DRUG BENEFIT LIST - divisionsbc.ca HEALTH BENEFITS First Nations and Inuit Health Branch DRUG...

NON-INSURED HEALTH BENEFITS First Nations and Inuit Health Branch

DRUG BENEFIT LIST

2014

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

Non-Insured Health Benefits

INTRODUCTION Drug Benefit List

Effective 2014

Introduction to NIHB Drug Benefit List Effective 2014

ii

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 ........................................................................ 23 24:00 Cardiovascular Drugs .......................................................................................... 27 28:00 Central Nervous System Agents .......................................................................... 50 32:00 Contraceptives (Non-Oral) ................................................................................... 83 36:00 Diagnostic Agents ................................................................................................ 84 40:00 Electrolytic, Caloric and Water Balance ............................................................... 85 48:00 Respiratory Tract Agents ..................................................................................... 88 52:00 Eye, Ear, Nose and Throat Preparations ............................................................. 89 56:00 Gastrointestinal Drugs ......................................................................................... 95 60:00 Gold Compounds ............................................................................................... 103 64:00 Heavy Metal Antagonists ................................................................................... 104 68:00 Hormones and Synthetic Substitutes ................................................................. 105 80:00 Serums, Toxoids and Vaccines.......................................................................... 114 84:00 Skin and Mucous Membrane Agents ................................................................. 115 86:00 Smooth Muscle Relaxants ................................................................................. 123 88:00 Vitamins ............................................................................................................. 125 92:00 Unclassified Therapeutic Agents........................................................................ 128 94:00 Devices .............................................................................................................. 134 96:00 Pharmaceutical Aids .......................................................................................... 138

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


iii

1. BACKGROUND ON NON-INSURED HEALTH BENEFITS (NIHB) PROGRAM The Non-Insured Health Benefits (NIHB) Program of Health Canada provides coverage for approximately 808,686 (decrease attributed to the transfer of clients to the First Nations Health Authority (FNHA) in British Columbia) 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 (DBL) The Drug Benefit List (DBL) is a listing of the drugs provided as benefits by the 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 health professionals authorized to prescribe drugs within the scope of practice in their province or territory. The DBL is a tool for prescribers 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 Drug Expert Committee (CDEC) 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 CDEC recommendations and other specific relevant factors, such as mandate, priorities and resources. Please refer to 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. Paper (binder) versions of drug submissions are no longer accepted by the NIHB Program. 3.2 Line Extensions, Generics and All Other Submissions Submissions for line extensions, generics and all other submissions are reviewed internally or by the NIHB Drugs and Therapeutics Advisory Committee (DTAC). Generic drug products are considered for inclusion on the formulary based on provincial interchangeability lists and other relevant factors.

http://www.cadth.ca/


iv

3.2.1 Drugs and Therapeutics Advisory Committee (DTAC) The DTAC provides formulary listing recommendations for drug products to the NIHB Program. The NIHB Program makes listing decisions based on DTAC recommendations and other specific relevant factors, such as mandate, priorities and resources. The DTAC is an advisory body of highly qualified health professionals who bring impartial and practical expert medical and pharmaceutical advice to the NIHB Program to promote improvement in the health outcomes of First Nations and Inuit clients through effective use of pharmaceuticals. The approach is evidence-based and the advice reflects medical and scientific knowledge, current utilization trends, current clinical practice, health care delivery and specific departmental client healthcare needs.

3.2.2 Submission Requirements All submissions for drug products that are line extensions, generics and all other types of submissions must be submitted to the NIHB Program. Only drug products with a Health Canada Notice of Compliance (NOC) 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 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 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 Policy Development - Pharmacy Non-Insured Health Benefits First Nations and Inuit Health Branch, Health Canada 200 Eglantine Driveway, 2nd Floor Postal Locator 1902A Tunney's Pasture Ottawa, Ontario K1A 0K9

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


v

electronically with a confirmatory email message. Paper (binder) versions of drug submissions are no longer accepted by the NIHB Program.

4. BENEFIT CRITERIA The following criteria are the framework for the NIHB Program DBL. The criteria provide the basis for decisions about drugs on the formulary relating to:

A. Drug Benefit 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 an NOC;

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 NIHB Program, with assistance from the CDEC and the NIHB DTAC, 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 clients;

• 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/territorial 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;


vi

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.


vii

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. An example of a category of drugs with a quantity and frequency limit is smoking cessation products. Recipients are eligible to receive up to three treatment courses of nicotine replacement therapy (NRT) within a 12-month period with quantity limits, which include 2 courses of NRT patches and 1 course of NRT products used PRN (i.e. gums, lozenges, inhalers).

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).


viii

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. Examples of categories of drugs or drug products* that are not considered for coverage under the NIHB Program under any circumstances are listed in Appendix E

Anti-obesity drugs; Household products (e.g. regular soaps and shampoos); Cosmetics; Alternative therapies, including glucosamine and evening primrose oil; Megavitamins; Drugs with investigational/experimental status; Vaccines Medications for travel Hair growth stimulants; Fertility agents and impotence drugs; Selected over-the-counter products; Codeine containing cough preparations.

*Note: List of excluded drugs or drug products is not exhaustive and may be modified as necessary 5. POLICIES

A. Best Price Alternative and Interchangeability The 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). 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 NIHB Program with: 1. a completed and signed Canada Vigilance Adverse Reaction Reporting Form: ‘Report of

suspected adverse reactions to health products in Canada’ and, 2. the prescription with “No Substitution” or “No Sub” handwritten. Upon receipt, the pharmacist will forward a copy of the prescription to NIHB for review. The prescriber is responsible for sending a copy of the form to the Canada Vigilance Program. Forms can be obtained by calling the Canada Vigilance Program 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 copy from the Compendium of Pharmaceuticals and Specialties. NOTE: The Canada Vigilance Adverse Reaction Reporting 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


ix

medication and the prescriber feels that further adjustment during the prescribed period is unlikely. Prescriptions for opioids have a maximum 30–day supply. 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 up to the regional maximum of the Program, 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 NSAIDs 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 on-line updates to the DBL. Medications on the Short term Dispensing list are identified in the DBL using the symbol ST beside the medication strength and dosage form. The following are exceptions to the STD policy: • Refills for intermittent treatment of a chronic disorder or refills of a medication which is prescribed to be taken on an “as needed” (PRN) basis. Note: Medications prescribed to be taken on an “as needed” (PRN) basis and dispensed chronically may be subject to audit and recovery. • Prescriptions for dose changes. • The following drug categories: opioids, methadone. • The following dosage forms: injectable and suppository. • Refills or new prescriptions when prescribed/dispensed in accordance with a court order. • Others as identified by the NIHB Program 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 the medications listed below in which short-term dispensing is deemed medically necessary, the Program will compensate up to one full dispensing fee every seven days, up to the regional maximum of the Program. If these medications are dispensed daily, the Program will compensate 1/7th of this fee: • Anticonvulsants; • Antidepressants; • Antipsychotics; • Benzodiazepines; • Stimulants; and • Nicotine Replacement Therapy. 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


x

dispensing fee per 28 day period. For the medications listed above the Program will pay no more than full dispensing fee per 7 day period. A refill is defined as the second and all subsequent fills for a given strength and dosage of a drug.

6. FORMULARY FOR CHRONIC RENAL FAILURE PATIENTS Clients with chronic renal failure are eligible to receive a list of supplemental benefits that are not included in the NIHB DBL but which are required on a long-term basis. Some supplemental benefits include: darbepoetin alfa products (except in provinces where NIHB clients 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 clients requiring drugs on the special formulary will be identified for coverage through the usual prior approval process. Once the client 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 Clients 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 prescriber. Once completed and submitted, the recipient will be eligible for all medications on the Palliative Care Formulary if the following criteria are met: The client: 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 client 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 will be granted upon receipt of another completed Palliative Care Application Form. 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 DTAC is an important component of the NIHB Drug Use Evaluation (DUE) Program which provides advice to the NIHB Program, to promote effective, efficient and optimal drug therapy to First Nations and Inuit recipients. 9. GENERAL INFORMATION Sources of information about the NIHB Program include:

The NIHB section of the Health Canada website which provides background information on the program and a copy of the DBL. This can be found at: www.healthcanada.gc.ca/nihb

NIHB DBL Updates are available to pharmacists and to prescribers via the Health Canada website. These updates can be found at: http://www.hc-sc.gc.ca/fniah-spnia/pubs/nihb-ssna/index-

http://www.healthcanada.gc.ca/nihb

http://www.hc-sc.gc.ca/fniah-spnia/pubs/nihb-ssna/index-eng.php%23drug-med


xi

eng.php#drug-med Information about the NIHB Program can also be obtained by contacting: Non-Insured Health Benefits First Nations and Inuit Health Branch

200 Eglantine Driveway, 2nd Floor Postal Locator 1902A Tunney's Pasture

Ottawa, Ontario K1A 0K9

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 NIHB DBL 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/pubs/nihb-ssna/index-eng.php%23drug-med


xii

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


xiii

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


10

DRUG BENEFIT LIST

Non-Insured Health BenefitsHealth Canada

04:00 ANTIHISTAMINE DRUGS

04:00.00 ANTIHISTAMINE DRUGS

CETIRIZINE HCL

1MG/ML SyrupST

02238337 REACTINE JNO10MG Tablet

ST

02315955 ALLERGY RELIEF ES PMS02231603 APO-CETIRIZINE APX02223554 REACTINE JNO

20MG TabletST

02315963 PMS-CETIRIZINE PMS01900978 REACTINE JNO

CHLORPHENIRAMINE MALEATE

12MG Sustained Release TabletST

00738964 CHLOR-TRIPOLON SCH4MG Tablet

ST

00738972 CHLOR-TRIPOLON SCH00021288 NOVOPHENIRAM TEV

DESLORATADINE

0.5MG/ML SyrupST

02247193 AERIUS KIDS SCH5MG Tablet

ST

02243919 AERIUS SCH02369656 ALLERNIX MULTI SYMPTOM TEP02338424 DESLORATADINE APX02298155 DESLORATADINE ALLERGY

CONTROLPMS

DIPHENHYDRAMINE HCL

25MG Capsule

00757683 PMS-DIPHENHYDRAMINE PMS50MG Capsule

02019671 BENADRYL WLA00757691 PMS-DIPHENHYDRAMINE PMS

2.5MG/ML Elixir

00804193 ALLERNIX RPH02019736 BENADRYL WLA00833266 DIPHENHYDRAMINE HCL TAN02298503 JAMP-DIPHENHYDRAMINE JAP00792705 PMS-DIPHENHYDRAMINE PMS

50MG/ML Injection

00596612 DIPHENHYDRAMINE SDZ00878200 PMS-DIPHENHYDRAMINE PMS

1.25MG/ML Liquid

02019698 BENADRYL CHILD WLA25MG Tablet

02176483 ALLER-AIDE RPH01949454 ALLERGY TAN02229492 ALLERGY FORMULA SDR02097583 ALLERNIX RPH02017849 BENADRYL WLA02257548 DIPHENHYDRAMINE JAP

04:00.00 ANTIHISTAMINE DRUGS

DIPHENHYDRAMINE HCL

50MG Tablet

02097575 ALLERNIX PLUS RPH02257556 DIPHENHYDRAMINE JAP02230398 DIPHENHYDRAMINE HCL TAN

FEXOFENADINE HCL

60MG TabletST

02231462 ALLEGRA AVT120MG Tablet

ST

02242819 ALLEGRA 24HR SAC

KETOTIFEN FUMARATE

0.2MG/ML SyrupST

02221330 APO-KETOTIFEN APX02176084 NOVO-KETOTIFEN TEV02231679 PMS-KETOTIFEN PMS

1MG TabletST

02230730 NOVO-KETOTIFEN TEV02231680 PMS-KETOTIFEN PMS00577308 ZADITEN NVR

LORATADINE

1MG/ML SyrupST

02019973 CLARITIN SCH02241523 CLARITIN KIDS SCH

10MG TabletST

02243880 APO-LORATADINE APX00782696 CLARITIN SCH02244692 LORATADINE VTH02280159 LORATADINE VTH *

Page 1 of 1382014


08:00 ANTI-INFECTIVE AGENTS

08:08.00 ANTHELMINTICS

MEBENDAZOLE

100MG Tablet

00556734 VERMOX JNO

PYRANTEL PAMOATE

50MG/ML Suspension

01944355 COMBANTRIN PFI125MG Tablet

01944363 COMBANTRIN PFI

08:12.06 CEPHALOSPORINS

CEFACLOR

250MG Capsule

02230263 APO-CEFACLOR APX00465186 CECLOR PHH02237729 SCHEIN-CEFACLOR SCN

500MG Capsule

02230264 APO-CEFACLOR APX00465194 CECLOR PHH02237730 SCHEIN-CEFACLOR SCN

25MG/ML Suspension

00465208 CECLOR PHH50MG/ML Suspension

00465216 CECLOR PHH75MG/ML Suspension

02237502 APO-CEFACLOR APX00832804 CECLOR BID PHH

CEFADROXIL

500MG Capsule

02240774 APO-CEFADROXIL APX02235134 NOVO-CEFADROXIL TEV02311062 PRO-CEFADROXIL PDL

CEFIXIME

20MG/ML Suspension

00868965 SUPRAX SAC400MG Tablet

00868981 SUPRAX SAC

CEFPROZIL

25MG/ML Suspension

02293943 APO-CEFPROZIL APX02347261 AURO-CEFPROZIL AUR02163675 CEFZIL BMS02329204 RAN-CEFPROZIL RBY02303426 SANDOZ CEFPROZIL SDZ

50MG/ML Suspension


08:12.06 CEPHALOSPORINS

CEFPROZIL

250MG Tablet


500MG Tablet


CEFUROXIME AXETIL

25MG/ML Suspension

02212307 CEFTIN GSK250MG Tablet

02244393 APO-CEFUROXIME APX02344823 AURO-CEFUROXIME APL02212277 CEFTIN GSK02242656 RATIO-CEFUROXIME RPH

500MG Tablet

02244394 APO-CEFUROXIME APX02344831 AURO-CEFUROXIME APL02212285 CEFTIN GSK02311453 PRO-CEFUROXIME PDL02242657 RATIO-CEFUROXIME RPH

CEPHALEXIN

250MG Capsule

00342084 NOVO-LEXIN TEV500MG Capsule

00342114 NOVO-LEXIN TEV25MG/ML Suspension

02177862 DOM-CEPHALEXIN DPC00342106 NOVO-LEXIN TEV

50MG/ML Suspension

02177870 DOM-CEPHALEXIN DPC00342092 NOVO-LEXIN TEV

250MG Tablet

00768723 APO-CEPHALEX APX02177846 DOM-CEPHALEXIN DPC00583413 NOVO-LEXIN TEV00828858 PDL-CEPHALEXIN PDL02177781 PMS-CEPHALEXIN PMS

500MG Tablet

00768715 APO-CEPHALEX APX02177854 DOM-CEPHALEXIN DPC00583421 NOVO-LEXIN TEV00828866 PDL-CEPHALEXIN PDL02177803 PMS-CEPHALEXIN PMS

Page 2 of 1382014


08:12.12 MACROLIDES

AZITHROMYCIN

20MG/ML Suspension

02315157 NOVO-AZITHROMYCIN TEV02274388 PMS-AZITHROMYCIN PMS02332388 SANDOZ-AZITHROMYCIN SDZ02223716 ZITHROMAX PFI

40MG/ML Suspension

02315165 NOVO-AZITHROMYCIN TEV02274396 PMS-AZITHROMYCIN PMS02332396 SANDOZ-AZITHROMYCIN SDZ02223724 ZITHROMAX PFI

250MG Tablet

02247423 APO-AZITHROMYCIN APX02330881 AZITHROMYCIN SAN02255340 CO-AZITHROMYCIN ACT02278499 DOM-AZITHROMYCIN DOM02278359 GEN-AZITHROMYCIN GEN02267845 NOVO-AZITHROMYCIN TEV02278588 PHL-AZITHROMYCIN PMI02261634 PMS-AZITHROMYCIN PMS02310600 PRO-AZITHROMYCINE PDL02275287 RATIO-AZITHROMYCIN RPH02265826 SANDOZ-AZITHROMYCIN SDZ02212021 ZITHROMAX PFI

600MG Tablet

02256088 CO-AZITHROMYCIN ACT02261642 PMS-AZITHROMYCIN PMS02231143 ZITHROMAX PFI

CLARITHROMYCIN

500MG Extended Release Tablet

02244756 BIAXIN XL ABB250MG Film Coated Tablet

02274744 APO-CLARITHROMYCIN APX01984853 BIAXIN ABB02248856 GEN-CLARITHROMYCIN GEN02247573 PMS-CLARITHROMYCIN PMS02324482 PRO-CLARITHROMYCIN PDL02361426 RAN-CLARITHROMYCIN RBY02247818 RATIO-CLARITHROMYCIN RPH02248804 TEVA-CLARITHROMYCIN TEV

500MG Film Coated Tablet

02274752 APO-CLARITHROMYCIN APX02126710 BIAXIN ABB02351005 DOM-CLARITHROMYCIN SEV02248857 GEN-CLARITHROMYCIN GEN02247574 PMS-CLARITHROMYCIN PMS02324490 PRO-CLARITHROMYCIN PDL02361434 RAN-CLARITHROMYCIN RBY02247819 RATIO-CLARITHROMYCIN RPH02346532 RIVA-CLARITHROMYCIN RIV02248805 TEVA-CLARITHROMYCIN TEP

25MG/ML Suspension

02390442 ACCEL-CLARITHROMYCIN ACP02146908 BIAXIN ABB02408988 CLARITHROMYCIN SAN

08:12.12 MACROLIDES

CLARITHROMYCIN

50MG/ML Suspension

02390450 ACCEL-CLARITHROMYCIN ACP02244641 BIAXIN ABB02408996 CLARITHROMYCIN SAN

ERYTHROMYCIN

250MG Enteric Coated Capsule

00726672 APO-ERYTHRO APX00607142 ERYC PFI

333MG Enteric Coated Capsule

01925938 APO-ERYTHRO APX333MG Enteric Coated Tablet

00873454 ERYC PFI00769991 P.C.E. ABB

250MG Tablet

00682020 APO-ERYTHRO BASE APX

ERYTHROMYCIN ESTOLATE

50MG/ML Suspension

00262595 NOVO-RYTHRO ESTOLATE TEV

ERYTHROMYCIN ETHYLSUCCINATE

600MG Tablet

00637416 APO-ERYTHRO-S APX00583782 EES-600 ABB00704377 ERYTHRO-ES PDL

ERYTHROMYCIN ETHYLSUCCINATE &

SULFISOXAZOLE ACETYL

40MG & 120MG/ML Suspension

00583405 PEDIAZOLE ABB

ERYTHROMYCIN STEARATE

250MG Tablet

00545678 APO-ERYTHRO-S APX00563854 ERYTHROMYCIN PDL

500MG Tablet

00688568 APO-ERYTHRO S APX00704393 ERYTHRO PDL

08:12.16 PENICILLINS

AMOXICILLIN

250MG Capsule

02352710 AMOXICILLIN SAN02401495 AMOXICILLIN SIV00628115 APO-AMOXI APX02388073 AURO-AMOXICILLIN AUR02238171 GEN-AMOXICILLIN GEN00406724 NOVAMOXIN TEV02230243 PMS-AMOXICILLIN PMS

Page 3 of 1382014



AMOXICILLIN

500MG Capsule

02352729 AMOXICILLIN SAN02401509 AMOXICILLIN SIV00628123 APO-AMOXI APX02388081 AURO-AMOXICILLIN AUR02238172 GEN-AMOXICILLIN GEN00406716 NOVAMOXIN TEV02230244 PMS-AMOXICILLIN PMS00644315 PRO-AMOX PDL

125MG Chewable Tablet

02036347 NOVAMOXIN TEV250MG Chewable Tablet

02036355 NOVAMOXIN TEV25MG/ML Suspension

02352745 AMOXICILLIN SAN02352761 AMOXICILLIN SUGAR

REDUCEDSAN

00628131 APO-AMOXI APX00452149 NOVAMOXIN TEV01934171 NOVAMOXIN SUGAR

REDUCEDTEV

02230245 PMS-AMOXICILLIN PMS50MG/ML Suspension

02352753 AMOXICILLIN SAN02401541 AMOXICILLIN SIV02352788 AMOXICILLIN SUGAR

REDUCEDSAN

00628158 APO-AMOXI APX02230880 APO-AMOXI SUGAR FREE APX00452130 NOVAMOXIN TEV01934163 NOVAMOXIN SUGAR

REDUCEDTEV

02230246 PMS-AMOXICILLIN PMS00644331 PRO-AMOX PDL

AMOXICILLIN, CLAVULANIC ACID

25MG & 6.25MG/ML Suspension

02243986 APO-AMOXI CLAV APX01916882 CLAVULIN-F 125 GSK


02288559 APO-AMOXI CLAV APX02238831 CLAVULIN 200 GSK


02243987 APO-AMOXI CLAV APX01916874 CLAVULIN-F 250 GSK


02238830 CLAVULIN 400 GSK250MG & 125MG Tablet

02243350 APO-AMOXI CLAV APX500MG & 125MG Tablet

02326515 AMOXI-CLAV PDL02243351 APO-AMOXI CLAV APX01916858 CLAVULIN-F GSK02243771 RATIO-ACLAVULANATE RPH


AMOXICILLIN, CLAVULANIC ACID

875MG & 125MG Tablet

02326523 AMOXI-CLAV PDL02245623 APO-AMOXI CLAV APX02238829 CLAVULIN GSK02248138 NOVO-CLAVAMOXIN TEV02247021 RATIO-ACLAVULANATE RPH

AMPICILLIN

250MG Capsule

00020877 NOVO-AMPICILLIN TEV500MG Capsule

00020885 NOVO-AMPICILLIN TEV50MG/ML Suspension

00603287 APO-AMPICILLIN APX

CLOXACILLIN

250MG Capsule

02069660 CLOXACILLINE PRO00337765 NOVO-CLOXIN TEV

500MG Capsule

02069679 CLOXACILLINE PRO00337773 NOVO-CLOXIN TEV

25MG/ML Suspension

00337757 NOVO-CLOXIN TEV

PENICILLIN V POTASSIUM

25MG/ML Suspension

00642223 APO-PEN VK APX60MG/ML Suspension

00642231 APO-PEN VK APX00391603 NOVO-PEN VK TEV

300MG Tablet

00642215 APO-PEN VK APX00717568 NU-PEN VK NXP00468029 PENICILLINE V PDL

PIVMECILLINAM HCL

200MG Tablet

00657212 SELEXID LEO

Page 4 of 1382014


08:12.18 QUINOLONES

CIPROFLOXACIN HCL

250MG Tablet

02229521 APO-CIPROFLOX APX02381907 AURO-CIPROFLOXACIN AUR02155958 CIPRO BAY02353318 CIPROFLOXACIN SAN02386119 CIPROFLOXACIN SIV02247339 CO-CIPROFLOXACIN ACT02245647 GEN-CIPROFLOXACIN GEN02380358 JAMP-CIPROFLOXACIN JAP02379686 MAR-CIPROFLOXACIN MAR02317427 MINT-CIPROFLOXACIN MIN02161737 NOVO-CIPROFLOXACIN TEV02251310 PHL-CIPROFLOXACIN PHH02248437 PMS-CIPROFLOXACIN PMS02317796 PRO-CIPROFLOXACIN PDL02303728 RAN-CIPROFLOX RBY02246825 RATIO-CIPROFLOXACIN RPH02251221 RIVA-CIPROFLOXACIN RIV02248756 SANDOZ-CIPROFLOXACIN SDZ02379627 SEPTA-CIPROFLOXACIN SPT02266962 TARO-CIPROFLOXACIN TAR

500MG Tablet

02229522 APO-CIPROFLOX APX02381923 AURO-CIPROFLOXACIN AUR02155966 CIPRO BAY02353326 CIPROFLOXACIN SAN02386127 CIPROFLOXACIN SIV02247340 CO-CIPROFLOXACIN ACT02251280 DOM-CIPROFLOXACIN DPC02245648 GEN-CIPROFLOXACIN GEN02380366 JAMP-CIPROFLOXACIN JAP02379694 MAR-CIPROFLOXACIN MAR02317435 MINT-CIPROFLOXACIN MIN02161745 NOVO-CIPROFLOXACIN TEV02251329 PHL-CIPROFLOXACIN PHH02248438 PMS-CIPROFLOXACIN PMS02317818 PRO-CIPROFLOXACIN PDL02303736 RAN-CIPROFLOX RBY02246826 RATIO-CIPROFLOXACIN RPH02248757 RHOXAL-CIPROFLOXACIN RHO02251248 RIVA-CIPROFLOXACIN RIV02379635 SEPTA-CIPROFLOXACIN SPT02266970 TARO-CIPROFLOXACIN TAR

08:12.18 QUINOLONES

CIPROFLOXACIN HCL

750MG Tablet

02229523 APO-CIPROFLOX APX02381931 AURO-CIPROFLOXACIN AUR02155974 CIPRO BAY02353334 CIPROFLOXACIN SAN02247341 CO-CIPROFLOXACIN ACT02245649 GEN-CIPROFLOXACIN GEN02380374 JAMP-CIPROFLOXACIN JAP02379708 MAR-CIPROFLOXACIN MAR02317443 MINT-CIPROFLOXACIN MIN02161753 NOVO-CIPROFLOXACIN TEV02251337 PHL-CIPROFLOXACIN PHH02248439 PMS-CIPROFLOXACIN PMS02303744 RAN-CIPROFLOX RBY02246827 RATIO-CIPROFLOXACIN RPH02248758 RHOXAL-CIPROFLOXACIN RHO02251256 RIVA-CIPROFLOXACIN RIV02379643 SEPTA-CIPROFLOXACIN SPT

LEVOFLOXACIN

Limited use benefit (prior approval not required).

Coverage will be limited to a maximum of 30 days.250MG Tablet

02284707 APO-LEVOFLOXACIN APX02315424 CO-LEVOFLOXACIN ACT02236841 LEVAQUIN JNO02313979 MYLAN-LEVOFLOXACIN MYL02248262 NOVO-LEVOFLOXACIN TEV02284677 PMS-LEVOFLOXACIN PMS02298635 SANDOZ LEVOFLOXACIN SDZ

500MG Tablet

02284715 APO-LEVOFLOXACIN APX02315432 CO-LEVOFLOXACIN ACT02236842 LEVAQUIN JNO02313987 MYLAN-LEVOFLOXACIN MYL02248263 NOVO-LEVOFLOXACIN TEV02284685 PMS-LEVOFLOXACIN PMS02298643 SANDOZ LEVOFLOXACIN SDZ

750MG Tablet

02325942 APO-LEVOFLOXACIN APX02315440 CO-LEVOFLOXACIN ACT02246804 LEVAQUIN JNO02285649 NOVO-LEVOFLOXACIN TEV02305585 PMS-LEVOFLOXACIN PMS02298651 SANDOZ LEVOFLOXACIN SDZ

NORFLOXACIN

400MG Tablet

02229524 APO-NORFLOX APX02269627 CO-NORFLOXACIN ACT02237682 NOVO-NORFLOXACIN TEV02246596 PMS-NORFLOXACIN PMS

OFLOXACIN

200MG Tablet

02231529 APO-OFLOX APX

Page 5 of 1382014


08:12.18 QUINOLONES

OFLOXACIN

300MG Tablet

02231531 APO-OFLOX APX02243475 NOVO-OFLOXACIN TEV

400MG Tablet

02231532 APO-OFLOX APX

08:12.20 SULFONAMIDES

SULFAMETHOXAZOLE

500MG Tablet

00421480 APO-SULFAMETHOXAZOLE APX

SULFAMETHOXAZOLE, TRIMETHOPRIM

40MG & 8MG/ML Suspension

00726540 NOVO-TRIMEL TEV100MG & 20MG Tablet

00445266 APO-SULFATRIM PED APX400MG & 80MG Tablet

00445274 APO-SULFATRIM APX00510637 NOVO-TRIMEL TEV


00445282 APO-SULFATRIM DS APX00510645 NOVO-TRIMEL DS TEV00512524 PROTRIN DF PRO

SULFASALAZINE

500MG Enteric Coated Tablet

00598488 PMS-SULFASALAZINE PMS02064472 SALAZOPYRIN PFI

500MG Tablet

00598461 PMS-SULFASALAZINE PMS02064480 SALAZOPYRIN PFI

08:12.24 TETRACYCLINES

DOXYCYCLINE

100MG Capsule

00740713 APO-DOXY APX00817120 DOXYCIN RIV02351234 DOXYCYCLINE SAN00725250 NOVO-DOXYLIN TEV

100MG Tablet

00874256 APO-DOXY APX00860751 DOXYCIN RIV02351242 DOXYCYCLINE SAN00887064 DOXYTAB PDL02158574 NOVO-DOXYLIN TEV

08:12.24 TETRACYCLINES

MINOCYCLINE HCL

Limited 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 Capsule

02084090 APO-MINOCYCLINE APX02239667 DOM-MINOCYCLINE DPC02287226 MINOCYCLINE SAN02108143 NOVO-MINOCYCLINE TEV02153394 PDL-MINOCYCLINE PDL02239238 PMS-MINOCYCLINE PMS02294419 PMS-MINOCYCLINE PMS01914138 RATIO-MINOCYCLINE RPH02242080 RIVA-MINOCYCLINE RIV02237313 SANDOZ-MINOCYCLINE SDZ

100MG Capsule

02084104 APO-MINOCYCLINE APX02239668 DOM-MINOCYCLINE DPC02173506 MINOCIN STI02239982 MINOCYCLINE IVX02287234 MINOCYCLINE SAN02108151 NOVO-MINOCYCLINE TEV02154366 PDL-MINOCYCLINE PDL02294427 PMS-MINOCYCLINE PMS02239239 PMS-MONOCYCLINE PMS01914146 RATIO-MINOCYCLINE RPH02242081 RIVA-MINOCYCLINE RIV02237314 SANDOZ-MINOCYCLINE SDZ

TETRACYCLINE HCL

250MG Capsule

00580929 APO-TETRA APX00156744 TETRACYCLINE PRO

08:12.28 MISCELLANEOUS ANTIBIOTICS

CLINDAMYCIN HCL

150MG Capsule

02245232 APO-CLINDAMYCIN APX02400529 CLINDAMYCIN SAN02248525 CLINDAMYCINE PDL00030570 DALACIN C PFI02258331 GEN-CLINDAMYCIN GEN02241709 NOVO-CLINDAMYCIN TEV

300MG Capsule

02245233 APO-CLINDAMYCIN APX02400537 CLINDAMYCIN SAN02248526 CLINDAMYCINE PDL02182866 DALACIN C PFI02258358 GEN-CLINDAMYCIN GEN02241710 NOVO-CLINDAMYCIN TEV

CLINDAMYCIN PALMITATE HCL

15MG/ML Solution

00225851 DALACIN C PFI

Page 6 of 1382014


08:12.28 MISCELLANEOUS ANTIBIOTICS

LINEZOLID


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 Injection

02243685 ZYVOXAM PFI600MG Tablet

02243684 ZYVOXAM PFI

08:14.04 ALLYLAMINES

TERBINAFINE HCL

250MG Tablet

02320134 AURO-TERBINAFINE AUR02299275 DOM-TERBINAFINE DOM02357070 JAMP-TERBINAFINE JAP02294273 PMS-TERBINAFINE PMS02353121 TERBINAFINE SAN02385279 TERBINAFINE SIV02242735 TERBINAFINE-250 PDL

250MG Tablet

02239893 APO-TERBINAFINE APX02254727 CO-TERBINAFINE ACT02242503 GEN-TERBINAFINE GEN02031116 LAMISIL NVR02240346 NOVO-TERBINAFINE TEV02240807 PMS-TERBINAFINE PMS02262177 SANDOZ-TERBINAFINE SDZ

08:14.08 AZOLES

FLUCONAZOLE

150MG Capsule

02241895 APO-FLUCONAZOLE APX02311690 CANESORAL BAY02323419 CO FLUCONAZOLE ACT02141442 DIFLUCAN PFI02243645 NOVO-FLUCONAZOLE TEV02246620 PMS-FLUCONAZOLE PMS02282348 PMS-FLUCONAZOLE PMS02255510 RIVA-FLUCONAZOLE RIV

10MG/ML Suspension

02024152 DIFLUCAN PFI

08:14.08 AZOLES

FLUCONAZOLE

50MG Tablet

02237370 APO-FLUCONAZOLE APX02281260 CO FLUCONAZOLE ACT00891800 DIFLUCAN PFI02245292 GEN-FLUCONAZOLE GEN02236978 NOVO-FLUCONAZOLE TEV02245643 PMS-FLUCONAZOLE PMS02249294 TARO-FLUCONAZOLE TAR

100MG Tablet

02237371 APO-FLUCONAZOLE APX02281279 CO FLUCONAZOLE ACT02246109 DOM-FLUCONAZOLE PMS02245293 GEN-FLUCONAZOLE GEN02236979 NOVO-FLUCONAZOLE TEV02245644 PMS-FLUCONAZOLE PMS02310686 PRO-FLUCONAZOLE PDL02249308 TAR0-FLUCONAZOLE TAR

ITRACONAZOLE

100MG Capsule

02047454 SPORANOX JNO10MG/ML Solution

02231347 SPORANOX JNO

KETOCONAZOLE

200MG Tablet

02237235 APO-KETOCONAZOLE APX02231061 NOVO-KETOCONAZOLE TEV

VORICONAZOLE


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

50MG Tablet

02256460 VFEND PFI200MG Tablet

02256479 VFEND PFI

08:14.28 POLYENES

NYSTATIN

100,000U/ML Suspension

02125145 DOM-NYSTATIN DPC00792667 PMS-NYSTATIN PMS02194201 RATIO-NYSTATIN RPH

500,000U Tablet

02194198 RATIO-NYSTATIN RPH

08:16.04 ANTITUBERCULOSIS AGENTS

ETHAMBUTOL HCL

100MG Tablet

00247960 ETIBI VAE400MG Tablet

00247979 ETIBI VAE

Page 7 of 1382014


08:16.04 ANTITUBERCULOSIS AGENTS

ISONIAZID

10MG/ML Syrup

00265500 ISOTAMINE VAE00577812 PMS-ISONIAZID PMS

300MG Tablet

00272655 ISOTAMINE VAE00577804 PMS-ISONIAZID PMS

PYRAZINAMIDE

500MG Tablet

00618810 PMS-PYRAZINAMIDE PMS00283991 TEBRAZID VAE

RIFABUTIN

150MG Capsule

02063786 MYCOBUTIN PFI

RIFAMPIN

150MG Capsule

02091887 RIFADIN SAC00393444 ROFACT VAE

300MG Capsule

02092808 RIFADIN SAC00343617 ROFACT VAE

08:18.04 ADAMANTANES

AMANTADINE HCL

100MG Capsule

02130963 DOM-AMANTADINE DPC02139200 GEN-AMANTADINE GEN01990403 PMS-AMANTADINE PMS

10MG/ML Syrup

02022826 PMS-AMANTADINE PMS

08:18.08 ANTIRETROVIRALS

ABACAVIR

20MG/ML Oral Liquid

02240358 ZIAGEN GSK300MG Tablet

02240357 ZIAGEN GSK

ABACAVIR, LAMIVUDINE


02269341 KIVEXA GSK

ABACAVIR, LAMIVUDINE, ZIDOVUDINE

300MG & 150MG & 300MG Tablet

02244757 TRIZIVIR GSK

ATAZANAVIR SULFATE

150MG Capsule

02248610 REYATAZ BMS200MG Capsule

02248611 REYATAZ BMS300MG Capsule

02294176 REYATAZ BMS


COBICISTAT, EMTRICITABINE,

ELVITEGRAVIR, TENOFOVIR

150MG & 200MG & 150MG & 300MG Tablet

02397137 STRIBILD GIL

DARUNAVIR ETHANOLATE

75MG Tablet

02338432 PREZISTA JNO150MG Tablet




02393050 PREZISTA KEG

DIDANOSINE

125MG Capsule

02244596 VIDEX EC BMS200MG Capsule



02244599 VIDEX EC BMS

EFAVIRENZ

50MG Capsule

02239886 SUSTIVA BMS200MG Capsule

02239888 SUSTIVA BMS600MG Tablet

02381524 MYLAN-EFAVIRENZ MYL02246045 SUSTIVA BMS02389762 TEVA-EFAVIRENZ TEP

EFAVIRENZ, TENOFOVIR, EMTRICITABINE


02300699 ATRIPLA BMS

EMTRICITABINE, RILPIVIRINE, TENOFOVIR

DISOPROXIL FUMARATE


02374129 COMPLERA GIL

EMTRICITABINE, TENOFOVIR DISOPROXIL

FUMARATE

200MG& 300MG Tablet

02274906 TRUVADA GIL

Page 8 of 1382014



ETRAVIRINE


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 Tablet

02306778 INTELENCE JNO200MG Tablet

02375931 INTELENCE KEG

FOSAMPRENAVIR CALCIUM

50MG/ML Oral Suspension

02261553 TELZIR GSK700MG Tablet

02261545 TELZIR GSK

INDINAVIR SULFATE

200MG Capsule

02229161 CRIXIVAN FRS400MG Capsule

02229196 CRIXIVAN FRS

LAMIVUDINE

10MG/ML Solution

02192691 3TC GSK100MG Tablet

02393239 APO-LAMIVUDINE HBV APX02239193 HEPTOVIR GSK

150MG Tablet

02192683 3TC GSK02369052 APO-LAMIVUDINE APX

300MG Tablet

02247825 3TC GSK02369060 APO-LAMIVUDINE APX

LAMIVUDINE, ZIDOVUDINE


02375540 APO-LAMIVUDINE-ZIDOVUDINE APX02239213 COMBIVIR GSK02387247 TEVA-

LAMIVUDINE/ZIDOVUDINETEP

LOPINAVIR, RITONAVIR

133.3MG & 33.3MG Capsule

02243643 KALETRA ABB80MG & 20MG/ML Oral Solution

02243644 KALETRA ABB100MG & 25MG Tablet

02312301 KALETRA ABV200MG & 50MG Tablet

02285533 KALETRA ABB


MARAVIROC


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 Tablet

02299844 CELSENTRI VII300MG Tablet

02299852 CELSENTRI VII

NELFINAVIR MESYLATE

50MG/G Powder for Suspension

02238618 VIRACEPT PFI250MG Tablet

02238617 VIRACEPT PFI625MG Tablet

02248761 VIRACEPT PFI

NEVIRAPINE

200MG Tablet

02318601 AURO-NEVIRAPINE AUR02387727 MYLAN-NEVIRAPINE MYL02405776 PMS-NEVIRAPINE PMS02352893 TEVA-NEVIRAPINE TEP02238748 VIRAMUNE BOE

RALTEGRAVIR


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 Tablet

02301881 ISENTRESS FRS

RILPIVIRINE HYDROCHLORIDE

25MG Tablet

02370603 EDURANT KEG

RITONAVIR

100MG Capsule

02241480 NORVIR SEC ABB80MG/ML Liquid

02229145 NORVIR ABB100MG Tablet

02357593 NORVIR ABV

SAQUINAVIR MESYLATE

200MG Capsule

02216965 INVIRASE HLR500MG Tablet

02279320 INVIRASE HLR

Page 9 of 1382014



STAVUDINE

15MG Capsule

02216086 ZERIT BMS20MG Capsule



02216116 ZERIT BMS

TENOFOVIR DISOPROXIL FUMARATE


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

245MG Tablet

02247128 VIREAD GIL

TIPRANAVIR


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 Capsule

02273322 APTIVUS BOE

ZIDOVUDINE

100MG Capsule

01946323 APO-ZIDOVUDINE APX01902660 RETROVIR GSK

10MG/ML Syrup

01902652 RETROVIR GSK

08:18.20 INTERFERONS

PEGINTERFERON ALFA-2A


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 Injection

02248077 PEGASYS HLR180MCG/1ML Injection

02248078 PEGASYS HLR

08:18.20 INTERFERONS

PEGINTERFERON ALFA-2A, RIBAVIRIN





180MCG/0.5ML & 200MG Injection & Tablet

02253429 PEGASYS RBV HLR180MCG/1ML & 200MG Injection & Tablet

02253410 PEGASYS RBV HLR

PEGINTERFERON ALFA-2B, RIBAVIRIN





50MCG/0.5ML & 200MG Injection & Capsule

02246026 PEGETRON SCH02254573 PEGETRON REDIPEN SCH

80MCG/0.5ML & 200MG Injection & Capsule

02254581 PEGETRON REDIPEN SCH100MCG/0.5ML & 200MG Injection & Capsule



02246030 PEGETRON SCH02254646 PEGETRON REDIPEN SCH

08:18.32 NUCLEOSIDES AND

NUCLEOTIDES

ACYCLOVIR

40MG/ML Suspension

00886157 ZOVIRAX GSK200MG Tablet

02286556 ACYCLOVIR SAN02207621 APO-ACYCLOVIR APX02242784 GEN-ACYCLOVIR GEN02285959 NOVO-ACYCLOVIR TEV02078627 RATIO-ACYCLOVIR RPH00634506 ZOVIRAX GSK

Page 10 of 1382014



NUCLEOTIDES

ACYCLOVIR

400MG Tablet

02286564 ACYCLOVIR SAN02207648 APO-ACYCLOVIR APX02242463 GEN-ACYCLOVIR GEN02285967 NOVO-ACYCLOVIR TEV02078635 RATIO-ACYCLOVIR RPH01911627 ZOVIRAX GSK

800MG Tablet

02286572 ACYCLOVIR SAN02207656 APO-ACYCLOVIR APX02242464 GEN-ACYCLOVIR GEN02285975 NOVO-ACYCLOVIR TEV02078651 RATIO-ACYCLOVIR RPH

ENTECAVIR


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 Tablet

02396955 APO-ENTECAVIR APX

FAMCICLOVIR

125MG Tablet

02292025 APO-FAMCICLOVIR APX02305682 CO FAMCICLOVIR ACT02324865 FAMCICLOVIR PDL02229110 FAMVIR NVR02278081 PMS-FAMCICLOVIR PMS02278634 SANDOZ-FAMCICLOVIR SDZ

250MG Tablet

02292041 APO-FAMCICLOVIR APX02305690 CO FAMCICLOVIR ACT02229129 FAMVIR NVR02278103 PMS-FAMCICLOVIR PMS02278642 SANDOZ-FAMCICLOVIR SDZ

500MG Tablet

02292068 APO-FAMCICLOVIR APX02305704 CO FAMCICLOVIR ACT02177102 FAMVIR NVR02278111 PMS-FAMCICLOVIR PMS02278650 SANDOZ-FAMCICLOVIR SDZ

GANCICLOVIR SODIUM

500MG Injection

02162695 CYTOVENE HLR


NUCLEOTIDES

VALACYCLOVIR HCL

500MG Tablet

02331748 CO VALACYCLOVIR ACT02307936 DOM-VALACYCLOVIR DOM02351579 MYLAN-VALACYCLOVIR MYL02357534 NOVO-VALACYCLOVIR TEP02315173 PRO-VALACYCLOVIR PDL02316447 RIVA-VALACYCLOVIR RIV02219492 VALTREX GSK

VALGANCICLOVIR HCL

450MG Tablet

02393824 APO-VALGANCICLOVIR APX02245777 VALCYTE HLR

08:18.40

BOCEPREVIR


For the treatment of chronic hepatitis C (CHC) genotype 1 infection in adult patients with compensated liver disease, in combination with peginterferon alpha (a or b) + ribavirin), and the following criteria:

-detectable levels of hepatitis C virus RNA in the last six months;- fibrosis stage of F2, F3 or F4;-one course of treatment only (maximum of 44 weeks, based on response).

200MG Capsule

02370816 VICTRELIS FRS

BOCEPREVIR, PEGINTERFERON, RIBAVIRIN


For the treatment of chronic hepatitis C (CHC) genotype 1 infection in adult patients with compensated liver disease, in combination with peginterferon alpha (a or b) + ribavirin), and the following criteria:


200MG & 100 MCG & 200MG Kit

02371456 VICTRELIS TRIPLE FRS200MG & 120 MCG & 200MG Kit



02371448 VICTRELIS TRIPLE FRS

Page 11 of 1382014


08:18.92 MISCELLANEOUS ANTIVIRALS

TELAPREVIR


For the treatment of chronic Hepatitis C in treatment-naïve and treatment experienced patients who meet all the following criteria before consideration:- HCV genotype 1 - Detectable levels of hepatitis C virus HCV RNA in the last six months.- Fibrosis stage F2 or greater (Metavir scale or equivalent). Copy of report is required - No diagnosis of cirrhosis OR compensated liver disease (cirrhosis with a Child Pugh Score = A (5-6))

375MG Tablet

02371553 INCIVEK VPC

08:30.04 AMEBICIDES

DIIODOHYDROXYQUIN

210MG Tablet

01997769 DIODOQUIN GLE650MG Tablet

01997750 DIODOQUIN GLE

PAROMOMYCIN SULFATE

250MG Capsule

02078759 HUMATIN ERF

08:30.08 ANTIMALARIALS

CHLOROQUINE PHOSPHATE

250MG Tablet

00021261 NOVO-CHLOROQUINE TEV

HYDROXYCHLOROQUINE SULFATE

200MG Tablet

02246691 APO-HYDROXYQUINE APX02252600 GEN-HYDROXYCHLOROQUINE GEN02017709 PLAQUENIL SAC

PRIMAQUINE PHOSPHATE

26.3MG Tablet

02017776 PRIMAQUINE SAC

PYRIMETHAMINE

25MG Tablet

00004774 DARAPRIM GSK

08:30.92 MISCELLANEOUS

ANTIPROTOZOALS

ATOVAQUONE

150MG/ML Suspension

02217422 MEPRON GSK

METRONIDAZOLE

500MG Capsule

02248562 APO-METRONIDAZOLE APX00783137 TRIKACIDE PMS

250MG Tablet

00545066 APO-METRONIDAZOLE APX00420409 METRONIDAZOLE PDL

08:36.00 URINARY ANTI-INFECTIVES

NITROFURANTOIN

50MG Capsule

02231015 NOVO-FURANTOIN TEV100MG Capsule

02063662 MACROBID PGP02231016 NOVO-FURANTOIN TEV

50MG Tablet

00319511 APO-NITROFURANTOIN APX100MG Tablet

00312738 APO-NITROFURANTOIN APX

TRIMETHOPRIM

100MG Tablet

02243116 APO-TRIMETHOPRIM APX200MG Tablet

02243117 APO-TRIMETHOPRIM APX

Page 12 of 1382014


10:00 ANTINEOPLASTIC AGENTS

10:00.00 ANTINEOPLASTIC AGENTS

ALTRETAMINE

50MG Capsule

02126230 HEXALEN LIL

ANASTROZOLE

1MG Tablet

02374420 APO-ANASTROZOLE APX02224135 ARIMIDEX AZC02394898 CO-ANASTROZOLE ACT02339080 JAMP-ANASTROZOLE JAP02379562 MAR-ANASTROZOLE MAR02379104 MED-ANASTROZOLE GMP02393573 MINT-ANASTROZOLE MIN02361418 MYLAN-ANASTROZOLE MYL02320738 PMS-ANASTROZOLE PMS02328690 RAN-ANASTROZOLE RBY02392259 RIVA-ANASTROZOLE RIV02338467 SANDOZ ANASTROZOLE SDZ02365650 TARO-ANASTROZOLE TAR02313049 TEVA-ANASTROZOLE TEP

BICALUTAMIDE

50MG Tablet

02296063 APO-BICALUTAMIDE APX02325985 BICALUTAMIDE ACC02382423 BICALUTAMIDE SIV02184478 CASODEX AZC02274337 CO-BICALUTAMIDE ACT02302403 GEN-BICALUTAMIDE GEN02357216 JAMP-BICALUTAMIDE JAP02270226 NOVO-BICALUTAMIDE TEV02275589 PMS-BICALUTAMIDE PMS02311038 PRO-BICALUTAMIDE PDL02371324 RAN-BICALUTAMIDE RBY02276089 SANDOZ-BICALUTAMIDE SDZ

BUSERELIN ACETATE

1MG/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 Injection

02240749 SUPREFACT DEPOT 3 MONTHS

SAC

BUSULFAN

2MG Tablet

00004618 MYLERAN GSK

CAPECITABINE

150MG Tablet

02400022 TEVA-CAPECITABINE TEP02238453 XELODA HLR


CAPECITABINE

500MG Tablet

02400030 TEVA-CAPECITABINE TEP02238454 XELODA HLR

CHLORAMBUCIL

2MG Tablet

00004626 LEUKERAN GSK

CYCLOPHOSPHAMIDE

25MG Tablet

02241795 PROCYTOX BAT50MG Tablet

02241796 PROCYTOX BAT

CYPROTERONE ACETATE

50MG Tablet

00704431 ANDROCUR BEX02245898 APO-CYPROTERONE APX02390760 MED-CYPROTERONE GMP02395797 RIVA-CYPROTERONE RIV

DEGARELIX ACETATE

80MG/VIAL Injection

02337029 FIRMAGON FEI120MG/VIAL Injection

02337037 FIRMAGON FEI

ERLOTINIB HYDROCLORIDE


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 Tablet

02269015 TARCEVA HLR150MG Tablet

02269023 TARCEVA HLR

ETOPOSIDE

50MG Capsule

00616192 VEPESID BMS

EXEMESTANE

25MG Tablet

02242705 AROMASIN PFI02390183 CO EXEMESTANE ACT

FLUDARABINE PHOSPHATE

10MG Tablet

02246226 FLUDARA BEX

FLUTAMIDE

250MG Tablet

02238560 APO-FLUTAMIDE APX00637726 EUFLEX SCH02230089 NOVO-FLUTAMIDE TEV02230104 PMS-FLUTAMIDE PMS

Page 13 of 1382014



GOSERELIN ACETATE

3.6MG/DEPOT Injection

02049325 ZOLADEX AZC10.8MG/DEPOT Injection

02225905 ZOLADEX LA AZC

HYDROXYUREA

500MG Capsule

02247937 APO-HYDROXYUREA APX02242920 GEN-HYDROXYUREA GEN00465283 HYDREA BMS02343096 HYDROXYUREA SAN

IMATINIB MESYLATE


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

100MG Tablet

02355337 APO-IMATINIB APX02253275 GLEEVEC NVR02399806 TEVA-IMATINIB TEP

400MG Tablet

02355345 APO-IMATINIB APX02253283 GLEEVEC NOV02399814 TEVA-IMATINIB TEP

INTERFERON ALFA-2B

6,000,000IU/ML Injection

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

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




02240695 INTRON A SCH


LETROZOLE

2.5MG Tablet

02358514 APO-LETROZOLE APX02231384 FEMARA NVR02373009 JAMP-LETROZOLE JAP02338459 LETROZOLE ACC02347997 LETROZOLE TEP02348969 LETROZOLE ACT02402025 LETROZOLE PDL02373424 MAR-LETROZOLE MAR02322315 MED-LETROZOLE GMP02372169 MYL-LETROZOLE MYL02309114 PMS-LETROZOLE PMS02372282 RAN-LETROZOLE RBY02344815 SANDOZ LETROZOLE SDZ02343657 TEVA-LETROZOLE TEP

LEUPROLIDE ACETATE

3.75MG/VIAL Injection

00884502 LUPRON DEPOT ABB7.5MG/VIAL Injection



02248240 ELIGARD SAC02230248 LUPRON DEPOT ABB

30MG/VIAL Injection

02248999 ELIGARD SAC02239833 LUPRON DEPOT ABB

45MG/VIAL Injection

02268892 ELIGARD SAC

LOMUSTINE

10MG Capsule

00360430 CEENU BMS40MG Capsule

00360422 CEENU BMS100MG Capsule

00360414 CEENU BMS

MEGESTROL ACETATE

40MG/ML Suspension

02168979 MEGACE BMS40MG Tablet

02195917 APO-MEGESTROL APX160MG Tablet

02195925 APO-MEGESTROL APX

MELPHALAN

2MG Tablet

00004715 ALKERAN GSK

MERCAPTOPURINE

50MG Tablet

00004723 PURINETHOL TEV

Page 14 of 1382014



METHOTREXATE SODIUM

10MG/ML Injection

02182947 METHOTREXATE MAY25MG/ML Injection

02182777 METHOTREXATE MAY02182955 METHOTREXATE MAY02398427 METHOTREXATE SDZ02099705 NOVO-METHOTREXATE TEV

2.5MG Tablet

02182963 APO-METHOTREXATE APX02170698 METHOTREXATE WAY02244798 RATIO-METHOTREXATE RPH

10MG Tablet

02182750 METHOTREXATE MAY

MITOTANE

500MG Tablet

00463221 LYSODREN BMS

NILUTAMIDE

50MG Tablet

02221861 ANANDRON SAC

PROCARBAZINE HCL

50MG Capsule

00012750 NATULAN SIG

RITUXIMAB


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 Injection

02241927 RITUXAN HLR

SUNITINIB MALATE

Limited 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 Capsule

02280795 SUTENT PFI25MG Capsule

02280809 SUTENT PFI50MG Capsule

02280817 SUTENT PFI


TAMOXIFEN CITRATE

10MG Tablet

00812404 APO-TAMOX APX02088428 GEN-TAMOXIFEN GEN00851965 NOVO-TAMOXIFEN TEV02237459 PMS-TAMOXIFEN PMS

20MG Tablet

00812390 APO-TAMOX APX02089858 GEN-TAMOXIFEN GEN02048485 NOLVADEX D AZC00851973 NOVO-TAMOXIFEN TEV02237460 PMS-TAMOXIFEN PMS

TEMOZOLOMIDE


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 Capsule

02241093 TEMODAL SCH20MG Capsule

02395274 CO TEMOZOLOMIDE ACT02241094 TEMODAL SCH

100MG Capsule


140MG Capsule

02395290 CO TEMOZOLOMIDE ACT02312794 TEMODAL FRS

250MG Capsule


THIOGUANINE

40MG Tablet

00282081 LANVIS GSK

TRETINOIN

10MG Capsule

02145839 VESANOID HLR

TRIPTORELIN PAMOATE

3.75MG/VIAL Injection

02240000 TRELSTAR WAT11.25MG/VIAL Injection

02243856 TRELSTAR LA WAT

VINCRISTINE SULFATE

1MG/ML Injection

02143305 VINCRISTINE SULFATE TEV02183013 VINCRISTINE SULFATE MAY

Page 15 of 1382014


12:00 AUTONOMIC DRUGS

12:04.00 PARASYMPATHOMIMETIC

AGENTS

BETHANECHOL CHLORIDE

10MG Tablet

01947958 DUVOID SHI25MG Tablet

01947931 DUVOID SHI50MG Tablet

01947923 DUVOID SHI

GALANTAMINE HYDROBROMIDE


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; OR•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)

8MG Extended Release Capsule

02339439 MYLAN-GALANTAMINE ER MYL02316943 PAT-GALANTAMINE ER JNO02398370 PMS-GALANTAMINE ER PMS02377950 TEVA-GALANTAMINE ER TEP





NEOSTIGMINE BROMIDE

15MG Tablet

00869945 PROSTIGMIN VAE


AGENTS

PILOCARPINE HCL

5MG Tablet

02402483 PILOCARPINE STE02216345 SALAGEN PFI

PYRIDOSTIGMINE BROMIDE

180MG Sustained Release Tablet

00869953 MESTINON-SR VAE60MG Tablet

00869961 MESTINON VAE

RIVASTIGMINE



Criteria for coverage at every six month interval:•Diagnosis is still mild to moderate Alzheimer‟s disease; AND•MMSE score > 10; OU•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)

1.5MG Capsule

02336715 APO-RIVASTIGMINE APX02242115 EXELON NOV02406985 MINT-RIVASTIGMINE MIN02332809 MYLAN-RIVASTIGMINE MYL02305984 NOVO-RIVASTIGMINE TEV02306034 PMS-RIVASTIGMINE PMS02311283 RATIO-RIVASTIGMINE TEP02324563 SANDOZ RIVASTIGMINE SDZ

3MG Capsule


Page 16 of 1382014



AGENTS

RIVASTIGMINE



Criteria for coverage at every six month interval:•Diagnosis is still mild to moderate Alzheimer‟s disease; AND•MMSE score > 10; OU•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)

4.5MG Capsule


6MG Capsule


2MG/ML O/L

02245240 EXELON NOV

12:08.04 ANTIPARKINSONIAN AGENTS

BENZTROPINE MESYLATE

1MG/ML Injection

02238903 BENZTROPINE OMEGA OMG1MG Tablet

00706531 PMS-BENZTROPINE PMS2MG Tablet

00426857 APO-BENZTROPINE APX00587265 PMS-BENZTROPINE PMS

12:08.04 ANTIPARKINSONIAN AGENTS

ETHOPROPAZINE HCL

50MG Tablet

01927744 PARSITAN ERF

PROCYCLIDINE HCL

0.5MG/ML Elixir

00587362 PMS-PROCYCLIDINE PMS2.5MG Tablet

00649392 PMS-PROCYCLIDINE PMS5MG Tablet

00587354 PMS-PROCYCLIDINE PMS

ROPINIROLE HCL

0.25MG Tablet

02232565 REQUIP GSK1MG Tablet



02232569 REQUIP GSK

TRIHEXYPHENIDYL HCL

0.4MG/ML Liquid

00885398 PMS-TRIHEXYPHENIDYL PMS2MG Tablet

00545058 APO-TRIHEX APX5MG Tablet

00545074 APO-TRIHEX APX

12:08.08 ANTIMUSCARINICS /

ANTISPASMODICS

IPRATROPIUM BROMIDE

250MCG/ML Inhalation Solution (Multi-Dose)

02126222 APO-IPRAVENT APX02239131 GEN-IPRATROPIUM GEN02210479 NOVO-IPRAMIDE TEV02231136 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 GEN02231244 PMS-IPRATROPIUM UDV PMS02231245 PMS-IPRATROPIUM UDV PMS02097168 RATIO-IPRATROPIUM UDV RPH99001446 RATIO-IPRATROPIUM UDV RPH *

20MCG/INHALATION Inhaler HFA

02247686 ATROVENT HFA BOE0.03% Nasal Spray

02246083 APO-IPRAVENT APX02240508 DOM-IPRATROPIUM DPC02239627 PMS-IPRATROPIUM PMS

0.06% Nasal Spray

02246084 APO-IPRAVENT APX

Page 17 of 1382014



ANTISPASMODICS

IPRATROPIUM BROMIDE, SALBUTAMOL

0.2MG & 1MG/ML Inhalation Solution (Unit Dose)

02231675 COMBIVENT BOE02272695 GEN-COMBO GEN

SCOPOLAMINE BUTYLBROMIDE

10MG Tablet

00363812 BUSCOPAN BOE

TIOTROPIUM BROMIDE MONOHYDRATE


For patients with chronic obstructive pulmonary disease (COPD) and who:

-did not respond to a trial of ipratropium (Atrovent); OR-did not have a previous trial of ipratropium, but who have moderate to severe COPD, defined as <60% FEV1, FEV1/FVC<0.7 and MRC 3 to 5.

18MCG Powder for Inhalation (Capsule)

02246793 SPIRIVA BOE

12:12.04 ALPHA ADRENERGIC AGONISTS

MIDODRINE HCL

2.5MG Tablet

02278677 APO-MIDODRINE APX5MG Tablet

02278685 APO-MIDODRINE APX

12:12.08 BETA ADRENERGIC AGONISTS

FORMOTEROL 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.

OR

•For the treatment of Chronic Obstructive Pulmonary Disease (COPD) in patients not adequately controlled with either ipratropium, tiotropium or a short acting beta-agonist.

12MCG/CAP Powder for Inhalation

02230898 FORADIL NVR

FORMOTEROL FUMARATE DIHYDRATE


For the treatment of asthma in patients who are using optimal corticosteroid therapy and experiencing breakthrough symptoms requiring regular use of rapid onset, short duration bronchodilator

6MCG/DOSE Dry Powder Inhaler

02237225 OXEZE TURBUHALER AZC12MCG/DOSE Dry Powder Inhaler

02237224 OXEZE TURBUHALER AZC


FORMOTEROL FUMARATE DIHYDRATE,

BUDESONIDE


•For the treatment of reversible obstructive airway disease in patients who are not adequately controlled on medium doses of inhaled corticosteroids (e.g. fluticasone 251-500mcg 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.

OR ONE OF THE FOLLOWING

•For the treatment of moderate* COPD, if a patient continues to be symptomatic after an adequate trial of a long acting anticholinergic AND a long acting beta-agonist.

•For the treatment of severe** COPD, if a patient continues to be symptomatic after an adequate trial of a long acting anticholinergic OR a long acting beta-agonist.

6MCG & 100MCG/INHALATION Inhaler

02245385 SYMBICORT 100 TURBUHALER AZC6MCG & 200MCG/INHALATION Inhaler

02245386 SYMBICORT 200 TURBUHALER AZC

FORMOTEROL FUMARATE DIHYDRATE,

MOMETASONE FUROATE


For the treatment of reversible obstructive airway disease in patients who are not adequately controlled on medium doses of inhaled corticosteroids (e.g. fluticasone 200-500mcg 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.

5MCG & 100MCG Inhaler

02361752 ZENHALE FRS5MCG & 200MCG Inhaler

02361760 ZENHALE FRS5MCG & 50MCG Inhaler

02361744 ZENHALE FRS

INDACATEROL MALEATE


For the treatment of Chronic Obstructive Pulmonary Disease (COPD) in patients not adequately controlled with either ipratropium, tiotropium or a short acting beta-agonist.

75MCG Capsule

02376938 ONBREZ NOV

IPRATROPIUM BROMIDE, SALBUTAMOL

0.2MG & 1MG/ML Inhalation Solution (Unit Dose)

02243789 RATIO-IPRA SAL RPH

ORCIPRENALINE SULFATE

2MG/ML Syrup

02236783 APO-ORCIPRENALINE APX

Page 18 of 1382014



SALBUTAMOL

5MG/ML Inhalation Solution (Multi-Dose)

02139324 DOM-SALBUTAMOL DPC02069571 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

1MG/ML Inhalation Solution (Unit Dose)

02216949 DOM-SALBUTAMOL DPC02208229 PMS-SALBUTAMOL PMS01986864 RATIO-SALBUTAMOL RPH02213419 VENTOLIN PF GSK

2MG/ML Inhalation Solution (Unit Dose)

02208237 PMS-SALBUTAMOL PMS02213427 VENTOLIN PF GSK

100MCG/INHALATION Inhaler CFC-Free

02232570 AIROMIR MMH02245669 APO-SALVENT CFC FREE APX


02326450 NOVO-SALBUTAMOL TEV02241497 VENTOLIN HFA GSK

2MG Tablet

02146843 APO-SALVENT APX4MG Tablet

02146851 APO-SALVENT APX

SALMETEROL XINAFOATE


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, tiotropium or a short acting beta-agonist.

50MCG/DOSE Powder Diskus

02231129 SEREVENT DISKUS GSK50MCG/INHALATION Powder for Inhalation

02214261 SEREVENT DISKHALER GSK


SALMETEROL XINAFOATE, FLUTICASONE

PROPIONATE


•For the treatment of reversible obstructive airway disease in patients who are not adequately controlled on medium doses of inhaled corticosteroids (e.g. fluticasone 251-500mcg 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.


•For the treatment of moderate* COPD, if a patient continues to be symptomatic after an adequate trial of a long acting anticholinergic AND a long acting beta-agonist.

•For the treatment of severe** COPD, if a patient continues to be symptomatic after an adequate trial of a long acting anticholinergic OR a long acting beta-agonist.

25MCG & 125MCG INHALATION Inhaler

02245126 ADVAIR GSK25MCG & 250MCG INHALATION Inhaler

02245127 ADVAIR GSK50MCG & 100MCG Inhaler

02240835 ADVAIR DISKUS 100 GSK50MCG & 250MCG Inhaler

02240836 ADVAIR DISKUS 250 GSK50MCG & 500MCG Inhaler

02240837 ADVAIR DISKUS 500 GSK

TERBUTALINE SULFATE

500MCG/INHALATION Powder for Inhalation

00786616 BRICANYL TURBUHALER AZC

12:12.12 ALPHA AND BETA ADRENERGIC

AGONISTS

EPINEPHRINE

0.15MG/0.15ML Injection

02382059 ALLERJECT SAC02268205 TWINJECT PAL

0.3MG/0.3ML Injection

02382067 ALLERJECT SAC0.5MG/ML Injection

00578657 EPIPEN JR AXL1MG/ML Injection

00155357 ADRENALIN ERF00721891 EPINEPHRINE ABB00509558 EPIPEN AXL02247310 TWINJECT PAL

1MG/ML Topical Solution

00155365 ADRENALIN ERF

Page 19 of 1382014


12:16.00 SYMPATHOLYTIC AGENTS

DIHYDROERGOTAMINE MESYLATE

1MG/ML Injection

00027243 DIHYDROERGOTAMINE STE02241163 DIHYDROERGOTAMINE SDZ

4MG/ML Nasal Spray

02228947 MIGRANAL STE

12:16.04 ALPHA-ADRENERGIC BLOCKING

AGENTS

ALFUZOSIN HYDROCHLORIDE


02315866 APO-ALFUZOSIN ER APX02304678 SANDOZ ALFUZOSIN SDZ02314282 TEVA-ALFUZOSIN PR TEP02245565 XATRAL SAC

TAMSULOSIN HCL

0.4MG Long Acting CapsuleST

02298570 MYLAN-TAMSULOSIN MYL02281392 NOVO-TAMSULOSIN TEV02294265 RATIO-TAMSULOSIN RPH09857334 RATIO-TAMSULOSIN RAT02295121 SANDOZ TAMSULOSIN SDZ

0.4MG Long Acting TabletST

02362406 APO-TAMSULOSIN CR APX02270102 FLOMAX CR BOE02340208 SANDOZ TAMSULOSIN SDZ

12:20.04 CENTRALL ACTING SKELETAL

MUSCLE RELAXANTS

CYCLOBENZAPRINE 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 Tablet

02177145 APO-CYCLOBENZAPRINE APX02348853 AURO-CYCLOBENZAPRINE AUR02220644 CYCLOBENZAPRINE PDL02287064 CYCLOBENZAPRINE SAN02238633 DOM-CYCLOBENZAPRINE DPC02231353 GEN-CYCLOPRINE GEN02357127 JAMP-CYCLOBENZAPRINE JAP02080052 NOVO-CYCLOPRINE TEV02249359 PHL-CYCLOBENZAPRINE PMI02212048 PMS-CYCLOBENZAPRINE PMS02236506 RATIO-CYCLOBENZAPRINE RPH02242079 RIVA-CYCLOBENZAPRINE RIV

12:20.04 CENTRALL ACTING SKELETAL

MUSCLE RELAXANTS

TIZANIDINE HCL


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

4MG Tablet

02259893 APO-TIZANIDINE APX02272059 GEN-TIZANIDINE GEN02239170 ZANAFLEX ELN

12:20.08 DIRECT-ACTING SKELETAL

MUSCLE RELAXANTS

DANTROLENE SODIUM

25MG Capsule

01997602 DANTRIUM PGP100MG Capsule

01997653 DANTRIUM PGP

12:20.12 GABA-DERIVATIVE SKELETAL

MUSCLE RELAXANTS

BACLOFEN

10MG Tablet

02139332 APO-BACLOFEN APX02152584 BACLOFEN PDL02287021 BACLOFEN SAN02138271 DOM-BACLOFEN DPC02088398 GEN-BACLOFEN GEN00455881 LIORESAL NVR02236963 PHL-BACLOFEN PHH02063735 PMS-BACLOFEN PMS02236507 RATIO-BACLOFEN RPH02242150 RIVA-BACLOFEN RIV

20MG Tablet

02139391 APO-BACLOFEN APX02152592 BACLOFEN PDL02287048 BACLOFEN SAN02138298 DOM-BACLOFEN DPC02088401 GEN-BACLOFEN GEN00636576 LIORESAL DS NVR02236964 PHL-BACLOFEN PHH02063743 PMS-BACLOFEN PMS02236508 RATIO-BACLOFEN RPH02242151 RIVA-BACLOFEN RIV

Page 20 of 1382014


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 or lozenges when one year has elapsed from the day the initial prescription was filled.

2MG GumST

02091933 NICORETTE JNO80000396 THRIVE NOV

4MG GumST

02091941 NICORETTE PLUS PMJ80000118 NICOTINE PER80000402 THRIVE NOV94799972 THRIVE NOV

NICOTINE (INHALER)


For smoking cessation:Coverage is limited to 945 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 or lozenges when one year has elapsed from the day the initial prescription was filled.

10MG InhalerST

02241742 NICORETTE JNO

NICOTINE (LOZENGES)

1MG Lozenges

80007461 THRIVE NOV94799970 THRIVE NOV

2MG LozengesST

02247347 NICORETTE JNO80007464 THRIVE NOV94799968 THRIVE NOV

4MG LozengesST

02247348 NICORETTE JNO


DRUGS

NICOTINE (PATCH)


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 168 patches or Nicoderm 140 patches or Nicotrol 140 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.

5MG PatchST

02028697 NICOTROL TRANSDERMAL 5MG

WAR

10MG PatchST


WAR

15MG PatchST


WAR

17.5MG PatchST

02241227 TRANSDERMAL NICOTINE NVC35MG Patch

ST

02241226 TRANSDERMAL NICOTINE NVC52.5MG Patch

ST

02241228 TRANSDERMAL NICOTINE NVC7MG Patch (Habitrol)

ST

01943057 HABITROL NVC14MG Patch (Habitrol)

ST

01943065 HABITROL NVC21MG Patch (Habitrol)

ST

01943073 HABITROL NVC36MG Patch (Nicoderm)

ST

02093111 NICODERM PMJ78MG Patch (Nicoderm)

ST

02093138 NICODERM PMJ114MG Patch (Nicoderm)

ST

02093146 NICODERM PMJ8.3MG/10CM2 Patch (Nicotrol)

ST

02065738 NICOTROL TRANSDERMAL JNO16.6MG/20CM2 Patch (Nicotrol)

ST

02065754 NICOTROL TRANSDERMAL JNO24.9MG/30CM2 Patch (Nicotrol)

ST

02065762 NICOTROL TRANSDERMAL JNO

Page 21 of 1382014



DRUGS

VARENICLINE


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 Tablet

02291177 CHAMPIX PFI1MG Tablet

02291185 CHAMPIX PFI0.5MG & 1MG Tablets

02298309 CHAMPIX STARTER PACK PFI

Page 22 of 1382014


20:00 BLOOD FORMATION

COAGULATION AND

THROMBOSIS

20:04.04 IRON PREPARATIONS

FERROUS FUMARATE

300MG CapsuleST

02237556 EURO-FER EUR00482064 NEO FER NEO01923420 PALAFER GSK

300MG/5ML Oral LiquidST

02246590 FERRATE O/L EUO20MG Suspension

ST

80029822 JAMP FERROUS FUMARATE JAP60MG/ML Suspension

ST

01923439 PALAFER GSK300MG Tablet

ST

00031089 FERROUS FUMARATE PED

FERROUS GLUCONATE

300MG TabletST

00545031 APO-FERROUS GLUCONATE APX00031097 FERROUS GLUCONATE PED00041157 FERROUS GLUCONATE PMS80009681 FERROUS GLUCONATE WAM80000435 NOVO-FERROGLUC TEV

324MG TabletST

00582727 FERROUS GLUCONATE VTH *

FERROUS SULFATE

15MG/ML DropST

02237385 FERODAN ODN02232202 PEDIAFER EUR02222574 PMS-FERROUS SULFATE PMS

75MG/ML DropST

00762954 FER-IN-SOL MJO30MG/ML Oral Liquid

80008295 JAMP FERROUS SULPHATE LIQUID

JAP

75MG/ML Oral Liquid

80008309 JAMP FERROUS SULPHATE INFANT

JAP

6MG/ML SyrupST

00017884 FER-IN-SOL MJO02242863 PEDIAFER EUR

30MG/ML SyrupST

00758469 FERODAN ODN00792675 PMS-FERROUS SULFATE PMS

300MG TabletST

01912518 APO-FERROUS SULFATE FC APX02246733 EURO-FERROUS SULFATE EUR02248699 FERODAN ODN00031100 FERROUS SULFATE PED00346918 FERROUS SULFATE PMT00782114 FERROUS SULFATE VTH *00586323 PMS-FERROUS SULFATE PMS

20:04.04 IRON PREPARATIONS

IRON

100MG CapsuleST

80024232 JAMP-FER JAP

IRON DEXTRAN

50MG/ML Injection

02205963 DEXIRON GEN02221780 INFUFER SDZ

IRON SUCROSE

20MG/ML Injection

02243716 VENOFER LUI

20:12.04 ANTICOAGULANTS

APIXABAN

Limited use benefit (prior approval required)

For at risk patients* with non-valvular atrial fibrillation who require apixaban for the prevention of stroke and systemic embolism AND in whom: trial of warfarin (please provide a copy of INR records for the last two months of warfarin therapy); OR inability to regularly monitor via INR testing (i.e., no access to INR testing services at a laboratory, clinic, pharmacy and at home).

* At risk patients with atrial fibrillation are defined as those with a CHADS2 score of ≥1.# Inadequate anticoagulation is defined as INR testing results that are outside the desired INR range for at least 35% of the tests during the monitoring period, i.e., adequate anticoagulation is defined as INR test results that are within the desired INR range for at least 65% of the tests during the monitoring period.

2.5MG Tablet

02377233 ELIQUIS BMS5MG Tablet

02397714 ELIQUIS BMS

DABIGATRAN ETEXILATE MESILATE


For at risk patients* with non-valvular atrial fibrillation who require dabigatran for the prevention of stroke and systemic embolism AND in whom: of warfarin (please provide a copy of INR records for the last two months of warfarin therapy); OR inability to regularly monitor via INR testing (i.e., no access to INR testing services at a laboratory, clinic, pharmacy and at home).

110MG Capsule

02312441 PRADAXA BOE150MG Capsule

02358808 PRADAXA BOE

Page 23 of 1382014



DALTEPARIN SODIUM

10,000IU/ML Injection

02132664 FRAGMIN PMJ25,000IU/ML Injection (Multi-Dose)

02231171 FRAGMIN PMJ2,500IU/0.2ML Injection (Pre-filled Syringe)

02132621 FRAGMIN PMJ5,000IU/0.2ML Injection (Pre-filled Syringe)

02132648 FRAGMIN PMJ7500IU/0.3ML Injection (Pre-filled Syringe)

02352648 FRAGMIN PFI10000IU/0.4ML Injection (Pre-filled Syringe)




02352680 FRAGMIN PFI

ENOXAPARIN SODIUM

30MG/0.3ML Injection

02012472 LOVENOX SAC40MG/0.4ML Injection



02378434 LOVENOX SAC100MG/1ML Injection


02242692 LOVONEX HP SAC150MG/1ML Injection

02378469 LOVONEX HP SAC300MG/3ML Injection

02236564 LOVENOX SAC

HEPARIN SODIUM

1,000U/ML Injection

00453811 HEPARIN LEO LEO02303086 HEPARIN SODIUM SDZ

5,000U/ML Injection

02382334 HEPARIN SODIUM PFI10,000U/ML Injection

00579718 HEPARIN LEO LEO02303094 HEPARIN SODIUM SDZ02303108 HEPARIN SODIUM SDZ

25,000U/ML Injection

00453781 HEPARIN LEO LEO10U/ML Lock Flush

00725323 HEPARIN LOCK FLUSH ABB


HEPARIN SODIUM

100U/ML Lock Flush

00727520 HEPARIN LEO LEO00725315 HEPARIN LOCK FLUSH HOS

NADROPARIN CALCIUM


02236913 FRAXIPARINE GSK19,000IU/ML Injection

02240114 FRAXIPARINE FORTE GSK

NICOUMALONE

1MG Tablet

00010383 SINTROM PED4MG Tablet

00010391 SINTROM PED

RIVAROXABAN


Criteria for Rivaroxaban 15 mg, 20mg tablets (Xarelto) for Stroke Prevention in Atrial Fibrillation (SPAF)For the prevention of stroke and systemic embolism in at-risk patients* who have non-valvular atrial fibrillation (AF) AND in whom: •Anticoagulation is inadequate# following a two-month trial on warfarin (please provide copy of INR records for the last two months of warfarin therapy); OR•Anticoagulation with warfarin is contraindicated; ;OR•Anticoagulation is not possible due to inability to regularly monitor via International Normalized Ratio (INR) testing (i.e., no access to INR testing service at a laboratory, clinic, pharmacy, and at home) Criteria for Rivaroxaban 15 mg, 20mg tablets (Xarelto) for Deep Vein Thrombosis (DVT)

•For the treatment of deep vein thrombosis (DVT) in patients without symptomatic pulmonary embolism (PE) for a duration of up to six months.

15MG Tablet

02378604 XARELTO BAY20MG Tablet

02378612 XARELTO B A

RIVAROXABAN (10)


For the prevention of venous thromboembolism following total knee replacement or total hip replacement surgery, for up to 35 days.

10MG Tablet

02316986 XARELTO BAY

TINZAPARIN SODIUM

10,000IU/ML (2ML) Injection

02167840 INNOHEP LEO20,000IU/ML (2ML) Injection

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

02231478 INNOHEP LEO

Page 24 of 1382014



TINZAPARIN SODIUM

10,000IU/ML Injection (Pre-filled Syringe)

02229755 INNOHEP LEO3500U SYG




02358182 INNOHEP LEO

WARFARIN SODIUM

1MG Tablet

02242924 APO-WARFARIN APX01918311 COUMADIN BMS02244462 GEN-WARFARIN GEN02265273 NOVO-WARFARIN TEV02242680 TARO-WARFARIN TAR02344025 WARFARIN SAN

2MG Tablet


2.5MG Tablet


3MG Tablet


4MG Tablet


5MG Tablet



WARFARIN SODIUM

6MG Tablet

02240206 COUMADIN BMS02287501 GEN-WARFARIN GEN02242686 TARO-WARFARIN TAR02344092 WARFARIN SAN

7.5MG Tablet

02287528 GEN-WARFARIN GEN02242697 TARO-WARFARIN TAR02344106 WARFARIN SAN

10MG Tablet

02242929 APO-WARFARIN APX01918362 COUMADIN BMS02244467 GEN-WARFARIN GEN02242687 TARO-WARFARIN TAR02344114 WARFARIN SAN

20:12.18 PLATELET AGGREGATION

INHIBITORS

ANAGRELIDE HCL

0.5MG CapsuleST

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

CLOPIDOGREL BISULFATE


Limit of 12 months following a client‟s initial cardiovascular event (stroke, acute coronary syndrome (ACS) or stent). Continued coverage beyond one year will be provided for patients with a previous stroke or transient ischemic attack (TIA) and be considered for patients with ACS or stent placement with appropriate rationale from the client`s cardiologist or treating physician.

75MG TabletST

02252767 APO-CLOPIDOGREL APX02385813 CLOPIDOGREL SIV02394820 CLOPIDOGREL PDL02400553 CLOPIDOGREL SAN02303027 CO CLOPIDOGREL ACT02378507 DOM-CLOPIDOGREL DOM02408910 MINT-CLOPIDOGREL MIN02351536 MYLAN-CLOPIDOGREL MYL02238682 PLAVIX SAC02348004 PMS CLOPIDOGREL PMS02379813 RAN-CLOPIDOGREL RBY02388529 RIVA CLOPIDOGREL RIV02359316 SANDOZ CLOPIDOGREL SDZ02293161 TEVA-CLOPIDOGREL TEP

TICLOPIDINE HCL

250MG TabletST

02237701 APO-TICLOPIDINE APX02239744 GEN-TICLOPIDINE GEN02236848 NOVO-TICLOPIDINE TEV02343045 TICLOPIDINE SAN

Page 25 of 1382014


20:16.00 HEMATOPOIETIC AGENTS

FILGRASTIM

300MCG/ML Injection

01968017 NEUPOGEN AMG

PEGFILGRASTIM


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 Injection

02249790 NEULASTA AMG

20:24.00 HEMORRHEOLOGIC AGENTS

PENTOXIFYLLINE


02230090 APO-PENTOXIFYL APX

20:28.16 HEMOSTATICS

TRANEXAMIC ACID

500MG Tablet

02064405 CYKLOKAPRON PFI02401231 TRANEXAMIC ACID STE

Page 26 of 1382014


24:00 CARDIOVASCULAR DRUGS

24:04.04 ANTIARRHYTHMIC AGENTS

AMIODARONE HCL

100MG TabletST

02292173 PMS-AMIODARONE PMS200MG Tablet

ST

02364336 AMIODARONE SAN02385465 AMIODARONE SIV02246194 APO-AMIODARONE APX02036282 CORDARONE WAY02246331 DOM-AMIODARONE PMS02240604 GEN-AMIODARONE GEN02239835 NOVO-AMIODARONE TEV02242472 PMS-AMIODARONE PMS02309661 PRO-AMIODARONE-200 PDL02240071 RATIO-AMIODARONE RPH02245781 RIVA-AMIODARONE PHH02247217 RIVA-AMIODARONE RIV02243836 SANDOZ-AMIODARONE SDZ

DISOPYRAMIDE

100MG CapsuleST

02224801 RYTHMODAN SAC

FLECAINIDE ACETATE

50MG TabletST

02275538 APO-FLECAINIDE APX01966197 TAMBOCOR MMH

100MG TabletST

02275546 APO-FLECAINIDE APX01966200 TAMBOCOR MMH

MEXILETINE HCL

100MG CapsuleST

02230359 NOVO-MEXILETINE TEV200MG Capsule

ST

02230360 NOVO-MEXILETINE TEV

PROCAINAMIDE HCL

250MG CapsuleST

00713325 APO-PROCAINAMIDE APX375MG Capsule

ST

00713333 APO-PROCAINAMIDE APX500MG Capsule

ST

00713341 APO-PROCAINAMIDE APX250MG Sustained Release Tablet

ST

00638692 PROCAN SR PFI500MG Sustained Release Tablet

ST

00638676 PROCAN SR PFI750MG Sustained Release Tablet

ST

00638684 PROCAN SR PFI

24:04.04 ANTIARRHYTHMIC AGENTS

PROPAFENONE HYDROCHLORIDE

150MG TabletST

02243324 APO-PROPAFENONE APX02245372 GEN-PROPAFENONE GEN02243727 PMS-PROPAFENONE PMS02294559 PMS-PROPAFENONE PMS02243783 PROPAFENONE PDL02343053 PROPAFENONE SAN00603708 RYTHMOL ABB

300MG TabletST

02243325 APO-PROPAFENONE APX02245373 GEN-PROPAFENONE GEN02243728 PMS-PROPAFENONE PMS02294575 PMS-PROPAFENONE PMS02243784 PROPAFENONE PDL02343061 PROPAFENONE SAN00603716 RYTHMOL ABB

24:04.08 CARDIOTONIC AGENTS

DIGOXIN

0.05MG/ML ElixirST

02242320 LANOXIN VIR0.0625MG Tablet

ST

02335700 TOLOXIN PED0.125MG Tablet

ST

02335719 TOLOXIN PED0.25MG Tablet

ST

02335727 TOLOXIN PED

24:06.04 BILE ACID SEQUESTRANTS

CHOLESTYRAMINE RESIN

4G PowderST

00890960 PMS-CHOLESTYRAMINE LIGHT PMS02210320 PMS-CHOLESTYRAMINE

REGULARPMS

COLESTIPOL HCL

5G GranulesST

00642975 COLESTID PFI02132699 COLESTID ORANGE PFI

1G TabletST

02132680 COLESTID PFI

Page 27 of 1382014


24:06.05 CHOLESTEROL ABSORPTION

INHIBITORS

EZETIMIBE


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 DERIVATIVES

BEZAFIBRATE


02083523 BEZALIP SR HLR200MG Tablet

ST

02240331 PMS-BEZAFIBRATE PMS

FENOFIBRATE

67MG CapsuleST

02243180 APO-FENO-MICRO APX02243551 NOVO-FENOFIBRATE TEV

100MG CapsuleST

02225980 APO-FENOFIBRATE APX160MG Capsule

ST

02250004 FENOMAX CIP200MG Capsule

ST

02239864 APO-FENO-MICRO APX02286092 FENOFIBRATE MICRO SAN02240360 FENO-MICRO PDL02240210 GEN-FENOFIBRATE GEN02146959 LIPIDIL MICRO FOU02243552 NOVO-FENOFIBRATE TEV02250039 RATIO-FENOFIBRATE RPH02247306 RIVA-FENOFIBRATE MICRO RIV

48MG TabletST

02269074 LIPIDIL EZ FOU02390698 SANDOZ FENOFIBRATE E SDZ

100MG TabletST

02246859 APO-FENO-SUPER APX02356570 FENOFIBRATE-S SAN02241601 LIPIDIL SUPRA FOU02289083 NOVO-FENOFIBRATE-S TEV02310228 PRO-FENO-SUPER PDL02288044 SANDOZ FENOFIBRATE S SDZ

145MG TabletST

02269082 LIPIDIL EZ FOU02390701 SANDOZ FENOFIBRATE E SDZ

24:06.06 FIBRIC ACID DERIVATIVES

FENOFIBRATE

160MG TabletST

02246860 APO-FENO-SUPER APX02356589 FENOFIBRATE-S SAN02241602 LIPIDIL SUPRA FOU02289091 NOVO-FENOFIBRATE-S TEV02310236 PRO-FENO-SUPER PDL02288052 SANDOZ FENOFIBRATE S SDZ

GEMFIBROZIL

300MG CapsuleST

01979574 APO-GEMFIBROZIL APX02241608 DOM-GEMFIBROZIL DPC02185407 GEN-FIBRO GEN02241704 NOVO-GEMFIBROZIL TEV02239951 PMS-GEMFIBROZIL PMS

600MG TabletST

01979582 APO-GEMFIBROZIL APX02230580 DOM-GEMFIBROZIL DPC02136058 GEMFIBROZIL PDL02230476 GEN-GEMFIBROZIL GEN02142074 NOVO-GEMFIBROZIL TEV02242126 RIVA-GEMFIBROZIL RIV

24:06.08 HMG-COA REDUCTASE

INHIBITORS

ATORVASTATIN CALCIUM

10MG TabletST

02295261 APO-ATORVASTATIN APX02346486 ATORVASTATIN PDL02348624 ATORVASTATIN RPH02348705 ATORVASTATIN SAN02387891 ATORVASTATIN SIV02396424 ATORVASTATIN APX02411350 ATORVASTATIN-10 SIV02310899 CO ATORVASTATIN ACT02355612 DOM-ATORVASTATIN DOM02288346 GD-ATORVASTATIN PFI02391058 JAMP-ATORVASTATIN JAP02230711 LIPITOR PFI02373203 MYLAN-ATORVASTATIN MYL02302675 NOVO-ATORVASTATIN TEV02313448 PMS-ATORVASTATIN PMS02399377 PMS-ATORVASTATIN PMS02313707 RAN-ATORVASTATIN RBY02350297 RATIO-ATORVASTATIN RPH02324946 SANDOZ ATORVASTATIN SDZ

Page 28 of 1382014



INHIBITORS


20MG TabletST


40MG TabletST



INHIBITORS


80MG TabletST

02295318 APO-ATORVASTATIN APX02346516 ATORVASTATIN PDL02348659 ATORVASTATIN RPH02348748 ATORVASTATIN SAN02387921 ATORVASTATIN SIV02396459 ATORVASTATIN APX02411385 ATORVASTATIN-80 SIV02310929 CO ATORVASTATIN ACT02288370 GD-ATORVASTATIN PFI02390182 JAMP-ATORVASTATIN JAP02243097 LIPITOR PFI02373246 MYLAN-ATORVASTATIN MYL02302713 NOVO-ATORVASTATIN TEV02313472 PMS-ATORVASTATIN PMS02399407 PMS-ATORVASTATIN PMS02313758 RAN-ATORVASTATIN RBY02350335 RATIO-ATORVASTATIN RPH02324970 SANDOZ ATORVASTATIN SDZ

FLUVASTATIN SODIUM

20MG CapsuleST

02061562 LESCOL NVR02400235 SANDOZ FLUVASTATIN SDZ02299224 TEVA-FLUVASTATIN TEP

40MG CapsuleST

02061570 LESCOL NVR02400243 SANDOZ FLUVASTATIN SDZ02299232 TEVA-FLUVASTATIN TEP

80MG Extended Release TabletST

02250527 LESCOL XL NOV

LOVASTATIN

20MG TabletST

02220172 APO-LOVASTATIN APX02248572 CO-LOVASTATIN ACT02243127 GEN-LOVASTATIN GEN02353229 LOVASTATIN SAN00795860 MEVACOR FRS02246542 NOVO-LOVASTATIN TEV02246013 PMS-LOVASTATIN PMS02312670 PRO-LOVASTATIN PDL02272288 RIVA-LOVASTATIN RIV02247056 SANDOZ-LOVASTATIN SDZ

40MG TabletST

02220180 APO-LOVASTATIN APX02248573 CO-LOVASTATIN ACT02243129 GEN-LOVASTATIN GEN02353237 LOVASTATIN SAN00795852 MEVACOR FRS02246543 NOVO-LOVASTATIN TEV02246014 PMS-LOVASTATIN PMS02312689 PRO-LOVASTATIN PDL02272296 RIVA-LOVASTATIN RIV02247057 SANDOZ-LOVASTATIN SDZ

Page 29 of 1382014



INHIBITORS

PRAVASTATIN SODIUM

10MG TabletST

02243506 APO-PRAVASTATIN APX02248182 CO PRAVASTATIN 10MG TAB ACT02249723 DOM-PRAVASTATIN DPC02257092 GEN-PRAVASTATIN GEN02330954 JAMP-PRAVASTATIN JAP02317451 MINT-PRAVASTATIN MIN02247008 NOVO-PRAVASTATIN TEV02249766 PHL-PRAVASTATIN PMI02247655 PMS-PRAVASTATIN PMS00893749 PRAVACHOL BMS02356546 PRAVASTATIN SAN02389703 PRAVASTATIN SIV02243824 PRAVASTATIN-10 PDL02284421 RAN-PRAVASTATIN RBY02246930 RATIO-PRAVASTATIN RPH02247856 RHOXAL-PRAVASTATIN RHO02270234 RIVA-PRAVASTATIN RIV02301792 ZYM-PRAVASTATIN SOR

20MG TabletST



INHIBITORS

PRAVASTATIN SODIUM

40MG TabletST


ROSUVASTATIN CALCIUM

5MG TabletST

02337975 APO-ROSUVASTATIN APX02339765 CO ROSUVASTATIN ACT02265540 CRESTOR AZC02386704 DOM-ROSUVASTATIN DOM02391252 JAMP-ROSUVASTATIN JAP02397781 MINT-ROSUVASTATIN MIN02381265 MYLAN-ROSUVASTATIN MYL02378523 PMS-ROSUVASTATIN PMS02382644 RAN-ROSUVASTATIN RBY02380013 RIVA-ROSUVASTATIN RIV02381176 ROSUVASTATIN PDL02389037 ROSUVASTATIN SIV02405628 ROSUVASTATIN SAN02411628 ROSUVASTATIN-5 SIV02338726 SANDOZ ROSUVASTATIN SDZ02354608 TEVA-ROSUVASTATIN TEP

10MG TabletST


Page 30 of 1382014



INHIBITORS

ROSUVASTATIN CALCIUM

20MG TabletST


40MG TabletST

02338009 APO-ROSUVASTATIN APX02339803 CO ROSUVASTATIN ACT02247164 CRESTOR AZC02391287 JAMP-ROSUVASTATIN JAP02397838 MINT-ROSUVASTATIN MIN02381303 MYLAN-ROSUVASTATIN MYL02378566 PMS-ROSUVASTATIN PMS02382679 RAN-ROSUVASTATIN RBY02380102 RIVA-ROSUVASTATIN RIV02381206 ROSUVASTATIN PDL02389061 ROSUVASTATIN SIV02405652 ROSUVASTATIN SAN02411652 ROSUVASTATIN-40 SIV02338750 SANDOZ ROSUVASTATIN SDZ02354632 TEVA-ROSUVASTATIN TEP


INHIBITORS

SIMVASTATIN

5MG TabletST

02247011 APO-SIMVASTATIN APX02248103 CO-SIMVASTATIN ACT02253747 DOM-SIMVASTATIN DPC02281619 DOM-SIMVASTATIN PMS02246582 GEN-SIMVASTATIN GEN02331020 JAMP-SIMVASTATIN JAP02375591 JAMP-SIMVASTATIN JAP02375036 MAR-SIMVASTATIN MAR02372932 MINT-SIMVASTATIN MIN02250144 NOVO-SIMVASTATIN TEV02281546 PHL-SIMVASTATIN PMI02252619 PMS-SIMVASTATIN PMS02269252 PMS-SIMVASTATIN PMS02329131 RAN-SIMVASTATIN RBY02247067 RATIO-SIMVASTATIN RPH02247827 RHOXAL-SIMVASTATIN RHO02247297 RIVA-SIMVASTATIN RIV02284723 SIMVASTATIN SAN02386291 SIMVASTATIN SIV02378884 SIMVASTATIN-ODAN ODN00884324 ZOCOR FRS02300907 ZYM-SIMVASTATIN ZYM

10MG TabletST

02247012 APO-SIMVASTATIN APX02248104 CO-SIMVASTATIN ACT02253755 DOM-SIMVASTATIN DPC02281627 DOM-SIMVASTATIN PMS02246583 GEN-SIMVASTATIN GEN02331039 JAMP-SIMVASTATIN JAP02375605 JAMP-SIMVASTATIN JAP02375044 MAR-SIMVASTATIN MAR02372940 MINT-SIMVASTATIN MIN02250152 NOVO-SIMVASTATIN TEV02281554 PHL-SIMVASTATIN PMI02252635 PMS-SIMVASTATIN PMS02269260 PMS-SIMVASTATIN PMS02329158 RAN-SIMVASTATIN RBY02247068 RATIO-SIMVASTATIN RPH02247298 RIVA-SIMVASTATIN RIV02247828 SANDOZ-SIMVASTATIN SDZ02284731 SIMVASTATIN SAN02386305 SIMVASTATIN SIV02247221 SIMVASTATIN-10 PDL02378892 SIMVASTATIN-ODAN ODN02265885 TARO-SIMVASTATIN TAR00884332 ZOCOR FRS02300915 ZYM-SIMVASTATIN ZYM

Page 31 of 1382014



INHIBITORS

SIMVASTATIN

20MG TabletST

02247013 APO-SIMVASTATIN APX02248105 CO-SIMVASTATIN ACT02253763 DOM-SIMVASTATIN DPC02281635 DOM-SIMVASTATIN PMS02246737 GEN-SIMVASTATIN GEN02331047 JAMP-SIMVASTATIN JAP02375613 JAMP-SIMVASTATIN JAP02375052 MAR-SIMVASTATIN MAR02372959 MINT-SIMVASTATIN MIN02250160 NOVO-SIMVASTATIN TEV02281562 PHL-SIMVASTATIN PMI02252643 PMS-SIMVASTATIN PMS02269279 PMS-SIMVASTATIN PMS02329166 RAN-SIMVASTATIN RBY02247299 RIVA-SIMVASTATIN RIV02247830 SANDOZ-SIMVASTATIN SDZ02284758 SIMVASTATIN SAN02386313 SIMVASTATIN SIV02247222 SIMVASTATIN-20 PDL02378906 SIMVASTATIN-ODAN ODN02265893 TARO-SIMVASTATIN TAR00884340 ZOCOR FRS02300923 ZYM-SIMVASTATIN ZYM

40MG TabletST

02247014 APO-SIMVASTATIN APX02248106 CO-SIMVASTATIN ACT02253771 DOM-SIMVASTATIN DPC02281643 DOM-SIMVASTATIN PMS02246584 GEN-SIMVASTATIN GEN02331055 JAMP-SIMVASTATIN JAP02375621 JAMP-SIMVASTATIN JAP02375060 MAR-SIMVASTATIN MAR02372967 MINT-SIMVASTATIN MIN02250179 NOVO-SIMVASTATIN TEV02281570 PHL-SIMVASTATIN PMI02252651 PMS-SIMVASTATIN PMS02269287 PMS-SIMVASTATIN PMS02329174 RAN-SIMVASTATIN RBY02247300 RIVA-SIMVASTATIN RIV02247831 SANDOZ-SIMVASTATIN SDZ02284766 SIMVASTATIN SAN02386321 SIMVASTATIN SIV02247223 SIMVASTATIN-40 PDL02378914 SIMVASTATIN-ODAN ODN02265907 TARO-SIMVASTATIN TAR00884359 ZOCOR FRS02300931 ZYM-SIMVASTATIN ZYM


INHIBITORS

SIMVASTATIN

80MG TabletST

02247015 APO-SIMVASTATIN APX02248107 CO-SIMVASTATIN ACT02253798 DOM-SIMVASTATIN DPC02281651 DOM-SIMVASTATIN PMS02246585 GEN-SIMVASTATIN GEN02331063 JAMP-SIMVASTATIN JAP02375648 JAMP-SIMVASTATIN JAP02375079 MAR-SIMVASTATIN MAR02372975 MINT-SIMVASTATIN MIN02250187 NOVO-SIMVASTATIN TEV02281589 PHL-SIMVASTATIN PMI02252678 PMS-SIMVASTATIN PMS02269295 PMS-SIMVASTATIN PMS02329182 RAN-SIMVASTATIN RBY02247071 RATIO-SIMVASTATIN RPH02247301 RIVA-SIMVASTATIN RIV02247833 SANDOZ-SIMVASTATIN SDZ02247224 SIMVASTATIN PDL02284774 SIMVASTATIN SAN02386348 SIMVASTATIN SIV02378922 SIMVASTATIN-ODAN ODN02240332 ZOCOR FRS02300974 ZYM-SIMVASTATIN ZYM

24:08.16 CENTRAL ALPHA-AGONISTS

CLONIDINE HCL

0.025MG TabletST

00519251 DIXARIT BOE02304163 NOVO-CLONIDINE TEV

0.1MG TabletST

00259527 CATAPRES BOE01910396 CLONIDINE PRO02046121 NOVO-CLONIDINE TEV

0.2MG TabletST

00868957 APO-CLONIDINE APX00291889 CATAPRES BOE01908162 CLONIDINE PRO02046148 NOVO-CLONIDINE TEV

METHYLDOPA

125MG TabletST

00360252 APO-METHYLDOPA APX250MG Tablet

ST

00360260 APO-METHYLDOPA APX500MG Tablet

ST

00426830 APO-METHYLDOPA APX

METHYLDOPA, HYDROCHLOROTHIAZIDE

250MG & 15MG TabletST

00441708 APO-METHAZIDE-15 APX250MG & 25MG Tablet

ST

00441716 APO-METHAZIDE-25 APX

Page 32 of 1382014


24:08.20 DIRECT VASODILATORS

DIAZOXIDE

100MG CapsuleST

00503347 PROGLYCEM SCH

HYDRALAZINE HCL

10MG TabletST

00441619 APO-HYDRALAZINE APX01913638 HYDRALAZINE PDL

25MG TabletST

00441627 APO-HYDRALAZINE APX50MG Tablet

ST

00441635 APO-HYDRALAZINE APX00759481 NOVO-HYLAZIN TEV

MINOXIDIL

2.5MG TabletST

00514497 LONITEN PFI10MG Tablet

ST

00514500 LONITEN PFI

24:12.08 NITRATES AND NITRITES

ISOSORBIDE DINITRATE

5MG Sublingual TabletST

00670944 APO-ISDN APX10MG Tablet

ST

00441686 APO-ISDN APX00786667 PMS-ISOSORBIDE PMS

30MG TabletST

00441694 APO-ISDN APX

ISOSORBIDE-5-MONONITRATE


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

NITROGLYCERIN

2% Ointment

01926454 NITROL SQU0.2 Patch

ST

02407442 MYLAN-NITRO MYL0.2MG Patch

ST

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

0.4 PatchST


ST


0.6 PatchST

02407469 MYLAN-NITRO MYL

24:12.08 NITRATES AND NITRITES

NITROGLYCERIN

0.6MG PatchST


0.8 PatchST


ST

02011271 NITRO-DUR KEY0.4MG Spray

ST

02393433 APO-NITROGLYCERIN APX02243588 GEN-NITRO GEN02238998 RHO-NITRO PUMPSPRAY SAC

0.4MG/DOSE Spray

02231441 NITROLINGUAL PUMPSPRAY SAC0.3MG Sublingual Tablet

00037613 NITROSTAT PFI0.6MG Sublingual Tablet

00037621 NITROSTAT PFI

24:12.12 PHOSPHODIESTERASE

INHIBITORS

SILDENAFIL CITRATE


Maximum dose covered is 20 mg three times a day

Patients with World Health Organization (WHO) class III pulmonary artery hypertension (PAH), either idiopathic (i.e. primary) or associated with a congenital or systemic condition (e.g. connective tissue disease) and confirmed by right heart catheterization; ANDwho have failed to respond to conventional therapy; ORwho have contraindications to conventional agents.

20MG TabletST

02319500 RATIO-SILDENAFIL R TEP02279401 REVATIO PFI

TADALAFIL


Maximum dose covered is 40 mg daily

Patients with World Health Organization (WHO) class III pulmonary artery hypertension (PAH), either idiopathic (i.e. primary) or associated with a congenital or systemic condition (e.g. connective tissue disease) and confirmed by right heart catheterization; ANDwho have failed to respond to conventional therapy; ORwho have contraindications to conventional agents

20MG TabletST

02338327 ADCIRCA LIL

Page 33 of 1382014



VASODILATING AGENTS

AMBRISENTAN


Maximum dose covered is 10 mg once daily. Patients with World Health Organization (WHO) class III pulmonary artery hypertension (PAH), either idiopathic (i.e. primary) or associated with a congenital or systemic condition (e.g. connective tissue disease) and confirmed by right heart catheterization; AND-who have failed to respond to sildenafil OR tadalafil; OR-who have contraindications to sildenafil OR tadalafil.

5MG TabletST

02307065 VOLIBRIS GSK10MG Tablet

ST

02307073 VOLIBRIS GSK

BOSENTAN

Limited use benefit (prior approval required). Maximum dose covered is 125 mg twice daily

-Patients with World Health Organization (WHO) class III pulmonary artery hypertension (PAH), either idiopathic (i.e. primary) or associated with a congenital or systemic condition (e.g. connective tissue disease) and confirmed by right heart catheterization; AND-who have failed to respond to sildenafil OR tadalafil; OR-who have contraindications to sildenafil OR tadalafil.

62.5MG TabletST

02386194 CO BOSENTAN ACT02383497 MYLAN-BOSENTAN MYL02383012 PMS-BOSENTAN PMS02386275 SANDOZ BOSENTAN SDZ02244981 TRACLEER ACN

125MG TabletST

02386208 CO BOSENTAN ACT02383500 MYLAN-BOSENTAN MYL02383020 PMS-BOSENTAN PMS02386283 SANDOZ BOSENTAN SDZ02244982 TRACLEER ACN

DIPYRIDAMOLE

25MG TabletST

00895644 APO-DIPYRIDAMOLE APX50MG Tablet

ST

00895652 APO-DIPYRIDAMOLE APX00571245 APO-DIPYRIDAMOLE SC APX

75MG TabletST

00895660 APO-DIPYRIDAMOLE APX00601845 APO-DIPYRIDAMOLE SC APX

DIPYRIDAMOLE, ACETYLSALICYLIC ACID


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

24:20.00 ALPHA ADRENERGIC BLOCKING

AGENTS

DOXAZOSIN MESYLATE

1MG TabletST

02240588 APO-DOXAZOSIN APX01958100 CARDURA 1 PFI02240978 DOXAZOSIN PDL02240498 GEN-DOXAZOSIN GEN02242728 NOVO-DOXAZOSIN TEV02244527 PMS-DOXAZOSIN PMS

2MG TabletST


4MG TabletST


PRAZOSIN HCL

1MG TabletST

00882801 APO-PRAZO APX00560952 MINIPRESS ERF01934198 NOVO-PRAZIN TEV

2MG TabletST


5MG TabletST


TERAZOSIN HCL

1MG TabletST

02234502 APO-TERAZOSIN APX02243746 DOM-TERAZOSIN DPC00818658 HYTRIN ABB02396289 MYLAN-TERAZOSIN MYL02230805 NOVO-TERAZOSIN TEV02237476 PDL-TERAZOSIN PDL02243518 PMS-TERAZOSIN PMS02218941 RATIO-TERAZOSIN RPH02350475 TERAZOSIN SAN

Page 34 of 1382014


24:20.00 ALPHA ADRENERGIC BLOCKING

AGENTS

TERAZOSIN HCL

2MG TabletST


5MG TabletST


10MG TabletST


24:24.00 BETA ADRENERGIC BLOCKING

AGENTS

ACEBUTOLOL HCL

100MG TabletST

02164396 ACEBUTOLOL PDL02286246 ACEBUTOLOL SAN02147602 APO-ACEBUTOLOL APX02237721 GEN-ACEBUTOLOL GEN02237885 GEN-ACEBUTOLOL (TYPE S) GEN02204517 NOVO-ACEBUTOLOL TEV02257599 SANDOZ-ACEBUTOLOL SDZ01926543 SECTRAL SAC

200MG TabletST



AGENTS

ACEBUTOLOL HCL

400MG TabletST


ATENOLOL

25MG TabletST

02303647 GEN-ATENOLOL GEN02367556 JAMP-ATENOLOL JAP02371979 MAR-ATENOLOL MAR02368013 MINT-ATENOLOL MIN02266660 NOVO-ATENOL TEV02247182 PHL-ATENOLOL SIV02246581 PMS-ATENOLOL PMS02326701 PRO-ATENOLOL PDL02373963 RAN-ATENOLOL RBY02277379 RIVA-ATENOLOL RIV02368633 SEPTA-ATENOLOL SPT

50MG TabletST

00773689 APO-ATENOL APX00828807 ATENOLOL PDL02255545 CO-ATENOLOL ACT02229467 DOM-ATENOLOL DPC02146894 GEN-ATENOLOL GEN02367564 JAMP-ATENOLOL JAP02371987 MAR-ATENOLOL MAR02368021 MINT-ATENOLOL MIN01912062 NOVO-ATENOL TEV02238316 PHL-ATENOLOL PHH02237600 PMS-ATENOLOL PMS02267985 RAN-ATENOLOL RBY02171791 RATIO-ATENOLOL RPH02242094 RIVA-ATENOLOL RIV02231731 SANDOZ-ATENOLOL SDZ02368641 SEPTA-ATENOLOL SPT02039532 TENORMIN AZC

Page 35 of 1382014



AGENTS

ATENOLOL

100MG TabletST

00773697 APO-ATENOL APX00828793 ATENOLOL PDL02255553 CO-ATENOLOL ACT02229468 DOM-ATENOLOL DPC02147432 GEN-ATENOLOL GEN02367572 JAMP-ATENOLOL JAP02371995 MAR-ATENOLOL MAR02368048 MINT-ATENOLOL MIN01912054 NOVO-ATENOL TEV02238318 PHL-ATENOLOL PHH02237601 PMS-ATENOLOL PMS02267993 RAN-ATENOLOL RBY02171805 RATIO-ATENOLOL RPH02242093 RIVA-ATENOLOL RIV02368668 SEPTA-ATENOLOL SPT02039540 TENORMIN AZC

ATENOLOL, CHLORTHALIDONE


02248763 APO-ATENIDONE APX02302918 NOVO-ATENOLTHALIDONE TEV02049961 TENORETIC AZC


02248764 APO-ATENIDONE APX02302926 NOVO-ATENOLTHALIDONE TEV02049988 TENORETIC AZC

BISOPROLOL FUMARATE

5MG TabletST

02256134 APO-BISOPROLOL APX02321556 BISOPROLOL SOR02383055 BISOPROLOL SIV02391589 BISOPROLOL SAN02384418 MYLAN-BISOPROLOL MYL02267470 NOVO-BIPOPROLOL TEV02302632 PMS-BISOPROLOL PMS02306999 PRO-BISOPROLOL-5 PDL02247439 SANDOZ-BISOPROLOL SDZ

10MG TabletST

02256177 APO-BISOPROLOL APX02321572 BISOPROLOL SOR02383063 BISOPROLOL SIV02391597 BISOPROLOL SAN02384426 MYLAN-BISOPROLOL MYL02267489 NOVO-BIPOPROLOL TEV02302640 PMS-BISOPROLOL PMS02307006 PRO-BISOPROLOL-10 PDL02247440 SANDOZ-BISOPROLOL SDZ


AGENTS

CARVEDILOL

3.125MG TabletST

02247933 APO-CARVEDILOL APX02248752 CARVEDILOL SIV02364913 CARVEDILOL SAN02248748 DOM-CARVEDILOL DPC02368897 JAMP-CARVEDILOL JAP02347512 MYLAN-CARVEDILOL MYL02245914 PMS-CARVEDILOL PMS02324504 PRO-CARVEDILOL PDL02268027 RAN-CARVEDILOL RBY02252309 RATIO-CARVEDILOL RPH02338068 ZYM-CARVEDILOL ZYM

6.25MG TabletST


12.5MG TabletST


25MG TabletST


LABETALOL HCL

100MG TabletST

02106272 TRANDATE SHI200MG Tablet

ST

02106280 TRANDATE SHI

Page 36 of 1382014



AGENTS

METOPROLOL TARTRATE


02285169 APO-METOPROLOL SR APX00658855 LOPRESOR SR NVR02351404 METOPROLOL SR PDL02303396 SANDOZ-METOPROLOL SR SDZ


02285177 APO-METOPROLOL SR APX00534560 LOPRESOR SR NVR02351412 METOPROLOL SR PDL02303418 SANDOZ-METOPROLOL SR SDZ

25MG TabletST

02246010 APO-METOPROLOL APX02252252 DOM-METOPROLOL-L DPC02302055 GEN-METOPROLOL (TYPE L) GEN02356813 JAMP-METOPROLOL-L JAP02296713 METOPROLOL-25 PDL02315106 METOPROLOL-L SOR02261898 NOVO-METOPROL CT TEV02248855 PMS-METOPROLOL-L PMS02315300 RIVA-METOPROLOL L RIV

50MG TabletST

00618632 APO-METOPROLOL APX00749354 APO-METOPROLOL-L APX02172550 DOM-METOPROLOL-B DPC02231121 DOM-METOPROLOL-L DPC02174545 GEN-METOPROLOL-L GEN02356821 JAMP-METOPROLOL-L JAP00397423 LOPRESOR NVR00648019 METOPROLOL PDL02350394 METOPROLOL SAN02315114 METOPROLOL-L SOR00648035 NOVO-METOPROL TEV00842648 NOVO-METOPROL TEV02145413 PMS-METOPROLOL-B PMS02230803 PMS-METOPROLOL-L PMS02315319 RIVA-METOPROLOL L RIV02354187 SANDOZ METOPROLOL (L) SDZ

100MG TabletST

00618640 APO-METOPROLOL APX00751170 APO-METOPROLOL-L APX02172569 DOM-METOPROLOL-B DPC02231122 DOM-METOPROLOL-L DPC02174553 GEN-METOPROLOL-L GEN02356848 JAMP-METOPROLOL-L JAP00397431 LOPRESOR NVR00648027 METOPROLOL PDL02350408 METOPROLOL SAN02315122 METOPROLOL-L SOR00648043 NOVO-METOPROL TEV00842656 NOVO-METOPROL-B TEV02145421 PMS-METOPROLOL-B PMS02230804 PMS-METOPROLOL-L PMS02315327 RIVA-METOPROLOL L RIV02354195 SANDOZ METOPROLOL (L) SDZ


AGENTS

NADOLOL

40MG TabletST

00782505 APO-NADOL APX00828815 NADOLOL PDL

80MG TabletST

00782467 APO-NADOL APX00818704 NADOLOL PDL

160MG TabletST

00782475 APO-NADOL APX

PINDOLOL

5MG TabletST

00755877 APO-PINDOL APX02231650 DOM-PINDOLOL DPC00869007 NOVO-PINDOL TEV00828416 PINDOLOL PDL02231536 PMS-PINDOLOL PMS02261782 SANDOZ-PINDOLOL SDZ00417270 VISKEN NVR

10MG TabletST


15MG TabletST


PINDOLOL, HYDROCHLOROTHIAZIDE


00568627 VISKAZIDE NVR10MG & 50MG Tablet

ST

00568635 VISKAZIDE NVR

PROPRANOLOL HCL

60MG Long Acting CapsuleST

02042231 INDERAL LA WAY80MG Long Acting Capsule

ST


ST


ST

02042274 INDERAL LA WAY10MG Tablet

ST

02137313 DOM-PROPRANOLOL DPC00496480 NOVO-PRANOL TEV

Page 37 of 1382014



AGENTS

PROPRANOLOL HCL

20MG TabletST

00740675 NOVO-PRANOL TEV40MG Tablet

ST

02137321 DOM-PROPRANOLOL DPC00496499 NOVO-PRANOL TEV

80MG TabletST

02137348 DOM-PROPRANOLOL DPC00496502 NOVO-PRANOL TEV00582271 PMS-PROPRANOLOL PMS

120MG TabletST

00504335 APO-PROPRANOLOL APX00582298 PMS-PROPRANOLOL PMS

SOTALOL HCL

80MG TabletST

02210428 APO-SOTALOL APX02270625 CO-SOTALOL ACT02238634 DOM-SOTALOL DPC02229778 GEN-SOTALOL GEN02368617 JAMP-SOTALOL JAP02231181 NOVO-SOTALOL TEV02238768 PHL-SOTALOL PHH02238326 PMS-SOTALOL PMS02316528 PRO-SOTALOL PDL02084228 RATIO-SOTALOL RPH02242156 RIVA-SOTALOL RIV02257831 SANDOZ-SOTALOL SDZ02385988 SOTALOL SIV

160MG TabletST

02167794 APO-SOTALOL APX02270633 CO-SOTALOL ACT02238635 DOM-SOTALOL DPC02229779 GEN-SOTALOL GEN02368625 JAMP-SOTALOL JAP02231182 NOVO-SOTALOL TEV02238769 PHL-SOTALOL PHH02238327 PMS-SOTALOL PMS02316536 PRO-SOTALOL PDL02084236 RATIO-SOTALOL RPH02257858 RHOXAL-SOTALOL RHO02242157 RIVA-SOTALOL RIV02385996 SOTALOL SIV

TIMOLOL MALEATE

5MG TabletST

00755842 APO-TIMOL APX01947796 NOVO-TIMOL TEV00812455 TIMOLOL PDL

10MG TabletST

00755850 APO-TIMOL APX01947818 NOVO-TIMOL TEV00812447 TIMOLOL PDL


AGENTS

TIMOLOL MALEATE

20MG TabletST

00755869 APO-TIMOL APX01947826 NOVO-TIMOL TEV

24:28.08 DIHYDROPYRIDINES

AMLODIPINE

2.5MG TabletST

02326795 AMLODIPINE PDL02385783 AMLODIPINE SIV02378744 AMLODIPINE-ODAN ODN02326825 DOM-AMLODIPINE DOM02280124 GD-AMLODIPINE PFI02357186 JAMP-AMLODIPINE JAP02371707 MAR-AMLODIPINE MAR02326760 PHL-AMLODIPINE PMI02295148 PMS-AMLODIPINE PMS02398877 RAN-AMLODIPINE RBY02331489 RIVA-AMLODIPINE RIV02330474 SANDOZ-AMLODIPINE SDZ02357704 SEPTA-AMLODIPINE SPT

5MG TabletST

02341093 ACCEL-AMLODIPINE ACP02331284 AMLODIPINE SAN02385791 AMLODIPINE SIV02378760 AMLODIPINE-ODAN ODN02273373 APO-AMLODIPINE APX02397072 AURO-AMLODIPINE AUR02297485 CO AMLODIPINE ACT02326833 DOM-AMLODIPINE DOM02280132 GD-AMLODIPINE PFI02357194 JAMP-AMLODIPINE JAP02371715 MAR-AMLODIPINE MAR02362651 MINT-AMLODIPINE MIN02272113 MYLAN-AMLODIPINE MYL00878928 NORVASC PFI02326779 PHL-AMLODIPINE PMI02284065 PMS-AMLODIPINE PMS02321858 RAN-AMLODIPINE RBY02259605 RATIO-AMLODIPINE RPH02331497 RIVA-AMLODIPINE RIV02284383 SANDOZ-AMLODIPINE SDZ02357712 SEPTA-AMLODIPINE SPT02250497 TEVA-AMLODIPINE TEP02326809 ZYM-AMLODIPINE ZYM02342790 ZYM-AMLODIPINE ZYM

Page 38 of 1382014



AMLODIPINE

10MG TabletST

02341107 ACCEL-AMLODIPINE ACP02331292 AMLODIPINE SAN02385805 AMLODIPINE SIV02378779 AMLODIPINE-ODAN ODN02273381 APO-AMLODIPINE APX02397080 AURO-AMLODIPINE AUR02297493 CO AMLODIPINE ACT02326841 DOM-AMLODIPINE DOM02280140 GD-AMLODIPINE PFI02357208 JAMP-AMLODIPINE JAP02371723 MAR-AMLODIPINE MAR02362678 MINT-AMLODIPINE MIN02272121 MYLAN-AMLODIPINE MYL00878936 NORVASC PFI02326787 PHL-AMLODIPINE PMI02284073 PMS-AMLODIPINE PMS02321866 RAN-AMLODIPINE RBY02259613 RATIO-AMLODIPINE RPH02331500 RIVA-AMLODIPINE RIV02284391 SANDOZ-AMLODIPINE SDZ02357720 SEPTA-AMLODIPINE SPT02250500 TEVA-AMLODIPINE TEP02326817 ZYM-AMLODIPINE ZYM02342804 ZYM-AMLODIPINE ZYM

AMLODIPINE, ATORVASTATIN

5MG & 10MG TabletST

02273233 CADUET PFI02362759 GD-

AMLODIPINE/ATORVASTATINPFI

02404222 PMS-AMLODIPINE/ATORVASTATIN

PMS

5MG & 20MG TabletST

02273241 CADUET PFI02362767 GD-



PMS

5MG & 40MG TabletST

02273268 CADUET PFI02362775 GD-


5MG & 80MG TabletST

02273276 CADUET PFI02362783 GD-



02273284 CADUET PFI02362791 GD-



PMS


AMLODIPINE, ATORVASTATIN


02273292 CADUET PFI02362805 GD-



PMS


02273306 CADUET PFI02362813 GD-



02273314 CADUET PFI02362821 GD-


AMLODIPINE, TELMISARTAN

5MG & 40MG TabletST

02371022 TWYNSTA BOE5MG & 80MG Tablet

ST


ST


ST

02371057 TWYNSTA BOE

FELODIPINE

2.5MG Extended Release TabletST

02057778 PLENDIL AZC5MG Extended Release Tablet

ST

00851779 PLENDIL AZC02280264 SANDOZ-FELODIPINE SDZ09857203 SANDOZ-FELODIPINE SDZ *


00851787 PLENDIL AZC02280272 SANDOZ-FELODIPINE SDZ09857204 SANDOZ-FELODIPINE SDZ *

NIFEDIPINE

5MG CapsuleST

00725110 APO-NIFED APX02235897 PMS-NIFEDIPINE PMS

10MG CapsuleST

00755907 APO-NIFED APX02235898 PMS-NIFEDIPINE PMS


02237618 ADALAT XL BAY30MG Extended Release Tablet

ST

02155907 ADALAT XL BAY02349167 MYLAN-NIFEDIPINE ER MYL


02155990 ADALAT XL BAY02321149 MYLAN-NIFEDIPINE ER MYL


02197448 APO-NIFED PA APX

Page 39 of 1382014



NIFEDIPINE


02181525 APO-NIFED PA APX

NIMODIPINE

30MG TabletST

02325926 NIMOTOP BAY

24:28.92 MISCELLANEOUS CALCIUM-

CHANNEL BLOCKING AGENTS

DILTIAZEM HCL

120MG Controlled Delivery CapsuleST

02230997 APO-DILTIAZ CD APX02097249 CARDIZEM CD BPC02231472 DILTIAZEM CD PDL02400421 DILTIAZEM CD SAN02242538 NOVO-DILTAZEM CD TEV02355752 PMS-DILTIAZEM CD PMS02229781 RATIO-DILTIAZEM CD RPH02243338 SANDOZ-DILTIAZEM CD SDZ







120MG Extended Release CapsuleST

02291037 APO-DILTIAZ TZ APX02370611 CO DILTIAZEM CD ACT02370441 CO DILTIAZEM T ACT02231150 TIAZAC BPC



DILTIAZEM HCL








02291088 APO-DILTIAZ TZ APX02370522 CO DILTIAZEM T ACT02231155 TIAZAC BPC


02256738 TIAZAC XC BPC180MG Extended Release Tablet

ST


ST


ST


ST

02256770 TIAZAC XC BPC60MG Sustained Release Capsule

ST

02222957 APO-DILTIAZ SR APX90MG Sustained Release Capsule

ST

02222965 APO-DILTIAZ SR APX120MG Sustained Release Capsule

ST

02222973 APO-DILTIAZ SR APX02271605 NOVO-DILTIAZEM HCL ER BOV02245918 SANDOZ-DILTIAZEM T SDZ

180MG Sustained Release CapsuleST

02271613 NOVO-DILTIAZEM HCL ER BOV02245919 SANDOZ-DILTIAZEM T SDZ







Page 40 of 1382014




DILTIAZEM HCL

30MG TabletST

00771376 APO-DILTIAZ APX00828785 DILTIAZEM PDL00862924 NOVO-DILTIAZEM TEV

60MG TabletST

00771384 APO-DILTIAZ APX00828777 DILTIAZEM PDL00862932 NOVO-DILTIAZEM TEV

VERAPAMIL HCL


02231676 COVERA-HS PFI240MG Extended Release Tablet

ST

02231677 COVERA-HS PFI120MG Sustained Release Tablet

ST

02246893 APO-VERAP SR APX02210347 GEN-VERAPAMIL SR GEN01907123 ISOPTIN SR ABB02324156 PRO-VERAPAMIL SR PDL


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


02246895 APO-VERAP SR APX02240321 DOM-VERAPAMIL SR DPC02210363 GEN-VERAPAMIL SR GEN00742554 ISOPTIN SR ABB02211920 NOVO-VERAMIL SR TEV02238276 PHL-VERAPAMIL PHH02237791 PMS-VERAPAMIL SR PMS02312697 PRO-VERAPAMIL SR PDL02248082 RIVA-VERAPAMIL SR RIV

80MG TabletST

00782483 APO-VERAP APX02237921 GEN-VERAPAMIL GEN00812331 NOVO-VERAMIL TEV00871028 VERAPAMIL PDL

120MG TabletST

00782491 APO-VERAP APX02237922 GEN-VERAPAMIL GEN00812358 NOVO-VERAMIL TEV

24:32.04 ANGIOTENSIN-CONVERTING

ENZYME INHIBITORS

BENAZEPRIL HCL

5MG TabletST

02290332 APO-BENAZEPRIL APX00885835 LOTENSIN NVR

10MG TabletST

02290340 APO-BENAZEPRIL APX


ENZYME INHIBITORS

BENAZEPRIL HCL

20MG TabletST

02273918 APO-BENAZEPRIL APX00885851 LOTENSIN NVR

CAPTOPRIL

6.25MG TabletST

01999559 APO-CAPTO APX12.5MG Tablet

ST

00893595 APO-CAPTO APX02242788 CAPTOPRIL ZYM02238551 DOM-CAPTOPRIL DPC02163551 GEN-CAPTOPRIL GEN01942964 NOVO-CAPTORIL TEV

25MG TabletST

00893609 APO-CAPTO APX01910337 CAPTOPRIL PDL02242789 CAPTOPRIL ZYM02238552 DOM-CAPTOPRIL DPC02163578 GEN-CAPTOPRIL GEN01942972 NOVO-CAPTORIL TEV

50MG TabletST

00893617 APO-CAPTO APX02242790 CAPTOPRIL ZYM02238553 DOM-CAPTOPRIL DPC02163586 GEN-CAPTOPRIL GEN01942980 NOVO-CAPTORIL TEV

100MG TabletST

00893625 APO-CAPTO APX02242791 CAPTOPRIL ZYM02238554 DOM-CAPTOPRIL DPC02163594 GEN-CAPTOPRIL GEN01942999 NOVO-CAPTORIL TEV02230206 PMS-CAPTOPRIL PMS

CILAZAPRIL

1MG TabletST

02291134 APO-CILAZAPRIL APX02350963 CILAZAPRIL SAN02283778 GEN-CILAZAPRIL GEN02266350 NOVO-CILAZAPRIL TEV02280442 PMS-CILAZAPRIL PMS

2.5MG TabletST

02291142 APO-CILAZAPRIL APX02350971 CILAZAPRIL SAN02285215 CO CILAZAPRIL ACT02283786 GEN-CILAZAPRIL GEN01911473 INHIBACE HLR02266369 NOVO-CILAZAPRIL TEV02280450 PMS-CILAZAPRIL PMS

Page 41 of 1382014



ENZYME INHIBITORS

CILAZAPRIL

5MG TabletST

02291150 APO-CILAZAPRIL APX02350998 CILAZAPRIL SAN02285223 CO CILAZAPRIL ACT02283794 GEN-CILAZAPRIL GEN01911481 INHIBACE HLR02266377 NOVO-CILAZAPRIL TEV02280469 PMS-CILAZAPRIL PMS

CILAZAPRIL, HYDROCHLOROTHIAZIDE

5MG & 12.5MG TabletST

02284987 APO-CILAZAPRIL HCTZ APX02181479 INHIBACE PLUS HLR02313731 NOVO-CILAZAPRIL /HCTZ TEV

ENALAPRIL MALEATE

2.5MG TabletST

02020025 APO ENALAPRIL APX02291878 CO ENALAPRIL ACT02400650 ENALAPRIL SAN02300036 GEN-ENALAPRIL GEN02300680 NOVO-ENALAPRIL TEV02300079 PMS-ENALAPRIL PMS02311402 PRO-ENALAPRIL PDL02352230 RAN-ENALAPRIL RBY02299984 RATIO-ENALAPRIL RPH02300796 RIVA-ENALAPRIL RIV02299933 SANDOZ ENALAPRIL SDZ02323478 SIG-ENALAPRIL SIG02300117 TARO-ENALAPRIL TAR00851795 VASOTEC FRS

5MG TabletST



ENZYME INHIBITORS

ENALAPRIL MALEATE

10MG TabletST


20MG TabletST


ENALAPRIL MALEATE,

HYDROCHLOROTHIAZIDE


02352923 APO-ENALAPRIL MALEATE/HCTZ

APX

02300222 NOVO-ENALAPRIL/HCTZ TEV10MG & 25MG Tablet

ST

02352931 APO-ENALAPRIL MALEATE/HCTZ

APX

02300230 NOVO-ENALAPRIL/HCTZ TEV00657298 VASERETIC FRS

FOSINOPRIL SODIUM

10MG TabletST

02266008 APO-FOSINOPRIL APX02332566 FOSINOPRIL RBY02303000 FOSINOPRIL-10 PDL02262401 GEN-FOSINOPRIL GEN02331004 JAMP-FOSINOPRIL JAP01907107 MONOPRIL BMS02247802 NOVO-FOSINOPRIL TEV02255944 PMS-FOSINOPRIL PMS02294524 RAN-FOSINOPRIL RBY02265923 RIVA-FOSINOPRIL RIV

Page 42 of 1382014



ENZYME INHIBITORS

FOSINOPRIL SODIUM

20MG TabletST

02266016 APO-FOSINOPRIL APX02332574 FOSINOPRIL RBY02303019 FOSINOPRIL-20 PDL02262428 GEN-FOSINOPRIL GEN02331012 JAMP-FOSINOPRIL JAP01907115 MONOPRIL BMS02247803 NOVO-FOSINOPRIL TEV02255952 PMS-FOSINOPRIL PMS02294532 RAN-FOSINOPRIL RBY02265931 RIVA-FOSINOPRIL RIV

LISINOPRIL

5MG TabletST

09853685 APO-LISINOPRIL APX *02217481 APO-LISINOPRIL (TYPE Z) APX02394472 AURO-LISINOPRIL AUR02271443 CO LISINOPRIL ACT02274833 GEN-LISINOPRIL GEN02361531 JAMP-LISINOPRIL JAP02386232 LISINOPRIL SIV02285061 NOVO-LISINOPRIL (TYPE P) TEV02285118 NOVO-LISINOPRIL (TYPE Z) TEV02292203 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 APX *02217503 APO-LISINOPRIL (TYPE Z) APX02394480 AURO-LISINOPRIL AUR02271451 CO LISINOPRIL ACT02274841 GEN-LISINOPRIL GEN02361558 JAMP-LISINOPRIL JAP02386240 LISINOPRIL SIV02285088 NOVO-LISINOPRIL (TYPE P) TEV02285126 NOVO-LISINOPRIL (TYPE Z) TEV02292211 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


ENZYME INHIBITORS

LISINOPRIL

20MG TabletST

09854010 APO-LISINOPRIL APX *02217511 APO-LISINOPRIL (TYPE Z) APX02394499 AURO-LISINOPRIL AUR02271478 CO LISINOPRIL ACT02274868 GEN-LISINOPRIL GEN02361566 JAMP-LISINOPRIL JAP02386259 LISINOPRIL SIV02285096 NOVO-LISINOPRIL (TYPE P) TEV02285134 NOVO-LISINOPRIL (TYPE Z) TEV02292238 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, HYDROCHLOROTHIAZIDE


02261979 APO-LISINOPRIL/HCTZ APX02297736 GEN-LISINOPRIL HCTZ GEN02362945 LISINOPRIL/HCTZ (TYPE Z) SAN02302136 NOVO-LISINOPRIL/HCTZ

(TYPE P)TEV

02301768 NOVO-LISINOPRIL/HCTZ (TYPE Z)

TEV

02302365 SANDOZ LISINOPRIL HCT SDZ02103729 ZESTORETIC AZC


02261987 APO-LISINOPRIL/HCTZ APX02297744 GEN-LISINOPRIL HCTZ GEN02362953 LISINOPRIL/HCTZ (TYPE Z) SAN02302144 NOVO-LISINOPRIL (TYPE P) TEV02301776 NOVO-LISINOPRIL/HCTZ

(TYPE Z)TEV

00884413 PRINZIDE FRS02302373 SANDOZ LISINOPRIL HCT SDZ02045737 ZESTORETIC AZC


02261995 APO-LISINOPRIL/HCTZ APX02297752 GEN-LISINOPRIL HCTZ GEN02362961 LISINOPRIL/HCTZ (TYPE Z) SAN02302152 NOVO-LISINOPRIL/HCTZ

(TYPE P)TEV

02301784 NOVO-LISINOPRIL/HCTZ (TYPE Z)

TEV

02302381 SANDOZ LISINOPRIL HCT SDZ02045729 ZESTORETIC AZC

PERINDOPRIL ERBUMINE

2MG TabletST

02123274 COVERSYL SEV

Page 43 of 1382014



ENZYME INHIBITORS

PERINDOPRIL ERBUMINE

4MG TabletST

02123282 COVERSYL SEV8MG Tablet

ST

02246624 COVERSYL SEV

PERINDOPRIL ERBUMINE, INDAPAMIDE


02246569 COVERSYL PLUS SEV8MG/2.5MG Tablet

ST

02321653 COVERSYL PLUS HD SEV

QUINAPRIL HCL

5MG TabletST

01947664 ACCUPRIL PFI02248499 APO-QUINAPRIL APX

10MG TabletST


20MG TabletST


40MG TabletST


QUINAPRIL HCL, HYDROCHLOROTHIAZIDE


02237367 ACCURETIC PFI02408767 APO-QUINAPRIL/HCTZ APX





RAMIPRIL

1.25MG CapsuleST

02221829 ALTACE SAC02251515 APO-RAMIPRIL APX02387387 AURO-RAMIPRIL AUR02295482 CO RAMIPRIL ACT02308371 DOM-RAMIPRIL DOM02331101 JAMP-RAMIPRIL JAP02301148 MYLAN-RAMIPRIL MYL02295369 PMS-RAMIPRIL PMS02310023 PRO-RAMIPRIL PDL02299372 RAMIPRIL RIV02308363 RAMIPRIL SIV02310503 RAN-RAMIPRIL RBY02287692 RATIO-RAMIPRIL RPH


ENZYME INHIBITORS

RAMIPRIL

2.5MG CapsuleST

02221837 ALTACE SAC02251531 APO-RAMIPRIL APX02387395 AURO-RAMIPRIL AUR02295490 CO RAMIPRIL ACT02287951 DOM-RAMIPRIL DOM02331128 JAMP-RAMIPRIL JAP02301156 MYLAN-RAMIPRIL MYL02247945 NOVO-RAMIPRIL TEV02247917 PMS-RAMIPRIL PMS02310066 PRO-RAMIPRIL PDL02255316 RAMIPRIL PMS02287927 RAMIPRIL SIV02374846 RAMIPRIL SAN02411563 RAMIPRIL-2.5 SIV02310511 RAN-RAMIPRIL RBY02287706 RATIO-RAMIPRIL RPH

5MG CapsuleST

02221845 ALTACE SAC02251574 APO-RAMIPRIL APX02387409 AURO-RAMIPRIL AUR02295504 CO RAMIPRIL ACT02287978 DOM-RAMIPRIL DOM02331136 JAMP-RAMIPRIL JAP02301164 MYLAN-RAMIPRIL MYL02247946 NOVO-RAMIPRIL TEV02247918 PMS-RAMIPRIL PMS02310074 PRO-RAMIPRIL PDL02255324 RAMIPRIL PMS02287935 RAMIPRIL SIV02374854 RAMIPRIL SAN02411571 RAMIPRIL-5 SIV02310538 RAN-RAMIPRIL RBY

10MG CapsuleST

02221853 ALTACE SAC02251582 APO-RAMIPRIL APX02387417 AURO-RAMIPRIL AUR02295512 CO RAMIPRIL ACT02287986 DOM-RAMIPRIL DOM02331144 JAMP-RAMIPRIL JAP02301172 MYLAN-RAMIPRIL MYL02247947 NOVO-RAMIPRIL TEV02247919 PMS-RAMIPRIL PMS02310104 PRO-RAMIPRIL PDL02255332 RAMIPRIL PMS02287943 RAMIPRIL SIV02374862 RAMIPRIL SAN02411598 RAMIPRIL-10 SIV02310546 RAN-RAMIPRIL RBY

15MG CapsuleST

02325381 APO-RAMIPRIL APX02343932 PMS-RAMIPRIL PMS

1.25MG TabletST

02291398 SANDOZ RAMIPRIL SDZ

Page 44 of 1382014



ENZYME INHIBITORS

RAMIPRIL

2.5MG TabletST

02291401 SANDOZ RAMIPRIL SDZ5MG Tablet

ST

02291428 SANDOZ RAMIPRIL SDZ10MG Tablet

ST

02291436 SANDOZ RAMIPRIL SDZ

RAMIPRIL, HYDROCHLOROTHIAZIDE

2.5MG & 12.5MG TabletST

02283131 ALTACE HCT SAC02354004 APO-RAMIPRIL/HCTZ APX02342138 PMS-RAMIPRIL-HCTZ PMS02388332 TEVA-RAMIPRIL/HCTZ TEP



5MG & 25MG TabletST



02283166 ALTACE HCT SAC02342154 PMS-RAMIPRIL-HCTZ PMS02388359 TEVA-RAMIPRIL/HCTZ TEP



TRANDOLAPRIL

0.5MG CapsuleST

02231457 MAVIK ABB1MG Capsule

ST


ST


ST

02239267 MAVIK ABB

24:32.08 ANGIOTENSIN II RECEPTOR

ANTAGONISTS

CANDESARTAN CILEXETIL

4MG TabletST

02365340 APO-CANDESARTAN APX02239090 ATACAND AZE02388693 CANDESARTAN SIV02388901 CANDESARTAN SAN02376520 CO-CANDESARTAN ACT02386496 JAMP-CANDESARTAN JAP02379120 MYLAN-CANDESARTAN MYL02391171 PMS-CANDESARTAN PMS02380684 RAN-CANDESARTAN RBY02326957 SANDOZ CANDESARTAN SDZ

8MG TabletST

02365359 APO-CANDESARTAN APX02239091 ATACAND AZC02377934 CANDESARTAN PDL02388707 CANDESARTAN SIV02388928 CANDESARTAN SAN02376539 CO-CANDESARTAN ACT02395762 DOM-CANDESARTAN DOM02386518 JAMP-CANDESARTAN JAP02379139 MYLAN-CANDESARTAN MYL02391198 PMS-CANDESARTAN PMS02380692 RAN-CANDESARTAN RBY02326965 SANDOZ CANDESARTAN SDZ02366312 TEVA-CANDESARTAN TEP

16MG TabletST

02365367 APO-CANDESARTAN APX02239092 ATACAND AZC02377942 CANDESARTAN PDL02388715 CANDESARTAN SIV02388936 CANDESARTAN SAN02376547 CO-CANDESARTAN ACT02386526 JAMP-CANDESARTAN JAP02379147 MYLAN-CANDESARTAN MYL02391201 PMS-CANDESARTAN PMS02380706 RAN-CANDESARTAN RBY02326973 SANDOZ CANDESARTAN SDZ02366320 TEVA-CANDESARTAN TEP

32MG TabletST

02399105 APO-CANDESARTAN APX02311658 ATACAND AZE02376555 CO-CANDESARTAN ACT02386534 JAMP-CANDESARTAN JAP02379155 MYLAN-CANDESARTAN MYL02391228 PMS-CANDESARTAN PMS02380714 RAN-CANDESARTAN RBY02392267 SANDOZ CANDESARTAN SDZ02366339 TEVA-CANDESARTAN TEP

Page 45 of 1382014



ANTAGONISTS

CANDESARTAN CILEXETIL,

HYDROCHLOROTHIAZIDE


02367866 APO-CANDESARTAN/HCTZ APX02244021 ATACAND PLUS AZC02394812 CANDESARTAN HCT SIV02394804 CANDESARTAN/HCTZ SAN02388650 CO CANDESARTAN/HCTZ ACT02374897 MYLAN-CANDESART/HCTZ MYL02391295 PMS-CANDESARTAN/HCTZ ACT02327902 SANDOZ CANDESARTAN PLUS SDZ02395541 TEVA-CANDESARTAN/HCTZ TEP


02395126 APO-CANDESARTAN/HCTZ APX02332922 ATACAND PLUS AZE02395568 TEVA-CANDESARTAN/HCTZ TEP


02395134 APO-CANDESARTAN/HCTZ APX02332957 ATACAND PLUS AZE02395576 TEVA-CANDESARTAN/HCTZ TEP

EPOSARTAN MESYLATE

400MG TabletST

02240432 TEVETEN SPH600MG Tablet

ST

02243942 TEVETEN SPH

EPOSARTAN MESYLATE,

HYDROCHLOROTHIAZIDE

600MG/12.5MG TabletST

02253631 TEVETEN PLUS SPH

IRBESARTAN

150MG TabletST

02328089 CO IRBESARTAN ACT02372193 DOM-IRBESARTAN DOM02365200 IRBESARTAN PDL02372371 IRBESARTAN SAN02385295 IRBESARTAN SIV02347318 MYLAN-IRBESARTAN MYL02317079 PMS-IRBESARTAN PMS02406829 RAN-IRBESARTAN RBY02316404 RATIO-IRBESARTAN RTP02328488 SANDOZ IRBESARTAN SDZ02315998 TEVA-IRBESARTAN TEP

300MG TabletST

02328100 CO IRBESARTAN ACT02365219 IRBESARTAN PDL02372398 IRBESARTAN SAN02385309 IRBESARTAN SIV02347326 MYLAN-IRBESARTAN MYL02317087 PMS-IRBESARTAN PMS02406837 RAN-IRBESARTAN RBY02316412 RATIO-IRBESARTAN RTP02328496 SANDOZ IRBESARTAN SDZ02316005 TEVA-IRBESARTAN TEP


ANTAGONISTS

IRBESARTAN

75MG TabletST

02328070 CO IRBESARTAN ACT02365197 IRBESARTAN PDL02372347 IRBESARTAN SAN02385287 IRBESARTAN SIV02347296 MYLAN-IRBESARTAN MYL02317060 PMS-IRBESARTAN PMS02406810 RAN-IRBESARTAN RBY02316390 RATIO-IRBESARTAN RTP02328461 SANDOZ IRBESARTAN SDZ02315971 TEVA-IRBESARTAN TEP

75MG TabletST

02386968 APO-IRBESARTAN APX02237923 AVAPRO SAC

150MG TabletST


300MG TabletST


IRBESARTAN, HYDROCHLOROTHIAZIDE


02387646 APO-IRBESARTAN/HCTZ APX02241818 AVALIDE SAC02357399 CO IRBESARTAN/HCT ACT02385317 IRBESARTAN HCT SIV02365162 IRBESARTAN/HCTZ PDL02372886 IRBESARTAN/HCTZ SAN02392992 MINT-IRBESARTAN/HCTZ MIN02328518 PMS-IRBESARTAN/HCT PMS02363208 RAN-IRBESARTAN HCTZ RBY02330512 RATIO-IRBESARTAN HCTZ RTP02337428 SANDOZ IRBESARTAN HCTZ SDZ02316013 TEVA-IRBESARTAN/HCTZ TEP



Page 46 of 1382014



ANTAGONISTS

IRBESARTAN, HYDROCHLOROTHIAZIDE



LOSARTAN POTASSIUM

25MG TabletST

02379058 APO-LOSARTAN APX02354829 CO LOSARTAN ACT02182815 COZAAR FRS02398834 JAMP-LOSARTAN JAP02388790 LOSARTAN SIV02388863 LOSARTAN SAN02368277 MYLAN-LOSARTAN MYL02309750 PMS-LOSARTAN PMS02313332 SANDOZ LOSARTAN SDZ02380838 TEVA-LOSARTAN TEP

50MG TabletST

02353504 APO-LOSARTAN APX02354837 CO LOSARTAN ACT02182874 COZAAR FRS02398842 JAMP-LOSARTAN JAP02388804 LOSARTAN SIV02388871 LOSARTAN SAN02368285 MYLAN-LOSARTAN MYL02309769 PMS-LOSARTAN PMS02404478 RAN-LOSARTAN RBY02313340 SANDOZ LOSARTAN SDZ02357968 TEVA-LOSARTAN TEP

100MG TabletST

02353512 APO-LOSARTAN APX02354845 CO LOSARTAN ACT02182882 COZAAR FRS02398850 JAMP-LOSARTAN JAP02388812 LOSARTAN SIV02388898 LOSARTAN SAN02368293 MYLAN-LOSARTAN MYL02309777 PMS-LOSARTAN PMS02404486 RAN-LOSARTAN RBY02313359 SANDOZ LOSARTAN SDZ02357976 TEVA-LOSARTAN TEP


ANTAGONISTS

LOSARTAN POTASSIUM,

HYDROCHLOROTHIAZIDE


02371235 APO-LOSARTAN/HCTZ APX02388251 CO LOSARTAN/HCT ACT02230047 HYZAAR FRS02408244 JAMP-LOSARTAN HCTZ JAP02388960 LOSARTAN/HCT SIV02389657 MINT-LOSARTAN/HCTZ MIN02378078 MYLAN-LOSARTAN/HCTZ MYL02392224 PMS-LOSARTAN-HCTZ PMS02313375 SANDOZ LOSARTAN HCT SDZ02358263 TEVA-LOSARTAN HCTZ TEP


02371243 APO-LOSARTAN/HCTZ APX02388278 CO LOSARTAN/HCT ACT02297841 HYZAAR FRS02388979 LOSARTAN/HCT SIV02389665 MINT-LOSARTAN/HCTZ MIN02378086 MYLAN-LOSARTAN/HCTZ MYL02392232 PMS-LOSARTAN-HCTZ PMS02362449 SANDOZ LOSARTAN HCT SDZ02377144 TEVA-LOSARTAN HCTZ TEP


02371251 APO-LOSARTAN/HCTZ APX02388286 CO LOSARTAN/HCT ACT02241007 HYZAAR DS FRS02408252 JAMP-LOSARTAN HCTZ JAP02388987 LOSARTAN/HCT SIV02389673 MINT-LOSARTAN/HCTZ MIN02378094 MYLAN-LOSARTAN/HCTZ MYL02392240 PMS-LOSARTAN-HCTZ PMS02313383 SANDOZ LOSARTAN HCT SDZ02377152 TEVA-LOSARTAN HCTZ TEP

OLMESARTAN MEDOXOMIL

20MG TabletST

02318660 OLMETEC FRS40MG Tablet

ST

02318679 OLMETEC FRS

OLMESARTAN MEDOXOMIL,

HYDROCHLOROTHIAZIDE


02319616 OLMETEC PLUS FRS40MG & 12.5MG Tablet

ST

02319624 OLMETEC PLUS FRS40MG & 25MG Tablet

ST

02319632 OLMETEC PLUS FRS

Page 47 of 1382014



ANTAGONISTS

TELMISARTAN

40MG TabletST

02393247 CO TELMISARTAN ACT02240769 MICARDIS BOE02376717 MYLAN-TELMISARTAN MYL02391236 PMS-TELMISARTAN PMS02375958 SANDOZ TELMISARTAN SDZ02388944 TELMISARTAN SAN02390345 TELMISARTAN SIV02395223 TELMISARTAN PDL02320177 TEVA-TELMISARTAN TEP

80MG TabletST

02393255 CO TELMISARTAN ACT02240770 MICARDIS BOE02376725 MYLAN-TELMISARTAN MYL02391244 PMS-TELMISARTAN PMS02375966 SANDOZ TELMISARTAN SDZ02388952 TELMISARTAN SAN02390353 TELMISARTAN SIV02395231 TELMISARTAN PDL02320185 TEVA-TELMISARTAN TEP

TELMISARTAN, HYDROCHLOROTHIAZIDE


02393263 CO TELMISARTAN/HCT ACT02244344 MICARDIS PLUS BOE02373564 MYLAN-TELMISARTAN HCTZ MYL02401665 PMS-TELMISARTAN-HCTZ PMS02393557 SANDOZ TELMISARTAN HCT SDZ02390302 TELMISARTAN HCTZ SIV02395355 TELMISARTAN/HCTZ SAN02395525 TELMISARTAN/HCTZ PDL02330288 TEVA-TELMISARTAN HCTZ TEP


02393271 CO TELMISARTAN/HCT ACT02318709 MICARDIS PLUS BOE02373572 MYLAN-TELMISARTAN HCTZ MYL02393565 SANDOZ TELMISARTAN HCT SDZ02390310 TELMISARTAN HCTZ SIV02395363 TELMISARTAN/HCTZ SAN02395533 TELMISARTAN/HCTZ PDL02379252 TEVA-TELMISARTAN HCTZ TEP

VALSARTAN

80MG CapsuleST

02236808 DIOVAN 80MG CAP NOV


ANTAGONISTS

VALSARTAN

40MG TabletST

02371510 APO-VALSARTAN APX02337487 CO VALSARTAN ACT02270528 DIOVAN NVR02383527 MYLAN-VALSARTAN MYL02312999 PMS-VALSARTAN PMS02363062 RAN-VALSARTAN RBY02356740 SANDOZ VALSARTAN SDZ02356643 TEVA-VALSARTAN TEP02366940 VALSARTAN SAN02367726 VALSARTAN PDL02384523 VALSARTAN SIV

80MG TabletST


160MG TabletST


320MG TabletST

02371545 APO-VALSARTAN APX02337517 CO VALSARTAN ACT02289504 DIOVAN NVR02383551 MYLAN-VALSARTAN MYL02344564 PMS-VALSARTAN PMS02356775 SANDOZ VALSARTAN SDZ02356686 TEVA-VALSARTAN TEP02366975 VALSARTAN SAN02367750 VALSARTAN PDL02384566 VALSARTAN SIV

Page 48 of 1382014



ANTAGONISTS

VALSARTAN, HYDROCHLOROTHIAZIDE


02382547 APO-VALSARTAN/HCTZ APX02241900 DIOVAN-HCT NVR02373734 MYLAN-VALSARTAN HCTZ MYL02356694 SANDOZ VALSARTAN HCT SDZ02356996 TEVA-VALSARTAN/HCTZ TEP02384736 VALSARTAN HCT SIV02367769 VALSARTAN-HCTZ PDL


02382555 APO-VALSARTAN/HCTZ APX02241901 DIOVAN-HCT NVR02373742 MYLAN-VALSARTAN HCTZ MYL02356708 SANDOZ VALSARTAN HCT SDZ02357003 TEVA-VALSARTAN/HCTZ TEP02367017 VALSARTAN HCT SAN02384744 VALSARTAN HCT SIV02367777 VALSARTAN-HCTZ PDL


02382563 APO-VALSARTAN/HCTZ APX02246955 DIOVAN-HCT NVR02373750 MYLAN-VALSARTAN HCTZ MYL02356716 SANDOZ VALSARTAN HCT SDZ02357011 TEVA-VALSARTAN/HCTZ TEP02367025 VALSARTAN HCT SAN02384752 VALSARTAN HCT SIV02367785 VALSARTAN-HCTZ PDL


02382571 APO-VALSARTAN/HCTZ APX02308908 DIOVAN-HCT NOV02373769 MYLAN-VALSARTAN HCTZ MYL02356724 SANDOZ VALSARTAN HCT SDZ02357038 TEVA-VALSARTAN/HCTZ TEP02367033 VALSARTAN HCT SAN02384760 VALSARTAN HCT SIV


02382598 APO-VALSARTAN/HCTZ APX02308916 DIOVAN-HCT NOV02373777 MYLAN-VALSARTAN HCTZ MYL02356732 SANDOZ VALSARTAN HCT SDZ02357046 TEVA-VALSARTAN/HCTZ TEP02367009 VALSARTAN HCT SAN02367041 VALSARTAN HCT SAN02384779 VALSARTAN HCT SIV

24:32.20 MINERALOCORTICOIDE

(ALDOSTERONE) RECEPTOR

ANTAGONISTS

SPIRONOLACTONE

25MG TabletST

00028606 ALDACTONE PFI00613215 NOVO-SPIROTON TEV

24:32.20 MINERALOCORTICOIDE

(ALDOSTERONE) RECEPTOR

ANTAGONISTS

SPIRONOLACTONE

100MG TabletST

00285455 ALDACTONE PFI00613223 NOVO-SPIROTON TEV

Page 49 of 1382014


28:00 CENTRAL NERVOUS SYSTEM

AGENTS

28:08.04 NONSTEROIDAL ANTI-

INFLAMMATORY AGENTS

ACETYLSALICYLIC ACID


ASA 80 mg tablets are a benefit to clients age 21 years and under to allow access for use in pediatric conditions (e.g. Kawasaki Syndrome).

80MG Chewable TabletST

02269139 ACETYLSALICYLIC ACID JAP02321750 ASA ZYM02009013 ASAPHEN PMS02280167 ASATAB ODN02296004 LOWPRIN EUR02311518 PRO-ASA PRO02202352 RIVASA RIV

80MG Delayed Release TabletST

02283905 ACETYLSALICYLIC ACID JAP02321769 ASA EC SOR02238545 ASAPHEN EC PMS02311496 PRO-ASA EC PRO


02372177 ASA 81MG VTH02283700 PRAXIS ASA EC PMS


02247550 ASAPHEN EC PMS325MG Delayed Release Tablet

ST

02352427 ASATAB EC ODN02284529 PMS-ASA EC PMS


02352435 ASATAB EC ODN02284537 PMS-ASA EC PMS

81MG Enteric Coated TabletST

02243101 ASA PMS02244993 ASA PMS02243896 ASA EC PMS02237726 ASPIRIN BCD02242281 ENTROPHEN EC PED02243801 EQUATE DAILY LOW-DOSE PMS


00510696 APO-ASEN ECT APX02010526 ASA VTH02150417 ASPIRIN BCD02050161 ENTROPHEN WAM00010332 ENTROPHEN-5 WAM00216666 NOVASEN TEV02285371 PMS-ASA EC PMS


00794244 ASA WSB02046261 ASA FRS00472476 ENTERIC COATED ASA APX00010340 ENTROPHEN ECT FRS01905392 ENTROPHEN-10 FRS00229296 NOVASEN TEV


INFLAMMATORY AGENTS




150MG SuppositoryST

00785547 PMS-ASA PMS650MG Suppository

ST

00582867 ASA JNO80MG Tablet

ST

02150352 ASPIRIN BCD02250675 EURO-ASA EUR02295563 LOWPRIN EUR02202360 RIVASA RIV

325MG TabletST

00472468 APO-ASA APX00036145 ASA PED00230324 ASA TEV00530336 ASA VTH *02150328 ASPIRIN BCD

CELECOXIB


For patients who have:

¨A history of serious gastrointestinal complications (e.g. ulcer, bleeding, perforation);

OR

¨Multiple (at least two) risk factors for serious gastrointestinal complications (e.g. age >60, concurrent use of ASA, SSRIs, corticosteroids, anticoagulants or antiplatelet agents).

100MG Capsule

02239941 CELEBREX PFI200MG Capsule

02239942 CELEBREX PFI

DICLOFENAC SODIUM


00839175 APO-DICLO APX02231662 DOM-DICLOFENAC DPC00808539 NOVO-DIFENAC TEV02231502 PMS-DICLOFENAC PMS


00839183 APO-DICLO APX02352397 DICLOFENAC EC SAN00870978 DICLOFENAC-50 PDL02231663 DOM-DICLOFENAC DPC00808547 NOVO-DIFENAC TEV02231503 PMS-DICLOFENAC PMS00514012 VOLTAREN NVR


02352400 DICLOFENAC SR SAN02261901 SANDOZ-DICLOFENAC SR SDZ

Page 50 of 1382014



INFLAMMATORY AGENTS

DICLOFENAC SODIUM


02261944 SANDOZ-DICLOFENAC SR SDZ50MG Suppository

02231506 PMS-DICLOFENAC PMS00632724 VOLTAREN NVR

100MG Suppository

02231508 PMS-DICLOFENAC PMS00632732 VOLTAREN NVR


02162814 APO-DICLO SR APX02224119 DICLOFENAC-SR PDL02231664 DOM-DICLOFENAC SR DPC02158582 NOVO-DIFENAC SR TEV02231504 PMS-DICLOFENAC SR PMS00782459 VOLTAREN SR NVR


02091194 APO-DICLO SR APX02224127 DICLOFENAC-SR PDL02048698 NOVO-DIFENAC SR TEV02231505 PMS-DICLOFENAC SR PMS00590827 VOLTAREN SR NVR

25MG Tablet

02261952 SANDOZ-DICLOFENAC SDZ50MG Tablet

02261960 SANDOZ-DICLOFENAC SDZ

DICLOFENAC SODIUM, MISOPROSTOL

50MG & 200MCG Tablet

01917056 ARTHROTEC PFI02397145 CO DICLO-MISO ACT02400596 SANDOZ DICLO/MISOPROS SDZ

75MG & 200MCG Tablet

02229837 ARTHROTEC PFI02397153 CO DICLO-MISO ACT02400618 SANDOZ DICLO/MISOPROS SDZ

DIFLUNISAL

250MG Tablet

02039486 APO-DIFLUNISAL APX02048493 NOVO-DIFLUNISAL TEV

500MG Tablet

02039494 APO-DIFLUNISAL APX

FLURBIPROFEN

50MG Tablet

01912046 APO-FLURBIPROFEN APX02100509 NOVO-FLURPROFEN TEV

100MG Tablet

01912038 APO-FLURBIPROFEN APX02100517 NOVO-FLURPROFEN TEV

IBUPROFEN

100MG Chewable Tablet

02246403 ADVIL JUNIOR STRENGTH WRI


INFLAMMATORY AGENTS

IBUPROFEN

40MG/ML Drop

02242522 ADVIL PEDIATRIC WRI02238626 CHILDREN'S MOTRIN MCL

20MG/ML Oral Liquid

02232297 CHILDREN'S ADVIL WRI02242365 CHILDREN'S MOTRIN JNO

100MG Tablet

02240527 MOTRIN JUNIOR STRENGTH MCL200MG Tablet

01933558 ADVIL WRI00441643 APO-IBUPROFEN APX02257912 IBUPROFEN PMT02272849 IBUPROFEN JAP02314754 IBUPROFEN PMS02314762 IBUPROFEN PMS02186934 MOTRIN MCL

300MG Tablet

00441651 APO-IBUPROFEN APX400MG Tablet

00506052 APO-IBUPROFEN APX00636533 IBUPROFEN PDL02314770 IBUPROFEN PMS02317338 JAMP IBUPROFEN JAP02401290 JAMP IBUPROFEN JAP

600MG Tablet

00585114 APO-IBUPROFEN APX00658804 IBUPROFEN PDL00629359 NOVO-PROFEN TEV

INDOMETHACIN

25MG Capsule

00611158 APO-INDOMETHACIN APX00337420 NOVO-METHACIN TEV00646261 PRO-INDO PDL

50MG Capsule

00611166 APO-INDOMETHACIN APX00337439 NOVO-METHACIN TEV00646288 PRO-INDO PDL

50MG Suppository

02231799 SAB-INDOMETHACIN SIL100MG Suppository

01934139 RATIO-INDOMETHACIN RPH02231800 SAB-INDOMETHACIN SIL

KETOPROFEN

50MG Capsule

00790427 APO-KETO APX02150808 PMS-KETOPROFEN PMS


00790435 APO KETO-E APX02150816 PMS-KETOPROFEN PMS

Page 51 of 1382014



INFLAMMATORY AGENTS

KETOPROFEN


00842664 APO-KETO-E APX02150824 PMS-KETOPROFEN PMS

100MG Suppository

02015951 PMS-KETOPROFEN PMS200MG Sustained Release Tablet

02172577 APO-KETO SR APX

MEFENAMIC ACID

250MG Capsule

02229452 APO-MEFENAMIC APX02237826 DOM-MEFENAMIC ACID DPC

MELOXICAM

7.5MG Tablet

02248973 APO-MELOXICAM APX02390884 AURO-MELOXICAM AUR02250012 CO-MELOXICAM ACT02248605 DOM-MELOXICAM DPC02255987 GEN-MELOXICAM GEN02324326 MELOXICAM PDL02353148 MELOXICAM SAN02242785 MOBICOX BOE02258315 NOVO-MELOXICAM TEV02248607 PHL-MELOXICAM PHH02248267 PMS-MELOXICAM PMS02247889 RATIO-MELOXICAM RPH

15MG Tablet

02248974 APO-MELOXICAM APX02390892 AURO-MELOXICAM AUR02250020 CO-MELOXICAM ACT02248606 DOM-MELOXICAM DPC02255995 GEN-MELOXICAM GEN02353156 MELOXICAM SAN02242786 MOBICOX BOE02258323 NOVO-MELOXICAM TEV02248608 PHL-MELOXICAM PHH02248268 PMS-MELOXICAM PMS02248031 RATIO-MELOXICAM RPH

NAPROXEN


02246699 APO-NAPROXEN EC APX02350785 NAPROXEN EC SAN02243312 NOVO-NAPROX TEV


02246700 APO-NAPROXEN EC APX02162415 NAPROSYN E HLR02350793 NAPROXEN EC SAN02243313 NOVO-NAPROX TEV02294702 PMS-NAPROXEN EC PMS02310945 PRO-NAPROXEN EC PDL


INFLAMMATORY AGENTS

NAPROXEN


02246701 APO-NAPROXEN EC APX02241024 GEN-NAPROXEN EC GEN02162423 NAPROSYN E HLR02350807 NAPROXEN EC SAN02243314 NOVO-NAPROX TEV02294710 PMS-NAPROXEN EC PMS02310953 PRO-NAPROXEN EC PDL

25MG/ML Suspension

02162431 NAPROSYN HLR750MG Sustained Release Tablet

02162466 NAPROSYN SR HLR125MG Tablet

00522678 APO-NAPROXEN APX250MG Tablet

00522651 APO-NAPROXEN APX00590762 NAPROXEN PDL02350750 NAPROXEN SAN00565350 NOVO-NAPROX TEV02240786 RIVA-NAPROXEN RIV

375MG Tablet

00600806 APO-NAPROXEN APX02243432 GEN-NAPROXEN GEN00655686 NAPROXEN PDL02350769 NAPROXEN SAN00627097 NOVO-NAPROX TEV02240787 RIVA-NAPROXEN RIV

500MG Tablet

00592277 APO-NAPROXEN APX00618721 NAPROXEN PDL02350777 NAPROXEN SAN00589861 NOVO-NAPROX TEV02240788 RIVA-NAPROXEN RIV

NAPROXEN SODIUM

220MG Tablet

02362430 NAPROXEN PMS275MG Tablet

02162725 ANAPROX HLR00784354 APO-NAPRO NA APX00887056 NAPROXEN NA PDL02351013 NAPROXEN SODIUM SAN00778389 NOVO-NAPROX SODIUM TEV

550MG Tablet

02162717 ANAPROX DS HLR01940309 APO-NAPRO NA DS APX02351021 NAPROXEN SODIUM DS SAN02153386 NAPROXEN-NA DF PDL02026600 NOVO-NAPROX SODIUM DS TEV02240828 RIVA-NAPROXEN SODIUM RIV

Page 52 of 1382014



INFLAMMATORY AGENTS

PIROXICAM

10MG Capsule

00642886 APO-PIROXICAM APX00836249 PMS-PIROXICAM PMS

20MG Capsule

00642894 APO-PIROXICAM APX02239536 DOM-PIROXICAM DPC00836230 PMS-PIROXICAM PMS

10MG Suppository

02154420 PMS-PIROXICAM PMS20MG Suppository

02154463 PMS-PIROXICAM PMS10MG Tablet

00695718 NOVO-PIROCAM TEV20MG Tablet

00695696 NOVO-PIROCAM TEV

SULINDAC

150MG Tablet

00778354 APO-SULIN APX00745588 NOVO-SUNDAC TEV

200MG Tablet

00778362 APO-SULIN APX00745596 NOVO-SUNDAC TEV

TIAPROFENIC ACID

200MG Tablet

02179679 NOVO-TIAPROFENIC TEV02230827 PMS-TIAPROFENIC PMS

300MG Tablet

02231060 DOM-TIAPROFENIC DPC02179687 NOVO-TIAPROFENIC TEV

28:08.08 OPIATE AGONISTS

ACETAMINOPHEN, CAFFEINE CITRATE,

CODEINE PHOSPHATE


For safety reasons NIHB has implemented a dose limit on acetaminophen. The limit accumulates against the amount of acetaminophen claimed to the program from plain acetaminophen and/or acetaminophen in combination with opioids such as codeine (i.e. Tylenol® #3) or oxycodone (i.e. Percocet®). A total of 360 grams of acetaminophen is permitted in a 100-day period, for a total daily dose of 3600mg/day.


00293504 ATASOL-15 HOR02232388 EXDOL-15 PED


00293512 ATASOL-30 HOR02232389 EXDOL-30 PED


ACETAMINOPHEN, CAFFEINE, CODEINE

PHOSPHATE




00653241 RATIO-LENOLTEC NO.2 RPH02163934 TYLENOL WITH CODEINE NO.2 JNO


00653276 RATIO-LENOLTEC NO.3 RPH02163926 TYLENOL WITH CODEINE NO.3 JNO

ACETAMINOPHEN, CODEINE PHOSPHATE



32MG & 1.6MG/ML Elixir

00816027 PMS-ACETAMINOPHEN WITH CODEINE

PMS

300MG & 30MG Tablet

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

ACETAMINOPHEN, OXYCODONE HCL



325MG & 2.5MG Tablet

01916491 PERCOCET DEMI BMS325MG & 5MG Tablet

02324628 APO-OXYCODONE/ACET APX01916548 ENDOCET EDM02361361 OXYCODONE/ACET SAN01916475 PERCOCET BMS02327171 PRO-OXYCOD ACET PDL00608165 RATIO-OXYCOCET RPH02242468 RIVACOCET RIV02307898 SANDOZ OXYCOD ACET SDZ

Page 53 of 1382014



ACETYLSALICYLIC ACID, CAFFEINE CITRATE,

CODEINE PHOSPHATE


To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented an opioid dose limit of 500 mg morphine equivalents per day for non-cancer, non-palliative pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 100-day period (i.e. 50 000 morphine equivalents over 100 days).


02234510 282 PED375MG & 30MG & 30MG Tablet

02238645 292 PED

ACETYLSALICYLIC ACID, OXYCODONE HCL



325MG & 5MG Tablet

00608157 RATIO-OXYCODAN RPH

CODEINE MONOHYDRATE, CODEINE

SULFATE TRIHYDRATE

Limited 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 Tablet

02230302 CODEINE CONTIN CR PFR100MG Long Acting Tablet



02163799 CODEINE CONTIN CR PFR


CODEINE PHOSPHATE



2MG/ML Liquid

00380571 LINCTUS CODEINE ATL5MG/ML Syrup

00050024 CODEINE PHOSPHATE ATL00779474 RATIO-CODEINE RPH

15MG Tablet

00779458 CODEINE RPH02009889 CODEINE TRI00593435 RATIO-CODEINE RPH

30MG Tablet

00593451 CODEINE PHOSPHATE RPH02009757 CODEINE PHOSPHATE TRI02243979 PMS-CODEINE PMS

FENTANYL

Limited 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 dosetitration and adjunctive therapy including laxatives and antiemetics.


12MCG Patch

02311925 TEVA-FENTANYL TEP12MCG/H Patch

02386844 CO FENTANYL ACT02395657 FENTANYL PDL02396696 MYLAN-FENTANYL MYL02341379 PMS-FENTANYL PMS02330105 RAN-FENTANYL RBY02327112 SANDOZ FENTANYL SDZ

25MCG/H Patch

02314630 APO-FENTANYL APX02386852 CO FENTANYL ACT02275813 DURAGESIC MAT JNO02395665 FENTANYL PDL02396718 MYLAN-FENTANYL MYL02341387 PMS-FENTANYL PMS02330113 RAN-FENTANYL RBY02327120 SANDOZ FENTANYL SDZ02282941 TEVA-FENTANYL RPH

Page 54 of 1382014



FENTANYL



50MCG/H Patch


75MCG/H Patch


100MCG/H Patch



HYDROMORPHONE 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.

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.

To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented an opioid dose limit of 500 mg morphine equivalents per day for non-malignant pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 100-day period (i.e. 50 000 morphine equivalents over 100 days).

3MG Controlled Release Capsule

02125323 HYDROMORPH CONTIN PFR4.5MG Controlled Release Capsule

02359502 HYDROMORPH CONTIN PFR6MG Controlled Release Capsule






02125390 HYDROMORPH CONTIN PFR1MG/ML Oral Liquid

00786535 DILAUDID ABB01916386 PMS-HYDROMORPHONE PMS

3MG Suppository

01916394 PMS-HYDROMORPHONE PMS1MG Tablet

02364115 APO-HYDROMORPHONE APX00705438 DILAUDID ABB02192101 PHL-HYDROMORPHONE PHH00885444 PMS-HYDROMORPHONE PMS02319403 TEVA-HYDROMORPHONE TEP

2MG Tablet


4MG Tablet


Page 55 of 1382014



HYDROMORPHONE HCL




8MG Tablet


METHADONE HCL

10mg/mL Liquid

02394596 METHADOSE MAT02394618 METHADOSE SUGARFREE MAT

METHADONE HCL (PA)

limited use benefit (prior approval required) with the following criteria:

Prescriber is registered with Health Canada and is eligible to prescribe methadone for the management of pain. AND For the management of moderate to severe cancer pain or chronic non-cancer pain, as an alternative to other opioids. OR, For the management of pain for palliative care patients. Pharmacists may only dispense a maximum supply of 30 days at one time.

Methadone pseudo DINs listed for the treatment of pain should not be used for methadone maintenance therapy. Methadone for the treatment of opioid dependency is an open benefit covered under the NIHB Program (Methadone maintenance therapy pseudo DIN 908835). For information regarding the adjudication rules of methadone for the treatment of opioid dependency, please refer to the NIHB Provider Guide for Pharmacy Benefits.

1MG/ML Liquid

02247694 METADOL PAL10MG/ML Liquid

02241377 METADOL PAL1MG Tablet




02247701 METADOL PAL


MORPHINE HCL




00776181 M.O.S. SR VAE60MG Sustained Release Tablet

00776203 M.O.S. SR VAE1MG/ML Syrup

00614491 DOLORAL 1 ATL00607762 RATIO-MORPHINE RPH

5MG/ML Syrup

00614505 DOLORAL 5 ATL00514217 M.O.S. VAE00607770 RATIO-MORPHINE RPH

10MG/ML Syrup

00632503 M.O.S. 10 VAE00690783 RATIO-MORPHINE RPH

20MG/ML Syrup

00690791 RATIO-MORPHINE RPH50MG/ML Syrup

00690236 M.O.S. 50 VAE10MG Tablet




00690244 M.O.S. 60 VAE

MORPHINE SULFATE



50MG/ML Drop

00705799 STATEX PMS5MG Suppository



00596965 STATEX PMS10MG Sustained Release Capsule

02242163 KADIAN MAY02019930 M-ESLON SAC

Page 56 of 1382014



MORPHINE SULFATE



15MG Sustained Release Capsule

02177749 M-ESLON SAC20MG Sustained Release Capsule

02184435 KADIAN SR MAY30MG Sustained Release Capsule

02019949 M-ESLON SR SAC50MG Sustained Release Capsule

02184443 KADIAN SR MAY60MG Sustained Release Capsule

02019957 M-ESLON SR SAC100MG Sustained Release Capsule

02184451 KADIAN SR MAY02019965 M-ESLON SR SAC

200MG Sustained Release Capsule

02177757 M-ESLON SR SAC15MG Sustained Release Tablet

02350815 MORPHINE SR SAN02015439 MS CONTIN SR PFR02244790 RATIO-MORPHINE SULFATE

SRRPH

02302764 TEVA-MORPHINE SR 15MG TAB

TEP



SRRPH


TEP



SRRPH


TEP


02350920 MORPHINE SR SAN02014319 MS CONTIN SR PFR02302799 TEVA-MORPHINE SR 100MG

TABTEP


02350947 MORPHINE SR SAN02014327 MS CONTIN SR PFR02302802 TEVA-MORPHINE SR 200MG

TABTEP

1MG/ML Syrup

00591467 STATEX PMS


MORPHINE SULFATE



5MG/ML Syrup

00591475 STATEX PMS10MG/ML Syrup

00647217 STATEX PMS5MG Tablet

02009773 M.O.S. SULFATE VAE02014203 MS IR PFR00594652 STATEX PMS

10MG Tablet

02009765 M.O.S. SULFATE VAE02014211 MS IR PFR00594644 STATEX PMS

20MG Tablet

02014238 MS IR PFR25MG Tablet

02009749 M.O.S. SULFATE VAE00594636 STATEX PMS

30MG Tablet

02014254 MS IR PFR50MG Tablet

02009706 M.O.S. SULFATE VAE00675962 STATEX PMS

OXYCODONE HCL



10MG Suppository

00392480 SUPEUDOL SIL20MG Suppository

00392472 SUPEUDOL SIL5MG Tablet

02325950 OXYCODONE PDL02231934 OXY-IR PFR02319977 PMS-OXYCODONE PMS00789739 SUPEUDOL SDZ

10MG Tablet

02240131 OXY-IR PFR02319985 PMS-OXYCODONE PMS00443948 SUPEUDOL SDZ

Page 57 of 1382014



OXYCODONE HCL



20MG Tablet

02240132 OXY-IR PFR02319993 PMS-OXYCODONE PMS02262983 SUPEUDOL SDZ

28:08.12 OPIATE PARTIAL AGONISTS

BUPRENORPHINE, NALOXONE


For the treatment of opioid dependence in patients who have a contraindication to methadone due to:• Evidence of (or high risk for) QT interval prolongation; and• Prescribed by a physician with experience in substitution treatment in Opioid drug dependence or completion of an accredited Suboxone Education Program.

8MG & 2MG Tablet

02295709 SUBOXONE RBP09991204 SUBOXONE MAINTENANCE UNK

28:08.92 MISCELLANEOUS ANALGESICS

AND ANTIPYRETICS

ACETAMINOPHEN




02129957 ACETAMIN CHILD WTR01905856 ACETAMINOPHEN TRI02017458 ACETAMINOPHEN RIV02015676 CHILDREN'S ACETAMINOPHEN TAN


02017431 ACETAMINOPHEN RIV02231011 FEVERHALT PED02230934 TANTAPHEN GRAPE TAN

80MG/ML DropST

01904140 ACETAMINOPHEN TAN01905864 ACETAMINOPHEN TRI00631353 ATASOL HOR02230787 FEVERHALT PED02263793 PEDIAPHEN EUR02027801 PEDIATRIX RPH00887587 PMS-ACETAMINOPHEN PMS00875988 TEMPRA MJO02046059 TYLENOL GRAPE MCL


AND ANTIPYRETICS

ACETAMINOPHEN



16MG/ML LiquidST

01905848 ACETAMINOPHEN TRI02263807 PEDIAPHEN EUR00792713 PMS-ACETAMINOPHEN PMS00884553 TEMPRA MJO

32MG/ML LiquidST

01901389 ACETAMINOPHEN JAP01958836 ACETAMINOPHEN TRI02263831 PEDIAPHEN EUR02027798 PEDIATRIX RPH00792691 PMS-ACETAMINOPHEN PMS00875996 TEMPRA DOUBLE STRENGTH MJO02046040 TYLENOL MCL

120MG Suppository

00553328 ABENOL GSK01919385 ABENOL PED02230434 ACET 120 PMS02046660 PMS-ACETAMINOPHEN PMS

160MG Suppository

02230435 ACET PMS325MG Suppository

01919393 ABENOL PED02230436 ACET 325 PMS02046687 PMS-ACETAMINOPHEN PMS

650MG Suppository

01919407 ABENOL PED02230437 ACET 650 PMS02046695 PMS-ACETAMINOPHEN PMS

80MG/ML SuspensionST

02237390 ACETAMINOPHEN PER80MG Tablet

ST

02238295 CHILDREN'S TYLENOL SOFT CHEWS

JNO

02263815 PEDIAPHEN CHEWABLE TAB 80MG

EUO

160MG TabletST

02142805 ACETAMINOPHEN WTR02263823 PEDIAPHEN CHEWABLE TAB

160MGEUO

02347792 TYLENOL JR STRENGTH FASTMELTS

JNO

02241361 TYLENOL JUNIOR STRENGTH JNO

Page 58 of 1382014



AND ANTIPYRETICS

ACETAMINOPHEN



325MG TabletST

00374148 ACETAMINOPHEN WAM00382752 ACETAMINOPHEN PRO00589241 ACETAMINOPHEN PMS00605751 ACETAMINOPHEN VTH *00743542 ACETAMINOPHEN PMT00789801 ACETAMINOPHEN TRI01938088 ACETAMINOPHEN JAP02022214 ACETAMINOPHEN RIV00544981 APO-ACETAMINOPHEN APX02229873 APO-ACETAMINOPHEN APX00293482 ATASOL HOR00389218 NOVO-GESIC TEV00559393 TYLENOL MCL00723894 TYLENOL MCL

500MG TabletST

00386626 ACETAMINOPHEN PDL00549703 ACETAMINOPHEN PMT00567663 ACETAMINOPHEN PED00589233 ACETAMINOPHEN PMS00605778 ACETAMINOPHEN VTH00789798 ACETAMINOPHEN TRI01939122 ACETAMINOPHEN JAP02022222 ACETAMINOPHEN RIV02252813 ACETAMINOPHEN PMT02255251 ACETAMINOPHEN PMT00545007 APO-ACETAMINOPHEN APX02229977 APO-ACETAMINOPHEN APX00013668 ATASOL FORTE HOR02355299 JAMP-ACETAMINOPHEN JAP00482323 NOVO-GESIC TEV00892505 PMS-ACETAMINOPHEN PMS01962353 TANTAPHEN TAN00559407 TYLENOL EXTRA STRENGTH MCL00723908 TYLENOL EXTRA STRENGTH MCL

FLOCTAFENINE

200MG Tablet

02244680 APO-FLOCTAFENINE APX400MG Tablet

02244681 APO-FLOCTAFENINE APX

28:12.04 ANTICONVULSANTS -

BARBITURATES

PRIMIDONE

125MG TabletST

00399310 APO-PRIMIDONE APX250MG Tablet

ST

00396761 APO-PRIMIDONE APX


BENZODIAZEPINES

CLONAZEPAM


To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 60 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e. 6 000 diazepam equivalents over 100 days). This limit will be lowered by 10 mg of diazepam equivalents per day every three months until an acceptable limit is reached. According to the product monograph for diazepam, the recommended usual adult dosage is up to 40 mg per day.

0.25MG TabletST

02179660 PMS-CLONAZEPAM PMS0.5MG Tablet

ST

02177889 APO-CLONAZEPAM APX02230366 CLONAPAM VAE02270641 CO-CLONAZEPAM ACT02130998 DOM-CLONAZEPAM DPC02224100 DOM-CLONAZEPAM-R DPC02230950 GEN-CLONAZEPAM GEN02239024 NOVO-CLONAZEPAM TEV02145227 PHL-CLONAZEPAM PHH02236948 PHL-CLONAZEPAM-R PMI02048701 PMS-CLONAZEPAM PMS02207818 PMS-CLONAZEPAM R PMS02311593 PRO-CLONAZEPAM PDL02242077 RIVA-CLONAZEPAM RIV00382825 RIVOTRIL HLR02233960 SANDOZ-CLONAZEPAM SDZ02345676 ZYM-CLONAZEPAM ZYM

1MG TabletST

02230368 CLONAPAM VAE02270668 CO-CLONAZEPAM ACT02145235 PHL-CLONAZEPAM PHH02048728 PMS-CLONAZEPAM PMS02311607 PRO-CLONAZEPAM PDL02233982 SANDOZ-CLONAZEPAM SDZ02303329 ZYM-CLONAZEPAM ZYM

Page 59 of 1382014



BENZODIAZEPINES

CLONAZEPAM



2MG TabletST

02177897 APO-CLONAZEPAM APX02230369 CLONAPAM VAE02270676 CO-CLONAZEPAM ACT02131013 DOM-CLONAZEPAM DPC02230951 GEN-CLONAZEPAM GEN02239025 NOVO-CLONAZEPAM TEV02145243 PHL-CLONAZEPAM PHH02048736 PMS-CLONAZEPAM PMS02311615 PRO-CLONAZEPAM PDL02242078 RIVA-CLONAZEPAM RIV00382841 RIVOTRIL HLR02233985 SANDOZ-CLONAZEPAM SDZ02303337 ZYM-CLONAZEPAM ZYM


HYDANTOINS

PHENYTOIN

30MG CapsuleST

00022772 DILANTIN PFI100MG Capsule

ST

00022780 DILANTIN PFI50MG Chewable Tablet

ST

00023698 DILANTIN INFATABS PFI6MG/ML Suspension

00023442 DILANTIN 30 PFI25MG/ML Suspension

00023450 DILANTIN 125 PFI02250896 TARO-PHENYTOIN TAR

28:12.20 ANTICONVULSANTS-

SUCCINIMIDES

ETHOSUXIMIDE

250MG CapsuleST

00022799 ZARONTIN ERF50MG/ML Syrup

00023485 ZARONTIN ERF

METHSUXIMIDE

300MG CapsuleST

00022802 CELONTIN ERF


ANTICONVULSANTS

CARBAMAZEPINE


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


02231540 PMS-CARBAMAZEPINE PMS02261863 SANDOZ-CARBAMAZEPINE SDZ02244404 TARO-CARBAMAZEPINE TAR00665088 TEGRETOL NVR


02261839 SANDOZ-CARBAMAZEPINE SDZ400MG Extended Release Tablet

ST

02261847 SANDOZ-CARBAMAZEPINE SDZ20MG/ML Suspension

02367394 TARO-CARBAMAZEPINE TAR02194333 TEGRETOL NVR


02238222 DOM-CARBAMAZEPINE CR DPC02241882 GEN-CARBAMAZEPINE CR GEN02231543 PMS-CARBAMAZEPINE SRT PMS02237907 TARO-CARBAMAZEPINE CR TAR00773611 TEGRETOL CR NVR


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

200MG TabletST

00402699 APO-CARBAMAZEPINE APX00578460 CARBAMAZEPINE PDL00782718 NOVO-CARBAMAZ TEV00010405 TEGRETOL NVR

DIVALPROEX SODIUM


02239698 APO-DIVALPROEX APX02400499 DIVALPROEX SAN00596418 EPIVAL ABB02239701 NOVO-DIVALPROEX TEV02244138 PMS-DIVALPROEX PMS


02239699 APO-DIVALPROEX APX02240342 DIVALPROEX PDL02400502 DIVALPROEX SAN00596426 EPIVAL ABB02239702 NOVO-DIVALPROEX TEV02244139 PMS-DIVALPROEX PMS

Page 60 of 1382014



ANTICONVULSANTS

DIVALPROEX SODIUM


02239700 APO-DIVALPROEX APX02400510 DIVALPROEX SAN02240343 DIVALPROEX EC PDL00596434 EPIVAL ABB02239703 NOVO-DIVALPROEX TEV02244140 PMS-DIVALPROEX PMS

GABAPENTIN


For safety reasons NIHB has implemented a dose limit on gabapentin. The limit accumulates against the amount of gabapentin claimed to the program. A total of 400 grams of gabapentin is permitted in a 100-day period, for a total daily dose of 4000mg/day.

100MG CapsuleST

02244304 APO-GABAPENTIN APX02321203 AURO-GABAPENTIN AUR02256142 CO-GABAPENTIN ACT02243743 DOM-GABAPENTIN DPC02246314 GABAPENTIN SIV02304775 GABAPENTIN SOR02353245 GABAPENTIN SAN02248259 GEN-GABAPENTIN GEN02361469 JAMP-GABAPENTIN JAP02084260 NEURONTIN PFI02244513 NOVO-GABAPENTIN TEV02243446 PMS-GABAPENTIN PMS02310449 PRO-GABAPENTIN PDL02319055 RAN-GABAPENTIN RBY02251167 RIVA-GABAPENTIN RIV

300MG CapsuleST

02244305 APO-GABAPENTIN APX02321211 AURO-GABAPENTIN AUR02256150 CO-GABAPENTIN ACT02243744 DOM-GABAPENTIN DPC02246315 GABAPENTIN SIV02304783 GABAPENTIN SOR02353253 GABAPENTIN SAN02248260 GEN-GABAPENTIN GEN02361485 JAMP-GABAPENTIN JAP02084279 NEURONTIN PFI02244514 NOVO-GABAPENTIN TEV02243447 PMS-GABAPENTIN PMS02310457 PRO-GABAPENTIN PDL02319063 RAN-GABAPENTIN RBY02251175 RIVA-GABAPENTIN RIV


ANTICONVULSANTS

GABAPENTIN



400MG CapsuleST

02244306 APO-GABAPENTIN APX02321238 AURO-GABAPENTIN AUR02256169 CO-GABAPENTIN ACT02243745 DOM-GABAPENTIN DPC02246316 GABAPENTIN SIV02304791 GABAPENTIN SOR02353261 GABAPENTIN SAN02248261 GEN-GABAPENTIN GEN02361493 JAMP-GABAPENTIN JAP02084287 NEURONTIN PFI02244515 NOVO-GABAPENTIN TEV02243448 PMS-GABAPENTIN PMS02310465 PRO-GABAPENTIN PDL02319071 RAN-GABAPENTIN RBY02260905 RATIO-GABAPENTIN RPH02251183 RIVA-GABAPENTIN RIV

600MG TabletST

02293358 APO-GABAPENTIN APX02388200 GABAPENTIN SIV02285843 GD-GABAPENTIN PFI02402289 JAMP-GABAPENTIN JAP02397471 MYLAN-GABAPENTIN MYL02239717 NEURONTIN PFI02248457 NOVO-GABAPENTIN TEV02255898 PMS-GABAPENTIN PMS02310473 PRO-GABAPENTIN PDL02260913 RATIO-GABAPENTIN RPH02259796 RIVA-GABAPENTIN RIV

800MG TabletST

02293366 APO-GABAPENTIN APX02388219 GABAPENTIN SIV02402297 JAMP-GABAPENTIN JAP02397498 MYLAN-GABAPENTIN MYL02239718 NEURONTIN PFI02247346 NOVO-GABAPENTIN TEV02255901 PMS-GABAPENTIN PMS02310481 PRO-GABAPENTIN PDL02260921 RATIO-GABAPENTIN RPH02259818 RIVA-GABAPENTIN RIV

Page 61 of 1382014



ANTICONVULSANTS

LACOSAMIDE

Limited use benefit (prior approval required).For adjunctive therapy in patients with refractory partial-onset seizures who meet all of the following criteria:a- Are under the care of a physician experienced in the treatment of epilepsy, ANDb- Are currently receiving two or more antiepileptic medications, ANDc- Have failed or demonstrated intolerance to at least two other antiepileptic medications.

50MG TabletST

02357615 VIMPAT UCB100MG Tablet

ST


ST


ST

02357658 VIMPAT UCB

LAMOTRIGINE


02243803 LAMICTAL GSK5MG Chewable Tablet

ST

02240115 LAMICTAL GSK25MG Tablet

ST

02245208 APO-LAMOTRIGINE APX02381354 AURO-LAMOTRIGINE AUR02265494 GEN-LAMOTRIGINE GEN02142082 LAMICTAL GSK02302969 LAMOTRIGINE PDL02343010 LAMOTRIGINE SAN02248232 NOVO-LAMOTRIGINE TEV02246897 PMS-LAMOTRIGINE PMS

100MG TabletST


150MG TabletST



ANTICONVULSANTS

LEVETIRACETAM


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 two anti-epileptic medications used either as monotherapy or in combination.

250MG TabletST

02285924 APO-LEVETIRACETAM APX02375249 AURO-LEVETIRACETAM AUR02274183 CO-LEVETIRACETAM ACT02403005 JAMP-LEVETIRACETAM JAP02247027 KEPPRA UCB02353342 LEVETIRACETAM SAN02296101 PMS-LEVETIRACETAM PMS02396106 RAN-LEVETIRACETAM RBY

500MG TabletST

02285932 APO-LEVETIRACETAM APX02375257 AURO-LEVETIRACETAM AUR02274191 CO-LEVETIRACETAM ACT02297418 DOM-LEVETIRACETAM DOM02403021 JAMP-LEVETIRACETAM JAP02247028 KEPPRA UCB02353350 LEVETIRACETAM SAN02296128 PMS-LEVETIRACETAM PMS02311380 PRO-LEVETIRACETAM PDL02396114 RAN-LEVETIRACETAM RBY

750MG TabletST

02285940 APO-LEVETIRACETAM APX02375265 AURO-LEVETIRACETAM AUR02274205 CO-LEVETIRACETAM ACT02403048 JAMP-LEVETIRACETAM JAP02247029 KEPPRA UCB02353369 LEVETIRACETAM SAN02296136 PMS-LEVETIRACETAM PMS02311399 PRO-LEVETIRACETAM PDL02396122 RAN-LEVETIRACETAM RBY

Page 62 of 1382014



ANTICONVULSANTS

PREGABALIN


For the treatment of neuropathic pain in patients who have failed to effectively treat their pain with a tricyclic antidepressant (TCA)

OR

For the treatment of neuropathic pain in patients who have a contraindication or intolerance with a TCA.

The dose of pregabalin is limited to a maximum of 600 mg per day

25MG CapsuleST

02394235 APO-PREGABALIN APX02402912 CO PREGABALIN ACT02402556 DOM-PREGABALIN DOM02360136 GD-PREGABALIN PFI02268418 LYRICA PFI02359596 PMS-PREGABALIN PMS02396483 PREGABALIN PDL02403692 PREGABALIN SIV02405539 PREGABALIN SAN02411725 PREGABALIN-25 SIV02392801 RAN-PREGABALIN RBY02377039 RIVA-PREGABALIN RIV02390817 SANDOZ PREGABALIN SDZ02361159 TEVA-PREGABALIN TEP

50MG CapsuleST

02394243 APO-PREGABALIN APX02402920 CO PREGABALIN ACT02402564 DOM-PREGABALIN DOM02360144 GD-PREGABALIN PFI02268426 LYRICA PFI02359618 PMS-PREGABALIN PMS02396505 PREGABALIN PDL02403706 PREGABALIN SIV02405547 PREGABALIN SAN02392828 RAN-PREGABALIN RBY02377047 RIVA-PREGABALIN RIV02390825 SANDOZ PREGABALIN SDZ02361175 TEVA-PREGABALIN TEP

50MG CapsuleST

02411733 PREGABALIN-50 SIV


ANTICONVULSANTS

PREGABALIN



OR



75MG CapsuleST


150MG CapsuleST


300MG CapsuleST

02394294 APO-PREGABALIN APX02402998 CO PREGABALIN ACT02360209 GD-PREGABALIN PFI02268485 LYRICA PFI02359642 PMS-PREGABALIN PMS02396548 PREGABALIN PDL02403730 PREGABALIN SIV02405598 PREGABALIN SAN02392860 RAN-PREGABALIN RBY02377071 RIVA-PREGABALIN RIV02390868 SANDOZ PREGABALIN SDZ02361248 TEVA-PREGABALIN TEP

Page 63 of 1382014



ANTICONVULSANTS

RUFINAMIDE


-For the adjunctive treatment of seizures associated with Lennox-Gastaux syndrome in adults and children 4 years and older when prescribed by a neurologist or experienced specialist-Patient has failed or is intolerant to or has contraindications to at least two adjunctive antiepileptic drugs

100MG TabletST

02369613 BANZEL 100MG TAB EIS200MG Tablet

ST

02369621 BANZEL 200MG TAB EIS400MG Tablet

ST

02369648 BANZEL 400MG TAB EIS

TOPIRAMATE

15MG Sprinkle CapsuleST

02239907 TOPAMAX SPRINKLE JNO25MG Sprinkle Capsule

ST

02239908 TOPAMAX SPRINKLE JNO25MG Tablet

ST

02351307 ACCEL-TOPIRAMATE ACP02279614 APO-TOPIRAMATE APX02345803 AURO-TOPIRAMATE APL02287765 CO TOPIRAMATE ACT02271141 DOM-TOPIRAMATE DPC *02263351 GEN-TOPIRAMATE GEN02315645 MINT-TOPIRAMATE MIN02248860 NOVO-TOPIRAMATE TEV02271184 PHL-TOPIRAMATE PMI02262991 PMS-TOPIRAMATE PMS02313650 PRO-TOPIRAMATE PDL02396076 RAN-TOPIRAMATE RBY02260050 SANDOZ-TOPIRAMATE SDZ02230893 TOPAMAX JNO02356856 TOPIRAMATE SAN02389460 TOPIRAMATE SIV02325136 ZYM-TOPIRAMATE ZYM

50MG TabletST

02312085 PMS-TOPIRAMATE PMS


ANTICONVULSANTS

TOPIRAMATE

100MG TabletST

02351315 ACCEL-TOPIRAMATE ACP02279630 APO-TOPIRAMATE APX02345838 AURO-TOPIRAMATE APL02287773 CO TOPIRAMATE ACT02271168 DOM-TOPIRAMATE DPC *02263378 GEN-TOPIRAMATE GEN02315653 MINT-TOPIRAMATE MIN02248861 NOVO-TOPIRAMATE TEV02271192 PHL-TOPIRAMATE PMI02263009 PMS-TOPIRAMATE PMS02313669 PRO-TOPIRAMATE PDL02396084 RAN-TOPIRAMATE RBY02260069 SANDOZ-TOPIRAMATE SDZ02230894 TOPAMAX JNO02356864 TOPIRAMATE SAN02389487 TOPIRAMATE SIV02325144 ZYM-TOPIRAMATE ZYM

200MG TabletST

02351323 ACCEL-TOPIRAMATE ACP02279649 APO-TOPIRAMATE APX02345846 AURO-TOPIRAMATE APL02287781 CO TOPIRAMATE ACT02271176 DOM-TOPIRAMATE DPC *02263386 GEN-TOPIRAMATE GEN02315661 MINT-TOPIRAMATE MIN02248862 NOVO-TOPIRAMATE TEV02313677 PDL-TOPIRAMATE PDL02271206 PHL-TOPIRAMATE PMI02263017 PMS-TOPIRAMATE PMS02396092 RAN-TOPIRAMATE RBY02267837 SANDOZ-TOPIRAMATE SDZ02230896 TOPAMAX JNO02356872 TOPIRAMATE SAN02325152 ZYM-TOPIRAMATE ZYM

VALPROATE, SODIUM

50MG/ML Syrup

02238370 APO-VALPROIC APX00443832 DEPAKENE ABB02238817 DOM-VALPROIC ACID DPC02236807 PMS-VALPROIC ACID PMS

VALPROIC ACID

250MG CapsuleST

02238048 APO-VALPROIC APX00443840 DEPAKENE ABB02231030 DOM-VALPROIC ACID DPC02184648 GEN-VALPROIC GEN02100630 NOVO-VALPROIC TEV02238546 PDL-VALPROIC PDL02230768 PMS-VALPROIC ACID PMS02239714 SANDOZ-VALPROIC SDZ

Page 64 of 1382014



ANTICONVULSANTS

VALPROIC ACID

500MG Enteric Coated CapsuleST

02231031 DOM-VALPROIC ACID DPC02218321 NOVO-VALPROIC TEV02260662 PHL-VALPROIC ACID PHH02229628 PMS-VALPROIC ACID PMS

VIGABATRIN

500MG Powder

02068036 SABRIL OVA500MG Tablet

ST

02065819 SABRIL OVA

28:16.04 ANTIDEPRESSANTS

AMITRIPTYLINE HCL

10MG TabletST

00370991 AMITRIPTYLINE PRO00335053 APO-AMITRIPTYLINE APX02403137 APO-AMITRIPTYLINE APX02248131 DOM-AMITRIPTYLINE DPC00654523 PMS-AMITRIPTYLINE PMS

25MG TabletST

00371009 AMITRIPTYLINE PRO00335061 APO-AMITRIPTYLINE APX02403145 APO-AMITRIPTYLINE APX02248132 DOM-AMITRIPTYLINE DPC00654515 PMS-AMITRIPTYLINE PMS02247303 PMS-AMITRIPTYLINE PMS

50MG TabletST

00456349 AMITRIPTYLINE PDL00335088 APO-AMITRIPTYLINE APX02403153 APO-AMITRIPTYLINE APX02248133 DOM-AMITRIPTYLINE DPC00271152 LEVATE ICN02247304 PMS-AMITRIPTYLINE PMS

75MG TabletST

00754129 APO-AMITRIPTYLINE APX02403161 APO-AMITRIPTYLINE APX00405612 LEVATE VAE

BUPROPION HCL (WELLBUTRIN)


Coverage of Wellbutrin XL and Bupropion SR is limited to 300 mg per day. (Note: this product will not be approved for coverage for smoking cessation).


02382075 MYLAN-BUPROPION XL MYL02275090 WELLBUTRIN XL FRS


02382083 MYLAN-BUPROPION XL MYL02275104 WELLBUTRIN XL FRS


BUPROPION HCL (WELLBUTRIN)




02331616 BUPROPION SR PDL02391562 BUPROPION SR SAN02325373 PMS-BUPROPION SR PMS02285657 RATIO-BUPROPION RPH02275074 SANDOZ-BUPROPION SR SDZ


02391570 BUPROPION SR SAN02313421 PMS-BUPROPION SR PMS02325357 PRO-BUPROPION SR PDL02285665 RATIO-BUPROPION RPH02275082 SANDOZ-BUPROPION SR SDZ02237825 WELLBUTRIN SR BPC

BUPROPION HCL (ZYBAN)


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.


02238441 ZYBAN BPC

CITALOPRAM

10MG TabletST

02355248 ACCEL-CITALOPRAM ACP02301822 CITALOPRAM MEL02387948 CITALOPRAM SIV02273055 DOM-CITALOPRAM PMS02370085 JAMP-CITALOPRAM JAP02371871 MAR-CITALOPRAM MAR02370077 MINT-CITALOPRAM MIN02273543 PHL-CITALOPRAM PMI02270609 PMS-CITALOPRAM PMS02325047 PRO-CITALOPRAM PDL02312336 TEVA-CITALOPRAM TEV

Page 65 of 1382014



CITALOPRAM

20MG TabletST

02355256 ACCEL-CITALOPRAM ACP02246056 APO-CITALOPRAM APX02275562 AURO-CITALOPRAM AUR02239607 CELEXA LUD02301830 CITALOPRAM MEL02353660 CITALOPRAM SAN02387956 CITALOPRAM SIV02257513 CITALOPRAM-20 PDL02306239 CITALOPRAM-ODAN ODN02248050 CO-CITALOPRAM ACT02248942 DOM-CITALOPRAM DPC02246594 GEN-CITALOPRAM GEN02371898 MAR-CITALOPRAM MAR02293218 NOVO-CITALOPRAM TEV02248944 PHL-CITALOPRAM PHH02248010 PMS-CITALOPRAM PMS02285622 RAN-CITALO RBY02303264 RIVA-CITALOPRAM RIV02248170 SANDOZ-CITALOPRAM SDZ02355272 SEPTA-CITALOPRAM SPT

40MG TabletST

02355264 ACCEL-CITALOPRAM ACP02246057 APO-CITALOPRAM APX02275570 AURO-CITALOPRAM AUR02239608 CELEXA LUD02301849 CITALOPRAM MEL02353679 CITALOPRAM SAN02387964 CITALOPRAM SIV02306247 CITALOPRAM-ODAN ODN02248051 CO-CITALOPRAM ACT02248943 DOM-CITALOPRAM DPC02246595 GEN-CITALOPRAM GEN02371901 MAR-CITALOPRAM MAR02293226 NOVO-CITALOPRAM TEV02248945 PHL-CITALOPRAM PHH02248011 PMS-CITALOPRAM PMS02285630 RAN-CITALO RBY02249286 RIVA-CITALOPRAM RIV02303272 RIVA-CITALOPRAM RIV02248171 SANDOZ-CITALOPRAM SDZ02355280 SEPTA-CITALOPRAM SPT

CLOMIPRAMINE HCL

10MG TabletST

00330566 ANAFRANIL ORY02040786 APO-CLOMIPRAMINE APX02244816 CO-CLOMIPRAMINE ACT02230256 NOVO-CLOPAMINE TEV

25MG TabletST



CLOMIPRAMINE HCL

50MG TabletST


DESIPRAMINE HCL

10MG TabletST

02216248 APO-DESIPRAMINE APX02223341 NOVO-DESIPRAMINE TEV

25MG TabletST

02216256 APO-DESIPRAMINE APX02130092 DOM-DESIPRAMINE DPC02223325 NOVO-DESIPRAMINE TEV

50MG TabletST

02216264 APO-DESIPRAMINE APX02130106 DOM-DESIPRAMINE DPC02223333 NOVO-DESIPRAMINE TEV01946277 PMS-DESIPRAMINE PMS

75MG TabletST

02216272 APO-DESIPRAMINE APX02223368 NOVO-DESIPRAMINE TEV01946242 PMS-DESIPRAMINE PMS

100MG TabletST

02216280 APO-DESIPRAMINE APX

DOXEPIN HCL

10MG CapsuleST

02049996 APO-DOXEPIN APX00024325 SINEQUAN ERF

25MG CapsuleST

02050005 APO-DOXEPIN APX01913425 NOVO-DOXEPIN TEV00024333 SINEQUAN ERF

50MG CapsuleST


75MG CapsuleST


100MG CapsuleST


150MG CapsuleST

01913476 NOVO-DOXEPIN TEV

DULOXETINE

30MG Delayed Release CapsuleST

02301482 CYMBALTA LIL60MG Delayed Release Capsule

ST

02301490 CYMBALTA LIL

Page 66 of 1382014



ESCITALOPRAM

10MG TabletST

02263238 CIPRALEX LUK02391449 CIPRALEX MELTZ LUK

20MG TabletST

02263254 CIPRALEX LUK02391457 CIPRALEX MELTZ LUK

FLUOXETINE HCL

10MG CapsuleST

02216353 APO-FLUOXETINE APX02242177 CO-FLUOXETINE SCN02177617 DOM-FLUOXETINE DPC02286068 FLUOXETINE SAN02374447 FLUOXETINE SIV02237813 GEN-FLUOXETINE GEN02401894 JAMP-FLUOXETINE JAP02392909 MAR-FLUOXETINE MAR02380560 MINT-FLUOXETINE MIN02216582 NOVO-FLUOXETINE TEV02223481 PHL-FLUOXETINE PHH02177579 PMS-FLUOXETINE PMS02314991 PRO-FLUOXETINE PDL02018985 PROZAC LIL02405695 RAN-FLUOXETINE RBY02242123 RIVA-FLUOXETINE RIV02243486 SANDOZ-FLUOXETINE SDZ02302659 ZYM-FLUOXETINE ZYM

20MG CapsuleST

02216361 APO-FLUOXETINE APX02242178 CO-FLUOXETINE SCN02177625 DOM-FLUOXETINE DPC02286076 FLUOXETINE SAN02374455 FLUOXETINE SIV02237814 GEN-FLUOXETINE GEN02386402 JAMP-FLUOXETINE JAP02392917 MAR-FLUOXETINE MAR02380579 MINT-FLUOXETINE MIN02216590 NOVO-FLUOXETINE TEV02223503 PHL-FLUOXETINE PHH02177587 PMS-FLUOXETINE PMS02315009 PRO-FLUOXETINE PDL00636622 PROZAC LIL02405709 RAN-FLUOXETINE RBY02242124 RIVA-FLUOXETINE RIV02243487 SANDOZ-FLUOXETINE SDZ02302667 ZYM-FLUOXETINE ZYM

4MG/ML Liquid

02231328 APO-FLUOXETINE APX


FLUVOXAMINE MALEATE

50MG TabletST

02231329 APO-FLUVOXAMINE APX02255529 CO-FLUVOXAMINE ACT02241347 DOM-FLUVOXAMINE DPC02236753 FLUVOXAMINE PDL01919342 LUVOX SPH02239953 NOVO-FLUVOXAMINE TEV02218453 RATIO-FLUVOXAMINE RPH02303345 RIVA-FLUVOX RIV02247054 SANDOZ-FLUVOXAMINE SDZ

100MG TabletST

02231330 APO-FLUVOXAMINE APX02255537 CO-FLUVOXAMINE ACT02241348 DOM-FLUVOXAMINE DPC02236754 FLUVOXAMINE PDL01919369 LUVOX SPH02239954 NOVO-FLUVOXAMINE TEV02218461 RATIO-FLUVOXAMINE RPH02247055 SANDOZ-FLUVOXAMINE SDZ

IMIPRAMINE HCL

10MG TabletST

00360201 APO-IMIPRAMINE APX00021504 NOVO-PRAMINE TEV

25MG TabletST

00312797 APO-IMIPRAMINE APX50MG Tablet

ST

00326852 APO-IMIPRAMINE APX00021520 NOVO-PRAMINE TEV

75MG TabletST

00644579 APO-IMIPRAMINE APX

MAPROTILINE HCL

25MG TabletST

02158612 NOVO-MAPROTILINE TEV50MG Tablet

ST

02158620 NOVO-MAPROTILINE TEV75MG Tablet

ST

02158639 NOVO-MAPROTILINE TEV

MIRTAZAPINE

15MG Orally Disintegrating TabletST

02299801 AURO-MIRTAZAPINE OD AUR02279894 NOVO-MIRTAZAPINE OD TEV02248542 REMERON RD ORG





Page 67 of 1382014



MIRTAZAPINE

15MG TabletST

02286610 APO-MIRTAZAPINE APX02256096 GEN-MIRTAZAPINE GEN02281732 MIRTAZAPINE MEL02273942 PMS-MIRTAZAPINE PMS02312778 PRO-MIRTAZAPINE PDL02250594 RHOXAL-MIRTAZAPINE RHO02325179 ZYM-MIRTAZAPINE ZYM

30MG TabletST

02286629 APO-MIRTAZAPINE APX02274361 CO-MIRTAZAPINE ACT02252287 DOM-MIRTAZAPINE DPC02256118 GEN-MIRTAZAPINE GEN02370689 MIRTAZAPINE SAN02259354 NOVO-MIRTAZAPINE TEV02252279 PHL-MIRTAZAPINE PHH02248762 PMS-MIRTAZAPINE PMS02312786 PRO-MIRTAZAPINE PDL02270927 RATIO-MIRTAZAPINE RPH02243910 REMERON ORG02265265 RIVA-MIRTAZAPINE RIV02250608 SANDOZ-MIRTAZAPINE SDZ02325187 ZYM-MIRTAZAPINE ZYM

45MG TabletST

02286637 APO-MIRTAZAPINE APX02256126 GEN-MIRTAZAPINE GEN

MOCLOBEMIDE

100MG TabletST

02232148 APO-MOCLOBEMIDE APX02239746 NOVO-MOCLOBEMIDE TEV

150MG TabletST

02232150 APO-MOCLOBEMIDE APX00899356 MANERIX HLR02239747 NOVO-MOCLOBEMIDE TEV02243218 PMS-MOCLOBEMIDE PMS

300MG TabletST

02240456 APO-MOCLOBEMIDE APX02166747 MANERIX HLR02239748 NOVO-MOCLOBEMIDE TEV02243219 PMS-MOCLOBEMIDE PMS

NORTRIPTYLINE HCL

10MG CapsuleST

02223511 APO-NORTRIPTYLINE APX00015229 AVENTYL PHH02178729 DOM-NORTRIPTYLINE DPC02231781 NOVO-NORTRIPTYLINE TEV02177692 PMS-NORTRIPTYLINE PMS

25MG CapsuleST

02223538 APO-NORTRIPTYLINE APX00015237 AVENTYL PHH02178737 DOM-NORTRIPTYLINE DPC02231782 NOVO-NORTRIPTYLINE TEV02177706 PMS-NORTRIPTYLINE PMS


PAROXETINE HCL

10MG TabletST

02240907 APO-PAROXETINE APX02383276 AURO-PAROXETINE AUR02262746 CO-PAROXETINE ACT02248447 DOM-PAROXETINE DPC02248012 GEN-PAROXETINE GEN02368862 JAMP-PAROXETINE JAP02248556 NOVO-PAROXETINE TEV02248913 PAROXETINE PDL02282844 PAROXETINE SAN02302012 PAROXETINE SOR02388227 PAROXETINE SIV02027887 PAXIL GSK02248450 PHL-PAROXETINE PHH02247750 PMS-PAROXETINE PMS02248559 RIVA-PAROXETINE RIV

20MG TabletST

02240908 APO-PAROXETINE APX02262754 CO-PAROXETINE ACT02248448 DOM-PAROXETINE DPC02248013 GEN-PAROXETINE GEN02368870 JAMP-PAROXETINE JAP02248557 NOVO-PAROXETINE TEV02248914 PAROXETINE PDL02282852 PAROXETINE SAN02302020 PAROXETINE SOR02388235 PAROXETINE SIV01940481 PAXIL GSK02248451 PHL-PAROXETINE PHH02247751 PMS-PAROXETINE PMS02248560 RIVA-PAROXETINE RIV02254751 SANDOZ-PAROXETINE SDZ

20MG TabletST

02383284 AURO-PAROXETINE AUR30MG Tablet

ST

02240909 APO-PAROXETINE APX02383292 AURO-PAROXETINE AUR02262762 CO-PAROXETINE ACT02248449 DOM-PAROXETINE DPC02248014 GEN-PAROXETINE GEN02368889 JAMP-PAROXETINE JAP02248558 NOVO-PAROXETINE TEV02248915 PAROXETINE PDL02282860 PAROXETINE SAN02302039 PAROXETINE SOR02388243 PAROXETINE SIV01940473 PAXIL GSK02248452 PHL-PAROXETINE PHH02247752 PMS-PAROXETINE PMS02248561 RIVA-PAROXETINE RIV02254778 SANDOZ-PAROXETINE SDZ

40MG TabletST

02293749 PMS-PAROXETINE PMS

Page 68 of 1382014



PHENELZINE SULFATE

15MG TabletST

00476552 NARDIL PFI

SERTRALINE

25MG CapsuleST

02238280 APO-SERTRALINE APX02390906 AURO-SERTRALINE AUR02287390 CO SERTRALINE ACT02245748 DOM-SERTRALINE DPC02242519 GEN-SERTRALINE GEN02357143 JAMP-SERTRALINE JAP02402378 MINT-SERTRALINE MIN02240485 NOVO-SERTRALINE TEV02245824 PHL-SERTRALINE PHH02244838 PMS-SERTRALINE PMS02374552 RAN-SERTRALINE RBY02248496 RIVA-SERTRALINE RIV02245159 SANDOZ-SERTRALINE SDZ02303779 SERTRALINE MEL02353520 SERTRALINE SAN02386070 SERTRALINE SIV02241302 SERTRALINE-25 PDL02132702 ZOLOFT PFI

50MG CapsuleST



SERTRALINE

100MG CapsuleST


TRANYLCYPROMINE SULFATE

10MG TabletST

01919598 PARNATE GSK

TRAZODONE HCL

50MG TabletST

02147637 APO-TRAZODONE APX02128950 DOM-TRAZODONE DPC02231683 GEN-TRAZODONE GEN02144263 NOVO-TRAZODONE TEV02236941 PHL-TRAZODONE PHH01937227 PMS-TRAZODONE PMS02277344 RATIO-TRAZODONE RPH02164353 TRAZODONE PDL02348772 TRAZODONE SAN02230284 TRAZOREL VAE

75MG TabletST

02237339 PMS-TRAZODONE PMS100MG Tablet

ST

02147645 APO-TRAZODONE APX02128969 DOM-TRAZODONE DPC02231684 GEN-TRAZODONE GEN02144271 NOVO-TRAZODONE TEV02236942 PHL-TRAZODONE PHH01937235 PMS-TRAZODONE PMS02277352 RATIO-TRAZODONE RPH02164361 TRAZODONE PDL02348780 TRAZODONE SAN02230285 TRAZOREL VAE

150MG TabletST

02147653 APO-TRAZODONE D APX02144298 NOVO-TRAZODONE TEV02165406 NU-TRAZODONE D NXP02277360 RATIO-TRAZODONE RPH02164388 TRAZODONE PDL02348799 TRAZODONE SAN

Page 69 of 1382014



TRIMIPRAMINE MALEATE

75MG CapsuleST

02070987 APO-TRIMIP APX12.5MG Tablet

ST

00740799 APO-TRIMIPRAMINE APX25MG Tablet

ST

00740802 APO-TRIMIPRAMINE APX01940430 NOVO-TRIPRAMINE TEV

50MG TabletST


100MG TabletST


VENLAFAXINE HCL

37.5MG Sustained Release CapsuleST

02331683 APO-VENLAFAXINE XR APX02237279 EFFEXOR XR WAY02275023 NOVO-VENLAFAXINE XR TEV02278545 PMS-VENLAFAXINE XR PMS02380072 RAN-VENLAFAXINE XR RBY02339242 VENLAFAXINE XR PDL02354713 VENLAFAXINE XR SAN02385929 VENLAFAXINE XR SIV


02331691 APO-VENLAFAXINE XR APX02299305 DOM-VENLAFAXINE XR DOM02237280 EFFEXOR XR WAY02275031 NOVO-VENLAFAXINE XR TEV02278553 PMS-VENLAFAXINE XR PMS02380080 RAN-VENLAFAXINE XR RBY02339250 VENLAFAXINE XR PDL02354721 VENLAFAXINE XR SAN02385937 VENLAFAXINE XR SIV


02331705 APO-VENLAFAXINE XR APX02237282 EFFEXOR XR WAY02275058 NOVO-VENLAFAXINE XR TEV02278561 PMS-VENLAFAXINE XR PMS02380099 RAN-VENLAFAXINE XR RBY02339269 VENLAFAXINE XR PDL02354748 VENLAFAXINE XR SAN02385945 VENLAFAXINE XR SIV

28:16.08 ANTIPSYCHOTIC AGENTS

ARIPIPRAZOLE

Limited use benefit (prior approval required). For the treatment of schizophrenia and schizoaffective disorders in patients who havea. Intolerance or lack of response to an adequate trial of another antipsychotic agent; ORb. A contraindication to another antipsychotic agent

2MG TabletST

02322374 ABILIFY BMS


ARIPIPRAZOLE

Limited use benefit (prior approval required). For the treatment of schizophrenia and schizoaffective disorders in patients who havea. Intolerance or lack of response to an adequate trial of another antipsychotic agent; ORb. A contraindication to another antipsychotic agent

5MG TabletST

02322382 ABILIFY BMS10MG Tablet

ST


ST


ST


ST

02322455 ABILIFY BMS

ASENAPINE

Limited use benefit (prior approval required). For the acute treatment of manic or mixed episodes associated with bipolar I disorder as either:

- Monotherapy, after a trial of lithium or divalproex sodium has failed or is contraindicated, and trials of two atypical antipsychotic agents have failed due to intolerance or lack of response

OR

- Co-therapy with lithium or divalproex sodium, after trials of two atypical antipsychotic agents have failed due to intolerance or lack of response.

5MG Sublingual TabletST

02374803 SAPHRIS FRS10MG Sublingual Tablet

ST

02374811 SAPHRIS FRS

CHLORPROMAZINE

25MG/ML Injection

00743518 CHLORPROMAZINE HCL SDZ25MG Tablet

ST

00232823 NOVO-CHLORPROMAZINE TEV50MG Tablet

ST

00232807 NOVO-CHLORPROMAZINE TEV100MG Tablet

ST

00232831 NOVO-CHLORPROMAZINE TEV

CLOZAPINE

25MG TabletST

02248034 APO-CLOZAPINE APX00894737 CLOZARIL NVR02247243 GEN-CLOZAPINE GEN

100MG TabletST

02248035 APO-CLOZAPINE APX00894745 CLOZARIL NVR02247244 GEN-CLOZAPINE GEN

Page 70 of 1382014



FLUPENTHIXOL DECANOATE

20MG/ML Injection

02156032 FLUANXOL DEPOT LUD100MG/ML Injection

02156040 FLUANXOL DEPOT LUD

FLUPENTHIXOL DIHYDROCHLORIDE

0.5MG TabletST

02156008 FLUANXOL LUD3MG Tablet

ST

02156016 FLUANXOL LUD

FLUPHENAZINE DECANOATE

25MG/ML Injection

02091275 PMS-FLUPHENAZINE PMS100MG/ML Injection

00755575 MODECATE BMS02241928 PMS-FLUPHENAZINE PMS

FLUPHENAZINE HCL

1MG TabletST

00405345 APO-FLUPHENAZINE APX2MG Tablet

ST

00410632 APO-FLUPHENAZINE APX5MG Tablet

ST

00405361 APO-FLUPHENAZINE APX

HALOPERIDOL

5MG/ML InjectionST

00808652 HALOPERIDOL SDZ02366010 HALOPERIDOL OMG

2MG/ML Solution

00759503 PMS-HALOPERIDOL PMS0.5MG Tablet

ST

00396796 APO-HALOPERIDOL APX00363685 NOVO-PERIDOL TEV

1MG TabletST


2MG TabletST

00363669 NOVO-PERIDOL TEV5MG Tablet

ST

00363650 NOVO-PERIDOL TEV10MG Tablet

ST


20MG TabletST

00768820 NOVO-PERIDOL TEV

HALOPERIDOL DECANOATE

50MG/ML Injection

02130297 HALOPERIDOL LA SDZ02230707 PMS-HALOPERIDOL LA PMS


HALOPERIDOL DECANOATE

100MG/ML Injection

02130300 HALOPERIDOL LA SDZ02239640 HALOPERIDOL LA OMG02230708 PMS-HALOPERIDOL LA PMS

LOXAPINE HCL

25MG/ML Oral Liquid

02239101 PMS-LOXAPINE PMS

LOXAPINE SUCCINATE

2.5MG TabletST

02242868 PMS-LOXAPINE PMS5MG Tablet

ST

02239918 DOM-LOXAPINE DPC02236943 PHL-LOXAPINE PHH02230837 PMS-LOXAPINE PMS

10MG TabletST

02239919 DOM-LOXAPINE DPC02236944 PHL-LOXAPINE PHH02230838 PMS-LOXAPINE PMS

25MG TabletST

02239920 DOM-LOXAPINE DPC02236945 PDL-LOXAPINE PHH02230839 PMS-LOXAPINE PMS

50MG TabletST

02239921 DOM-LOXAPINE DPC02236946 PDL-LOXAPINE PHH02230840 PMS-LOXAPINE PMS

METHOTRIMEPRAZINE

2MG TabletST

02238403 APO-METHOPRAZINE APX5MG Tablet

ST

02238404 APO-METHOPRAZINE APX02232903 PMS-METHOTRIMEPRAZINE PMS

25MG TabletST

02238405 APO-METHOPRAZINE APX01964925 NOVO-MEPRAZINE TEV

50MG TabletST

02238406 APO-METHOPRAZINE APX

OLANZAPINE


02360616 APO-OLANZAPINE ODT APX02327562 CO OLANZAPINE ODT ACT02389088 MAR-OLANZAPINE ODT MAR02382709 MYLAN-OLANZAPINE ODT MYL02338645 OLANZAPINE ODT PDL02343665 OLANZAPINE ODT SIV02352974 OLANZAPINE ODT SAN02303191 PMS-OLANZAPINE ODT PMS02327775 SANDOZ OLANZAPINE ODT SDZ02321343 TEVA-OLANZAPINE OD TEP02243086 ZYPREXA ZYDIS LIL

Page 71 of 1382014



OLANZAPINE





2.5MG TabletST

02281791 APO-OLANZAPINE APX02325659 CO OLANZAPINE ACT02337878 MYLAN-OLANZAPINE MYL02276712 NOVO-OLANZAPINE TEV02311968 OLANZAPINE PDL02372819 OLANZAPINE SAN02385864 OLANZAPINE SIV02403064 RAN-OLANZAPINE RBY02337126 RIVA-OLANZAPINE RIV02310341 SANDOZ-OLANZAPINE PDL02229250 ZYPREXA LIL

5MG TabletST



OLANZAPINE

7.5MG TabletST


10MG TabletST


15MG TabletST


PERICYAZINE

5MG CapsuleST

01926780 NEULEPTIL ERF10MG Capsule

ST

01926772 NEULEPTIL ERF20MG Capsule

ST

01926764 NEULEPTIL ERF10MG/ML Drop

01926756 NEULEPTIL ERF

PERPHENAZINE

3.2MG/ML Liquid

00751898 PMS-PERPHENAZINE PMS2MG Tablet

ST

00335134 APO-PERPHENAZINE APX4MG Tablet

ST

00335126 APO-PERPHENAZINE APX

Page 72 of 1382014



PERPHENAZINE

8MG TabletST

00335118 APO-PERPHENAZINE APX16MG Tablet

ST

00335096 APO-PERPHENAZINE APX

PIMOZIDE

2MG TabletST

02245432 APO-PIMOZIDE APX00313815 ORAP PHH

4MG TabletST

02245433 APO-PIMOZIDE APX00313823 ORAP PHH

PIPOTIAZINE PALMITATE

25MG/ML Injection

01926667 PIPORTIL L4 SAC50MG/ML Injection

00894672 PIPORTIL L4 RHO *

PROCHLORPERAZINE

5MG/ML InjectionST

00789747 PROCHLORPERAZINE SDZ10MG Suppository

ST

00753688 PMS-PROCHLORPERAZINE PMS00789720 PROCHLORPERAZINE SIL

5MG TabletST

00886440 APO-PROCHLORAZINE APX00753661 PMS-PROCHLORPERAZINE PMS

10MG TabletST

00886432 APO-PROCHLORAZINE APX00753637 PMS-PROCHLORPERAZINE PMS

QUETIAPINE FUMARATE


02407671 SANDOZ QUETIAPINE XRT SDZ02300184 SEROQUEL XR AZE02395444 TEVA-QUETIAPINE XR TEP










QUETIAPINE FUMARATE

25MG TabletST

02390205 AURO-QUETIAPINE AUR02298996 DOM-QUETIAPINE DOM02330415 JAMP-QUETIAPINE JAP02299054 PHL-QUETIAPINE PMI02317346 PRO-QUETIAPINE PDL02317893 QUETIAPINE SIV02353164 QUETIAPINE SAN02397099 RAN-QUETIAPINE RBY02316692 RIVA-QUETIAPINE RIV02236951 SEROQUEL AZC

50MG TabletST

02361892 PMS-QUETIAPINE VTH100MG Tablet

ST

02390213 AURO-QUETIAPINE AUR02299003 DOM-QUETIAPINE DOM02330423 JAMP-QUETIAPINE JAP02299062 PHL-QUETIAPINE PMI02317354 PRO-QUETIAPINE PDL02317907 QUETIAPINE MEL02353172 QUETIAPINE SAN02397102 RAN-QUETIAPINE RBY02316706 RIVA-QUETIAPINE RIV02236952 SEROQUEL AZC

200MG TabletST


300MG TabletST


RISPERIDONE

0.5MG Orally Disintegrating TabletST

02247704 RISPERDAL-M JNO1MG Orally Disintegrating Tablet

ST

02291789 PMS-RISPERIDONE ODT PMS02247705 RISPERDAL-M JNO

Page 73 of 1382014



RISPERIDONE







1MG/ML SolutionST

02280396 APO-RISPERIDONE APX02279266 PMS-RISPERIDONE PMS02236950 RISPERDAL JNO

0.25MG TabletST

02282119 APO-RISPERIDONE APX02282585 CO-RISPERIDONE ACT02282240 GEN-RISPERIDONE GEN02359529 JAMP-RISPERIDONE JAP02371766 MAR-RISPERIDONE MAR02359790 MINT-RISPERIDONE MIN02282690 NOVO-RISPERIDONE TEV02258439 PHL-RISPERIDONE PMI02252007 PMS-RISPERIDONE PMS02312700 PRO-RISPERIDONE PDL02328305 RAN-RISPERIDONE RBY02264757 RATIO-RISPERIDONE RPH02240551 RISPERDAL JNO02303485 RISPERIDONE MEL02356880 RISPERIDONE SAN02283565 RIVA-RISPERIDONE RIV

0.5MG TabletST

02282127 APO-RISPERIDONE APX02282593 CO-RISPERIDONE ACT02278448 DOM-RISPERIDONE DOM02282259 GEN-RISPERIDONE GEN02359537 JAMP-RISPERIDONE JAP02371774 MAR-RISPERIDONE MAR02359804 MINT-RISPERIDONE MIN02264188 NOVO-RISPERIDONE TEV02258447 PHL-RISPERIDONE PMI02252015 PMS-RISPERIDONE PMS02312719 PRO-RISPERIDONE PDL02328313 RAN-RISPERIDONE RBY02264765 RATIO-RISPERIDONE RPH02240552 RISPERDAL JNO02303493 RISPERIDONE MEL02356899 RISPERIDONE SAN02283573 RIVA-RISPERIDONE RIV


RISPERIDONE

1MG TabletST

02282135 APO-RISPERIDONE APX02282607 CO-RISPERIDONE ACT02278456 DOM-RISPERIDONE DOM02282267 GEN-RISPERIDONE GEN02359545 JAMP-RISPERIDONE JAP02371782 MAR-RISPERIDONE MAR02359812 MINT-RISPERIDONE MIN02264196 NOVO-RISPERIDONE TEV02258455 PHL-RISPERIDONE PMI02252023 PMS-RISPERIDONE PMS02312727 PRO-RISPERIDONE PDL02328321 RAN-RISPERIDONE RBY02264773 RATIO-RISPERIDONE RPH02025280 RISPERDAL JNO02303507 RISPERIDONE MEL02356902 RISPERIDONE SAN02283581 RIVA-RISPERIDONE RIV02279800 SANDOZ-RISPERIDONE SDZ

2MG TabletST

02359820 MINT-RISPERIDONE MIN2MG Tablet

ST

02282143 APO-RISPERIDONE APX02282615 CO-RISPERIDONE ACT02278464 DOM-RISPERIDONE DOM02282275 GEN-RISPERIDONE GEN02359553 JAMP-RISPERIDONE JAP02371790 MAR-RISPERIDONE MAR02264218 NOVO-RISPERIDONE TEV02258463 PHL-RISPERIDONE PMI02252031 PMS-RISPERIDONE PMS02312735 PRO-RISPERIDONE PDL02328348 RAN-RISPERIDONE RBY02264781 RATIO-RISPERIDONE RPH02025299 RISPERDAL JNO02303515 RISPERIDONE MEL02356910 RISPERIDONE SAN02283603 RIVA-RISPERIDONE RIV02279819 SANDOZ-RISPERIDONE SDZ

Page 74 of 1382014



RISPERIDONE

3MG TabletST

02282151 APO-RISPERIDONE APX02282623 CO-RISPERIDONE ACT02278472 DOM-RISPERIDONE DOM02282283 GEN-RISPERIDONE GEN02359561 JAMP-RISPERIDONE JAP02371804 MAR-RISPERIDONE MAR02359839 MINT-RISPERIDONE MIN02264226 NOVO-RISPERIDONE TEV02258471 PHL-RISPERIDONE PMI02252058 PMS-RISPERIDONE PMS02312743 PRO-RISPERIDONE PDL02328364 RAN-RISPERIDONE RBY02264803 RATIO-RISPERIDONE RPH02025302 RISPERDAL JNO02303523 RISPERIDONE MEL02356929 RISPERIDONE SAN02283611 RIVA-RISPERIDONE RIV02279827 SANDOZ-RISPERIDONE SDZ

4MG TabletST

02282178 APO-RISPERIDONE APX02282631 CO-RISPERIDONE ACT02282291 GEN-RISPERIDONE GEN02359588 JAMP-RISPERIDONE JAP02371812 MAR-RISPERIDONE MAR02359847 MINT-RISPERIDONE MIN02264234 NOVO-RISPERIDONE TEV02258498 PHL-RISPERIDONE PMI02252066 PMS-RISPERIDONE PMS02312751 PRO-RISPERIDONE PDL02328372 RAN-RISPERIDONE RBY02264811 RATIO-RISPERIDONE RPH02025310 RISPERDAL JNO02303531 RISPERIDONE MEL02356937 RISPERIDONE SAN02283638 RIVA-RISPERIDONE RIV02279835 SANDOZ-RISPERIDONE SDZ

THIOPROPERAZINE MESYLATE

10MG TabletST

01927639 MAJEPTIL ERF

THIOTHIXENE

2MG CapsuleST

00024430 NAVANE ERF5MG Capsule

ST

00024449 NAVANE ERF10MG Capsule

ST

00024457 NAVANE ERF

TRIFLUOPERAZINE HCL

10MG/ML Liquid

00751871 PMS-TRIFLUOPERAZINE PMS1MG Tablet

ST

00345539 APO-TRIFLUOPERAZINE APX


TRIFLUOPERAZINE HCL

2MG TabletST

00312754 APO-TRIFLUOPERAZINE APX5MG Tablet

ST


ST


ST

00595942 APO-TRIFLUOPERAZINE APX

ZIPRASIDONE


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 CapsuleST

02298597 ZELDOX PFI40MG Capsule

ST


ST


ST

02298627 ZELDOX PFI

28:20.04 AMPHETAMINES

DEXTROAMPHETAMINE SULFATE


01924559 DEXEDRINE SPANSULE GSK15MG Sustained Release Capsule

ST

01924567 DEXEDRINE SPANSULE GSK5MG Tablet

ST

01924516 DEXEDRINE GSK

LISDEXAMFETAMINE DIMESYLATE

20MG CapsuleST

02347156 VYVANSE 20MG CAP BCM30MG Capsule

ST


ST


ST


ST

02347172 VYVANSE 60MG CAP BCM

28:20.32

METHYLPHENIDATE HCL


02247732 CONCERTA 18MG TAB JNO02315068 TEVA-METHYLPHENIDATE ER

18MGTEP

Page 75 of 1382014


28:20.32

METHYLPHENIDATE HCL


02320312 SANDOZ-METHYLPHENIDATE SR 20MG

SDZ



27MGTEP



36MGTEP


02330377 APO-METHYLPHENIDATE 54MG ER

APX


54MGTEP

5MG TabletST

02326221 METHYLPHENIDATE 5MG TAB PDL10MG Tablet

ST

02326248 METHYLPHENIDATE 10MG TAB PDL20MG Tablet

ST

02326256 METHYLPHENIDATE 20MG TAB PDL

28:20.92 MISC ANOREXIGENIC AGENTS &

RESPIRATORY & CEREBRAL

STIMULANT

METHYLPHENIDATE HCL


02266687 APO-METHYLPHENIDATE SR APX5MG Tablet

ST

02273950 APO-METHYLPHENIDATE APX02234749 PMS-METHYLPHENIDATE PMS

10MG TabletST


20MG TabletST


MODAFINIL

100MG TabletST

02239665 ALERTEC DPY

28:24.08 ANXIOLYTICS, SEDATIVES AND

HYPNOTICS - BENZODIAZEPINES

ALPRAZOLAM



0.25MG TabletST

01908189 ALPRAZOLAM PDL02349191 ALPRAZOLAM SAN00865397 APO-ALPRAZ APX02137534 GEN-ALPRAZOLAM GEN02400111 JAMP-ALPRAZOLAM JAP01913484 NOVO-ALPRAZOL TEV00548359 XANAX PFI

0.5MG TabletST

01908170 ALPRAZOLAM PDL02349205 ALPRAZOLAM SAN00865400 APO-ALPRAZ APX02137542 GEN-ALPRAZOLAM GEN02400138 JAMP-ALPRAZOLAM JAP01913492 NOVO-ALPRAZOL TEV00548367 XANAX PFI

1MG TabletST

02248706 ALPRAZOLAM PDL02243611 APO-ALPRAZ APX02229813 GEN-ALPRAZOLAM GEN02400146 JAMP-ALPRAZOLAM JAP00723770 XANAX PFI

2MG TabletST

02243612 APO-ALPRAZ APX02229814 GEN-ALPRAZOLAM GEN02400154 JAMP-ALPRAZOLAM JAP00813958 XANAX TS PFI

BROMAZEPAM



1.5MG TabletST

02177153 APO-BROMAZEPAM APX

Page 76 of 1382014




BROMAZEPAM



3MG TabletST

02177161 APO-BROMAZEPAM APX02220520 BROMAZEPAM PDL00518123 LECTOPAM HLR02230584 NOVO-BROMAZEPAM TEV

6MG TabletST

02177188 APO-BROMAZEPAM APX02220539 BROMAZEPAM PDL00518131 LECTOPAM HLR02230585 NOVO-BROMAZEPAM TEV

CLOBAZAM

10MG TabletST

02244638 APO-CLOBAZAM APX02248454 CLOBAZAM PDL02247230 DOM-CLOBAZAM DPC02221799 FRISIUM PED02238334 NOVO-CLOBAZAM TEV02244474 PMS-CLOBAZAM PMS

DIAZEPAM



1MG/ML Oral SolutionST

00891797 PMS-DIAZEPAM PMS2MG Tablet

ST

00405329 APO-DIAZEPAM APX00434396 DIAZEPAM PDL02247490 PMS-DIAZEPAM PMS

5MG TabletST

00362158 APO-DIAZEPAM APX00313580 DIAZEPAM PRO02247491 PMS-DIAZEPAM PMS00013285 VALIUM HLR



DIAZEPAM



10MG TabletST

00405337 APO-DIAZEPAM APX00434388 DIAZEPAM PDL02247492 PMS-DIAZEPAM PMS

LORAZEPAM



0.5MG TabletST

00655740 APO-LORAZEPAM APX02410745 APO-LORAZEPAM

SUBLINGUALAPX

02041413 ATIVAN WAY02041456 ATIVAN SUBLINGUAL WAY02245784 DOM-LORAZEPAM DPC02351072 LORAZEPAM SAN00711101 NOVO-LORAZEM TEV00728187 PMS-LORAZEPAM PMS00655643 PRO-LORAZEPAM PDL

1MG TabletST


SUBLINGUALAPX


Page 77 of 1382014




LORAZEPAM



2MG TabletST


SUBLINGUALAPX


NITRAZEPAM



5MG TabletST

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

10MG TabletST

02245231 APO-NITRAZEPAM APX00511536 MOGADON ICN02229655 NITRAZADON VAE02234007 SANDOZ-NITRAZEPAM SDZ



OXAZEPAM



10MG TabletST

00402680 APO-OXAZEPAM APX00497754 OXAZEPAM PDL00414247 OXPAM VAE00568392 ZAPEX RIV

15MG TabletST

00402745 APO-OXAZEPAM APX00497762 OXAZEPAM PDL00568406 ZAPEX RIV

30MG TabletST

00402737 APO-OXAZEPAM APX00497770 OXAZEPAM PDL00414263 OXPAM VAE00568414 ZAPEX RIV

TEMAZEPAM



15MG CapsuleST

02225964 APO-TEMAZEPAM APX02244814 CO-TEMAZEPAM ACT02229756 DOM-TEMAZEPAM DPC02230095 NOVO-TEMAZEPAM TEV02243023 RATIO-TEMAZEPAM RPH00604453 RESTORIL ORY02229760 TEMAZEPAM PDL

30MG CapsuleST

02225972 APO-TEMAZEPAM APX02244815 CO-TEMAZEPAM ACT02229758 DOM-TEMAZEPAM DPC02230102 NOVO-TEMAZEPAM TEV02243024 RATIO-TEMAZEPAM RPH00604461 RESTORIL ORY02229761 TEMAZEPAM PDL

Page 78 of 1382014




TRIAZOLAM



0.125MG TabletST

00808563 APO-TRIAZO APX0.25MG Tablet

ST

00808571 APO-TRIAZO APX

28:24.92 MISCELLANEOUS ANXIOLYTICS,

SEDATIVES, AND HYPNOTICS

HYDROXYZINE HCL

10MG Capsule

00739618 HYDROXYZINE PDL00738824 NOVO-HYDROXYZIN TEV02241192 RIVA-HYDROXYZIN RIV

25MG Capsule


50MG Capsule


2MG/ML Syrup

00024694 ATARAX ERF00741817 PMS-HYDROXYZINE PMS

10MG Tablet

00646059 APO-HYDROXYZINE APX25MG Tablet

00646024 APO-HYDROXYZINE APX50MG Tablet

00646016 APO-HYDROXYZINE APX

28:28.00 ANTIMANIC AGENTS

LITHIUM CARBONATE

150MG Capsule

02242837 APO-LITHIUM CARB APX09857532 APO-LITHIUM CARBONATE APX02013231 LITHANE ERF02216132 PMS-LITHIUM CARBONATE PMS

300MG Capsule

02242838 APO-LITHIUM CARB APX09857540 APO-LITHIUM CARBONATE APX00236683 CARBOLITH VAE00406775 LITHANE ERF02216140 PMS-LITHIUM CARBONATE PMS

28:28.00 ANTIMANIC AGENTS

LITHIUM CARBONATE

600MG Capsule

02011239 CARBOLITH VAE02216159 PMS-LITHIUM CARBONATE PMS


02266695 APO-LITHIUM CARBONATE APX

LITHIUM CITRATE

60MG/ML Syrup

02074834 PMS-LITHIUM CITRATE PMS

28:32.28 SELECTIVE SEROTONIN

AGONISTS

ALMOTRIPTAN MALATE


A total of 12 tablets (or injections) are permitted in a 30-day period.

6.25MG Tablet

02405792 APO-ALMOTRIPTAN APX02248128 AXERT MCL02398435 MYLAN-ALMOTRIPTAN MYL

12.5MG Tablet

02405806 APO-ALMOTRIPTAN APX02248129 AXERT MCL02398443 MYLAN-ALMOTRIPTAN MYL02405334 SANDOZ ALMOTRIPTAN SDZ

NARATRIPTAN HCL



1MG Tablet

02237820 AMERGE GSK02314290 TEVA-NARATRIPTAN TEP

2.5MG Tablet

02237821 AMERGE GSK02322323 SANDOZ NARATRIPTAN SDZ02314304 TEVA-NARATRIPTAN TEP

RIZATRIPTAN



5MG Orally Disintegrating Tablet

02393484 APO-RIZATRIPTAN RPD APX02374730 CO-RIZATRIPTAN ODT ACT02240518 MAXALT RPD FRS02379198 MYLAN-RIZATRIPTAN ODT MYL02393360 PMS-RIZATRIPTAN RDT PMS02351870 SANDOZ RIZATRIPTAN ODT SDZ

Page 79 of 1382014



AGONISTS

RIZATRIPTAN



10MG Orally Disintegrating Tablet

02393492 APO-RIZATRIPTAN RPD APX02374749 CO-RIZATRIPTAN ODT ACT02396203 DOM-RIZATRIPTAN RDT DOM02240519 MAXALT RPD FRS02379201 MYLAN-RIZATRIPTAN ODT MYL02393379 PMS-RIZATRIPTAN RDT PMS02351889 SANDOZ RIZATRIPTAN ODT SDZ

5MG Tablet

02393468 APO-RIZATRIPTAN APX02380455 JAMP-RIZATRIPTAN JAP02379651 MAR-RIZATRIPTAN MAR

10MG Tablet

02393476 APO-RIZATRIPTAN APX02381702 CO RIZATRIPTAN ACT02380463 JAMP-RIZATRIPTAN JAP02379678 MAR-RIZATRIPTAN MAR02240521 MAXALT FRS

SUMATRIPTAN HEMISULFATE

5MG Nasal Spray

02230418 IMITREX GSK20MG Nasal Spray

02230420 IMITREX GSK

SUMATRIPTAN SUCCINATE



12MG/ML Injection

02212188 IMITREX GSK99000598 IMITREX GSK *02361698 TARO-SUMATRIPTAN TAR

25MG Tablet

02257882 CO-SUMATRIPTAN ACT02270749 DOM-SUMATRIPTAN DPC02268906 GEN-SUMATRIPTAN GEN02286815 NOVO-SUMATRIPTAN DF TEV02256428 PMS-SUMATRIPTAN PMS02286513 SUMATRIPTAN SAN


AGONISTS

SUMATRIPTAN SUCCINATE



50MG Tablet

02268388 APO-SUMATRIPTAN APX02257890 CO-SUMATRIPTAN ACT02270757 DOM-SUMATRIPTAN DPC02268914 GEN-SUMATRIPTAN GEN02212153 IMITREX DF GSK02286823 NOVO-SUMATRIPTAN DF TEV02256436 PMS-SUMATRIPTAN PMS02324652 PRO-SUMATRIPTAN PDL02263025 SANDOZ-SUMATRIPTAN SDZ02286521 SUMATRIPTAN SAN02385570 SUMATRIPTAN DF SIV

100MG Tablet

02268396 APO-SUMATRIPTAN APX02257904 CO-SUMATRIPTAN ACT02270765 DOM-SUMATRIPTAN DPC02268922 GEN-SUMATRIPTAN GEN02212161 IMITREX DF GSK02239367 NOVO-SUMATRIPTAN TEV02286831 NOVO-SUMATRIPTAN DF TEV02256444 PMS-SUMATRIPTAN PMS02324660 PRO-SUMATRIPTAN PDL02263033 SANDOZ-SUMATRIPTAN SDZ02286548 SUMATRIPTAN SAN02385589 SUMATRIPTAN DF SIV

ZOLMITRIPTAN



2.5MG Orally Disintegrating Tablet

02381575 APO-ZOLMITRIPTAN RAPID APX02387158 MYLAN ZOLMITRIPTAN ODT MYL02324768 PMS-ZOLMITRIPTAN ODT PMS02362996 SANDOZ ZOLMITRIPTAN ODT SDZ02342545 TEVA-ZOLMITRIPTAN OD TEP02379988 ZOLMITRIPTAN ODT PDL02243045 ZOMIG RAPIMELT AZC

2.5MG Tablet

02380951 APO-ZOLMITRIPTAN APX02389525 DOM-ZOLMITRIPTAN DOM02369036 MYLAN ZOLMITRIPTAN MYL02324229 PMS-ZOLMITRIPTAN PMS02401304 RIVA-ZOLMITRIPTAN RIV02362988 SANDOZ ZOLMITRIPTAN SDZ02313960 TEVA-ZOLMITRIPTAN TEP02379929 ZOLMITRIPTAN PDL02238660 ZOMIG AZC

Page 80 of 1382014


28:32.92 MISCELLANEOUS ANTIMIGRANE

AGENTS

FLUNARIZINE HCL

5MG Capsule

02246082 APO-FLUNARIZINE APX

PIZOTYLINE HYDROGEN MALATE

0.5MG Tablet

00329320 SANDOMIGRAN PED1MG Tablet

00511552 SANDOMIGRAN DS PED

28:36.12 ANTIPARKINSONIAN AGENTS -

CATECHOL-O-

METHYLTRANSFERASE (COMT)

INHIBITORS

ENTACAPONE

200MG TabletST

02243763 COMTAN NVR02390337 MYLAN-ENTACAPONE MYL02380005 SANDOZ ENTACAPONE SDZ02375559 TEVA-ENTACAPONE TEP


DOPAMINE PRECURSORS

LEVODOPA, BENZERAZIDE

50MG & 12.5MG CapsuleST

00522597 PROLOPA HLR100MG & 25MG Capsule

ST

00386464 PROLOPA HLR200MG & 50MG Capsule

ST

00386472 PROLOPA HLR

LEVODOPA, CARBIDOPA

100MG & 25MG Controlled Release TabletST

02272873 APO-LEVOCARB CR AAP02028786 SINEMET CR BMS

200MG & 50MG Controlled Release TabletST

02245211 APO-LEVOCARB CR APX00870935 SINEMET CR BMS


02195933 APO-LEVOCARB APX02244494 NOVO-LEVOCARBIDOPA TEV00355658 SINEMET BMS


02195941 APO-LEVOCARB APX02244495 NOVO-LEVOCARBIDOPA TEV02311178 PRO-LEVOCARB PDL00513997 SINEMET BMS


02195968 APO-LEVOCARB APX02244496 NOVO-LEVOCARBIDOPA TEV00328219 SINEMET BMS


DOPAMINE PRECURSORS

LEVODOPA, CARBIDOPA, ENTACAPONE

50MG & 12.5MG & 200MG TabletST

02305933 STALEVO NOV75MG & 18.75MG & 200MG Tablet

ST

02337827 STALEVO NOV100MG & 25MG & 200MG Tablet

ST


ST


ST

02305968 STALEVO NOV


DOPAMINE RECEPTOR

AGONISTS

BROMOCRIPTINE MESYLATE

5MG Capsule

02230454 APO-BROMOCRIPTINE APX02238637 DOM-BROMOCRIPTINE DPC02236949 PMS-BROMOCRIPTINE PMS

2.5MG Tablet

02087324 APO-BROMOCRIPTINE APX02238636 DOM-BROMOCRIPTINE DPC02231702 PMS-BROMOCRIPTINE PMS

CABERGOLINE


For treatment of hyperprolactinemia in patients who have failed therapy with or are intolerant to bromocriptine.

0.5MG Tablet

02301407 CO CABERGOLINE ACT02242471 DOSTINEX PFI

PRAMIPEXOLE DIHYDROCHLORIDE

0.25MG TabletST

02292378 APO-PRAMIPEXOLE APX02297302 CO PRAMIPEXOLE ACT02309017 DOM-PRAMIPEXOLE DOM02237145 MIRAPEX BOE09857268 MIRAPEX (ONT) BOE *02376350 MYLAN-PRAMIPEXOLE MYL02269309 NOVO-PRAMIPEXOLE TEV02290111 PMS-PRAMIPREXOLE PMS02309122 PRAMIPEXOLE SIV02367602 PRAMIPEXOLE SAN02325802 PRO-PRAMIPEXOLE PDL02315262 SANDOZ-PRAMIPEXOLE SDZ

Page 81 of 1382014



DOPAMINE RECEPTOR

AGONISTS

PRAMIPEXOLE DIHYDROCHLORIDE

0.5MG TabletST

02292386 APO-PRAMIPEXOLE APX02297310 CO PRAMIPEXOLE ACT02241594 MIRAPEX BOE02376369 MYLAN-PRAMIPEXOLE MYL02269317 NOVO-PRAMIPEXOLE TEV02290138 PMS-PRAMIPREXOLE PMS02309130 PRAMIPEXOLE SIV02367610 PRAMIPEXOLE SAN02325810 PRO-PRAMIPEXOLE PDL02315270 SANDOZ-PRAMIPEXOLE SDZ

1MG TabletST

02292394 APO-PRAMIPEXOLE APX02297329 CO PRAMIPEXOLE ACT02237146 MIRAPEX BOE09857269 MIRAPEX (ONT) BOE *02376377 MYLAN-PRAMIPEXOLE MYL02269325 NOVO-PRAMIPEXOLE TEV02290146 PMS-PRAMIPREXOLE PMS02309149 PRAMIPEXOLE SIV02325829 PRO-PRAMIPEXOLE PDL02315289 SANDOZ-PRAMIPEXOLE SDZ

1.5MG TabletST

02292408 APO-PRAMIPEXOLE APX02297337 CO PRAMIPEXOLE ACT02237147 MIRAPEX BOE09857270 MIRAPEX (ONT) BOE *02376385 MYLAN-PRAMIPEXOLE MYL02269333 NOVO-PRAMIPEXOLE TEV02290154 PMS-PRAMIPREXOLE PMS02309157 PRAMIPEXOLE SIV02325837 PRO-PRAMIPEXOLE PDL02315297 SANDOZ-PRAMIPEXOLE SDZ

ROPINIROLE HCL

0.25MG TabletST

02337746 APO-ROPINIROLE APX02316846 CO-ROPINIROLE ACT02352338 JAMP-ROPINIROLE JAP02326590 PMS-ROPINIROLE PMS02314037 RAN-ROPINIROLE RBY02353040 ROPINIROLE SAN

1MG TabletST



DOPAMINE RECEPTOR

AGONISTS

ROPINIROLE HCL

2MG TabletST


5MG TabletST



MONOAMINE OXIDASE B

INHIBITORS

SELEGILINE HCL

5MG TabletST

02230641 APO-SELEGILINE APX02238340 DOM-SELEGILINE DPC02231036 GEN-SELEGILINE GEN02068087 NOVO-SELEGILINE TEV

28:92.00 MISCELLANEOUS CENTRAL

NERVOUS SYSTEM AGENTS

ACAMPROSATE CALCIUM


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 Delayed Release Tablet

02293269 CAMPRAL MYL

BETAHISTINE HCL

8MG Tablet

02280183 NOVO-BETAHISTINE TEV16MG Tablet

02374757 CO BETAHISTINE ACT02280191 NOVO-BETAHISTINE TEV02243878 SERC SPH

24MG Tablet

02374765 CO BETAHISTINE ACT02280205 NOVO-BETAHISTINE TEV02247998 SERC SPH

TETRABENAZINE

25MG Tablet

02407590 APO-TETRABENAZINE APX02199270 NITOMAN LHL02402424 PMS-TETRABENAZINE PMS

Page 82 of 1382014


32:00 CONTRACEPTIVES (NON-ORAL)

32:00.00 CONTRACEPTIVES (NON-ORAL)

CONDOM, MALE

Device

99400527 CONDOM, LATEX, LUBRICATED

99400485 CONDOM, LATEX, LUBRICATED, NONOXYNOL

99400486 CONDOM, LATEX, NON-LUBRICATED

99400786 CONDOM, NON-LATEX, LUBRICATED

INTRAUTERINE DEVICE


Coverage is granted for 1 device every 12 months.Device

98099999 FLEXI-T IUD PRN99401085 LIBERTE UT380 SHORT MSC99401086 LIBERTE UT380 STANDARD MSC99400482 NOVA-T IUD BEX

Page 83 of 1382014


36:00 DIAGNOSTIC AGENTS (DX)

36:00.00 DIAGNOSTIC AGENTS (DX)

THYROTROPIN ALFA

0.9MG/ML Powder for Solution

02246016 THYROGEN GEE

36:26.00 DX - DIABETES MELLITUS

GLUCOSE OXIDASE, PEROXIDASE

Accu-Chek Advantage Strip

97799824 ACCU-CHEK ADVANTAGE ROCAccu-Chek Aviva Strip

97799814 ACCU-CHEK AVIVA ROD09857178 ACCU-CHEK AVIVA (ON) ROC

Accu-Chek Compact Strip

97799962 ACCU-CHEK COMPACT ROD09854282 ACCU-CHEK COMPACT (ON) ROD *

Accu-Chek Mobile Strip

97799497 ACCU-CHEK MOBILE ROC09857452 ACCU-CHEK MOBILE (ON) ROC

Accutrend Strip

09853162 ACCUTREND (ON) ROD97799959 ACCUTREND GLUCOSE ROC

Ascensia Breeze 2 Strip

97799748 ASCENSIA BREEZE 2 BAY09857293 ASCENSIA BREEZE 2 (ON) BAY

Ascensia Contour Strip

97799702 ASCENSIA CONTOUR BAY09857127 ASCENSIA CONTOUR (ON) BAY

BG Star Strip

97799465 BG STAR SAC09857422 BG STAR (ON) SAC

Contour Next Strip

97799459 CONTOUR NEXT BAY09857453 CONTOUR NEXT (ON) BAY

EZ Health Oracle Strip

97799564 EZ HEALTH ORACLE TRE09857357 EZ HEALTH ORACLE (ON) TRE

Freestyle Strip

97799829 FREESTYLE THS09857141 FREESTYLE (ON) THS

Freestyle Lite Strip

09857297 FREESTYLE LITE (ON) ABBiTest Strip

97799692 ITEST AUC09857348 ITEST (ON) AUC

Medi+Sure Strip

97799403 MEDI+SURE MSD09857432 MEDI+SURE (ON) MSD

One Touch Ultra Strip

97799985 ONE TOUCH ULTRA JAJ09854290 ONE TOUCH ULTRA (ON) JAJ *

One Touch Verio Strip

09857392 ONE TOUCH VERIO (ON) JAJ97799475 ONETOUCH VERIO JAJ

36:26.00 DX - DIABETES MELLITUS


Precision Xtra Strip

97799840 PRECISION XTRA AUC09854070 PRECISION XTRA (ON) AUC

True Test Strip

97799532 TRUETEST HODTrue Track Strip

09857283 TRUETRACK (ON) AUC

36:88.00 DX - URINE AND FECES

CONTENTS


Diastix Strip

97799914 DIASTIX BAY

SODIUM NITROPRUSSIDE

Strip

00035092 KETOSTIX BAY00977322 KETOSTIX BAY *00980595 KETOSTIX BAY99067074 KETOSTIX (MB) BAY *09853286 KETOSTIX (ON) BAY *

Page 84 of 1382014


40:00 ELECTROLYTIC, CALORIC, AND

WATER BALANCE

40:08.00 ALKALINIZING AGENTS

CITRIC ACID, SODIUM CITRATE

66.8MG & 100MG/ML Solution

00721344 DICITRATE PMS

SODIUM BICARBONATE

300MG Tablet

00481912 SODIUM BICARBONATE XEN

40:10.00 AMMONIA DETOXICANTS

LACTULOSE

667MG/ML Oral LiquidST

02242814 APO-LACTULOSE APX02247383 EURO-LAC EUR02295881 JAMP-LACTULOSE JAP00703486 PMS-LACTULOSE PMS00854409 RATIO-LACTULOSE RPH02331551 TEVA-LACTULOSE TEP

40:12.00 REPLACEMENT PREPARATIONS

CALCIUM

100MG Oral LiquidST

80002626 SOLUCAL JAP80025527 SOLUCAL GREEN APPLE JAP80025523 SOLUCAL RASPBERRY JAP80006877 WAMPOLE MINERAL CALCIUM JAP

500MG TabletST

80003773 CALCIUM TRI

CALCIUM & VITAMIN D

500MG & 400IU Chewable Tablet

80009628 CALODAN D ODN80009412 M-CAL D MAN

500MG & 400IU Oral LiquidST

80008126 SOLUCAL D JAP80025543 SOLUCAL D CITRUS JAP80025541 SOLUCAL D RASPBERRY JAP

250MG & 200IU TabletST

80013612 CI-CAL D EUR500MG & 1000IU Tablet

ST

80019536 M-CAL D MAN500MG & 125IU Tablet

ST

80017196 CAL-500 D PRO80004966 CALCITE D RIV80004968 CALCIUM D TRI80004281 PHARMA-CAL D PMS

500MG & 400IU Tablet

80003919 BIOCAL-D FORTE BMI80004963 CALCITE 500 D RIV80004969 CALCIUM + D TRI80017190 CAL-D 400 PDL80002703 NU-CAL D ODN80015351 PRIVA CAL D FORTE PHA


CALCIUM & VITAMIN D


80019533 M-CAL D MAN

CALCIUM CARBONATE

500MG TabletST

00682039 APO-CAL 500 APX02240240 CALCIUM PMT80003658 CALCIUM WNP80017732 CALCIUM PRO02246040 CALCIUM CARBONATE JAP02237352 EURO-CAL EUR00618098 NU-CAL ODN00622443 O-CALCIUM 500 VTH80001408 OYSTER SHELL CALCIUM NUR

CALCIUM CARBONATE, CHOLECALCIFEROL


00730599 CALCIUM CARBONATE WITH VIT D

PMT

02237351 EURO-CAL D EUR00720798 NEO CAL-D-500 NEO

CALCIUM CARBONATE, VITAMIN D

500MG & 400IU Chewable Tablet

80002901 CARBOCAL D EUR500MG & 125IU Tablet

ST

02246041 JAMP CALCIUM + VITAMIN D JAP500MG & 400IU Tablet

80002623 CALCIUM WITH VITAMIN D JAP02245511 CARBOCAL D EUR80002122 J CAL-D JAP99100832 JAMP-CALCIUM + VIT D JAP80013329 M-CAL D MAN

ELECTROLYTE & DEXTROSE

Miscellaneous

80023410 HYDRALYTE ELECTROLYTE POPS

HPP

Powder

80026860 HYDRALYTE ELECTROLYTE PWD

HPP

3.56G & 300MG & 470MG & 530MG Powder

01931563 GASTROLYTE REG SAC5.1 G /SAC Powder

80027403 JAMP REHYDRALYTE JAPSolution

80026861 HYDRALYTE ELECTROLYTE SOL

HPP

25MG & 2.2MG & 2.2MG & 0.9MG/ML Solution

00630365 PEDIALYTE ABB02219883 PEDIATRIC ELECTROLYTE PMS

MAGNESIUM

100MG/ML Oral Liquid

00026697 RATIO-MAGNESIUM RPH

Page 85 of 1382014



POTASSIUM CHLORIDE

25MEQ Effervescent TabletST

02085992 K LYTE WPC8MMOL Long Acting Capsule

ST

02042304 MICRO-K EXTENCAPS WAY02244068 RIVA-K RIV

8MMOL Long Acting TabletST

00602884 APO-K APX02246734 EURO-K 600 EUR80035346 MK 8 MAN00613274 PRO-600K PDL

10MMOL Long Acting TabletST

80026332 MK 10 MAN20MMOL Long Acting Tablet

ST

02242261 EURO-K 20 EUR02243975 RIVA-K 20 RIV

1.33MEQ/ML Oral LiquidST

02238604 PMS-POTASSIUM PMS20MEQ Oral Liquid

ST

80024835 JAMP-POTASSIUM CHLORIDE JAP8MMOL Tablet

ST

80013005 JAMP-K 8 JAP20MMOL Tablet

ST

80013007 JAMP-K 20 JAP80025624 MK 20 MAN

600MG TabletST

80040226 SLOW-K NOV

SODIUM CHLORIDE

0.9% Inhalation Diluent

02094657 BACTERIOSTATIC NACL BIO00801267 SODIUM CHLORIDE UNK *02058235 SODIUM CHLORIDE BDH

0.9% Injection

00060208 SODIUM CHLORIDE BAT00402249 SODIUM CHLORIDE ABB02150204 SODIUM CHLORIDE OMG99002329 SODIUM CHLORIDE AUT *

40:17.00 CALCIUM-REMOVING RESINS

CALCIUM POLYSTYRENE SULFONATE

1G binds with approx 1.6mmol K Powder

02017741 RESONIUM CALCIUM SAC

40:18.00 ION-REMOVING AGENTS

SODIUM POLYSTYRENE SULFONATE

1G binds with approx 1mmol K Powder

02026961 KAYEXALATE SAC00765252 K-EXIT OMG00755338 PMS-SOD POLYSTYRENE

SULFONAPMS

250MG/ML Oral Suspension

00769541 PMS-SOD POLYSTYRENE SULF

PMS

40:18.00 ION-REMOVING AGENTS

SODIUM POLYSTYRENE SULFONATE

250MG/ML Retention Enema

00769533 PMS-SOD POLYSTYRENE SULF

PMS

40:20.00 CALORIC AGENTS

LEVOCARNITINE


• For treatment of carnitine deficiency100MG/ML Oral Liquid

02144336 CARNITOR SIG200MG/ML Solution

02144344 CARNITOR IV SIG330MG Tablet

02144328 CARNITOR SIG

40:28.08 LOOP DIURETICS

ETHACRYNIC ACID

25MG TabletST

02258528 EDECRIN FRS

FUROSEMIDE

10MG/ML SolutionST

02224720 LASIX SAC20MG Tablet

ST

00396788 APO-FUROSEMIDE APX02247371 BIO-FUROSEMIDE BMI02248124 DOM-FUROSEMIDE BMI00496723 FUROSEMIDE PDL02351420 FUROSEMIDE SAN02224690 LASIX SAC00337730 NOVO-SEMIDE TEV02247493 PMS-FUROSEMIDE PMS

40MG TabletST

00362166 APO-FUROSEMIDE APX02247372 BIO-FUROSEMIDE BMI02248125 DOM-FUROSEMIDE BMI00397792 FUROSEMIDE PDL02351439 FUROSEMIDE SAN02224704 LASIX SAC00337749 NOVO-SEMIDE TEV02247494 PMS-FUROSEMIDE PMS

80MG TabletST

00707570 APO-FUROSEMIDE APX00667080 FUROSEMIDE PDL02351447 FUROSEMIDE SAN00765953 NOVO-SEMIDE TEV

500MG TabletST

02224755 LASIX SAC

40:28.16 POTASSIUM SPARING DIURETICS

AMILORIDE HCL

5MG TabletST

02249510 APO-AMILORIDE APX

Page 86 of 1382014


40:28.16 POTASSIUM SPARING DIURETICS

AMILORIDE HCL, HYDROCHLOROTHIAZIDE

5MG & 50MG TabletST

00870943 AMI-HYDRO PDL00784400 APO-AMILZIDE APX01937219 NOVAMILOR TEV

TRIAMTERENE, HYDROCHLOROTHIAZIDE


00441775 APO-TRIAZIDE APX00532657 NOVO-TRIAMZIDE TEV00519367 PRO-TRIAZIDE PRO02240846 RIVA-ZIDE RIV

40:28.20 TIAZIDE DIURETICS

HYDROCHLOROTHIAZIDE

12.5MG TabletST

02327856 APO-HYDRO APX02274086 PMS-HYDROCHLOROTHIAZIDE PMS

25MG TabletST

00326844 APO-HYDROCLOROTHIAZIDE APX02247170 BIO-HYDROCHLOROTHIAZIDE BMI02248134 DOM-HYDROCHLOROTHIAZIDE DPC00341975 HYDROCHLOROTHIAZIDE PDL02360594 HYDROCHLOROTHIAZIDE SAN00021474 NOVO-HYDRAZIDE TEV02247386 PMS-HYDROCHLOROTHIAZIDE PMS

50MG TabletST

02360608 HYDROCHLOROTHIAZIDE SAN50MG Tablet

ST

00312800 APO-HYDRO APX02247171 BIO-HYDROCHLOROTHIAZIDE BMI02248135 DOM-HYDROCHLOROTHIAZIDE DPC00021482 NOVO-HYDRAZIDE TEV02247387 PMS-HYDROCHLOROTHIAZIDE PMS

100MG TabletST

00644552 APO-HYDRO APX00532088 HYDROCHLOROTHIAZIDE PDL

SPIRONOLACTONE, HYDROCHLOROTHIAZIDE


00180408 ALDACTAZIDE-25 PFI00613231 NOVO-SPIROZINE-25 TEV


00594377 ALDACTAZIDE-50 PFI00657182 NOVO-SPIROZINE-50 TEV

40:28.24 THIAZIDE LIKE DIURETICS

CHLORTHALIDONE

50MG TabletST

00360279 APO-CHLORTHALIDONE APX100MG Tablet

ST

00360287 APO-CHLORTHALIDONE APX

40:28.24 THIAZIDE LIKE DIURETICS

INDAPAMIDE

1.25MG TabletST

02245246 APO-INDAPAMIDE APX02239913 DOM-INDAPAMIDE DPC02240067 GEN-INDAPAMIDE GEN02373904 JAMP-INDAPAMIDE JAP02179709 LOZIDE SEV02240349 PHL-INDAPAMIDE PHH02239619 PMS-INDAPAMIDE PMS02312530 PRO-INDAPAMIDE PDL02247245 RIVA-INDAPAMIDE RIV

2.5MG TabletST

02223678 APO-INDAPAMIDE APX02239917 DOM-INDAPAMIDE DPC02153483 GEN-INDAPAMIDE GEN02373912 JAMP-INDAPAMIDE JAP00564966 LOZIDE SEV02231184 NOVO-INDAPAMIDE TEV02239620 PMS-INDAPAMIDE PMS02312549 PRO-INDAPAMIDE PDL02242125 RIVA-INDAPAMIDE RIV

METOLAZONE

2.5MG TabletST

00888400 ZAROXOLYN AVT

40:36.00 IRRIGATING SOLUTIONS

WATER

Injection

00402257 STERILE WATER FOR INJ OMG02142546 STERILE WATER FOR INJ HOS

40:40.00 URICOSURIC AGENTS

SULFINPYRAZONE

200MG Tablet

00441767 APO-SULFINPYRAZONE APX

Page 87 of 1382014


48:00 RESPIRATORY TRACT AGENTS

48:10.24 LEUKOTRIENE MODIFIERS

MONTELUKAST


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 Tablet

02377608 APO-MONTELUKAST APX02399865 MAR-MONTELUKAST MAR02379317 MONTELUKAST SAN02379821 MONTELUKAST PDL02382458 MONTELUKAST SIV02380749 MYLAN-MONTELUKAST MYL02354977 PMS-MONTELUKAST PMS02402793 RAN-MONTELUKAST RBY02330385 SANDOZ MONTELUKAST TEP02243602 SINGULAIR FRS02355507 TEVA- MONTELUKAST TEP

5MG Chewable Tablet

02377616 APO-MONTELUKAST APX02399873 MAR-MONTELUKAST MAR02379325 MONTELUKAST SAN02379848 MONTELUKAST PDL02382466 MONTELUKAST SIV02380757 MYLAN-MONTELUKAST MYL02354985 PMS-MONTELUKAST PMS02402807 RAN-MONTELUKAST RBY02330393 SANDOZ MONTELUKAST TEP02238216 SINGULAIR FRS02355515 TEVA- MONTELUKAST TEP

4MG Granules

02358611 SANDOZ MONTELUKAST SDZ02247997 SINGULAIR FRS

10MG Tablet

02374609 APO-MONTELUKAST APX02376695 DOM-MONTELUKAST DOM02391422 JAMP-MONTELUKAST JAP02399997 MAR-MONTELUKAST MAR02379333 MONTELUKAST SAN02379856 MONTELUKAST PDL02382474 MONTELUKAST SIV02368226 MYLAN-MONTELUKAST MYL02373947 PMS-MONTELUKAST PMS02389517 RAN-MONTELUKAST RBY02328593 SANDOZ MONTELUKAST SDZ02238217 SINGULAIR FRS02355523 TEVA- MONTELUKAST TEP

48:10.24 LEUKOTRIENE MODIFIERS

ZAFIRLUKAST



20MG Tablet

02236606 ACCOLATE AZC

48:10.32 MAST CELL STABILIZERS

SODIUM CROMOGLYCATE

100MG Capsule

00500895 NALCROM AVT10MG/ML Inhalation Solution (Unit Dose)

02046113 PMS-SOD CROMOGLYCATE PMS2% Nasal Solution

01950541 CROMOLYN PMS2% Ophth Solution

02009277 CROMOLYN PMS02230621 OPTICROM ALL

Page 88 of 1382014


52:00 EYE, EAR, NOSE AND THROAT

(EENT) PREPARATIONS

52:02.00 EENT - ANTIALLERGIC AGENTS

LEVOCABASTINE HCL

0.05% Nasal Spray

02020017 LIVOSTIN JNO

NEDOCROMIL SODIUM

2% Ophth Solution

02241407 ALOCRIL ALL

OLOPATADINE HCL

0.1% Ophth Solution

02305054 APO-OLOPATADINE APX02233143 PATANOL ALC02358913 SANDOZ OLOPATADINE SDZ

SODIUM CROMOGLYCATE

2% Nasal Solution

02231390 APO-CROMOLYN APX

52:04.04 EENT - ANTIBACTERIALS

BACITRACIN ZINC, POLYMYXIN B SULFATE

500IU & 10,000IU/G Ophth Ointment

02160889 OPTIMYXIN SDZ02239157 POLYSPORIN PFI

CHLORAMPHENICOL

1% Ophth Ointment

02026260 DIOCHLORAM DKT0.5% Ophth Solution

02023857 DIOCHLORAM DKT

CIPROFLOXACIN HCL

0.3% Ophth Ointment

02200864 CILOXAN ALC0.3% Ophth Solution

02263130 APO-CIPROFLOX APX01945270 CILOXAN ALC02387131 SANDOZ CIPROFLOXACIN SDZ

CIPROFLOXACIN HCL, DEXAMETHASONE

0.3%/0.1% Otic Solution

02252716 CIPRODEX ALC

ERYTHROMYCIN

5MG/G Ophth Ointment

02326663 ERYTHROMYCIN STG01912755 PMS-ERYTHROMYCIN PMS

FRAMYCETIN SULFATE

0.5% Ophth Ointment

02224895 SOFRAMYCIN STERILE EYE ERF0.5% Ophth Solution

02224887 SOFRAMYCIN ERF

GENTAMICIN SULFATE

0.3% Ophth Ointment

02023776 DIOGENT DKT

52:04.04 EENT - ANTIBACTERIALS

GENTAMICIN SULFATE

0.3% Solution

02023822 DIOGENT DKT02219581 GENTAMICIN SPH00776521 PMS-GENTAMICIN PMS

GRAMICIDIN, POLYMYXIN B SULFATE

0.025MG & 10,000U/ML Solution

00701785 OPTIMYXIN EYE/EAR SDZ02239156 POLYSPORIN EYE/EAR WLA

OFLOXACIN

0.3% Ophth Solution

02248398 APO-OFLOXACIN APX02143291 OCUFLOX ALL02247189 SANDOZ OFLOXACIN SDZ

POLYMYXIN B SULFATE, TRIMETHOPRIM

SULFATE

10,000U & 1MG/ML Ophth Solution

02240363 PMS-POLYTRIMETHOPRIM PMS02011956 POLYTRIM ALL02239234 SANDOZ POLYTRIMETHOPRIM SDZ

SULFACETAMIDE SODIUM

10% Ophth Solution

02023830 DIOSULF DKT

TOBRAMYCIN

0.3% Ophth Ointment

00614254 TOBREX ALC0.3% Ophth Solution

02241755 SANDOZ-TOBRAMYCIN SDZ00513962 TOBREX ALC

52:04.20 EENT - ANTIVIRALS

TRIFLURIDINE

1% Ophth Solution

00687456 VIROPTIC GSK

52:08.08 EENT - CORTICOSTEROIDS

BECLOMETHASONE DIPROPIONATE

50MCG/DOSE Nasal Spray

02238796 APO-BECLOMETHASONE APX02172712 GEN-BECLO AQ GEN02228300 RIVANASE AQ RIV

BETAMETHASONE SODIUM PHOSPHATE,

GENTAMICIN SULFATE

0.1% & 0.3% Ophth Ointment

00586706 GARASONE SCH

BUDESONIDE


02241003 GEN-BUDESONIDE AQ GEN02231923 RHINOCORT AQ AZC


02230648 GEN-BUDESONIDE AQ GEN

Page 89 of 1382014



BUDESONIDE

100MCG/DOSE Powder

02035324 RHINOCORT TURBUHALER AZC

DEXAMETHASONE

0.1% Ophth Ointment

00042579 MAXIDEX ALC0.1% Ophth Solution

02023865 DIODEX DKT00785261 PMS-DEXAMETHASONE PMS00739839 SANDOZ-DEXAMETHASONE SDZ

0.1% Ophth Suspension

00042560 MAXIDEX ALC

DEXAMETHASONE, TOBRAMYCIN


00778915 TOBRADEX ALC0.1% & 0.3% Ophth Suspension

00778907 TOBRADEX ALC

FLUMETHASONE PIVALATE, CLIOQUINOL

0.02% & 1% Otic Solution

00074454 LOCACORTEN VIOFORM PAL

FLUOROMETHOLONE

0.1% Ophth Solution

02238568 PMS-FLUOROMETHOLONE PMS00432814 SANDOZ FLUOROMETHOLONE SDZ


00247855 FML ALL0.25% Ophth Suspension

00707511 FML FORTE ALL

FLUOROMETHOLONE ACETATE

0.1% Ophth Solution

00756784 FLAREX ALC

FLUTICASONE PROPIONATE


02294745 APO-FLUTICASONE APX02213672 FLONASE GSK02296071 RATIO-FLUTICASONE RPH

FRAMYCETIN SULFATE, GRAMICIDIN,

DEXAMETHASONE

5MG & 0.05MG/ML & 0.5MG Ophth/Otic Solution

02224623 SOFRACORT EYE/EAR SAC

MOMETASONE FUROATE

50MCG Nasal Spray

02403587 APO-MOMETASONE APX02238465 NASONEX SCH

PREDNISOLONE ACETATE


00299405 PRED MILD ALL


PREDNISOLONE ACETATE

1% Ophth Suspension

00301175 PRED FORTE ALL00700401 RATIO-PREDNISOLONE RPH01916203 SANDOZ-PREDNISOLONE SDZ

PREDNISOLONE ACETATE, SULFACETAMIDE

SODIUM

0.2% & 10% Ophth Ointment

00307246 BLEPHAMIDE ALL0.5% & 10% Ophth Solution

02023814 DIOPTIMYD DKT0.2% & 10% Ophth Suspension

00807788 BLEPHAMIDE ALL

PREDNISOLONE SODIUM PHOSPHATE

0.5% Ophth Solution

02148498 PREDNISOLONE CUV

TRIAMCINOLONE ACETONIDE


02213834 NASACORT AQ SAC

52:08.20 EENT - NONSTEROIDAL ANTI-

INFLAMMATORY AGENTS

DICLOFENAC SODIUM

0.1% Ophth Solution

01940414 VOLTAREN NVR

KETOROLAC TROMETHAMINE

0.5% Ophth Solution

01968300 ACULAR ALL02245821 APO-KETOROLAC APX

52:12.00 EENT - CONTACT LENS

SOLUTION

HYPROMELLOSE

3MG Ophth Solution

02231289 GENTEAL ARTIFICIAL TEARS NVC

52:20.00 EENT - MIOTICS

CARBACHOL

1.5% Ophth Solution

00000655 ISOPTO CARBACHOL ALC

52:24.00 EENT - MYDRIATICS

ATROPINE SULFATE

1% Ophth Solution

02023695 ATROPINE DKT02148358 ATROPINE SULPHATE MINIMS NVR00035017 ISOPTO ATROPINE ALC

CYCLOPENTOLATE HCL

0.5% Ophth Solution

02148331 CYCLOPENTOLATE NVR

Page 90 of 1382014


52:24.00 EENT - MYDRIATICS

CYCLOPENTOLATE HCL

1% Ophth Solution

00252506 CYCLOGYL ALC02148382 CYCLOPENTOLATE MINIMS NVR02023644 DIOPENTOLATE DKT

DIPIVEFRIN HCL

0.1% Ophth Solution

02242232 APO-DIPIVEFRIN APX02237868 PMS-DIPIVEFRIN PMS

HOMATROPINE HBR

2% Ophth Solution

00000779 ISOPTO HOMATROPINE ALC5% Ophth Solution

00000787 ISOPTO HOMATROPINE ALC

52:28.00 EENT - MOUTHWASHES AND

GARGLES

BENZYDAMINE 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% Rinse

02239044 APO-BENZYDAMINE APX02239537 DOM-BENZYDAMINE DPC02229799 NOVO-BENZYDAMINE TEV02229777 PMS-BENZYDAMINE PMS

CHLORHEXIDINE GLUCONATE

0.12% Rinse

02240433 PERICHLOR PMS02237452 PERIDEX MMH02207796 PERIOGARD COP

52:32.00 EENT - VASOCONSTRICTORS

ANTAZOLINE PHOSPHATE, NAPHAZOLINE HCL

0.5% & 0.05% Ophth Solution

00433519 ALBALON A ALL

NAPHAZOLINE HCL

0.1% Ophth Solution

00001147 ALBALON ALL00390283 NAPHCON FORTE ALC

PHENYLEPHRINE HCL

0.12% Ophth Solution

00395161 PREFRIN LIQUIFILM ALL2.5% Ophth Solution

02027100 DIONEPHRINE DKT00465763 MYDFRIN ALC02148447 PHENYLEPHRINE MINIMS NVR

10% Ophth Solution

02148455 PHENYLEPHRINE NVR

52:40.04 EENT - ALPHA-ADRENERGIC

AGONISTS

BRIMONIDINE TARTRATE

0.2% Ophth Solution

02236876 ALPHAGAN ALL02260077 APO-BRIMONIDINE APX02246284 PMS-BRIMONIDINE PMS02243026 RATIO-BRIMONIDINE RPH02305429 SANDOZ BRIMONIDINE 0.2%

OP SOLSDZ

BRIMONIDINE TARTRATE (ALPHAGAN P)


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


02248151 ALPHAGAN P ALL

BRIMONIDINE TARTRATE, TIMOLOL MALEATE


02248347 COMBIGAN ALL

52:40.08 EENT - BETA-ADRENERGIC

BLOCKING AGENTS

BETAXOLOL HCL

0.5% Ophth Solution

02235971 SANDOZ-BETAXOLOL SDZ0.25% Ophth Suspension

01908448 BETOPTIC S ALC

LEVOBUNOLOL HCL


02241575 APO-LEVOBUNOLOL APX00751286 BETAGAN ALL02031159 RATIO-LEVOBUNOLOL RPH

0.5% Ophth Solution

00637661 BETAGAN ALL02237991 PMS-LEVOBUNOLOL PMS02031167 RATIO-LEVOBUNOLOL RPH02241716 SANDOZ-LEVOBUNOLOL SDZ

TIMOLOL MALEATE

0.25% 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

02242276 TIMOLOL MALEATE-EX PMS0.25% Ophth Solution

00755826 APO-TIMOP APX02048523 NOVO-TIMOL TEV02083353 PMS-TIMOLOL PMS

Page 91 of 1382014


52:40.08 EENT - BETA-ADRENERGIC

BLOCKING AGENTS

TIMOLOL MALEATE

0.5% Ophth Solution

00755834 APO-TIMOP APX02083345 PMS-TIMOLOL PMS00451207 TIMOPTIC FRS

52:40.12 EENT - CARBONIC ANHYDRASE

INHIBITORS

ACETAZOLAMIDE

250MG Tablet

00545015 APO-ACETAZOLAMIDE APX

BRINZOLAMIDE

1% Ophth Suspension

02238873 AZOPT ALC

BRINZOLAMIDE, TIMOLOL MALEATE

1% & 0.5% Ophth Suspension

02331624 AZARGA ALC

DORZOLAMIDE HCL

2% Ophth Solution

02316307 SANDOZ DORZOLAMIDE SDZ02216205 TRUSOPT FRS

DORZOLAMIDE HCL, TIMOLOL MALEATE

20MG & 5MG/ML Ophth Solution

02299615 APO-DORZO-TIMOP APX02404389 CO DORZOTIMOLOL ACT02240113 COSOPT FRS02344351 SANDOZ

DORZOLAMIDE/TIMOLOLSDZ

02320525 TEVA-DORZOTIMOL TEP

METHAZOLAMIDE

50MG Tablet

02245882 APO-METHAZOLAMIDE APX


CARBACHOL


00042544 MIOSTAT ALC3% Ophth Solution

00000663 ISOPTO CARBACHOL ALC

PILOCARPINE HCL

4% Ophth Gel

00575240 PILOPINE HS ALC1% Ophth Solution

00000841 ISOPTO CARPINE ALC02229556 PILOCARPINE SCN

2% Ophth Solution

00000868 ISOPTO CARPINE ALC4% Ophth Solution

02023733 DIOCARPINE DKT00000884 ISOPTO CARPINE ALC


PILOCARPINE NITRATE

2% Ophth Solution

02148463 PILOCARPINE NITRATE MINIMS

NVR

52:40.28 EENT - PROSTAGLANDIN AGENTS

BIMATOPROST


02324997 LUMIGAN RC ALL

LATANOPROST


02296527 APO-LATANOPROST APX02254786 CO LATANOPROST ACT02373041 GD-LATANOPROST PFI02367335 SANDOZ LATANOPROST SDZ02231493 XALATAN PFI

LATANOPROST, TIMOLOL MALEATE


02373068 GD-LATANOPROST/TIMOLOL PFI02404591 PMS-LATANOPROST-TIMOLOL PMS02394685 SANDOZ

LATANOPROST/TIMOLOLSDZ

02393921 TEVA-LATANOPROST/TIMOLOL TEP02246619 XALACOM PFI

TIMOLOL MALEATE, TRAVOPROST


02278251 DUO TRAV ALC

TRAVOPROST


02318008 TRAVATAN Z ALC

52:92.00 MISCELLANEOUS EENT DRUGS

APRACLONIDINE HCL

0.5% Ophth Solution

02076306 IOPIDINE ALC

DEXTRAN 70,

HYDROXYPROPYLMETHYLCELLULOSE


00390291 TEARS NATURALE ALC01943308 TEARS NATURALE FREE ALC00743445 TEARS NATURALE II ALC

DIPIVEFRIN HCL, LEVOBUNOLOL HCL


02209071 PROBETA ALL

HYDROXYPROPYLMETHYLCELLULOSE

0.5% Ophth Solution

00000809 ISOPTO TEARS ALC1% Ophth Solution

00000817 ISOPTO TEARS ALC

Page 92 of 1382014



HYPROLOSE

5MG Ophth Solution

02250624 LACRISERT FRS

IPRATROPIUM BROMIDE

0.03% Nasal Spray

02163705 ATROVENT BOE0.06% Nasal Spray

02163713 ATROVENT BOE

LODOXAMIDE TROMETHAMINE

0.1% Ophth Solution

00893560 ALOMIDE ALC

MACROGOL, PROPYLENE GLYCOL

15% & 20% Nasal Gel

02220806 PMS-RHINARIS PMS00551805 SECARIS PMS

15% & 20% Nasal Spray

00732230 RHINARIS PMS

MINERAL OIL, PETROLATUM

80% & 20% Ophth Ointment

02125706 DUOLUBE BSH

MINERAL OIL, WHITE PETROLATUM


00210889 LACRI LUBE ALL

PETROLATUM, LANOLIN, MINERAL OIL

94% & 3% & 3% Ophth Ointment

02082519 TEARS NATURALE P.M. ALC

PETROLATUM, PETROLATUM LIQUID

85% & 15% Ophth Ointment

02133288 HYPOTEARS NVR

POLYVINYL ALCOHOL

1% Ophth Solution

02133253 HYPOTEARS NVR1.4% Ophth Solution

02229570 ARTIFICIAL TEARS PMS00579408 TEARS PLUS ALL

POLYVINYL ALCOHOL, POVIDONE


02229632 ARTIFICIAL TEARS EXTRA PMS


RANIBIZUMAB


For the treatment of:a. Diabetic Macular Edema (DME)b. Wet Age-Related Macular Degeneration (w-AMD)Criteria for coverage of ranibizumab (Lucentis) for DME and w-AMD:• Administered by a qualified ophthalmologist experienced in intravitreal injections• Interval between doses not shorter than 1 monthNote: Coverage will be limited to a maximum of 1 vial of Lucentis per eye treated every 30 daysFor the treatment of diabetic macular edema (DME) for patients who meet the following:• Clinically significant diabetic macular edema for whom laser photocoagulation is also indicated; AND• Have a hemoglobin A1c of less than 11%Initial Coverage for the treatment of neovascular wet age-related macular degeneration (wAMD) where all of the following apply to the eye to be treated:• Best Corrected Visual Acuity (BCVA) is between 6/12 and 6/96• The lesion size is less than or equal to 12 disc areas in greatest linear dimension• There is evidence of recent (< 3 months) presumed disease progression (blood vessel growth, as indicated by fluorescein angiography, or optical coherence tomography (OCT))Note: Coverage will not be approved for patients:• With permanent retinal damage as defined by the Royal College of Ophthalmology guidelines.• Receiving concurrent treatment with verteporfinContinued Coverage:Treatment with Lucentis for wAMD should be continued only in people who maintain adequate response to therapyTreatment with Lucentis should be permanently discontinued if any one of the following occurs:• Reduction in BCVA in the treated eye to less than 15 letters (absolute) on two (2) consecutive visits in the treated eye, attributed toAMD in the absence of other pathology• Reductions in BCVA of 30 letters or more compared to eitherbaseline and/or best recorded level since baseline as this mayindicate either poor treatment effect, adverse events or both.• There is evidence of deterioration of the lesion morphology despite optimum treatment over three (3) consecutive visits.

10MG/ML Injection

02296810 LUCENTIS NOV

SODIUM CARBOXYMETHYL CELLULOSE

0.5% 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 CHLORIDE

0.7% Nasal Solution

00857777 OTRIVIN SALINE NVC

Page 93 of 1382014



SODIUM CHLORIDE

0.7% Nasal Spray

00810436 OTRIVIN SALINE NVC9MG/ML Nasal Spray

80024381 SALINEX SDZ80024901 SALINEX DROPS SDZ

5% Ophth Ointment

00750816 MURO-128 BSH5% Ophth Solution

00750824 MURO-128 BSH

TIMOLOL MALEATE


02238770 DOM-TIMOLOL DPC0.5% Ophth Solution

02238771 DOM-TIMOLOL DPC

VERTEPORFIN


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

15MG/VIAL Injection

02242367 VISUDYNE QLT

Page 94 of 1382014


56:00 GASTROINTESTINAL DRUGS

56:04.00 ANTACIDS AND ADSORBENTS

BISMUTH SUBSALICYLATE

17.6MG/ML Liquid

02097079 PEPTO BISMOL PGI262MG Tablet

02177994 PEPTO BISMOL PGI

MAG OXIDE

420MG Tablet

00299448 MAGNESIUM OXIDE SWS

56:08.00 ANTIDIARRHEA AGENTS

LOPERAMIDE HCL

0.2MG/ML Liquid

02192667 DIARR-EZE PMS02016095 PMS-LOPERAMIDE PMS

2MG/15ML Oral Solution

02291800 IMODIUM JNO2MG Tablet

02170272 ANTI-DIARRHEAL STA02212005 APO-LOPERAMIDE APX02229552 DIARR-EZE PMS02256452 DIARRHEA RELIEF VTH02239535 DOM-LOPERAMIDE DPC02183862 IMODIUM MCL02225182 LOPERAMIDE PDL02132591 NOVO-LOPERAMIDE TEV02228351 PMS-LOPERAMIDE PMS02238211 RIVA-LOPERAMIDE RIV02257564 SANDOZ-LOPERAMIDE SDZ

56:12.00 CATHARTICS AND LAXATIVES

BISACODYL

5MG Delayed Release Tablet

02273411 BISACODYL-ODAN ODN5MG Enteric Coated Tablet

00545023 APO-BISACODYL APX00714488 BISACOLAX ICN00254142 DULCOLAX BOE00587273 PMS-BISACODYL PMS

5MG Suppository

00003867 DULCOLAX BOE10MG Suppository

00261327 BISACOLAX ICN00003875 DULCOLAX BOE00582883 PMS-BISACODYL PMS00404802 RATIO-BISACODYL RPH02229743 SOFLAX EX PMS

5MG Tablet

02246039 JAMP-BISACODYL JAP

BISACODYL (POLYETHYLENE GLYCOL BASE)

10MG Suppository

02241091 MAGIC BULLET DCM


CITRIC ACID, MAGNESIUM OXIDE, SODIUM

PICOSULFATE

Powder

02254794 PICO-SALAX FEI02317966 PURG-ODAN ODN

DIOCTYL CALCIUM SULFOSUCCINATE

240MG CapsuleST

02245080 APO-DOCUSATE CALCIUM APX00830275 DOCUSATE CALCIUM TAR00842044 NOVO-DOCUSATE CALCIUM TEV00664553 PMS-DOCUSATE CALCIUM PMS00809055 RATIO-DOCUSATE CALCIUM RPH

DIOCTYL SODIUM SULFOSUCCINATE

100MG 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 EUO02020084 NOVO-DOCUSATE TEV00703494 PMS-DOCUSATE SODIUM PMS00870196 RATIO-DOCUSATE SODIUM RPH00514888 SELAX ODN01994344 SOFLAX PMS

200MG CapsuleST

02029529 SOFLAX PMS250MG Capsule

ST

02006596 SELAX ODN10MG/ML Drop

ST

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

50MG/ML SyrupST

00848417 PMS-DOCUSATE SODIUM PMS

DIOCTYL SODIUM SULFOSUCCINATE, SENNA


00026123 SENOKOT S PFR

DIOCTYL SODIUM SULFOSUCCINATE,

SENNOSIDES


02247390 EURO-SENNA S EUR

Page 95 of 1382014



DOCUSATE CALCIUM

240MG CapsuleST

02283255 JAMP-DOCUSATE CALCIUM JAP

DOCUSATE SODIUM

100MG CapsuleST

02245946 DOCUSATE SODIUM JAP02326086 DOCUSATE SODIUM PDL02303825 EURO-DOCUSATE C EUR02281031 STOOL SOFTENER PMS02357305 STOOL SOFTENER VTH

4MG/ML SyrupST

02238283 DOCUSATE SODIUM ATL02283239 DOCUSATE SODIUM JAP00695033 SELAX ODN

50MG/ML SyrupST

02283220 DOCUSATE SODIUM JAP

GLYCERIN

Adult Suppository

02020394 GLYCERIN TCH80029765 JAMP GLYCERIN JAP

GLYCERINE

Adult Suppository

00873462 GLYCERIN RPH *01926039 GLYCERIN WLA

Pediatric Suppository

02020815 GLYCERIN INFANT RPH01926047 GLYCERIN INFANT & CHILD PFI

MACROGOL, POTASSIUM CHLORIDE, SODIUM

BICARBONATE, SODIUM CHLORIDE, SODIUM

SULFATE

60G & 750MG & 1.68G & 1.46G & 5.68G/L Powder

00677442 COLYTE ZYM00652512 GOLYTELY BAX00777838 PEGLYTE PMS

MAGNESIUM CITRATE

50MG/ML Oral Liquid

00262609 CITRO MAG TCH

MAGNESIUM HYDROXIDE

80MG/ML Liquid

02150646 MILK OF MAGNESIA PLAIN/SUGARFREE

BCD

80MG/ML Oral Liquid

02245289 MILK OF MAGNESIA PMS311MG Tablet

02150638 MILK OF MAGNESIA BCD

MINERAL OIL

78% Jelly

00608734 LANSOYL GEL AXC02186926 LANSOYL GEL SUGARFREE AXC


MINERAL OIL

Liquid

01935348 MINERAL OIL (HEAVY) 100% USP

RWP

PLANTAGO SEED

50% Powder

00599875 MUCILLIUM PMS

POLYETHYLENE GLYCOL & ELECTROL

Oral Liquid

02326302 BI-PEGLYTE TROUSSE PEI

POLYETHYLENE GLYCOL 3350

1G/G Powder

02317680 LAX-A-DAY 1G/G PDR PED02358034 PEG 3350 PDR MDS

POLYETHYLENE GLYCOL, POTASSIUM

CHLORIDE, SODIUM BICARBONATE, SODIUM

CHLORIDE, SODIUM SULFATE

Oral Liquid

02147793 KLEAN-PREP RVX

PSYLLIUM HYDROPHILIC MUCILLOID

680MG/G Powder

02174812 METAMUCIL ORIGINAL TEXTURE

PGI

02174790 METAMUCIL SM TEXT ORANGE PGI02174782 METAMUCIL SM TEXT

ORANGE S/FPGI

02174804 METAMUCIL SM TEXT UNFLAV PGI

SENNOSIDES

1.7MG/ML LiquidST

02144379 SENNALAX PMS02084651 SENNAPREP PMS00367729 SENOKOT PFR

1.7MG/ML Oral LiquidST

80024394 JAMP-SENNAQUIL JAP8.6MG Tablet

ST

02247389 EURO-SENNA EUR80009595 JAMP-SENNA JAP80043280 M-SENNOSIDES MAN00896411 PMS-SENNOSIDES PMS01949292 RIVA-SENNA RIV02237105 SENNA LAXATIVE SDR02068109 SENNATAB PMS00026158 SENOKOT PFR

12MG TabletST

00896403 PMS-SENNOSIDES PMS

SODIUM CITRATE, SODIUM LAURYL

SULFOACETATE, SORBITOL

90MG & 9MG & 625MG Enema

02063905 MICROLAX PMS

Page 96 of 1382014



SODIUM PHOSPHATE DIBASIC, SODIUM

PHOSPHATE MONOBASIC

180MG & 480MG/ML Oral Liquid

02230399 PMS-PHOSPHATES SOLUTION PMS60MG & 160MG/ML Rectal Liquid

02096900 ENEMOL DPC00009911 FLEET ENEMA FRS

60MG & 160MG/ML PED Rectal Liquid

00108065 FLEET ENEMA PEDIATRIC JAJ

56:14.00 CHOLELITHOLYTIC AGENTS

URSODIOL

250MG TabletST

02281317 PHL-URSODIOL C PMI02273497 PMS-URSODIOL PMS02238984 URSO AXC

500MG TabletST

02281325 PHL-URSODIOL C PMI02273500 PMS-URSODIOL PMS02245894 URSO DS AXC

56:16.00 DIGESTANTS

ANETHOLE

25MG Tablet

02240344 SIALOR PAL

LACTASE

Oral Liquid

99100157 LACTEEZE DROPS AUT3,000U Tablet

02200384 DAIRY DIGESTIVE PER02239139 DAIRY DIGESTIVE SDR02017512 DAIRY FREE KIN01951637 DAIRYAID TAN02230653 LACTAID JNO

4,500U Tablet

02239140 DAIRY DIGESTIVE EXTRA STRENGTH

SDR

02224909 DAIRY FREE EXTRA STRENGTH

KIN

02230654 LACTAID EXTRA STRENGTH JNO

LIPASE, AMYLASE, PROTEASE

5,000U & 16,600U & 18,750U CapsuleST

02239007 CREON 5 MINIMICROSPHERES SPH8,000U & 30,000U & 30,000U Capsule

ST

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

ST

02239008 CREON 20 MINIMICROSPHERES

SPH

4,000U & 12,000U & 12,000U Capsule (Enteric Coated

Particles)

ST

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

Particles)

ST

02203324 ULTRASE MS 4 AXC

56:16.00 DIGESTANTS

LIPASE, AMYLASE, PROTEASE


Particles)

ST

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

Particles)

ST


Particles)

ST


SPH


Particles)

ST

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

Particles)

ST


Particles)

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

8,000U & 30,000U & 30,000U TabletST

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

ST

02241933 VIOKASE AXC

56:20.00 EMETICS

IPECAC

14MG/ML Syrup

00378801 IPECAC XEN

56:22.08 ANTIHISTAMINES

DIMENHYDRINATE

50MG/ML Injection

00392537 DIMENHYDRINATE SDZ00013579 GRAVOL HOR

3MG/ML Liquid

00230197 GRAVOL HOR25MG Suppository

00783595 GRAVOL HOR50MG Suppository

00392553 DIMENHYDRINATE SIL100MG Suppository

00013609 GRAVOL ADULT HOR15MG Tablet

00511196 GRAVOL HOR

Page 97 of 1382014


56:22.08 ANTIHISTAMINES

DIMENHYDRINATE

50MG Tablet

00363766 APO-DIMENHYDRINATE APX00013803 GRAVOL HOR02245416 JAMP-DIMENHYDRINATE JAP00399779 NAUSEATOL SIL00021423 NOVODIMENATE TEV00586331 PMS-DIMENHYDRINATE PMS00605786 TRAVEL AID VTH

DOXYLAMINE SUCCINATE, PYRIDOXINE HCL

10MG & 10MG Tablet

00609129 DICLECTIN DUI

56:22.20 5-HT3 RECEPTOR ANTAGONISTS

DOLASETRON MESYLATE

100MG Tablet

02231379 ANZEMET SAC

GRANISETRON

1MG Tablet

02308894 GRANISETRON AAP02185881 KYTRIL HLR

ONDANSETRON HCL DIHYDRATE

4MG/CM Film

02389983 ONDISSOLVE ODF TAK8MG/CM Film

02389991 ONDISSOLVE ODF TAK0.8MG/ML Liquid

02229639 ZOFRAN GSK4MG Tablet

02288184 APO-ONDANSETRON APX02296349 CO-ONDANSETRON ACT02313685 JAMP-ONDANSETRON JAP02371731 MAR-ONDANSETRON MAR02297868 MYLAN-ONDANSETRON MYL02264056 NOVO-ONDANSETRON TEV02306212 ONDANSETRON-ODAN ODN02278618 PHL-ONDANSETRON PMI02258188 PMS-ONDANSETRON PMS02278529 RATIO-ONDANSETRON RPH02274310 SANDOZ-ONDANSETRON SDZ02376091 SEPTA-ONDANSETRON SPT02213567 ZOFRAN GSK02239372 ZOFRAN ODT GSK02344440 ZYM-ONDANSETRON ZYM

56:22.20 5-HT3 RECEPTOR ANTAGONISTS

ONDANSETRON HCL DIHYDRATE

8MG Tablet

02288192 APO-ONDANSETRON APX02296357 CO-ONDANSETRON ACT02313693 JAMP-ONDANSETRON JAP02371758 MAR-ONDANSETRON MAR02297876 MYLAN-ONDANSETRON MYL02264064 NOVO-ONDANSETRON TEV02325160 ONDANSETRON PDL02306220 ONDANSETRON-ODAN ODN02278626 PHL-ONDANSETRON PMI02258196 PMS-ONDANSETRON PMS02278537 RATIO-ONDANSETRON RPH02274329 SANDOZ-ONDANSETRON SDZ02376105 SEPTA-ONDANSETRON SPT02213575 ZOFRAN GSK02239373 ZOFRAN ODT GSK02344459 ZYM-ONDANSETRON ZYM

56:22.92 MISCELLANEOUS ANTIEMETICS

NABILONE


• For patients who are experiencing nausea and vomiting due to cancer chemotherapy or radiation;

OR

• patient is palliative (diagnosed with a terminal illness or disease which is expected to be the primary cause of death within six months or less

0.25MG Capsule

02312263 CESAMET VAE02358077 RAN-NABILONE RBY02392925 TEVA-NABILONE TEP

0.5MG Capsule

02256193 CESAMET VAE02393581 CO NABILONE ACT02380900 PMS-NABILONE PMS02358085 RAN-NABILONE RBY02384884 TEVA-NABILONE TEP

1MG Capsule

00548375 CESAMET VAE02393603 CO NABILONE ACT02380919 PMS-NABILONE PMS02358093 RAN-NABILONE RBY02384892 TEVA-NABILONE TEP

56:28.12 HISTAMINE H2-ANTAGONISTS

CIMETIDINE

200MG TabletST

00584215 APO-CIMETIDINE APX00582409 NOVO-CIMETINE TEV02229717 PMS-CIMETIDINE PMS

Page 98 of 1382014



CIMETIDINE

300MG TabletST

00487872 APO-CIMETIDINE APX02231287 DOM-CIMETIDINE DPC02227444 GEN-CIMETIDINE GEN00582417 NOVO-CIMETINE TEV02229718 PMS-CIMETIDINE PMS

400MG TabletST

00600059 APO-CIMETIDINE APX02231288 DOM-CIMETIDINE DPC02227452 GEN-CIMETIDINE GEN00603678 NOVO-CIMETINE TEV02229719 PMS-CIMETIDINE PMS

600MG TabletST

00600067 APO-CIMETIDINE APX00618705 CIMETIDINE PDL02231290 DOM-CIMETIDINE DPC02227460 GEN-CIMETIDINE GEN00603686 NOVO-CIMETINE TEV02229720 PMS-CIMETIDINE PMS

800MG TabletST

00749494 APO-CIMETIDINE APX02227479 GEN-CIMETIDINE GEN00663727 NOVO-CIMETINE TEV02229721 PMS-CIMETIDINE PMS

FAMOTIDINE

20MG TabletST

01953842 APO-FAMOTIDINE APX02351102 FAMOTIDINE SAN02196018 GEN-FAMOTIDINE GEN02022133 NOVO-FAMOTIDINE TEV02237148 ULCIDINE VAE

40MG TabletST

01953834 APO-FAMOTIDINE APX02351110 FAMOTIDINE SAN02196026 GEN-FAMOTIDINE GEN02022141 NOVO-FAMOTIDINE TEV02237149 ULCIDINE VAE

NIZATIDINE

150MG CapsuleST

02220156 APO-NIZATIDINE APX00778338 AXID PHH02185814 DOM-NIZATIDINE DPC02240457 NOVO-NIZATIDINE TEV02177714 PMS-NIZATIDINE PMS

300MG CapsuleST

02220164 APO-NIZATIDINE APX00778346 AXID PHH02238195 NIZATIDINE PHH02240458 NOVO-NIZATIDINE TEV02177722 PMS-NIZATIDINE PMS


RANITIDINE HCL

15MG/ML Oral SolutionST

02280833 APO-RANITIDINE APX02242940 NOVO-RANITIDINE TEV

150MG TabletST

00733059 APO-RANITIDINE APX02248570 CO-RANITIDINE ACT02207761 GEN-RANITIDINE GEN02293471 MAXIMUM STRENGTH ACID

REDUCERPMS

02367378 MYL-RANITIDINE MYL00828564 NOVO-RANIDINE TEV02242453 PMS-RANITIDINE PMS00740748 RANITIDINE PDL02353016 RANITIDINE SAN02385953 RANITIDINE SIV02336480 RAN-RANITIDINE RBY00828823 RATIO-RANITIDINE RPH02245782 RIVA-RANITIDINE PHH02247814 RIVA-RANTIDINE RIV02243229 SANDOZ-RANITIDINE SDZ02212331 ZANTAC GSK

300MG TabletST

00733067 APO-RANITIDINE APX02248571 CO-RANITIDINE ACT02207788 GEN-RANITIDINE GEN02367386 MYL-RANITIDINE MYL02242454 PMS-RANITIDINE PMS00740756 RANITIDINE PDL02353024 RANITIDINE SAN02385961 RANITIDINE SIV02336502 RAN-RANITIDINE RBY00828688 RATIO-RANITIDINE RPH02245783 RIVA-RANITIDINE PHH02247815 RIVA-RANITIDINE RIV02243230 SANDOZ-RANITIDINE SDZ02212358 ZANTAC GSK

56:28.28 PROSTAGLANDINS

MISOPROSTOL

100MCG TabletST

02244022 APO-MISOPROSTOL APX200MCG Tablet

ST

02244023 APO-MISOPROSTOL APX02244125 PMS-MISOPROSTOL PMS

56:28.32 PROTECTANTS

SUCRALFATE

200MG/ML SuspensionST

02103567 SULCRATE PLUS AXC1G Tablet

ST

02125250 APO-SUCRALFATE APX02045702 NOVO-SUCRALATE TEV02130939 SUCRALFATE-1 PDL02100622 SULCRATE AXC

Page 99 of 1382014


56:28.36 PROTON-PUMP INHIBITORS

AMOXICILLIN, CLARITHROMYCIN,

LANSOPRAZOLE

500MG & 500MG & 30MG Kit

02238525 HP-PAC ABB

LANSOPRAZOLE

(Please refer to Appendix A).


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


02293811 APO-LANSOPRAZOLE APX02357682 LANSOPRAZOLE SAN02385767 LANSOPRAZOLE SIV02353830 MYLAN-LANSOPRAZOLE MYL02395258 PMS-LANSOPRAZOLE PMS02165503 PREVACID ABB02402610 RAN-LANSOPRAZOLE RBY02385643 SANDOZ LANSOPRAZOLE SDZ02280515 TEVA-LANSOPRAZOLE TEP


02293838 APO-LANSOPRAZOLE APX02357690 LANSOPRAZOLE SAN02366282 LANSOPRAZOLE PDL02385775 LANSOPRAZOLE SIV02410389 LANSOPRAZOLE SIV02353849 MYLAN-LANSOPRAZOLE MYL02395266 PMS-LANSOPRAZOLE PMS02165511 PREVACID ABB02402629 RAN-LANSOPRAZOLE RBY02385651 SANDOZ LANSOPRAZOLE SDZ02280523 TEVA-LANSOPRAZOLE TEP

LANSOPRAZOLE ODT



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.


02249464 PREVACID FASTAB TAK30MG Delayed Release Tablet

ST

02249472 PREVACID FASTAB TAK


OMEPRAZOLE





02329425 MYLAN-OMEPRAZOLE GEN02296438 SANDOZ OMEPRAZOLE SDZ


02245058 APO-OMEPRAZOLE APX00846503 LOSEC AZC02329433 MYLAN-OMEPRAZOLE GEN02339927 OMEPRAZOLE PDL02348691 OMEPRAZOLE SAN02385384 OMEPRAZOLE SIV02411857 OMEPRAZOLE SIV02320851 PMS-OMEPRAZOLE PMS02403617 RAN-OMEPRAZOLE RBY02296446 SANDOZ OMEPRAZOLE SDZ


02333430 DOM-OMEPRAZOLE DR DOM02190915 LOSEC AZC02310260 PMS-OMEPRAZOLE DR PMS02374870 RAN-OMEPRAZOLE RBU02260867 RATIO-OMEPRAZOLE RPH02295415 TEVA-OMEPRAZOLE TEP

OMEPRAZOLE (PA)





02230737 LOSEC AZC02260859 RATIO-OMEPRAZOLE RPH

Page 100 of 1382014



PANTOPRAZOLE





02300486 ACT PANTOPRAZOLE ACT02292920 APO-PANTOPRAZOLE APX02310007 DOM-PANTOPRAZOLE DOM02299585 MYLAN-PANTOPRAZOLE MYL02309866 PANTOPRAZOLE MEL02310201 PANTOPRAZOLE SOR02318695 PANTOPRAZOLE PDL02370808 PANTOPRAZOLE SAN02385759 PANTOPRAZOLE SIV02307871 PMS-PANTOPRAZOLE PMS02316463 RIVA-PANTOPRAZOLE RIV02301083 SANDOZ-PANTOPRAZOLE SDZ02285487 TEVA-PANTOPRAZOLE TEP


02229453 PANTOLOC NCC02305046 RAN-PANTOPRAZOLE RBL

PANTOPRAZOLE MAGNESIUM

40MG Tablet

02267233 TECTA TAK

RABEPRAZOLE SODIUM





02345579 APO-RABEPRAZOLE APX02408392 MYLAN-RABEPRAZOLE MYL02296632 NOVO-RABEPRAZOLE TEV02243796 PARIET EC JNO02381737 PAT-RABEPRAZOLE EC KLA02310805 PMS-RABEPRAZOLE EC PMS02315181 PRO-RABEPRAZOLE PDL02356511 RABEPRAZOLE SAN02385449 RABEPRAZOLE SIV02298074 RAN-RABEPRAZOLE RBY02330083 RIVA-RABEPRAZOLE EC RIV02314177 SANDOZ-RABEPRAZOLE SDZ


RABEPRAZOLE SODIUM





02345587 APO-RABEPRAZOLE APX02320460 DOM-RABEPRAZOLE DOM02408406 MYLAN-RABEPRAZOLE MYL02296640 NOVO-RABEPRAZOLE TEV02243797 PARIET EC JNO02381745 PAT-RABEPRAZOLE EC KLA02310813 PMS-RABEPRAZOLE EC PMS02315203 PRO-RABEPRAZOLE PDL02356538 RABEPRAZOLE SAN02385457 RABEPRAZOLE SIV02298082 RAN-RABEPRAZOLE RBY02330091 RIVA-RABEPRAZOLE EC RIV02314185 SANDOZ-RABEPRAZOLE SDZ

56:32.00 PROKINETIC AGENTS

DOMPERIDONE MALEATE

10MG Tablet

02103613 APO-DOMPERIDONE APX02238315 DOM-DOMPERIDONE DPC02236857 DOMPERIDONE PDL02238341 DOMPERIDONE SIV02350440 DOMPERIDONE SAN02278669 GEN-DOMPERIDONE GEN02369206 JAMP-DOMPERIDONE JAP02157195 NOVO-DOMPERIDONE TEV02236466 PMS-DOMPERIDONE PMS02268078 RAN-DOMPERIDONE RBY01912070 RATIO-DOMPERIDONE RPH

METOCLOPRAMIDE HCL

1MG/ML Oral Liquid

02230433 PMS-METOCLOPRAMIDE PMS5MG Tablet

00842826 APO-METOCLOP APX02230431 PMS-METOCLOPRAMIDE PMS

10MG Tablet

00842834 APO-METOCLOP APX02230432 PMS-METOCLOPRAMIDE PMS

56:36.00 ANTI-INFLAMMATORY AGENTS

5-AMINOSALICYLIC ACID


02099683 PENTASA FEI800MG Delayed Release Tablet

ST

02267217 ASACOL WAC2G/60G Enema

02112795 SALOFALK AXC4G/60G Enema

02112809 SALOFALK AXC

Page 101 of 1382014


56:36.00 ANTI-INFLAMMATORY AGENTS



01997580 ASACOL WAC500MG Enteric Coated Tablet

ST

02112787 SALOFALK AXC500MG Suppository

ST


MESALAZINE

1G/100ML Enema

02153521 PENTASA FEI4G/100ML Enema

02153556 PENTASA FEI400MG Enteric Coated Tablet

ST

02171929 NOVO 5-ASA TEV500MG Enteric Coated Tablet

ST

01914030 MESASAL GSK1.2G Extended Release Tablet

ST

02297558 MEZAVANT BCM1G Suppository

ST

02153564 PENTASA FEI1000MG Suppository

ST


OLSALAZINE SODIUM

250MG CapsuleST

02063808 DIPENTUM LUD

Page 102 of 1382014


60:00 GOLD COMPOUNDS

60:00.00 GOLD COMPOUNDS

AURANOFIN

3MG Capsule

01916823 RIDAURA SQU

SODIUM AUROTHIOMALATE

10MG/ML Injection

01927620 MYOCHRYSINE SAC02245456 SODIUM AUROTHIOMALATE SDZ

25MG/ML Injection

01927612 MYOCHRYSINE SAC50MG/ML Injection

02245458 SODIUM AUROTHIOMALATE SDZ

Page 103 of 1382014


64:00 HEAVY METAL ANTAGONISTS

64:00.00 HEAVY METAL ANTAGONISTS

PENICILLAMINE

250MG Capsule

00016055 CUPRIMINE FRS

Page 104 of 1382014


68:00 HORMONES AND SYNTHETIC

SUBSTITUTES

68:04.00 ADRENALS


50MCG Inhaler CFC-Free

02242029 QVAR MMH100MCG Inhaler CFC-Free

02242030 QVAR MMH

BUDESONIDE

0.125MG/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

CICLESONIDE

100MG/ACT Inhaler

02285606 ALVESCO NCC200MG/ACT Inhaler

02285614 ALVESCO NCC

CORTISONE ACETATE

25MG Tablet

00280437 CORTISONE VAE

DEXAMETHASONE

0.1MG/ML Elixir

01946897 PMS-DEXAMETHASONE PMS0.5MG Tablet

02261081 APO-DEXAMETHASONE APX00295094 DEXASONE VAE02237044 PHL-DEXAMETHASONE PHH01964976 PMS-DEXAMETHASONE PMS02240684 RATIO-DEXAMETHASONE RPH

0.75MG Tablet

00285471 DEXASONE VAE01964968 PMS-DEXAMETHASONE PMS

2MG Tablet

02279363 PMS-DEXAMETHASONE PMS4MG Tablet

02250055 APO-DEXAMETHASONE APX00489158 DEXASONE VAE02237046 PHL-DEXAMETHASONE PHH01964070 PMS-DEXAMETHASONE PMS02311267 PRO-DEXAMETHASONE PRO02240687 RATIO-DEXAMETHASONE RPH

68:04.00 ADRENALS

DEXAMETHASONE PHOSPHATE

4MG/ML Injection

00664227 DEXAMETHASONE SDZ01977547 DEXAMETHASONE CYX02204266 DEXAMETHASONE-OMEGA OMG

10MG/ML Injection

00874582 DEXAMETHASONE SDZ02204274 DEXAMETHASONE-OMEGA OMG00783900 PMS-DEXAMETHASONE PMS

FLUDROCORTISONE ACETATE

0.1MG Tablet

02086026 FLORINEF SHI



02244291 FLOVENT HFA 50 GSK125MCG/INHALATION Inhaler HFA

02244292 FLOVENT HFA 125 GSK250MCG/INHALATION Inhaler HFA

02244293 FLOVENT HFA 250 GSK50MCG/DOSE Powder Diskus

02237244 FLOVENT DISKUS GSK100MCG/DOSE Powder Diskus



02237247 FLOVENT DISKUS GSK

HYDROCORTISONE

10MG Tablet

00030910 CORTEF PFI20MG Tablet

00030929 CORTEF PFI

METHYLPREDNISOLONE

4MG Tablet

00030988 MEDROL PFI16MG Tablet

00036129 MEDROL PFI

METHYLPREDNISOLONE ACETATE

40MG/ML Suspension for Injection

00030759 DEPO-MEDROL PMJ02245400 METHYLPREDNISOLONE

ACETATESDZ

02245407 METHYLPREDNISOLONE ACETATE

SDZ


00030767 DEPO-MEDROL PMJ02245406 METHYLPREDNISOLONE

ACETATESDZ

02245408 METHYLPREDNISOLONE ACETATE

SDZ

20MG/ML Suspension for Injection (Multi-Dose)

01934325 DEPO-MEDROL PMJ

Page 105 of 1382014


68:04.00 ADRENALS

METHYLPREDNISOLONE ACETATE

40MG/ML Suspension for Injection (Multi-Dose)

01934333 DEPO-MEDROL PMJ80MG/ML Suspension for Injection (Multi-Dose)

01934341 DEPO-MEDROL PMJ

MOMETASONE FUROATE

200MCG Powder for Inhalation

02243595 ASMANEX TWISTHALER FRS400MCG Powder for Inhalation

02243596 ASMANEX TWISTHALER FRS

PREDNISOLONE SODIUM PHOSPHATE

1MG/ML Oral Liquid

02230619 PEDIAPRED AVT02245532 PMS-PREDNISOLONE PMS

PREDNISONE

1MG Tablet

00598194 APO-PREDNISONE APX00271373 WINPRED VAE

5MG Tablet

00312770 APO-PREDNISONE APX00156876 PREDNISONE PRO

50MG Tablet

00550957 APO-PREDNISONE APX00232378 NOVO-PREDNISONE TEV00607517 PREDNISONE PRO



01999761 KENALOG-10 WSB02229540 TRIAMCINOLONE SDZ


01999869 KENALOG-40 WSB02229550 TRIAMCINOLONE SDZ09857128 TRIAMCINOLONE ACETONIDE

(5ML)SIL

TRIAMCINOLONE DIACETATE


01977555 STERILE TRIAMCINOLONE CYX

TRIAMCINOLONE HEXACETONIDE


02194155 ARISTOSPAN VAO

68:08.00 ANDROGENS

DANAZOL

50MG Capsule

02018144 CYCLOMEN SAC100MG Capsule

02018152 CYCLOMEN SAC200MG Capsule

02018160 CYCLOMEN SAC

68:08.00 ANDROGENS

TESTOSTERONE CYPIONATE

100MG/ML Injection

00030783 DEPO-TESTOSTERONE PFI02246063 TESTOSTERONE CYPIONATE SDZ

TESTOSTERONE ENANTHATE

200MG/ML Injection

00029246 DELATESTRYL BMS00739944 PMS-TESTOSTERONE PMS

TESTOSTERONE UNDECANOATE

40MG Capsule

00782327 ANDRIOL ORG02322498 PMS-TESTOSTERONE PMS

68:12.00 CONTRACEPTIVES

ETHINYL ESTRADIOL, DESOGESTREL

25MCG & 150MCG (21) Tablet

02272903 LINESSA (21) ORG25MCG & 150MCG (28) Tablet

02257238 LINESSA (28) ORG30MCG & 150MCG (21) Tablet

02317192 APRI (21) TEP02396491 FREYA (21) FAM02042487 MARVELON (21) ORG02410249 MIRVALA (21) APX


02317206 APRI (28) TEP02396610 FREYA (28) FAM02042479 MARVELON (28) ORG02410257 MIRVALA (28) APX02042533 ORTHO CEPT (28) JNO

ETHINYL ESTRADIOL, DROSPIRENONE

30MCG & 2MG (28) Tablet

02321157 YAZ BAY30MCG & 3MG (21) Tablet

02261723 YASMIN (21) BEX02410788 ZAMINE (21) APX02385058 ZARAH (21) ACT


02261731 YASMIN (28) BEX02410796 ZAMINE (28) APX02385066 ZARAH (28) ACT

ETHINYL ESTRADIOL, ETHYNODIOL

DIACETATE


00469327 DEMULEN 30 (21) PFI30MCG & 2MG (28) Tablet

00471526 DEMULEN 30 (28) PFI

ETHINYL ESTRADIOL, ETONOGESTREL

11.4MG & 2.6MG Device

02253186 NUVARING ORG

Page 106 of 1382014



ETHINYL ESTRADIOL, LEVONORGESTREL


02236974 ALESSE (21) WAY02387875 ALYSENA (21) APX02298538 AVIANE (21) BAR02388138 ESME (21) FAM02401185 LUTERA (21) ACT


02236975 ALESSE (28) WAY02387883 ALYSENA (28) APX02298546 AVIANE (28) BAR02388146 ESME (28) FAM02401207 LUTERA (28) ACT

10MCG & 30MCG & 150MCG Tablet

02346176 SEASONIQUE TEV30MCG & 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 Tablet

02296659 SEASONALE TEP30MCG & 150MCG (21) Tablet

02042320 MIN OVRAL (21) WAY02387085 OVIMA (21) APX02295946 PORTIA (21) BAR


02042339 MIN OVRAL (28) WAY02387093 OVIMA (28) APX02295954 PORTIA (28) BAR

ETHINYL ESTRADIOL, NORELGESTROMIN

0.6MG & 6MG PATCH

02248297 EVRA JNO

ETHINYL ESTRADIOL, NORETHINDRONE

35MCG & 0.5MG (21) Tablet

02187086 BREVICON 0.5/35 (21) PFI00317047 ORTHO 0.5/35 (21) JNO

35MCG & 0.5MG (28) Tablet

02187094 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




02189062 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


ACETATE


00315966 MINESTRIN 1/20 (21) GCL20MCG & 1MG (28) Tablet

00343838 MINESTRIN 1/20 (28) GCL30MCG & 1.5MG (21) Tablet

00297143 LOESTRIN 1.5/30 (21) GCL30MCG & 1.5MG (28) Tablet

00353027 LOESTRIN 1.5/30 (28) GCL

ETHINYL ESTRADIOL, NORGESTIMATE

25MCG & 0.180MG (7), 25MCG & 0.215MG (7), 25MCG &

0.25MG (7) (21) Tablet

02258560 TRI-CYCLEN LO (21) JNO25MCG & 0.180MG (7), 25MCG & 0.215MG (7), 25MCG &

0.25MG (7), (28) Tablet

02258587 TRI-CYCLEN LO (28) 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

LEVONORGESTREL

0.75MG Tablet

02364905 NEXT CHOICE ACT02285576 NORLEVO LAP02371189 OPTION 2 PER02241674 PLAN B BAR

LEVONORGESTREL INTRAUTERINE INSERT


Coverage is granted for 1 device every 2 years.52MG Intrauterine Insert

02243005 MIRENA BAY

Page 107 of 1382014



NORETHINDRONE

0.35MG (28) Tablet

00037605 MICRONOR (28) JNO

68:16.04 ESTROGENS

CONJUGATED ESTROGENS

0.3MG Tablet

02043394 PREMARIN WAY0.625MG Tablet

02043408 PREMARIN WAY1.25MG Tablet

02043424 PREMARIN WAY0.625MG/G Vaginal Cream

02043440 PREMARIN WAY

CONJUGATED ESTROGENS,

MEDROXYPROGESTERONE ACETATE

0.625MG & 2.5MG Kit

02242878 PREMPLUS WAY0.625MG & 5MG Kit

02242879 PREMPLUS WAY

ESTRADIOL

0.06% Gel

02238704 ESTROGEL SCH0.39MG Patch

02245676 ESTRADOT 25 NVR0.585MG Patch

02243999 ESTRADOT 37.5 NVR0.78MG Patch



02244002 ESTRADOT 100 NVR5MG Patch

02243722 OESCLIM PAL10MG Patch

02243724 OESCLIM PAL50MCG Patch

02246967 SANDOZ-ESTRADIOL DERM SDZ75MCG Patch

02246968 SANDOZ-ESTRADIOL DERM SDZ100MCG Patch

00756792 ESTRADERM NVR02246969 SANDOZ-ESTRADIOL DERM SDZ

0.5MG Tablet

02225190 ESTRACE SHI1MG Tablet

02148587 ESTRACE SHI2MG Tablet

02148595 ESTRACE SHI

68:16.04 ESTROGENS

ESTRADIOL

2MG Vaginal Ring

02168898 ESTRING PMJ

ESTRADIOL (ESTRADIOL HEMIHYDRATE)

25MCG Patch

02247499 CLIMARA 25 BEX50MCG Patch



02231510 CLIMARA 100 BEX10MCG Tablet

02325462 VAGIFEM NOO

ESTRADIOL, NORETHINDRONE ACETATE

0.51MG & 4.8MG Patch

02241837 ESTALIS 250/50 NVR0.62MG & 2.7MG Patch

02241835 ESTALIS 140/50 NVR

ESTRONE

1MG/G Vaginal Cream

00727369 NEO-ESTRONE NEO

ESTROPIPATE

0.625MG Tablet

02089793 OGEN PFI

68:16.12 ESTROGEN AGONISTS-

ANTAGONISTS

RALOXIFENE 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 Tablet

02279215 APO-RALOXIFENE APX02358840 CO RALOXIFENE ACT02239028 EVISTA LIL02358921 PMS-RALOXIFENE PMS02312298 TEVA-RALOXIFENE TEP

68:18.00 GONADOTROPINS

NAFARELIN ACETATE

2MG/ML Nasal Solution

02188783 SYNAREL PFI

68:20.02 ALPHA-GLUCOSIDASE

INHIBITORS

ACARBOSE

50MG TabletST

02190885 GLUCOBAY BAY

Page 108 of 1382014


68:20.02 ALPHA-GLUCOSIDASE

INHIBITORS

ACARBOSE

100MG TabletST

02190893 GLUCOBAY BAY

68:20.04 BIGUANIDES

METFORMIN HCL

500MG TabletST

02167786 APO-METFORMIN APX02257726 CO-METFORMIN ACT02229994 DOM-METFORMIN DPC02148765 GEN-METFORMIN GEN02099233 GLUCOPHAGE SAC02229516 GLYCON VAE02380196 JAMP-METFORMIN JAP02380722 JAMP-METFORMIN

BLACKBERRYJAP

02378620 MAR-METFORMIN MAR02242794 METFORMIN ZYM02353377 METFORMIN SAN02378841 METFORMIN MAR02385341 METFORMIN SIV02388766 MINT-METFORMIN MIN02045710 NOVO-METFORMIN TEV02223562 PMS-METFORMIN PMS02314908 PRO-METFORMIN PDL02269031 RAN-METFORMIN RBY02242974 RATIO-METFORMIN RPH02239081 RIVA-METFORMIN RIV02246820 SANDOZ-METFORMIN FC SDZ02379767 SEPTA-METFORMIN SPT

850MG TabletST

02229785 APO-METFORMIN APX02257734 CO-METFORMIN ACT02242726 DOM-METFORMIN DPC02229656 GEN-METFORMIN GEN02162849 GLUCOPHAGE SAC02239214 GLYCON VAE *02380218 JAMP-METFORMIN JAP02380730 JAMP-METFORMIN

BLACKBERRYJAP

02378639 MAR-METFORMIN MAR02242793 METFORMIN ZYM02353385 METFORMIN SAN02378868 METFORMIN MAR02385368 METFORMIN SIV02388774 MINT-METFORMIN MIN02230475 NOVO-METFORMIN TEV02242589 PMS-METFORMIN PMS02314894 PRO-METFORMIN PDL02269058 RAN-METFORMIN RBY02242931 RATIO-METFORMIN RPH02242783 RIVA-METFORMIN RIV02246821 SANDOZ-METFORMIN SDZ02379775 SEPTA-METFORMIN SPT

68:20.04 BIGUANIDES

SITAGLIPTIN, METFORMIN


• For the treatment of patients with type 2 diabetes mellitus who: did not achieve glycemic control or who demonstrated intolerance to an adequate trial of metformin AND a sulfonylurea.


02333872 JANUMET FRS50MG & 500MG Tablet

ST

02333856 JANUMET FRS50MG & 850MG Tablet

ST

02333864 JANUMET FRS

68:20.05

LINAGLIPTIN


For the treatment of patients with type 2 diabetes mellitus who: did not achieve glycemic control or who demonstrated intolerance to an adequate trial of metformin AND a sulfonylurea.

5MG TabletST

02370921 TRAJENTA BOE

SAXAGLIPTIN HCL



2.5MG TabletST

02375842 ONGLYZA BMS5MG Tablet

ST

02333554 ONGLYZA BMS

SITAGLIPTIN



25MG TabletST

02388839 JANUVIA MSP50MG Tablet

ST

02388847 JANUVIA MSP100MG Tablet

ST

02303922 JANUVIA FRS

68:20.08 INSULINS

INSULIN (30% NEUTRAL & 70% ISOPHANE)

HUMAN BIOSYNTHETIC

100U/ML (10ML) Injection

02024217 NOVOLIN GE 30/70 NOO100U/ML (3ML) Injection

02025248 NOVOLIN GE 30/70 PENFILL NOO09853812 NOVOLIN GE 30/70 PENFILL NOO

Page 109 of 1382014


68:20.08 INSULINS


HUMAN BIOSYNTHETIC


02024314 NOVOLIN GE 40/60 PENFILL NOO


HUMAN BIOSYNTHETIC


02024322 NOVOLIN GE 50/50 PENFILL NOO

INSULIN (ISOPHANE) HUMAN BIOSYNTHETIC


00587737 HUMULIN N LIL02024225 NOVOLIN GE NPH NOO


01959239 HUMULIN N CARTRIDGE LIL09853804 HUMULIN N CARTRIDGE (ON) LIL02403447 HUMULIN N KWIKPEN LIL02024268 NOVOLIN GE NPH PENFILL NOO09853782 NOVOLIN GE NPH PENFILL

(ON)NOO

INSULIN (ZINC CRYSTALLINE) HUMAN

BIOSYNTHETIC (RDNA ORIGIN)


00586714 HUMULIN R LIL100U/ML (3ML) Injection

01959220 HUMULIN R CARTRIDGE LIL09853766 HUMULIN R CARTRIDGE (ON) LIL

INSULIN ASPART


02245397 NOVORAPID NOO100U/ML (3ML) Injection

02244353 NOVORAPID NOO02377209 NOVORAPID FLEXTOUCH NOO

INSULIN DETEMIR


02271842 LEVEMIR PENFILL NOO

INSULIN GLARGINE


02245689 LANTUS SAC100U/ML (3ML) Injection

02251930 LANTUS CARTRIDGE SAC02294338 LANTUS SOLOSTAR SAC

INSULIN GLULISINE


02279460 APIDRA SAC100U/ML (3ML) Injection

02279479 APIDRA CARTRIDGE SAC02294346 APIDRA SOLOSTAR SAC

INSULIN HUMAN BIOSYNTHETIC


02024233 NOVOLIN GE TORONTO NOO

68:20.08 INSULINS

INSULIN HUMAN BIOSYNTHETIC


02024284 NOVOLIN GE TORONTO PENFILL

09853774 NOVOLIN GE TORONTO PENFILL (ON)

NOO

INSULIN HUMAN BIOSYNTHETIC 30% &

ISOPHANE 70%


00795879 HUMULIN 30/70 LIL100U/ML (3ML) Injection

01959212 HUMULIN 30/70 CARTRIDGE LIL09853855 HUMULIN 30/70 CARTRIDGE

(ON)LIL

INSULIN LISPRO


02229704 HUMALOG 10ML LIL100U/ML (3ML) Injection

02229705 HUMALOG CARTRIDGE LIL09853715 HUMALOG CARTRIDGE (ON) LIL *02403412 HUMALOG KWIKPEN LIL

INSULIN LISPRO (25%), INSULIN LISPRO

PROTAMINE SUSPENSION (75%)


02240294 HUMALOG MIX 25 LIL02403420 HUMALOG MIX 25 KWIKPEN LIL

INSULIN LISPRO (50%), INSULIN LISPRO

PROTAMINE SUSPENSION (50%)


02240297 HUMALOG MIX 50 KWIKPEN LIL02403439 HUMALOG MIX 50 KWIKPEN LIL

68:20.16 MEGLITINIDES

NATEGLINIDE

60MG TabletST

02245438 STARLIX NVR120MG Tablet

ST

02245439 STARLIX NVR

REPAGLINIDE

0.5MG TabletST

02355663 APO-REPAGLINIDE APX02321475 CO-REPAGLINIDE ACT02239924 GLUCONORM NOO02354926 PMS-REPAGLINIDE PMS02357453 SANDOZ REPAGLINIDE SDZ

1MG TabletST

02321483 CO-REPAGLINIDE ACT02239925 GLUCONORM NOO02354934 PMS-REPAGLINIDE PMS02357461 SANDOZ REPAGLINIDE SDZ

Page 110 of 1382014


68:20.16 MEGLITINIDES

REPAGLINIDE

2MG TabletST

02321491 CO-REPAGLINIDE ACT02239926 GLUCONORM NOO02354942 PMS-REPAGLINIDE PMS02357488 SANDOZ REPAGLINIDE PFI

68:20.20 ANTIDIABETIC AGENTS -

SULFONYLUREAS

GLICLAZIDE

30MG TabletST

02242987 DIAMICRON MR SEV02297795 GLICLAZIDE MR AAP

60MG TabletST

02356422 DIAMICRON MR SEV80MG Tablet

ST

02245247 APO-GLICLAZIDE APX00765996 DIAMICRON SEV02229519 GEN-GLICLAZIDE GEN02248453 GLICLAZIDE PDL02287072 GLICLAZIDE SAN02238103 TEVA-GLICLAZIDE TEV

GLYBURIDE

2.5MG TabletST

01913654 APO-GLYBURIDE APX02224550 DIABETA SAC00808733 GEN-GLYBE GEN01959352 GLYBURIDE PDL02350459 GLYBURIDE SAN01913670 NOVO-GLYBURIDE TEV01900927 RATIO-GLYBURIDE RPH02248008 SANDOZ-GLYBURIDE SDZ

5MG TabletST

01913662 APO-GLYBURIDE APX02224569 DIABETA SAC02234514 DOM-GLYBURIDE DPC00720941 EUGLUCON PMS00808741 GEN-GLYBE GEN02350467 GLYBURIDE SAN01913689 NOVO-GLYBURIDE TEV02236734 PMS-GLYBURIDE PMS02316544 PRO-GLYBURIDE PDL01900935 RATIO-GLYBURIDE RPH02236548 RIVA-GLYBURIDE PHH02248009 SANDOZ-GLYBURIDE SDZ

TOLBUTAMIDE

500MG TabletST

00312762 APO-TOLBUTAMIDE APX

68:20.28 THIAZOLIDINEDIONES

PIOGLITAZONE HCL


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 ACT02307634 DOM-PIOGLITAZONE DOM02298279 GEN-PIOGLITAZONE GEN02326477 JAMP-PIOGLITAZONE MIN02274914 NOVO-PIOGLITAZONE TEV02307669 PHL-PIOGLITAZONE PMI02374013 PIOGLITAZONE SIV02391600 PIOGLITAZONE ACC02303124 PMS-PIOGLITAZONE PMS02312050 PRO-PIOGLITAZONE PDL02375850 RAN-PIOGLITAZONE RBY02301423 RATIO-PIOGLITAZONE RPH02297906 SANDOZ PIOGLITAZONE SDZ02320754 ZYM-PIOGLITAZONE ZYM

30MG TabletST

02303450 ACCEL PIOGLITAZONE ACP02242573 ACTOS LIL02302950 APO-PIOGLITAZONE APX02302888 CO PIOGLITAZONE ACT02307642 DOM-PIOGLITAZONE DOM02298287 GEN-PIOGLITAZONE GEN02326485 JAMP-PIOGLITAZONE MIN02365529 JAMP-PIOGLITAZONE JAP02274922 NOVO-PIOGLITAZONE TEV02307677 PHL-PIOGLITAZONE PMI02339587 PIOGLITAZONE ACC02374021 PIOGLITAZONE SIV02303132 PMS-PIOGLITAZONE PMS02312069 PRO-PIOGLITAZONE PDL02375869 RAN-PIOGLITAZONE RBY02301431 RATIO-PIOGLITAZONE RPH02297914 SANDOZ PIOGLITAZONE SDZ02320762 ZYM-PIOGLITAZONE ZYM

Page 111 of 1382014


68:20.28 THIAZOLIDINEDIONES

PIOGLITAZONE HCL



45MG TabletST

02303469 ACCEL PIOGLITAZONE ACP02242574 ACTOS LIL02302977 APO-PIOGLITAZONE APX02302896 CO PIOGLITAZONE ACT02307650 DOM-PIOGLITAZONE DOM02298295 GEN-PIOGLITAZONE GEN02326493 JAMP-PIOGLITAZONE MIN02365537 JAMP-PIOGLITAZONE JAP02274930 NOVO-PIOGLITAZONE TEV02307723 PHL-PIOGLITAZONE PMI02339595 PIOGLITAZONE ACC02374048 PIOGLITAZONE SIV02303140 PMS-PIOGLITAZONE PMS02312077 PRO-PIOGLITAZONE PDL02375877 RAN-PIOGLITAZONE RBY02301458 RATIO-PIOGLITAZONE RPH02297922 SANDOZ PIOGLITAZONE SDZ02320770 ZYM-PIOGLITAZONE ZYM

ROSIGLITAZONE MALEATE



2MG TabletST

02241112 AVANDIA GSK4MG Tablet

ST

02241113 AVANDIA GSK8MG Tablet

ST

02241114 AVANDIA GSK

68:22.12 GLYCOGENOLYTIC AGENTS

GLUCAGON RECOMBINANT DNA ORGIN

1MG/ML Injection

02333619 GLUCAGEN NOO02333627 GLUCAGEN HYPOKIT NOO02243297 GLUCAGON LIL

68:24.00 PARATHYROID

CALCITONIN SALMON (SYNTHETIC)

200IU/ML Injection

01926691 CALCIMAR SAC

68:28.00 PITUITARY

DESMOPRESSIN ACETATE

4MCG/ML Injection

00873993 DDAVP FEI0.1MG/ML Nasal Solution

00402516 DDAVP FEI

68:28.00 PITUITARY

DESMOPRESSIN ACETATE

0.1MG/ML Nasal Spray

02242465 APO-DESMOPRESSIN APX00836362 DDAVP FEI

0.1MG Tablet

02284030 APO-DESMOPRESSIN APX00824305 DDAVP FEI02287730 NOVO-DESMOPRESSIN TEV02304368 PMS-DESMOPRESSIN PMS

0.2MG Tablet

02284049 APO-DESMOPRESSIN APX00824143 DDAVP FEI02287749 NOVO-DESMOPRESSIN TEV02304376 PMS-DESMOPRESSIN PMS

60MCG Tablet

02284995 DDAVP MELT FEI120MCG Tablet

02285002 DDAVP MELT FEI240MCG Tablet

02285010 DDAVP MELT FEI

68:29.04 SOMATOSTATIN AGONISTS

LANREOTIDE


02283395 SOMATULINE AUTOGEL IPS90MG/0.3ML Injection

02283409 SOMATULINE AUTOGEL IPS120MG/0.5ML Injection

02283417 SOMATULINE AUTOGEL IPS

OCTREOTIDE

10MG/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 NVR200MCG/ML Injection


OMG

02049392 SANDOSTATIN NOV500MCG/ML Injection


OMG

00839213 SANDOSTATIN NVR

Page 112 of 1382014


68:32.00 PROGESTINS

DIENOGEST

2MG Tablet

02374900 VISANNE BAY

MEDROXYPROGESTERONE ACETATE

50MG/ML Injection

00030848 DEPO-PROVERA PFI150MG/ML Injection

00585092 DEPO-PROVERA PFI02322250 MEDROXYPROGESTERONE SDZ

2.5MG Tablet

02244726 APO-MEDROXY APX02247581 DOM-

MEDROXYPROGESTERONEDPC

02221284 NOVO-MEDRONE TEV02253550 PDL-MEDROXY PDL00708917 PROVERA PFI

5MG Tablet



02221292 NOVO-MEDRONE TEV02253577 PDL-MEDROXY PDL00030937 PROVERA PFI02010739 PROVERA PAK PFI

10MG Tablet



02221306 NOVO-MEDRONE TEV00729973 PROVERA PFI02010933 PROVERA PFI

100MG Tablet

02267640 APO-MEDROXY APX

68:36.04 THYROID AGENTS

LEVOTHYROXINE 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 ABB0.1MG Tablet

ST


68:36.04 THYROID AGENTS

LEVOTHYROXINE SODIUM

0.112MG TabletST


0.125MG TabletST


0.137MG TabletST


0.15MG TabletST


0.175MG TabletST


0.2MG TabletST


0.3MG TabletST


THYROID

30MG TabletST

00023949 THYROID ERF60MG Tablet

ST

00023957 THYROID ERF125MG Tablet

ST

00023965 THYROID ERF

68:36.08 ANTITHYROID AGENTS

PROPYLTHIOURACIL

50MG TabletST

00010200 PROPYL THYRACIL SQU100MG Tablet

ST

00010219 PROPYL THYRACIL SQU

THIAMAZOLE

5MG TabletST

00015741 TAPAZOLE PAL10MG Tablet

ST

02296039 TAPAZOLE PAL

Page 113 of 1382014


80:00 SERUMS, TOXOIDS, AND

VACCINES

80:04.00 SERUMS

DOLICHOVESPULA ARENARIA VENOM

PROTEIN

120MCG Injection

01948946 YELLOW HORNET VENOM PROTEIN

ALK

DOLICHOVESPULA MACULATA VENOM

PROTEIN EXTRACT

120MCG Injection

01949004 WHITE FACED HORNET VENOM

ALK

HONEY BEE VENOM PROTEIN EXTRACT

1.1MG Injection

01948903 HONEY BEE VENOM ALK120MCG Injection

01948911 HONEY BEE VENOM ALK02226197 VENOMIL HONEY BEE VENOM HOL

550MCG Injection

02220075 HONEY BEE VENOM HOL

NON POLLEN

Injection

00299979 ALLERGENIC EXTRACT NON POLLENS

CEN

00514713 ALLERGENIC EXTRACTS MSL

POLISTES SPP VENOM PROTEIN EXTRACT

1.1MG Injection

01948970 WASP VENOM PROTEIN ALK

POLLEN

Injection

00299987 ALLERGENIC EXTRACT POLLENS

CEN

00464988 POLLINEX R BCA

POLLEN AND NON POLLEN

Injection

00648922 CENTER-AL CEN

VESPULA SPP VENOM PROTEIN EXTRACT

1.1MG Injection

01948954 YELLOW JACKET VENOM PROTEIN

ALG

120MCG Injection


ALK

WASP VENOM PROTEIN

120MCG Injection

02226219 VENOMIL WASP VENOM PROTEIN

HOL

550MCG Injection

02220091 WASP VENOM PROTEIN HOL

80:04.00 SERUMS

WHITE FACED HORNET VENOM PROTEIN

120MCG Injection

02226235 VENOMIL WHITE FACED HORNET VENOM PROTEIN

HOL

WHITE FACED HORNET VENOM PROTEIN,

YELLOW HORNET VENOM PROTEIN, YELLOW

JACKET VENOM PROTEIN

120MCG Injection

01948881 MIXED VESPID VENOM PROTEIN

ALK

02226294 VENOMIL MIXED VESPID VENOM PROTEIN

HOL

550MCG Injection

02221314 MIXED VESPID VENOM PROTEIN

HOL

YELLOW HORNET VENOM PROTEIN

100MCG/ML Injection

02226251 YELLOW JACKET HORNET VENOM PROTEIN

BAY

500MCG Injection

02220083 YELLOW HORNET VENOM PROTEIN

HOL

YELLOW JACKET VENOM PROTEIN

120MCG Injection

02226286 VENOMIL YELLOW JACKET VENOM PROTEIN

HOL

550MCG Injection


BAY

Page 114 of 1382014


84:00 SKIN AND MUCOUS

MEMBRANE AGENTS (SMMA)

84:04.04 SMMA - ANTIBIOTICS

BACITRACIN

500IU Ointment

00584908 BACITIN PMS02351714 BACITRACIN JAP

BACITRACIN ZINC, POLYMYXIN B SULFATE

500IU & 10,000IU Ointment

02237227 POLYSPORIN ANTIBIOTIC PFI

CLINDAMYCIN PHOSPHATE

1% Solution

02243659 CLINDA-T VAO00582301 DALACIN T PFI02266938 TARO-CLINDAMYCIN TAR

2% Vaginal Cream

02060604 DALACIN PMJ

ERYTHROMYCIN, TRETINOIN

4% & 0.01% Gel

02015994 STIEVAMYCIN MILD STI4% & 0.025% Gel

01905112 STIEVAMYCIN STI4% & 0.05% Gel

01945262 STIEVAMYCIN FORTE STI

FUSIDATE SODIUM

2% Ointment

00586676 FUCIDIN LEO

FUSIDIC ACID

2% Cream

00586668 FUCIDIN LEO

GRAMICIDIN, POLYMYXIN B SULFATE

0.25MG & 10,000IU Cream

02230844 POLYSPORIN ANTIBIOTIC PFI

MUPIROCIN

2% Cream

02239757 BACTROBAN GSK2% Ointment

01916947 BACTROBAN GSK02279983 TARO-MUPIROCIN 2%

OINTMENTTAR

POLYMYXIN B SULFATE, BACITRACIN

10,000IU & 500IU Ointment

02304473 ANTIBIOTIC OINTMENT PED00876488 BACIMYXIN PMS00621366 BIODERM ODN01942921 POLYTOPIC SDZ

84:04.06 SMMA - ANTIVIRALS

ACYCLOVIR

5% Cream

02039524 ZOVIRAX GSK5% Ointment

00569771 ZOVIRAX GSK

84:04.08 SMMA - ANTIFUNGALS

CLOTRIMAZOLE

1% Cream

02150867 CANESTEN BCD00812382 CLOTRIMADERM TAR

1% & 200MG Cream & Vaginal Suppository

02264099 CANESTEN 3 COMFORT COMBI PAK

BCD


02264102 CANESTEN 1 COMFORT COMBI PAK

BCD

1% Vaginal Cream


2% Vaginal Cream


KETOCONAZOLE

2% Cream

02245662 KETODERM TAR2% Shampoo

02182920 NIZORAL MCL

MICONAZOLE NITRATE

2% Cream

02085852 MICATIN MCL02126567 MONISTAT-DERM MCL


02126257 MONISTAT 7 DUAL PAK MCL2% & 400MG Cream & Vaginal Suppository

02126249 MONISTAT 3 DUAL PAK MCL2% Vaginal Cream

02231106 MICOZOLE TAR02084309 MONISTAT 7 MCL

400MG Vaginal Suppository

02171775 MICONAZOLE VTH02126605 MONISTAT 3 MCL

NYSTATIN

100,000IU Cream

00716871 NYADERM TAR02194236 RATIO-NYSTATIN RPH

100,000IU Ointment

02194228 RATIO-NYSTATIN RPH25,000IU Vaginal Cream

00716901 NYADERM TAR100,000IU Vaginal Cream

02194163 RATIO-NYSTATIN RPH

Page 115 of 1382014


84:04.08 SMMA - ANTIFUNGALS

TERBINAFINE HCL

1% Cream

02031094 LAMISIL NVR

TERCONAZOLE

0.4% Vaginal Cream

02247651 TARO-TERCONAZOLE TAR00894729 TERAZOL 7 JNO

0.8% & 80MG Vaginal Cream & Vaginal Suppository

02130874 TERAZOL 3 DUAL PAK JNO80MG Vaginal Suppository

00894710 TERAZOL 3 JNO

TOLNAFTATE

1% Cream

00576034 TINACTIN SCH1% Powder

01919245 ATHLETES FOOT SPRAY SCH00576042 TINACTIN SCH02029081 ZEASORB AF STI

1% Spray

00576050 TINACTIN AEROSOL SCH

84:04.12 SMMA - SCABICIDES AND

PEDICULICIDES

CROTAMITON

10% Cream

00623377 EURAX NVC

ISOPROPYL MYRISTATE

50% Solution

02279592 RESULTZ ALN

PERMETHRIN

5% Cream

02219905 NIX DERMAL GSK5% Lotion

02231348 KWELLADA-P GSK1% Rinse

02231480 KWELLADA-P GSK00771368 NIX WLA

PIPERONYL BUTOXIDE, PYRETHRINS

3% & 0.3% Shampoo

02125447 R & C GSK

84:04.92 SMMA - MISCELLANEOUS LOCAL

ANTI-INFECTIVES

BENZOYL PEROXIDE

5% Gel (Alcohol Base)

02162113 BENZAGEL NVC00263702 PANOXYL-5 STI

10% Gel (Alcohol Base)

00263699 PANOXYL-10 STI20% Gel (Alcohol Base)

00373036 PANOXYL-20 STI


ANTI-INFECTIVES

BENZOYL PEROXIDE

2.5% Gel (Water Base)

02214830 PANOXYL AQUAGEL STI4% Gel (Water Base)

01975382 SOLUGEL STI5% Gel (Water Base)

00899453 BENZAC AC GAC01925180 BENZAC W5 GAC *02214849 PANOXYL AQUAGEL STI

8% Gel (Water Base)

02019825 SOLUGEL STI2.5% Lotion

02046539 OXY 5 GSK5% Lotion

02166607 BENZAGEL 5 NVC00374326 OXYDERM VAE

10% Lotion

00370568 BENOXYL STI5% Soap

00483184 PANOXYL-5 STI10% Soap

00527661 PANOXYL-10 STI5% Wash

00896276 BENZAC W GAC02162121 BENZAGEL NVC02214857 PANOXYL STI

10% Wash

01925199 BENZAC W GAC

CHLORHEXIDINE ACETATE

0.5% Dressing

00433497 BACTIGRAS SNE

CHLORHEXIDINE GLUCONATE

2% Liquid

01938991 STANHEXIDINE OMG4% Liquid

01938983 STANHEXIDINE OMG

HYDROGEN PEROXIDE

3% Liquid

00167703 HYDROGEN PEROXIDE 10V RWP00485721 HYDROGEN PEROXIDE 10V RPH *00579297 PEROXIDE D'HYDROGENE ATL

ISOPROPYL ALCOHOL

70% Liquid

00426539 DUONALC VAE

METRONIDAZOLE

0.75% Cream

02226839 METROCREAM GAC1% Cream

02156091 NORITATE SAC02242919 ROSASOL STI

Page 116 of 1382014



ANTI-INFECTIVES

METRONIDAZOLE

0.75% Gel

02092832 METROGEL GAC1% Gel

02297809 METROGEL GAC0.75% Lotion

02248206 METROLOTION GAC10% Vaginal Cream

01926861 FLAGYL SAC0.75% Vaginal Gel

02125226 NIDAGEL MMH

METRONIDAZOLE, NYSTATIN

100MG & 20,000U/G Vaginal Cream

01926845 FLAGYSTATIN AVT500MG & 100,000IU Vaginal Suppository

01926829 FLAGYSTATIN AVT

POVIDONE-IODINE

10% Liquid

00158348 BETADINE PFR

SELENIUM SULFIDE

2.5% Lotion

00243000 SELSUN ABB00594601 VERSEL VAO

SILVER SULFADIAZINE

1% Cream

02010917 DERMAZIN PMS00323098 FLAMAZINE SNE09854037 FLAMAZINE 50G SNE *

TRICLOSAN

0.5% Liquid

00266507 ADASEPT ODN00632317 TERSASEPTIC STI

84:06.00 SMMA - ANTI-INFLAMMATORY

AGENTS

AMCINONIDE

0.1% Cream

02192284 CYCLOCORT STI02247098 RATIO-AMCINONIDE RPH02246714 TARO-AMCINONIDE TAR

0.1% Lotion

02192276 CYCLOCORT STI02247097 RATIO-AMCINONIDE RPH

0.1% Ointment

02192268 CYCLOCORT STI02247096 RATIO-AMCINONIDE RPH


0.025% Cream

02089602 PROPADERM SHI


AGENTS

BETAMETHASONE DIPROPIONATE

0.05% Cream

00323071 DIPROSONE SCH00804991 RATIO-TOPISONE RPH02122049 ROSONE RIV01925350 TARO-SONE TAR

0.05% Lotion

00417246 DIPROSONE SCH00809187 RATIO-TOPISONE RPH02122030 ROSONE RIV

0.05% Ointment

00344923 DIPROSONE SCH00805009 RATIO-TOPISONE RPH02122057 ROSONE RIV

BETAMETHASONE DIPROPIONATE IN

PROPYLENE GLYCOL

0.05% Cream

00688622 DIPROLENE SCH00849650 RATIO-TOPILENE GLYCOL RPH02122073 ROLENE RIV

0.05% Lotion


0.05% Ointment


BETAMETHASONE DIPROPIONATE,

CLOTRIMAZOLE

0.05% & 1% Cream

00611174 LOTRIDERM SCH

BETAMETHASONE DIPROPIONATE,

SALICYLIC ACID

0.05% & 2% Lotion

00578428 DIPROSALIC SCH02245688 RATIO-TOPISALIC RPH

0.05% & 3% Ointment

00578436 DIPROSALIC SCH

BETAMETHASONE DISODIUM PHOSPHATE

0.05MG/ML Enema

02060884 BETNESOL SHI

BETAMETHASONE VALERATE

0.05% Cream

00535427 RATIO-ECTOSONE RPH0.1% Cream

00716626 BETADERM TAR02357844 CELESTODERM V VAO00804541 PREVEX B STI00535435 RATIO-ECTOSONE RPH

Page 117 of 1382014



AGENTS

BETAMETHASONE VALERATE

0.05% Lotion

00653209 RATIO-ECTOSONE RPH0.1% Lotion

00750050 RATIO-ECTOSONE RPH01940112 RIVASONE RIV

0.05% Ointment

00716642 BETADERM TAR0.1% Ointment

00716650 BETADERM TAR0.1% Scalp Lotion

00716634 BETADERM TAR00027944 VALISONE SCH

BETAMETHASONE, CALCIPOTRIOL

0.5MG & 50MCG Gel

02319012 DOVOBET LEO

BUDESONIDE

0.02MG/ML Enema

02052431 ENTOCORT AZC

CLOBETASOL PROPIONATE

0.05% Cream

02245523 CLOBETASOL PROPIONATE TAR02213265 DERMOVATE TAR02024187 GEN-CLOBETASOL GEN02093162 NOVO-CLOBETASOL TEV02232191 PMS-CLOBETASOL PMS02309521 PMS-CLOBETASOL PMS01910272 RATIO-CLOBETASOL RPH

0.05% Ointment

02245524 CLOBETASOL PROPIONATE TAR02213273 DERMOVATE TAR02026767 GEN-CLOBETASOL GEN02126192 NOVO-CLOBETASOL TEV02309548 PMS-CLOBETASOL PMS01910280 RATIO-CLOBETASOL RPH

0.05% Scalp Lotion

02213281 DERMOVATE TAR02216213 GEN-CLOBETASOL GEN02232195 PMS-CLOBETASOL PMS01910299 RATIO-CLOBETASOL RPH

0.05% Solution

02245522 CLOBETASOL PROPIONATE TAR

CLOBETASONE BUTYRATE

0.05% Cream

02214415 EUMOVATE GSK

DESONIDE

0.05% Cream

02229315 PMS-DESONIDE PMS02154862 TRIDESILON SCN


AGENTS

DESONIDE

0.05% Ointment

02115522 DESOCORT GAC02229323 PMS-DESONIDE PMS02154870 TRIDESILON SCN

DESOXIMETASONE

0.05% Cream

02221918 TOPICORT SAC0.25% Cream

02221896 TOPICORT SAC0.05% Gel

02221926 TOPICORT SAC0.25% Ointment

02221934 TOPICORT SAC

DIFLUCORTOLONE VALERATE

0.1% Cream

00587826 NERISONE STI00587818 NERISONE OILY STI

0.1% Ointment

00587834 NERISONE STI

DIFLUCORTOLONE VALERATE, SALICYLIC

ACID

0.1% & 3% Cream

02028719 NERISALIC OILY STI

FLUOCINOLONE ACETONIDE

0.025% Ointment

02162512 SYNALAR MDC0.01% Scalp Lotion

00873292 DERMA-SMOOTHE HIL

FLUOCINONIDE

0.05% Cream

02161923 LIDEX MDC00716863 LYDERM OPT

0.05% Emollient Cream

02163152 LIDEMOL MDC00598933 TIAMOL TAR

0.05% Gel

02236997 LYDERM OPT02161974 TOPSYN HLR

0.05% Ointment

02161966 LIDEX HLR02236996 LYDERM OPT


0.05% Cream

02089912 CUTIVATE GSK

HALOBETASOL PROPIONATE

0.05% Cream

01962701 ULTRAVATE WSB

Page 118 of 1382014



AGENTS

HALOBETASOL PROPIONATE

0.05% Ointment

01962728 ULTRAVATE WSB

HYDROCORTISONE

0.5% Cream

80021088 CORTATE SPL00564281 HYDROSONE TCH

1% Cream

02086034 BARRIERE HC SHI00192597 EMO CORT STI00804533 PREVEX HC STI

2.5% Cream

00595799 EMO CORT STI100MG/60ML Enema

02112736 CORTENEMA AXC00230316 HYCORT VAE

0.5% Lotion

80021087 CORTATE SPL1% Lotion

00192600 EMO CORT STI00578541 SARNA HC STI

2.5% Lotion

00595802 EMO CORT STI00641154 EMO CORT SCALP STI00856711 SARNA HC STI

0.5% Ointment

80021085 CORTATE SPL00716685 CORTODERM TAR

1% Ointment

00716693 CORTODERM TAR

HYDROCORTISONE ACETATE

10% Aerosol Foam

00579335 CORTIFOAM SQU0.5% Cream

00716820 HYDERM TAR1% Cream

00716839 HYDERM TAR2% Cream

00749834 NEO-HC NEO1% Lotion

00681997 DERMAFLEX HC NEO

HYDROCORTISONE ACETATE, ZINC SULFATE

0.5% & 0.5% Ointment

02128446 ANODAN-HC ODN00505773 ANUSOL HC PFI02209764 EGOZINC-HC PMS00607789 RATIO-HEMCORT HC RPH02247691 SANDOZ-ANUZINC HC SDZ


AGENTS

HYDROCORTISONE ACETATE, ZINC SULFATE

10MG & 10MG Suppository

02236399 ANODAN-HC ODN00476285 ANUSOL HC PFI02210517 EGOZINC HC PMS00607797 RATIO-HEMCORT HC RPH02240112 RIVASOL-HC RIV02242798 SAB-ANUZINC HC SAB

HYDROCORTISONE ACETATE, ZINC SULFATE,

PRAMOXINE HCL

0.5% & 0.5% & 1% Ointment

00505781 ANUGESIC HC PFI02234466 PROCTODAN HC ODN

10MG & 10MG & 20MG Suppository

00476242 ANUGESIC HC PFI02240851 PROCTODAN HC ODN02242797 SAB-ANUZINC HC PLUS SAB

HYDROCORTISONE VALERATE

0.2% Cream

02242984 HYDROVAL TAR0.2% Ointment

02242985 HYDROVAL TAR

HYDROCORTISONE, DIBUCAINE HCL,

ESCULIN, FRAMYCETIN SULFATE

5MG & 5MG & 10MG & 10MG Ointment

02247322 PROCTOL ODN02223252 PROCTOSEDYL AXC02226383 RATIO-PROCTOSONE RPH02242527 SANDOZ-PROCTOMYXIN HC SDZ

5MG & 5MG & 10MG & 10MG Suppository

02247882 PROCTOL ODN02223260 PROCTOSEDYL AXC02226391 RATIO-PROCTOSONE RPH02242528 SAB-PROCTOMYXIN HC SAB

HYDROCORTISONE, UREA

1% Cream

00681989 DERMAFLEX HC NEB1% & 10% Cream

00503134 UREMOL HC STI1% & 10% Lotion

00560022 UREMOL HC STI

HYDROCORTISONE/ZINC

0.5% & 0.5% Ointment

02387239 JAMP ZINC-HC JAP

MOMETASONE FUROATE

0.1% Cream

00851744 ELOCOM SCH02367157 TARO-MOMETASONE TAR

Page 119 of 1382014



AGENTS

MOMETASONE FUROATE

0.1% Lotion

00871095 ELOCOM SCH02266385 TARO-MOMETASONE TAR

0.1% Ointment

00851736 ELOCOM SCH02244769 PMS-MOMETASONE PMS02270862 PMS-MOMETASONE PMS02248130 RATIO-MOMETASONE RPH02264749 TARO-MOMETASONE TAR


0.1% 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 HCL

2% Liquid

01968823 LIDODAN VISCOUS ODN00811874 PMS-LIDOCAINE VISCOUS PMS00001686 XYLOCAINE VISCOUS AZC

LIDOCAINE, PRILOCAINE

2.5% & 2.5% Cream

00886858 EMLA AZC2.5% & 2.5% Patch

02057794 EMLA AZC

84:16.00 SMMA - CELL STIMULANTS AND

PROLIFERANTS

TRETINOIN

0.01% Cream

00897329 RETIN A JAJ00657204 STIEVA-A STI01926497 VITAMIN A ACID SAC

0.025% Cream

00897310 RETIN A JAJ00578576 STIEVA-A STI01926500 VITAMIN A ACID SAC

0.05% Cream

00443794 RETIN A JAJ00518182 STIEVA-A STI

0.1% Cream

00870021 RETIN A JAJ00662348 STIEVA-A FORTE STI01926527 VITAMIN A ACID SAC

84:16.00 SMMA - CELL STIMULANTS AND

PROLIFERANTS

TRETINOIN

0.01% Gel

01926462 VITAMIN A ACID SAC0.025% Gel

00587966 STIEVA-A STI01926470 VITAMIN A ACID SAC

0.05% Gel

00641863 STIEVA-A STI01926489 VITAMIN A ACID SAC

0.025% Solution

00578568 STIEVA-A STI

84:24.12 BASIC OINTMENTS AND

PROTECTANTS

DIMETHICONE

20% Cream

02060841 BARRIERE WPC

PETROLATUM

67% Cream

00635189 PREVEX STI

ZINC OXIDE

15% Cream

02215799 ZINC HJS25% Ointment

00532576 IHLES PASTE RPH00886327 IHLES PASTE ATL

40% Ointment

02239160 ZINCOFAX EXTRA STRENGTH GSK

84:28.00 KERATOLYTIC AGENTS

ADAPALENE

0.1% Cream

02231592 DIFFERIN GAC0.1% Gel

02148749 DIFFERIN GAC

CANTHARIDIN, PODOPHYLLIN, SALICYLIC

ACID

1% & 2% & 30% Liquid

00772011 CANTHARONE PLUS DOR1% & 5% & 30% Liquid

00589500 CANTHACUR PS PMS

DITHRANOL

0.1% Cream

00537594 ANTHRANOL-1 MTI0.2% Cream

00537608 ANTHRANOL-2 MTI0.4% Lotion

00695351 ANTHRASCALP MTI1% Ointment

00566756 ANTHRAFORTE MTI

Page 120 of 1382014


84:28.00 KERATOLYTIC AGENTS

DITHRANOL

2% Ointment

00566748 ANTHRAFORTE MTI

FORMALDEHYDE, LACTIC ACID, SALICYLIC

ACID

10% & 5% & 25% Ointment

00513091 DUOPLANT STI

LACTIC ACID, SALICYLIC ACID

17% & 17% Liquid

00370576 DUOFILM STI

PODOFILOX

0.5% Solution

01945149 CONDYLINE CDX

PODOPHYLLIN

25% Liquid

00598208 PODOFILM PMS

SALICYLIC ACID

27% Gel

01939645 DUOFORTE 27 STI170MG/ML Gel

00614246 COMPOUND W GEL WHR20% Liquid

00690333 SOLUVER DER26% Liquid

00754951 OCCLUSAL HP GEN27% Liquid

00837733 SOLUVER PLUS DER40% Plaster

01974335 CLEAR AWAY SCH4% Shampoo

00666106 SEBCUR DER

84:32.00 KERATOPLASTIC AGENTS

COAL TAR

10% Gel

00344508 TARGEL ODN20% Liquid

00358495 ODANS LIQUOR CARBONIS DETERGENT

ODN

0.5% Shampoo

02240645 NEUTROGENA T/GEL JAJ1% Shampoo

00632295 TERSA-TAR MILD STI3% Shampoo

00632309 TERSA-TAR STI4.3% Shampoo

00740314 PENTRAX GEN

COAL TAR, JUNIPER TAR, PINE TAR

1% Shampoo

00249866 POLYTAR STI

84:32.00 KERATOPLASTIC AGENTS

COAL TAR, JUNIPER TAR, PINE TAR, ZINC

PYRITHIONE

0.166% & 0.166% & 0.166% & 1% Shampoo

00628042 MULTI-TAR PLUS MILD VAE *0.33% & 0.33% & 0.33% & 1% Shampoo

02240942 MULTITAR PLUS VAE

COAL TAR, SALICYLIC ACID

8% & 2% Gel

00560448 P&S PLUS BAK *10% & 3% Liquid

00510335 TARGEL SA ODN10% & 4% Shampoo

00666114 SEBCUR-T DER

COAL TAR, SALICYLIC ACID, SULFUR

2% & 2% & 2% Shampoo

00444448 STEREX IDE

84:50.06 PIGMENTING AGENTS

METHOXSALEN

10MG Capsule

00252654 OXSORALEN VAE01946374 OXSORALEN VAE

1% Lotion

01907476 OXSORALEN VAE

84:92.00 MISCELLANEOUS SKIN AND

MUCOUS MEMBRANE AGENTS

ACITRETIN

Open benefit (prior approval not required).

Soriatane 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 Capsule

02070847 SORIATANE HLR25MG Capsule

02070863 SORIATANE HLR

AZELAIC ACID

15% Gel

02270811 FINACEA BAY

BETAMETHASONE, CALCIPOTRIOL

0.5MG & 50MCG Ointment

02244126 DOVOBET LEO

CALCIPOTRIOL

50MCG/G Cream

02150956 DOVONEX LEO50MCG/G Ointment

01976133 DOVONEX LEO50MCG/ML Solution

02194341 DOVONEX LEO

Page 121 of 1382014




CAPSAICIN

0.025% Cream

02157101 CAPSAICIN VAO02244952 ZODERM EUO00740306 ZOSTRIX GEN

0.075% Ointment

02157128 CAPSAICIN HP VAO

COLLAGENASE

250U Ointment

02063670 SANTYL KNO

FLUOROURACIL

5% Cream

00330582 EFUDEX VAE

IMIQUIMOD


-For the treatment of condylomata acuminate (genital warts) in patients who have failed:-self-applied podophyllotoxin (podofilox 0.5% solution); OR-provider-applied podophyllum resin (10%-25%)

50MG/G Cream

02239505 ALDARA VAE

ISOTRETINOIN


Accutane 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 Capsule

00582344 ACCUTANE HLR02257955 CLARUS PRE

40MG Capsule

00582352 ACCUTANE HLR02257963 CLARUS PRE

PIMECROLIMUS


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)



Note: Contraindicated in children less than 2 years of age.0.03% Ointment

02244149 PROTOPIC AST



TACROLIMUS (PROTOPIC)



Note: Contraindicated in children less than 2 years of age.0.1% Ointment

02244148 PROTOPIC AST

TAZAROTENE

0.05% Gel

02230784 TAZORAC ALL0.1% Gel

02230785 TAZORAC ALL

VITAMIN E

30IU Ointment

01910787 VITAMIN E JLF

Page 122 of 1382014


86:00 SMOOTH MUSCLE RELAXANTS

86:12.00 GENITOURINARY SMOOTH

MUSCLE RELAXANTS

DARIFENACIN HYDROBROMIDE


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.

7.5MG Extended Release TabletST

02273217 ENABLEX MRL15MG Extended Release Tablet

ST

02273225 ENABLEX MRL

FLAVOXATE HCL

200MG TabletST

00728179 URISPAS PAL

OXYBUTYNIN CHLORIDE

1MG/ML SyrupST

02231089 APO-OXYBUTYNIN APX02223376 PMS-OXYBUTYNIN PMS

2.5MG TabletST

02240549 PMS-OXYBUTYNIN PMS5MG Tablet

ST

02163543 APO-OXYBUTYNIN APX02241285 DOM-OXYBUTYNIN DPC02230800 GEN-OXYBUTYNIN GEN02230394 NOVO-OXYBUTYNIN TEV02220059 OXYBUTYNIN VAE02350238 OXYBUTYNIN SAN02220636 OXYBUTYNINE PDL02240550 PMS-OXYBUTYNIN PMS02299364 RIVA-OXYBUTYNIN RIV

TOLTERODINE




02244612 DETROL LA PFI4MG Extended Release Capsule

ST

02244613 DETROL LA PFI1MG Tablet

ST

02239064 DETROL PFI2MG Tablet

ST

02239065 DETROL PFI

86:12.00 GENITOURINARY SMOOTH

MUSCLE RELAXANTS

TROSPIUM CHLORIDE


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.

20MG TabletST

02275066 TROSEC ORY

86:12.04 ANTIMUSCARINICS

SOLIFENACIN SUCCINATE


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 Tablet

ST

02277271 VESICARE AST

86:16.00 RESPIRATORY SMOOTH

MUSCLE RELAXANTS

OXTRIPHYLLINE

20MG/ML Elixir

00476366 CHOLEDYL PFI100MG Tablet

00441724 APO-OXTRIPHYLLINE APX200MG Tablet

00441732 APO-OXTRIPHYLLINE APX300MG Tablet

00511692 APO-OXTRIPHYLLINE APX

THEOPHYLLINE

5.33MG/ML Elixir

00575151 PMS-THEOPHYLLINE PMS00466409 PULMOPHYLLIN RIV00627410 THEOPHYLLINE ATL

5.33MG/ML Solution

01966219 THEOLAIR MMH100MG Sustained Release Tablet

00692689 APO-THEO APX02230085 NOVO-THEOPHYL SR TEV


00692697 APO-THEO LA APX02230086 NOVO-THEOPHYL SR TEV


00692700 APO-THEO LA APX02230087 NOVO-THEOPHYL SR TEV


02360101 THEO ER AAP02014165 UNIPHYL PFR

Page 123 of 1382014


86:16.00 RESPIRATORY SMOOTH

MUSCLE RELAXANTS

THEOPHYLLINE


02360128 THEO ER AAP02014181 UNIPHYL PFR

Page 124 of 1382014


88:00 VITAMINS

88:04.00 VITAMIN A

VITAMIN A

10,000IU CapsuleST

00557447 VIT A VTH *00297720 VITAMIN A JAM

25,000IU CapsuleST

00021067 VITAMIN A TEV50,000IU Capsule

ST

00021075 VITAMIN A TEV

88:08.00 VITAMIN B COMPLEX

CYANOCOBALAMIN

100MCG/ML Injection

00497533 VITAMIN B12 ABB02241500 VITAMIN B12 SDZ

1,000MCG/ML Injection

01987003 CYANOCOBALAMIN CYX02052717 CYANOCOBALAMIN TAR00521515 VIT B12 SDZ00038830 VITAMIN B12 ABB

250MCG TabletST

00335940 VITAMIN B12 JAM1000MCG Tablet

ST

80028902 JAMP-VITAMIN B12 JAP02237736 VITAMIN B12 SWS80003575 VITAMIN B12 PMT

CYANOCOBALAMINE

0.2MG/ML Oral Liquid

80026092 JAMP-VITAMINE JAP100MCG Tablet

ST

80015265 JAMP-VITAMINE JAP250MCG Tablet

ST

80015294 JAMP-VITAMINE JAP

FOLIC ACID

1MG TabletST

00318973 FOLIC ACID JAM00647039 FOLIC ACID VTH02048841 FOLIC ACID PMT02236747 FOLIC ACID PED

5MG TabletST

00426849 APO-FOLIC ACID APX02285673 EURO-FOLIC EUR02366061 JAMP FOLIC ACID JAP

NIACIN

50MG TabletST

00041084 NIACIN PMS100MG Tablet

ST

00268585 NIACIN VAE


NIACIN

500MG TabletST

00294950 NIACIN VAE01939130 NIACIN ODN02247004 NIACIN PMT00557412 NIACIN YEAST FREE VTH00309737 VITAMIN B3 JAM

PYRIDOXINE HCL

25MG TabletST

00122645 VITAMIN B6 JAM00232475 VITAMIN B6 PMS01943200 VITAMIN B6 ODN

50MG TabletST

00252689 VITAMIN B6 VAE00305227 VITAMIN B6 JAM00608599 VITAMIN B6 PMS *

100MG TabletST

00263958 VITAMIN B6 VAE00329185 VITAMIN B6 JAM00450677 VITAMIN B6 VTH *02239348 VITAMIN B6 PMT

THIAMINE HCL

100MG/ML Injection

02241983 BETAXIN ABB02243525 THIAMINE CYX00816078 VITAMIN B1 SIL

50MG TabletST

00268631 VITAMIN B1 VAE100MG Tablet

ST

00232467 VITAMIN B1 PMS *00294853 VITAMIN B1 VAE00407011 VITAMIN B1 JAM02239350 VITAMIN B1 PMT

88:12.00 VITAMIN C

ASCORBIC ACID


00266051 VITAMIN C PMT500MG Chewable Tablet

ST

00274240 VITAMIN C PED00322997 VITAMIN C LAL *00784591 VITAMIN C VTH *02243893 VITAMIN C PMT02245721 VITAMIN C PMT


00760587 VITAMIN C PMT250MG Tablet

ST

00221244 VIT C ADA00557811 VIT C VTH *00162515 VITAMIN C PMT

Page 125 of 1382014


88:12.00 VITAMIN C

ASCORBIC ACID

500MG TabletST

00266086 ASCORBIC ACID PMT00041114 VIT C ADA00322326 VIT C LAL00036188 VITAMIN C PED00557838 VITAMIN C VTH *01922378 VITAMIN C SWS02163268 VITAMIN C JAM02244469 VITAMIN C PMT

1000MG TabletST

00354376 VITAMIN C PMT

88:16.00 VITAMIN D

ALFACALCIDOL

0.25MCG CapsuleST

00474517 ONE-ALPHA LEO1MCG Capsule

ST

00474525 ONE-ALPHA LEO2MCG/ML Oral Liquid

ST

02240329 ONE-ALPHA LEO

CALCITRIOL

0.25MCG CapsuleST

00481823 ROCALTROL HLR0.5MCG Capsule

ST

00481815 ROCALTROL HLR

CHOLECALCIFEROL

400IU CapsuleST

02242651 EURO D EUR10,000IU Capsule

ST

02253178 EURO D EUR02371499 PHARMA-D PMS

50,000IU CapsuleST

02301911 OSTOFORTE TPH400IU/ML Drop

ST

00762881 D VI SOL MJO02231624 PEDIAVIT D EUR

400IU TabletST

00765384 VITAMIN D LAL02238729 VITAMIN D VTH02240624 VITAMIN D WAM02240858 VITAMIN D PMT

1,000IU TabletST

02245842 VITAMIN D PMT10,000IU Tablet

ST

00821772 D-TABS RIV10,000UI Tablet

ST

02379007 JAMP-VITAMINE D JAP

ERGOCALCIFEROL

50,000IU CapsuleST

02237450 D-FORTE EUR

88:16.00 VITAMIN D

ERGOCALCIFEROL

8,288IU/ML SolutionST

02017598 DRISDOL SAC

VITAMIN D

400IU Capsule

80006629 D-GEL JAP80001145 PHARMA D PED80005560 RIVA-D RIV80008590 VITAMIN D BMI

800IU Capsule

80007769 D-GEL JAP80003010 EURO D EUR80008446 VITAMIN D BMI

1,000 IU CapsuleST

80007766 D-GEL JAP1000IU Capsule

ST

80008496 PHARMA-D PMS400IU Liquid

ST

80019649 D3-DOL JAP400IU/ML Liquid

80003038 VITAMIN D JAP400U/ML Liquid

ST

80038155 DECAXIL ORM8,288 IU/M Liquid

ST

80020776 D2-DOL JAP400IU Tablet

80002452 VITAMIN D WNP80009578 VITAMIN D SWS

1000IU Tablet

80000436 VITAMIN D JAM80002169 VITAMIN D PMS80003663 VITAMIN D WNP80009580 VITAMIN D SWS

88:20.00 VITAMIN E

VITAMIN E

200IU CapsuleST

00122831 VITAMIN E JAM400IU Capsule

ST

00122858 VITAMIN E JAM50IU/ML Liquid

ST

02162075 AQUASOL E NVC

88:28.00 MULTIVITAMIN PREPARATIONS

MULTIVATAMINS (PRENATAL)

Tablet

80001842 CENTRUM MATERNA WYA

Page 126 of 1382014



MULTIVITAMINS (PEDIATRIC)


Pediatric multivitamins are benefits for children up to 6 years of age.

DropST

00762946 POLY-VI-SOL MJOLiquid

ST

00558079 INFANTOL HORTablet

ST

80020794 CENTRUM JUNIOR COMPLETE TB

PFI

80011134 CENTRUM JUNIOR COMPLETE TAB

WYE

02247975 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

02229535 MULTI-PRE AND POST NATAL PED80005770 PRENATAL & POSTPARTUM PMT02241235 PRENATAL AND POSTPARTUM SDR

VITAMIN A, CHOLECALCIFEROL, ASCORBIC

ACID

2,500IU & 666.67IU & 50MG/ML DropST

02229790 PEDIAVIT EUR00762903 TR- VI-SOL MJO

88:32.00

MAGNESIUM OXIDE

100MG TabletST

02068400 MAGNESIUM JAM

Page 127 of 1382014


92:00 UNCLASSIFIED THERAPEUTIC

AGENTS

92:00.00 UNCLASSIFIED THERAPEUTIC

AGENTS

EXTEMPORANEOUS MIXTURE

Miscellaneous

00999997 EXTEMPORANEOUS MIXTURE (ATL)

*

00990019 EXTEMPORANEOUS MIXTURE (BC) (SK)

*

00999994 EXTEMPORANEOUS MIXTURE (ON)

*

00999999 EXTEMPORANEOUS MIXTURE (QC) (AB)

*

PENTOSAN POLYSULFATE SODIUM

100MG Capsule

02029448 ELMIRON JNO

SEVELAMER HYDROCHLORIDE

Limited 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 Tablet

02244310 RENAGEL GEE *

USTEKINUMAB


For the treatment of moderate to severe psoriasis according to established criteria.



02320673 STELARA JNO90MG/ML Injection

02320681 STELARA JNO

WATER

100% Injection

99002264 STERILE WATER AUT *00905178 WATER FOR INJECTION UNK *00038202 WATER STERILE ABB *

92:01.00 NATURAL HEALTH PRODUCTS

SENNOSIDES

8.6MG Tablet

80009182 JAMP-SENNOSIDES JAP12MG Tablet

80009183 JAMP-SENNOSIDES JAP

92:01.40

CALCIUM CARBONATE

500MG Tablet

80001122 PHARMA-CAL PED

92:01.88

ANHYDROUS MAGNESIUM CITRATE

50MG/ML Solution

80001809 CITRODAN ODN

ERGOCALCIFEROL

8,288IU/ML Solution

80003615 ERDOL ODN

MAGNESIUM

25MG Oral Liquid

80009357 JAMP-MAGNESIUM JAP100MG/ML Oral Liquid

80004109 MAGNESIUM-ODAN ODN28MG Tablet

80009539 JAMP-MAGNESIUM GLUCONATE

JAP

MULTIVITAMINS (PEDIATRIC)



Liquid

80008471 JAMP-MULTIVITAMIN A/D/ C DROPS

JAP

POTASSIUM CHLORIDE

20MMOL Long Acting Tablet

80004415 ODAN K-20 ODN8MEQ Tablet

80008214 ODAN K-8 ODN

PYRIDOXINE HCL

25MG Tablet

80002890 VITAMIN B6 JAP

SODIUM PHOSPHATE

Oral Liquid

80000689 PHOSLAX ODN

THIAMINE

50MG Tablet

02245506 EURO-B1 EUR80009633 JAMP-VITAMIN B1 JAP

100MG Tablet

80009588 JAMP-VITAMIN B1 JAP

Page 128 of 1382014


92:08.00

DUTASTERIDE


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 Capsule

02247813 AVODART GSK

FINASTERIDE


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 Tablet

02365383 APO-FINASTERIDE APX02354462 CO FINASTERIDE ACT02376709 DOM-FINASTERIDE DOM02350270 FINASTERIDE PDL02357224 JAMP-FINASTERIDE JAP02389878 MINT-FINASTERIDE MIN02356058 MYLAN-FINASTERIDE MYL02310112 PMS-FINASTERIDE PMS02010909 PROSCAR FRS02371820 RAN-FINASTERIDE RBY02306905 RATIO-FINASTERIDE TEP02322579 SANDOZ FINASTERIDE SDZ02348500 TEVA-FINASTERIDE TEP

92:12.00

LEUCOVORIN CALCIUM

5MG Tablet

02170493 LEUCOVORIN CALCIUM WAY

92:16.00

ALLOPURINOL

100MG TabletST

00449687 ALLOPRIN VAE00555681 ALLOPURINOL PDL02402769 APO-ALLOPURINOL APX02396327 MAR-ALLOPURINOL MAR00402818 ZYLOPRIM AAP

200MG TabletST

00514209 ALLOPRIN VAE02130157 ALLOPURINOL PDL02402777 APO-ALLOPURINOL APX02396335 MAR-ALLOPURINOL MAR00479799 ZYLOPRIM AAP

92:16.00

ALLOPURINOL

300MG TabletST

00454354 ALLOPRIN VAE00294322 ALLOPURINOL APX00555703 ALLOPURINOL PDL02402785 APO-ALLOPURINOL APX02396343 MAR-ALLOPURINOL MAR00402796 ZYLOPRIM AAP

COLCHICINE

0.6MG Tablet

00572349 COLCHICINE ODN02373823 JAMP-COLCHICINE JAP02402181 PMS-COLCHICINE PMS

1MG Tablet

00621374 COLCHICINE ODN

FEBUXOSTAT

Limited use benefit (prior approval required).For patients with symptomatic gout who have documented hypersensitivity to allopurinol

80MG Tablet

02357380 ULORIC TAK

92:24.00

ALENDRONATE SODIUM


For the treatment of:

a. - Paget's Disease ORb. - Osteoporosis in patients who are 60 years of age or over ORc. - Osteoporosis in patients under 60 who have documented hip, vertebral or other fractures ORd. - Osteoporosis in patients under 60 with no evidence of fracture but who have a high (>20%) 10-year fracture risk ORe. - Osteoporosis or risk of osteoporosis in patients under 60 who have been, or who will be, on systemic corticosteroid therapy equivalent to a dose of prednisone ≥ 7.5mg per day for ≥3 months.

5MG TabletST

02248727 APO-ALENDRONATE APX02248251 NOVO-ALENDRONATE TEV02384698 RAN-ALENDRONATE RBY02288079 SANDOZ ALENDRONATE SDZ

10MG TabletST

02248728 APO-ALENDRONATE APX02388545 AURO-ALENDRONATE AUR02270129 GEN-ALENDRONATE GEN02394863 MINT-ALENDRONATE MIN02247373 NOVO-ALENDRONATE TEV02288087 SANDOZ ALENDRONATE SDZ

40MG TabletST

02258102 CO-ALENDRONATE ACT

Page 129 of 1382014


92:24.00

ALENDRONATE SODIUM




70MG TabletST

02352966 ALENDRONATE SAN02303078 ALENDRONATE-70 PDL02299712 ALENDRONATE-FC SIV02248730 APO-ALENDRONATE APX02388553 AURO-ALENDRONATE AUR02258110 CO-ALENDRONATE ACT02282763 DOM-ALENDRONATE DOM02245329 FOSAMAX FRS02286335 GEN-ALENDRONATE GEN02385031 JAMP-ALENDRONATE JAP02394871 MINT-ALENDRONATE MIN02261715 NOVO-ALENDRONATE TEV02273179 PMS-ALENDRONATE PMS02284006 PMS-ALENDRONATE FC PMS02275279 RATIO-ALENDRONATE RPH02270889 RIVA-ALENDRONATE RIV02288109 SANDOZ ALENDRONATE SDZ02302004 ZYM-ALENDRONATE FC SOR

ALENDRONATE SODIUM, VITAMIN D3




70MG & 2800U TabletST

02276429 FOSAVANCE FRS02403633 TEVA-ALENDRONATE

CHOLECALCIFEROLTEP

70MG & 5600U TabletST

02314940 FOSAVANCE FRS02403641 TEVA-ALENDRONATE

CHOLECALCIFEROLTEP

92:24.00

DENOSUMAB (P)

Limited use benefit (prior approval required).For women with postmenopausal osteoporosis who would otherwise be eligible for coverage of oral bisphosphonates, but for whom:- bisphosphonates are contraindicated due to hypersensitivity or abnormalities of the esophagus (e.g., esophageal stricture or achalasia); ANDHave at least two of the following:- age >70 years- a prior fragility fracture- a bone mineral density (BMD) T-score ≤ -2.5

60MG/ML Injection (Pre-filled Syringe)

02343541 PROLIA AMG

ETIDRONATE DISODIUM

200MG Tablet

02248686 CO-ETIDRONATE ACT02245330 GEN-ETIDRONATE GEN

ETIDRONATE DISODIUM, CALCIUM

CARBONATE


02263866 CO-ETIDROCAL ACT02176017 DIDROCAL PGP02353210 ETIDROCAL SAN02247323 MYLAN-ETI-CAL CAREPAC GEN02324199 NOVO-ETIDROCAL TEV

PAMIDRONATE DISODIUM

30MG Injection

02059762 AREDIA IV NVR02244550 PAMIDRONATE DISODIUM MAY02264951 RHOXAL-PAMIDRONATE RHO

60MG Injection

02244551 PAMIDRONATE DISODIUM HOS02264978 RHOXAL-PAMIDRONATE SDZ

90MG Injection

02059789 AREDIA IV NVR02244552 PAMIDRONATE DISODIUM MAY02245999 PMS-PAMIDRONATE PMS02264986 RHOXAL-PAMIDRONATE SDZ

RISEDRONATE SODIUM



a. - Osteoporosis in patients who are 60 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 Tablet

02298376 TEVA-RISEDRONATE TEP

Page 130 of 1382014


92:24.00

RISEDRONATE SODIUM




5MG Tablet

02242518 ACTONEL PGP30MG Tablet

02239146 ACTONEL PGP02298384 TEVA-RISEDRONATE TEP

35MG Tablet

02246896 ACTONEL PGP02353687 APO-RISEDRONATE APX02309831 DOM-RISEDRONATE DOM02368552 JAMP-RISEDRONATE JAP02357984 MYLAN-RISEDRONATE MYL02302209 PMS-RISEDRONATE PMS02347474 RISEDRONATE PDL02352141 RISEDRONATE SIV02370255 RISEDRONATE SAN02411407 RISEDRONATE-35 SIV02341077 RIVA-RISEDRONATE RIV02327295 SANDOZ RISEDRONATE SDZ02298392 TEVA-RISEDRONATE TEP

ZOLEDRONIC ACID


• For the treatment of Paget‟s disease. Coverage will be granted for one dose per 12 month period. OR.

• For women with postmenopausal osteoporosis who would otherwise be eligible for coverage of oral bisphosphonates*, but who have a contraindication to bisphosphonates due to hypersensitivity or abnormalities of the esophagus (e.g, esophageal stricture or achalasia); ANDwho have at least two of the following: • age >70 years • a prior fragility fracture • a bone mineral density (BMD) T-score ≤ - 2.5. • a bone mineral density (BMD) T-score ≤ -2.5.

5MG/100ML Injection

02269198 ACLASTA NOV

92:36.00 DISEASE-MODIFYING

ANTIRHEUMATIC AGENTS

ABATACEPT


For the treatment of:• Rheumatoid Arthritis according to established criteria. • Juvenile Idiopathic Arthritis

(Please refer to Appendix A).250MG/VIAL Injection

02282097 ORENCIA 250MG/VIAL INJ BMS

ADALIMUMAB


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. • Juvenile idiopathic arthritis according to established criteria.(Please refer to Appendix A).

40MG/Vial Injection

02258595 HUMIRA ABB

CERTOLIZUMAB PEGOL


For the treatment of:• Rheumatoid Arthritis according to established criteria.


200MG/ML Injection

02331675 CIMZIA UCB

ETANERCEPT


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 IMX

GOLIMUMAB


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).


02324784 SIMPONI KEG02324776 SIMPONI PRE-FILLED KEG

Page 131 of 1382014


92:36.00 DISEASE-MODIFYING

ANTIRHEUMATIC AGENTS

INFLIXIMAB


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 Injection

02244016 REMICADE CER

LEFLUNOMIDE

10MG Tablet

02256495 APO-LEFLUNOMIDE APX02241888 ARAVA SAC02351668 LEFLUNOMIDE SAN02319225 MYLAN-LEFLUNOMIDE MYL02288265 PMS-LEFLUNOMIDE PMS02283964 SANDOZ LEFLUNOMIDE SDZ02261251 TEVA-LEFLUNOMIDE TEV

20MG Tablet

02256509 APO-LEFLUNOMIDE APX02241889 ARAVA SAC02351676 LEFLUNOMIDE SAN02319233 MYLAN-LEFLUNOMIDE MYL02288273 PMS-LEFLUNOMIDE PMS02283972 SANDOZ LEFLUNOMIDE SDZ02261278 TEVA-LEFLUNOMIDE TEV

TOCILIZUMAB

Limited use benefit (prior approval required).For the treatment of adult patients with moderate to severely active rheumatoid arthritis who have failed to respond to an adequate trial of an anti-TNF agent.(Please refer to Appendix A).

80MG/4ML Injection

02350092 ACTEMRA HLR200MG/10ML Injection

02350106 ACTEMRA HLR400MG/20ML Injection

02350114 ACTEMRA HLR

92:44.00

AZATHIOPRINE

50MG Tablet

02242907 APO-AZATHIOPRINE APX02243371 AZATHIOPRINE PDL02343002 AZATHIOPRINE SAN00004596 IMURAN GSK

92:44.00

CYCLOSPORINE


For transplant therapy.10MG Capsule

02237671 NEORAL NVR25MG Capsule

02150689 NEORAL NVR02247073 SANDOZ-CYCLOSPORINE SDZ

50MG Capsule


100MG Capsule


100MG/ML Solution

02150697 NEORAL NVR

MYCOPHENOLATE MOFETIL


For transplant therapy.250MG Capsule

02352559 APO-MYCOPHENOLATE APX02192748 CELLCEPT HLR02386399 JAMP-MYCOPHENOLATE JAP02371154 MYLAN-MYCOPHENOLATE MYL02320630 SANDOZ MYCOPHENOLATE SDZ02364883 TEVA-MYCOPHENOLATE TEP

500MG Tablet

02352567 APO-MYCOPHENOLATE APX02237484 CELLCEPT HLR02379996 CO MYCOPHENOLATE ACT02380382 JAMP-MYCOPHENOLATE JAP02370549 MYLAN-MYCOPHENOLATE MYL02313855 SANDOZ MYCOPHENOLATE SDZ02348675 TEVA-MYCOPHENOLATE TEP

MYCOPHENOLATE SODIUM


For transplant therapy.180MG Enteric Coated Tablet

02264560 MYFORTIC NVR360MG Enteric Coated Tablet

02264579 MYFORTIC NVR

SIROLIMUS


Coverage will be provided as a second line therapy for patients failing mycophenolate mofetil.

1MG/ML Oral Liquid

02243237 RAPAMUNE WAY1MG Tablet

02247111 RAPAMUNE WAY

Page 132 of 1382014


92:44.00

TACROLIMUS


For transplant therapy.0.5MG Capsule

02243144 PROGRAF AST1MG Capsule

02175991 PROGRAF AST5MG Capsule

02175983 PROGRAF AST0.5MG Extended Release Capsule

02296462 ADVAGRAF AST1MG Extended Release Capsule



02296489 ADVAGRAF AST5MG/ML Injection

02176009 PROGRAF AST

92:92.00

BOTULINUM 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)

50U Injection

09857386 BOTOX ALL100U Injection

01981501 BOTOX ALL200U Injection

09857387 BOTOX ALL

CYPROTERONE ACETATE, ETHINYL

ESTRADIOL

2MG & 35MCG Tablet

02290308 CYESTRA-35 PMS02233542 DIANE-35 BAY02309556 NOVO-

CYPROTERONE/ETHINYL ESTRADIOL

TEV

INCOBOTULINUMTOXINA


-Treatment of strabismus and blepharospasm associated with dystonia, including benign essential blepharospasm or VII nerve disorder in patients 12 years of age or older-Treatment of cervical dystonia (spasmodic torticollis)

100U/VIAL Injection

02324032 XEOMIN MEZ

Page 133 of 1382014


94:00 DEVICES

94:00.00 DEVICES

NEEDLE (NON-INSULIN)

Needle

99400528 NEEDLES (NON-INSULIN) DISPOSABLE

SPACER DEVICE


Coverage is granted for 1 spacer device every 12 months.Device

96899962 AEROCHAMBER AC BOYZ TRU96899963 AEROCHAMBER AC GIRLZ TRU96899969 AEROCHAMBER PLUS FLOW-

VU LGTRU

96899970 AEROCHAMBER PLUS FLOW-VU MED

TRU

96899968 AEROCHAMBER PLUS FLOW-VU MOUTH

TRU

96899971 AEROCHAMBER PLUS FLOW-VU SM

TRU

99400507 E-Z SPACER WEP99400511 E-Z SPACER (MASK ONLY) WEP99400508 E-Z SPACER WITH SMALL

MASKWEP

99400501 OPTICHAMBER AUC96899961 OPTICHAMBER DIAMOND

(CHAMBER)AUC

96899958 OPTICHAMBER DIAMOND (LARGE M)

AUC

96899959 OPTICHAMBER DIAMOND (MEDIUM M)

AUC

96899960 OPTICHAMBER DIAMOND (MEDIUM M)

AUC

99400504 OPTICHAMBER LARGE MASK AUC99400503 OPTICHAMBER MEDIUM MASK AUC99400502 OPTICHAMBER SMALL MASK AUC99400505 OPTIHALER AUC99400787 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

SYRINGE & NEEDLE (NON-INSULIN)

Syringe & Needle

99400534 NON-INSULIN 1CC99400536 NON-INSULIN 3CC99400537 NON-INSULIN 5CC99400538 NON-INSULIN 10CC

94:00.00 DEVICES

SYRINGE (NON-INSULIN)

Syringe

99400823 LUER LOCK (DISP) 30CC BTD99400549 LUER LOCK (DISP) 60CC99400529 NON-INSULIN (DISP) 1CC99400531 NON-INSULIN (DISP) 3CC99400532 NON-INSULIN (DISP) 5CC99400533 NON-INSULIN (DISP) 10CC

94:01.00 DEVICES (DIABETIC)

INSULIN PUMP SUPPLIES

Device

99401049 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 ALCOHOL

00809357 ALCOHOL SWABS BD BTD70% Swab

00480452 ALCOHOL PREP SWAB PFD02247809 ALCOHOL SWAB TIP02240759 B-D ALCOHOL SWAB BTD99438102 MONOJECT ALCOHOL WIPES SHM00795232 WEBCOL ALCOHOL PREP JAJ

Page 134 of 1382014



LANCET

Lancet

97799817 ACCU-CHEK MULTICLIX ROD99401068 BD LATITUDE BTD97799466 BG STAR SAC97799541 EZ HEALTH ORACLE TRE00900834 FINGERSTIX BAY00995965 FINGERSTIX BAY00977839 FREESTYLE THS *99401063 FREESTYLE THS97799766 ITEST LANCETS 28G (100) AUC97799767 ITEST LANCETS 33G (100) AUC00901555 LIFESCAN REGULAR JAJ97799388 MEDI+SURE SOFT 30G TWIST MEC97799389 MEDI+SURE SOFT 33G TWIST MEC00906190 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) MPD97799431 ONE TOUCH DELICA 30G JAJ00965561 ONE TOUCH DELICA 33G JAJ00901359 ONE TOUCH ULTRA SOFT JAJ97799501 ONETOUCH DELICA 33G JAJ00905917 SOFT TOUCH ROD00000165 SOFTCLIX BOE97799945 SOFTCLIX ROC00902144 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

MAGNIFIER

Magnifier

99400550 SYRINGE SCALE MAGNIFIER

NEEDLE

Needle

97799526 BD AUTOSHIELD PEN NEEDLE BTD00908452 B-D PEN BTD00977756 NOVOFINE NOO

29G X 12MM Needle

97799566 INSUPEN 29GX12MM NEEDLE DPI30G X 8MM Needle



97799568 INSUPEN 31GX8MM NEEDLE DPI


NEEDLE

32G X 4MM Needle

97799527 BD ULTRA-FINE NANO PEN NEEDLE

BTD

32G X 6MM Needle


97799570 INSUPEN 32GX8MM NEEDLE DPI22G Needle

00977616 B-D DISPOSABLE 1 INCH 5155 BTD00977624 B-D DISPOSABLE 1½ INCH

5156BTD

25G Needle

00977071 B-D DISPOSABLE 5/8 INCH 5122

BTD

00977063 B-D DISPOSABLE 1½ INCH 5127

BTD

27G Needle

00977012 B-D DISPOSABLE ½ INCH 5109 BTD28G Needle

99221028 NOVOFINE INSULIN PEN 28G NOO29G Needle

00977101 B-D ULTRA-FINE PEN BTD00900513 OWEN MUMFORD UNIFINE

PENTIPS 1/2 INCHAUC

00908185 ULTRAFINE PEN ULTRA-FINE 29G

BTD

29G X 12.7MM Needle

97799561 SUPER-FINE STANDARD 29G-12.7MM

PMS

29G X 12MM Needle

97799543 ULTI 29GX1/2 INC SHARP CONTAIN

UMI

30G Needle

00921114 NOVOFINE NOO00908169 NOVOFINE 30G NOO99117796 NOVOFINE INSULIN PEN 30G NOO97799467 NOVOTWIST TIP NEEDLE 30G NOO

31G Needle

00909114 BD ULTRA-FINE III PEN NEEDLES

BTD

00977011 B-D ULTRA-FINE PEN III BTD00900511 OWEN MUMFORD UNIFINE

PENTIPS 1/4 INCHAUC

00900512 OWEN MUMFORD UNIFINE PENTIPS 5/16 INCH

AUC

31G X 4.5MM Needle

97799404 CLICKFINE PEN NEEDLE 31G 4.5MM

AUC

31G X 5MM Needle

97799563 SUPER-FINE MICRO 31G-5MM NEEDL

PMS

Page 135 of 1382014



NEEDLE

31G X 6MM Needle

97799405 CLICKFINE PEN NEEDLE 31G 6MM

AUC

97799545 ULTI 31GX1/4 INC SHARP CONTAIN

UMI

31G X 8MM Needle

97799406 CLICKFINE PEN NEEDLE 31G 8MM

AUC

97799441 LIFE BRAND PEN NEEDLE 31G 8MM

HOD

97799562 SUPER-FINE XTRA 31G-8MM NEEDLE

PMS

97799544 ULTI 31GX5/16 INC SHARP CONTAI

UMI

32G Needle

97799821 NOVOFINE 32G 6MM NOO97799468 NOVOTWIST TIP NEEDLE 32G NOO

32G X 4MM Needle

97799440 ULTICARE PEN NEEDLE 32GX4MM

DPI

SHARPS CONTAINER

Device

99401026 B-D SHARPS CONTAINER 1.4L BTD99401027 B-D SHARPS CONTAINER 3.1L BTD

SYRINGE

Syringe

97799510 ULTICARE LOW DEAD SPACE SYG

UMI

0.3CC Syringe

00977961 B-D MICRO-FINE BTD00977977 B-D ULTRA-FINE / ULTRA-FINE

IIBTD

00977951 MONOJECT SHM99254011 MONOJECT DISP 3/10CC (100) SHM99253047 MONOJECT DISP 3/10CC (30) SHM00920053 SYRN MONOJECT SHM00900506 ULTICARE 29G AUC00964018 ULTICARE 29G AUC00900503 ULTICARE 30G AUC00964174 ULTICARE 30G AUC00920193 ULTRA-FINE BTD

0.5CC Syringe

00977985 B-D ULTRA-FINE II BTD00920177 MICRO-FINE BTD00920355 MONOJECT SHM99432799 MONOJECT (100) SHM99432633 MONOJECT (30) SHM00900505 ULTICARE 29G AUC00963941 ULTICARE 29G AUC00900502 ULTICARE 30G AUC00964115 ULTICARE 30G AUC00920207 ULTRA-FINE BTD


SYRINGE

1CC Syringe

99328369 B-D ULTRA-FINE BTD00920045 MONOJECT SHM *99433383 MONOJECT (100) SHM99432914 MONOJECT (30) SHM00900504 ULTICARE 29G AUC00963895 ULTICARE 29G AUC00900501 ULTICARE 30G AUC00964069 ULTICARE 30G AUC00920215 ULTRA-FINE BTD00909238 ULTRA-FINE II 30G BTD

28GX0.5CC Syringe

97799518 ULTICARE 0.5CC 28G SYG 1/2 INC

UMI

28GX1CC Syringe

97799517 ULTICARE 1CC 28G SYG 1/2 INCH

UMI

29GX0.3CC Syringe

97799509 ULTI SYG WITH ULTIG 29G 1/2 IN

UMI

29GX0.5CC Syringe


UMI

29GX1CC Syringe


UMI

97799997 ULTICARE INSULIN SYR 29G 1CC

AUC

97799906 ULTIGUARD INSULIN SYR 29G.1CC

AUC

29GX3CC Syringe

97799999 ULTICARE INSULIN SYR 29G.3CC

AUC


AUC

29GX5CC Syringe


AUC


AUC

30GX0.3CC Syringe


UMI

97799506 ULTI SYG WITH ULTIG 30G 5/16 I

UMI

30GX0.5CC Syringe


UMI


UMI

Page 136 of 1382014



SYRINGE

30GX1CC Syringe


UMI


UMI


AUC


AUC

30GX3CC Syringe


AUC


AUC

30GX5CC Syringe

97799995 ULTICARE INSULIN SYR30G.5CC

AUC


AUC

31GX0.3CC Syringe


UMI

97799513 ULTICARE 0.3CC 31G SYG 5/16 IN

UMI

31GX0.5CC Syringe


UMI

97799512 ULTICARE 0.5CC 31G SYG 5/16 IN

UMI

31GX1CC Syringe


UMI

97799511 ULTICARE 1CC 31G SYG 5/16 INCH

UMI

SYRINGE & NEEDLE

0.3CC Syringe and Needle

99328419 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

0.5CC Syringe and Needle

99328377 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 BTD

1CC Syringe and Needle

99262295 B-D INJECT-EASE WITH MICRO-FINE

BTD

99767467 B-D MICRO-FINE INSULIN 100U BTD00901911 B-D MICRO-FINE INSULIN 28G BTD00906816 SYRN INSULIN ULTRA 29G BTD


SYRINGE CASE

Syringe Case

99400552 MYHEALTH SYRINGE CASE-7 AUC99400551 MYHEALTH SYRINGE CASE-

SINGLEAUC

SYRINGE WITH NEEDLE

3/10CC X 31G Syringe

97799425 BD 0.3ML SYR WITH U/F 6MM NEED

BTD

Page 137 of 1382014


96:00 PHARMACEUTICAL AIDS

96:00.00 PHARMACEUTICAL AIDS

METHADONE HCL

Powder

00908835 METHADONE WIL

METHADONE HCL (PA)

limited use benefit (prior approval required) with the following criteria:


Methadone pseudo DINs listed for the treatment of pain should not be used for methadone maintenance therapy. Methadone for the treatment of opioid dependency is an open benefit covered under the NIHB Program (Methadone maintenance therapy pseudo DIN 908835). For information regarding the adjudication rules of methadone for the treatment of opioid dependency, please refer to the NIHB Provider Guide for Pharmacy Benefits.

Powder

09991180 METHADONE POWDER (PAIN) UNK

POLYETHYLENE GLYCOL

Powder

09991007 POLYETHYLENE GLYCOL WIL09991054 POLYETHYLENE GLYCOL 3350

PWDWIL

Page 138 of 1382014

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 30 days.

250MG Tablet02284707 APO-LEVOFLOXACIN APX

02315424 CO-LEVOFLOXACIN ACT

02236841 LEVAQUIN JNO

02313979 MYLAN-LEVOFLOXACIN MYL

02248262 NOVO-LEVOFLOXACIN TEV

02284677 PMS-LEVOFLOXACIN PMS02298635 SANDOZ LEVOFLOXACIN SDZ


02315432 CO-LEVOFLOXACIN ACT

02236842 LEVAQUIN JNO

02313987 MYLAN-LEVOFLOXACIN MYL

02248263 NOVO-LEVOFLOXACIN TEV02284685 PMS-LEVOFLOXACIN PMS

02298643 SANDOZ LEVOFLOXACIN SDZ


02315440 CO-LEVOFLOXACIN ACT02246804 LEVAQUIN JNO

02285649 NOVO-LEVOFLOXACIN TEV02305585 PMS-LEVOFLOXACIN PMS

02298651 SANDOZ LEVOFLOXACIN SDZ

08:12.24 TETRACYCLINESMINOCYCLINE HCL



50MG Capsule02084090 APO-MINOCYCLINE APX

02239667 DOM-MINOCYCLINE DPC02287226 MINOCYCLINE SAN

02108143 NOVO-MINOCYCLINE TEV

02153394 PDL-MINOCYCLINE PDL02239238 PMS-MINOCYCLINE PMS

02294419 PMS-MINOCYCLINE PMS

01914138 RATIO-MINOCYCLINE RPH

02242080 RIVA-MINOCYCLINE RIV

02237313 SANDOZ-MINOCYCLINE SDZ

Page A-1 de 662014


08:12.24 TETRACYCLINESMINOCYCLINE HCL



100MG Capsule02084104 APO-MINOCYCLINE APX

02239668 DOM-MINOCYCLINE DPC

02173506 MINOCIN STI

02239982 MINOCYCLINE IVX

02287234 MINOCYCLINE SAN

02108151 NOVO-MINOCYCLINE TEV02154366 PDL-MINOCYCLINE PDL

02294427 PMS-MINOCYCLINE PMS

02239239 PMS-MONOCYCLINE PMS

01914146 RATIO-MINOCYCLINE RPH

02242081 RIVA-MINOCYCLINE RIV

02237314 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.

50MG Tablet02256460 VFEND PFI

200MG Tablet02256479 VFEND PFI

08:18.08 ANTIRETROVIRALSETRAVIRINE


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

200MG Tablet02375931 INTELENCE KEG

Page A-2 de 662014


08:18.08 ANTIRETROVIRALSMARAVIROC


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

300MG Tablet02299852 CELSENTRI VII

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

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

Page A-3 de 662014


08:18.20 INTERFERONSPEGINTERFERON ALFA-2B, RIBAVIRIN





50MCG/0.5ML & 200MG Injection & Capsule02246026 PEGETRON SCH

02254573 PEGETRON REDIPEN SCH

80MCG/0.5ML & 200MG Injection & Capsule02254581 PEGETRON REDIPEN SCH



150MCG/0.5ML & 200MG Injection & Capsule02246030 PEGETRON SCH02254646 PEGETRON REDIPEN SCH

08:18.32 NUCLEOSIDES AND NUCLEOTIDESENTECAVIR


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 Tablet02396955 APO-ENTECAVIR APX

08:18.40BOCEPREVIR


For the treatment of chronic hepatitis C (CHC) genotype 1 infection in adult patients with compensated liver disease, in combination with peginterferon alpha (a or b+ ribavirin), and the following criteria:


200MG Capsule02370816 VICTRELIS FRS

BOCEPREVIR, PEGINTERFERON, RIBAVIRINLimited use benefit (prior approval required).

For the treatment of chronic hepatitis C (CHC) genotype 1 infection in adult patients with compensated liver disease, in combination with peginterferon alpha (a or b+ ribavirin), and the following criteria:


200MG & 100 MCG & 200MG Kit02371456 VICTRELIS TRIPLE FRS




Page A-4 de 662014


08:18.92 MISCELLANEOUS ANTIVIRALSTELAPREVIR


For the treatment of chronic Hepatitis C in treatment-naïve and treatment experienced patients who meet all the following criteria before consideration:- HCV genotype 1 - Detectable levels of hepatitis C virus HCV RNA in the last six months.- Fibrosis stage F2 or greater (Metavir scale or equivalent). Copy of report is required - No diagnosis of cirrhosis OR compensated liver disease (cirrhosis with a Child Pugh Score = A (5-6))

375MG Tablet02371553 INCIVEK VPC

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.

100MG Tablet02269015 TARCEVA HLR

150MG Tablet02269023 TARCEVA HLR

IMATINIB MESYLATELimited use benefit (prior approval required).

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

100MG Tablet02355337 APO-IMATINIB APX

02253275 GLEEVEC NVR

02399806 TEVA-IMATINIB TEP

400MG Tablet02355345 APO-IMATINIB APX

02253283 GLEEVEC NOV

02399814 TEVA-IMATINIB TEP

RITUXIMABLimited 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.

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).



12.5MG Capsule02280795 SUTENT PFI

Page A-5 de 662014


10:00.00 ANTINEOPLASTIC AGENTSSUNITINIB MALATE

Limited use benefit (Prior approval required).



25MG Capsule02280809 SUTENT PFI

50MG Capsule02280817 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.

5MG Capsule02241093 TEMODAL SCH

20MG Capsule02395274 CO TEMOZOLOMIDE ACT

02241094 TEMODAL SCH



140MG Capsule02395290 CO TEMOZOLOMIDE ACT02312794 TEMODAL FRS



12:00 AUTONOMIC DRUGS12:04.00 PARASYMPATHOMIMETIC AGENTS

GALANTAMINE HYDROBROMIDELimited 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; OR•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)

8MG Extended Release Capsule02339439 MYLAN-GALANTAMINE ER MYL

02316943 PAT-GALANTAMINE ER JNO

02398370 PMS-GALANTAMINE ER PMS

02377950 TEVA-GALANTAMINE ER TEP

Page A-6 de 662014


12:04.00 PARASYMPATHOMIMETIC AGENTSGALANTAMINE HYDROBROMIDE












RIVASTIGMINELimited use benefit (prior approval required).



1.5MG Capsule02336715 APO-RIVASTIGMINE APX02242115 EXELON NOV

02406985 MINT-RIVASTIGMINE MIN

02332809 MYLAN-RIVASTIGMINE MYL

02305984 NOVO-RIVASTIGMINE TEV02306034 PMS-RIVASTIGMINE PMS

02311283 RATIO-RIVASTIGMINE TEP

02324563 SANDOZ RIVASTIGMINE SDZ

Page A-7 de 662014


12:04.00 PARASYMPATHOMIMETIC AGENTSRIVASTIGMINE




3MG Capsule02336723 APO-RIVASTIGMINE APX

02242116 EXELON NOV


02332817 MYLAN-RIVASTIGMINE MYL02305992 NOVO-RIVASTIGMINE TEV02306042 PMS-RIVASTIGMINE PMS



4.5MG Capsule02336731 APO-RIVASTIGMINE APX

02242117 EXELON NOV02407000 MINT-RIVASTIGMINE MIN


02306018 NOVO-RIVASTIGMINE TEV

02306050 PMS-RIVASTIGMINE PMS



6MG Capsule02336758 APO-RIVASTIGMINE APX

02242118 EXELON NOV



02306026 NOVO-RIVASTIGMINE TEV

02306069 PMS-RIVASTIGMINE PMS



2MG/ML O/L02245240 EXELON NOV

12:08.08 ANTIMUSCARINICS / ANTISPASMODICSTIOTROPIUM BROMIDE MONOHYDRATE


For patients with chronic obstructive pulmonary disease (COPD) and who:

-did not respond to a trial of ipratropium (Atrovent); OR-did not have a previous trial of ipratropium, but who have moderate to severe COPD, defined as <60% FEV1, FEV1/FVC<0.7 and MRC 3 to 5.

18MCG Powder for Inhalation (Capsule)02246793 SPIRIVA BOE

Page A-8 de 662014


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.

OR

•�For the treatment of Chronic Obstructive Pulmonary Disease (COPD) in patients not adequately controlled with either ipratropium, tiotropium or a short acting betagonist.

12MCG/CAP Powder for Inhalation02230898 FORADIL NVR

FORMOTEROL FUMARATE DIHYDRATELimited 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 rapid onset, short duration bronchodilator

6MCG/DOSE Dry Powder Inhaler02237225 OXEZE TURBUHALER AZC

12MCG/DOSE Dry Powder Inhaler02237224 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 251-500mcg 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.


•�For the treatment of moderate* COPD, if a patient continues to be symptomatic after an adequate trial of a long acting anticholinergic AND a long acting beta-agonist.

•�For the treatment of severe** COPD, if a patient continues to be symptomatic after an adequate trial of a long acting anticholinergic OR a long acting beta-agonis

6MCG & 100MCG/INHALATION Inhaler02245385 SYMBICORT 100 TURBUHALER AZC

6MCG & 200MCG/INHALATION Inhaler02245386 SYMBICORT 200 TURBUHALER AZC

FORMOTEROL FUMARATE DIHYDRATE, MOMETASONE FUROATELimited 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. fluticasone200-500mcg 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.

5MCG & 100MCG Inhaler02361752 ZENHALE FRS



INDACATEROL MALEATELimited use benefit (prior approval required).

For the treatment of Chronic Obstructive Pulmonary Disease (COPD) in patients not adequately controlled with either ipratropium, tiotropium or a short acting beta-agonist.

75MCG Capsule02376938 ONBREZ NOV

Page A-9 de 662014


12:12.08 BETA ADRENERGIC AGONISTSSALMETEROL XINAFOATE


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, tiotropium or a short acting beta-agonist.

50MCG/DOSE Powder Diskus02231129 SEREVENT DISKUS GSK

50MCG/INHALATION Powder for Inhalation02214261 SEREVENT DISKHALER GSK

SALMETEROL XINAFOATE, FLUTICASONE PROPIONATELimited 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 251-500mcg 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.


•�For the treatment of moderate* COPD, if a patient continues to be symptomatic after an adequate trial of a long acting anticholinergic AND a long acting beta-agonist.

•�For the treatment of severe** COPD, if a patient continues to be symptomatic after an adequate trial of a long acting anticholinergic OR a long acting beta-agonis

25MCG & 125MCG INHALATION Inhaler02245126 ADVAIR GSK

25MCG & 250MCG INHALATION Inhaler02245127 ADVAIR GSK

50MCG & 100MCG Inhaler02240835 ADVAIR DISKUS 100 GSK



12:20.04 CENTRALL ACTING SKELETAL MUSCLE RELAXANTSCYCLOBENZAPRINE HCL


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 APX

02348853 AURO-CYCLOBENZAPRINE AUR02220644 CYCLOBENZAPRINE PDL

02287064 CYCLOBENZAPRINE SAN

02238633 DOM-CYCLOBENZAPRINE DPC

02231353 GEN-CYCLOPRINE GEN

02357127 JAMP-CYCLOBENZAPRINE JAP

02080052 NOVO-CYCLOPRINE TEV

02249359 PHL-CYCLOBENZAPRINE PMI

02212048 PMS-CYCLOBENZAPRINE PMS02236506 RATIO-CYCLOBENZAPRINE RPH

02242079 RIVA-CYCLOBENZAPRINE RIV

Page A-10 de 662014


12:20.04 CENTRALL ACTING SKELETAL MUSCLE RELAXANTSTIZANIDINE HCL


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

4MG Tablet02259893 APO-TIZANIDINE APX

02272059 GEN-TIZANIDINE GEN

02239170 ZANAFLEX ELN

12:92.00 MISCELLANEOUS AUTONOMIC DRUGSNICOTINE (GUM)


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 or lozenges when one year has elapsed from the day the initial prescription was filled.

2MG Gum02091933 NICORETTE JNO

80000396 THRIVE NOV

4MG Gum02091941 NICORETTE PLUS PMJ80000118 NICOTINE PER

80000402 THRIVE NOV

94799972 THRIVE NOV

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

For smoking cessation:Coverage is limited to 945 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 or lozenges when one year has elapsed from the day the initial prescription was filled.

10MG Inhaler02241742 NICORETTE JNO

NICOTINE (LOZENGES)1MG Lozenges

80007461 THRIVE NOV94799970 THRIVE NOV

2MG Lozenges02247347 NICORETTE JNO

80007464 THRIVE NOV

94799968 THRIVE NOV

4MG Lozenges02247348 NICORETTE JNO

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



5MG Patch02028697 NICOTROL TRANSDERMAL 5MG WAR


Page A-11 de 662014


12:92.00 MISCELLANEOUS AUTONOMIC DRUGSNICOTINE (PATCH)





17.5MG Patch02241227 TRANSDERMAL NICOTINE NVC

35MG Patch02241226 TRANSDERMAL NICOTINE NVC

52.5MG Patch02241228 TRANSDERMAL NICOTINE NVC

7MG Patch (Habitrol)01943057 HABITROL NVC



36MG Patch (Nicoderm)02093111 NICODERM PMJ



8.3MG/10CM2 Patch (Nicotrol)02065738 NICOTROL TRANSDERMAL JNO



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, 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

1MG Tablet02291185 CHAMPIX PFI

0.5MG & 1MG Tablets02298309 CHAMPIX STARTER PACK PFI

Page A-12 de 662014


20:00 BLOOD FORMATION COAGULATION AND THROMBOSIS20:12.04 ANTICOAGULANTS

APIXABANLimited use benefit (prior approval required)

For at risk patients* with non-valvular atrial fibrillation who require apixaban for the prevention of stroke and systemic embolism AND in whom: � Anticoagulation is inadequate# with a two-month trial of warfarin (please provide a copy of INR records for the last two months of warfarin therapy); OR � Anticoagulation with warfarin is contraindicated.;OR � Anticoagulation with warfarin is not possible due to inability to regularly monitor via INR testing (i.e., no access to INR testing services at a laboratory, clinic, pharmacy and at home).

* At risk patients with atrial fibrillation are defined as those with a CHADS2 score of ≥1.# Inadequate anticoagulation is defined as INR testing results that are outside the desired INR range for at least 35% of the tests during the monitoring period, i.e., adequate anticoagulation is defined as INR test results that are within the desired INR range for at least 65% of the tests during the monitoring period.

2.5MG Tablet02377233 ELIQUIS BMS

5MG Tablet02397714 ELIQUIS BMS

DABIGATRAN ETEXILATE MESILATELimited use benefit (prior approval required).

For at risk patients* with non-valvular atrial fibrillation who require dabigatran for the prevention of stroke and systemic embolism AND in whom: � Anticoagulation is inadequate with a two-month trial of warfarin (please provide a copy of INR records for the last two months of warfarin therapy); OR � Anticoagulation with warfarin is contraindicated. OR � Anticoagulation with warfarin is not possible due to inability to regularly monitor via INR testing (i.e., no access to INR testing services at a laboratory, clinic, pharmacy and at home).

110MG Capsule02312441 PRADAXA BOE

150MG Capsule02358808 PRADAXA BOE

RIVAROXABANLimited use benefit (prior approval required).

Criteria for Rivaroxaban 15 mg, 20mg tablets (Xarelto) for Stroke Prevention in Atrial Fibrillation (SPAF)For the prevention of stroke and systemic embolism in at-risk patients* who have non-valvular atrial fibrillation (AF) AND in whom: •�Anticoagulation is inadequate# following a two-month trial on warfarin (please provide copy of INR records for the last two months of warfarin therapy); OR•�Anticoagulation with warfarin is contraindicated; ;OR•�Anticoagulation is not possible due to inability to regularly monitor via International Normalized Ratio (INR) testing (i.e., no access to INR testing service at a laboratory, clinic, pharmacy, and at home)

Criteria for Rivaroxaban 15 mg, 20mg tablets (Xarelto) for Deep Vein Thrombosis (DVT)•�For the treatment of deep vein thrombosis (DVT) in patients without symptomatic pulmonary embolism (PE) for a duration of up to six months.

Note: The recommended dose of rivaroxaban for patients initiating DVT treatment is 15 mg twice daily for 3 weeks, followed by 20 mg once daily. NIHB Program coverage for rivaroxaban is an alternative to heparin/warfarin for up to 6 months. When used for greater than 6 months, rivaroxaban is more costly than heparin/warfarin. IF THE INTENDED DURATION OF THERAPY IS GREATER THAN 6 MONTHS, INITIATION OF HEPARIN/WARFARIN SHOULD BE CONSIDERED.

15MG Tablet02378604 XARELTO BAY

20MG Tablet02378612 XARELTO B A

RIVAROXABAN (10)Limited use benefit (prior approval not required).

For the prevention of venous thromboembolism following total knee replacement or total hip replacement surgery, for up to 35 days.

10MG Tablet02316986 XARELTO BAY

Page A-13 de 662014


20:12.18 PLATELET AGGREGATION INHIBITORSCLOPIDOGREL BISULFATE


Limit of 12 months following a client’s initial cardiovascular event (stroke, acute coronary syndrome (ACS) or stent). Continued coverage beyond one year will be provided for patients with a previous stroke or transient ischemic attack (TIA) and be considered for patients with ACS or stent placement with appropriate rationale from the client`s cardiologist or treating physician.

75MG Tablet02252767 APO-CLOPIDOGREL APX

02385813 CLOPIDOGREL SIV

02394820 CLOPIDOGREL PDL

02400553 CLOPIDOGREL SAN

02303027 CO CLOPIDOGREL ACT

02378507 DOM-CLOPIDOGREL DOM02408910 MINT-CLOPIDOGREL MIN

02351536 MYLAN-CLOPIDOGREL MYL

02238682 PLAVIX SAC

02348004 PMS CLOPIDOGREL PMS

02379813 RAN-CLOPIDOGREL RBY

02388529 RIVA CLOPIDOGREL RIV

02359316 SANDOZ CLOPIDOGREL SDZ02293161 TEVA-CLOPIDOGREL TEP

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

24:12.12 PHOSPHODIESTERASE INHIBITORSSILDENAFIL CITRATE


Maximum dose covered is 20 mg three times a day

Patients with World Health Organization (WHO) class III pulmonary artery hypertension (PAH), either idiopathic (i.e. primary) or associated with a congenital or systemic condition (e.g. connective tissue disease) and confirmed by right heart catheterization; ANDwho have failed to respond to conventional therapy; ORwho have contraindications to conventional agents.

20MG Tablet02319500 RATIO-SILDENAFIL R TEP02279401 REVATIO PFI

Page A-14 de 662014


24:12.12 PHOSPHODIESTERASE INHIBITORSTADALAFIL


Maximum dose covered is 40 mg daily

Patients with World Health Organization (WHO) class III pulmonary artery hypertension (PAH), either idiopathic (i.e. primary) or associated with a congenital or systemic condition (e.g. connective tissue disease) and confirmed by right heart catheterization; ANDwho have failed to respond to conventional therapy; ORwho have contraindications to conventional agents

20MG Tablet02338327 ADCIRCA LIL

24:12.92 MISCELLANEOUS VASODILATING AGENTSAMBRISENTAN


Maximum dose covered is 10 mg once daily. Patients with World Health Organization (WHO) class III pulmonary artery hypertension (PAH), either idiopathic (i.e. primary) or associated with a congenital or systemic condition (e.g. connective tissue disease) and confirmed by right heart catheterization; AND-who have failed to respond to sildenafil OR tadalafil; OR-who have contraindications to sildenafil OR tadalafil.

5MG Tablet02307065 VOLIBRIS GSK

10MG Tablet02307073 VOLIBRIS GSK

BOSENTANLimited use benefit (prior approval required). Maximum dose covered is 125 mg twice daily

-Patients with World Health Organization (WHO) class III pulmonary artery hypertension (PAH), either idiopathic (i.e. primary) or associated with a congenital or systemic condition (e.g. connective tissue disease) and confirmed by right heart catheterization; AND-who have failed to respond to sildenafil OR tadalafil; OR-who have contraindications to sildenafil OR tadalafil.

62.5MG Tablet02386194 CO BOSENTAN ACT

02383497 MYLAN-BOSENTAN MYL

02383012 PMS-BOSENTAN PMS02386275 SANDOZ BOSENTAN SDZ

02244981 TRACLEER ACN

125MG Tablet02386208 CO BOSENTAN ACT

02383500 MYLAN-BOSENTAN MYL

02383020 PMS-BOSENTAN PMS02386283 SANDOZ BOSENTAN SDZ02244982 TRACLEER ACN

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 Capsule02242119 AGGRENOX BOE

Page A-15 de 662014


28:00 CENTRAL NERVOUS SYSTEM AGENTS28:08.04 NONSTEROIDAL ANTI-INFLAMMATORY AGENTS

ACETYLSALICYLIC ACIDLimited use benefit (prior approval is not required).


80MG Chewable Tablet02269139 ACETYLSALICYLIC ACID JAP

02321750 ASA ZYM

02009013 ASAPHEN PMS

02280167 ASATAB ODN

02296004 LOWPRIN EUR

02311518 PRO-ASA PRO02202352 RIVASA RIV

80MG Delayed Release Tablet02283905 ACETYLSALICYLIC ACID JAP

02321769 ASA EC SOR

02238545 ASAPHEN EC PMS

02311496 PRO-ASA EC PRO

80MG Tablet02150352 ASPIRIN BCD

02250675 EURO-ASA EUR

02295563 LOWPRIN EUR

02202360 RIVASA RIV

CELECOXIBLimited use benefit (prior approval required).

For patients who have:

¨�A history of serious gastrointestinal complications (e.g. ulcer, bleeding, perforation);

OR

¨�Multiple (at least two) risk factors for serious gastrointestinal complications (e.g. age >60, concurrent use of ASA, SSRIs, corticosteroids, anticoagulants or antiplatelet agents).

100MG Capsule02239941 CELEBREX PFI

200MG Capsule02239942 CELEBREX PFI

28:08.08 OPIATE AGONISTSACETAMINOPHEN, CAFFEINE CITRATE, CODEINE PHOSPHATE


For safety reasons NIHB has implemented a dose limit on acetaminophen. The limit accumulates against the amount of acetaminophen claimed to the program from plain acetaminophen and/or acetaminophen in combination with opioids such as codeine (i.e. Tylenol® #3) or oxycodone (i.e. Percocet®). A total of 360 gramsof acetaminophen is permitted in a 100-day period, for a total daily dose of 3600mg/day.

300MG & 30MG & 15MG Tablet00293504 ATASOL-15 HOR

02232388 EXDOL-15 PED

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

Page A-16 de 662014


28:08.08 OPIATE AGONISTSACETAMINOPHEN, CAFFEINE, CODEINE PHOSPHATE



300MG & 15MG & 15MG Tablet00653241 RATIO-LENOLTEC NO.2 RPH


300MG & 15MG & 30MG Tablet00653276 RATIO-LENOLTEC NO.3 RPH


ACETAMINOPHEN, CODEINE PHOSPHATELimited use benefit (prior approval is not required).


32MG & 1.6MG/ML Elixir00816027 PMS-ACETAMINOPHEN WITH CODEINE PMS

300MG & 30MG Tablet01999648 ACET CODEINE 30 PMS

02232658 PROCET-30 PDL

00608882 RATIO-EMTEC-30 RPH

00789828 TRIATEC-30 TRI

ACETAMINOPHEN, OXYCODONE HCLLimited use benefit (prior approval is not required).


325MG & 2.5MG Tablet01916491 PERCOCET DEMI BMS

325MG & 5MG Tablet02324628 APO-OXYCODONE/ACET APX01916548 ENDOCET EDM02361361 OXYCODONE/ACET SAN

01916475 PERCOCET BMS

02327171 PRO-OXYCOD ACET PDL

00608165 RATIO-OXYCOCET RPH

02242468 RIVACOCET RIV

02307898 SANDOZ OXYCOD ACET SDZ

ACETYLSALICYLIC ACID, CAFFEINE CITRATE, CODEINE PHOSPHATELimited use benefit (prior approval is not required).

To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented an opioid dose limit of 500 mg morphine equivalents per day for non-cancer, non-palliative pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 100-day period (i.e. 50 000morphine equivalents over 100 days).

375MG & 30MG & 15MG Tablet02234510 282 PED

375MG & 30MG & 30MG Tablet02238645 292 PED

Page A-17 de 662014


28:08.08 OPIATE AGONISTSACETYLSALICYLIC ACID, OXYCODONE HCL



325MG & 5MG Tablet00608157 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 PHOSPHATELimited use benefit (prior approval is not required).


2MG/ML Liquid00380571 LINCTUS CODEINE ATL

5MG/ML Syrup00050024 CODEINE PHOSPHATE ATL00779474 RATIO-CODEINE RPH

15MG Tablet00779458 CODEINE RPH

02009889 CODEINE TRI

00593435 RATIO-CODEINE RPH

30MG Tablet00593451 CODEINE PHOSPHATE RPH

02009757 CODEINE PHOSPHATE TRI02243979 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 dosetitration and adjunctive therapy including laxatives and antiemetics.


12MCG Patch02311925 TEVA-FENTANYL TEP

Page A-18 de 662014


28:08.08 OPIATE AGONISTSFENTANYL



12MCG/H Patch02386844 CO FENTANYL ACT

02395657 FENTANYL PDL

02396696 MYLAN-FENTANYL MYL02341379 PMS-FENTANYL PMS02330105 RAN-FENTANYL RBY

02327112 SANDOZ FENTANYL SDZ

25MCG/H Patch02314630 APO-FENTANYL APX

02386852 CO FENTANYL ACT

02275813 DURAGESIC MAT JNO

02395665 FENTANYL PDL02396718 MYLAN-FENTANYL MYL

02341387 PMS-FENTANYL PMS

02330113 RAN-FENTANYL RBY

02327120 SANDOZ FENTANYL SDZ02282941 TEVA-FENTANYL RPH

50MCG/H Patch02314649 APO-FENTANYL APX02386879 CO FENTANYL ACT



02396726 MYLAN-FENTANYL MYL




02282968 TEVA-FENTANYL RPH


02386887 CO FENTANYL ACT




02341409 PMS-FENTANYL PMS02330148 RAN-FENTANYL RBY




02386895 CO FENTANYL ACT02275856 DURAGESIC MAT JNO02395703 FENTANYL PDL






Page A-19 de 662014


28:08.08 OPIATE AGONISTSHYDROMORPHONE HCL




3MG Controlled Release Capsule02125323 HYDROMORPH CONTIN PFR

4.5MG Controlled Release Capsule02359502 HYDROMORPH CONTIN PFR







1MG/ML Oral Liquid00786535 DILAUDID ABB01916386 PMS-HYDROMORPHONE PMS

3MG Suppository01916394 PMS-HYDROMORPHONE PMS

1MG Tablet02364115 APO-HYDROMORPHONE APX

00705438 DILAUDID ABB

02192101 PHL-HYDROMORPHONE PHH00885444 PMS-HYDROMORPHONE PMS

02319403 TEVA-HYDROMORPHONE TEP



02249928 PHL-HYDROMORPHONE PHH

00885436 PMS-HYDROMORPHONE PMS02319411 TEVA-HYDROMORPHONE TEP




00885401 PMS-HYDROMORPHONE PMS





00885428 PMS-HYDROMORPHONE PMS


Page A-20 de 662014


28:08.08 OPIATE AGONISTSMETHADONE HCL

10mg/mL Liquid02394596 METHADOSE MAT

02394618 METHADOSE SUGARFREE MAT

METHADONE HCL (PA)limited use benefit (prior approval required) with the following criteria:


Methadone pseudo DINs listed for the treatment of pain should not be used for methadone maintenance therapy. Methadone for the treatment of opioid dependencyis an open benefit covered under the NIHB Program (Methadone maintenance therapy pseudo DIN 908835). For information regarding the adjudication rules of methadone for the treatment of opioid dependency, please refer to the NIHB Provider Guide for Pharmacy Benefits.

1MG/ML Liquid02247694 METADOL PAL

10MG/ML Liquid02241377 METADOL PAL

1MG Tablet02247698 METADOL PAL




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


30MG Sustained Release Tablet00776181 M.O.S. SR VAE

60MG Sustained Release Tablet00776203 M.O.S. SR VAE

1MG/ML Syrup00614491 DOLORAL 1 ATL

00607762 RATIO-MORPHINE RPH

5MG/ML Syrup00614505 DOLORAL 5 ATL

00514217 M.O.S. VAE00607770 RATIO-MORPHINE RPH

10MG/ML Syrup00632503 M.O.S. 10 VAE

00690783 RATIO-MORPHINE RPH

20MG/ML Syrup00690791 RATIO-MORPHINE RPH

50MG/ML Syrup00690236 M.O.S. 50 VAE

10MG Tablet00690198 M.O.S. 10 VAE



Page A-21 de 662014


28:08.08 OPIATE AGONISTSMORPHINE HCL




MORPHINE SULFATELimited use benefit (prior approval is not required).


50MG/ML Drop00705799 STATEX PMS

5MG Suppository00632228 STATEX PMS



10MG Sustained Release Capsule02242163 KADIAN MAY

02019930 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




02019965 M-ESLON SR SAC


15MG Sustained Release Tablet02350815 MORPHINE SR SAN02015439 MS CONTIN SR PFR

02244790 RATIO-MORPHINE SULFATE SR RPH

02302764 TEVA-MORPHINE SR 15MG TAB TEP

30MG Sustained Release Tablet02350890 MORPHINE SR SAN

02014297 MS CONTIN SR PFR02244791 RATIO-MORPHINE SULFATE SR RPH



02014300 MS CONTIN SR PFR

02244792 RATIO-MORPHINE SULFATE SR RPH02302780 TEVA-MORPHINE SR 60MG TAB TEP

Page A-22 de 662014


28:08.08 OPIATE AGONISTSMORPHINE SULFATE




02014319 MS CONTIN SR PFR



02014327 MS CONTIN SR PFR02302802 TEVA-MORPHINE SR 200MG TAB TEP

1MG/ML Syrup00591467 STATEX PMS



5MG Tablet02009773 M.O.S. SULFATE VAE

02014203 MS IR PFR

00594652 STATEX PMS

10MG Tablet02009765 M.O.S. SULFATE VAE02014211 MS IR PFR

00594644 STATEX PMS

20MG Tablet02014238 MS IR PFR

25MG Tablet02009749 M.O.S. SULFATE VAE

00594636 STATEX PMS

30MG Tablet02014254 MS IR PFR

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

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


10MG Suppository00392480 SUPEUDOL SIL

20MG Suppository00392472 SUPEUDOL SIL

5MG Tablet02325950 OXYCODONE PDL

02231934 OXY-IR PFR

02319977 PMS-OXYCODONE PMS

00789739 SUPEUDOL SDZ

Page A-23 de 662014


28:08.08 OPIATE AGONISTSOXYCODONE HCL



10MG Tablet02240131 OXY-IR PFR

02319985 PMS-OXYCODONE PMS

00443948 SUPEUDOL SDZ

20MG Tablet02240132 OXY-IR PFR

02319993 PMS-OXYCODONE PMS02262983 SUPEUDOL SDZ

28:08.12 OPIATE PARTIAL AGONISTSBUPRENORPHINE, NALOXONE


For the treatment of opioid dependence in patients who have a contraindication to methadone due to:• Evidence of (or high risk for) QT interval prolongation; and• Prescribed by a physician with experience in substitution treatment in Opioid drug dependence or completion of an accredited Suboxone Education Program.

8MG & 2MG Tablet02295709 SUBOXONE RBP

09991204 SUBOXONE MAINTENANCE UNK

28:08.92 MISCELLANEOUS ANALGESICS AND ANTIPYRETICSACETAMINOPHEN



80MG Chewable Tablet02129957 ACETAMIN CHILD WTR

01905856 ACETAMINOPHEN TRI

02017458 ACETAMINOPHEN RIV02015676 CHILDREN'S ACETAMINOPHEN TAN

160MG Chewable Tablet02017431 ACETAMINOPHEN RIV

02231011 FEVERHALT PED

02230934 TANTAPHEN GRAPE TAN

80MG/ML Drop01904140 ACETAMINOPHEN TAN01905864 ACETAMINOPHEN TRI

00631353 ATASOL HOR

02230787 FEVERHALT PED

02263793 PEDIAPHEN EUR

02027801 PEDIATRIX RPH

00887587 PMS-ACETAMINOPHEN PMS

00875988 TEMPRA MJO

02046059 TYLENOL GRAPE MCL

16MG/ML Liquid01905848 ACETAMINOPHEN TRI

02263807 PEDIAPHEN EUR00792713 PMS-ACETAMINOPHEN PMS

00884553 TEMPRA MJO

Page A-24 de 662014





32MG/ML Liquid01901389 ACETAMINOPHEN JAP

01958836 ACETAMINOPHEN TRI

02263831 PEDIAPHEN EUR

02027798 PEDIATRIX RPH


00875996 TEMPRA DOUBLE STRENGTH MJO02046040 TYLENOL MCL

120MG Suppository02046660 PMS-ACETAMINOPHEN PMS



80MG/ML Suspension02237390 ACETAMINOPHEN PER

80MG Tablet02238295 CHILDREN'S TYLENOL SOFT CHEWS JNO

02263815 PEDIAPHEN CHEWABLE TAB 80MG EUO

160MG Tablet02142805 ACETAMINOPHEN WTR

02263823 PEDIAPHEN CHEWABLE TAB 160MG EUO

02347792 TYLENOL JR STRENGTH FASTMELTS JNO

02241361 TYLENOL JUNIOR STRENGTH JNO

325MG Tablet00374148 ACETAMINOPHEN WAM

00382752 ACETAMINOPHEN PRO

00589241 ACETAMINOPHEN PMS00605751 ACETAMINOPHEN VTH *

00743542 ACETAMINOPHEN PMT

00789801 ACETAMINOPHEN TRI01938088 ACETAMINOPHEN JAP

02022214 ACETAMINOPHEN RIV

00544981 APO-ACETAMINOPHEN APX

02229873 APO-ACETAMINOPHEN APX00293482 ATASOL HOR

00389218 NOVO-GESIC TEV

00559393 TYLENOL MCL

00723894 TYLENOL MCL

Page A-25 de 662014





500MG Tablet00386626 ACETAMINOPHEN PDL


00567663 ACETAMINOPHEN PED

00589233 ACETAMINOPHEN PMS

00605778 ACETAMINOPHEN VTH

00789798 ACETAMINOPHEN TRI01939122 ACETAMINOPHEN JAP

02022222 ACETAMINOPHEN RIV





00013668 ATASOL FORTE HOR02355299 JAMP-ACETAMINOPHEN JAP

00482323 NOVO-GESIC TEV


01962353 TANTAPHEN TAN

00559407 TYLENOL EXTRA STRENGTH MCL00723908 TYLENOL EXTRA STRENGTH MCL

28:12.08 ANTICONVULSANTS - BENZODIAZEPINESCLONAZEPAM



0.25MG Tablet02179660 PMS-CLONAZEPAM PMS

0.5MG Tablet02177889 APO-CLONAZEPAM APX

02230366 CLONAPAM VAE02270641 CO-CLONAZEPAM ACT

02130998 DOM-CLONAZEPAM DPC

02224100 DOM-CLONAZEPAM-R DPC

02230950 GEN-CLONAZEPAM GEN02239024 NOVO-CLONAZEPAM TEV

02145227 PHL-CLONAZEPAM PHH

02236948 PHL-CLONAZEPAM-R PMI

02048701 PMS-CLONAZEPAM PMS

02207818 PMS-CLONAZEPAM R PMS

02311593 PRO-CLONAZEPAM PDL

02242077 RIVA-CLONAZEPAM RIV00382825 RIVOTRIL HLR02233960 SANDOZ-CLONAZEPAM SDZ

02345676 ZYM-CLONAZEPAM ZYM

Page A-26 de 662014


28:12.08 ANTICONVULSANTS - BENZODIAZEPINESCLONAZEPAM



1MG Tablet02230368 CLONAPAM VAE

02270668 CO-CLONAZEPAM ACT



02311607 PRO-CLONAZEPAM PDL02233982 SANDOZ-CLONAZEPAM SDZ

02303329 ZYM-CLONAZEPAM ZYM

2MG Tablet02177897 APO-CLONAZEPAM APX

02230369 CLONAPAM VAE

02270676 CO-CLONAZEPAM ACT

02131013 DOM-CLONAZEPAM DPC02230951 GEN-CLONAZEPAM GEN

02239025 NOVO-CLONAZEPAM TEV



02311615 PRO-CLONAZEPAM PDL02242078 RIVA-CLONAZEPAM RIV

00382841 RIVOTRIL HLR

02233985 SANDOZ-CLONAZEPAM SDZ02303337 ZYM-CLONAZEPAM ZYM

28:12.92 MISCELLANEOUS ANTICONVULSANTSGABAPENTIN



100MG Capsule02244304 APO-GABAPENTIN APX

02321203 AURO-GABAPENTIN AUR

02256142 CO-GABAPENTIN ACT02243743 DOM-GABAPENTIN DPC

02246314 GABAPENTIN SIV

02304775 GABAPENTIN SOR

02353245 GABAPENTIN SAN02248259 GEN-GABAPENTIN GEN

02361469 JAMP-GABAPENTIN JAP

02084260 NEURONTIN PFI

02244513 NOVO-GABAPENTIN TEV

02243446 PMS-GABAPENTIN PMS

02310449 PRO-GABAPENTIN PDL

02319055 RAN-GABAPENTIN RBY02251167 RIVA-GABAPENTIN RIV

Page A-27 de 662014







02256150 CO-GABAPENTIN ACT

02243744 DOM-GABAPENTIN DPC


02304783 GABAPENTIN SOR02353253 GABAPENTIN SAN02248260 GEN-GABAPENTIN GEN






02319063 RAN-GABAPENTIN RBY02251175 RIVA-GABAPENTIN RIV



02256169 CO-GABAPENTIN ACT02243745 DOM-GABAPENTIN DPC

02246316 GABAPENTIN SIV02304791 GABAPENTIN SOR

02353261 GABAPENTIN SAN

02248261 GEN-GABAPENTIN GEN





02310465 PRO-GABAPENTIN PDL02319071 RAN-GABAPENTIN RBY

02260905 RATIO-GABAPENTIN RPH02251183 RIVA-GABAPENTIN RIV

600MG Tablet02293358 APO-GABAPENTIN APX


02285843 GD-GABAPENTIN PFI02402289 JAMP-GABAPENTIN JAP

02397471 MYLAN-GABAPENTIN MYL





02260913 RATIO-GABAPENTIN RPH02259796 RIVA-GABAPENTIN RIV

Page A-28 de 662014





800MG Tablet02293366 APO-GABAPENTIN APX



02397498 MYLAN-GABAPENTIN MYL


02247346 NOVO-GABAPENTIN TEV02255901 PMS-GABAPENTIN PMS02310481 PRO-GABAPENTIN PDL

02260921 RATIO-GABAPENTIN RPH

02259818 RIVA-GABAPENTIN RIV

LACOSAMIDELimited use benefit (prior approval required).For adjunctive therapy in patients with refractory partial-onset seizures who meet all of the following criteria:a- Are under the care of a physician experienced in the treatment of epilepsy, ANDb- Are currently receiving two or more antiepileptic medications, ANDc- Have failed or demonstrated intolerance to at least two other antiepileptic medications.

50MG Tablet02357615 VIMPAT UCB




LEVETIRACETAMLimited use benefit (prior approval required).


250MG Tablet02285924 APO-LEVETIRACETAM APX

02375249 AURO-LEVETIRACETAM AUR

02274183 CO-LEVETIRACETAM ACT

02403005 JAMP-LEVETIRACETAM JAP

02247027 KEPPRA UCB

02353342 LEVETIRACETAM SAN

02296101 PMS-LEVETIRACETAM PMS02396106 RAN-LEVETIRACETAM RBY


02375257 AURO-LEVETIRACETAM AUR02274191 CO-LEVETIRACETAM ACT

02297418 DOM-LEVETIRACETAM DOM

02403021 JAMP-LEVETIRACETAM JAP02247028 KEPPRA UCB

02353350 LEVETIRACETAM SAN

02296128 PMS-LEVETIRACETAM PMS

02311380 PRO-LEVETIRACETAM PDL

02396114 RAN-LEVETIRACETAM RBY

Page A-29 de 662014


28:12.92 MISCELLANEOUS ANTICONVULSANTSLEVETIRACETAM




02375265 AURO-LEVETIRACETAM AUR

02274205 CO-LEVETIRACETAM ACT

02403048 JAMP-LEVETIRACETAM JAP

02247029 KEPPRA UCB

02353369 LEVETIRACETAM SAN02296136 PMS-LEVETIRACETAM PMS02311399 PRO-LEVETIRACETAM PDL

02396122 RAN-LEVETIRACETAM RBY

PREGABALINLimited use benefit (prior approval required).


OR



25MG Capsule02394235 APO-PREGABALIN APX

02402912 CO PREGABALIN ACT

02402556 DOM-PREGABALIN DOM02360136 GD-PREGABALIN PFI02268418 LYRICA PFI

02359596 PMS-PREGABALIN PMS

02396483 PREGABALIN PDL

02403692 PREGABALIN SIV

02405539 PREGABALIN SAN

02411725 PREGABALIN-25 SIV

02392801 RAN-PREGABALIN RBY02377039 RIVA-PREGABALIN RIV

02390817 SANDOZ PREGABALIN SDZ

02361159 TEVA-PREGABALIN TEP

50MG Capsule02394243 APO-PREGABALIN APX02402920 CO PREGABALIN ACT

02402564 DOM-PREGABALIN DOM02360144 GD-PREGABALIN PFI

02268426 LYRICA PFI





02392828 RAN-PREGABALIN RBY02377047 RIVA-PREGABALIN RIV



50MG Capsule02411733 PREGABALIN-50 SIV

Page A-30 de 662014


28:12.92 MISCELLANEOUS ANTICONVULSANTSPREGABALIN



OR




02402939 CO PREGABALIN ACT02402572 DOM-PREGABALIN DOM02360152 GD-PREGABALIN PFI

02268434 LYRICA PFI





02411741 PREGABALIN-75 SIV02392836 RAN-PREGABALIN RBY

02377055 RIVA-PREGABALIN RIV




02402955 CO PREGABALIN ACT

02402580 DOM-PREGABALIN DOM02360179 GD-PREGABALIN PFI

02268450 LYRICA PFI





02411768 PREGABALIN-150 SIV02392844 RAN-PREGABALIN RBY02377063 RIVA-PREGABALIN RIV




02402998 CO PREGABALIN ACT02360209 GD-PREGABALIN PFI

02268485 LYRICA PFI




02405598 PREGABALIN SAN02392860 RAN-PREGABALIN RBY

02377071 RIVA-PREGABALIN RIV02390868 SANDOZ PREGABALIN SDZ


Page A-31 de 662014


28:12.92 MISCELLANEOUS ANTICONVULSANTSRUFINAMIDE


-For the adjunctive treatment of seizures associated with Lennox-Gastaux syndrome in adults and children 4 years and older when prescribed by a neurologist or experienced specialist-Patient has failed or is intolerant to or has contraindications to at least two adjunctive antiepileptic drugs

100MG Tablet02369613 BANZEL 100MG TAB EIS



28:16.04 ANTIDEPRESSANTSBUPROPION HCL (WELLBUTRIN)



150MG Extended Release Tablet02382075 MYLAN-BUPROPION XL MYL02275090 WELLBUTRIN XL FRS

300MG Extended Release Tablet02382083 MYLAN-BUPROPION XL MYL

02275104 WELLBUTRIN XL FRS

100MG Sustained Release Tablet02331616 BUPROPION SR PDL

02391562 BUPROPION SR SAN02325373 PMS-BUPROPION SR PMS02285657 RATIO-BUPROPION RPH

02275074 SANDOZ-BUPROPION SR SDZ

150MG Sustained Release Tablet02391570 BUPROPION SR SAN

02313421 PMS-BUPROPION SR PMS

02325357 PRO-BUPROPION SR PDL

02285665 RATIO-BUPROPION RPH02275082 SANDOZ-BUPROPION SR SDZ

02237825 WELLBUTRIN SR BPC

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 BPC

28:16.08 ANTIPSYCHOTIC AGENTSARIPIPRAZOLE


For the treatment of schizophrenia and schizoaffective disorders in patients who havea. Intolerance or lack of response to an adequate trial of another antipsychotic agent; ORb. A contraindication to another antipsychotic agent

2MG Tablet02322374 ABILIFY BMS



Page A-32 de 662014


28:16.08 ANTIPSYCHOTIC AGENTSARIPIPRAZOLE


For the treatment of schizophrenia and schizoaffective disorders in patients who havea. Intolerance or lack of response to an adequate trial of another antipsychotic agent; ORb. A contraindication to another antipsychotic agent




ASENAPINELimited use benefit (prior approval required). For the acute treatment of manic or mixed episodes associated with bipolar I disorder as either:

- Monotherapy, after a trial of lithium or divalproex sodium has failed or is contraindicated, and trials of two atypical antipsychotic agents have failed due to intolerance or lack of response

OR

- Co-therapy with lithium or divalproex sodium, after trials of two atypical antipsychotic agents have failed due to intolerance or lack of response.

5MG Sublingual Tablet02374803 SAPHRIS FRS

10MG Sublingual Tablet02374811 SAPHRIS FRS

ZIPRASIDONELimited 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




28:24.08 ANXIOLYTICS, SEDATIVES AND HYPNOTICS - BENZODIAZEPINESALPRAZOLAM



0.25MG Tablet01908189 ALPRAZOLAM PDL

02349191 ALPRAZOLAM SAN00865397 APO-ALPRAZ APX

02137534 GEN-ALPRAZOLAM GEN

02400111 JAMP-ALPRAZOLAM JAP

01913484 NOVO-ALPRAZOL TEV

00548359 XANAX PFI

Page A-33 de 662014


28:24.08 ANXIOLYTICS, SEDATIVES AND HYPNOTICS - BENZODIAZEPINESALPRAZOLAM



0.5MG Tablet01908170 ALPRAZOLAM PDL

02349205 ALPRAZOLAM SAN

00865400 APO-ALPRAZ APX


02400138 JAMP-ALPRAZOLAM JAP01913492 NOVO-ALPRAZOL TEV

00548367 XANAX PFI

1MG Tablet02248706 ALPRAZOLAM PDL

02243611 APO-ALPRAZ APX


02400146 JAMP-ALPRAZOLAM JAP00723770 XANAX PFI

2MG Tablet02243612 APO-ALPRAZ APX


02400154 JAMP-ALPRAZOLAM JAP00813958 XANAX TS PFI

BROMAZEPAMLimited use benefit (prior approval is not required).


1.5MG Tablet02177153 APO-BROMAZEPAM APX

3MG Tablet02177161 APO-BROMAZEPAM APX

02220520 BROMAZEPAM PDL

00518123 LECTOPAM HLR

02230584 NOVO-BROMAZEPAM TEV

6MG Tablet02177188 APO-BROMAZEPAM APX02220539 BROMAZEPAM PDL00518131 LECTOPAM HLR

02230585 NOVO-BROMAZEPAM TEV

DIAZEPAMLimited use benefit (prior approval is not required).


1MG/ML Oral Solution00891797 PMS-DIAZEPAM PMS

2MG Tablet00405329 APO-DIAZEPAM APX

00434396 DIAZEPAM PDL

02247490 PMS-DIAZEPAM PMS

Page A-34 de 662014


28:24.08 ANXIOLYTICS, SEDATIVES AND HYPNOTICS - BENZODIAZEPINESDIAZEPAM




00313580 DIAZEPAM PRO


00013285 VALIUM HLR


00434388 DIAZEPAM PDL


LORAZEPAMLimited use benefit (prior approval is not required).


0.5MG Tablet00655740 APO-LORAZEPAM APX

02410745 APO-LORAZEPAM SUBLINGUAL APX

02041413 ATIVAN WAY

02041456 ATIVAN SUBLINGUAL WAY

02245784 DOM-LORAZEPAM DPC02351072 LORAZEPAM SAN00711101 NOVO-LORAZEM TEV

00728187 PMS-LORAZEPAM PMS

00655643 PRO-LORAZEPAM PDL

1MG Tablet00655759 APO-LORAZEPAM APX

02410753 APO-LORAZEPAM SUBLINGUAL APX02041421 ATIVAN WAY


02245785 DOM-LORAZEPAM DPC

02351080 LORAZEPAM SAN

00637742 NOVO-LORAZEM TEV

00728195 PMS-LORAZEPAM PMS00655651 PRO-LORAZEPAM PDL

2MG Tablet00655767 APO-LORAZEPAM APX

02410761 APO-LORAZEPAM SUBLINGUAL APX

02041448 ATIVAN WAY


02245786 DOM-LORAZEPAM DPC

02351099 LORAZEPAM SAN

00637750 NOVO-LORAZEM TEV00728209 PMS-LORAZEPAM PMS

00655678 PRO-LORAZEPAM PDL

Page A-35 de 662014


28:24.08 ANXIOLYTICS, SEDATIVES AND HYPNOTICS - BENZODIAZEPINESNITRAZEPAM



5MG Tablet02245230 APO-NITRAZEPAM APX

00511528 MOGADON ICN

02229654 NITRAZADON VAE

02234003 SANDOZ-NITRAZEPAM SDZ

10MG Tablet02245231 APO-NITRAZEPAM APX

00511536 MOGADON ICN

02229655 NITRAZADON VAE

02234007 SANDOZ-NITRAZEPAM SDZ

OXAZEPAMLimited use benefit (prior approval is not required).


10MG Tablet00402680 APO-OXAZEPAM APX

00497754 OXAZEPAM PDL

00414247 OXPAM VAE

00568392 ZAPEX RIV


00497762 OXAZEPAM PDL

00568406 ZAPEX RIV


00497770 OXAZEPAM PDL00414263 OXPAM VAE

00568414 ZAPEX RIV

TEMAZEPAMLimited use benefit (prior approval is not required).


15MG Capsule02225964 APO-TEMAZEPAM APX02244814 CO-TEMAZEPAM ACT

02229756 DOM-TEMAZEPAM DPC

02230095 NOVO-TEMAZEPAM TEV

02243023 RATIO-TEMAZEPAM RPH00604453 RESTORIL ORY

02229760 TEMAZEPAM PDL

Page A-36 de 662014


28:24.08 ANXIOLYTICS, SEDATIVES AND HYPNOTICS - BENZODIAZEPINESTEMAZEPAM



30MG Capsule02225972 APO-TEMAZEPAM APX

02244815 CO-TEMAZEPAM ACT

02229758 DOM-TEMAZEPAM DPC

02230102 NOVO-TEMAZEPAM TEV

02243024 RATIO-TEMAZEPAM RPH00604461 RESTORIL ORY

02229761 TEMAZEPAM PDL

TRIAZOLAMLimited use benefit (prior approval is not required).


0.125MG Tablet00808563 APO-TRIAZO APX

0.25MG Tablet00808571 APO-TRIAZO APX

28:32.28 SELECTIVE SEROTONIN AGONISTSALMOTRIPTAN MALATE



6.25MG Tablet02405792 APO-ALMOTRIPTAN APX

02248128 AXERT MCL

02398435 MYLAN-ALMOTRIPTAN MYL

12.5MG Tablet02405806 APO-ALMOTRIPTAN APX

02248129 AXERT MCL

02398443 MYLAN-ALMOTRIPTAN MYL

02405334 SANDOZ ALMOTRIPTAN SDZ

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


1MG Tablet02237820 AMERGE GSK

02314290 TEVA-NARATRIPTAN TEP

2.5MG Tablet02237821 AMERGE GSK02322323 SANDOZ NARATRIPTAN SDZ02314304 TEVA-NARATRIPTAN TEP

Page A-37 de 662014


28:32.28 SELECTIVE SEROTONIN AGONISTSRIZATRIPTAN



5MG Orally Disintegrating Tablet02393484 APO-RIZATRIPTAN RPD APX

02374730 CO-RIZATRIPTAN ODT ACT

02240518 MAXALT RPD FRS

02379198 MYLAN-RIZATRIPTAN ODT MYL

02393360 PMS-RIZATRIPTAN RDT PMS

02351870 SANDOZ RIZATRIPTAN ODT SDZ

10MG Orally Disintegrating Tablet02393492 APO-RIZATRIPTAN RPD APX02374749 CO-RIZATRIPTAN ODT ACT

02396203 DOM-RIZATRIPTAN RDT DOM

02240519 MAXALT RPD FRS

02379201 MYLAN-RIZATRIPTAN ODT MYL

02393379 PMS-RIZATRIPTAN RDT PMS

02351889 SANDOZ RIZATRIPTAN ODT SDZ

5MG Tablet02393468 APO-RIZATRIPTAN APX

02380455 JAMP-RIZATRIPTAN JAP

02379651 MAR-RIZATRIPTAN MAR

10MG Tablet02393476 APO-RIZATRIPTAN APX02381702 CO RIZATRIPTAN ACT

02380463 JAMP-RIZATRIPTAN JAP02379678 MAR-RIZATRIPTAN MAR

02240521 MAXALT FRS

SUMATRIPTAN SUCCINATELimited use benefit (prior approval is not required).


12MG/ML Injection02212188 IMITREX GSK

99000598 IMITREX GSK *

02361698 TARO-SUMATRIPTAN TAR

25MG Tablet02257882 CO-SUMATRIPTAN ACT

02270749 DOM-SUMATRIPTAN DPC

02268906 GEN-SUMATRIPTAN GEN02286815 NOVO-SUMATRIPTAN DF TEV02256428 PMS-SUMATRIPTAN PMS

02286513 SUMATRIPTAN SAN

50MG Tablet02268388 APO-SUMATRIPTAN APX

02257890 CO-SUMATRIPTAN ACT


02268914 GEN-SUMATRIPTAN GEN02212153 IMITREX DF GSK

02286823 NOVO-SUMATRIPTAN DF TEV

02256436 PMS-SUMATRIPTAN PMS

02324652 PRO-SUMATRIPTAN PDL

02263025 SANDOZ-SUMATRIPTAN SDZ02286521 SUMATRIPTAN SAN

02385570 SUMATRIPTAN DF SIV

Page A-38 de 662014


28:32.28 SELECTIVE SEROTONIN AGONISTSSUMATRIPTAN SUCCINATE



100MG Tablet02268396 APO-SUMATRIPTAN APX

02257904 CO-SUMATRIPTAN ACT


02268922 GEN-SUMATRIPTAN GEN

02212161 IMITREX DF GSK

02239367 NOVO-SUMATRIPTAN TEV

02286831 NOVO-SUMATRIPTAN DF TEV02256444 PMS-SUMATRIPTAN PMS02324660 PRO-SUMATRIPTAN PDL

02263033 SANDOZ-SUMATRIPTAN SDZ

02286548 SUMATRIPTAN SAN

02385589 SUMATRIPTAN DF SIV

ZOLMITRIPTANLimited use benefit (prior approval is not required).


2.5MG Orally Disintegrating Tablet02381575 APO-ZOLMITRIPTAN RAPID APX

02387158 MYLAN ZOLMITRIPTAN ODT MYL

02324768 PMS-ZOLMITRIPTAN ODT PMS

02362996 SANDOZ ZOLMITRIPTAN ODT SDZ

02342545 TEVA-ZOLMITRIPTAN OD TEP02379988 ZOLMITRIPTAN ODT PDL

02243045 ZOMIG RAPIMELT AZC

2.5MG Tablet02380951 APO-ZOLMITRIPTAN APX

02389525 DOM-ZOLMITRIPTAN DOM

02369036 MYLAN ZOLMITRIPTAN MYL

02324229 PMS-ZOLMITRIPTAN PMS02401304 RIVA-ZOLMITRIPTAN RIV

02362988 SANDOZ ZOLMITRIPTAN SDZ

02313960 TEVA-ZOLMITRIPTAN TEP

02379929 ZOLMITRIPTAN PDL

02238660 ZOMIG AZC

28:36.20 ANTIPARKINSONIAN AGENTS - DOPAMINE RECEPTOR AGONISTSCABERGOLINE


For treatment of hyperprolactinemia in patients who have failed therapy with or are intolerant to bromocriptine.

0.5MG Tablet02301407 CO CABERGOLINE ACT

02242471 DOSTINEX PFI

28:92.00 MISCELLANEOUS CENTRAL NERVOUS SYSTEM AGENTSACAMPROSATE CALCIUM


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 Delayed Release Tablet02293269 CAMPRAL MYL

Page A-39 de 662014


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

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

Coverage is granted for 1 device every 12 months.

Device98099999 FLEXI-T IUD PRN

99401085 LIBERTE UT380 SHORT MSC

99401086 LIBERTE UT380 STANDARD MSC

99400482 NOVA-T IUD BEX

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 Chewable Tablet02377608 APO-MONTELUKAST APX02399865 MAR-MONTELUKAST MAR

02379317 MONTELUKAST SAN

02379821 MONTELUKAST PDL

02382458 MONTELUKAST SIV

02380749 MYLAN-MONTELUKAST MYL

02354977 PMS-MONTELUKAST PMS02402793 RAN-MONTELUKAST RBY02330385 SANDOZ MONTELUKAST TEP

02243602 SINGULAIR FRS

02355507 TEVA- MONTELUKAST TEP

5MG Chewable Tablet02377616 APO-MONTELUKAST APX

02399873 MAR-MONTELUKAST MAR


02379848 MONTELUKAST PDL02382466 MONTELUKAST SIV


02354985 PMS-MONTELUKAST PMS02402807 RAN-MONTELUKAST RBY

02330393 SANDOZ MONTELUKAST TEP



Page A-40 de 662014


48:10.24 LEUKOTRIENE MODIFIERSMONTELUKAST



4MG Granules02358611 SANDOZ MONTELUKAST SDZ


10MG Tablet02374609 APO-MONTELUKAST APX

02376695 DOM-MONTELUKAST DOM

02391422 JAMP-MONTELUKAST JAP02399997 MAR-MONTELUKAST MAR


02379856 MONTELUKAST PDL

02382474 MONTELUKAST SIV


02373947 PMS-MONTELUKAST PMS

02389517 RAN-MONTELUKAST RBY02328593 SANDOZ MONTELUKAST SDZ



ZAFIRLUKASTLimited use benefit (prior approval required).


20MG Tablet02236606 ACCOLATE AZC

52:00 EYE, EAR, NOSE AND THROAT (EENT) PREPARATIONS52:28.00 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 APX

02239537 DOM-BENZYDAMINE DPC02229799 NOVO-BENZYDAMINE TEV02229777 PMS-BENZYDAMINE PMS

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 ALL

Page A-41 de 662014


52:92.00 MISCELLANEOUS EENT DRUGSRANIBIZUMAB


For the treatment of:a. Diabetic Macular Edema (DME)b. Wet Age-Related Macular Degeneration (w-AMD)Criteria for coverage of ranibizumab (Lucentis) for DME and w-AMD:• Administered by a qualified ophthalmologist experienced in intravitreal injections• Interval between doses not shorter than 1 monthNote: Coverage will be limited to a maximum of 1 vial of Lucentis per eye treated every 30 daysFor the treatment of diabetic macular edema (DME) for patients who meet the following:• Clinically significant diabetic macular edema for whom laser photocoagulation is also indicated; AND• Have a hemoglobin A1c of less than 11%Initial Coverage for the treatment of neovascular wet age-related macular degeneration (wAMD) where all of the following apply to the eye to be treated:• Best Corrected Visual Acuity (BCVA) is between 6/12 and 6/96• The lesion size is less than or equal to 12 disc areas in greatest linear dimension• There is evidence of recent (< 3 months) presumed disease progression (blood vessel growth, as indicated by fluorescein angiography, or optical coherence tomography (OCT))Note: Coverage will not be approved for patients:• With permanent retinal damage as defined by the Royal College of Ophthalmology guidelines.• Receiving concurrent treatment with verteporfinContinued Coverage:Treatment with Lucentis for wAMD should be continued only in people who maintain adequate response to therapyTreatment with Lucentis should be permanently discontinued if any one of the following occurs:• Reduction in BCVA in the treated eye to less than 15 letters (absolute) on two (2) consecutive visits in the treated eye, attributed toAMD in the absence of other pathology• Reductions in BCVA of 30 letters or more compared to eitherbaseline and/or best recorded level since baseline as this mayindicate either poor treatment effect, adverse events or both.• There is evidence of deterioration of the lesion morphology despite optimum treatment over three (3) consecutive visits.

10MG/ML Injection02296810 LUCENTIS NOV

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

56:00 GASTROINTESTINAL DRUGS56:22.92 MISCELLANEOUS ANTIEMETICS

NABILONELimited use benefit (prior approval required).


OR


0.25MG Capsule02312263 CESAMET VAE

02358077 RAN-NABILONE RBY

02392925 TEVA-NABILONE TEP

0.5MG Capsule02256193 CESAMET VAE02393581 CO NABILONE ACT

02380900 PMS-NABILONE PMS02358085 RAN-NABILONE RBY


Page A-42 de 662014


56:22.92 MISCELLANEOUS ANTIEMETICSNABILONE



OR


1MG Capsule00548375 CESAMET VAE

02393603 CO NABILONE ACT

02380919 PMS-NABILONE PMS

02358093 RAN-NABILONE RBY02384892 TEVA-NABILONE TEP

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.

All proton pump inhibitors (open benefit and limited use (LU) PPIs) have a maximum quantity limit of 400 tablets/capsules per 180 day period. This quantity limit wilbe 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 PPtablets/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 APX

02357682 LANSOPRAZOLE SAN02385767 LANSOPRAZOLE SIV

02353830 MYLAN-LANSOPRAZOLE MYL

02395258 PMS-LANSOPRAZOLE PMS

02165503 PREVACID ABB

02402610 RAN-LANSOPRAZOLE RBY

02385643 SANDOZ LANSOPRAZOLE SDZ

02280515 TEVA-LANSOPRAZOLE TEP

30MG Sustained Release Capsule02293838 APO-LANSOPRAZOLE APX

02357690 LANSOPRAZOLE SAN02366282 LANSOPRAZOLE PDL

02385775 LANSOPRAZOLE SIV

02410389 LANSOPRAZOLE SIV

02353849 MYLAN-LANSOPRAZOLE MYL02395266 PMS-LANSOPRAZOLE PMS

02165511 PREVACID ABB

02402629 RAN-LANSOPRAZOLE RBY

02385651 SANDOZ LANSOPRAZOLE SDZ

02280523 TEVA-LANSOPRAZOLE TEP

Page A-43 de 662014


56:28.36 PROTON-PUMP INHIBITORSLANSOPRAZOLE ODT







15MG Delayed Release Tablet02249464 PREVACID FASTAB TAK

30MG Delayed Release Tablet02249472 PREVACID FASTAB TAK

OMEPRAZOLEThe 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 Delayed Release Capsule02329425 MYLAN-OMEPRAZOLE GEN02296438 SANDOZ OMEPRAZOLE SDZ

20MG Delayed Release Capsule02245058 APO-OMEPRAZOLE APX

00846503 LOSEC AZC

02329433 MYLAN-OMEPRAZOLE GEN

02339927 OMEPRAZOLE PDL

02348691 OMEPRAZOLE SAN

02385384 OMEPRAZOLE SIV02411857 OMEPRAZOLE SIV

02320851 PMS-OMEPRAZOLE PMS

02403617 RAN-OMEPRAZOLE RBY

02296446 SANDOZ OMEPRAZOLE SDZ

Page A-44 de 662014


56:28.36 PROTON-PUMP INHIBITORSOMEPRAZOLE







20MG Delayed Release Tablet02333430 DOM-OMEPRAZOLE DR DOM02190915 LOSEC AZC

02310260 PMS-OMEPRAZOLE DR PMS

02374870 RAN-OMEPRAZOLE RBU

02260867 RATIO-OMEPRAZOLE RPH

02295415 TEVA-OMEPRAZOLE TEP

OMEPRAZOLE (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 Delayed Release Tablet02230737 LOSEC AZC

02260859 RATIO-OMEPRAZOLE RPH

Page A-45 de 662014


56:28.36 PROTON-PUMP INHIBITORSPANTOPRAZOLE







40MG Delayed Release Tablet02300486 ACT PANTOPRAZOLE ACT02292920 APO-PANTOPRAZOLE APX

02310007 DOM-PANTOPRAZOLE DOM

02299585 MYLAN-PANTOPRAZOLE MYL

02309866 PANTOPRAZOLE MEL

02310201 PANTOPRAZOLE SOR

02318695 PANTOPRAZOLE PDL

02370808 PANTOPRAZOLE SAN02385759 PANTOPRAZOLE SIV

02307871 PMS-PANTOPRAZOLE PMS

02316463 RIVA-PANTOPRAZOLE RIV

02301083 SANDOZ-PANTOPRAZOLE SDZ

02285487 TEVA-PANTOPRAZOLE TEP

40MG Enteric Coated Tablet02229453 PANTOLOC NCC

02305046 RAN-PANTOPRAZOLE RBL

Page A-46 de 662014


56:28.36 PROTON-PUMP INHIBITORSRABEPRAZOLE SODIUM







10MG Enteric Coated Tablet02345579 APO-RABEPRAZOLE APX02408392 MYLAN-RABEPRAZOLE MYL

02296632 NOVO-RABEPRAZOLE TEV

02243796 PARIET EC JNO

02381737 PAT-RABEPRAZOLE EC KLA

02310805 PMS-RABEPRAZOLE EC PMS

02315181 PRO-RABEPRAZOLE PDL

02356511 RABEPRAZOLE SAN02385449 RABEPRAZOLE SIV

02298074 RAN-RABEPRAZOLE RBY

02330083 RIVA-RABEPRAZOLE EC RIV

02314177 SANDOZ-RABEPRAZOLE SDZ

20MG Enteric Coated Tablet02345587 APO-RABEPRAZOLE APX

02320460 DOM-RABEPRAZOLE DOM

02408406 MYLAN-RABEPRAZOLE MYL02296640 NOVO-RABEPRAZOLE TEV

02243797 PARIET EC JNO

02381745 PAT-RABEPRAZOLE EC KLA

02310813 PMS-RABEPRAZOLE EC PMS

02315203 PRO-RABEPRAZOLE PDL

02356538 RABEPRAZOLE SAN

02385457 RABEPRAZOLE SIV02298082 RAN-RABEPRAZOLE RBY

02330091 RIVA-RABEPRAZOLE EC RIV02314185 SANDOZ-RABEPRAZOLE SDZ

68:00 HORMONES AND SYNTHETIC SUBSTITUTES68:12.00 CONTRACEPTIVES

LEVONORGESTREL0.75MG Tablet

02364905 NEXT CHOICE ACT

02285576 NORLEVO LAP

02371189 OPTION 2 PER

02241674 PLAN B BAR

Page A-47 de 662014


68:12.00 CONTRACEPTIVESLEVONORGESTREL INTRAUTERINE INSERT


Coverage is granted for 1 device every 2 years.

52MG Intrauterine Insert02243005 MIRENA BAY

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 APX02358840 CO RALOXIFENE ACT

02239028 EVISTA LIL

02358921 PMS-RALOXIFENE PMS

02312298 TEVA-RALOXIFENE TEP

68:20.04 BIGUANIDESSITAGLIPTIN, METFORMIN



50MG & 1000MG Tablet02333872 JANUMET FRS



68:20.05LINAGLIPTIN


For the treatment of patients with type 2 diabetes mellitus who: did not achieve glycemic control or who demonstrated intolerance to an adequate trial of metformin AND a sulfonylurea.

5MG Tablet02370921 TRAJENTA BOE

SAXAGLIPTIN HCLLimited use benefit (prior approval required).


2.5MG Tablet02375842 ONGLYZA BMS

5MG Tablet02333554 ONGLYZA BMS

SITAGLIPTINLimited use benefit (prior approval required).


25MG Tablet02388839 JANUVIA MSP

50MG Tablet02388847 JANUVIA MSP

Page A-48 de 662014


68:20.05SITAGLIPTIN



100MG Tablet02303922 JANUVIA FRS

68:20.28 THIAZOLIDINEDIONESPIOGLITAZONE HCL



15MG Tablet02303442 ACCEL PIOGLITAZONE ACP02242572 ACTOS LIL

02302942 APO-PIOGLITAZONE APX

02302861 CO PIOGLITAZONE ACT

02307634 DOM-PIOGLITAZONE DOM

02298279 GEN-PIOGLITAZONE GEN02326477 JAMP-PIOGLITAZONE MIN

02274914 NOVO-PIOGLITAZONE TEV

02307669 PHL-PIOGLITAZONE PMI

02374013 PIOGLITAZONE SIV

02391600 PIOGLITAZONE ACC

02303124 PMS-PIOGLITAZONE PMS

02312050 PRO-PIOGLITAZONE PDL02375850 RAN-PIOGLITAZONE RBY

02301423 RATIO-PIOGLITAZONE RPH

02297906 SANDOZ PIOGLITAZONE SDZ

02320754 ZYM-PIOGLITAZONE ZYM

30MG Tablet02303450 ACCEL PIOGLITAZONE ACP

02242573 ACTOS LIL

02302950 APO-PIOGLITAZONE APX02302888 CO PIOGLITAZONE ACT


02298287 GEN-PIOGLITAZONE GEN

02326485 JAMP-PIOGLITAZONE MIN02365529 JAMP-PIOGLITAZONE JAP


02307677 PHL-PIOGLITAZONE PMI02339587 PIOGLITAZONE ACC



02312069 PRO-PIOGLITAZONE PDL

02375869 RAN-PIOGLITAZONE RBY




Page A-49 de 662014


68:20.28 THIAZOLIDINEDIONESPIOGLITAZONE HCL



45MG Tablet02303469 ACCEL PIOGLITAZONE ACP

02242574 ACTOS LIL

02302977 APO-PIOGLITAZONE APX

02302896 CO PIOGLITAZONE ACT


02298295 GEN-PIOGLITAZONE GEN02326493 JAMP-PIOGLITAZONE MIN02365537 JAMP-PIOGLITAZONE JAP


02307723 PHL-PIOGLITAZONE PMI

02339595 PIOGLITAZONE ACC



02312077 PRO-PIOGLITAZONE PDL02375877 RAN-PIOGLITAZONE RBY




ROSIGLITAZONE MALEATELimited use benefit (prior approval required).


2MG Tablet02241112 AVANDIA GSK



84:00 SKIN AND MUCOUS MEMBRANE AGENTS (SMMA)84:92.00 MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS

ACITRETINOpen benefit (prior approval not required).

Soriatane 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

IMIQUIMODLimited use benefit (prior approval required).

-For the treatment of condylomata acuminate (genital warts) in patients who have failed:-self-applied podophyllotoxin (podofilox 0.5% solution); OR-provider-applied podophyllum resin (10%-25%)

50MG/G Cream02239505 ALDARA VAE

Page A-50 de 662014


84:92.00 MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTSISOTRETINOIN


Accutane 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 HLR

02257955 CLARUS PRE

40MG Capsule00582352 ACCUTANE HLR

02257963 CLARUS PRE

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 HYDROBROMIDELimited use benefit (prior approval required).


7.5MG Extended Release Tablet02273217 ENABLEX MRL

15MG Extended Release Tablet02273225 ENABLEX MRL

TOLTERODINELimited use benefit (prior approval required).


2MG Extended Release Capsule02244612 DETROL LA PFI

4MG Extended Release Capsule02244613 DETROL LA PFI

1MG Tablet02239064 DETROL PFI

2MG Tablet02239065 DETROL PFI

Page A-51 de 662014


86:12.00 GENITOURINARY SMOOTH MUSCLE RELAXANTSTROSPIUM CHLORIDE


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.

20MG Tablet02275066 TROSEC ORY

86:12.04 ANTIMUSCARINICSSOLIFENACIN SUCCINATE


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 Tablet02277263 VESICARE AST

10MG Tablet02277271 VESICARE AST

88:00 VITAMINS88:28.00 MULTIVITAMIN PREPARATIONS

MULTIVATAMINS (PRENATAL)Tablet

80001842 CENTRUM MATERNA WYA

MULTIVITAMINS (PEDIATRIC)Limited use benefit (prior approval is not required).


Drop00762946 POLY-VI-SOL MJO

Liquid00558079 INFANTOL HOR

Tablet80020794 CENTRUM JUNIOR COMPLETE TB PFI80011134 CENTRUM JUNIOR COMPLETE TAB WYE

02247975 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).

Tablet02229535 MULTI-PRE AND POST NATAL PED80005770 PRENATAL & POSTPARTUM PMT

02241235 PRENATAL AND POSTPARTUM SDR

92:00 UNCLASSIFIED THERAPEUTIC AGENTS92:00.00 UNCLASSIFIED THERAPEUTIC 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 phosphatebinders (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 *

Page A-52 de 662014


92:00.00 UNCLASSIFIED THERAPEUTIC AGENTSUSTEKINUMAB


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

90MG/ML Injection02320681 STELARA JNO

92:01.88MULTIVITAMINS (PEDIATRIC)



Liquid80008471 JAMP-MULTIVITAMIN A/D/ C DROPS JAP

92:08.00DUTASTERIDE


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

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 Tablet02365383 APO-FINASTERIDE APX

02354462 CO FINASTERIDE ACT

02376709 DOM-FINASTERIDE DOM

02350270 FINASTERIDE PDL

02357224 JAMP-FINASTERIDE JAP02389878 MINT-FINASTERIDE MIN

02356058 MYLAN-FINASTERIDE MYL02310112 PMS-FINASTERIDE PMS

02010909 PROSCAR FRS

02371820 RAN-FINASTERIDE RBY

02306905 RATIO-FINASTERIDE TEP

02322579 SANDOZ FINASTERIDE SDZ

02348500 TEVA-FINASTERIDE TEP

92:16.00FEBUXOSTAT

Limited use benefit (prior approval required).For patients with symptomatic gout who have documented hypersensitivity to allopurinol

80MG Tablet02357380 ULORIC TAK

Page A-53 de 662014


92:24.00ALENDRONATE SODIUM



a. - Paget's Disease ORb. - Osteoporosis in patients who are 60 years of age or over ORc. - Osteoporosis in patients under 60 who have documented hip, vertebral or other fractures ORd. - Osteoporosis in patients under 60 with no evidence of fracture but who have a high (>20%) 10-year fracture risk ORe. - Osteoporosis or risk of osteoporosis in patients under 60 who have been, or who will be, on systemic corticosteroid therapy equivalent to a dose of prednisone ≥7.5mg per day for ≥3 months.

5MG Tablet02248727 APO-ALENDRONATE APX02248251 NOVO-ALENDRONATE TEV02384698 RAN-ALENDRONATE RBY

02288079 SANDOZ ALENDRONATE SDZ

10MG Tablet02248728 APO-ALENDRONATE APX

02388545 AURO-ALENDRONATE AUR

02270129 GEN-ALENDRONATE GEN

02394863 MINT-ALENDRONATE MIN02247373 NOVO-ALENDRONATE TEV

02288087 SANDOZ ALENDRONATE SDZ

40MG Tablet02258102 CO-ALENDRONATE ACT

70MG Tablet02352966 ALENDRONATE SAN

02303078 ALENDRONATE-70 PDL02299712 ALENDRONATE-FC SIV

02248730 APO-ALENDRONATE APX

02388553 AURO-ALENDRONATE AUR

02258110 CO-ALENDRONATE ACT

02282763 DOM-ALENDRONATE DOM

02245329 FOSAMAX FRS

02286335 GEN-ALENDRONATE GEN

02385031 JAMP-ALENDRONATE JAP02394871 MINT-ALENDRONATE MIN02261715 NOVO-ALENDRONATE TEV

02273179 PMS-ALENDRONATE PMS

02284006 PMS-ALENDRONATE FC PMS

02275279 RATIO-ALENDRONATE RPH

02270889 RIVA-ALENDRONATE RIV

02288109 SANDOZ ALENDRONATE SDZ02302004 ZYM-ALENDRONATE FC SOR

ALENDRONATE SODIUM, VITAMIN D3Limited use benefit (prior approval required).



70MG & 2800U Tablet02276429 FOSAVANCE FRS

02403633 TEVA-ALENDRONATE CHOLECALCIFEROL TEP

Page A-54 de 662014


92:24.00ALENDRONATE SODIUM, VITAMIN D3




70MG & 5600U Tablet02314940 FOSAVANCE FRS02403641 TEVA-ALENDRONATE CHOLECALCIFEROL TEP

DENOSUMAB (P)Limited use benefit (prior approval required).For women with postmenopausal osteoporosis who would otherwise be eligible for coverage of oral bisphosphonates, but for whom:- bisphosphonates are contraindicated due to hypersensitivity or abnormalities of the esophagus (e.g., esophageal stricture or achalasia); ANDHave at least two of the following:- age >70 years- a prior fragility fracture- a bone mineral density (BMD) T-score ≤ -2.5

60MG/ML Injection (Pre-filled Syringe)02343541 PROLIA AMG

RISEDRONATE SODIUMLimited use benefit (prior approval required).



5MG Tablet02298376 TEVA-RISEDRONATE TEP

5MG Tablet02242518 ACTONEL PGP


02298384 TEVA-RISEDRONATE TEP


02353687 APO-RISEDRONATE APX

02309831 DOM-RISEDRONATE DOM

02368552 JAMP-RISEDRONATE JAP02357984 MYLAN-RISEDRONATE MYL02302209 PMS-RISEDRONATE PMS

02347474 RISEDRONATE PDL

02352141 RISEDRONATE SIV

02370255 RISEDRONATE SAN

02411407 RISEDRONATE-35 SIV

02341077 RIVA-RISEDRONATE RIV

02327295 SANDOZ RISEDRONATE SDZ02298392 TEVA-RISEDRONATE TEP

Page A-55 de 662014


92:24.00ZOLEDRONIC ACID


• For the treatment of Paget’s disease. Coverage will be granted for one dose per 12 month period. OR.

• For women with postmenopausal osteoporosis who would otherwise be eligible for coverage of oral bisphosphonates*, but who have a contraindication to bisphosphonates due to hypersensitivity or abnormalities of the esophagus (e.g, esophageal stricture or achalasia); ANDwho have at least two of the following: • age >70 years • a prior fragility fracture • a bone mineral density (BMD) T-score ≤ -2.5. • a bone mineral density (BMD) T-score ≤ -2.5.

5MG/100ML Injection02269198 ACLASTA NOV

92:36.00 DISEASE-MODIFYING ANTIRHEUMATIC AGENTSABATACEPT


Coverage is provided for the 2 indications.

1. For the treatment of severely active RHEUMATOID ARTHRITIS:

Criteria for initial for one year coverage:•�Prescribed by a rheumatologist

Coverage is provided for in adult patients ≥ 18 years for use, in combination with methotrexate (MTX) or other disease modifying anti-rheumatic drugs (DMARDs), for the reduction in signs and symptoms of severely active RA who has failed:

• MTX (oral or parenteral) at a dose ≥ 20 mg weekly (≥ 15 mg weekly if patient is ≥ 65 years) for a minimum of 12 weeks of continuous treatment. Note: Patients who do not exhibit a clinical response to oral MTX or who experience gastrointestinal intolerance may consider a trial of parenteral MTX.

AND• MTX in combination with at least two other DMARDS, such as sulfasalazine and hydroxychloroquine, for a minimum of 12 weeks of continuous treatment.

AND• Etanercept OR adalimumab OR golimumab OR certolizumab OR abatacept (SC): minimum of 12 weeks trial

OR, if the patient has a contraindication or intolerance to MTX and has failed:• Combination of at least two DMARDS, such as sulfasalazine, hydroxychloroquine, azathioprine, leflunomide, cyclosporine or gold, for a minimum of 12 weeks of continuous treatment.

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; and1000 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 innumber of swollen joints, number of tender joints, ESR or CRP, duration of morning stiffness, Physician Global Assessment scale and Patient Global Assessment scale.

2. For the treatment of JUVENILE IDIOPATHIC ARTHRITIS in children 6 to 17 years who meet all of the following:

Criteria for initial for one year coverage:•�Prescribed by a rheumatologist

•≥ 5 swollen joints; AND•≥ 3 joints with limited range of motion and/or pain/tenderness;ANDCondition is refractory to an adequate trial of a therapeutic dose of MTX. An adequate trial is defined as at least 3 months of oral or parenteral MTX at 10mg/m2 weekly (unless significant toxicity limits the dose tolerated)

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 100kg; 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.

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 100kg; 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 250MG/VIAL INJ BMS

Page A-56 de 662014


92:36.00 DISEASE-MODIFYING ANTIRHEUMATIC AGENTSADALIMUMAB


Coverage is provided in adult patients ≥ 18 years for coverage for a MAXIMUM dose of 40mg every 2 weeks the 2 indications.

1. For the treatment of severely active RHEUMATOID ARTHRITIS

Criteria for initial for one year:•�Prescribed by a rheumatologist

Coverage is provided for use, in combination with methotrexate (MTX) or other disease modifying anti-rheumatic drugs (DMARDs), for the reduction in signs andsymptoms of severely active RA in adult patients ≥ 18 years who has failed:

• MTX (oral or parenteral) at a dose ≥ 20 mg weekly (≥ 15 mg weekly if patient is ≥ 65 years) for a minimum of 12 weeks of continuous treatment. Note: Patientswho do not exhibit a clinical response to oral MTX or who experience gastrointestinal intolerance may consider a trial of parenteral MTX.


OR, if the patient has a contraindication or intolerance to MTX and has failed:

• Combination of at least two DMARDS, such as sulfasalazine, hydroxychloroquine, azathioprine, leflunomide, cyclosporine or gold, for a minimum of 12 weeks ofcontinuous treatment.

2. For the treatment of moderate to severe PSORIATIC ARTHRITIS


Client must have at least two of the following:•5 or more swollen joints•if less than 5 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 inflammation

Patient 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

3. For the treatment of ANKYLOSING SPONDYLITIS


Client who meet the following criteria:

•BASDAI > 4 AND

•patient is refractory to a 4 week trial of at least 3 NSAIDs at maximum tolerated dose AND for peripheral joint involvement, patient is refractory to weeklyparenteral (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.

4. For the treatment of patients with moderate to severe PSORIASIS

Criteria for initial for one year:Prescribed by a dermatologist

Client 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 SeverityIndex (PASI) score and the Dermatology Life Quality Index (DLQI).

Page A-57 de 662014


92:36.00 DISEASE-MODIFYING ANTIRHEUMATIC AGENTS

5. For the treatment of moderately to severely active CROHN'S DISEASE.

Criteria for initial for one year:Prescribed by a gastroenterology specialist

Initial treatment will allow for an induction dose of adalimumab 160mg followed by 80mg 2 weeks later. Maintenance therapy will only be provided at a dose not exceeding 40mg every two weeks.

Criteria for initial four week coverage are: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; PLUS•azathioprine 2 to 2.5 mg/kg/day for a minimum of 3 months; OR•6-mercaptopurine 50 to 70 mg/day for a minimum of 3 months; OR•MTX (oral or parenteral) 15 to 25 mg, per week for a minimum of 3 months.

6. For the treatment of severely active polyarticular JUVENILE IDIOPATHIC ARTHRITIS in children 4 to 17 years


Client who meet ALL of the following criteria:• 5 swollen joints; AND• 3 joints with limited range of motion and/or pain/tenderness; AND• Condition is refractory an adequate trial of a therapeutic dose of MTX. An adequate trial is defined as at least 3 months of oral or parenteral MTX at 10mg/m2 weekly (unless significant toxicity limits the dose tolerated)

40MG/Vial Injection02258595 HUMIRA ABB

CERTOLIZUMAB PEGOLLimited use benefit (prior approval required).

Coverage is provided in adult patients ≥ 18 years. 1. For the treatment of severely active RHEUMATOID ARTHRITIS


Coverage is provided at a dose of 400mg at weeks 0, 2, and 4, followed by 200mg every other week or 400mg every 4 weeks.





• Combination of at least two DMARDS, such as sulfasalazine, hydroxychloroquine, azathioprine, leflunomide, cyclosporine or gold, for a minimum of 12 weeks ofcontinuous treatment

Note: Criteria will be confirmed against patient‟s medication history. Coverage beyond one year will be based on improvement in number of swollen joints, numberof tender joints, ESR, CRP, duration of morning stiffness, Physician Global Assessment scale and Patient Global Assessment scale.

200MG/ML Injection02331675 CIMZIA UCB

Page A-58 de 662014


92:36.00 DISEASE-MODIFYING ANTIRHEUMATIC AGENTSETANERCEPT


The coverage of etanercept in adult patients ≥ 18 years is set at a MAXIMUM dose of 50mg weekly for the four indications.1.

For the treatment of severely active RHEUMATOID ARTHRITIS

Criteria for initial one year:- Prescribed by a rheumatologist

Coverage is provided for use, in combination with methotrexate (MTX) or other disease modifying anti-rheumatic drugs (DMARDs), for the reduction in signs and symptoms of severely active RA in adult patients ≥ 18 years who have failed:

- MTX (oral or parenteral a dose ≥ 20mg weekly (≥ 15 mg weekly if patient is ≥ 65 years) for a minimum of 12 weeks of continuous treatment. Note: Patients who do not exhibit a clinical response to oral MTX or who experience gastrointestinal intolerance may consider a trial of parenteral MTX.

AND- MTX in combination with at least two other DMARDs, such as sulfasalazine and hydroxycholorquine, for a minimum of 12 weeks of continuous treatment.


- Combination of at least two DMARDs, such as sulfasalazine, hydroxychloroquine, azathioprine, leflunomide, cyclosporine or gold, for a minimum of 12 weeks of contiuous treament, or are refractory to a combination of at least 2 DMARDs


Criteria for initial for one year:- Prescribed by a rheumatologist

Client must have at least two of the following:

- 5 or more swollen joints- if less than 5 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 imflammation

Patient 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


Criteria for initial one year:- Prescribed by rheumatologist

Client who meet all of the following criteria:- 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 ANDsulfasalazine 2g/day for four months

Note: For axial involvement, patient does not need to be tried on MTX or sulfasalazine.


Criteria who meet all the following criteria:

- ≥ 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

Page A-59 de 662014

JDUMAIS

Sticky Note

MigrationConfirmed set by JDUMAIS

JDUMAIS

Sticky Note

Accepted set by JDUMAIS

JDUMAIS

Sticky Note

MigrationConfirmed set by JDUMAIS

JDUMAIS

Sticky Note

Marked set by JDUMAIS

JDUMAIS

Typewritten Text

JDUMAIS

Typewritten Text

JDUMAIS

Typewritten Text

JDUMAIS

Typewritten Text

JDUMAIS

Typewritten Text

JDUMAIS

Typewritten Text


92:36.00 DISEASE-MODIFYING ANTIRHEUMATIC AGENTSETANERCEPT


The coverage of etanercept in adult patients ≥ 18 years is set at a MAXIMUM dose of 50mg weekly for the four indications.1.

For the treatment of severely active RHEUMATOID ARTHRITIS

Criteria for initial one year:- Prescribed by a rheumatologist

Coverage is provided for use, in combination with methotrexate (MTX) or other disease modifying anti-rheumatic drugs (DMARDs), for the reduction in signs and symptoms of severely active RA in adult patients ≥ 18 years who have failed:

- MTX (oral or parenteral a dose ≥ 20mg weekly (≥ 15 mg weekly if patient is ≥ 65 years) for a minimum of 12 weeks of continuous treatment. Note: Patients who do not exhibit a clinical response to oral MTX or who experience gastrointestinal intolerance may consider a trial of parenteral MTX.

AND- MTX in combination with at least two other DMARDs, such as sulfasalazine and hydroxycholorquine, for a minimum of 12 weeks of continuous treatment.


- Combination of at least two DMARDs, such as sulfasalazine, hydroxychloroquine, azathioprine, leflunomide, cyclosporine or gold, for a minimum of 12 weeks of contiuous treament, or are refractory to a combination of at least 2 DMARDs


Criteria for initial for one year:- Prescribed by a rheumatologist

Client must have at least two of the following:

- 5 or more swollen joints- if less than 5 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 imflammation

Patient 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


Criteria for initial one year:- Prescribed by rheumatologist

Client who meet all of the following criteria:

- 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 ANDsulfasalazine 2g/day for four months

Note: For axial involvement, patient does not need to be tried on MTX or sulfasalazine.


Criteria who meet all the following criteria: - ≥ 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).

50MG/ML Injection 02274728 ENBREL IMX

2014 Page A-60 de 66


92:36.00 DISEASE-MODIFYING ANTIRHEUMATIC AGENTSGOLIMUMAB


The coverage of golimumab in adult patients ≥ 18 years is set at a MAXIMUM dose of 50mg every month for the 3 indications.

1. For the treatment of severely active RHEUMATOID ARTHRITIS.:


Client who meet all of the following criteria:








Client who meet all least 2 of the following criteria:

- 5 or more swollen joints- if less than 5 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 inflammation

Patient 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.

3. 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 weeklyparenteral (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 KEG02324776 SIMPONI PRE-FILLED KEG

Page A-61 de 662014


92:36.00 DISEASE-MODIFYING ANTIRHEUMATIC AGENTSINFLIXIMAB


The coverage of etanercept in adult patients ≥ 18 years for 12 weeks for the 4 indications.

1. For the treatment of severely active RHEUMATOID ARTHRITIS



• MTX (oral or parenteral) at a dose ≥ 20 mg weekly (≥ 15 mg weekly if patient is ≥ 65 years) for a minimum of 12 weeks of continuous treatment. Note: Patients who do not exhibit a clinical response to oral MTX or who experience gastrointestinal intolerance may consider a trial of parenteral MTX.


AND• Etanercept OR adalimumab OR golimumab OR certolizumab OR abatacept (SC): minimum of 12 weeks trial



CRITERIA FOR CONTINUED COVERAGE FOR INFLIXIMAB BEYOND TWELVE WEEKS

Patient 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

2. For the treatment of FISTULIZING CROHN‟S DISEASE

Criteria for initial for one year:•�Prescribed by a gastroenterology specialist

The 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 initialdoses.

Patient meets all the following criteria:

•Patient is an adult with actively draining perianal or entercutaneous fistula(e) that have recurred or persisted despite:-a course of appropriate antibiotic therapy (e.g. ciprofloxacin with or without metronidazole for a minimum of 3 weeks)PLUS-immunosuppressive therapy:•azathioprine 2 to 2.5mg/kg/day for a minimum of 6 weeks or treatment discontinued before 6 weeks due to severe adverse reactions.OR•6-mercaptopurine, 50-70mg/day for a minimum of 6 weeks or treatment discontinued before 6 weeks due to severe adverse reactions.OR• OR Other.

3. For the treatment for SEVERE ACTIVE CROHN`S DISEASE

Criteria for initial for one year:•�Prescribed by a gastroenterology specialist

The 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 initialdoses.

Patient meets the following criteria:

Patient is an adult with severe active Crohn‟s disease that has recurred or persisted despite:•Therapy with 5-ASA products (at least 3g/day for a minimum of 6 weeks).PLUS•Glucocorticoids equivalent to prednisone 40mg/day for a minimum of 2 weeks.OR •Treatment discontinued due to serious adverse reactions OROR

Page A-62 de 662014


92:36.00 DISEASE-MODIFYING ANTIRHEUMATIC AGENTS•Contraindication to glucocorticoid therapy.PLUS•Azathioprine 2 to 2.5mg/kg/day for a minimum of 3 months.OR•6-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 CER

TOCILIZUMABLimited use benefit (prior approval required).

The coverage of tocilizumab is for 16 weeks. Patient must had a tuberculin skin test performed. Tocilizumab should not be used in combination with anti-TNF agents.

1. For the treatment of moderate to severely active RHEUMATOID ARTHRITIS


For patients who have failed to respond to an adequate trial of an anti-TNF agent Note: Treatment should be combined with methotrexate or other DMARD.

Coverage is initially provided for 16 weeks at an initial dose of 4 mg/kg/dose every 4 weeks.

2. For the treatment of active SYSTEMIC JUVENILE IDIOPATHIC ARTHRITIS Criteria for initial for one year:•�Prescribed by a rheumatologist

Coverage is for patients two years of age and older who have responded inadequately to non-steroidal anti-inflammatory drugs (NSAIDs) and systemic corticosteroids (with or without methotrexate), due to intolerance or lack of efficacy. Coverage is initially provided for 16-week at a dose of 12 mg/kg once every two weeks for children weighing < 30 kg and 8 mg/kg for children weighing > 30 kg.

80MG/4ML Injection02350092 ACTEMRA HLR



92:44.00CYCLOSPORINE


For transplant therapy.

10MG Capsule02237671 NEORAL NVR


02247073 SANDOZ-CYCLOSPORINE SDZ





100MG/ML Solution02150697 NEORAL NVR

Page A-63 de 662014


92:44.00MYCOPHENOLATE MOFETIL



250MG Capsule02352559 APO-MYCOPHENOLATE APX

02192748 CELLCEPT HLR

02386399 JAMP-MYCOPHENOLATE JAP

02371154 MYLAN-MYCOPHENOLATE MYL

02320630 SANDOZ MYCOPHENOLATE SDZ

02364883 TEVA-MYCOPHENOLATE TEP

500MG Tablet02352567 APO-MYCOPHENOLATE APX02237484 CELLCEPT HLR

02379996 CO MYCOPHENOLATE ACT

02380382 JAMP-MYCOPHENOLATE JAP

02370549 MYLAN-MYCOPHENOLATE MYL

02313855 SANDOZ MYCOPHENOLATE SDZ

02348675 TEVA-MYCOPHENOLATE TEP

MYCOPHENOLATE SODIUMLimited use benefit (prior approval required).


180MG Enteric Coated Tablet02264560 MYFORTIC NVR

360MG Enteric Coated Tablet02264579 MYFORTIC NVR

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

TACROLIMUSLimited use benefit (prior approval required).


0.5MG Capsule02243144 PROGRAF AST

1MG Capsule02175991 PROGRAF AST

5MG Capsule02175983 PROGRAF AST

0.5MG Extended Release Capsule02296462 ADVAGRAF AST

1MG Extended Release Capsule02296470 ADVAGRAF AST



5MG/ML Injection02176009 PROGRAF AST

Page A-64 de 662014


92:92.00BOTULINUM 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)

50U Injection09857386 BOTOX ALL



INCOBOTULINUMTOXINALimited use benefit (prior approval required).

-Treatment of strabismus and blepharospasm associated with dystonia, including benign essential blepharospasm or VII nerve disorder in patients 12 years of age or older-Treatment of cervical dystonia (spasmodic torticollis)

100U/VIAL Injection02324032 XEOMIN MEZ

94:00 DEVICES94:00.00 DEVICES

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

Coverage is granted for 1 spacer device every 12 months.

Device96899962 AEROCHAMBER AC BOYZ TRU

96899963 AEROCHAMBER AC GIRLZ TRU

96899969 AEROCHAMBER PLUS FLOW-VU LG TRU

96899970 AEROCHAMBER PLUS FLOW-VU MED TRU96899968 AEROCHAMBER PLUS FLOW-VU MOUTH TRU

96899971 AEROCHAMBER PLUS FLOW-VU SM TRU

99400507 E-Z SPACER WEP99400511 E-Z SPACER (MASK ONLY) WEP

99400508 E-Z SPACER WITH SMALL MASK WEP

99400501 OPTICHAMBER AUC

96899961 OPTICHAMBER DIAMOND (CHAMBER) AUC

96899958 OPTICHAMBER DIAMOND (LARGE M) AUC

96899959 OPTICHAMBER DIAMOND (MEDIUM M) AUC

96899960 OPTICHAMBER DIAMOND (MEDIUM M) AUC

99400504 OPTICHAMBER LARGE MASK AUC99400503 OPTICHAMBER MEDIUM MASK AUC99400502 OPTICHAMBER SMALL MASK AUC

99400505 OPTIHALER AUC

99400787 POCKET CHAMBER MCA

99400791 POCKET CHAMBER WITH ADULT MASK MCA

99400788 POCKET CHAMBER WITH INFANT MASK MCA

99400790 POCKET CHAMBER WITH MEDIUM MASK MCA99400789 POCKET CHAMBER WITH SMALL MASK MCA

Page A-65 de 662014


96:00 PHARMACEUTICAL AIDS96:00.00 PHARMACEUTICAL AIDS

METHADONE HCL (PA)limited use benefit (prior approval required) with the following criteria:


Methadone pseudo DINs listed for the treatment of pain should not be used for methadone maintenance therapy. Methadone for the treatment of opioid dependencyis an open benefit covered under the NIHB Program (Methadone maintenance therapy pseudo DIN 908835). For information regarding the adjudication rules of methadone for the treatment of opioid dependency, please refer to the NIHB Provider Guide for Pharmacy Benefits.

Powder09991180 METHADONE POWDER (PAIN) UNK

Page A-66 de 662014

Page

Non-Insured Health BenefitsAppendix ALimited Use Benefits and Criteria

Page Page1

172821729232ABILIFY49ACCEL PIOGLITAZONE41ACCOLATE51ACCUTANE17ACET CODEINE 3024ACETAMIN CHILD24ACETAMINOPHEN16ACETYLSALICYLIC ACID56ACLASTA46ACT PANTOPRAZOLE63ACTEMRA55ACTONEL49ACTOS15ADCIRCA64ADVAGRAF10ADVAIR10ADVAIR DISKUS 10010ADVAIR DISKUS 25010ADVAIR DISKUS 50065AEROCHAMBER AC BOYZ65AEROCHAMBER AC GIRLZ65AEROCHAMBER PLUS FLOW-VU

LG65AEROCHAMBER PLUS FLOW-VU

MED65AEROCHAMBER PLUS FLOW-VU

MOUTH65AEROCHAMBER PLUS FLOW-VU

SM15AGGRENOX50ALDARA54ALENDRONATE54ALENDRONATE-7054ALENDRONATE-FC41ALPHAGAN P33ALPRAZOLAM37AMERGE25APO-ACETAMINOPHEN54APO-ALENDRONATE37APO-ALMOTRIPTAN33APO-ALPRAZ41APO-BENZYDAMINE34APO-BROMAZEPAM26APO-CLONAZEPAM14APO-CLOPIDOGREL10APO-CYCLOBENZAPRINE34APO-DIAZEPAM4APO-ENTECAVIR

19APO-FENTANYL53APO-FINASTERIDE27APO-GABAPENTIN20APO-HYDROMORPHONE5APO-IMATINIB

43APO-LANSOPRAZOLE29APO-LEVETIRACETAM1APO-LEVOFLOXACIN

35APO-LORAZEPAM35APO-LORAZEPAM SUBLINGUAL1APO-MINOCYCLINE

40APO-MONTELUKAST

64APO-MYCOPHENOLATE36APO-NITRAZEPAM44APO-OMEPRAZOLE36APO-OXAZEPAM17APO-OXYCODONE/ACET46APO-PANTOPRAZOLE49APO-PIOGLITAZONE30APO-PREGABALIN47APO-RABEPRAZOLE48APO-RALOXIFENE55APO-RISEDRONATE7APO-RIVASTIGMINE

38APO-RIZATRIPTAN38APO-RIZATRIPTAN RPD38APO-SUMATRIPTAN36APO-TEMAZEPAM11APO-TIZANIDINE37APO-TRIAZO39APO-ZOLMITRIPTAN39APO-ZOLMITRIPTAN RAPID3APTIVUS

16ASA16ASA EC16ASAPHEN16ASAPHEN EC16ASATAB16ASPIRIN24ATASOL26ATASOL FORTE16ATASOL-1516ATASOL-3035ATIVAN35ATIVAN SUBLINGUAL54AURO-ALENDRONATE10AURO-CYCLOBENZAPRINE27AURO-GABAPENTIN29AURO-LEVETIRACETAM50AVANDIA53AVODART37AXERT32BANZEL 100MG TAB32BANZEL 200MG TAB32BANZEL 400MG TAB65BOTOX34BROMAZEPAM32BUPROPION SR39CAMPRAL40CARNITOR40CARNITOR IV16CELEBREX64CELLCEPT3CELSENTRI

52CENTRUM JUNIOR COMPLETE TB

52CENTRUM JUNIOR COMPLETE TAB

52CENTRUM MATERNA42CESAMET12CHAMPIX12CHAMPIX STARTER PACK24CHILDREN'S ACETAMINOPHEN25CHILDREN'S TYLENOL SOFT

CHEWS

58CIMZIA51CLARUS26CLONAPAM14CLOPIDOGREL15CO BOSENTAN39CO CABERGOLINE14CO CLOPIDOGREL19CO FENTANYL53CO FINASTERIDE64CO MYCOPHENOLATE42CO NABILONE49CO PIOGLITAZONE30CO PREGABALIN48CO RALOXIFENE38CO RIZATRIPTAN6CO TEMOZOLOMIDE

54CO-ALENDRONATE26CO-CLONAZEPAM18CODEINE18CODEINE CONTIN CR18CODEINE PHOSPHATE27CO-GABAPENTIN29CO-LEVETIRACETAM1CO-LEVOFLOXACIN

38CO-RIZATRIPTAN ODT38CO-SUMATRIPTAN36CO-TEMAZEPAM10CYCLOBENZAPRINE51DETROL51DETROL LA34DIAZEPAM20DILAUDID21DOLORAL 121DOLORAL 554DOM-ALENDRONATE41DOM-BENZYDAMINE26DOM-CLONAZEPAM26DOM-CLONAZEPAM-R14DOM-CLOPIDOGREL10DOM-CYCLOBENZAPRINE53DOM-FINASTERIDE27DOM-GABAPENTIN29DOM-LEVETIRACETAM35DOM-LORAZEPAM1DOM-MINOCYCLINE

41DOM-MONTELUKAST45DOM-OMEPRAZOLE DR46DOM-PANTOPRAZOLE49DOM-PIOGLITAZONE30DOM-PREGABALIN47DOM-RABEPRAZOLE55DOM-RISEDRONATE38DOM-RIZATRIPTAN RDT38DOM-SUMATRIPTAN36DOM-TEMAZEPAM39DOM-ZOLMITRIPTAN39DOSTINEX19DURAGESIC MAT51ELIDEL13ELIQUIS51ENABLEX59ENBREL17ENDOCET

Page A-1 of 42014

Page


Page Page16EURO-ASA48EVISTA16EXDOL-1516EXDOL-307EXELON

65E-Z SPACER65E-Z SPACER (MASK ONLY)65E-Z SPACER WITH SMALL MASK14EZETROL19FENTANYL24FEVERHALT53FINASTERIDE40FLEXI-T IUD52FLINTSTONES EXTRA C9FORADIL

54FOSAMAX54FOSAVANCE27GABAPENTIN28GD-GABAPENTIN30GD-PREGABALIN54GEN-ALENDRONATE33GEN-ALPRAZOLAM26GEN-CLONAZEPAM10GEN-CYCLOPRINE27GEN-GABAPENTIN49GEN-PIOGLITAZONE38GEN-SUMATRIPTAN11GEN-TIZANIDINE5GLEEVEC

12HABITROL58HUMIRA20HYDROMORPH CONTIN38IMITREX38IMITREX DF5INCIVEK

52INFANTOL2INTELENCE3ISENTRESS

26JAMP-ACETAMINOPHEN54JAMP-ALENDRONATE33JAMP-ALPRAZOLAM10JAMP-CYCLOBENZAPRINE53JAMP-FINASTERIDE27JAMP-GABAPENTIN29JAMP-LEVETIRACETAM41JAMP-MONTELUKAST53JAMP-MULTIVITAMIN A/D/ C

DROPS64JAMP-MYCOPHENOLATE49JAMP-PIOGLITAZONE55JAMP-RISEDRONATE38JAMP-RIZATRIPTAN48JANUMET48JANUVIA22KADIAN22KADIAN SR29KEPPRA43LANSOPRAZOLE34LECTOPAM1LEVAQUIN

29LEVETIRACETAM40LIBERTE UT380 SHORT40LIBERTE UT380 STANDARD

18LINCTUS CODEINE35LORAZEPAM44LOSEC16LOWPRIN42LUCENTIS30LYRICA21M.O.S.21M.O.S. 1021M.O.S. 2021M.O.S. 4021M.O.S. 5022M.O.S. 6021M.O.S. SR23M.O.S. SULFATE40MAR-MONTELUKAST38MAR-RIZATRIPTAN38MAXALT38MAXALT RPD22M-ESLON22M-ESLON SR21METADOL66METHADONE POWDER (PAIN)21METHADOSE21METHADOSE SUGARFREE2MINOCIN1MINOCYCLINE

54MINT-ALENDRONATE14MINT-CLOPIDOGREL53MINT-FINASTERIDE7MINT-RIVASTIGMINE

48MIRENA36MOGADON40MONTELUKAST22MORPHINE SR22MS CONTIN SR23MS IR52MULTI-PRE AND POST NATAL64MYFORTIC39MYLAN ZOLMITRIPTAN39MYLAN ZOLMITRIPTAN ODT37MYLAN-ALMOTRIPTAN15MYLAN-BOSENTAN32MYLAN-BUPROPION XL14MYLAN-CLOPIDOGREL19MYLAN-FENTANYL53MYLAN-FINASTERIDE28MYLAN-GABAPENTIN6MYLAN-GALANTAMINE ER

43MYLAN-LANSOPRAZOLE1MYLAN-LEVOFLOXACIN

40MYLAN-MONTELUKAST64MYLAN-MYCOPHENOLATE44MYLAN-OMEPRAZOLE46MYLAN-PANTOPRAZOLE47MYLAN-RABEPRAZOLE55MYLAN-RISEDRONATE7MYLAN-RIVASTIGMINE

38MYLAN-RIZATRIPTAN ODT63NEORAL14NEULASTA27NEURONTIN47NEXT CHOICE12NICODERM

11NICORETTE11NICORETTE PLUS11NICOTINE12NICOTROL TRANSDERMAL11NICOTROL TRANSDERMAL 10MG12NICOTROL TRANSDERMAL 15MG11NICOTROL TRANSDERMAL 5MG36NITRAZADON47NORLEVO40NOVA-T IUD54NOVO-ALENDRONATE33NOVO-ALPRAZOL41NOVO-BENZYDAMINE34NOVO-BROMAZEPAM26NOVO-CLONAZEPAM10NOVO-CYCLOPRINE27NOVO-GABAPENTIN25NOVO-GESIC1NOVO-LEVOFLOXACIN

35NOVO-LORAZEM1NOVO-MINOCYCLINE

49NOVO-PIOGLITAZONE47NOVO-RABEPRAZOLE7NOVO-RIVASTIGMINE

39NOVO-SUMATRIPTAN38NOVO-SUMATRIPTAN DF36NOVO-TEMAZEPAM44OMEPRAZOLE9ONBREZ

48ONGLYZA65OPTICHAMBER65OPTICHAMBER DIAMOND

(CHAMBER)65OPTICHAMBER DIAMOND

(LARGE M)65OPTICHAMBER DIAMOND

(MEDIUM M)65OPTICHAMBER LARGE MASK65OPTICHAMBER MEDIUM MASK65OPTICHAMBER SMALL MASK65OPTIHALER47OPTION 256ORENCIA 250MG/VIAL INJ36OXAZEPAM9OXEZE TURBUHALER

36OXPAM23OXYCODONE17OXYCODONE/ACET23OXY-IR46PANTOLOC46PANTOPRAZOLE47PARIET EC6PAT-GALANTAMINE ER

47PAT-RABEPRAZOLE EC1PDL-MINOCYCLINE

24PEDIAPHEN25PEDIAPHEN CHEWABLE TAB

160MG25PEDIAPHEN CHEWABLE TAB

80MG24PEDIATRIX3PEGASYS3PEGASYS RBV

Page A-2 of 42014

Page


Page Page4PEGETRON4PEGETRON REDIPEN

17PERCOCET17PERCOCET DEMI26PHL-CLONAZEPAM26PHL-CLONAZEPAM-R10PHL-CYCLOBENZAPRINE20PHL-HYDROMORPHONE49PHL-PIOGLITAZONE49PIOGLITAZONE47PLAN B14PLAVIX14PMS CLOPIDOGREL24PMS-ACETAMINOPHEN17PMS-ACETAMINOPHEN WITH

CODEINE54PMS-ALENDRONATE54PMS-ALENDRONATE FC41PMS-BENZYDAMINE15PMS-BOSENTAN32PMS-BUPROPION SR26PMS-CLONAZEPAM26PMS-CLONAZEPAM R18PMS-CODEINE10PMS-CYCLOBENZAPRINE34PMS-DIAZEPAM19PMS-FENTANYL53PMS-FINASTERIDE27PMS-GABAPENTIN6PMS-GALANTAMINE ER

20PMS-HYDROMORPHONE43PMS-LANSOPRAZOLE29PMS-LEVETIRACETAM1PMS-LEVOFLOXACIN

35PMS-LORAZEPAM1PMS-MINOCYCLINE2PMS-MONOCYCLINE

40PMS-MONTELUKAST42PMS-NABILONE44PMS-OMEPRAZOLE45PMS-OMEPRAZOLE DR23PMS-OXYCODONE46PMS-PANTOPRAZOLE49PMS-PIOGLITAZONE30PMS-PREGABALIN47PMS-RABEPRAZOLE EC48PMS-RALOXIFENE55PMS-RISEDRONATE7PMS-RIVASTIGMINE

38PMS-RIZATRIPTAN RDT38PMS-SUMATRIPTAN39PMS-ZOLMITRIPTAN39PMS-ZOLMITRIPTAN ODT65POCKET CHAMBER65POCKET CHAMBER WITH ADULT

MASK65POCKET CHAMBER WITH INFANT

MASK65POCKET CHAMBER WITH

MEDIUM MASK65POCKET CHAMBER WITH SMALL

MASK52POLY-VI-SOL

13PRADAXA30PREGABALIN31PREGABALIN-15030PREGABALIN-2530PREGABALIN-5031PREGABALIN-7552PRENATAL & POSTPARTUM52PRENATAL AND POSTPARTUM43PREVACID44PREVACID FASTAB16PRO-ASA16PRO-ASA EC32PRO-BUPROPION SR17PROCET-3026PRO-CLONAZEPAM27PRO-GABAPENTIN64PROGRAF29PRO-LEVETIRACETAM55PROLIA35PRO-LORAZEPAM17PRO-OXYCOD ACET49PRO-PIOGLITAZONE47PRO-RABEPRAZOLE53PROSCAR38PRO-SUMATRIPTAN51PROTOPIC47RABEPRAZOLE54RAN-ALENDRONATE14RAN-CLOPIDOGREL19RAN-FENTANYL53RAN-FINASTERIDE27RAN-GABAPENTIN43RAN-LANSOPRAZOLE29RAN-LEVETIRACETAM40RAN-MONTELUKAST42RAN-NABILONE44RAN-OMEPRAZOLE46RAN-PANTOPRAZOLE49RAN-PIOGLITAZONE30RAN-PREGABALIN47RAN-RABEPRAZOLE64RAPAMUNE54RATIO-ALENDRONATE32RATIO-BUPROPION18RATIO-CODEINE10RATIO-CYCLOBENZAPRINE17RATIO-EMTEC-3053RATIO-FINASTERIDE28RATIO-GABAPENTIN17RATIO-LENOLTEC NO.217RATIO-LENOLTEC NO.31RATIO-MINOCYCLINE

21RATIO-MORPHINE22RATIO-MORPHINE SULFATE SR45RATIO-OMEPRAZOLE17RATIO-OXYCOCET18RATIO-OXYCODAN49RATIO-PIOGLITAZONE7RATIO-RIVASTIGMINE

14RATIO-SILDENAFIL R36RATIO-TEMAZEPAM63REMICADE52RENAGEL

36RESTORIL14REVATIO55RISEDRONATE55RISEDRONATE-355RITUXAN

14RIVA CLOPIDOGREL54RIVA-ALENDRONATE26RIVA-CLONAZEPAM17RIVACOCET10RIVA-CYCLOBENZAPRINE27RIVA-GABAPENTIN1RIVA-MINOCYCLINE

46RIVA-PANTOPRAZOLE30RIVA-PREGABALIN47RIVA-RABEPRAZOLE EC55RIVA-RISEDRONATE16RIVASA39RIVA-ZOLMITRIPTAN26RIVOTRIL54SANDOZ ALENDRONATE37SANDOZ ALMOTRIPTAN15SANDOZ BOSENTAN14SANDOZ CLOPIDOGREL19SANDOZ FENTANYL53SANDOZ FINASTERIDE43SANDOZ LANSOPRAZOLE1SANDOZ LEVOFLOXACIN

40SANDOZ MONTELUKAST64SANDOZ MYCOPHENOLATE37SANDOZ NARATRIPTAN44SANDOZ OMEPRAZOLE17SANDOZ OXYCOD ACET49SANDOZ PIOGLITAZONE30SANDOZ PREGABALIN55SANDOZ RISEDRONATE7SANDOZ RIVASTIGMINE

38SANDOZ RIZATRIPTAN ODT39SANDOZ ZOLMITRIPTAN39SANDOZ ZOLMITRIPTAN ODT32SANDOZ-BUPROPION SR26SANDOZ-CLONAZEPAM63SANDOZ-CYCLOSPORINE1SANDOZ-MINOCYCLINE

36SANDOZ-NITRAZEPAM46SANDOZ-PANTOPRAZOLE47SANDOZ-RABEPRAZOLE38SANDOZ-SUMATRIPTAN33SAPHRIS10SEREVENT DISKHALER10SEREVENT DISKUS61SIMPONI61SIMPONI PRE-FILLED40SINGULAIR50SORIATANE8SPIRIVA

22STATEX53STELARA24SUBOXONE24SUBOXONE MAINTENANCE38SUMATRIPTAN38SUMATRIPTAN DF23SUPEUDOL5SUTENT

Page A-3 of 42014

Page


Page Page9SYMBICORT 100 TURBUHALER9SYMBICORT 200 TURBUHALER

26TANTAPHEN24TANTAPHEN GRAPE5TARCEVA

38TARO-SUMATRIPTAN36TEMAZEPAM6TEMODAL

24TEMPRA25TEMPRA DOUBLE STRENGTH40TEVA- MONTELUKAST54TEVA-ALENDRONATE

CHOLECALCIFEROL14TEVA-CLOPIDOGREL18TEVA-FENTANYL53TEVA-FINASTERIDE6TEVA-GALANTAMINE ER

20TEVA-HYDROMORPHONE5TEVA-IMATINIB

43TEVA-LANSOPRAZOLE23TEVA-MORPHINE SR 100MG TAB22TEVA-MORPHINE SR 15MG TAB23TEVA-MORPHINE SR 200MG TAB22TEVA-MORPHINE SR 30MG TAB22TEVA-MORPHINE SR 60MG TAB64TEVA-MYCOPHENOLATE42TEVA-NABILONE37TEVA-NARATRIPTAN45TEVA-OMEPRAZOLE46TEVA-PANTOPRAZOLE30TEVA-PREGABALIN48TEVA-RALOXIFENE55TEVA-RISEDRONATE39TEVA-ZOLMITRIPTAN39TEVA-ZOLMITRIPTAN OD11THRIVE15TRACLEER48TRAJENTA12TRANSDERMAL NICOTINE17TRIATEC-3052TROSEC25TYLENOL26TYLENOL EXTRA STRENGTH24TYLENOL GRAPE25TYLENOL JR STRENGTH

FASTMELTS25TYLENOL JUNIOR STRENGTH17TYLENOL WITH CODEINE NO.217TYLENOL WITH CODEINE NO.353ULORIC35VALIUM52VESICARE2VFEND4VICTRELIS4VICTRELIS TRIPLE

29VIMPAT3VIREAD

42VISUDYNE15VOLIBRIS32WELLBUTRIN SR32WELLBUTRIN XL33XANAX34XANAX TS

13XARELTO65XEOMIN11ZANAFLEX36ZAPEX33ZELDOX9ZENHALE

39ZOLMITRIPTAN39ZOLMITRIPTAN ODT39ZOMIG39ZOMIG RAPIMELT32ZYBAN54ZYM-ALENDRONATE FC26ZYM-CLONAZEPAM49ZYM-PIOGLITAZONE2ZYVOXAM

Page A-4 of 42014

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 AGENTS

DARBEPOETIN ALFA

25MCG/ML Injection

02246354 ARANESP AMG40MCG/ML Injection




02246360 ARANESP AMG

EPOETIN ALFA


02206072 EPREX JNO5,000IU/ML Injection

02243400 EPREX JNO1,000IU/0.5ML Prefilled Syringe






02243403 EPREX JNO10,000IU/ML Prefilled Syringe


02243239 EPREX JNO40,000IU/ML Prefilled Syringe

02240722 EPREX JNO

40:00 ELECTROLYTIC, CALORIC, AND

WATER BALANCE


CALCIUM (CALCIUM GLUCONOLACTATE,

CALCIUM CARBONATE)

300MG & 2940MG Effervescent Tablet

02232482 CALCIUM SANDOZ NVC1750MG & 2327MG Effervescent Tablet

02232483 GRAMCAL NVC

CALCIUM CARBONATE

500MG Capsule

00648353 CALSAN NVC500MG Chewable Tablet

00705373 CALCIUM WAM00648345 CALSAN NVC

250MG Tablet

00682047 APO-CAL 250 APX00645958 CALCIUM TEV

PHOSPHORUS

500MG Effervescent Tablet

00225819 PHOSPHATE-NOVARTIS NVR

ZINC GLUCONATE

50MG Tablet

00503169 ZINC VTH00505463 ZINC JAM


56:04.00 ANTACIDS AND ADSORBENTS

ALUMINUM HYDROXIDE

500MG Capsule

02135620 BASALJEL AXC60MG/ML Liquid

00572527 ALUGEL ATL64MG/ML Liquid

02125862 AMPHOJEL AXC600MG Tablet

02124971 AMPHOJEL AXC

CALCIUM CARBONATE

500MG Tablet

01970240 TUMS GSK750MG Tablet

01967932 TUMS EXTRA STRENGTH GSK1000MG Tablet

02151138 TUMS ULTRA STRENGTH GSK

Page B-1 of 22014


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.

88:00 VITAMINS


VITAMIN B COMPLEX

Tablet

00123803 B COMPLEX PLUS C JAM

88:12.00 VITAMIN C

VITAMIN B COMPLEX WITH VITAMIN C

Tablet

02245391 DIAMINE EUO


MULTIVITAMINS

Tablet

02244872 REPLAVITE WNP00558796 STRESS PLEX C JAM

96:00 PHARMACEUTICAL AIDS

96:00.00 PHARMACEUTICAL AIDS

NUTRITIONAL SUPPLEMENT

Liquid

09853723 NEPRO ABB00907995 NOVASOURCE NVR09853731 SUPLENA ABB

235ML Liquid

99002639 NEPRO ABB99002647 SUPLENA ABB

Powder

09991056 RESOURCE BENEPROTEIN NVR

Page B-2 of 22014

Page


1ALUGEL1ALUMINUM HYDROXIDE

1AMPHOJEL1APO-CAL 2501ARANESP2B COMPLEX PLUS C1BASALJEL1CALCIUM1CALCIUM (CALCIUM

GLUCONOLACTATE, CALCIUM

CARBONATE)

1CALCIUM CARBONATE

1CALCIUM SANDOZ1CALSAN1DARBEPOETIN ALFA

2DIAMINE1EPOETIN ALFA

1EPREX1GRAMCAL2MULTIVITAMINS

2NEPRO2NOVASOURCE2NUTRITIONAL SUPPLEMENT

1PHOSPHATE-NOVARTIS1PHOSPHORUS

2REPLAVITE2RESOURCE BENEPROTEIN2STRESS PLEX C2SUPLENA1TUMS1TUMS EXTRA STRENGTH1TUMS ULTRA STRENGTH2VITAMIN B COMPLEX

2VITAMIN B COMPLEX WITH

VITAMIN C

1ZINC1ZINC GLUCONATE

Page B-1 of 12014

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 DRUGS


ANTISPASMODICS

ATROPINE SULFATE

0.4mg/mL Injection

00392782 ATROPINE SULFATE SDZ

00497231 ATROPINE SULFATE ABB


0.6mg/mL Injection

00012076 ATROPINE SULFATE GSK


00497258 ATROPINE SULFATE ABB

GLYCOPYRROLATE

0.2mg/mL Injection

02039508 GLYCOPYRROLATE SDZ

HYOSCINE BUTYLBROMIDE

20mg/mL Injection

00363839 BUSCOPAN BOE

02229868 HYOSCINE SDZ


ANTISPASMODICS

SCOPOLAMINE HYDROBROMIDE

0.4mg/mL Injection

00541869 SCOPOLAMINE ABB

02242810 SCOPOLAMINE OMG

0.6mg/mL Injection

00541877 SCOPOLAMINE ABB

02242811 SCOPOLAMINE OMG

1.5MG Patch

80024336 TRANSDERM-V NOV

Page C-1 of 62014






28:00 CENTRAL NERVOUS SYSTEM

AGENTS

28:04.00 GENERAL ANESTHETICS

KETAMINE

10mg/mL Injection

00224391 KETALAR ERF

02246795 KETAMINE SDZ

50mg/mL Injection

00224405 KETALAR ERF

02246796 KETAMINE SDZ


FENTANYL

12mcg Transdermal Patch


02311925 TEVA-FENTANYL TEV

12mcg/h Transdermal Patch

02341379 PMS-FENTANYL MTX PMS

02330105 RAN-FENTANYL MATRIX RBY


FENTANYL







02314630 NOVO-FENTANYL TEV






Page C-2 of 62014







FENTANYL

















FENTANYL






FENTANYL CITRATE

50mcg/mL Injection

00888346 FENTANYL CITRATE HOS

02126648 FENTANYL CITRATE HOS

02240434 FENTANYL CITRATE SDZ

HYDROMORPHONE HYDROCHLORIDE

2mg/mL Injection

02145901 HYDROMORPHONE SDZ

10mg/mL Injection

02145928 HYDROMORPHONE HP SDZ

20mg/mL Injection


Page C-3 of 62014







HYDROMORPHONE HYDROCHLORIDE

50mg/mL Injection


METHADONE HYDROCHLORIDE

1mg/mL Liquid


10mg/mL Liquid


1MG Tablet


5MG Tablet


10MG Tablet


25MG Tablet



MORPHINE SULFATE

0.5mg/mL Injection

02021056 MORPHINE LP EPIDURAL SDZ

01949047 MORPHINE-EPD ABB

1mg/mL Injection

01980696 MORPHINE SDZ

02021048 MORPHINE LP EPIDURAL SDZ

01949055 MORPHINE-EPD ABB

2mg/mL Injection

00850314 MORPHINE ABB



5mg/mL Injection


10mg/mL Injection

00850322 MORPHINE ABB

00392588 MORPHINE SULFATE SDZ

Page C-4 of 62014







MORPHINE SULFATE

15mg/mL Injection

00392561 MORPHINE SULFATE SDZ

25mg/mL Injection

00676411 MORPHINE HP SDZ

50mg/mL Injection

02137267 MORPHINE FAU

00617288 MORPHINE HP SDZ


METHOTRIMEPRAZINE

25mg/mL Injection

01927698 NOZINAN SAC

28:24.08 ANXIOLYTICS, SEDATIVES AND HYPNOTICS - BENZODIAZEPINES

DIAZEPAM

5mg/mL Injection

02065614 DIAZEMULS VL ACG

00399728 DIAZEPAM SDZ



LORAZEPAM

4mg/mL Injection

02243278 LORAZEPAM SDZ

MIDAZOLAM

1mg/mL Injection

02240285 MIDAZOLAM SDZ

02242904 MIDAZOLAM PPC

02243934 MIDAZOLAM TEV

5mg/mL Injection

02240286 MIDAZOLAM SDZ

02242905 MIDAZOLAM PPC

02243935 MIDAZOLAM TEV

Page C-5 of 62014








NABILONE

0.25MG Capsule

02312263 CESAMET VAE



0.5MG Capsule







NABILONE

1MG Capsule






56:32.00 PROKINETIC AGENTS

METOCLOPRAMIDE

5mg/mL Injection

02185431 METOCLOPRAMIDE SDZ

02243563 METOCLOPRAMIDE OMEGA OMG

56:92.00 MISCELLANEOUS GI DRUGS

METHYLNALTREXONE BROMIDE

20mg/mL Injection

02308215 RELISTOR WYE

Page C-6 of 62014

APPENDIX D LIST OF DRUG MANUFACTURERS

MFR Manufacturer Name MFR Manufacturer Name

Non-Insured Health BenefitsAppendix D

List of Drug Manufacturers

AAP AA PHARMA INC.

ABB ABBOTT LABORATORIES LIMITED

ACG ACTAVIS GROUP PTC EHF

ACN ACTELION PHARMACEUTICALS LTD

ACP ACCEL PHARMA INC

ADA ADAMS LABS LIMITED

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

AUR AURO PHARMA INC

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

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

CDX CANDERM PHARMA

CEN CENTOCOR INCORPORATED

CIP CIPHER PHARMACEUTICALS INCORPORATED

COB COBALT PHARMACEUTICALS INCORPORATED

COP COLGATE ORAL PHRAMACEUTICALS INCORPORATED

CUV CHAUVIN PHARMACEUTICALS LIMITED

CYX CYTEX PHARMACEUTICALS INCORPORATED

DCM D & C MOBILITY

DDP THE D DROPS COMPANY INCORPORATED

DER DERMIK LABORATORIES CANADA INCORPORATED

DKT DIOPTIC LABORATORIES INCORPORATED

DOR DORMER LABORATORIES INCORPORATED

DPC DOMINION PHARMACAL

DPI DOMREX PHARMA INC

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

Page D-1 of 42014




FEI FERRING INCORPORATED

FOU FOURNIER PHARMA INCORPORATED

FRS MERCK FROSST CANADA LIMITED

GAC GALDERMA CANADA INCORPORATED

GCL GALEN CHEMICALS LIMITED

GEE GENZYME CANADA INCORPORATED

GIL GILEAD SCIENCES INCORPORATED

GLE GLENWOOD LABORATORIES CANADA LIMITED

GMP GENERIC MEDICAL PARTNERS INC

GSC GELDA SCIENTIFIC & INDUSTRIAL DEVELOPMENT CORP

GSK GLAXOSMITHKLINE INCORPORATED

HIL HILL DERMACEUTICALS INCORPORATED

HJS H.J. SUTTON INDUSTRIES LIMITED

HLR HOFFMAN-LAROCHE LIMITED

HOL HOLLISTER LIMITED

HOR CARTER-HORNER CORPORATION

HOS HOSPIRA HEALTHCARE CORPORATION

HPC HEALTHPOINT CANADA ULC

HRA HRA PHARMA

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

LAL LABORATOIRE LALCO INCORPORATED

LEO LEO PHARMA INCORPORATED

LIL ELI LILLY CANADA INCORPORATED

LUD LUNDBECK CANADA INCORPORATED

MAB MEDA AB

MAN MANTRA PHARMA INC

MAR MARCAN PHARMACEUTICALS INC

MAY MAYNE PHARMA (CANADA) INCORPORATED

MCA MCARTHUR MEDICAL SALES INCORPORATED

MCL MCNEIL CONSUMER PRODUCTS COMPANY

MDC MEDICIS CANADA CORPORATION

MDS MEDISCA PHARMACEUTIQUE INC

MDT MEDTRONIC OF CANADA LIMITED

MEL MELIAPHARM INC

MET MEDICAL TEXTILES MARKETING INCORPORATED

MEZ MERZ PHARMACEUTICALS GMBH

MIN MINT PHARMACEUTICALS INCORPORATED

MJO MEAD JOHNSON CANADA INCORPORATED

MMH 3M PHARMACEUTICALS

MMT MM THERAPEUTICS INC.

MPD MEDICAL PLASTIC DEVICES INCORPORATED

MSL MEDIC SAVOURE LIMITED

MSP MERCK FROSST / SCHERING PHARMA GP

MTH MM THERAPEUTICS INC

MTI MEDICAN TECHNOLOGIES INCORPORATED

MYL MYLAN PHARMACEUTICALS ULC

NCA NOVA DIABETES CARE

NEO NEOLAB INCORPORATED

Page D-2 of 42014




NOO NOVO NORDISK CANADA INCORPORATED

NUR NUTRICORP INTERNATIONAL

NVC NOVARTIS CONSUMER HEALTH CANADA INCORPORATED

NVR NOVARTIS PHARMACEUTICALS CANADA INCORPORATED

NXP NU-PHARM 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

PDL PRO DOC LIMITED

PED PENDOPHARM INCORPORATED

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

PMJ PHARMACIA CANADA INCORPORATED

PMS PHARMASCIENCE INCORPORATED

PMT PHARMETICS INCORPORATED

PPC PHARMACEUTICAL PARTNERS OF CANADA,INC

PRO PROVAL PHARMA INCORPORATED

QLT QLT INCORPORATED

RBP RB PHARMACEUTICALS LIMITED

RIV LABORATORIE RIVA INCORPORATED

ROD ROCHE DIAGNOSTICS

RPH RATIOPHARM INCORPORATED

RVX RIVEX PHARMA INCORPORATED

RWP RW PACKAGING LIMITED

SAC SANOFI-AVENTIS CANADA

SAN SANIS HEALTH INC

SCH SCHERING CANADA INCORPORATED

SCN SCHEIN PHARMACEUTICAL CANADA INCORPORATED

SDR STANLEY PHARMACEUTICALS LIMITED

SDZ SANDOZ CANADA INCORPORATED

SEV SERVIER CANADA INCORPORATED

SHI SHIRE CANADA INCORPORATED

SHM SHERWOOD INCORPORATED

SIG SIGMA-TAU PHARMACEUTICALS INCORPORATED

SNE SMITH & NEPHEW INCORPORATED

SOR SORRES PHARMA INC

SPH SOLVAY PHARMA INCORPORATED

SQU SQUIRE PHARMACEUTICALS INCORPORATED

STE STERIMAX INCORPORATED

STG LABORATOIRES STERIGEN INC

STI STIEFEL CANADA INCORPORATED

SUN SUN PHARMA GLOBAL FZE

SWS SWISS HERBAL REMEDIES LIMITED

TAK TAKEDA PHARMACEUTICALS AMERICA INC

TAN TANTA PHARMACEUTICALS INCORPORATED

TAR TARO PHARMACEUTICALS INCORPORATED

TEV TEVA CANADA LIMITED

TIP H & P INDUSTRIES / THE TRIAD-GROUP

TRE TREMBLAY HARRISON INC

Page D-3 of 42014




TRI TRIANON LABORATORIES INCORPORATED

TRT TRITON PHARMA INCORPORATED

TRU TRUDELL MEDICAL INTERNATIONAL

TSN TRIMEDIC SUPPLY NETWORK LTD

UCB UBC PHARMA INCORPORATED

UMI ULTIMED, INCORPORATED

VAE VALEANT CANADA LIMITED

VAO VALEO PHARMA INCORPORATED

VTH VITA HEALTH PRODUCTS 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

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

ZYM ZYMCAN PHARMACEUTICALS

Page D-4 of 42014

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);Tranxene® and generics (clorazepate); andImovane® and generics (zopiclone).

The following drugs are excluded from the NIHB Program as recommended by the Common Drug Review (CDR) and the NIHB Drugs and Therapeutics Advisory Committee (DTAC) 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 E

EXCLUSIONS

DIN BRAND NAMEMFR

02248722 ALL ACULAR LS 0.4% OPHTHALMIC SOLUTION02259052 AST AMEVIVE 15MG/0.5ML POWDER FOR SOLUTION02247916 BAY CIPRO XL 500MG TABLET02251787 BAY CIPRO XL 1000MG TABLET02248417 FEI GYNAZOLE-1 VAG CREAM 2%02216167 SAC IMOVANE 5MG TABLET01926799 SAC IMOVANE 7.5MG TABLET02244521 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 12014

ALPHABETICAL INDEX OF DRUG PRODUCTS

Page


Page Page542825429293TC


8ABACAVIR

8ABACAVIR, LAMIVUDINE

8ABACAVIR, LAMIVUDINE,

ZIDOVUDINE

131ABATACEPT

58ABENOL70ABILIFY82ACAMPROSATE CALCIUM

108ACARBOSE

111ACCEL PIOGLITAZONE38ACCEL-AMLODIPINE65ACCEL-CITALOPRAM3ACCEL-CLARITHROMYCIN

64ACCEL-TOPIRAMATE88ACCOLATE84ACCU-CHEK ADVANTAGE84ACCU-CHEK AVIVA84ACCU-CHEK AVIVA (ON)84ACCU-CHEK COMPACT84ACCU-CHEK COMPACT (ON)84ACCU-CHEK MOBILE84ACCU-CHEK MOBILE (ON)

135ACCU-CHEK MULTICLIX44ACCUPRIL44ACCURETIC

122ACCUTANE84ACCUTREND (ON)84ACCUTREND GLUCOSE35ACEBUTOLOL35ACEBUTOLOL HCL

58ACET58ACET 12058ACET 32558ACET 65053ACET CODEINE 3058ACETAMIN CHILD58ACETAMINOPHEN

58ACETAMINOPHEN53ACETAMINOPHEN, CAFFEINE

CITRATE, CODEINE PHOSPHATE

53ACETAMINOPHEN, CAFFEINE,

CODEINE PHOSPHATE

53ACETAMINOPHEN, CODEINE

PHOSPHATE

53ACETAMINOPHEN, OXYCODONE

HCL

92ACETAZOLAMIDE

50ACETYLSALICYLIC ACID50ACETYLSALICYLIC ACID

54ACETYLSALICYLIC ACID,

CAFFEINE CITRATE, CODEINE

PHOSPHATE

54ACETYLSALICYLIC ACID,

OXYCODONE HCL

121ACITRETIN

131ACLASTA101ACT PANTOPRAZOLE132ACTEMRA131ACTONEL111ACTOS90ACULAR

10ACYCLOVIR

10ACYCLOVIR39ADALAT XL

131ADALIMUMAB

120ADAPALENE

134ADAPTOR117ADASEPT33ADCIRCA

134ADHESIVE PAD WITH COTTON134ADHESIVE PAD WITHOUT

COTTON19ADRENALIN

133ADVAGRAF19ADVAIR19ADVAIR DISKUS 10019ADVAIR DISKUS 25019ADVAIR DISKUS 50051ADVIL51ADVIL JUNIOR STRENGTH51ADVIL PEDIATRIC1AERIUS1AERIUS KIDS

134AEROCHAMBER AC BOYZ134AEROCHAMBER AC GIRLZ134AEROCHAMBER PLUS FLOW-VU

LG134AEROCHAMBER PLUS FLOW-VU

MED134AEROCHAMBER PLUS FLOW-VU

MOUTH134AEROCHAMBER PLUS FLOW-VU

SM34AGGRENOX25AGRYLIN19AIROMIR91ALBALON91ALBALON A

134ALCOHOL PREP SWAB134ALCOHOL SWAB134ALCOHOL SWABS BD87ALDACTAZIDE-2587ALDACTAZIDE-5049ALDACTONE

122ALDARA130ALENDRONATE129ALENDRONATE SODIUM

130ALENDRONATE SODIUM,

VITAMIN D3

130ALENDRONATE-70130ALENDRONATE-FC76ALERTEC

107ALESSE (21)107ALESSE (28)126ALFACALCIDOL

20ALFUZOSIN HYDROCHLORIDE

14ALKERAN1ALLEGRA1ALLEGRA 24HR1ALLER-AIDE

114ALLERGENIC EXTRACT NON POLLENS

114ALLERGENIC EXTRACT POLLENS114ALLERGENIC EXTRACTS

1ALLERGY1ALLERGY FORMULA

1ALLERGY RELIEF ES19ALLERJECT1ALLERNIX1ALLERNIX MULTI SYMPTOM1ALLERNIX PLUS

129ALLOPRIN129ALLOPURINOL

129ALLOPURINOL79ALMOTRIPTAN MALATE

89ALOCRIL93ALOMIDE91ALPHAGAN91ALPHAGAN P76ALPRAZOLAM76ALPRAZOLAM

44ALTACE45ALTACE HCT13ALTRETAMINE

105ALVESCO107ALYSENA (21)107ALYSENA (28)

8AMANTADINE HCL

34AMBRISENTAN

117AMCINONIDE

79AMERGE87AMI-HYDRO86AMILORIDE HCL

87AMILORIDE HCL,

HYDROCHLOROTHIAZIDE

27AMIODARONE27AMIODARONE HCL

65AMITRIPTYLINE65AMITRIPTYLINE HCL

38AMLODIPINE

38AMLODIPINE39AMLODIPINE, ATORVASTATIN

39AMLODIPINE, TELMISARTAN

38AMLODIPINE-ODAN3AMOXICILLIN

3AMOXICILLIN4AMOXICILLIN SUGAR REDUCED

100AMOXICILLIN,

CLARITHROMYCIN,

LANSOPRAZOLE

4AMOXICILLIN, CLAVULANIC ACID

4AMOXI-CLAV4AMPICILLIN

66ANAFRANIL25ANAGRELIDE HCL

15ANANDRON52ANAPROX52ANAPROX DS13ANASTROZOLE

106ANDRIOL13ANDROCUR97ANETHOLE

128ANHYDROUS MAGNESIUM

CITRATE

119ANODAN-HC91ANTAZOLINE PHOSPHATE,

NAPHAZOLINE HCL

120ANTHRAFORTE120ANTHRANOL-1120ANTHRANOL-2120ANTHRASCALP

Page I-1 of 242014

Page


Page Page115ANTIBIOTIC OINTMENT95ANTI-DIARRHEAL

119ANUGESIC HC119ANUSOL HC98ANZEMET

110APIDRA110APIDRA CARTRIDGE110APIDRA SOLOSTAR23APIXABAN

42APO ENALAPRIL51APO KETO-E35APO-ACEBUTOLOL59APO-ACETAMINOPHEN92APO-ACETAZOLAMIDE10APO-ACYCLOVIR

129APO-ALENDRONATE20APO-ALFUZOSIN ER

129APO-ALLOPURINOL79APO-ALMOTRIPTAN76APO-ALPRAZ86APO-AMILORIDE87APO-AMILZIDE27APO-AMIODARONE65APO-AMITRIPTYLINE38APO-AMLODIPINE3APO-AMOXI4APO-AMOXI CLAV4APO-AMOXI SUGAR FREE4APO-AMPICILLIN

13APO-ANASTROZOLE50APO-ASA50APO-ASEN ECT36APO-ATENIDONE35APO-ATENOL28APO-ATORVASTATIN

132APO-AZATHIOPRINE3APO-AZITHROMYCIN

20APO-BACLOFEN89APO-BECLOMETHASONE41APO-BENAZEPRIL17APO-BENZTROPINE91APO-BENZYDAMINE13APO-BICALUTAMIDE95APO-BISACODYL36APO-BISOPROLOL91APO-BRIMONIDINE76APO-BROMAZEPAM81APO-BROMOCRIPTINE85APO-CAL 50045APO-CANDESARTAN46APO-CANDESARTAN/HCTZ41APO-CAPTO60APO-CARBAMAZEPINE36APO-CARVEDILOL2APO-CEFACLOR2APO-CEFADROXIL2APO-CEFPROZIL2APO-CEFUROXIME2APO-CEPHALEX1APO-CETIRIZINE

87APO-CHLORTHALIDONE41APO-CILAZAPRIL42APO-CILAZAPRIL HCTZ98APO-CIMETIDINE

5APO-CIPROFLOX66APO-CITALOPRAM3APO-CLARITHROMYCIN6APO-CLINDAMYCIN

77APO-CLOBAZAM66APO-CLOMIPRAMINE59APO-CLONAZEPAM32APO-CLONIDINE25APO-CLOPIDOGREL70APO-CLOZAPINE89APO-CROMOLYN20APO-CYCLOBENZAPRINE13APO-CYPROTERONE66APO-DESIPRAMINE

112APO-DESMOPRESSIN105APO-DEXAMETHASONE77APO-DIAZEPAM50APO-DICLO51APO-DICLO SR51APO-DIFLUNISAL41APO-DILTIAZ40APO-DILTIAZ CD40APO-DILTIAZ SR40APO-DILTIAZ TZ98APO-DIMENHYDRINATE91APO-DIPIVEFRIN34APO-DIPYRIDAMOLE34APO-DIPYRIDAMOLE SC60APO-DIVALPROEX95APO-DOCUSATE CALCIUM95APO-DOCUSATE SODIUM

101APO-DOMPERIDONE92APO-DORZO-TIMOP34APO-DOXAZOSIN66APO-DOXEPIN6APO-DOXY

42APO-ENALAPRIL MALEATE/HCTZ11APO-ENTECAVIR3APO-ERYTHRO3APO-ERYTHRO BASE3APO-ERYTHRO S3APO-ERYTHRO-S

11APO-FAMCICLOVIR99APO-FAMOTIDINE28APO-FENOFIBRATE28APO-FENO-MICRO28APO-FENO-SUPER54APO-FENTANYL23APO-FERROUS GLUCONATE23APO-FERROUS SULFATE FC

129APO-FINASTERIDE27APO-FLECAINIDE59APO-FLOCTAFENINE7APO-FLUCONAZOLE

81APO-FLUNARIZINE67APO-FLUOXETINE71APO-FLUPHENAZINE51APO-FLURBIPROFEN13APO-FLUTAMIDE90APO-FLUTICASONE67APO-FLUVOXAMINE

125APO-FOLIC ACID42APO-FOSINOPRIL86APO-FUROSEMIDE

61APO-GABAPENTIN28APO-GEMFIBROZIL

111APO-GLICLAZIDE111APO-GLYBURIDE71APO-HALOPERIDOL33APO-HYDRALAZINE87APO-HYDRO87APO-HYDROCLOROTHIAZIDE55APO-HYDROMORPHONE12APO-HYDROXYQUINE14APO-HYDROXYUREA79APO-HYDROXYZINE51APO-IBUPROFEN14APO-IMATINIB67APO-IMIPRAMINE87APO-INDAPAMIDE51APO-INDOMETHACIN17APO-IPRAVENT46APO-IRBESARTAN46APO-IRBESARTAN/HCTZ33APO-ISDN33APO-ISMN86APO-K51APO-KETO52APO-KETO SR7APO-KETOCONAZOLE

52APO-KETO-E90APO-KETOROLAC1APO-KETOTIFEN

85APO-LACTULOSE9APO-LAMIVUDINE9APO-LAMIVUDINE HBV9APO-LAMIVUDINE-ZIDOVUDINE

62APO-LAMOTRIGINE100APO-LANSOPRAZOLE92APO-LATANOPROST

132APO-LEFLUNOMIDE14APO-LETROZOLE62APO-LEVETIRACETAM91APO-LEVOBUNOLOL81APO-LEVOCARB81APO-LEVOCARB CR5APO-LEVOFLOXACIN

43APO-LISINOPRIL43APO-LISINOPRIL (TYPE Z)43APO-LISINOPRIL/HCTZ79APO-LITHIUM CARB79APO-LITHIUM CARBONATE95APO-LOPERAMIDE1APO-LORATADINE

77APO-LORAZEPAM77APO-LORAZEPAM SUBLINGUAL47APO-LOSARTAN47APO-LOSARTAN/HCTZ29APO-LOVASTATIN

113APO-MEDROXY52APO-MEFENAMIC14APO-MEGESTROL52APO-MELOXICAM

109APO-METFORMIN32APO-METHAZIDE-1532APO-METHAZIDE-2592APO-METHAZOLAMIDE71APO-METHOPRAZINE

Page I-2 of 242014

Page


Page Page15APO-METHOTREXATE32APO-METHYLDOPA76APO-METHYLPHENIDATE76APO-METHYLPHENIDATE 54MG

ER76APO-METHYLPHENIDATE SR

101APO-METOCLOP37APO-METOPROLOL37APO-METOPROLOL SR37APO-METOPROLOL-L12APO-METRONIDAZOLE18APO-MIDODRINE6APO-MINOCYCLINE

68APO-MIRTAZAPINE99APO-MISOPROSTOL68APO-MOCLOBEMIDE90APO-MOMETASONE88APO-MONTELUKAST

132APO-MYCOPHENOLATE37APO-NADOL52APO-NAPRO NA52APO-NAPRO NA DS52APO-NAPROXEN52APO-NAPROXEN EC39APO-NIFED39APO-NIFED PA78APO-NITRAZEPAM12APO-NITROFURANTOIN33APO-NITROGLYCERIN99APO-NIZATIDINE5APO-NORFLOX

68APO-NORTRIPTYLINE5APO-OFLOX

89APO-OFLOXACIN72APO-OLANZAPINE71APO-OLANZAPINE ODT89APO-OLOPATADINE

100APO-OMEPRAZOLE98APO-ONDANSETRON18APO-ORCIPRENALINE78APO-OXAZEPAM

123APO-OXTRIPHYLLINE123APO-OXYBUTYNIN53APO-OXYCODONE/ACET

101APO-PANTOPRAZOLE68APO-PAROXETINE4APO-PEN VK

26APO-PENTOXIFYL72APO-PERPHENAZINE73APO-PIMOZIDE37APO-PINDOL

111APO-PIOGLITAZONE53APO-PIROXICAM81APO-PRAMIPEXOLE30APO-PRAVASTATIN34APO-PRAZO

106APO-PREDNISONE63APO-PREGABALIN59APO-PRIMIDONE27APO-PROCAINAMIDE73APO-PROCHLORAZINE27APO-PROPAFENONE38APO-PROPRANOLOL44APO-QUINAPRIL

44APO-QUINAPRIL/HCTZ101APO-RABEPRAZOLE108APO-RALOXIFENE44APO-RAMIPRIL45APO-RAMIPRIL/HCTZ99APO-RANITIDINE

110APO-REPAGLINIDE131APO-RISEDRONATE74APO-RISPERIDONE16APO-RIVASTIGMINE80APO-RIZATRIPTAN79APO-RIZATRIPTAN RPD82APO-ROPINIROLE30APO-ROSUVASTATIN19APO-SALVENT19APO-SALVENT CFC FREE82APO-SELEGILINE69APO-SERTRALINE31APO-SIMVASTATIN38APO-SOTALOL99APO-SUCRALFATE6APO-SULFAMETHOXAZOLE6APO-SULFATRIM6APO-SULFATRIM DS6APO-SULFATRIM PED

87APO-SULFINPYRAZONE53APO-SULIN80APO-SUMATRIPTAN15APO-TAMOX20APO-TAMSULOSIN CR78APO-TEMAZEPAM34APO-TERAZOSIN7APO-TERBINAFINE6APO-TETRA

82APO-TETRABENAZINE123APO-THEO123APO-THEO LA25APO-TICLOPIDINE38APO-TIMOL91APO-TIMOP20APO-TIZANIDINE

111APO-TOLBUTAMIDE64APO-TOPIRAMATE69APO-TRAZODONE69APO-TRAZODONE D87APO-TRIAZIDE79APO-TRIAZO75APO-TRIFLUOPERAZINE17APO-TRIHEX12APO-TRIMETHOPRIM70APO-TRIMIP70APO-TRIMIPRAMINE11APO-VALGANCICLOVIR64APO-VALPROIC48APO-VALSARTAN49APO-VALSARTAN/HCTZ70APO-VENLAFAXINE XR41APO-VERAP41APO-VERAP SR25APO-WARFARIN10APO-ZIDOVUDINE80APO-ZOLMITRIPTAN80APO-ZOLMITRIPTAN RAPID92APRACLONIDINE HCL

106APRI (21)106APRI (28)10APTIVUS

126AQUASOL E132ARAVA130AREDIA IV13ARIMIDEX70ARIPIPRAZOLE

120ARISTOCORT C120ARISTOCORT R106ARISTOSPAN13AROMASIN51ARTHROTEC93ARTIFICIAL TEARS93ARTIFICIAL TEARS EXTRA50ASA50ASA 81MG50ASA EC

101ASACOL50ASAPHEN50ASAPHEN EC50ASATAB50ASATAB EC84ASCENSIA BREEZE 284ASCENSIA BREEZE 2 (ON)84ASCENSIA CONTOUR84ASCENSIA CONTOUR (ON)

125ASCORBIC ACID

126ASCORBIC ACID70ASENAPINE

106ASMANEX TWISTHALER50ASPIRIN45ATACAND46ATACAND PLUS79ATARAX58ATASOL59ATASOL FORTE53ATASOL-1553ATASOL-308ATAZANAVIR SULFATE

35ATENOLOL35ATENOLOL

36ATENOLOL, CHLORTHALIDONE

116ATHLETES FOOT SPRAY77ATIVAN77ATIVAN SUBLINGUAL28ATORVASTATIN28ATORVASTATIN CALCIUM

28ATORVASTATIN-1029ATORVASTATIN-2029ATORVASTATIN-4029ATORVASTATIN-8012ATOVAQUONE

8ATRIPLA90ATROPINE90ATROPINE SULFATE

90ATROPINE SULPHATE MINIMS93ATROVENT17ATROVENT HFA

103AURANOFIN

129AURO-ALENDRONATE38AURO-AMLODIPINE3AURO-AMOXICILLIN2AURO-CEFPROZIL

Page I-3 of 242014

Page


Page Page2AURO-CEFUROXIME5AURO-CIPROFLOXACIN

66AURO-CITALOPRAM20AURO-CYCLOBENZAPRINE61AURO-GABAPENTIN62AURO-LAMOTRIGINE62AURO-LEVETIRACETAM43AURO-LISINOPRIL52AURO-MELOXICAM67AURO-MIRTAZAPINE OD9AURO-NEVIRAPINE

68AURO-PAROXETINE73AURO-QUETIAPINE44AURO-RAMIPRIL69AURO-SERTRALINE7AURO-TERBINAFINE

64AURO-TOPIRAMATE46AVALIDE

112AVANDIA46AVAPRO68AVENTYL

107AVIANE (21)107AVIANE (28)129AVODART79AXERT99AXID92AZARGA

132AZATHIOPRINE132AZATHIOPRINE

121AZELAIC ACID

3AZITHROMYCIN3AZITHROMYCIN

92AZOPT115BACIMYXIN115BACITIN115BACITRACIN115BACITRACIN

89BACITRACIN ZINC, POLYMYXIN B

SULFATE

20BACLOFEN20BACLOFEN

86BACTERIOSTATIC NACL116BACTIGRAS115BACTROBAN64BANZEL 100MG TAB64BANZEL 200MG TAB64BANZEL 400MG TAB

120BARRIERE119BARRIERE HC137BD 0.3ML SYR WITH U/F 6MM

NEED134B-D ALCOHOL SWAB135BD AUTOSHIELD PEN NEEDLE135B-D DISPOSABLE 5/8 INCH 5122135B-D DISPOSABLE ½ INCH 5109135B-D DISPOSABLE 1 INCH 5155135B-D DISPOSABLE 1½ INCH 5127135B-D DISPOSABLE 1½ INCH 5156137B-D INJECT-EASE WITH MICRO-

FINE137B-D INSULIN 1/3CC 29G UF 1137B-D INSULIN 50U 29G135BD LATITUDE136B-D MICRO-FINE137B-D MICRO-FINE 1/3CC

137B-D MICRO-FINE INSULIN 100U137B-D MICRO-FINE INSULIN 28G137B-D MICRO-FINE INSULIN 50U135B-D PEN136B-D SHARPS CONTAINER 1.4L136B-D SHARPS CONTAINER 3.1L136B-D ULTRA-FINE136B-D ULTRA-FINE / ULTRA-FINE II136B-D ULTRA-FINE II135BD ULTRA-FINE III PEN NEEDLES135BD ULTRA-FINE NANO PEN

NEEDLE135B-D ULTRA-FINE PEN135B-D ULTRA-FINE PEN III89BECLOMETHASONE

DIPROPIONATE

1BENADRYL1BENADRYL CHILD

41BENAZEPRIL HCL

116BENOXYL116BENZAC AC116BENZAC W116BENZAC W5116BENZAGEL116BENZAGEL 5116BENZOYL PEROXIDE

17BENZTROPINE MESYLATE

17BENZTROPINE OMEGA91BENZYDAMINE HCL

117BETADERM117BETADINE91BETAGAN82BETAHISTINE HCL

117BETAMETHASONE

DIPROPIONATE

117BETAMETHASONE

DIPROPIONATE IN PROPYLENE

GLYCOL

117BETAMETHASONE

DIPROPIONATE, CLOTRIMAZOLE

117BETAMETHASONE

DIPROPIONATE, SALICYLIC ACID

117BETAMETHASONE DISODIUM

PHOSPHATE

89BETAMETHASONE SODIUM

PHOSPHATE, GENTAMICIN

SULFATE

117BETAMETHASONE VALERATE

118BETAMETHASONE,

CALCIPOTRIOL

125BETAXIN91BETAXOLOL HCL

16BETHANECHOL CHLORIDE

117BETNESOL91BETOPTIC S28BEZAFIBRATE

28BEZALIP SR84BG STAR84BG STAR (ON)3BIAXIN3BIAXIN XL

13BICALUTAMIDE

13BICALUTAMIDE92BIMATOPROST

85BIOCAL-D FORTE115BIODERM

86BIO-FUROSEMIDE87BIO-HYDROCHLOROTHIAZIDE96BI-PEGLYTE TROUSSE95BISACODYL

95BISACODYL (POLYETHYLENE

GLYCOL BASE)

95BISACODYL-ODAN95BISACOLAX95BISMUTH SUBSALICYLATE

36BISOPROLOL36BISOPROLOL FUMARATE

90BLEPHAMIDE11BOCEPREVIR

11BOCEPREVIR, PEGINTERFERON,

RIBAVIRIN

34BOSENTAN

133BOTOX133BOTULINUM TOXIN TYPE A

107BREVICON 0.5/35 (21)107BREVICON 0.5/35 (28)107BREVICON 1/35 (21)107BREVICON 1/35 (28)19BRICANYL TURBUHALER91BRIMONIDINE TARTRATE

91BRIMONIDINE TARTRATE

(ALPHAGAN P)

91BRIMONIDINE TARTRATE,

TIMOLOL MALEATE

92BRINZOLAMIDE

92BRINZOLAMIDE, TIMOLOL

MALEATE

76BROMAZEPAM

77BROMAZEPAM81BROMOCRIPTINE MESYLATE

89BUDESONIDE

58BUPRENORPHINE, NALOXONE

65BUPROPION HCL (WELLBUTRIN)

65BUPROPION HCL (ZYBAN)

65BUPROPION SR18BUSCOPAN13BUSERELIN ACETATE

13BUSULFAN

81CABERGOLINE

39CADUET85CAL-500 D

112CALCIMAR121CALCIPOTRIOL

85CALCITE 500 D85CALCITE D

112CALCITONIN SALMON

(SYNTHETIC)

126CALCITRIOL

85CALCIUM85CALCIUM

85CALCIUM & VITAMIN D

85CALCIUM + D85CALCIUM CARBONATE85CALCIUM CARBONATE

85CALCIUM CARBONATE WITH VIT D

85CALCIUM CARBONATE,

CHOLECALCIFEROL

85CALCIUM CARBONATE, VITAMIN

D

85CALCIUM D

Page I-4 of 242014

Page


Page Page86CALCIUM POLYSTYRENE

SULFONATE

85CALCIUM WITH VITAMIN D85CAL-D 40085CALODAN D82CAMPRAL45CANDESARTAN45CANDESARTAN CILEXETIL

46CANDESARTAN CILEXETIL,

HYDROCHLOROTHIAZIDE

46CANDESARTAN HCT46CANDESARTAN/HCTZ7CANESORAL

115CANESTEN115CANESTEN 1 COMFORT COMBI

PAK115CANESTEN 3 COMFORT COMBI

PAK120CANTHACUR PS120CANTHARIDIN, PODOPHYLLIN,

SALICYLIC ACID

120CANTHARONE PLUS13CAPECITABINE

122CAPSAICIN

122CAPSAICIN122CAPSAICIN HP41CAPTOPRIL

41CAPTOPRIL90CARBACHOL

60CARBAMAZEPINE60CARBAMAZEPINE

85CARBOCAL D79CARBOLITH40CARDIZEM CD34CARDURA 134CARDURA 234CARDURA 486CARNITOR86CARNITOR IV36CARVEDILOL36CARVEDILOL

13CASODEX32CATAPRES2CECLOR2CECLOR BID

14CEENU2CEFACLOR

2CEFADROXIL

2CEFIXIME

2CEFPROZIL

2CEFTIN2CEFUROXIME AXETIL

2CEFZIL50CELEBREX50CELECOXIB

117CELESTODERM V66CELEXA

132CELLCEPT93CELLUVISC60CELONTIN9CELSENTRI

114CENTER-AL127CENTRUM JUNIOR COMPLETE

TB

127CENTRUM JUNIOR COMPLETE TAB

126CENTRUM MATERNA2CEPHALEXIN

131CERTOLIZUMAB PEGOL

98CESAMET1CETIRIZINE HCL

22CHAMPIX22CHAMPIX STARTER PACK58CHILDREN'S ACETAMINOPHEN51CHILDREN'S ADVIL51CHILDREN'S MOTRIN58CHILDREN'S TYLENOL SOFT

CHEWS13CHLORAMBUCIL

89CHLORAMPHENICOL

116CHLORHEXIDINE ACETATE

91CHLORHEXIDINE GLUCONATE

12CHLOROQUINE PHOSPHATE

1CHLORPHENIRAMINE MALEATE

70CHLORPROMAZINE

70CHLORPROMAZINE HCL87CHLORTHALIDONE

1CHLOR-TRIPOLON126CHOLECALCIFEROL

123CHOLEDYL27CHOLESTYRAMINE RESIN

85CI-CAL D105CICLESONIDE

41CILAZAPRIL41CILAZAPRIL

42CILAZAPRIL,

HYDROCHLOROTHIAZIDE

89CILOXAN98CIMETIDINE

99CIMETIDINE131CIMZIA67CIPRALEX67CIPRALEX MELTZ5CIPRO

89CIPRODEX5CIPROFLOXACIN5CIPROFLOXACIN HCL

89CIPROFLOXACIN HCL,

DEXAMETHASONE

65CITALOPRAM

65CITALOPRAM66CITALOPRAM-2066CITALOPRAM-ODAN95CITRIC ACID, MAGNESIUM

OXIDE, SODIUM PICOSULFATE

85CITRIC ACID, SODIUM CITRATE

96CITRO MAG128CITRODAN

3CLARITHROMYCIN3CLARITHROMYCIN

1CLARITIN1CLARITIN KIDS

122CLARUS4CLAVULIN4CLAVULIN 2004CLAVULIN 4004CLAVULIN-F4CLAVULIN-F 1254CLAVULIN-F 250

121CLEAR AWAY135CLICKFINE PEN NEEDLE 31G

4.5MM136CLICKFINE PEN NEEDLE 31G 6MM136CLICKFINE PEN NEEDLE 31G 8MM108CLIMARA 100108CLIMARA 25108CLIMARA 50108CLIMARA 75

6CLINDAMYCIN6CLINDAMYCIN HCL

6CLINDAMYCIN PALMITATE HCL

115CLINDAMYCIN PHOSPHATE

6CLINDAMYCINE115CLINDA-T77CLOBAZAM

77CLOBAZAM118CLOBETASOL PROPIONATE

118CLOBETASOL PROPIONATE118CLOBETASONE BUTYRATE

66CLOMIPRAMINE HCL

59CLONAPAM59CLONAZEPAM

32CLONIDINE32CLONIDINE HCL

25CLOPIDOGREL25CLOPIDOGREL BISULFATE

115CLOTRIMADERM115CLOTRIMAZOLE

4CLOXACILLIN

4CLOXACILLINE70CLOZAPINE

70CLOZARIL38CO AMLODIPINE28CO ATORVASTATIN82CO BETAHISTINE34CO BOSENTAN81CO CABERGOLINE46CO CANDESARTAN/HCTZ41CO CILAZAPRIL25CO CLOPIDOGREL51CO DICLO-MISO40CO DILTIAZEM CD40CO DILTIAZEM T92CO DORZOTIMOLOL42CO ENALAPRIL13CO EXEMESTANE11CO FAMCICLOVIR54CO FENTANYL

129CO FINASTERIDE7CO FLUCONAZOLE

46CO IRBESARTAN46CO IRBESARTAN/HCT92CO LATANOPROST43CO LISINOPRIL47CO LOSARTAN47CO LOSARTAN/HCT

132CO MYCOPHENOLATE98CO NABILONE72CO OLANZAPINE71CO OLANZAPINE ODT

111CO PIOGLITAZONE81CO PRAMIPEXOLE30CO PRAVASTATIN 10MG TAB

Page I-5 of 242014

Page


Page Page30CO PRAVASTATIN 20MG TAB30CO PRAVASTATIN 40MG TAB63CO PREGABALIN

108CO RALOXIFENE44CO RAMIPRIL80CO RIZATRIPTAN30CO ROSUVASTATIN69CO SERTRALINE48CO TELMISARTAN48CO TELMISARTAN/HCT15CO TEMOZOLOMIDE64CO TOPIRAMATE11CO VALACYCLOVIR48CO VALSARTAN

121COAL TAR

121COAL TAR, JUNIPER TAR, PINE

TAR

121COAL TAR, JUNIPER TAR, PINE

TAR, ZINC PYRITHIONE

121COAL TAR, SALICYLIC ACID

121COAL TAR, SALICYLIC ACID,

SULFUR

129CO-ALENDRONATE13CO-ANASTROZOLE35CO-ATENOLOL3CO-AZITHROMYCIN

13CO-BICALUTAMIDE8COBICISTAT, EMTRICITABINE,

ELVITEGRAVIR, TENOFOVIR

45CO-CANDESARTAN5CO-CIPROFLOXACIN

66CO-CITALOPRAM66CO-CLOMIPRAMINE59CO-CLONAZEPAM54CODEINE54CODEINE CONTIN CR54CODEINE MONOHYDRATE,

CODEINE SULFATE TRIHYDRATE

54CODEINE PHOSPHATE54CODEINE PHOSPHATE

130CO-ETIDROCAL130CO-ETIDRONATE67CO-FLUOXETINE67CO-FLUVOXAMINE61CO-GABAPENTIN95COLACE

129COLCHICINE

129COLCHICINE27COLESTID27COLESTID ORANGE27COLESTIPOL HCL

62CO-LEVETIRACETAM5CO-LEVOFLOXACIN

122COLLAGENASE

29CO-LOVASTATIN96COLYTE2COMBANTRIN

91COMBIGAN18COMBIVENT9COMBIVIR

52CO-MELOXICAM109CO-METFORMIN68CO-MIRTAZAPINE8COMPLERA

121COMPOUND W GEL

81COMTAN75CONCERTA 18MG TAB76CONCERTA 27MG TAB76CONCERTA 36MG TAB76CONCERTA 54MG TAB83CONDOM, LATEX, LUBRICATED83CONDOM, LATEX, LUBRICATED,

NONOXYNOL83CONDOM, LATEX, NON-

LUBRICATED83CONDOM, MALE

83CONDOM, NON-LATEX, LUBRICATED

121CONDYLINE108CONJUGATED ESTROGENS

108CONJUGATED ESTROGENS,

MEDROXYPROGESTERONE

ACETATE

5CO-NORFLOXACIN84CONTOUR NEXT84CONTOUR NEXT (ON)98CO-ONDANSETRON68CO-PAROXETINE99CO-RANITIDINE27CORDARONE

110CO-REPAGLINIDE74CO-RISPERIDONE79CO-RIZATRIPTAN ODT82CO-ROPINIROLE

119CORTATE105CORTEF119CORTENEMA119CORTIFOAM105CORTISONE105CORTISONE ACETATE

119CORTODERM31CO-SIMVASTATIN92COSOPT38CO-SOTALOL80CO-SUMATRIPTAN97COTAZYM97COTAZYM ECS 897COTAZYM ECS 2078CO-TEMAZEPAM7CO-TERBINAFINE

25COUMADIN41COVERA-HS43COVERSYL44COVERSYL PLUS44COVERSYL PLUS HD47COZAAR97CREON 10 MINIMICROSPHERES97CREON 20 MINIMICROSPHERES97CREON 25 MINIMICROSPHERES97CREON 5 MINIMICROSPHERES30CRESTOR9CRIXIVAN

88CROMOLYN116CROTAMITON

104CUPRIMINE118CUTIVATE125CYANOCOBALAMIN125CYANOCOBALAMIN

125CYANOCOBALAMINE

107CYCLEN (21)

107CYCLEN (28)20CYCLOBENZAPRINE20CYCLOBENZAPRINE HCL

117CYCLOCORT91CYCLOGYL

106CYCLOMEN90CYCLOPENTOLATE90CYCLOPENTOLATE HCL

91CYCLOPENTOLATE MINIMS13CYCLOPHOSPHAMIDE

132CYCLOSPORINE

133CYESTRA-3526CYKLOKAPRON66CYMBALTA13CYPROTERONE ACETATE

133CYPROTERONE ACETATE,

ETHINYL ESTRADIOL

11CYTOVENE126D VI SOL126D2-DOL126D3-DOL23DABIGATRAN ETEXILATE

MESILATE

97DAIRY DIGESTIVE97DAIRY DIGESTIVE EXTRA

STRENGTH97DAIRY FREE97DAIRY FREE EXTRA STRENGTH97DAIRYAID

115DALACIN6DALACIN C

115DALACIN T24DALTEPARIN SODIUM

106DANAZOL

20DANTRIUM20DANTROLENE SODIUM

12DARAPRIM123DARIFENACIN HYDROBROMIDE

8DARUNAVIR ETHANOLATE

112DDAVP112DDAVP MELT126DECAXIL13DEGARELIX ACETATE

106DELATESTRYL106DEMULEN 30 (21)106DEMULEN 30 (28)130DENOSUMAB (P)

64DEPAKENE105DEPO-MEDROL113DEPO-PROVERA106DEPO-TESTOSTERONE119DERMAFLEX HC118DERMA-SMOOTHE117DERMAZIN118DERMOVATE66DESIPRAMINE HCL

1DESLORATADINE1DESLORATADINE

1DESLORATADINE ALLERGY CONTROL

112DESMOPRESSIN ACETATE

118DESOCORT118DESONIDE

118DESOXIMETASONE

123DETROL

Page I-6 of 242014

Page


Page Page123DETROL LA90DEXAMETHASONE

105DEXAMETHASONE105DEXAMETHASONE PHOSPHATE

90DEXAMETHASONE, TOBRAMYCIN

105DEXAMETHASONE-OMEGA105DEXASONE75DEXEDRINE75DEXEDRINE SPANSULE23DEXIRON92DEXTRAN 70,

HYDROXYPROPYLMETHYLCELLU

LOSE

75DEXTROAMPHETAMINE SULFATE

126D-FORTE126D-GEL111DIABETA111DIAMICRON111DIAMICRON MR133DIANE-3595DIARR-EZE95DIARRHEA RELIEF84DIASTIX77DIAZEPAM

77DIAZEPAM33DIAZOXIDE

85DICITRATE98DICLECTIN50DICLOFENAC EC50DICLOFENAC SODIUM

51DICLOFENAC SODIUM,

MISOPROSTOL

50DICLOFENAC SR50DICLOFENAC-5051DICLOFENAC-SR8DIDANOSINE

130DIDROCAL113DIENOGEST

120DIFFERIN7DIFLUCAN

118DIFLUCORTOLONE VALERATE

118DIFLUCORTOLONE VALERATE,

SALICYLIC ACID

51DIFLUNISAL

27DIGOXIN

20DIHYDROERGOTAMINE20DIHYDROERGOTAMINE

MESYLATE

12DIIODOHYDROXYQUIN

60DILANTIN60DILANTIN 3060DILANTIN 12560DILANTIN INFATABS55DILAUDID41DILTIAZEM40DILTIAZEM CD40DILTIAZEM HCL

97DIMENHYDRINATE97DIMENHYDRINATE

120DIMETHICONE

92DIOCARPINE89DIOCHLORAM95DIOCTYL CALCIUM

SULFOSUCCINATE

95DIOCTYL SODIUM

SULFOSUCCINATE

95DIOCTYL SODIUM

SULFOSUCCINATE, SENNA

95DIOCTYL SODIUM

SULFOSUCCINATE, SENNOSIDES

90DIODEX12DIODOQUIN89DIOGENT91DIONEPHRINE91DIOPENTOLATE90DIOPTIMYD89DIOSULF48DIOVAN48DIOVAN 80MG CAP49DIOVAN-HCT

102DIPENTUM1DIPHENHYDRAMINE1DIPHENHYDRAMINE HCL

1DIPHENHYDRAMINE HCL91DIPIVEFRIN HCL

92DIPIVEFRIN HCL, LEVOBUNOLOL

HCL

117DIPROLENE117DIPROSALIC117DIPROSONE34DIPYRIDAMOLE

34DIPYRIDAMOLE,


27DISOPYRAMIDE

120DITHRANOL

60DIVALPROEX61DIVALPROEX EC60DIVALPROEX SODIUM

32DIXARIT95DOCUSATE CALCIUM96DOCUSATE CALCIUM

95DOCUSATE SODIUM96DOCUSATE SODIUM

98DOLASETRON MESYLATE

114DOLICHOVESPULA ARENARIA

VENOM PROTEIN

114DOLICHOVESPULA MACULATA

VENOM PROTEIN EXTRACT

56DOLORAL 156DOLORAL 5

130DOM-ALENDRONATE8DOM-AMANTADINE

27DOM-AMIODARONE65DOM-AMITRIPTYLINE38DOM-AMLODIPINE35DOM-ATENOLOL28DOM-ATORVASTATIN3DOM-AZITHROMYCIN

20DOM-BACLOFEN91DOM-BENZYDAMINE81DOM-BROMOCRIPTINE45DOM-CANDESARTAN41DOM-CAPTOPRIL60DOM-CARBAMAZEPINE CR36DOM-CARVEDILOL2DOM-CEPHALEXIN

99DOM-CIMETIDINE5DOM-CIPROFLOXACIN

65DOM-CITALOPRAM

3DOM-CLARITHROMYCIN77DOM-CLOBAZAM59DOM-CLONAZEPAM59DOM-CLONAZEPAM-R25DOM-CLOPIDOGREL20DOM-CYCLOBENZAPRINE66DOM-DESIPRAMINE50DOM-DICLOFENAC51DOM-DICLOFENAC SR95DOM-DOCUSATE SODIUM

101DOM-DOMPERIDONE129DOM-FINASTERIDE

7DOM-FLUCONAZOLE67DOM-FLUOXETINE67DOM-FLUVOXAMINE86DOM-FUROSEMIDE61DOM-GABAPENTIN28DOM-GEMFIBROZIL

111DOM-GLYBURIDE87DOM-HYDROCHLOROTHIAZIDE87DOM-INDAPAMIDE17DOM-IPRATROPIUM46DOM-IRBESARTAN62DOM-LEVETIRACETAM95DOM-LOPERAMIDE77DOM-LORAZEPAM71DOM-LOXAPINE

113DOM-MEDROXYPROGESTERONE52DOM-MEFENAMIC ACID52DOM-MELOXICAM

109DOM-METFORMIN37DOM-METOPROLOL-B37DOM-METOPROLOL-L6DOM-MINOCYCLINE

68DOM-MIRTAZAPINE88DOM-MONTELUKAST99DOM-NIZATIDINE68DOM-NORTRIPTYLINE7DOM-NYSTATIN

100DOM-OMEPRAZOLE DR123DOM-OXYBUTYNIN101DOM-PANTOPRAZOLE68DOM-PAROXETINE

101DOMPERIDONE101DOMPERIDONE MALEATE

37DOM-PINDOLOL111DOM-PIOGLITAZONE53DOM-PIROXICAM81DOM-PRAMIPEXOLE30DOM-PRAVASTATIN63DOM-PREGABALIN37DOM-PROPRANOLOL73DOM-QUETIAPINE

101DOM-RABEPRAZOLE44DOM-RAMIPRIL

131DOM-RISEDRONATE74DOM-RISPERIDONE80DOM-RIZATRIPTAN RDT30DOM-ROSUVASTATIN19DOM-SALBUTAMOL82DOM-SELEGILINE69DOM-SERTRALINE31DOM-SIMVASTATIN38DOM-SOTALOL

Page I-7 of 242014

Page


Page Page80DOM-SUMATRIPTAN78DOM-TEMAZEPAM34DOM-TERAZOSIN7DOM-TERBINAFINE

53DOM-TIAPROFENIC94DOM-TIMOLOL64DOM-TOPIRAMATE69DOM-TRAZODONE11DOM-VALACYCLOVIR64DOM-VALPROIC ACID70DOM-VENLAFAXINE XR41DOM-VERAPAMIL SR80DOM-ZOLMITRIPTAN92DORZOLAMIDE HCL

92DORZOLAMIDE HCL, TIMOLOL

MALEATE

81DOSTINEX118DOVOBET121DOVONEX34DOXAZOSIN34DOXAZOSIN MESYLATE

66DOXEPIN HCL

6DOXYCIN6DOXYCYCLINE

6DOXYCYCLINE98DOXYLAMINE SUCCINATE,

PYRIDOXINE HCL

6DOXYTAB126DRISDOL126D-TABS95DULCOLAX66DULOXETINE

92DUO TRAV121DUOFILM121DUOFORTE 2793DUOLUBE

116DUONALC121DUOPLANT54DURAGESIC MAT

129DUTASTERIDE

16DUVOID86EDECRIN9EDURANT3EES-6008EFAVIRENZ

8EFAVIRENZ, TENOFOVIR,

EMTRICITABINE

70EFFEXOR XR122EFUDEX119EGOZINC HC119EGOZINC-HC85ELECTROLYTE & DEXTROSE

122ELIDEL14ELIGARD23ELIQUIS

128ELMIRON119ELOCOM113ELTROXIN120EMLA119EMO CORT119EMO CORT SCALP

8EMTRICITABINE, RILPIVIRINE,

TENOFOVIR DISOPROXIL

FUMARATE

8EMTRICITABINE, TENOFOVIR

DISOPROXIL FUMARATE

123ENABLEX42ENALAPRIL42ENALAPRIL MALEATE

42ENALAPRIL MALEATE,

HYDROCHLOROTHIAZIDE

131ENBREL53ENDOCET97ENEMOL24ENOXAPARIN SODIUM

81ENTACAPONE

11ENTECAVIR

50ENTERIC COATED ASA118ENTOCORT50ENTROPHEN50ENTROPHEN EC50ENTROPHEN ECT50ENTROPHEN-1050ENTROPHEN-519EPINEPHRINE

19EPINEPHRINE19EPIPEN19EPIPEN JR60EPIVAL46EPOSARTAN MESYLATE

46EPOSARTAN MESYLATE,

HYDROCHLOROTHIAZIDE

50EQUATE DAILY LOW-DOSE128ERDOL126ERGOCALCIFEROL

13ERLOTINIB HYDROCLORIDE

3ERYC3ERYTHRO3ERYTHRO-ES3ERYTHROMYCIN3ERYTHROMYCIN

3ERYTHROMYCIN ESTOLATE

3ERYTHROMYCIN

ETHYLSUCCINATE

3ERYTHROMYCIN

ETHYLSUCCINATE &

SULFISOXAZOLE ACETYL

3ERYTHROMYCIN STEARATE

115ERYTHROMYCIN, TRETINOIN

67ESCITALOPRAM

107ESME (21)107ESME (28)108ESTALIS 140/50108ESTALIS 250/50108ESTRACE108ESTRADERM108ESTRADIOL

108ESTRADIOL (ESTRADIOL

HEMIHYDRATE)

108ESTRADIOL, NORETHINDRONE

ACETATE

108ESTRADOT 100108ESTRADOT 25108ESTRADOT 37.5108ESTRADOT 50108ESTRADOT 75108ESTRING108ESTROGEL108ESTRONE

108ESTROPIPATE

131ETANERCEPT

86ETHACRYNIC ACID

7ETHAMBUTOL HCL

106ETHINYL ESTRADIOL,

DESOGESTREL


DROSPIRENONE


ETHYNODIOL DIACETATE


ETONOGESTREL


LEVONORGESTREL


NORELGESTROMIN


NORETHINDRONE


NORETHINDRONE ACETATE


NORGESTIMATE

17ETHOPROPAZINE HCL

60ETHOSUXIMIDE

7ETIBI130ETIDROCAL130ETIDRONATE DISODIUM

130ETIDRONATE DISODIUM,

CALCIUM CARBONATE

13ETOPOSIDE

9ETRAVIRINE

13EUFLEX111EUGLUCON118EUMOVATE116EURAX126EURO D50EURO-ASA

128EURO-B185EURO-CAL85EURO-CAL D95EURO-DOCUSATE96EURO-DOCUSATE C23EURO-FER23EURO-FERROUS SULFATE

125EURO-FOLIC86EURO-K 2086EURO-K 60085EURO-LAC96EURO-SENNA95EURO-SENNA S

113EUTHYROX108EVISTA107EVRA53EXDOL-1553EXDOL-3016EXELON13EXEMESTANE

128EXTEMPORANEOUS MIXTURE

128EXTEMPORANEOUS MIXTURE (ATL)

128EXTEMPORANEOUS MIXTURE (BC) (SK)

128EXTEMPORANEOUS MIXTURE (ON)

128EXTEMPORANEOUS MIXTURE (QC) (AB)

Page I-8 of 242014

Page


Page Page84EZ HEALTH ORACLE84EZ HEALTH ORACLE (ON)

134E-Z SPACER134E-Z SPACER (MASK ONLY)134E-Z SPACER WITH SMALL MASK28EZETIMIBE

28EZETROL11FAMCICLOVIR

11FAMCICLOVIR99FAMOTIDINE

99FAMOTIDINE11FAMVIR

129FEBUXOSTAT

39FELODIPINE

14FEMARA28FENOFIBRATE

28FENOFIBRATE MICRO28FENOFIBRATE-S28FENOMAX28FENO-MICRO54FENTANYL54FENTANYL

23FER-IN-SOL23FERODAN23FERRATE O/L23FERROUS FUMARATE23FERROUS FUMARATE

23FERROUS GLUCONATE

23FERROUS GLUCONATE23FERROUS SULFATE

23FERROUS SULFATE58FEVERHALT1FEXOFENADINE HCL

26FILGRASTIM

121FINACEA129FINASTERIDE

129FINASTERIDE135FINGERSTIX13FIRMAGON

117FLAGYL117FLAGYSTATIN117FLAMAZINE117FLAMAZINE 50G90FLAREX

123FLAVOXATE HCL

27FLECAINIDE ACETATE

97FLEET ENEMA97FLEET ENEMA PEDIATRIC83FLEXI-T IUD

127FLINTSTONES EXTRA C59FLOCTAFENINE

20FLOMAX CR90FLONASE

105FLORINEF105FLOVENT DISKUS105FLOVENT HFA 125105FLOVENT HFA 250105FLOVENT HFA 5071FLUANXOL71FLUANXOL DEPOT7FLUCONAZOLE

13FLUDARA13FLUDARABINE PHOSPHATE

105FLUDROCORTISONE ACETATE

90FLUMETHASONE PIVALATE,

CLIOQUINOL

81FLUNARIZINE HCL

118FLUOCINOLONE ACETONIDE

118FLUOCINONIDE

90FLUOROMETHOLONE

90FLUOROMETHOLONE ACETATE

122FLUOROURACIL

67FLUOXETINE67FLUOXETINE HCL

71FLUPENTHIXOL DECANOATE

71FLUPENTHIXOL

DIHYDROCHLORIDE

71FLUPHENAZINE DECANOATE

71FLUPHENAZINE HCL

51FLURBIPROFEN

13FLUTAMIDE

90FLUTICASONE PROPIONATE

29FLUVASTATIN SODIUM

67FLUVOXAMINE67FLUVOXAMINE MALEATE

90FML90FML FORTE

125FOLIC ACID125FOLIC ACID

18FORADIL121FORMALDEHYDE, LACTIC ACID,

SALICYLIC ACID

18FORMOTEROL FUMARATE


DIHYDRATE


DIHYDRATE, BUDESONIDE


DIHYDRATE, MOMETASONE

FUROATE

130FOSAMAX9FOSAMPRENAVIR CALCIUM

130FOSAVANCE42FOSINOPRIL42FOSINOPRIL SODIUM

42FOSINOPRIL-1043FOSINOPRIL-2024FRAGMIN89FRAMYCETIN SULFATE

90FRAMYCETIN SULFATE,

GRAMICIDIN, DEXAMETHASONE

24FRAXIPARINE24FRAXIPARINE FORTE84FREESTYLE84FREESTYLE (ON)84FREESTYLE LITE (ON)

106FREYA (21)106FREYA (28)77FRISIUM

115FUCIDIN86FUROSEMIDE86FUROSEMIDE

115FUSIDATE SODIUM

115FUSIDIC ACID

61GABAPENTIN61GABAPENTIN

16GALANTAMINE HYDROBROMIDE

11GANCICLOVIR SODIUM

89GARASONE

85GASTROLYTE REG38GD-AMLODIPINE39GD-AMLODIPINE/ATORVASTATIN28GD-ATORVASTATIN61GD-GABAPENTIN92GD-LATANOPROST92GD-LATANOPROST/TIMOLOL63GD-PREGABALIN28GEMFIBROZIL

28GEMFIBROZIL35GEN-ACEBUTOLOL35GEN-ACEBUTOLOL (TYPE S)10GEN-ACYCLOVIR

129GEN-ALENDRONATE76GEN-ALPRAZOLAM8GEN-AMANTADINE

27GEN-AMIODARONE3GEN-AMOXICILLIN

25GEN-ANAGRELIDE35GEN-ATENOLOL3GEN-AZITHROMYCIN

20GEN-BACLOFEN89GEN-BECLO AQ13GEN-BICALUTAMIDE89GEN-BUDESONIDE AQ41GEN-CAPTOPRIL60GEN-CARBAMAZEPINE CR41GEN-CILAZAPRIL99GEN-CIMETIDINE5GEN-CIPROFLOXACIN

66GEN-CITALOPRAM3GEN-CLARITHROMYCIN6GEN-CLINDAMYCIN

118GEN-CLOBETASOL59GEN-CLONAZEPAM70GEN-CLOZAPINE18GEN-COMBO20GEN-CYCLOPRINE

101GEN-DOMPERIDONE34GEN-DOXAZOSIN42GEN-ENALAPRIL

130GEN-ETIDRONATE99GEN-FAMOTIDINE28GEN-FENOFIBRATE28GEN-FIBRO7GEN-FLUCONAZOLE

67GEN-FLUOXETINE42GEN-FOSINOPRIL61GEN-GABAPENTIN28GEN-GEMFIBROZIL

111GEN-GLICLAZIDE111GEN-GLYBE12GEN-HYDROXYCHLOROQUINE14GEN-HYDROXYUREA87GEN-INDAPAMIDE17GEN-IPRATROPIUM17GEN-IPRATROPIUM UDV62GEN-LAMOTRIGINE43GEN-LISINOPRIL43GEN-LISINOPRIL HCTZ29GEN-LOVASTATIN52GEN-MELOXICAM

109GEN-METFORMIN37GEN-METOPROLOL (TYPE L)

Page I-9 of 242014

Page


Page Page37GEN-METOPROLOL-L68GEN-MIRTAZAPINE52GEN-NAPROXEN52GEN-NAPROXEN EC33GEN-NITRO

123GEN-OXYBUTYNIN68GEN-PAROXETINE

111GEN-PIOGLITAZONE30GEN-PRAVASTATIN27GEN-PROPAFENONE99GEN-RANITIDINE74GEN-RISPERIDONE82GEN-SELEGILINE69GEN-SERTRALINE31GEN-SIMVASTATIN38GEN-SOTALOL80GEN-SUMATRIPTAN89GENTAMICIN89GENTAMICIN SULFATE

15GEN-TAMOXIFEN90GENTEAL ARTIFICIAL TEARS7GEN-TERBINAFINE

25GEN-TICLOPIDINE20GEN-TIZANIDINE64GEN-TOPIRAMATE69GEN-TRAZODONE64GEN-VALPROIC41GEN-VERAPAMIL41GEN-VERAPAMIL SR25GEN-WARFARIN14GLEEVEC

111GLICLAZIDE111GLICLAZIDE

111GLICLAZIDE MR112GLUCAGEN112GLUCAGEN HYPOKIT112GLUCAGON112GLUCAGON RECOMBINANT DNA

ORGIN

108GLUCOBAY110GLUCONORM109GLUCOPHAGE84GLUCOSE OXIDASE,

PEROXIDASE

111GLYBURIDE

111GLYBURIDE96GLYCERIN

96GLYCERIN96GLYCERIN INFANT96GLYCERIN INFANT & CHILD96GLYCERINE

109GLYCON131GOLIMUMAB

96GOLYTELY14GOSERELIN ACETATE

89GRAMICIDIN, POLYMYXIN B

SULFATE

98GRANISETRON98GRANISETRON

97GRAVOL97GRAVOL ADULT21HABITROL

118HALOBETASOL PROPIONATE

71HALOPERIDOL

71HALOPERIDOL

71HALOPERIDOL DECANOATE

71HALOPERIDOL LA24HEPARIN LEO24HEPARIN LOCK FLUSH24HEPARIN SODIUM24HEPARIN SODIUM

9HEPTOVIR13HEXALEN91HOMATROPINE HBR

114HONEY BEE VENOM114HONEY BEE VENOM PROTEIN

EXTRACT

100HP-PAC110HUMALOG 10ML110HUMALOG CARTRIDGE110HUMALOG CARTRIDGE (ON)110HUMALOG KWIKPEN110HUMALOG MIX 25110HUMALOG MIX 25 KWIKPEN110HUMALOG MIX 50 KWIKPEN12HUMATIN

131HUMIRA110HUMULIN 30/70110HUMULIN 30/70 CARTRIDGE110HUMULIN 30/70 CARTRIDGE (ON)110HUMULIN N110HUMULIN N CARTRIDGE110HUMULIN N CARTRIDGE (ON)110HUMULIN N KWIKPEN110HUMULIN R110HUMULIN R CARTRIDGE110HUMULIN R CARTRIDGE (ON)119HYCORT119HYDERM33HYDRALAZINE33HYDRALAZINE HCL

85HYDRALYTE ELECTROLYTE POPS

85HYDRALYTE ELECTROLYTE PWD85HYDRALYTE ELECTROLYTE SOL14HYDREA87HYDROCHLOROTHIAZIDE87HYDROCHLOROTHIAZIDE

105HYDROCORTISONE

119HYDROCORTISONE ACETATE

119HYDROCORTISONE ACETATE,

ZINC SULFATE

119HYDROCORTISONE ACETATE,

ZINC SULFATE, PRAMOXINE HCL

119HYDROCORTISONE VALERATE

119HYDROCORTISONE, DIBUCAINE

HCL, ESCULIN, FRAMYCETIN

SULFATE

119HYDROCORTISONE, UREA

119HYDROCORTISONE/ZINC

116HYDROGEN PEROXIDE

116HYDROGEN PEROXIDE 10V55HYDROMORPH CONTIN55HYDROMORPHONE HCL

119HYDROSONE119HYDROVAL12HYDROXYCHLOROQUINE

SULFATE

92HYDROXYPROPYLMETHYLCELLU

LOSE

14HYDROXYUREA14HYDROXYUREA

79HYDROXYZINE79HYDROXYZINE HCL

93HYPOTEARS93HYPROLOSE

90HYPROMELLOSE

34HYTRIN47HYZAAR47HYZAAR DS51IBUPROFEN51IBUPROFEN

120IHLES PASTE14IMATINIB MESYLATE

33IMDUR67IMIPRAMINE HCL

122IMIQUIMOD

80IMITREX80IMITREX DF95IMODIUM

132IMURAN12INCIVEK

133INCOBOTULINUMTOXINA

18INDACATEROL MALEATE

87INDAPAMIDE

37INDERAL LA9INDINAVIR SULFATE

51INDOMETHACIN

127INFANTOL132INFLIXIMAB

23INFUFER134INFUSION SETS41INHIBACE42INHIBACE PLUS24INNOHEP

109INSULIN (30% NEUTRAL & 70%

ISOPHANE) HUMAN

BIOSYNTHETIC


ISOPHANE) HUMAN

BIOSYNTHETIC


ISOPHANE) HUMAN

BIOSYNTHETIC

110INSULIN (ISOPHANE) HUMAN

BIOSYNTHETIC

110INSULIN (ZINC CRYSTALLINE)

HUMAN BIOSYNTHETIC (RDNA

ORIGIN)

110INSULIN ASPART

110INSULIN DETEMIR

110INSULIN GLARGINE

110INSULIN GLULISINE

110INSULIN HUMAN BIOSYNTHETIC

110INSULIN HUMAN BIOSYNTHETIC

30% & ISOPHANE 70%

110INSULIN LISPRO

110INSULIN LISPRO (25%), INSULIN

LISPRO PROTAMINE

SUSPENSION (75%)

110INSULIN LISPRO (50%), INSULIN

LISPRO PROTAMINE

SUSPENSION (50%)

137INSULIN LO DOSE MICRO 28G

Page I-10 of 242014

Page


Page Page134INSULIN PUMP BATTERY134INSULIN PUMP CARTRIDGES134INSULIN PUMP SUPPLIES

135INSUPEN 29GX12MM NEEDLE135INSUPEN 30GX8MM NEEDLE135INSUPEN 31GX6MM NEEDLE135INSUPEN 31GX8MM NEEDLE135INSUPEN 32GX6MM NEEDLE135INSUPEN 32GX8MM NEEDLE

9INTELENCE14INTERFERON ALFA-2B

83INTRAUTERINE DEVICE

14INTRON A9INVIRASE

92IOPIDINE97IPECAC97IPECAC

17IPRATROPIUM BROMIDE

18IPRATROPIUM BROMIDE,

SALBUTAMOL

46IRBESARTAN

46IRBESARTAN46IRBESARTAN HCT46IRBESARTAN,

HYDROCHLOROTHIAZIDE

46IRBESARTAN/HCTZ23IRON

23IRON DEXTRAN

23IRON SUCROSE

9ISENTRESS8ISONIAZID

116ISOPROPYL ALCOHOL

116ISOPROPYL MYRISTATE

41ISOPTIN SR90ISOPTO ATROPINE90ISOPTO CARBACHOL92ISOPTO CARPINE91ISOPTO HOMATROPINE92ISOPTO TEARS33ISOSORBIDE DINITRATE

33ISOSORBIDE-5-MONONITRATE

8ISOTAMINE122ISOTRETINOIN

84ITEST84ITEST (ON)

135ITEST LANCETS 28G (100)135ITEST LANCETS 33G (100)

7ITRACONAZOLE

85J CAL-D85JAMP CALCIUM + VITAMIN D23JAMP FERROUS FUMARATE23JAMP FERROUS SULPHATE

INFANT23JAMP FERROUS SULPHATE

LIQUID125JAMP FOLIC ACID96JAMP GLYCERIN51JAMP IBUPROFEN85JAMP REHYDRALYTE

119JAMP ZINC-HC59JAMP-ACETAMINOPHEN

130JAMP-ALENDRONATE76JAMP-ALPRAZOLAM38JAMP-AMLODIPINE13JAMP-ANASTROZOLE

35JAMP-ATENOLOL28JAMP-ATORVASTATIN13JAMP-BICALUTAMIDE95JAMP-BISACODYL85JAMP-CALCIUM + VIT D45JAMP-CANDESARTAN36JAMP-CARVEDILOL5JAMP-CIPROFLOXACIN

65JAMP-CITALOPRAM129JAMP-COLCHICINE20JAMP-CYCLOBENZAPRINE98JAMP-DIMENHYDRINATE1JAMP-DIPHENHYDRAMINE

96JAMP-DOCUSATE CALCIUM101JAMP-DOMPERIDONE23JAMP-FER

129JAMP-FINASTERIDE67JAMP-FLUOXETINE42JAMP-FOSINOPRIL61JAMP-GABAPENTIN87JAMP-INDAPAMIDE86JAMP-K 2086JAMP-K 885JAMP-LACTULOSE14JAMP-LETROZOLE62JAMP-LEVETIRACETAM43JAMP-LISINOPRIL47JAMP-LOSARTAN47JAMP-LOSARTAN HCTZ

128JAMP-MAGNESIUM128JAMP-MAGNESIUM GLUCONATE109JAMP-METFORMIN109JAMP-METFORMIN BLACKBERRY37JAMP-METOPROLOL-L88JAMP-MONTELUKAST

128JAMP-MULTIVITAMIN A/D/ C DROPS

132JAMP-MYCOPHENOLATE98JAMP-ONDANSETRON68JAMP-PAROXETINE

111JAMP-PIOGLITAZONE86JAMP-POTASSIUM CHLORIDE30JAMP-PRAVASTATIN73JAMP-QUETIAPINE44JAMP-RAMIPRIL

131JAMP-RISEDRONATE74JAMP-RISPERIDONE80JAMP-RIZATRIPTAN82JAMP-ROPINIROLE30JAMP-ROSUVASTATIN96JAMP-SENNA96JAMP-SENNAQUIL

128JAMP-SENNOSIDES69JAMP-SERTRALINE31JAMP-SIMVASTATIN38JAMP-SOTALOL7JAMP-TERBINAFINE

128JAMP-VITAMIN B1125JAMP-VITAMIN B12125JAMP-VITAMINE126JAMP-VITAMINE D109JANUMET109JANUVIA86K LYTE

56KADIAN57KADIAN SR9KALETRA

86KAYEXALATE106KENALOG-10106KENALOG-4062KEPPRA7KETOCONAZOLE

115KETODERM51KETOPROFEN

90KETOROLAC TROMETHAMINE

84KETOSTIX84KETOSTIX (MB)84KETOSTIX (ON)1KETOTIFEN FUMARATE

86K-EXIT8KIVEXA

96KLEAN-PREP116KWELLADA-P98KYTRIL36LABETALOL HCL

62LACOSAMIDE

93LACRI LUBE93LACRISERT97LACTAID97LACTAID EXTRA STRENGTH97LACTASE

97LACTEEZE DROPS121LACTIC ACID, SALICYLIC ACID

85LACTULOSE

62LAMICTAL7LAMISIL9LAMIVUDINE

9LAMIVUDINE, ZIDOVUDINE

62LAMOTRIGINE62LAMOTRIGINE

135LANCET

27LANOXIN112LANREOTIDE

100LANSOPRAZOLE

100LANSOPRAZOLE100LANSOPRAZOLE ODT

96LANSOYL GEL96LANSOYL GEL SUGARFREE

110LANTUS110LANTUS CARTRIDGE110LANTUS SOLOSTAR15LANVIS86LASIX92LATANOPROST

92LATANOPROST, TIMOLOL

MALEATE

96LAX-A-DAY 1G/G PDR77LECTOPAM

132LEFLUNOMIDE

132LEFLUNOMIDE29LESCOL29LESCOL XL14LETROZOLE14LETROZOLE

129LEUCOVORIN CALCIUM129LEUCOVORIN CALCIUM

13LEUKERAN14LEUPROLIDE ACETATE

Page I-11 of 242014

Page


Page Page5LEVAQUIN

65LEVATE110LEVEMIR PENFILL62LEVETIRACETAM

62LEVETIRACETAM91LEVOBUNOLOL HCL

89LEVOCABASTINE HCL

86LEVOCARNITINE

81LEVODOPA, BENZERAZIDE

81LEVODOPA, CARBIDOPA

81LEVODOPA, CARBIDOPA,

ENTACAPONE

5LEVOFLOXACIN

107LEVONORGESTREL

107LEVONORGESTREL

INTRAUTERINE INSERT

113LEVOTHYROXINE SODIUM

83LIBERTE UT380 SHORT83LIBERTE UT380 STANDARD

118LIDEMOL118LIDEX120LIDOCAINE HCL

120LIDOCAINE, PRILOCAINE

120LIDODAN VISCOUS136LIFE BRAND PEN NEEDLE 31G

8MM135LIFESCAN REGULAR109LINAGLIPTIN

54LINCTUS CODEINE106LINESSA (21)106LINESSA (28)

7LINEZOLID

20LIORESAL20LIORESAL DS97LIPASE, AMYLASE, PROTEASE

28LIPIDIL EZ28LIPIDIL MICRO28LIPIDIL SUPRA28LIPITOR75LISDEXAMFETAMINE

DIMESYLATE

43LISINOPRIL43LISINOPRIL

43LISINOPRIL,

HYDROCHLOROTHIAZIDE

43LISINOPRIL/HCTZ (TYPE Z)79LITHANE79LITHIUM CARBONATE

79LITHIUM CITRATE

89LIVOSTIN90LOCACORTEN VIOFORM93LODOXAMIDE TROMETHAMINE

107LOESTRIN 1.5/30 (21)107LOESTRIN 1.5/30 (28)14LOMUSTINE

33LONITEN95LOPERAMIDE95LOPERAMIDE HCL

9LOPINAVIR, RITONAVIR

37LOPRESOR37LOPRESOR SR1LORATADINE

1LORATADINE77LORAZEPAM

77LORAZEPAM

47LOSARTAN47LOSARTAN POTASSIUM

47LOSARTAN POTASSIUM,

HYDROCHLOROTHIAZIDE

47LOSARTAN/HCT100LOSEC41LOTENSIN

117LOTRIDERM29LOVASTATIN29LOVASTATIN

24LOVENOX24LOVONEX HP50LOWPRIN71LOXAPINE HCL

71LOXAPINE SUCCINATE

87LOZIDE93LUCENTIS

134LUER LOCK (DISP) 30CC134LUER LOCK (DISP) 60CC92LUMIGAN RC14LUPRON DEPOT

107LUTERA (21)107LUTERA (28)67LUVOX

118LYDERM63LYRICA15LYSODREN56M.O.S.56M.O.S. 1056M.O.S. 2056M.O.S. 4056M.O.S. 5056M.O.S. 6056M.O.S. SR57M.O.S. SULFATE12MACROBID96MACROGOL, POTASSIUM

CHLORIDE, SODIUM

BICARBONATE, SODIUM


93MACROGOL, PROPYLENE

GLYCOL

95MAG OXIDE

95MAGIC BULLET85MAGNESIUM

127MAGNESIUM96MAGNESIUM CITRATE

96MAGNESIUM HYDROXIDE

95MAGNESIUM OXIDE127MAGNESIUM OXIDE

128MAGNESIUM-ODAN135MAGNIFIER

75MAJEPTIL68MANERIX67MAPROTILINE HCL

129MAR-ALLOPURINOL38MAR-AMLODIPINE13MAR-ANASTROZOLE35MAR-ATENOLOL9MARAVIROC

5MAR-CIPROFLOXACIN65MAR-CITALOPRAM67MAR-FLUOXETINE14MAR-LETROZOLE

109MAR-METFORMIN

88MAR-MONTELUKAST71MAR-OLANZAPINE ODT98MAR-ONDANSETRON74MAR-RISPERIDONE80MAR-RIZATRIPTAN31MAR-SIMVASTATIN

106MARVELON (21)106MARVELON (28)102MATERNA45MAVIK80MAXALT79MAXALT RPD90MAXIDEX99MAXIMUM STRENGTH ACID

REDUCER85M-CAL D2MEBENDAZOLE

13MED-ANASTROZOLE13MED-CYPROTERONE84MEDI+SURE84MEDI+SURE (ON)

135MEDI+SURE SOFT 30G TWIST135MEDI+SURE SOFT 33G TWIST135MEDISENSE14MED-LETROZOLE

105MEDROL113MEDROXYPROGESTERONE113MEDROXYPROGESTERONE

ACETATE

52MEFENAMIC ACID

14MEGACE14MEGESTROL ACETATE

52MELOXICAM52MELOXICAM

14MELPHALAN

12MEPRON14MERCAPTOPURINE

102MESALAZINE

102MESASAL56M-ESLON57M-ESLON SR16MESTINON16MESTINON-SR56METADOL96METAMUCIL ORIGINAL TEXTURE96METAMUCIL SM TEXT ORANGE96METAMUCIL SM TEXT ORANGE

S/F96METAMUCIL SM TEXT UNFLAV

109METFORMIN109METFORMIN HCL

138METHADONE56METHADONE HCL

56METHADONE HCL (PA)

138METHADONE POWDER (PAIN)56METHADOSE56METHADOSE SUGARFREE92METHAZOLAMIDE

15METHOTREXATE15METHOTREXATE SODIUM

71METHOTRIMEPRAZINE

121METHOXSALEN

60METHSUXIMIDE

32METHYLDOPA

Page I-12 of 242014

Page


Page Page32METHYLDOPA,

HYDROCHLOROTHIAZIDE

76METHYLPHENIDATE 10MG TAB76METHYLPHENIDATE 20MG TAB76METHYLPHENIDATE 5MG TAB75METHYLPHENIDATE HCL

105METHYLPREDNISOLONE

105METHYLPREDNISOLONE

ACETATE

105METHYLPREDNISOLONE ACETATE

101METOCLOPRAMIDE HCL

87METOLAZONE

37METOPROLOL37METOPROLOL SR37METOPROLOL TARTRATE

37METOPROLOL-2537METOPROLOL-L

116METROCREAM117METROGEL117METROLOTION12METRONIDAZOLE12METRONIDAZOLE

117METRONIDAZOLE, NYSTATIN

29MEVACOR27MEXILETINE HCL

102MEZAVANT48MICARDIS48MICARDIS PLUS

115MICATIN115MICONAZOLE115MICONAZOLE NITRATE

115MICOZOLE136MICRO-FINE86MICRO-K EXTENCAPS96MICROLAX

135MICROLET108MICRONOR (28)18MIDODRINE HCL

20MIGRANAL96MILK OF MAGNESIA96MILK OF MAGNESIA

PLAIN/SUGARFREE107MIN OVRAL (21)107MIN OVRAL (28)96MINERAL OIL

96MINERAL OIL (HEAVY) 100% USP93MINERAL OIL, PETROLATUM

93MINERAL OIL, WHITE

PETROLATUM

107MINESTRIN 1/20 (21)107MINESTRIN 1/20 (28)34MINIPRESS33MINITRAN6MINOCIN6MINOCYCLINE6MINOCYCLINE HCL

33MINOXIDIL

129MINT-ALENDRONATE38MINT-AMLODIPINE13MINT-ANASTROZOLE35MINT-ATENOLOL5MINT-CIPROFLOXACIN

65MINT-CITALOPRAM25MINT-CLOPIDOGREL

129MINT-FINASTERIDE67MINT-FLUOXETINE46MINT-IRBESARTAN/HCTZ47MINT-LOSARTAN/HCTZ

109MINT-METFORMIN30MINT-PRAVASTATIN74MINT-RISPERIDONE16MINT-RIVASTIGMINE30MINT-ROSUVASTATIN69MINT-SERTRALINE31MINT-SIMVASTATIN64MINT-TOPIRAMATE92MIOSTAT81MIRAPEX81MIRAPEX (ONT)

107MIRENA67MIRTAZAPINE

68MIRTAZAPINE106MIRVALA (21)106MIRVALA (28)99MISOPROSTOL

15MITOTANE

114MIXED VESPID VENOM PROTEIN86MK 1086MK 2086MK 852MOBICOX68MOCLOBEMIDE

76MODAFINIL

71MODECATE78MOGADON90MOMETASONE FUROATE

115MONISTAT 3115MONISTAT 3 DUAL PAK115MONISTAT 7115MONISTAT 7 DUAL PAK115MONISTAT-DERM136MONOJECT136MONOJECT (100)136MONOJECT (30)134MONOJECT ALCOHOL WIPES136MONOJECT DISP 3/10CC (100)136MONOJECT DISP 3/10CC (30)135MONOLET ORIGINAL135MONOLET THIN42MONOPRIL88MONTELUKAST

88MONTELUKAST56MORPHINE HCL

57MORPHINE SR56MORPHINE SULFATE

51MOTRIN51MOTRIN JUNIOR STRENGTH

135MPD THIN (100)135MPD THIN (200)135MPD ULTRA THIN (100)135MPD ULTRA THIN (200)57MS CONTIN SR57MS IR96M-SENNOSIDES96MUCILLIUM

127MULTI-PRE AND POST NATAL121MULTITAR PLUS121MULTI-TAR PLUS MILD

126MULTIVATAMINS (PRENATAL)

127MULTIVITAMINS (PEDIATRIC)

127MULTIVITAMINS (PRENATAL)

115MUPIROCIN

94MURO-1288MYCOBUTIN

132MYCOPHENOLATE MOFETIL

132MYCOPHENOLATE SODIUM

91MYDFRIN132MYFORTIC137MYHEALTH SYRINGE CASE-7137MYHEALTH SYRINGE CASE-

SINGLE80MYLAN ZOLMITRIPTAN80MYLAN ZOLMITRIPTAN ODT79MYLAN-ALMOTRIPTAN38MYLAN-AMLODIPINE13MYLAN-ANASTROZOLE28MYLAN-ATORVASTATIN36MYLAN-BISOPROLOL34MYLAN-BOSENTAN65MYLAN-BUPROPION XL46MYLAN-CANDESART/HCTZ45MYLAN-CANDESARTAN36MYLAN-CARVEDILOL25MYLAN-CLOPIDOGREL8MYLAN-EFAVIRENZ

81MYLAN-ENTACAPONE130MYLAN-ETI-CAL CAREPAC54MYLAN-FENTANYL

129MYLAN-FINASTERIDE61MYLAN-GABAPENTIN16MYLAN-GALANTAMINE ER46MYLAN-IRBESARTAN

100MYLAN-LANSOPRAZOLE132MYLAN-LEFLUNOMIDE

5MYLAN-LEVOFLOXACIN47MYLAN-LOSARTAN47MYLAN-LOSARTAN/HCTZ88MYLAN-MONTELUKAST

132MYLAN-MYCOPHENOLATE9MYLAN-NEVIRAPINE

39MYLAN-NIFEDIPINE ER33MYLAN-NITRO72MYLAN-OLANZAPINE71MYLAN-OLANZAPINE ODT

100MYLAN-OMEPRAZOLE98MYLAN-ONDANSETRON

101MYLAN-PANTOPRAZOLE81MYLAN-PRAMIPEXOLE

101MYLAN-RABEPRAZOLE44MYLAN-RAMIPRIL

131MYLAN-RISEDRONATE16MYLAN-RIVASTIGMINE79MYLAN-RIZATRIPTAN ODT30MYLAN-ROSUVASTATIN20MYLAN-TAMSULOSIN48MYLAN-TELMISARTAN48MYLAN-TELMISARTAN HCTZ34MYLAN-TERAZOSIN11MYLAN-VALACYCLOVIR48MYLAN-VALSARTAN49MYLAN-VALSARTAN HCTZ13MYLERAN

Page I-13 of 242014

Page


Page Page14MYL-LETROZOLE99MYL-RANITIDINE

103MYOCHRYSINE98NABILONE

37NADOLOL37NADOLOL

24NADROPARIN CALCIUM

108NAFARELIN ACETATE

88NALCROM91NAPHAZOLINE HCL

91NAPHCON FORTE52NAPROSYN52NAPROSYN E52NAPROSYN SR52NAPROXEN52NAPROXEN

52NAPROXEN EC52NAPROXEN NA52NAPROXEN SODIUM52NAPROXEN SODIUM

52NAPROXEN SODIUM DS52NAPROXEN-NA DF79NARATRIPTAN HCL

69NARDIL90NASACORT AQ90NASONEX

110NATEGLINIDE

15NATULAN98NAUSEATOL75NAVANE89NEDOCROMIL SODIUM

135NEEDLE

134NEEDLE (NON-INSULIN)

134NEEDLES (NON-INSULIN) DISPOSABLE

9NELFINAVIR MESYLATE

85NEO CAL-D-50023NEO FER

108NEO-ESTRONE119NEO-HC132NEORAL16NEOSTIGMINE BROMIDE

118NERISALIC OILY118NERISONE118NERISONE OILY26NEULASTA72NEULEPTIL26NEUPOGEN61NEURONTIN

121NEUTROGENA T/GEL9NEVIRAPINE

107NEXT CHOICE125NIACIN125NIACIN

125NIACIN YEAST FREE21NICODERM21NICORETTE21NICORETTE PLUS21NICOTINE21NICOTINE (GUM)

21NICOTINE (INHALER)

21NICOTINE (LOZENGES)

21NICOTINE (PATCH)

21NICOTROL TRANSDERMAL

21NICOTROL TRANSDERMAL 10MG21NICOTROL TRANSDERMAL 15MG21NICOTROL TRANSDERMAL 5MG24NICOUMALONE

117NIDAGEL39NIFEDIPINE

15NILUTAMIDE

40NIMODIPINE

40NIMOTOP82NITOMAN78NITRAZADON78NITRAZEPAM

33NITRO-DUR12NITROFURANTOIN

33NITROGLYCERIN

33NITROL33NITROLINGUAL PUMPSPRAY33NITROSTAT

116NIX116NIX DERMAL99NIZATIDINE99NIZATIDINE

115NIZORAL15NOLVADEX D

114NON POLLEN

134NON-INSULIN 1CC134NON-INSULIN 3CC134NON-INSULIN 5CC134NON-INSULIN (DISP) 1CC134NON-INSULIN (DISP) 3CC134NON-INSULIN (DISP) 5CC134NON-INSULIN (DISP) 10CC134NON-INSULIN 10CC108NORETHINDRONE

5NORFLOXACIN

116NORITATE107NORLEVO68NORTRIPTYLINE HCL

38NORVASC9NORVIR9NORVIR SEC

87NOVAMILOR3NOVAMOXIN4NOVAMOXIN SUGAR REDUCED

50NOVASEN83NOVA-T IUD

102NOVO 5-ASA35NOVO-ACEBUTOLOL10NOVO-ACYCLOVIR

129NOVO-ALENDRONATE76NOVO-ALPRAZOL27NOVO-AMIODARONE4NOVO-AMPICILLIN

35NOVO-ATENOL36NOVO-ATENOLTHALIDONE28NOVO-ATORVASTATIN3NOVO-AZITHROMYCIN

91NOVO-BENZYDAMINE82NOVO-BETAHISTINE13NOVO-BICALUTAMIDE36NOVO-BIPOPROLOL77NOVO-BROMAZEPAM41NOVO-CAPTORIL60NOVO-CARBAMAZ

2NOVO-CEFADROXIL12NOVO-CHLOROQUINE70NOVO-CHLORPROMAZINE41NOVO-CILAZAPRIL42NOVO-CILAZAPRIL /HCTZ98NOVO-CIMETINE5NOVO-CIPROFLOXACIN

66NOVO-CITALOPRAM4NOVO-CLAVAMOXIN6NOVO-CLINDAMYCIN

77NOVO-CLOBAZAM118NOVO-CLOBETASOL59NOVO-CLONAZEPAM32NOVO-CLONIDINE66NOVO-CLOPAMINE4NOVO-CLOXIN

20NOVO-CYCLOPRINE133NOVO-CYPROTERONE/ETHINYL

ESTRADIOL66NOVO-DESIPRAMINE

112NOVO-DESMOPRESSIN50NOVO-DIFENAC51NOVO-DIFENAC SR51NOVO-DIFLUNISAL40NOVO-DILTAZEM CD41NOVO-DILTIAZEM40NOVO-DILTIAZEM HCL ER98NOVODIMENATE60NOVO-DIVALPROEX95NOVO-DOCUSATE95NOVO-DOCUSATE CALCIUM

101NOVO-DOMPERIDONE34NOVO-DOXAZOSIN66NOVO-DOXEPIN6NOVO-DOXYLIN

42NOVO-ENALAPRIL42NOVO-ENALAPRIL/HCTZ

130NOVO-ETIDROCAL99NOVO-FAMOTIDINE28NOVO-FENOFIBRATE28NOVO-FENOFIBRATE-S23NOVO-FERROGLUC

135NOVOFINE135NOVOFINE 30G136NOVOFINE 32G 6MM135NOVOFINE INSULIN PEN 28G135NOVOFINE INSULIN PEN 30G

7NOVO-FLUCONAZOLE67NOVO-FLUOXETINE51NOVO-FLURPROFEN13NOVO-FLUTAMIDE67NOVO-FLUVOXAMINE42NOVO-FOSINOPRIL12NOVO-FURANTOIN61NOVO-GABAPENTIN28NOVO-GEMFIBROZIL59NOVO-GESIC

111NOVO-GLYBURIDE87NOVO-HYDRAZIDE79NOVO-HYDROXYZIN33NOVO-HYLAZIN87NOVO-INDAPAMIDE17NOVO-IPRAMIDE7NOVO-KETOCONAZOLE

Page I-14 of 242014

Page


Page Page1NOVO-KETOTIFEN

62NOVO-LAMOTRIGINE81NOVO-LEVOCARBIDOPA5NOVO-LEVOFLOXACIN2NOVO-LEXIN

109NOVOLIN GE 30/70109NOVOLIN GE 30/70 PENFILL110NOVOLIN GE 40/60 PENFILL110NOVOLIN GE 50/50 PENFILL110NOVOLIN GE NPH110NOVOLIN GE NPH PENFILL110NOVOLIN GE NPH PENFILL (ON)110NOVOLIN GE TORONTO110NOVOLIN GE TORONTO PENFILL110NOVOLIN GE TORONTO PENFILL

(ON)43NOVO-LISINOPRIL (TYPE P)43NOVO-LISINOPRIL (TYPE Z)43NOVO-LISINOPRIL/HCTZ (TYPE P)43NOVO-LISINOPRIL/HCTZ (TYPE Z)95NOVO-LOPERAMIDE77NOVO-LORAZEM29NOVO-LOVASTATIN67NOVO-MAPROTILINE

113NOVO-MEDRONE52NOVO-MELOXICAM71NOVO-MEPRAZINE

109NOVO-METFORMIN51NOVO-METHACIN15NOVO-METHOTREXATE37NOVO-METOPROL37NOVO-METOPROL CT37NOVO-METOPROL-B27NOVO-MEXILETINE6NOVO-MINOCYCLINE

68NOVO-MIRTAZAPINE67NOVO-MIRTAZAPINE OD68NOVO-MOCLOBEMIDE52NOVO-NAPROX52NOVO-NAPROX SODIUM52NOVO-NAPROX SODIUM DS99NOVO-NIZATIDINE5NOVO-NORFLOXACIN

68NOVO-NORTRIPTYLINE6NOVO-OFLOXACIN

72NOVO-OLANZAPINE98NOVO-ONDANSETRON

123NOVO-OXYBUTYNIN68NOVO-PAROXETINE4NOVO-PEN VK

71NOVO-PERIDOL1NOVOPHENIRAM

37NOVO-PINDOL111NOVO-PIOGLITAZONE53NOVO-PIROCAM67NOVO-PRAMINE81NOVO-PRAMIPEXOLE37NOVO-PRANOL30NOVO-PRAVASTATIN34NOVO-PRAZIN

106NOVO-PREDNISONE51NOVO-PROFEN

101NOVO-RABEPRAZOLE44NOVO-RAMIPRIL

99NOVO-RANIDINE99NOVO-RANITIDINE

110NOVORAPID110NOVORAPID FLEXTOUCH74NOVO-RISPERIDONE16NOVO-RIVASTIGMINE3NOVO-RYTHRO ESTOLATE

19NOVO-SALBUTAMOL82NOVO-SELEGILINE86NOVO-SEMIDE69NOVO-SERTRALINE31NOVO-SIMVASTATIN38NOVO-SOTALOL49NOVO-SPIROTON87NOVO-SPIROZINE-2587NOVO-SPIROZINE-5099NOVO-SUCRALATE80NOVO-SUMATRIPTAN80NOVO-SUMATRIPTAN DF53NOVO-SUNDAC15NOVO-TAMOXIFEN20NOVO-TAMSULOSIN78NOVO-TEMAZEPAM34NOVO-TERAZOSIN7NOVO-TERBINAFINE

123NOVO-THEOPHYL SR53NOVO-TIAPROFENIC25NOVO-TICLOPIDINE38NOVO-TIMOL64NOVO-TOPIRAMATE69NOVO-TRAZODONE87NOVO-TRIAMZIDE6NOVO-TRIMEL6NOVO-TRIMEL DS

70NOVO-TRIPRAMINE135NOVOTWIST TIP NEEDLE 30G136NOVOTWIST TIP NEEDLE 32G11NOVO-VALACYCLOVIR64NOVO-VALPROIC70NOVO-VENLAFAXINE XR41NOVO-VERAMIL41NOVO-VERAMIL SR25NOVO-WARFARIN85NU-CAL85NU-CAL D4NU-PEN VK

69NU-TRAZODONE D106NUVARING115NYADERM

7NYSTATIN

85O-CALCIUM 500121OCCLUSAL HP112OCTREOTIDE

112OCTREOTIDE ACETATE OMEGA89OCUFLOX

128ODAN K-20128ODAN K-8121ODANS LIQUOR CARBONIS

DETERGENT108OESCLIM

5OFLOXACIN

108OGEN71OLANZAPINE

72OLANZAPINE

71OLANZAPINE ODT47OLMESARTAN MEDOXOMIL

47OLMESARTAN MEDOXOMIL,

HYDROCHLOROTHIAZIDE

47OLMETEC47OLMETEC PLUS89OLOPATADINE HCL

102OLSALAZINE SODIUM

100OMEPRAZOLE100OMEPRAZOLE

100OMEPRAZOLE (PA)

18ONBREZ98ONDANSETRON98ONDANSETRON HCL DIHYDRATE

98ONDANSETRON-ODAN98ONDISSOLVE ODF

135ONE TOUCH DELICA 30G135ONE TOUCH DELICA 33G84ONE TOUCH ULTRA84ONE TOUCH ULTRA (ON)

135ONE TOUCH ULTRA SOFT84ONE TOUCH VERIO (ON)

126ONE-ALPHA135ONETOUCH DELICA 33G84ONETOUCH VERIO

109ONGLYZA134OPTICHAMBER134OPTICHAMBER DIAMOND

(CHAMBER)134OPTICHAMBER DIAMOND

(LARGE M)134OPTICHAMBER DIAMOND

(MEDIUM M)134OPTICHAMBER LARGE MASK134OPTICHAMBER MEDIUM MASK134OPTICHAMBER SMALL MASK88OPTICROM

134OPTIHALER89OPTIMYXIN89OPTIMYXIN EYE/EAR

107OPTION 2120ORACORT73ORAP18ORCIPRENALINE SULFATE

131ORENCIA 250MG/VIAL INJ107ORTHO 0.5/35 (28)107ORTHO 0.5/35 (21)107ORTHO 7/7/7 (21)107ORTHO 7/7/7 (28)107ORTHO 1/35 (21)107ORTHO 1/35 (28)106ORTHO CEPT (28)126OSTOFORTE93OTRIVIN SALINE

107OVIMA (21)107OVIMA (28)135OWEN MUMFORD UNIFINE

PENTIPS 1/2 INCH135OWEN MUMFORD UNIFINE

PENTIPS 1/4 INCH135OWEN MUMFORD UNIFINE

PENTIPS 5/16 INCH78OXAZEPAM

78OXAZEPAM18OXEZE TURBUHALER

Page I-15 of 242014

Page


Page Page78OXPAM

121OXSORALEN123OXTRIPHYLLINE

116OXY 5123OXYBUTYNIN123OXYBUTYNIN CHLORIDE

123OXYBUTYNINE57OXYCODONE57OXYCODONE HCL

53OXYCODONE/ACET116OXYDERM57OXY-IR85OYSTER SHELL CALCIUM

121P&S PLUS3P.C.E.

23PALAFER130PAMIDRONATE DISODIUM130PAMIDRONATE DISODIUM

97PANCREASE MT 1097PANCREASE MT 1697PANCREASE MT 4

116PANOXYL116PANOXYL AQUAGEL116PANOXYL-10116PANOXYL-20116PANOXYL-5101PANTOLOC101PANTOPRAZOLE101PANTOPRAZOLE

101PANTOPRAZOLE MAGNESIUM

101PARIET EC69PARNATE12PAROMOMYCIN SULFATE

68PAROXETINE68PAROXETINE HCL

17PARSITAN89PATANOL16PAT-GALANTAMINE ER

101PAT-RABEPRAZOLE EC68PAXIL2PDL-CEPHALEXIN

71PDL-LOXAPINE113PDL-MEDROXY

6PDL-MINOCYCLINE34PDL-TERAZOSIN64PDL-TOPIRAMATE64PDL-VALPROIC23PEDIAFER85PEDIALYTE58PEDIAPHEN58PEDIAPHEN CHEWABLE TAB

160MG58PEDIAPHEN CHEWABLE TAB

80MG106PEDIAPRED85PEDIATRIC ELECTROLYTE58PEDIATRIX

127PEDIAVIT126PEDIAVIT D

3PEDIAZOLE96PEG 3350 PDR10PEGASYS10PEGASYS RBV10PEGETRON

10PEGETRON REDIPEN26PEGFILGRASTIM

10PEGINTERFERON ALFA-2A

10PEGINTERFERON ALFA-2A,

RIBAVIRIN

10PEGINTERFERON ALFA-2B,

RIBAVIRIN

96PEGLYTE104PENICILLAMINE

4PENICILLIN V POTASSIUM

4PENICILLINE V101PENTASA128PENTOSAN POLYSULFATE

SODIUM

26PENTOXIFYLLINE

121PENTRAX95PEPTO BISMOL53PERCOCET53PERCOCET DEMI91PERICHLOR72PERICYAZINE

91PERIDEX43PERINDOPRIL ERBUMINE

44PERINDOPRIL ERBUMINE,

INDAPAMIDE

91PERIOGARD116PERMETHRIN

116PEROXIDE D'HYDROGENE72PERPHENAZINE

120PETROLATUM

93PETROLATUM, LANOLIN,

MINERAL OIL

93PETROLATUM, PETROLATUM

LIQUID

126PHARMA D128PHARMA-CAL85PHARMA-CAL D

126PHARMA-D69PHENELZINE SULFATE

91PHENYLEPHRINE91PHENYLEPHRINE HCL

91PHENYLEPHRINE MINIMS60PHENYTOIN

38PHL-AMLODIPINE35PHL-ATENOLOL3PHL-AZITHROMYCIN

20PHL-BACLOFEN5PHL-CIPROFLOXACIN

65PHL-CITALOPRAM59PHL-CLONAZEPAM59PHL-CLONAZEPAM-R20PHL-CYCLOBENZAPRINE

105PHL-DEXAMETHASONE67PHL-FLUOXETINE55PHL-HYDROMORPHONE87PHL-INDAPAMIDE71PHL-LOXAPINE52PHL-MELOXICAM68PHL-MIRTAZAPINE98PHL-ONDANSETRON68PHL-PAROXETINE

111PHL-PIOGLITAZONE30PHL-PRAVASTATIN73PHL-QUETIAPINE74PHL-RISPERIDONE

69PHL-SERTRALINE31PHL-SIMVASTATIN38PHL-SOTALOL64PHL-TOPIRAMATE69PHL-TRAZODONE97PHL-URSODIOL C65PHL-VALPROIC ACID41PHL-VERAPAMIL

128PHOSLAX95PICO-SALAX16PILOCARPINE16PILOCARPINE HCL

92PILOCARPINE NITRATE

92PILOCARPINE NITRATE MINIMS92PILOPINE HS

122PIMECROLIMUS

73PIMOZIDE

37PINDOLOL

37PINDOLOL37PINDOLOL,

HYDROCHLOROTHIAZIDE

111PIOGLITAZONE111PIOGLITAZONE HCL

116PIPERONYL BUTOXIDE,

PYRETHRINS

73PIPORTIL L473PIPOTIAZINE PALMITATE

53PIROXICAM

134PISTON ROD4PIVMECILLINAM HCL

81PIZOTYLINE HYDROGEN MALATE

107PLAN B96PLANTAGO SEED

12PLAQUENIL25PLAVIX39PLENDIL25PMS CLOPIDOGREL58PMS-ACETAMINOPHEN53PMS-ACETAMINOPHEN WITH

CODEINE130PMS-ALENDRONATE130PMS-ALENDRONATE FC

8PMS-AMANTADINE27PMS-AMIODARONE65PMS-AMITRIPTYLINE38PMS-AMLODIPINE39PMS-

AMLODIPINE/ATORVASTATIN3PMS-AMOXICILLIN

25PMS-ANAGRELIDE13PMS-ANASTROZOLE50PMS-ASA50PMS-ASA EC35PMS-ATENOLOL28PMS-ATORVASTATIN3PMS-AZITHROMYCIN

20PMS-BACLOFEN17PMS-BENZTROPINE91PMS-BENZYDAMINE28PMS-BEZAFIBRATE13PMS-BICALUTAMIDE95PMS-BISACODYL36PMS-BISOPROLOL34PMS-BOSENTAN91PMS-BRIMONIDINE

Page I-16 of 242014

Page


Page Page81PMS-BROMOCRIPTINE65PMS-BUPROPION SR45PMS-CANDESARTAN46PMS-CANDESARTAN/HCTZ41PMS-CAPTOPRIL60PMS-CARBAMAZEPINE60PMS-CARBAMAZEPINE SRT36PMS-CARVEDILOL2PMS-CEPHALEXIN1PMS-CETIRIZINE

27PMS-CHOLESTYRAMINE LIGHT27PMS-CHOLESTYRAMINE

REGULAR41PMS-CILAZAPRIL98PMS-CIMETIDINE5PMS-CIPROFLOXACIN

65PMS-CITALOPRAM3PMS-CLARITHROMYCIN

77PMS-CLOBAZAM118PMS-CLOBETASOL59PMS-CLONAZEPAM59PMS-CLONAZEPAM R54PMS-CODEINE

129PMS-COLCHICINE20PMS-CYCLOBENZAPRINE66PMS-DESIPRAMINE

112PMS-DESMOPRESSIN118PMS-DESONIDE90PMS-DEXAMETHASONE77PMS-DIAZEPAM50PMS-DICLOFENAC51PMS-DICLOFENAC SR40PMS-DILTIAZEM CD98PMS-DIMENHYDRINATE1PMS-DIPHENHYDRAMINE

91PMS-DIPIVEFRIN60PMS-DIVALPROEX95PMS-DOCUSATE CALCIUM95PMS-DOCUSATE SODIUM

101PMS-DOMPERIDONE34PMS-DOXAZOSIN42PMS-ENALAPRIL89PMS-ERYTHROMYCIN11PMS-FAMCICLOVIR54PMS-FENTANYL23PMS-FERROUS SULFATE

129PMS-FINASTERIDE7PMS-FLUCONAZOLE

90PMS-FLUOROMETHOLONE67PMS-FLUOXETINE71PMS-FLUPHENAZINE13PMS-FLUTAMIDE42PMS-FOSINOPRIL86PMS-FUROSEMIDE61PMS-GABAPENTIN16PMS-GALANTAMINE ER28PMS-GEMFIBROZIL89PMS-GENTAMICIN

111PMS-GLYBURIDE71PMS-HALOPERIDOL71PMS-HALOPERIDOL LA87PMS-HYDROCHLOROTHIAZIDE55PMS-HYDROMORPHONE79PMS-HYDROXYZINE

87PMS-INDAPAMIDE17PMS-IPRATROPIUM17PMS-IPRATROPIUM UDV46PMS-IRBESARTAN46PMS-IRBESARTAN/HCT33PMS-ISMN8PMS-ISONIAZID

33PMS-ISOSORBIDE51PMS-KETOPROFEN1PMS-KETOTIFEN

85PMS-LACTULOSE62PMS-LAMOTRIGINE

100PMS-LANSOPRAZOLE92PMS-LATANOPROST-TIMOLOL

132PMS-LEFLUNOMIDE14PMS-LETROZOLE62PMS-LEVETIRACETAM91PMS-LEVOBUNOLOL5PMS-LEVOFLOXACIN

120PMS-LIDOCAINE VISCOUS43PMS-LISINOPRIL79PMS-LITHIUM CARBONATE79PMS-LITHIUM CITRATE95PMS-LOPERAMIDE77PMS-LORAZEPAM47PMS-LOSARTAN47PMS-LOSARTAN-HCTZ29PMS-LOVASTATIN71PMS-LOXAPINE52PMS-MELOXICAM

109PMS-METFORMIN71PMS-METHOTRIMEPRAZINE76PMS-METHYLPHENIDATE

101PMS-METOCLOPRAMIDE37PMS-METOPROLOL-B37PMS-METOPROLOL-L6PMS-MINOCYCLINE

68PMS-MIRTAZAPINE99PMS-MISOPROSTOL68PMS-MOCLOBEMIDE

120PMS-MOMETASONE6PMS-MONOCYCLINE

88PMS-MONTELUKAST98PMS-NABILONE52PMS-NAPROXEN EC9PMS-NEVIRAPINE

39PMS-NIFEDIPINE99PMS-NIZATIDINE5PMS-NORFLOXACIN

68PMS-NORTRIPTYLINE7PMS-NYSTATIN

71PMS-OLANZAPINE ODT100PMS-OMEPRAZOLE100PMS-OMEPRAZOLE DR98PMS-ONDANSETRON

123PMS-OXYBUTYNIN57PMS-OXYCODONE

130PMS-PAMIDRONATE101PMS-PANTOPRAZOLE68PMS-PAROXETINE72PMS-PERPHENAZINE97PMS-PHOSPHATES SOLUTION37PMS-PINDOLOL

111PMS-PIOGLITAZONE

53PMS-PIROXICAM89PMS-POLYTRIMETHOPRIM86PMS-POTASSIUM81PMS-PRAMIPREXOLE30PMS-PRAVASTATIN

106PMS-PREDNISOLONE63PMS-PREGABALIN73PMS-PROCHLORPERAZINE17PMS-PROCYCLIDINE27PMS-PROPAFENONE38PMS-PROPRANOLOL8PMS-PYRAZINAMIDE

73PMS-QUETIAPINE101PMS-RABEPRAZOLE EC108PMS-RALOXIFENE44PMS-RAMIPRIL45PMS-RAMIPRIL-HCTZ99PMS-RANITIDINE

110PMS-REPAGLINIDE93PMS-RHINARIS

131PMS-RISEDRONATE74PMS-RISPERIDONE73PMS-RISPERIDONE ODT16PMS-RIVASTIGMINE79PMS-RIZATRIPTAN RDT82PMS-ROPINIROLE30PMS-ROSUVASTATIN19PMS-SALBUTAMOL96PMS-SENNOSIDES69PMS-SERTRALINE31PMS-SIMVASTATIN88PMS-SOD CROMOGLYCATE86PMS-SOD POLYSTYRENE SULF86PMS-SOD POLYSTYRENE

SULFONA95PMS-SODIUM DOCUSATE38PMS-SOTALOL6PMS-SULFASALAZINE

80PMS-SUMATRIPTAN15PMS-TAMOXIFEN48PMS-TELMISARTAN48PMS-TELMISARTAN-HCTZ34PMS-TERAZOSIN7PMS-TERBINAFINE

106PMS-TESTOSTERONE82PMS-TETRABENAZINE

123PMS-THEOPHYLLINE53PMS-TIAPROFENIC91PMS-TIMOLOL64PMS-TOPIRAMATE69PMS-TRAZODONE75PMS-TRIFLUOPERAZINE17PMS-TRIHEXYPHENIDYL97PMS-URSODIOL64PMS-VALPROIC ACID48PMS-VALSARTAN70PMS-VENLAFAXINE XR41PMS-VERAPAMIL SR80PMS-ZOLMITRIPTAN80PMS-ZOLMITRIPTAN ODT

134POCKET CHAMBER134POCKET CHAMBER WITH ADULT

MASK134POCKET CHAMBER WITH INFANT

MASK

Page I-17 of 242014

Page


Page Page134POCKET CHAMBER WITH

MEDIUM MASK134POCKET CHAMBER WITH SMALL

MASK121PODOFILM121PODOFILOX

121PODOPHYLLIN

114POLISTES SPP VENOM PROTEIN

EXTRACT

114POLLEN

114POLLEN AND NON POLLEN

114POLLINEX R138POLYETHYLENE GLYCOL138POLYETHYLENE GLYCOL

96POLYETHYLENE GLYCOL &

ELECTROL

96POLYETHYLENE GLYCOL 3350

138POLYETHYLENE GLYCOL 3350 PWD

96POLYETHYLENE GLYCOL,

POTASSIUM CHLORIDE, SODIUM

BICARBONATE, SODIUM


115POLYMYXIN B SULFATE,

BACITRACIN

89POLYMYXIN B SULFATE,

TRIMETHOPRIM SULFATE

89POLYSPORIN115POLYSPORIN ANTIBIOTIC89POLYSPORIN EYE/EAR

121POLYTAR115POLYTOPIC89POLYTRIM93POLYVINYL ALCOHOL

93POLYVINYL ALCOHOL,

POVIDONE

127POLY-VI-SOL107PORTIA (21)107PORTIA (28)86POTASSIUM CHLORIDE

117POVIDONE-IODINE

23PRADAXA81PRAMIPEXOLE81PRAMIPEXOLE

DIHYDROCHLORIDE

30PRAVACHOL30PRAVASTATIN30PRAVASTATIN SODIUM

30PRAVASTATIN-1030PRAVASTATIN-2030PRAVASTATIN-4050PRAXIS ASA EC34PRAZOSIN HCL

84PRECISION XTRA84PRECISION XTRA (ON)90PRED FORTE90PRED MILD90PREDNISOLONE90PREDNISOLONE ACETATE

90PREDNISOLONE ACETATE,

SULFACETAMIDE SODIUM

90PREDNISOLONE SODIUM

PHOSPHATE

106PREDNISONE

106PREDNISONE91PREFRIN LIQUIFILM

63PREGABALIN

63PREGABALIN63PREGABALIN-15063PREGABALIN-2563PREGABALIN-5063PREGABALIN-75

108PREMARIN108PREMPLUS127PRENATAL & POSTPARTUM127PRENATAL AND POSTPARTUM100PREVACID100PREVACID FASTAB120PREVEX117PREVEX B119PREVEX HC

8PREZISTA12PRIMAQUINE12PRIMAQUINE PHOSPHATE

59PRIMIDONE

43PRINIVIL43PRINZIDE85PRIVA CAL D FORTE86PRO-600K27PRO-AMIODARONE-2004PRO-AMOX

50PRO-ASA50PRO-ASA EC35PRO-ATENOLOL3PRO-AZITHROMYCINE

92PROBETA13PRO-BICALUTAMIDE36PRO-BISOPROLOL-1036PRO-BISOPROLOL-565PRO-BUPROPION SR27PROCAINAMIDE HCL

27PROCAN SR15PROCARBAZINE HCL

36PRO-CARVEDILOL2PRO-CEFADROXIL2PRO-CEFUROXIME

53PROCET-3073PROCHLORPERAZINE73PROCHLORPERAZINE

5PRO-CIPROFLOXACIN65PRO-CITALOPRAM3PRO-CLARITHROMYCIN

59PRO-CLONAZEPAM119PROCTODAN HC119PROCTOL119PROCTOSEDYL17PROCYCLIDINE HCL

13PROCYTOX105PRO-DEXAMETHASONE42PRO-ENALAPRIL28PRO-FENO-SUPER7PRO-FLUCONAZOLE

67PRO-FLUOXETINE61PRO-GABAPENTIN

111PRO-GLYBURIDE33PROGLYCEM

133PROGRAF87PRO-INDAPAMIDE51PRO-INDO33PRO-ISMN

62PRO-LEVETIRACETAM81PRO-LEVOCARB

130PROLIA43PRO-LISINOPRIL81PROLOPA77PRO-LORAZEPAM29PRO-LOVASTATIN

109PRO-METFORMIN68PRO-MIRTAZAPINE52PRO-NAPROXEN EC53PRO-OXYCOD ACET

117PROPADERM27PROPAFENONE27PROPAFENONE

HYDROCHLORIDE

111PRO-PIOGLITAZONE81PRO-PRAMIPEXOLE37PROPRANOLOL HCL

113PROPYL THYRACIL113PROPYLTHIOURACIL

73PRO-QUETIAPINE101PRO-RABEPRAZOLE44PRO-RAMIPRIL74PRO-RISPERIDONE

129PROSCAR38PRO-SOTALOL16PROSTIGMIN80PRO-SUMATRIPTAN

122PROTOPIC64PRO-TOPIRAMATE87PRO-TRIAZIDE6PROTRIN DF

11PRO-VALACYCLOVIR113PROVERA113PROVERA PAK41PRO-VERAPAMIL SR67PROZAC96PSYLLIUM HYDROPHILIC

MUCILLOID

105PULMICORT NEBUAMP105PULMICORT TURBUHALER123PULMOPHYLLIN95PURG-ODAN14PURINETHOL2PYRANTEL PAMOATE

8PYRAZINAMIDE

16PYRIDOSTIGMINE BROMIDE

125PYRIDOXINE HCL

12PYRIMETHAMINE

73QUETIAPINE73QUETIAPINE FUMARATE

44QUINAPRIL HCL

44QUINAPRIL HCL,

HYDROCHLOROTHIAZIDE

105QVAR116R & C101RABEPRAZOLE101RABEPRAZOLE SODIUM

108RALOXIFENE HCL

9RALTEGRAVIR

44RAMIPRIL

44RAMIPRIL45RAMIPRIL,

HYDROCHLOROTHIAZIDE

44RAMIPRIL-10

Page I-18 of 242014

Page


Page Page44RAMIPRIL-2.544RAMIPRIL-5

129RAN-ALENDRONATE38RAN-AMLODIPINE13RAN-ANASTROZOLE35RAN-ATENOLOL28RAN-ATORVASTATIN13RAN-BICALUTAMIDE45RAN-CANDESARTAN36RAN-CARVEDILOL2RAN-CEFPROZIL5RAN-CIPROFLOX

66RAN-CITALO3RAN-CLARITHROMYCIN

25RAN-CLOPIDOGREL101RAN-DOMPERIDONE42RAN-ENALAPRIL54RAN-FENTANYL

129RAN-FINASTERIDE67RAN-FLUOXETINE42RAN-FOSINOPRIL61RAN-GABAPENTIN93RANIBIZUMAB

46RAN-IRBESARTAN46RAN-IRBESARTAN HCTZ99RANITIDINE99RANITIDINE HCL

100RAN-LANSOPRAZOLE14RAN-LETROZOLE62RAN-LEVETIRACETAM43RAN-LISINOPRIL47RAN-LOSARTAN

109RAN-METFORMIN88RAN-MONTELUKAST98RAN-NABILONE72RAN-OLANZAPINE

100RAN-OMEPRAZOLE101RAN-PANTOPRAZOLE111RAN-PIOGLITAZONE30RAN-PRAVASTATIN63RAN-PREGABALIN73RAN-QUETIAPINE

101RAN-RABEPRAZOLE44RAN-RAMIPRIL99RAN-RANITIDINE74RAN-RISPERIDONE82RAN-ROPINIROLE30RAN-ROSUVASTATIN69RAN-SERTRALINE31RAN-SIMVASTATIN64RAN-TOPIRAMATE48RAN-VALSARTAN70RAN-VENLAFAXINE XR

132RAPAMUNE4RATIO-ACLAVULANATE

10RATIO-ACYCLOVIR130RATIO-ALENDRONATE117RATIO-AMCINONIDE27RATIO-AMIODARONE38RATIO-AMLODIPINE35RATIO-ATENOLOL28RATIO-ATORVASTATIN3RATIO-AZITHROMYCIN

20RATIO-BACLOFEN

95RATIO-BISACODYL91RATIO-BRIMONIDINE65RATIO-BUPROPION36RATIO-CARVEDILOL2RATIO-CEFUROXIME5RATIO-CIPROFLOXACIN3RATIO-CLARITHROMYCIN

118RATIO-CLOBETASOL54RATIO-CODEINE20RATIO-CYCLOBENZAPRINE

105RATIO-DEXAMETHASONE40RATIO-DILTIAZEM CD95RATIO-DOCUSATE CALCIUM95RATIO-DOCUSATE SODIUM

101RATIO-DOMPERIDONE117RATIO-ECTOSONE53RATIO-EMTEC-3042RATIO-ENALAPRIL28RATIO-FENOFIBRATE

129RATIO-FINASTERIDE90RATIO-FLUTICASONE67RATIO-FLUVOXAMINE61RATIO-GABAPENTIN

111RATIO-GLYBURIDE119RATIO-HEMCORT HC51RATIO-INDOMETHACIN18RATIO-IPRA SAL17RATIO-IPRATROPIUM UDV46RATIO-IRBESARTAN46RATIO-IRBESARTAN HCTZ85RATIO-LACTULOSE53RATIO-LENOLTEC NO.253RATIO-LENOLTEC NO.391RATIO-LEVOBUNOLOL43RATIO-LISINOPRIL P43RATIO-LISINOPRIL Z85RATIO-MAGNESIUM52RATIO-MELOXICAM

109RATIO-METFORMIN15RATIO-METHOTREXATE6RATIO-MINOCYCLINE

68RATIO-MIRTAZAPINE120RATIO-MOMETASONE56RATIO-MORPHINE57RATIO-MORPHINE SULFATE SR7RATIO-NYSTATIN

100RATIO-OMEPRAZOLE98RATIO-ONDANSETRON53RATIO-OXYCOCET54RATIO-OXYCODAN

111RATIO-PIOGLITAZONE30RATIO-PRAVASTATIN90RATIO-PREDNISOLONE

119RATIO-PROCTOSONE44RATIO-RAMIPRIL99RATIO-RANITIDINE74RATIO-RISPERIDONE16RATIO-RIVASTIGMINE19RATIO-SALBUTAMOL33RATIO-SILDENAFIL R31RATIO-SIMVASTATIN38RATIO-SOTALOL20RATIO-TAMSULOSIN78RATIO-TEMAZEPAM

34RATIO-TERAZOSIN117RATIO-TOPILENE GLYCOL117RATIO-TOPISALIC117RATIO-TOPISONE69RATIO-TRAZODONE1REACTINE

93REFRESH LIQUIGEL93REFRESH PLUS93REFRESH TEARS68REMERON67REMERON RD

132REMICADE128RENAGEL110REPAGLINIDE

17REQUIP134RESERVOIR 5XX 1.8ML SYRINGE134RESERVOIR 7XX 3.0ML SYRINGE86RESONIUM CALCIUM78RESTORIL

116RESULTZ120RETIN A10RETROVIR33REVATIO8REYATAZ

93RHINARIS89RHINOCORT AQ90RHINOCORT TURBUHALER33RHO-NITRO PUMPSPRAY25RHOXAL-ANAGRELIDE5RHOXAL-CIPROFLOXACIN

68RHOXAL-MIRTAZAPINE130RHOXAL-PAMIDRONATE30RHOXAL-PRAVASTATIN31RHOXAL-SIMVASTATIN38RHOXAL-SOTALOL

103RIDAURA8RIFABUTIN

8RIFADIN8RIFAMPIN

9RILPIVIRINE HYDROCHLORIDE

131RISEDRONATE130RISEDRONATE SODIUM

131RISEDRONATE-3574RISPERDAL73RISPERDAL-M73RISPERIDONE

74RISPERIDONE9RITONAVIR

15RITUXAN15RITUXIMAB

25RIVA CLOPIDOGREL130RIVA-ALENDRONATE27RIVA-AMIODARONE38RIVA-AMLODIPINE13RIVA-ANASTROZOLE35RIVA-ATENOLOL20RIVA-BACLOFEN5RIVA-CIPROFLOXACIN

66RIVA-CITALOPRAM3RIVA-CLARITHROMYCIN

59RIVA-CLONAZEPAM53RIVACOCET20RIVA-CYCLOBENZAPRINE13RIVA-CYPROTERONE

Page I-19 of 242014

Page


Page Page126RIVA-D42RIVA-ENALAPRIL28RIVA-FENOFIBRATE MICRO7RIVA-FLUCONAZOLE

67RIVA-FLUOXETINE67RIVA-FLUVOX42RIVA-FOSINOPRIL61RIVA-GABAPENTIN28RIVA-GEMFIBROZIL

111RIVA-GLYBURIDE79RIVA-HYDROXYZIN87RIVA-INDAPAMIDE86RIVA-K86RIVA-K 2043RIVA-LISINOPRIL95RIVA-LOPERAMIDE29RIVA-LOVASTATIN

109RIVA-METFORMIN37RIVA-METOPROLOL L6RIVA-MINOCYCLINE

68RIVA-MIRTAZAPINE52RIVA-NAPROXEN52RIVA-NAPROXEN SODIUM89RIVANASE AQ72RIVA-OLANZAPINE

123RIVA-OXYBUTYNIN101RIVA-PANTOPRAZOLE68RIVA-PAROXETINE30RIVA-PRAVASTATIN63RIVA-PREGABALIN73RIVA-QUETIAPINE

101RIVA-RABEPRAZOLE EC99RIVA-RANITIDINE99RIVA-RANTIDINE

131RIVA-RISEDRONATE74RIVA-RISPERIDONE30RIVA-ROSUVASTATIN24RIVAROXABAN

24RIVAROXABAN (10)

50RIVASA96RIVA-SENNA69RIVA-SERTRALINE31RIVA-SIMVASTATIN

119RIVASOL-HC118RIVASONE38RIVA-SOTALOL16RIVASTIGMINE

11RIVA-VALACYCLOVIR41RIVA-VERAPAMIL SR87RIVA-ZIDE80RIVA-ZOLMITRIPTAN59RIVOTRIL79RIZATRIPTAN

126ROCALTROL8ROFACT

117ROLENE82ROPINIROLE17ROPINIROLE HCL

116ROSASOL112ROSIGLITAZONE MALEATE

117ROSONE30ROSUVASTATIN30ROSUVASTATIN CALCIUM

30ROSUVASTATIN-10

31ROSUVASTATIN-2031ROSUVASTATIN-4030ROSUVASTATIN-564RUFINAMIDE

27RYTHMODAN27RYTHMOL

119SAB-ANUZINC HC119SAB-ANUZINC HC PLUS51SAB-INDOMETHACIN

119SAB-PROCTOMYXIN HC65SABRIL16SALAGEN6SALAZOPYRIN

19SALBUTAMOL

121SALICYLIC ACID

94SALINEX94SALINEX DROPS19SALMETEROL XINAFOATE

19SALMETEROL XINAFOATE,


101SALOFALK81SANDOMIGRAN81SANDOMIGRAN DS

112SANDOSTATIN112SANDOSTATIN LAR129SANDOZ ALENDRONATE20SANDOZ ALFUZOSIN79SANDOZ ALMOTRIPTAN13SANDOZ ANASTROZOLE28SANDOZ ATORVASTATIN34SANDOZ BOSENTAN91SANDOZ BRIMONIDINE 0.2% OP

SOL45SANDOZ CANDESARTAN46SANDOZ CANDESARTAN PLUS2SANDOZ CEFPROZIL

89SANDOZ CIPROFLOXACIN25SANDOZ CLOPIDOGREL51SANDOZ DICLO/MISOPROS92SANDOZ DORZOLAMIDE92SANDOZ DORZOLAMIDE/TIMOLOL42SANDOZ ENALAPRIL81SANDOZ ENTACAPONE28SANDOZ FENOFIBRATE E28SANDOZ FENOFIBRATE S54SANDOZ FENTANYL

129SANDOZ FINASTERIDE90SANDOZ FLUOROMETHOLONE29SANDOZ FLUVASTATIN46SANDOZ IRBESARTAN46SANDOZ IRBESARTAN HCTZ

100SANDOZ LANSOPRAZOLE92SANDOZ LATANOPROST92SANDOZ

LATANOPROST/TIMOLOL132SANDOZ LEFLUNOMIDE14SANDOZ LETROZOLE5SANDOZ LEVOFLOXACIN

43SANDOZ LISINOPRIL43SANDOZ LISINOPRIL HCT47SANDOZ LOSARTAN47SANDOZ LOSARTAN HCT37SANDOZ METOPROLOL (L)88SANDOZ MONTELUKAST

132SANDOZ MYCOPHENOLATE

79SANDOZ NARATRIPTAN89SANDOZ OFLOXACIN71SANDOZ OLANZAPINE ODT89SANDOZ OLOPATADINE

100SANDOZ OMEPRAZOLE53SANDOZ OXYCOD ACET

111SANDOZ PIOGLITAZONE89SANDOZ POLYTRIMETHOPRIM63SANDOZ PREGABALIN73SANDOZ QUETIAPINE XRT44SANDOZ RAMIPRIL

110SANDOZ REPAGLINIDE131SANDOZ RISEDRONATE16SANDOZ RIVASTIGMINE79SANDOZ RIZATRIPTAN ODT30SANDOZ ROSUVASTATIN20SANDOZ TAMSULOSIN48SANDOZ TELMISARTAN48SANDOZ TELMISARTAN HCT48SANDOZ VALSARTAN49SANDOZ VALSARTAN HCT80SANDOZ ZOLMITRIPTAN80SANDOZ ZOLMITRIPTAN ODT35SANDOZ-ACEBUTOLOL27SANDOZ-AMIODARONE38SANDOZ-AMLODIPINE

119SANDOZ-ANUZINC HC35SANDOZ-ATENOLOL3SANDOZ-AZITHROMYCIN

91SANDOZ-BETAXOLOL13SANDOZ-BICALUTAMIDE36SANDOZ-BISOPROLOL65SANDOZ-BUPROPION SR60SANDOZ-CARBAMAZEPINE5SANDOZ-CIPROFLOXACIN

66SANDOZ-CITALOPRAM59SANDOZ-CLONAZEPAM

132SANDOZ-CYCLOSPORINE90SANDOZ-DEXAMETHASONE51SANDOZ-DICLOFENAC50SANDOZ-DICLOFENAC SR40SANDOZ-DILTIAZEM CD40SANDOZ-DILTIAZEM T

108SANDOZ-ESTRADIOL DERM11SANDOZ-FAMCICLOVIR39SANDOZ-FELODIPINE67SANDOZ-FLUOXETINE67SANDOZ-FLUVOXAMINE

111SANDOZ-GLYBURIDE91SANDOZ-LEVOBUNOLOL43SANDOZ-LISINOPRIL95SANDOZ-LOPERAMIDE29SANDOZ-LOVASTATIN

109SANDOZ-METFORMIN109SANDOZ-METFORMIN FC76SANDOZ-METHYLPHENIDATE SR

20MG37SANDOZ-METOPROLOL SR6SANDOZ-MINOCYCLINE

68SANDOZ-MIRTAZAPINE78SANDOZ-NITRAZEPAM72SANDOZ-OLANZAPINE98SANDOZ-ONDANSETRON

101SANDOZ-PANTOPRAZOLE

Page I-20 of 242014

Page


Page Page68SANDOZ-PAROXETINE37SANDOZ-PINDOLOL81SANDOZ-PRAMIPEXOLE90SANDOZ-PREDNISOLONE

119SANDOZ-PROCTOMYXIN HC101SANDOZ-RABEPRAZOLE99SANDOZ-RANITIDINE74SANDOZ-RISPERIDONE19SANDOZ-SALBUTAMOL69SANDOZ-SERTRALINE31SANDOZ-SIMVASTATIN38SANDOZ-SOTALOL80SANDOZ-SUMATRIPTAN7SANDOZ-TERBINAFINE

89SANDOZ-TOBRAMYCIN64SANDOZ-TOPIRAMATE64SANDOZ-VALPROIC

122SANTYL70SAPHRIS9SAQUINAVIR MESYLATE

119SARNA HC109SAXAGLIPTIN HCL

2SCHEIN-CEFACLOR18SCOPOLAMINE BUTYLBROMIDE

107SEASONALE107SEASONIQUE121SEBCUR121SEBCUR-T93SECARIS35SECTRAL95SELAX

107SELECT 1/35 (21)107SELECT 1/35 (28)82SELEGILINE HCL

117SELENIUM SULFIDE

4SELEXID117SELSUN96SENNA LAXATIVE96SENNALAX96SENNAPREP96SENNATAB96SENNOSIDES

96SENOKOT95SENOKOT S38SEPTA-AMLODIPINE35SEPTA-ATENOLOL5SEPTA-CIPROFLOXACIN

66SEPTA-CITALOPRAM109SEPTA-METFORMIN98SEPTA-ONDANSETRON82SERC19SEREVENT DISKHALER19SEREVENT DISKUS73SEROQUEL73SEROQUEL XR69SERTRALINE

69SERTRALINE69SERTRALINE-10069SERTRALINE-2569SERTRALINE-50

128SEVELAMER HYDROCHLORIDE

136SHARPS CONTAINER

97SIALOR42SIG-ENALAPRIL

33SILDENAFIL CITRATE

117SILVER SULFADIAZINE

131SIMPONI131SIMPONI PRE-FILLED31SIMVASTATIN31SIMVASTATIN

31SIMVASTATIN-1032SIMVASTATIN-2032SIMVASTATIN-4031SIMVASTATIN-ODAN81SINEMET81SINEMET CR66SINEQUAN88SINGULAIR24SINTROM

132SIROLIMUS

109SITAGLIPTIN

109SITAGLIPTIN, METFORMIN

86SLOW-K103SODIUM AUROTHIOMALATE

103SODIUM AUROTHIOMALATE85SODIUM BICARBONATE

85SODIUM BICARBONATE93SODIUM CARBOXYMETHYL

CELLULOSE

86SODIUM CHLORIDE86SODIUM CHLORIDE

96SODIUM CITRATE, SODIUM

LAURYL SULFOACETATE,

SORBITOL

88SODIUM CROMOGLYCATE

84SODIUM NITROPRUSSIDE

128SODIUM PHOSPHATE

97SODIUM PHOSPHATE DIBASIC,

SODIUM PHOSPHATE

MONOBASIC

86SODIUM POLYSTYRENE

SULFONATE

95SOFLAX95SOFLAX EX95SOFLAX SYRUP90SOFRACORT EYE/EAR89SOFRAMYCIN89SOFRAMYCIN STERILE EYE

135SOFT TOUCH135SOFTCLIX135SOFTCLIX SELECT123SOLIFENACIN SUCCINATE

85SOLUCAL85SOLUCAL D85SOLUCAL D CITRUS85SOLUCAL D RASPBERRY85SOLUCAL GREEN APPLE85SOLUCAL RASPBERRY

116SOLUGEL121SOLUVER121SOLUVER PLUS112SOMATULINE AUTOGEL121SORIATANE38SOTALOL38SOTALOL HCL

134SPACER DEVICE

18SPIRIVA49SPIRONOLACTONE

87SPIRONOLACTONE,

HYDROCHLOROTHIAZIDE

7SPORANOX81STALEVO

116STANHEXIDINE110STARLIX56STATEX10STAVUDINE

128STELARA121STEREX106STERILE TRIAMCINOLONE128STERILE WATER87STERILE WATER FOR INJ

120STIEVA-A120STIEVA-A FORTE115STIEVAMYCIN115STIEVAMYCIN FORTE115STIEVAMYCIN MILD96STOOL SOFTENER8STRIBILD

58SUBOXONE58SUBOXONE MAINTENANCE99SUCRALFATE

99SUCRALFATE-199SULCRATE99SULCRATE PLUS89SULFACETAMIDE SODIUM

6SULFAMETHOXAZOLE

6SULFAMETHOXAZOLE,

TRIMETHOPRIM

6SULFASALAZINE

87SULFINPYRAZONE

53SULINDAC

80SUMATRIPTAN80SUMATRIPTAN DF80SUMATRIPTAN HEMISULFATE

80SUMATRIPTAN SUCCINATE

15SUNITINIB MALATE

135SUPER-FINE MICRO 31G-5MM NEEDL

135SUPER-FINE STANDARD 29G-12.7MM

136SUPER-FINE XTRA 31G-8MM NEEDLE

57SUPEUDOL2SUPRAX

13SUPREFACT13SUPREFACT DEPOT 2 MONTHS13SUPREFACT DEPOT 3 MONTHS8SUSTIVA

15SUTENT18SYMBICORT 100 TURBUHALER18SYMBICORT 200 TURBUHALER

118SYNALAR108SYNAREL107SYNPHASIC (21)107SYNPHASIC (28)113SYNTHROID136SYRINGE

137SYRINGE & NEEDLE

134SYRINGE & NEEDLE (NON-

INSULIN)

134SYRINGE (NON-INSULIN)

137SYRINGE CASE

135SYRINGE SCALE MAGNIFIER

Page I-21 of 242014

Page


Page Page137SYRINGE WITH NEEDLE

137SYRN INS U-II 3/10CC 30G137SYRN INSULIN MICRO 3/10CC

28G137SYRN INSULIN U-II 30G137SYRN INSULIN ULTRA 29G137SYRN INSULIN ULTRA 3/10CC 29G136SYRN MONOJECT133TACROLIMUS

122TACROLIMUS (PROTOPIC)

33TADALAFIL

27TAMBOCOR15TAMOXIFEN CITRATE

20TAMSULOSIN HCL

59TANTAPHEN58TANTAPHEN GRAPE

113TAPAZOLE7TAR0-FLUCONAZOLE

13TARCEVA121TARGEL121TARGEL SA117TARO-AMCINONIDE13TARO-ANASTROZOLE60TARO-CARBAMAZEPINE60TARO-CARBAMAZEPINE CR5TARO-CIPROFLOXACIN

115TARO-CLINDAMYCIN42TARO-ENALAPRIL7TARO-FLUCONAZOLE

119TARO-MOMETASONE115TARO-MUPIROCIN 2% OINTMENT60TARO-PHENYTOIN31TARO-SIMVASTATIN

117TARO-SONE80TARO-SUMATRIPTAN

116TARO-TERCONAZOLE25TARO-WARFARIN

122TAZAROTENE

122TAZORAC92TEARS NATURALE92TEARS NATURALE FREE92TEARS NATURALE II93TEARS NATURALE P.M.93TEARS PLUS8TEBRAZID

101TECTA60TEGRETOL60TEGRETOL CR12TELAPREVIR

48TELMISARTAN48TELMISARTAN

48TELMISARTAN HCTZ48TELMISARTAN,

HYDROCHLOROTHIAZIDE

48TELMISARTAN/HCTZ9TELZIR

78TEMAZEPAM78TEMAZEPAM

15TEMODAL15TEMOZOLOMIDE

58TEMPRA58TEMPRA DOUBLE STRENGTH10TENOFOVIR DISOPROXIL

FUMARATE

36TENORETIC

35TENORMIN116TERAZOL 3116TERAZOL 3 DUAL PAK116TERAZOL 734TERAZOSIN34TERAZOSIN HCL

7TERBINAFINE7TERBINAFINE HCL

7TERBINAFINE-25019TERBUTALINE SULFATE

116TERCONAZOLE

117TERSASEPTIC121TERSA-TAR121TERSA-TAR MILD106TESTOSTERONE CYPIONATE106TESTOSTERONE CYPIONATE

106TESTOSTERONE ENANTHATE

106TESTOSTERONE UNDECANOATE

82TETRABENAZINE

6TETRACYCLINE6TETRACYCLINE HCL

88TEVA- MONTELUKAST130TEVA-ALENDRONATE

CHOLECALCIFEROL20TEVA-ALFUZOSIN PR38TEVA-AMLODIPINE13TEVA-ANASTROZOLE45TEVA-CANDESARTAN46TEVA-CANDESARTAN/HCTZ13TEVA-CAPECITABINE65TEVA-CITALOPRAM3TEVA-CLARITHROMYCIN

25TEVA-CLOPIDOGREL92TEVA-DORZOTIMOL8TEVA-EFAVIRENZ

81TEVA-ENTACAPONE54TEVA-FENTANYL

129TEVA-FINASTERIDE29TEVA-FLUVASTATIN16TEVA-GALANTAMINE ER

111TEVA-GLICLAZIDE55TEVA-HYDROMORPHONE14TEVA-IMATINIB46TEVA-IRBESARTAN46TEVA-IRBESARTAN/HCTZ85TEVA-LACTULOSE9TEVA-LAMIVUDINE/ZIDOVUDINE

100TEVA-LANSOPRAZOLE92TEVA-LATANOPROST/TIMOLOL

132TEVA-LEFLUNOMIDE14TEVA-LETROZOLE47TEVA-LOSARTAN47TEVA-LOSARTAN HCTZ75TEVA-METHYLPHENIDATE ER

18MG76TEVA-METHYLPHENIDATE ER



54MG57TEVA-MORPHINE SR 100MG TAB57TEVA-MORPHINE SR 15MG TAB57TEVA-MORPHINE SR 200MG TAB57TEVA-MORPHINE SR 30MG TAB

57TEVA-MORPHINE SR 60MG TAB132TEVA-MYCOPHENOLATE98TEVA-NABILONE79TEVA-NARATRIPTAN9TEVA-NEVIRAPINE

71TEVA-OLANZAPINE OD100TEVA-OMEPRAZOLE101TEVA-PANTOPRAZOLE63TEVA-PREGABALIN73TEVA-QUETIAPINE XR

108TEVA-RALOXIFENE45TEVA-RAMIPRIL/HCTZ

130TEVA-RISEDRONATE30TEVA-ROSUVASTATIN48TEVA-TELMISARTAN48TEVA-TELMISARTAN HCTZ48TEVA-VALSARTAN49TEVA-VALSARTAN/HCTZ80TEVA-ZOLMITRIPTAN80TEVA-ZOLMITRIPTAN OD46TEVETEN46TEVETEN PLUS

123THEO ER123THEOLAIR123THEOPHYLLINE

123THEOPHYLLINE113THIAMAZOLE

125THIAMINE128THIAMINE

125THIAMINE HCL

15THIOGUANINE

75THIOPROPERAZINE MESYLATE

75THIOTHIXENE

21THRIVE84THYROGEN

113THYROID113THYROID

84THYROTROPIN ALFA

118TIAMOL53TIAPROFENIC ACID

40TIAZAC40TIAZAC XC25TICLOPIDINE25TICLOPIDINE HCL

38TIMOLOL38TIMOLOL MALEATE

92TIMOLOL MALEATE,

TRAVOPROST

91TIMOLOL MALEATE-EX92TIMOPTIC91TIMOPTIC-XE

116TINACTIN116TINACTIN AEROSOL24TINZAPARIN SODIUM

18TIOTROPIUM BROMIDE

MONOHYDRATE

10TIPRANAVIR

20TIZANIDINE HCL

90TOBRADEX89TOBRAMYCIN

89TOBREX132TOCILIZUMAB

111TOLBUTAMIDE

116TOLNAFTATE

Page I-22 of 242014

Page


Page Page27TOLOXIN

123TOLTERODINE

64TOPAMAX64TOPAMAX SPRINKLE

118TOPICORT64TOPIRAMATE

64TOPIRAMATE118TOPSYN127TR- VI-SOL34TRACLEER

109TRAJENTA36TRANDATE45TRANDOLAPRIL

26TRANEXAMIC ACID

26TRANEXAMIC ACID21TRANSDERMAL NICOTINE33TRANSDERM-NITRO69TRANYLCYPROMINE SULFATE

92TRAVATAN Z98TRAVEL AID92TRAVOPROST

69TRAZODONE69TRAZODONE HCL

69TRAZOREL15TRELSTAR15TRELSTAR LA15TRETINOIN

106TRIAMCINOLONE90TRIAMCINOLONE ACETONIDE

106TRIAMCINOLONE ACETONIDE (5ML)

106TRIAMCINOLONE DIACETATE

106TRIAMCINOLONE

HEXACETONIDE

87TRIAMTERENE,

HYDROCHLOROTHIAZIDE

53TRIATEC-3079TRIAZOLAM

117TRICLOSAN

107TRI-CYCLEN (21)107TRI-CYCLEN (28)107TRI-CYCLEN LO (21)107TRI-CYCLEN LO (28)118TRIDESILON75TRIFLUOPERAZINE HCL

89TRIFLURIDINE

17TRIHEXYPHENIDYL HCL

12TRIKACIDE12TRIMETHOPRIM

70TRIMIPRAMINE MALEATE

33TRINIPATCH15TRIPTORELIN PAMOATE

107TRIQUILAR (21)107TRIQUILAR (28)

8TRIZIVIR123TROSEC123TROSPIUM CHLORIDE

84TRUETEST84TRUETRACK (ON)92TRUSOPT8TRUVADA

134TUBING19TWINJECT39TWYNSTA

58TYLENOL59TYLENOL EXTRA STRENGTH58TYLENOL GRAPE58TYLENOL JR STRENGTH

FASTMELTS58TYLENOL JUNIOR STRENGTH53TYLENOL WITH CODEINE NO.253TYLENOL WITH CODEINE NO.399ULCIDINE

129ULORIC135ULTI 29GX1/2 INC SHARP

CONTAIN136ULTI 31GX1/4 INC SHARP

CONTAIN136ULTI 31GX5/16 INC SHARP

CONTAI136ULTI SYG WITH ULTIG 29G 1/2 IN136ULTI SYG WITH ULTIG 30G 1/2 IN136ULTI SYG WITH ULTIG 30G 5/16 I137ULTI SYG WITH ULTIG 31G 5/16 I137ULTICARE 0.3CC 31G SYG 5/16 IN136ULTICARE 0.5CC 28G SYG 1/2 INC137ULTICARE 0.5CC 31G SYG 5/16 IN136ULTICARE 1CC 28G SYG 1/2 INCH137ULTICARE 1CC 31G SYG 5/16

INCH136ULTICARE 29G136ULTICARE 30G136ULTICARE INSULIN SYR 29G 1CC136ULTICARE INSULIN SYR 29G.3CC136ULTICARE INSULIN SYR 29G.5CC137ULTICARE INSULIN SYR 30G.1CC137ULTICARE INSULIN SYR 30G.3CC137ULTICARE INSULIN SYR30G.5CC136ULTICARE LOW DEAD SPACE

SYG136ULTICARE PEN NEEDLE

32GX4MM136ULTIGUARD INSULIN SYR

29G.1CC136ULTIGUARD INSULIN SYR





30G.5CC136ULTRA-FINE135ULTRA-FINE II136ULTRA-FINE II 30G135ULTRAFINE PEN ULTRA-FINE 29G97ULTRASE MS 497ULTRASE MT 1297ULTRASE MT 20

118ULTRAVATE135UNILET COMFORT TOUCH123UNIPHYL119UREMOL HC123URISPAS97URSO97URSO DS97URSODIOL

128USTEKINUMAB

108VAGIFEM

11VALACYCLOVIR HCL

11VALCYTE11VALGANCICLOVIR HCL

118VALISONE77VALIUM64VALPROATE, SODIUM

64VALPROIC ACID

48VALSARTAN48VALSARTAN

49VALSARTAN HCT49VALSARTAN,

HYDROCHLOROTHIAZIDE

49VALSARTAN-HCTZ11VALTREX22VARENICLINE

42VASERETIC42VASOTEC70VENLAFAXINE HCL

70VENLAFAXINE XR23VENOFER

114VENOMIL HONEY BEE VENOM114VENOMIL MIXED VESPID VENOM

PROTEIN114VENOMIL WASP VENOM PROTEIN114VENOMIL WHITE FACED HORNET

VENOM PROTEIN114VENOMIL YELLOW JACKET

VENOM PROTEIN19VENTOLIN19VENTOLIN HFA19VENTOLIN PF13VEPESID41VERAPAMIL41VERAPAMIL HCL

2VERMOX117VERSEL94VERTEPORFIN

15VESANOID123VESICARE114VESPULA SPP VENOM PROTEIN

EXTRACT

7VFEND11VICTRELIS11VICTRELIS TRIPLE8VIDEX EC

65VIGABATRIN

62VIMPAT15VINCRISTINE SULFATE15VINCRISTINE SULFATE

97VIOKASE9VIRACEPT9VIRAMUNE

10VIREAD89VIROPTIC

113VISANNE37VISKAZIDE37VISKEN94VISUDYNE

125VIT A125VIT B12125VIT C125VITAMIN A125VITAMIN A

120VITAMIN A ACID

Page I-23 of 242014

Page


Page Page127VITAMIN A, CHOLECALCIFEROL,

ASCORBIC ACID

125VITAMIN B1125VITAMIN B12125VITAMIN B3125VITAMIN B6125VITAMIN C126VITAMIN D126VITAMIN D

122VITAMIN E122VITAMIN E

34VOLIBRIS50VOLTAREN51VOLTAREN SR7VORICONAZOLE

75VYVANSE 20MG CAP75VYVANSE 30MG CAP75VYVANSE 40MG CAP75VYVANSE 50MG CAP75VYVANSE 60MG CAP85WAMPOLE MINERAL CALCIUM25WARFARIN25WARFARIN SODIUM

114WASP VENOM PROTEIN114WASP VENOM PROTEIN

87WATER

128WATER FOR INJECTION128WATER STERILE134WEBCOL ALCOHOL PREP65WELLBUTRIN SR65WELLBUTRIN XL

114WHITE FACED HORNET VENOM114WHITE FACED HORNET VENOM

PROTEIN

114WHITE FACED HORNET VENOM

PROTEIN, YELLOW HORNET

VENOM PROTEIN, YELLOW

JACKET VENOM PROTEIN

106WINPRED92XALACOM92XALATAN76XANAX76XANAX TS24XARELTO20XATRAL13XELODA

133XEOMIN120XYLOCAINE VISCOUS106YASMIN (21)106YASMIN (28)106YAZ114YELLOW HORNET VENOM

PROTEIN114YELLOW HORNET VENOM

PROTEIN

114YELLOW JACKET HORNET VENOM PROTEIN

114YELLOW JACKET VENOM PROTEIN

114YELLOW JACKET VENOM

PROTEIN

1ZADITEN88ZAFIRLUKAST

106ZAMINE (21)106ZAMINE (28)20ZANAFLEX

99ZANTAC78ZAPEX

106ZARAH (21)106ZARAH (28)60ZARONTIN87ZAROXOLYN

116ZEASORB AF75ZELDOX18ZENHALE10ZERIT43ZESTORETIC43ZESTRIL8ZIAGEN

10ZIDOVUDINE

120ZINC120ZINC OXIDE

120ZINCOFAX EXTRA STRENGTH75ZIPRASIDONE

3ZITHROMAX31ZOCOR

122ZODERM98ZOFRAN98ZOFRAN ODT14ZOLADEX14ZOLADEX LA

131ZOLEDRONIC ACID

80ZOLMITRIPTAN

80ZOLMITRIPTAN80ZOLMITRIPTAN ODT69ZOLOFT80ZOMIG80ZOMIG RAPIMELT

122ZOSTRIX10ZOVIRAX65ZYBAN

129ZYLOPRIM130ZYM-ALENDRONATE FC38ZYM-AMLODIPINE36ZYM-CARVEDILOL59ZYM-CLONAZEPAM67ZYM-FLUOXETINE68ZYM-MIRTAZAPINE98ZYM-ONDANSETRON

111ZYM-PIOGLITAZONE30ZYM-PRAVASTATIN31ZYM-SIMVASTATIN64ZYM-TOPIRAMATE72ZYPREXA71ZYPREXA ZYDIS7ZYVOXAM

Page I-24 of 242014

Date post:	07-Jun-2018
Category:	Documents
Upload:	voxuyen
View:	215 times
Download:	0 times

DRUG BENEFIT LIST - divisionsbc.ca HEALTH BENEFITS First Nations and Inuit Health Branch DRUG...

Documents