOSINOPRIL RPH02265923 RIVA-FOSINOPRIL RIV

20mg TabletST

02266016 APO-FOSINOPRIL APX02332574 FOSINOPRIL RBY02262428 GEN-FOSINOPRIL GEN02331012 JAMP-FOSINOPRIL JMP01907115 MONOPRIL BMS02247803 NOVO-FOSINOPRIL NOP02303019 PDL-FOSINOPRIL PDL02255952 PMS-FOSINOPRIL PMS02294532 RAN-FOSINOPRIL RBY02275260 RATIO-FOSINOPRIL RPH02265931 RIVA-FOSINOPRIL RIV

Page 38 of 1242010



LISINOPRIL5mg TabletST

09853685 APO-LISINOPRIL APX02217481 APO-LISINOPRIL (TYPE Z) APX02271443 CO LISINOPRIL COB02274833 GEN-LISINOPRIL GEN02285061 NOVO-LISINOPRIL (TYPE P) NOP02285118 NOVO-LISINOPRIL (TYPE Z) NOP02292203 PMS-LISINOPRIL PMS00839388 PRINIVIL FRS02310961 PRO-LISINOPRIL PDL02294230 RAN-LISINOPRIL RBY02256797 RATIO-LISINOPRIL P RPH02299879 RATIO-LISINOPRIL Z RPH02300958 RIVA-LISINOPRIL RIV02289199 SANDOZ LISINOPRIL SDZ02049333 ZESTRIL AZC

10mg TabletST

09853960 APO-LISINOPRIL APX02217503 APO-LISINOPRIL (TYPE Z) APX02271451 CO LISINOPRIL COB02274841 GEN-LISINOPRIL GEN02285088 NOVO-LISINOPRIL (TYPE P) NOP02285126 NOVO-LISINOPRIL (TYPE Z) NOP02292211 PMS-LISINOPRIL PMS00839396 PRINIVIL FRS02310988 PRO-LISINOPRIL PDL02294249 RAN-LISINOPRIL RBY02256800 RATIO-LISINOPRIL P RPH02299887 RATIO-LISINOPRIL Z RPH02300982 RIVA-LISINOPRIL RIV02289202 SANDOZ-LISINOPRIL SDZ02049376 ZESTRIL AZC

20mg TabletST

09854010 APO-LISINOPRIL APX02217511 APO-LISINOPRIL (TYPE Z) APX02271478 CO LISINOPRIL COB02274868 GEN-LISINOPRIL GEN02285096 NOVO-LISINOPRIL (TYPE P) NOP02285134 NOVO-LISINOPRIL (TYPE Z) NOP02292238 PMS-LISINOPRIL PMS00839418 PRINIVIL FRS02310996 PRO-LISINOPRIL PDL02294257 RAN-LISINOPRIL RBY02256819 RATIO-LISINOPRIL P RPH02299895 RATIO-LISINOPRIL Z RPH02300990 RIVA-LISINOPRIL RIV02289229 SANDOZ LISINOPRIL SDZ02049384 ZESTRIL AZC


LISINOPRIL, HYDROCHLOROTHIAZIDE10mg & 12.5mg TabletST

02261979 APO-LISINOPRIL/HCTZ APX02297736 GEN-LISINOPRIL HCTZ GEN02302136 NOVO-LISINOPRIL/HCTZ

(TYPE P)NOP

02301768 NOVO-LISINOPRIL/HCTZ (TYPE Z)

NOP

02108194 PRINZIDE FRS02302365 SANDOZ LISINOPRIL HCT SDZ02103729 ZESTORETIC AZC


02261987 APO-LISINOPRIL/HCTZ APX02297744 GEN-LISINOPRIL HCTZ GEN02302144 NOVO-LISINOPRIL (TYPE P) NOP02301776 NOVO-LISINOPRIL/HCTZ

(TYPE Z)NOP

00884413 PRINZIDE FRS02302373 SANDOZ LISINOPRIL HCT SDZ02045737 ZESTORETIC AZC


02261995 APO-LISINOPRIL/HCTZ APX02297752 GEN-LISINOPRIL HCTZ GEN02302152 NOVO-LISINOPRIL/HCTZ

(TYPE P)NOP

02301784 NOVO-LISINOPRIL/HCTZ (TYPE Z)

NOP

02302381 SANDOZ LISINOPRIL HCT SDZ02045729 ZESTORETIC AZC

PERINDOPRIL ERBUMINE2mg TabletST

02123274 COVERSYL SEV4mg TabletST

02123282 COVERSYL SEV8mg TabletST

02246624 COVERSYL SEV

PERINDOPRIL ERBUMINE, INDAPAMIDE4mg & 1.25mg TabletST

02246569 COVERSYL PLUS SEV

PERINDOPRIL ERBUMINE,INDAPAMIDE8mg/2.5mg TabletST

02321653 COVERSYL PLUS HD SEV

QUINAPRIL HCL5mg TabletST

01947664 ACCUPRIL PFI10mg TabletST



01947699 ACCUPRIL PFI

Page 39 of 1242010



QUINAPRIL HCL, HYDROCHLOROTHIAZIDE10mg & 12.5mg TabletST

02237367 ACCURETIC PFI20mg & 12.5mg TabletST

02237368 ACCURETIC PFI20mg & 25mg TabletST

02237369 ACCURETIC PFI

RAMIPRIL1.25mg CapsuleST

02221829 ALTACE SAC02251515 APO-RAMIPRIL APX02295482 CO RAMIPRIL COB02301148 GEN-RAMIPRIL GEN02331101 JAMP-RAMIPRIL JMP02295369 PMS-RAMIPRIL PMS02299372 RAMIPRIL PMS02310503 RAN RAMIPRIL RBY02287692 RATIO-RAMIPRIL RPH

2.5mg CapsuleST

02221837 ALTACE SAC02251531 APO-RAMIPRIL APX02295490 CO RAMIPRIL COB02301156 GEN-RAMIPRIL GEN02331128 JAMP-RAMIPRIL JMP02247945 NOVO-RAMIPRIL NOP02247917 PMS-RAMIPRIL PMS02255316 RAMIPRIL PMS02310511 RAN RAMIPRIL RBY02287706 RATIO-RAMIPRIL RPH

5mg CapsuleST


10mg CapsuleST


1.25mg TabletST

02291398 SANDOZ RAMIPRIL SDZ


RAMIPRIL2.5mg TabletST

02291401 SANDOZ RAMIPRIL SDZ5mg TabletST



02325381 APO-RAMIPRIL APX02311194 RATIO-RAMIPRIL RPH

RAMIPRIL, HYDROCHLOROTHIAZIDE2.5mg/12.5mg TabletST

02283131 ALTACE HCT SAC5mg/12.5mg TabletST

02283158 ALTACE HCT SAC5mg/25mg TabletST

02283174 ALTACE HCT SAC10mg/12.5mg TabletST

02283166 ALTACE HCT SAC10mg/25mg TabletST

02283182 ALTACE HCT SAC

TRANDOLAPRIL0.5mg CapsuleST

02231457 MAVIK ABB1mg CapsuleST



02239267 MAVIK ABB

24:32.08 ANGIOTENSIN II RECEPTOR ANTAGONISTS

CANDESARTAN CILEXETIL4mg TabletST

02239090 ATACAND AZE8mg TabletST

02239091 ATACAND AZC16mg TabletST

02239092 ATACAND AZC32mg TabletST

02311658 ATACAND AZC

CANDESARTAN CILEXETIL, HYDROCHLOROTHIAZIDE

16mg/12.5mg TabletST

02244021 ATACAND PLUS AZC32mg/12.5mg TabletST

02332922 ATACAND PLUS AZE32mg/25mg TabletST

02332957 ATACAND PLUS AZE

Page 40 of 1242010



EPOSARTAN MESYLATE400mg TabletST

02240432 TEVETEN SPH600mg TabletST

02243942 TEVETEN SPH

EPOSARTAN MESYLATE, HYDROCHLOROTHIAZIDE


02253631 TEVETEN PLUS SPH

IRBESARTAN75mg TabletST

02237923 AVAPRO SAC150mg TabletST

02237924 AVAPRO SAC300mg TabletST

02237925 AVAPRO SAC

IRBESARTAN, HYDROCHLOROTHIAZIDE150mg & 12.5mg TabletST

02241818 AVALIDE SAC300mg & 12.5mg TabletST

02241819 AVALIDE SAC300mg & 25mg TabletST

02280213 AVALIDE SAC

LOSARTAN POTASSIUM25mg TabletST

02182815 COZAAR FRS50mg TabletST

02182874 COZAAR FRS100mg TabletST

02182882 COZAAR FRS

LOSARTAN POTASSIUM, HYDROCHLOROTHIAZIDE


02230047 HYZAAR FRS100mg & 12.5mg TabletST

02297841 HYZAAR FRS100mg & 25mg TabletST

02241007 HYZAAR DS FRS

OLMESARTAN MEDOXOMIL5mg TabletST

02318652 OLMETEC SCH20mg TabletST

02318660 OLMETEC SCH40mg TabletST

02318679 OLMETEC SCH


OLMESARTAN MEDOXOMIL, HYDROCHLORTHIAZIDE


02319616 OLMETEC PLUS SCH40mg/12.5mg TabletST

02319624 OLMETEC PLUS SCH40mg/25mg TabletST

02319632 OLMETEC PLUS SCH

TELMISARTAN40mg TabletST

02240769 MICARDIS BOE80mg TabletST

02240770 MICARDIS BOE

TELMISARTAN, HYDROCHLOROTHIAZIDE80mg & 12.5mg TabletST

02244344 MICARDIS PLUS BOE80mg & 25mg TabletST

02318709 MICARDIS PLUS BOE

VALSARTAN40mg TabletST

02270528 DIOVAN NVR80mg TabletST

02236808 DIOVAN NOV02244781 DIOVAN NVR

160mg TabletST

02244782 DIOVAN NVR320mg TabletST

02289504 DIOVAN NVR

VALSARTAN, HYDROCHLOROTHIAZIDE80mg & 12.5mg TabletST

02241900 DIOVAN-HCT NVR160mg & 12.5mg TabletST

02241901 DIOVAN-HCT NVR160mg & 25mg TabletST

02246955 DIOVAN-HCT NVR320mg & 12.5mg TabletST

02308908 DIOVAN-HCT NOV320mg & 25mg TabletST

02308916 DIOVAN-HCT NOV

24:32.20 MINERALOCORTICOIDE (ALDOSTERONE) RECEPTOR ANTAGONISTS

SPIRONOLACTONE25mg TabletST

00028606 ALDACTONE PFI00613215 NOVO-SPIROTON NOP

100mg TabletST

00285455 ALDACTONE PFI00613223 NOVO-SPIROTON NOP

Page 41 of 1242010


28:00 CENTRAL NERVOUS SYSTEM AGENTS

28:08.04 NONSTEROIDAL ANTI-INFLAMMATORY AGENTS

ACETYLSALICYLIC ACID80mg Chewable TabletST

02009013 ASAPHEN PMS02269139 JAMP-ASA JMP02202352 RIVASA RIV

80mg Delayed Release TabletST

02283905 ACETYLSALICYLIC ACID JMP02238545 ASAPHEN EC PMS


02247550 ASAPHEN EC PMS325mg Delayed Release TabletST

02284529 PMS-ASA EC PMS650mg Delayed Release TabletST

02284537 PMS-ASA EC PMS81mg Enteric Coated TabletST

02243101 ASA PMS02244993 ASA PMS02237726 ASPIRIN BCD02242281 ENTROPHEN EC PED02283700 PRAXIS ASA EC PMS

325mg Enteric Coated TabletST

00510696 APO-ASEN ECT APX02010526 ASA VTH02150417 ASPIRIN BCD02050161 ENTROPHEN WAM00010332 ENTROPHEN-5 WAM00216666 NOVASEN NOP02285371 PMS-ASA EC PMS


00472476 ASA APX00794244 ASA WSB02046261 ASA FRS01905392 ENTROPHEN-10 FRS00229296 NOVASEN NOP

150mg Suppository00785547 PMS-ASA PMS

650mg Suppository00582867 ASA JNO

80mg TabletST

02150352 ASPIRIN BCD02250675 EURO-ASA EUR02311496 PRO-ASA 80MG EC TAB PRO02311518 PRO-ASA 80MG TAB PRO02202360 RIVASA RIV02321750 ZYM-ASA ZYM02321769 ZYM-ASA EC ZYM


ACETYLSALICYLIC ACID325mg TabletST

00472468 APO-ASA APX00036145 ASA PED00230324 ASA NOP00530336 ASA VTH02150328 ASPIRIN BCD

650mg TabletST

00010340 ENTROPHEN 10 FRS

CELECOXIBLimited use benefit (prior approval required).

For patients with osteoarthritis who have failed therapy with acetaminophen and who:a. - have failed to achieve adequate response with 2 other listed NSAIDs, orb. - have experienced an adverse event attributable to 2 other listed NSAIDs, orc. - have a history of a serious gastrointestinal complication such as bleeding or perforation.

For patients with rheumatoid arthritis who:a. - have failed to achieve adequate response with 2 other listed NSAIDs, orb. - have experienced an adverse event attributable to 2 other listed NSAIDs, orc. - have a history of a serious gastrointestinal complication such as bleeding or perforation.

100mg Capsule02239941 CELEBREX PFI


DICLOFENAC SODIUM25mg Delayed Release Tablet

02302616 PMS-DICLOFENAC 25MG DR PMS50mg Delayed Release Tablet

02302624 PMS-DICLOFENAC 50MG DR PMS25mg Enteric Coated Tablet

00839175 APO-DICLO APX00870951 DICLOFENAC-25 PDL02231662 DOM-DICLOFENAC DPC00808539 NOVO-DIFENAC NOP00886017 NU-DICLO NXP02231502 PMS-DICLOFENAC PMS02261952 SANDOZ-DICLOFENAC SDZ

50mg Enteric Coated Tablet00839183 APO-DICLO APX00870978 DICLOFENAC-50 PDL02231663 DOM-DICLOFENAC DPC00808547 NOVO-DIFENAC NOP00886025 NU-DICLO NXP02231503 PMS-DICLOFENAC PMS02261960 SANDOZ-DICLOFENAC SDZ00514012 VOLTAREN NVR

Page 42 of 1242010



DICLOFENAC SODIUM50mg Suppository

02231506 PMS-DICLOFENAC PMS02241224 SANDOZ DICLOFENAC SDZ02261928 SANDOZ-DICLOFENAC SDZ00632724 VOLTAREN NVR

100mg Suppository02231508 PMS-DICLOFENAC PMS02241225 SANDOZ DICLOFENAC SDZ02261936 SANDOZ-DICLOFENAC SDZ00632732 VOLTAREN NVR

75mg Sustained Release Tablet02224119 DICLOFENAC-SR PDL02231664 DOM-DICLOFENAC SR DPC02158582 NOVO-DIFENAC SR NOP02228203 NU-DICLO SR NXP02231504 PMS-DICLOFENAC SR PMS02261901 SANDOZ-DICLOFENAC SR SDZ00782459 VOLTAREN SR NVR

100mg Sustained Release Tablet02091194 APO-DICLO SR APX02224127 DICLOFENAC-SR PDL02231665 DOM-DICLOFENAC SR DPC02048698 NOVO-DIFENAC SR NOP02228211 NU-DICLO SR NXP02231505 PMS-DICLOFENAC SR PMS02261944 SANDOZ-DICLOFENAC SR SDZ00590827 VOLTAREN SR NVR

DICLOFENAC SODIUM, MISOPROSTOL50mg & 200mcg Tablet

01917056 ARTHROTEC PFI75mg & 200mcg Tablet

02229837 ARTHROTEC PFI

DIFLUNISAL250mg Tablet

02039486 APO-DIFLUNISAL APX02048493 NOVO-DIFLUNISAL NOP

500mg Tablet02039494 APO-DIFLUNISAL APX02058413 NU-DIFLUNISAL NXP

FLURBIPROFEN50mg Tablet

00647942 ANSAID PFI01912046 APO-FLURBIPROFEN APX01947729 FLURBIPROFEN PRO02100509 NOVO-FLURPROFEN NOP02020661 NU-FLURBIPROFEN NXP


FLURBIPROFEN100mg Tablet

00600792 ANSAID PFI01912038 APO-FLURBIPROFEN APX01947737 FLURBIPROFEN PRO02100517 NOVO-FLURPROFEN NOP02020688 NU-FLURBIPROFEN NXP

IBUPROFEN200mg Capsule

02241769 ADVIL LIQUI-GEL WRI02281384 IBUPROFEN APX

400mg Capsule02248231 ADVIL LIQUI-GEL WAY02310880 IBUPROFEN APX

100mg Chewable Tablet02246403 ADVIL JUNIOR STRENGTH WRI

40mg/mL Drop02242522 ADVIL PEDIATRIC WRI02238626 CHILDREN'S MOTRIN MCL

20mg/mL Oral Liquid02232297 CHILDREN'S ADVIL WRI02242365 CHILDREN'S MOTRIN JNO

100mg Tablet02240527 MOTRIN JUNIOR STRENGTH MCL

200mg Tablet01933558 ADVIL WRI00441643 APO-IBUPROFEN APX00636517 IBUPROFEN PDL02238004 IBUPROFEN VTH02257912 IBUPROFEN PMT02272849 IBUPROFEN VTH02186934 MOTRIN MCL

300mg Tablet00441651 APO-IBUPROFEN APX00636525 IBUPROFEN PDL02020696 NU-IBUPROFEN NXP

400mg Tablet00506052 APO-IBUPROFEN APX00636533 IBUPROFEN PDL02317338 JAMP IBUPROFEN JMP02020718 NU-IBUPROFEN NXP00836133 PMS-IBUPROFEN PMS

600mg Tablet00585114 APO-IBUPROFEN APX00658804 IBUPROFEN PDL00629359 NOVO-PROFEN NOP02020726 NU-IBUPROFEN NXP

Page 43 of 1242010



INDOMETHACIN25mg Capsule

00611158 APO-INDOMETHACIN APX00337420 NOVO-METHACIN NOP00865850 NU-INDO NXP00646261 PRO-INDO PDL

50mg Capsule00611166 APO-INDOMETHACIN APX00337439 NOVO-METHACIN NOP00865869 NU-INDO NXP00646288 PRO-INDO PDL

50mg Suppository02231799 SANDOZ INDOMETHACIN SDZ

100mg Suppository01934139 RATIO-INDOMETHACIN RPH02231800 SANDOZ INDOMETHACIN SDZ

KETOPROFEN50mg Capsule

00790427 APO-KETO APX02044633 NU-KETOPROFEN NXP02150808 PMS-KETOPROFEN PMS

50mg Enteric Coated Tablet00790435 APO KETO-E APX02150816 PMS-KETOPROFEN PMS

100mg Enteric Coated Tablet00842664 APO-KETO-E APX02150824 PMS-KETOPROFEN PMS

50mg Suppository02148773 PMS-KETOPROFEN PMS

100mg Suppository02015951 PMS-KETOPROFEN PMS

200mg Sustained Release Tablet02172577 APO-KETO SR APX02210487 KETOPROFEN-SR PDL

MEFENAMIC ACID250mg Capsule

02229452 APO-MEFENAMIC APX02237826 DOM-MEFENAMIC ACID DPC02230408 MEFENAMIC PDL02229569 NU-MEFENAMIC NXP

MELOXICAM7.5mg Tablet

02248973 APO-MELOXICAM APX02250012 CO MELOXICAM COB02248605 DOM-MELOXICAM DPC02255987 GEN-MELOXICAM GEN02242785 MOBICOX BOE02258315 NOVO-MELOXICAM NOP02248607 PHL-MELOXICAM PHH02248267 PMS-MELOXICAM PMS02247889 RATIO-MELOXICAM RPH


MELOXICAM15mg Tablet

02248974 APO-MELOXICAM APX02250020 CO MELOXICAM COB02248606 DOM-MELOXICAM DPC02255995 GEN-MELOXICAM GEN02242786 MOBICOX BOE02258323 NOVO-MELOXICAM NOP02248608 PHL-MELOXICAM PHH02248268 PMS-MELOXICAM PMS02248031 RATIO-MELOXICAM RPH

NAPROXEN250mg Enteric Coated Tablet

02246699 APO-NAPROXEN EC APX02162792 NAPROSYN E HLR02243312 NOVO-NAPROX NOP

375mg Enteric Coated Tablet02246700 APO-NAPROXEN EC APX02162415 NAPROSYN E HLR02243313 NOVO-NAPROX NOP02294702 PMS-NAPROXEN EC PMS

500mg Enteric Coated Tablet02246701 APO-NAPROXEN EC APX02241024 GEN-NAPROXEN EC GEN02162423 NAPROSYN E HLR02243314 NOVO-NAPROX NOP02294710 PMS-NAPROXEN EC PMS02310953 PRO-NAPROXEN EC PDL

25mg/mL Suspension02162431 NAPROSYN HLR

750mg Sustained Release Tablet02162466 NAPROSYN SR HLR

125mg Tablet00522678 APO-NAPROXEN APX00590754 NAPROXEN PDL00865621 NU-NAPROX NXP

250mg Tablet00522651 APO-NAPROXEN APX00590762 NAPROXEN PDL00565350 NOVO-NAPROX NOP00865648 NU-NAPROX NXP02240786 RIVA-NAPROXEN RIV

375mg Tablet00600806 APO-NAPROXEN APX02243432 GEN-NAPROXEN GEN00655686 NAPROXEN PDL00627097 NOVO-NAPROX NOP00865656 NU-NAPROX NXP02240787 RIVA-NAPROXEN RIV

Page 44 of 1242010



NAPROXEN500mg Tablet

00592277 APO-NAPROXEN APX00618721 NAPROXEN PDL00589861 NOVO-NAPROX NOP00865664 NU-NAPROX NXP02240788 RIVA-NAPROXEN RIV

NAPROXEN SODIUM275mg Tablet

02162725 ANAPROX HLR00784354 APO-NAPRO NA APX00887056 NAPROXEN NA PDL00778389 NOVO-NAPROX SODIUM NOP

550mg Tablet02162717 ANAPROX DS HLR01940309 APO-NAPRO NA DS APX02153386 NAPROXEN-NA DF PDL02026600 NOVO-NAPROX SODIUM DS NOP02240828 RIVA-NAPROXEN SODIUM RIV

PIROXICAM10mg Capsule

00642886 APO-PIROXICAM APX02171813 GEN-PIROXICAM GEN00865761 NU-PIROX NXP00658839 PIROXICAM PDL00836249 PMS-PIROXICAM PMS

20mg Capsule00642894 APO-PIROXICAM APX02239536 DOM-PIROXICAM DPC02171821 GEN-PIROXICAM GEN00865788 NU-PIROX NXP00658820 PIROXICAM PDL00836230 PMS-PIROXICAM PMS

10mg Suppository02154420 PMS-PIROXICAM PMS

20mg Suppository02154463 PMS-PIROXICAM PMS

10mg Tablet00695718 NOVO-PIROCAM NOP

20mg Tablet00695696 NOVO-PIROCAM NOP

SULINDAC150mg Tablet

00778354 APO-SULIN APX00745588 NOVO-SUNDAC NOP02042576 NU-SULINDAC NXP00808628 SULINDAC PDL


SULINDAC200mg Tablet

00778362 APO-SULIN APX00745596 NOVO-SUNDAC NOP02042584 NU-SULINDAC NXP02239164 PENTA-SULINDAC PEN00808636 SULINDAC PDL

TIAPROFENIC ACID200mg Tablet

02179679 NOVO-TIAPROFENIC NOP02231249 PENTA-TIAPROFENIC PEN02230827 PMS-TIAPROFENIC PMS

300mg Tablet02136120 APO-TIAPROFENIC APX02231060 DOM-TIAPROFENIC DPC02179687 NOVO-TIAPROFENIC NOP02146886 NU-TIAPROFENIC NXP02231250 PENTA-TIAPROFENIC PEN02145014 TIAPROFENIC PDL

28:08.08 OPIATE AGONISTSACETAMINOPHEN, CAFFEINE CITRATE, CODEINE PHOSPHATE

300mg & 15mg & 15mg Tablet00706515 PMS-ACET 2 PMS00653241 RATIO-LENOLTEC NO.2 RPH02163934 TYLENOL WITH CODEINE NO.2 JNO

300mg & 15mg & 30mg Tablet00653276 RATIO-LENOLTEC NO.3 RPH02163926 TYLENOL WITH CODEINE NO.3 JNO

300mg & 30mg & 15mg Tablet00293504 ATASOL-15 HOR02232388 EXDOL-15 PED

300mg & 30mg & 30mg Tablet00293512 ATASOL-30 HOR02232389 EXDOL-30 PED

ACETAMINOPHEN, CODEINE PHOSPHATE32mg & 1.6mg/mL Elixir

00816027 PMS-ACETAMINOPHEN WITH CODEINE

PMS

02163942 TYLENOL WITH CODEINE JNO300mg & 30mg Tablet

01999648 ACET CODEINE 30 PMS02232658 PROCET-30 PDL00608882 RATIO-EMTEC-30 RPH00789828 TRIATEC-30 TRI

300mg & 60mg Tablet00621463 LENOLTEC NO.4 RPH02163918 TYLENOL WITH CODEINE NO.4 JNO

ACETAMINOPHEN, OXYCODONE HCL325mg & 2.5mg Tablet

01916491 PERCOCET DEMI BMS

Page 45 of 1242010


28:08.08 OPIATE AGONISTSACETAMINOPHEN, OXYCODONE HCL

325mg & 5mg Tablet02324628 APO-OXYCODONE/ACET APX01916548 ENDOCET EDM02307898 NOVO-OXYCODONE ACET NOP01916475 PERCOCET BMS02245758 PMS-OXYCODONE

ACETAMINOPHENPMS

02327171 PRO-OXYCOD ACET PDL00608165 RATIO-OXYCOCET RPH02242468 RIVACOCET RIV

ACETYLSALICYLIC ACID, CAFFEINE CITRATE, CODEINE PHOSPHATE

375mg & 30mg & 15mg Tablet02234510 282 PED

375mg & 30mg & 30mg Tablet02238645 292 PED

ACETYLSALICYLIC ACID, OXYCODONE HCL325mg & 5mg Tablet

01916572 PERCODAN BMS00608157 RATIO-OXYCODAN RPH

CODEINE MONOHYDRATE, CODEINE SULFATE TRIHYDRATELimited use benefit (prior approval required).

For treatment of:a. - chronic pain and palliative care patients as an alternative to products containing codeine in combination with acetaminophen or ASA with or without caffeine, orb. - chronic pain and palliative care patients as an alternative to regular release codeine tablets when large doses are required.

50mg Long Acting Tablet02230302 CODEINE CONTIN CR PFR




CODEINE PHOSPHATE30mg/mL Injection

00544884 CODEINE SDZ00497282 CODEINE PHOSPHATE ABB

60mg/mL Injection00497290 CODEINE PHOSPHATE ABB

2mg/mL Liquid00380571 LINCTUS CODEINE ATL

5mg/mL Syrup00050024 CODEINE PHOSPHATE ATL00779474 RATIO-CODEINE RPH

28:08.08 OPIATE AGONISTSCODEINE PHOSPHATE

15mg Tablet00779458 CODEINE RPH02009889 CODEINE RIV02243978 PMS-CODEINE PMS00593435 RATIO-CODEINE RPH

30mg Tablet02009757 CODEINE RIV00593451 CODEINE PHOSPHATE RPH02243979 PMS-CODEINE PMS

FENTANYLLimited use benefit (prior approval required).

For the management of chronic pain in patients who are unresponsive or intolerant to at least one long-acting oral sustained released product, such as morphine, hydromorphone and oxycodone, despite appropriate dose titration and adjunctive therapy including laxatives and antiemetics.

12mcg/h Transdermal Patch02341379 PMS-FENTANYL MTX PMS02330105 RAN-FENTANYL MATRIX

PATCH 12RBY

02311925 RATIO-FENTANYL RPH02327112 SANDOZ FENTANYL SDZ

25mcg/h Transdermal Patch02275813 DURAGESIC MAT JNO02314630 NOVO-FENTANYL NOP02341387 PMS-FENTANYL MTX PMS02249391 RAN-FENTANYL RBY02330113 RAN-FENTANYL MATRIX RBY02282941 RATIO-FENTANYL RPH02327120 SANDOZ FENTANYL SDZ



Page 46 of 1242010


28:08.08 OPIATE AGONISTSFENTANYLLimited use benefit (prior approval required).


100mcg/h Transdermal Patch02275856 DURAGESIC MAT JNO02314665 NOVO-FENTANYL NOP02341417 PMS-FENTANYL MTX PMS02249448 RAN-FENTANYL RBY02330156 RAN-FENTANYL MATRIX RBY02282984 RATIO-FENTANYL RPH02327163 SANDOZ FENTANYL

TRANSDERMAL SYSTEMSDZ

HYDROMORPHONE HCLLimited use benefit. Prior approval required for controlled release capsules only. Regular release dosage forms are full benefits and do not require prior approval.

For treatment of moderate to severe chronic pain when other opioids such as morphine have been ineffective in controlling pain or in patients experiencing intolerable side effects.

3mg Controlled Release Capsule02125323 HYDROMORPH CONTIN PFR






2mg/mL Injection00627100 DILAUDID ABB02145901 HYDROMORPHONE SDZ

10mg/mL Injection00622133 DILAUDID HP ABB02145928 HYDROMORPHONE HP 10 SDZ

20mg/mL Injection02146118 DILAUDID HP PLUS ABB02145936 HYDROMORPHONE HP 20 SDZ

50mg/mL Injection02145863 DILAUDID XP ABB02146126 HYDROMORPHONE HP 50 SDZ99003163 HYDROMORPHONE HP 50 SDZ

1mg/mL Oral Liquid00786535 DILAUDID ABB01916386 PMS-HYDROMORPHONE PMS

28:08.08 OPIATE AGONISTSHYDROMORPHONE HCLLimited use benefit. Prior approval required for controlled release capsules only. Regular release dosage forms are full benefits and do not require prior approval.


3mg Suppository00125105 DILAUDID ABB01916394 PMS-HYDROMORPHONE PMS

1mg Tablet00705438 DILAUDID ABB02192101 PHL-HYDROMORPHONE PHH00885444 PMS-HYDROMORPHONE PMS




MEPERIDINE HCLLimited use benefit (prior approval not required).

Limited to 2 weeks supply for acute pain. Coverage will be limited to 60 tablets per one month period.

25mg/mL Injection00497444 PETHIDINE ABB

50mg/mL Injection02242003 DEMEROL ABB00725765 MEPERIDINE SDZ00497452 PETHIDINE ABB



50mg Tablet02138018 DEMEROL SAC

MORPHINE HCL30mg Sustained Release Tablet

00776181 M.O.S. SR VAE60mg Sustained Release Tablet

00776203 M.O.S. SR VAE

Page 47 of 1242010


28:08.08 OPIATE AGONISTSMORPHINE HCL

1mg/mL Syrup00614491 DOLORAL 1 ATL00607762 RATIO-MORPHINE RPH

5mg/mL Syrup00614505 DOLORAL 5 ATL00607770 RATIO-MORPHINE RPH

10mg/mL Syrup00632503 M.O.S. 10 VAE00690783 RATIO-MORPHINE RPH

20mg/mL Syrup00690791 RATIO-MORPHINE RPH

50mg/mL Syrup00690236 M.O.S. 50 VAE

10mg Tablet00690198 M.O.S. 10 VAE




MORPHINE SULFATE20mg/mL Drop

00621935 STATEX PMS50mg/mL Drop

00705799 STATEX PMS0.5mg/mL Injection

02021056 MORPHINE LP SDZ01949047 MORPHINE SULFATE ABB

1mg/mL Injection02021048 MORPHINE LP SDZ01949055 MORPHINE SULFATE ABB01980696 MORPHINE SULFATE SDZ

2mg/mL Injection00850314 MORPHINE SULFATE ABB01964437 MORPHINE SULFATE SDZ02242484 MORPHINE SULFATE SDZ

5mg/mL Injection01964429 MORPHINE SULFATE SDZ

10mg/mL Injection00392588 MORPHINE SULFATE SDZ00850322 MORPHINE SULFATE ABB

15mg/mL Injection00392561 MORPHINE SULFATE SDZ

25mg/mL Injection00676411 MORPHINE HP 25 SDZ

50mg/mL Injection00617288 MORPHINE HP 50 SDZ02137267 MORPHINE SULFATE HOS

5mg Suppository00632228 STATEX PMS

28:08.08 OPIATE AGONISTSMORPHINE SULFATE



10mg Sustained Release Capsule02242163 KADIAN MAY02019930 M-ESLON SAC

15mg Sustained Release Capsule02177749 M-ESLON SAC

20mg Sustained Release Capsule02184435 KADIAN SR MAY

30mg Sustained Release Capsule02019949 M-ESLON SR SAC

50mg Sustained Release Capsule02184443 KADIAN SR MAY


100mg Sustained Release Capsule02184451 KADIAN SR MAY02019965 M-ESLON SR SAC


15mg Sustained Release Tablet02015439 MS CONTIN SR PFR02302764 NOVO-MORPHINE SR NOP02245284 PMS-MORPHINE SULFATE PMS02244790 RATIO-MORPHINE SULFATE

SRRPH


SRRPH


SRRPH

100mg Sustained Release Tablet02014319 MS CONTIN SR PFR02302799 NOVO-MORPHINE SR NOP02245287 PMS-MORPHINE SR PMS

200mg Sustained Release Tablet02014327 MS CONTIN SR PFR02302802 NOVO-MORPHINE SR NOP02245288 PMS-MORPHINE SR PMS

1mg/mL Syrup00591467 STATEX PMS


Page 48 of 1242010


28:08.08 OPIATE AGONISTSMORPHINE SULFATE


5mg Tablet02009773 M.O.S. SULFATE VAE02014203 MS IR PFR00594652 STATEX PMS

10mg Tablet02009765 M.O.S. SULFATE VAE02014211 MS IR PFR00594644 STATEX PMS

20mg Tablet02014238 MS IR PFR

25mg Tablet02009749 M.O.S. SULFATE VAE00594636 STATEX PMS

30mg Tablet02014254 MS IR PFR

50mg Tablet02009706 M.O.S. SULFATE VAE00675962 STATEX PMS

OXYCODONE HCLLimited use benefit. Prior approval required for controlled release tablets only. Regular release dosage forms are full benefits and do not require prior approval.


5mg Controlled Release Tablet02258129 OXYCONTIN PFR








10mg Suppository00392480 SUPEUDOL SDZ

20mg Suppository00392472 SUPEUDOL SDZ

5mg Tablet02231934 OXY-IR PFR02319977 PMS-OXYCODONE PMS00789739 SUPEUDOL SDZ

28:08.08 OPIATE AGONISTSOXYCODONE HCLLimited use benefit. Prior approval required for controlled release tablets only. Regular release dosage forms are full benefits and do not require prior approval.




28:08.12 OPIATE PARTIAL AGONISTSPENTAZOCINE HCL

50mg Tablet02137984 TALWIN SAC

PENTAZOCINE LACTATE30mg/mL Injection

02241976 TALWIN ABB

28:08.92 MISCELLANEOUS ANALGESICS AND ANTIPYRETICS

ACETAMINOPHEN80mg Chewable TabletST

02129957 ACETAMIN CHILD WTR01905856 ACETAMINOPHEN TRI02017458 ACETAMINOPHEN RIV02015676 CHILDREN'S

ACETAMINOPHENTAN

02263815 PEDIAPHEN CHEWABLE EUR160mg Chewable TabletST

02017431 ACETAMINOPHEN RIV02231011 FEVERHALT PED02263823 PEDIAPHEN CHEWABLE EUR02230934 TANTAPHEN GRAPE TAN00876038 TEMPRA CHILDREN MJO

80mg/mL Drop01904140 ACETAMINOPHEN TAN01905864 ACETAMINOPHEN TRI00631353 ATASOL HOR02230787 FEVERHALT PED02263793 PEDIAPHEN EUR02027801 PEDIATRIX RPH00887587 PMS-ACETAMINOPHEN PMS00875988 TEMPRA MJO02046059 TYLENOL GRAPE MCL

16mg/mL Liquid01905848 ACETAMINOPHEN TRI02263807 PEDIAPHEN EUR00792713 PMS-ACETAMINOPHEN PMS00884553 TEMPRA MJO

Page 49 of 1242010



ACETAMINOPHEN32mg/mL Liquid

01901389 ACETAMINOPHEN JMP01958836 ACETAMINOPHEN TRI02263831 PEDIAPHEN EUR02027798 PEDIATRIX RPH00792691 PMS-ACETAMINOPHEN PMS00875996 TEMPRA DOUBLE STRENGTH MJO02046040 TYLENOL MCL

120mg Suppository01919385 ABENOL PED02230434 ACET 120 PMS02046660 PMS-ACETAMINOPHEN PMS

160mg Suppository02230435 ACET PMS



80mg TabletST

02238295 CHILDREN'S TYLENOL SOFT CHEWS

JNO

160mg TabletST

02142805 ACETAMINOPHEN WTR02021420 CEPHANOL RIV02241361 TYLENOL JUNIOR STRENGTH JNO

325mg TabletST

00374148 ACETAMINOPHEN WAM00382752 ACETAMINOPHEN PRO00589241 ACETAMINOPHEN PMS00605751 ACETAMINOPHEN VTH00743542 ACETAMINOPHEN PMT00789801 ACETAMINOPHEN TRI01938088 ACETAMINOPHEN JMP02022214 ACETAMINOPHEN RIV00544981 APO-ACETAMINOPHEN APX02229873 APO-ACETAMINOPHEN APX00293482 ATASOL HOR00389218 NOVO-GESIC NOP00891177 PMS-ACETAMINOPHEN PMS00559393 TYLENOL MCL00723894 TYLENOL MCL


ACETAMINOPHEN500mg TabletST

00386626 ACETAMINOPHEN PDL00549703 ACETAMINOPHEN PMT00567663 ACETAMINOPHEN PED00589233 ACETAMINOPHEN PMS00605778 ACETAMINOPHEN VTH00789798 ACETAMINOPHEN TRI01939122 ACETAMINOPHEN JMP02022222 ACETAMINOPHEN RIV02252813 ACETAMINOPHEN PMT02255251 ACETAMINOPHEN PMT00545007 APO-ACETAMINOPHEN APX02229977 APO-ACETAMINOPHEN APX00013668 ATASOL FORTE HOR00482323 NOVO-GESIC NOP00892505 PMS-ACETAMINOPHEN PMS01962353 TANTAPHEN TAN00863270 TYLENOL MCL00559407 TYLENOL EXTRA STRENGTH MCL00723908 TYLENOL EXTRA STRENGTH MCL

FLOCTAFENINE200mg Tablet

02244680 APO-FLOCTAFENINE APX400mg Tablet

02244681 APO-FLOCTAFENINE APX

28:12.04 ANTICONVULSANTS - BARBITURATES

PHENOBARBITAL5mg/mL Liquid

00645575 PMS-PHENOBARBITAL PMS15mg Tablet

00178799 PHENOBARBITAL PMS30mg Tablet



00178829 PHENOBARBITAL PMS

PRIMIDONE125mg Tablet

00399310 APO-PRIMIDONE APX250mg Tablet

00396761 APO-PRIMIDONE APX

28:12.08 ANTICONVULSANTS - BENZODIAZEPINES

CLONAZEPAM0.25MG Tablet

02236947 PHL-CLONAZEPAM 0.25MG PMI02179660 PMS-CLONAZEPAM PMS

Page 50 of 1242010


28:12.08 ANTICONVULSANTS - BENZODIAZEPINES

CLONAZEPAM0.5mg Tablet

02177889 APO-CLONAZEPAM APX02230366 CLONAPAM VAE02220598 CLONAZEPAM PDL02270641 CO CLONAZEPAM COB02130998 DOM-CLONAZEPAM DPC02224100 DOM-CLONAZEPAM-R DPC02230950 GEN-CLONAZEPAM GEN02237277 MED-CLONAZEPAM MEC02239024 NOVO-CLONAZEPAM NOP02173344 NU-CLONAZEPAM NXP02145227 PHL-CLONAZEPAM PHH02236948 PHL-CLONAZEPAM-R 0.5MG PMI02048701 PMS-CLONAZEPAM PMS02207818 PMS-CLONAZEPAM R PMS02311593 PRO-CLONAZEPAM PDL02103656 RATIO-CLONAZEPAM RPH02242077 RIVA-CLONAZEPAM RIV00382825 RIVOTRIL HLR02233960 SANDOZ-CLONAZEPAM SDZ02303310 ZYM-CLONAZEPAM ZYM02345676 ZYM-CLONAZEPAM ZYM

1mg Tablet02230368 CLONAPAM VAE02270668 CO CLONAZEPAM COB02145235 PHL-CLONAZEPAM PHH02048728 PMS-CLONAZEPAM PMS02311607 PRO-CLONAZEPAM PDL02233982 SANDOZ-CLONAZEPAM SDZ02303329 ZYM-CLONAZEPAM ZYM

2mg Tablet02177897 APO-CLONAZEPAM APX02230369 CLONAPAM VAE02220601 CLONAZEPAM PDL02270676 CO CLONAZEPAM COB02131013 DOM-CLONAZEPAM DPC02230951 GEN-CLONAZEPAM GEN02237278 MED-CLONAZEPAM MEC02239025 NOVO-CLONAZEPAM NOP02173352 NU-CLONAZEPAM NXP02145243 PHL-CLONAZEPAM PHH02048736 PMS-CLONAZEPAM PMS02311615 PRO-CLONAZEPAM PDL02103737 RATIO-CLONAZEPAM RPH02242078 RIVA-CLONAZEPAM RIV00382841 RIVOTRIL HLR02233985 SANDOZ-CLONAZEPAM SDZ02303337 ZYM-CLONAZEPAM ZYM

28:12.12 ANTICONVULSANTS - HYDANTOINS

PHENYTOIN30mg Capsule

00022772 DILANTIN PFI

28:12.12 ANTICONVULSANTS - HYDANTOINS

PHENYTOIN100mg Capsule

00022780 DILANTIN PFI50mg Chewable Tablet

00023698 DILANTIN INFATABS PFI6mg/mL Suspension

00023442 DILANTIN 30 PFI25mg/mL Suspension

00023450 DILANTIN 125 PFI02250896 TARO-PHENYTOIN TAR

28:12.20 ANTICONVULSANTS- SUCCINIMIDES

ETHOSUXIMIDE250mg Capsule

00022799 ZARONTIN ERF50mg/mL Syrup

00023485 ZARONTIN ERF

METHSUXIMIDE300mg Capsule

00022802 CELONTIN ERF

28:12.92 MISCELLANEOUS ANTICONVULSANTS

CARBAMAZEPINE100mg Chewable Tablet

02231542 PMS-CARBAMAZEPINE PMS02261855 SANDOZ-CARBAMAZEPINE SDZ02244403 TARO-CARBAMAZEPINE TAR00369810 TEGRETOL NVR

200mg Chewable Tablet02231540 PMS-CARBAMAZEPINE PMS02261863 SANDOZ-CARBAMAZEPINE SDZ02244404 TARO-CARBAMAZEPINE TAR00665088 TEGRETOL NVR

200mg Extended Release Tablet02261839 SANDOZ-CARBAMAZEPINE SDZ

400mg Extended Release Tablet02261847 SANDOZ-CARBAMAZEPINE SDZ

20mg/mL Suspension02194333 TEGRETOL NVR

200mg Sustained Release Tablet02238222 DOM-CARBAMAZEPINE CR DPC02241882 GEN-CARBAMAZEPINE CR GEN02231543 PMS-CARBAMAZEPINE SRT PMS02237907 TARO-CARBAMAZEPINE CR TAR00773611 TEGRETOL CR NVR

Page 51 of 1242010



CARBAMAZEPINE400mg Sustained Release Tablet

02238223 DOM-CARBAMAZEPINE CR DPC02241883 GEN-CARBAMAZEPINE CR GEN02231544 PMS-CARBAMAZEPINE SRT PMS02237908 TARO-CARBAMAZEPINE CR TAR00755583 TEGRETOL CR NVR

200mg Tablet00402699 APO-CARBAMAZEPINE APX00578460 CARBAMAZEPINE PDL00782718 NOVO-CARBAMAZ NOP02042568 NU-CARBAMAZEPINE NXP00010405 TEGRETOL NVR

DIVALPROEX SODIUM125mg Delayed Release Tablet

02265133 GEN-DIVALPROEX GEN250mg Delayed Release Tablet

02265141 GEN-DIVALPROEX GEN500mg Delayed Release Tablet

02265168 GEN-DIVALPROEX GEN125mg Enteric Coated Tablet

02239698 APO-DIVALPROEX APX00596418 EPIVAL ABB02239701 NOVO-DIVALPROEX NOP02239517 NU-DIVALPROEX NXP02244138 PMS-DIVALPROEX PMS

250mg Enteric Coated Tablet02239699 APO-DIVALPROEX APX00596426 EPIVAL ABB02239702 NOVO-DIVALPROEX NOP02239518 NU-DIVALPROEX NXP02244139 PMS-DIVALPROEX PMS

500mg Enteric Coated Tablet02239700 APO-DIVALPROEX APX02240343 DIVALPROEX EC PDL00596434 EPIVAL ABB02239703 NOVO-DIVALPROEX NOP02239519 NU-DIVALPROEX NXP02244140 PMS-DIVALPROEX PMS


GABAPENTIN100mg Capsule

02244304 APO-GABAPENTIN APX02256142 CO GABAPENTIN COB02243743 DOM-GABAPENTIN DPC02248259 GEN-GABAPENTIN GEN02084260 NEURONTIN PFI02244513 NOVO-GABAPENTIN NOP02246314 PHL-GABAPENTIN PMI02243446 PMS-GABAPENTIN PMS02310449 PRO-GABAPENTIN PDL02319055 RAN-GABAPENTIN RBY02260883 RATIO-GABAPENTIN RPH02251167 RIVA-GABAPENTIN RIV02304775 ZYM-GABAPENTIN ZYM

300mg Capsule02244305 APO-GABAPENTIN APX02256150 CO GABAPENTIN COB02243744 DOM-GABAPENTIN DPC02249375 GABAPENTIN PRE02273853 GABAPENTIN GEN02248260 GEN-GABAPENTIN GEN02084279 NEURONTIN PFI02244514 NOVO-GABAPENTIN NOP02246315 PHL-GABAPENTIN PMI02243447 PMS-GABAPENTIN PMS02310457 PRO-GABAPENTIN PDL02319063 RAN-GABAPENTIN RBY02260891 RATIO-GABAPENTIN RPH02251175 RIVA-GABAPENTIN RIV02304783 ZYM-GABAPENTIN ZYM

400mg Capsule02244306 APO-GABAPENTIN APX02256169 CO GABAPENTIN COB02243745 DOM-GABAPENTIN DPC02249383 GABAPENTIN PRE02248261 GEN-GABAPENTIN GEN02084287 NEURONTIN PFI02244515 NOVO-GABAPENTIN NOP02246316 PHL-GABAPENTIN PMI02243448 PMS-GABAPENTIN PMS02310465 PRO-GABAPENTIN PDL02319071 RAN-GABAPENTIN RBY02260905 RATIO-GABAPENTIN RPH02251183 RIVA-GABAPENTIN RIV02304791 ZYM-GABAPENTIN ZYM

600mg Tablet02293358 APO-GABAPENTIN APX02239717 NEURONTIN PFI02248457 NOVO-GABAPENTIN NOP02255898 PMS-GABAPENTIN PMS02310473 PRO-GABAPENTIN PDL02260913 RATIO-GABAPENTIN RPH02259796 RIVA-GABAPENTIN RIV

Page 52 of 1242010



GABAPENTIN800mg Tablet

02293366 APO-GABAPENTIN APX02239718 NEURONTIN PFI02247346 NOVO-GABAPENTIN NOP02255901 PMS-GABAPENTIN PMS02310481 PRO-GABAPENTIN PDL02260921 RATIO-GABAPENTIN RPH02259818 RIVA-GABAPENTIN RIV

LAMOTRIGINE2mg Chewable Tablet

02243803 LAMICTAL GSK5mg Chewable Tablet

02240115 LAMICTAL GSK25mg Tablet

02245208 APO-LAMOTRIGINE APX02265494 GEN-LAMOTRIGINE GEN02142082 LAMICTAL GSK02302969 LAMOTRIGINE PDL02248232 NOVO-LAMOTRIGINE NOP02246897 PMS-LAMOTRIGINE PMS02243352 RATIO-LAMOTRIGINE RPH

100mg Tablet02245209 APO-LAMOTRIGINE APX02265508 GEN-LAMOTRIGINE GEN02142104 LAMICTAL GSK02302985 LAMOTRIGINE PDL02248233 NOVO-LAMOTRIGINE NOP02246898 PMS-LAMOTRIGINE PMS02243353 RATIO-LAMOTRIGINE RPH

150mg Tablet02245210 APO-LAMOTRIGINE APX02265516 GEN-LAMOTRIGINE GEN02142112 LAMICTAL GSK02302993 LAMOTRIGINE PDL02248234 NOVO-LAMOTRIGINE NOP02246899 PMS-LAMOTRIGINE PMS02246963 RATIO-LAMOTRIGINE RPH

LEVETIRACETAMLimited use benefit (prior approval required).

For the use in combination with other anti-epileptic medication(s) in the treatment of partial seizures in patients who are refractory to adequate trials of three anti-epileptic medications used either as monotherapy or in combination. This product must be prescribed by a Neurologist.

250mg Tablet02285924 APO-LEVETIRACETAM APX02274183 CO LEVETIRACETAM COB02247027 KEPPRA UCB02296101 PMS-LEVETIRACETAM PMS


LEVETIRACETAMLimited use benefit (prior approval required).




TOPIRAMATE15mg Sprinkle Capsule

02239907 TOPAMAX SPRINKLE JNO25mg Sprinkle Capsule

02239908 TOPAMAX SPRINKLE JNO25mg Tablet

02279614 APO-TOPIRAMATE APX02287765 CO TOPIRAMATE COB02271141 DOM-TOPIRAMATE DPC02263351 GEN-TOPIRAMATE GEN02315645 MINT-TOPIRAMATE MIN02248860 NOVO-TOPIRAMATE NOP02271184 PHL-TOPIRAMATE PMI02262991 PMS-TOPIRAMATE PMS02313650 PRO-TOPIRAMATE PDL02256827 RATIO-TOPIRAMATE RPH02260050 SANDOZ-TOPIRAMATE SDZ02230893 TOPAMAX JNO02325136 ZYM-TOPIRAMATE ZYM

50mg Tablet02312085 PMS-TOPIRAMATE PMS

100mg Tablet02279630 APO-TOPIRAMATE APX02287773 CO TOPIRAMATE COB02271168 DOM-TOPIRAMATE DPC02263378 GEN-TOPIRAMATE GEN02315653 MINT-TOPIRAMATE MIN02248861 NOVO-TOPIRAMATE NOP02271192 PHL-TOPIRAMATE PMI02263009 PMS-TOPIRAMATE PMS02313669 PRO-TOPIRAMATE PDL02256835 RATIO-TOPIRAMATE RPH02260069 SANDOZ-TOPIRAMATE SDZ02230894 TOPAMAX JNO02325144 ZYM-TOPIRAMATE ZYM

Page 53 of 1242010



TOPIRAMATE200mg Tablet

02279649 APO-TOPIRAMATE APX02287781 CO TOPIRAMATE COB02271176 DOM-TOPIRAMATE DPC02263386 GEN-TOPIRAMATE GEN02315661 MINT-TOPIRAMATE MIN02248862 NOVO-TOPIRAMATE NOP02313677 PDL-TOPIRAMATE PDL02271206 PHL-TOPIRAMATE PMI02263017 PMS-TOPIRAMATE PMS02256843 RATIO-TOPIRAMATE RPH02267837 SANDOZ-TOPIRAMATE SDZ02230896 TOPAMAX JNO02325152 ZYM-TOPIRAMATE ZYM

VALPROATE, SODIUM50mg/mL Syrup

02238370 APO-VALPROIC APX00443832 DEPAKENE ABB02238817 DOM-VALPROIC ACID DPC02236807 PMS-VALPROIC ACID PMS02140063 RATIO-VALPROIC RPH

VALPROIC ACID250mg Capsule

02238048 APO-VALPROIC APX00443840 DEPAKENE ABB02231030 DOM-VALPROIC ACID DPC02184648 GEN-VALPROIC GEN02230663 MED-VALPROIC ACID MEC02100630 NOVO-VALPROIC NOP02237830 NU-VALPROIC NXP02238546 PDL-VALPROIC PDL02231248 PENTA-VALPROIC PEN02230768 PMS-VALPROIC ACID PMS02140047 RATIO-VALPROIC ACID RPH02239714 SANDOZ-VALPROIC SDZ

500mg Enteric Coated Capsule02231031 DOM-VALPROIC ACID DPC02218321 NOVO-VALPROIC NOP02260662 PHL-VALPROIC ACID PHH02229628 PMS-VALPROIC ACID PMS02140055 RATIO-VALPROIC ACID RPH02239713 SANDOZ-VALPROIC SDZ

VIGABATRIN500mg Powder

02068036 SABRIL OVA500mg Tablet

02065819 SABRIL OVA

28:16.04 ANTIDEPRESSANTSAMITRIPTYLINE HCL

10mg Tablet00370991 AMITRIPTYLINE PRO00335053 APO-AMITRIPTYLINE APX02248131 DOM-AMITRIPTYLINE DPC00037400 NOVO-TRIPTYN NOP02247302 PMS-AMITRIPTYLINE PMS

25mg Tablet00371009 AMITRIPTYLINE PRO00335061 APO-AMITRIPTYLINE APX02248132 DOM-AMITRIPTYLINE DPC00037419 NOVO-TRIPTYN NOP02247303 PMS-AMITRIPTYLINE PMS

50mg Tablet00456349 AMITRIPTYLINE PDL00335088 APO-AMITRIPTYLINE APX02248133 DOM-AMITRIPTYLINE DPC00271152 LEVATE ICN00037427 NOVO-TRIPTYN NOP02247304 PMS-AMITRIPTYLINE PMS

75mg Tablet00754129 APO-AMITRIPTYLINE APX00354295 ELAVIL FRS00405612 LEVATE VAE

BUPROPION HCL100mg Sustained Release Tablet

02325373 RATIO-BUPROPION SR PMS

BUPROPION HCL (WELLBUTRIN)Limited use benefit (prior approval required).

For treatment of depression in patients unresponsive to or intolerant of other listed antidepressants. (Note: this product will not be approved for coverage for smoking cessation).

100mg Sustained Release Tablet02285657 RATIO-BUPROPION RPH02275074 SANDOZ-BUPROPION SR SDZ

150mg Sustained Release Tablet02313421 PMS-BUPROPION SR PMS02285665 RATIO-BUPROPION RPH02275082 SANDOZ-BUPROPION SR SDZ02237825 WELLBUTRIN SR BPC02275090 WELLBUTRIN XL BOV

300mg Sustained Release Tablet02275104 WELLBUTRIN XL BOV

BUPROPION HCL (ZYBAN)Limited use benefit with quantity and frequency limits (prior approval is not required).

For smoking cessation:Coverage is limited to 180 tablets during a one-year period. The year starts on the date the first prescription is filled. Once this quantity has been reached, the client is eligible again for coverage for bupropion HCl when one year has elapsed from the day the initial prescription was filled.

150mg Sustained Release Tablet02238441 ZYBAN SR BPC

Page 54 of 1242010


28:16.04 ANTIDEPRESSANTSCITALOPRAM

10mg Tablet02312336 NOVO-CITALOPRAM NOP02273543 PHI-CITALOPRAM PMI02270609 PMS-CITALOPRAM PMS02303256 RIVA-CITALOPRAM RIV02301822 ZYM-CITALOPRAM ZYM

20mg Tablet02246056 APO-CITALOPRAM APX02239607 CELEXA LUD02257513 CITALOPRAM-20 PDL02248050 CO CITALOPRAM COB02248942 DOM-CITALOPRAM DPC02246594 GEN-CITALOPRAM GEN02313405 JAMP-CITALOPRAM JMP02304686 MINT-CITALOPRAM MIN02293218 NOVO-CITALOPRAM NOP02248996 NU-CITALOPRAM NXP02248944 PHL-CITALOPRAM PHH02248010 PMS-CITALOPRAM PMS02249227 PREM-CITALOPRAM PRE02285622 RAN-CITALO RBY02268000 RAN-CITALOPRAM RBY02252112 RATIO-CITALOPRAM RPH02249278 RIVA-CITALOPRAM RIV02303264 RIVA-CITALOPRAM RIV02248170 SANDOZ-CITALOPRAM SDZ02301830 ZYM-CITALOPRAM ZYM

30mg Tablet02296152 CTP ORY

40mg Tablet02246057 APO-CITALOPRAM APX02239608 CELEXA LUD02257521 CITALOPRAM PDL02248051 CO CITALOPRAM COB02248943 DOM-CITALOPRAM DPC02246595 GEN-CITALOPRAM GEN02313413 JAMP-CITALOPRAM JMP02304694 MINT-CITALOPRAM MIN02293226 NOVO-CITALOPRAM NOP02248997 NU-CITALOPRAM NXP02248945 PHL-CITALOPRAM PHH02248011 PMS-CITALOPRAM PMS02249235 PREM-CITALOPRAM PRE02285630 RAN-CITALO RBY02268019 RAN-CITALOPRAM RBY02252120 RATIO-CITALOPRAM RPH02249286 RIVA-CITALOPRAM RIV02303272 RIVA-CITALOPRAM RIV02248171 SANDOZ-CITALOPRAM SDZ02301849 ZYM-CITALOPRAM ZYM

28:16.04 ANTIDEPRESSANTSCLOMIPRAMINE HCL

10mg Tablet00330566 ANAFRANIL ORY02040786 APO-CLOMIPRAMINE APX02130122 CLOMIPRAMINE PDL02244816 CO CLOMIPRAMINE COB02188996 MED-CLOMIPRAMINE MEC02230256 NOVO-CLOPAMINE NOP



DESIPRAMINE HCL10mg Tablet

02216248 APO-DESIPRAMINE APX02222981 DESIPRAMINE PDL02223341 NOVO-DESIPRAMINE NOP02211939 NU-DESIPRAMINE NXP

25mg Tablet02216256 APO-DESIPRAMINE APX02223007 DESIPRAMINE PDL02130092 DOM-DESIPRAMINE DPC02223325 NOVO-DESIPRAMINE NOP02211947 NU-DESIPRAMINE NXP

50mg Tablet02216264 APO-DESIPRAMINE APX02223015 DESIPRAMINE PDL02130106 DOM-DESIPRAMINE DPC02223333 NOVO-DESIPRAMINE NOP02211955 NU-DESIPRAMINE NXP01946277 PMS-DESIPRAMINE PMS

75mg Tablet02216272 APO-DESIPRAMINE APX02223023 DESIPRAMINE PDL02223368 NOVO-DESIPRAMINE NOP02211963 NU-DESIPRAMINE NXP01946242 PMS-DESIPRAMINE PMS

100mg Tablet02216280 APO-DESIPRAMINE APX02223031 DESIPRAMINE PDL02211971 NU-DESIPRAMINE NXP

Page 55 of 1242010


28:16.04 ANTIDEPRESSANTSDOXEPIN HCL

10mg Capsule02049996 APO-DOXEPIN APX00024325 SINEQUAN ERF

25mg Capsule02050005 APO-DOXEPIN APX01913425 NOVO-DOXEPIN NOP00024333 SINEQUAN ERF




150mg Capsule01913476 NOVO-DOXEPIN NOP

10mg Tablet02150727 DOXEPINE PDL






DULOXETINE HCLLimited use benefit (prior approval required).

For the treatment of neuropathic pain in patients with diabetes who have:a.- failed an adequate trial with TWO alternative agents (such as a tricyclic antidepressant or anticonvulsant) due to intolerance or lack of response orb.- a contraindication to alternative agents

The dose of duloxetine will be limited to a maximum of 60 mg daily.Note that NIHB has adopted a Common Drug Review CEDAC recommendation that Cymbalta NOT be added to public drug plan formularies for the treatment of major depressive disorder.

30mg Sustained Release Capsule02301482 CYMBALTA LIL


28:16.04 ANTIDEPRESSANTSFLUOXETINE HCL

10mg Capsule02216353 APO-FLUOXETINE APX02242177 CO-FLUOXETINE SCN02177617 DOM-FLUOXETINE DPC02220121 FLUOXETINE PDL02237813 GEN-FLUOXETINE GEN02216582 NOVO-FLUOXETINE NOP02192756 NU-FLUOXETINE NXP02223481 PHL-FLUOXETINE PHH02177579 PMS-FLUOXETINE PMS02314991 PRO-FLUOXETINE PDL02018985 PROZAC LIL02241371 RATIO-FLUOXETINE RPH02242123 RIVA-FLUOXETINE RIV02243486 SANDOZ-FLUOXETINE SDZ02302659 ZYM-FLUOXETINE ZYM

20mg Capsule02216361 APO-FLUOXETINE APX02242178 CO-FLUOXETINE SCN02177625 DOM-FLUOXETINE DPC02220148 FLUOXETINE PDL02237814 GEN-FLUOXETINE GEN02216590 NOVO-FLUOXETINE NOP02192764 NU-FLUOXETINE NXP02223503 PHL-FLUOXETINE PHH02177587 PMS-FLUOXETINE PMS02315009 PRO-FLUOXETINE PDL00636622 PROZAC LIL02241374 RATIO-FLUOXETINE RPH02242124 RIVA-FLUOXETINE RIV02243487 SANDOZ-FLUOXETINE SDZ02302667 ZYM-FLUOXETINE ZYM

40mg Capsule02245283 FXT ORY

4mg/mL Liquid02231328 APO-FLUOXETINE APX02177595 PMS-FLUOXETINE PMS

FLUVOXAMINE MALEATE50mg Tablet

02231329 APO-FLUVOXAMINE APX02255529 CO FLUVOXAMINE COB02241347 DOM-FLUVOXAMINE DPC02236753 FLUVOXAMINE PDL01919342 LUVOX SPH02239953 NOVO-FLUVOXAMINE NOP02231192 NU-FLUVOXAMINE NXP02240682 PMS-FLUVOXAMINE PMS02218453 RATIO-FLUVOXAMINE RPH02303345 RIVA-FLUVOX RIV02247054 SANDOZ-FLUVOXAMINE SDZ

Page 56 of 1242010


28:16.04 ANTIDEPRESSANTSFLUVOXAMINE MALEATE

100mg Tablet02231330 APO-FLUVOXAMINE APX02255537 CO FLUVOXAMINE COB02241348 DOM-FLUVOXAMINE DPC02236754 FLUVOXAMINE PDL01919369 LUVOX SPH02239954 NOVO-FLUVOXAMINE NOP02231193 NU-FLUVOXAMINE NXP02240683 PMS-FLUVOXAMINE PMS02218461 RATIO-FLUVOXAMINE RPH02303361 RIVA-FLUVOX RIV02247055 SANDOZ-FLUVOXAMINE SDZ

IMIPRAMINE HCL10mg Tablet

00360201 APO-IMIPRAMINE APX00371017 IMIPRAMINE PRO00021504 NOVO-PRAMINE NOP

25mg Tablet00312797 APO-IMIPRAMINE APX00371025 IMIPRAMINE PRO

50mg Tablet00326852 APO-IMIPRAMINE APX00456357 IMIPRAMINE PDL00021520 NOVO-PRAMINE NOP

75mg Tablet00644579 APO-IMIPRAMINE APX

MAPROTILINE HCL25mg Tablet

02158612 NOVO-MAPROTILINE NOP50mg Tablet

02158620 NOVO-MAPROTILINE NOP75mg Tablet

02158639 NOVO-MAPROTILINE NOP

MIRTAZAPINE15mg Orally Disintegrating Tablet

02279894 NOVO-MIRTAZAPINE OD NOP02248542 REMERON RD ORG

30mg Orally Disintegrating Tablet02279908 NOVO-MIRTAZAPINE OD NOP02248543 REMERON RD ORG

45mg Orally Disintegrating Tablet02279916 NOVO-MIRTAZAPINE OD NOP02248544 REMERON RD ORG

15mg Tablet02286610 APO-MIRTAZAPINE APX02256096 GEN-MIRTAZAPINE GEN02281732 MIRTAZAPINE MEL02273942 PMS-MIRTAZAPINE PMS02312778 PRO-MIRTAZAPINE PDL02250594 RHOXAL-MIRTAZAPINE RHO

28:16.04 ANTIDEPRESSANTSMIRTAZAPINE

30mg Tablet02286629 APO-MIRTAZAPINE APX02274361 CO MIRTAZAPINE COB02252287 DOM-MIRTAZAPINE DPC02256118 GEN-MIRTAZAPINE GEN02259354 NOVO-MIRTAZAPINE NOP02252279 PHL-MIRTAZAPINE PHH02248762 PMS-MIRTAZAPINE PMS02312786 PRO-MIRTAZAPINE PDL02270927 RATIO-MIRTAZAPINE RPH02243910 REMERON ORG02265265 RIVA-MIRTAZAPINE RIV02250608 SANDOZ-MIRTAZAPINE SDZ02325179 ZYM-MIRTAZAPINE ZYM02325187 ZYM-MIRTAZAPINE ZYM

45mg Tablet02286637 APO-MIRTAZAPINE APX02256126 GEN-MIRTAZAPINE GEN

MOCLOBEMIDE100mg Tablet

02232148 APO-MOCLOBEMIDE APX02236928 MOCLOBEMIDE PDL02239746 NOVO-MOCLOBEMIDE NOP02237111 NU-MOCLOBEMIDE NXP

150mg Tablet02232150 APO-MOCLOBEMIDE APX00899356 MANERIX HLR02239747 NOVO-MOCLOBEMIDE NOP02237112 NU-MOCLOBEMIDE NXP02243218 PMS-MOCLOBEMIDE PMS

300mg Tablet02240456 APO-MOCLOBEMIDE APX02166747 MANERIX HLR02239748 NOVO-MOCLOBEMIDE NOP02243219 PMS-MOCLOBEMIDE PMS

NORTRIPTYLINE HCL10mg Capsule

02223511 APO-NORTRIPTYLINE APX00015229 AVENTYL PHH02178729 DOM-NORTRIPTYLINE DPC02231686 GEN-NORTRIPTYLINE GEN02231781 NOVO-NORTRIPTYLINE NOP02223139 NU-NORTRIPTYLINE NXP02177692 PMS-NORTRIPTYLINE PMS02240789 RATIO-NORTRIPTYLINE RPH

25mg Capsule02223538 APO-NORTRIPTYLINE APX00015237 AVENTYL PHH02178737 DOM-NORTRIPTYLINE DPC02231782 NOVO-NORTRIPTYLINE NOP02223147 NU-NORTRIPTYLINE NXP02177706 PMS-NORTRIPTYLINE PMS

Page 57 of 1242010


28:16.04 ANTIDEPRESSANTSPAROXETINE HCL

10mg Tablet02240907 APO-PAROXETINE APX02262746 CO PAROXETINE COB02248447 DOM-PAROXETINE DPC02248012 GEN-PAROXETINE GEN02248556 NOVO-PAROXETINE NOP02248719 NU-PAROXETINE NXP02248913 PAROXETINE PDL02027887 PAXIL GSK02248450 PHL-PAROXETINE PHH02247750 PMS-PAROXETINE PMS02247810 RATIO-PAROXETINE RPH02254743 RHOXAL-PAROXETINE RHO02248559 RIVA-PAROXETINE RIV02269422 SANDOZ-PAROXETINE SDZ02302012 ZYM-PAROXETINE ZYM

20mg Tablet02240908 APO-PAROXETINE APX02262754 CO PAROXETINE COB02248448 DOM-PAROXETINE DPC02248013 GEN-PAROXETINE GEN02248557 NOVO-PAROXETINE NOP02248720 NU-PAROXETINE NXP02248914 PAROXETINE PDL01940481 PAXIL GSK02248451 PHL-PAROXETINE PHH02247751 PMS-PAROXETINE PMS02247811 RATIO-PAROXETINE RPH02248560 RIVA-PAROXETINE RIV02254751 SANDOZ-PAROXETINE SDZ02269430 SANDOZ-PAROXETINE SDZ02302020 ZYM-PAROXETINE ZYM

30mg Tablet02240909 APO-PAROXETINE APX02262762 CO PAROXETINE COB02248449 DOM-PAROXETINE DPC02248014 GEN-PAROXETINE GEN02248558 NOVO-PAROXETINE NOP02248721 NU-PAROXETINE NXP02248915 PAROXETINE PDL01940473 PAXIL GSK02248452 PHL-PAROXETINE PHH02247752 PMS-PAROXETINE PMS02251361 PREM-PAROXETINE PRE02247812 RATIO-PAROXETINE RPH02248561 RIVA-PAROXETINE RIV02254778 SANDOZ-PAROXETINE SDZ02269449 SANDOZ-PAROXETINE SDZ02302039 ZYM-PAROXETINE ZYM

40mg Tablet02293749 PMS-PAROXETINE PMS

PHENELZINE SULFATE15mg Tablet

00476552 NARDIL PFI

28:16.04 ANTIDEPRESSANTSSERTRALINE

25mg Capsule02238280 APO-SERTRALINE APX02287390 CO SERTRALINE COB02245748 DOM-SERTRALINE DPC02242519 GEN-SERTRALINE GEN09857435 GEN-SERTRALINE (ONT) GEN02240485 NOVO-SERTRALINE NOP02247047 NU-SERTRALINE NXP02245824 PHL-SERTRALINE PHH02244838 PMS-SERTRALINE PMS02245787 RATIO-SERTRALINE RPH09857460 RHOXAL-SERTRALINE (ONT) RHO02248496 RIVA-SERTRALINE RIV02245159 SANDOZ-SERTRALINE SDZ02241302 SERTRALINE-25 PDL02132702 ZOLOFT PFI02303779 ZYM-SERTRALINE ZYM



TRANYLCYPROMINE SULFATE10mg Tablet

01919598 PARNATE GSK

Page 58 of 1242010


28:16.04 ANTIDEPRESSANTSTRAZODONE HCL

50mg Tablet02147637 APO-TRAZODONE APX00579351 DESYREL BMS02128950 DOM-TRAZODONE DPC02231683 GEN-TRAZODONE GEN02144263 NOVO-TRAZODONE NOP02165384 NU-TRAZODONE NXP02232543 PENTA-TRAZODONE PEN02236941 PHL-TRAZODONE PHH01937227 PMS-TRAZODONE PMS02053187 RATIO-TRAZODONE RPH02277344 RATIO-TRAZODONE RPH02164353 TRAZODONE PDL02230284 TRAZOREL VAE

75mg Tablet02237339 PMS-TRAZODONE PMS

100mg Tablet02147645 APO-TRAZODONE APX00579378 DESYREL BMS02128969 DOM-TRAZODONE DPC02231684 GEN-TRAZODONE GEN02144271 NOVO-TRAZODONE NOP02165392 NU-TRAZODONE NXP02232544 PENTA-TRAZODONE PEN02236942 PHL-TRAZODONE PHH01937235 PMS-TRAZODONE PMS02053195 RATIO-TRAZODONE RPH02277352 RATIO-TRAZODONE RPH02164361 TRAZODONE PDL02230285 TRAZOREL VAE

150mg Tablet02147653 APO-TRAZODONE D APX00702277 DESYREL DIVIDOSE BMS02231685 GEN-TRAZODONE GEN02144298 NOVO-TRAZODONE NOP02165406 NU-TRAZODONE D NXP02053209 RATIO-TRAZODONE RPH02277360 RATIO-TRAZODONE RPH02164388 TRAZODONE PDL

TRIMIPRAMINE MALEATE75mg Capsule

02070987 APO-TRIMIP APX02147599 TRIMIPRAMINE PDL

12.5mg Tablet00740799 APO-TRIMIPRAMINE APX02020599 NU-TRIMIPRAMINE NXP00761702 TRIMIPRAMINE PRO

25mg Tablet00740802 APO-TRIMIPRAMINE APX01940430 NOVO-TRIPRAMINE NOP02020602 NU-TRIMIPRAMINE NXP00761710 TRIMIPRAMINE PDL

28:16.04 ANTIDEPRESSANTSTRIMIPRAMINE MALEATE



VENLAFAXINE HCL37.5mg Sustained Release Capsule

02331683 APO-VENLAFAXINE XR APX02304317 CO VENLAFAXINE XR COB02237279 EFFEXOR XR WAY02310279 GEN-VENLAFAXINE XR GEN02275023 NOVO-VENLAFAXINE XR NOP02278545 PMS-VENLAFAXINE XR PMS02273969 RATIO-VENLAFAXINE XR RPH02307774 RIVA-VENLAFAXINE XR RIV02310317 SANDOZ VENLAFAXINE XR SDZ

75mg Sustained Release Capsule02331691 APO-VENLAFAXINE XR APX02304325 CO VENLAFAXINE XR COB02237280 EFFEXOR XR WAY02310287 GEN-VENLAFAXINE XR GEN02275031 NOVO-VENLAFAXINE XR NOP02278553 PMS-VENLAFAXINE XR PMS02273977 RATIO-VENLAFAXINE SR RPH02307782 RIVA-VENLAFAXINE XR RIV02310325 SANDOZ VENLAFAXINE XR SDZ

150mg Sustained Release Capsule02331705 APO-VENLAFAXINE XR APX02304333 CO VENLAFAXINE XR COB02237282 EFFEXOR XR WAY02310295 GEN-VENLAFAXINE XR GEN02275058 NOVO-VENLAFAXINE XR NOP02278561 PMS-VENLAFAXINE XR PMS02273985 RATIO-VENLAFAXINE XR RPH02307790 RIVA-VENLAFAXINE XR RIV02310333 SANDOZ VENLAFAXINE XR SDZ

28:16.08 ANTIPSYCHOTIC AGENTSCHLORPROMAZINE

25mg/mL Injection00743518 CHLORPROMAZINE HCL SDZ

25mg Tablet00232823 NOVO-CHLORPROMAZINE NOP



Page 59 of 1242010


28:16.08 ANTIPSYCHOTIC AGENTSCLOZAPINE

25mg Tablet02248034 APO-CLOZAPINE APX00894737 CLOZARIL NVR02247243 GEN-CLOZAPINE GEN

50mg Tablet02305003 GEN-CLOZAPINE GEN

100mg Tablet02248035 APO-CLOZAPINE APX00894745 CLOZARIL NVR02247244 GEN-CLOZAPINE GEN

200mg Tablet02305011 GEN-CLOZAPINE GEN

FLUPENTHIXOL DECANOATE20mg/mL Injection

02156032 FLUANXOL DEPOT LUD100mg/mL Injection

02156040 FLUANXOL DEPOT LUD

FLUPENTHIXOL DIHYDROCHLORIDE0.5mg Tablet

02156008 FLUANXOL LUD3mg Tablet

02156016 FLUANXOL LUD

FLUPHENAZINE DECANOATE25mg/mL Injection

02239636 FLUPHENAZINE OMEGA OMG02091275 PMS-FLUPHENAZINE PMS

100mg/mL Injection02242570 FLUPHENAZINE OMEGA OMG00755575 MODECATE BMS02241928 PMS-FLUPHENAZINE PMS

FLUPHENAZINE HCL0.5mg/mL Elixir

00893420 PMS-FLUPHENAZINE PMS1mg Tablet

00405345 APO-FLUPHENAZINE APX00563846 FLUPHENAZINE PDL

2mg Tablet00410632 APO-FLUPHENAZINE APX00563838 FLUPHENAZINE PDL

5mg Tablet00405361 APO-FLUPHENAZINE APX

HALOPERIDOL5mg/mL Injection

00808652 HALOPERIDOL SDZ2mg/mL Solution

00759503 PMS-HALOPERIDOL PMS0.5mg Tablet

00396796 APO-HALOPERIDOL APX00587796 HALOPERIDOL PDL00363685 NOVO-PERIDOL NOP

28:16.08 ANTIPSYCHOTIC AGENTSHALOPERIDOL

1mg Tablet00396818 APO-HALOPERIDOL APX00587788 HALOPERIDOL PDL00363677 NOVO-PERIDOL NOP




20mg Tablet00768820 NOVO-PERIDOL NOP

HALOPERIDOL DECANOATE50mg/mL Injection

02130297 HALOPERIDOL LA SDZ02230707 PMS-HALOPERIDOL LA PMS

100mg/mL Injection02130300 HALOPERIDOL LA SDZ02239640 HALOPERIDOL LA OMG02230708 PMS-HALOPERIDOL LA PMS

LOXAPINE HCL25mg/mL Oral Liquid

02239101 PMS-LOXAPINE PMS

LOXAPINE SUCCINATE2.5mg Tablet

02242868 PMS-LOXAPINE PMS5mg Tablet

02239918 DOM-LOXAPINE DPC02237534 NU-LOXAPINE NXP02238196 PDL-LOXAPINE PDL02236943 PHL-LOXAPINE PHH02230837 PMS-LOXAPINE PMS

10mg Tablet02239919 DOM-LOXAPINE DPC02237535 NU-LOXAPINE NXP02238197 PDL-LOXAPINE PDL02236944 PHL-LOXAPINE PHH02230838 PMS-LOXAPINE PMS

25mg Tablet02239920 DOM-LOXAPINE DPC02237536 NU-LOXAPINE NXP02236945 PDL-LOXAPINE PHH02238198 PDL-LOXAPINE PDL02230839 PMS-LOXAPINE PMS

Page 60 of 1242010


28:16.08 ANTIPSYCHOTIC AGENTSLOXAPINE SUCCINATE

50mg Tablet02239921 DOM-LOXAPINE DPC02237537 NU-LOXAPINE NXP02236946 PDL-LOXAPINE PHH02238199 PDL-LOXAPINE PDL02230840 PMS-LOXAPINE PMS

METHOTRIMEPRAZINE2mg Tablet

02238403 APO-METHOPRAZINE APX02239632 METHOTRIMEPRAZINE PDL

5mg Tablet02238404 APO-METHOPRAZINE APX02239633 METHOTRIMEPRAZINE PDL02232903 PMS-METHOTRIMEPRAZINE PMS

25mg Tablet02238405 APO-METHOPRAZINE APX02239634 METHOTRIMEPRAZINE PDL01964925 NOVO-MEPRAZINE NOP

50mg Tablet02238406 APO-METHOPRAZINE APX02239635 METHOTRIMEPRAZINE PDL

OLANZAPINE5mg Orally Disintegrating Tablet

02327562 CO OLANZAPINE ODT CBT02321343 NOVO-OLANZAPINE ODT NOP02303191 PMS-OLANZAPINE ODT PMS02327775 SANDOZ OLANZAPINE ODT SDZ02243086 ZYPREXA ZYDIS LIL

10mg Orally Disintegrating Tablet02327570 CO OLANZAPINE ODT CBT02321351 NOVO-OLANZAPINE ODT NOP02303205 PMS-OLANZAPINE ODT PMS02327783 SANDOZ OLANZAPINE ODT SDZ02243087 ZYPREXA ZYDIS LIL

15mg Orally Disintegrating Tablet02281848 APO-OLANZAPINE APX02327589 CO OLANZAPINE ODT CBT02321378 NOVO-OLANZAPINE ODT NOP02303213 PMS-OLANZAPINE ODT PMS02327791 SANDOZ OLANZAPINE ODT SDZ02243088 ZYPREXA ZYDIS LIL

2.5mg Tablet02281791 APO-OLANZAPINE APX02325659 CO OLANZAPINE CBT02276712 NOVO-OLANZAPINE NOP02303116 PMS-OLANZAPINE PMS02229250 ZYPREXA LIL

5mg Tablet02281805 APO-OLANZAPINE APX02325667 CO OLANZAPINE CBT02276720 NOVO-OLANZAPINE NOP02303159 PMS-OLANZAPINE PMS02229269 ZYPREXA LIL

28:16.08 ANTIPSYCHOTIC AGENTSOLANZAPINE

7.5mg Tablet02281813 APO-OLANZAPINE APX02325675 CO OLANZAPINE CBT02276739 NOVO-OLANZAPINE NOP02303167 PMS-OLANZAPINE PMS02229277 ZYPREXA LIL

10mg Tablet02281821 APO-OLANZAPINE APX02325683 CO OLANZAPINE CBT02276747 NOVO-OLANZAPINE NOP02303175 PMS-OLANZAPINE PMS02229285 ZYPREXA LIL

15mg Tablet02325691 CO OLANZAPINE CBT02276755 NOVO-OLANZAPINE NOP02303183 PMS-OLANZAPINE PMS02238850 ZYPREXA LIL

20mg Tablet02325713 CO OLANZAPINE CBT

PERICYAZINE5mg Capsule

01926780 NEULEPTIL ERF10mg Capsule

01926772 NEULEPTIL ERF20mg Capsule

01926764 NEULEPTIL ERF10mg/mL Drop

01926756 NEULEPTIL ERF

PERPHENAZINE3.2mg/mL Liquid

00751898 PMS-PERPHENAZINE PMS2mg Tablet

00335134 APO-PERPHENAZINE APX00563757 PERPHENAZINE PDL

4mg Tablet00335126 APO-PERPHENAZINE APX00563749 PERPHENAZINE PDL



PIMOZIDE2mg Tablet

02245432 APO-PIMOZIDE APX00313815 ORAP PHH

4mg Tablet02245433 APO-PIMOZIDE APX00313823 ORAP PHH

Page 61 of 1242010


28:16.08 ANTIPSYCHOTIC AGENTSPIPOTIAZINE PALMITATE

25mg/mL Injection01926667 PIPORTIL L4 SAC

50mg/mL Injection00894672 PIPORTIL L4 RHO

PROCHLORPERAZINE5mg/mL Injection

00789747 PROCHLORPERAZINE SDZ10mg Suppository

00753688 PMS-PROCHLORPERAZINE PMS00789720 PROCHLORPERAZINE SDZ

5mg Tablet00886440 APO-PROCHLORAZINE APX01964399 NU-PROCHLOR NXP00753661 PMS-PROCHLORPERAZINE PMS

10mg Tablet00886432 APO-PROCHLORAZINE APX01964402 NU-PROCHLOR NXP00753637 PMS-PROCHLORPERAZINE PMS

QUETIAPINE FUMARATE25mg Tablet

02313901 APO-QUETIAPINE APX02316080 CO QUETIAPINE COB02307804 GEN-QUETIAPINE GEN02330415 JAMP-QUETIAPINE JMP02284235 NOVO-QUETIAPINE NOP02299054 PHL-QUETIAPINE PMI02296551 PMS-QUETIAPINE PMS02317346 PRO-QUETIAPINE PDL02311704 RATIO-QUETIAPINE RPH02316692 RIVA-QUETIAPINE RIV02313995 SANDOZ-QUETIAPINE SDZ02236951 SEROQUEL AZC02317893 ZYM-QUETIAPINE ZYM

100mg Tablet02313928 APO-QUETIAPINE APX02316099 CO QUETIAPINE COB02307812 GEN-QUETIAPINE GEN02330423 JAMP-QUETIAPINE JMP02284243 NOVO-QUETIAPINE NOP02299062 PHL-QUETIAPINE PMI02296578 PMS-QUETIAPINE PMS02317354 PRO-QUETIAPINE PDL02311712 RATIO-QUETIAPINE RPH02316706 RIVA-QUETIAPINE RIV02314002 SANDOZ-QUETIAPINE SDZ02236952 SEROQUEL AZC02317907 ZYM-QUETIAPINE ZYM

150mg Tablet02284251 NOVO-QUETIAPINE NOP

28:16.08 ANTIPSYCHOTIC AGENTSQUETIAPINE FUMARATE



RISPERIDONE0.5mg Orally Disintegrating Tablet

02247704 RISPERDAL-M JNO1mg Orally Disintegrating Tablet




02268094 RISPERDAL-M JNO1mg/mL Solution

02280396 APO-RISPERIDONE APX02279266 PMS-RISPERIDONE PMS02236950 RISPERDAL JNO

Page 62 of 1242010


28:16.08 ANTIPSYCHOTIC AGENTSRISPERIDONE

0.25mg Tablet02282119 APO-RISPERIDONE APX02282585 CO RISPERIDONE COB02282240 GEN-RISPERIDONE GEN02282690 NOVO-RISPERIDONE NOP02258439 PHL-RISPERIDONE PMI02252007 PMS-RISPERIDONE PMS02312700 PRO-RISPERIDONE PDL02280906 RAN-RISPERIDONE RBY02264757 RATIO-RISPERIDONE RPH02328305 RBX-RISPERIDONE RBY02240551 RISPERDAL JNO02283565 RIVA-RISPERIDONE RIV02303655 SANDOZ RISPERIDONE SDZ02279509 SANDOZ-RISPERIDONE SDZ02303485 ZYM-RISPERIDONE ZYM

0.5mg Tablet02282127 APO-RISPERIDONE APX02282593 CO RISPERIDONE COB02282259 GEN-RISPERIDONE GEN02264188 NOVO-RISPERIDONE NOP02258447 PHL-RISPERIDONE PMI02252015 PMS-RISPERIDONE PMS02312719 PRO-RISPERIDONE PDL02280914 RAN-RISPERIDONE RBY02264765 RATIO-RISPERIDONE RPH02328313 RBX-RISPERIDONE RBY02240552 RISPERDAL JNO02283573 RIVA-RISPERIDONE RIV02303663 SANDOZ RISPERIDONE SDZ02303493 ZYM-RISPERIDONE ZYM

1mg Tablet02282135 APO-RISPERIDONE APX02282607 CO RISPERIDONE COB02282267 GEN-RISPERIDONE GEN02264196 NOVO-RISPERIDONE NOP02258455 PHL-RISPERIDONE PMI02252023 PMS-RISPERIDONE PMS02312727 PRO-RISPERIDONE PDL02280922 RAN-RISPERIDONE RBY02264773 RATIO-RISPERIDONE RPH02328321 RBX-RISPERIDONE RBY02025280 RISPERDAL JNO02283581 RIVA-RISPERIDONE RIV02279800 SANDOZ-RISPERIDONE SDZ02303507 ZYM-RISPERIDONE ZYM

28:16.08 ANTIPSYCHOTIC AGENTSRISPERIDONE




THIOPROPERAZINE MESYLATE10mg Tablet

01927639 MAJEPTIL ERF

THIOTHIXENE2mg Capsule

00024430 NAVANE ERF5mg Capsule

00024449 NAVANE ERF

Page 63 of 1242010


28:16.08 ANTIPSYCHOTIC AGENTSTHIOTHIXENE

10mg Capsule00024457 NAVANE ERF

TRIFLUOPERAZINE HCL10mg/mL Liquid

00751871 PMS-TRIFLUOPERAZINE PMS1mg Tablet

00345539 APO-TRIFLUOPERAZINE APX00386529 TRIFLUOPERAZINE PRO

2mg Tablet00312754 APO-TRIFLUOPERAZINE APX00386510 TRIFLUOPERAZINE PRO

5mg Tablet00312746 APO-TRIFLUOPERAZINE APX00386502 TRIFLUOPERAZINE PRO

10mg Tablet00326836 APO-TRIFLUOPERAZINE APX00389943 TRIFLUOPERAZINE PDL

20mg Tablet00595942 APO-TRIFLUOPERAZINE APX

ZIPRASIDONE HCL MONOHYDRATELimited use benefit (prior approval required).

For the treatment of schizophrenia and schizoaffective disorders in patients who have:a.- intolerance or lack of response to an adequate trial of another antipsychotic agent orb.- a contraindication to another antipsychotic agent

20MG Capsule02298597 ZELDOX PFI

40MG Capsule02298600 ZELDOX PFI

60mg Capsule02298619 ZELDOX PFI

80mg Capsule02298627 ZELDOX PFI

28:20.04 AMPHETAMINESDEXTROAMPHETAMINE SULFATE

10mg Sustained Release Capsule01924559 DEXEDRINE SPANSULE GSK

15mg Sustained Release Capsule01924567 DEXEDRINE SPANSULE GSK

5mg Tablet01924516 DEXEDRINE GSK

28:20.92 MISC ANOREXIGENIC AGENTS & RESPIRATORY & CEREBRAL STIMULANT

METHYLPHENIDATE HCL20mg Extended Release Tablet

02266687 APO-METHYLPHENIDATE APX

28:20.92 MISC ANOREXIGENIC AGENTS & RESPIRATORY & CEREBRAL STIMULANT

METHYLPHENIDATE HCL20mg Sustained Release Tablet

00632775 RITALIN SR NVR02320312 SANDOZ-METHYLPHENIDATE

SRSDZ

5mg Tablet02273950 APO-METHYLPHENIDATE APX02234749 PMS-METHYLPHENIDATE PMS

10mg Tablet02249324 APO-METHYLPHENIDATE APX00584991 PMS-METHYLPHENIDATE PMS00005606 RITALIN NVR

20mg Tablet02249332 APO-METHYLPHENIDATE APX00585009 PMS-METHYLPHENIDATE PMS00005614 RITALIN NVR

MODAFINIL100mg Tablet

02239665 ALERTEC DPY02285398 APO-MODAFINIL APX

28:24.08 ANXIOLYTICS, SEDATIVES AND HYPNOTICS - BENZODIAZEPINES

ALPRAZOLAM0.25mg Tablet

01908189 ALPRAZOLAM PDL00865397 APO-ALPRAZ APX02137534 GEN-ALPRAZOLAM GEN02237264 MED-ALPRAZOLAM MEC01913484 NOVO-ALPRAZOL NOP01913239 NU-ALPRAZ NXP00548359 XANAX PFI

0.5mg Tablet01908170 ALPRAZOLAM PDL00865400 APO-ALPRAZ APX02137542 GEN-ALPRAZOLAM GEN02237265 MED-ALPRAZOLAM MEC01913492 NOVO-ALPRAZOL NOP01913247 NU-ALPRAZ NXP00548367 XANAX PFI

1mg Tablet02248706 ALPRAZOLAM PDL02243611 APO-ALPRAZ APX02229813 GEN-ALPRAZOLAM GEN00723770 XANAX PFI

2mg Tablet02243612 APO-ALPRAZ APX02229814 GEN-ALPRAZOLAM GEN00813958 XANAX TS PFI

Page 64 of 1242010



BROMAZEPAM1.5mg Tablet

02177153 APO-BROMAZEPAM APX02220512 BROMAZEPAM PDL02192705 GEN-BROMAZEPAM GEN02230666 MED-BROMAZEPAM MEC02171856 NU-BROMAZEPAM NXP

3mg Tablet02177161 APO-BROMAZEPAM APX02220520 BROMAZEPAM PDL02192713 GEN-BROMAZEPAM GEN00518123 LECTOPAM HLR02230667 MED-BROMAZEPAM MEC02230584 NOVO-BROMAZEPAM NOP02171864 NU-BROMAZEPAM NXP

6mg Tablet02177188 APO-BROMAZEPAM APX02220539 BROMAZEPAM PDL02192721 GEN-BROMAZEPAM GEN00518131 LECTOPAM HLR02230668 MED-BROMAZEPAM MEC02230585 NOVO-BROMAZEPAM NOP02171872 NU-BROMAZEPAM NXP

CLOBAZAM10mg Tablet

02244638 APO-CLOBAZAM APX02248454 CLOBAZAM PDL02247230 DOM-CLOBAZAM DPC02221799 FRISIUM PED02238334 NOVO-CLOBAZAM NOP02244474 PMS-CLOBAZAM PMS02238797 RATIO-CLOBAZAM RPH

DIAZEPAM1mg/mL Oral Solution

00891797 PMS-DIAZEPAM PMS2mg Tablet

00405329 APO-DIAZEPAM APX00434396 DIAZEPAM PDL02247490 PMS-DIAZEPAM PMS

5mg Tablet00362158 APO-DIAZEPAM APX00313580 DIAZEPAM PRO02247491 PMS-DIAZEPAM PMS00013285 VALIUM HLR

10mg Tablet00405337 APO-DIAZEPAM APX00434388 DIAZEPAM PDL02247492 PMS-DIAZEPAM PMS00013773 VIVOL AXX


LORAZEPAM0.5mg Tablet

00655740 APO-LORAZEPAM APX02041413 ATIVAN WAY02041456 ATIVAN SUBLINGUAL WAY02245784 DOM-LORAZEPAM DPC00711101 NOVO-LORAZEM NOP00865672 NU-LORAZ NXP00655643 PRO-LORAZEPAM PDL

1mg Tablet00655759 APO-LORAZEPAM APX02041421 ATIVAN WAY02041464 ATIVAN SUBLINGUAL WAY02245785 DOM-LORAZEPAM DPC00637742 NOVO-LORAZEM NOP00865680 NU-LORAZ NXP00655651 PRO-LORAZEPAM PDL

2mg Tablet00655767 APO-LORAZEPAM APX02041448 ATIVAN WAY02041472 ATIVAN SUBLINGUAL WAY02245786 DOM-LORAZEPAM DPC00637750 NOVO-LORAZEM NOP00865699 NU-LORAZ NXP00655678 PRO-LORAZEPAM PDL

NITRAZEPAM5mg Tablet

02245230 APO-NITRAZEPAM APX00511528 MOGADON ICN02229654 NITRAZADON VAE02234003 SANDOZ-NITRAZEPAM SDZ

10mg Tablet02245231 APO-NITRAZEPAM APX00511536 MOGADON ICN02229655 NITRAZADON VAE02234007 SANDOZ-NITRAZEPAM SDZ

OXAZEPAM10mg Tablet

00402680 APO-OXAZEPAM APX00497754 OXAZEPAM PDL00568392 ZAPEX RIV

15mg Tablet00402745 APO-OXAZEPAM APX00497762 OXAZEPAM PDL00568406 ZAPEX RIV

30mg Tablet00402737 APO-OXAZEPAM APX00497770 OXAZEPAM PDL00568414 ZAPEX RIV

Page 65 of 1242010



TEMAZEPAM15mg Capsule

02225964 APO-TEMAZEPAM APX02244814 CO TEMAZEPAM COB02229756 DOM-TEMAZEPAM DPC02231615 GEN-TEMAZEPAM GEN02237294 MED-TEMAZEPAM MEC02230095 NOVO-TEMAZEPAM NOP02223570 NU-TEMAZEPAM NXP02239071 PENTA-TEMAZEPAM PEN02229455 PMS-TEMAZEPAM PMS02243023 RATIO-TEMAZEPAM RPH00604453 RESTORIL ORY02229760 TEMAZEPAM PDL

30mg Capsule02225972 APO-TEMAZEPAM APX02244815 CO TEMAZEPAM COB02229758 DOM-TEMAZEPAM DPC02231616 GEN-TEMAZEPAM GEN02237295 MED-TEMAZEPAM MEC02230102 NOVO-TEMAZEPAM NOP02223589 NU-TEMAZEPAM NXP02239072 PENTA-TEMAZEPAM PEN02229456 PMS-TEMAZEPAM PMS02273047 PMS-TEMAZEPAM PMS02243024 RATIO-TEMAZEPAM RPH00604461 RESTORIL ORY02229761 TEMAZEPAM PDL

TRIAZOLAM0.125mg Tablet

00808563 APO-TRIAZO APX01995227 GEN-TRIAZOLAM GEN00886084 NU-TRIAZO NXP

0.25mg Tablet00808571 APO-TRIAZO APX01913506 GEN-TRIAZOLAM GEN00886092 NU-TRIAZO NXP00860824 TRIAZOLAM PDL

28:24.92 MISCELLANEOUS ANXIOLYTICS, SEDATIVES, AND HYPNOTICS

HYDROXYZINE HCL10mg Capsule

00739618 HYDROXYZINE PDL00738824 NOVO-HYDROXYZIN NOP02241192 RIVA-HYDROXYZIN RIV

25mg Capsule00739626 HYDROXYZINE PDL00738832 NOVO-HYDROXYZIN NOP02241193 RIVA-HYDROXYZIN RIV

50mg Capsule00739634 HYDROXYZINE PDL00738840 NOVO-HYDROXYZIN NOP02241194 RIVA-HYDROXYZIN RIV

28:24.92 MISCELLANEOUS ANXIOLYTICS, SEDATIVES, AND HYPNOTICS

HYDROXYZINE HCL2mg/mL Syrup

00024694 ATARAX ERF00741817 PMS-HYDROXYZINE PMS

10mg Tablet00646059 APO-HYDROXYZINE APX



28:28.00 ANTIMANIC AGENTSLITHIUM CARBONATE

150mg Capsule02242837 APO-LITHIUM CARB APX09857532 APO-LITHIUM CARBONATE APX02013231 LITHANE ERF02216132 PMS-LITHIUM CARBONATE PMS

300mg Capsule02242838 APO-LITHIUM CARB APX09857540 APO-LITHIUM CARBONATE APX00236683 CARBOLITH VAE00406775 LITHANE ERF02216140 PMS-LITHIUM CARBONATE PMS

600mg Capsule02011239 CARBOLITH VAE02216159 PMS-LITHIUM CARBONATE PMS

LITHIUM CITRATE60mg/mL Syrup

02074834 PMS-LITHIUM CITRATE PMS

28:32.28 SELECTIVE SEROTONIN AGONISTS

ALMOTRIPTAN MALATE6.25mg Tablet

02248128 AXERT MCL12.5mg Tablet

02248129 AXERT MCL

NARATRIPTAN HCL1mg Tablet

02237820 AMERGE GSK02314290 NOVO-NARATRIPTAN NOP

2.5mg Tablet02237821 AMERGE GSK02314304 NOVO-NARATRIPTAN NOP02322323 SANDOZ NARATRIPTAN SDZ

RIZATRIPTAN5mg Tablet

02240520 MAXALT FRS10mg Tablet

02240521 MAXALT FRS

Page 66 of 1242010


28:32.28 SELECTIVE SEROTONIN AGONISTS

RIZATRIPTAN5mg Wafer

02240518 MAXALT RPD FRS10mg Wafer

02240519 MAXALT RPD FRS

SUMATRIPTAN HEMISULFATE5mg Nasal Spray

02230418 IMITREX GSK20mg Nasal Spray

02230420 IMITREX GSK

SUMATRIPTAN SUCCINATE12mg/mL Injection

02212188 IMITREX GSK99000598 IMITREX GSK

25mg Tablet02257882 CO SUMATRIPTAN COB02270749 DOM-SUMATRIPTAN DPC02268906 GEN-SUMATRIPTAN GEN02286815 NOVO-SUMATRIPTAN DF NOP02256428 PMS-SUMATRIPTAN PMS

50mg Tablet02268388 APO-SUMATRIPTAN APX02257890 CO SUMATRIPTAN COB02270757 DOM-SUMATRIPTAN DPC02268914 GEN-SUMATRIPTAN GEN02212153 IMITREX DF GSK02286823 NOVO-SUMATRIPTAN DF NOP02256436 PMS-SUMATRIPTAN PMS02271583 RATIO-SUMATRIPTAN RPH02263025 SANDOZ-SUMATRIPTAN SDZ

100mg Tablet02268396 APO-SUMATRIPTAN APX02257904 CO SUMATRIPTAN COB02270765 DOM-SUMATRIPTAN DPC02268922 GEN-SUMATRIPTAN GEN02212161 IMITREX DF GSK02239367 NOVO-SUMATRIPTAN NOP02286831 NOVO-SUMATRIPTAN DF NOP02256444 PMS-SUMATRIPTAN PMS02271591 RATIO-SUMATRIPTAN RPH02263033 SANDOZ-SUMATRIPTAN SDZ

ZOLMITRIPTAN2.5mg Tablet

02238660 ZOMIG AZC02243045 ZOMIG RAPIMELT AZC

28:32.92 MISCELLANEOUS ANTIMIGRANE AGENTS

PIZOTYLINE HYDROGEN MALATE0.5mg Tablet

00329320 SANDOMIGRAN PED

28:32.92 MISCELLANEOUS ANTIMIGRANE AGENTS

PIZOTYLINE HYDROGEN MALATE1mg Tablet

00511552 SANDOMIGRAN DS PED

28:36.08 ANTIPARKINSONIAN AGENTS - ANTICHOLINERGIC AGENTS

BENZTROPINE MESYLATE1mg/mL Injection

02238903 BENZTROPINE OMEGA OMG1mg Tablet

00706531 PMS-BENZTROPINE PMS2mg Tablet

00426857 APO-BENZTROPINE APX00563862 BENZTROPINE PDL00587265 PMS-BENZTROPINE PMS

ETHOPROPAZINE HCL50mg Tablet

01927744 PARSITAN ERF

PROCYCLIDINE HCL0.5mg/mL Elixir

00587362 PMS-PROCYCLIDINE PMS2.5mg Tablet

00649392 PMS-PROCYCLIDINE PMS5mg Tablet

00587354 PMS-PROCYCLIDINE PMS

TRIHEXYPHENIDYL HCL0.4mg/mL Liquid

00885398 PMS-TRIHEXYPHENIDYL PMS2mg Tablet

00545058 APO-TRIHEX APX00572802 TRIHEXYPHEN PRO

5mg Tablet00545074 APO-TRIHEX APX00572799 TRIHEXYPHEN PDL

28:36.12 ANTIPARKINSONIAN AGENTS - CATECHOL-O-METHYLTRANSFERASE (COMT) INHIBITORS

ENTACAPONE200mg TabletST

02243763 COMTAN NVR

28:36.16 ANTIPARKINSONIAN AGENTS - DOPAMINE PRECURSORS

LEVODOPA, BENZERAZIDE50mg & 12.5mg CapsuleST

00522597 PROLOPA HLR100mg & 25mg CapsuleST

00386464 PROLOPA HLR

Page 67 of 1242010


28:36.16 ANTIPARKINSONIAN AGENTS - DOPAMINE PRECURSORS

LEVODOPA, BENZERAZIDE200mg & 50mg CapsuleST

00386472 PROLOPA HLR

LEVODOPA, CARBIDOPA100mg & 25mg Controlled Release TabletST

02272873 APO-LEVOCARB CR APX02028786 SINEMET CR BMS

200mg & 50mg Controlled Release TabletST

00870935 SINEMET CR BMS100mg & 10mg TabletST

02195933 APO-LEVOCARB APX02244494 NOVO-LEVOCARBIDOPA NOP02182831 NU-LEVOCARB NXP00355658 SINEMET BMS


02195941 APO-LEVOCARB APX02244495 NOVO-LEVOCARBIDOPA NOP02182823 NU-LEVOCARB NXP02311178 PRO-LEVOCARB PDL00513997 SINEMET BMS


02195968 APO-LEVOCARB APX02244496 NOVO-LEVOCARBIDOPA NOP02182858 NU-LEVOCARB NXP00328219 SINEMET BMS

LEVODOPA, CARBIDOPA,ENTACAPONE50mg & 12.5mg & 200mg TabletST

02305933 STALEVO NOV75mg & 18.75mg & 200mg TabletST

02337827 STALEVO NOV100mg & 25mg & 200mg TabletST



02305968 STALEVO NOV

28:36.20 ANTIPARKINSONIAN AGENTS - DOPAMINE RECEPTOR AGONISTS

BROMOCRIPTINE MESYLATE5mg Capsule

02230454 APO-BROMOCRIPTINE APX02230719 BROMOCRIPTINE PRO02238637 DOM-BROMOCRIPTINE DPC02236949 PMS-BROMOCRIPTINE PMS

2.5mg Tablet02087324 APO-BROMOCRIPTINE APX02153378 BROMOCRIPTINE PRO02238636 DOM-BROMOCRIPTINE DPC02231702 PMS-BROMOCRIPTINE PMS


PRAMIPEXOLE DIHYDROCHLORIDE0.25mg TabletST

02292378 APO-PRAMIPEXOLE APX02297302 CO PRAMIPEXOLE CBT02237145 MIRAPEX BOE09857268 MIRAPEX (ONT) BOE02269309 NOVO-PRAMIPEXOLE NOP02290111 PMS-PRAMIPREXOLE PMS02315262 SANDOZ-PRAMIPEXOLE SDZ

0.5mg TabletST

02292386 APO-PRAMIPEXOLE APX02297310 CO PRAMIPEXOLE CBT02241594 MIRAPEX BOE02269317 NOVO-PRAMIPEXOLE NOP02290138 PMS-PRAMIPREXOLE PMS02315270 SANDOZ-PRAMIPEXOLE SDZ

1mg TabletST


1.5mg TabletST


ROPINIROLE HCL0.25mg TabletST

02337746 APO-ROPINIROLE APX02316846 CO-ROPINIROLE CBT02326590 PMS-ROPINIROLE PMS02314037 RAN-ROPINIROLE RBY02232565 REQUIP GSK

1mg TabletST


2mg TabletST


Page 68 of 1242010



ROPINIROLE HCL5mg TabletST


28:36.32 ANTIPARKINSONIAN AGENTS - MONOAMINE OXIDASE B INHIBITORS

SELEGILINE HCL5mg TabletST

02230641 APO-SELEGILINE APX02238340 DOM-SELEGILINE DPC02231036 GEN-SELEGILINE GEN02237289 MED-SELEGILINE MEC02068087 NOVO-SELEGILINE NOP02230717 NU-SELEGILINE NXP02238102 PMS-SELEGILINE PMS02231479 SELEGILINE PDL

28:92.00 MISCELLANEOUS CENTRAL NERVOUS SYSTEM AGENTS

ACAMPROSATE CALCIUMLimited use benefit (prior approval required).

For patients who have been abstinent from alcohol for at least four days and where available, are currently enrolled in an alcohol addiction treatment program

333mg Sustained Release Tablet02293269 CAMPRAL MYL

Page 69 of 1242010


32:00 CONTRACEPTIVES (NON-ORAL)32:00.00 CONTRACEPTIVES (NON-ORAL)

CONDOM, FEMALEDevice

99400484 REALITY FEMALE CONDOM PMS

CONDOM, MALEDevice

99400527 CONDOM, LATEX, LUBRICATED

99400485 CONDOM, LATEX, LUBRICATED, NONOXYNOL

99400486 CONDOM, LATEX, NON-LUBRICATED

99400786 CONDOM, NON-LATEX, LUBRICATED

DIAPHRAGMDevice

09991126 OMNIFLEX DIAPHRAGM 75 CSU

INTRAUTERINE DEVICEDevice

98099999 FLEXI-T IUD PRN99400482 NOVA-T IUD BEX

Page 70 of 1242010


36:00 DIAGNOSTIC AGENTS (DX)36:00.00 DIAGNOSTIC AGENTS (DX)

THYROTROPIN ALFA0.9mg/mL Powder for Solution

02246016 THYROGEN GEE

36:26.00 DX - DIABETES MELLITUSGLUCOSE OXIDASE, PEROXIDASE

Glucose Control Solution00909556 ADVANTAGE ROD00977943 ASCENSIA AUTODISC BAY00977307 ASCENSIA ELITE BAY00920143 FASTTAKE JAJ99463968 GLUCOFILM BAY00906867 MEDISENSE AUC00977845 ONE TOUCH JAJ99480004 ONE TOUCH JAJ99925768 ONE TOUCH JAJ

Accu-Chek Advantage Strip00905348 ACCU-CHEK ADVANTAGE ROD00921076 ACCU-CHEK ADVANTAGE ROD00950883 ACCU-CHEK ADVANTAGE ROD09854002 ACCU-CHEK ADVANTAGE ROD44123021 ACCU-CHEK ADVANTAGE ROD97799960 ACCU-CHEK ADVANTAGE ROD99002884 ACCU-CHEK ADVANTAGE ROD

Accu-Chek Aviva Strip97799814 ACCU-CHEK AVIVA (100) ROD97799815 ACCU-CHEK AVIVA (50) ROD

Accu-Chek Compact Strip00901370 ACCU-CHEK COMPACT ROD00950900 ACCU-CHEK COMPACT ROD00965960 ACCU-CHEK COMPACT ROD00965979 ACCU-CHEK COMPACT ROD09854282 ACCU-CHEK COMPACT ROD44123026 ACCU-CHEK COMPACT ROD97799962 ACCU-CHEK COMPACT ROD99004364 ACCU-CHEK COMPACT ROD

Accutrend Strip00906697 ACCUTREND ROD00977031 ACCUTREND ROD09853162 ACCUTREND ROD44123006 ACCUTREND ROD

Advantage Strip00908290 ADVANTAGE ROD00924061 ADVANTAGE ROD00950661 ADVANTAGE ROD44123008 ADVANTAGE ROD

Ascensia Autodisc Strip00904945 ASCENSIA AUTODISC BAY00950878 ASCENSIA AUTODISC BAY09853693 ASCENSIA AUTODISC BAY44123019 ASCENSIA AUTODISC BAY97799926 ASCENSIA AUTODISC BAY99002604 ASCENSIA AUTODISC BAY


Ascensia Breeze 2 Strip00964816 ASCENSIA BREEZE 2 BAY00977119 ASCENSIA BREEZE 2 BAY09991084 ASCENSIA BREEZE 2 BAY44123038 ASCENSIA BREEZE 2 BAY99100388 ASCENSIA BREEZE 2 BAY

Ascensia Contour Strip00950924 ASCENSIA CONTOUR BAY00964476 ASCENSIA CONTOUR BAY09857127 ASCENSIA CONTOUR BAY44123037 ASCENSIA CONTOUR BAY97799702 ASCENSIA CONTOUR BAY97799877 ASCENSIA CONTOUR (100) BAY97799878 ASCENSIA CONTOUR (50) BAY

Ascensia Elite Strip00920363 ASCENSIA ELITE BAY00950572 ASCENSIA ELITE BAY00980100 ASCENSIA ELITE BAY09854088 ASCENSIA ELITE BAY44123002 ASCENSIA ELITE BAY97799923 ASCENSIA ELITE BAY

BD Test Strip00900142 BD TEST BTD00950911 BD TEST BTD09857132 BD TEST BTD44123030 BD TEST BTD99100002 BD TEST BTD99401067 BD TEST BTD

Chemstrip-BG for Accu-Chek Strip09853189 CHEMSTRIP BG ROD00990027 CHEMSTRIP-BG ROD44123009 CHEMSTRIP-BG ROD97799958 CHEMSTRIP-BG ROD

Encore Strip00920371 ENCORE BAY00980200 ENCORE BAY09853103 ENCORE BAY44123003 ENCORE BAY97799922 ENCORE BAY

EZ Health Strip97799564 EZ HEALTH ORACLE (100) TRE97799565 EZ HEALTH ORACLE (50) TRE

FastTake Strip00903531 FASTTAKE JAJ00950882 FASTTAKE JAJ00967084 FASTTAKE JAJ00967092 FASTTAKE JAJ00967106 FASTTAKE JAJ09854029 FASTTAKE JAJ44123017 FASTTAKE JAJ97799982 FASTTAKE JAJ99002809 FASTTAKE JAJ

Page 71 of 1242010



Freestyle Strip00901388 FREESTYLE ABB00905500 FREESTYLE ABB00950907 FREESTYLE ABB09857141 FREESTYLE ABB44123028 FREESTYLE ABB97799829 FREESTYLE ABB99004704 FREESTYLE ABB99401062 FREESTYLE ABB97799596 FREESTYLE LITE ABB97799597 FREESTYLE LITE ABB

Itest Strip97799770 ITEST AUC

Life Brand Strip97799593 LIFE BRAND HOD97799594 LIFE BRAND HOD

Novamax Strip97799583 NOVAMAX NCA97799584 NOVAMAX NCA

One Touch Strip00905399 ONE TOUCH JAJ00950459 ONE TOUCH JAJ09853243 ONE TOUCH JAJ44123011 ONE TOUCH JAJ97799976 ONE TOUCH JAJ

One Touch Ultra Strip00907000 ONE TOUCH ULTRA JAJ00950893 ONE TOUCH ULTRA JAJ09854290 ONE TOUCH ULTRA JAJ44123025 ONE TOUCH ULTRA JAJ97799985 ONE TOUCH ULTRA JAJ99004240 ONE TOUCH ULTRA JAJ99401057 ONE TOUCH ULTRA JAJ

Precision Plus Strip00906298 PRECISION PLUS

ELECTRODESAUC

00977057 PRECISION PLUS ELECTRODES

AUC


AUC


AUC

Precision Xtra Strip00908437 PRECISION XTRA AUC00909300 PRECISION XTRA AUC00950894 PRECISION XTRA AUC00986763 PRECISION XTRA AUC09854070 PRECISION XTRA AUC97799840 PRECISION XTRA AUC99004119 PRECISION XTRA AUC

Prestige Smart System Strip99401066 PRESTIGE SMART SYSTEM THR


Sidekick Strip00950948 SIDEKICK HOD44123035 SIDEKICK AUC97799601 SIDEKICK HOD99100412 SIDEKICK HOD

Surestep Strip00999482 SURESTEP JAJ09853634 SURESTEP JAJ44123012 SURESTEP JAJ97799979 SURESTEP JAJ99000318 SURESTEP JAJ

Truetrack Strip00950957 TRUETRACK HOD97799602 TRUETRACK HOD97799603 TRUETRACK HOD99100413 TRUETRACK HOD

36:88.00 DX - URINE AND FECES CONTENTS

CUPRIC SULFATETablet

00035122 CLINITEST BAY00977314 CLINITEST BAY00980420 CLINITEST BAY99067017 CLINITEST BAY

GLUCOSE OXIDASE, PEROXIDASEStrip

00035130 DIASTIX BAY00977160 DIASTIX BAY00980641 DIASTIX BAY99159954 DIASTIX BAY

SODIUM NITROPRUSSIDEStrip

00035092 KETOSTIX BAY00977322 KETOSTIX BAY00980595 KETOSTIX BAY09853286 KETOSTIX BAY99067074 KETOSTIX BAY

Tablet00035106 ACETEST BAY00977292 ACETEST BAY00980560 ACETEST BAY09853294 ACETEST BAY

Page 72 of 1242010


40:00 ELECTROLYTIC, CALORIC, AND WATER BALANCE

40:08.00 ALKALINIZING AGENTSCITRIC ACID, SODIUM CITRATE

66.8mg & 100mg/mL Solution00721344 DICITRATE PMS

SODIUM BICARBONATE300mg Tablet

00481912 SODIUM BICARBONATE XEN

40:12.00 REPLACEMENT PREPARATIONSCALCIUM CARBONATE

500mg TabletST

00682039 APO-CAL 500 APX00674346 CAL-500 PDL00621722 CALCIUM HAL02240240 CALCIUM PMT80003773 CALCIUM TRI02246040 CALCIUM CARBONATE JMP02237352 EURO-CAL EUR00645923 NOVO-CALCIUM NOP00618098 NU-CAL ODN00622443 O-CALCIUM 500 VTH80001122 PMS-CALCIUM PMS

CALCIUM CARBONATE, CHOLECALCIFEROL500mg & 125IU TabletST

00752673 CAL-500-D PRO80004966 CALCITE D 500 RIV00688770 CALCITE D-500 RIV02244161 CALCIUM 500 + D 400 TRI00702986 CALCIUM 500MG WITH VIT D HAL02246041 CALCIUM CARBONATE WITH D JMP00730599 CALCIUM CARBONATE WITH

VIT DPMT

00688975 CALCIUM D-500 TRI02237351 EURO-CAL D EUR00720798 NEO CAL-D-500 NEO02043025 OS-CAL D 500MG WAY80004281 PMS-CALCIUM/VITAMIN D PMS

500mg & 400IU TabletST

02244130 CALCITE 500 + D 400 RIV80004963 CALCITE 500 + D 400 RIV80004969 CALCIUM 500 + D 400 TRI80002623 CALCIUM 500MG WITH VIT D JMP02245511 CARBOCAL D EUR80002901 CARBOCAL D EUR80002122 JAMP-CALCIUM+VITAM D JMP

CALCIUM LACTOGLUCONATE20mg/mL Oral Liquid

80002626 CALCIUM WITHOUT SUGAR JMP20mg/mL Oral Liquid

80006877 WAMPOLE MINERAL CALCIUM JMP

40:12.00 REPLACEMENT PREPARATIONSCALCIUM, VITAMIN D

500mg & 400IU TabletST

80015351 PRIVA CAL D FORTE PHA500mg & 400U TabletST

80003919 BIOCAL-D FORTE BMI

ELECTROLYTE & DEXTROSE3.56g & 300mg & 470mg & 530mg Powder

01931563 GASTROLYTE REG SAC25mg & 2.2mg & 2.2mg & 0.9mg/mL Solution

00630365 PEDIALYTE ABB02219883 PEDIATRIC ELECTROLYTE PMS

MAGNESIUM25mg Oral Liquid

80009357 JAMP-MAGNESIUM GLUCONATE

JMP

28mg Tablet80009539 JAMP-MAGNESIUM

GLUCONATEJMP

100mg Tablet02068400 MAGNESIUM JAM

MAGNESIUM CITRATE5.40% Oral Liquid

00262609 CITRO MAG 15GM/300ML TCH

MAGNESIUM GLUCONATE100mg/mL Oral Liquid

00026697 RATIO-MAGNESIUM RPH

POTASSIUM CHLORIDE25MEQ Effervescent TabletST

02085992 K LYTE WPC8mmol Long Acting CapsuleST

02242291 EURO-K8 EUR02244068 RIVA-K RIV

8mmol Long Acting TabletST

00602884 APO-K APX02246734 EURO-K 600 EUR00613274 PRO-600K PDL00074225 SLOW K NVR

20mmol Long Acting TabletST

02242261 EURO-K 20 EUR00713376 K-DUR KEY80004415 ODAN K-20 ODN02243975 RIVA-K 20 RIV

1.33MEQ/mL Oral LiquidST

01918303 K 10 GSK02238604 PMS-POTASSIUM PMS

25MEQ PowderST

02089580 K LYTE WPC

Page 73 of 1242010


40:12.00 REPLACEMENT PREPARATIONSSODIUM CHLORIDE

0.9% Inhalation Diluent02094657 BACTERIOSTATIC NACL BIO00801267 SODIUM CHLORIDE02058235 SODIUM CHLORIDE BDH

0.9% Injection00060208 SODIUM CHLORIDE BAT00402249 SODIUM CHLORIDE ABB02150204 SODIUM CHLORIDE OMG99002329 SODIUM CHLORIDE

40:17.00 CALCIUM-REMOVING RESINSCALCIUM POLYSTYRENE SULFONATE

1g binds with approx 1.6mmol K Powder02017741 RESONIUM CALCIUM SAC

40:18.00 ION-REMOVING AGENTSSODIUM POLYSTYRENE SULFONATE

1g binds with approx 1mmol K Powder02026961 KAYEXALATE SAC00765252 K-EXIT OMG00755338 PMS-SOD POLYSTYRENE

SULFONAPMS

250mg/mL Oral Suspension00769541 PMS-SOD POLYSTYRENE

SULFPMS

250mg/mL Retention Enema00769533 PMS-SOD POLYSTYRENE

SULFPMS

40:20.00 CALORIC AGENTSLEVOCARNITINELimited use benefit (prior approval required).

For treatment of carnitine deficiency.100mg/mL Oral Liquid

02144336 CARNITOR SIG200mg/mL Solution

02144344 CARNITOR IV SIG330mg Tablet

02144328 CARNITOR SIG

40:28.08 LOOP DIURETICSETHACRYNIC ACID

25mg TabletST

02258528 EDECRIN FRS

FUROSEMIDE10mg/mL SolutionST

02224720 LASIX SAC

40:28.08 LOOP DIURETICSFUROSEMIDE

20mg TabletST

00396788 APO-FUROSEMIDE APX02247371 BIO-FUROSEMIDE BMI02248124 DOM-FUROSEMIDE BMI00496723 FUROSEMIDE PDL02224690 LASIX SAC00337730 NOVO-SEMIDE NOP02239224 NU-FUROSEMIDE NXP02247493 PMS-FUROSEMIDE PMS

40mg TabletST

00362166 APO-FUROSEMIDE APX02247372 BIO-FUROSEMIDE BMI02248125 DOM-FUROSEMIDE BMI00397792 FUROSEMIDE PDL02224704 LASIX SAC00337749 NOVO-SEMIDE NOP02239225 NU-FUROSEMIDE NXP02247494 PMS-FUROSEMIDE PMS

80mg TabletST

00707570 APO-FUROSEMIDE APX00667080 FUROSEMIDE PDL00765953 NOVO-SEMIDE NOP

500mg TabletST

02224755 LASIX SAC

40:28.16 POTASSIUM SPARING DIURETICSAMILORIDE HCL

5mg TabletST

02249510 APO-AMILORIDE APX00487805 MIDAMOR OBP

AMILORIDE HCL, HYDROCHLOROTHIAZIDE5mg & 50mg TabletST

00870943 AMI-HYDRO PDL00784400 APO-AMILZIDE APX02257378 GEN-AMILAZIDE GEN00487813 MODURET OBP01937219 NOVAMILOR NOP00886106 NU-AMILZIDE NXP02231254 PENTA-AMILOR HCTZ PEN

TRIAMTERENE, HYDROCHLOROTHIAZIDE50mg & 25mg TabletST

00441775 APO-TRIAZIDE APX00532657 NOVO-TRIAMZIDE NOP00865532 NU-TRIAZIDE NXP00519367 PRO-TRIAZIDE PRO02240846 RIVA-ZIDE RIV

40:28.20 TIAZIDE DIURETICSHYDROCHLOROTHIAZIDE

12.5mg Tablet02327856 APO-HYDRO APX02274086 PMS-HYDROCHLOROTHIAZIDE BMI

Page 74 of 1242010


40:28.20 TIAZIDE DIURETICSHYDROCHLOROTHIAZIDE

25mg TabletST

00326844 APO-HYDROCLOROTHIAZIDE APX02247170 BIO-HYDROCHLOROTHIAZIDE BMI02248134 DOM-

HYDROCHLOROTHIAZIDEDPC

00341975 HYDROCHLOROTHIAZIDE PDL00021474 NOVO-HYDRAZIDE NOP02250659 NU-HYDRO NXP02247386 PMS-HYDROCHLOROTHIAZIDE PMS

50mg TabletST

00312800 APO-HYDRO APX02247171 BIO-HYDROCHLOROTHIAZIDE BMI02248135 DOM-

HYDROCHLOROTHIAZIDEDPC

00156604 HYDROCHLOROTHIAZIDE PRO00021482 NOVO-HYDRAZIDE NOP02250667 NU-HYDRO NXP02247387 PMS-HYDROCHLOROTHIAZIDE PMS

100mg TabletST

00644552 APO-HYDRO APX00532088 HYDROCHLOROTHIAZIDE PDL

SPIRONOLACTONE, HYDROCHLOROTHIAZIDE25mg & 25mg TabletST

00180408 ALDACTAZIDE-25 PFI00613231 NOVO-SPIROZINE-25 NOP


00594377 ALDACTAZIDE-50 PFI00657182 NOVO-SPIROZINE-50 NOP

40:28.24 THIAZIDE LIKE DIURETICSCHLORTHALIDONE

50mg TabletST

00360279 APO-CHLORTHALIDONE APX100mg TabletST

00360287 APO-CHLORTHALIDONE APX

INDAPAMIDE1.25mg TabletST

02245246 APO-INDAPAMIDE APX02239913 DOM-INDAPAMIDE DPC02240067 GEN-INDAPAMIDE GEN02227339 INDAPAMIDE PRO02179709 LOZIDE SEV02240349 PHL-INDAPAMIDE PHH02239619 PMS-INDAPAMIDE PMS02312530 PRO-INDAPAMIDE PDL02247245 RIVA-INDAPAMIDE RIV

40:28.24 THIAZIDE LIKE DIURETICSINDAPAMIDE

2.5mg TabletST

02223678 APO-INDAPAMIDE APX02239917 DOM-INDAPAMIDE DPC02153483 GEN-INDAPAMIDE GEN02049341 INDAPAMIDE PRO00564966 LOZIDE SEV02231184 NOVO-INDAPAMIDE NOP02223597 NU-INDAPAMIDE NXP02239620 PMS-INDAPAMIDE PMS02312549 PRO-INDAPAMIDE PDL02242125 RIVA-INDAPAMIDE RIV

METOLAZONE2.5mg TabletST

00888400 ZAROXOLYN AVT

40:36.00 IRRIGATING SOLUTIONSWATER

Injection00402257 STERILE WATER FOR INJ OMG02142546 STERILE WATER FOR INJ HOS

40:40.00 URICOSURIC AGENTSPROBENECID

500mg Tablet00294926 BENURYL VAE

SULFINPYRAZONE200mg Tablet

00441767 APO-SULFINPYRAZONE APX02045699 NU-SULFINPYRAZONE NXP

Page 75 of 1242010


48:00 RESPIRATORY TRACT AGENTS48:08.00 ANTITUSSIVES

BROMPHENIRAMINE MALEATE, DEXTROMETHORPHAN HBR, PHENYLEPHRINE HCL

Oral Liquid02243969 DIMETAPP DM COUGH &

COLDWRI

CHLORPHENIRAMINE MALEATE, DEXTROMETHORPHAN HBR, PSEUDOEPHEDRINE HCL

0.2mg & 1.5mg & 3mg/mL Syrup00896179 TRIAMINIC DM NIGHT TIME NVC

DEXTROMETHORPHAN HBR15mg/mL Oral Liquid

02241495 DM COUGH SYRUP THC1.5mg/mL Sugar Free Liquid

02215268 BENYLIN DM CHILD WLA3mg/mL Sugar Free Liquid

01928775 BALMINIL DM RPH01944738 BENYLIN DM WLA00511013 DM SANS SUCRE TRI01928791 KOFFEX DM RPH

6mg/mL Sustained Release Sugar Free Liquid02231404 BENYLIN DM NIGHTTIME WLA

6mg/mL Sustained Release Suspension02018403 DELSYM NVC02231313 TRIAMINIC DM NVC

1.5mg/mL Syrup01953966 ROBITUSSIN PEDIATRIC WRI

2.5mg/mL Syrup00729655 BUCKLEYS DM BUY

3mg/mL Syrup00522791 BRONCHOPHAN FORTE DM ATL00800813 COUGH SYRUP RPH00833231 COUGH SYRUP

DEXTROMETHORPHANTAN

01928783 KOFFEX DM RPH

DEXTROMETHORPHAN HBR, PSEUDOEPHEDRINE HCL

7.5mg & 15mg Oral Liquid02243062 TRIAMINIC COUGH &

CONGESTIONNVC

1.5mg & 3mg/mL Sugar Free Liquid01944746 BENYLIN DM-D CHILD WLA

3mg & 6mg/mL Sugar Free Liquid01944711 BENYLIN DM-D WLA

48:10.24 LEUKOTRIENE MODIFIERSMONTELUKASTLimited use benefit (prior approval required).

For treatment of:a. - asthma when used in patients on concurrent steroid therapy.b. - asthma patients not well controlled with or intolerant to inhaled corticosteroids.

4mg Chewable Tablet02243602 SINGULAIR FRS


4mg Granules02247997 SINGULAIR FRS

10mg Tablet02238217 SINGULAIR FRS

ZAFIRLUKASTLimited use benefit (prior approval required).


20mg Tablet02236606 ACCOLATE AZC

48:10.32 MAST CELL STABILIZERSSODIUM CROMOGLYCATE

100mg Capsule00500895 NALCROM AVT

10mg/mL Inhalation Solution (Unit Dose)02231671 NU-CROMOLYN NXP02046113 PMS-SOD CROMOGLYCATE PMS

2% Nasal Solution01950541 CROMOLYN PMS

2% Ophth Solution02009277 CROMOLYN PMS02230621 OPTICROM ALL

Page 76 of 1242010


52:00 EYE, EAR, NOSE AND THROAT (EENT) PREPARATIONS

52:02.00 EENT - ANTIALLERGIC AGENTSLEVOCABASTINE HCL

0.05% Nasal Spray02020017 LIVOSTIN JNO

0.05% Ophth Suspension02131625 LIVOSTIN NVR

SODIUM CROMOGLYCATE2% Nasal Solution

02231390 APO-CROMOLYN APX

52:04.04 EENT - ANTIBACTERIALSBACITRACIN ZINC, POLYMYXIN B SULFATE

500IU & 10,000IU/g Ophth Ointment02160889 OPTIMYXIN SDZ02239157 POLYSPORIN PFI

CHLORAMPHENICOL1% Ophth Ointment

02026260 DIOCHLORAM DKT01980564 PENTAMYCETIN SDZ

0.25% Ophth Solution01980556 PENTAMYCETIN SDZ

0.5% Ophth Solution02023857 DIOCHLORAM DKT02164051 PENTAMYCETIN SDZ

CIPROFLOXACIN HCL0.3% Ophth Ointment

02200864 CILOXAN 0.3% ALC0.3% Ophth Solution

02263130 APO-CIPROFLOX APX01945270 CILOXAN ALC02253933 PMS-CIPROFLOXACIN PMS

CIPROFLOXACIN HCL, DEXAMETHASONELimited use benefit (prior approval required).

a.- for children 16 years old and under (prior approval not required)b.- for acute otitis media with otorrhea through tympanostomy tubes who require treatmentc.- for acute otitis externa in the presence of tympanostomy tube or known perforation of the tympanic membrane

0.3%/0.1% Otic Solution02252716 CIPRODEX ALC

CIPROFLOXACIN HCL, HYDROCORTISONELimited use benefit (prior approval required).

For treatment of acute diffuse bacterial external otitis. Criteria for coverage include:a. - failure to respond to other listed topical antibiotics, orb. - contraindications to other listed topical antibiotics.

2mg & 10mg/mL Otic Suspension02240035 CIPRO HC ALC

52:04.04 EENT - ANTIBACTERIALSERYTHROMYCIN

5mg/g Ophth Ointment02237041 ERYTHROMYCIN PHH01912755 PMS-ERYTHROMYCIN PMS

FRAMYCETIN SULFATE0.5% Ophth Ointment

02224895 SOFRAMYCIN STERILE EYE ERF0.5% Ophth Solution

02224887 SOFRAMYCIN ERF

GENTAMICIN SULFATE0.3% Ophth Ointment

02023776 DIOGENT DKT00028339 GARAMYCIN SCH02230888 SANDOZ-GENTAMICIN SDZ

0.3% Solution02023822 DIOGENT DKT00512192 GARAMYCIN SCH00512184 GARAMYCIN OTIC SCH02219581 GENTAMICIN SPH00776521 PMS-GENTAMICIN PMS02229440 SANDOZ-GENTAMICIN SDZ02229441 SANDOZ-GENTAMICIN OTIC SDZ

GRAMICIDIN, NEOMYCIN SULFATE, POLYMYXIN B SULFATE

0.025mg & 2.5mg & 10,000U/mL Solution00807435 OPTIMYXIN PLUS EYE/EAR SDZ

GRAMICIDIN, POLYMYXIN B SULFATE0.025mg & 10,000U/mL Solution

00701785 OPTIMYXIN EYE/EAR SDZ02239156 POLYSPORIN EYE/EAR WLA

OFLOXACIN0.3% Ophth Solution

02248398 APO-OFLOXACIN APX02143291 OCUFLOX ALL02252570 PMS-OFLOXACIN PMS

POLYMYXIN B SULFATE, TRIMETHOPRIM SULFATE

10,000U & 1mg/mL Ophth Solution02240363 PMS-POLYTRIMETHOPRIM PMS02011956 POLYTRIM ALL

SULFACETAMIDE SODIUM10% Ophth Solution

02023830 DIOSULF DKT

TOBRAMYCIN0.3% Ophth Ointment

00614254 TOBREX ALC0.3% Ophth Solution

02239577 PMS-TOBRAMYCIN PMS02241755 SANDOZ-TOBRAMYCIN SDZ00513962 TOBREX ALC

Page 77 of 1242010


52:04.20 EENT - ANTIVIRALSTRIFLURIDINE

1% Ophth Solution02248529 SANDOZ-TRIFLURIDINE SDZ00687456 VIROPTIC GSK

52:08.08 EENT - CORTICOSTEROIDSBECLOMETHASONE DIPROPIONATE

50mcg/Dose Nasal Spray02238796 APO-BECLOMETHASONE APX02172712 GEN-BECLO AQ GEN02237379 MED-BECLOMETHASONE AQ MEC02238577 NU-BECLOMETHASONE NXP00872318 RATIO-BECLOMETHASONE AQ RPH02228300 RIVANASE AQ RIV

BETAMETHASONE SODIUM PHOSPHATE, GENTAMICIN SULFATE

0.1% & 0.3% Ophth Ointment00586706 GARASONE SCH

0.1% & 0.3% Solution00682217 GARASONE OPHTH/OTIC SCH02244999 SANDOZ-PENTASONE

OPHTH/OTICSDZ

BUDESONIDE64mcg/Dose Nasal Spray

02241003 GEN-BUDESONIDE AQ GEN02231923 RHINOCORT AQ AZC

100mcg/Dose Nasal Spray02230648 GEN-BUDESONIDE AQ GEN

100mcg/Dose Powder02035324 RHINOCORT TURBUHALER AZC

DEXAMETHASONE0.1% Ophth Ointment

00042579 MAXIDEX ALC0.1% Ophth Solution

02023865 DIODEX DKT00785261 PMS-DEXAMETHASONE PMS00739839 SANDOZ-DEXAMETHASONE SDZ

0.1% Ophth Suspension00042560 MAXIDEX ALC

DEXAMETHASONE, TOBRAMYCIN0.1% & 0.3% Ophth Ointment

00778915 TOBRADEX ALC0.1% & 0.3% Ophth Suspension

00778907 TOBRADEX ALC

FLUMETHASONE PIVALATE, CLIOQUINOL0.02% & 1% Otic Solution

00074454 LOCACORTEN VIOFORM PAL

FLUNISOLIDE0.025% Nasal Solution

00878790 RATIO-FLUNISOLIDE RPH

52:08.08 EENT - CORTICOSTEROIDSFLUNISOLIDE

0.025% Nasal Spray02239288 APO-FLUNISOLIDE APX01927167 PMS-FLUNISOLIDE PMS

FLUOROMETHOLONE0.1% Ophth Solution

02238568 PMS-FLUOROMETHOLONE PMS0.1% Ophth Suspension

00247855 FML ALL0.25% Ophth Suspension

00707511 FML FORTE ALL

FLUOROMETHOLONE ACETATE0.1% Ophth Solution

00756784 FLAREX ALC

FLUTICASONE PROPIONATE50mcg/Dose Nasal Spray

02294745 APO-FLUTICASONE APX02213672 FLONASE GSK02296071 RATIO-FLUTICASONE RPH

FRAMYCETIN SULFATE, GRAMICIDIN, DEXAMETHASONE

5mg & 0.05mg/mL & 0.5mg Ophth/Otic Solution02247920 SANDOZ-OPTICORT SDZ02224623 SOFRACORT EYE/EAR SAC

HYDROCORTISONE, NEOMYCIN SULFATE, POLYMYXIN B SULFATE

10mg & 3.5mg & 10,000U/mL Otic Solution01912828 CORTISPORIN GSK02230386 SANDOZ-CORTIMYXIN SDZ

MOMETASONE FUROATE50mcg Nasal Spray

02238465 NASONEX SCH

PREDNISOLONE ACETATE0.12% Ophth Suspension

00299405 PRED MILD ALL01916181 SANDOZ PREDNISOLONE SDZ

1% Ophth Suspension02023768 DIOPRED DKT00301175 PRED FORTE ALL00700401 RATIO-PREDNISOLONE RPH01916203 SANDOZ-PREDNISOLONE SDZ

PREDNISOLONE ACETATE, SULFACETAMIDE SODIUM

0.2% & 10% Ophth Ointment00307246 BLEPHAMIDE ALL

0.5% & 10% Ophth Solution02023814 DIOPTIMYD DKT

0.2% & 10% Ophth Suspension00807788 BLEPHAMIDE ALL

Page 78 of 1242010


52:08.08 EENT - CORTICOSTEROIDSPREDNISOLONE SODIUM PHOSPHATE

0.5% Ophth Solution02148498 PREDNISOLONE CUV

TRIAMCINOLONE ACETONIDE55mcg/Dose Nasal Spray

02213834 NASACORT AQ SAC

52:08.20 EENT - NONSTEROIDAL ANTI-INFLAMMATORY AGENTS

DICLOFENAC SODIUM0.1% Ophth Solution

01940414 VOLTAREN NVR

FLURBIPROFEN SODIUM0.03% Ophth Solution

00766046 OCUFEN ALL

KETOROLAC TROMETHAMINE0.5% Ophth Solution

01968300 ACULAR ALL02245821 APO-KETOROLAC APX02247461 RATIO-KETOROLAC RPH

52:20.00 EENT - MIOTICSCARBACHOL

1.5% Ophth Solution00000655 ISOPTO CARBACHOL ALC

52:24.00 EENT - MYDRIATICSATROPINE SULFATE

1% Ophth Ointment00252484 ATROPINE ALC

1% Ophth Solution02023695 ATROPINE DKT02148358 ATROPINE SULPHATE MINIMS NVR00035017 ISOPTO ATROPINE ALC

CYCLOPENTOLATE HCL0.5% Ophth Solution

02148331 CYCLOPENTOLATE NVR1% Ophth Solution

00252506 CYCLOGYL ALC02148382 CYCLOPENTOLATE MINIMS NVR02023644 DIOPENTOLATE DKT

DIPIVEFRIN HCL0.1% Ophth Solution

02242232 APO-DIPIVEFRIN APX02237868 PMS-DIPIVEFRIN PMS

HOMATROPINE HBR2% Ophth Solution

00000779 ISOPTO HOMATROPINE ALC5% Ophth Solution

00000787 ISOPTO HOMATROPINE ALC

52:28.00 EENT - MOUTHWASHES AND GARGLES

BENZYDAMINE HCLLimited use benefit (prior approval required).

For:a. - treatment of radiation mucositis and oral ulcerative complications of chemotherapy.b. - use in immunocompromised patients who are at risk of mucosal breakdown.

0.15% Rinse02239044 APO-BENZYDAMINE APX02239537 DOM-BENZYDAMINE DPC02229799 NOVO-BENZYDAMINE NOP02229777 PMS-BENZYDAMINE PMS02230170 RATIO-BENZYDAMINE RPH

1.5mg/mL Rinse02310422 NOVO-BENZYDAMINE NOP

CHLORHEXIDINE GLUCONATE0.12% Rinse

02240433 PERICHLOR PMS02237452 PERIDEX MMH02207796 PERIOGARD COP

52:32.00 EENT - VASOCONSTRICTORSANTAZOLINE PHOSPHATE, NAPHAZOLINE HCL

0.5% & 0.05% Ophth Solution00433519 ALBALON A ALL

NAPHAZOLINE HCL0.1% Ophth Solution

00001147 ALBALON ALL00390283 NAPHCON FORTE ALC

PHENYLEPHRINE HCL0.12% Ophth Solution

00395161 PREFRIN LIQUIFILM ALL2.5% Ophth Solution

02027100 DIONEPHRINE DKT00465763 MYDFRIN ALC02148447 PHENYLEPHRINE MINIMS NVR

10% Ophth Solution02148455 PHENYLEPHRINE NVR

52:40.04 EENT - ALPHA-ADRENERGIC AGONISTS

BRIMONIDINE TARTRATE0.2% Ophth Solution

02236876 ALPHAGAN ALL02260077 APO-BRIMONIDINE APX02246284 PMS-BRIMONIDINE PMS02243026 RATIO-BRIMONIDINE RPH02305429 SANDOZ BRIMONIDINE SDZ

Page 79 of 1242010


52:40.04 EENT - ALPHA-ADRENERGIC AGONISTS

BRIMONIDINE TARTRATE (ALPHAGAN P)Limited use benefit (prior approval required).

For patients who are intolerant to brimonidine tartrate 0.2% or benzalkonium chloride.

0.15% Ophth Solution02248151 ALPHAGAN P ALL02301334 APO-BRIMONIDINE P APX

BRIMONIDINE TARTRATE, TIMOLOL MALEATE0.2% & 0.5% Ophth Solution

02248347 COMBIGAN ALL

52:40.08 EENT - BETA-ADRENERGIC BLOCKING AGENTS

BETAXOLOL HCL0.5% Ophth Solution

02235971 SANDOZ-BETAXOLOL SDZ0.25% Ophth Suspension

01908448 BETOPTIC S ALC

LEVOBUNOLOL HCL0.25% Ophth Solution

02241575 APO-LEVOBUNOLOL APX00751286 BETAGAN ALL02031159 RATIO-LEVOBUNOLOL RPH02241715 SANDOZ-LEVOBUNOLOL SDZ

0.5% Ophth Solution00637661 BETAGAN ALL02237991 PMS-LEVOBUNOLOL PMS02031167 RATIO-LEVOBUNOLOL RPH02241716 SANDOZ-LEVOBUNOLOL SDZ

TIMOLOL MALEATE0.25% Long Acting Ophth Solution

02171880 TIMOPTIC-XE FRS0.5% Long Acting Ophth Solution

02171899 TIMOPTIC-XE FRS0.25% Ophth Gel Solution

02242275 TIMOLOL MALEATE-EX PMS0.5% Ophth Gel Solution

02290812 APO-TIMOP APX02242276 TIMOLOL MALEATE-EX PMS

0.25% Ophth Solution00755826 APO-TIMOP APX02238770 DOM-TIMOLOL DPC00893773 GEN-TIMOLOL GEN02084317 MED-TIMOLOL MEC02048523 NOVO-TIMOL NOP02083353 PMS-TIMOLOL PMS02166712 SANDOZ-TIMOLOL SDZ

52:40.08 EENT - BETA-ADRENERGIC BLOCKING AGENTS

TIMOLOL MALEATE0.5% Ophth Solution

00755834 APO-TIMOP APX02238771 DOM-TIMOLOL DPC00893781 GEN-TIMOLOL GEN02084325 MED-TIMOLOL MEC02083345 PMS-TIMOLOL PMS02166720 SANDOZ-TIMOLOL SDZ00451207 TIMOPTIC FRS

52:40.12 EENT - CARBONIC ANHYDRASE INHIBITORS

ACETAZOLAMIDE250mg Tablet

00545015 APO-ACETAZOLAMIDE APX

BRINZOLAMIDE1% Ophth Suspension

02238873 AZOPT ALC

BRINZOLAMIDE/TIMOLOL MALEATE1%/0.5% Ophth Solution

02331624 AZARGA ALC

DORZOLAMIDE HCL2% Ophth Solution

02216205 TRUSOPT FRS

DORZOLAMIDE HCL, TIMOLOL MALEATE20mg & 5mg/mL Ophth Solution

02240113 COSOPT FRS

METHAZOLAMIDE50mg Tablet

02245882 APO-METHAZOLAMIDE APX

52:40.20 EENT - MIOTICSCARBACHOL

0.01% Ophth Solution00042544 MIOSTAT ALC

3% Ophth Solution00000663 ISOPTO CARBACHOL ALC

PILOCARPINE HCL4% Ophth Gel

00575240 PILOPINE HS ALC1% Ophth Solution

00000841 ISOPTO CARPINE ALC02229556 PILOCARPINE SCN

2% Ophth Solution00000868 ISOPTO CARPINE ALC

4% Ophth Solution02023733 DIOCARPINE DKT00000884 ISOPTO CARPINE ALC

Page 80 of 1242010


52:40.20 EENT - MIOTICSPILOCARPINE NITRATE

2% Ophth Solution02148463 PILOCARPINE NITRATE

MINIMSNVR

4% Ophth Solution02148471 PILOCARPINE NITRATE

MINIMSNVR

52:40.28 EENT - PROSTAGLANDIN AGENTS

BIMATOPROST0.01% Ophth Solution

02324997 LUMIGAN ALL0.03% Ophth Solution

02245860 LUMIGAN ALL

LATANOPROST0.005% Ophth Solution

02231493 XALATAN PFI

TIMOLOL MALEATE, TRAVOPROST0.5% & 0.004% Ophth Solution

02278251 DUO TRAV ALC

TRAVOPROST0.004% Ophth Solution

02244896 TRAVATAN ALC02318008 TRAVATAN Z ALC

52:92.00 MISCELLANEOUS EENT DRUGSALUMINUM ACETATE, BENZETHONIUM CHLORIDE

0.5% & 0.03% Otic Solution00674222 BURO-SOL STI

APRACLONIDINE HCL0.5% Ophth Solution

02076306 IOPIDINE ALC

DEXTRAN 70, HYDROXYPROPYLMETHYLCELLULOSE

0.1% & 0.3% Ophth Solution00390291 TEARS NATURALE ALC01943308 TEARS NATURALE FREE ALC00743445 TEARS NATURALE II ALC

DIPIVEFRIN HCL, LEVOBUNOLOL HCL0.1% & 0.5% Ophth Solution

02209071 PROBETA ALL

HYDROXYPROPYLMETHYLCELLULOSE0.5% Ophth Solution

00000809 ISOPTO TEARS ALC00889806 SANDOZ EYELUBE SDZ

1% Ophth Solution00000817 ISOPTO TEARS ALC00874965 SANDOZ EYELUBE SDZ

52:92.00 MISCELLANEOUS EENT DRUGSIPRATROPIUM BROMIDE

0.03% Nasal Spray02163705 ATROVENT BOE

0.06% Nasal Spray02163713 ATROVENT BOE

LODOXAMIDE TROMETHAMINE0.1% Ophth Solution

00893560 ALOMIDE ALC

MACROGOL, PROPYLENE GLYCOL15% & 20% Nasal Gel

02220806 PMS-RHINARIS PMS00551805 SECARIS PMS

15% & 20% Nasal Spray00732230 RHINARIS PMS

MINERAL OIL, PETROLATUM80% & 20% Ophth Ointment

02125706 DUOLUBE BSH

MINERAL OIL, WHITE PETROLATUM55.5% & 42.5% Ophth Ointment

00210889 LACRI LUBE ALL

PETROLATUM, LANOLIN, MINERAL OIL94% & 3% & 3% Ophth Ointment

02082519 TEARS NATURALE P.M. ALC

PETROLATUM, PETROLATUM LIQUID85% & 15% Ophth Ointment

02133288 HYPOTEARS NVR

POLYVINYL ALCOHOL1% Ophth Solution

02133253 HYPOTEARS NVR1.4% Ophth Solution

02229570 ARTIFICIAL TEARS PMS00045616 LIQUIFILM TEARS ALL00579408 TEARS PLUS ALL

POLYVINYL ALCOHOL, POVIDONE1.4% & 0.6% Ophth Solution

02229632 ARTIFICIAL TEARS EXTRA PMS

SODIUM CARBOXYMETHYL CELLULOSE0.5% Ophth Solution

02049260 REFRESH PLUS ALL1% Ophth Solution

00870153 CELLUVISC ALL10mg/mL Ophth Solution

02244650 REFRESH LIQUIGEL ALL0.5% Ophth Solution (Multi-Dose)

02231008 REFRESH TEARS ALL

SODIUM CHLORIDE0.7% Nasal Solution

00857777 OTRIVIN SALINE NVC

Page 81 of 1242010


52:92.00 MISCELLANEOUS EENT DRUGSSODIUM CHLORIDE

0.7% Nasal Spray00810436 OTRIVIN SALINE NVC

0.9% Nasal Spray02231476 HYDRA SENSE (ISOTONIC,

STERILE SEAWATER)SCH

02030861 NASAL SALINE PDD00489530 SALINEX SDZ

5% Ophth Ointment00750816 MURO-128 BSH

5% Ophth Solution00750824 MURO-128 BSH02245735 SANDOZ-SODIUM CHLORIDE SDZ

VERTEPORFINLimited use benefit (prior approval required).

For treatment of age related macular degeneration for patients with this diagnosis who are being treated by a certified ophthalmologist.

15mg/Vial Injection02242367 VISUDYNE QLT

Page 82 of 1242010


56:00 GASTROINTESTINAL DRUGS56:04.00 ANTACIDS AND ADSORBENTS

BISMUTH SUBSALICYLATE17.6mg/mL Liquid

02097079 PEPTO BISMOL PGI262mg Tablet

02177994 PEPTO BISMOL PGI

MAG OXIDE420mg Tablet

00299448 MAGNESIUM OXIDE SWS

56:08.00 ANTIDIARRHEA AGENTSLOPERAMIDE HCL

0.2mg/mL LiquidST

02192667 DIARR-EZE PMS02016095 PMS-LOPERAMIDE PMS

2mg TabletST

02212005 APO-LOPERAMIDE APX02229552 DIARR-EZE PMS02248994 DIARRHEA RELIEF PMS02256452 DIARRHEA RELIEF VTH02239535 DOM-LOPERAMIDE DPC02183862 IMODIUM MCL02225182 LOPERAMIDE PDL02132591 NOVO-LOPERAMIDE NOP02228351 PMS-LOPERAMIDE PMS02233998 RHOXAL-LOPERAMIDE RHO02238211 RIVA-LOPERAMIDE RIV02257564 SANDOZ-LOPERAMIDE SDZ

56:12.00 CATHARTICS AND LAXATIVESBISACODYL


00545023 APO-BISACODYL APX00420433 BISACODYL PRO00714488 BISACOLAX ICN00254142 DULCOLAX BOE02246039 JAMP-BISACODYL JMP00587273 PMS-BISACODYL PMS

5mg Suppository00003867 DULCOLAX BOE

10mg Suppository00754595 APO-BISACODYL APX00261327 BISACOLAX ICN00003875 DULCOLAX BOE00582883 PMS-BISACODYL PMS00404802 RATIO-BISACODYL RPH02229743 SOFLAX EX PMS

BISACODYL (POLYETHYLENE GLYCOL BASE)Limited use benefit (prior approval required).

For treatment of constipation in patients with spinal cord injury.10mg Suppository

02241091 MAGIC BULLET DCM

56:12.00 CATHARTICS AND LAXATIVESCITRIC ACID, MAGNESIUM OXIDE, SODIUM PICOSULFATE

Oral Liquid02317966 PURG-ODAN ODN

Powder02254794 PICO-SALAX FEI

DIOCTYL CALCIUM SULFOSUCCINATE240mg CapsuleST

02245080 APO-DOCUSATE CALCIUM APX00830275 DOCUSATE CALCIUM TAR02283255 JAMP-DOCUSATE CALCIUM JMP00842044 NOVO-DOCUSATE CALCIUM NOP00664553 PMS-DOCUSATE CALCIUM PMS00809055 RATIO-DOCUSATE CALCIUM RPH

DIOCTYL SODIUM SULFOSUCCINATE100mg CapsuleST

02245079 APO-DOCUSATE SODIUM APX02106256 COLACE WPC00716731 DOCUSATE SODIUM TAR00794406 DOCUSATE SODIUM SDR00830267 DOCUSATE SODIUM TRI02246036 DOCUSATE SODIUM RPH02239658 DOM-DOCUSATE SODIUM DPC02247385 EURO-DOCUSATE EUR02020084 NOVO-DOCUSATE NOP00703494 PMS-DOCUSATE SODIUM PMS00870196 RATIO-DOCUSATE SODIUM RPH00514888 SELAX ODN01994344 SOFLAX PMS

200mg CapsuleST

02029529 SOFLAX PMS250mg CapsuleST

02006596 SELAX ODN10mg/mL DropST

02090163 COLACE WPC00870218 DOCUSATE SODIUM RPH00880140 PMS-SODIUM DOCUSATE PMS02006723 SOFLAX PMS

4mg/mL SyrupST

02086018 COLACE WPC00703508 PMS-DOCUSATE SODIUM PMS00870226 RATIO-DOCUSATE SODIUM RPH02006758 SOFLAX SYRUP PMS

20mg/mL SyrupST

02283239 DOCUSATE SODIUM JMP50mg/mL SyrupST

02283220 DOCUSATE SODIUM JMP00848417 PMS-DOCUSATE SODIUM PMS

DIOCTYL SODIUM SULFOSUCCINATE, SENNA50mg & 187mg TabletST

00026123 SENOKOT S PFR

Page 83 of 1242010


56:12.00 CATHARTICS AND LAXATIVESDIOCTYL SODIUM SULFOSUCCINATE, SENNOSIDES

100mg CapsuleST

02245946 DOCUSATE SODIUM JMP50mg & 8.6mg TabletST

02247390 EURO-SENNA S EUR

DOCUSATE SODIUM100mg CapsuleST

02326086 DOCUSATE SODIUM PDL02303825 EURO-DOCUSATE EUR

FIBER469mg TabletST

00595829 NOVO-FIBRE NOP

GLYCERINEAdult Suppository

00873462 GLYCERIN RPH01926039 GLYCERIN WLA00812250 GLYCERINE WLA00884022 GLYCERINE RPH

Pediatric Suppository02020815 GLYCERIN INFANT RPH01926047 GLYCERIN INFANT & CHILD PFI

LACTULOSE667mg/mL Oral LiquidST

02242814 APO-LACTULOSE APX02247383 EURO-LAC EUR02280078 GPI-LACTULOSE OBP02295881 LACTULOSE JMP00703486 PMS-LACTULOSE PMS02311275 PRO-LACTULOSE PRO00690686 RATIO-LACTULOSE RPH00854409 RATIO-LACTULOSE RPH

MACROGOL, POTASSIUM CHLORIDE, SODIUM BICARBONATE, SODIUM CHLORIDE, SODIUM SULFATE

60g & 750mg & 1.68g & 1.46g & 5.68g/L Powder00677442 COLYTE ZYM00652512 GOLYTELY BAX00777838 PEGLYTE PMS

MAGNESIUM HYDROXIDE80mg/mL Liquid

02150646 MILK OF MAGNESIA PLAIN/SUGARFREE

BCD

311mg Tablet02150638 MILK OF MAGNESIA BCD

MINERAL OIL78% Jelly

00608734 LANSOYL GEL AXC02186926 LANSOYL GEL SUGARFREE AXC

56:12.00 CATHARTICS AND LAXATIVESMINERAL OIL

Liquid01935348 MINERAL OIL (HEAVY) 100%

USPRWP

PLANTAGO SEED50% Powder

00599875 MUCILLIUM PMS

POLYETHYLENE GLYCOLPowder

09991007 POLYETHYLENE GLYCOL WIL

POLYETHYLENE GLYCOL 3350Powder

09991054 POLYETHYLENE GLYCOL 3350 WIL1g/g Powder

02317680 LAX-A-DAY PED

POLYETHYLENE GLYCOL, POTASSIUM CHLORIDE, SODIUM BICARBONATE, SODIUM CHLORIDE, SODIUM SULFATE

Oral Liquid02147793 KLEAN-PREP RVX

PSYLLIUM HYDROPHILIC MUCILLOID680mg/g Powder

02174812 METAMUCIL ORIGINAL TEXTURE

PGI

02174790 METAMUCIL SM TEXT ORANGE

PGI

02174782 METAMUCIL SM TEXT ORANGE S/F

PGI

02174804 METAMUCIL SM TEXT UNFLAV PGI

SENNOSIDES1.7mg/mL LiquidST

02144379 SENNALAX PMS02084651 SENNAPREP PMS00367729 SENOKOT PFR00367737 X-PREP PFR

8.6mg TabletST

02247389 EURO-SENNA EUR80009182 JAMP-SENNOSIDES JMP00896411 PMS-SENNOSIDES PMS01949292 RIVA-SENNA RIV02089653 SANDOZ-SENNOSIDES SDZ02237105 SENNA LAXATIVE SDR02068109 SENNATAB PMS00026158 SENOKOT PFR

12MG TabletST

80009183 JAMP-SENNOSIDES JMP00896403 PMS-SENNOSIDES PMS02089645 SANDOZ-SENNOSIDES SDZ

SODIUM CITRATE, SODIUM LAURYL SULFOACETATE, SORBITOL

90mg & 9mg & 625mg Enema02063905 MICROLAX PMS

Page 84 of 1242010


56:12.00 CATHARTICS AND LAXATIVESSODIUM PHOSPHATE DIBASIC, SODIUM PHOSPHATE MONOBASIC

180mg & 480mg/mL Oral Liquid02206218 PHOSPHO SODA FLEET

LAXATIVEJAJ

02230399 PMS-PHOSPHATES SOLUTION PMS60mg & 160mg/mL Rectal Liquid

02096900 ENEMOL DPC00009911 FLEET ENEMA FRS

60mg & 160mg/mL PED Rectal Liquid00108065 FLEET ENEMA PEDIATRIC JAJ

56:14.00 CHOLELITHOLYTIC AGENTSURSODIOL

250mg TabletST

02281317 PHL-URSODIOL C PHH02273497 PMS-URSODIOL PMS02238984 URSO AXC

500mg TabletST

02281325 PHL-URSODIOL C PHH02273500 PMS-URSODIOL PMS02245894 URSO DS AXC

56:16.00 DIGESTANTSLACTASE

3,550U Capsule02016478 LACTRASE RIV

Oral Liquid00903981 LACTAID MCL

3,000U Tablet02200384 DAIRY DIGESTIVE PER02239139 DAIRY DIGESTIVE SDR02017512 DAIRY FREE KIN01951637 DAIRYAID TAN02230653 LACTAID JNO

4,500U Tablet02239140 DAIRY DIGESTIVE EXTRA

STRENGTHSDR

02224909 DAIRY FREE EXTRA STRENGTH

KIN

02230654 LACTAID EXTRA STRENGTH JNO

LIPASE, AMYLASE, PROTEASE5,000U & 16,600U & 18,750U CapsuleST

02239007 CREON 5 MINIMICROSPHERES

SPH

8,000U & 30,000U & 30,000U CapsuleST

00263818 COTAZYM ORG20,000U & 66,400U & 75,000U CapsuleST


SPH

4,000U & 11,000U & 11,000U Capsule (Enteric Coated Particles)

ST

02181215 COTAZYM ECS4 ORG

56:16.00 DIGESTANTSLIPASE, AMYLASE, PROTEASE


ST

00789445 PANCREASE MT 4 JNO4,500U & 20,000U & 25,000U Capsule (Enteric Coated Particles)

ST

02203324 ULTRASE MS 4 AXC8,000U & 30,000U & 30,000U Capsule (Enteric Coated Particles)

ST

00502790 COTAZYM ECS 8 ORG10,000U & 30,000U & 30,000U Capsule (Enteric Coated Particles)

ST


ST


SPH


ST

02045834 ULTRASE MT 12 AXC16,000U & 48,000U & 48,000U Capsule (Enteric Coated Particles)

ST


ST

00821373 COTAZYM ECS 20 ORG20,000U & 65,000 & 65,000U Capsule (Enteric Coated Particles)

ST

02045869 ULTRASE MT 20 AXC25,000U & 74,000U & 62,500U Capsule (Enteric Coated Particles)

ST


SPH

24,000U & 100,000U & 100,000U/g PowderST

02230020 VIOKASE AXC8,000U & 30,000U & 30,000U TabletST

02230019 VIOKASE AXC16,000U & 60,000U & 60,000U TabletST

02241933 VIOKASE AXC

56:20.00 EMETICSIPECAC

7% Syrup00721328 PMS-IPECAC PMS

14mg/mL Syrup00378801 IPECAC XEN

56:22.08 ANTIHISTAMINESDIMENHYDRINATE

50mg/mL Injection00392537 DIMENHYDRINATE SDZ00013579 GRAVOL HOR

3mg/mL LiquidST

00230197 GRAVOL HOR

Page 85 of 1242010


56:22.08 ANTIHISTAMINESDIMENHYDRINATE

25mg Suppository00783595 GRAVOL HOR

50mg Suppository00392553 DIMENHYDRINATE SDZ00013595 GRAVOL HOR

15mg TabletST

00511196 GRAVOL HOR50mg TabletST

00363766 APO-DIMENHYDRINATE APX00156655 DIMENHYDRINATE PRO00013803 GRAVOL HOR00399779 NAUSEATOL SDZ00021423 NOVODIMENATE NOP00586331 PMS-DIMENHYDRINATE PMS00272671 TRAVAMINE ICN00605786 TRAVEL AID VTH02245416 TRAVEL TABLET JMP

DOXYLAMINE SUCCINATE, PYRIDOXINE HCL10mg & 10mg Tablet

00609129 DICLECTIN DUI

MECLIZINE HCL25mg Chewable TabletST

00220442 BONAMINE JNO

56:22.20 5-HT3 RECEPTOR ANTAGONISTSDOLASETRON MESYLATE

20mg/mL Injection02231380 ANZEMET SAC

50mg Tablet02231378 ANZEMET SAC

100mg Tablet02231379 ANZEMET SAC

GRANISETRON1mg Tablet

02308894 APO-GRANISETRON APX02185881 KYTRIL HLR

ONDANSETRON HCL4mg Tablet

02296349 CO-ONDANSETRON CBT02344440 ZYM-ONDANSETRON ZYM

8mg Tablet02296357 CO-ONDANSETRON CBT02344459 ZYM-ONDANSETRON ZYM

ONDANSETRON HCL DIHYDRATE0.8mg/mL Liquid

02291967 APO-ONDANSETRON APX02229639 ZOFRAN GSK

56:22.20 5-HT3 RECEPTOR ANTAGONISTSONDANSETRON HCL DIHYDRATE

4mg Tablet02288184 APO-ONDANSETRON APX02297868 GEN-ONDANSETRON GEN02313685 JAMP ONDANSETRON JMP02305259 MINT-ONDANSETRON MIN02264056 NOVO-ONDANSETRON NOP02278618 PHL-ONDANSETRON PHH02258188 PMS-ONDANSETRON PMS02312247 RAN-ONDANSETRON RBY02278529 RATIO-ONDANSETRON RPH02274310 SANDOZ-ONDANSETRON SDZ02213567 ZOFRAN GSK02239372 ZOFRAN ODT GSK

8mg Tablet02288192 APO-ONDANSETRON APX02297876 GEN-ONDANSETRON 8MG

TABGEN

02313693 JAMP ONDANSETRON JMP02305267 MINT-ONDANSETRON MIN02264064 NOVO-ONDANSETRON NOP02278626 PHL-ONDANSETRON PHH02258196 PMS-ONDANSETRON PMS02312255 RAN-ONDANSETRON RBY02278537 RATIO-ONDANSETRON RPH02274329 SANDOZ-ONDANSETRON SDZ02213575 ZOFRAN GSK02239373 ZOFRAN ODT GSK

56:22.92 MISCELLANEOUS ANTIEMETICSAPREPITANTLimited use benefit (prior approval required).

When used in combination with a 5-HT3 antagonist and dexamethasone for the prevention of acute and delayed nausea and vomiting due to highly emetogenic cancer chemotherapy (eg. Cisplatin > 70mg/m2) in patients who have experienced emesis despite treatment with a combination of a 5-HT3 antagonist and dexamethasone in a previous cycle of highly emetogenic chemotherapy.

80mg Capsule02298791 EMEND FRS


125mg & 80mg Capsule02298813 EMEND TRI PACK FRS

DOMPERIDONE MALEATE10mg Tablet

02103613 APO-DOMPERIDONE APX02238315 DOM-DOMPERIDONE DPC02236857 DOMPERIDONE PDL02278669 GEN-DOMPERIDONE GEN02157195 NOVO-DOMPERIDONE NOP02231477 NU-DOMPERIDONE NXP02236466 PMS-DOMPERIDONE PMS02268078 RAN-DOMPERIDONE RBY01912070 RATIO-DOMPERIDONE RPH

Page 86 of 1242010


56:22.92 MISCELLANEOUS ANTIEMETICSNABILONE

0.25mg Capsule02312263 CESAMET VAE

0.5mg Capsule02256193 CESAMET VAE

1mg Capsule00548375 CESAMET VAE

56:28.12 HISTAMINE H2-ANTAGONISTSCIMETIDINE

200mg TabletST

00584215 APO-CIMETIDINE APX02227436 GEN-CIMETIDINE GEN00582409 NOVO-CIMETINE NOP00865796 NU-CIMET NXP00596469 PDL-CIMETIDINE PDL02229717 PMS-CIMETIDINE PMS

300mg TabletST

00487872 APO-CIMETIDINE APX00596477 CIMETIDINE PDL02231287 DOM-CIMETIDINE DPC02227444 GEN-CIMETIDINE GEN00582417 NOVO-CIMETINE NOP00865818 NU-CIMET NXP02229718 PMS-CIMETIDINE PMS

400mg TabletST


600mg TabletST


800mg TabletST

00749494 APO-CIMETIDINE APX02227479 GEN-CIMETIDINE GEN00663727 NOVO-CIMETINE NOP02229721 PMS-CIMETIDINE PMS

56:28.12 HISTAMINE H2-ANTAGONISTSFAMOTIDINE

20mg TabletST

01953842 APO-FAMOTIDINE APX02241372 FAMOTIDINE PDL02196018 GEN-FAMOTIDINE GEN02022133 NOVO-FAMOTIDINE NOP02024195 NU-FAMOTIDINE NXP02238342 PENTA-FAMOTIDINE PEN00710121 PEPCID FRS02237148 ULCIDINE VAE

40mg TabletST

01953834 APO-FAMOTIDINE APX02241373 FAMOTIDINE PDL02196026 GEN-FAMOTIDINE GEN02022141 NOVO-FAMOTIDINE NOP02024209 NU-FAMOTIDINE NXP02238343 PENTA-FAMOTIDINE PEN00710113 PEPCID FRS02237149 ULCIDINE VAE

NIZATIDINE150mg CapsuleST

02220156 APO-NIZATIDINE APX00778338 AXID PHH02185814 DOM-NIZATIDINE DPC02246046 GEN-NIZATIDINE GEN02239558 NIZATIDINE PDL02240457 NOVO-NIZATIDINE NOP02177714 PMS-NIZATIDINE PMS

300mg CapsuleST

02220164 APO-NIZATIDINE APX00778346 AXID PHH02246047 GEN-NIZATIDINE GEN02238195 NIZATIDINE PHH02239559 NIZATIDINE PDL02240458 NOVO-NIZATIDINE NOP02177722 PMS-NIZATIDINE PMS

RANITIDINE HCL15mg/mL Oral SolutionST

02280833 APO-RANITIDINE APX02242940 NOVO-RANITIDINE NOP02212374 ZANTAC GSK

Page 87 of 1242010


56:28.12 HISTAMINE H2-ANTAGONISTSRANITIDINE HCL

150mg TabletST

00733059 APO-RANITIDINE APX02265591 BCI-RANITIDINE BAK02248570 CO RANITIDINE COB02207761 GEN-RANITIDINE GEN02293471 MAXIMUM STRENGTH ACID

REDUCERPMS

02219077 MED-RANITIDINE MEC00828564 NOVO-RANIDINE NOP00865737 NU-RANIT NXP02242453 PMS-RANITIDINE PMS00740748 RANITIDINE PDL00828823 RATIO-RANITIDINE RPH02245782 RIVA-RANITIDINE PHH02247814 RIVA-RANTIDINE RIV02243229 SANDOZ-RANITIDINE SDZ02212331 ZANTAC GSK

300mg TabletST

00733067 APO-RANITIDINE APX02265605 BCI-RANITIDINE BAK02248571 CO RANITIDINE COB02207788 GEN-RANITIDINE GEN02219085 MED-RANITIDINE MEC00828556 NOVO-RANIDINE NOP00865745 NU-RANIT NXP02242454 PMS-RANITIDINE PMS00740756 RANITIDINE PDL00828688 RATIO-RANITIDINE RPH02245783 RIVA-RANITIDINE PHH02247815 RIVA-RANITIDINE RIV02243230 SANDOZ-RANITIDINE SDZ02212358 ZANTAC GSK

56:28.28 PROSTAGLANDINSMISOPROSTOL

100mcg TabletST

02244022 APO-MISOPROSTOL APX200mcg TabletST

02244023 APO-MISOPROSTOL APX02248846 MISOPROSTOL PDL02244125 PMS-MISOPROSTOL PMS

56:28.32 PROTECTANTSSUCRALFATE

200mg/mL SuspensionST

02103567 SULCRATE PLUS AXC1g TabletST

02125250 APO-SUCRALFATE APX02045702 NOVO-SUCRALATE NOP02134829 NU-SUCRALFATE NXP02130939 SUCRALFATE-1 PDL02100622 SULCRATE AXC

56:28.36 PROTON-PUMP INHIBITORSAMOXICILLIN, CLARITHROMYCIN, LANSOPRAZOLE

500mg & 500mg & 30mg Kit02238525 HP-PAC ABB

LANSOPRAZOLE(Please refer to Appendix A).

Limited use benefit (prior approval not required).

Coverage will be limited to 400 tablets/capsules every 180 days.


02293811 APO-LANSOPRAZOLE APX02280515 NOVO-LANSOPRAZOLE NOP02165503 PREVACID ABB


02293838 APO-LANSOPRAZOLE APX02280523 NOVO-LANSOPRAZOLE NOP02165511 PREVACID ABB

LANSOPRAZOLE ODT(Please refer to Appendix A).

Limited use benefit (prior approval required).

Coverage will be limited to 400 tablets/capsules every 180 days.•For children 12 years of age or under who are unable to swallow the capsule formulation•For patients with dysphagia or a feeding tube when the use of the capsule formulation is not possible.

15MG Orally Disintegrating TabletST

02249464 PREVACID FASTAB TAK30MG Orally Disintegrating TabletST

02249472 PREVACID FASTAB TAK

Page 88 of 1242010


56:28.36 PROTON-PUMP INHIBITORSOMEPRAZOLE MAGNESIUM (PA)(Please refer to Appendix A).


Coverage will be limited to 400 tablets/capsules every 180 days.Coverage will be provided for the following medical conditions if the patient has tried at least 30 days each of two of the following open benefit PPIs: Omeprazole (Losec®), Rabeprazole (Pariet®), Pantoprazole sodium (Pantoloc®), Lansoprazole (Prevacid®):•For treatment of confirmed gastric and duodenal ulcers. OR•For mild to moderate gastroesophageal reflux disease (GERD) in patients who have failed on or not tolerated a 4-week trial of histamine-2 receptor antagonists. OR•For severe gastroesophageal reflux disease (GERD) and complications as first-line therapy for a maximum period of 3 months. Patients should be reassessed endoscopically or with step-down therapy using a histamine-2 receptor antagonist. OR•For treatment of nonsteroidal anti-inflammatory drug (NSAID)-induced ulcers where the NSAID must be continued. OR•For prevention of NSAID-induced ulcers in patients who have history of ulcer complications, are over the age of 65 years, have comorbid disease such as cardiovascular disease or coagulopathies or are on concomitant medications which increase risk of ulcers or bleeding. OR•Zollinger-Ellison Syndrome*. OR•Barrett's Esophagus*. OR•Esophagitis associated with connective tissue disease.(*) Diagnosis must be confirmed by a specialist qualified to diagnose and treat condition


02230737 LOSEC AZC02260859 RATIO-OMEPRAZOLE RPH

OMEPRAZOLE, OMEPRAZOLE MAGNESIUM (NO PA)(Please refer to Appendix A).



10mg CapsuleST

02119579 LOSEC AZC02329425 MYLAN-OMEPRAZOLE GEN02296438 SANDOZ OMEPRAZOLE SDZ

20mg CapsuleST

02245058 APO-OMEPRAZOLE APX00846503 LOSEC AZC02329433 MYLAN-OMEPRAZOLE GEN02320851 PMS-OMEPRAZOLE PMS02296446 SANDOZ OMEPRAZOLE SDZ


02190915 LOSEC AZC02310260 PMS-OMEPRAZOLE PMS02260867 RATIO-OMEPRAZOLE RPH

56:28.36 PROTON-PUMP INHIBITORSPANTOPRAZOLE MAGNESIUM(Please refer to Appendix A).


Coverage will be limited to 400 tablets/capsules every 180 days.Coverage will be provided for the following medical conditions if the patient has tried at least 30 days each of two of the following open benefit PPIs: Omeprazole (Losec®), Rabeprazole (Pariet®), Pantoprazole sodium (Pantoloc®), Lansoprazole (Prevacid®):•For treatment of confirmed gastric and duodenal ulcers. OR•For mild to moderate gastroesophageal reflux disease (GERD) in patients who have failed on or not tolerated a 4-week trial of histamine-2 receptor antagonists. OR•For severe gastroesophageal reflux disease (GERD) and complications as first-line therapy for a maximum period of 3 months. Patients should be reassessed endoscopically or with step-down therapy using a histamine-2 receptor antagonist. OR•For treatment of nonsteroidal anti-inflammatory drug (NSAID)-induced ulcers where the NSAID must be continued. OR•For prevention of NSAID-induced ulcers in patients who have history of ulcer complications, are over the age of 65 years, have comorbid disease such as cardiovascular disease or coagulopathies or are on concomitant medications which increase risk of ulcers or bleeding. OR•Zollinger-Ellison Syndrome*. OR•Barrett's Esophagus*. OR•Esophagitis associated with connective tissue disease.(*) Diagnosis must be confirmed by a specialist qualified to diagnose and treat condition


02267233 TECTA NCC

PANTOPRAZOLE SODIUM(Please refer to Appendix A).




02292920 APO-PANTOPRAZOLE APX02300486 CO PANTOPRAZOLE COB02299585 GEN-PANTOPRAZOLE GEN02285487 NOVO-PANTOPRAZOLE NOP02229453 PANTOLOC NYC02318695 PANTOPRAZOLE PDL02309866 PHL-PANTOPRAZOLE PMI02307871 PMS-PANTOPRAZOLE PMS02305046 RAN-PANTOPRAZOLE RBY02308703 RATIO-PANTOPRAZOLE RPH02310201 RIVA-PANTOPRAZOLE ZYM02316463 RIVA-PANTOPRAZOLE RIV02301083 SANDOZ-PANTOPRAZOLE SDZ

Page 89 of 1242010


56:28.36 PROTON-PUMP INHIBITORSRABEPRAZOLE SODIUM(Please refer to Appendix A).




02296632 NOVO-RABEPRAZOLE NOP02243796 PARIET EC JNO02310805 PMS-RABEPRAZOLE PMS02315181 PRO-RABEPRAZOLE PDL02298074 RAN-RABEPRAZOLE RBY02314177 SANDOZ-RABEPRAZOLE SDZ


02296640 NOVO-RABEPRAZOLE NOP02243797 PARIET EC JNO02310813 PMS-RABEPRAZOLE PMS02315203 PRO-RABEPRAZOLE PDL02298082 RAN-RABEPRAZOLE RBY02330091 RIVA-RABEPRAZOLE RIV02314185 SANDOZ-RABEPRAZOLE SDZ

56:32.00 PROKINETIC AGENTSMETOCLOPRAMIDE HCL

1mg/mL Oral Liquid02230433 PMS-METOCLOPRAMIDE PMS

5mg Tablet00842826 APO-METOCLOP APX00871001 METOCLOPRAMIDE PDL02143275 NU-METOCLOPRAMIDE NXP02230431 PMS-METOCLOPRAMIDE PMS

10mg Tablet00842834 APO-METOCLOP APX00870994 METOCLOPRAMIDE PDL02143283 NU-METOCLOPRAMIDE NXP02230432 PMS-METOCLOPRAMIDE PMS

56:36.00 ANTI-INFLAMMATORY AGENTS5-AMINOSALICYLIC ACID


02099683 PENTASA FEI2g/60g Enema

02112795 SALOFALK AXC4g/60g Enema

02112809 SALOFALK AXC400mg Enteric Coated TabletST

01997580 ASACOL PGP500mg Enteric Coated TabletST

02112787 SALOFALK AXC800mg Enteric Coated TabletST

02267217 ASACOL WAC500mg Suppository

02112760 SALOFALK AXC

56:36.00 ANTI-INFLAMMATORY AGENTSMESALAZINE

1g/100mL Enema02153521 PENTASA FEI

4g/100mL Enema02153556 PENTASA FEI


02171929 NOVO 5-ASA NOP500mg Enteric Coated TabletST

01914030 MESASAL GSK1g Suppository

02153564 PENTASA FEI1000mg Suppository

02242146 SALOFALK AXC

OLSALAZINE SODIUM250mg CapsuleST

02063808 DIPENTUM LUD

Page 90 of 1242010


60:00 GOLD COMPOUNDS60:00.00 GOLD COMPOUNDS

AURANOFIN3mg Capsule

01916823 RIDAURA SQU

SODIUM AUROTHIOMALATE10mg/mL Injection

01927620 MYOCHRYSINE SAC02245456 SODIUM AUROTHIOMALATE SDZ

25mg/mL Injection01927612 MYOCHRYSINE SAC02245457 SODIUM AUROTHIOMALATE SDZ

50mg/mL Injection02245458 SODIUM AUROTHIOMALATE SDZ

Page 91 of 1242010


64:00 HEAVY METAL ANTAGONISTS64:00.00 HEAVY METAL ANTAGONISTS

PENICILLAMINE250mg Capsule

00016055 CUPRIMINE FRS

Page 92 of 1242010


68:00 HORMONES AND SYNTHETIC SUBSTITUTES

68:04.00 ADRENALSBECLOMETHASONE DIPROPIONATE

50mcg Inhaler02242029 QVAR MMH

100mcg Inhaler02242030 QVAR MMH

BUDESONIDE0.125mg/mL Inhalation Solution

02229099 PULMICORT NEBUAMP AZC0.25mg/mL Inhalation Solution

01978918 PULMICORT NEBUAMP AZC0.5mg/mL Inhalation Solution

01978926 PULMICORT NEBUAMP AZC100mcg Powder for Inhalation

00852074 PULMICORT TURBUHALER AZC200mcg Powder for Inhalation

00851752 PULMICORT TURBUHALER AZC400mcg Powder for Inhalation

00851760 PULMICORT TURBUHALER AZC

CICLESONIDE100mg/Inhalation Inhaler

02285606 ALVESCO NYC200mg/Inhalation Inhaler

02285614 ALVESCO NYC

CORTISONE ACETATE25mg Tablet

00280437 CORTISONE VAE

DEXAMETHASONE0.1mg/mL Elixir

01946897 PMS-DEXAMETHASONE PMS0.5mg Tablet

02261081 APO-DEXAMETHASONE APX02237044 PHL-DEXAMETHASONE PHH01964976 PMS-DEXAMETHASONE PMS02240684 RATIO-DEXAMETHASONE RPH

0.75mg Tablet00285471 DEXASONE VAE01964968 PMS-DEXAMETHASONE PMS02240685 RATIO-DEXAMETHASONE RPH

2mg Tablet02279363 PMS-DEXAMETHASONE PMS

4mg Tablet02250055 APO-DEXAMETHASONE APX00489158 DEXASONE VAE02237046 PHL-DEXAMETHASONE PHH01964070 PMS-DEXAMETHASONE PMS02311267 PRO-DEXAMETHASONE PRO02240687 RATIO-DEXAMETHASONE RPH

68:04.00 ADRENALSDEXAMETHASONE PHOSPHATE

4mg/mL Injection00664227 DEXAMETHASONE SDZ01977547 DEXAMETHASONE CYX02204266 DEXAMETHASONE-OMEGA OMG

10mg/mL Injection00874582 DEXAMETHASONE SDZ00783900 PMS-DEXAMETHASONE PMS

FLUDROCORTISONE ACETATE0.1mg Tablet

02086026 FLORINEF SHI

FLUTICASONE PROPIONATE50mcg/Inhalation Inhaler

02244291 FLOVENT HFA 50 GSK125mcg/Inhalation Inhaler

02244292 FLOVENT HFA 125 GSK250mcg/Inhalation Inhaler

02244293 FLOVENT HFA 250 GSK50mcg/Dose Powder Diskus

02237244 FLOVENT DISKUS GSK100mcg/Dose Powder Diskus



02237247 FLOVENT DISKUS GSK

HYDROCORTISONE10mg Tablet

00030910 CORTEF PFI20mg Tablet

00030929 CORTEF PFI

METHYLPREDNISOLONE4mg Tablet

00030988 MEDROL PFI16mg Tablet

00036129 MEDROL PFI

METHYLPREDNISOLONE ACETATE40mg/mL Suspension for Injection

00030759 DEPO-MEDROL PMJ02245400 METHYLPREDNISOLONE

ACETATESDZ

02245407 METHYLPREDNISOLONE ACETATE

SDZ

80mg/mL Suspension for Injection00030767 DEPO-MEDROL PMJ02245406 METHYLPREDNISOLONE

ACETATESDZ

02245408 METHYLPREDNISOLONE ACETATE

SDZ

20mg/mL Suspension for Injection (Multi-Dose)01934325 DEPO-MEDROL PMJ

Page 93 of 1242010


68:04.00 ADRENALSMETHYLPREDNISOLONE ACETATE



PREDNISOLONE SODIUM PHOSPHATE1mg/mL Oral Liquid

02230619 PEDIAPRED AVT02245532 PMS-PREDNISOLONE PMS

PREDNISONE1mg Tablet

00598194 APO-PREDNISONE APX00271373 WINPRED VAE

5mg Tablet00312770 APO-PREDNISONE APX00156876 PREDNISONE PRO

50mg Tablet00550957 APO-PREDNISONE APX00232378 NOVO-PREDNISONE NOP00607517 PREDNISONE PRO

TRIAMCINOLONE ACETONIDE10mg/mL Suspension for Injection

01999761 KENALOG-10 WSB02229540 TRIAMCINOLONE SDZ

40mg/mL Suspension for Injection01999869 KENALOG-40 WSB02229550 TRIAMCINOLONE SDZ09857128 TRIAMCINOLONE ACETONIDE

(5ML)SDZ

TRIAMCINOLONE DIACETATE40mg/mL Suspension for Injection

01977555 STERILE TRIAMCINOLONE CYX

TRIAMCINOLONE HEXACETONIDE20mg/mL Suspension for Injection

02194155 ARISTOSPAN VAO

68:08.00 ANDROGENSDANAZOL

50mg Capsule02018144 CYCLOMEN SAC



TESTOSTERONE CYPIONATE100mg/mL Injection

00030783 DEPO-TESTOSTERONE PFI02246063 TESTOSTERONE CYPIONATE SDZ

68:08.00 ANDROGENSTESTOSTERONE ENANTHATE

200mg/mL Injection00029246 DELATESTRYL BMS00739944 PMS-TESTOSTERONE PMS

TESTOSTERONE UNDECANOATE40mg Capsule

00782327 ANDRIOL ORG02322498 PMS-TESTOSTERONE PMS

68:12.00 CONTRACEPTIVESETHINYL ESTRADIOL, DESOGESTREL

25mcg & 150mcg (21) Tablet02272903 LINESSA (21) ORG

25mcg & 150mcg (28) Tablet02257238 LINESSA (28) ORG

30mcg & 150mcg (21) Tablet02317192 APRI 21 BAR02042487 MARVELON (21) ORG

30mcg & 150mcg (28) Tablet02317206 APRI 28 BAR02042479 MARVELON (28) ORG02042533 ORTHO CEPT (28) JNO

ETHINYL ESTRADIOL, D-NORGESTREL50mcg & 250mcg (21) Tablet

02043033 OVRAL (21) WAY

ETHINYL ESTRADIOL, DROSPIRENONE3mg/0.02mg Tablet

02321157 YAZ BAY30mcg & 3mg (21) Tablet

02261723 YASMIN (21) BEX30mcg & 3mg (28) Tablet

02261731 YASMIN (28) BEX

ETHINYL ESTRADIOL, ETHYNODIOL DIACETATE

30mcg & 2mg (21) Tablet00469327 DEMULEN 30 (21) PFI

30mcg & 2mg (28) Tablet00471526 DEMULEN 30 (28) PFI

ETHINYL ESTRADIOL, ETONOGESTRELLimited use benefit (prior approval required).

For patients who are intolerant to or unable to take oral contraceptives.

11.4mg & 2.6mg Device02253186 NUVARING ORG

ETHINYL ESTRADIOL, LEVONORGESTREL20mcg & 100mcg (21) Tablet

02236974 ALESSE (21) WAY02298538 AVIANE 21 BAR

Page 94 of 1242010


68:12.00 CONTRACEPTIVESETHINYL ESTRADIOL, LEVONORGESTREL

20mcg & 100mcg (28) Tablet02236975 ALESSE (28) WAY02298546 AVIANE 28 BAR

30mcg & 0.05mg (6), 40mcg & 0.075mg (5), 30mcg & 0.125mg (10) (21) Tablet

00707600 TRIQUILAR (21) BEX30mcg & 0.05mg (6), 40mcg & 0.075mg (5), 30mcg & 0.125mg (10), (28) Tablet

00707503 TRIQUILAR (28) BEX30mcg & 150mcg (21) Tablet

02042320 MIN OVRAL (21) WAY02295946 PORTIA 21 BAR

30mcg & 150mcg (28) Tablet02042339 MIN OVRAL (28) WAY02295954 PORTIA 28 BAR

ETHINYL ESTRADIOL, NORETHINDRONE35mcg & 0.5mg (21) Tablet

02187086 BREVICON 0.5/35 (21) PFI00317047 ORTHO 0.5/35 (21) JNO

35mcg & 0.5mg (28) Tablet02187094 BREVICON 0.5/35 (28) PFI00340731 ORTHO 0.5/35 (28) JNO

35mcg & 0.5mg (7), 35mcg & 1mg (9), 35mcg & 0.5mg (5) (21) Tablet

02187108 SYNPHASIC (21) PFI35mcg & 0.5mg (7), 35mcg & 1mg (9), 35mcg & 0.5mg (5) (28) Tablet

02187116 SYNPHASIC (28) PFI35mcg & 1mg (21) Tablet

02189054 BREVICON 1/35 (21) PFI00372846 ORTHO 1/35 (21) JNO02197502 SELECT 1/35 (21) DSP

35mcg & 1mg (28) Tablet02189062 BREVICON 1/35 (28) PFI00372838 ORTHO 1/35 (28) JNO02199297 SELECT 1/35 (28) DSP

35mcg & 500mcg (7), 35mcg & 750mcg (7), 35mcg & 1mg (7) (21) Tablet

00602957 ORTHO 7/7/7 (21) JNO35mcg & 500mcg (7), 35mcg & 750mcg (7), 35mcg & 1mg (7), (28) Tablet

00602965 ORTHO 7/7/7 (28) JNO

ETHINYL ESTRADIOL, NORETHINDRONE ACETATE

20mcg & 1mg (21) Tablet00315966 MINESTRIN 1/20 (21) GCL

20mcg & 1mg (28) Tablet00343838 MINESTRIN 1/20 (28) GCL

30mcg & 1.5mg (21) Tablet00297143 LOESTRIN 1.5/30 (21) GCL

30mcg & 1.5mg (28) Tablet00353027 LOESTRIN 1.5/30 (28) GCL

68:12.00 CONTRACEPTIVESETHINYL ESTRADIOL, NORGESTIMATE

25mcg & 0.180mg (7), 25mcg & 0.215mg (7), 25mcg & 0.25mg (7) (21) Tablet

02258560 TRI-CYCLEN LO JNO25mcg & 0.180mg (7), 25mcg & 0.215mg (7), 25mcg & 0.25mg (7), (28) Tablet

02258587 TRI-CYCLEN LO JNO35mcg & 0.180mg (7), 35mcg & 0.215mg (7), 35mcg & 0.25mg (7) (21) Tablet

02028700 TRI-CYCLEN (21) JNO35mcg & 0.180mg (7), 35mcg & 0.215mg (7), 35mcg & 0.25mg (7), (28) Tablet

02029421 TRI-CYCLEN (28) JNO35mcg & 0.25mg (21) Tablet

01968440 CYCLEN (21) JNO35mcg & 0.25mg (28) Tablet

01992872 CYCLEN (28) JNO

LEVONORGESTREL52mg Intrauterine Insert

02243005 MIRENA BAY0.75mg Tablet

02285576 NORLEVO LAP02241674 PLAN B BAR

NORETHINDRONE0.35mg (28) Tablet

00037605 MICRONOR (28) JNO

68:16.04 ESTROGENSCONJUGATED ESTROGENS

0.3mg Tablet02043394 PREMARIN WAY

0.625mg Tablet00265470 C.E.S. VAE02043408 PREMARIN WAY

1.25mg Tablet02043424 PREMARIN WAY

0.625mg/g Vaginal Cream02043440 PREMARIN WAY

CONJUGATED ESTROGENS, MEDROXYPROGESTERONE ACETATE

0.625mg & 2.5mg Kit02242878 PREMPLUS WAY

0.625mg & 5mg Kit02242879 PREMPLUS WAY

ESTRADIOL0.06% Gel

02238704 ESTROGEL SCH0.39mg Patch

02245676 ESTRADOT 25 NVR0.585mg Patch

02243999 ESTRADOT 37.5 NVR

Page 95 of 1242010


68:16.04 ESTROGENSESTRADIOL

0.78mg Patch02244000 ESTRADOT 50 NVR



5mg Patch02243722 OESCLIM PAL

10mg Patch02243724 OESCLIM PAL

25mcg Patch00756849 ESTRADERM NVR

50mcg Patch00756857 ESTRADERM NVR02246967 SANDOZ-ESTRADIOL DERM SDZ

75mcg Patch02246968 SANDOZ-ESTRADIOL DERM SDZ

100mcg Patch00756792 ESTRADERM NVR02246969 SANDOZ-ESTRADIOL DERM SDZ

0.5mg Tablet02225190 ESTRACE SHI

1mg Tablet02148587 ESTRACE SHI

2mg Tablet02148595 ESTRACE SHI

2mg Vaginal Ring02168898 ESTRING PMJ

25mcg Vaginal Tablet02241332 VAGIFEM NOO

ESTRADIOL (ESTRADIOL HEMIHYDRATE)25mcg Patch

02247499 CLIMARA 25 BEX50mcg Patch



02231510 CLIMARA 100 BEX

ESTRADIOL, NORETHINDRONE ACETATE0.51mg & 4.8mg Patch

02241837 ESTALIS 250/50 NVR0.62mg & 2.7mg Patch

02241835 ESTALIS 140/50 NVR

ESTRONE1mg/g Vaginal Cream

00727369 NEO-ESTRONE NEO

68:16.04 ESTROGENSESTROPIPATE

0.625mg Tablet02089793 OGEN PFI



ETHINYL ESTRADIOL, NORETHINDRONE ACETATE

1mg/5mcg Tablet02242531 FEMHRT WCI

68:16.12 ESTROGEN AGONISTS-ANTAGONISTS

RALOXIFENE HCLLimited use benefit (prior approval required).

For:a.- secondary prevention of osteoporosis in women who experience failure on bisphosphonates.b. - secondary prevention of osteoporosis in women who have a personal history or a first degree relative with a history of breast cancer.

60mg Tablet02279215 APO-RALOXIFENE APX02239028 EVISTA LIL02312298 NOVO-RALOXIFENE NOP

68:18.00 GONADOTROPINSNAFARELIN ACETATE

2mg/mL Nasal Solution02188783 SYNAREL PFI

68:20.02 ALPHA-GLUCOSIDASE INHIBITORS

ACARBOSE50mg TabletST

02190885 GLUCOBAY BAY100mg TabletST

02190893 GLUCOBAY BAY

Page 96 of 1242010


68:20.04 BIGUANIDESMETFORMIN HCL

500mg TabletST

02167786 APO-METFORMIN APX02257726 CO METFORMIN COB02229994 DOM-METFORMIN DPC02148765 GEN-METFORMIN GEN02099233 GLUCOPHAGE SAC02229516 GLYCON VAE02230670 MED-METFORMIN MEC02220628 METFORMIN PDL02242794 METFORMIN ZYM02045710 NOVO-METFORMIN NOP02162822 NU-METFORMIN NXP02223562 PMS-METFORMIN PMS02314908 PRO-METFORMIN PDL02269031 RAN-METFORMIN RBY02242974 RATIO-METFORMIN RPH02233999 RHOXAL-METFORMIN RHO02239081 RIVA-METFORMIN RIV02246820 SANDOZ-METFORMIN FC SDZ

850mg TabletST

02229785 APO-METFORMIN APX02257734 CO METFORMIN COB02242726 DOM-METFORMIN DPC02229656 GEN-METFORMIN GEN02162849 GLUCOPHAGE SAC02239214 GLYCON VAE02231058 METFORMIN PDL02242793 METFORMIN ZYM02230475 NOVO-METFORMIN NOP02229517 NU-METFORMIN NXP02242589 PMS-METFORMIN PMS02314894 PRO-METFORMIN PDL02269058 RAN-METFORMIN RBY02242931 RATIO-METFORMIN RPH02242783 RIVA-METFORMIN RIV02246821 SANDOZ-METFORMIN SDZ

68:20.08 INSULINSINSULIN (30% NEUTRAL & 70% ISOPHANE) HUMAN BIOSYNTHETIC

100U/mL Injection02024217 NOVOLIN GE 30/70 10ML NOO

100U/mL (3mL) Injection00908134 NOVOLIN GE 30/70 PENFILL NOO00920681 NOVOLIN GE 30/70 PENFILL NOO09853812 NOVOLIN GE 30/70 PENFILL NOO

INSULIN (40% NEUTRAL & 60% ISOPHANE) HUMAN BIOSYNTHETIC

100U/mL (3mL) Injection02024314 NOVOLIN GE 40/60 PENFILL NOO

INSULIN (50% NEUTRAL & 50% ISOPHANE) HUMAN BIOSYNTHETIC

100U/mL (3mL) Injection02024322 NOVOLIN GE 50/50 PENFILL NOO

68:20.08 INSULINSINSULIN (ISOPHANE) HUMAN BIOSYNTHETIC

100U/mL Injection00587737 HUMULIN N 10ML LIL02024225 NOVOLIN GE NPH 10ML NOO

100U/mL (1.5mL) Injection01959239 HUMULIN N CARTRIDGE LIL99000342 NOVOLIN GE NPH PENFILL NOO

100U/mL (3mL) Injection00908991 HUMULIN N CARTRIDGE LIL09853804 HUMULIN N CARTRIDGE LIL99001586 HUMULIN N CARTRIDGE LIL09853782 NOVOLIN GE NPH PENFILL NOO99000334 NOVOLIN GE NPH PENFILL NOO

100U/mL Injection (Pre-filled Pen)02241310 HUMULIN N LIL

INSULIN (ZINC CRYSTALLINE) HUMAN BIOSYNTHETIC (RDNA ORIGIN)

100U/mL Injection00586714 HUMULIN R 10ML LIL

100U/mL (1.5mL) Injection01959220 HUMULIN R CARTRIDGE LIL

100U/mL (3mL) Injection09853766 HUMULIN R CARTRIDGE LIL99001594 HUMULIN R CARTRIDGE LIL

INSULIN ASPART100U/mL Injection

02245397 NOVORAPID NOO100U/mL (3mL) Injection

02244353 NOVORAPID NOO

INSULIN GLULISINE100U/mL Injection

02279460 APIDRA SAC02279479 APIDRA SAC02294346 APIDRA SOLOSTAR SAC

INSULIN HUMAN BIOSYNTHETIC100U/mL Injection

02024233 NOVOLIN GE TORONTO NOO100U/mL (3mL) Injection

00908746 NOVOLIN GE TORONTO PENFILL

NOO


NOO


NOO

INSULIN HUMAN BIOSYNTHETIC 20% & ISOPHANE 80%

100U/mL (3mL) Injection09853847 HUMULIN 20/80 CARTRIDGE LIL99001616 HUMULIN 20/80 CARTRIDGE LIL

Page 97 of 1242010


68:20.08 INSULINSINSULIN HUMAN BIOSYNTHETIC 30% & ISOPHANE 70%

100U/mL Injection00795879 HUMULIN 30/70 LIL

100U/mL (1.5mL) Injection00909009 HUMULIN 30/70 CARTRIDGE LIL01959212 HUMULIN 30/70 CARTRIDGE LIL

100U/mL (3mL) Injection09853855 HUMULIN 30/70 CARTRIDGE LIL99001632 HUMULIN 30/70 CARTRIDGE LIL

INSULIN LISPRO100IU/mL Injection

02229704 HUMALOG 10ML LIL100U/mL (1.5mL) Injection

02229705 HUMALOG CARTRIDGE LIL100U/mL (3mL) Injection

02233562 HUMALOG CARTRIDGE LIL09853715 HUMALOG CARTRIDGE LIL99002817 HUMALOG CARTRIDGE LIL

100IU/mL Injection (Pre-filled Pen)02241283 HUMALOG LIL

INSULIN ZINC SUSPENSION MEDIUM HUMAN BIOSYNTHETIC (RDNA ORIGIN)

100U/mL Injection00646148 HUMULIN L 10ML LIL

68:20.16 MEGLITINIDESNATEGLINIDE

60mg TabletST

02245438 STARLIX NVR120mg TabletST

02245439 STARLIX NVR

REPAGLINIDE0.5mg TabletST

02239924 GLUCONORM NOO1mg TabletST

02239925 GLUCONORM NOO2mg TabletST

02239926 GLUCONORM NOO

68:20.20 ANTIDIABETIC AGENTS - SULFONYLUREAS

GLICLAZIDE30mg TabletST

02297795 APO-GLICLAZIDE MR APX02242987 DIAMICRON MR SEV

68:20.20 ANTIDIABETIC AGENTS - SULFONYLUREAS

GLICLAZIDE80mg TabletST

02245247 APO-GLICLAZIDE APX00765996 DIAMICRON SEV02229519 GEN-GLICLAZIDE GEN02248453 GLICLAZIDE PDL02238103 NOVO-GLICLAZIDE NOP02294400 PMS-GLICAZIDE PMS02155850 PROVAL-GLICLAZIDE PRO

GLYBURIDE2.5mg TabletST

01913654 APO-GLYBURIDE APX02224550 DIABETA SAC02234513 DOM-GLYBURIDE DPC00720933 EUGLUCON PMS00808733 GEN-GLYBE GEN01959352 GLYBURIDE PDL02084341 MED-GLYBE MEC01913670 NOVO-GLYBURIDE NOP02020734 NU-GLYBURIDE NXP01900927 RATIO-GLYBURIDE RPH02236543 RIVA-GLYBURIDE RIV02248008 SANDOZ-GLYBURIDE SDZ

5mg TabletST

01913662 APO-GLYBURIDE APX02224569 DIABETA SAC02234514 DOM-GLYBURIDE DPC00720941 EUGLUCON PMS00808741 GEN-GLYBE GEN01959360 GLYBURIDE PDL02085887 MED-GLYBE MEC01913689 NOVO-GLYBURIDE NOP02020742 NU-GLYBURIDE NXP02316544 PDL-GLYBURIDE PDL02236734 PMS-GLYBURIDE PMS01900935 RATIO-GLYBURIDE RPH02236548 RIVA-GLYBURIDE PHH02248009 SANDOZ-GLYBURIDE SDZ

TOLBUTAMIDE500mg TabletST

00312762 APO-TOLBUTAMIDE APX00156663 TOLBUTAMIDE PRO

Page 98 of 1242010


68:20.28 THIAZOLIDINEDIONESPIOGLITAZONE HCLLimited use benefit (prior approval required).

For treatment of type 2 diabetic patients who are not adequately controlled by or are intolerant to metformin and sulfonylureas or for whom these products are contraindicated.

15mg TabletST

02303442 ACCEL PIOGLITAZONE ACP02242572 ACTOS LIL02302942 APO-PIOGLITAZONE APX02302861 CO PIOGLITAZONE COB02307634 DOM-PIOGLITAZONE DOM02298279 GEN-PIOGLITAZONE GEN02326477 MINT-PIOGLITAZONE MIN02274914 NOVO-PIOGLITAZONE NOP02307669 PHL-PIOGLITAZONE PMI02303124 PMS-PIOGLITAZONE PMS02312050 PRO-PIOGLITAZONE PDL02301423 RATIO-PIOGLITAZONE RPH02297906 SANDOZ PIOGLITAZONE SDZ02320754 ZYM-PIOGLITAZONE ZYM

30mg TabletST


45mg TabletST


68:20.28 THIAZOLIDINEDIONESROSIGLITAZONE MALEATELimited use benefit (prior approval required).


2mg TabletST

02241112 AVANDIA GSK4mg TabletST

02241113 AVANDIA GSK8mg TabletST

02241114 AVANDIA GSK

68:22.12 GLYCOGENOLYTIC AGENTSGLUCAGON RECOMBINANT DNA ORGIN

1mg/mL Injection02243297 GLUCAGON LIL

68:24.00 PARATHYROIDCALCITONIN SALMON (MIACALCIN)Limited use benefit (prior approval required).

For treatment of patients with postmenopausal osteoporosis who have failed therapy, are intolerant to, or who have contraindications to both bisphosphonates and raloxifene.

200IU/Dose Nasal Spray02247585 APO-CALCITONIN APX02240775 MIACALCIN NVR02261766 SANDOZ-CALCITONIN SDZ

CALCITONIN SALMON (SYNTHETIC)200IU/mL Injection

01926691 CALCIMAR SAC

68:28.00 PITUITARYDESMOPRESSIN ACETATE

4mcg/mL Injection00873993 DDAVP FEI

0.1mg/mL Nasal Solution00402516 DDAVP FEI

0.1mg/mL Nasal Spray02242465 APO-DESMOPRESSIN APX00836362 DDAVP FEI

0.1mg Tablet02284030 APO-DESMOPRESSIN APX00824305 DDAVP FEI02287730 NOVO-DESMOPRESSIN NOP02304368 PMS-DESMOPRESSIN PMS

0.2mg Tablet02284049 APO-DESMOPRESSIN APX00824143 DDAVP FEI02287749 NOVO-DESMOPRESSIN NOP02304376 PMS-DESMOPRESSIN PMS

60mcg Tablet02284995 DDAVP MELT FEI


Page 99 of 1242010


68:28.00 PITUITARYDESMOPRESSIN ACETATE


68:32.00 PROGESTINSMEDROXYPROGESTERONE ACETATE

50mg/mL Injection00030848 DEPO-PROVERA PFI

150mg/mL Injection00585092 DEPO-PROVERA PFI02322250 MEDROXYPROGESTERONE SDZ

2.5mg Tablet02244726 APO-MEDROXY APX02247581 DOM-

MEDROXYPROGESTERONEDPC

02229838 GEN-MEDROXY GEN02221284 NOVO-MEDRONE NOP02252740 NU-MEDROXY NXP02253550 PDL-MEDROXY PDL00708917 PROVERA PFI

5mg Tablet02244727 APO-MEDROXY APX02247582 DOM-


02229839 GEN-MEDROXY GEN02221292 NOVO-MEDRONE NOP02252759 NU-MEDROXY NXP02253577 PDL-MEDROXY PDL00030937 PROVERA PFI02010739 PROVERA PAK PFI

10mg Tablet02277298 APO-MEDROXY APX02247583 DOM-


02229840 GEN-MEDROXY GEN02221306 NOVO-MEDRONE NOP00729973 PROVERA PFI02010933 PROVERA PFI

100mg Tablet02267640 APO-MEDROXY APX00030945 PROVERA PFI

68:36.04 THYROID AGENTSLEVOTHYROXINE SODIUM

0.025mg TabletST

02264323 EUTHYROX GEN02172062 SYNTHROID ABB

0.05mg TabletST

02213192 ELTROXIN GSK02264331 EUTHYROX GEN02172070 SYNTHROID ABB

0.075mg TabletST


0.088mg TabletST

02172097 SYNTHROID ABB

68:36.04 THYROID AGENTSLEVOTHYROXINE SODIUM

0.1mg TabletST


0.112mg TabletST


0.125mg TabletST


0.137mg TabletST


0.15mg TabletST


0.175mg TabletST


0.2mg TabletST


0.3mg TabletST


THYROID30mg TabletST

00023949 THYROID ERF60mg TabletST

00023957 THYROID ERF125mg TabletST

00023965 THYROID ERF

68:36.08 ANTITHYROID AGENTSPROPYLTHIOURACIL

50mg TabletST

00010200 PROPYL THYRACIL SQU100mg TabletST

00010219 PROPYL THYRACIL SQU

THIAMAZOLE5mg TabletST

00015741 TAPAZOLE PAL10mg TabletST

02296039 TAPAZOLE PAL

Page 100 of 1242010


80:00 SERUMS, TOXOIDS, AND VACCINES

80:04.00 SERUMSDOLICHOVESPULA ARENARIA VENOM PROTEIN

120mcg Injection01948946 YELLOW HORNET VENOM

PROTEINALK

DOLICHOVESPULA MACULATA VENOM PROTEIN EXTRACT

120mcg Injection01949004 WHITE FACED HORNET

VENOMALK

HONEY BEE VENOM PROTEIN EXTRACT1.1mg Injection

01948903 HONEY BEE VENOM ALK120mcg Injection

01948911 HONEY BEE VENOM ALK02226197 VENOMIL HONEY BEE VENOM HOL

550mcg Injection02220075 HONEY BEE VENOM HOL

NON POLLENInjection

00299979 ALLERGENIC EXTRACT NON POLLENS

ALK

00514713 ALLERGENIC EXTRACTS MSL

POLISTES SPP VENOM PROTEIN EXTRACT1.1mg Injection

01948970 WASP VENOM PROTEIN ALK

POLLENInjection

00299987 ALLERGENIC EXTRACT POLLENS

ALK

00464988 POLLINEX R BEN

POLLEN AND NON POLLENInjection

00648922 CENTER-AL ALK

VESPULA SPP VENOM PROTEIN EXTRACT1.1mg Injection

01948954 YELLOW JACKET VENOM PROTEIN

ALG

120mcg Injection01948962 YELLOW JACKET VENOM

PROTEINALK

WASP VENOM PROTEIN120mcg Injection

02226219 VENOMIL WASP VENOM PROTEIN

HOL

550mcg Injection02220091 WASP VENOM PROTEIN HOL

80:04.00 SERUMSWHITE FACED HORNET VENOM PROTEIN

120mcg Injection02226235 VENOMIL WHITE FACED

HORNET VENOM PROTEINHOL

WHITE FACED HORNET VENOM PROTEIN, YELLOW HORNET VENOM PROTEIN, YELLOW JACKET VENOM PROTEIN

120mcg Injection01948881 MIXED VESPID VENOM

PROTEINALK

02226294 VENOMIL MIXED VESPID VENOM PROTEIN

HOL

550mcg Injection02221314 MIXED VESPID VENOM

PROTEINHOL

YELLOW HORNET VENOM PROTEIN100mcg/mL Injection

02226251 YELLOW JACKET HORNET VENOM PROTEIN

BAY

500mcg Injection02220083 YELLOW HORNET VENOM

PROTEINHOL

YELLOW JACKET VENOM PROTEIN120mcg Injection

02226286 VENOMIL YELLOW JACKET VENOM PROTEIN

HOL

550mcg Injection02220113 YELLOW JACKET VENOM

PROTEINBAY

Page 101 of 1242010


84:00 SKIN AND MUCOUS MEMBRANE AGENTS (SMMA)

84:04.04 SMMA - ANTIBIOTICSBACITRACIN

500IU Ointment00584908 BACITIN PMS

BACITRACIN ZINC, POLYMYXIN B SULFATE500IU & 10,000IU Ointment

02237227 POLYSPORIN ANTIBIOTIC PFI

CLINDAMYCIN PHOSPHATE1% Solution

00582301 DALACIN T PFI02266938 TARO-CLINDAMYCIN TAR

2% Vaginal Cream02060604 DALACIN PMJ

ERYTHROMYCIN, TRETINOIN4% & 0.01% Gel

02015994 STIEVAMYCIN MILD STI4% & 0.025% Gel

01905112 STIEVAMYCIN STI4% & 0.05% Gel

01945262 STIEVAMYCIN FORTE STI

FUSIDATE SODIUM2% Ointment

00586676 FUCIDIN LEO

FUSIDIC ACID2% Cream

00586668 FUCIDIN LEO

GRAMICIDIN, POLYMYXIN B SULFATE0.25mg & 10,000IU Cream

02230844 POLYSPORIN ANTIBIOTIC PFI

MUPIROCIN2% Cream

02239757 BACTROBAN GSK2% Ointment

01916947 BACTROBAN GSK02279983 TARO-MUPIROCIN 2%

OINTMENTTAR

POLYMYXIN B SULFATE, BACITRACIN10,000IU & 500IU Ointment

00792217 ANTIBIOTIC PDD00876488 BACIMYXIN PMS00621366 BIODERM ODN01942921 POLYTOPIC SDZ

84:04.06 SMMA - ANTIVIRALSACYCLOVIR

5% Cream02039524 ZOVIRAX GSK

84:04.06 SMMA - ANTIVIRALSACYCLOVIR

5% Ointment00569771 ZOVIRAX GSK

IDOXURIDINE0.1% Topical Solution

00001317 HERPLEX-D LIQUIFILM ALL02237187 SANDOZ-IDOXURIDINE SDZ

84:04.08 SMMA - ANTIFUNGALSCLOTRIMAZOLE

1% Cream02150867 CANESTEN BCD00812382 CLOTRIMADERM TAR

1% & 200mg Cream & Vaginal Suppository02264099 CANESTEN 3 COMFORT

COMBI PAKBCD

1% & 500mg Cream & Vaginal Suppository02264102 CANESTEN 1 COMFORT

COMBI PAKBCD

1% Vaginal Cream02150891 CANESTEN BCD00812366 CLOTRIMADERM TAR

2% Vaginal Cream02150905 CANESTEN BCD00812374 CLOTRIMADERM TAR

KETOCONAZOLE2% Cream

02245662 KETODERM TAR2% Shampoo

02182920 NIZORAL MCL

MICONAZOLE NITRATE2% Cream

02085852 MICATIN MCL02126567 MONISTAT-DERM MCL

2% & 100mg Cream & Vaginal Suppository02126257 MONISTAT 7 DUAL PAK MCL

2% & 400mg Cream & Vaginal Suppository02126249 MONISTAT 3 DUAL PAK MCL

2% Vaginal Cream02231106 MICOZOLE TAR00980625 MONISTAT MCL02084309 MONISTAT 7 MCL

400mg Vaginal Suppository02171775 MICONAZOLE VTH02126605 MONISTAT 3 MCL

NYSTATIN100,000IU Cream

00716871 NYADERM TAR02194236 RATIO-NYSTATIN RPH

100,000IU Ointment02194228 RATIO-NYSTATIN RPH

Page 102 of 1242010


84:04.08 SMMA - ANTIFUNGALSNYSTATIN

Powder00907472 NYSTATIN WLR

25,000IU Vaginal Cream00716901 NYADERM TAR

100,000IU Vaginal Cream02194163 RATIO-NYSTATIN RPH

100,000IU Vaginal Tablet02194171 RATIO-NYSTATIN RPH

TERBINAFINE HCL1% Cream

02031094 LAMISIL NVR

TERCONAZOLE0.4% Vaginal Cream

02247651 TARO-TERCONAZOLE TAR00894729 TERAZOL 7 JNO

0.8% & 80mg Vaginal Cream & Vaginal Suppository02130874 TERAZOL 3 DUAL PAK JNO

TOLNAFTATE1% Cream

00576034 TINACTIN SCH1% Powder

01919245 ATHLETES FOOT SPRAY SCH00576042 TINACTIN SCH02029081 ZEASORB AF STI

1% Spray00576050 TINACTIN AEROSOL SCH

84:04.12 SMMA - SCABICIDES AND PEDICULICIDES

CROTAMITON10% Cream

00623377 EURAX NVC

ISOPROPYL MYRISTATE50% Solution

02279592 RESULTZ NYC

LINDANE1% Lotion

00703591 PMS-LINDANE PMS1% Shampoo

00430617 HEXIT ODN00703605 PMS-LINDANE PMS

PERMETHRIN5% Cream

02219905 NIX DERMAL GSK5% Lotion

02231348 KWELLADA-P GSK1% Rinse

02231480 KWELLADA-P GSK00771368 NIX WLA

84:04.12 SMMA - SCABICIDES AND PEDICULICIDES

PIPERONYL BUTOXIDE, PYRETHRINS3% & 0.3% Shampoo

02125447 R & C GSK

84:04.92 SMMA - MISCELLANEOUS LOCAL ANTI-INFECTIVES

BENZOYL PEROXIDE2.5% Gel (Acetone Base)

00406813 ACETOXYL STI5% Gel (Alcohol Base)

02162113 BENZAGEL NVC00263702 PANOXYL-5 STI

10% Gel (Alcohol Base)00263699 PANOXYL-10 STI

20% Gel (Alcohol Base)00373036 PANOXYL-20 STI

2.5% Gel (Water Base)02214830 PANOXYL AQUAGEL STI

4% Gel (Water Base)01975382 SOLUGEL STI

5% Gel (Water Base)00899453 BENZAC AC GAC01925180 BENZAC W5 GAC02214849 PANOXYL AQUAGEL STI

8% Gel (Water Base)02019825 SOLUGEL STI

10% Gel (Water Base)01912437 BENZAC AC GAC01908871 DESQUAM X WSB

2.5% Lotion02046539 OXY 5 GSK

5% Lotion02166607 BENZAGEL 5 NVC00374326 OXYDERM VAE

10% Lotion00370568 BENOXYL STI

5% Soap00483184 PANOXYL-5 STI

10% Soap00527661 PANOXYL-10 STI

5% Wash00896276 BENZAC W GAC02162121 BENZAGEL NVC02214857 PANOXYL STI

10% Wash01925199 BENZAC W GAC

CHLORHEXIDINE ACETATE0.5% Dressing

00433497 BACTIGRAS SNE00905097 BACTIGRAS 5X5CM SNE00960330 BACTIGRAS 5X5CM SNE

Page 103 of 1242010


84:04.92 SMMA - MISCELLANEOUS LOCAL ANTI-INFECTIVES

CHLORHEXIDINE GLUCONATE2% Liquid

01938991 STANHEXIDINE OMG4% Liquid

01938983 STANHEXIDINE OMG

HYDROGEN PEROXIDE3% Liquid

00167703 HYDROGEN PEROXIDE 10V RWP00485721 HYDROGEN PEROXIDE 10V RPH00579297 PEROXIDE D'HYDROGENE ATL

METRONIDAZOLE0.75% Cream

02226839 METROCREAM GAC1% Cream

02156091 NORITATE SAC02242919 ROSASOL STI

0.75% Gel02092832 METROGEL GAC

1% Gel02297809 METROGEL GAC

0.75% Lotion02248206 METROLOTION GAC

10% Vaginal Cream01926861 FLAGYL SAC

0.75% Vaginal Gel02125226 NIDAGEL MMH

METRONIDAZOLE, NYSTATIN100mg & 20,000U/g Vaginal Cream

01926845 FLAGYSTATIN AVT500mg & 100,000IU Vaginal Suppository

01926829 FLAGYSTATIN AVT

POVIDONE-IODINE10% Liquid

00158348 BETADINE PFR

SELENIUM SULFIDE2.5% Lotion

00243000 SELSUN ABB00594601 VERSEL VAO

SILVER SULFADIAZINE1% Cream

02010917 DERMAZIN PMS00323098 FLAMAZINE SNE09854037 FLAMAZINE 50G SNE

TRICLOSAN0.5% Liquid

00632317 TERSASEPTIC STI

84:06.00 SMMA - ANTI-INFLAMMATORY AGENTS

AMCINONIDE0.1% Cream

02192284 CYCLOCORT STI02247098 RATIO-AMCINONIDE RPH02246714 TARO-AMCINONIDE TAR

0.1% Lotion02192276 CYCLOCORT STI02247097 RATIO-AMCINONIDE RPH

0.1% Ointment02192268 CYCLOCORT STI02247096 RATIO-AMCINONIDE RPH

BECLOMETHASONE DIPROPIONATE0.025% Cream

02089602 PROPADERM SHI

BETAMETHASONE DIPROPIONATE0.05% Cream

00323071 DIPROSONE SCH00804991 RATIO-TOPISONE RPH02122049 ROSONE RIV01925350 TARO-SONE TAR

0.05% Lotion00417246 DIPROSONE SCH00809187 RATIO-TOPISONE RPH02122030 ROSONE RIV

0.05% Ointment00344923 DIPROSONE SCH00805009 RATIO-TOPISONE RPH02122057 ROSONE RIV

BETAMETHASONE DIPROPIONATE IN PROPYLENE GLYCOL

0.05% Cream00688622 DIPROLENE SCH00849650 RATIO-TOPILENE GLYCOL RPH02122073 ROLENE RIV

0.05% Lotion00862975 DIPROLENE SCH01927914 RATIO-TOPILENE GLYCOL RPH02122065 ROLENE RIV

0.05% Ointment00629367 DIPROLENE SCH00849669 RATIO-TOPILENE GLYCOL RPH02122081 ROLENE RIV

BETAMETHASONE DIPROPIONATE, CLOTRIMAZOLE

0.05% & 1% Cream00611174 LOTRIDERM SCH

BETAMETHASONE DIPROPIONATE, SALICYLIC ACID

0.05% & 2% Lotion00578428 DIPROSALIC SCH02245688 RATIO-TOPISALIC RPH

Page 104 of 1242010



BETAMETHASONE DIPROPIONATE, SALICYLIC ACID

0.05% & 3% Ointment00578436 DIPROSALIC SCH

BETAMETHASONE DISODIUM PHOSPHATE0.05mg/mL Enema

02060884 BETNESOL SHI

BETAMETHASONE VALERATE0.05% Cream

00535427 RATIO-ECTOSONE RPH0.1% Cream

00716626 BETADERM TAR00804541 PREVEX B STI00535435 RATIO-ECTOSONE RPH

0.05% Lotion00653209 RATIO-ECTOSONE RPH

0.1% Lotion00750050 RATIO-ECTOSONE RPH01940112 RIVASONE RIV

0.05% Ointment00716642 BETADERM TAR

0.1% Ointment00716650 BETADERM TAR

0.1% Scalp Lotion00716634 BETADERM TAR00027944 VALISONE SCH

BUDESONIDE0.02mg/mL Enema

02052431 ENTOCORT AZC

CLOBETASOL PROPIONATE0.05% Cream

02245523 CLOBETASOL PROPIONATE TAR02213265 DERMOVATE TAR02024187 GEN-CLOBETASOL GEN02093162 NOVO-CLOBETASOL NOP02232191 PMS-CLOBETASOL PMS01910272 RATIO-CLOBETASOL RPH

0.05% Ointment02245524 CLOBETASOL PROPIONATE TAR02213273 DERMOVATE TAR02026767 GEN-CLOBETASOL GEN02126192 NOVO-CLOBETASOL NOP02232193 PMS-CLOBETASOL PMS01910280 RATIO-CLOBETASOL RPH

0.05% Scalp Lotion02213281 DERMOVATE TAR02216213 GEN-CLOBETASOL GEN02232195 PMS-CLOBETASOL PMS01910299 RATIO-CLOBETASOL RPH

0.05% Solution02245522 CLOBETASOL PROPIONATE TAR


CLOBETASONE BUTYRATE0.05% Cream

02214415 EUMOVATE GSK

DESONIDE0.05% Cream

02229315 PMS-DESONIDE PMS02154862 TRIDESILON SCN

0.05% Lotion02115514 DESOCORT GAC

0.05% Ointment02115522 DESOCORT GAC02229323 PMS-DESONIDE PMS02154870 TRIDESILON SCN

DESOXIMETASONE0.05% Cream

02221918 TOPICORT SAC0.25% Cream

02221896 TOPICORT SAC0.05% Gel

02221926 TOPICORT SAC0.25% Ointment

02221934 TOPICORT SAC

DIFLUCORTOLONE VALERATE0.1% Cream

00587826 NERISONE STI00587818 NERISONE OILY STI

0.1% Ointment00587834 NERISONE STI

DIFLUCORTOLONE VALERATE, SALICYLIC ACID

0.1% & 3% Cream02028719 NERISALIC OILY STI

FLUOCINOLONE ACETONIDE0.025% Ointment

02162512 SYNALAR MDC0.01% Scalp Lotion

00873292 DERMA-SMOOTHE HIL0.01% Shampoo

02242738 CAPEX GAC

FLUOCINONIDE0.05% Cream

02161923 LIDEX MDC00716863 LYDERM OPT

0.05% Emollient Cream02163152 LIDEMOL MDC00598933 TIAMOL TAR

0.05% Gel02236997 LYDERM OPT02161974 TOPSYN HLR

Page 105 of 1242010



FLUOCINONIDE0.05% Ointment

02161966 LIDEX HLR02236996 LYDERM OPT

FLUTICASONE PROPIONATE0.05% Cream

02089912 CUTIVATE GSK

HALCINONIDE0.1% Cream

02011921 HALOG WSB

HALOBETASOL PROPIONATE0.05% Cream

01962701 ULTRAVATE WSB0.05% Ointment

01962728 ULTRAVATE WSB

HYDROCORTISONE0.5% Cream

00513288 CORTATE SCH1% Cream

02086034 BARRIERE HC SHI00192597 EMO CORT STI00804533 PREVEX HC STI

2.5% Cream00595799 EMO CORT STI

100mg/60mL Enema02112736 CORTENEMA AXC00230316 HYCORT VAE

0.5% Lotion00513253 CORTATE SCH

1% Lotion00192600 EMO CORT STI00578541 SARNA HC STI

2.5% Lotion00595802 EMO CORT STI00641154 EMO CORT SCALP STI00856711 SARNA HC STI

0.5% Ointment00513261 CORTATE SCH00716685 CORTODERM TAR

1% Ointment00716693 CORTODERM TAR

HYDROCORTISONE ACETATE10% Aerosol Foam

00579335 CORTIFOAM SQU0.5% Cream

00716820 HYDERM TAR1% Cream

00716839 HYDERM TAR2% Cream

00749834 NEO-HC NEO


HYDROCORTISONE ACETATE1% Lotion

00681997 DERMAFLEX HC NEO

HYDROCORTISONE ACETATE, ZINC SULFATE0.5% & 0.5% Ointment

02128446 ANODAN-HC ODN00505773 ANUSOL HC PFI02209764 EGOZINC-HC PMS00607789 RATIO-HEMCORT HC RPH02179547 RIVASOL HC RIV02247691 SANDOZ-ANUZINC HC SDZ

10mg & 10mg Suppository02236399 ANODAN-HC ODN00476285 ANUSOL HC PFI02210517 EGOZINC HC PMS00607797 RATIO-HEMCORT HC RPH02240112 RIVASOL-HC RIV02242798 SANDOZ ANUZINC HC SDZ

HYDROCORTISONE ACETATE, ZINC SULFATE, PRAMOXINE HCL

0.5% & 0.5% & 1% Ointment00505781 ANUGESIC HC PFI02234466 PROCTODAN HC ODN02247692 SANDOZ-ANUZINC HC PLUS SDZ

10mg & 10mg & 20mg Suppository00476242 ANUGESIC HC PFI02240851 PROCTODAN HC ODN02242797 SANDOZ ANUZINC HC PLUS SDZ

HYDROCORTISONE VALERATE0.2% Cream

02242984 HYDROVAL TAR0.2% Ointment

02242985 HYDROVAL TAR01910132 WESTCORT WSB

HYDROCORTISONE, DIBUCAINE HCL, ESCULIN, FRAMYCETIN SULFATE

5mg & 5mg & 10mg & 10mg Ointment02247322 PROCTOL ODN02223252 PROCTOSEDYL AXC02226383 RATIO-PROCTOSONE RPH02242527 SANDOZ-PROCTOMYXIN HC SDZ

5mg & 5mg & 10mg & 10mg Suppository02247882 PROCTOL ODN02223260 PROCTOSEDYL AXC02226391 RATIO-PROCTOSONE RPH02242528 SANDOZ PROCTOMYXIN HC SDZ

HYDROCORTISONE, UREA1% & 10% Cream

00503134 UREMOL HC STI1% & 10% Lotion

00560022 UREMOL HC STI

Page 106 of 1242010



MOMETASONE FUROATE0.1% Cream

00851744 ELOCOM SCH0.1% Lotion

00871095 ELOCOM SCH02266385 TARO-MOMETASONE TAR

0.1% Ointment00851736 ELOCOM SCH02244769 PMS-MOMETASONE PMS02270862 PMS-MOMETASONE PMS02248130 RATIO-MOMETASONE RPH02264749 TARO-MOMETASONE TAR

TRIAMCINOLONE ACETONIDE0.1% Cream

02194058 ARISTOCORT R VAO0.5% Cream

02194066 ARISTOCORT C VAO0.1% Ointment

02194031 ARISTOCORT R VAO0.1% Paste

01964054 ORACORT TAR

84:08.00 SMMA - ANTIPRURITICS AND LOCAL ANESTHETICS

LIDOCAINE HCL2% Liquid

01968823 LIDODAN VISCOUS ODN00811874 PMS-LIDOCAINE VISCOUS PMS00001686 XYLOCAINE VISCOUS AZC

LIDOCAINE, PRILOCAINE2.5% & 2.5% Cream

00886858 EMLA AZC2.5% & 2.5% Patch

02057794 EMLA AZC

84:16.00 SMMA - CELL STIMULANTS AND PROLIFERANTS

TRETINOIN0.01% Cream

00897329 RETIN A JAJ00657204 STIEVA-A STI

0.025% Cream00897310 RETIN A JAJ00578576 STIEVA-A STI

0.05% Cream00443794 RETIN A JAJ00518182 STIEVA-A STI

0.1% Cream00870021 RETIN A JAJ00662348 STIEVA-A FORTE STI

0.01% Gel01926462 VITAMIN A ACID SAC

84:16.00 SMMA - CELL STIMULANTS AND PROLIFERANTS

TRETINOIN0.025% Gel

00587966 STIEVA-A STI01926470 VITAMIN A ACID SAC

0.05% Gel00641863 STIEVA-A STI01926489 VITAMIN A ACID SAC

0.025% Solution00578568 STIEVA-A STI

84:24.12 BASIC OINTMENTS AND PROTECTANTS

DIMETHICONE20% Cream

02060841 BARRIERE WPC

PETROLATUM67% Cream

00635189 PREVEX STI

ZINC OXIDE15% Cream

02215799 ZINC OXIDE CREAM 15% HJS25% Ointment

00532576 IHLES PASTE RPH40% Ointment

02239160 ZINCOFAX EXTRA STRENGTH GSK

84:28.00 KERATOLYTIC AGENTSADAPALENE

0.1% Cream02231592 DIFFERIN GAC

0.1% Gel02148749 DIFFERIN GAC

CANTHARIDIN0.7% Liquid

00589497 CANTHACUR PMS00619035 CANTHARONE DOR

CANTHARIDIN, PODOPHYLLIN, SALICYLIC ACID

1% & 2% & 30% Liquid00772011 CANTHARONE PLUS DOR

1% & 5% & 30% Liquid00589500 CANTHACUR PS PMS

DITHRANOL0.1% Cream

00537594 ANTHRANOL-1 MTI0.2% Cream

00537608 ANTHRANOL-2 MTI0.4% Lotion

00695351 ANTHRASCALP MTI

Page 107 of 1242010


84:28.00 KERATOLYTIC AGENTSDITHRANOL

1% Ointment00566756 ANTHRAFORTE MTI

2% Ointment00566748 ANTHRAFORTE MTI

FORMALDEHYDE, LACTIC ACID, SALICYLIC ACID

10% & 5% & 25% Ointment00513091 DUOPLANT STI

LACTIC ACID, SALICYLIC ACID17% & 17% Liquid

00370576 DUOFILM STI

PODOFILOX0.5% Solution

01945149 CONDYLINE CDX

PODOPHYLLIN25% Liquid

00598208 PODOFILM PMS

SALICYLIC ACID27% Gel

01939645 DUOFORTE 27 STI20% Liquid

00690333 SOLUVER DER26% Liquid

00754951 OCCLUSAL HP GEN27% Liquid

00837733 SOLUVER PLUS DER15% Plaster

02050285 TRANS PLANTAR WSB02050293 TRANS-VER-SAL WSB

40% Plaster01974335 CLEAR AWAY SCH

4% Shampoo00666106 SEBCUR DER

SALICYLIC ACID, TRICLOSAN2% & 0.5% Gel

00754927 PANOXYL ACNE STI

84:32.00 KERATOPLASTIC AGENTSCOAL TAR

10% Gel00344508 TARGEL ODN

20% Liquid00358495 ODANS LIQUOR CARBONIS

DETERGENTODN

1% Shampoo00632295 TERSA-TAR MILD STI

3% Shampoo00632309 TERSA-TAR STI

84:32.00 KERATOPLASTIC AGENTSCOAL TAR

4.3% Shampoo00740314 PENTRAX GEN

2.5% Solution01908855 BALNETAR WSB

COAL TAR, JUNIPER TAR, PINE TAR1% Shampoo

00249866 POLYTAR STI

COAL TAR, JUNIPER TAR, PINE TAR, ZINC PYRITHIONE

0.166% & 0.166% & 0.166% & 1% Shampoo00628042 MULTI-TAR PLUS MILD VAE

0.33% & 0.33% & 0.33% & 1% Shampoo02240942 MULTITAR PLUS VAE

COAL TAR, SALICYLIC ACID8% & 2% Gel

00560448 P&S PLUS BAK10% & 3% Liquid

00510335 TARGEL SA ODN10% & 4% Shampoo

00666114 SEBCUR-T DER

COAL TAR, SALICYLIC ACID, SULFUR2% & 2% & 2% Shampoo

00444448 STEREX IDE

84:50.06 PIGMENTING AGENTSMETHOXSALEN

10mg Capsule00252654 OXSORALEN VAE01946374 OXSORALEN VAE00646237 ULTRA MOP CDX

1% Lotion01907476 OXSORALEN VAE00698059 ULTRA MOP CDX

84:92.00 MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS

ACITRETINSoriatane should be used with caution in women of childbearing potential due to its teratogenicity. Pregnancy must be excluded. Effective contraception must be used. Manufacturer's literature regarding contraindications and warnings, should be consulted prior to prescribing or dispensing this drug.

10mg Capsule02070847 SORIATANE HLR

25mg Capsule02070863 SORIATANE HLR

CALCIPOTRIOL50mcg/g Cream

02150956 DOVONEX LEO

Page 108 of 1242010



CALCIPOTRIOL50mcg/g Ointment

01976133 DOVONEX LEO50mcg/mL Solution

02194341 DOVONEX LEO

CAPSAICIN0.025% Cream

02157101 CAPSAICIN VAO02244952 ZODERM EUR00740306 ZOSTRIX GEN

0.075% Cream02004240 ZOSTRIX HP GEN

0.075% Ointment02157128 CAPSAICIN HP VAO

COLLAGENASE250U Ointment

02063670 SANTYL HPC

FLUOROURACIL5% Cream

00330582 EFUDEX VAE

ISOTRETINOINAccutane should be used with caution in women of childbearing potential due to its teratogenicity. Pregnancy must be excluded. Effective contraception must be used. Manufacturer's literature regarding contraindications and warnings should be consulted prior to prescribing or dispensing this drug.

10mg Capsule00582344 ACCUTANE HLR02257955 CLARUS PRE

40mg Capsule00582352 ACCUTANE HLR02257963 CLARUS PRE

PIMECROLIMUSLimited use benefit (prior approval required).

For patients who have failed topical corticosteroid therapy or have experienced side effects from such treatment.

Note: Contraindicated in children less than 2 years of age.1% Cream

02247238 ELIDEL NVC

TACROLIMUS (PROTOPIC)Limited use benefit (prior approval required).


Note: Contraindicated in children less than 2 years of age.0.03% Ointment

02244149 PROTOPIC AST0.1% Ointment

02244148 PROTOPIC AST


TAZAROTENE0.05% Cream

02243894 TAZORAC ALL0.1% Cream

02243895 TAZORAC ALL0.05% Gel

02230784 TAZORAC ALL0.1% Gel

02230785 TAZORAC ALL

VITAMIN E30IU Ointment

01910787 VITAMIN E JLF

Page 109 of 1242010


86:00 SMOOTH MUSCLE RELAXANTS86:12.00 GENITOURINARY SMOOTH

MUSCLE RELAXANTSDARIFENACIN HYDROBROMIDE

7.5mg Long Acting Tablet02273217 ENABLEX NOV

15mg Long Acting Tablet02273225 ENABLEX NOV

FLAVOXATE HCL200mg TabletST

02244842 APO-FLAVOXATE APX00728179 URISPAS PAL

OXYBUTYNIN CHLORIDE1mg/mL SyrupST

02231089 APO-OXYBUTYNIN APX02223376 PMS-OXYBUTYNIN PMS

2.5mg TabletST

02240549 PMS-OXYBUTYNIN PMS5mg TabletST

02163543 APO-OXYBUTYNIN APX02241285 DOM-OXYBUTYNIN DPC02230800 GEN-OXYBUTYNIN GEN02230394 NOVO-OXYBUTYNIN NOP02158590 NU-OXYBUTYN NXP02220636 OXYBUTYNINE PDL02239073 PENTA-OXYBUTYNIN PEN02240550 PMS-OXYBUTYNIN PMS02299364 RIVA-OXYBUTYNIN RIV

SOLIFENACIN SUCCINATELimited use benefit (prior approval required).

For symptomatic relief in patients with an overactive bladder with symptoms of urinary frequency, urgency or urge incontinence in patients who have failed on or are intolerant of therapy with oxybutynin.

5mg TabletST

02277263 VESICARE AST10mg TabletST

02277271 VESICARE AST

TOLTERODINELimited use benefit (prior approval required).

For the symptomatic relief of patients with an overactive bladder with symptoms of urinary frequency, urgency or urge incontinence or any combination of these in patients who have failed on or are intolerant of therapy with oxybutynin.


02244612 DETROL LA PFI4mg Extended Release CapsuleST

02244613 DETROL LA PFI1mg TabletST

02239064 DETROL PFI2mg TabletST

02239065 DETROL PFI

86:12.00 GENITOURINARY SMOOTH MUSCLE RELAXANTS

TROSPIUM CHLORIDELimited use benefit (prior approval required).


20mg TabletST

02275066 TROSEC ORY

86:16.00 RESPIRATORY SMOOTH MUSCLE RELAXANTS

AMINOPHYLLINE225mg Sustained Release Tablet

02014270 PHYLLOCONTIN PFR350mg Sustained Release Tablet

02014289 PHYLLOCONTIN PFR

OXTRIPHYLLINE20mg/mL Elixir

00476366 CHOLEDYL PFI00792942 PMS-OXTRIPHYLLINE PMS

100mg Tablet00441724 APO-OXTRIPHYLLINE APX



THEOPHYLLINE5.33mg/mL Elixir

00575151 PMS-THEOPHYLLINE PMS00466409 PULMOPHYLLIN RIV00627410 THEOPHYLLINE ATL

5.33mg/mL Solution01966219 THEOLAIR MMH

100mg Sustained Release Tablet00692689 APO-THEO APX02230085 NOVO-THEOPHYL SR NOP

200mg Sustained Release Tablet00692697 APO-THEO LA APX02230086 NOVO-THEOPHYL SR NOP

300mg Sustained Release Tablet00692700 APO-THEO LA APX02230087 NOVO-THEOPHYL SR NOP

400mg Sustained Release Tablet02014165 UNIPHYL PFR

600mg Sustained Release Tablet02014181 UNIPHYL PFR

Page 110 of 1242010


88:00 VITAMINS88:04.00 VITAMIN A

VITAMIN A10,000IU CapsuleST

00557447 VIT A VTH00253820 VITAMIN A NOP00297720 VITAMIN A JAM

25,000IU CapsuleST

00021067 VITAMIN A NOP50,000IU CapsuleST

00021075 VITAMIN A NOP

88:08.00 VITAMIN B COMPLEXCYANOCOBALAMIN

100mcg/mL Injection00497533 VITAMIN B12 ABB02241500 VITAMIN B12 SDZ

1,000mcg/mL Injection01987003 CYANOCOBALAMIN CYX02052717 CYANOCOBALAMIN TAR00521515 VIT B12 SDZ00038830 VITAMIN B12 ABB

25mcg TabletST

00406988 VITAMIN B12 JAM50mcg TabletST


00450642 VIT B12 VTH02023598 VITAMIN B12 PMT

250mcg TabletST


80003575 VITAMIN B12 PMT

FOLIC ACID1mg TabletST

00318973 FOLIC ACID JAM00647039 FOLIC ACID VTH02048841 FOLIC ACID PMT02236747 FOLIC ACID PED

5mg TabletST

00426849 APO-FOLIC ACID APX02285673 EURO-FOLIC EUR00563781 FOLIC ACID PDL

NIACIN50mg TabletST

00041084 NIACIN PMS100mg TabletST

00268585 NIACIN VAE

88:08.00 VITAMIN B COMPLEXNIACIN

500mg TabletST

00294950 NIACIN VAE01939130 NIACIN ODN02247004 NIACIN PMT00557412 NIACIN YEAST FREE VTH00309737 VITAMIN B3 JAM

PYRIDOXINE HCL25mg TabletST

00122645 VITAMIN B6 JAM00232475 VITAMIN B6 PMS01943200 VITAMIN B6 ODN80002890 VITAMIN B6 JMP

50mg TabletST

00252689 VITAMIN B6 VAE00305227 VITAMIN B6 JAM00608599 VITAMIN B6 PMS

100mg TabletST

00329185 VITAMIN B6 JAM00450677 VITAMIN B6 VTH00464325 VITAMIN B6 PED00653993 VITAMIN B6 LAL02239348 VITAMIN B6 PMT

THIAMINE HCL100mg/mL Injection

02241983 BETAXIN ABB02243525 THIAMINE CYX00816078 VITAMIN B1 SDZ

50mg TabletST

80009633 JAMP-VITAMIN B1 JMP00268631 VITAMIN B1 VAE

100mg TabletST

00232467 VITAMIN B1 PMS00407011 VITAMIN B1 JAM

88:12.00 VITAMIN CASCORBIC ACID

250mg Chewable TabletST

00784575 VIT C VTH00266051 VITAMIN C PMT00274232 VITAMIN C PED00372498 VITAMIN C LAL

500mg Chewable TabletST

00274240 VITAMIN C PED00322997 VITAMIN C LAL00784591 VITAMIN C VTH02243893 VITAMIN C PMT02245721 VITAMIN C PMT


00760587 VITAMIN C PMT100mg TabletST

00466646 APO-C APX

Page 111 of 1242010


88:12.00 VITAMIN CASCORBIC ACID

250mg TabletST

00466638 APO-C APX00221244 VIT C ADA00557811 VIT C VTH00162515 VITAMIN C PMT

500mg TabletST

00266086 ASCORBIC ACID PMT00041114 VIT C ADA00322326 VIT C LAL00036188 VITAMIN C PED00316873 VITAMIN C LAL00557838 VITAMIN C VTH00721581 VITAMIN C PVR01922378 VITAMIN C SWS02244469 VITAMIN C PMT

1000mg TabletST

00466603 APO-C APX00854670 C 1000 NUL00897256 REDOXON HLR00354376 VITAMIN C PMT

88:16.00 VITAMIN DALFACALCIDOL

0.25mcg CapsuleST

00474517 ONE-ALPHA LEO1mcg CapsuleST

00474525 ONE-ALPHA LEO2mcg/mL Oral LiquidST

02240329 ONE-ALPHA LEO

CALCITRIOL0.25mcg CapsuleST

00481823 ROCALTROL HLR0.5mcg CapsuleST

00481815 ROCALTROL HLR1mcg/mL SolutionST

00824291 ROCALTROL HLR

CHOLECALCIFEROL400IU CapsuleST

02242651 EURO D EUR80006629 JAMP-VITAMIN D JMP02243976 RIVA-D RIV80005560 RIVA-D 400 UNIT CAP RIV

800IU CapsuleST

80007769 JAMP VIT D3 JMP10,000IU CapsuleST

02253178 EURO D EUR50,000IU CapsuleST

02301911 OSTOFORTE TRT400IU DropST

80001869 BABY DDROPS DDP80001792 DDROPS VITAMIN D DDP

88:16.00 VITAMIN DCHOLECALCIFEROL

400IU/mL DropST

00762881 D VI SOL MJO80003038 JAMP-VITAMIN D JMP02231624 PEDIAVIT D EUR

1000IU DropST

80001791 DDROPS VITAMIN D DDP400IU TabletST

00765384 VITAMIN D LAL02229879 VITAMIN D SWS02238729 VITAMIN D VTH02240624 VITAMIN D WAM02240858 VITAMIN D PMT02244759 VITAMIN D WNP

1,000IU TabletST

00299383 VITAMIN D JAM00323179 VITAMIN D SWS02245842 VITAMIN D PMT

10,000IU TabletST

00821772 D-TABS RIV

ERGOCALCIFEROL50,000IU CapsuleST

02237450 D-FORTE EUR8,288IU/mL SolutionST

02017598 DRISDOL SAC

VITAMIN D400IU CapsuleST

80008590 VITAMIN D BMI800IU CapsuleST

80003010 EURO D EUR80008446 VITAMIN D BMI

88:20.00 VITAMIN EALPHA TOCOPHERYL

400IU CapsuleST

00122858 VITAMIN E NATUAL SOURCE JAM

VITAMIN E50IU/mL LiquidST

02162075 AQUASOL E NVC77IU/mL Liquid

02212889 AQUASOL E NVC

88:28.00 MULTIVITAMIN PREPARATIONSMULTIVITAMINS (PEDIATRIC)Limited use benefit (prior approval is not required).

Pediatric multivitamins are benefits for children up to 6 years of age.

Chewable TabletST

00336300 MULTI-VITAMINS CHILD NOPDropST

00558060 INFANTOL HOR00762946 POLY-VI-SOL MJO

Page 112 of 1242010


88:28.00 MULTIVITAMIN PREPARATIONSMULTIVITAMINS (PEDIATRIC)Limited use benefit (prior approval is not required).


LiquidST

00558079 INFANTOL HORTabletST

80011134 CENTRUM JUNIOR COMPLETE WYE02247975 FLINTSTONES EXTRA C BCD

MULTIVITAMINS (PRENATAL)Limited use benefit (prior approval is not required.).

Prenatal and postnatal vitamins are benefits only for women of childbearing age (12 to 50 years).

TabletST

80001842 CENTRUM MATERNA WAY02229535 MULTI-PRE AND POST NATAL PED00815241 NEO-TINIC NEO80005770 PRENATAL & POSTPARTUM PMT02240840 PRENATAL AND POSTPARTUM VTH02241235 PRENATAL AND POSTPARTUM SDR02244374 PRENATAL VITAMINS AND

MINERALSPMT

VITAMIN A, CHOLECALCIFEROL, ASCORBIC ACIDLimited use benefit (prior approval is not required).


2,500IU & 666.67IU & 50mg/mL DropST

02229790 PEDIAVIT EUR00762903 TR- VI-SOL MJO

Oral LiquidST

80008471 JAMP-MULTIVITAMIN A/D/C DROPS

JMP

Page 113 of 1242010


92:00 UNCLASSIFIED THERAPEUTIC AGENTS

92:00.00 UNCLASSIFIED THERAPEUTIC AGENTS

ABATACEPTLimited use benefit (prior approval required).

For the treatment of:• Rheumatoid Arthritis according to established criteria. • Juvenile Idiopathic Arthritis

(Please refer to Appendix A).250mg/Vial Injection

02282097 ORENCIA BMS

ADALIMUMABLimited use benefit (prior approval required).

For the treatment of:• Rheumatoid Arthritis according to established criteria. • Psoriatic Arthritis according to established criteria. • Ankylosing Spondylitis according to established criteria. • Psoriasis according to established criteria. • Crohn's disease according to established criteria. (Please refer to Appendix A).

40mg/0.8mL Injection09857327 HUMIRA PEN ABB97799757 HUMIRA PEN ABB09857326 HUMIRA PRE-FILL ABB97799756 HUMIRA PRE-FILL ABB

40mg/Vial Injection02258595 HUMIRA ABB

ALENDRONATE SODIUMLimited use benefit (prior approval required).

For the treatment of:

a. - Osteoporosis in patients who are 65 years of age and over orb. - Osteoporosis in patients who have documented hip, vertebral or other fractures orc. - Paget's Disease ord. - Osteoporosis in patients with no evidence of fracture but who have a high (>20%) 10-year fracture risk ore. - Osteoporosis in patients with moderate 10-year fracture risk (10-20%) and use of systemic glucocorticoid therapy > 3 months

5mg TabletST

02248727 APO-ALENDRONATE APX02233055 FOSAMAX FRS02270110 GEN-ALENDRONATE GEN02248251 NOVO-ALENDRONATE NOP02288079 SANDOZ ALENDRONATE SDZ

10mg TabletST

02248728 APO-ALENDRONATE APX02201011 FOSAMAX FRS02270129 GEN-ALENDRONATE GEN02247373 NOVO-ALENDRONATE NOP02288087 SANDOZ ALENDRONATE SDZ


ALENDRONATE SODIUMLimited use benefit (prior approval required).



40mg TabletST

02258102 CO ALENDRONATE COB02201038 FOSAMAX FRS

70mg TabletST

02303078 ALENDRONATE-70 PDL02248730 APO-ALENDRONATE APX02258110 CO ALENDRONATE COB02245329 FOSAMAX FRS02286335 GEN-ALENDRONATE GEN02261715 NOVO-ALENDRONATE NOP02299712 PHL-ALENDRONATE PMI02273179 PMS-ALENDRONATE PMS02284006 PMS-ALENDRONATE FC PMS02275279 RATIO-ALENDRONATE RPH02270889 RIVA-ALENDRONATE RIV02288109 SANDOZ ALENDRONATE SDZ02302004 ZYM-ALENDRONATE ZYM

ALENDRONATE SODIUM, VITAMIN D3Limited use benefit (prior approval required).



70mg/2800U TabletST

02276429 FOSAVANCE FRS70mg/5600U TabletST

02314940 FOSAVANCE MSP

ALFUZOSIN HYDROCHLORIDE10mg Sustained Release TabletST

02315866 APO-ALFUZOSIN ER APX02304678 SANDOZ ALFUZOSIN SDZ02245565 XATRAL SAC

Page 114 of 1242010



ALLOPURINOL100mg TabletST

00449687 ALLOPRIN VAE00555681 ALLOPURINOL PDL00402818 APO-ALLOPURINOL APX00364282 NOVO-PUROL NOP

200mg TabletST

00514209 ALLOPRIN VAE02130157 ALLOPURINOL PDL00479799 APO-ALLOPURINOL APX00565342 NOVO-PUROL NOP

300mg TabletST

00454354 ALLOPRIN VAE00555703 ALLOPURINOL PDL00402796 APO-ALLOPURINOL APX00363693 NOVO-PUROL NOP00294322 ZYLOPRIM GSK

AZATHIOPRINE50mg Tablet

02242907 APO-AZATHIOPRINE APX00004596 IMURAN GSK02248843 NU-AZATHIOPRINE NXP

BETAHISTINE HCL16mg Tablet

02280191 NOVO-BETAHISTINE NOP02243878 SERC SPH

24mg Tablet02280205 NOVO-BETAHISTINE NOP02247998 SERC SPH

BOTULINUM TOXIN TYPE ALimited use benefit (prior approval required).

For the treatment of: a. - strabismus and blepharospasm associated with dystonia, including benign essential blepharospasm or VII nerve disorder in patients 12 years of age or older b. - cervical dystonia (spasmodic torticollis)

100IU Injection01981501 BOTOX ALL

CABERGOLINELimited use benefit (prior approval required).

For treatment of hyperprolactinemia in patients who have failed therapy with or are intolerant to bromocriptine.

0.5mg Tablet02301407 CO CABERGOLINE COB02242471 DOSTINEX PFI


CLOSTRIDIUM BOTULINUM NEUROTOXINLimited use benefit (prior approval required).

For: a. - the treatment of strabismus and blepharospasm associated with dystonia, including benign essential blepharospasm or VII nerve disorder in patients 12 years of age or older orb. - the treatment of cervical dystonia (spasmodic torticollis)

100U/vial Injection02324032 XEOMIN MEZ

COLCHICINE0.6mg Tablet

00572349 COLCHICINE ODN1mg Tablet

00621374 COLCHICINE ODN

CYCLOSPORINELimited use benefit (prior approval required).

For transplant therapy.10mg Capsule

02237671 NEORAL NVR25mg Capsule

02150689 NEORAL NVR02247073 SANDOZ-CYCLOSPORINE SDZ

50mg Capsule02150662 NEORAL NVR02247074 SANDOZ-CYCLOSPORINE SDZ


100mg/mL Solution02150697 NEORAL NVR

CYPROTERONE ACETATE, ETHINYL ESTRADIOL

2mg & 35mcg Tablet02290308 CYESTRA-35 PMS02233542 DIANE-35 BAY02309556 NOVO-

CYPROTERONE/ETHINYL ESTRADIOL

NOP

DUTASTERIDELimited use benefit (prior approval required).

a. - For treatment of Benign Prostatic Hyperplasia (BPH) in patients who do not tolerate or have not responded to an adrenergic blocker. orb. - For use in combination therapy when monotherapy with an alpha-blocker is not sufficient.

0.5mg CapsuleST

02247813 AVODART GSK

Page 115 of 1242010



ERGOCALCIFEROL8288IU/mL Oral LiquidST

80003615 ERDOL ODN

ETANERCEPTLimited use benefit (prior approval required).

For the treatment of:• Rheumatoid Arthritis according to established criteria. • Psoriatic Arthritis according to established criteria. • Ankylosing Spondylitis according to established criteria. • Juvenile Idiopathic Arthritis

(Please refer to Appendix A).25mg/Vial Injection

02242903 ENBREL IMX50mg/mL Injection

02274728 ENBREL IMX99100373 ENBREL SURECLICK AMG

ETIDRONATE DISODIUM200mg TabletST

02248686 CO ETIDRONATE COB01997629 DIDRONEL PGP02245330 GEN-ETIDRONATE GEN

ETIDRONATE DISODIUM, CALCIUM CARBONATE


02263866 CO-ETIDROCAL COB02176017 DIDROCAL PGP02247323 GEN-ETI-CAL CP GEN02324199 NOVO-ETIDRONATECAL KIT NOP

EXTEMPORANEOUS MIXTUREMiscellaneous

00990019 EXTEMPORANEOUS MIXTURE00999994 EXTEMPORANEOUS MIXTURE00999997 EXTEMPORANEOUS MIXTURE00999999 EXTEMPORANEOUS MIXTURE00915000 STERILE EXTEMPORANEOUS

MIXTURE (QC)

FINASTERIDELimited use benefit (prior approval required).

a. - For treatment of Benign Prostatic Hyperplasia (BPH) in patients who do not tolerate or have not responded to an alpha-adrenergic blocker.orb. - For use in combination therapy when monotherapy with an alpha-blocker is not sufficient.

5mg TabletST

02348500 NOVO-FINASTERIDE NOP02310112 PMS-FINASTERIDE PMS02010909 PROSCAR FRS02306905 RATIO-FINASTERIDE RPH02322579 SANDOZ FINASTERIDE SDZ


FLUNARIZINE HCL5mg Capsule

02246082 APO-FLUNARIZINE APX

GOLIMUMABLimited use benefit (prior approval required).

For the treatment of:• Rheumatoid Arthritis according to established criteria. • Psoriatic Arthritis according to established criteria. • Ankylosing Spondylitis according to established criteria. (Please refer to Appendix A).

50mg/0.5mL Injection02324784 SIMPONI AUTO INJECTOR CER02324776 SIMPONI PRE-FILLED

SYRINGECER

INFLIXIMABLimited use benefit (prior approval required).

For treatment of:•Fistulizing Crohn’s disease according to established criteria.•For adult patients with moderately to severely active Crohn’s Disease who have had an inadequate response to conventional therapy.(Please refer to Appendix A).

or•Rheumatoid Arthritis according to established criteria(Please refer to Appendix A).

100mg/Vial Injection02244016 REMICADE CEN

LANREOTIDE60mg/0.3mL Injection

02283395 SOMATULINE AUTOGEL IPS90mg/0.3mL Injection

02283409 SOMATULINE AUTOGEL IPS120mg/0.5mL Injection

02283417 SOMATULINE AUTOGEL IPS

LEFLUNOMIDELimited use benefit (prior approval required).

For treatment of patients with rheumatoid arthritis who:a. - have failed treatment with methotrexate: weekly dose (PO, SC or IM) of 20mg or greater (15mg or greater if patient is 65 years of age or older) for more than 8 weeks.b. - cannot tolerate or have contraindications to methotrexate.

10mg Tablet02256495 APO-LEFLUNOMIDE APX02241888 ARAVA SAC02319225 GEN-LEFLUNOMIDE GEN02261251 NOVO-LEFLUNOMIDE NOP02288265 PMS-LEFLUNOMIDE PMS02283964 SANDOZ LEFLUNOMIDE SDZ

Page 116 of 1242010



LEFLUNOMIDELimited use benefit (prior approval required).



LEUCOVORIN CALCIUM5mg Tablet

02170493 LEUCOVORIN CALCIUM WAY

MYCOPHENOLATE MOFETILLimited use benefit (prior approval required).

For transplant therapy.250mg Capsule

02192748 CELLCEPT HLR500mg Tablet

02237484 CELLCEPT HLR

MYCOPHENOLATE SODIUMLimited use benefit (prior approval required).

For transplant therapy.180mg Enteric Coated Tablet

02264560 MYFORTIC NVR360mg Enteric Coated Tablet

02264579 MYFORTIC NVR

NEDOCROMIL SODIUM2% Ophth Solution

02241407 ALOCRIL ALL

OCTREOTIDE10mg/Vial Injection

02239323 SANDOSTATIN LAR NVR20mg/Vial Injection

02239324 SANDOSTATIN LAR NVR30mg/Vial Injection

02239325 SANDOSTATIN LAR NVR50mcg/mL Injection

02248639 OCTREOTIDE ACETATE OMEGA

OMG

00839191 SANDOSTATIN NVR100mcg/mL Injection


OMG

00839205 SANDOSTATIN NVR


OCTREOTIDE200mcg/mL Injection


OMG

02049392 SANDOSTATIN NOV500mcg/mL Injection


OMG

00839213 SANDOSTATIN NVR

PAMIDRONATE DISODIUM30mg Injection

02059762 AREDIA IV NVR02244550 PAMIDRONATE DISODIUM MAY02264951 RHOXAL-PAMIDRONATE RHO

60mg Injection02244551 PAMIDRONATE DISODIUM HOS02264978 RHOXAL-PAMIDRONATE SDZ

90mg Injection02059789 AREDIA IV NVR02244552 PAMIDRONATE DISODIUM MAY02245999 PMS-PAMIDRONATE PMS02264986 RHOXAL-PAMIDRONATE SDZ

PENTOSAN POLYSULFATE SODIUM100mg Capsule

02029448 ELMIRON JNO

RISEDRONATE SODIUMLimited use benefit (prior approval required).



5mg TabletST

02242518 ACTONEL PGP02298376 NOVO-RISEDRONATE NOP

30mg TabletST


35mg TabletST


Page 117 of 1242010



SIROLIMUSLimited use benefit (prior approval required).

Coverage will be provided as a second line therapy for patients failing mycophenolate mofetil.

1mg/mL Oral Liquid02243237 RAPAMUNE WAY

1mg Tablet02247111 RAPAMUNE WAY

TAMSULOSIN HCL0.4mg Long Acting CapsuleST

02281392 NOVO-TAMSULOSIN NOP02294885 RAN-TAMSULOSIN RBY02294265 RATIO-TAMSULOSIN RPH02295121 SANDOZ TAMSULOSIN SDZ

0.4mg Long Acting TabletST

02270102 FLOMAX CR BOE

TAMSULOSIN HYDROCHLORIDE0.4mg Sustained Release CapsuleST

02298570 GEN-TAMSULOSIN MYL

TETRABENAZINE25mg Tablet

02199270 NITOMAN LHL

USTEKINUMABLimited use benefit (prior approval required).

For the treatment of moderate to severe psoriasis in patients who meet the following criteria:a. - Body surface area involvement greater than 10% and/or significant involvement of the face, hands, feet or genital region andb. - Intolerance or lack of response to methotrexate and cyclosporine orc. - A contraindication to methotrexate and/or cyclosporine andd. - Intolerance or lack of response to phototherapy ore. - Inability to access phototherapy

Coverage beyond 16 weeks will be based on a significant reduction in the Body Surface Area (BSA) involved and improvements in the Psoriasis Area Severity Index (PASI) score and the Dermatology Life Quality Index (DLQI).

45mg/0.5mL Injection02320673 STELARA JNO

WATER100% Injection

00038202 STERILE WATER ABB99002264 STERILE WATER00905178 WATER FOR INJECTION00905194 WATER FOR INJECTION00905224 WATER FOR INJECTION


ZOLEDRONIC ACIDLimited use benefit (prior approval required).

For the treatment of Paget’s disease. Coverage will be granted for one dose per 12 month period.

5mg/100mL Injection02269198 ACLASTA NOV

92:44.00TACROLIMUSLimited use benefit (prior approval required).

For transplant therapy.0.5mg Capsule

02243144 PROGRAF AST1mg Capsule

02175991 PROGRAF AST5mg Capsule

02175983 PROGRAF AST5mg/mL Injection

02176009 PROGRAF AST0.5mg Long Acting Capsule

02296462 ADVAGRAF AST1mg Long Acting Capsule

02296470 ADVAGRAF AST5mg Long Acting Capsule

02296489 ADVAGRAF AST

Page 118 of 1242010


94:00 DEVICES94:00.00 DEVICES

HYDROXYPROPYLCELLULOSE5mg Ophthalmic Insert

00889970 LACRISERT LAMELLE FRS

94:00.00 DEVICESSPACER DEVICE

Page 119 of 1242010



Device99400496 ACE ADAPTORS AUC99400497 ACE KIT AUC99400495 ACE MDI SPACER AUC99400500 ACE SPACER WITH LARGE

MASKAUC

99400499 ACE SPACER WITH MEDIUM MASK

AUC

99400498 ACE SPACER WITH SMALL MASK

AUC

00964905 AEROCHAMBER AC BOYZ TRU00964891 AEROCHAMBER AC GIRLZ TRU96899994 AEROCHAMBER MAX VHC

WITH ADULT MASKTRU

96899995 AEROCHAMBER MAX VHC WITH CHILD MASK

TRU

96899996 AEROCHAMBER MAX VHC WITH INFANT MASK

TRU

96899997 AEROCHAMBER MAX VHC WITH MOUTHPIECE

TRU

99400487 AEROCHAMBER PLUS VHC ADULT

TRU

99400488 AEROCHAMBER PLUS VHC WITH ADULT MASK

TRU

99400490 AEROCHAMBER PLUS VHC WITH INFANT MASK

TRU

99400489 AEROCHAMBER PLUS VHC WITH PEDIATRIC MASK

TRU

99400507 E-Z SPACER WEP99400511 E-Z SPACER (MASK ONLY) WEP99400508 E-Z SPACER WITH SMALL

MASKWEP

99400501 OPTICHAMBER AUC99400504 OPTICHAMBER LARGE MASK AUC99400503 OPTICHAMBER MEDIUM MASK AUC99400502 OPTICHAMBER SMALL MASK AUC99400505 OPTIHALER AUC99400506 OPTIVENT IN-LINE MDI

SPACERAUC

99400787 POCKET CHAMBER MCA99400791 POCKET CHAMBER WITH

ADULT MASKMCA

99400788 POCKET CHAMBER WITH INFANT MASK

MCA

99400790 POCKET CHAMBER WITH MEDIUM MASK

MCA

99400789 POCKET CHAMBER WITH SMALL MASK

MCA

99400512 RONDO INHALATION CHAMBER

KIN

99400516 RONDO INHALATION CHAMBER-CHILD MASK

KIN

99400515 RONDO INHALATION CHAMBER-INFANT MASK

KIN

99400514 RONDO INHALATION CHAMBER-NEONATAL MASK

KIN

99400513 RONDO INHALATION CHAMBER-UNIVERSAL MASK

KIN

99400517 SPACE CHAMBER AUC


Device99400521 SPACE CHAMBER ADULT

LARGE MASKAUC

99400520 SPACE CHAMBER ADULT REGULAR MASK

AUC

99400518 SPACE CHAMBER INFANT MASK

AUC

99400519 SPACE CHAMBER PEDIATRIC MASK

AUC

99400491 VENT 170 SPACER NDE99400493 VENT 170 SPACER AND MASK NDE99400492 VENT 170 SPACER DELUXE NDE99400494 VENTAHALER GSK

Kit99400777 ACE LARGE MASK

ACCESSARY KITAUC

99400776 ACE MEDIUM MASK ACCESSARY KIT

AUC

99400775 ACE SMALL MASK ACCESSARY KIT

AUC

SYRINGE & NEEDLE (NON-INSULIN)Syringe & Needle

99400534 NON-INSULIN 1CC99400536 NON-INSULIN 3CC99400537 NON-INSULIN 5CC99400538 NON-INSULIN 10CC

SYRINGE (NON-INSULIN)Syringe

99400530 LUER LOCK (DISP) 3CC99400535 LUER LOCK (DISP) 5CC99400539 LUER LOCK (DISP) 10CC99400548 LUER LOCK (DISP) 20CC99400823 LUER LOCK (DISP) 30CC BTD99400549 LUER LOCK (DISP) 60CC99400531 NON-INSULIN (DISP) 3CC99400532 NON-INSULIN (DISP) 5CC99400533 NON-INSULIN (DISP) 10CC

1 Syringe99400529 NON-INSULIN (DISP) 1CC

VENTODISK DISKHALERDevice

00905739 VENTODISK DISKHALER GSK

94:01.00 DEVICES (DIABETIC)GLUCOMETER BATTERIES

Device99401030 BATTERIES - 1.5 VOLT99401031 BATTERIES - 3 VOLT99401029 BATTERIES - AAA99401056 BATTERIES - LITHIUM99401032 BATTERIES - SIZE J 6V

Page 120 of 1242010


94:01.00 DEVICES (DIABETIC)INSULIN PUMP SUPPLIES

Device99401049 ADAPTOR AUC99401052 ADHESIVE PAD WITH COTTON AUC99401053 ADHESIVE PAD WITHOUT

COTTONAUC

99401050 INFUSION SETS AUC99401038 INSULIN PUMP BATTERY AUC99401047 INSULIN PUMP CARTRIDGES AUC99401048 PISTON ROD AUC09991061 RESERVOIR 5XX 1.8ML

SYRINGEMDT

09991062 RESERVOIR 7XX 3.0ML SYRINGE

MDT

99401051 TUBING AUC

ISOPROPYL ALCOHOL70% Swab

00480452 ALCOHOL PREP SWAB PFD02247809 ALCOHOL SWAB TIP00809357 ALCOHOL SWABS BD BTD02240759 B-D ALCOHOL SWAB BTD99438102 MONOJECT ALCOHOL WIPES SHM00795232 WEBCOL ALCOHOL PREP JAJ

94:01.00 DEVICES (DIABETIC)LANCET

Lancet97799817 ACCU-CHEK MULTICLIX ROD99401068 BD LATITUDE BTD97799541 EZ HEALTH ORACLE LANCETS TRE00900834 FINGERSTIX BAY00995965 FINGERSTIX BAY00977839 FREESTYLE ABB99401063 FREESTYLE ABB97799766 ITEST LANCETS 28G (100) AUC97799767 ITEST LANCETS 33G (100) AUC00977853 LIFESCAN FINE POINT JAJ00901555 LIFESCAN REGULAR JAJ00906190 MEDISENSE AUC00906239 MICROLET BAY00977493 MICROLET BAY00977543 MONOLET ORIGINAL SHM99401055 MONOLET THIN SHM97799810 MPD THIN (100) MPD97799811 MPD THIN (200) MPD97799807 MPD ULTRA THIN (100) MPD97799808 MPD ULTRA THIN (200) MPD00901359 ONE TOUCH ULTRA SOFT JAJ00905917 SOFT TOUCH ROD00977952 SOFT TOUCH ROD99493957 SOFT TOUCH ROD00000165 SOFTCLIX BOE00902144 SOFTCLIX SELECT BOE00977373 SOFTCLIX SELECT BOE00900141 ULTRA-FINE II BTD00977659 ULTRA-FINE II BTD00977051 UNILET COMFORT TOUCH BAY00977896 UNILET COMFORT TOUCH BAY00984167 UNILET COMFORT TOUCH BAY

LANCING DEVICEDevice

99401025 B-D LANCET BTD99401020 GLUCOLET BAY99401021 GLUCOLET 2 BAY99401014 MEDISENSE TLC AUC99401017 MICROLET BAY99401015 MONOJECTOR SHM99401016 PENLET PLUS JAJ99401022 REGULAR ENDCAPS FOR

GLUCOLETBAY

99401018 REGULAR ENDCAPS FOR MICROLET

BAY

99401024 SOFTTOUCH ROD99401023 SUPER ENDCAPS FOR

GLUCOLETBAY

99401019 SUPER ENDCAPS FOR MICROLET

BAY

MAGNIFIERMagnifier

99400550 SYRINGE SCALE MAGNIFIER

Page 121 of 1242010


94:01.00 DEVICES (DIABETIC)NEEDLE

Needle00908452 B-D PEN BTD00977756 NOVOFINE NOO

22g Needle00977616 B-D DISPOSABLE 1 INCH 5155 BTD00977624 B-D DISPOSABLE 1½ INCH

5156BTD

25g Needle00977071 B-D DISPOSABLE 5/8 INCH

5122BTD

00977063 B-D DISPOSABLE 1½ INCH 5127

BTD

27g Needle00977012 B-D DISPOSABLE ½ INCH 5109 BTD

28g Needle99221028 NOVOFINE INSULIN PEN 28G NOO

29g Needle00977101 B-D ULTRA-FINE PEN BTD97799897 BD ULTRA-FINE PEN NEEDLE

29GBTD

00900513 OWEN MUMFORD UNIFINE PENTIPS 1/2 INCH

AUC

97799561 SUPER-FINE STANDARD 29G 12.7MM

PMS

00908185 ULTRAFINE PEN ULTRA-FINE 29G

BTD

29GX12MM Needle97799543 ULTI 29GX1/2 WITH SHARP

CONTAINERUMI

30g Needle00921114 NOVOFINE NOO00908169 NOVOFINE 30G NOO99117796 NOVOFINE INSULIN PEN 30G NOO

31g Needle00977011 B-D ULTRA-FINE PEN III BTD00900511 OWEN MUMFORD UNIFINE

PENTIPS 1/4 INCHAUC

00900512 OWEN MUMFORD UNIFINE PENTIPS 5/16 INCH

AUC

97799563 SUPER-FINE MICRO 31G 5MM PMS97799562 SUPER-FINE XTRA 31G 8MM PMS


CONTAINERUMI


CONTAINERUMI

32g Needle97799821 NOVOFINE 32G 6MM NOO

NEEDLE (NON-INSULIN)Needle

99400528 NEEDLES (NON-INSULIN) DISPOSABLE

94:01.00 DEVICES (DIABETIC)SHARPS CONTAINER

Device99401026 B-D SHARPS CONTAINER 1.4L BTD99401027 B-D SHARPS CONTAINER 3.1L BTD99401028 B-D SHARPS CONTAINER 3.8L SHM

SYRINGE0.3cc Syringe

00977961 B-D MICRO-FINE BTD00977977 B-D ULTRA-FINE / ULTRA-FINE

IIBTD

00920169 MICRO-FINE BTD00977951 MONOJECT SHM99254011 MONOJECT DISP 3/10CC (100) SHM99253047 MONOJECT DISP 3/10CC (30) SHM00920053 SYRN MONOJECT SHM00920193 ULTRA-FINE BTD

0.5cc Syringe00977985 B-D ULTRA-FINE II BTD00920177 MICRO-FINE BTD00920355 MONOJECT SHM99432799 MONOJECT (100) SHM99432633 MONOJECT (30) SHM00920207 ULTRA-FINE BTD

1cc Syringe99328369 B-D ULTRA-FINE BTD00920045 MONOJECT SHM99433383 MONOJECT (100) SHM99432914 MONOJECT (30) SHM00920215 ULTRA-FINE BTD00909238 ULTRA-FINE II 30G BTD

Page 122 of 1242010


94:01.00 DEVICES (DIABETIC)SYRINGE & NEEDLE

0.3cc Syringe and Needle99328419 B-D INSULIN 1/3CC 29G UF 1 BTD99639286 B-D MICRO-FINE 1/3CC BTD00909092 SYRN INS U-II 3/10CC 30G BTD00905690 SYRN INSULIN MICRO 3/10CC

28GBTD

00906786 SYRN INSULIN ULTRA 3/10CC 29G

BTD

97799509 ULTI SYG WITH ULTIGUARD 29G 1/2

UMI


UMI


UMI


UMI

00900506 ULTICARE 29G UMI00964018 ULTICARE 29G UMI00900503 ULTICARE 30G UMI00964174 ULTICARE 30G UMI97799513 ULTICARE 31G SYG 5/16 UMI97799999 ULTICARE INSULIN SYR

29G.3CCUMI

97799996 ULTICARE INSULIN SYR 30G.3CC

UMI

97799908 ULTIGUARD INSULIN SYR 29G.3CC

UMI


UMI

0.5cc Syringe and Needle99328377 B-D INSULIN 50U 29G BTD99221044 B-D MICRO-FINE INSULIN 50U BTD00983004 INSULIN LO DOSE MICRO 28G BTD00909084 SYRN INSULIN U-II 30G BTD00906727 SYRN INSULIN ULTRA 29G BTD97799508 ULTI SYG WITH ULTIGUARD

29G 1/2UMI


UMI


UMI


UMI

97799518 ULTICARE 28G SYG 1/2 UMI00900505 ULTICARE 29G UMI00963941 ULTICARE 29G UMI00900502 ULTICARE 30G UMI00964115 ULTICARE 30G UMI97799512 ULTICARE 31G SYG 5/16 UMI97799998 ULTICARE INSULIN SYR

29G.5CCUMI

97799995 ULTICARE INSULIN SYR30G.5CC

UMI

97799510 ULTICARE LOW DEAD SPACE SYG

UMI


UMI


UMI

94:01.00 DEVICES (DIABETIC)SYRINGE & NEEDLE

1cc Syringe and Needle99262295 B-D INJECT-EASE WITH

MICRO-FINEBTD

99767467 B-D MICRO-FINE INSULIN 100U BTD00901911 B-D MICRO-FINE INSULIN 28G BTD00906816 SYRN INSULIN ULTRA 29G BTD97799507 ULTI SYG WITH ULTIGUARD

29G 1/2UMI


UMI


UMI


UMI

97799517 ULTICARE 28G SYG 1/2 UMI00900504 ULTICARE 29G UMI00963895 ULTICARE 29G UMI00900501 ULTICARE 30G UMI00964069 ULTICARE 30G UMI97799511 ULTICARE 31G SYG 5/16 UMI97799997 ULTICARE INSULIN SYR

29G.1CCUMI

97799994 ULTICARE INSULIN SYR 30G.1CC

UMI


UMI


UMI

SYRINGE CASESyringe Case

99400552 MYHEALTH SYRINGE CASE-7 AUC99400551 MYHEALTH SYRINGE CASE-

SINGLEAUC

Page 123 of 1242010


96:00 PHARMACEUTICAL AIDS96:00.00 PHARMACEUTICAL AIDS

LACTOSE100mg TabletST

00501190 PLACEBO ODN

METHADONE HCLPowder

00908835 METHADONE WIL

Page 124 of 1242010

APPENDIX A

LIMITED USE BENEFITS AND CRITERIA

Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria

08:00 ANTI-INFECTIVE AGENTS08:12.18 QUINOLONES

LEVOFLOXACINLimited use benefit (prior approval not required).

Coverage will be limited to a maximum of 14 days.



08:12.24 TETRACYCLINESMINOCYCLINE HCL



50mg Capsule02084090 APO-MINOCYCLINE APX02239667 DOM-MINOCYCLINE DPC02237875 MED-MINOCYCLINE MEC02173514 MINOCIN STI02108143 NOVO-MINOCYCLINE NOP02153394 PDL-MINOCYCLINE PDL02239238 PMS-MINOCYCLINE PMS02294419 PMS-MINOCYCLINE PMS01914138 RATIO-MINOCYCLINE RPH02242080 RIVA-MINOCYCLINE RIV02237313 SANDOZ-MINOCYCLINE SDZ

Page A-1 de 322010


08:12.24 TETRACYCLINESMINOCYCLINE HCL



100mg Capsule02084104 APO-MINOCYCLINE APX02239668 DOM-MINOCYCLINE DPC02237876 MED-MINOCYCLINE MEC02173506 MINOCIN STI02239982 MINOCYCLINE IVX02108151 NOVO-MINOCYCLINE NOP02154366 PDL-MINOCYCLINE PDL02294427 PMS-MINOCYCLINE PMS02239239 PMS-MONOCYCLINE PMS01914146 RATIO-MINOCYCLINE RPH02242081 RIVA-MINOCYCLINE RIV02237314 SANDOZ-MINOCYCLINE SDZ

08:12.28 MISCELLANEOUS ANTIBIOTICSLINEZOLID


Tablets:

For treatment of proven vancomycin-resistant enterococci (VRE) infections when other antibiotics are not available, and for the treatment of proven Methicillin-Resistant Staphylococcus aureus (MRSA) infections in patients who cannot tolerate or who had an idiosyncratic reaction with Vancomycin.

I.V. solution:

When linezolid cannot be administered orally in the above mentioned situations.

2mg/mL Injection02243685 ZYVOXAM PFI

600mg Tablet02243684 ZYVOXAM PFI

08:14.08 AZOLESVORICONAZOLE


For the treatment of:a. - patients with invasive aspergillosis.b. - culture proven invasive candidiasis with documented resistance to fluconazole.



08:18.08 ANTIRETROVIRALSDARUNAVIR


For the management of HIV in patients who failed or have experienced adverse events to three or more listed protease inhibitors.




Page A-2 de 322010


08:18.08 ANTIRETROVIRALSEFAVIRENZ, EMTRICITABINE, TENOFOVIR DISOPROXIL FUMARATE


For the treatment of HIV-1 infection adults where the virus is susceptible to each of tenofovir, emtricitabine and efavirenz, and:a. - Atripla is used to replace existing therapy with its component drugs, orb. - the patient is treatment naïve, orc. - the patient has established viral suppression but requires antiretroviral therapy modification due to intolerance or adverse effects.

Note: Criteria will be confirmed against medication history.

600mg & 200mg & 300mg Tablet02300699 ATRIPLA BMS

EMTRICITABINE, TENOFOVIR DISOPROXIL FUMARATELimited use benefit (prior approval required).

For the treatment of patients with HIV infection where the virus is susceptible to both emtricitabine and tenofovir AND where the triple-entity antiretroviral agent (tenofovir/ emtricitabine/efavirenz) is not indicated due to one of the following:a. - efavirenz resistance b. - adverse effects secondary to efavirenz

200mg/300mg Tablet02274906 TRUVADA GIL

ETRAVIRINELimited use benefit (prior approval required).

For use in combination with other antiretroviral agents for treatment-experienced patients with HIV-1 infection who:a.- have failed prior antiretroviral therapy; andb. - have HIV-1 strains resistant to multiple antiretroviral agents, including NNRTIs

100mg Tablet02306778 INTELENCE JNO

MARAVIROCLimited use benefit (prior approval required).

For the treatment of HIV-1 infection, given in combination with other antiretroviral agents, in patients who have:a. - CR5 tropic viruses; andb. - documented resistance to at least one agent from each of the three major classes of antiretroviral agents (nucleoside reverse transcriptase inhibitors, non-nucleoside reverse transcriptase inhibitors, and protease inhibitors)



RALTEGRAVIRLimited use benefit (prior approval required).

For the treatment of HIV infection in patients who are antiretroviral experienced and have virologic failure due to resistance to at least one agent from each of the three major classes of antiretroviral agents, nucleoside/tide reverse transcriptase inhibitors, non-nucleoside reverse transcriptase inhibitors and protease inhibitors.

400mg Tablet02301881 ISENTRESS FRS

TENOFOVIR DISOPROXIL FUMARATELimited use benefit (prior approval required).

For the management of HIV disease in patients who have failed or have experienced adverse events to an alternative nucleoside reverse transcriptase inhibitor.

245mg Tablet02247128 VIREAD GIL

TIPRANAVIRLimited use benefit (prior approval required).

For the management of HIV disease in patients a. - who have failed all currently listed protease inhibitorsb. - intolerant to all currently listed protease inhibitors

250mg Capsule02273322 APTIVUS BOE

Page A-3 de 322010


08:18.20 INTERFERONSPEGINTERFERON ALFA-2A





180mcg/0.5mL Injection02248077 PEGASYS HLR

180mcg/1mL Injection02248078 PEGASYS HLR

PEGINTERFERON ALFA-2A, RIBAVIRINLimited use benefit (prior approval required).




180mcg/0.5mL & 200mg Injection & Tablet02253429 PEGASYS RBV HLR

180mcg/1mL & 200mg Injection & Tablet02253410 PEGASYS RBV HLR

PEGINTERFERON ALFA-2BLimited use benefit (prior approval required).



b. - For genotypes 2 or 3, initial coverage for a maximum of 24 weeks will be approved. Renewals will not be covered.





PEGINTERFERON ALFA-2B, RIBAVIRINLimited use benefit (prior approval required).







Page A-4 de 322010


08:18.20 INTERFERONSPEGINTERFERON ALFA-2B, RIBAVIRIN







08:18.32 NUCLEOSIDES AND NUCLEOTIDESADEFOVIR DIPIVOXIL


For the treatment of chronic hepatitis B infection when used in combination with lamivudine in patients who have developed failure to lamivudine, as defined by an increase in HBV DNA of ≥ 1 log10 IU/mL above the nadir, measured on two separate occasions within an interval of at least one month, after the first three months of lamivudine therapy, and when failure to lamivudine is not due to poor adherence to therapy.

10mg Tablet02247823 HEPSERA GIL

ENTECAVIRLimited use benefit (prior approval required).

For the treatment of chronic hepatitis B infection in patients with cirrhosis documented on radiologic or histologic grounds and a HBV DNA concentration above 2000IU/mL.

0.5mg Tablet02282224 BARACLUDE BMS

10:00 ANTINEOPLASTIC AGENTS10:00.00 ANTINEOPLASTIC AGENTS

ERLOTINIB HYDROCLORIDELimited use benefit (prior approval required).

Treatment of non-small cell lung cancer (NSCLC) after failure of at least one prior chemotherapy regimen, and whose EGFR expression status is positive or unknown.



IMATINIB MESYLATELimited use benefit (prior approval required).

a.- For the treatment of patients with chronic myeloid leukemia in blast crisis, accelerated phase, or in chronic phase after failure of interferon-alpha therapy.b.- For the treatment of patients with gastrointestinal stromal tumour.c.- For newly diagnosed adult patients with Philadelphia chromosome-positive chronic myeloid leukemia (CML).

100mg Tablet02253275 GLEEVEC NVR

400mg Tablet02253283 GLEEVEC NOV

Page A-5 de 322010


10:00.00 ANTINEOPLASTIC AGENTSRITUXIMAB


Prescribed by a rheumatologist for treatment of adult patients with severely active rheumatoid arthritis who have failed to respond to a trial of an anti-TNF agent. Treatment should be combined with methotrexate. Rituximab should not be used in combination with anti-TNF agents.

For continued coverage for rituximab beyond twenty-four weeks, patient must meet all the following criteria:a. - Initially prescribed by a rheumatologistb. - Patient has been assessed after the twentieth to twenty-fourth week of rituximab therapy and meets the response criteria of:c. - a >20% reduction in number of tender and swollen joints d. - a >20% improvement in physician global assessment scale.e. - either a >20% improvement in the patient global assessment scale or a >20% reduction in the acute phase as measured by ESR or CRP.

10mg/mL Injection02241927 RITUXAN HLR

SUNITINIB MALATELimited use benefit (Prior approval required).

Criteria for initial six month coverage of Sutent:For patients with histologically proven unresectable or recurrent/metastatic GIST who have failed or are unable to tolerate imatinib therapy. Sunitinib will not be funded concomitantly with imatinib.

Criteria for assessment at every six months:There is no objective evidence of disease progression.

12.5mg Capsule02280795 SUTENT PFI



TEMOZOLOMIDELimited use benefit (prior approval required).

For: a. - treatment of adult patients with glioblastoma multiforme or anaplastic astrocytoma, and documented evidence of recurrence or progression after standard therapy (resection, radiotherapy, and chemotherapy).b. - treatment of adult patients with newly diagnosed glioblastoma multiforme concomitantly with radiotherapy and then as maintenance treatment.





Page A-6 de 322010


12:00 AUTONOMIC DRUGS12:04.00 PARASYMPATHOMIMETIC AGENTS

DONEPEZIL HCLLimited use benefit (prior approval required).





GALANTAMINELimited use benefit (prior approval required).






Page A-7 de 322010


12:04.00 PARASYMPATHOMIMETIC AGENTSRIVASTIGMINE




1.5mg Capsule02242115 EXELON NOV02332809 MYLAN-RIVASTIGMINE MYL02305984 NOVO-RIVASTIGMINE NOP02306034 PMS-RIVASTIGMINE PMS

3mg Capsule02242116 EXELON NOV02332817 MYLAN-RIVASTIGMINE MYL02305992 NOVO-RIVASTIGMINE NOP02306042 PMS-RIVASTIGMINE PMS

4.5mg Capsule02242117 EXELON NOV02332825 MYLAN-RIVASTIGMINE MYL02306018 NOVO-RIVASTIGMINE NOP02306050 PMS-RIVASTIGMINE PMS

6mg Capsule02242118 EXELON NOV02332833 MYLAN-RIVASTIGMINE MYL02306026 NOVO-RIVASTIGMINE NOP02306069 PMS-RIVASTIGMINE PMS

2mg/mL Oral Liquid02245240 EXELON NOV

12:08.08 ANTIMUSCARINICS / ANTISPASMODICSTIOTROPIUM BROMIDE MONOHYDRATE


For the treatment of moderate* to severe* chronic obstructive pulmonary disease (COPD), in patients who continue to be symptomatic after an adequate trial (3 months) of ipatropium, at a dose of 8-12 puffs daily.

*Canadian Thoracic Society COPD Classification by Symptoms/Disability and Lung FunctionModerate: shortness of breath from COPD causing the patient to stop after walking about 100 meters (after a few minutes) on level ground (MRC 3 to 4); 50% ≤ FEV1 < 80% predicted, FEV1/FVC <0.7

Severe: shortness of breath from COPD leaving the patient too breathless to leave the house or breathless after undressing (MRC 5), or in the presence of chronic respiratory failure or clinical signs of right heart failure; 30% ≤ FEV1 < 50% predicted, FEV1/FVC <0.7

18mcg Powder for Inhalation (Capsule)02246793 SPIRIVA BOE

Page A-8 de 322010


12:12.08 BETA ADRENERGIC AGONISTSFORMOTEROL FUMARATE

Limited use benefit (prior approval required).For the treatment of asthma in patients who are using optimal corticosteroid therapy and experiencing breakthrough symptoms requiring regular use of a rapid onset, short duration bronchodilator. Oxeze is not intended for the relief of acute asthma symptoms: patients must have access to an inhaled fast-acting bronchodilator (beta-2 agonist) for symptomatic relief.

12mcg/Capsule Powder for Inhalation02230898 FORADIL NVR

FORMOTEROL FUMARATE DIHYDRATE6mcg/Dose Dry Powder Inhaler

02237225 OXEZE TURBUHALER AZC12mcg/Dose Dry Powder Inhaler

02237224 OXEZE TURBUHALER AZC

FORMOTEROL FUMARATE DIHYDRATE, BUDESONIDELimited use benefit (prior approval required).

For the treatment of reversible obstructive airway disease in patients who are not adequately controlled on medium doses of inhaled corticosteroids ( e.g. fluticasone 250 - 500 mcg daily, or the equivalent) as the sole agent and require addition of a long- acting beta agonist. Patients using this combination product must also have access to a short-acting bronchodilator for symptomatic relief.

6mcg & 100mcg/Inhalation Inhaler02245385 SYMBICORT 100 TURBUHALER AZC

6mcg & 200mcg/Inhalation Inhaler02245386 SYMBICORT 200 TURBUHALER AZC

SALMETEROL XINAFOATELimited use benefit (prior approval required).

a. - For the treatment of asthma in patients who are using optimal corticosteroid therapy and experiencing breakthrough symptoms requiring regular use of a rapid onset, short duration bronchodilator. Serevent is not intended for the relief of acute asthma symptoms: patients must have access to an inhaled fast-acting bronchodilator (beta-2 agonist) for symptomatic relief.b. - For the treatment of Chronic Obstructive Pulmonary Disease (COPD) in patients not adequately controlled with ipratropium.

50mcg/inhalation Powder Diskus02231129 SEREVENT DISKUS GSK

50mcg/Inhalation Powder for Inhalation02214261 SEREVENT DISKHALER GSK

SALMETEROL XINAFOATE, FLUTICASONE PROPIONATELimited use benefit (prior approval required).










Page A-9 de 322010


12:12.08 BETA ADRENERGIC AGONISTSSALMETEROL XINAFOATE, FLUTICASONE PROPIONATE








12:20.04 CENTRALL ACTING SKELETAL MUSCLE RELAXANTSCYCLOBENZAPRINE HCL

Limited use benefit (prior approval is not required).

For relief of muscle spasm associated with acute, painful musculoskeletal conditions. Coverage is limited to 60mg per day for three (3) weeks, renewable every two(2) months.

10mg Tablet02177145 APO-CYCLOBENZAPRINE APX02220644 CYCLOBENZAPRINE PDL02238633 DOM-CYCLOBENZAPRINE DPC02231353 GEN-CYCLOPRINE GEN02080052 NOVO-CYCLOPRINE NOP02171848 NU-CYCLOBENZAPRINE NXP02249359 PHL-CYCLOBENZAPRINE PHH02212048 PMS-CYCLOBENZAPRINE PMS02236506 RATIO-CYCLOBENZAPRINE RPH02242079 RIVA-CYCLOBENZAPRINE RIV

TIZANIDINE HCLLimited use benefit (prior approval required).

For treatment of spasticity in patients with multiple sclerosis, who have failed therapy with or are intolerant to baclofen.

4mg Tablet02259893 APO-TIZANIDINE APX02272059 GEN-TIZANIDINE GEN02239170 ZANAFLEX ELN

12:92.00 MISCELLANEOUS AUTONOMIC DRUGSVARENICLINE

Limited use benefit with quantity and frequency limits (prior approval is not required).

Coverage will be limited to 165 tablets during a one-year period. The year starts on the date the first prescription is filled. Once this quantity has been reached, theclient is eligible again for coverage for varenicline (Champix®) when one year has elapsed from the day the initial prescription was filled.

0.5mg Tablet02291177 CHAMPIX PFI

0.5mg & 1mg Tablet02298309 CHAMPIX STARTER PACK PFI

1mg Tablet02291185 CHAMPIX PFI

Page A-10 de 322010


20:00 BLOOD FORMATION COAGULATION AND THROMBOSIS20:12.18 PLATELET AGGREGATION INHIBITORS

CLOPIDOGREL BISULFATELimited use benefit (one-year duration, prior approval required).

a. - Patients with intra-coronary stent implantation following insertion.b. - Patients with acute coronary syndrome (ACS) (unstable angina or non-ST-segment elevation MI), in combination with ASA.

75mg Tablet02238682 PLAVIX SAC

20:16.00 HEMATOPOIETIC AGENTSPEGFILGRASTIM


a. - To decrease the incidence of infection, as manifested by febrile neutropenia, in patients with non-myeloid malignancies receiving myelosuppressive antineoplastic drugs with curative intent.andb. - Where access to a health care facility is problematic.

10mg/mL Injection02249790 NEULASTA AMG

24:00 CARDIOVASCULAR DRUGS24:06.05 CHOLESTEROL ABSORPTION INHIBITORS

EZETIMIBELimited use benefit (prior approval required).

a.- 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 “statin” doses.

b.- For use as monotherapy in the management of hypercholesterolemia in patients intolerant to HMG-CoA reductase inhibitors.

10mg Tablet02247521 EZETROL MSP

24:12.92 MISCELLANEOUS VASODILATING AGENTSDIPYRIDAMOLE, ACETYLSALICYLIC ACID


For secondary prevention of stroke or transient ischemic attacks (TIAs) in patients who have failed therapy with ASA alone.

200mg & 25mg Capsule02242119 AGGRENOX BOE

28:00 CENTRAL NERVOUS SYSTEM AGENTS28:08.04 NONSTEROIDAL ANTI-INFLAMMATORY AGENTS

CELECOXIBLimited use benefit (prior approval required).

For patients with osteoarthritis who have failed therapy with acetaminophen and who:a. - have failed to achieve adequate response with 2 other listed NSAIDs, orb. - have experienced an adverse event attributable to 2 other listed NSAIDs, orc. - have a history of a serious gastrointestinal complication such as bleeding or perforation.

For patients with rheumatoid arthritis who:a. - have failed to achieve adequate response with 2 other listed NSAIDs, orb. - have experienced an adverse event attributable to 2 other listed NSAIDs, orc. - have a history of a serious gastrointestinal complication such as bleeding or perforation.



Page A-11 de 322010


28:08.08 OPIATE AGONISTSCODEINE MONOHYDRATE, CODEINE SULFATE TRIHYDRATE


For treatment of:a. - chronic pain and palliative care patients as an alternative to products containing codeine in combination with acetaminophen or ASA with or without caffeine, orb. - chronic pain and palliative care patients as an alternative to regular release codeine tablets when large doses are required.





FENTANYLLimited use benefit (prior approval required).


12mcg/h Transdermal Patch02341379 PMS-FENTANYL MTX PMS02330105 RAN-FENTANYL MATRIX PATCH 12 RBY02311925 RATIO-FENTANYL RPH02327112 SANDOZ FENTANYL SDZ




100mcg/h Transdermal Patch02275856 DURAGESIC MAT JNO02314665 NOVO-FENTANYL NOP02341417 PMS-FENTANYL MTX PMS02249448 RAN-FENTANYL RBY02330156 RAN-FENTANYL MATRIX RBY02282984 RATIO-FENTANYL RPH02327163 SANDOZ FENTANYL TRANSDERMAL SYSTEM SDZ

Page A-12 de 322010


28:08.08 OPIATE AGONISTSHYDROMORPHONE HCL

Limited use benefit. Prior approval required for controlled release capsules only. Regular release dosage forms are full benefits and do not require prior approval.








MEPERIDINE HCLLimited use benefit (prior approval not required).

Limited to 2 weeks supply for acute pain. Coverage will be limited to 60 tablets per one month period.

50mg Tablet02138018 DEMEROL SAC

OXYCODONE HCLLimited use benefit. Prior approval required for controlled release tablets only. Regular release dosage forms are full benefits and do not require prior approval.







28:12.92 MISCELLANEOUS ANTICONVULSANTSLEVETIRACETAM





Page A-13 de 322010


28:12.92 MISCELLANEOUS ANTICONVULSANTSLEVETIRACETAM




28:16.04 ANTIDEPRESSANTSBUPROPION HCL

100mg Sustained Release Tablet02325373 RATIO-BUPROPION SR PMS

BUPROPION HCL (WELLBUTRIN)Limited use benefit (prior approval required).

For treatment of depression in patients unresponsive to or intolerant of other listed antidepressants. (Note: this product will not be approved for coverage for smoking cessation).

100mg Sustained Release Tablet02285657 RATIO-BUPROPION RPH02275074 SANDOZ-BUPROPION SR SDZ

150mg Sustained Release Tablet02313421 PMS-BUPROPION SR PMS02285665 RATIO-BUPROPION RPH02275082 SANDOZ-BUPROPION SR SDZ02237825 WELLBUTRIN SR BPC02275090 WELLBUTRIN XL BOV

300mg Sustained Release Tablet02275104 WELLBUTRIN XL BOV

BUPROPION HCL (ZYBAN)Limited use benefit with quantity and frequency limits (prior approval is not required).

For smoking cessation:Coverage is limited to 180 tablets during a one-year period. The year starts on the date the first prescription is filled. Once this quantity has been reached, the clientis eligible again for coverage for bupropion HCl when one year has elapsed from the day the initial prescription was filled.

150mg Sustained Release Tablet02238441 ZYBAN SR BPC

DULOXETINE HCLLimited use benefit (prior approval required).

For the treatment of neuropathic pain in patients with diabetes who have:a.- failed an adequate trial with TWO alternative agents (such as a tricyclic antidepressant or anticonvulsant) due to intolerance or lack of response orb.- a contraindication to alternative agents

The dose of duloxetine will be limited to a maximum of 60 mg daily.Note that NIHB has adopted a Common Drug Review CEDAC recommendation that Cymbalta NOT be added to public drug plan formularies for the treatment of major depressive disorder.



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40:00 ELECTROLYTIC, CALORIC, AND WATER BALANCE40:20.00 CALORIC AGENTS

LEVOCARNITINELimited use benefit (prior approval required).

For treatment of carnitine deficiency.

100mg/mL Oral Liquid02144336 CARNITOR SIG

200mg/mL Solution02144344 CARNITOR IV SIG

330mg Tablet02144328 CARNITOR SIG

48:00 RESPIRATORY TRACT AGENTS48:10.24 LEUKOTRIENE MODIFIERS

MONTELUKASTLimited use benefit (prior approval required).




4mg Granules02247997 SINGULAIR FRS

10mg Tablet02238217 SINGULAIR FRS

ZAFIRLUKASTLimited use benefit (prior approval required).


20mg Tablet02236606 ACCOLATE AZC

52:00 EYE, EAR, NOSE AND THROAT (EENT) PREPARATIONS52:04.04 EENT - ANTIBACTERIALS

CIPROFLOXACIN HCL, DEXAMETHASONELimited use benefit (prior approval required).

a.- for children 16 years old and under (prior approval not required)b.- for acute otitis media with otorrhea through tympanostomy tubes who require treatmentc.- for acute otitis externa in the presence of tympanostomy tube or known perforation of the tympanic membrane

0.3%/0.1% Otic Solution02252716 CIPRODEX ALC

CIPROFLOXACIN HCL, HYDROCORTISONELimited use benefit (prior approval required).

For treatment of acute diffuse bacterial external otitis. Criteria for coverage include:a. - failure to respond to other listed topical antibiotics, orb. - contraindications to other listed topical antibiotics.

2mg & 10mg/mL Otic Suspension02240035 CIPRO HC ALC

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52:28.00 EENT - MOUTHWASHES AND GARGLESBENZYDAMINE HCL


For:a. - treatment of radiation mucositis and oral ulcerative complications of chemotherapy.b. - use in immunocompromised patients who are at risk of mucosal breakdown.

0.15% Rinse02239044 APO-BENZYDAMINE APX02239537 DOM-BENZYDAMINE DPC02229799 NOVO-BENZYDAMINE NOP02229777 PMS-BENZYDAMINE PMS02230170 RATIO-BENZYDAMINE RPH

1.5mg/mL Rinse02310422 NOVO-BENZYDAMINE NOP

52:40.04 EENT - ALPHA-ADRENERGIC AGONISTSBRIMONIDINE TARTRATE (ALPHAGAN P)


For patients who are intolerant to brimonidine tartrate 0.2% or benzalkonium chloride.

0.15% Ophth Solution02248151 ALPHAGAN P ALL02301334 APO-BRIMONIDINE P APX

52:92.00 MISCELLANEOUS EENT DRUGSVERTEPORFIN


For treatment of age related macular degeneration for patients with this diagnosis who are being treated by a certified ophthalmologist.

15mg/Vial Injection02242367 VISUDYNE QLT

56:00 GASTROINTESTINAL DRUGS56:12.00 CATHARTICS AND LAXATIVES

BISACODYL (POLYETHYLENE GLYCOL BASE)Limited use benefit (prior approval required).

For treatment of constipation in patients with spinal cord injury.

10mg Suppository02241091 MAGIC BULLET DCM

56:22.92 MISCELLANEOUS ANTIEMETICSAPREPITANT


When used in combination with a 5-HT3 antagonist and dexamethasone for the prevention of acute and delayed nausea and vomiting due to highly emetogenic cancer chemotherapy (eg. Cisplatin > 70mg/m2) in patients who have experienced emesis despite treatment with a combination of a 5-HT3 antagonist and dexamethasone in a previous cycle of highly emetogenic chemotherapy.



125mg & 80mg Capsule02298813 EMEND TRI PACK FRS

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56:28.36 PROTON-PUMP INHIBITORSLANSOPRAZOLE

The following PPI status change is primarily based on the Canadian Optimal Medication Prescribing and Utilization Service (COMPUS) report on optimal PPI therapy. The report concluded that;•All PPIs are equally efficacious•Double dose PPI is not necessary for initial therapy•Double dose PPI is effective in H. Pylori eradication; however, treatment is not needed beyond 14 days.

PPI use has been associated with increased risk of hip fracture, community-acquired pneumonia and Clostridium difficile associated diarrhea. Although further study is needed to establish clinical significance, it is prudent to use the lowest dose and shortest duration of therapy required to control symptoms.

Effective July 5, 2010, all proton pump inhibitors (open benefit and limited use (LU) PPIs) will have a maximum quantity limit of 400 tablets/capsules per 180 day period. This quantity limit will be in effect for the entire class of PPIs. •For example, if a patient fills 30 tablets of rabeprazole, then switch to 30 tablets of omeprazole, then switch to 30 capsules of lansoprazole, this will count as 90 PPI tablets/capsules towards the quantity limit. •Patients taking two rabeprazole 10mg tablets a day can be switched to one rabeprazole 20mg tablet a day to avoid reaching the quantity limit•Patients taking two omeprazole 10mg tablets/capsules a day can be switched to one omeprazole 20mg tablet/capsule a day to avoid reaching the quantity limit

Patients with Zollinger Ellison Syndrome, Barrett’s esophagus, erosive esophagitis and those who remain symptomatic on a single dose PPI will be eligible for additional doses above 400 tablets/capsules per 180 days through the prior approval process.



15mg Sustained Release Capsule02293811 APO-LANSOPRAZOLE APX02280515 NOVO-LANSOPRAZOLE NOP02165503 PREVACID ABB

30mg Sustained Release Capsule02293838 APO-LANSOPRAZOLE APX02280523 NOVO-LANSOPRAZOLE NOP02165511 PREVACID ABB

LANSOPRAZOLE ODTThe following PPI status change is primarily based on the Canadian Optimal Medication Prescribing and Utilization Service (COMPUS) report on optimal PPI therapy. The report concluded that;•All PPIs are equally efficacious•Double dose PPI is not necessary for initial therapy•Double dose PPI is effective in H. Pylori eradication; however, treatment is not needed beyond 14 days.






15MG Orally Disintegrating Tablet02249464 PREVACID FASTAB TAK

30MG Orally Disintegrating Tablet02249472 PREVACID FASTAB TAK

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56:28.36 PROTON-PUMP INHIBITORSOMEPRAZOLE MAGNESIUM (PA)







10mg Delayed Release Tablet02230737 LOSEC AZC02260859 RATIO-OMEPRAZOLE RPH

OMEPRAZOLE, OMEPRAZOLE MAGNESIUM (NO PA)The following PPI status change is primarily based on the Canadian Optimal Medication Prescribing and Utilization Service (COMPUS) report on optimal PPI therapy. The report concluded that;•All PPIs are equally efficacious•Double dose PPI is not necessary for initial therapy•Double dose PPI is effective in H. Pylori eradication; however, treatment is not needed beyond 14 days.






10mg Capsule02119579 LOSEC AZC02329425 MYLAN-OMEPRAZOLE GEN02296438 SANDOZ OMEPRAZOLE SDZ

20mg Capsule02245058 APO-OMEPRAZOLE APX00846503 LOSEC AZC02329433 MYLAN-OMEPRAZOLE GEN02320851 PMS-OMEPRAZOLE PMS02296446 SANDOZ OMEPRAZOLE SDZ

20mg Delayed Release Tablet02190915 LOSEC AZC02310260 PMS-OMEPRAZOLE PMS02260867 RATIO-OMEPRAZOLE RPH

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56:28.36 PROTON-PUMP INHIBITORSPANTOPRAZOLE MAGNESIUM







40mg Enteric Coated Tablet02267233 TECTA NCC

PANTOPRAZOLE SODIUMThe following PPI status change is primarily based on the Canadian Optimal Medication Prescribing and Utilization Service (COMPUS) report on optimal PPI therapy. The report concluded that;•All PPIs are equally efficacious•Double dose PPI is not necessary for initial therapy•Double dose PPI is effective in H. Pylori eradication; however, treatment is not needed beyond 14 days.






40mg Enteric Coated Tablet02292920 APO-PANTOPRAZOLE APX02300486 CO PANTOPRAZOLE COB02299585 GEN-PANTOPRAZOLE GEN02285487 NOVO-PANTOPRAZOLE NOP02229453 PANTOLOC NYC02318695 PANTOPRAZOLE PDL02309866 PHL-PANTOPRAZOLE PMI02307871 PMS-PANTOPRAZOLE PMS02305046 RAN-PANTOPRAZOLE RBY02308703 RATIO-PANTOPRAZOLE RPH02310201 RIVA-PANTOPRAZOLE ZYM02316463 RIVA-PANTOPRAZOLE RIV02301083 SANDOZ-PANTOPRAZOLE SDZ

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56:28.36 PROTON-PUMP INHIBITORSRABEPRAZOLE SODIUM







10mg Enteric Coated Tablet02296632 NOVO-RABEPRAZOLE NOP02243796 PARIET EC JNO02310805 PMS-RABEPRAZOLE PMS02315181 PRO-RABEPRAZOLE PDL02298074 RAN-RABEPRAZOLE RBY02314177 SANDOZ-RABEPRAZOLE SDZ

20mg Enteric Coated Tablet02296640 NOVO-RABEPRAZOLE NOP02243797 PARIET EC JNO02310813 PMS-RABEPRAZOLE PMS02315203 PRO-RABEPRAZOLE PDL02298082 RAN-RABEPRAZOLE RBY02330091 RIVA-RABEPRAZOLE RIV02314185 SANDOZ-RABEPRAZOLE SDZ

68:00 HORMONES AND SYNTHETIC SUBSTITUTES68:12.00 CONTRACEPTIVES

ETHINYL ESTRADIOL, ETONOGESTRELLimited use benefit (prior approval required).

For patients who are intolerant to or unable to take oral contraceptives.

11.4mg & 2.6mg Device02253186 NUVARING ORG

68:16.12 ESTROGEN AGONISTS-ANTAGONISTSRALOXIFENE HCL


For:a.- secondary prevention of osteoporosis in women who experience failure on bisphosphonates.b. - secondary prevention of osteoporosis in women who have a personal history or a first degree relative with a history of breast cancer.

60mg Tablet02279215 APO-RALOXIFENE APX02239028 EVISTA LIL02312298 NOVO-RALOXIFENE NOP

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68:20.28 THIAZOLIDINEDIONESPIOGLITAZONE HCL



15mg Tablet02303442 ACCEL PIOGLITAZONE ACP02242572 ACTOS LIL02302942 APO-PIOGLITAZONE APX02302861 CO PIOGLITAZONE COB02307634 DOM-PIOGLITAZONE DOM02298279 GEN-PIOGLITAZONE GEN02326477 MINT-PIOGLITAZONE MIN02274914 NOVO-PIOGLITAZONE NOP02307669 PHL-PIOGLITAZONE PMI02303124 PMS-PIOGLITAZONE PMS02312050 PRO-PIOGLITAZONE PDL02301423 RATIO-PIOGLITAZONE RPH02297906 SANDOZ PIOGLITAZONE SDZ02320754 ZYM-PIOGLITAZONE ZYM



ROSIGLITAZONE MALEATELimited use benefit (prior approval required).


2mg Tablet02241112 AVANDIA GSK

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68:20.28 THIAZOLIDINEDIONESROSIGLITAZONE MALEATE





68:24.00 PARATHYROIDCALCITONIN SALMON (MIACALCIN)


For treatment of patients with postmenopausal osteoporosis who have failed therapy, are intolerant to, or who have contraindications to both bisphosphonates and raloxifene.

200IU/Dose Nasal Spray02247585 APO-CALCITONIN APX02240775 MIACALCIN NVR02261766 SANDOZ-CALCITONIN SDZ

84:00 SKIN AND MUCOUS MEMBRANE AGENTS (SMMA)84:92.00 MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS

PIMECROLIMUSLimited use benefit (prior approval required).


Note: Contraindicated in children less than 2 years of age.

1% Cream02247238 ELIDEL NVC

TACROLIMUS (PROTOPIC)Limited use benefit (prior approval required).


Note: Contraindicated in children less than 2 years of age.

0.03% Ointment02244149 PROTOPIC AST

0.1% Ointment02244148 PROTOPIC AST

86:00 SMOOTH MUSCLE RELAXANTS86:12.00 GENITOURINARY SMOOTH MUSCLE RELAXANTS

DARIFENACIN HYDROBROMIDE7.5mg Long Acting Tablet

02273217 ENABLEX NOV15mg Long Acting Tablet

02273225 ENABLEX NOV

SOLIFENACIN SUCCINATELimited use benefit (prior approval required).

For symptomatic relief in patients with an overactive bladder with symptoms of urinary frequency, urgency or urge incontinence in patients who have failed on or areintolerant of therapy with oxybutynin.

5mg Tablet02277263 VESICARE AST

10mg Tablet02277271 VESICARE AST

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86:12.00 GENITOURINARY SMOOTH MUSCLE RELAXANTSTOLTERODINE



2mg Extended Release Capsule02244612 DETROL LA PFI

4mg Extended Release Capsule02244613 DETROL LA PFI

1mg Tablet02239064 DETROL PFI

2mg Tablet02239065 DETROL PFI

TROSPIUM CHLORIDELimited use benefit (prior approval required).


20mg Tablet02275066 TROSEC ORY

88:00 VITAMINS88:28.00 MULTIVITAMIN PREPARATIONS

MULTIVITAMINS (PEDIATRIC)Limited use benefit (prior approval is not required).


Chewable Tablet00336300 MULTI-VITAMINS CHILD NOP

Drop00558060 INFANTOL HOR00762946 POLY-VI-SOL MJO

Liquid00558079 INFANTOL HOR

Tablet80011134 CENTRUM JUNIOR COMPLETE WYE02247975 FLINTSTONES EXTRA C BCD

MULTIVITAMINS (PRENATAL)Limited use benefit (prior approval is not required.).

Prenatal and postnatal vitamins are benefits only for women of childbearing age (12 to 50 years).

Tablet80001842 CENTRUM MATERNA WAY02229535 MULTI-PRE AND POST NATAL PED00815241 NEO-TINIC NEO80005770 PRENATAL & POSTPARTUM PMT02240840 PRENATAL AND POSTPARTUM VTH02241235 PRENATAL AND POSTPARTUM SDR02244374 PRENATAL VITAMINS AND MINERALS PMT

VITAMIN A, CHOLECALCIFEROL, ASCORBIC ACIDLimited use benefit (prior approval is not required).


Oral Liquid80008471 JAMP-MULTIVITAMIN A/D/C DROPS JMP

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92:00 UNCLASSIFIED THERAPEUTIC AGENTS92:00.00 UNCLASSIFIED THERAPEUTIC AGENTS

ABATACEPTLimited use benefit (prior approval required).

For the treatment of severely active RHEUMATOID ARTHRITIS in adult patients who have failed to respond to another biologic agent (infliximab, etanercept, OR adalimumab). Treatment should be combined with DMARDs. Criteria will be confirmed against patient’s medication history.

Note: Initial one-year coverage for rheumatoid arthritis is provided at a dose of 500 mg for patients weighing < 60 kg; 750 mg for patients weighing 60 to 100 kg; and 1000 mg for patients weighing > 100 kg. Doses are given at 0, 2 and 4 weeks, then every 4 weeks. Coverage beyond one year will be based on improvement in number of swollen joints, number of tender joints, ESR or CRP, duration of morning stiffness, Physician Global Assessment scale and Patient Global Assessment scale.

For the treatment of JUVENILE IDIOPATHIC ARTHRITIS in children 6 to 17 years with moderate to severe active polyarticular JUVENILE IODIOPATHIC ARTHRITIS who have failed to respond to a trial of etanercept. Criteria will be confirmed against patient’s medication history.

Note: Initial 16-week coverage for juvenile idiopathic arthritis is provided at a dose of 10 mg/kg for children weighing < 75 kg; 750 mg for children weighing 75 to 100 kg; and 1000 mg for patients weighing > 100 kg. Doses are given at 0, 2, and 4 weeks, then every 4 weeks. Coverage beyond 16 weeks will be based on improvement in number of active joints, number of joints with loss of range of motion, ESR, Physician Global Assessment scale, Patient or Parent Global Assessment scale and Child Health Assessment Questionnaire.

250mg/Vial Injection02282097 ORENCIA BMS

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92:00.00 UNCLASSIFIED THERAPEUTIC AGENTSADALIMUMAB


Criteria for initial one year coverage for a MAXIMUM dose of 40mg every 2 weeks:1. Prescribed by a rheumatologist, AND2. Patient has had a tuberculin skin test performed

3. For the treatment of severely active RHEUMATOID ARTHRITIS:•Patient is refractory to methotrexate weekly parenteral (SC or IM) at 20mg or greater (15mg or greater if patient is >65 years of age) for more than 8 weeksPLUS a minimum of two of the following:•leflunomide: 20mg daily for 10 weeks OR•gold: weekly injections for 20 weeks OR•cyclosporine: 2-5 mg/kg/day for 12 weeks OR•azathioprine: 2-3 mg/kg/day for 3 months OR•sulfasalazine at least 2g daily for 3 monthsPLUS one of the following combinations:•methotrexate with cyclosporine (minimum 4 month trial on both) OR•methotrexate with hydroxychloroquine and sulfasalazine (minimum 4 month trial on triple therapy) OR•methotrexate with gold (minimum 12 week trial) OR•in patients who are intolerant or who have contraindication to methotrexate therapy, or are refractory to a combination of at least 2 DMARDS

4. For the treatment of moderate to severe PSORIATIC ARTHRITIS with at least two of the following:•five or more swollen joints•if less than five swollen joints, at least one joint proximal to, or including wrist or ankle•more than one joint with erosion on imaging study•dactylitis of two or more digits•tenosynovitis refractory to oral NSAIDs and steroid injections•enthesitis refractory to oral NSAIDs and steroid injections (not required for Achilles tendon)•inflammatory spinal symptoms refractory to two NSAIDs (minimum four weeks trial each) and has a BASDAI greater than 4•daily use of corticosteroids•use of opioids > 12 hours per day for pain resulting from inflammationPatient is refractory to:•NSAIDs and•methotrexate weekly parenteral (SC or IM) at 20mg or greater (15mg or greater if patient is >65 years of age) for more than 8 weeksPLUS a minimum of one of the following:•leflunomide: 20mg daily for 10 weeks OR•gold: weekly injections for 20 weeks OR•cyclosporine: 2-5 mg/kg/day for 12 weeks OR•sulfasalazine at least 2g daily for 3 months

5. For the treatment of ANKYLOSING SPONDYLITIS when the following criteria are met:•BASDAI > 4 AND•patient is refractory to a three month trial of at least 3 NSAIDs at maximum tolerated dose AND for peripheral joint involvement, patient is refractory to weekly parenteral (SC or IM) at 20mg or greater (15mg or greater if patient is >65 years of age) for more than 8 weeks AND sulfasalazine 2g/day for four months.NOTE: For axial involvement, patient does not need to be tried on methotrexate or sulfasalazine.

6. For the treatment of patients with moderate to severe PSORIASIS who meet all of the following criteria:•Body surface area involvement greater than 10% and/or significant involvement of the face, hands, feet or genital region AND•Intolerance or lack of response to methotrexate AND cyclosporine OR•A contraindication to methotrexate and/or cyclosporine AND•Intolerance or lack of response to phototherapy OR•Inability to access phototherapyCoverage beyond 16 weeks will be based on a significant reduction in the Body Surface Area (BSA) involved and improvements in the Psoriasis Area Severity Index (PASI) score and the Dermatology Life Quality Index (DLQI).

7. For the treatment of moderately to severely active CROHN'S DISEASE. Initial treatment will allow for an induction dose of adalimumab 160mg followed by 80mg2 weeks later. Maintenance therapy will only be provided at a dose not exceeding 40mg every two weeks. Criteria for initial four week coverage for the treatment of moderate to severely active Crohn's disease:Patient is an adult with moderate to severely active Crohn's disease refractory to:•therapy with 5-ASA products (at least 3g/day for a minimum of 6 weeks);PLUS•glucorticoids equivalent to prednisone 40mg/day for a minimum of 2 weeks; OR•treatment discontinued due to serious adverse reactions; OR•contraindication to glucorticoid therapy;

40mg/0.8mL Injection09857327 HUMIRA PEN ABB97799757 HUMIRA PEN ABB09857326 HUMIRA PRE-FILL ABB97799756 HUMIRA PRE-FILL ABB

40mg/Vial Injection02258595 HUMIRA ABB

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92:00.00 UNCLASSIFIED THERAPEUTIC AGENTSALENDRONATE SODIUM




5mg Tablet02248727 APO-ALENDRONATE APX02233055 FOSAMAX FRS02270110 GEN-ALENDRONATE GEN02248251 NOVO-ALENDRONATE NOP02288079 SANDOZ ALENDRONATE SDZ

10mg Tablet02248728 APO-ALENDRONATE APX02201011 FOSAMAX FRS02270129 GEN-ALENDRONATE GEN02247373 NOVO-ALENDRONATE NOP02288087 SANDOZ ALENDRONATE SDZ

40mg Tablet02258102 CO ALENDRONATE COB02201038 FOSAMAX FRS

70mg Tablet02303078 ALENDRONATE-70 PDL02248730 APO-ALENDRONATE APX02258110 CO ALENDRONATE COB02245329 FOSAMAX FRS02286335 GEN-ALENDRONATE GEN02261715 NOVO-ALENDRONATE NOP02299712 PHL-ALENDRONATE PMI02273179 PMS-ALENDRONATE PMS02284006 PMS-ALENDRONATE FC PMS02275279 RATIO-ALENDRONATE RPH02270889 RIVA-ALENDRONATE RIV02288109 SANDOZ ALENDRONATE SDZ02302004 ZYM-ALENDRONATE ZYM

ALENDRONATE SODIUM, VITAMIN D3Limited use benefit (prior approval required).



70mg/2800U Tablet02276429 FOSAVANCE FRS

70mg/5600U Tablet02314940 FOSAVANCE MSP

Page A-26 de 322010


92:00.00 UNCLASSIFIED THERAPEUTIC AGENTSBOTULINUM TOXIN TYPE A


For the treatment of: a. - strabismus and blepharospasm associated with dystonia, including benign essential blepharospasm or VII nerve disorder in patients 12 years of age or older b. - cervical dystonia (spasmodic torticollis)

100IU Injection01981501 BOTOX ALL

CABERGOLINELimited use benefit (prior approval required).

For treatment of hyperprolactinemia in patients who have failed therapy with or are intolerant to bromocriptine.

0.5mg Tablet02301407 CO CABERGOLINE COB02242471 DOSTINEX PFI

CLOSTRIDIUM BOTULINUM NEUROTOXINLimited use benefit (prior approval required).

For: a. - the treatment of strabismus and blepharospasm associated with dystonia, including benign essential blepharospasm or VII nerve disorder in patients 12 years of age or older orb. - the treatment of cervical dystonia (spasmodic torticollis)

100U/vial Injection02324032 XEOMIN MEZ

CYCLOSPORINELimited use benefit (prior approval required).

For transplant therapy.

10mg Capsule02237671 NEORAL NVR




100mg/mL Solution02150697 NEORAL NVR

DUTASTERIDELimited use benefit (prior approval required).

a. - For treatment of Benign Prostatic Hyperplasia (BPH) in patients who do not tolerate or have not responded to an adrenergic blocker. orb. - For use in combination therapy when monotherapy with an alpha-blocker is not sufficient.

0.5mg Capsule02247813 AVODART GSK

Page A-27 de 322010


92:00.00 UNCLASSIFIED THERAPEUTIC AGENTSETANERCEPT


Criteria for initial one year coverage for a MAXIMUM dose of 50mg weekly:1. Prescribed by a rheumatologist, AND2. Patient has had a tuberculin skin test performed

3. For the treatment of severely active RHEUMATOID ARTHRITIS:•Patient is refractory to methotrexate weekly parenteral (SC or IM) at 20mg or greater (15mg or greater if patient is >65 years of age) for more than 8 weeksPLUS a minimum of two of the following:•leflunomide: 20mg daily for 10 weeks OR•gold: weekly injections for 20 weeks OR•cyclosporine: 2-5 mg/kg/day for 12 weeks OR•azathioprine: 2-3 mg/kg/day for 3 months OR•sulfasalazine at least 2g daily for 3 monthsPLUS one of the following combinations:•methotrexate with cyclosporine (minimum 4 month trial on both) OR•methotrexate with hydroxychloroquine and sulfasalazine (minimum 4 month trial on triple therapy) OR•methotrexate with gold (minimum 12 week trial) OR•in patients who are intolerant or who have contraindication to methotrexate therapy, or are refractory to a combination of at least 2 DMARDS

4. For the treatment of moderate to severe PSORIATIC ARTHRITIS with at least two of the following:•five or more swollen joints•if less than five swollen joints, at least one joint proximal to, or including wrist or ankle•more than one joint with erosion on imaging study•dactylitis of two or more digits•tenosynovitis refractory to oral NSAIDs and steroid injections•enthesitis refractory to oral NSAIDs and steroid injections (not required for Achilles tendon)•inflammatory spinal symptoms refractory to two NSAIDs (minimum four weeks trial each) and has a BASDAI greater than 4•daily use of corticosteroids•use of opioids > 12 hours per day for pain resulting from inflammationPatient is refractory to:•NSAIDs and•methotrexate weekly parenteral (SC or IM) at 20mg or greater (15mg or greater if patient is >65 years of age) for more than 8 weeksPLUS a minimum of one of the following:•leflunomide: 20mg daily for 10 weeks OR•gold: weekly injections for 20 weeks OR•cyclosporine: 2-5 mg/kg/day for 12 weeks OR•sulfasalazine at least 2g daily for 3 months

5. For the treatment of ANKYLOSING SPONDYLITIS when the following criteria are met:•BASDAI > 4 AND•patient is refractory to a three month trial of at least 3 NSAIDs at maximum tolerated dose AND for peripheral joint involvement, patient is refractory to weekly parenteral (SC or IM) at 20mg or greater (15mg or greater if patient is >65 years of age) for more than 8 weeks AND sulfasalazine 2g/day for four months.NOTE: For axial involvement, patient does not need to be tried on methotrexate or sulfasalazine.

6. For the treatment of severely active polyarticular JUVENILE IDIOPATHIC ARTHRITIS in children 4 to 17 years where the following criteria are met:•≥ 5 swollen joints; AND•≥ 3 joints with limited range of motion and/or pain/tenderness; AND•Condition is refractory to an adequate trial of a therapeutic dose of methotrexate. An adequate trial is defined as at least 3 months of parenteral methotrexate at 10mg/m2 weekly (unless significant toxicity limits the dose tolerated)

25mg/Vial Injection02242903 ENBREL IMX

50mg/mL Injection02274728 ENBREL IMX99100373 ENBREL SURECLICK AMG

FINASTERIDELimited use benefit (prior approval required).

a. - For treatment of Benign Prostatic Hyperplasia (BPH) in patients who do not tolerate or have not responded to an alpha-adrenergic blocker.orb. - For use in combination therapy when monotherapy with an alpha-blocker is not sufficient.

5mg Tablet02348500 NOVO-FINASTERIDE NOP02310112 PMS-FINASTERIDE PMS02010909 PROSCAR FRS02306905 RATIO-FINASTERIDE RPH02322579 SANDOZ FINASTERIDE SDZ

Page A-28 de 322010


92:00.00 UNCLASSIFIED THERAPEUTIC AGENTSGOLIMUMAB


Criteria for initial one year coverage for a MAXIMUM dose of 50 mg every month for RHEUMATOID ARTHRITIS, PSORIATIC ARTHRITIS, ANKYLOSING SPONDYLITIS:1. Prescribed by a rheumatologist, AND2. Patient has had a tuberculin skin test performed AND3. For the treatment of severely active RHEUMATOID ARTHRITIS:- Patient is refractory to methotrexate weekly parenteral (SC or IM) at 20 mg or greater (15mg or greater if patient is >65 years of age) for more than 8 weeksPLUS a minimum of two of the following:- leflunomide: 20mg daily for 10 weeks OR- gold: weekly injections for 20 weeks OR- cyclosporine: 2-5 mg/kg/day for 12 weeks OR- azathioprine: 2-3 mg/kg/day for 3 months OR- sulfasalazine at least 2g daily for 3 monthsPLUS one of the following combinations:- methotrexate with cyclosporine (minimum 4 month trial on both) OR- methotrexate with hydroxychloroquine and sulfasalazine (minimum 4 month trial on triple therapy) OR- methotrexate with gold (minimum 12 week trial) OR- in patients who are intolerant or who have contraindication to methotrexate therapy, or are refractory to a combination of at least 2 DMARDS OR4. For the treatment of moderate to severe PSORIATIC ARTHRITIS with at least two of the following:- five or more swollen joints- if less than five swollen joints, at least one joint proximal to, or including wrist or ankle- more than one joint with erosion on imaging study- dactylitis of two or more digits- tenosynovitis refractory to oral NSAIDs and steroid injections- enthesitis refractory to oral NSAIDs and steroid injections (not required for Achilles tendon)- inflammatory spinal symptoms refractory to two NSAIDs (minimum four weeks trial each) and has a BASDAI greater than 4 - daily use of corticosteroids- use of opioids > 12 hours per day for pain resulting from inflammationPatient is refractory to:- NSAIDs and- methotrexate weekly parenteral (SC or IM) at 20mg or greater (15mg or greater if patient is >65 years of age) for more than 8 weeks PLUS a minimum of one of the following:- leflunomide: 20mg daily for 10 weeks OR- gold: weekly injections for 20 weeks OR- cyclosporine: 2-5 mg/kg/day for 12 weeks OR- sulfasalazine at least 2g daily for 3 months OR5. For the treatment of ANKYLOSING SPONDYLITIS when the following criteria are met:- BASDAI > 4 AND- patient is refractory to a three month trial of at least 3 NSAIDs at maximum tolerated dose AND for peripheral joint involvement, patient is refractory to weekly parenteral (SC or IM) at 20mg or greater (15mg or greater if patient is >65 years of age) for more than 8 weeks AND sulfasalazine 2g/day for four months.NOTE: For axial involvement, patient does not need to be tried on methotrexate or sulfasalazine.

50mg/0.5mL Injection02324784 SIMPONI AUTO INJECTOR CER02324776 SIMPONI PRE-FILLED SYRINGE CER

Page A-29 de 322010


92:00.00 UNCLASSIFIED THERAPEUTIC AGENTSINFLIXIMAB

CRITERIA FOR INITIAL TWELVE WEEKS OF COVERAGE FOR INFLIXIMAB FOR RHEUMATOID ARTHRITIS•Prescribed by a rheumatologist •Infliximab for use in combination with methotrexate for the treatment of severely active rheumatoid arthritisNote: Initial coverage is provided for 3 doses of 3mg/kg of infliximab ONLY. Patient is refractory to:•Methotrexate: oral therapy at 20mg or greater total weekly dosage (15mg or greater if patient is <65 years of age) for more than 8 weeks. AND•Methotrexate: weekly parenteral (SC or IM) at 20mg or greater (15mg or greater if patient is >65 years of age) for more than 8 weeks. PLUS•Leflunomide: 20mg daily for 10 weeksPLUS•Gold: weekly injections for 20 weeks OR•Sulfaslazine: at least 2 gm daily for 3 months OR•Azathioprine: 2-3mg/kg/day for 3 months PLUS One of the following combinations:•Methotrexate with cyclosporine (minimum 4 month trial on both) OR•Methotrexate with hydroxychloroquine and sulfasalazine (minimum 4 month trial on triple therapy) OR•Methotrexate with gold (minimum 12 week trial) OR•Methotrexate with leflunomide (minimum 8 week trial) OR•In patients who are intolerant or who have contraindications to methotrexate therapy, refractory to a combination of a least 2 DMARDs. PLUSEtanercept or Adalimumab: minimum of 12 week trial

CRITERIA FOR CONTINUED COVERAGE FOR INFLIXIMAB BEYOND TWELVE WEEKSPatient meets all the following criteria:• Initially prescribed by a rheumatologist• Previous failure to etanercept or adalimumab• Patient has been assessed after the eighth to twelfth week of infliximab therapy and meets the following response criteria >20% reduction in number of tender and swollen joints PLUS >20% improvement in physician global assessment scalePLUS EITHER>20% improvement in the patient global assessment scale, OR>20% reduction in the acute phase as measured by ESR or CRP

REQUEST FOR INITIAL COVERAGE OF INFLIXIMAB FOR FISTULIZING CROHN’S DISEASEThe initial coverage will allow for 3 doses of 5mg/kg/dose, administered at 0, 2 and 6 weeks. For continued coverage, patient must be reassessed after the initial doses.•Infliximab is being prescribed by a gastroenterologist•Patient is an adult with actively draining perianal or entercutaneous fistula(e) that have recurred or persisted despite:1.a course of appropriate antibiotic therapy (e.g. ciprofloxacin with or without metronidazole for a minimum of 3 weeks)PLUS2.immunosuppressive therapy:•azathioprine 2 to 2.5mg/kg/day for a minimum of 6 weeks or treatment discontinued at < 6 weeks due to severe adverse reactions. OR•6-mercaptopurine 50-70mg/day for a minimum of 6 weeks or treatment discontinued at <6 weeks due to severe adverse reactions. OR•Other.

REQUEST FOR INITIAL COVERAGE OF INFLIXIMAB FOR SEVERE ACTIVE CROHN’S DISEASEThe initial coverage will allow for 3 doses of 5mg/kg/dose, administered at 0, 2 and 6 weeks. For continued coverage, patient must be reassessed after the initial doses.•Infliximab is being prescribed by a gastroenterologist•Patient is an adult with severe active Crohn’s disease that has recurred or persisted despite:1. Therapy with 5-ASA products (at least 3g/day for a minimum of 6 weeks). PLUS2. Glucocorticoids equivalent to prednisone 40mg/day for a minimum of 2 weeks. OR Treatment discontinued due to serious adverse reactions.OR Contraindication to glucocorticoid therapy.PLUS3. Azathioprine 2 to 2.5mg/kg/day for a minimum of 3 months. OR6-mercaptopurine 50 to 70mg/day for a minimum of 3 months. OR Methotrexate 15 to 25mg/week for a minimum of 3 months.

100mg/Vial Injection02244016 REMICADE CEN

Page A-30 de 322010


92:00.00 UNCLASSIFIED THERAPEUTIC AGENTSLEFLUNOMIDE





MYCOPHENOLATE MOFETILLimited use benefit (prior approval required).


250mg Capsule02192748 CELLCEPT HLR

500mg Tablet02237484 CELLCEPT HLR

MYCOPHENOLATE SODIUMLimited use benefit (prior approval required).


180mg Enteric Coated Tablet02264560 MYFORTIC NVR

360mg Enteric Coated Tablet02264579 MYFORTIC NVR

RISEDRONATE SODIUMLimited use benefit (prior approval required).



5mg Tablet02242518 ACTONEL PGP02298376 NOVO-RISEDRONATE NOP



Page A-31 de 322010


92:00.00 UNCLASSIFIED THERAPEUTIC AGENTSSIROLIMUS


Coverage will be provided as a second line therapy for patients failing mycophenolate mofetil.

1mg/mL Oral Liquid02243237 RAPAMUNE WAY

1mg Tablet02247111 RAPAMUNE WAY

ZOLEDRONIC ACIDLimited use benefit (prior approval required).

For the treatment of Paget’s disease. Coverage will be granted for one dose per 12 month period.

5mg/100mL Injection02269198 ACLASTA NOV

92:44.00TACROLIMUS



0.5mg Capsule02243144 PROGRAF AST

1mg Capsule02175991 PROGRAF AST

5mg Capsule02175983 PROGRAF AST

5mg/mL Injection02176009 PROGRAF AST

0.5mg Long Acting Capsule02296462 ADVAGRAF AST

1mg Long Acting Capsule02296470 ADVAGRAF AST

5mg Long Acting Capsule02296489 ADVAGRAF AST

Page A-32 de 322010

Page

Non-Insured Health BenefitsAppendix ALimited Use Benefits and Criteria

Page Page1

21ACCEL PIOGLITAZONE15ACCOLATE32ACLASTA31ACTONEL21ACTOS32ADVAGRAF9ADVAIR9ADVAIR DISKUS 1009ADVAIR DISKUS 250

10ADVAIR DISKUS 50011AGGRENOX26ALENDRONATE-7016ALPHAGAN P26APO-ALENDRONATE16APO-BENZYDAMINE16APO-BRIMONIDINE P22APO-CALCITONIN10APO-CYCLOBENZAPRINE17APO-LANSOPRAZOLE31APO-LEFLUNOMIDE13APO-LEVETIRACETAM1APO-LEVOFLOXACIN1APO-MINOCYCLINE

18APO-OMEPRAZOLE19APO-PANTOPRAZOLE21APO-PIOGLITAZONE20APO-RALOXIFENE10APO-TIZANIDINE3APTIVUS

31ARAVA7ARICEPT3ATRIPLA

21AVANDIA27AVODART5BARACLUDE

27BOTOX15CARNITOR15CARNITOR IV11CELEBREX31CELLCEPT3CELSENTRI

23CENTRUM JUNIOR COMPLETE23CENTRUM MATERNA10CHAMPIX10CHAMPIX STARTER PACK15CIPRO HC15CIPRODEX26CO ALENDRONATE27CO CABERGOLINE13CO LEVETIRACETAM19CO PANTOPRAZOLE21CO PIOGLITAZONE12CODEINE CONTIN CR1CO-LEVOFLOXACIN

10CYCLOBENZAPRINE14CYMBALTA13DEMEROL23DETROL23DETROL LA16DOM-BENZYDAMINE10DOM-CYCLOBENZAPRINE1DOM-LEVOFLOXACIN

1DOM-MINOCYCLINE21DOM-PIOGLITAZONE27DOSTINEX12DURAGESIC MAT22ELIDEL16EMEND16EMEND TRI PACK22ENABLEX28ENBREL28ENBREL SURECLICK20EVISTA

8EXELON11EZETROL23FLINTSTONES EXTRA C

9FORADIL26FOSAMAX26FOSAVANCE26GEN-ALENDRONATE10GEN-CYCLOPRINE31GEN-LEFLUNOMIDE

1GEN-LEVOFLOXACIN19GEN-PANTOPRAZOLE21GEN-PIOGLITAZONE10GEN-TIZANIDINE

5GLEEVEC5HEPSERA

25HUMIRA25HUMIRA PEN25HUMIRA PRE-FILL13HYDROMORPH CONTIN23INFANTOL

3INTELENCE3ISENTRESS

23JAMP-MULTIVITAMIN A/D/C DROPS

13KEPPRA1LEVAQUIN1LEVOFLOXACIN

18LOSEC16MAGIC BULLET

1MED-MINOCYCLINE22MIACALCIN

1MINOCIN2MINOCYCLINE

21MINT-PIOGLITAZONE23MULTI-PRE AND POST NATAL23MULTI-VITAMINS CHILD31MYFORTIC18MYLAN-OMEPRAZOLE

8MYLAN-RIVASTIGMINE27NEORAL23NEO-TINIC11NEULASTA26NOVO-ALENDRONATE16NOVO-BENZYDAMINE10NOVO-CYCLOPRINE12NOVO-FENTANYL28NOVO-FINASTERIDE17NOVO-LANSOPRAZOLE31NOVO-LEFLUNOMIDE

1NOVO-LEVOFLOXACIN1NOVO-MINOCYCLINE

19NOVO-PANTOPRAZOLE

21NOVO-PIOGLITAZONE20NOVO-RABEPRAZOLE20NOVO-RALOXIFENE31NOVO-RISEDRONATE8NOVO-RIVASTIGMINE

10NU-CYCLOBENZAPRINE20NUVARING24ORENCIA9OXEZE TURBUHALER

13OXYCONTIN19PANTOLOC19PANTOPRAZOLE20PARIET EC1PDL-MINOCYCLINE4PEGASYS4PEGASYS RBV4PEGETRON4PEGETRON REDIPEN

26PHL-ALENDRONATE10PHL-CYCLOBENZAPRINE1PHL-LEVOFLOXACIN

19PHL-PANTOPRAZOLE21PHL-PIOGLITAZONE11PLAVIX26PMS-ALENDRONATE26PMS-ALENDRONATE FC16PMS-BENZYDAMINE14PMS-BUPROPION SR10PMS-CYCLOBENZAPRINE12PMS-FENTANYL MTX28PMS-FINASTERIDE31PMS-LEFLUNOMIDE13PMS-LEVETIRACETAM1PMS-LEVOFLOXACIN1PMS-MINOCYCLINE2PMS-MONOCYCLINE

18PMS-OMEPRAZOLE19PMS-PANTOPRAZOLE21PMS-PIOGLITAZONE20PMS-RABEPRAZOLE8PMS-RIVASTIGMINE

23POLY-VI-SOL23PRENATAL & POSTPARTUM23PRENATAL AND POSTPARTUM23PRENATAL VITAMINS AND

MINERALS17PREVACID17PREVACID FASTAB2PREZISTA

32PROGRAF21PRO-PIOGLITAZONE20PRO-RABEPRAZOLE28PROSCAR22PROTOPIC12RAN-FENTANYL12RAN-FENTANYL MATRIX12RAN-FENTANYL MATRIX PATCH

1219RAN-PANTOPRAZOLE20RAN-RABEPRAZOLE32RAPAMUNE26RATIO-ALENDRONATE16RATIO-BENZYDAMINE

Page A-1 of 22010

Page

Non-Insured Health BenefitsAppendix ALimited Use Benefits and Criteria

Page Page14RATIO-BUPROPION14RATIO-BUPROPION SR10RATIO-CYCLOBENZAPRINE12RATIO-FENTANYL28RATIO-FINASTERIDE1RATIO-MINOCYCLINE

18RATIO-OMEPRAZOLE19RATIO-PANTOPRAZOLE21RATIO-PIOGLITAZONE30REMICADE7REMINYL ER6RITUXAN

26RIVA-ALENDRONATE10RIVA-CYCLOBENZAPRINE1RIVA-MINOCYCLINE

19RIVA-PANTOPRAZOLE20RIVA-RABEPRAZOLE26SANDOZ ALENDRONATE12SANDOZ FENTANYL12SANDOZ FENTANYL

TRANSDERMAL SYSTEM28SANDOZ FINASTERIDE31SANDOZ LEFLUNOMIDE1SANDOZ LEVOFLOXACIN

18SANDOZ OMEPRAZOLE21SANDOZ PIOGLITAZONE14SANDOZ-BUPROPION SR22SANDOZ-CALCITONIN27SANDOZ-CYCLOSPORINE1SANDOZ-MINOCYCLINE

19SANDOZ-PANTOPRAZOLE20SANDOZ-RABEPRAZOLE9SEREVENT DISKHALER9SEREVENT DISKUS

29SIMPONI AUTO INJECTOR29SIMPONI PRE-FILLED SYRINGE15SINGULAIR8SPIRIVA6SUTENT9SYMBICORT 100 TURBUHALER9SYMBICORT 200 TURBUHALER5TARCEVA

19TECTA6TEMODAL

23TROSEC3TRUVADA4UNITRON PEG

22VESICARE2VFEND3VIREAD

16VISUDYNE14WELLBUTRIN SR14WELLBUTRIN XL27XEOMIN10ZANAFLEX14ZYBAN SR26ZYM-ALENDRONATE21ZYM-PIOGLITAZONE2ZYVOXAM

Page A-2 of 22010

APPENDIX B

SPECIAL FORMULARY FOR CHRONIC RENAL FAILURE PATIENTS

Non-Insured Health BenefitsAppendix BSpecial Formulary for Chronic Renal Failure Patients

The Special Formulary for Chronic Renal Failure Patients defines selected drugs (for example: darbepoetin alfa, calcium products, water-soluble multivitamin products and selected nutritional products formulated for renal patients) that are covered for identified eligible NIHB clients in chronic renal failure. These drugs are covered in addition to the drugs and products listed in the NIHB Drug Benefit List.

20:00 BLOOD FORMATION COAGULATION AND THROMBOSIS

20:16.00 HEMATOPOIETIC AGENTSDARBEPOETIN ALFA

25mcg/mL Injection02246354 ARANESP AMG





EPOETIN ALFA20,000IU/mL Injection

02206072 EPREX JNO20000IU/0.5mL injection

02243239 EPREX JNO5,000IU/mL Injection

02243400 EPREX JNO30000IU/0.75mL Injection

02288680 EPREX JNO1,000IU/0.5mL Prefilled Syringe






02243403 EPREX JNO10,000IU/mL Prefilled Syringe

02231587 EPREX JNO40,000IU/mL Prefilled Syringe

02240722 EPREX JNO

40:00 ELECTROLYTIC, CALORIC, AND WATER BALANCE

40:08.00 ALKALINIZING AGENTSSODIUM BICARBONATE

500mg Tablet00392839 SANDOZ SOD BICARBONATE SDZ

40:12.00 REPLACEMENT PREPARATIONSCALCIUM (CALCIUM GLUCONOLACTATE, CALCIUM CARBONATE)

300mg & 2940mg Effervescent Tablet02232482 CALCIUM SANDOZ NVC

1750mg & 2327mg Effervescent Tablet02232483 GRAMCAL NVC

CALCIUM CARBONATE500mg Capsule

00648353 CALSAN NVC500mg Chewable Tablet

00705373 CALCIUM WAM00648345 CALSAN NVC

250mg Tablet00682047 APO-CAL 250 APX00645958 CALCIUM NOP

CALCIUM CITRATE300mg Tablet

02231833 CALCIUM CITRATE WNP

PHOSPHORUS500mg Effervescent Tablet

00225819 PHOSPHATE-NOVARTIS NVR

ZINC GLUCONATE50mg Tablet

00503169 ZINC VTH00505463 ZINC JAM

Page B-1 of 22010

Non-Insured Health BenefitsAppendix BSpecial Formulary for Chronic Renal Failure Patients

The Special Formulary for Chronic Renal Failure Patients defines selected drugs (for example: darbepoetin alfa, calcium products, water-soluble multivitamin products and selected nutritional products formulated for renal patients) that are covered for identified eligible NIHB clients in chronic renal failure. These drugs are covered in addition to the drugs and products listed in the NIHB Drug Benefit List.

40:18.19 PHOSPHATE - REMOVING AGENTS

SEVELAMER HYDROCHLORIDELimited Use Benefit ( Prior approval required ).

a. - patients with elevated phosphate levels OR elevated phosphate X calcium product despite dietary restriction of phosphate and use of calcium-based phosphate binders (short term elevations should be managed with aluminium based binders)b. - patients with elevated calcium levels despite discontinuation of calcium binder, and Vitamin D analogue and/or modification of dialysate calciumc. - patients with adynamic bone disease and low PTH levels (<100 pg/ml or <0.9 pmol/L) with normal or elevated calcium levels

800mg Tablet02244310 RENAGEL GEE

56:00 GASTROINTESTINAL DRUGS56:04.00 ANTACIDS AND ADSORBENTS

ALUMINUM HYDROXIDE500mg Capsule

02135620 BASALJEL AXC60mg/mL Liquid

00572527 ALUGEL ATL64mg/mL Liquid

02125862 AMPHOJEL AXC600mg Tablet

02124971 AMPHOJEL AXC

CALCIUM CARBONATE500mg Tablet

01970240 TUMS GSK750mg Tablet

01967932 TUMS EXTRA STRENGTH GSK1000mg Tablet

02151138 TUMS ULTRA STRENGTH GSK

88:00 VITAMINS88:12.00 VITAMIN C

VITAMIN B COMPLEXTablet

00123803 B COMPLEX PLUS C JAM

VITAMIN B COMPLEX WITH VITAMIN CTablet

02245391 DIAMINE EUR

88:28.00 MULTIVITAMIN PREPARATIONSMULTIVITAMINS

Tablet02244872 REPLAVITE WNP80007498 REPLAVITE WNP00558796 STRESS PLEX C JAM

96:00 PHARMACEUTICAL AIDS96:00.00 PHARMACEUTICAL AIDS

NUTRITIONAL SUPPLEMENTLiquid

09854258 NOVASOURCE RENAL NESLiquid

09853723 NEPRO ABB00907995 NOVASOURCE NVR09853731 SUPLENA ABB

235mL Liquid99002639 NEPRO ABB99002647 SUPLENA ABB

Powder09991056 RESOURCE BENEPROTEIN NVR

Page B-2 of 22010

APPENDIX C

PALLIATIVE CARE FORMULARY

Non-Insured Health BenefitsAppendix CPalliative Care Formulary

Effective April 1, 2009, recipients diagnosed with a terminal illness and are near the end of life will be eligible to receive a list of supplemental benefits that are not included in the NIHB Drug Benefit List. The Palliative Care Formulary includes medications used to provide comfort to those near the end of life.

Requests for any of the DINs below will generate a Palliative Care Application Form, faxed to the prescribing physician. Once completed and submitted, the recipient will be eligible for all medications on the Palliative Care Formulary if the following criteria are met:

The recipient:1. is not receiving care in a provincially funded hospital or provincially funded long-term care facility and2. has been diagnosed with a terminal illness or disease which is expected to be the primary cause of death within six months or less

Once approved, the recipient will be eligible for all medications on the Palliative Care Formulary for six months without the need for further prior approval. If coverage is required beyond the initial six months, an additional six months may be granted upon receipt of another Palliative Care Application Form completed.Please note: During the six month coverage period, a maximum 30 day supply will be reimbursed at any one time.

12:00 AUTONOMIC DRUGS12:08.08 ANTIMUSCARINICS /

ANTISPASMODICSATROPINE SULFATE

0.4mg/mL Injection00392782 ATROPINE SULFATE SDZ00497231 ATROPINE SULFATE ABB00960624 ATROPINE SULFATE SAB

0.6mg/mL Injection00012076 ATROPINE SULFATE GSK00392693 ATROPINE SULFATE SDZ00497258 ATROPINE SULFATE ABB

GLYCOPYRROLATE0.2mg/mL Injection

02039508 GLYCOPYRROLATE SDZ

HYOSCINE BUTYLBROMIDE20mg/mL Injection

00363839 BUSCOPAN BOE02229868 HYOSCINE SDZ

SCOPOLAMINE HYDROBROMIDE0.4mg/mL Injection

00541869 SCOPOLAMINE ABB0.6mg/mL Injection

00541877 SCOPOLAMINE ABB

28:00 CENTRAL NERVOUS SYSTEM AGENTS

28:08.08 OPIATE AGONISTSFENTANYL

12mcg Transdermal Patch02311925 RATIO-FENTANYL

TRANSDERMAL SYSTEMRPH

02327112 SANDOZ FENTANYL 12MCG/HR PATCH

SDZ

12mcg/h Transdermal Patch02341379 PMS-FENTANYL MTX PMS02330105 RAN-FENTANYL MATRIX RBY

25mcg Transdermal Patch02330113 RAN-FENTANYL MATRIX

PATCH 25RBY

02249391 RAN-FENTANYL TRANSDERMAL SYSTEM

RBY

02282941 RATIO-FENTANYL TRANSDERMAL SYSTEM

RPH


SDZ

25mcg/h Transdermal Patch02275813 DURAGESIC MAT 25MCG/HR

PATCHJNO

02314630 NOVO-FENTANYL 25MCG PATCH

NOP

02341387 PMS-FENTANYL MTX PMS50mcg Transdermal Patch

02330121 RAN-FENTANYL MATRIX PATCH 50

RBY


RBY


RPH


SDZ

Page C-1 of 32010






28:08.08 OPIATE AGONISTSFENTANYL


PATCHJNO


NOP


02330148 RAN-FENTANYL MATRIX PATCH 75

RBY


RBY


RPH


SDZ


PATCHJNO


NOP



RBY

02282984 RATIO-FENTANYL 100MCG/HR PATCH

RPH


SDZ


PATCHJNO


NOP

02341417 PMS-FENTANYL MTX PMS02330156 RAN-FENTANYL MATRIX

PATCH 100RBY

28:08.08 OPIATE AGONISTSFENTANYL CITRATE

50mcg/mL Injection00888346 FENTANYL CITRATE HOS02126648 FENTANYL CITRATE HOS02240434 FENTANYL CITRATE SDZ

28:16.08 ANTIPSYCHOTIC AGENTSMETHOTRIMEPRAZINE

25mg/mL Injection01927698 NOZINAN SAC


DIAZEPAM5mg/mL Injection

02065614 DIAZEMULS VL ACG00399728 DIAZEPAM SDZ

LORAZEPAM4mg/mL Injection

02243278 LORAZEPAM SDZ

MIDAZOLAM1mg/mL Injection

02240285 MIDAZOLAM SDZ02242904 MIDAZOLAM PPC02243934 MIDAZOLAM NOP

5mg/mL Injection02240286 MIDAZOLAM SDZ02242905 MIDAZOLAM PPC02243935 MIDAZOLAM NOP

Page C-2 of 32010






56:00 GASTROINTESTINAL DRUGS56:32.00 PROKINETIC AGENTS

METOCLOPRAMIDE5mg/mL Injection

02185431 METOCLOPRAMIDE SDZ02243563 METOCLOPRAMIDE OMEGA OMG

56:92.00 MISCELLANEOUS GI DRUGSMETHYLNALTREXONE BROMIDE

20mg/mL Injection02308215 RELISTOR WYE

Page C-3 of 32010

APPENDIX D

LIST OF DRUG MANUFACTURERS

MFR Manufacturer Name MFR Manufacturer Name

Non-Insured Health BenefitsAppendix DList of Drug Manufacturers

ABB ABBOTT LABORATORIES LIMITED

ACT ACTI-FORM LIMITED

ADA ADAMS LABS LIMITED

AGO AGOURON PHARMACEUTICALS CANADA INCORPORATED

ALC ALCON CANADA INCORPORATED

ALG ALLERGOLOGISK LAB A/S

ALK ALK ABELLO A/S

ALL ALLERGAN INCORPORATED

AMG AMGEN CANADA INCORPORATED

APX APOTEX INCORPORATED

AST ASTELLAS PHARMA CANADA INCORPORATED

ATL LABORATORIE ATLAS INCORPORATED

AUC AUTO CONTROL

AVT AVENTIS PHARMA INCORPORATED

AXC AXCAN PHARMA INCORPORATED

AXL ALLEREX LABORATORY LIMITED

AXX AXXESS PHARMA INCORPORATED

AZC ASTRAZENECA CANADA INCORPORATED

BAK BAKER CUMMINS INCORPORATED.

BAR BARR PHARMACEUTICALS INCORPORATED

BAT BAXTER CORPORATION

BAX BRAINTREE LAB INCORPORATED

BAY BAYER INCORPORATED, HEALTHCARE/DIAGNOSTICS

BCD BAYER INCORPORATED, CONSUMER CARE DIVISION

BDH BDH INCORPORATED

BEN BENCARD ALLERGY LABORATORIES

BEX BERLEX CANADA INCORPORATED

BIH BIOENHANCE MEDICAL INCORPORATED

BIO BIONICHE PHARMA (CANADA) LIMITED

BMI BIOMED 2002 INCORPORATED

BMS BRISTOL-MYERS SQUIBB CANADA

BOE BOEHRINGER INGELHEIM (CANADA) LIMITED

BPC BIOVAIL PHARMACEUTICALS CANADA

BSH BAUSCH & LOMB CANADA INCORPORATED

BTD BECTON DICKINSON

BUY W.K. BUCKLEY LIMITED

CBS CENTER LABORATORIES INCORPORATED

CDX CANDERM PHARMA

CEN CENTOCOR INCORPORATED

CIP CIPHER PHARMACEUTICALS INCORPORATED

COB COBALT PHARMACEUTICALS INCORPORATED

COP COLGATE ORAL PHRAMACEUTICALS INCORPORATED

COS COSMAIR CANADA INCORPORATED

CUV CHAUVIN PHARMACEUTICALS LIMITED

CYX CYTEX PHARMACEUTICALS INCORPORATED

DAW DAWSON TRADERS LIMITED

DCL D.C. LABS LIMITED

DCM D & C MOBILITY

DDP THE D DROPS COMPANY INCORPORATED

DER DERMIK LABORATORIES CANADA INCORPORATED

DES DESBERGERS LIMITED

DKT DIOPTIC LABORATORIES INCORPORATED

DOR DORMER LABORATORIES INCORPORATED

DPC DOMINION PHARMACAL

DPT DERMTEK PHARMACEUTIQUE LIMITED

Page D-1 of 42010



DPY DRAXIS HEALTH INCORPORATED

DSP DISPENSA PHARM CANADA LIMITED

DUI DUCHESNAY INCORPORATED

EDM ENDO CANADA INCORPORATED

ELN ELAN PHARMACEUTICALS INCORPORATED

ERF ERFA CANADA INCORPORATED

EUR EURO-PHARM INTERNATIONAL CANADA INCORPORATED

FEI FERRING INCORPORATED

FER FERRARIS MEDICAL

FOU FOURNIER PHARMA INCORPORATED

FRS MERCK FROSST CANADA LIMITED

FTP FTP- PHARMACAL INCORPORATED

FUJ FUJISAWA CANADA INCORPORATED

GAC GALDERMA CANADA INCORPORATED

GCC GERMIPHENE CORPORATION

GCL GALEN CHEMICALS LIMITED

GEE GENZYME CANADA INCORPORATED

GEN GENPHARM ULC

GIL GILEAD SCIENCES INCORPORATED

GLE GLENWOOD LABORATORIES CANADA LIMITED

GSK GLAXOSMITHKLINE INCORPORATED

HAL HALL LABORATORIES LIMITED

HIL HILL DERMACEUTICALS INCORPORATED

HJS H.J. SUTTON INDUSTRIES LIMITED

HLR HOFFMAN-LAROCHE LIMITED

HMR HOECHST MARION ROUSSELL CANADA INCORPORATED

HOL HOLLISTER LIMITED

HOR CARTER-HORNER CORPORATION

HOS HOSPIRA HEALTHCARE CORPORATION

HPC HEALTHPOINT CANADA ULC

ICN ICN CANADA LIMITED

IDE INTERNATIONAL DERMATOLOGICALS INCORPORATED

IMX IMMUNEX CORPORATION

IPS IPSEN LIMITED

IVX IVAX PHARMACEUTICALS INCORPORATED.

JAJ JOHNSON & JOHNSON

JAM C.E. JAMIESON COMPANY LIMITED

JLF J.L.FREEMAN

JMP JAMP PHARMA CORPORATION

JNO JANSSEN-ORTHO INCORPORATED

KEY KEY PHARMACEUTICALS INCORPORATED

KIN KINSMOR PHARMACEUTICALS INCORPORATED

LAL LABORATOIRE LALCO INCORPORATED

LEO LEO PHARMA INCORPORATED

LHL LIFEHEALTH LIMITED

LIF LIFESCAN CANADA LIMITED

LIL ELI LILLY CANADA INCORPORATED

LIN LINSON PHARMA CORPORATION

LIO LIOH INCORPORATED

LUD LUNDBECK CANADA INCORPORATED

MAY MAYNE PHARMA (CANADA) INCORPORATED

MCA MCARTHUR MEDICAL SALES INCORPORATED

MCL MCNEIL CONSUMER PRODUCTS COMPANY

MDC MEDICIS CANADA CORPORATION

MDT MEDTRONIC OF CANADA LIMITED

MEC MEDICAN PHARMA INCORPORATED

MET MEDICAL TEXTILES MARKETING INCORPORATED

MIN MINT PHARMACEUTICALS INCORPORATED

MIO MEDIMMUNE ONCOLOGY INCORPORATED

Page D-2 of 42010



MJO MEAD JOHNSON CANADA INCORPORATED

MMH 3M PHARMACEUTICALS

MPD MEDICAL PLASTIC DEVICES INCORPORATED

MSL MEDIC SAVOURE LIMITED

MSP MERCK FROSST / SCHERING PHARMA GP

MTI MEDICAN TECHNOLOGIES INCORPORATED

NAB NABI BIOPHARMACEUTICALS

NDE NORDIC DESIGN

NEO NEOLAB INCORPORATED

NOO NOVO NORDISK CANADA INCORPORATED

NOP NOVOPHARM LIMITED

NUL NU-LIFE NUTRITIONAL PRODUCTS

NUR NUTRICORP INTERNATIONAL

NVC NOVARTIS CONSUMER HEALTH CANADA INCORPORATED

NVR NOVARTIS PHARMACEUTICALS CANADA INCORPORATED

NXP NU-PHARM INCORPORATED

NYC NYCOMED CANADA INCORPORATED

OBP ORBUS PHARMA INCORPORATED

ODN ODAN LABORATORIES LIMITED

OMG OMEGA LABORATORIES LIMITED

OPT OPTREX LABS LIMITED

ORG ORGANON CANADA LIMITED

ORY ORYX PHARMACEUTICALS INCORPORATED

OVA OVATION PHARMACEUTICALS INCORPORATED

PAL PALADIN LABS INCORPORATED

PCO PERSON & COVEY INCORPORATED

PDD PRODEMDIS ENTREPRISE

PDL PRO DOC LIMITED

PED PENDOPHARM INCORPORATED

PEN PENTAPHARM

PER PERRIGO INTERNATIONAL

PFD PROFESSIONAL DISPOSABLES

PFI PFIZER CANADA INCORPORATED

PFR PURDUE PHARMA

PGI PROCTOR & GAMBLE INCORPORATED

PGP PROCTOR & GAMBLE PHARMACEUTICALS INCORPORATED

PHH PHARMEL INCORPORATED

PHS PANGEO PHARMA (CANADA) INCORPORATED

PMJ PHARMACIA CANADA INCORPORATED

PMS PHARMASCIENCE INCORPORATED

PMT PHARMETICS INCORPORATED

PRE PREMPHARM INCORPORATED

PRO PROVAL PHARMA INCORPORATED

PVR PHARMAVITE CORPORATION

QLT QLT INCORPORATED

RBY RANBAXY PHARMACEUTICALS CANADA INCORPORATED

RHO RHOXALPHARMA INCORPORATED

RHP RHODIAPHARM INCORPORATED

RIV LABORATORIE RIVA INCORPORATED

ROD ROCHE DIAGNOSTICS

RPH RATIOPHARM INCORPORATED

RVX RIVEX PHARMA INCORPORATED

RWP RW PACKAGING LIMITED

SAB SABEX 2002 INCORPORATED

SAC SANOFI-AVENTIS CANADA

SBC SMITHKLINE BEECHAM CONSUMER HEALTHCARE INCORPORATED.

SCH SCHERING CANADA INCORPORATED

SCN SCHEIN PHARMACEUTICAL CANADA INCORPORATED

SDR STANLEY PHARMACEUTICALS LIMITED

Page D-3 of 42010



SDZ SANDOZ CANADA INCORPORATED

SEA SEARLE CANADA

SEV SERVIER CANADA INCORPORATED

SHI SHIRE CANADA INCORPORATED

SHM SHERWOOD INCORPORATED

SIG SIGMA-TAU PHARMACEUTICALS INCORPORATED

SNE SMITH & NEPHEW INCORPORATED

SPH SOLVAY PHARMA INCORPORATED

SQU SQUIRE PHARMACEUTICALS INCORPORATED

STE STERIMAX INCORPORATED

STI STIEFEL CANADA INCORPORATED

SWS SWISS HERBAL REMEDIES LIMITED

TAN TANTA PHARMACEUTICALS INCORPORATED

TAR TARO PHARMACEUTICALS INCORPORATED

TCD TRANS CANADERM INCORPORATED

THC TRILLIUM HEALTH CARE PRODUCTS INC.

THR THERMOR LIMITED

TIP TRIAD PHARMACEUTICALS

TPX THERAPEX INCORPORATED

TRI TRIANON LABORATORIES INCORPORATED

TRT TRITON PHARMA INCORPORATED

TRU TRUDELL MEDICAL INTERNATIONAL

UCB UBC PHARMA INCORPORATED

VAE VALEANT CANADA LIMITED

VAO VALEO PHARMA INCORPORATED

VIR VIRCO PHARMACEUTICALS CANADA INCORPORATED

VLB VITALAB

VTH VITA HEALTH PRODUCTS INCORPORATED

WAB WAYMAR PHARMACEUTICALS INCORPORATED

WAM WAMPOLE INCORPORATED

WAT WATSON LABORATORIES INCORPORATED

WAY WYETH CANADA

WCC WOMEN'S CAPITAL CORPORATION

WCI WARNER CHILCOTT COMPANY INCORPORATED

WEP WE PHARMACEUTICALS

WLA WARNER-LAMBERT CONSUMER HEALTHCARE INCORPORATED

WLR WIL RICHARDS COMPANY

WNP WN PHARMACEUTICALS LIMITED

WPC WELLSPRING PHARMACEUTICAL CANADA CORPORATION

WRI WHITEHALL-ROBINS INCORPORATED

WSB WESTWOOD SQUIBB INCORPORATED

WTR WESTCAN PHARMACEUTICALS LIMITED

XEN XENEX LABS INCORPORATED

ZIL ZILA PHARMACEUTICALS

ZYM ZYMCAN PHARMACEUTICALS

Page D-4 of 42010

APPENDIX E

LIST OF EXCLUSIONS

Certain drug products are not within the scope of the program. These products will not be reimbursed as benefits under the NIHB Program:

Anti-obesity drugs; Household products (regular soaps and shampoos); Cosmetics; Alternative therapies, including glucosamine and evening primrose oil; Megavitamins; Drugs with investigational/experimental status; Vaccinations for travel indications; Hair growth stimulants; Fertility agents and impotence drugs; Selected over-the-counter products; Codeine containing cough preparations; Dalmane®, Somnol® and generics (flurazepam);Darvon® and 642® (propoxyphene); Fiorinal®, Fiorinal® C ¼, Fiorinal® C ½ and generics (Butalbital containing analgesics with and without codeine);Librium®, Solium®, Medilium® and generics (chlordiazepoxide);Stadol TM NS and generics (butorphanol tartrate nasal spray); andTranxene® and generics (clorazepate).

The following drugs will be excluded from the NIHB Program as recommended by the Common Drug Review (CDR) and the Federal Pharmacy and Therapeutics Committee (FPT) because published evidence does not support the clinical value or cost of the drug relative to existing therapies, or there is insufficient clinical evidence to support coverage.Of Note: The Appeal Process and the Emergency Supply Policy will not apply for the following drug products.

Non-Insured Health BenefitsAppendix EEXCLUSIONS

DIN BRAND NAMEMFR02248722 ALL ACULAR LS 0.4% OPHTHALMIC SOLUTION02259052 AST AMEVIVE 15MG/0.5ML POWDER FOR SOLUTION02247916 BAY CIPRO XL 500MG TABLET02251787 BAY CIPRO XL 1000MG TABLET02268507 BPC GLUMETZA 1000MG EXTENDED RELEASE TABLET02268493 BPC GLUMETZA 500MG EXTENDED RELEASE TABLET02248417 FEI GYNAZOLE-1 VAG CREAM 2%02244521 AZC NEXIUM 20MG SR TABLET02244522 AZC NEXIUM 40MG SR TABLET02241804 SPH PANTOLOC 20MG EC TABLET02248503 GSK PAXIL CR 12.5MG EXTENDED RELEASE TABLET02248504 GSK PAXIL CR 25MG EXTENDED RELEASE TABLET02229437 NAB PHOSLO 667MG TABLET02256290 PFI RELPAX 20MG TABLET02256304 PFI RELPAX 40MG TABLET

Page E-1 of 12010

Page


Page Page73462824629293TC

905-AMINOSALICYLIC ACID8ABACAVIR8ABACAVIR, LAMIVUDINE8ABACAVIR, LAMIVUDINE,

ZIDOVUDINE114ABATACEPT50ABENOL69ACAMPROSATE CALCIUM96ACARBOSE99ACCEL PIOGLITAZONE76ACCOLATE71ACCU-CHEK ADVANTAGE71ACCU-CHEK AVIVA (100)71ACCU-CHEK AVIVA (50)71ACCU-CHEK COMPACT

121ACCU-CHEK MULTICLIX39ACCUPRIL40ACCURETIC

109ACCUTANE71ACCUTREND

120ACE ADAPTORS120ACE KIT120ACE LARGE MASK ACCESSARY

KIT120ACE MDI SPACER120ACE MEDIUM MASK ACCESSARY

KIT120ACE SMALL MASK ACCESSARY

KIT120ACE SPACER WITH LARGE MASK120ACE SPACER WITH MEDIUM

MASK120ACE SPACER WITH SMALL MASK31ACEBUTOLOL31ACEBUTOLOL HCL50ACET50ACET 12050ACET 32550ACET 65045ACET CODEINE 3049ACETAMIN CHILD49ACETAMINOPHEN49ACETAMINOPHEN45ACETAMINOPHEN, CAFFEINE

CITRATE, CODEINE PHOSPHATE45ACETAMINOPHEN, CODEINE

PHOSPHATE45ACETAMINOPHEN, OXYCODONE

HCL80ACETAZOLAMIDE72ACETEST

103ACETOXYL42ACETYLSALICYLIC ACID42ACETYLSALICYLIC ACID46ACETYLSALICYLIC ACID,

CAFFEINE CITRATE, CODEINE PHOSPHATE

46ACETYLSALICYLIC ACID, OXYCODONE HCL

108ACITRETIN118ACLASTA19ACTIFED

117ACTONEL99ACTOS79ACULAR11ACYCLOVIR35ADALAT XL

114ADALIMUMAB107ADAPALENE121ADAPTOR11ADEFOVIR DIPIVOXIL

121ADHESIVE PAD WITH COTTON121ADHESIVE PAD WITHOUT

COTTON19ADRENALIN

118ADVAGRAF19ADVAIR19ADVAIR DISKUS 10019ADVAIR DISKUS 25019ADVAIR DISKUS 50071ADVANTAGE43ADVIL43ADVIL JUNIOR STRENGTH43ADVIL LIQUI-GEL43ADVIL PEDIATRIC

120AEROCHAMBER AC BOYZ120AEROCHAMBER AC GIRLZ120AEROCHAMBER MAX VHC WITH

ADULT MASK120AEROCHAMBER MAX VHC WITH

CHILD MASK120AEROCHAMBER MAX VHC WITH

INFANT MASK120AEROCHAMBER MAX VHC WITH

MOUTHPIECE120AEROCHAMBER PLUS VHC

ADULT120AEROCHAMBER PLUS VHC WITH

ADULT MASK120AEROCHAMBER PLUS VHC WITH

INFANT MASK120AEROCHAMBER PLUS VHC WITH

PEDIATRIC MASK30AGGRENOX23AGRYLIN18AIROMIR79ALBALON79ALBALON A

121ALCOHOL PREP SWAB121ALCOHOL SWAB121ALCOHOL SWABS BD75ALDACTAZIDE-2575ALDACTAZIDE-5041ALDACTONE

114ALENDRONATE SODIUM114ALENDRONATE SODIUM,

VITAMIN D3114ALENDRONATE-7064ALERTEC94ALESSE (21)95ALESSE (28)

112ALFACALCIDOL114ALFUZOSIN HYDROCHLORIDE14ALKERAN

1ALLEGRA1ALLER-AIDE

101ALLERGENIC EXTRACT NON POLLENS

101ALLERGENIC EXTRACT POLLENS101ALLERGENIC EXTRACTS

1ALLERGY1ALLERGY FORMULA1ALLERGY RELIEF ES1ALLERNIX1ALLERNIX PLUS

115ALLOPRIN115ALLOPURINOL115ALLOPURINOL66ALMOTRIPTAN MALATE

117ALOCRIL81ALOMIDE

112ALPHA TOCOPHERYL79ALPHAGAN80ALPHAGAN P64ALPRAZOLAM64ALPRAZOLAM40ALTACE40ALTACE HCT13ALTRETAMINE81ALUMINUM ACETATE,

BENZETHONIUM CHLORIDE93ALVESCO8AMANTADINE HCL

18AMATINE104AMCINONIDE66AMERGE74AMI-HYDRO74AMILORIDE HCL74AMILORIDE HCL,

HYDROCHLOROTHIAZIDE110AMINOPHYLLINE25AMIODARONE HCL54AMITRIPTYLINE54AMITRIPTYLINE HCL34AMLODIPINE35AMLODIPINE, ATORVASTATIN4AMOXICILLIN

88AMOXICILLIN, CLARITHROMYCIN, LANSOPRAZOLE

4AMOXICILLIN, CLAVULANIC ACID4AMPICILLIN

55ANAFRANIL23ANAGRELIDE HCL14ANANDRON45ANAPROX45ANAPROX DS13ANASTROZOLE94ANDRIOL13ANDROCUR

106ANODAN-HC43ANSAID79ANTAZOLINE PHOSPHATE,

NAPHAZOLINE HCL108ANTHRAFORTE107ANTHRANOL-1107ANTHRANOL-2107ANTHRASCALP102ANTIBIOTIC106ANUGESIC HC106ANUSOL HC86ANZEMET97APIDRA

Page I-1 of 232010

Page


Page Page97APIDRA SOLOSTAR38APO ENALAPRIL44APO KETO-E31APO-ACEBUTOLOL50APO-ACETAMINOPHEN80APO-ACETAZOLAMIDE11APO-ACYCLOVIR

114APO-ALENDRONATE114APO-ALFUZOSIN ER115APO-ALLOPURINOL64APO-ALPRAZ74APO-AMILORIDE74APO-AMILZIDE25APO-AMIODARONE54APO-AMITRIPTYLINE35APO-AMLODIPINE4APO-AMOXI4APO-AMOXI CLAV4APO-AMPICILLIN

42APO-ASA42APO-ASEN ECT32APO-ATENIDONE31APO-ATENOL26APO-ATORVASTATIN

115APO-AZATHIOPRINE3APO-AZITHROMYCIN

20APO-BACLOFEN78APO-BECLOMETHASONE37APO-BENAZEPRIL67APO-BENZTROPINE79APO-BENZYDAMINE13APO-BICALUTAMIDE83APO-BISACODYL32APO-BISOPROLOL79APO-BRIMONIDINE80APO-BRIMONIDINE P65APO-BROMAZEPAM68APO-BROMOCRIPTINE

111APO-C73APO-CAL 50099APO-CALCITONIN37APO-CAPTO52APO-CARBAMAZEPINE32APO-CARVEDILOL2APO-CEFACLOR2APO-CEFADROXIL2APO-CEFPROZIL2APO-CEFUROXIME3APO-CEPHALEX1APO-CETIRIZINE

75APO-CHLORTHALIDONE37APO-CILAZAPRIL38APO-CILAZAPRIL HCTZ87APO-CIMETIDINE5APO-CIPROFLOX

55APO-CITALOPRAM3APO-CLARITHROMYCIN6APO-CLINDAMYCIN

65APO-CLOBAZAM55APO-CLOMIPRAMINE51APO-CLONAZEPAM29APO-CLONIDINE4APO-CLOXI

60APO-CLOZAPINE

77APO-CROMOLYN19APO-CYCLOBENZAPRINE13APO-CYPROTERONE55APO-DESIPRAMINE99APO-DESMOPRESSIN93APO-DEXAMETHASONE65APO-DIAZEPAM42APO-DICLO43APO-DICLO SR43APO-DIFLUNISAL36APO-DILTIAZ35APO-DILTIAZ CD36APO-DILTIAZ SR36APO-DILTIAZ TZ86APO-DIMENHYDRINATE79APO-DIPIVEFRIN30APO-DIPYRIDAMOLE52APO-DIVALPROEX83APO-DOCUSATE CALCIUM83APO-DOCUSATE SODIUM86APO-DOMPERIDONE30APO-DOXAZOSIN56APO-DOXEPIN

6APO-DOXY3APO-ERYTHRO3APO-ERYTHRO BASE3APO-ERYTHRO S3APO-ERYTHRO-S

11APO-FAMCICLOVIR87APO-FAMOTIDINE26APO-FENOFIBRATE26APO-FENO-MICRO26APO-FENO-SUPER22APO-FERROUS GLUCONATE22APO-FERROUS SULFATE FC

110APO-FLAVOXATE25APO-FLECAINIDE50APO-FLOCTAFENINE

7APO-FLUCONAZOLE116APO-FLUNARIZINE78APO-FLUNISOLIDE56APO-FLUOXETINE60APO-FLUPHENAZINE43APO-FLURBIPROFEN13APO-FLUTAMIDE78APO-FLUTICASONE56APO-FLUVOXAMINE

111APO-FOLIC ACID38APO-FOSINOPRIL74APO-FUROSEMIDE52APO-GABAPENTIN26APO-GEMFIBROZIL98APO-GLICLAZIDE98APO-GLICLAZIDE MR98APO-GLYBURIDE86APO-GRANISETRON60APO-HALOPERIDOL29APO-HYDRALAZINE74APO-HYDRO75APO-HYDROCLOROTHIAZIDE12APO-HYDROXYQUINE13APO-HYDROXYUREA66APO-HYDROXYZINE43APO-IBUPROFEN

57APO-IMIPRAMINE75APO-INDAPAMIDE44APO-INDOMETHACIN17APO-IPRAVENT29APO-ISDN29APO-ISMN73APO-K44APO-KETO44APO-KETO SR7APO-KETOCONAZOLE

44APO-KETO-E79APO-KETOROLAC1APO-KETOTIFEN

84APO-LACTULOSE53APO-LAMOTRIGINE88APO-LANSOPRAZOLE

116APO-LEFLUNOMIDE53APO-LEVETIRACETAM80APO-LEVOBUNOLOL68APO-LEVOCARB68APO-LEVOCARB CR5APO-LEVOFLOXACIN

39APO-LISINOPRIL39APO-LISINOPRIL (TYPE Z)39APO-LISINOPRIL/HCTZ66APO-LITHIUM CARB66APO-LITHIUM CARBONATE83APO-LOPERAMIDE65APO-LORAZEPAM27APO-LOVASTATIN

100APO-MEDROXY44APO-MEFENAMIC14APO-MEGESTROL44APO-MELOXICAM97APO-METFORMIN29APO-METHAZIDE-1529APO-METHAZIDE-2580APO-METHAZOLAMIDE61APO-METHOPRAZINE14APO-METHOTREXATE29APO-METHYLDOPA64APO-METHYLPHENIDATE90APO-METOCLOP33APO-METOPROLOL32APO-METOPROLOL SR33APO-METOPROLOL-L12APO-METRONIDAZOLE6APO-MINOCYCLINE

57APO-MIRTAZAPINE88APO-MISOPROSTOL57APO-MOCLOBEMIDE64APO-MODAFINIL33APO-NADOL45APO-NAPRO NA45APO-NAPRO NA DS44APO-NAPROXEN44APO-NAPROXEN EC35APO-NIFED35APO-NIFED PA65APO-NITRAZEPAM12APO-NITROFURANTOIN87APO-NIZATIDINE5APO-NORFLOX

57APO-NORTRIPTYLINE

Page I-2 of 232010

Page


Page Page6APO-OFLOX

77APO-OFLOXACIN61APO-OLANZAPINE89APO-OMEPRAZOLE86APO-ONDANSETRON18APO-ORCIPRENALINE65APO-OXAZEPAM

110APO-OXTRIPHYLLINE110APO-OXYBUTYNIN46APO-OXYCODONE/ACET89APO-PANTOPRAZOLE58APO-PAROXETINE4APO-PEN VK

24APO-PENTOXIFYL61APO-PERPHENAZINE61APO-PIMOZIDE33APO-PINDOL99APO-PIOGLITAZONE45APO-PIROXICAM68APO-PRAMIPEXOLE27APO-PRAVASTATIN30APO-PRAZO94APO-PREDNISONE50APO-PRIMIDONE62APO-PROCHLORAZINE25APO-PROPAFENONE34APO-PROPRANOLOL62APO-QUETIAPINE96APO-RALOXIFENE40APO-RAMIPRIL87APO-RANITIDINE62APO-RISPERIDONE68APO-ROPINIROLE18APO-SALVENT18APO-SALVENT CFC FREE69APO-SELEGILINE58APO-SERTRALINE28APO-SIMVASTATIN34APO-SOTALOL88APO-SUCRALFATE6APO-SULFAMETHOXAZOLE6APO-SULFATRIM6APO-SULFATRIM DS6APO-SULFATRIM PED

75APO-SULFINPYRAZONE45APO-SULIN67APO-SUMATRIPTAN15APO-TAMOX66APO-TEMAZEPAM30APO-TERAZOSIN7APO-TERBINAFINE6APO-TETRA

110APO-THEO110APO-THEO LA45APO-TIAPROFENIC24APO-TICLOPIDINE34APO-TIMOL80APO-TIMOP20APO-TIZANIDINE98APO-TOLBUTAMIDE53APO-TOPIRAMATE59APO-TRAZODONE59APO-TRAZODONE D74APO-TRIAZIDE

66APO-TRIAZO64APO-TRIFLUOPERAZINE67APO-TRIHEX12APO-TRIMETHOPRIM59APO-TRIMIP59APO-TRIMIPRAMINE11APO-VALACYCLOVIR54APO-VALPROIC59APO-VENLAFAXINE XR37APO-VERAP36APO-VERAP SR23APO-WARFARIN10APO-ZIDOVUDINE81APRACLONIDINE HCL86APREPITANT94APRI 2194APRI 2810APTIVUS

112AQUASOL E116ARAVA117AREDIA IV16ARICEPT13ARIMIDEX

107ARISTOCORT C107ARISTOCORT R94ARISTOSPAN13AROMASIN43ARTHROTEC81ARTIFICIAL TEARS81ARTIFICIAL TEARS EXTRA42ASA90ASACOL42ASAPHEN42ASAPHEN EC71ASCENSIA AUTODISC71ASCENSIA BREEZE 271ASCENSIA CONTOUR71ASCENSIA CONTOUR (100)71ASCENSIA CONTOUR (50)71ASCENSIA ELITE

111ASCORBIC ACID112ASCORBIC ACID42ASPIRIN40ATACAND40ATACAND PLUS66ATARAX49ATASOL50ATASOL FORTE45ATASOL-1545ATASOL-30

8ATAZANAVIR SULFATE31ATENOLOL31ATENOLOL32ATENOLOL, CHLORTHALIDONE

103ATHLETES FOOT SPRAY65ATIVAN65ATIVAN SUBLINGUAL26ATORVASTATIN CALCIUM12ATOVAQUONE

8ATRIPLA79ATROPINE79ATROPINE SULFATE79ATROPINE SULPHATE MINIMS81ATROVENT

17ATROVENT HFA91AURANOFIN41AVALIDE99AVANDIA41AVAPRO57AVENTYL94AVIANE 2195AVIANE 28

115AVODART66AXERT87AXID80AZARGA

115AZATHIOPRINE3AZITHROMYCIN

80AZOPT112BABY DDROPS102BACIMYXIN102BACITIN102BACITRACIN77BACITRACIN ZINC, POLYMYXIN

B SULFATE20BACLOFEN20BACLOFEN74BACTERIOSTATIC NACL

103BACTIGRAS103BACTIGRAS 5X5CM102BACTROBAN76BALMINIL DM

108BALNETAR11BARACLUDE

107BARRIERE106BARRIERE HC120BATTERIES - 1.5 VOLT120BATTERIES - 3 VOLT120BATTERIES - AAA120BATTERIES - LITHIUM120BATTERIES - SIZE J 6V31BCI-ATENOLOL27BCI-PRAVASTATIN88BCI-RANITIDINE28BCI-SIMVASTATIN

121B-D ALCOHOL SWAB122B-D DISPOSABLE 5/8 INCH 5122122B-D DISPOSABLE ½ INCH 5109122B-D DISPOSABLE 1 INCH 5155122B-D DISPOSABLE 1½ INCH 5127122B-D DISPOSABLE 1½ INCH 5156123B-D INJECT-EASE WITH MICRO-

FINE123B-D INSULIN 1/3CC 29G UF 1123B-D INSULIN 50U 29G121B-D LANCET121BD LATITUDE122B-D MICRO-FINE123B-D MICRO-FINE 1/3CC123B-D MICRO-FINE INSULIN 100U123B-D MICRO-FINE INSULIN 28G123B-D MICRO-FINE INSULIN 50U122B-D PEN122B-D SHARPS CONTAINER 1.4L122B-D SHARPS CONTAINER 3.1L122B-D SHARPS CONTAINER 3.8L71BD TEST

122B-D ULTRA-FINE122B-D ULTRA-FINE / ULTRA-FINE II

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Page Page122B-D ULTRA-FINE II122B-D ULTRA-FINE PEN122B-D ULTRA-FINE PEN III122BD ULTRA-FINE PEN NEEDLE

29G78BECLOMETHASONE

DIPROPIONATE1BENADRYL1BENADRYL CHILD

37BENAZEPRIL HCL103BENOXYL75BENURYL76BENYLIN DM76BENYLIN DM CHILD76BENYLIN DM NIGHTTIME76BENYLIN DM-D76BENYLIN DM-D CHILD

103BENZAC AC103BENZAC W103BENZAC W5103BENZAGEL103BENZAGEL 5103BENZOYL PEROXIDE67BENZTROPINE67BENZTROPINE MESYLATE67BENZTROPINE OMEGA79BENZYDAMINE HCL

105BETADERM104BETADINE80BETAGAN

115BETAHISTINE HCL104BETAMETHASONE

DIPROPIONATE104BETAMETHASONE

DIPROPIONATE IN PROPYLENE GLYCOL

104BETAMETHASONE DIPROPIONATE, CLOTRIMAZOLE

104BETAMETHASONE DIPROPIONATE, SALICYLIC ACID

105BETAMETHASONE DISODIUM PHOSPHATE

78BETAMETHASONE SODIUM PHOSPHATE, GENTAMICIN SULFATE

105BETAMETHASONE VALERATE111BETAXIN80BETAXOLOL HCL16BETHANECHOL CHLORIDE

105BETNESOL80BETOPTIC S25BEZAFIBRATE25BEZALIP SR3BIAXIN3BIAXIN XL

13BICALUTAMIDE81BIMATOPROST73BIOCAL-D FORTE

102BIODERM74BIO-FUROSEMIDE75BIO-HYDROCHLOROTHIAZIDE83BISACODYL83BISACODYL83BISACODYL (POLYETHYLENE

GLYCOL BASE)83BISACOLAX

83BISMUTH SUBSALICYLATE32BISOPROLOL FUMARATE78BLEPHAMIDE86BONAMINE

115BOTOX115BOTULINUM TOXIN TYPE A95BREVICON 0.5/35 (21)95BREVICON 0.5/35 (28)95BREVICON 1/35 (21)95BREVICON 1/35 (28)19BRICANYL TURBUHALER79BRIMONIDINE TARTRATE80BRIMONIDINE TARTRATE

(ALPHAGAN P)80BRIMONIDINE TARTRATE,

TIMOLOL MALEATE80BRINZOLAMIDE80BRINZOLAMIDE/TIMOLOL

MALEATE65BROMAZEPAM65BROMAZEPAM68BROMOCRIPTINE68BROMOCRIPTINE MESYLATE76BROMPHENIRAMINE MALEATE,

DEXTROMETHORPHAN HBR, PHENYLEPHRINE HCL

1BROMPHENIRAMINE MALEATE, PHENYLEPHRINE HCL

76BRONCHOPHAN FORTE DM76BUCKLEYS DM78BUDESONIDE54BUPROPION HCL54BUPROPION HCL (WELLBUTRIN)54BUPROPION HCL (ZYBAN)81BURO-SOL17BUSCOPAN13BUSERELIN ACETATE13BUSULFAN

112C 100095C.E.S.

115CABERGOLINE35CADUET19CAFERGOT73CAL-50073CAL-500-D99CALCIMAR

108CALCIPOTRIOL73CALCITE 500 + D 40073CALCITE D 50073CALCITE D-50099CALCITONIN SALMON

(MIACALCIN)99CALCITONIN SALMON

(SYNTHETIC)112CALCITRIOL73CALCIUM73CALCIUM 500 + D 40073CALCIUM 500MG WITH VIT D73CALCIUM CARBONATE73CALCIUM CARBONATE73CALCIUM CARBONATE WITH D73CALCIUM CARBONATE WITH VIT

D73CALCIUM CARBONATE,

CHOLECALCIFEROL73CALCIUM D-500

73CALCIUM LACTOGLUCONATE74CALCIUM POLYSTYRENE

SULFONATE73CALCIUM WITHOUT SUGAR73CALCIUM, VITAMIN D69CAMPRAL40CANDESARTAN CILEXETIL40CANDESARTAN CILEXETIL,

HYDROCHLOROTHIAZIDE7CANESORAL

102CANESTEN102CANESTEN 1 COMFORT COMBI

PAK102CANESTEN 3 COMFORT COMBI

PAK107CANTHACUR107CANTHACUR PS107CANTHARIDIN107CANTHARIDIN, PODOPHYLLIN,

SALICYLIC ACID107CANTHARONE107CANTHARONE PLUS13CAPECITABINE

105CAPEX37CAPOTEN

109CAPSAICIN109CAPSAICIN109CAPSAICIN HP37CAPTOPRIL37CAPTOPRIL79CARBACHOL51CARBAMAZEPINE52CARBAMAZEPINE73CARBOCAL D66CARBOLITH35CARDIZEM CD30CARDURA 130CARDURA 230CARDURA 474CARNITOR74CARNITOR IV32CARVEDILOL13CASODEX29CATAPRES2CECLOR2CECLOR BID

14CEENU2CEFACLOR2CEFADROXIL2CEFIXIME2CEFPROZIL2CEFPROZIL MONOHYDRATE2CEFTIN2CEFUROXIME AXETIL2CEFZIL

42CELEBREX42CELECOXIB55CELEXA

117CELLCEPT81CELLUVISC51CELONTIN9CELSENTRI

101CENTER-AL113CENTRUM JUNIOR COMPLETE113CENTRUM MATERNA

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Page Page2CEPHALEXIN

50CEPHANOL87CESAMET1CETIRIZINE HCL

21CHAMPIX21CHAMPIX STARTER PACK71CHEMSTRIP BG71CHEMSTRIP-BG49CHILDREN'S ACETAMINOPHEN43CHILDREN'S ADVIL43CHILDREN'S MOTRIN50CHILDREN'S TYLENOL SOFT

CHEWS13CHLORAMBUCIL77CHLORAMPHENICOL

103CHLORHEXIDINE ACETATE79CHLORHEXIDINE GLUCONATE12CHLOROQUINE PHOSPHATE1CHLORPHENIRAMINE MALEATE

76CHLORPHENIRAMINE MALEATE, DEXTROMETHORPHAN HBR, PSEUDOEPHEDRINE HCL

59CHLORPROMAZINE59CHLORPROMAZINE HCL75CHLORTHALIDONE1CHLOR-TRIPOLON1CHLOR-TRIPOLON ND

112CHOLECALCIFEROL110CHOLEDYL25CHOLESTYRAMINE RESIN93CICLESONIDE37CILAZAPRIL38CILAZAPRIL,

HYDROCHLOROTHIAZIDE77CILOXAN77CILOXAN 0.3%87CIMETIDINE87CIMETIDINE5CIPRO

77CIPRO HC77CIPRODEX5CIPROFLOXACIN5CIPROFLOXACIN HCL

77CIPROFLOXACIN HCL, DEXAMETHASONE

77CIPROFLOXACIN HCL, HYDROCORTISONE

5CIPROFLOXCIN55CITALOPRAM55CITALOPRAM55CITALOPRAM-2083CITRIC ACID, MAGNESIUM

OXIDE, SODIUM PICOSULFATE73CITRIC ACID, SODIUM CITRATE73CITRO MAG 15GM/300ML3CLARITHROMYCIN1CLARITIN1CLARITIN EXTRA1CLARITIN KIDS

109CLARUS4CLAVULIN4CLAVULIN 2004CLAVULIN 4004CLAVULIN-F4CLAVULIN-F 125

4CLAVULIN-F 250108CLEAR AWAY96CLIMARA 10096CLIMARA 2596CLIMARA 5096CLIMARA 75

6CLINDAMYCIN HCL7CLINDAMYCIN PALMITATE HCL

102CLINDAMYCIN PHOSPHATE6CLINDAMYCINE

72CLINITEST65CLOBAZAM65CLOBAZAM

105CLOBETASOL PROPIONATE105CLOBETASOL PROPIONATE105CLOBETASONE BUTYRATE55CLOMIPRAMINE55CLOMIPRAMINE HCL51CLONAPAM50CLONAZEPAM51CLONAZEPAM29CLONIDINE29CLONIDINE HCL23CLOPIDOGREL BISULFATE

115CLOSTRIDIUM BOTULINUM NEUROTOXIN

102CLOTRIMADERM102CLOTRIMAZOLE

4CLOXACILLIN4CLOXACILLINE

60CLOZAPINE60CLOZARIL

114CO ALENDRONATE35CO AMLODIPINE31CO ATENOLOL26CO ATORVASTATIN

3CO AZITHROMYCIN13CO BICALUTAMIDE

115CO CABERGOLINE37CO CILAZAPRIL

5CO CIPROFLOXACIN55CO CITALOPRAM55CO CLOMIPRAMINE51CO CLONAZEPAM38CO ENALAPRIL

116CO ETIDRONATE11CO FAMCICLOVIR

7CO FLUCONAZOLE56CO FLUVOXAMINE52CO GABAPENTIN53CO LEVETIRACETAM39CO LISINOPRIL27CO LOVASTATIN44CO MELOXICAM97CO METFORMIN57CO MIRTAZAPINE

5CO NORFLOXACIN61CO OLANZAPINE61CO OLANZAPINE ODT89CO PANTOPRAZOLE58CO PAROXETINE99CO PIOGLITAZONE68CO PRAMIPEXOLE27CO PRAVASTATIN

62CO QUETIAPINE40CO RAMIPRIL88CO RANITIDINE63CO RISPERIDONE58CO SERTRALINE28CO SIMVASTATIN34CO SOTALOL67CO SUMATRIPTAN66CO TEMAZEPAM7CO TERBINAFINE

53CO TOPIRAMATE59CO VENLAFAXINE XR

108COAL TAR108COAL TAR, JUNIPER TAR, PINE

TAR108COAL TAR, JUNIPER TAR, PINE

TAR, ZINC PYRITHIONE108COAL TAR, SALICYLIC ACID108COAL TAR, SALICYLIC ACID,

SULFUR46CODEINE46CODEINE CONTIN CR46CODEINE MONOHYDRATE,

CODEINE SULFATE TRIHYDRATE46CODEINE PHOSPHATE46CODEINE PHOSPHATE

116CO-ETIDROCAL56CO-FLUOXETINE83COLACE

115COLCHICINE115COLCHICINE25COLESTID25COLESTID ORANGE25COLESTIPOL HCL5CO-LEVOFLOXACIN

109COLLAGENASE84COLYTE2COMBANTRIN

80COMBIGAN17COMBIVENT9COMBIVIR

67COMTAN70CONDOM, FEMALE70CONDOM, LATEX, LUBRICATED70CONDOM, LATEX, LUBRICATED,

NONOXYNOL70CONDOM, LATEX, NON-

LUBRICATED70CONDOM, MALE70CONDOM, NON-LATEX,

LUBRICATED108CONDYLINE95CONJUGATED ESTROGENS95CONJUGATED ESTROGENS,

MEDROXYPROGESTERONE ACETATE

86CO-ONDANSETRON25CORDARONE68CO-ROPINIROLE

106CORTATE93CORTEF

106CORTENEMA106CORTIFOAM93CORTISONE93CORTISONE ACETATE78CORTISPORIN

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Page Page106CORTODERM80COSOPT85COTAZYM85COTAZYM ECS 885COTAZYM ECS 2085COTAZYM ECS476COUGH SYRUP76COUGH SYRUP

DEXTROMETHORPHAN23COUMADIN36COVERA-HS39COVERSYL39COVERSYL PLUS39COVERSYL PLUS HD41COZAAR85CREON 10 MINIMICROSPHERES85CREON 20 MINIMICROSPHERES85CREON 25 MINIMICROSPHERES85CREON 5 MINIMICROSPHERES27CRESTOR9CRIXIVAN

76CROMOLYN103CROTAMITON55CTP72CUPRIC SULFATE92CUPRIMINE

106CUTIVATE111CYANOCOBALAMIN111CYANOCOBALAMIN95CYCLEN (21)95CYCLEN (28)19CYCLOBENZAPRINE19CYCLOBENZAPRINE HCL

104CYCLOCORT79CYCLOGYL94CYCLOMEN79CYCLOPENTOLATE79CYCLOPENTOLATE HCL79CYCLOPENTOLATE MINIMS13CYCLOPHOSPHAMIDE

115CYCLOSPORINE115CYESTRA-3524CYKLOKAPRON56CYMBALTA13CYPROTERONE ACETATE

115CYPROTERONE ACETATE, ETHINYL ESTRADIOL

11CYTOVENE13CYTOXAN

112D VI SOL85DAIRY DIGESTIVE85DAIRY DIGESTIVE EXTRA

STRENGTH85DAIRY FREE85DAIRY FREE EXTRA STRENGTH85DAIRYAID

102DALACIN6DALACIN C

102DALACIN T22DALTEPARIN SODIUM94DANAZOL20DANTRIUM20DANTROLENE SODIUM12DARAPRIM

110DARIFENACIN HYDROBROMIDE

8DARUNAVIR99DDAVP99DDAVP MELT

112DDROPS VITAMIN D94DELATESTRYL76DELSYM47DEMEROL94DEMULEN 30 (21)94DEMULEN 30 (28)54DEPAKENE93DEPO-MEDROL

100DEPO-PROVERA94DEPO-TESTOSTERONE

106DERMAFLEX HC105DERMA-SMOOTHE104DERMAZIN105DERMOVATE55DESIPRAMINE55DESIPRAMINE HCL99DESMOPRESSIN ACETATE

105DESOCORT105DESONIDE105DESOXIMETASONE103DESQUAM X59DESYREL59DESYREL DIVIDOSE

110DETROL110DETROL LA78DEXAMETHASONE93DEXAMETHASONE93DEXAMETHASONE PHOSPHATE78DEXAMETHASONE,

TOBRAMYCIN93DEXAMETHASONE-OMEGA93DEXASONE64DEXEDRINE64DEXEDRINE SPANSULE22DEXIRON81DEXTRAN 70,

HYDROXYPROPYLMETHYLCELLULOSE

64DEXTROAMPHETAMINE SULFATE

76DEXTROMETHORPHAN HBR76DEXTROMETHORPHAN HBR,

PSEUDOEPHEDRINE HCL112D-FORTE98DIABETA98DIAMICRON98DIAMICRON MR

115DIANE-3570DIAPHRAGM83DIARR-EZE83DIARRHEA RELIEF72DIASTIX65DIAZEPAM65DIAZEPAM29DIAZOXIDE73DICITRATE86DICLECTIN42DICLOFENAC SODIUM43DICLOFENAC SODIUM,

MISOPROSTOL42DICLOFENAC-2542DICLOFENAC-50

43DICLOFENAC-SR8DIDANOSINE

116DIDROCAL116DIDRONEL107DIFFERIN

7DIFLUCAN105DIFLUCORTOLONE VALERATE105DIFLUCORTOLONE VALERATE,

SALICYLIC ACID43DIFLUNISAL25DIGOXIN19DIHYDROERGOTAMINE19DIHYDROERGOTAMINE

MESYLATE12DIIODOHYDROXYQUIN51DILANTIN51DILANTIN 3051DILANTIN 12551DILANTIN INFATABS47DILAUDID47DILAUDID HP47DILAUDID HP PLUS47DILAUDID XP36DILTIAZEM35DILTIAZEM CD35DILTIAZEM HCL85DIMENHYDRINATE85DIMENHYDRINATE1DIMETAPP COLD

76DIMETAPP DM COUGH & COLD107DIMETHICONE80DIOCARPINE77DIOCHLORAM83DIOCTYL CALCIUM

SULFOSUCCINATE83DIOCTYL SODIUM

SULFOSUCCINATE83DIOCTYL SODIUM

SULFOSUCCINATE, SENNA84DIOCTYL SODIUM

SULFOSUCCINATE, SENNOSIDES

78DIODEX12DIODOQUIN77DIOGENT79DIONEPHRINE79DIOPENTOLATE78DIOPRED78DIOPTIMYD77DIOSULF41DIOVAN41DIOVAN-HCT90DIPENTUM1DIPHENHYDRAMINE1DIPHENHYDRAMINE HCL1DIPHENHYDRAMINE HCL

79DIPIVEFRIN HCL81DIPIVEFRIN HCL,

LEVOBUNOLOL HCL104DIPROLENE104DIPROSALIC104DIPROSONE30DIPYRIDAMOLE30DIPYRIDAMOLE,

ACETYLSALICYLIC ACID25DISOPYRAMIDE

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Page Page107DITHRANOL52DIVALPROEX EC52DIVALPROEX SODIUM29DIXARIT76DM COUGH SYRUP76DM SANS SUCRE83DOCUSATE CALCIUM83DOCUSATE SODIUM84DOCUSATE SODIUM86DOLASETRON MESYLATE

101DOLICHOVESPULA ARENARIA VENOM PROTEIN

101DOLICHOVESPULA MACULATA VENOM PROTEIN EXTRACT

48DOLORAL 148DOLORAL 58DOM-AMANTADINE

54DOM-AMITRIPTYLINE34DOM-AMLODIPINE31DOM-ATENOLOL20DOM-BACLOFEN79DOM-BENZYDAMINE68DOM-BROMOCRIPTINE37DOM-CAPTOPRIL51DOM-CARBAMAZEPINE CR32DOM-CARVEDILOL2DOM-CEFACLOR2DOM-CEPHALEXIN

87DOM-CIMETIDINE5DOM-CIPROFLOXACIN

55DOM-CITALOPRAM65DOM-CLOBAZAM51DOM-CLONAZEPAM51DOM-CLONAZEPAM-R19DOM-CYCLOBENZAPRINE55DOM-DESIPRAMINE42DOM-DICLOFENAC43DOM-DICLOFENAC SR83DOM-DOCUSATE SODIUM86DOM-DOMPERIDONE56DOM-FLUOXETINE56DOM-FLUVOXAMINE74DOM-FUROSEMIDE52DOM-GABAPENTIN26DOM-GEMFIBROZIL98DOM-GLYBURIDE75DOM-HYDROCHLOROTHIAZIDE75DOM-INDAPAMIDE17DOM-IPRATROPIUM5DOM-LEVOFLOXACIN

83DOM-LOPERAMIDE65DOM-LORAZEPAM60DOM-LOXAPINE

100DOM-MEDROXYPROGESTERONE44DOM-MEFENAMIC ACID44DOM-MELOXICAM97DOM-METFORMIN33DOM-METOPROLOL-B33DOM-METOPROLOL-L6DOM-MINOCYCLINE

57DOM-MIRTAZAPINE35DOM-NIFEDIPINE87DOM-NIZATIDINE57DOM-NORTRIPTYLINE7DOM-NYSTATIN

110DOM-OXYBUTYNIN58DOM-PAROXETINE86DOMPERIDONE86DOMPERIDONE MALEATE33DOM-PINDOLOL99DOM-PIOGLITAZONE45DOM-PIROXICAM27DOM-PRAVASTATIN34DOM-PROPRANOLOL18DOM-SALBUTAMOL69DOM-SELEGILINE58DOM-SERTRALINE28DOM-SIMVASTATIN34DOM-SOTALOL67DOM-SUMATRIPTAN66DOM-TEMAZEPAM30DOM-TERAZOSIN45DOM-TIAPROFENIC80DOM-TIMOLOL53DOM-TOPIRAMATE59DOM-TRAZODONE54DOM-VALPROIC ACID37DOM-VERAPAMIL SR16DONEPEZIL HCL80DORZOLAMIDE HCL80DORZOLAMIDE HCL, TIMOLOL

MALEATE115DOSTINEX108DOVONEX30DOXAZOSIN30DOXAZOSIN MESYLATE56DOXEPIN HCL56DOXEPINE

6DOXYCIN6DOXYCYCLINE6DOXYCYCLINE

86DOXYLAMINE SUCCINATE, PYRIDOXINE HCL

6DOXYTAB112DRISDOL112D-TABS83DULCOLAX56DULOXETINE HCL81DUO TRAV

108DUOFILM108DUOFORTE 2781DUOLUBE

108DUOPLANT46DURAGESIC MAT

115DUTASTERIDE16DUVOID74EDECRIN

3EES-6008EFAVIRENZ8EFAVIRENZ, EMTRICITABINE,

TENOFOVIR DISOPROXIL FUMARATE

59EFFEXOR XR109EFUDEX106EGOZINC HC106EGOZINC-HC54ELAVIL73ELECTROLYTE & DEXTROSE

109ELIDEL14ELIGARD

117ELMIRON107ELOCOM100ELTROXIN86EMEND86EMEND TRI PACK

107EMLA106EMO CORT106EMO CORT SCALP

9EMTRICITABINE, TENOFOVIR DISOPROXIL FUMARATE

110ENABLEX38ENALAPRIL MALEATE38ENALAPRIL MALEATE,

HYDROCHLOROTHIAZIDE116ENBREL116ENBREL SURECLICK71ENCORE46ENDOCET85ENEMOL22ENOXAPARIN SODIUM67ENTACAPONE11ENTECAVIR

105ENTOCORT42ENTROPHEN42ENTROPHEN 1042ENTROPHEN EC42ENTROPHEN-1042ENTROPHEN-519EPINEPHRINE19EPINEPHRINE19EPIPEN19EPIPEN JR52EPIVAL41EPOSARTAN MESYLATE41EPOSARTAN MESYLATE,

HYDROCHLOROTHIAZIDE116ERDOL112ERGOCALCIFEROL19ERGOTAMINE TARTRATE,

CAFFEINE13ERLOTINIB HYDROCLORIDE3ERYC3ERYTHRO3ERYTHRO-ES3ERYTHROMYCIN3ERYTHROMYCIN3ERYTHROMYCIN ESTOLATE3ERYTHROMYCIN

ETHYLSUCCINATE3ERYTHROMYCIN STEARATE

102ERYTHROMYCIN, TRETINOIN96ESTALIS 140/5096ESTALIS 250/5096ESTRACE96ESTRADERM95ESTRADIOL96ESTRADIOL (ESTRADIOL

HEMIHYDRATE)96ESTRADIOL, NORETHINDRONE

ACETATE96ESTRADOT 10095ESTRADOT 2595ESTRADOT 37.596ESTRADOT 5096ESTRADOT 75

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Page Page96ESTRING95ESTROGEL96ESTRONE96ESTROPIPATE

116ETANERCEPT74ETHACRYNIC ACID7ETHAMBUTOL HCL

94ETHINYL ESTRADIOL, DESOGESTREL

94ETHINYL ESTRADIOL, D-NORGESTREL

94ETHINYL ESTRADIOL, DROSPIRENONE

94ETHINYL ESTRADIOL, ETHYNODIOL DIACETATE

94ETHINYL ESTRADIOL, ETONOGESTREL

94ETHINYL ESTRADIOL, LEVONORGESTREL

95ETHINYL ESTRADIOL, NORETHINDRONE

95ETHINYL ESTRADIOL, NORETHINDRONE ACETATE

95ETHINYL ESTRADIOL, NORGESTIMATE

67ETHOPROPAZINE HCL51ETHOSUXIMIDE7ETIBI

116ETIDRONATE DISODIUM116ETIDRONATE DISODIUM,

CALCIUM CARBONATE13ETOPOSIDE9ETRAVIRINE

13EUFLEX98EUGLUCON

105EUMOVATE103EURAX112EURO D42EURO-ASA73EURO-CAL73EURO-CAL D83EURO-DOCUSATE22EURO-FER22EURO-FERROUS SULFATE

111EURO-FOLIC73EURO-K 2073EURO-K 60073EURO-K884EURO-LAC84EURO-SENNA84EURO-SENNA S

100EUTHYROX96EVISTA45EXDOL-1545EXDOL-3017EXELON13EXEMESTANE

116EXTEMPORANEOUS MIXTURE116EXTEMPORANEOUS MIXTURE71EZ HEALTH ORACLE (100)71EZ HEALTH ORACLE (50)

121EZ HEALTH ORACLE LANCETS120E-Z SPACER120E-Z SPACER (MASK ONLY)120E-Z SPACER WITH SMALL MASK25EZETIMIBE

25EZETROL11FAMCICLOVIR87FAMOTIDINE87FAMOTIDINE11FAMVIR71FASTTAKE35FELODIPINE14FEMARA96FEMHRT26FENOFIBRATE26FENOMAX26FENO-MICRO46FENTANYL22FER-IN-SOL22FERODAN22FERRATE O/L22FERROUS FUMARATE22FERROUS FUMARATE22FERROUS GLUCONATE22FERROUS GLUCONATE22FERROUS SULFATE22FERROUS SULFATE49FEVERHALT

1FEXOFENADINE HCL84FIBER24FILGRASTIM

116FINASTERIDE121FINGERSTIX104FLAGYL104FLAGYSTATIN104FLAMAZINE104FLAMAZINE 50G78FLAREX

110FLAVOXATE HCL25FLECAINIDE ACETATE85FLEET ENEMA85FLEET ENEMA PEDIATRIC70FLEXI-T IUD

113FLINTSTONES EXTRA C50FLOCTAFENINE

118FLOMAX CR78FLONASE93FLORINEF93FLOVENT DISKUS93FLOVENT HFA 12593FLOVENT HFA 25093FLOVENT HFA 5060FLUANXOL60FLUANXOL DEPOT

7FLUCONAZOLE13FLUDARA13FLUDARABINE PHOSPHATE93FLUDROCORTISONE ACETATE78FLUMETHASONE PIVALATE,

CLIOQUINOL116FLUNARIZINE HCL78FLUNISOLIDE

105FLUOCINOLONE ACETONIDE105FLUOCINONIDE78FLUOROMETHOLONE78FLUOROMETHOLONE ACETATE

109FLUOROURACIL56FLUOXETINE56FLUOXETINE HCL

60FLUPENTHIXOL DECANOATE60FLUPENTHIXOL

DIHYDROCHLORIDE60FLUPHENAZINE60FLUPHENAZINE DECANOATE60FLUPHENAZINE HCL60FLUPHENAZINE OMEGA43FLURBIPROFEN43FLURBIPROFEN79FLURBIPROFEN SODIUM13FLUTAMIDE78FLUTICASONE PROPIONATE27FLUVASTATIN SODIUM56FLUVOXAMINE56FLUVOXAMINE MALEATE78FML78FML FORTE

111FOLIC ACID111FOLIC ACID18FORADIL

108FORMALDEHYDE, LACTIC ACID, SALICYLIC ACID

18FORMOTEROL FUMARATE18FORMOTEROL FUMARATE

DIHYDRATE18FORMOTEROL FUMARATE

DIHYDRATE, BUDESONIDE114FOSAMAX

9FOSAMPRENAVIR CALCIUM114FOSAVANCE38FOSINOPRIL38FOSINOPRIL SODIUM22FRAGMIN77FRAMYCETIN SULFATE78FRAMYCETIN SULFATE,

GRAMICIDIN, DEXAMETHASONE23FRAXIPARINE23FRAXIPARINE FORTE72FREESTYLE72FREESTYLE LITE65FRISIUM

102FUCIDIN7FUCIDIN FC

74FUROSEMIDE74FUROSEMIDE7FUSIDATE SODIUM

102FUSIDIC ACID56FXT52GABAPENTIN52GABAPENTIN16GALANTAMINE11GANCICLOVIR SODIUM77GARAMYCIN77GARAMYCIN OTIC78GARASONE78GARASONE OPHTH/OTIC73GASTROLYTE REG34GD-AMLODIPINE26GD-ATORVASTATIN26GEMFIBROZIL26GEMFIBROZIL31GEN-ACEBUTOLOL31GEN-ACEBUTOLOL (TYPE S)11GEN-ACYCLOVIR

114GEN-ALENDRONATE

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Page Page64GEN-ALPRAZOLAM8GEN-AMANTADINE

74GEN-AMILAZIDE25GEN-AMIODARONE35GEN-AMLODIPINE4GEN-AMOXICILLIN

23GEN-ANAGRELIDE31GEN-ATENOLOL3GEN-AZITHROMYCIN

20GEN-BACLOFEN78GEN-BECLO AQ13GEN-BICALUTAMIDE65GEN-BROMAZEPAM78GEN-BUDESONIDE AQ37GEN-CAPTOPRIL51GEN-CARBAMAZEPINE CR37GEN-CILAZAPRIL87GEN-CIMETIDINE5GEN-CIPROFLOXACIN

55GEN-CITALOPRAM3GEN-CLARITHROMYCIN6GEN-CLINDAMYCIN

105GEN-CLOBETASOL51GEN-CLONAZEPAM60GEN-CLOZAPINE17GEN-COMBO19GEN-CYCLOPRINE13GEN-CYPROTERONE35GEN-DILTIAZEM52GEN-DIVALPROEX86GEN-DOMPERIDONE30GEN-DOXAZOSIN38GEN-ENALAPRIL

116GEN-ETI-CAL CP116GEN-ETIDRONATE87GEN-FAMOTIDINE26GEN-FENOFIBRATE26GEN-FIBRO7GEN-FLUCONAZOLE

56GEN-FLUOXETINE38GEN-FOSINOPRIL52GEN-GABAPENTIN26GEN-GEMFIBROZIL98GEN-GLICLAZIDE98GEN-GLYBE12GEN-HYDROXYCHLOROQUINE13GEN-HYDROXYUREA75GEN-INDAPAMIDE17GEN-IPRATROPIUM17GEN-IPRATROPIUM UDV53GEN-LAMOTRIGINE

116GEN-LEFLUNOMIDE5GEN-LEVOFLOXACIN

39GEN-LISINOPRIL39GEN-LISINOPRIL HCTZ27GEN-LOVASTATIN

100GEN-MEDROXY44GEN-MELOXICAM97GEN-METFORMIN33GEN-METOPROLOL33GEN-METOPROLOL (TYPE L)33GEN-METOPROLOL-L57GEN-MIRTAZAPINE44GEN-NAPROXEN

44GEN-NAPROXEN EC35GEN-NIFEDIPINE XL30GEN-NITRO87GEN-NIZATIDINE57GEN-NORTRIPTYLINE86GEN-ONDANSETRON86GEN-ONDANSETRON 8MG TAB

110GEN-OXYBUTYNIN89GEN-PANTOPRAZOLE58GEN-PAROXETINE33GEN-PINDOLOL99GEN-PIOGLITAZONE45GEN-PIROXICAM27GEN-PRAVASTATIN25GEN-PROPAFENONE62GEN-QUETIAPINE40GEN-RAMIPRIL88GEN-RANITIDINE63GEN-RISPERIDONE18GEN-SALBUTAMOL18GEN-SALBUTAMOL PF69GEN-SELEGILINE58GEN-SERTRALINE58GEN-SERTRALINE (ONT)28GEN-SIMVASTATIN34GEN-SOTALOL67GEN-SUMATRIPTAN77GENTAMICIN77GENTAMICIN SULFATE15GEN-TAMOXIFEN

118GEN-TAMSULOSIN66GEN-TEMAZEPAM

7GEN-TERBINAFINE24GEN-TICLOPIDINE80GEN-TIMOLOL20GEN-TIZANIDINE53GEN-TOPIRAMATE59GEN-TRAZODONE66GEN-TRIAZOLAM54GEN-VALPROIC59GEN-VENLAFAXINE XR37GEN-VERAPAMIL36GEN-VERAPAMIL SR23GEN-WARFARIN14GLEEVEC98GLICLAZIDE98GLICLAZIDE99GLUCAGON99GLUCAGON RECOMBINANT DNA

ORGIN96GLUCOBAY71GLUCOFILM

121GLUCOLET121GLUCOLET 2120GLUCOMETER BATTERIES98GLUCONORM97GLUCOPHAGE71GLUCOSE OXIDASE,

PEROXIDASE98GLYBURIDE98GLYBURIDE84GLYCERIN84GLYCERIN INFANT84GLYCERIN INFANT & CHILD84GLYCERINE

84GLYCERINE97GLYCON

116GOLIMUMAB84GOLYTELY13GOSERELIN ACETATE84GPI-LACTULOSE77GRAMICIDIN, NEOMYCIN

SULFATE, POLYMYXIN B SULFATE

77GRAMICIDIN, POLYMYXIN B SULFATE

86GRANISETRON85GRAVOL20HABITROL

106HALCINONIDE106HALOBETASOL PROPIONATE106HALOG60HALOPERIDOL60HALOPERIDOL60HALOPERIDOL DECANOATE60HALOPERIDOL LA22HEPALEAN23HEPALEAN LOK23HEPARIN LEO22HEPARIN LOCK FLUSH22HEPARIN SODIUM11HEPSERA9HEPTOVIR

102HERPLEX-D LIQUIFILM13HEXALEN

103HEXIT79HOMATROPINE HBR

101HONEY BEE VENOM101HONEY BEE VENOM PROTEIN

EXTRACT88HP-PAC98HUMALOG98HUMALOG 10ML98HUMALOG CARTRIDGE12HUMATIN

114HUMIRA114HUMIRA PEN114HUMIRA PRE-FILL97HUMULIN 20/80 CARTRIDGE98HUMULIN 30/7098HUMULIN 30/70 CARTRIDGE98HUMULIN L 10ML97HUMULIN N97HUMULIN N 10ML97HUMULIN N CARTRIDGE97HUMULIN R 10ML97HUMULIN R CARTRIDGE

106HYCORT106HYDERM82HYDRA SENSE (ISOTONIC,

STERILE SEAWATER)29HYDRALAZINE29HYDRALAZINE HCL13HYDREA74HYDROCHLOROTHIAZIDE75HYDROCHLOROTHIAZIDE93HYDROCORTISONE

106HYDROCORTISONE ACETATE106HYDROCORTISONE ACETATE,

ZINC SULFATE

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Page Page106HYDROCORTISONE ACETATE,

ZINC SULFATE, PRAMOXINE HCL106HYDROCORTISONE VALERATE106HYDROCORTISONE, DIBUCAINE

HCL, ESCULIN, FRAMYCETIN SULFATE

78HYDROCORTISONE, NEOMYCIN SULFATE, POLYMYXIN B SULFATE

106HYDROCORTISONE, UREA104HYDROGEN PEROXIDE104HYDROGEN PEROXIDE 10V47HYDROMORPH CONTIN47HYDROMORPHONE47HYDROMORPHONE HCL47HYDROMORPHONE HP 1047HYDROMORPHONE HP 2047HYDROMORPHONE HP 50

106HYDROVAL12HYDROXYCHLOROQUINE

SULFATE119HYDROXYPROPYLCELLULOSE81HYDROXYPROPYLMETHYLCELL

ULOSE13HYDROXYUREA66HYDROXYZINE66HYDROXYZINE HCL81HYPOTEARS30HYTRIN41HYZAAR41HYZAAR DS43IBUPROFEN43IBUPROFEN

102IDOXURIDINE107IHLES PASTE14IMATINIB MESYLATE29IMDUR57IMIPRAMINE57IMIPRAMINE HCL67IMITREX67IMITREX DF83IMODIUM

115IMURAN75INDAPAMIDE75INDAPAMIDE33INDERAL LA9INDINAVIR SULFATE

44INDOMETHACIN112INFANTOL116INFLIXIMAB22INFUFER

121INFUSION SETS37INHIBACE38INHIBACE PLUS23INNOHEP97INSULIN (30% NEUTRAL & 70%

ISOPHANE) HUMAN BIOSYNTHETIC

97INSULIN (40% NEUTRAL & 60% ISOPHANE) HUMAN BIOSYNTHETIC

97INSULIN (50% NEUTRAL & 50% ISOPHANE) HUMAN BIOSYNTHETIC

97INSULIN (ISOPHANE) HUMAN BIOSYNTHETIC

97INSULIN (ZINC CRYSTALLINE) HUMAN BIOSYNTHETIC (RDNA ORIGIN)

97INSULIN ASPART97INSULIN GLULISINE97INSULIN HUMAN BIOSYNTHETIC97INSULIN HUMAN BIOSYNTHETIC

20% & ISOPHANE 80%98INSULIN HUMAN BIOSYNTHETIC

30% & ISOPHANE 70%98INSULIN LISPRO

123INSULIN LO DOSE MICRO 28G121INSULIN PUMP BATTERY121INSULIN PUMP CARTRIDGES121INSULIN PUMP SUPPLIES98INSULIN ZINC SUSPENSION

MEDIUM HUMAN BIOSYNTHETIC (RDNA ORIGIN)

9INTELENCE14INTERFERON ALFA-2B70INTRAUTERINE DEVICE14INTRON A

9INVIRASE81IOPIDINE85IPECAC85IPECAC17IPRATROPIUM BROMIDE17IPRATROPIUM BROMIDE,

SALBUTAMOL41IRBESARTAN41IRBESARTAN,

HYDROCHLOROTHIAZIDE22IRON DEXTRAN

9ISENTRESS8ISONIAZID

121ISOPROPYL ALCOHOL103ISOPROPYL MYRISTATE36ISOPTIN SR79ISOPTO ATROPINE79ISOPTO CARBACHOL80ISOPTO CARPINE79ISOPTO HOMATROPINE81ISOPTO TEARS29ISOSORBIDE29ISOSORBIDE DINITRATE29ISOSORBIDE-5-MONONITRATE

8ISOTAMINE109ISOTRETINOIN72ITEST

121ITEST LANCETS 28G (100)121ITEST LANCETS 33G (100)

7ITRACONAZOLE43JAMP IBUPROFEN86JAMP ONDANSETRON22JAMP SULFATE FERREUX

112JAMP VIT D335JAMP-AMLODIPINE42JAMP-ASA83JAMP-BISACODYL73JAMP-CALCIUM+VITAM D55JAMP-CITALOPRAM

1JAMP-DIPHENHYDRAMINE83JAMP-DOCUSATE CALCIUM38JAMP-FOSINOPRIL73JAMP-MAGNESIUM GLUCONATE

113JAMP-MULTIVITAMIN A/D/C DROPS

27JAMP-PRAVASTATIN62JAMP-QUETIAPINE40JAMP-RAMIPRIL84JAMP-SENNOSIDES28JAMP-SIMVASTATIN

111JAMP-VITAMIN B1112JAMP-VITAMIN D73K 1073K LYTE48KADIAN48KADIAN SR9KALETRA

74KAYEXALATE73K-DUR94KENALOG-1094KENALOG-4053KEPPRA7KETOCONAZOLE

102KETODERM44KETOPROFEN44KETOPROFEN-SR79KETOROLAC TROMETHAMINE72KETOSTIX1KETOTIFEN FUMARATE

74K-EXIT8KIVEXA

84KLEAN-PREP76KOFFEX DM

103KWELLADA-P86KYTRIL32LABETALOL HCL81LACRI LUBE

119LACRISERT LAMELLE85LACTAID85LACTAID EXTRA STRENGTH85LACTASE

108LACTIC ACID, SALICYLIC ACID124LACTOSE85LACTRASE84LACTULOSE84LACTULOSE53LAMICTAL7LAMISIL9LAMIVUDINE9LAMIVUDINE, ZIDOVUDINE

53LAMOTRIGINE53LAMOTRIGINE

121LANCET121LANCING DEVICE25LANOXIN

116LANREOTIDE88LANSOPRAZOLE88LANSOPRAZOLE ODT84LANSOYL GEL84LANSOYL GEL SUGARFREE15LANVIS74LASIX81LATANOPROST84LAX-A-DAY65LECTOPAM

116LEFLUNOMIDE45LENOLTEC NO.4

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Page Page27LESCOL27LESCOL XL14LETROZOLE14LETROZOLE

117LEUCOVORIN CALCIUM117LEUCOVORIN CALCIUM13LEUKERAN14LEUPROLIDE ACETATE5LEVAQUIN

54LEVATE22LEVENOX HP53LEVETIRACETAM80LEVOBUNOLOL HCL77LEVOCABASTINE HCL74LEVOCARNITINE67LEVODOPA, BENZERAZIDE68LEVODOPA, CARBIDOPA68LEVODOPA,

CARBIDOPA,ENTACAPONE5LEVOFLOXACIN5LEVOFLOXACIN

22LEVONEX HP95LEVONORGESTREL

100LEVOTHYROXINE SODIUM105LIDEMOL105LIDEX107LIDOCAINE HCL107LIDOCAINE, PRILOCAINE107LIDODAN VISCOUS72LIFE BRAND

121LIFESCAN FINE POINT121LIFESCAN REGULAR46LINCTUS CODEINE

103LINDANE94LINESSA (21)94LINESSA (28)7LINEZOLID

20LIORESAL20LIORESAL DS85LIPASE, AMYLASE, PROTEASE26LIPIDIL EZ26LIPIDIL MICRO26LIPIDIL SUPRA26LIPITOR81LIQUIFILM TEARS39LISINOPRIL39LISINOPRIL,

HYDROCHLOROTHIAZIDE66LITHANE66LITHIUM CARBONATE66LITHIUM CITRATE77LIVOSTIN78LOCACORTEN VIOFORM81LODOXAMIDE TROMETHAMINE95LOESTRIN 1.5/30 (21)95LOESTRIN 1.5/30 (28)14LOMUSTINE29LONITEN83LOPERAMIDE83LOPERAMIDE HCL26LOPID9LOPINAVIR, RITONAVIR

33LOPRESOR32LOPRESOR SR

1LORATADINE1LORATADINE1LORATADINE,

PSEUDOEPHEDRINE SULFATE65LORAZEPAM41LOSARTAN POTASSIUM41LOSARTAN POTASSIUM,

HYDROCHLOROTHIAZIDE89LOSEC37LOTENSIN

104LOTRIDERM27LOVASTATIN22LOVENOX60LOXAPINE HCL60LOXAPINE SUCCINATE75LOZIDE

120LUER LOCK (DISP) 3CC120LUER LOCK (DISP) 5CC120LUER LOCK (DISP) 10CC120LUER LOCK (DISP) 20CC120LUER LOCK (DISP) 30CC120LUER LOCK (DISP) 60CC81LUMIGAN14LUPRON DEPOT56LUVOX

105LYDERM14LYSODREN48M.O.S. 1048M.O.S. 2048M.O.S. 4048M.O.S. 5048M.O.S. 6047M.O.S. SR49M.O.S. SULFATE12MACROBID12MACRODANTIN84MACROGOL, POTASSIUM

CHLORIDE, SODIUM BICARBONATE, SODIUM CHLORIDE, SODIUM SULFATE

81MACROGOL, PROPYLENE GLYCOL

83MAG OXIDE83MAGIC BULLET73MAGNESIUM73MAGNESIUM73MAGNESIUM CITRATE73MAGNESIUM GLUCONATE84MAGNESIUM HYDROXIDE83MAGNESIUM OXIDE

121MAGNIFIER63MAJEPTIL57MANERIX57MAPROTILINE HCL

9MARAVIROC94MARVELON (21)94MARVELON (28)

102MATERNA40MAVIK66MAXALT67MAXALT RPD78MAXIDEX88MAXIMUM STRENGTH ACID

REDUCER2MEBENDAZOLE

86MECLIZINE HCL31MED-ACEBUTOLOL31MED-ACEBUTOLOL (TYPE S)64MED-ALPRAZOLAM8MED-AMANTADINE4MED-AMOXICILLIN

31MED-ATENOLOL20MED-BACLOFEN78MED-BECLOMETHASONE AQ65MED-BROMAZEPAM37MED-CAPTOPRIL55MED-CLOMIPRAMINE51MED-CLONAZEPAM36MED-DILTIAZEM26MED-GEMFIBROZIL98MED-GLYBE71MEDISENSE

121MEDISENSE TLC97MED-METFORMIN33MED-METOPROLOL6MED-MINOCYCLINE

33MED-PINDOLOL88MED-RANITIDINE93MEDROL

100MEDROXYPROGESTERONE100MEDROXYPROGESTERONE

ACETATE18MED-SALBUTAMOL69MED-SELEGILINE34MED-SOTALOL66MED-TEMAZEPAM80MED-TIMOLOL54MED-VALPROIC ACID37MED-VERAPAMIL44MEFENAMIC44MEFENAMIC ACID14MEGACE14MEGESTROL14MEGESTROL ACETATE44MELOXICAM14MELPHALAN47MEPERIDINE47MEPERIDINE HCL12MEPRON14MERCAPTOPURINE90MESALAZINE90MESASAL48M-ESLON48M-ESLON SR16MESTINON16MESTINON-SR84METAMUCIL ORIGINAL TEXTURE84METAMUCIL SM TEXT ORANGE84METAMUCIL SM TEXT ORANGE

S/F84METAMUCIL SM TEXT UNFLAV97METFORMIN97METFORMIN HCL

124METHADONE124METHADONE HCL80METHAZOLAMIDE14METHOTREXATE14METHOTREXATE SODIUM61METHOTRIMEPRAZINE

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Page Page61METHOTRIMEPRAZINE

108METHOXSALEN51METHSUXIMIDE29METHYLDOPA29METHYLDOPA29METHYLDOPA,

HYDROCHLOROTHIAZIDE64METHYLPHENIDATE HCL93METHYLPREDNISOLONE93METHYLPREDNISOLONE

ACETATE93METHYLPREDNISOLONE

ACETATE19METHYSERGIDE MALEATE90METOCLOPRAMIDE90METOCLOPRAMIDE HCL75METOLAZONE33METOPROLOL32METOPROLOL TARTRATE

104METROCREAM104METROGEL104METROLOTION12METRONIDAZOLE12METRONIDAZOLE

104METRONIDAZOLE, NYSTATIN27MEVACOR25MEXILETINE HCL99MIACALCIN41MICARDIS41MICARDIS PLUS

102MICATIN102MICONAZOLE102MICONAZOLE NITRATE102MICOZOLE122MICRO-FINE84MICROLAX

121MICROLET95MICRONOR (28)74MIDAMOR18MIDODRINE HCL19MIGRANAL84MILK OF MAGNESIA84MILK OF MAGNESIA

PLAIN/SUGARFREE95MIN OVRAL (21)95MIN OVRAL (28)84MINERAL OIL84MINERAL OIL (HEAVY) 100% USP81MINERAL OIL, PETROLATUM81MINERAL OIL, WHITE

PETROLATUM95MINESTRIN 1/20 (21)95MINESTRIN 1/20 (28)30MINIPRESS30MINITRAN6MINOCIN6MINOCYCLINE6MINOCYCLINE HCL

29MINOXIDIL5MINT-CIPROFLOXACIN

55MINT-CITALOPRAM86MINT-ONDANSETRON99MINT-PIOGLITAZONE27MINT-PRAVASTATIN53MINT-TOPIRAMATE

80MIOSTAT68MIRAPEX68MIRAPEX (ONT)95MIRENA57MIRTAZAPINE57MIRTAZAPINE88MISOPROSTOL88MISOPROSTOL14MITOTANE

101MIXED VESPID VENOM PROTEIN44MOBICOX57MOCLOBEMIDE57MOCLOBEMIDE64MODAFINIL60MODECATE74MODURET65MOGADON78MOMETASONE FUROATE

102MONISTAT102MONISTAT 3102MONISTAT 3 DUAL PAK102MONISTAT 7102MONISTAT 7 DUAL PAK102MONISTAT-DERM32MONOCOR

122MONOJECT122MONOJECT (100)122MONOJECT (30)121MONOJECT ALCOHOL WIPES122MONOJECT DISP 3/10CC (100)122MONOJECT DISP 3/10CC (30)121MONOJECTOR121MONOLET ORIGINAL121MONOLET THIN38MONOPRIL76MONTELUKAST47MORPHINE HCL48MORPHINE HP 2548MORPHINE HP 5048MORPHINE LP48MORPHINE SULFATE48MORPHINE SULFATE43MOTRIN43MOTRIN JUNIOR STRENGTH

121MPD THIN (100)121MPD THIN (200)121MPD ULTRA THIN (100)121MPD ULTRA THIN (200)48MS CONTIN SR49MS IR84MUCILLIUM

113MULTI-PRE AND POST NATAL108MULTITAR PLUS108MULTI-TAR PLUS MILD112MULTIVITAMINS (PEDIATRIC)113MULTIVITAMINS (PRENATAL)112MULTI-VITAMINS CHILD102MUPIROCIN82MURO-128

8MYCOBUTIN117MYCOPHENOLATE MOFETIL117MYCOPHENOLATE SODIUM79MYDFRIN

117MYFORTIC

123MYHEALTH SYRINGE CASE-7123MYHEALTH SYRINGE CASE-

SINGLE32MYLAN-CARVEDILOL35MYLAN-NIFEDIPINE ER89MYLAN-OMEPRAZOLE17MYLAN-RIVASTIGMINE13MYLERAN91MYOCHRYSINE16MYOTONACHOL87NABILONE33NADOLOL33NADOLOL23NADROPARIN CALCIUM1NADRYL

96NAFARELIN ACETATE76NALCROM79NAPHAZOLINE HCL79NAPHCON FORTE44NAPROSYN44NAPROSYN E44NAPROSYN SR44NAPROXEN44NAPROXEN45NAPROXEN NA45NAPROXEN SODIUM45NAPROXEN-NA DF66NARATRIPTAN HCL58NARDIL79NASACORT AQ82NASAL SALINE78NASONEX98NATEGLINIDE14NATULAN86NAUSEATOL63NAVANE

117NEDOCROMIL SODIUM122NEEDLE122NEEDLE (NON-INSULIN)122NEEDLES (NON-INSULIN)

DISPOSABLE9NELFINAVIR MESYLATE

73NEO CAL-D-50022NEO FER96NEO-ESTRONE

106NEO-HC115NEORAL16NEOSTIGMINE BROMIDE

113NEO-TINIC105NERISALIC OILY105NERISONE105NERISONE OILY24NEULASTA61NEULEPTIL24NEUPOGEN52NEURONTIN9NEVIRAPINE

111NIACIN111NIACIN111NIACIN YEAST FREE20NICODERM20NICORETTE20NICORETTE PLUS20NICOTINE (GUM)

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Page Page20NICOTINE (PATCH)20NICOTROL TRANSDERMAL23NICOUMALONE

104NIDAGEL35NIFEDIPINE35NIFEDIPINE PA14NILUTAMIDE30NIMODIPINE30NIMOTOP

118NITOMAN65NITRAZADON65NITRAZEPAM30NITRO-DUR12NITROFURANTOIN29NITROGLYCERIN29NITROL30NITROLINGUAL PUMPSPRAY30NITROSTAT

103NIX103NIX DERMAL87NIZATIDINE87NIZATIDINE

102NIZORAL15NOLVADEX D

101NON POLLEN120NON-INSULIN 1CC120NON-INSULIN 3CC120NON-INSULIN 5CC120NON-INSULIN (DISP) 1CC120NON-INSULIN (DISP) 3CC120NON-INSULIN (DISP) 5CC120NON-INSULIN (DISP) 10CC120NON-INSULIN 10CC95NORETHINDRONE5NORFLOXACIN

104NORITATE95NORLEVO57NORTRIPTYLINE HCL35NORVASC9NORVIR9NORVIR SEC

72NOVAMAX74NOVAMILOR4NOVAMOXIN4NOVAMOXIN SUGAR REDUCED

42NOVASEN70NOVA-T IUD90NOVO 5-ASA31NOVO-ACEBUTOLOL11NOVO-ACYCLOVIR

114NOVO-ALENDRONATE64NOVO-ALPRAZOL25NOVO-AMIODARONE35NOVO-AMLODIPINE4NOVO-AMPICILLIN

31NOVO-ATENOL32NOVO-ATENOLTHALIDONE26NOVO-ATORVASTATIN3NOVO-AZITHROMYCIN

79NOVO-BENZYDAMINE115NOVO-BETAHISTINE13NOVO-BICALUTAMIDE32NOVO-BIPOPROLOL65NOVO-BROMAZEPAM

73NOVO-CALCIUM37NOVO-CAPTORIL52NOVO-CARBAMAZ

2NOVO-CEFADROXIL12NOVO-CHLOROQUINE59NOVO-CHLORPROMAZINE25NOVO-CHOLAMINE25NOVO-CHOLAMINE LIGHT37NOVO-CILAZAPRIL38NOVO-CILAZAPRIL/HCTZ87NOVO-CIMETINE

5NOVO-CIPROFLOXACIN55NOVO-CITALOPRAM

4NOVO-CLAVAMOXIN6NOVO-CLINDAMYCIN

65NOVO-CLOBAZAM105NOVO-CLOBETASOL51NOVO-CLONAZEPAM29NOVO-CLONIDINE55NOVO-CLOPAMINE

4NOVO-CLOXIN19NOVO-CYCLOPRINE

115NOVO-CYPROTERONE/ETHINYL ESTRADIOL

55NOVO-DESIPRAMINE99NOVO-DESMOPRESSIN42NOVO-DIFENAC43NOVO-DIFENAC SR43NOVO-DIFLUNISAL35NOVO-DILTAZEM CD36NOVO-DILTIAZEM36NOVO-DILTIAZEM ER86NOVODIMENATE52NOVO-DIVALPROEX83NOVO-DOCUSATE83NOVO-DOCUSATE CALCIUM86NOVO-DOMPERIDONE30NOVO-DOXAZOSIN56NOVO-DOXEPIN

6NOVO-DOXYLIN38NOVO-ENALAPRIL38NOVO-ENALAPRIL/HCTZ

116NOVO-ETIDRONATECAL KIT87NOVO-FAMOTIDINE26NOVO-FENOFIBRATE26NOVO-FENOFIBRATE-S46NOVO-FENTANYL22NOVO-FERROGLUC84NOVO-FIBRE

116NOVO-FINASTERIDE122NOVOFINE122NOVOFINE 30G122NOVOFINE 32G 6MM122NOVOFINE INSULIN PEN 28G122NOVOFINE INSULIN PEN 30G

7NOVO-FLUCONAZOLE56NOVO-FLUOXETINE43NOVO-FLURPROFEN13NOVO-FLUTAMIDE56NOVO-FLUVOXAMINE38NOVO-FOSINOPRIL12NOVO-FURANTOIN52NOVO-GABAPENTIN26NOVO-GEMFIBROZIL

50NOVO-GESIC98NOVO-GLICLAZIDE98NOVO-GLYBURIDE75NOVO-HYDRAZIDE66NOVO-HYDROXYZIN29NOVO-HYLAZIN75NOVO-INDAPAMIDE17NOVO-IPRAMIDE7NOVO-KETOCONAZOLE1NOVO-KETOTIFEN

53NOVO-LAMOTRIGINE88NOVO-LANSOPRAZOLE

116NOVO-LEFLUNOMIDE68NOVO-LEVOCARBIDOPA5NOVO-LEVOFLOXACIN2NOVO-LEXIN

97NOVOLIN GE 30/70 10ML97NOVOLIN GE 30/70 PENFILL97NOVOLIN GE 40/60 PENFILL97NOVOLIN GE 50/50 PENFILL97NOVOLIN GE NPH 10ML97NOVOLIN GE NPH PENFILL97NOVOLIN GE TORONTO97NOVOLIN GE TORONTO PENFILL39NOVO-LISINOPRIL (TYPE P)39NOVO-LISINOPRIL (TYPE Z)39NOVO-LISINOPRIL/HCTZ (TYPE P)39NOVO-LISINOPRIL/HCTZ (TYPE Z)83NOVO-LOPERAMIDE65NOVO-LORAZEM27NOVO-LOVASTATIN57NOVO-MAPROTILINE

100NOVO-MEDRONE44NOVO-MELOXICAM61NOVO-MEPRAZINE97NOVO-METFORMIN44NOVO-METHACIN14NOVO-METHOTREXATE33NOVO-METOPROL33NOVO-METOPROL CT33NOVO-METOPROL-B25NOVO-MEXILETINE6NOVO-MINOCYCLINE

57NOVO-MIRTAZAPINE57NOVO-MIRTAZAPINE OD57NOVO-MOCLOBEMIDE48NOVO-MORPHINE SR33NOVO-NADOLOL44NOVO-NAPROX45NOVO-NAPROX SODIUM45NOVO-NAPROX SODIUM DS66NOVO-NARATRIPTAN87NOVO-NIZATIDINE5NOVO-NORFLOXACIN

57NOVO-NORTRIPTYLINE6NOVO-OFLOXACIN

61NOVO-OLANZAPINE61NOVO-OLANZAPINE ODT86NOVO-ONDANSETRON

110NOVO-OXYBUTYNIN46NOVO-OXYCODONE ACET89NOVO-PANTOPRAZOLE58NOVO-PAROXETINE4NOVO-PEN VK

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Page Page60NOVO-PERIDOL1NOVOPHENIRAM

33NOVO-PINDOL99NOVO-PIOGLITAZONE45NOVO-PIROCAM57NOVO-PRAMINE68NOVO-PRAMIPEXOLE34NOVO-PRANOL27NOVO-PRAVASTATIN30NOVO-PRAZIN94NOVO-PREDNISONE43NOVO-PROFEN

115NOVO-PUROL62NOVO-QUETIAPINE90NOVO-RABEPRAZOLE96NOVO-RALOXIFENE40NOVO-RAMIPRIL88NOVO-RANIDINE87NOVO-RANITIDINE97NOVORAPID

117NOVO-RISEDRONATE63NOVO-RISPERIDONE17NOVO-RIVASTIGMINE3NOVO-RYTHRO ESTOLATE3NOVO-RYTHRO

ETHYLSUCCINATE18NOVO-SALBUTAMOL HFA69NOVO-SELEGILINE74NOVO-SEMIDE58NOVO-SERTRALINE28NOVO-SIMVASTATIN34NOVO-SOTALOL41NOVO-SPIROTON75NOVO-SPIROZINE-2575NOVO-SPIROZINE-5088NOVO-SUCRALATE67NOVO-SUMATRIPTAN67NOVO-SUMATRIPTAN DF45NOVO-SUNDAC15NOVO-TAMOXIFEN

118NOVO-TAMSULOSIN66NOVO-TEMAZEPAM30NOVO-TERAZOSIN7NOVO-TERBINAFINE

110NOVO-THEOPHYL SR45NOVO-TIAPROFENIC24NOVO-TICLOPIDINE34NOVO-TIMOL53NOVO-TOPIRAMATE59NOVO-TRAZODONE74NOVO-TRIAMZIDE6NOVO-TRIMEL6NOVO-TRIMEL DS

59NOVO-TRIPRAMINE54NOVO-TRIPTYN54NOVO-VALPROIC59NOVO-VENLAFAXINE XR37NOVO-VERAMIL37NOVO-VERAMIL SR23NOVO-WARFARIN31NU-ACEBUTOLOL11NU-ACYCLOVIR64NU-ALPRAZ74NU-AMILZIDE

4NU-AMOXI4NU-AMPI

31NU-ATENOL115NU-AZATHIOPRINE20NU-BACLO78NU-BECLOMETHASONE65NU-BROMAZEPAM73NU-CAL37NU-CAPTO52NU-CARBAMAZEPINE

2NU-CEFACLOR3NU-CEPHALEX

87NU-CIMET5NU-CIPROFLOXACIN

55NU-CITALOPRAM51NU-CLONAZEPAM29NU-CLONIDINE

4NU-CLOXI6NU-COTRIMOX6NU-COTRIMOX DS

76NU-CROMOLYN19NU-CYCLOBENZAPRINE55NU-DESIPRAMINE42NU-DICLO43NU-DICLO SR43NU-DIFLUNISAL36NU-DILTIAZ35NU-DILTIAZ CD52NU-DIVALPROEX86NU-DOMPERIDONE

6NU-DOXYCYCLINE3NU-ERYTHROMYCIN S

87NU-FAMOTIDINE26NU-FENOFIBRATE26NU-FENO-MICRO56NU-FLUOXETINE43NU-FLURBIPROFEN56NU-FLUVOXAMINE74NU-FUROSEMIDE26NU-GEMFIBROZIL98NU-GLYBURIDE29NU-HYDRAL75NU-HYDRO43NU-IBUPROFEN75NU-INDAPAMIDE44NU-INDO17NU-IPRATROPIUM UDV

7NU-KETOCON44NU-KETOPROFEN

1NU-KETOTIFEN68NU-LEVOCARB65NU-LORAZ27NU-LOVASTATIN60NU-LOXAPINE

100NU-MEDROXY44NU-MEFENAMIC14NU-MEGESTROL97NU-METFORMIN90NU-METOCLOPRAMIDE33NU-METOP57NU-MOCLOBEMIDE44NU-NAPROX35NU-NIFED35NU-NIFEDIPINE PA

57NU-NORTRIPTYLINE110NU-OXYBUTYN58NU-PAROXETINE5NU-PEN VK

24NU-PENTOXIFYL33NU-PINDOL45NU-PIROX27NU-PRAVASTATIN30NU-PRAZO62NU-PROCHLOR25NU-PROPAFENONE34NU-PROPRANOLOL88NU-RANIT18NU-SALBUTAMOL69NU-SELEGILINE58NU-SERTRALINE28NU-SIMVASTATIN34NU-SOTALOL88NU-SUCRALFATE75NU-SULFINPYRAZONE45NU-SULINDAC66NU-TEMAZEPAM30NU-TERAZOSIN7NU-TERBINAFINE6NU-TETRA

45NU-TIAPROFENIC24NU-TICLOPIDINE34NU-TIMOLOL59NU-TRAZODONE59NU-TRAZODONE D74NU-TRIAZIDE66NU-TRIAZO59NU-TRIMIPRAMINE54NU-VALPROIC94NUVARING37NU-VERAP37NU-VERAP SR

102NYADERM7NYSTATIN

103NYSTATIN73O-CALCIUM 500

108OCCLUSAL HP117OCTREOTIDE117OCTREOTIDE ACETATE OMEGA79OCUFEN77OCUFLOX73ODAN K-20

108ODANS LIQUOR CARBONIS DETERGENT

96OESCLIM6OFLOXACIN

96OGEN61OLANZAPINE41OLMESARTAN MEDOXOMIL41OLMESARTAN MEDOXOMIL,

HYDROCHLORTHIAZIDE41OLMETEC41OLMETEC PLUS90OLSALAZINE SODIUM89OMEPRAZOLE MAGNESIUM (PA)89OMEPRAZOLE, OMEPRAZOLE

MAGNESIUM (NO PA)70OMNIFLEX DIAPHRAGM 7586ONDANSETRON HCL86ONDANSETRON HCL DIHYDRATE

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Page Page71ONE TOUCH72ONE TOUCH ULTRA

121ONE TOUCH ULTRA SOFT112ONE-ALPHA120OPTICHAMBER120OPTICHAMBER LARGE MASK120OPTICHAMBER MEDIUM MASK120OPTICHAMBER SMALL MASK76OPTICROM

120OPTIHALER77OPTIMYXIN77OPTIMYXIN EYE/EAR77OPTIMYXIN PLUS EYE/EAR

120OPTIVENT IN-LINE MDI SPACER107ORACORT61ORAP18ORCIPRENALINE SULFATE

114ORENCIA95ORTHO 0.5/35 (28)95ORTHO 0.5/35 (21)95ORTHO 7/7/7 (21)95ORTHO 7/7/7 (28)95ORTHO 1/35 (21)95ORTHO 1/35 (28)94ORTHO CEPT (28)73OS-CAL D 500MG

112OSTOFORTE81OTRIVIN SALINE94OVRAL (21)

122OWEN MUMFORD UNIFINE PENTIPS 1/2 INCH



65OXAZEPAM65OXAZEPAM18OXEZE TURBUHALER33OXPRENOLOL HCL

108OXSORALEN110OXTRIPHYLLINE103OXY 5110OXYBUTYNIN CHLORIDE110OXYBUTYNINE49OXYCODONE HCL49OXYCONTIN

103OXYDERM49OXY-IR

108P&S PLUS22PALAFER

117PAMIDRONATE DISODIUM117PAMIDRONATE DISODIUM85PANCREASE MT 1085PANCREASE MT 1685PANCREASE MT 4

103PANOXYL108PANOXYL ACNE103PANOXYL AQUAGEL103PANOXYL-10103PANOXYL-20103PANOXYL-589PANTOLOC89PANTOPRAZOLE89PANTOPRAZOLE MAGNESIUM89PANTOPRAZOLE SODIUM

90PARIET EC58PARNATE12PAROMOMYCIN SULFATE58PAROXETINE58PAROXETINE HCL67PARSITAN58PAXIL11PDL-ACYCLOVIR

2PDL-CEFACLOR3PDL-CEPHALEXIN

87PDL-CIMETIDINE30PDL-DIPYRIDAMOLE13PDL-FLUTAMIDE38PDL-FOSINOPRIL98PDL-GLYBURIDE29PDL-ISOSORBIDE60PDL-LOXAPINE

100PDL-MEDROXY6PDL-MINOCYCLINE5PDL-NORFLOXACINE

30PDL-TERAZOSIN24PDL-TICLOPIDINE54PDL-TOPIRAMATE54PDL-VALPROIC22PEDIAFER73PEDIALYTE49PEDIAPHEN49PEDIAPHEN CHEWABLE94PEDIAPRED73PEDIATRIC ELECTROLYTE49PEDIATRIX

113PEDIAVIT112PEDIAVIT D10PEGASYS10PEGASYS RBV10PEGETRON10PEGETRON REDIPEN24PEGFILGRASTIM10PEGINTERFERON ALFA-2A10PEGINTERFERON ALFA-2A,

RIBAVIRIN10PEGINTERFERON ALFA-2B10PEGINTERFERON ALFA-2B,

RIBAVIRIN84PEGLYTE

4PEN VEE4PENBRITIN

92PENICILLAMINE4PENICILLIN V BENZATHINE4PENICILLIN V POTASSIUM5PENICILLINE V

121PENLET PLUS31PENTA-ACEBUTOLOL74PENTA-AMILOR HCTZ

4PENTA-AMOXICILLIN31PENTA-ATENOLOL37PENTA-CAPTOPRIL36PENTA-DILTIAZEM87PENTA-FAMOTIDINE26PENTA-GEMFIBROZIL33PENTA-METOPROLOL12PENTAMIDINE12PENTAMIDINE ISETHIONATE77PENTAMYCETIN

110PENTA-OXYBUTYNIN90PENTASA45PENTA-SULINDAC66PENTA-TEMAZEPAM45PENTA-TIAPROFENIC59PENTA-TRAZODONE54PENTA-VALPROIC49PENTAZOCINE HCL49PENTAZOCINE LACTATE

117PENTOSAN POLYSULFATE SODIUM

24PENTOXIFYLLINE108PENTRAX87PEPCID83PEPTO BISMOL46PERCOCET45PERCOCET DEMI46PERCODAN79PERICHLOR61PERICYAZINE79PERIDEX39PERINDOPRIL ERBUMINE39PERINDOPRIL ERBUMINE,

INDAPAMIDE39PERINDOPRIL

ERBUMINE,INDAPAMIDE79PERIOGARD

103PERMETHRIN104PEROXIDE D'HYDROGENE61PERPHENAZINE61PERPHENAZINE30PERSANTINE47PETHIDINE

107PETROLATUM81PETROLATUM, LANOLIN,

MINERAL OIL81PETROLATUM, PETROLATUM

LIQUID58PHENELZINE SULFATE50PHENOBARBITAL50PHENOBARBITAL79PHENYLEPHRINE79PHENYLEPHRINE HCL79PHENYLEPHRINE MINIMS51PHENYTOIN55PHI-CITALOPRAM

114PHL-ALENDRONATE34PHL-AMLODIPINE31PHL-ATENOLOL3PHL-AZITHROMYCIN

20PHL-BACLOFEN32PHL-CARVEDILOL5PHL-CIPROFLOXACIN

55PHL-CITALOPRAM51PHL-CLONAZEPAM50PHL-CLONAZEPAM 0.25MG51PHL-CLONAZEPAM-R 0.5MG19PHL-CYCLOBENZAPRINE93PHL-DEXAMETHASONE56PHL-FLUOXETINE52PHL-GABAPENTIN47PHL-HYDROMORPHONE75PHL-INDAPAMIDE5PHL-LEVOFLOXACIN

60PHL-LOXAPINE

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Page Page44PHL-MELOXICAM57PHL-MIRTAZAPINE86PHL-ONDANSETRON89PHL-PANTOPRAZOLE58PHL-PAROXETINE99PHL-PIOGLITAZONE27PHL-PRAVASTATIN62PHL-QUETIAPINE63PHL-RISPERIDONE58PHL-SERTRALINE28PHL-SIMVASTATIN34PHL-SOTALOL53PHL-TOPIRAMATE59PHL-TRAZODONE85PHL-URSODIOL C54PHL-VALPROIC ACID85PHOSPHO SODA FLEET

LAXATIVE110PHYLLOCONTIN83PICO-SALAX80PILOCARPINE80PILOCARPINE HCL81PILOCARPINE NITRATE81PILOCARPINE NITRATE MINIMS80PILOPINE HS

109PIMECROLIMUS61PIMOZIDE33PINDOLOL33PINDOLOL33PINDOLOL,

HYDROCHLOROTHIAZIDE99PIOGLITAZONE HCL

103PIPERONYL BUTOXIDE, PYRETHRINS

62PIPORTIL L462PIPOTIAZINE PALMITATE45PIROXICAM45PIROXICAM

121PISTON ROD5PIVMECILLINAM HCL

67PIZOTYLINE HYDROGEN MALATE124PLACEBO95PLAN B84PLANTAGO SEED12PLAQUENIL23PLAVIX35PLENDIL45PMS-ACET 249PMS-ACETAMINOPHEN45PMS-ACETAMINOPHEN WITH

CODEINE114PMS-ALENDRONATE114PMS-ALENDRONATE FC

8PMS-AMANTADINE25PMS-AMIODARONE54PMS-AMITRIPTYLINE34PMS-AMLODIPINE4PMS-AMOXICILLIN

23PMS-ANAGRELIDE42PMS-ASA42PMS-ASA EC31PMS-ATENOLOL26PMS-ATORVASTATIN3PMS-AZITHROMYCIN

20PMS-BACLOFEN

67PMS-BENZTROPINE79PMS-BENZYDAMINE26PMS-BEZAFIBRATE13PMS-BICALUTAMIDE83PMS-BISACODYL32PMS-BISOPROLOL79PMS-BRIMONIDINE68PMS-BROMOCRIPTINE54PMS-BUPROPION SR73PMS-CALCIUM73PMS-CALCIUM/VITAMIN D37PMS-CAPTOPRIL51PMS-CARBAMAZEPINE51PMS-CARBAMAZEPINE SRT32PMS-CARVEDILOL

3PMS-CEPHALEXIN1PMS-CETIRIZINE

25PMS-CHOLESTYRAMINE LIGHT25PMS-CHOLESTYRAMINE

REGULAR37PMS-CILAZAPRIL87PMS-CIMETIDINE

5PMS-CIPROFLOXACIN55PMS-CITALOPRAM

3PMS-CLARITHROMYCIN65PMS-CLOBAZAM

105PMS-CLOBETASOL50PMS-CLONAZEPAM51PMS-CLONAZEPAM R46PMS-CODEINE19PMS-CYCLOBENZAPRINE55PMS-DESIPRAMINE99PMS-DESMOPRESSIN

105PMS-DESONIDE78PMS-DEXAMETHASONE65PMS-DIAZEPAM42PMS-DICLOFENAC42PMS-DICLOFENAC 25MG DR42PMS-DICLOFENAC 50MG DR43PMS-DICLOFENAC SR86PMS-DIMENHYDRINATE

1PMS-DIPHENHYDRAMINE79PMS-DIPIVEFRIN52PMS-DIVALPROEX83PMS-DOCUSATE CALCIUM83PMS-DOCUSATE SODIUM86PMS-DOMPERIDONE30PMS-DOXAZOSIN

6PMS-DOXYCYCLINE38PMS-ENALAPRIL77PMS-ERYTHROMYCIN11PMS-FAMCICLOVIR26PMS-FENOFIBRATE MICRO46PMS-FENTANYL MTX22PMS-FERROUS SULFATE

116PMS-FINASTERIDE7PMS-FLUCONAZOLE

78PMS-FLUNISOLIDE78PMS-FLUOROMETHOLONE56PMS-FLUOXETINE60PMS-FLUPHENAZINE13PMS-FLUTAMIDE56PMS-FLUVOXAMINE38PMS-FOSINOPRIL

74PMS-FUROSEMIDE52PMS-GABAPENTIN26PMS-GEMFIBROZIL77PMS-GENTAMICIN98PMS-GLICAZIDE98PMS-GLYBURIDE60PMS-HALOPERIDOL60PMS-HALOPERIDOL LA74PMS-HYDROCHLOROTHIAZIDE47PMS-HYDROMORPHONE66PMS-HYDROXYZINE43PMS-IBUPROFEN75PMS-INDAPAMIDE85PMS-IPECAC17PMS-IPRATROPIUM17PMS-IPRATROPIUM UDV29PMS-ISMN8PMS-ISONIAZID

29PMS-ISOSORBIDE44PMS-KETOPROFEN1PMS-KETOTIFEN

84PMS-LACTULOSE53PMS-LAMOTRIGINE

116PMS-LEFLUNOMIDE14PMS-LETROZOLE53PMS-LEVETIRACETAM80PMS-LEVOBUNOLOL5PMS-LEVOFLOXACIN

107PMS-LIDOCAINE VISCOUS103PMS-LINDANE39PMS-LISINOPRIL66PMS-LITHIUM CARBONATE66PMS-LITHIUM CITRATE83PMS-LOPERAMIDE27PMS-LOVASTATIN60PMS-LOXAPINE44PMS-MELOXICAM97PMS-METFORMIN61PMS-METHOTRIMEPRAZINE64PMS-METHYLPHENIDATE90PMS-METOCLOPRAMIDE33PMS-METOPROLOL-B33PMS-METOPROLOL-L6PMS-MINOCYCLINE

57PMS-MIRTAZAPINE88PMS-MISOPROSTOL57PMS-MOCLOBEMIDE

107PMS-MOMETASONE6PMS-MONOCYCLINE

48PMS-MORPHINE SR48PMS-MORPHINE SULFATE44PMS-NAPROXEN EC35PMS-NIFEDIPINE87PMS-NIZATIDINE5PMS-NORFLOXACIN

57PMS-NORTRIPTYLINE7PMS-NYSTATIN

77PMS-OFLOXACIN61PMS-OLANZAPINE61PMS-OLANZAPINE ODT89PMS-OMEPRAZOLE86PMS-ONDANSETRON

110PMS-OXTRIPHYLLINE110PMS-OXYBUTYNIN

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Page Page49PMS-OXYCODONE46PMS-OXYCODONE

ACETAMINOPHEN117PMS-PAMIDRONATE89PMS-PANTOPRAZOLE58PMS-PAROXETINE61PMS-PERPHENAZINE50PMS-PHENOBARBITAL85PMS-PHOSPHATES SOLUTION33PMS-PINDOLOL99PMS-PIOGLITAZONE45PMS-PIROXICAM77PMS-POLYTRIMETHOPRIM73PMS-POTASSIUM68PMS-PRAMIPREXOLE27PMS-PRAVASTATIN94PMS-PREDNISOLONE62PMS-PROCHLORPERAZINE67PMS-PROCYCLIDINE25PMS-PROPAFENONE34PMS-PROPRANOLOL8PMS-PYRAZINAMIDE

62PMS-QUETIAPINE90PMS-RABEPRAZOLE40PMS-RAMIPRIL88PMS-RANITIDINE81PMS-RHINARIS62PMS-RISPERIDONE17PMS-RIVASTIGMINE68PMS-ROPINIROLE18PMS-SALBUTAMOL69PMS-SELEGILINE84PMS-SENNOSIDES58PMS-SERTRALINE28PMS-SIMVASTATIN76PMS-SOD CROMOGLYCATE74PMS-SOD POLYSTYRENE SULF74PMS-SOD POLYSTYRENE

SULFONA83PMS-SODIUM DOCUSATE34PMS-SOTALOL6PMS-SULFASALAZINE

67PMS-SUMATRIPTAN15PMS-TAMOXIFEN66PMS-TEMAZEPAM30PMS-TERAZOSIN7PMS-TERBINAFINE

94PMS-TESTOSTERONE110PMS-THEOPHYLLINE45PMS-TIAPROFENIC80PMS-TIMOLOL77PMS-TOBRAMYCIN53PMS-TOPIRAMATE59PMS-TRAZODONE64PMS-TRIFLUOPERAZINE67PMS-TRIHEXYPHENIDYL85PMS-URSODIOL11PMS-VALACYCLOVIR54PMS-VALPROIC ACID59PMS-VENLAFAXINE XR37PMS-VERAPAMIL SR

120POCKET CHAMBER120POCKET CHAMBER WITH ADULT

MASK

120POCKET CHAMBER WITH INFANT MASK

120POCKET CHAMBER WITH MEDIUM MASK

120POCKET CHAMBER WITH SMALL MASK

108PODOFILM108PODOFILOX108PODOPHYLLIN101POLISTES SPP VENOM PROTEIN

EXTRACT101POLLEN101POLLEN AND NON POLLEN101POLLINEX R84POLYETHYLENE GLYCOL84POLYETHYLENE GLYCOL84POLYETHYLENE GLYCOL 335084POLYETHYLENE GLYCOL 335084POLYETHYLENE GLYCOL,

POTASSIUM CHLORIDE, SODIUM BICARBONATE, SODIUM CHLORIDE, SODIUM SULFATE

102POLYMYXIN B SULFATE, BACITRACIN

77POLYMYXIN B SULFATE, TRIMETHOPRIM SULFATE

77POLYSPORIN102POLYSPORIN ANTIBIOTIC77POLYSPORIN EYE/EAR

108POLYTAR102POLYTOPIC77POLYTRIM81POLYVINYL ALCOHOL81POLYVINYL ALCOHOL,

POVIDONE112POLY-VI-SOL95PORTIA 2195PORTIA 2873POTASSIUM CHLORIDE

104POVIDONE-IODINE68PRAMIPEXOLE

DIHYDROCHLORIDE27PRAVACHOL27PRAVASTATIN SODIUM27PRAVASTATIN-1027PRAVASTATIN-2027PRAVASTATIN-4042PRAXIS ASA EC30PRAZOSIN30PRAZOSIN HCL72PRECISION PLUS ELECTRODES72PRECISION XTRA78PRED FORTE78PRED MILD79PREDNISOLONE78PREDNISOLONE ACETATE78PREDNISOLONE ACETATE,

SULFACETAMIDE SODIUM79PREDNISOLONE SODIUM

PHOSPHATE94PREDNISONE94PREDNISONE79PREFRIN LIQUIFILM95PREMARIN

5PREM-CIPROFLOXACIN55PREM-CITALOPRAM

58PREM-PAROXETINE95PREMPLUS

113PRENATAL & POSTPARTUM113PRENATAL AND POSTPARTUM113PRENATAL VITAMINS AND

MINERALS72PRESTIGE SMART SYSTEM88PREVACID88PREVACID FASTAB

107PREVEX105PREVEX B106PREVEX HC

8PREZISTA12PRIMAQUINE12PRIMAQUINE PHOSPHATE50PRIMIDONE39PRINIVIL39PRINZIDE73PRIVA CAL D FORTE73PRO-600K25PRO-AMIODARONE4PRO-AMOX

42PRO-ASA 80MG EC TAB42PRO-ASA 80MG TAB3PRO-AZITHROMYCIN

75PROBENECID81PROBETA13PRO-BICALUTAMIDE32PRO-BISOPROLOL25PROCAINAMIDE HCL25PROCAN SR14PROCARBAZINE HCL2PRO-CEFADROXIL2PRO-CEFUROXIME

45PROCET-3062PROCHLORPERAZINE62PROCHLORPERAZINE5PRO-CIPROFLOXACIN

51PRO-CLONAZEPAM106PROCTODAN HC106PROCTOL106PROCTOSEDYL67PROCYCLIDINE HCL13PROCYTOX93PRO-DEXAMETHASONE26PRO-FENO-SUPER7PRO-FLUCONAZOLE

56PRO-FLUOXETINE52PRO-GABAPENTIN29PROGLYCEM

118PROGRAF12PRO-HYDROXYQUINE75PRO-INDAPAMIDE44PRO-INDO29PRO-ISMN84PRO-LACTULOSE68PRO-LEVOCARB39PRO-LISINOPRIL67PROLOPA65PRO-LORAZEPAM27PRO-LOVASTATIN97PRO-METFORMIN57PRO-MIRTAZAPINE44PRO-NAPROXEN EC

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Page Page46PRO-OXYCOD ACET

104PROPADERM25PROPAFENONE25PROPAFENONE

HYDROCHLORIDE99PRO-PIOGLITAZONE34PROPRANOLOL33PROPRANOLOL HCL

100PROPYL THYRACIL100PROPYLTHIOURACIL62PRO-QUETIAPINE90PRO-RABEPRAZOLE63PRO-RISPERIDONE

116PROSCAR34PRO-SOTALOL16PROSTIGMIN

109PROTOPIC53PRO-TOPIRAMATE74PRO-TRIAZIDE6PROTRIN6PROTRIN DF

11PRO-VALACYCLOVIR98PROVAL-GLICLAZIDE

100PROVERA100PROVERA PAK56PROZAC19PSEUDOEPHEDRINE HCL,

TRIPROLIDINE HCL84PSYLLIUM HYDROPHILIC

MUCILLOID93PULMICORT NEBUAMP93PULMICORT TURBUHALER

110PULMOPHYLLIN83PURG-ODAN14PURINETHOL2PYRANTEL PAMOATE8PYRAZINAMIDE

16PYRIDOSTIGMINE BROMIDE111PYRIDOXINE HCL12PYRIMETHAMINE62QUETIAPINE FUMARATE39QUINAPRIL HCL40QUINAPRIL HCL,

HYDROCHLOROTHIAZIDE93QVAR

103R & C90RABEPRAZOLE SODIUM96RALOXIFENE HCL9RALTEGRAVIR

40RAMIPRIL40RAMIPRIL40RAMIPRIL,

HYDROCHLOROTHIAZIDE40RAN RAMIPRIL35RAN-AMLODIPINE31RAN-ATENOLOL26RAN-ATORVASTATIN32RAN-CARVEDILOL2RAN-CEFPROZIL5RAN-CIPROFLOX5RAN-CIPROFLOXACIN

55RAN-CITALO55RAN-CITALOPRAM86RAN-DOMPERIDONE46RAN-FENTANYL

46RAN-FENTANYL MATRIX46RAN-FENTANYL MATRIX PATCH

1238RAN-FOSINOPRIL52RAN-GABAPENTIN88RANITIDINE87RANITIDINE HCL39RAN-LISINOPRIL27RAN-LOVASTATIN97RAN-METFORMIN86RAN-ONDANSETRON89RAN-PANTOPRAZOLE27RAN-PRAVASTATIN90RAN-RABEPRAZOLE63RAN-RISPERIDONE68RAN-ROPINIROLE28RAN-SIMVASTATIN

118RAN-TAMSULOSIN118RAPAMUNE

4RATIO-ACLAVULANATE11RATIO-ACYCLOVIR

114RATIO-ALENDRONATE104RATIO-AMCINONIDE25RATIO-AMIODARONE35RATIO-AMLODIPINE31RATIO-ATENOLOL26RATIO-ATORVASTATIN

3RATIO-AZITHROMYCIN20RATIO-BACLOFEN78RATIO-BECLOMETHASONE AQ79RATIO-BENZYDAMINE13RATIO-BICALUTAMIDE83RATIO-BISACODYL79RATIO-BRIMONIDINE54RATIO-BUPROPION54RATIO-BUPROPION SR32RATIO-CARVEDILOL

2RATIO-CEFUROXIME5RATIO-CIPROFLOXACIN

55RATIO-CITALOPRAM3RATIO-CLARITHROMYCIN

65RATIO-CLOBAZAM105RATIO-CLOBETASOL51RATIO-CLONAZEPAM46RATIO-CODEINE19RATIO-CYCLOBENZAPRINE93RATIO-DEXAMETHASONE35RATIO-DILTIAZEM CD83RATIO-DOCUSATE CALCIUM83RATIO-DOCUSATE SODIUM86RATIO-DOMPERIDONE

6RATIO-DOXYCYCLINE105RATIO-ECTOSONE45RATIO-EMTEC-3038RATIO-ENALAPRIL26RATIO-FENOFIBRATE46RATIO-FENTANYL

116RATIO-FINASTERIDE78RATIO-FLUNISOLIDE56RATIO-FLUOXETINE78RATIO-FLUTICASONE56RATIO-FLUVOXAMINE38RATIO-FOSINOPRIL52RATIO-GABAPENTIN

98RATIO-GLYBURIDE106RATIO-HEMCORT HC44RATIO-INDOMETHACIN17RATIO-IPRA SAL17RATIO-IPRATROPIUM UDV79RATIO-KETOROLAC84RATIO-LACTULOSE53RATIO-LAMOTRIGINE45RATIO-LENOLTEC NO.245RATIO-LENOLTEC NO.380RATIO-LEVOBUNOLOL39RATIO-LISINOPRIL P39RATIO-LISINOPRIL Z27RATIO-LOVASTATIN73RATIO-MAGNESIUM44RATIO-MELOXICAM97RATIO-METFORMIN14RATIO-METHOTREXATE6RATIO-MINOCYCLINE

57RATIO-MIRTAZAPINE107RATIO-MOMETASONE48RATIO-MORPHINE48RATIO-MORPHINE SULFATE SR57RATIO-NORTRIPTYLINE7RATIO-NYSTATIN

89RATIO-OMEPRAZOLE86RATIO-ONDANSETRON46RATIO-OXYCOCET46RATIO-OXYCODAN89RATIO-PANTOPRAZOLE58RATIO-PAROXETINE24RATIO-PENTOXIFYLLINE99RATIO-PIOGLITAZONE27RATIO-PRAVASTATIN78RATIO-PREDNISOLONE

106RATIO-PROCTOSONE62RATIO-QUETIAPINE40RATIO-RAMIPRIL88RATIO-RANITIDINE63RATIO-RISPERIDONE17RATIO-RIVASTIGMINE18RATIO-SALBUTAMOL18RATIO-SALBUTAMOL HFA58RATIO-SERTRALINE28RATIO-SIMVASTATIN34RATIO-SOTALOL67RATIO-SUMATRIPTAN

118RATIO-TAMSULOSIN66RATIO-TEMAZEPAM30RATIO-TERAZOSIN

104RATIO-TOPILENE GLYCOL53RATIO-TOPIRAMATE

104RATIO-TOPISALIC104RATIO-TOPISONE59RATIO-TRAZODONE54RATIO-VALPROIC54RATIO-VALPROIC ACID59RATIO-VENLAFAXINE SR59RATIO-VENLAFAXINE XR63RBX-RISPERIDONE1REACTINE

70REALITY FEMALE CONDOM112REDOXON81REFRESH LIQUIGEL

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Page Page81REFRESH PLUS81REFRESH TEARS

121REGULAR ENDCAPS FOR GLUCOLET

121REGULAR ENDCAPS FOR MICROLET

57REMERON57REMERON RD

116REMICADE16REMINYL ER35RENEDIL98REPAGLINIDE68REQUIP

121RESERVOIR 5XX 1.8ML SYRINGE121RESERVOIR 7XX 3.0ML SYRINGE74RESONIUM CALCIUM66RESTORIL

103RESULTZ107RETIN A10RETROVIR8REYATAZ

81RHINARIS78RHINOCORT AQ78RHINOCORT TURBUHALER30RHO-NITRO PUMPSPRAY31RHOTRAL23RHOXAL-ANAGRELIDE5RHOXAL-CIPROFLOXACIN

83RHOXAL-LOPERAMIDE97RHOXAL-METFORMIN57RHOXAL-MIRTAZAPINE

117RHOXAL-PAMIDRONATE58RHOXAL-PAROXETINE27RHOXAL-PRAVASTATIN58RHOXAL-SERTRALINE (ONT)28RHOXAL-SIMVASTATIN34RHOXAL-SOTALOL91RIDAURA8RIFABUTIN8RIFADIN8RIFAMPIN8RIMACTANE

117RISEDRONATE SODIUM62RISPERDAL62RISPERDAL-M62RISPERIDONE64RITALIN64RITALIN SR9RITONAVIR

15RITUXAN15RITUXIMAB

114RIVA-ALENDRONATE25RIVA-AMIODARONE34RIVA-AMLODIPINE31RIVA-ATENOLOL3RIVA-AZITHROMYCIN

20RIVA-BACLOFEN5RIVA-CIPROFLOXACIN

55RIVA-CITALOPRAM6RIVA-CLINDAMYCIN

51RIVA-CLONAZEPAM46RIVACOCET19RIVA-CYCLOBENZAPRINE

112RIVA-D112RIVA-D 400 UNIT CAP

38RIVA-ENALAPRIL26RIVA-FENOFIBRATE MICRO

7RIVA-FLUCONAZOLE56RIVA-FLUOXETINE56RIVA-FLUVOX38RIVA-FOSINOPRIL52RIVA-GABAPENTIN26RIVA-GEMFIBROZIL98RIVA-GLYBURIDE66RIVA-HYDROXYZIN75RIVA-INDAPAMIDE73RIVA-K73RIVA-K 2039RIVA-LISINOPRIL83RIVA-LOPERAMIDE27RIVA-LOVASTATIN97RIVA-METFORMIN33RIVA-METOPROLOL L

6RIVA-MINOCYCLINE57RIVA-MIRTAZAPINE44RIVA-NAPROXEN45RIVA-NAPROXEN SODIUM78RIVANASE AQ

5RIVA-NORFLOXACIN110RIVA-OXYBUTYNIN89RIVA-PANTOPRAZOLE58RIVA-PAROXETINE27RIVA-PRAVASTATIN62RIVA-QUETIAPINE90RIVA-RABEPRAZOLE88RIVA-RANITIDINE88RIVA-RANTIDINE63RIVA-RISPERIDONE23RIVAROXABAN42RIVASA84RIVA-SENNA58RIVA-SERTRALINE28RIVA-SIMVASTATIN

106RIVASOL HC106RIVASOL-HC105RIVASONE34RIVA-SOTALOL17RIVASTIGMINE

7RIVA-TERBINAFINE11RIVA-VALACYCLOVIR59RIVA-VENLAFAXINE XR37RIVA-VERAPAMIL37RIVA-VERAPAMIL SR74RIVA-ZIDE51RIVOTRIL66RIZATRIPTAN76ROBITUSSIN PEDIATRIC

112ROCALTROL8ROFACT

104ROLENE120RONDO INHALATION CHAMBER120RONDO INHALATION CHAMBER-

CHILD MASK120RONDO INHALATION CHAMBER-

INFANT MASK120RONDO INHALATION CHAMBER-

NEONATAL MASK120RONDO INHALATION CHAMBER-

UNIVERSAL MASK68ROPINIROLE HCL

104ROSASOL99ROSIGLITAZONE MALEATE

104ROSONE27ROSUVASTATIN CALCIUM25RYTHMODAN25RYTHMODAN LA25RYTHMOL54SABRIL6SALAZOPYRIN

18SALBUTAMOL108SALICYLIC ACID108SALICYLIC ACID, TRICLOSAN82SALINEX18SALMETEROL XINAFOATE19SALMETEROL XINAFOATE,

FLUTICASONE PROPIONATE90SALOFALK67SANDOMIGRAN67SANDOMIGRAN DS

117SANDOSTATIN117SANDOSTATIN LAR114SANDOZ ALENDRONATE114SANDOZ ALFUZOSIN106SANDOZ ANUZINC HC106SANDOZ ANUZINC HC PLUS79SANDOZ BRIMONIDINE2SANDOZ CEFPROZIL

43SANDOZ DICLOFENAC38SANDOZ ENALAPRIL81SANDOZ EYELUBE26SANDOZ FENOFIBRATE S46SANDOZ FENTANYL47SANDOZ FENTANYL

TRANSDERMAL SYSTEM116SANDOZ FINASTERIDE44SANDOZ INDOMETHACIN

116SANDOZ LEFLUNOMIDE14SANDOZ LETROZOLE5SANDOZ LEVOFLOXACIN

39SANDOZ LISINOPRIL39SANDOZ LISINOPRIL HCT66SANDOZ NARATRIPTAN61SANDOZ OLANZAPINE ODT89SANDOZ OMEPRAZOLE99SANDOZ PIOGLITAZONE78SANDOZ PREDNISOLONE

106SANDOZ PROCTOMYXIN HC40SANDOZ RAMIPRIL63SANDOZ RISPERIDONE17SANDOZ RIVASTIGMINE

118SANDOZ TAMSULOSIN59SANDOZ VENLAFAXINE XR31SANDOZ-ACEBUTOLOL25SANDOZ-AMIODARONE34SANDOZ-AMLODIPINE

106SANDOZ-ANUZINC HC106SANDOZ-ANUZINC HC PLUS31SANDOZ-ATENOLOL3SANDOZ-AZITHROMYCIN

80SANDOZ-BETAXOLOL13SANDOZ-BICALUTAMIDE32SANDOZ-BISOPROLOL54SANDOZ-BUPROPION SR99SANDOZ-CALCITONIN51SANDOZ-CARBAMAZEPINE

Page I-19 of 232010

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Page Page5SANDOZ-CIPROFLOXACIN

55SANDOZ-CITALOPRAM3SANDOZ-CLARITHROMYCIN

51SANDOZ-CLONAZEPAM78SANDOZ-CORTIMYXIN

115SANDOZ-CYCLOSPORINE78SANDOZ-DEXAMETHASONE42SANDOZ-DICLOFENAC43SANDOZ-DICLOFENAC SR35SANDOZ-DILTIAZEM CD36SANDOZ-DILTIAZEM T96SANDOZ-ESTRADIOL DERM11SANDOZ-FAMCICLOVIR35SANDOZ-FELODIPINE56SANDOZ-FLUOXETINE56SANDOZ-FLUVOXAMINE77SANDOZ-GENTAMICIN77SANDOZ-GENTAMICIN OTIC98SANDOZ-GLYBURIDE

102SANDOZ-IDOXURIDINE80SANDOZ-LEVOBUNOLOL39SANDOZ-LISINOPRIL83SANDOZ-LOPERAMIDE27SANDOZ-LOVASTATIN97SANDOZ-METFORMIN97SANDOZ-METFORMIN FC64SANDOZ-METHYLPHENIDATE SR32SANDOZ-METOPROLOL SR33SANDOZ-METOPROLOL-L6SANDOZ-MINOCYCLINE

57SANDOZ-MIRTAZAPINE65SANDOZ-NITRAZEPAM86SANDOZ-ONDANSETRON78SANDOZ-OPTICORT89SANDOZ-PANTOPRAZOLE58SANDOZ-PAROXETINE78SANDOZ-PENTASONE

OPHTH/OTIC33SANDOZ-PINDOLOL68SANDOZ-PRAMIPEXOLE78SANDOZ-PREDNISOLONE

106SANDOZ-PROCTOMYXIN HC62SANDOZ-QUETIAPINE90SANDOZ-RABEPRAZOLE88SANDOZ-RANITIDINE63SANDOZ-RISPERIDONE18SANDOZ-SALBUTAMOL84SANDOZ-SENNOSIDES58SANDOZ-SERTRALINE28SANDOZ-SIMVASTATIN82SANDOZ-SODIUM CHLORIDE34SANDOZ-SOTALOL67SANDOZ-SUMATRIPTAN7SANDOZ-TERBINAFINE

24SANDOZ-TICLOPIDINE80SANDOZ-TIMOLOL77SANDOZ-TOBRAMYCIN53SANDOZ-TOPIRAMATE78SANDOZ-TRIFLURIDINE54SANDOZ-VALPROIC19SANSERT

109SANTYL9SAQUINAVIR MESYLATE

106SARNA HC

4SCHEIN-AMOXICILLIN2SCHEIN-CEFACLOR

17SCOPOLAMINE BUTYLBROMIDE108SEBCUR108SEBCUR-T81SECARIS31SECTRAL83SELAX95SELECT 1/35 (21)95SELECT 1/35 (28)69SELEGILINE69SELEGILINE HCL

104SELENIUM SULFIDE5SELEXID

104SELSUN84SENNA LAXATIVE84SENNALAX84SENNAPREP84SENNATAB84SENNOSIDES84SENOKOT83SENOKOT S

115SERC18SEREVENT DISKHALER18SEREVENT DISKUS62SEROQUEL58SERTRALINE58SERTRALINE-10058SERTRALINE-2558SERTRALINE-50

122SHARPS CONTAINER72SIDEKICK38SIG-ENALAPRIL

104SILVER SULFADIAZINE116SIMPONI AUTO INJECTOR116SIMPONI PRE-FILLED SYRINGE28SIMVASTATIN28SIMVASTATIN-1028SIMVASTATIN-2028SIMVASTATIN-4068SINEMET68SINEMET CR56SINEQUAN76SINGULAIR23SINTROM

118SIROLIMUS73SLOW K91SODIUM AUROTHIOMALATE91SODIUM AUROTHIOMALATE73SODIUM BICARBONATE73SODIUM BICARBONATE81SODIUM CARBOXYMETHYL

CELLULOSE74SODIUM CHLORIDE74SODIUM CHLORIDE84SODIUM CITRATE, SODIUM

LAURYL SULFOACETATE, SORBITOL

76SODIUM CROMOGLYCATE72SODIUM NITROPRUSSIDE85SODIUM PHOSPHATE DIBASIC,

SODIUM PHOSPHATE MONOBASIC

74SODIUM POLYSTYRENE SULFONATE

83SOFLAX83SOFLAX EX83SOFLAX SYRUP78SOFRACORT EYE/EAR77SOFRAMYCIN77SOFRAMYCIN STERILE EYE

121SOFT TOUCH121SOFTCLIX121SOFTCLIX SELECT121SOFTTOUCH110SOLIFENACIN SUCCINATE103SOLUGEL108SOLUVER108SOLUVER PLUS116SOMATULINE AUTOGEL108SORIATANE34SOTALOL34SOTALOL HCL

120SPACE CHAMBER120SPACE CHAMBER ADULT LARGE

MASK120SPACE CHAMBER ADULT

REGULAR MASK120SPACE CHAMBER INFANT MASK120SPACE CHAMBER PEDIATRIC

MASK119SPACER DEVICE17SPIRIVA41SPIRONOLACTONE75SPIRONOLACTONE,

HYDROCHLOROTHIAZIDE7SPORANOX

68STALEVO104STANHEXIDINE98STARLIX48STATEX9STAVUDINE

118STELARA108STEREX116STERILE EXTEMPORANEOUS

MIXTURE (QC)94STERILE TRIAMCINOLONE

118STERILE WATER75STERILE WATER FOR INJ

107STIEVA-A107STIEVA-A FORTE102STIEVAMYCIN102STIEVAMYCIN FORTE102STIEVAMYCIN MILD88SUCRALFATE88SUCRALFATE-188SULCRATE88SULCRATE PLUS77SULFACETAMIDE SODIUM6SULFAMETHOXAZOLE6SULFAMETHOXAZOLE,

TRIMETHOPRIM6SULFASALAZINE

75SULFINPYRAZONE45SULINDAC45SULINDAC67SUMATRIPTAN HEMISULFATE67SUMATRIPTAN SUCCINATE15SUNITINIB MALATE

Page I-20 of 232010

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Page Page121SUPER ENDCAPS FOR

GLUCOLET121SUPER ENDCAPS FOR

MICROLET122SUPER-FINE MICRO 31G 5MM122SUPER-FINE STANDARD 29G

12.7MM122SUPER-FINE XTRA 31G 8MM49SUPEUDOL2SUPRAX

13SUPREFACT13SUPREFACT DEPOT 2 MONTHS13SUPREFACT DEPOT 3 MONTHS72SURESTEP8SUSTIVA

15SUTENT18SYMBICORT 100 TURBUHALER18SYMBICORT 200 TURBUHALER8SYMMETREL

105SYNALAR96SYNAREL95SYNPHASIC (21)95SYNPHASIC (28)

100SYNTHROID122SYRINGE123SYRINGE & NEEDLE120SYRINGE & NEEDLE (NON-

INSULIN)120SYRINGE (NON-INSULIN)123SYRINGE CASE121SYRINGE SCALE MAGNIFIER123SYRN INS U-II 3/10CC 30G123SYRN INSULIN MICRO 3/10CC

28G123SYRN INSULIN U-II 30G123SYRN INSULIN ULTRA 29G123SYRN INSULIN ULTRA 3/10CC 29G122SYRN MONOJECT118TACROLIMUS109TACROLIMUS (PROTOPIC)49TALWIN25TAMBOCOR15TAMOFEN15TAMOXIFEN15TAMOXIFEN CITRATE

118TAMSULOSIN HCL118TAMSULOSIN HYDROCHLORIDE18TANTA-ORCIPRENALINE50TANTAPHEN49TANTAPHEN GRAPE

100TAPAZOLE7TAR0-FLUCONAZOLE

13TARCEVA108TARGEL108TARGEL SA104TARO-AMCINONIDE51TARO-CARBAMAZEPINE51TARO-CARBAMAZEPINE CR5TARO-CIPROFLOXACIN

102TARO-CLINDAMYCIN38TARO-ENALAPRIL7TARO-FLUCONAZOLE

107TARO-MOMETASONE102TARO-MUPIROCIN 2% OINTMENT51TARO-PHENYTOIN

28TARO-SIMVASTATIN104TARO-SONE103TARO-TERCONAZOLE23TARO-WARFARIN

109TAZAROTENE109TAZORAC81TEARS NATURALE81TEARS NATURALE FREE81TEARS NATURALE II81TEARS NATURALE P.M.81TEARS PLUS

8TEBRAZID89TECTA51TEGRETOL51TEGRETOL CR41TELMISARTAN41TELMISARTAN,

HYDROCHLOROTHIAZIDE9TELZIR

66TEMAZEPAM66TEMAZEPAM15TEMODAL15TEMOZOLOMIDE49TEMPRA49TEMPRA CHILDREN50TEMPRA DOUBLE STRENGTH10TENOFOVIR DISOPROXIL

FUMARATE32TENORETIC31TENORMIN

103TERAZOL 3 DUAL PAK103TERAZOL 730TERAZOSIN HCL

7TERBINAFINE HCL19TERBUTALINE SULFATE

103TERCONAZOLE104TERSASEPTIC108TERSA-TAR108TERSA-TAR MILD94TESTOSTERONE CYPIONATE94TESTOSTERONE CYPIONATE94TESTOSTERONE ENANTHATE94TESTOSTERONE UNDECANOATE

118TETRABENAZINE6TETRACYCLINE6TETRACYCLINE HCL

41TEVETEN41TEVETEN PLUS

110THEOLAIR110THEOPHYLLINE110THEOPHYLLINE100THIAMAZOLE111THIAMINE111THIAMINE HCL15THIOGUANINE63THIOPROPERAZINE MESYLATE63THIOTHIXENE71THYROGEN

100THYROID100THYROID71THYROTROPIN ALFA

105TIAMOL45TIAPROFENIC45TIAPROFENIC ACID

36TIAZAC36TIAZAC XC24TICLOPIDINE HCL34TIMOLOL34TIMOLOL MALEATE81TIMOLOL MALEATE,

TRAVOPROST80TIMOLOL MALEATE-EX80TIMOPTIC80TIMOPTIC-XE

103TINACTIN103TINACTIN AEROSOL23TINZAPARIN SODIUM17TIOTROPIUM BROMIDE

MONOHYDRATE10TIPRANAVIR20TIZANIDINE HCL78TOBRADEX77TOBRAMYCIN77TOBREX98TOLBUTAMIDE98TOLBUTAMIDE

103TOLNAFTATE25TOLOXIN

110TOLTERODINE53TOPAMAX53TOPAMAX SPRINKLE

105TOPICORT53TOPIRAMATE

105TOPSYN113TR- VI-SOL32TRANDATE40TRANDOLAPRIL24TRANEXAMIC ACID

108TRANS PLANTAR30TRANSDERM-NITRO

108TRANS-VER-SAL58TRANYLCYPROMINE SULFATE33TRASICOR86TRAVAMINE81TRAVATAN81TRAVATAN Z86TRAVEL AID86TRAVEL TABLET81TRAVOPROST59TRAZODONE59TRAZODONE HCL59TRAZOREL15TRELSTAR15TRELSTAR LA24TRENTAL15TRETINOIN94TRIAMCINOLONE79TRIAMCINOLONE ACETONIDE94TRIAMCINOLONE ACETONIDE

(5ML)94TRIAMCINOLONE DIACETATE94TRIAMCINOLONE

HEXACETONIDE76TRIAMINIC COUGH &

CONGESTION76TRIAMINIC DM76TRIAMINIC DM NIGHT TIME74TRIAMTERENE,

HYDROCHLOROTHIAZIDE

Page I-21 of 232010

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Page Page45TRIATEC-3066TRIAZOLAM66TRIAZOLAM

104TRICLOSAN95TRI-CYCLEN (21)95TRI-CYCLEN (28)95TRI-CYCLEN LO

105TRIDESILON64TRIFLUOPERAZINE64TRIFLUOPERAZINE HCL78TRIFLURIDINE67TRIHEXYPHEN67TRIHEXYPHENIDYL HCL12TRIMETHOPRIM59TRIMIPRAMINE59TRIMIPRAMINE MALEATE30TRINIPATCH15TRIPTORELIN PAMOATE95TRIQUILAR (21)95TRIQUILAR (28)8TRIZIVIR

110TROSEC110TROSPIUM CHLORIDE72TRUETRACK80TRUSOPT9TRUVADA

121TUBING19TWINJECT50TYLENOL50TYLENOL EXTRA STRENGTH49TYLENOL GRAPE50TYLENOL JUNIOR STRENGTH45TYLENOL WITH CODEINE45TYLENOL WITH CODEINE NO.245TYLENOL WITH CODEINE NO.345TYLENOL WITH CODEINE NO.487ULCIDINE

122ULTI 29GX1/2 WITH SHARP CONTAINER



123ULTI SYG WITH ULTIGUARD 29G 1/2




123ULTICARE 28G SYG 1/2123ULTICARE 29G123ULTICARE 30G123ULTICARE 31G SYG 5/16123ULTICARE INSULIN SYR 29G.1CC123ULTICARE INSULIN SYR 29G.3CC123ULTICARE INSULIN SYR 29G.5CC123ULTICARE INSULIN SYR 30G.1CC123ULTICARE INSULIN SYR 30G.3CC123ULTICARE INSULIN SYR30G.5CC123ULTICARE LOW DEAD SPACE

SYG123ULTIGUARD INSULIN SYR

29G.1CC

123ULTIGUARD INSULIN SYR 29G.3CC





108ULTRA MOP122ULTRA-FINE121ULTRA-FINE II122ULTRA-FINE II 30G122ULTRAFINE PEN ULTRA-FINE 29G85ULTRASE MS 485ULTRASE MT 1285ULTRASE MT 20

106ULTRAVATE121UNILET COMFORT TOUCH110UNIPHYL10UNITRON PEG

106UREMOL HC110URISPAS85URSO85URSO DS85URSODIOL

118USTEKINUMAB96VAGIFEM11VALACYCLOVIR HCL11VALCYTE11VALGANCICLOVIR HCL

105VALISONE65VALIUM54VALPROATE, SODIUM54VALPROIC ACID41VALSARTAN41VALSARTAN,

HYDROCHLOROTHIAZIDE11VALTREX21VARENICLINE38VASERETIC38VASOTEC59VENLAFAXINE HCL

101VENOMIL HONEY BEE VENOM101VENOMIL MIXED VESPID VENOM

PROTEIN101VENOMIL WASP VENOM

PROTEIN101VENOMIL WHITE FACED

HORNET VENOM PROTEIN101VENOMIL YELLOW JACKET

VENOM PROTEIN120VENT 170 SPACER120VENT 170 SPACER AND MASK120VENT 170 SPACER DELUXE120VENTAHALER18VENTODISK18VENTODISK & DISKHALER

120VENTODISK DISKHALER120VENTODISK DISKHALER18VENTOLIN18VENTOLIN HFA18VENTOLIN PF18VENTOLIN ROTACAPS13VEPESID

37VERAPAMIL36VERAPAMIL HCL2VERMOX

104VERSEL82VERTEPORFIN15VESANOID

110VESICARE101VESPULA SPP VENOM PROTEIN

EXTRACT7VFEND8VIDEX EC

54VIGABATRIN15VINCRISTINE SULFATE15VINCRISTINE SULFATE85VIOKASE9VIRACEPT9VIRAMUNE

10VIREAD78VIROPTIC33VISKAZIDE33VISKEN82VISUDYNE

111VIT A111VIT B12111VIT C111VITAMIN A111VITAMIN A107VITAMIN A ACID113VITAMIN A, CHOLECALCIFEROL,

ASCORBIC ACID111VITAMIN B1111VITAMIN B12111VITAMIN B3111VITAMIN B6111VITAMIN C112VITAMIN D112VITAMIN D109VITAMIN E109VITAMIN E112VITAMIN E NATUAL SOURCE65VIVOL42VOLTAREN43VOLTAREN SR7VORICONAZOLE

73WAMPOLE MINERAL CALCIUM23WARFARIN SODIUM

101WASP VENOM PROTEIN101WASP VENOM PROTEIN75WATER

118WATER FOR INJECTION121WEBCOL ALCOHOL PREP54WELLBUTRIN SR54WELLBUTRIN XL

106WESTCORT101WHITE FACED HORNET VENOM101WHITE FACED HORNET VENOM

PROTEIN101WHITE FACED HORNET VENOM

PROTEIN, YELLOW HORNET VENOM PROTEIN, YELLOW JACKET VENOM PROTEIN

94WINPRED81XALATAN64XANAX64XANAX TS

Page I-22 of 232010

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Page Page23XARELTO

114XATRAL13XELODA

115XEOMIN84X-PREP

107XYLOCAINE VISCOUS94YASMIN (21)94YASMIN (28)94YAZ

101YELLOW HORNET VENOM PROTEIN

101YELLOW HORNET VENOM PROTEIN

101YELLOW JACKET HORNET VENOM PROTEIN

101YELLOW JACKET VENOM PROTEIN

101YELLOW JACKET VENOM PROTEIN

1ZADITEN76ZAFIRLUKAST20ZANAFLEX87ZANTAC65ZAPEX51ZARONTIN75ZAROXOLYN

103ZEASORB AF64ZELDOX9ZERIT

39ZESTORETIC39ZESTRIL8ZIAGEN

10ZIDOVUDINE107ZINC OXIDE107ZINC OXIDE CREAM 15%107ZINCOFAX EXTRA STRENGTH64ZIPRASIDONE HCL

MONOHYDRATE3ZITHROMAX

28ZOCOR109ZODERM86ZOFRAN86ZOFRAN ODT13ZOLADEX13ZOLADEX LA

118ZOLEDRONIC ACID67ZOLMITRIPTAN58ZOLOFT67ZOMIG67ZOMIG RAPIMELT

109ZOSTRIX109ZOSTRIX HP11ZOVIRAX54ZYBAN SR

115ZYLOPRIM114ZYM-ALENDRONATE34ZYM-AMLODIPINE42ZYM-ASA42ZYM-ASA EC32ZYM-BISOPROLOL32ZYM-CARVEDILOL55ZYM-CITALOPRAM51ZYM-CLONAZEPAM56ZYM-FLUOXETINE52ZYM-GABAPENTIN

33ZYM-METOPROLOL-L57ZYM-MIRTAZAPINE86ZYM-ONDANSETRON58ZYM-PAROXETINE99ZYM-PIOGLITAZONE27ZYM-PRAVASTATIN62ZYM-QUETIAPINE63ZYM-RISPERIDONE58ZYM-SERTRALINE28ZYM-SIMVASTATIN53ZYM-TOPIRAMATE61ZYPREXA61ZYPREXA ZYDIS

7ZYVOXAM

Page I-23 of 232010

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