BULLETIN # 77 · 2018. 7. 19. · Bulletin #77 Effective: April 16, 2014 DIN TRADE NAME GENERIC...

The following amendments will take effect on April 16, 2014

The amended Manitoba Specified Drug Regulation and Drug Interchangeability Formulary Regulation will beavailable on the Manitoba Health websitehttp://www.gov.mb.ca/health/mdbif on the effectivedate of April 16, 2014

Bulletin 77 is currently available for download:http://www.gov.mb.ca/health/mdbif/bulletin77.pdf

BULLETIN # 77Manitoba Drug Benefits and

Interchangeability Formulary Amendments

Inside This IssuePart 1 Additions Page 1-7Part 2 Additions Page 7-9Part 3 Additions Page 9-13New Interchangeable Categories Page 13-14New Interchangeable Products Page 14-29Product Deletions Page 29-30Category Deletions Page 30Interchangeable Product Price Changes Page 30-38Discontinued Products Page 38Manufacturer Updates Page 38

Bulletin #77Effective: April 16, 2014

DIN TRADE NAME GENERIC STRENGTH FORM MFR*

022862460228625402286262

Acebutolol acebutolol100 mg200 mg400 mg

Tablets SAH

022865560228656402286572

Acyclovir acyclovir200 mg400 mg800 mg

Tablets SAH

0234919102349205

Alprazolam alprazolam0.25 mg0.5 mg

Tablets SAH

02364336 Amiodarone amiodarone 200 mg Tablets SAH

0235274502352753

Amoxicillin amoxicillin125 mg/5 mL250 mg/5 mL

Oral Suspension SAH

0235276102352788

Amoxicillin (sugar reduced)

amoxicillin125 mg/5 mL250 mg/5 mL

Oral Suspension SAH

0235271002352729

Amoxicillin amoxicillin250 mg500 mg

Tablets SAH

0242008202420090

Apo-Telmisartan telmisartan40 mg80 mg

Tablets APX

0242002302420031

Apo-Telmisartan/HCTZ telmisartan/HCTZ80/12.5 mg

80/25 mgTablets APX

022471820223831602238318

Atenolol atenolol25 mg50 mg

100 mgTablets SIP

0238807302388081

Auro-Amoxicillin amoxicillin250 mg500 mg

Tablets AUP

02404990 Auro-Anastrozole anastrozole 1 mg Tablets AUP

0238562702385635

Auro-Fluoxetine fluoxetine10 mg20 mg

Tablets AUP

023212030232121102321238

Auro-Gabapentin gabapentin100 mg300 mg400 mg

Tablets AUP

024060980240610102406128

Auro-Irbesartan irbesartan75 mg

150 mg300 mg

Tablets AUP

023813540238136202381370

Auro-Lamotrigine lamotrigine25 mg

100 mg150 mg

Tablets AUP

02404400 Auro-Letrozole letrozole 2.5 mg Tablets AUP

023944720239448002394499

Auro-Lisinopril lisinopril5 mg

10 mg20 mg

Tablets AUP

Part 1 Additions

1 of 38


024033230240333102403358

Auro-Losartan losartan25 mg50 mg

100 mgTablets AUP

02318601 Auro-Nevirapine nevirapine 200 mg Tablets AUP

023832760238328402383292

Auro-Paroxetine paroxetine10 mg20 mg30 mg

Tablets AUP

02390205023902130239024802390256

Auro-Quetiapine quetiapine

25 mg100 mg200 mg300 mg

Tablets AUP

023909060239091402390922

Auro-Sertraline sertraline25 mg50 mg

100 mgTablets AUP

02320134 Auro-Terbinafine terbinafine 250 mg Tablets AUP

023458030234583802345846

Auro-Topiramate topiramate25 mg

100 mg200 mg

Tablets AUP

02405040 Auro-Valacyclovir valacyclovir 500 mg Tablets AUP

02343002 Azathioprine azathioprine 50 mg Tablets SAH

0228702102287048

Baclofen baclofen10 mg20 mg

Tablets SAH

0239158902391597

Bisoprolol bisoprolol5 mg

10 mgTablets SAH

0239156202391570

Bupropion SR bupropion100 mg150 mg

Tablets SAH

023889010238892802388936

Candesartan candesartan4 mg8 mg

16 mgTablets SAH

023886930238870702388715

Candesartan candesartan4 mg8 mg

16 mgTablets SIP

02394804 Candesartan/HCTZ candesartan/hctz 16/12.5 mg Tablets SAH

02394812 Candesartan HCT candesartan/hctz 16/12.5 mg Tablets SIP

02364913023649210236494802364956

Carvedilol carvedilol

3.125 mg6.25 mg12.5 mg

25 mg

Tablets SAH

02400553 Clopidogrel clopidogrel 75 mg Tablets SAH

02352397 Diclofenac EC diclofenac 50 mg Tablets SAH

02352400 Diclofenac SR diclofenac 75 mg Tablets SAH

2 of 38


02400421024004480240045602400464

Diltiazem CD diltiazem

120 mg180 mg240 mg300 mg

Tablets SAH

024004990240050202400510

Divalproex divalproex125 mg250 mg500 mg

Tablets SAH

02350440 Domperidone domperidone 10 mg Tablets SAH

02238341 Domperidone domperidone 10 mg Tablets SIP

02351234 Doxycycline doxycycline 100 mg Capsules SAH

02351242 Doxycycline doxycycline 100 mg Tablets SAH

02400650024006690240067702400685

Enalapril enalapril

2.5 mg5 mg

10 mg20 mg

Tablets SAH

00794244 Enteric Coated ASA acetylsalicylic acid 650 mg Tablets JPC

02353210 Etidrocal etidronate/calcium 400/500 mg Tablets SAH

0235110202351110

Famotidine famitodine20 mg40 mg

Tablets SAH

0235657002356589

Fenofibrate-S fenofibrate 100 mg160 mg

Tablets SAH

0228606802286076

Fluoxetine fluoxetine10 mg20 mg

Tablets SAH

023514200235143902351447

Furosemide furosemide20 mg40 mg80 mg

Tablets SAH

023532450235325302353261

Gabapentin gabapentin100 mg300 mg400 mg

Tablets SAH

022463140224631502246316

Gabapentin gabapentin100 mg300 mg400 mg

Tablets SIP

02287072 Gliclazide gliclazide 80 mg Tablets SAH

0235045902350467

Glyburide glyburide2.5 mg

5 mgTablets SAH

02308894 Granisetron granisetron 1 mg Tablets AAA

0236059402360608

Hydrochlorothiazide hydrochlorothiazide25 mg50 mg

Tablets SAH

02343096 Hydroxyurea hydroxyurea 500 mg Tablets SAH

023723470237237102372398

Irbesartan irbesartan75 mg

150 mg300 mg

Tablets SAH

3 of 38


023852870238529502385309

Irbesartan irbesartan75 mg

150 mg300 mg

Tablets SIP

023728860237289402372908

Irbesartan/HCTZ irbesartan/hctz150/12.5 mg300/12.5 mg

300/25 mgTablets SAH

023853170238532502385333

Irbesartan HCT irbesartan/hctz150/12.5 mg300/12.5 mg

300/25 mgTablets SIP

0239161902366088

Jamp-Dicyclomine HCl dicyclomine10 mg20 mg

Tablets JPC

8004027980040277

Jamp-Quinine quinine200 mg300 mg

Tablets JPC

023430100234302902343037

Lamotrigine lamotrigine25 mg

100 mg150 mg

Tablets SAH

023629450236295302362961

Lisinopril/HCTZ lisinopril10/12.5 mg20/12.5 mg

20/25 mgTablets SAH

023510720235108002351099

Lorazepam lorazepam0.5 mg

1 mg2 mg

Tablets SAH

023887900238880402388812

Losartan losartan25 mg50 mg

100 mgTablets SIP

023889600238897902388987

Losartan HCT losartan/hctz50/12.5 mg

100/12.5 mg100/25 mg

Tablets SIP

0235322902353237

Lovastatin lovastatin20 mg40 mg

Tablets SAH

024119460241195402411962

Mar-Paroxetine paroxetine10 mg20 mg30 mg

Tablets MAR

02407841 Med-Exemestane exemestane 25 mg Tablets GMP

0235337702353385

Metformin metformin500 mg850 mg

Tablets SAH

0238534102385368

Metformin metformin500 mg850 mg

Tablets SIP

0235039402350408

Metoprolol metoprolol50 mg

100 mgTablets SAH

02393573 Mint-Anastrozole anastrozole 1 mg Tablets MPH

024057330240574102405768

Mint-Losartan losartan25 mg50 mg

100 mgTablets MPH

4 of 38


024023780240239402402408

Mint-Sertraline sertraline25 mg50 mg

100 mgCapsules MPH

0239171602391724

Mint-Zopiclone zopiclone5 mg

7.5 mgTablets MPH

02370689 Mirtazapine mirtazapine 30 mg Tablets SAH

023508150235089002350912

Morphine SR morphine15 mg30 mg60 mg

Tablets SAH

023507500235076902350777

Naproxen naproxen250 mg375 mg500 mg

Tablets SAH

0237281902372827023728350237284302372851

Olanzapine olanzapine

2.5 mg5 mg

7.5 mg10 mg15 mg

Tablets SAH

02352974 0235298202352990

Olanzapine ODT olanzapine5 mg

10 mg15 mg

Tablets SAH

023436650234367302343681

Olanzapine ODT olanzapine5 mg

10 mg15 mg

Tablets SIP

02350238 Oxybutynin oxybutynin 5 mg Tablets SAH

02361361 Oxycodone/Acet oxycodone/acetaminophen 5/325 mg Tablets SAH

022828440228285202282860

Paroxetine paroxetine10 mg20 mg30 mg

Tablets SAH

02402181 pms-Colchicine colchicine 0.6 mg Tablets PMS

023565460235655402356562

Pravastatin pravastatin10 mg20 mg40 mg

Tablets SAH

0234305302343061

Propafenone propafenone150 mg300 mg

Tablets SAH

02353164023531720235319902353202

Quetiapine quetiapine

25 mg100 mg200 mg300 mg

Tablets SAH

0235301602353024

Ranitidine ranitidine150 mg300 mg

Tablets SAH

024140900241410402414112

Ran-Olanzapine ODT olanzapine5 mg

10 mg15 mg

Tablets RAN

5 of 38


023568800235689902356902023569100235692902356937

Risperidone risperidone

0.25 mg0.5 mg

1 mg2 mg3 mg4 mg

Tablets SAH

02353040023530590235306702353075

Ropinirole ropinirole

0.25 mg1 mg2 mg5 mg

Tablets SAH

023535200235353902353547

Sertraline sertraline25 mg50 mg

100 mgTablets SAH

023860700238608902386097

Sertraline sertraline25 mg50 mg

100 mgTablets SIP

02365650 Taro-Anastrozole anastrozole 1 mg Tablets TAR

0239034502390353

Telmisartan telmisartan40 mg80 mg

Tablets SIP

0239535502385363

Telmisartan/HCTZ telmisartan/HCTZ80/12.5 mg

80/25 mgTablets SAH

0239030202390310

Telmisartan/HCTZ telmisartan/HCTZ80/12.5 mg

80/25 mgTablets SIP

02350475023504830235049102350505

Terazosin terazosin

1 mg2 mg5 mg

10 mg

Tablets SAH

02353121 Terbinafine terbinafine 250 mg Tablets SAH

02385279 Terbinafine terbinafine 250 mg Tablets SIP

0236010102360128

Theo ER theophylline400 mg600 mg

Tablets AAA

023568560235686402356872

Topiramate topiramate25 mg

100 mg200 mg

Tablets SAH

023487720234878002348799

Trazodone trazodone50 mg

100 mg150 mg

Tablets SAH

02366940023669590236696702366975

Valsartan valsartan

40 mg80 mg

160 mg320 mg

Tablets SAH

6 of 38


0234715602322951023471640232297802347172

Vyvanse lisdexamfetamine

20 mg30 mg40 mg50 mg60 mg

Capsules SHI

02326035 Zinda-Anastrozole anastrozole 1 mg Tablets ZIN

02378213 Zinda-Letrozole letrozole 2.5 mg Tablets ZIN

02344122 Zopiclone zopiclone 5 mg Tablets SAH

0238582102385848

Zopiclone zopiclone5 mg

7.5 mgTablets SIP

*Abbreviation of Manufacturers' Names

02380951 Apo-Zolmitriptan zolmitriptan 2.5 mg Tablets APX

02415542 Apo-Azithromycin Z azithromycin 250 mg Tablets APX

0233088102330911

Azithromycin azithromycin250 mg600 mg

Tablets SAH

0227456602274574

GD-Azithromycin azithromycin100 mg/5 mL200 mg/5 mL

Oral Suspension GEM

0234724502347253

Auro-Cefprozil cefprozil250 mg500 mg

Tablets AUP

0234726102347288

Auro-Cefprozil cefprozil125 mg/5 mL250 mg/5 mL

Oral Suspension AUP

0234482302344831

Auro-Cefuroxime cefuroxime250 mg500 mg

Tablets AUP

penicillin or sulfonamides).

(eg. amoxicillin);(d) Treatment of patients known to be allergic or unresponsive to alternative antibiotics (eg.penicillin or sulfonamides).

For the treatment of patients with mycobacterial infections due to mycobacterium avium andmycobacterium intracellulare.

(a) Step-down care following hospital separation in patients treated with intravenous cephalosporins;(b) Treatment of patients with infections not responding to alternative antibiotics (eg.amoxicillin);

(eg. amoxicillin);(d) Treatment of patients known to be allergic or unresponsive to alternative antibiotics (eg.

Part 2 Additions

(c) Treatment of infections caused by organisms known to be resistant to alternative antibiotics

(b) Treatment of patients with infections not responding to alternative antibiotics (eg.amoxicillin);(c) Treatment of infections caused by organisms known to be resistant to alternative antibiotics

(a) Step-down care following hospital separation in patients treated with intravenous cephalosporins;

For the treatment of ACUTE migraine attacks in patients where standard therapy has failed.

7 of 38


023819070238192302381931

Auro-Ciprofloxacin ciprofloxacin250 mg500 mg750 mg

Tablets AUP

023533180235332602353334

Ciprofloxacin ciprofloxacin250 mg500 mg750 mg

Tablets SAH

0238611902386127

Ciprofloxacin ciprofloxacin250 mg500 mg

Tablets SIP

(a) Step-down care following hospital separation in patients treated with parenteral antibiotics;(b) Treatment of Pseudomonal infections or resistant gram-negative infections;(c) Treatment of resistant Gonococcal infections;(d) Treatment of infections in persons allergic to alternative agents (eg. penicillins, cephalosporinsand sulfonamides);( e ) Treatment of infections in immunocompromised patients;(f) Treatment of diabetic foot infections and complications of orthopedic surgery;(g) Treatment of chronic bacterial prostatitis.

02348853 Auro-Cyclobenzaprine cyclobenzaprine 10 mg Tablets AUP

02287064 Cyclobenzaprine cyclobenzaprine 10 mg Tablets SAH

As an adjunct to rest and physical therapy for relief of muscle spasm associated with acute, painfulmusculoskeletal conditions not responding to alternative therapy.

02405814 Auro-Finasteride finasteride 5 mg Tablets AUPFor the treatment of symptomatic benign prostatic hyperplasia.

02401274 Auro-Montelukast montelukast 10 mg Tablets AUP

024086270240863502408643

Mint-Montelukast montelukast4 mg5 mg

10 mgTablets MPH

0238245802382466

Montelukast montelukast4 mg5 mg

Tablets SIP

0240898802408996

Clarithromycin clarithromycin125 mg/5 mL250 mg/5 mL

Oral Suspension SAH

(a) Not responding to or intolerant of alternative antibiotics (eg. amoxicillin and erythromycin);(b) With mycobacterial infections due to mycobacterium avium and mycobacterium intracellulare;(c) In combination therapy in the treatment of H. Pylori;(d) Pneumonia;(e) Infections requiring a macrolide (including CAP in patients 65 and older) with documented intoleranceto erythromycin.

(a) Indicated as adjunctive therapy for asthma in cases where: (i) maximum doses inhaled corticosteroids have not effectively controlled symptoms, or (ii) evidence of serious adverse effects associated with corticosteroids exists, eg. adrenal suppression, increased lung infections;(b) Indicated as first line therapy for exercise induced asthma.

8 of 38


0228722602287234

Minocycline minocycline50 mg

100 mgCapsules SAH

(a) For treatment of acne unresponsive to tetracycline or erythromycin;(b) For rheumatoid arthritis patients who have failed two other second line agents.

0228652102286548

Sumatriptan sumatriptan50 mg

100 mgTablets SAH

02343045 Ticlopidine ticlopidine 250 mg Tablets SAH

(a) For the secondary prevention of vascular ischemic events ie. myocardial infarction, or stroke(i) who are known to be or become intolerant to ASA, or(ii) who continue to have TIA or stroke symptoms or myocardial infarction while being treated with ASAor clopidogrel.NOTE: ASA should be first line for the secondary prevention of vascular ischemic events such as myocardial infarction or stroke. Before abandoning ASA, efforts should be made to improve tolerability of ASA by reducing the dose, taking it with food and using enteric coated ASA.(b) Post coronary stent implantation x 28 days in combination with ASA.

The following products will be considered for Pharmacare reimbursement upon an individual prescriber/patient request basis.

0236226002362279

Apo-Donepezil donepezil5 mg

10 mgTablets APX

0240056102400588

Auro-Donepezil donepezil5 mg

10 mgTablets AUP

0239759502397609

CO Donepezil donepezil5 mg

10 mgTablets ACV

0240441902404427

Jamp-Donepezil donepezil5 mg

10 mgTablets JPC

0240209202402106

Mar-Donepezil donepezil5 mg

10 mgTablets MAR

0232233102322358

pms-Donepezil donepezil5 mg

10 mgTablets PMS

0238150802381516

Ran-Donepezil donepezil5 mg

10 mgTablets RAN

0232866602328682

Sandoz Donepezil donepezil5 mg

10 mgTablets SDZ

0234060702340615

Teva-Donepezil donepezil5 mg

10 mgTablets TEV

Confirmed diagnosis of Alzheimer's Disease based on DSMIV criteria with:(a) Memory impairment (impaired ability to learn new information or to recall previouslylearned information); plus

For the treatment of ACUTE migraine attacks in patients where standard therapy has failed.

Part 3 Additions

9 of 38


(b) at least one of the following:▫ Aphasia; problems with language (receptive and expressive)▫ Apraxia; impaired ability to carry out motor activities despite intact motor function▫ Agnosia; failure of recognition - especially people▫ Disturbance in executive functioning

The above deficits must have:▫ Caused significant decline in functioning from previous levels; and ▫ A gradual onset and continued cognitive decline; and▫ The absence of other causative conditions; and▫ The deficits do not occur exclusively during the course of delirium; and▫ Normal test results for all of the following values: CBC, TSH, Electrolytes, Vitamin B12, and Glucose; and ▫ The initial MMSE score must be between 10 and 26 and measured within 30 days of the application.

02352966 Alendronate alendronate 70 mg Tablets SAH

02299712 Alendronate FC alendronate 70 mg Tablets SIP

0238854502388553

Auro-Alendronate alendronate10 mg70 mg

Tablets AUP

As per Fosamax criteria (http://www.gov.mb.ca/health/mdbif/edsnotice.pdf).

023752490237525702375265

Auro-Levetiracetam levetiracetam250 mg500 mg750 mg

Tablets AUP

023533420235335002353369

Levetiracetam levetiracetam250 mg500 mg750 mg

Tablets SAH

As per Keppra criteria (http://www.gov.mb.ca/health/mdbif/edsnotice.pdf).

0239088402390892

Auro-Meloxicam meloxicam7.5 mg15 mg

Tablets AUP

0235314802353156

Meloxicam meloxicam7.5 mg15 mg

Tablets SAH

As per Mobicox criteria (http://www.gov.mb.ca/health/mdbif/edsnotice.pdf).

023849060238491402384922

Auro-Pioglitazone pioglitazone15 mg30 mg45 mg

Tablets AUP

As per Actos criteria (http://www.gov.mb.ca/health/mdbif/edsnotice.pdf).

01981501 Botox onabotulinumtoxina 100 U Injection ALL

For the treatment of urinary incontinence due to neurogenic detrusor overactivity resulting from neurogenic bladder associated with multiple sclerosis or subcervical spinal cord injury in adults who had an inadequate response to or are intolerant of anticholinergic medications.

10 of 38


02351684 Diclofenac K diclofenac potassium 50 mg Tablets SAH

Criteria may be obtained from the EDS office at Manitoba Health.

02349124 Effient prasugrel HCl 10 mg Tablets LIL

In combination with acetylsalicylic acid (ASA) for patients with:▫ ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronaryintervention (PCI) who have not received antiplatelet therapy prior to arrival in the cauterization lab.Treatment will be initiated in hospital.OR▫ Acute coronary syndrome (ACS) who have failed on optimal clopidal and ASA therapy definted by definite stent thrombosis, or recurrent STEMI, or non-ST-segment elevation myocardial infarction (NSTEMI) managed or unstable angina (UA) after prior revasuclarization via PCI.

02377233 Eliquis apixaban 2.5 mg Tablets BMS

For the prophylaxis of venous thromboembolism (VTE) following elective total hip replacement surgeryor elective total knee replacement surgery, where the intial post-operative doses are administered in an acute care (hospital) setting.

0238963002389649

Inlyta axitinib1 mg5 mg

Tablets PFI

As a second-line treatment for patients with metastatic clear cell renal carcinoma (MRCC).

02248676 Iressa gefitinib 250 mg Tablets AZC

As first-line treatment for epidermal growth factor receptor (EGFR) mutation positive advanced/metastaticnon-small cell lung cancer.

023880060238801402388022

Jakavi ruxolitinib5 mg

15 mg20 mg

Tablets NVT

For treatment of patients with intermediate to high risk Myleofibrosis (MF).

02412268 Lactulose lactulose 667 mg/mL Syrup SAH

As per lactulose criteria (http://www.gov.mb.ca/health/mdbif/edsnotice.pdf).

0235768202357690

Lansoprazole lansoprazole15 mg30 mg

Tablets SAH

As per lansoprazole criteria (http://www.gov.mb.ca/health/mdbif/edsnotice.pdf).

0235166802351676

Leflunomide leflunomide10 mg20 mg

Tablets SAH

As per Arava criteria (http://www.gov.mb.ca/health/mdbif/edsnotice.pdf).

11 of 38


02401614024016220240163002401649

Med-Rivastigmine rivastigmine

1.5 mg3 mg

4.5 mg6 mg

Tablets GMP

02406985024069930240700002407019

Mint-Rivastigmine rivastigmine

1.5 mg3 mg

4.5 mg6 mg

Capsules MPH

As per Exelon criteria (http://www.gov.mb.ca/health/mdbif/edsnotice.pdf).

023507850235079302350807

Naproxen EC naproxen250 mg375 mg500 mg

Tablets SAH

Criteria may be obtained from the EDS office at Manitoba Health.

0238188502381893

Oralair allergen extract100 IR300 IR

Tablets PAL

For the seasonal treatment of grass pollen allergic rhinitis in patients that have not adequately responded to, or tolerated, conventional pharmacotherapy.

0233021002330237

pms-Betahistine betahistine16 mg24 mg

Tablets PMS

As per Serc criteria (http://www.gov.mb.ca/health/mdbif/edsnotice.pdf).

02358921 pms-Raloxifene raloxifene 60 mg Tablets PMS

As per Evista criteria (http://www.gov.mb.ca/health/mdbif/edsnotice.pdf).

02370255 Risedronate risedronate sodium 35 mg Tablets SAH

02411407 Risedronate-35 risedronate sodium 35 mg Tablets SIP

As per Actonel criteria (http://www.gov.mb.ca/health/mdbif/edsnotice.pdf).

022807950228080902280817

Sutent sutinib12.5 mg

25 mg50 mg

Capsules PFI

For the treatment of patients with unresectable locally advanced or metastatic, well-differentiated pancreatic neuroendocrine tumors (pancreatic NET) whose disease is progressive.

0235230302352311

Votrient pazopanib200 mg400 mg

Tablets GSK

As a first-line treatment for patients with advanced or metastatic clear cell renal cell carcinoma.

02407329 Xtandi enzalutamide 40 mg Capsules ASP

For the treatment of histologically confirmed metastatic castrate-resistant prostate cancer with disease progression after prior chemotherapy with Docetaxel.

12 of 38


02371065 Zytiga abiraterone 250 mg Tablets JAN

For the treatment of histologically confirmed metastatic castrate-resistant prostate cancer with diseaseprogression after prior androgen deprivation therapy OR with disease progression after prior chemotherapy with Docetaxel.

The following new interchangeable categories and products were added:

Generic Name - Strength - Form

DIN Trade Name Manufacturer

Acetylsalicylic Acid - 650 mg - Tablets $00010340 Entrophen PPI00794244 Enteric Coated ASA JPC

Cefuroxime - 250 mg - Tablets $02212277 Ceftin GSK02242656 ratio-Cefuroxime TEV 1.013202244393 Apo-Cefuroxime APX02344823 Auro-Cefuroxime AUP

Cefuroxime - 500 mg - Tablets $02212285 Ceftin GSK02242657 ratio-Cefuroxime TEV02244394 Apo-Cefuroxime APX02344831 Auro-Cefuroxime AUP

Dicyclomine - 10 mg - Tablets $02103087 Bentylol AXC02391619 Jamp-Dicyclomine HCL JPC

Dicyclomine - 20 mg - Tablets $02103095 Bentylol AXC02366088 Jamp-Dicyclomine HCL JPC

Donepezil - 5 mg - Tablets $ 02232043 Aricept PFI02400561 Auro-Donepezil AUP02397595 CO Donepezil ACV02381508 Ran-Donepezil RAN02340607 Teva-Donepezil TEV02404419 Jamp-Donepezil JPC02362260 Apo-Donepezil APX02402092 Mar-Donepezil MAR02322331 pms-Donepezil PMS02328666 Sandoz Donepezil SDZ

0.2501

3.65552.00722.00711.4336

1.01310.7236

0.0550

5.3798

0.0755

1.8454

0.1325

1.2047

1.1806

1.2047

1.1806

1.20471.2047

1.2046

1.18061.1806

New Interchangeable Categories

Price in Dollars

0.1169

0.2207

13 of 38


Donepezil - 10 mg - Tablets $ 02232044 Aricept PFI02400588 Auro-Donepezil AUP02397609 CO Donepezil ACV02381516 Ran-Donepezil RAN02340615 Teva-Donepezil TEV02404427 Jamp-Donepezil JPC02362279 Apo-Donepezil APX02402106 Mar-Donepezil MAR02322358 pms-Donepezil PMS02328682 Sandoz Donepezil SDZ

Theophylline - 400 mg - Tablets $02014165 Uniphyl PUR02360101 Theo ER AAA

Theophylline - 600 mg - Tablets $02014181 Uniphyl PUR02360128 Theo ER AAA

The following products have been added to existing interchangeable drug categories:

Acebutolol - 100 mg - Tablets $02286246 Acebutolol SAH

Acebutolol - 200 mg - Tablets $02286254 Acebutolol SAH

Acebutolol - 400 mg - Tablets $ 02286262 Acebutolol SAH

Acyclovir - 200 mg - Tablets $ 02286556 Acyclovir SAH



Alendronate - 10 mg - Tablets $ 02388545 Auro-Alendronate SAH

Alendronate - 70 mg - Tablets $ 02299712 Alendronate FC SIP02388553 Auro-Alendronate AUP02352966 Alendronate SAH

1.20461.1806

1.20471.20471.20471.2047

0.4524

1.18061.18061.1806

5.3798

New Interchangeable Products

0.1793

0.4987

0.3735

0.6699

0.9660

0.5534

2.51442.5144

0.5333

**2.5143

1.9015

0.2684

3.1412

14 of 38


Alprazolam - 0.25 mg - Tablets $02349191 Alprazolam SAH

Alprazolam - 0.5 mg - Tablets $ 02349205 Alprazolam SAH

Amiodarone - 200 mg - Tablets $ 02364336 Amiodarone SAH

Amoxicillin - 125 mg/5 mL - Suspension $02352745 Amoxicillin SAH02352761 Amoxicillin (sugar reduced) SAH

Amoxicillin - 250 mg/5 mL - Suspension $02352753 Amoxicillin SAH02352788 Amoxicillin (sugar reduced) SAH

Amoxicillin - 250 mg - Capsules $02388073 Auro-Amoxicillin AUP02352710 Amoxicillin SAH

Amoxicillin - 500 mg - Capsules $02388081 Auro-Amoxicillin AUP02352729 Amoxicillin SAH

Anastrozole - 1 mg - Tablets $02404990 Auro-Anastrozole AUP02393573 Mint-Anastrozole MPH02365650 Taro-Anastrozole TAR02326035 Zinda-Anastrozole ZIN

Atenolol - 25 mg - Tablets $02247182 Atenolol SIP



Azathioprine - 50 mg - Tablets $02343002 Azathioprine SAH

Azithromycin - 250 mg - Tablets $02330881 Azithromycin SAH02415542 Apo-Azithromycin Z APX

Azithromycin - 600 mg - Tablets $02330911 Azithromycin SAH

0.03530.0353

0.0540

0.1750

8.3873

1.27291.27291.2729

**1.2313

0.0609

0.0728

1.4268

0.2362

0.1750

0.0540

0.3417

0.0676

0.1437

0.3417

0.5960

1.2729

2.5346

15 of 38


Azithromycin - 100 mg/5 mL - Oral Suspension $ per mL02274566 GD-Azithromycin GEM

Azithromycin - 200 mg/5 mL - Oral Suspension $ per mL02274574 GD-Azithromycin GEM

Baclofen - 10 mg - Tablets $02287021 Baclofen SAH

Baclofen - 20 mg - Tablets $02287048 Baclofen SAH

Betahistine - 16 mg - Tablets $02330210 pms-Betahistine PMS

Betahistine - 24 mg - Tablets $02330237 pms-Betahistine PMS

Bisoprolol - 5 mg - Tablets $02391589 Bisoprolol SAH

Bisoprolol - 10 mg - Tablets $02391597 Bisoprolol SAH

Bupropion - 100 mg - Tablets $02391562 Bupropion SR SAH

Bupropion - 150 mg - Tablets $02391570 Bupropion SR SAH

Candesartan - 4 mg - Tablets $02388901 Candesartan SAH02388693 Candesartan SIP



Candesartan/HCTZ - 16/12.5 mg - Tablets $02394804 Candesartan/HCTZ SAH02394812 Candesartan HCT SIP

Carvedilol - 3.125 mg - Tablets $02364913 Carvedilol SAH

0.3990

0.4728

0.1700

0.2850

0.2850

0.3990

0.2850

0.3933

1.0580

0.7467

0.1770

0.1700

0.2850

0.3203

0.6234

0.0994

0.1450

0.4106

0.5040

16 of 38




Carvedilol - 25 mg - Tablets $02364956 Carvedilol SAH

Cefprozil - 250 mg - Tablets $02347245 Auro-Cefprozil AUP

Cefprozil - 500 mg - Tablets $02347253 Auro-Cefprozil AUP

Cefprozil - 125 mg/5 mL - Oral Suspension $ per mL02347261 Auro-Cefprozil AUP

Cefprozil - 250 mg/5 mL - Oral Suspension $ per mL02347288 Auro-Cefprozil AUP

Ciprofloxacin - 250 mg - Tablets $02381907 Auro-Ciprofloxacin AUP02353318 Ciprofloxacin SAH02386119 Ciprofloxacin SIP

Ciprofloxacin - 500 mg - Tablets $02381923 Auro-Ciprofloxacin AUP02353326 Ciprofloxacin SAH02386127 Ciprofloxacin SIP

Ciprofloxacin - 750 mg - Tablets $02381931 Auro-Ciprofloxacin AUP02353334 Ciprofloxacin SAH

Clarithromycin - 125 mg/5 mL - Tablets $02408988 Clarithromycin SAH

Clarithromycin - 250 mg/5 mL - Tablets $02408996 Clarithromycin SAH

Clopidogrel - 75 mg - Tablets $02400553 Clopidogrel SAH

Cyclobenzaprine - 10 mg - Tablets $02348853 Auro-Cyclobenzaprine AUP02287064 Cyclobenzaprine SAH

Diclofenac - 50 mg - Enteric Coated Tablets $02352397 Diclofenac EC SAH

0.4728

0.4728

0.6576

0.3937

0.6979

0.3765

1.2780

0.6186

0.4728

0.6979

0.3765

0.2047

0.3998

0.6186

0.1006

1.1329

2.2214

0.6979

1.2780

0.6186

0.2213

17 of 38


Diclofenac Potassium - 50 mg - Tablets02351684 Diclofenac K SAH

Diclofenac - 75 mg - Slow Release Tablets $02352400 Diclofenac SR SAH

Diltiazem - 120 mg - Capsules $02400421 Diltiazem CD SAH




Divalproex - 125 mg - Tablets $02400499 Divalproex SAH



Domperidone - 10 mg - Tablets $02350440 Domperidone SAH02238341 Domperidone SIP

Doxycycline - 100 mg - Capsules $02351234 Doxycycline SAH

Doxycycline - 100 mg - Tablets $02351242 Doxycycline SAH

Enalapril - 2.5 mg - Tablets $02400650 Enalapril SAH

Enalapril - 5 mg - Tablets $02400669 Enalapril SAH



1.0872

0.8698

0.6557

0.6277

0.4940

0.4331

0.6318

0.7612

0.0594

**0.5860

**0.5860

0.5325

0.1377

0.2475

0.4952

0.0594

0.9205

18 of 38


Etidronate/Calcium - 400/500 mg - Tablets $ per kit02353210 Etidrocal SAH

Exemestane - 25 mg - Tablets $02407841 Med-Exemestane GMP

Famotidine - 20 mg - Tablets $02351102 Famotidine SAH

Famotidine - 40 mg - Tablets $02351110 Famotidine SAH

Fenofibrate - 100 mg - Tablets $02356570 Fenofibrate-S SAH

Fenofibrate - 160 mg - Tablets $02356589 Fenofibrate-S SAH

Finasteride - 5 mg - Tablets $02405814 Auro-Finasteride AUP

Fluoxetine - 10 mg - Capsules $02385627 Auro-Fluoxetine AUP02286068 Fluoxetine SAH

Fluoxetine - 20 mg - Capsules $02385635 Auro-Fluoxetine AUP02286076 Fluoxetine SAH

Furosemide - 20 mg - Tablets $02351420 Furosemide SAH



Gabapentin - 100 mg - Capsules $02321203 Auro-Gabapentin AUP02353245 Gabapentin SAH02246314 Gabapentin SIP


0.4595

0.4598

0.25300.2530

29.9900

0.6486

1.1673

0.7877

0.8470

0.4598

3.9008

0.0445

0.0746

0.1342

0.4633

0.4595

0.10400.10400.1040

0.2530

19 of 38



Gliclazide - 80 mg - Tablets $02287072 Gliclazide SAH

Glyburide - 2.5 mg - Tablets $02350459 Glyburide SAH

Glyburide - 5 mg - Tablets $02350467 Glyburide SAH

Hydrochlorothiazide - 25 mg - Tablets $02360594 Hydrochlorothiazide SAH

Hydrochlorothiazide - 50 mg - Tablets $02360608 Hydrochlorothiazide SAH

Hydroxyurea - 500 mg - Tablets $02343096 Hydroxyurea SAH

Irbesartan - 75 mg - Tablets $02406098 Auro-Irbesartan AUP02372347 Irbesartan SAH02385287 Irbesartan SIP



Irbesartan/HCTZ - 150/12.5 mg - Tablets $02372886 Irbesartan/HCTZ SAH02385317 Irbesartan HCT SIP

Irbesartan/HCTZ - 300/12.5 mg - Tablets $02372894 Irbesartan/HCTZ SAH02385325 Irbesartan HCT SIP

Irbesartan/HCTZ - 300/25 mg - Tablets $02372908 Irbesartan/HCTZ SAH02385333 Irbesartan HCT SIP

0.3015

0.3073

0.3073

0.3073

0.3015

0.0474

0.3015

0.0649

0.3073

0.3073

1.1223

0.3073

0.3073

0.3073

0.0751

0.3052

0.3073

0.3073

0.3073

0.3073

0.3073

0.2790

0.0432

0.3052

20 of 38


Lactulose - 667 mg/mL - Syrup $ per mL02412268 Lactulose SAH

Lamotrigine - 25 mg - Tablets $02381354 Auro-Lamotrigine AUP02343010 Lamotrigine SAH



Lansoprazole - 15 mg - Capsules $02357682 Lansoprazole SAH

Lansoprazole - 30 mg - Capsules $02357690 Lansoprazole SAH

Leflunomide - 10 mg - Tablets $02351668 Leflunomide SAH

Leflunomide - 20 mg - Tablets $02351676 Leflunomide SAH

Letrozole - 2.5 mg - Tablets $02404400 Auro-Letrozole AUP02378213 Zinda-Letrozole ZIN

Levetiracetam - 250 mg - Tablets $02375249 Auro-Levetiracetam AUP02353342 Levetiracetam SAH



Lisinopril - 5 mg - Tablets $02394472 Auro-Lisinopril AUP


6.0417

1.35001.3500

0.0145

0.7000

0.7000

0.9750

1.3780

0.80000.8000

6.0417

1.3783

0.2297

0.9189

1.3780

0.4849

0.5827

0.2297

0.9189

1.3783

0.9750

21 of 38



Lisinopril/HCTZ - 10/12.5 mg - Tablets $02362945 Lisinopril/HCTZ SAH

Lisinopril/HCTZ - 20/12.5 mg - Tablets $02362953 Lisinopril/HCTZ SAH

Lisinopril/HCTZ - 20/25 mg - Tablets $02362961 Lisinopril/HCTZ SAH

Lorazepam - 0.5 mg - Tablets $02351072 Lorazepam SAH

Lorazepam - 1 mg - Tablets $02351080 Lorazepam SAH

Lorazepam - 2 mg - Tablets $02351099 Lorazepam SAH

Losartan - 25 mg - Tablets $02403323 Auro-Losartan AUP02388790 Losartan SIP02405733 Mint-Losartan MPH



Losartan/HCTZ - 50/12.5 mg - Tablets $02388960 Losartan HCT SIP

Losartan/HCTZ - 100/12.5 mg - Tablets $02388979 Losartan HCT SIP

Losartan/HCTZ - 100/25 mg - Tablets $02388987 Losartan HCT SIP

Lovastatin - 20 mg - Tablets $02353229 Lovastatin SAH

Lovastatin - 40 mg - Tablets $02353237 Lovastatin SAH

0.5835

0.7011

0.7001

0.3148

0.3148

0.3148

0.3147

0.3148

0.3148

0.3148

**0.3147

0.3082

0.7011

0.0359

0.0447

0.0699

0.3147

1.1997

2.2129

**0.3147

**0.3147

22 of 38


Meloxicam - 7.5 mg - Tablets $02390884 Auro-Meloxicam AUP02353148 Meloxicam SAH

Meloxicam - 15 mg - Tablets $02390892 Auro-Meloxicam AUP02353156 Meloxicam SAH

Metformin - 500 mg - Tablets $02353377 Metformin SAH02385341 Metformin SIP

Metformin - 850 mg - Tablets $02353385 Metformin SAH02385368 Metformin SIP

Metoprolol - 50 mg - Tablets $02350394 Metoprolol SAH

Metoprolol - 100 mg - Tablets $02350408 Metoprolol SAH

Minocycline - 50 mg - Capsules $02287226 Minocycline SAH

Minocycline - 100 mg - Capsules $02287234 Minocycline SAH

Mirtazpine - 30 mg - Tablets $02370689 Mirtazapine SAH

Montelukast - 4 mg - Tablets $02408627 Mint-Montelukast MPH02382458 Montelukast SIP

Montelukast - 5 mg - Tablets $02408635 Mint-Montelukast MPH02382466 Montelukast SIP

Montelukast - 10 mg - Tablets $02401274 Auro-Montelukast AUP02408643 Mint-Montelukast MPH

Morphine - 15 mg - Tablets $02350815 Morphine SR SAH


0.8195

0.5350

1.0332

0.5044

0.5565

0.6237

0.5405

0.6237

0.5405

0.8195

0.0587

0.0847

0.0587

0.0847

0.0639

0.1394

0.8580

0.3751

0.5664

0.3646

0.5565

23 of 38



Naproxen - 250 mg - Enteric Coated Tablets $02350785 Naproxen EC SAH



Naproxen - 250 mg - Tablets $02350750 Naproxen SAH



Naproxen Sodium - 275 mg - Tablets $02351013 Naproxen Sodium SAH

Naproxen Sodium - 550 mg - Tablets $02351021 Naproxen Sodium DS SAH

Nevirapine - 200 mg - Tablets $02318601 Auro-Nevirapine AUP

Olanzapine - 2.5 mg - Tablets $02372819 Olanzapine SAH

Olanzapine - 5 mg - Tablets $02372827 Olanzapine SAH

Olanzapine - 7.5 mg - Tablets $02372835 Olanzapine SAH



Olanzapine - 5 mg - Orally Disintigrating Tablets $02352974 Olanzapine ODT SAH02343665 Olanzapine ODT SIP02414090 Ran-Olanzapine ODT RAN

0.3119

1.2347

1.3479

1.7972

0.3764

0.7334

2.6958

0.9984

0.1175

0.1604

0.6894

0.3675

0.2321

0.4493

0.8986

0.89370.89370.8937

24 of 38




Oxybutynin - 5 mg - Tablets $02350238 Oxybutynin SAH

Oxycodone/Acetaminophen - 5/325 mg - Tablets $02361361 Oxycodone/Acet SAH

Paroxetine - 10 mg - Tablets $02383276 Auro-Paroxetine AUP02282844 Paroxetine SAH02411946 Mar-Paroxetine MAR



Pioglitazone - 15 mg - Tablets $02384906 Auro-Pioglitazone AUP



Pravastatin - 10 mg - Tablets $02356546 Pravastatin SAH



2.6777

0.5755

0.5809

0.8139

1.2237

0.2734

0.4778

2.6777

0.1285

0.9387

0.6714

0.4050

0.6320

0.6714

0.6320

0.9387

**0.5612

**0.4513

**0.4796

1.7857

2.6777

1.78571.7857

25 of 38


Quetiapine - 25 mg - Tablets $02390205 Auro-Quetiapine AUP02353164 Quetiapine SAH




Quinine - 200 mg - Capsules $80040279 Jamp-Quinine JPC

Quinine - 300 mg - Capsules $80040277 Jamp-Quinine JPC

Raloxifene - 60 mg - Tablets $02358921 pms-Raloxifene PMS

Ranitidine - 150 mg - Tablets $02353016 Ranitidine SAH

Ranitidine - 300 mg - Tablets $02353024 Ranitidine SAH

Risedronate - 35 mg - Tablets $02370255 Risedronate SAH02411407 Risedronate-35 SIP

Risperidone - 0.25 mg - Tablets $02356880 Risperidone SAH

Risperidone - 0.5 mg - Tablets $02356899 Risperidone SAH

Risperidone - 1 mg - Tablets $02356902 Risperidone SAH



2.4288

**0.4583

0.5782

0.8673

0.1252

2.4287

0.2896

0.2097

0.9656

0.3295

0.1235

0.3295

0.6617

0.9656

0.1800

0.3600

0.6617

0.2390

0.3750

0.1235

26 of 38



Rivastigmine - 1.5 mg - Capsules $02401614 Med-Rivastigmine GMP02406985 Mint-Rivastigmine MPH

Rivastigmine - 3 mg - Capsules $02401622 Med-Rivastigmine GMP02406993 Mint-Rivastigmine MPH

Rivastigmine - 4.5 mg - Capsules $02401630 Med-Rivastigmine GMP02407000 Mint-Rivastigmine MPH

Rivastigmine - 6 mg - Capsules $02401649 Med-Rivastigmine GMP02407019 Mint-Rivastigmine MPH

Ropinirole - 0.25 mg - Tablets $02353040 Ropinirole SAH

Ropinirole - 1 mg - Tablets $02353059 Ropinirole SAH



Sertraline - 25 mg - Capsules $02390906 Auro-Sertraline AUP02402378 Mint-Sertraline MPH02353520 Sertraline SAH02386070 Sertraline SIP



Sumatriptan - 50 mg - Tablets $02286521 Sumatriptan SAH

0.4200

1.3029

0.2004

1.3029

0.4000

1.0831

1.3029

9.0650

0.2004

0.4200

0.3577

0.3934

0.4200

0.4000

1.3029

1.1565

1.30291.3029

0.0894

1.3029

1.3029

0.4200

0.2004

0.4000

0.2004

0.4000

27 of 38


Sumatriptan - 100 mg - Tablets $02286548 Sumatriptan SAH

Telmisartan - 40 mg - Tablets $02420082 Apo-Telmisartan APX02390345 Telmisartan SIP

Telmisartan - 80 mg - Tablets $02420090 Apo-Telmisartan APX02390353 Telmisartan SIP

Telmisartan/Hydrochlorothiazide - 80/12.5 mg - Tablets $02420023 Apo-Telmisartan/HCTZ APX02395355 Telmisartan/HCTZ SAH02390302 Telmisartan/HCTZ SIP

Telmisartan/Hydrochlorothiazide - 80/25 mg - Tablets $02420031 Apo-Telmisartan/HCTZ APX02385363 Telmisartan/HCTZ SAH02390310 Telmisartan/HCTZ SIP

Terazosin - 1 mg - Tablets $02350475 Terazosin SAH




Terbinafine - 250 mg - Tablets $02320134 Auro-Terbinafine AUP02353121 Terbinafine SAH02385279 Terbinafine SIP

Ticlopidine - 250 mg - Tablets $02343045 Ticlopidine SAH

Topiramate - 25 mg - Tablets $02345803 Auro-Topiramate AUP02356856 Topiramate SAH


9.9867

0.2823

0.2823

1.2215

0.2821

0.6444

0.7574

1.8545

0.4225

0.6183

0.2821

0.2821

0.2823

0.2447

0.2823

0.2823

0.2821

0.3111

0.2823

0.6444

1.2215

1.85451.8545

28 of 38



Trazodone - 50 mg - Tablets $02348772 Trazodone SAH



Valacyclovir - 500 mg - Tablets $02405040 Auro-Valacyclovir AUP

Valsartan - 40 mg - Tablets $02366940 Valsartan SAH




Zolmitriptan - 2.5 mg - Tablets $02380951 Apo-Zolmitriptan APX

Zopiclone - 5 mg - Tablets $02391716 Mint-Zopiclone MPH02344122 Zopiclone SAH02385821 Zopiclone SIP

Zopiclone - 7.5 mg - Tablets $02391724 Mint-Zopiclone MPH02385848 Zopiclone SIP

** The price has resulted in a change to the lowest price in the category.

The following products have been deleted.

00176095 Cafergot ergotamine/caffeine 1 mg/100 mg Tablets

00392820 Dicyclomine dicyclomine 10 mg Tablets

01912747 Docusate docusate calcium 240 mg Capsules

Product Deletions

0.2957

0.2843

1.8239

0.2435

0.4352

0.3125

0.2957

0.22310.2199

4.6667

0.2231

0.6393

0.3975

0.8481

1.8239

0.3125

29 of 38


00722855 Docusate Calcium docusate calcium 240 mg Capsules

02139200 Mylan-Amantadine amantadine 100 mg Capsules

02184648 Mylan-Valproic valproic acid 250 mg Capsules

02230201 Novo-Ketorolac ketorolac 10 mg Tablets

02273551 pms-Fenofibrate Micro fenofibrate 200 mg Tablets

02230183 pms-Gemfibrozil gemfibrozil 600 mg Tablets

02306069 pms-Rivastigmine rivastigmine 6 mg Capsules

02247461 ratio-Ketorolac ketorolac 0.5%Ophthalmic

Solution02257564 Sandoz Loperamide loperamide 2 mg Tablets02247057 Sandoz Lovastatin lovastatin 40 mg Tablets02239713 Sandoz Valproic valproic acid 500 mg Capsules

- Benzydamine - 0.15% - Oral Rinse

- Dexamethasone - 0.75 mg - Tablets

- Docusate Calcium - 240 mg - Capsules

- Hydromorphone - 2 mg/mL - Injection

- Prednisone - 1 mg - Tablets

- Valproic Acid - 500 mg - Enteric Coated Capsules

The following changes in prices have occurred: ($)

02232570 Airomir salbutamol 100 mcg Inhaler **0.0284

02239665 Alertec modafinil 100 mg Tablets 1.5078

02236876 Alphagan brimonidine 0.2%Ophthalmic

Solution3.7862

02221829 Altace ramipril 1.25 mg Capsules 0.7964

02221837 Altace ramipril 2.5 mg Capsules 0.9141

02221845 Altace ramipril 5 mg Capsules 0.9152



02236859 Agrylin anagerlide 0.5 mg Tablets 6.3544

02245272 Amaryl glimipiride 1 mg Tablets 1.0139



02411318Apo-Amlodipine-Atorvastatin

amlodipine/atorvastatin 10/10 mg Tablets **0.6125



Interchangeable Product Price Changes

Category Deletions

30 of 38














02365367 Apo-Candesartan candesartan 16 mg Tablets 0.2850



02367866Apo-Candesartan/HCTZ

candesartan/HCTZ 16/12.5 mg Tablets **0.2993

02252767 Apo-Clopidogrel clopidogrel 75 mg Tablets 0.6576

02352931 Apo-Enalapril/HCTZ enalapril/HCTZ 10/25 mg Tablets **0.5479

02352923 Apo-Enalapril/HCTZ enalapril/HCTZ 5/12.5 mg Tablets **0.4927

02365383 Apo-Finasteride finasteride 5 mg Tablets 0.4633

02364115 Apo-Hydromorphone hydromorphone 1 mg Tablets 0.0950

02364123 Apo-Hydromorphone hydromorphone 2 mg Tablets 0.1416

02355337 Apo-Imatinib imatinib 100 mg Tablets **6.8187

02355345 Apo-Imatinib imatinib 400 mg Tablets **27.2743

02386976 Apo-Irbesartan irbesartan 150 mg Tablets **0.3025



02387646 Apo-Irbesartan irbesartan/HCTZ 150/12.5 mg Tablets **0.3024

02387654 Apo-Irbesartan HCTZ irbesartan/HCTZ 300/12.5 mg Tablets **0.3024

02375540Apo-Lamivudine-Zidovudine

lamivudine/zidovudine 150/300 mg Tablets **4.1765

02293811 Apo-Lansoprazole lamnsoprazole 15 mg Capsules **0.5000

02293838 Apo-Lansoprazole lamnsoprazole 30 mg Capsules **0.5000

02358514 Apo-Letrozole letrozole 2.5 mg Tablets 1.3780

02371243 Apo-Losartan/HCTZ losartan/HCTZ 100/12.5 mg Tablets 0.3082

02371251 Apo-Losartan/HCTZ losartan/HCTZ 100/25 mg Tablets 0.3147

02371235 Apo-Losartan/HCTZ losartan/HCTZ 50/12.5 mg Tablets 0.3147

02352559 Apo-Mycophenolate mycophenolate 250 mg Capsules **0.5155

02352567 Apo-Mycophenolate mycophenolate 500 mg Tablets **1.0310

02360624 Apo-Olanzapine ODT olanzapine ODT 10 mg Tablets 1.7857



31 of 38


02355663 Apo-Repaglinide repaglinide 0.5 mg Tablets 0.0996

02355671 Apo-Repaglinide repaglinide 1 mg Tablets 0.1036

02355698 Apo-Repaglinide repaglinide 2 mg Tablets 0.1075

02353687 Apo-Risedronate risedronate 35 mg Tablets 2.4275

02393476 Apo-Rizatriptan rizatriptan 10 mg Tablets 4.8933

02393468 Apo-Rizatriptan rizatriptan 5 mg Tablets 4.8933

02362406 Apo-Tamsulosin CR tamsulosin 0.4 mg Tablets 0.1500

02371537 Apo-Valsartan valsartan 160 mg Tablets 0.2957


02371510 Apo-Valsartan valsartan 40 mg Tablets **0.2910


02382555 Apo-Valsartan/HCTZ valsartan/HCTZ 160/12.5 mg Tablets 0.2957

02382563 Apo-Valsartan/HCTZ valsartan/HCTZ 160/25 mg Tablets 0.2957

02382571 Apo-Valsartan/HCTZ valsartan/HCTZ 320/12.5 mg Tablets **0.2913

02382598 Apo-Valsartan/HCTZ valsartan/HCTZ 320/25 mg Tablets **0.2913

02382547 Apo-Valsartan/HCTZ valsartan/HCTZ 80/12.5 mg Tablets **0.2957

02239090 Atacand candesartan 4 mg Tablets 0.9757

00015229 Aventyl nortriptyline 10 mg Capsules 0.2707

00015237 Aventyl nortriptyline 25 mg Capsules 0.5443

00778338 Axid nizatidine 150 mg Capsules 1.0603

00637661 Betagan levobunolol 0.5%Ophthalmic

Solution3.6916

02244641 Biaxin clarithromycin 250 mg/5 mL Suspension 0.640500461733 Carbolith lithium carbonate 150 mg Capsules 0.135200236683 Carbolith lithium carbonate 300 mg Capsules 0.105102011239 Carbolith lithium carbonate 600 mg Capsules 0.201602097249 Cardizem CD diltiazem 120 mg Capsules 1.725202097257 Cardizem CD diltiazem 180 mg Capsules 2.289702097265 Cardizem CD diltiazem 240 mg Capsules 3.037702097273 Cardizem CD diltiazem 300 mg Capsules 3.797102163659 Cefzil cefprozil 250 mg Tablets 2.119202163667 Cefzil cefprozil 500 mg Tablets 4.154702163675 Cefzil cefprozil 125 mg/5 mL Oral Liquid 0.206802163683 Cefzil cefprozil 250 mg/5 mL Oral Liquid 0.413902256193 Cesamet nabilone 0.5 mg Capsules 3.620600548375 Cesamet nabilone 1 mg Capsules 7.2409

01945270 Ciloxan ciprofloxacin 0.3%Ophthalmic

Solution2.3452

02239607 Celexa citalopram 20 mg Tablets 1.508902239608 Celexa citalopram 40 mg Tablets 1.5089

02091879 Clomid clomiphene 50 mg Tablets 6.2643

02258102 CO Alendronate alendronate 40 mg Tablets **3.0832

02243763 Comtan entacapone 200 mg Tablets 1.8141

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02112736 Cortenema hydrocortisone 100 mg/60 mL Enema 7.8415

01918311 Coumadin warfarin 1 mg Tablets 0.3960


01918346 Coumadin warfarin 2.5 mg Tablets 0.3350





01981242 Desferal desferoxamine 500 mg Tablets 16.7046

02242465 Desmopressin desmopressin 10 mcg Spray **15.5800

02224550 Diabeta glyburide 2.5 mg Tablets 0.150402224569 Diabeta glyburide 5 mg Tablets 0.269202244000 Estradot estradiol-17b 50 mcg Patch 3.146002244001 Estradot estradiol-17b 75 mcg Patch 3.372902244002 Estradot estradiol-17b 100 mcg Patch 3.564002231384 Femara letrozole 2.5 mg Tablets 7.2270

00247855 FML fluorometholone 0.1%Ophthalmic

Solution3.5332

02099233 Glucophage metformin 500 mg Tablets 0.2716

02162849 Glucophage metformin 850 mg Tablets 0.3986

00230316 Hycort hydrocortisone 100 mg/60 mL Liquid **6.0013

00818658 Hytrin terazosin 1 mg Tablets 0.8663




01926799 Imovane zopiclone 7.5 mg Tablets 1.4707

02216167 Imovane zopiclone 5 mg Tablets 1.1648

00004596 Imuran azathioprine 50 mg Tablets 1.1150

01907123 Isoptin SR verapamil 120 mg Tablets 1.5909



02026961 Kayexalate sodium polystyrene 1 mEq/g Powder 0.2037

02061562 Lescol fluvastatin 20 mg Tablets 1.0015

02061570 Lescol fluvastatin 40 mg Tablets 1.4073

02338459 Letrozole letrozole 2.5 mg Tablets 1.3780

02269074 Lipidil EZ fenofibrate 48 mg Tablets 0.4716

02269082 Lipidil EZ fenofibrate 145 mg Tablets 1.2075

00455881 Lioresal baclofen 10 mg Tablets 0.8307

00636576 Lioresal DS baclofen 20 mg Tablets 1.6382

00397423 Lopressor metoprolol 50 mg Tablets 0.3501

00397431 Lopressor metoprolol 100 mg Tablets 0.7182

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00658855 Lopressor SR metoprolol 100 mg Tablets 0.3921

00534560 Lopressor SR metoprolol 200 mg Tablets 0.711600846503 Losec omeprazole 20 mg Capsules 1.221001919342 Luvox fluvoxamine 50 mg Tablets 0.9856

01919369 Luvox fluvoxamine 100 mg Tablets 1.7721

00899356 Manerix moclobemide 150 mg Tablets 0.7070

02166747 Manerix moclobemide 300 mg Tablets 1.3881

02285398 Modafinil modafinil 100 mg Tablets 1.0200

00803499 Modulon trimebutine 200 mg Tablets 0.7729

00511536 Mogadon nitrazepam 10 mg Tablets 0.2500

00511528 Mogadon nitrazepam 5 mg Tablets 0.1700

02009773 MOS Sulfate morphine 5 mg Tablets **0.1412




02015439 MS Contin morphine 15 mg Tablets 0.7656





02199270 Nitoman morphine 25 mg Tablets 7.5545

02231441 Nitrolingual nitroglycerin 0.4 mg/dose Pumpspray 0.0822

02143291 Ocuflox ofloxacin 0.3%Ophthalmic

Solution2.7445

02291967 Ondansetron ondansetron 4 mg/5 mL Oral Solution **1.610002316943 PAT-Galantamine ER galantamine 8 mg Capsules 1.2465

02316951 PAT-Galantamine ER galantamine 16 mg Capsules 1.2465

02316978 PAT-Galantamine ER galantamine 24 mg Capsules 1.2465

02230619 Pediapred prednisolone 5 mg/mL Oral Liquid 0.1429

01916475 Percocet oxycodone/acetaminophen 5 mg/325 mg Tablets 0.9306

02017709 Plaquenil hydroxychloroquine 200 mg Tablets 0.6933

02238682 Plavix clopidogrel 75 mg Tablets 2.9838

02284006 pms-Alendronate FC alendronate 70 mg Tablets 2.5143

02237601 pms-Atenolol atenolol 100 mg Tablets 0.2362



02261642 pms-Azithromycin azithromycin 600 mg Tablets 7.6250

02063735 pms-Baclofen baclofen 10 mg Tablets 0.2911

02275589 pms-Bicalutamide bicalutamide 50 mg Tablets 3.8870

00582883 pms-Bisacodyl bisacodyl 10 mg Suppositories **0.5014

02302640 pms-Bisoprolol bisoprolol 10 mg Tablets 0.1450

02302632 pms-Bisoprolol bisoprolol 5 mg Tablets 0.0994

02383020 pms-Bosentan bosentan 125 mg Tablets 22.4500

02383012 pms-Bosentan bosentan 62.5 mg Tablets 22.4500

34 of 38


02230942 pms-Buspirone buspirone 10 mg Tablets **0.6521

02245916 pms-Carvedilol carvedilol 12.5 mg Tablets 0.4728

02245917 pms-Carvedilol carvedilol 25 mg Tablets 0.4728



02248437 pms-Ciprofloxacin ciprofloxacin 250 mg Tablets 0.6186



02236466 pms-Domperidone domperidone 10 mg Tablets 0.0594

02300095 pms-Enalapril enalapril 10 mg Tablets 0.7612

02300079 pms-Enalapril enalapril 2.5 mg Tablets 0.5325



02310112 pms-Finasteride finasteride 5 mg Tablets 0.4633

02177579 pms-Fluoxetine fluoxetine 10 mg Capsules 0.4595

02177587 pms-Fluoxetine fluoxetine 20 mg Capsules 0.4598

02243446 pms-Gabapentin gabapentin 100 mg Capsules 0.1040



00885444 pms-Hydromorphone hydromorphone 1 mg Tablets 0.0959

01916386 pms-Hydromorphone hydromorphone 1 mg/mL Syrup **0.0776

00741817 pms-Hydroxyzine hydroxyzine 10 mg/5 mL Syrup 0.0509

02239619 pms-Indapamide indapamide 1.25 mg Tablets 0.0745

02239620 pms-Indapamide indapamide 2.5 mg Tablets 0.1218

02239627 pms-Ipratropium ipratropium bromide 0.03% Nasal Spray 0.8322

02317079 pms-Irbesartan irbesartan 150 mg Tablets 0.3073



02328518 pms-Irbesartan-HCTZ irbesartan/HCTZ 150/12.5 mg Tablets 0.3073

02328526 pms-Irbesartan-HCTZ irbesartan/HCTZ 300/12.5 mg Tablets 0.3073

02328534 pms-Irbesartan-HCTZ irbesartan/HCTZ 300/25 mg Tablets 0.3052

00703486 pms-Lactulose lactulose 667 mg/mL Syrup 0.0145

02309114 pms-Letrozole letrozole 2.5 mg Tablets 1.3780

02296101 pms-Levetiracetam levetiracetam 250 mg Tablets 0.8000



02292211 pms-Lisinopril lisinopril 10 mg Tablets 0.5827



02216159 pms-Lithium Carbonate lithium carbonate 600 mg Capsules 0.1708

02309777 pms-Losartan losartan 100 mg Tablets 0.3148


35 of 38



02223562 pms-Metformin metformin 500 mg Tablets 0.0587

02242589 pms-Metformin metformin 850 mg Tablets 0.0847

02230804 pms-Metoprolol-L metoprolol 100 mg Tablets 0.1394

02230803 pms-Metoprolol-L metoprolol 50 mg Tablets 0.0639

02303175 pms-Olanzapine olanzapine 10 mg Tablets 1.7972


02303116 pms-Olanzapine olanzapine 2.5 mg Tablets 0.4493


02303167 pms-Olanzapine olanzapine 7.5 mg Tablets 1.3479

02303205 pms-Olanzapine ODT olanzapine 10 mg Tablets 1.7857



02258188 pms-Ondansetron ondansetron 4 mg Tablets 3.3495

02258196 pms-Ondansetron ondansetron 8 mg Tablets 5.1110

02247750 pms-Paroxetine paroxetine 10 mg Tablets 0.9387



02303124 pms-Pioglitazone pioglitazone 15 mg Tablets 0.5809



02247655 pms-Pravastatin pravastatin 10 mg Tablets 0.4050



02245532 pms-Prednisolone prednisolone 5 mg/5 mL Liquid 0.1048

02296578 pms-Quetiapine quetiapine 100 mg Tablets 0.3295




02252007 pms-Risperidone risperidone 0.25 mg Tablets 0.1252

02252015 pms-Risperidone risperidone 0.5 mg Tablets 0.2097

02252023 pms-Risperidone risperidone 1 mg Tablets 0.2896




02291797 pms-Risperidone ODT risperidone 2 mg Tablets 1.5280

02326612 pms-Ropinirole ropinirole 1 mg Tablets 0.3577



02244840 pms-Sertraline sertraline 100 mg Tablets 0.4200



02238327 pms-Sotalol sotalol 160 mg Caplets 0.1623

36 of 38


00598461 pms-Sulfasalazine sulfazalazine 500 mg Tablets 0.2517

02243521 pms-Terazosin terazosin 10 mg Tablets 0.6183




02294273 pms-Terbinafine terbinafine 250 mg Tablets 1.8545

02402424 pms-Tetrabenazine tetrabenazine 25 mg Tablets 3.3746

02273497 pms-Ursodiol C ursodiol 250 mg Tablets 1.088502273500 pms-Ursodiol C ursodiol 500 mg Tablets 2.064502241820 pms-Vancomycin vancomycin 500 mg Injection 31.0500

02241821 pms-Vancomycin vancomycin 1000 mg Injection 58.9900

02324768 pms-Zolmitriptan ODT zolmitriptan 2.5 mg Tablets 4.6067

02243426 pms-Zopiclone zopiclone 5 mg Tablets 0.2199

02240606 pms-Zopiclone zopiclone 7.5 mg Tablets 0.3125

02011956 Polytrim trimethoprim/polymyxin B 1 mg/1000 UOphthalmic

Solution3.6190

02223252 Proctosedyldibucaine/esculin/framycetin

5/10/10/5 mg Ointment 1.0348

02223260 Proctosedyldibucaine/esculin/framycetin

5/10/10/5 mg Suppositories 1.2925

02018985 Prozac fluoxetine 10 mg Capsules 2.211800636622 Prozac fluoxetine 20 mg Capsules 2.211802242763 Rilutek riluzole 50 mg Tablets 11.0597

00005606 Ritalin methylphenidate 10 mg Tablets 0.4454

00005614 Ritalin methylphenidate 20 mg Tablets 0.7780

00632775 Ritalin SR methylphenidate 20 mg Tablets 0.7814

00393444 Rofact rifampin 150 mg Capsules **0.7046

00343617 Rofact rifampin 300 mg Capsules **1.1090

01926543 Sectral acebutolol 100 mg Tablets 0.3886



02100622 Sulcrate sulcralfate 1 g Tablets 0.6663

00010405 Tegretol carbamazepine 200 mg Tablets 0.4866



00773611 Tegretol CR carbamazepine 200 mg Tablets 0.4906

00755583 Tegretol CR carbamazepine 400 mg Tablets 0.9811

02194333 Tegretol carbamazepine 100 mg/5 mL Tablets 0.0946

02231150 Tiazac diltiazem 120 mg Capsules 0.9765





37 of 38


00513962 Tobradex tobramycin 0.3%Ophthalmic

Solution1.9976

02245664 Trimebutine trimebutine 200 mg Tablets 0.5800

00718149 Tryptan l-tryptophan 500 mg Capsules 0.8455

02029456 Tryptan l-tryptophan 500 mg Tablets 0.8455

00654531 Tryptan l-tryptophan 1 g Tablets 1,6990

02238984 Urso ursodiol 250 mg Tablets 1.5989

02245894 Urso DS ursodiol 500 mg Tablets 3.0329

00687456 Viroptic trifluridine 1%Ophthalmic

Solution3.5450

00417270 Visken pindolol 5 mg Tablets 0.718200443174 Visken pindolol 10 mg Tablets 1.226200417289 Visken pindolol 40 mg Tablets 1.778900632724 Voltaren diclofenac sodium 50 mg Suppositories 1.635700514012 Voltaren diclofenac sodium 50 mg Tablets 1.089300881635 Voltaren SR diclofenac sodium 50 mg Tablets 1.0444

02237825 Wellbutrin SR bupropion 150 mg Tablets 1.0746

00402796 Zyloprim allopurinol 300 mg Tablets 0.2300

** The price change has resulted in a change to the lowest price in the category.

The following products will be deleted with the next Formulary amendments.

02231379 Anzemet dolasetron 100 mg Tablets

02176017 Didrocaletidronate disodium/calcium carbonate

400/500 mg Tablets

02185881 Kytril granisetron 1 mg Tablets02224690 Lasix furosemide 20 mg Tablets02224704 Lasix furosemide 40 mg Tablets01907107 Monopril fosinopril 10 mg Tablets01907115 Monopril fosinopril 20 mg Tablets02162431 Naprosyn naproxen 25 mg/mL Suspension

02253933 pms-Ciprofloxacin ciprofloxacin 0.3%Ophthalmic

Solution

02237991 pms-Levobunolol levobunolol 0.5%Ophthalmic

Solution

The following product has had a name change:

0227438802274396

Azithromycin(was: pms-Azithromycin)

azithromycin100 mg/5 mL200 mg/5 mL

PMS

Manufacturer Updates

Discontinued Products

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Date post:	17-Aug-2020
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BULLETIN # 77 · 2018. 7. 19. · Bulletin #77 Effective: April 16, 2014 DIN TRADE NAME GENERIC...

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