Saskatchewan Health
Formulary Fifty-Second Edition
Drug Plan
October 2002 - July 2003 Updated quarterly
Inquiries should be directed to: Pharmaceutical Services Division Drug Plan & Extended Benefits Branch Saskatchewan Health 2nd Floor, 3475 Albert Street Regina, Saskatchewan S4S 6X6 Website Address: http://formulary.drugplan.health.gov.sk.ca
Telephone inquiries should be directed as follows: Consumer Inquiries………………..……………Toll Free…….. …………………………………………….……...Regina….….. Pharmacy Inquiries………………………………Toll Free……. ………………………………………………..……Regina……… Special Support Program Inquiries……………Toll Free…….. …………………………………………….……....Regina….…... EDS, Palliative Care, "No Substitution" Inquiries…….………. EDS Requests (24-hour message system)…..Toll Free…….. Profile Release Program………………………………………... Pricing, Contract Inquiries………………………………………. Product Submission Inquiries………………………….……….. Research and Utilization Inquiries……………………………... Hospital Benefit List Inquiries………………………….………..
1-800-667-7581 (306) 787-3317 1-800-667-7578 (306) 787-3315 1-800-667-7581 (306) 787-3317 (306) 787-8744 1-800-667-2549 (306) 787-1661 (306) 787-3420 (306) 933-5599 (306) 787-3307 (306) 787-3224
Facsimile numbers: EDS Unit Fax (EDS requests, Palliative Care forms and "No Substitution" requests only)……………………. General Fax ………………………………………..…..………...
(306) 798-1089 (306) 787-8679
Copyright - 2002 Her Majesty the Queen in right of the Dominion of Canada, as represented by the Minister of Health of the Province of Saskatchewan. ISSN 0701-9823 Printed in Canada Saskatchewan Health Government of Saskatchewan Minister, The Honourable John T. Nilson, Q.C.
TABLE OF CONTENTS
The Saskatchewan Formulary Is Published Annually Updates will be provided: Winter 2003 Spring 2003
Please insert sticker updates in the section provided at the back of the Formulary.
TABLE OF CONTENTS MEMBERSHIP OF SASKATCHEWAN FORMULARY COMMITTEE.................................... . MEMBERSHIP OF SASKATCHEWAN DRUG QUALITY ASSESSMENT COMMITTEE ..... . PREFACE.............................................................................................................................. . NOTES CONCERNING THE FORMULARY......................................................................... . LEGEND................................................................................................................................ .
iv iv v ix xvii
PHARMACOLOGICAL - THERAPEUTIC CLASSIFICATION OF DRUGS 08:00 ANTI-INFECTIVE AGENTS..................................................................................... . 10:00 ANTINEOPLASTIC AGENTS.................................................................................. . 12:00 AUTONOMIC DRUGS............................................................................................. . 20:00 BLOOD FORMATION AND COAGULATION.......................................................... . 24:00 CARDIOVASCULAR DRUGS................................................................................. . 28:00 CENTRAL NERVOUS SYSTEM DRUGS............................................................... . 36:00 DIAGNOSTIC AGENTS.......................................................................................... . 40:00 ELECTROLYTIC, CALORIC AND WATER BALANCE........................................... . 48:00 COUGH PREPARATIONS...................................................................................... . 52:00 EYE, EAR, NOSE AND THROAT PREPARATIONS.............................................. . 56:00 GASTROINTESTINAL DRUGS............................................................................... . 60:00 GOLD COMPOUNDS.............................................................................................. . 64:00 METAL ANTAGONISTS.......................................................................................... . 68:00 HORMONES AND SUBSTITUTES......................................................................... . 84:00 SKIN AND MUCOUS MEMBRANE PREPARATIONS............................................ . 86:00 SMOOTH MUSCLE RELAXANTS.......................................................................... . 88:00 VITAMINS................................................................................................................ . 92:00 UNCLASSIFIED THERAPEUTIC AGENTS............................................................ .
2 24 28 40 46 76 120 124 130 132 144 154 156 158 180 202 206 210
APPENDICES APPENDIX A - EXCEPTION DRUG STATUS PROGRAM................................................ . APPENDIX B - HOSPITAL BENEFIT DRUG LIST............................................................. . APPENDIX C - TIPS ON PRESCRIPTION WRITING........................................................ . PRESCRIPTION REGULATIONS.............................................................. . APPENDIX D - GUIDELINES FOR REPORTING ADVERSE DRUG REACTIONS.......... . APPENDIX E - SPECIAL COVERAGES............................................................................ . APPENDIX F - TRIPLICATE PRESCRIPTION PROGRAM............................................... . APPENDIX G - CODES FOR PHARMACY ON-LINE CLAIMS PROCESSING................. . APPENDIX H - MAINTENANCE DRUG SCHEDULE........................................................ . APPENDIX I - TRIAL PRESCRIPTION PROGRAM MEDICATION LIST......................... . APPENDIX J - SASKATCHEWAN MS DRUGS PROGRAM............................................. .
222 259 292 294 296 301 306 309 311 312 313
INDICES INDEX A - PHARMACEUTICAL MANUFACTURERS LIST............................................... . INDEX B - THERAPEUTIC CLASSIFICATION LIST......................................................... . INDEX C - NUMERICAL LIST OF DRUG IDENTIFICATION NUMBERS.......................... . INDEX D - ALPHABETICAL LIST OF PHARMACEUTICAL PRODUCT NAMES.............. .
318 320 322 339
FORMULARY UPDATES...................................................................................................... . UPDATE INDEX.......…………………………………............................................................... .
360 378
ii
INTRODUCTION
COMMITTEES SASKATCHEWAN FORMULARY COMMITTEE (SFC)
SASKATCHEWAN DRUG QUALITY ASSESSMENT COMMITTEE (DQAC)
Dr. B.R. Schnell Chairperson
Dr. D. Quest Chairperson
Dr. M. Caughlin Saskatchewan Medical Association
Ms B. Evans College of Pharmacy & Nutrition
Ms S. Chow Saskatchewan Registered Nurses Association
Dr. I. Holmes College of Medicine Dr. A. Paus-Jenssen College of Medicine
Dr. R. Dobson Member at Large
Dr. A. K. Ramlall College of Medicine
Mr. M. Gaucher Saskatchewan Association of Health Organizations
Dr. B.R. Schnell Chair, SFC
Ms C. Kanhai Saskatchewan Pharmaceutical Association
Dr. Y. Shevchuk College of Pharmacy & Nutrition
Dr. J. de la Rey Nel College of Physicians & Surgeons
Dr. J. Sibley Department of Medicine, College of Medicine
Mr. G. Peters Saskatchewan Health
Dr. J. Tuchek Department of Pharmacology, College of Medicine
Dr. D. Quest Chair, DQAC
Dr. T. W. Wilson Departments of Medicine & Pharmacology, College of Medicine
Dr. D. Seibel Member at Large Dr. Y. Shevchuk College of Pharmacy & Nutrition STAFF ASSISTANCE
Ms Barbara J. Shea Executive Director, Drug Plan & Extended Benefits Branch
Ms Gail Bradley Pharmacist, Drug Plan & Extended Benefits Branch
Mr. Kevin Wilson Director, Pharmaceutical Services Drug Plan & Extended Benefits Branch
Dr. Lorne Davis Pharmacologist, Drug Plan & Extended Benefits Branch
Ms Margaret Baker Manager, Formulary & Special Benefits Drug Plan & Extended Benefits Branch iv
PREFACE OBJECTIVES The Drug Plan has been established to: • provide coverage to Saskatchewan residents for quality pharmaceutical products of proven therapeutic effectiveness; • reduce the direct cost of prescription drugs to Saskatchewan residents; • reduce the cost of drug materials; • encourage the rational use of prescription drugs. THE FORMULARY The Saskatchewan Formulary is a listing of the therapeutically effective drugs of proven high quality that have been approved for coverage under the Drug Plan. It is compiled by the Minister of Health with the advice of the Saskatchewan Formulary Committee (SFC). The SFC is advised and assisted by the Drug Quality Assessment Committee (DQAC). Members of both committees are appointed by the Minister of Health. The Saskatchewan Formulary is published annually in July, with quarterly updates. The ongoing work of the SFC includes the evaluation of new drug products as they are introduced, and the periodic re-evaluation of all products. The goal is to list a range and variety of drugs that will enable prescribers to select an effective course of therapy for most patients. THE DRUG REVIEW PROCESS When a new drug is introduced to the Canadian market, the manufacturer submits a request to the Drug Plan so that it can be considered for possible coverage. The request must be supported by scientific reports and manufacturing documents to show that the product meets accepted standards of quality, effectiveness and safety. The DQAC carries out an initial evaluation of the submission, with emphasis on clinical documents, such as reports of scientific studies comparing the new product with existing therapeutic alternatives. In the case of new brands of currently listed products, the DQAC evaluates comparative bioavailability studies and/or comparative clinical studies in order to determine compliance with accepted standards for interchangeability. The DQAC reports its findings to the SFC. Using this information, along with additional details of anticipated cost and impact on patterns of practice, the SFC makes a recommendation to the Minister of Health. These recommendations reflect the "Policy for Inclusion of Products in the Saskatchewan Formulary" (see pages ix-xii). The membership on the two Committees reflects their unique but complementary mandate. The DQAC is composed of clinical specialists in internal medicine and/or pharmacology, clinical pharmacists and pharmacologists. The SFC is made up of representatives of the associations or institutions related to the regulation, education, delivery and payment of drug therapy in Saskatchewan.
v
PRODUCT SUBMISSION PROCESS
MANUFACTURER SUBMISSION
MANUFACTURER SUBMISSION
ONCOLOGY INDICATION
DRUG QUALITY ASSESSMENT COMMITTEE (DQAC)
The DQAC reviews the clinical and pharmaceutical aspects of the submission and makes a recommendation to the Formulary Committee or the Advisory Committee on Institutional Pharmacy Practice.
AMBULATORY CARE INDICATION INSTITUTIONAL INDICATION
SASKATCHEWAN CANCER AGENCY PHARMACY & THERAPEUTICS COMMITTEE 2
SASKATCHEWAN FORMULARY COMMITTEE (SFC) 1
SASKATCHEWAN CANCER AGENCY BENEFIT DRUG LIST
ADVISORY COMMITTEE ON INSTITUTIONAL PHARMACY PRACTICE 3
HOSPITAL BENEFIT DRUG LIST SASKATCHEWAN FORMULARY
1
2
3
Considers pharmacoeconomic impact in addition to the clinical and pharmaceutical aspects reviewed by the DQAC. DQAC advises the Saskatchewan Cancer Agency Pharmacy & Therapeutics Committee regarding interchangeability and product quality issues. All products listed in the Saskatchewan Formulary are benefits when used in the hospital setting.
Note: All committee recommendations are subject to approval by the Minister of Health.
vi
REQUEST FOR PRODUCT ASSESSMENT Submission Process Any supplier wishing to have products listed in the Saskatchewan Formulary, the Hospital Benefits List or the Saskatchewan Cancer Agency Benefit List may submit requests for product assessment. The route a submission follows is determined by the indication of the products. There is no deadline date for submissions for listing in the Formulary. In general, submissions are reviewed in order of receipt. Clinical Documentation Single-Supplier Product Submissions Clinical documentation in support of products to be reviewed may be submitted at any time. The committees meet on a regular basis and will review submissions as quickly as possible upon receipt. Details of the criteria for product listings are published in each edition of the Formulary and in the quarterly updates to the Formulary. Clinical information should clearly illustrate the efficacy of the drug. Comparative studies against listed products demonstrating specific advantages of the drug should be included. Clinical data is not usually required for additional strengths of a dosage form unless the additional strength is intended for different indications, than listed products. Rationale for the additional strength should be included. Notification is required whenever there is a change in formulation or in the clinical information published in the product monograph, for any listed product as well as for any product under review. Interchangeable Product Submissions Comprehensive clinical data may not be required for new brands of drugs already listed in the Formulary. When a product may be considered as interchangeable with a listed product, the submission should include documentation to demonstrate bioequivalence. Comparative bioavailability data for one strength will apply to other strengths of the same product if they are dose proportionate. For solid oral dosage forms, comparative dissolution rate studies should be submitted. For topical preparations, oral liquids and injectable drug products, comparative physical parameters (e.g. viscosity, homogeneity, specific gravity, particle size distribution, pH, osmolarity, drop size, drug content per drop, surface tension, etc.) to demonstrate pharmaceutical equivalence. For a cross-referenced product, letters dated and signed by a senior company official from both the manufacturer making the submission, and the manufacturer of the crossreferenced product, should be submitted to confirm that the product is identical in all aspects, except for embossing and labelling. Manufacturing Documentation Manufacturing documentation, completed Certified Product Information Document (C.P.I.D.) should be submitted with the clinical documentation if possible, but will be accepted at a later date. A representative sample, packaged and labelled for sale in Canada should also be included.
vii
Economic Evaluation Price information including catalogue or estimated prices should be provided at the time of product submission. Submission of pharmacoeconomic analyses are encouraged. The National Pharmacoeconomic Guidelines serve as a guide. The Formulary Committee will routinely consider direct “medical” costs such as: • • • • •
impact on laboratory tests for monitoring, evaluation or diagnosis impact on physician office visits impact on hospitalization or institutionalization impact on surgical procedures increased or decreased incidence and severity of side effects.
The availability of quality-of-life analyses is encouraged. Additional Documentation Required: • A letter authorizing unrestricted communication regarding the drug product between the Saskatchewan Prescription Drug Plan and other federal, provincial and territorial (F/P/T) drug programs: 1. F/P/T health authorities and related facilities 2. Health Canada 3. Patented Medicine Prices Review Board (PMPRB) 4. Canadian Coordinating Office for Health Technology Assessment (CCOHTA) • Expected market share information is requested to allow for an accurate projection of the impact of a new product. • Product patent expiration date is requested to allow for consideration of the potential long-term economic impact of the product. • Copies of the initial product launch material, and any subsequent promotional material sent to physicians and pharmacists.
Submission Procedure Requests for product assessment, together with supporting clinical (including notice of compliance and product monograph) and manufacturing documentation should be sent to: Dr. Lorne Davis, Pharmacologist Department of Pharmacology, College of Medicine University of Saskatchewan, 107 Wiggins Road Saskatoon, Saskatchewan S7N 5E5 Copies of the covering letter, the product monograph, notice of compliance, pricing information and economic analysis should be sent to: Ms Margaret Baker, Manager, Formulary & Special Benefits Unit Drug Plan and Extended Benefits Branch, Saskatchewan Health 2nd Floor, 3475 Albert Street Regina, Saskatchewan S4S 6X6 viii
NOTES CONCERNING THE FORMULARY Benefits The Saskatchewan Formulary lists the drugs which are covered by the Drug Plan. A prescription is required for all drugs dispensed under the Drug Plan with the exception of insulin, blood-testing agents, and urine-testing agents used by diabetic patients. Certain drugs are covered under the Exception Drug Status Program (EDS) and require that specific medical criteria are met before coverage is granted. See Appendix A for more information regarding EDS. Eligibility With a few exceptions, all Saskatchewan residents with a valid Saskatchewan Health Services card are eligible for coverage under the Drug Plan. The exceptions include those who have prescription costs paid by another agency. For example: • • • • •
Health Canada, First Nations and Inuit Health Branch Workers' Compensation Board Veterans Affairs Canada members of the Royal Canadian Mounted Police members of the Canadian Forces
Policy for Inclusion of Products in the Saskatchewan Formulary 1.
Only products produced by manufacturers approved as acceptable suppliers by the SFC will be considered. Companies without their own manufacturing facilities may be recognized as approved suppliers if, in addition to meeting all other criteria outlined herein, they provide adequate assurance that the product supplied is made under an acceptable contractual arrangement which is approved by the SFC. The procedures used to evaluate a drug manufacturer include: • review of manufacturing facilities and procedures by: • manufacturers' reports to the Committee; • evaluation of selected documents pertaining to individual products; • laboratory analysis of products selected for testing; • exchange of information and views with Health Canada, and the Food and Drug Administration (Washington), on products and manufacturers, as well as studies relating to particular problems such as dissolution and bioavailability; • reference to experience and knowledge available to the Committee with relation to manufacturing practices and drug usage at the clinical level. The review of drug manufacturers is ongoing to ensure that the quality of products listed in the Saskatchewan Formulary is maintained.
2.
Only drug products formulated and produced in accordance with sound manufacturing principles and found to comply with official standards will be considered. The official standards include: • regulations under the Food and Drugs Act pertaining to drug manufacturing;
ix
• Good Manufacturing Practices for Drug Manufacturers and Importers, 3rd Edition, 1989- Health Canada; • official compendia-B.P., U.S.P., N.F. and/or appropriate in-house standards; • similar criteria, where applicable, as defined by International (WHO), U.S., and British authorities. 3.
Only drug products which are valid therapeutic agents, with proven clinical effectiveness, for the diagnosis, prevention or treatment of mental or physical disorders will be listed. The availability of suitable alternative agents, and potential for undesirable effects will be considered. The medical literature and clinical studies, supplied by the manufacturers or Committee members, are reviewed and evaluated to determine if the drug product is therapeutically effective for the treatment of the condition(s) for which the drug is indicated. The clinical literature is also reviewed to determine the therapeutic advantages or disadvantages in relation to alternative agents, which may or may not be listed in the Saskatchewan Formulary. The rate and severity of potential undesirable effects are reviewed and compared with those for alternative products. In reviewing products for which suitable alternatives are listed in the Formulary, consideration will be given to the following additional criteria: • clinical documentation must clearly demonstrate therapeutic advantages such as: • more effective for treatment of the condition(s) for which the drug is intended; • increased safety as shown by reduced toxicity and reduced incidence of adverse reactions and/or side effects; • improved dosing schedule; • reduced potential for abuse or inappropriate use; OR • anticipated cost of a product of equivalent therapeutic effectiveness must offer a potential economic advantage over listed alternatives.
4.
The cost of therapy relative to the clinical efficacy is reviewed and compared to the cost of therapy relative to the clinical efficacy of alternative agents. An increased cost may be justified if the drug product produces better clinical results in a significant portion of the patient population, demonstrates fewer or less severe undesirable effects, or has a dosage regime which improves patient compliance. The cost of oral combination products relative to the combined costs of the single entities, the cost of the various dosage strengths relative to therapeutic advantages, and the cost of additional dosage forms relative to the therapeutic advantages will be considered when reviewing such products.
5.
Some drug products will not be listed as regular benefits, but may be made available on Exception Drug Status for treatment of selected clinical indications. (See Appendix A)
x
6.
Oral combination products are required to meet the following additional criteria: • each component must make a contribution to the claimed effect; • the dosage of each component (amount, frequency, duration of therapeutic effect) must be such that the combination is safe and effective for a significant patient population, requiring such concurrent therapy as defined in the labelling; • a component may be added to: • enhance safety or effectiveness of the principal active ingredient; • minimize the potential for abuse of the principal active ingredient. • combination fixed ratio must be "right" for: • significant portion of patients; • significant amount of natural history of disease. • the manufacturer must provide the standards he has adopted for the product (inhouse or other) and these standards must be acceptable to the DQAC; • the manufacturer must provide evidence that he can consistently meet these standards.
7.
Sustained, prolonged or delayed release dosage forms are required to meet the following additional criteria: • clinical studies have demonstrated the sustained, prolonged or delayed action of the active ingredient; • the dosage form possesses therapeutic advantages in the treatment of the disease entity for which the product is indicated; • the manufacturer must provide the standards he has adopted for the product (inhouse or other) and these standards must be acceptable to the DQAC; • the manufacturer must provide evidence that he can consistently meet these standards.
8.
The various strengths of one dosage form will be considered if they possess therapeutic advantages and meet the required standards for quality and cost.
9.
The various dosage forms of a drug product will be evaluated individually.
10. Drug products not listed in the Schedules of the Food and Drugs Act, Narcotic Control Act or the Saskatchewan Pharmacy Act, but usually sold on prescription, will be considered for inclusion. 11. Products which contain the same amount of the same active ingredient in an equivalent dosage form and are of acceptable equivalent therapeutic effectiveness will be listed as interchangeable. 12. The following will not be listed: • • • •
fertility agents; drugs used in erectile dysfunction; certain over-the-counter preparations; drugs used primarily in hospitals; xi
• antineoplastic agents (these are provided to patients through the Saskatchewan Cancer Agency); • anti-tuberculosis drugs; • blood derivatives – immune serum globulin for prophylaxis against infectious hepatitis or measles or for treatment of immune deficiency disease is available from the Health Offices. • vaccines and sera - most immunological agents are available from the Health Offices. 13. Drug products identified by trade names deemed to be inappropriate, confusing and/or misleading may not be listed. Some examples include: • products with similar or identical trade names but containing different active ingredients; • products with a different strength of ingredient, manufactured by the same supplier, but with a different trade name. Policy for Formulary Deletion The Minister of Health may delete any product from the Saskatchewan Formulary under the following circumstances: 1. Upon the recommendation of the SFC: • where the standards of quality and/or production have altered and are not considered to meet accepted standards; • where new information demonstrates that the product does not have adequate therapeutic benefit; • where undesirable effects of the product make the continued listing of the product inappropriate; • where new products possessing clearly demonstrated therapeutic advantages have been listed, thereby making the continued listing of the product unnecessary. 2. Upon the recommendation of the Drug Plan where there are undesirable financial, supply or administrative implications to continued listing of a product, the Drug Plan will consult with the SFC prior to making a recommendation. The comments of the Committee will be brought to the attention of the Minister. 3. Where the Minister of Health believes a product should be deleted, the Minister will consult with the SFC before making a final decision. Exception Drug Status Certain drug products may be considered for Exception Drug Status coverage under one or more of the following circumstances: • the drug is ordinarily administered only to hospital inpatients and is being administered outside of a hospital because of unusual circumstances; • the drug is not ordinarily prescribed or administered in Saskatchewan but is being prescribed because it is required in the diagnosis or treatment of a patient having an illness, disability or condition rarely found in this province; • the drug is infrequently used since therapeutic alternatives listed in the Formulary are usually effective but are contraindicated or found to be ineffective because of the clinical condition of the patient; • the drug has been deleted from the Formulary, but is required by patients who were previously stabilized on the drug; xii
• the drug has potential for use in other than approved indications; • the drug has potential for the development of widespread inappropriate use; • the drug is more expensive than listed alternatives and offers an advantage in only a limited number of indications.
The following information is required to process Exception Drug Status requests: • patient name • patient Health Services Number (9 digits) • name of drug • diagnosis relevant to use of drug • prescriber name • prescriber phone number
Saskatchewan Prescription Drug Plan policy does not allow a fee to be charged to clients for Exception Drug Status applications made to the Drug Plan on the client's behalf. See Appendix A for further details regarding Exception Drug Status. "No Substitution" Prescriptions Drug Plan benefits will be based only on the lowest priced interchangeable brand as listed in the Formulary. Credit towards established deductibles or thresholds (for income based drug coverage under Special Support) will also be based on the lowest priced interchangeable brand. Although the Formulary will continue to list all approved brands, patients will, in addition to their normal share of cost, be responsible for any incremental cost associated with the selection of a higher cost brand. It is important to note that both generic and brand name products are manufactured under the same standards of good manufacturing practice, and that only those brands which meet the SFC's standards for bioequivalence are accepted as interchangeable in Saskatchewan. In cases where a patient experiences problems with a specific brand of a medication, a prescriber may make application for exemption from the cost of the "no sub" brand. (See Appendix E for details.) Adverse Drug Reactions The Health Protection Branch encourages the reporting of suspected adverse drug reactions. In Saskatchewan, prescribers, pharmacists, and other health professionals are encouraged to participate in the Sask ADR Program. Suspected adverse reactions are reported by the observers to this program, which in turn, will send the original report to the Health Protection Branch in Ottawa. See Appendix D for forms and guidelines. Index Drug products are listed numerically by DIN (drug identification number) as well as alphabetically by official name and brand name at the back of the Formulary.
xiii
Pharmacologic-Therapeutic Classification of Drugs The drugs are classified according to the pharmacologic-therapeutic classification developed by the American Society of Hospital Pharmacists for the purpose of the American Hospital Formulary Service. Permission to use this system has been granted by the American Society of Hospital Pharmacists. The Society is not responsible for the accuracy of transpositions or excerpts from the original content. Within each therapeutic classification the drugs are listed alphabetically according to their official names. Under each drug, acceptable products are listed. Drugs with multiple uses may be listed in one or more classes. Prescription Quantities The Drug Plan places no limitation on the quantities of drugs that may be prescribed. Prescribers shall exercise their professional judgment in determining the course and duration of treatment for their patients. However, in most cases, the Drug Plan will not pay benefits or credit deductibles for more than a 3-month supply of a drug at one time. The quantity dispensed for one dispensing fee shall be determined by the terms of the contract in force when the prescription was dispensed. For drugs listed on the Two Month and 100 Day maintenance drug lists, refer to Appendix H. Because of possible waste and the potential danger of storing large quantities of potent drugs in the home, the Drug Plan does not encourage the dispensing of unreasonably large quantities of prescription drugs. Release of Patient Drug Profiles Saskatchewan prescribers or pharmacists wishing to obtain a drug profile for patients in their care may do so by submitting a written request, stating the patient's name, address, date of birth and Health Services Number to the address below. The drug profile will include all claims for Formulary and Exception Drug Status drugs submitted to the Drug Plan on behalf of the patient in the previous 9-12 months. Please submit written request to: Executive Director Drug Plan & Extended Benefits Branch Saskatchewan Health 2nd Floor, 3475 Albert Street Regina, S4S 6X6 FAX: (306) 787-8679
xiv
LEGEND
LEGEND 11
Pharmacological-Therapeutic classification.
2
Pharmacological-Therapeutic sub-classification.
3
Nonproprietary or generic name of the drug.
4
An asterisk (*) to the left of a drug strength and dosage form indicates that the products listed below are interchangeable.
5
An asterisk (*) to the right of a price indicates that the Drug Plan has negotiated a contract price for that product. Pharmacists will dispense these products except where a prescriber indicates "no substitution" for a product in an interchangeable category (see page xiii). In cases where contracts have been negotiated with two suppliers of an interchangeable product, either brand may be used. The prices are expressed as decimal dollars.
66
The following symbol:⌧, to the left of a drug strength and dosage form indicates that the products listed below are NOT interchangeable.
77
Drug strength and dosage form.
88
The Drug Identification Number (DIN), which has been assigned by Health Canada, uniquely identifies the drug product and its manufacturer, name and strength of active ingredients, route of administration, and pharmaceutical dosage form.
99
This product requires Exception Drug Status (EDS) approval (see Appendix A for EDS criteria).
10 All active ingredients of combination products are listed. 10 11 Strengths of active ingredients are listed in the same order as the ingredients. This example indicates that the tablet contains 100mg of levodopa and 25mg of carbidopa. 12 Brand name of drug. 12 13 Three letter identification code assigned to each manufacturer. The codes are listed in Index 13 near the back of the Formulary. 14 The size of vials or ampoules of injectables is listed in brackets. 14 15 The size of a tube of ophthalmic ointments is listed in brackets. 15
xvi
1
08:00 ANTI-INFECTIVE AGENTS
2
08:12.16 ANTIBIOTICS (PENICILLINS)
3
AMOXICILLIN (AMOXYCILLIN) * 250MG CAPSULE
4
00865567 00406724 00628115 02181487 02238171 02239761
NU-AMOXI NOVAMOXIN APO-AMOXI LIN-AMOX GEN-AMOXICILLIN MED-AMOXICILLIN
NXP NOP APX LIN GPM MED
$
0.0898 * 0.1120 0.1120 0.1120 0.1120 0.1120
PMS ICN WYA
$
0.0814 0.1055 0.1321
BAY
$
2.7188
RTP NXP APX NOP BMY
$
0.4107 0.4107 0.4107 0.4107 0.6839
LUD
$
73.1900
SCH SAB
$
4.3400 4.3400
CONJUGATED ESTROGENS 6
⌧
0.625MG TABLET 00587281 00265470 02043408
PMS-CONJUGATED ESTROGENS C.E.S. PREMARIN
CIPROFLOXACIN 7
500MG TABLET
8
02155966
10 11
CIPRO (EDS)
9
LEVODOPA/CARBIDOPA * 100MG/25MG TABLET 02126168 02182823 02195941 02244495 00513997
RATIO-LEVODOPA/CARBIDOPA NU-LEVOCARB 12 APO-LEVOCARB NOVO-LEVOCARBIDOPA SINEMET
13
FLUPENTHIXOL DECANOATE 20MG/ML INJECTION SOLUTION (10ML) 02156032
GENTAMICIN SO4 * 5MG/G OPHTHALMIC OINTMENT (3.5G) 00028339 02230888
14
FLUANXOL DEPOT
GARAMYCIN GENTAMICIN SULFATE
xvii
15
5
ANTI-INFECTIVE AGENTS
8:00
08:00 ANTI-INFECTIVE AGENTS 08:04.00 AMEBICIDES
DIIODOHYDROXYQUIN 650MG TABLET 01997750
DIODOQUIN
GLW
$
0.7307
JAN
$
3.1592
BAY
$
5.7510
PFC
$
1.0444
PFC
$
0.2507
PFC
$
0.1719
08:08.00 ANTHELMINTICS
MEBENDAZOLE 100MG TABLET 00556734
VERMOX
PRAZIQUANTEL 600MG TABLET 02230897
BILTRICIDE
PYRANTEL PAMOATE 125MG TABLET 01944363
COMBANTRIN
50MG/ML ORAL SUSPENSION 01944355
COMBANTRIN
PYRVINIUM PAMOATE 10MG/ML ORAL SUSPENSION 02019809
VANQUIN
08:12.00 ANTIBIOTICS ANTIBIOTIC ASSOCIATED COLITIS OR PSEUDOMEMBRANOUS ENTEROCOLITIS IS A SEVERE POTENTIALLY FATAL COLITIS WHICH MAY FOLLOW THE ADMINISTRATION OF ANTIBIOTICS, MOST COMMONLY CLINDAMYCIN. THE SYNDROME IS CAUSED BY A BACTERIAL TOXIN. PATIENTS FOR WHOM ANTIBIOTICS ARE PRESCRIBED SHOULD BE ADVISED TO DISCONTINUE THERAPY AND REPORT TO THE PHYSICIAN IF A PERSISTANT DIARRHEA DEVELOPS AND/OR IF BLOOD OR MUCUS APPEARS IN THE STOOL, AND SHOULD BE ADVISED NOT TO USE ANTIDIARRHEAL PREPARATIONS WHILE ON THESE DRUGS AS THEY MAY EXACERBATE THE CONDITION. RECOMMENDED TREATMENT INCLUDES STOPPING ANTIBIOTICS AS SOON AS POSSIBLE, CAREFUL ATTENTION TO FLUIDS AND ELECTROLYTES AND THE USE OF AN APPROPRIATE ANTIBIOTIC (SUCH AS ORALLY ADMINISTERED METRONIDAZOLE OR VANCOMYCIN) DIRECTED AGAINST THE TOXIN PRODUCING ORGANISM.
2
08:00 ANTI-INFECTIVE AGENTS 08:12.02 ANTIBIOTICS (AMINOGLYCOSIDES)
GENTAMICIN SO4 * 40MG/ML INJECTION SOLUTION (2ML) 00223824 02145758 02242652
GARAMYCIN GENTAMICIN SULPHATE GENTAMICIN
SCH NOP SAB
$
4.3000 4.3000 4.3000
CCL
$
51.1700
APX GPM PFI
$
11.0779 11.0779 15.1868
GPM APX PMS PFI
$
3.5719 3.7693 3.7693 5.0581
GPM APX PMS PFI
$
6.3354 6.6867 6.6867 9.2146
PFI
$
1.0126
SCH
$
0.2775
SCH
$
0.4697
TOBRAMYCIN SEE APPENDIX A FOR EDS CRITERIA
60MG/ML INHALATION SOLUTION (5ML) 02239630
TOBI (EDS)
08:12.04 ANTIBIOTICS (ANTIFUNGALS)
FLUCONAZOLE SEE APPENDIX A FOR EDS CRITERIA
* 150MG CAPSULE 02241895 02245697 02141442
APO-FLUCONAZOLE GEN-FLUCONAZOLE DIFLUCAN
* 50MG TABLET 02245292 02237370 02245643 00891800
GEN-FLUCONAZOLE (EDS) APO-FLUCONAZOLE (EDS) PMS-FLUCONAZOLE (EDS) DIFLUCAN (EDS)
* 100MG TABLET 02245293 02237371 02245644 00891819
GEN-FLUCONAZOLE (EDS) APO-FLUCONAZOLE (EDS) PMS-FLUCONAZOLE (EDS) DIFLUCAN (EDS)
10MG/ML POWDER FOR ORAL SUSPENSION 02024152
DIFLUCAN P.O.S. (EDS)
GRISEOFULVIN (ULTRA-FINE) 250MG TABLET 00028274
FULVICIN U/F
500MG TABLET 00028282
FULVICIN U/F
3
08:00 ANTI-INFECTIVE AGENTS 08:12.04 ANTIBIOTICS (ANTIFUNGALS)
ITRACONAZOLE SEE APPENDIX A FOR EDS CRITERIA
100MG CAPSULE 02047454
SPORANOX (EDS)
JAN
$
3.7975
JAN
$
0.8075
NXP NOP APX MCL
$
1.2841 1.2841 1.2841 2.0383
RTP
$
0.0858
DOM RTP PMS PPZ
$
0.0534 0.0566 0.0643 0.1978
APX PMS GPM NOP NVR
$
2.7391 2.7391 2.7391 2.7393 3.8712
10MG/ML ORAL SOLUTION 02231347
SPORANOX (EDS)
KETOCONAZOLE SEE APPENDIX A FOR EDS CRITERIA
* 200MG TABLET 02122197 02231061 02237235 00633836
NU-KETOCON (EDS) NOVO-KETOCONAZOLE (EDS) APO-KETOCONAZOLE (EDS) NIZORAL (EDS)
NYSTATIN 500,000U TABLET 02194198
RATIO-NYSTATIN
* 100,000U/ML ORAL SUSPENSION 02125145 02194201 00792667 00248169
DOM-NYSTATIN RATIO-NYSTATIN PMS-NYSTATIN MYCOSTATIN
TERBINAFINE HCL * 250MG TABLET 02239893 02240807 02242503 02240346 02031116
APO-TERBINAFINE PMS-TERBINAFINE GEN-TERBINAFINE NOVO-TERBINAFINE LAMISIL
4
08:00 ANTI-INFECTIVE AGENTS 08:12.06 ANTIBIOTICS (CEPHALOSPORINS)
CEFACLOR Note: All forms and strengths of cefaclor are scheduled to be delisted from the Saskatchewan Formulary effective April 1, 2003. SEE APPENDIX A FOR EDS CRITERIA
* 250MG CAPSULE 02185830 02230263 02231432 02231691 02177633
PMS-CEFACLOR (EDS) APO-CEFACLOR (EDS) NU-CEFACLOR (EDS) NOVO-CEFACLOR (EDS) DOM-CEFACLOR (EDS)
PMS APX NXP NOP DOM
$
0.6977 0.6977 0.6977 0.6977 0.8722
PMS APX NXP NOP DOM
$
1.3699 1.3699 1.3699 1.3699 1.7124
PMS APX DOM PMS
$
0.0827 0.0827 0.0930 0.1183
PMS APX DOM PMS
$
0.1514 0.1514 0.1702 0.2164
PMS APX DOM PMS
$
0.2181 0.2181 0.2450 0.3117
AVT
$
3.3570
AVT
$
0.3598
* 500MG CAPSULE 02185849 02230264 02231433 02231693 02177641
PMS-CEFACLOR (EDS) APO-CEFACLOR (EDS) NU-CEFACLOR (EDS) NOVO-CEFACLOR (EDS) DOM-CEFACLOR (EDS)
* 25MG/ML ORAL SUSPENSION 02185857 02237500 02177668 00465208
PMS-CEFACLOR (EDS) APO-CEFACLOR (EDS) DOM-CEFACLOR (EDS) CECLOR (EDS)
* 50MG/ML ORAL SUSPENSION 02185865 02237501 02177676 00465216
PMS-CEFACLOR (EDS) APO-CEFACLOR (EDS) DOM-CEFACLOR (EDS) CECLOR (EDS)
* 75MG/ML ORAL SUSPENSION 02185873 02237502 02177684 00832804
PMS-CEFACLOR (EDS) APO-CEFACLOR (EDS) DOM-CEFACLOR (EDS) CECLOR BID (EDS)
CEFIXIME SEE APPENDIX A FOR EDS CRITERIA
400MG TABLET 02195984
SUPRAX (EDS)
20MG/ML ORAL SUSPENSION 02195992
SUPRAX (EDS)
5
08:00 ANTI-INFECTIVE AGENTS 08:12.06 ANTIBIOTICS (CEPHALOSPORINS)
CEFPROZIL SEE APPENDIX A FOR EDS CRITERIA
250MG TABLET 02163659
CEFZIL (EDS)
BMY
$
1.6601
BMY
$
3.2550
BMY
$
0.1622
BMY
$
0.3245
RTP APX GSK
$
1.0994 1.0994 1.5705
RTP APX GSK
$
2.1779 2.1779 3.1112
GSK
$
0.1736
NOP
$
0.1620
NOP
$
0.3240
NXP NOP APX PMS DOM
$
0.1272 * 0.1620 0.1620 0.1620 0.1966
NXP NOP APX PMS DOM
$
0.2544 * 0.3240 0.3240 0.3240 0.3871
NOP
$
0.0352
NOP
$
0.0712
500MG TABLET 02163667
CEFZIL (EDS)
25MG/ML ORAL SUSPENSION 02163675
CEFZIL (EDS)
50MG/ML ORAL SUSPENSION 02163683
CEFZIL (EDS)
CEFUROXIME AXETIL SEE APPENDIX A FOR EDS CRITERIA
* 250MG TABLET 02242656 02244393 02212277
RATIO-CEFUROXIME (EDS) APO-CEFUROXIME (EDS) CEFTIN (EDS)
* 500MG TABLET 02242657 02244394 02212285
RATIO-CEFUROXIME (EDS) APO-CEFUROXIME (EDS) CEFTIN (EDS)
25MG/ML ORAL SUSPENSION 02212307
CEFTIN (EDS)
CEPHALEXIN MONOHYDRATE 250MG CAPSULE 00342084
NOVO-LEXIN
500MG CAPSULE 00342114
NOVO-LEXIN
* 250MG TABLET 00865877 00583413 00768723 02177781 02177846
NU-CEPHALEX NOVO-LEXIN APO-CEPHALEX PMS-CEPHALEXIN DOM-CEPHALEXIN
* 500MG TABLET 00865885 00583421 00768715 02177803 02177854
NU-CEPHALEX NOVO-LEXIN APO-CEPHALEX PMS-CEPHALEXIN DOM-CEPHALEXIN
25MG/ML ORAL SUSPENSION 00342106
NOVO-LEXIN
50MG/ML ORAL SUSPENSION 00342092
NOVO-LEXIN 6
08:00 ANTI-INFECTIVE AGENTS 08:12.12 ANTIBIOTICS (MACROLIDES) PRESCRIPTIONS FOR SOLID DOSAGE FORMS OF ERYTHROMYCIN SHOULD BE FILLED WITH AN ERYTHROMYCIN BASE PREPARATION OF THE STRENGTH PRESCRIBED; DISPENSE THE STEARATE AND ESTOLATE ONLY WHEN SPECIFICALLY PRESCRIBED.
AZITHROMYCIN SEE APPENDIX A FOR EDS CRITERIA
250MG TABLET 02212021
ZITHROMAX (EDS)
PFI
$
5.3528
PFI
$
12.8464
PFI
$
1.1574
PFI
$
1.6722
ABB
$
1.6048
ABB
$
3.2095
ABB
$
2.7282
ABB
$
0.2817
ABB
$
0.5632
APX
$
0.1107
ABB
$
0.5137
PFI
$
0.5024
PFI
$
0.5581
NOP
$
0.0297
NOP
$
0.0598
600MG TABLET 02231143
ZITHROMAX (EDS)
20MG/ML ORAL SUSPENSION 02223716
ZITHROMAX (EDS)
40MG/ML ORAL SUSPENSION 02223724
ZITHROMAX (EDS)
CLARITHROMYCIN SEE APPENDIX A FOR EDS CRITERIA
250MG TABLET 01984853
BIAXIN BID (EDS)
500MG TABLET 02126710
BIAXIN BID (EDS)
500MG EXTENDED-RELEASE TABLET 02244756
BIAXIN XL (EDS)
25MG/ML ORAL SUSPENSION 02146908
BIAXIN (EDS)
50MG/ML ORAL SUSPENSION 02244641
BIAXIN (EDS)
ERYTHROMYCIN BASE 250MG TABLET 00682020
APO-ERYTHRO-BASE
333MG PARTICLE COATED TABLET 00769991
PCE
250MG CAPSULE (ENTERIC COATED PELLETS) 00607142
ERYC
333MG CAPSULE (ENTERIC COATED PELLETS) 00873454
ERYC
ERYTHROMYCIN ESTOLATE 25MG/ML ORAL SUSPENSION 00021172
NOVO-RYTHRO ESTOLATE
50MG/ML ORAL SUSPENSION 00262595
NOVO-RYTHRO ESTOLATE
7
08:00 ANTI-INFECTIVE AGENTS 08:12.12 ANTIBIOTICS (MACROLIDES)
ERYTHROMYCIN ETHYLSUCCINATE * 40MG/ML ORAL SUSPENSION 00605859 00000299
NOVO-RYTHRO ETHYLSUCC. EES 200
NOP ABB
$
0.0671 0.0748
NOP ABB
$
0.0899 0.1133
APX NXP
$
0.0940 0.0940
NXP NOP APX LIN GPM MED
$
0.0898 * 0.1120 0.1120 0.1120 0.1120 0.1120
NXP NOP APX LIN GPM MED
$
0.1748 * 0.2181 0.2181 0.2181 0.2181 0.2181
NOP
$
0.2512
NOP
$
0.3700
* 80MG/ML ORAL SUSPENSION 00652318 00453617
NOVO-RYTHRO ETHYLSUCC. EES 400
ERYTHROMYCIN STEARATE * 250MG TABLET 00545678 02051850
APO-ERYTHRO-S NU-ERYTHROMYCIN-S
08:12.16 ANTIBIOTICS (PENICILLINS)
AMOXICILLIN (AMOXYCILLIN) * 250MG CAPSULE 00865567 00406724 00628115 02181487 02238171 02239761
NU-AMOXI NOVAMOXIN APO-AMOXI LIN-AMOX GEN-AMOXICILLIN MED-AMOXICILLIN
* 500MG CAPSULE 00865575 00406716 00628123 02181495 02238172 02239762
NU-AMOXI NOVAMOXIN APO-AMOXI LIN-AMOX GEN-AMOXICILLIN MED-AMOXICILLIN
125MG CHEWABLE TABLET 02036347
NOVAMOXIN
250MG CHEWABLE TABLET 02036355
NOVAMOXIN
8
08:00 ANTI-INFECTIVE AGENTS 08:12.16 ANTIBIOTICS (PENICILLINS)
* 25MG/ML ORAL SUSPENSION 00865540 00452149 00628131 02181509
NU-AMOXI NOVAMOXIN APO-AMOXI LIN-AMOX
NXP NOP APX LIN
$
0.0174 * 0.0217 0.0217 0.0217
NXP NOP APX LIN
$
0.0261 * 0.0326 0.0326 0.0326
* 50MG/ML ORAL SUSPENSION 00865559 00452130 00628158 02181517
NU-AMOXI NOVAMOXIN APO-AMOXI LIN-AMOX
AMOXICILLIN TRIHYDRATE/POTASSIUM CLAVULANATE SEE APPENDIX A FOR EDS CRITERIA
* 250MG/125MG TABLET 02243350 02243770 01916866
APO-AMOXI CLAV (EDS) RATIO-AMOXI CLAV (EDS) CLAVULIN-250 (EDS)
APX RTP GSK
$
0.6632 0.6632 0.9943
APX RTP GSK
$
1.0136 1.0136 1.4915
GSK
$
2.2372
APX RTP GSK
$
0.0786 0.0786 0.1179
GSK
$
0.1452
APX RTP GSK
$
0.1322 0.1322 0.1979
GSK
$
0.2712
* 500MG/125MG TABLET 02243351 02243771 01916858
APO-AMOXI CLAV (EDS) RATIO-AMOXI CLAV (EDS) CLAVULIN-500 (EDS)
875MG/125MG TABLET 02238829
CLAVULIN-875 (EDS)
* 25MG/6.25MG/ML ORAL SUSPENSION 02243986 02244646 01916882
APO-AMOXI CLAV (EDS) RATIO-AMOXI CLAV (EDS) CLAVULIN-125F (EDS)
40MG/5.3MG/ML ORAL SUSPENSION 02238831
CLAVULIN-200 (EDS)
* 50MG/12.5MG/ML ORAL SUSPENSION 02243987 02244647 01916874
APO-AMOXI CLAV (EDS) RATIO-AMOXI CLAV (EDS) CLAVULIN-250F (EDS)
80MG/11.4MG/ML ORAL SUSPENSION 02238830
CLAVULIN-400 (EDS)
9
08:00 ANTI-INFECTIVE AGENTS 08:12.16 ANTIBIOTICS (PENICILLINS)
AMPICILLIN * 250MG CAPSULE 00020877 00603279 00717657
NOVO-AMPICILLIN APO-AMPI NU-AMPI
NOP APX NXP
$
0.0889 0.0889 0.0889
NOP APX NXP
$
0.1723 0.1723 0.1723
APX NXP
$
0.0174 0.0174
APX NXP
$
0.0285 0.0285
NOP APX NXP
$
0.1078 0.1078 0.1078
NOP APX NXP
$
0.2112 0.2112 0.2112
NOP APX NXP
$
0.0259 0.0259 0.0259
LIH
$
0.0537
NOP APX NXP LIH
$
0.0407 0.0407 0.0407 0.0407
APX
$
0.0266
* 500MG CAPSULE 00020885 00603295 00717673
NOVO-AMPICILLIN APO-AMPI NU-AMPI
* 25MG/ML ORAL SUSPENSION 00603260 00717495
APO-AMPI NU-AMPI
* 50MG/ML ORAL SUSPENSION 00603287 00717649
APO-AMPI NU-AMPI
CLOXACILLIN * 250MG CAPSULE 00337765 00618292 00717584
NOVO-CLOXIN APO-CLOXI NU-CLOXI
* 500MG CAPSULE 00337773 00618284 00717592
NOVO-CLOXIN APO-CLOXI NU-CLOXI
* 25MG/ML ORAL LIQUID 00337757 00644633 00717630
NOVO-CLOXIN APO-CLOXI NU-CLOXI
PENICILLIN V (BENZATHINE) 60MG/ML ORAL SUSPENSION 02229617
PEN-VEE
PENICILLIN V (POTASSIUM) * 300MG TABLET 00021202 00642215 00717568 02232391
NOVO-PEN-VK APO-PEN-VK NU-PEN-VK PVF-K 500
25MG/ML ORAL SOLUTION 00642223
APO-PEN-VK
10
08:00 ANTI-INFECTIVE AGENTS 08:12.16 ANTIBIOTICS (PENICILLINS)
PIVMECILLINAM HCL SEE APPENDIX A FOR EDS CRITERIA
200MG TABLET 00657212
SELEXID (EDS)
LEO
$
0.9203
08:12.24 ANTIBIOTICS (TETRACYCLINES) THE USE OF TETRACYCLINES DURING TOOTH DEVELOPMENT (LAST HALF OF PREGNANCY, INFANCY AND CHILDHOOD TO THE AGE OF 8 YEARS) MAY CAUSE PERMANENT TOOTH DISCOLORATION (YELLOW-GRAY-BROWN). THIS REACTION IS MORE COMMON DURING LONG-TERM USE OF TETRACYCLINES, BUT HAS BEEN OBSERVED FOLLOWING SHORT-TERM COURSES. ENAMEL HYPOPLASIA HAS ALSO BEEN REPORTED. TETRACYCLINE DRUGS, THEREFORE, SHOULD NOT BE USED IN THIS AGE GROUP UNLESS OTHER DRUGS ARE NOT LIKELY TO BE EFFECTIVE OR ARE CONTRAINDICATED.
DOXYCYCLINE * 100MG CAPSULE 02044668 00740713 00817120 02093103 00024368
NU-DOXYCYCLINE APO-DOXY DOXYCIN RATIO-DOXYCYCLINE VIBRAMYCIN
NXP APX GPM RTP PFI
$
0.5094 * 0.6359 0.6359 0.6359 1.8440
NXP APX GPM RTP NOP PFI
$
0.5094 * 0.6359 0.6359 0.6359 0.6359 1.8440
* 100MG TABLET 02044676 00874256 00860751 02091232 02158574 00578452
NU-DOXYCYCLINE APO-DOXY DOXYCIN RATIO-DOXYCYCLINE NOVO-DOXYLIN VIBRA-TABS
11
08:00 ANTI-INFECTIVE AGENTS 08:12.24 ANTIBIOTICS (TETRACYCLINES)
MINOCYCLINE HCL SEE APPENDIX A FOR EDS CRITERIA
* 50MG CAPSULE 01914138 02084090 02108143 02230735 02237313 02237875 02239238 02239667 02173514
RATIO-MINOCYCLINE (EDS) APO-MINOCYCLINE (EDS) NOVO-MINOCYCLINE (EDS) GEN-MINOCYCLINE (EDS) RHOXAL-MINOCYCLINE (EDS) MED-MINOCYCLINE (EDS) PMS-MINOCYCLINE (EDS) DOM-MINOCYCLINE (EDS) MINOCIN (EDS)
RTP APX NOP GPM RHO MED PMS DOM WYA
$
0.5805 0.5805 0.5805 0.5805 0.5805 0.5805 0.5805 0.6131 0.6456
RTP APX NOP GPM RHO MED PMS DOM WYA
$
1.1211 1.1211 1.1211 1.1211 1.1211 1.1211 1.1211 1.1769 1.2456
APX NXP
$
0.0689 0.0689
* 100MG CAPSULE 01914146 02084104 02108151 02230736 02237314 02237876 02239239 02239668 02173506
RATIO-MINOCYCLINE (EDS) APO-MINOCYCLINE (EDS) NOVO-MINOCYCLINE (EDS) GEN-MINOCYCLINE (EDS) RHOXAL-MINOCYCLINE (EDS) MED-MINOCYCLINE (EDS) PMS-MINOCYCLINE (EDS) DOM-MINOCYCLINE (EDS) MINOCIN (EDS)
TETRACYCLINE * 250MG CAPSULE 00580929 00717606
APO-TETRA NU-TETRA
08:12.28 ANTIBIOTICS (MISCELLANEOUS ANTIBIOTICS)
CLINDAMYCIN HCL SEE NOTE REGARDING ANTIBIOTIC ASSOCIATED COLITIS OR PSEUDOMEMBRANOUS ENTERCOLITIS UNDER SECTION 08:12.00 (ANTIBIOTICS)
* 150MG CAPSULE 02245232 02130033 02241709 00030570
APO-CLINDAMYCIN RATIO-CLINDAMYCIN NOVO-CLINDAMYCIN DALACIN C
APX RTP NOP PHU
$
0.5306 0.5895 0.5895 0.8896
APX RTP NOP PHU
$
1.0612 1.1791 1.1791 1.7792
* 300MG CAPSULE 02245233 02192659 02241710 02182866
APO-CLINDAMYCIN RATIO-CLINDAMYCIN NOVO-CLINDAMYCIN DALACIN C
12
08:00 ANTI-INFECTIVE AGENTS 08:12.28 ANTIBIOTICS (MISCELLANEOUS ANTIBIOTICS)
CLINDAMYCIN PALMITATE HCL SEE NOTE REGARDING ANTIBIOTIC ASSOCIATED COLITIS OR PSEUDOMEMBRANOUS ENTERCOLITIS UNDER SECTION 08:12.00 (ANTIBIOTICS)
15MG/ML ORAL SOLUTION 00225851
DALACIN C
PHU
$
0.1197
PHU
$
72.1390
LIL
$
7.1133
LIL
$
14.2266
PMS LIL
$
24.2000 28.4600
PMS LIL
$
48.3700 55.4500
NXP RTP APX GPM GSK
$
LINEZOLID SEE APPENDIX A FOR EDS CRITERIA
600MG TABLET 02243684
ZYVOXAM (EDS)
VANCOMYCIN HCL SEE APPENDIX A FOR EDS CRITERIA
125MG CAPSULE 00800430
VANCOCIN (EDS)
250MG CAPSULE 00788716
VANCOCIN (EDS)
* 500MG INJECTION 02241820 00015423
PMS-VANCOMYCIN (EDS) VANCOCIN (EDS)
* 1GM INJECTION 02241821 00722146
PMS-VANCOMYCIN (EDS) VANCOCIN (EDS)
08:18.00 ANTIVIRALS
ACYCLOVIR * 200MG TABLET 02197405 02078627 02207621 02242784 00634506
NU-ACYCLOVIR RATIO-AVIRAX APO-ACYCLOVIR GEN-ACYCLOVIR ZOVIRAX
13
0.7635 * 0.9530 0.9530 0.9530 1.2706
08:00 ANTI-INFECTIVE AGENTS 08:18.00 ANTIVIRALS
* 400MG TABLET 02078635 02197413 02207648 02242463 01911627
RATIO-AVIRAX NU-ACYCLOVIR APO-ACYCLOVIR GEN-ACYCLOVIR ZOVIRAX WELLSTAT PAC
RTP NXP APX GPM GSK
$
1.8758 1.8758 1.8758 1.8758 2.5010
NXP APX GPM RTP GSK
$
3.0985 3.0985 3.0985 3.0986 4.9181
DOM PMS BMY GPM MED BMY
$
0.4611 * 0.5620 0.5620 0.5620 0.5620 1.0703
BMY PMS DOM
$
0.0879 0.0879 0.0924
NVR
$
2.7451
NVR
$
3.6890
NVR
$
6.5534
HLR
$
4.5028
HLR
$
8.6334
GSK
$
3.2767
* 800MG TABLET 02197421 02207656 02242464 02078651 01911635
NU-ACYCLOVIR APO-ACYCLOVIR GEN-ACYCLOVIR RATIO-AVIRAX ZOVIRAX ZOSTAB PAC
AMANTADINE * 100MG CAPSULE 02130963 01990403 02034468 02139200 02199289 01914006
DOM-AMANTADINE PMS-AMANTADINE ENDANTADINE GEN-AMANTADINE MED-AMANTADINE SYMMETREL
* 10MG/ML SYRUP 01913999 02022826 02130971
SYMMETREL PMS-AMANTADINE DOM-AMANTADINE
FAMCICLOVIR 125MG TABLET 02229110
FAMVIR
250MG TABLET 02229129
FAMVIR
500MG TABLET 02177102
FAMVIR
GANCICLOVIR SO4 SEE APPENDIX A FOR EDS CRITERIA
250MG CAPSULE 02186802
CYTOVENE (EDS)
500MG CAPSULE 02240362
CYTOVENE (EDS)
VALACYCLOVIR 500MG CAPLET 02219492
VALTREX
14
08:00 ANTI-INFECTIVE AGENTS 08:18.08 ANTIRETROVIRAL AGENTS (NONNUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS)
DELAVIRDINE MESYLATE SEE APPENDIX A FOR EDS CRITERIA
100MG TABLET 02238348
RESCRIPTOR (EDS)
AGR
$
0.7789
BMY
$
1.2019
BMY
$
2.4033
BMY
$
4.7634
BOE
$
5.0453
EFAVIRENZ SEE APPENDIX A FOR EDS CRITERIA
50MG CAPSULE 02239886
SUSTIVA (EDS)
100MG CAPSULE 02239887
SUSTIVA (EDS)
200MG CAPSULE 02239888
SUSTIVA (EDS)
NEVIRAPINE SEE APPENDIX A FOR EDS CRITERIA
200MG TABLET 02238748
VIRAMUNE (EDS)
08:18.08 ANTIRETROVIRAL AGENTS (NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS)
ABACAVIR SO4 SEE APPENDIX A FOR EDS CRITERIA
300MG TABLET 02240357
ZIAGEN (EDS)
GSK
$
6.7500
GSK
$
0.4522
GSK
$
16.2500
20MG/ML ORAL SOLUTION 02240358
ZIAGEN (EDS)
ABACAVIR SO4/LAMIVUDINE/ZIDOVUDINE SEE APPENDIX A FOR EDS CRITERIA
300MG/150MG/300MG TABLET 02244757
TRIZIVIR (EDS)
15
08:00 ANTI-INFECTIVE AGENTS 08:18.08 ANTIRETROVIRAL AGENTS (NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS)
DIDANOSINE SEE APPENDIX A FOR EDS CITERIA
25MG CHEWABLE TABLET 01940511
VIDEX (EDS)
BMY
$
0.4178
BMY
$
0.8365
BMY
$
1.6728
BMY
$
2.5091
BMY
$
3.3635
BMY
$
5.3816
BMY
$
6.7270
BMY
$
10.7849
BMY
$
73.6100
GSK
$
4.7740
GSK
$
4.7740
GSK
$
0.3184
GSK
$
10.0000
50MG CHEWABLE TABLET 01940538
VIDEX (EDS)
100MG CHEWABLE TABLET 01940546
VIDEX (EDS)
150MG CHEWABLE TABLET 01940554
VIDEX (EDS)
125MG CAPSULE (ENTERIC COATED BEADLET) 02244596
VIDEX EC (EDS)
200MG CAPSULE (ENTERIC COATED BEADLET) 02244597
VIDEX EC (EDS)
250MG CAPSULE (ENTERIC COATED BEADLET) 02244598
VIDEX EC (EDS)
400MG CAPSULE (ENTERIC COATED BEADLET) 02244599
VIDEX EC (EDS)
4G POWDER FOR ORAL SOLUTION (PACKAGE) 01940635
VIDEX (EDS)
LAMIVUDINE SEE APPENDIX A FOR EDS CRITERIA
100MG TABLET 02239193
HEPTOVIR (EDS)
150MG TABLET 02192683
3TC (EDS)
10MG/ML ORAL SOLUTION 02192691
3TC (EDS)
LAMIVUDINE/ZIDOVUDINE SEE APPENDIX A FOR EDS CRITERIA
150MG/300MG TABLET 02239213
COMBIVIR (EDS)
16
08:00 ANTI-INFECTIVE AGENTS 08:18.08 ANTIRETROVIRAL AGENTS (NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS)
STAVUDINE SEE APPENDIX A FOR EDS CRITERIA
15MG CAPSULE 02216086
ZERIT (EDS)
BRI
$
4.1013
BRI
$
4.2641
BRI
$
4.4485
BRI
$
4.6113
HLR
$
2.3328
APX GSK
$
1.3020 1.8445
GSK
$
0.1962
GSK
$
17.5500
20MG CAPSULE 02216094
ZERIT (EDS)
30MG CAPSULE 02216108
ZERIT (EDS)
40MG CAPSULE 02216116
ZERIT (EDS)
ZALCITABINE SEE APPENDIX A FOR EDS CRITERIA
0.75MG TABLET 01990896
HIVID (EDS)
ZIDOVUDINE SEE APPENDIX A FOR EDS CRITERIA
* 100MG CAPSULE 01946323 01902660
APO-ZIDOVUDINE (EDS) RETROVIR (EDS)
10MG/ML SOLUTION 01902652
RETROVIR (EDS)
10MG/ML INJECTION SOLUTION 01902644
RETROVIR (EDS)
08:18.08 ANTIRETROVIRAL AGENTS (PROTEASE INHIBITORS)
AMPRENAVIR SEE APPENDIX A FOR EDS CRITERIA
50MG CAPSULE 02243541
AGENERASE (EDS)
GSK
$
0.6944
GSK
$
2.0450
GSK
$
0.2084
150MG CAPSULE 02243542
AGENERASE (EDS)
15MG/ML ORAL SOLUTION 02243543
AGENERASE (EDS)
17
08:00 ANTI-INFECTIVE AGENTS 08:18.08 ANTIRETROVIRAL AGENTS (PROTEASE INHIBITORS)
INDINAVIR SO4 SEE APPENDIX A FOR EDS CRITERIA
200MG CAPSULE 02229161
CRIXIVAN (EDS)
MSD
$
1.4300
MSD
$
2.9224
ABB
$
3.4612
ABB
$
2.1448
AGR
$
1.9200
AGR
$
0.3951
ABB
$
1.4491
ABB
$
1.1590
HLR
$
1.9312
HLR
$
1.1067
NOP SAW
$
0.0865 0.3481
400MG CAPSULE 02229196
CRIXIVAN (EDS)
LOPINAVIR/RITONAVIR SEE APPENDIX A FOR EDS CRITERIA
133.3MG/33.3MG CAPSULE 02243643
KALETRA (EDS)
80MG/20MG (ML) ORAL SOLUTION 02243644
KALETRA (EDS)
NELFINAVIR MESYLATE SEE APPENDIX A FOR EDS CRITERIA
250MG TABLET 02238617
VIRACEPT (EDS)
50MG/G ORAL POWDER 02238618
VIRACEPT (EDS)
RITONAVIR SEE APPENDIX A FOR EDS CRITERIA
100MG SOFT ELASTIC CAPSULE 02241480
NORVIR SEC (EDS)
80MG/ML ORAL SOLUTION 02229145
NORVIR (EDS)
SAQUINAVIR SEE APPENDIX A FOR EDS CRITERIA
200MG CAPSULE 02216965
INVIRASE (EDS)
200MG SOFT GELATIN CAPSULE 02239083
FORTOVASE (EDS)
08:20.00 ANTIMALARIAL AGENTS
CHLOROQUINE PHOSPHATE * 250MG TABLET 00021261 02017539
NOVO-CHLOROQUINE ARALEN
18
08:00 ANTI-INFECTIVE AGENTS 08:20.00 ANTIMALARIAL AGENTS
HYDROXYCHLOROQUINE SO4 200MG TABLET 02017709
PLAQUENIL
SAW
$
0.5686
GSK
$
1.2882
NOP ODN
$
0.1156 0.1156
NOP ODN
$
0.1802 0.1802
BAY
$
2.4098
BAY
$
2.7188
BAY
$
5.1284
BAY
$
0.5438
BMY
$
5.4359
JAN
$
4.8174
JAN
$
5.4359
PYRIMETHAMINE 25MG TABLET 00004774
DARAPRIM
QUININE SO4 * 200MG CAPSULE 00021008 00695440
NOVO-QUININE QUININE-ODAN
* 300MG CAPSULE 00021016 00695459
NOVO-QUININE QUININE-ODAN
08:22.00 QUINOLONES
CIPROFLOXACIN SEE APPENDIX A FOR EDS CRITERIA
250MG TABLET 02155958
CIPRO (EDS)
500MG TABLET 02155966
CIPRO (EDS)
750MG TABLET 02155974
CIPRO (EDS)
100MG/ML ORAL SUSPENSION 02237514
CIPRO (EDS)
GATIFLOXACIN SEE APPENDIX A FOR EDS CRITERIA
400MG TABLET 02243182
TEQUIN (EDS)
LEVOFLOXACIN SEE APPENDIX A FOR EDS CRITERIA
250MG TABLET 02236841
LEVAQUIN (EDS)
500MG TABLET 02236842
LEVAQUIN (EDS)
19
08:00 ANTI-INFECTIVE AGENTS 08:22.00 QUINOLONES
MOXIFLOXACIN HCL SEE APPENDIX A FOR EDS CRITERIA
400MG TABLET 02242965
AVELOX (EDS)
BAY
$
5.4359
APX NOP MSD
$
1.6554 1.6554 2.3648
PFR
$
21.7000
PFI
$
0.1825
NOP PGA
$
0.2470 0.3771
APX
$
0.1302
APX
$
0.1736
PGA
$
0.6700
NORFLOXACIN SEE APPENDIX A FOR EDS CRITERIA
* 400MG TABLET 02229524 02237682 00643025
APO-NORFLOX (EDS) NOVO-NORFLOXACIN (EDS) NOROXIN (EDS)
08:36.00 URINARY ANTI-INFECTIVES METHENAMINE SALTS ARE EFFECTIVE ONLY IN ACIDIC URINE AND ACIDIFICATION OF URINE TO PH 5.5 OR LESS IS RECOMMENDED.
FOSFOMYCIN TROMETHAMINE SEE APPENDIX A FOR EDS CRITERIA
3G ORAL POWDER (SACHET) 02240335
MONUROL (EDS)
METHENAMINE MANDELATE 500MG ENTERIC TABLET 00499013
MANDELAMINE
NITROFURANTOIN * 50MG CAPSULE (MACROCRYSTALS) 02231015 01997637
NOVO-FURANTOIN MACRODANTIN
50MG TABLET 00319511
APO-NITROFURANTOIN
100MG TABLET 00312738
APO-NITROFURANTOIN
NITROFURANTOIN MONOHYDRATE 100MG CAPSULE (MACROCRYSTALS) 02063662
MACROBID
20
08:00 ANTI-INFECTIVE AGENTS 08:36.00 URINARY ANTI-INFECTIVES
TRIMETHOPRIM * 100MG TABLET 02243116 00675229
APO-TRIMETHOPRIM PROLOPRIM
APX GSK
$
0.2052 0.3174
APX GSK
$
0.4216 0.6022
GSK
$
2.4199
ABB
$
0.1136
PMS RHO
$
0.9223 0.9223
NOP APX
$
0.0353 0.0749
NXP GSK APX NOP
$
0.0420 * 0.0523 0.0523 0.0523
* 200MG TABLET 02243117 00677590
APO-TRIMETHOPRIM PROLOPRIM
08:40.00 MISCELLANEOUS ANTI-INFECTIVES
ATOVAQUONE SEE APPENDIX A FOR EDS CRITERIA
150MG/ML SUSPENSION 02217422
MEPRON (EDS)
ERYTHROMYCIN ETHYLSUCCINATE/ SULFISOXAZOLE ACETATE 40MG(BASE)/120MG(BASE) PER ML ORAL SOLUTION 00583405
PEDIAZOLE
METRONIDAZOLE * 500MG CAPSULE 00783137 01926853
TRIKACIDE FLAGYL
* 250MG TABLET 00021555 00545066
NOVO-NIDAZOL APO-METRONIDAZOLE
SULFAMETHOXAZOLE/TRIMETHOPRIM (CO-TRIMOXAZOLE) * 400MG/80MG TABLET 00865710 00270636 00445274 00510637
NU-COTRIMOX SEPTRA APO-SULFATRIM NOVO-TRIMEL
21
08:00 ANTI-INFECTIVE AGENTS 08:40.00 MISCELLANEOUS ANTI-INFECTIVES
* 800MG/160MG TABLET 00865729 00445282 00510645 00368040
NU-COTRIMOX DS APO-SULFATRIM DS NOVO-TRIMEL DS SEPTRA D.S.
NXP APX NOP GSK
$
0.1062 * 0.1325 0.1325 0.1326
APX
$
0.0955
NOP APX NXP GSK
$
0.0215 0.0215 0.0215 0.0216
100MG/20MG PEDIATRIC TABLET 00445266
APO-SULFATRIM
* 40MG/8MG PER ML ORAL SUSPENSION 00726540 00846465 00865753 00270644
NOVO-TRIMEL APO-SULFATRIM NU-COTRIMOX SEPTRA
22
ANTINEOPLASTIC AGENTS
10:00
10:00 ANTINEOPLASTIC AGENTS 10:00.00 ANTINEOPLASTIC AGENTS
CYPROTERONE ACETATE SEE APPENDIX A FOR EDS CRITERIA
* 50MG TABLET 00704431 02229723 02232872
ANDROCUR (EDS) GEN-CYPROTERONE (EDS) NOVO-CYPROTERONE (EDS)
PMS GPM NOP
$
1.6375 1.6375 1.6375
PMS
$
79.1100
HLR
$
36.8900
HLR
$
110.6700
HLR
$
221.3400
SCH
$
36.8800
SCH
$
127.2600
SCH
$
122.9400
SCH
$
221.2800
SCH
$
368.8000
SCH
$
709.8000
100MG/ML INJECTION 00704423
ANDROCUR (EDS)
INTERFERON ALFA-2A SEE APPENDIX A FOR EDS CRITERIA
3 MILLION IU/1ML INJECTION SOLUTION ALBUMIN (HUMAN) FREE (1ML) 02217015
ROFERON-A (EDS)
9 MILLION IU/1ML INJECTION SOLUTION ALBUMIN (HUMAN) FREE (1ML) 02217058
ROFERON-A (EDS)
18 MILLION IU/3ML INJECTION SOLUTION ALBUMIN (HUMAN) FREE (3ML) 02217066
ROFERON-A (EDS)
INTERFERON ALFA-2B SEE APPENDIX A FOR EDS CRITERIA
6 MILLION IU/ML INJECTION SOLUTION ALBUMIN (HUMAN) FREE (0.5ML) 02238674
INTRON-A (EDS)
10 MILLION IU POWDER FOR INJECTION 02223406
INTRON-A (EDS)
10 MILLION IU/ML INJECTION SOLUTION ALBUMIN (HUMAN) FREE (0.5ML, 1ML) 02238675
INTRON-A (EDS)
18 MILLION IU/PEN MULTI-DOSE PEN (KIT) ALBUMIN (HUMAN) FREE 02240693
INTRON-A (EDS)
30 MILLION IU/PEN MULTI-DOSE PEN (KIT) ALBUMIN (HUMAN) FREE 02240694
INTRON-A (EDS)
60 MILLION IU/PEN MULTI-DOSE PEN (KIT) ALBUMIN (HUMAN) FREE 02240695
INTRON-A (EDS)
24
10:00 ANTINEOPLASTIC AGENTS 10:00.00 ANTINEOPLASTIC AGENTS
MEGESTROL SEE APPENDIX A FOR EDS CRITERIA
* 40MG TABLET 02176092 02185415 02195917 00386391
LIN-MEGESTROL (EDS) NU-MEGESTROL (EDS) APO-MEGESTROL (EDS) MEGACE (EDS)
LIN NXP APX BMY
$
0.9824 0.9824 0.9824 1.4572
APX LIN NXP BMY
$
3.9267 3.9350 3.9350 5.8302
BMY
$
1.1653
GSK
$
1.9899
SCH
$
425.8500
SCH
$
425.8500
SCH
$
425.8500
SCH
$
425.8500
* 160MG TABLET 02195925 02176106 02185423 00731323
APO-MEGESTROL (EDS) LIN-MEGESTROL (EDS) NU-MEGESTROL (EDS) MEGACE (EDS)
40MG/ML ORAL SUSPENSION 02168979
MEGACE OS (EDS)
MERCAPTOPURINE SEE APPENDIX A FOR EDS CRITERIA
50MG TABLET 00004723
PURINETHOL (EDS)
PEGINTERFERON ALFA-2B SEE APPENDIX A FOR EDS CRITERIA
50UG/0.5ML POWDER FOR INJECTION (VIAL) 02242966
PEG-INTRON (EDS)
80UG/0.5ML POWDER FOR INJECTION (VIAL) 02242967
PEG-INTRON (EDS)
120UG/0.5ML POWDER FOR INJECTION (VIAL) 02242968
PEG-INTRON (EDS)
150UG/0.5ML POWDER FOR INJECTION (VIAL) 02242969
PEG-INTRON (EDS)
25
AUTONOMIC DRUGS
12:00
12:00 AUTONOMIC DRUGS 12:04.00 PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS
BETHANECHOL CHLORIDE 10MG TABLET 01947958
DUVOID
RBP
$
0.2512
RBP MSD
$
0.4069 0.6847
RBP
$
0.5344
ICN
$
0.4742
ICN
$
0.4660
ICN
$
1.0196
PMS APX MSD
$
0.0228 * 0.0586 0.1558
MSD
$
5.1400
AVT
$
0.2013
* 25MG TABLET 01947931 00349739
DUVOID URECHOLINE
50MG TABLET 01947923
DUVOID
NEOSTIGMINE BROMIDE 15MG TABLET 00869945
PROSTIGMIN
PYRIDOSTIGMINE BROMIDE 60MG TABLET 00869961
MESTINON
180MG LONG ACTING TABLET 00869953
MESTINON
12:08.04 ANTIPARKINSONIAN AGENTS
BENZTROPINE MESYLATE * 2MG TABLET 00587265 00426857 00016357
PMS-BENZTROPINE APO-BENZTROPINE COGENTIN
1MG/ML INJECTION SOLUTION (2ML) 00016128
COGENTIN
ETHOPROPAZINE 50MG TABLET 01927744
PARSITAN
28
12:00 AUTONOMIC DRUGS 12:08.04 ANTIPARKINSONIAN AGENTS
PROCYCLIDINE HCL * 5MG TABLET 00004758 00587354 02125102 00306290
KEMADRIN PMS-PROCYCLIDINE DOM-PROCYCLIDINE PROCYCLID
GSK PMS DOM ICN
$
0.0277 0.0277 0.0291 0.0771
GSK PMS
$
0.0333 0.0333
APO-TRIHEX
APX
$
0.0326
APO-TRIHEX
APX
$
0.0586
ICN
$
0.0992
AVT
$
0.2157
AVT
$
0.0612
BOE
$
0.2613
* 0.5MG/ML ELIXIR 00004405 00587362
KEMADRIN PMS-PROCYCLIDINE
TRIHEXYPHENIDYL HCL 2MG TABLET 00545058
5MG TABLET 00545074
12:08.08 ANTIMUSCARINICS/ANTISPASMODICS
DICYCLOMINE HCL 10MG CAPSULE 00361933
FORMULEX
20MG TABLET 02103095
BENTYLOL
2MG/ML SYRUP 02102978
BENTYLOL
HYOSCINE BUTYLBROMIDE 10MG TABLET 00363812
BUSCOPAN
29
12:00 AUTONOMIC DRUGS 12:08.08 ANTIMUSCARINICS/ANTISPASMODICS
IPRATROPIUM BROMIDE NOTE: WHEN USING THE INHALATION SOLUTION CARE MUST BE TAKEN TO PREVENT CONTACT WITH EYES. A WELL FITTED NEBULIZER MASK MUST BE USED.
INHALER AEROSOL (PACKAGE) 00576158
ATROVENT
BOE
$
17.9200
RTP PMS APX BOE
$
0.8200 0.8200 0.8200 1.4301
RTP APX NOP PMS GPM BOE
$
0.6000 0.6000 0.6000 0.6000 0.6000 0.9532
NXP APX RTP GPM PMS BOE
$
1.3130 * 1.6384 1.6390 1.6390 1.6390 2.8610
* 0.0125% INHALATION SOLUTION (2ML) 02097176 02231135 02243827 02026759
RATIO-IPRATROPIUM UDV PMS-IPRATROPIUM APO-IPRAVENT ATROVENT
* 0.025% INHALATION SOLUTION 02097141 02126222 02210479 02231136 02239131 00731439
RATIO-IPRATROPIUM APO-IPRAVENT NOVO-IPRAMIDE PMS-IPRATROPIUM GEN-IPRATROPIUM ATROVENT
* 0.025% INHALATION SOLUTION (2ML) 02231785 02231494 02097168 02216221 02231245 01950681
NU-IPRATROPIUM APO-IPRAVENT RATIO-IPRATROPIUM UDV GEN-IPRATROPIUM PMS-IPRATROPIUM ATROVENT
IPRATROPIUM BROMIDE/SALBUTAMOL SO4 NOTE: SALBUTAMOL STRENGTHS ARE EXPRESSED IN TERMS OF SALBUTAMOL BASE EQUIVALENT.
20UG/100UG INHALER AEROSOL (PACKAGE) 02163721
COMBIVENT
BOE
$
21.0600
BOE
$
1.5930
ICN
$
0.1807
0.5MG/2.5MG INHALATION SOLUTION (2.5ML) 02231675
COMBIVENT
PROPANTHELINE BROMIDE 15MG TABLET 00294837
PROPANTHEL
12:12.00 SYMPATHOMIMETIC (ADRENERGIC) AGENTS
EPINEPHRINE 0.15MG/DOSE INJECTION SOLUTION (PACKAGE) 00578657
EPIPEN JR.
ALX
$
87.8900
ALX
$
87.8900
0.3MG/DOSE INJECTION SOLUTION (PACKAGE) 00509558
EPIPEN
30
12:00 AUTONOMIC DRUGS 12:12.00 SYMPATHOMIMETIC (ADRENERGIC) AGENTS
EPINEPHRINE HCL 1MG/ML INJECTION SOLUTION (1ML) 00155357
ADRENALIN
PFI
$
1.5700
BOE
$
10.6700
BOE
$
0.7628
BOE
$
1.5256
BOE
$
0.7628
NVR
$
0.7650
AST
$
34.4500
AST
$
45.9000
FENOTEROL HYDROBROMIDE 100UG INHALER AEROSOL (PACKAGE) 02006383
BEROTEC
0.025% INHALATION SOLUTION (2ML) 02056712
BEROTEC UDV
0.0625% INHALATION SOLUTION (2ML) 02056704
BEROTEC UDV
0.1% INHALATION SOLUTION 00541389
BEROTEC
FORMOTEROL FUMARATE SEE APPENDIX A FOR EDS CRITERIA
12UG/INHALATION POWDER CAPSULE 02230898
FORADIL (EDS)
6UG/DOSE POWDER FOR INHALATION (PACKAGE) 02237225
OXEZE TURBUHALER (EDS)
12UG/DOSE POWDER FOR INHALATION (PACKAGE) 02237224
OXEZE TURBUHALER (EDS)
FORMOTEROL FUMARATE DIHYDRATE/BUDESONIDE SEE APPENDIX A FOR EDS CRITERIA
6UG/100UG POWDER FOR INHALATION (PACKAGE) 02245385
SYMBICORT TURBUHALER(EDS)
AST
$
65.1000
AST
$
84.6300
AMATINE (EDS)
RBP
$
0.5290
AMATINE (EDS)
RBP
$
0.8935
RTP APX BOE
$
0.0415 0.0415 0.0656
6UG/200UG POWDER FOR INHALATION (PACKAGE) 02245386
SYMBICORT TURBUHALER(EDS)
MIDODRINE HCL SEE APPENDIX A FOR EDS CRITERIA
2.5MG TABLET 01934392
5MG TABLET 01934406
ORCIPRENALINE SO4 * 2MG/ML SYRUP 02152568 02236783 00249920
RATIO-ORCIPRENALINE APO-ORCIPRENALINE ALUPENT
31
12:00 AUTONOMIC DRUGS 12:12.00 SYMPATHOMIMETIC (ADRENERGIC) AGENTS
SALBUTAMOL SO4 NOTE: PRODUCT STRENGTHS ARE EXPRESSED IN TERMS OF SALBUTAMOL BASE EQUIVALENT.
* 2MG TABLET 00620955 02146843
NOVO-SALMOL APO-SALVENT
NOP APX
$
0.0705 0.0705
NOVO-SALMOL APO-SALVENT NU-SALBUTAMOL
NOP APX NXP
$
0.1164 0.1164 0.1164
GSK
$
1.4764
GSK
$
2.0514
GSK
$
0.0738
APX RTP NOP GSK
$
5.0400 5.0400 5.0400 13.3200
RTP MDA
$
5.0400 5.0500
PMS RTP APX GSK
$
0.4047 0.4047 0.4047 0.5398
$
0.5290 * 0.6603 0.6610 0.6610 0.6610 0.6610 0.7410 1.0480
* 4MG TABLET 00620963 02146851 02165376
200UG/DOSE AEROSOL POWDER DISK (8) 02214997
VENTODISK
400UG/DOSE AEROSOL POWDER DISK (8) 02215004
VENTODISK
0.4MG/ML ORAL LIQUID 02212390
VENTOLIN
* 100UG/DOSE INHALER AEROSOL (PACKAGE) 00790419 00851841 00874086 02213478 ⌧
APO-SALVENT RATIO-SALBUTAMOL NOVO-SALMOL VENTOLIN
100UG/DOSE INHALER AEROSOL (PACKAGE) (CFC-FREE) 02244914 02232570
RATIO-SALBUTAMOL HFA AIROMIR
* 0.5MG/ML INHALATION SOLUTION PRESERVATIVE FREE (2.5ML) 02208245 02239365 02243828 02022125
PMS-SALBUTAMOL RATIO-SALBUTAMOL P.F. APO-SALVENT VENTOLIN NEBULES P.F.
* 1MG/ML INHALATION SOLUTION PRESERVATIVE FREE (2.5ML) 02231783 02231488 01926934 01986864 02084333 02208229 02216949 02213419
NU-SALBUTAMOL APO-SALVENT GEN-SALBUTAMOL STERINEB RATIO-SALBUTAMOL MED-SALBUTAMOL PMS-SALBUTAMOL DOM-SALBUTAMOL VENTOLIN NEBULES P.F.
32
NXP APX GPM RTP MED PMS DOM GSK
12:00 AUTONOMIC DRUGS 12:12.00 SYMPATHOMIMETIC (ADRENERGIC) AGENTS
* 2MG/ML INHALATION SOLUTION PRESERVATIVE FREE (2.5ML) 02173360 02208237 02231678 02231784 02239366 01945203
GEN-SALBUTAMOL STERINEB PMS-SALBUTAMOL APO-SALVENT NU-SALBUTAMOL RATIO-SALBUTAMOL P.F. VENTOLIN NEBULES P.F.
GPM PMS APX NXP RTP GSK
$
1.2538 1.2538 1.2538 1.2538 1.2538 1.9905
RTP APX PMS RHO GPM DOM GSK
$
0.6402 0.6402 0.6402 0.6402 0.6402 0.7205 1.0167
GSK
$
54.0400
GSK
$
3.6022
GSK
$
54.0400
* 5MG/ML INHALATION SOLUTION 00860808 02046741 02069571 02154412 02232987 02139324 02213486
RATIO-SALBUTAMOL APO-SALVENT PMS-SALBUTAMOL RESPIR.SOL RHOXAL-SALBUTAMOL RES.SOL GEN-SALBUTAMOL RESPIR.SOL DOM-SALBUTAMOL RESPIR.SOL VENTOLIN RESPIRATOR SOLN.
SALMETEROL XINAFOATE SEE APPENDIX A FOR EDS CRITERIA
25UG/DOSE INHALER AEROSOL (PACKAGE) 02211742
SEREVENT (EDS)
50UG/DOSE AEROSOL POWDER DISK (4) 02214261
SEREVENT (EDS)
50UG/DOSE POWDER FOR INHALATION (PACKAGE) 02231129
SEREVENT DISKUS (EDS)
SALMETEROL XINAFOATE/FLUTICASONE PROPIONATE SEE APPENDIX A FOR EDS CRITERIA
25UG/125UG INHALER AEROSOL (PACKAGE) 02245126
ADVAIR (EDS)
GSK
$
93.1000
GSK
$
132.1600
$
77.8000
$
93.1000
$
132.1600
25UG/250UG INHALER AEROSOL (PACKAGE) 02245127
ADVAIR (EDS)
50UG/100UG POWDER FOR INHALATION (PACKAGE) 02240835
ADVAIR DISKUS (EDS)
GSK
50UG/250UG POWDER FOR INHALATION (PACKAGE) 02240836
ADVAIR DISKUS (EDS)
GSK
50UG/500UG POWDER FOR INHALATION (PACKAGE) 02240837
ADVAIR DISKUS (EDS)
33
GSK
12:00 AUTONOMIC DRUGS 12:12.00 SYMPATHOMIMETIC (ADRENERGIC) AGENTS
TERBUTALINE SO4 0.5MG/DOSE POWDER FOR INHALATION (PACKAGE) 00786616
BRICANYL TURBUHALER
AST
$
15.5200
12:16.00 SYMPATHOLYTIC AGENTS (ANTIMIGRAINE DRUGS)
DIHYDROERGOTAMINE MESYLATE * 1MG/ML INJECTION SOLUTION (1ML) 02241163 00027243
DIHYDROERGOTAMINE MESYL. DIHYDROERGOTAMINE-SANDOZ
SAB NVR
$
3.7200 4.5800
NVR
$
9.8200
NVR
$
2.3735
PMS
$
0.8229
NVR
$
0.6961
4MG/ML NASAL SPRAY 02228947
MIGRANAL
ERGOTAMINE TARTRATE/CAFFEINE/ BELLADONNA ALKALOIDS/PENTOBARBITAL 2MG/100MG/0.25MG/60MG SUPPOSITORY 00176214
CAFERGOT-PB
FLUNARIZINE HCL SEE APPENDIX A FOR EDS CRITERIA
5MG CAPSULE 00846341
SIBELIUM (EDS)
METHYSERGIDE MALEATE SEE APPENDIX A FOR EDS CRITERIA
2MG TABLET 00027499
SANSERT (EDS)
NARATRIPTAN HCL THE MAXIMUM QUANTITY THAT CAN BE CLAIMED THROUGH THE DRUG PLAN IS LIMITED TO 6 DOSES PER 30 DAYS WITHIN A 60 DAY PERIOD. SEE APPENDIX A FOR EDS CRITERIA.
1MG TABLET 02237820
AMERGE (EDS)
GSK
$
13.3350
GSK
$
14.0600
SANDOMIGRAN
NVR
$
0.3771
SANDOMIGRAN DS
NVR
$
0.6261
2.5MG TABLET 02237821
AMERGE (EDS)
PIZOTYLINE HYDROGEN MALATE 0.5MG TABLET 00329320
1MG TABLET 00511552
34
12:00 AUTONOMIC DRUGS 12:16.00 SYMPATHOLYTIC AGENTS (ANTIMIGRAINE DRUGS)
PROPRANOLOL SEE SECTION 24:04.00 (CARDIAC DRUGS)
RIZATRIPTAN BENZOATE THE MAXIMUM QUANTITY THAT CAN BE CLAIMED THROUGH THE DRUG PLAN IS LIMITED TO 6 DOSES PER 30 DAYS WITHIN A 60 DAY PERIOD. SEE APPENDIX A FOR EDS CRITERIA.
5MG TABLET 02240520
MAXALT (EDS)
MSD
$
14.0508
MAXALT (EDS)
MSD
$
14.0508
MAXALT RPD (EDS)
MSD
$
14.0508
MSD
$
14.0508
10MG TABLET 02240521
5MG WAFER 02240518
10MG WAFER 02240519
MAXALT RPD (EDS)
SUMATRIPTAN THE MAXIMUM QUANTITY THAT CAN BE CLAIMED THROUGH THE DRUG PLAN IS LIMITED TO 6 DOSES PER 30 DAYS WITHIN A 60 DAY PERIOD. SEE APPENDIX A FOR EDS CRITERIA.
25MG TABLET 02239738
IMITREX (EDS)
GSK
$
13.3347
GSK
$
14.0508
GSK
$
15.4785
GSK
$
41.7400
GSK
$
13.3400
GSK
$
14.0600
50MG TABLET 02212153
IMITREX (EDS)
100MG TABLET 02212161
IMITREX (EDS)
6MG/0.5ML INJECTION SOLUTION 02212188
IMITREX (EDS)
5MG NASAL SPRAY 02230418
IMITREX (EDS)
20MG NASAL SPRAY 02230420
IMITREX (EDS)
ZOLMITRIPTAN THE MAXIMUM QUANTITY THAT CAN BE CLAIMED THROUGH THE DRUG PLAN IS LIMITED TO 6 DOSES PER 30 DAYS WITHIN A 60 DAY PERIOD. SEE APPENDIX A FOR EDS CRITERIA.
2.5MG TABLET 02238660
ZOMIG (EDS)
AST
$
14.0510
AST
$
14.0510
2.5MG ORALLY DISPERSIBLE TABLET 02243045
ZOMIG RAPIMELT (EDS)
35
12:00 AUTONOMIC DRUGS 12:20.00 SKELETAL MUSCLE RELAXANTS
BACLOFEN * 10MG TABLET 02138271 02063735 02084449 02088398 02136090 02139332 02236507 00455881
DOM-BACLOFEN PMS-BACLOFEN MED-BACLOFEN GEN-BACLOFEN NU-BACLO APO-BACLOFEN RATIO-BACLOFEN LIORESAL
DOM PMS MED GPM NXP APX RTP NVR
$
0.2592 * 0.3159 0.3159 0.3159 0.3159 0.3159 0.3159 0.5014
DOM PMS MED GPM NXP APX RTP NVR
$
0.5046 * 0.6149 0.6149 0.6149 0.6149 0.6149 0.6149 0.9760
NVR
$
9.8800
NVR
$
147.9400
NVR
$
147.9400
NOP NXP APX PMS GPM RTP MED DOM JAN
$
0.4085 0.4085 0.4085 0.4085 0.4085 0.4085 0.4085 0.4289 0.6159
PGA
$
0.3955
PGA
$
0.7650
* 20MG TABLET 02138298 02063743 02084457 02088401 02136104 02139391 02236508 00636576
DOM-BACLOFEN PMS-BACLOFEN MED-BACLOFEN GEN-BACLOFEN NU-BACLO APO-BACLOFEN RATIO-BACLOFEN LIORESAL-DS
0.05MG/ML INJECTION (1ML) 02131048
LIORESAL INTRATHECAL(EDS)
0.5MG/ML INJECTION (20ML) 02131056
LIORESAL INTRATHECAL(EDS)
2MG/ML INJECTION (5ML) 02131064
LIORESAL INTRATHECAL(EDS)
CYCLOBENZAPRINE HCL SEE APPENDIX A FOR EDS CRITERIA
* 10MG TABLET 02080052 02171848 02177145 02212048 02231353 02236506 02237275 02238633 00782742
NOVO-CYCLOPRINE (EDS) NU-CYCLOBENZAPRINE (EDS) APO-CYCLOBENZAPRINE (EDS) PMS-CYCLOBENZAPRINE (EDS) GEN-CYCLOBENZAPRINE (EDS) RTP-CYCLOBENZAPRINE (EDS) MED-CYCLOBENZAPRINE (EDS) DOM-CYCLOBENZAPRINE (EDS) FLEXERIL (EDS)
DANTROLENE SODIUM 25MG CAPSULE 01997602
DANTRIUM
100MG CAPSULE 01997653
DANTRIUM
36
12:00 AUTONOMIC DRUGS 12:20.00 SKELETAL MUSCLE RELAXANTS
TIZANIDINE HCL SEE APPENDIX A FOR EDS CRITERIA
4MG TABLET 02239170
ZANAFLEX (EDS)
DPY
37
$
0.7387
BLOOD FORMATION AND COAGULATION
20:00
20:00 BLOOD FORMATION AND COAGULATION 20:04.04 IRON PREPARATIONS
IRON DEXTRAN SEE APPENDIX A FOR EDS CRITERIA
50MG/ML INJECTION SOLUTION (2ML) 02221780
INFUFER (EDS)
SAB
$
28.6300
SINTROM
NVR
$
0.2685
SINTROM
NVR
$
0.8442
PHU
$
5.1600
PHU
$
16.2800
PHU
$
37.1100
PHU
$
154.6200
AVT
$
6.5600
AVT
$
21.7000
AVT
$
65.1000
ORG
$
6.0400
20:12.04 ANTICOAGULANTS
ACENOCOUMAROL 1MG TABLET 00010383
4MG TABLET 00010391
DALTEPARIN SODIUM SEE APPENDIX A FOR EDS CRITERIA
2,500IU SYRINGE (0.2ML) 02132621
FRAGMIN (EDS)
10,000IU/ML INJECTION SOLUTION (1ML) 02132664
FRAGMIN (EDS)
25,000IU/ML SYRINGE (0.2ML, 0.4ML, 0.5ML, 0.6ML, 0.72ML) 02132648
FRAGMIN (EDS)
25,000IU/ML INJECTION SOLUTION (3.8ML) 02231171
FRAGMIN (EDS)
ENOXAPARIN SEE APPENDIX A FOR EDS CRITERIA
30MG/0.3ML SYRINGE (0.3ML) 02012472
LOVENOX (EDS)
100MG/ML SYRINGE (0.4ML, 0.6ML, 0.8ML, 1ML) 02236883
LOVENOX (EDS)
100MG/ML INJECTION SOLUTION (3ML) 02236564
LOVENOX (EDS)
HEPARIN 10,000 USP U/ML INJECTION SOLUTION (5ML) 00740497
HEPALEAN
40
20:00 BLOOD FORMATION AND COAGULATION 20:12.04 ANTICOAGULANTS
NADROPARIN CALCIUM SEE APPENDIX A FOR EDS CRITERIA
9,500IU/ML SYRINGE (0.3ML, 0.4ML, 0.6ML, 0.8ML, 1ML) 02236913
FRAXIPARINE (EDS)
SAW
$
9.7200
SAW
$
19.4300
LEO
$
34.7200
LEO
$
7.8800
LEO
$
69.4400
INNOHEP (EDS)
LEO
$
31.2500
TARO-WARFARIN APO-WARFARIN GEN-WARFARIN COUMADIN
TAR APX GPM BMY
$
0.2149 0.2149 0.2149 0.3071
TARO-WARFARIN APO-WARFARIN GEN-WARFARIN COUMADIN
TAR APX GPM BMY
$
0.2272 0.2272 0.2272 0.3247
TARO-WARFARIN APO-WARFARIN GEN-WARFARIN COUMADIN
TAR APX GPM BMY
$
0.1820 0.1820 0.1820 0.2600
TARO-WARFARIN APO-WARFARIN COUMADIN
TAR APX BMY
$
0.2536 0.2536 0.4025
19,000IU/ML SYRINGE (0.6ML, 0.8ML, 1ML) 02240114
FRAXIPARINE FORTE (EDS)
TINZAPARIN SODIUM SEE APPENDIX A FOR EDS CRITERIA
10,000IU/ML INJECTION SOLUTION (2ML) 02167840
INNOHEP (EDS)
10,000IU/ML SYRINGE (0.35ML, 0.45ML) 02229755
INNOHEP (EDS)
20,000IU/ML INJECTION SOLUTION (2ML) 02229515
INNOHEP (EDS)
20,000IU/ML SYRINGE (0.5ML, 0.7ML, 0.9ML) 02231478
WARFARIN * 1MG TABLET 02242680 02242924 02244462 01918311
* 2MG TABLET 02242681 02242925 02244463 01918338
* 2.5MG TABLET 02242682 02242926 02244464 01918346
* 3MG TABLET 02242683 02245618 02240205
41
20:00 BLOOD FORMATION AND COAGULATION 20:12.04 ANTICOAGULANTS
* 4MG TABLET 02242684 02242927 02244465 02007959
TARO-WARFARIN APO-WARFARIN GEN-WARFARIN COUMADIN
TAR APX GPM BMY
$
0.2817 0.2817 0.2817 0.4026
TARO-WARFARIN APO-WARFARIN GEN-WARFARIN COUMADIN
TAR APX GPM BMY
$
0.1823 0.1823 0.1823 0.2604
TAR APX GPM BMY
$
0.3271 0.3271 0.3271 0.4672
JAN
$
15.4700
JAN
$
30.9300
JAN
$
46.3900
JAN
$
61.8500
JAN
$
90.5000
JAN
$
119.0000
JAN
$
138.9500
JAN
$
290.6800
* 5MG TABLET 02242685 02242928 02244466 01918354
* 10MG TABLET 02242687 02242929 02244467 01918362
TARO-WARFARIN APO-WARFARIN GEN-WARFARIN COUMADIN
20:12.20 ANTIPLATELET DRUGS
SULFINPYRAZONE SEE SECTION 40:40:00 (URICOSURIC DRUGS)
20:16.00 HEMATOPOIETIC AGENTS
EPOETIN ALFA SEE APPENDIX A FOR EDS CRITERIA
1000IU/0.5ML PRE-FILLED SYRINGE 02231583
EPREX (EDS)
2000IU/0.5ML PRE-FILLED SYRINGE 02231584
EPREX (EDS)
3000IU/0.3ML PRE-FILLED SYRINGE 02231585
EPREX (EDS)
4000IU/0.4ML PRE-FILLED SYRINGE 02231586
EPREX (EDS)
6000IU/0.6ML PRE-FILLED SYRINGE 02243401
EPREX (EDS)
8000IU/0.8ML PRE-FILLED SYRINGE 02243403
EPREX (EDS)
10000IU/ML PRE-FILLED SYRINGE 02231587
EPREX (EDS)
20000IU STERILE SOLUTION FOR INJECTION 02206072
EPREX (EDS)
42
20:00 BLOOD FORMATION AND COAGULATION 20:16.00 HEMATOPOIETIC AGENTS
FILGRASTIM SEE APPENDIX A FOR EDS CRITERIA
300UG/ML INJECTION SOLUTION 01968017
NEUPOGEN (EDS)
AMG
$
246.5600
SAW
$
2.6057
RTP APX NXP AVT
$
0.4164 0.4164 0.4164 0.6629
NXP APX GPM PMS RHO DOM HLR
$
0.5985 * 0.7471 0.7472 0.7472 0.7472 0.7844 1.2982
20:24.00 HEMORRHEOLOGIC AGENTS
CLOPIDOGREL BISULFATE SEE APPENDIX A FOR EDS CRITERIA
75MG TABLET 02238682
PLAVIX (EDS)
PENTOXIFYLLINE * 400MG SUSTAINED RELEASE TABLET 01968432 02230090 02230401 02221977
RATIO-PENTOXIFYLLINE APO-PENTOXIFYLLINE SR NU-PENTOXIFYLLINE-SR TRENTAL
TICLOPIDINE HCL SEE APPENDIX A FOR EDS CRITERIA
* 250MG TABLET 02237560 02237701 02239744 02243327 02243587 02243808 02162776
NU-TICLOPIDINE (EDS) APO-TICLOPIDINE (EDS) GEN-TICLOPIDINE (EDS) PMS-TICLOPIDINE (EDS) RHOXAL-TICLOPIDINE (EDS) DOM-TICLOPIDINE (EDS) TICLID (EDS)
43
CARDIOVASCULAR DRUGS
24:00
24:00 CARDIOVASCULAR DRUGS 24:04.00 CARDIAC DRUGS
ACEBUTOLOL HCL * 100MG TABLET 02165546 01910140 02036290 02147602 02204517 02237721 02237885 02239754 02239758 01926543
NU-ACEBUTOLOL RHOTRAL MONITAN APO-ACEBUTOLOL NOVO-ACEBUTOLOL GEN-ACEBUTOLOL GEN-ACEBUTOLOL (TYPE S) MED-ACEBUTOLOL (TYPE S) MED-ACEBUTOLOL SECTRAL
NXP ROP WYA APX NOP GPM GPM MED MED AVT
$
0.1418 * 0.1769 0.1769 0.1769 0.1769 0.1769 0.1769 0.1769 0.1769 0.2949
NXP ROP WYA APX NOP GPM GPM MED MED AVT
$
0.2122 * 0.2648 0.2648 0.2648 0.2648 0.2648 0.2648 0.2648 0.2648 0.4424
NXP ROP WYA APX NOP GPM GPM MED MED AVT
$
0.4214 * 0.5260 0.5260 0.5260 0.5260 0.5260 0.5260 0.5260 0.5260 0.8803
* 200MG TABLET 02165554 01910159 02036436 02147610 02204525 02237722 02237886 02239755 02239759 01926551
NU-ACEBUTOLOL RHOTRAL MONITAN APO-ACEBUTOLOL NOVO-ACEBUTOLOL GEN-ACEBUTOLOL GEN-ACEBUTOLOL (TYPE S) MED-ACEBUTOLOL (TYPE S) MED-ACEBUTOLOL SECTRAL
* 400MG TABLET 02165562 01910167 02036444 02147629 02204533 02237723 02237887 02239756 02239760 01926578
NU-ACEBUTOLOL RHOTRAL MONITAN APO-ACEBUTOLOL NOVO-ACEBUTOLOL GEN-ACEBUTOLOL GEN-ACEBUTOLOL (TYPE S) MED-ACEBUTOLOL (TYPE S) MED-ACEBUTOLOL SECTRAL
AMIODARONE AMIODARONE IS INDICATED IN TREATMENT OF SEVERE CARDIAC ARRHYTHMIAS. THIS DRUG SHOULD ONLY BE USED UNDER THE SUPERVISION OF A CARDIOLOGIST OR AN INTERNIST WITH EQUIVALENT EXPERIENCE IN CARDIOLOGY.
* 200MG TABLET 02240071 02036282
RATIO-AMIODARONE CORDARONE
46
RTP WYA
$
1.4074 2.2339
24:00 CARDIOVASCULAR DRUGS 24:04.00 CARDIAC DRUGS
AMLODIPINE BESYLATE 5MG TABLET 00878928
NORVASC
PFI
$
1.3888
PFI
$
2.0615
DOM PMS APX NXP NOP GPM RTP MED RHO AST
$
0.2981 * 0.3814 0.3814 0.3814 0.3814 0.3814 0.3814 0.3814 0.3814 0.6054
DOM APX NXP NOP GPM RTP MED RHO PMS AST
$
0.4900 * 0.6268 0.6268 0.6268 0.6268 0.6268 0.6268 0.6268 0.6268 0.9952
BVL
$
0.3798
BVL
$
0.6293
10MG TABLET 00878936
NORVASC
ATENOLOL * 50MG TABLET 02229467 02237600 00773689 00886114 01912062 02146894 02171791 02188961 02231731 02039532
DOM-ATENOLOL PMS-ATENOLOL APO-ATENOL NU-ATENOL NOVO-ATENOL GEN-ATENOLOL RATIO-ATENOLOL MED-ATENOLOL RHOXAL-ATENOLOL TENORMIN
* 100MG TABLET 02229468 00773697 00886122 01912054 02147432 02171805 02188988 02231733 02237601 02039540
DOM-ATENOLOL APO-ATENOL NU-ATENOL NOVO-ATENOL GEN-ATENOLOL RATIO-ATENOLOL MED-ATENOLOL RHOXAL-ATENOLOL PMS-ATENOLOL TENORMIN
BISOPROLOL FUMARATE SEE APPENDIX A FOR EDS CRITERIA
5MG TABLET 02241148
MONOCOR (EDS)
10MG TABLET 02241149
MONOCOR (EDS)
CAPTOPRIL SEE SECTION 24:08.00 (HYPOTENSIVE DRUGS)
47
24:00 CARDIOVASCULAR DRUGS 24:04.00 CARDIAC DRUGS
CARVEDILOL SEE APPENDIX A FOR EDS CRITERIA
3.125MG TABLET 02229650
COREG (EDS)
GSK
$
1.3780
GSK
$
1.3780
GSK
$
1.3780
GSK
$
1.3780
VIR
$
0.2164
VIR
$
0.2164
VIR
$
0.2164
VIR
$
0.3538
NXP APX NOP RTP GPM MED BVL
$
0.1805 * 0.2252 0.2252 0.2252 0.2252 0.2252 0.4031
NXP APX NOP RTP GPM MED BVL
$
0.3161 * 0.3947 0.3947 0.3947 0.3947 0.3947 0.7070
6.25MG TABLET 02229651
COREG (EDS)
12.5MG TABLET 02229652
COREG (EDS)
25MG TABLET 02229653
COREG (EDS)
DIGOXIN 0.0625MG TABLET 02242321
LANOXIN
0.125MG TABLET 02242322
LANOXIN
0.25MG TABLET 02242323
LANOXIN
0.05MG/ML ELIXIR 02242320
LANOXIN
DILTIAZEM HCL * 30MG TABLET 00886068 00771376 00862924 00888524 02146916 02189038 02097370
NU-DILTIAZ APO-DILTIAZ NOVO-DILTAZEM RATIO-DILTIAZEM GEN-DILTIAZEM MED-DILTIAZEM CARDIZEM
* 60MG TABLET 00886076 00771384 00862932 00888532 02146924 02189046 02097389
NU-DILTIAZ APO-DILTIAZ NOVO-DILTAZEM RATIO-DILTIAZEM GEN-DILTIAZEM MED-DILTIAZEM CARDIZEM
48
24:00 CARDIOVASCULAR DRUGS 24:04.00 CARDIAC DRUGS
* 60MG SUSTAINED-RELEASE CAPSULE 02222957 02229406 02097214
APO-DILTIAZ SR NOVO-DILTAZEM SR CARDIZEM-SR
APX NOP BVL
$
0.3944 0.3944 0.7274
APX NOP BVL
$
0.5919 0.5919 0.9655
APX NOP BVL
$
0.7888 0.7888 1.2807
APX NXP NOP RHO RTP BVL
$
0.8703 0.8703 0.8703 0.8703 0.8704 1.3093
BVL
$
0.8773
RTP APX NXP NOP RHO BVL
$
1.1551 1.1551 1.1551 1.1551 1.1551 1.7380
BVL
$
1.1645
APX NXP NOP RHO RTP BVL
$
1.5322 1.5322 1.5322 1.5322 1.5323 2.3053
BVL
$
1.5445
* 90MG SUSTAINED-RELEASE CAPSULE 02222965 02229407 02097222
APO-DILTIAZ SR NOVO-DILTAZEM SR CARDIZEM-SR
* 120MG SUSTAINED-RELEASE CAPSULE 02222973 02229408 02097230
APO-DILTIAZ SR NOVO-DILTAZEM SR CARDIZEM-SR
* 120MG CONTROLLED DELIVERY CAPSULE 02230997 02231052 02242538 02243338 02229781 02097249
APO-DILTIAZ CD NU-DILTIAZ-CD NOVO-DILTAZEM CD RHOXAL-DILTIAZEM CD RATIO-DILTIAZEM CD CARDIZEM CD
120MG EXTENDED RELEASE CAPSULE 02231150
TIAZAC
* 180MG CONTROLLED DELIVERY CAPSULE 02229782 02230998 02231053 02242539 02243339 02097257
RATIO-DILTIAZEM CD APO-DILTIAZ CD NU-DILTIAZ-CD NOVO-DILTAZEM CD RHOXAL-DILTIAZEM CD CARDIZEM CD
180MG EXTENDED RELEASE CAPSULE 02231151
TIAZAC
* 240MG CONTROLLED DELIVERY CAPSULE 02230999 02231054 02242540 02243340 02229783 02097265
APO-DILTIAZ CD NU-DILTIAZ-CD NOVO-DILTAZEM CD RHOXAL-DILTIAZEM CD RATIO-DILTIAZEM CD CARDIZEM CD
240MG EXTENDED RELEASE CAPSULE 02231152
TIAZAC
49
24:00 CARDIOVASCULAR DRUGS 24:04.00 CARDIAC DRUGS
* 300MG CONTROLLED DELIVERY CAPSULE 02243341 02229526 02229784 02242541 02097273
RHOXAL-DILTIAZEM CD APO-DILTIAZ CD RATIO-DILTIAZEM CD NOVO-DILTAZEM CD CARDIZEM CD
RHO APX RTP NOP BVL
$
1.9102 1.9153 1.9153 1.9153 2.8816
BVL
$
1.9307
BVL
$
2.3289
AVT
$
0.2273
AVT
$
0.3212
RBP
$
0.5787
AVT
$
0.7617
MDA
$
0.5344
MDA
$
1.0688
DOM PMS PMS APX NOP APX NOP NXP GPM GPM MED DOM NVR AST
$
0.1039 * 0.1330 0.1330 0.1330 0.1330 0.1330 0.1330 0.1330 0.1330 0.1330 0.1330 0.1397 0.2232 0.2442
300MG EXTENDED RELEASE CAPSULE 02231154
TIAZAC
360MG EXTENDED RELEASE CAPSULE 02231155
TIAZAC
DISOPYRAMIDE 100MG CAPSULE 01989553
RYTHMODAN
150MG CAPSULE 01989561
RYTHMODAN
150MG CONTROLLED RELEASE TABLET 02030810
NORPACE-CR
250MG SUSTAINED RELEASE TABLET 02224836
RYTHMODAN-LA
FLECAINIDE ACETATE 50MG TABLET 01966197
TAMBOCOR
100MG TABLET 01966200
TAMBOCOR
METOPROLOL TARTRATE * 50MG TABLET 02172550 02145413 02230803 00618632 00648035 00749354 00842648 00865605 02174545 02230448 02239771 02231121 00397423 00402605
DOM-METOPROLOL PMS-METOPROLOL-B PMS-METOPROLOL-L APO-METOPROLOL NOVO-METOPROL APO-METOPROLOL-TYPE L NOVO-METOPROL (UNCOATED) NU-METOP GEN-METOPROLOL (TYPE L) GEN-METOPROLOL MED-METOPROLOL DOM-METOPROLOL-L LOPRESOR BETALOC
50
24:00 CARDIOVASCULAR DRUGS 24:04.00 CARDIAC DRUGS
* 100MG TABLET 02172569 02145421 02230804 00618640 00648043 00751170 00842656 00865613 02174553 02230449 02239772 02231122 00402540 00397431
DOM-METOPROLOL PMS-METOPROLOL-B PMS-METOPROLOL-L APO-METOPROLOL NOVO-METOPROL APO-METOPROLOL-TYPE L NOVO-METOPROL (UNCOATED) NU-METOP GEN-METOPROLOL (TYPE L) GEN-METOPROLOL MED-METOPROLOL DOM-METOPROLOL-L BETALOC LOPRESOR
DOM PMS PMS APX NOP APX NOP NXP GPM GPM MED DOM AST NVR
$
0.1885 * 0.2412 0.2412 0.2412 0.2412 0.2412 0.2412 0.2412 0.2412 0.2412 0.2412 0.2533 0.4178 0.4579
NVR
$
0.2659
AST NVR
$
0.4824 0.4824
NOP
$
0.3785
NOP
$
0.5068
PPZ APX RTP NOP
$
0.2675 0.2675 0.2675 0.2675
PPZ APX RTP NOP
$
0.3814 0.3814 0.3814 0.3814
PPZ APX RTP
$
0.7156 0.7156 0.7156
100MG SUSTAINED RELEASE TABLET 00658855 ⌧
LOPRESOR-SR
200MG SUSTAINED RELEASE TABLET 00497827 00534560
BETALOC DURULES LOPRESOR-SR
MEXILETINE HCL 100MG CAPSULE 02230359
NOVO-MEXILETINE
200MG CAPSULE 02230360
NOVO-MEXILETINE
NADOLOL * 40MG TABLET 00607126 00782505 00851663 02126753
CORGARD APO-NADOL RATIO-NADOLOL NOVO-NADOLOL
* 80MG TABLET 00463256 00782467 00851671 02126761
CORGARD APO-NADOL RATIO-NADOLOL NOVO-NADOLOL
* 160MG TABLET 00523372 00782475 00851698
CORGARD APO-NADOL RATIO-NADOLOL
51
24:00 CARDIOVASCULAR DRUGS 24:04.00 CARDIAC DRUGS
NIFEDIPINE * 5MG CAPSULE 00725110 02047462
APO-NIFED NOVO-NIFEDIN
APX NOP
$
0.2648 0.2648
APX NOP NXP DOM
$
0.2016 0.2016 0.2016 0.2117
APX NXP
$
0.2436 0.2436
APX NXP
$
0.4232 0.4232
BAY
$
0.8140
BAY
$
1.0091
ADALAT XL
BAY
$
1.5831
NU-PINDOL APO-PINDOL NOVO-PINDOL GEN-PINDOLOL MED-PINDOLOL PMS-PINDOLOL DOM-PINDOLOL VISKEN
NXP APX NOP GPM MED PMS DOM NVR
$
0.1985 * 0.2477 0.2477 0.2477 0.2477 0.2477 0.2601 0.4492
* 10MG CAPSULE 00755907 00756830 00865591 02236758
APO-NIFED NOVO-NIFEDIN NU-NIFED DOM-NIFEDIPINE
* 10MG SUSTAINED RELEASE TABLET 02197448 02212102
APO-NIFED PA NU-NIFEDIPINE-PA
* 20MG SUSTAINED RELEASE TABLET 02181525 02200937
APO-NIFED PA NU-NIFEDIPINE-PA
20MG EXTENDED-RELEASE TABLET 02237618
ADALAT XL
30MG EXTENDED-RELEASE TABLET 02155907
ADALAT XL
60MG EXTENDED-RELEASE TABLET 02155990
PINDOLOL * 5MG TABLET 00886149 00755877 00869007 02057808 02084376 02231536 02231650 00417270
52
24:00 CARDIOVASCULAR DRUGS 24:04.00 CARDIAC DRUGS
* 10MG TABLET 00886009 00755885 00869015 02057816 02084384 02231537 02238046 00443174
NU-PINDOL APO-PINDOL NOVO-PINDOL GEN-PINDOLOL MED-PINDOLOL PMS-PINDOLOL DOM-PINDOLOL VISKEN
NXP APX NOP GPM MED PMS DOM NVR
$
0.3447 * 0.4302 0.4302 0.4302 0.4302 0.4302 0.4517 0.7671
APX NOP NXP GPM MED PMS DOM NVR
$
0.6321 0.6321 0.6321 0.6321 0.6321 0.6321 0.6636 1.1127
APX
$
0.1913
APX
$
0.2497
APX
$
0.3321
PFI
$
0.1628
PFI SQU
$
0.3255 0.5122
PFI
$
0.4883
APX PMS GPM ABB
$
0.7395 0.7395 0.7395 0.9713
APX PMS GPM ABB
$
1.3037 1.3037 1.3037 1.7121
* 15MG TABLET 00755893 00869023 00886130 02057824 02084392 02231539 02238047 00417289
APO-PINDOL NOVO-PINDOL NU-PINDOL GEN-PINDOLOL MED-PINDOLOL PMS-PINDOLOL DOM-PINDOLOL VISKEN
PROCAINAMIDE HCL 250MG CAPSULE 00713325
APO-PROCAINAMIDE
375MG CAPSULE 00713333
APO-PROCAINAMIDE
500MG CAPSULE 00713341
APO-PROCAINAMIDE
250MG SUSTAINED RELEASE TABLET 00638692 ⌧
PROCAN-SR
500MG SUSTAINED RELEASE TABLET 00638676 00639885
PROCAN-SR PRONESTYL-SR
750MG SUSTAINED RELEASE TABLET 00638684
PROCAN-SR
PROPAFENONE HCL * 150MG TABLET 02243324 02243727 02245372 00603708
APO-PROPAFENONE PMS-PROPAFENONE GEN-PROPAFENONE RYTHMOL
* 300MG TABLET 02243325 02243728 02245373 00603716
APO-PROPAFENONE PMS-PROPAFENONE GEN-PROPAFENONE RYTHMOL
53
24:00 CARDIOVASCULAR DRUGS 24:04.00 CARDIAC DRUGS
PROPRANOLOL * 10MG TABLET 02137313 00402788 00582255 00496480 02042177
DOM-PROPRANOLOL APO-PROPRANOLOL PMS-PROPRANOLOL NOVO-PRANOL INDERAL
DOM APX PMS NOP WYA
$
0.0159 * 0.0209 0.0209 0.0261 0.0748
APX NOP NXP
$
0.0376 0.0376 0.0376
DOM APX NOP PMS NXP
$
0.0351 * 0.0378 0.0378 0.0378 0.0378
APX NOP PMS DOM
$
0.0635 0.0635 0.0635 0.0667
APX
$
0.1149
WYA
$
0.4532
WYA
$
0.5112
WYA
$
0.7870
WYA
$
0.9309
AST
$
0.4449
APX
$
0.1194
* 20MG TABLET 00663719 00740675 02044692
APO-PROPRANOLOL NOVO-PRANOL NU-PROPRANOLOL
* 40MG TABLET 02137321 00402753 00496499 00582263 02044706
DOM-PROPRANOLOL APO-PROPRANOLOL NOVO-PRANOL PMS-PROPRANOLOL NU-PROPRANOLOL
* 80MG TABLET 00402761 00496502 00582271 02137348
APO-PROPRANOLOL NOVO-PRANOL PMS-PROPRANOLOL DOM-PROPRANOLOL
120MG TABLET 00504335
APO-PROPRANOLOL
60MG LONG ACTING CAPSULE 02042231
INDERAL-LA
80MG LONG ACTING CAPSULE 02042258
INDERAL-LA
120MG LONG ACTING CAPSULE 02042266
INDERAL-LA
160MG LONG ACTING CAPSULE 02042274
INDERAL-LA
QUINIDINE BISULFATE 250MG SUSTAINED RELEASE TABLET 00249580
BIQUIN DURULES
QUINIDINE SO4 200MG TABLET 00441740
APO-QUINIDINE
54
24:00 CARDIOVASCULAR DRUGS 24:04.00 CARDIAC DRUGS
SOTALOL HCL * 80MG TABLET 02238634 00897272 02084228 02170833 02200996 02210428 02229778 02231181 02234008 02237269 02238326
DOM-SOTALOL SOTACOR RATIO-SOTALOL LINSOTALOL NU-SOTALOL APO-SOTALOL GEN-SOTALOL NOVO-SOTALOL RHOXAL-SOTALOL MED-SOTALOL PMS-SOTALOL
DOM BRI RTP LIN NXP APX GPM NOP RHO MED PMS
$
0.5282 * 0.6437 0.6437 0.6437 0.6437 0.6437 0.6437 0.6437 0.6437 0.6437 0.6437
DOM BRI RTP NXP APX LIN GPM NOP RHO MED PMS
$
0.5759 * 0.7044 0.7044 0.7044 0.7044 0.7044 0.7044 0.7044 0.7044 0.7044 0.7044
APX NOP NXP
$
0.1790 0.1790 0.1790
APX NOP NXP
$
0.2791 0.2791 0.2791
APX NOP
$
0.5431 0.5431
* 160MG TABLET 02238635 00483923 02084236 02163772 02167794 02170841 02229779 02231182 02234013 02237270 02238327
DOM-SOTALOL SOTACOR RATIO-SOTALOL NU-SOTALOL APO-SOTALOL LINSOTALOL GEN-SOTALOL NOVO-SOTALOL RHOXAL-SOTALOL MED-SOTALOL PMS-SOTALOL
TIMOLOL MALEATE * 5MG TABLET 00755842 01947796 02044609
APO-TIMOL NOVO-TIMOL NU-TIMOLOL
* 10MG TABLET 00755850 01947818 02044617
APO-TIMOL NOVO-TIMOL NU-TIMOLOL
* 20MG TABLET 00755869 01947826
APO-TIMOL NOVO-TIMOL
VERAPAMIL HCL SEE SECTION 24:08.00 (HYPOTENSIVE DRUGS)
55
24:00 CARDIOVASCULAR DRUGS 24:06.00 ANTILIPEMIC DRUGS
ATORVASTATIN CALCIUM 10MG TABLET 02230711
LIPITOR
PFI
$
1.7360
PFI
$
2.1700
PFI
$
2.3328
PFI
$
2.3328
PMS
$
0.7313
HLR
$
1.7360
BRI NOP PMS
$
0.6952 0.6952 0.6952
PMS BRI NOP
$
0.6952 0.6952 0.6952
PHU
$
0.8880
COLESTID
PHU
$
0.8880
COLESTID
PHU
$
0.2533
PMS APX GPM NOP DOM FFR
$
1.1816 1.1816 1.1816 1.1816 1.3785 1.8771
20MG TABLET 02230713
LIPITOR
40MG TABLET 02230714
LIPITOR
80MG TABLET 02243097
LIPITOR
BEZAFIBRATE SEE APPENDIX A FOR EDS CRITERIA
200MG TABLET 02240331
PMS-BEZAFIBRATE (EDS)
400MG SUSTAINED RELEASE TABLET 02083523
BEZALIP SR (EDS)
CHOLESTYRAMINE RESIN * 444MG/G ORAL POWDER (9G) 00464880 02139189 02210320
QUESTRAN NOVO-CHOLAMINE PMS-CHOLESTYRAMINE
* 800MG/G ORAL POWDER (5G) 00890960 01918486 02139197
PMS-CHOLESTYRAMINE LIGHT QUESTRAN LIGHT NOVO-CHOLAMINE LIGHT
COLESTIPOL HCL RESIN 5G GRANULES 00642975
COLESTID
7.5G GRANULES 02132699
1G TABLET 02132680
FENOFIBRATE * 200MG CAPSULE 02231780 02239864 02240210 02243552 02240337 02146959
PMS-FENOFIBR. MICRO APO-FENO-MICRO GEN-FENOFIBR. MICRO NOVO-FENOFIB. MICRO DOM-FENOFIBR. MICRO LIPIDIL-MICRO
56
24:00 CARDIOVASCULAR DRUGS 24:06.00 ANTILIPEMIC DRUGS
FLUVASTATIN SODIUM 20MG CAPSULE 02061562
LESCOL
NVR
$
0.8341
NVR
$
1.1677
DOM RTP APX NXP GPM PMS NOP PFI
$
0.2640 * 0.3216 0.3216 0.3216 0.3216 0.3216 0.3216 0.5375
DOM RTP APX NXP NOP PMS GPM MED PFI
$
0.5421 * 0.8160 0.8160 0.8160 0.8160 0.8160 0.8160 0.8160 1.0760
APX GPM RTP PMS MSD
$
1.5028 1.5028 1.5028 1.5028 1.8786
APX RTP PMS GPM MSD
$
2.7717 2.7717 2.7717 2.7719 3.4649
40MG CAPSULE 02061570
LESCOL
GEMFIBROZIL * 300MG CAPSULE 02241608 00851922 01979574 02058456 02185407 02239951 02241704 00599026
DOM-GEMFIBROZIL RATIO-GEMFIBROZIL APO-GEMFIBROZIL NU-GEMFIBROZIL GEN-GEMFIBROZIL PMS-GEMFIBROZIL NOVO-GEMFIBROZIL LOPID
* 600MG TABLET 02230580 00851930 01979582 02058464 02142074 02230183 02230476 02237292 00659606
DOM-GEMFIBROZIL RATIO-GEMFIBROZIL APO-GEMFIBROZIL NU-GEMFIBROZIL NOVO-GEMFIBROZIL PMS-GEMFIBROZIL GEN-GEMFIBROZIL MED-GEMFIBROZIL LOPID
LOVASTATIN * 20MG TABLET 02220172 02243127 02245822 02246013 00795860
APO-LOVASTATIN GEN-LOVASTATIN RATIO-LOVASTATIN PMS-LOVASTATIN MEVACOR
* 40MG TABLET 02220180 02245823 02246014 02243129 00795852
APO-LOVASTATIN RATIO-LOVASTATIN PMS-LOVASTATIN GEN-LOVASTATIN MEVACOR
57
24:00 CARDIOVASCULAR DRUGS 24:06.00 ANTILIPEMIC DRUGS
PRAVASTATIN * 10MG TABLET 02244350 02243506 02237373 02242865 00893749
NU-PRAVASTATIN APO-PRAVASTATIN LIN-PRAVASTATIN BIOPRAVASTATIN PRAVACHOL
NXP APX LIN BMI SQU
$
0.7982 * 1.0340 1.0345 1.0345 1.6421
NXP LIN BMI APX SQU
$
0.9416 * 1.2200 1.2200 1.2200 1.9368
NXP LIN APX BMI SQU
$
1.1341 * 1.4696 1.4696 1.4699 2.3328
MSD
$
0.9765
MSD
$
1.9313
MSD
$
2.3870
MSD
$
2.3870
MSD
$
2.3870
* 20MG TABLET 02244351 02237374 02242866 02243507 00893757
NU-PRAVASTATIN LIN-PRAVASTATIN BIOPRAVASTATIN APO-PRAVASTATIN PRAVACHOL
* 40MG TABLET 02244352 02237375 02243508 02242867 02222051
NU-PRAVASTATIN LIN-PRAVASTATIN APO-PRAVASTATIN BIOPRAVASTATIN PRAVACHOL
SIMVASTATIN 5MG TABLET 00884324
ZOCOR
10MG TABLET 00884332
ZOCOR
20MG TABLET 00884340
ZOCOR
40MG TABLET 00884359
ZOCOR
80MG TABLET 02240332
ZOCOR
24:08.00 HYPOTENSIVE DRUGS ANTIHYPERTENSIVE COMBINATION PRODUCTS: FIXED COMBINATION DRUGS ARE NOT INDICATED FOR INITIAL THERAPY OF HYPERTENSION. HYPERTENSION REQUIRES THERAPY TO BE TITRATED TO THE INDIVIDUAL PATIENT. IF THE FIXED COMBINATION REPRESENTS THE DOSAGE SO DETERMINED, ITS USE MAY BE MORE CONVENIENT IN PATIENT MANAGEMENT. THE TREATMENT OF HYPERTENSION IS NOT STATIC, BUT MUST BE RE-EVALUATED AS CONDITIONS IN EACH PATIENT WARRANT.
ACEBUTOLOL HCL SEE SECTION 24:04.00 (CARDIAC DRUGS)
58
24:00 CARDIOVASCULAR DRUGS 24:08.00 HYPOTENSIVE DRUGS
AMILORIDE HCL/HYDROCHLOROTHIAZIDE SEE NOTE REGARDING COMBINATION PRODUCTS UNDER SECTION 24:08.00 (HYPOTENSIVE DRUGS)
* 5MG/50MG TABLET 00886106 00784400 01937219 00487813
NU-AMILZIDE APO-AMILZIDE NOVAMILOR MODURET
NXP APX NOP MSD
$
0.1667 * 0.2080 0.2080 0.3816
AST
$
0.6732
AST
$
1.1033
NVR
$
0.6239
NVR
$
0.7378
NVR
$
0.8463
AST
$
1.1718
AST
$
1.1718
ATENOLOL SEE SECTION 24:04.00 (CARDIAC DRUGS)
ATENOLOL/CHLORTHALIDONE SEE NOTE REGARDING COMBINATION PRODUCTS UNDER SECTION 24:08.00 (HYPOTENSIVE DRUGS)
50MG/25MG TABLET 02049961
TENORETIC
100MG/25MG TABLET 02049988
TENORETIC
BENAZEPRIL HCL 5MG TABLET 00885835
LOTENSIN
10MG TABLET 00885843
LOTENSIN
20MG TABLET 00885851
LOTENSIN
CANDESARTAN CILEXETIL 8MG TABLET 02239091
ATACAND
16MG TABLET 02239092
ATACAND
CANDESARTAN CILEXETIL/HYDROCHLOROTHIAZIDE SEE NOTE REGARDING COMBINATION PRODUCTS UNDER SECTION 24:08.00 (HYPOTENSIVE DRUGS)
16MG/12.5MG TABLET 02244021
ATACAND PLUS
AST
59
$
1.1718
24:00 CARDIOVASCULAR DRUGS 24:08.00 HYPOTENSIVE DRUGS
CAPTOPRIL 6.25MG TABLET 01999559
APO-CAPTO
APX
$
0.1297
DOM SQU RTP APX NXP NOP GPM MED PMS ZYP
$
0.1888 * 0.2301 0.2301 0.2301 0.2301 0.2301 0.2301 0.2301 0.2301 0.2301
DOM SQU RTP APX NXP NOP GPM MED PMS ZYP
$
0.2672 * 0.3255 0.3255 0.3255 0.3255 0.3255 0.3255 0.3255 0.3255 0.3255
DOM SQU RTP APX NXP NOP GPM MED PMS ZYP
$
0.4978 * 0.6066 0.6066 0.6066 0.6066 0.6066 0.6066 0.6066 0.6066 0.6066
* 12.5MG TABLET 02238551 00695661 00851639 00893595 01913824 01942964 02163551 02188929 02230203 02242788
DOM-CAPTOPRIL CAPOTEN RATIO-CAPTOPRIL APO-CAPTO NU-CAPTO NOVO-CAPTORIL GEN-CAPTOPRIL MED-CAPTOPRIL PMS-CAPTOPRIL CAPTOPRIL
* 25MG TABLET 02238552 00546283 00851833 00893609 01913832 01942972 02163578 02188937 02230204 02242789
DOM-CAPTOPRIL CAPOTEN RATIO-CAPTOPRIL APO-CAPTO NU-CAPTO NOVO-CAPTORIL GEN-CAPTOPRIL MED-CAPTOPRIL PMS-CAPTOPRIL CAPTOPRIL
* 50MG TABLET 02238553 00546291 00851647 00893617 01913840 01942980 02163586 02188945 02230205 02242790
DOM-CAPTOPRIL CAPOTEN RATIO-CAPTOPRIL APO-CAPTO NU-CAPTO NOVO-CAPTORIL GEN-CAPTOPRIL MED-CAPTOPRIL PMS-CAPTOPRIL CAPTOPRIL
60
24:00 CARDIOVASCULAR DRUGS 24:08.00 HYPOTENSIVE DRUGS
* 100MG TABLET 00546305 00851655 00893625 01913859 01942999 02163594 02188953 02230206 02242791 02238554
CAPOTEN RATIO-CAPTOPRIL APO-CAPTO NU-CAPTO NOVO-CAPTORIL GEN-CAPTOPRIL MED-CAPTOPRIL PMS-CAPTOPRIL CAPTOPRIL DOM-CAPTOPRIL
SQU RTP APX NXP NOP GPM MED PMS ZYP DOM
$
1.1279 1.1279 1.1279 1.1279 1.1279 1.1279 1.1279 1.1279 1.1279 1.1843
INHIBACE
HLR
$
0.6402
INHIBACE
HLR
$
0.7378
INHIBACE
HLR
$
0.8572
HLR
$
0.8572
BOE
$
0.2270
BOE APX NXP NOP
$
0.1915 0.1915 0.1915 0.1915
BOE APX NXP NOP
$
0.3417 0.3417 0.3417 0.3417
CILAZAPRIL 1MG TABLET 01911465
2.5MG TABLET 01911473
5MG TABLET 01911481
CILAZAPRIL/HYDROCHLOROTHIAZIDE SEE NOTE REGARDING COMBINATION PRODUCTS UNDER SECTION 24:08.00 (HYPOTENSIVE DRUGS)
5MG/12.5MG TABLET 02181479
INHIBACE PLUS
CLONIDINE HCL SEE APPENDIX A FOR EDS CRITERIA
0.025MG TABLET 00519251
DIXARIT (EDS)
* 0.1MG TABLET 00259527 00868949 01913786 02046121
CATAPRES APO-CLONIDINE NU-CLONIDINE NOVO-CLONIDINE
* 0.2MG TABLET 00291889 00868957 01913220 02046148
CATAPRES APO-CLONIDINE NU-CLONIDINE NOVO-CLONIDINE
DILTIAZEM HCL NOTE: THE SUSTAINED RELEASE DOSAGE FORMS ARE APPROVED AS ANTIHYPERTENSIVE AGENTS (SEE SECTION 24:04.00)
61
24:00 CARDIOVASCULAR DRUGS 24:08.00 HYPOTENSIVE DRUGS
DOXAZOSIN MESYLATE * 1MG TABLET 02240498 02240588 02242728 02243215 02244527 01958100
GEN-DOXAZOSIN APO-DOXAZOSIN NOVO-DOXAZOSIN RATIO-DOXAZOSIN PMS-DOXAZOSIN CARDURA-1
GPM APX NOP RTP PMS AST
$
0.3760 0.3760 0.3760 0.3760 0.3760 0.5968
GEN-DOXAZOSIN APO-DOXAZOSIN NOVO-DOXAZOSIN RATIO-DOXAZOSIN PMS-DOXAZOSIN CARDURA-2
GPM APX NOP RTP PMS AST
$
0.4512 0.4512 0.4512 0.4512 0.4512 0.7161
GEN-DOXAZOSIN APO-DOXAZOSIN NOVO-DOXAZOSIN RATIO-DOXAZOSIN PMS-DOXAZOSIN CARDURA-4
GPM APX NOP RTP PMS AST
$
0.5865 0.5865 0.5865 0.5865 0.5865 0.9310
VASOTEC
MSD
$
0.7327
VASOTEC
MSD
$
0.8666
MSD
$
1.0416
MSD
$
1.2568
MSD
$
0.8666
MSD
$
1.0416
* 2MG TABLET 02240499 02240589 02242729 02243216 02244528 01958097
* 4MG TABLET 02240500 02240590 02242730 02243217 02244529 01958119
ENALAPRIL MALEATE 2.5MG TABLET 00851795
5MG TABLET 00708879
10MG TABLET 00670901
VASOTEC
20MG TABLET 00670928
VASOTEC
ENALAPRIL MALEATE/HYDROCHLOROTHIAZIDE SEE NOTE REGARDING COMBINATION PRODUCTS UNDER SECTION 24:08.00 (HYPOTENSIVE DRUGS)
5MG/12.5MG TABLET 02242826
VASERETIC
10MG/25MG TABLET 00657298
VASERETIC
62
24:00 CARDIOVASCULAR DRUGS 24:08.00 HYPOTENSIVE DRUGS
EPROSARTAN MESYLATE 300MG TABLET 02240431
TEVETEN
SLV
$
0.5534
SLV
$
0.7378
SLV
$
1.1067
AVT AST
$
0.5357 0.5360
AST AVT
$
0.7161 0.7161
AVT AST
$
1.0735 1.0742
BMY
$
0.8572
BMY
$
1.0308
APX NOP NXP NVR
$
0.1001 0.1001 0.1001 0.1539
APX NOP NXP NVR
$
0.1784 0.1784 0.1784 0.2643
APX NOP NXP NVR
$
0.2742 0.2742 0.2742 0.4149
400MG TABLET 02240432
TEVETEN
600MG TABLET 02243942
TEVETEN
FELODIPINE * 2.5MG SUSTAINED RELEASE TABLET 02221985 02057778
RENEDIL PLENDIL
* 5MG SUSTAINED RELEASE TABLET 00851779 02221993
PLENDIL RENEDIL
* 10MG SUSTAINED RELEASE TABLET 02222000 00851787
RENEDIL PLENDIL
FOSINOPRIL 10MG TABLET 01907107
MONOPRIL
20MG TABLET 01907115
MONOPRIL
HYDRALAZINE HCL * 10MG TABLET 00441619 00759465 01913204 00005525
APO-HYDRALAZINE NOVO-HYLAZIN NU-HYDRAL APRESOLINE
* 25MG TABLET 00441627 00759473 02004828 00005533
APO-HYDRALAZINE NOVO-HYLAZIN NU-HYDRAL APRESOLINE
* 50MG TABLET 00441635 00759481 02004836 00005541
APO-HYDRALAZINE NOVO-HYLAZIN NU-HYDRAL APRESOLINE
63
24:00 CARDIOVASCULAR DRUGS 24:08.00 HYPOTENSIVE DRUGS
IRBESARTAN 75MG TABLET 02237923
AVAPRO
BMY
$
1.1718
BMY
$
1.1718
BMY
$
1.1718
BMY
$
1.1718
BMY
$
1.1718
APX RBP
$
0.1787 0.2553
APO-LABETALOL TRANDATE
APX RBP
$
0.3161 0.4515
APO-LISINOPRIL PRINIVIL ZESTRIL
APX MSD AST
$
0.6576 0.7308 0.7310
APX MSD AST
$
0.8246 0.8780 0.8782
APX MSD AST
$
0.9917 1.0551 1.0551
150MG TABLET 02237924
AVAPRO
300MG TABLET 02237925
AVAPRO
IRBESARTAN/HYDROCHLOROTHIAZIDE SEE NOTE REGARDING COMBINATION PRODUCTS UNDER SECTION 24:08.00 (HYPOTENSIVE DRUGS)
150MG/12.5MG TABLET 02241818
AVALIDE
300MG/12.5MG TABLET 02241819
AVALIDE
LABETALOL HCL * 100MG TABLET 02243538 02106272
APO-LABETALOL TRANDATE
* 200MG TABLET 02243539 02106280
LISINOPRIL * 5MG TABLET 02217481 00839388 02049333
* 10MG TABLET 02217503 00839396 02049376
APO-LISINOPRIL PRINIVIL ZESTRIL
* 20MG TABLET 02217511 00839418 02049384
APO-LISINOPRIL PRINIVIL ZESTRIL
64
24:00 CARDIOVASCULAR DRUGS 24:08.00 HYPOTENSIVE DRUGS
LISINOPRIL/HYDROCHLOROTHIAZIDE SEE NOTE REGARDING COMBINATION PRODUCTS UNDER SECTION 24:08.00 (HYPOTENSIVE DRUGS)
* 10MG/12.5MG TABLET 02103729 02108194
ZESTORETIC PRINZIDE
AST MSD
$
0.8782 0.8782
MSD AST
$
1.0551 1.0551
MSD AST
$
1.0551 1.0551
MSD
$
1.1940
MSD
$
1.1940
MSD
$
1.1940
MSD
$
1.1940
MSD
$
1.1940
APX
$
0.0641
APX NXP
$
0.1519 0.1519
APX NXP
$
0.2306 0.2306
APX
$
0.1823
APX
$
0.1991
* 20MG/12.5MG TABLET 00884413 02045737
PRINZIDE ZESTORETIC
* 20MG/25MG TABLET 00884421 02045729
PRINZIDE ZESTORETIC
LOSARTAN POTASSIUM 25MG TABLET 02182815
COZAAR
50MG TABLET 02182874
COZAAR
100MG TABLET 02182882
COZAAR
LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE SEE NOTE REGARDING COMBINATION PRODUCTS UNDER SECTION 24:08.00 (HYPOTENSIVE DRUGS)
50MG/12.5MG TABLET 02230047
HYZAAR
100MG/25MG TABLET 02241007
HYZAAR DS
METHYLDOPA 125MG TABLET 00360252
APO-METHYLDOPA
* 250MG TABLET 00360260 00717509
APO-METHYLDOPA NU-MEDOPA
* 500MG TABLET 00426830 00717576
APO-METHYLDOPA NU-MEDOPA
METHYLDOPA/HYDROCHLOROTHIAZIDE SEE NOTE REGARDING COMBINATION PRODUCTS UNDER SECTION 24:08.00 (HYPOTENSIVE DRUGS)
250MG/15MG TABLET 00441708
APO-METHAZIDE-15
250MG/25MG TABLET 00441716
APO-METHAZIDE-25 65
24:00 CARDIOVASCULAR DRUGS 24:08.00 HYPOTENSIVE DRUGS
METOPROLOL TARTRATE SEE SECTION 24:04.00 (CARDIAC DRUGS)
MINOXIDIL SEE APPENDIX A FOR EDS CRITERIA
2.5MG TABLET 00514497
LONITEN (EDS)
PHU
$
0.3431
PHU
$
0.7564
NVR
$
0.2804
NVR
$
0.4249
NVR
$
0.4248
NVR
$
0.8496
COVERSYL
SEV
$
0.6510
COVERSYL
SEV
$
0.8138
NVR
$
0.7513
NVR
$
0.7513
10MG TABLET 00514500
LONITEN (EDS)
NADOLOL SEE SECTION 24:04.00 (CARDIAC DRUGS)
NIFEDIPINE SEE SECTION 24:04.00 (CARDIAC DRUGS)
OXPRENOLOL HCL 40MG TABLET 00402575
TRASICOR
80MG TABLET 00402583
TRASICOR
80MG SLOW RELEASE TABLET 00534579
SLOW TRASICOR
160MG SLOW RELEASE TABLET 00534587
SLOW TRASICOR
PERINDOPRIL ERBUMINE 2MG TABLET 02123274
4MG TABLET 02123282
PINDOLOL SEE SECTION 24:04.00 (CARDIAC DRUGS)
PINDOLOL/HYDROCHLOROTHIAZIDE SEE NOTE REGARDING COMBINATION PRODUCTS UNDER SECTION 24:08.00 (HYPOTENSIVE DRUGS)
10MG/25MG TABLET 00568627
VISKAZIDE
10MG/50MG TABLET 00568635
VISKAZIDE
66
24:00 CARDIOVASCULAR DRUGS 24:08.00 HYPOTENSIVE DRUGS
PRAZOSIN * 1MG TABLET 00882801 01913794 01934198 00560952
APO-PRAZO NU-PRAZO NOVO-PRAZIN MINIPRESS
APX NXP NOP PFI
$
0.1683 0.1683 0.1683 0.3084
APO-PRAZO NU-PRAZO NOVO-PRAZIN MINIPRESS
APX NXP NOP PFI
$
0.2275 0.2275 0.2275 0.4189
APO-PRAZO NU-PRAZO NOVO-PRAZIN RATIO-PRAZOSIN MINIPRESS
APX NXP NOP RTP PFI
$
0.3284 0.3284 0.3284 0.3284 0.5757
PFI
$
0.8915
PFI
$
0.8915
PFI
$
0.8915
PFI
$
0.8915
PFI
$
0.8914
PFI
$
0.8914
* 2MG TABLET 00882828 01913808 01934201 00560960
* 5MG TABLET 00882836 01913816 01934228 02139995 00560979
PROPRANOLOL SEE SECTION 24:04.00 (CARDIAC DRUGS)
QUINAPRIL HCL 5MG TABLET 01947664
ACCUPRIL
10MG TABLET 01947672
ACCUPRIL
20MG TABLET 01947680
ACCUPRIL
40MG TABLET 01947699
ACCUPRIL
QUINAPRIL HCL/HYDROCHLOROTHIAZIDE SEE NOTE REGARDING COMBINATION PRODUCTS UNDER SECTION 24:08.00 (HYPOTENSIVE DRUGS)
10MG/12.5MG TABLET 02237367
ACCURETIC
20MG/12.5MG TABLET 02237368
ACCURETIC
67
24:00 CARDIOVASCULAR DRUGS 24:08.00 HYPOTENSIVE DRUGS
RAMIPRIL 1.25MG CAPSULE 02221829
ALTACE
AVT
$
0.7053
AVT
$
0.8138
AVT
$
0.8138
AVT
$
1.0308
NOP PHU
$
0.0932 0.0934
PHU NOP
$
0.2426 0.2426
BOE
$
1.1610
BOE
$
1.1610
BOE
$
1.1610
2.5MG CAPSULE 02221837
ALTACE
5MG CAPSULE 02221845
ALTACE
10MG CAPSULE 02221853
ALTACE
SPIRONOLACTONE/HYDROCHLOROTHIAZIDE SEE NOTE REGARDING COMBINATION PRODUCTS UNDER SECTION 24:08.00 (HYPOTENSIVE DRUGS)
* 25MG/25MG TABLET 00613231 00180408
NOVO-SPIROZINE ALDACTAZIDE-25
* 50MG/50MG TABLET 00594377 00657182
ALDACTAZIDE-50 NOVO-SPIROZINE
TELMISARTAN 40MG TABLET 02240769
MICARDIS
80MG TABLET 02240770
MICARDIS
TELMISARTAN/HYDROCHLOROTHIAZIDE SEE NOTE REGARDING COMBINATION PRODUCTS UNDER SECTION 24:08.00 (HYPOTENSIVE DRUGS)
80MG/12.5MG TABLET 02244344
MICARDIS PLUS
68
24:00 CARDIOVASCULAR DRUGS 24:08.00 HYPOTENSIVE DRUGS
TERAZOSIN HCL * 1MG TABLET 02243746 02243518 02218941 02230805 02233047 02234502 00818658
DOM-TERAZOSIN PMS-TERAZOSIN RATIO-TERAZOSIN NOVO-TERAZOSIN NU-TERAZOSIN APO-TERAZOSIN HYTRIN
DOM PMS RTP NOP NXP APX ABB
$
0.3034 * 0.3787 0.3787 0.3787 0.3787 0.3787 0.6011
DOM-TERAZOSIN PMS-TERAZOSIN RATIO-TERAZOSIN NOVO-TERAZOSIN NU-TERAZOSIN APO-TERAZOSIN HYTRIN
DOM PMS RTP NOP NXP APX ABB
$
0.3857 * 0.4813 0.4813 0.4813 0.4813 0.4813 0.7641
DOM-TERAZOSIN PMS-TERAZOSIN RATIO-TERAZOSIN NOVO-TERAZOSIN NU-TERAZOSIN APO-TERAZOSIN HYTRIN
DOM PMS RTP NOP NXP APX ABB
$
0.5238 * 0.6538 0.6538 0.6538 0.6538 0.6538 1.0377
RTP NOP NXP APX PMS DOM ABB
$
0.9570 0.9570 0.9570 0.9570 0.9570 1.0049 1.5190
ABB
$
24.0900
MSD
$
0.4654
* 2MG TABLET 02243747 02243519 02218968 02230806 02233048 02234503 00818682
* 5MG TABLET 02243748 02243520 02218976 02230807 02233049 02234504 00818666
* 10MG TABLET 02218984 02230808 02233050 02234505 02243521 02243749 00818674
RATIO-TERAZOSIN NOVO-TERAZOSIN NU-TERAZOSIN APO-TERAZOSIN PMS-TERAZOSIN DOM-TERAZOSIN HYTRIN
1MG TABLET (7) 2MG TABLET (7) 5MG TABLET (14) (PACKAGE) 02187876
HYTRIN STARTER PACK
TIMOLOL MALEATE SEE SECTION 24:04.00 (CARDIAC DRUGS)
TIMOLOL/HYDROCHLOROTHIAZIDE SEE NOTE REGARDING COMBINATION PRODUCTS UNDER SECTION 24:08.00 (HYPOTENSIVE DRUGS)
10MG/25MG TABLET 00509353
TIMOLIDE
69
24:00 CARDIOVASCULAR DRUGS 24:08.00 HYPOTENSIVE DRUGS
TRANDOLAPRIL 0.5MG CAPSULE 02231457
MAVIK
ABB
$
0.6727
ABB
$
0.7812
ABB
$
0.8897
NXP APX NOP
$
0.0416 * 0.0518 0.0518
NVR
$
1.1393
NVR
$
1.1393
NVR
$
1.1393
NVR
$
1.1393
NOP NXP GPM MED APX ABB
$
0.2968 0.2968 0.2968 0.2968 0.3035 0.3043
APX NOP NXP GPM MED ABB
$
0.4612 0.4612 0.4612 0.4612 0.4612 0.4728
1MG CAPSULE 02231459
MAVIK
2MG CAPSULE 02231460
MAVIK
TRIAMTERENE/HYDROCHLOROTHIAZIDE SEE NOTE REGARDING COMBINATION PRODUCTS UNDER SECTION 24:08.00 (HYPOTENSIVE DRUGS)
* 50MG/25MG TABLET 00865532 00441775 00532657
NU-TRIAZIDE APO-TRIAZIDE NOVO-TRIAMZIDE
VALSARTAN 80MG CAPSULE 02236808
DIOVAN
160MG CAPSULE 02236809
DIOVAN
VALSARTAN/HYDROCHLOROTHIAZIDE SEE NOTE REGARDING COMBINATION PRODUCTS UNDER SECTION 24:08.00 (HYPOTENSIVE DRUGS)
80MG/12.5MG TABLET 02241900
DIOVAN-HCT
160MG/12.5MG TABLET 02241901
DIOVAN-HCT
VERAPAMIL HCL * 80MG TABLET 00812331 00886033 02237921 02239769 00782483 00554316
NOVO-VERAMIL NU-VERAP GEN-VERAPAMIL MED-VERAPAMIL APO-VERAP ISOPTIN
* 120MG TABLET 00782491 00812358 00886041 02237922 02239770 00554324
APO-VERAP NOVO-VERAMIL NU-VERAP GEN-VERAPAMIL MED-VERAPAMIL ISOPTIN
70
24:00 CARDIOVASCULAR DRUGS 24:08.00 HYPOTENSIVE DRUGS
* 120MG SUSTAINED RELEASE TABLET 02210347 01907123
GEN-VERAPAMIL SR ISOPTIN SR
GPM ABB
$
0.7487 1.1038
PHU
$
0.8463
GPM ABB
$
0.8463 1.2466
PHU
$
0.9462
DOM GPM NOP PMS ABB
$
0.7765 * 0.9462 0.9462 0.9462 1.6624
SLV
$
0.2546
SLV
$
0.4557
BOE
$
0.3008
BOE
$
0.4008
BOE
$
0.5398
BOE
$
0.8409
180MG CONTROLLED-ONSET EXTENDED-RELEASE TABLET 02231676
CHRONOVERA
* 180MG SUSTAINED RELEASE TABLET 02210355 01934317
GEN-VERAPAMIL SR ISOPTIN SR
240MG CONTROLLED-ONSET EXTENDED-RELEASE TABLET 02231677
CHRONOVERA
* 240MG SUSTAINED RELEASE TABLET 02240321 02210363 02211920 02237791 00742554
DOM-VERAPAMIL SR GEN-VERAPAMIL SR NOVO-VERAMIL SR PMS-VERAPAMIL SR ISOPTIN SR
24:12.00 VASODILATING DRUGS
BETAHISTINE HCL 8MG TABLET 02240601
SERC
16MG TABLET 02243878
SERC
DIPYRIDAMOLE SEE APPENDIX A FOR EDS CRITERIA
25MG TABLET 00067385
PERSANTINE (EDS)
50MG TABLET 00067393
PERSANTINE (EDS)
75MG TABLET 00452092
PERSANTINE (EDS)
DIPYRIDAMOLE/ACETYLSALICYLIC ACID SEE APPENDIX A FOR EDS CRITERIA
200MG/25MG CAPSULE 02242119
AGGRENOX (EDS)
71
24:00 CARDIOVASCULAR DRUGS 24:12.00 VASODILATING DRUGS
ISOSORBIDE DINITRATE * 10MG TABLET 00441686 00458686
APO-ISDN NOVO-SORBIDE
APX NOP
$
0.0174 0.0174
APX NOP
$
0.0375 0.0375
APX
$
0.0651
AST
$
0.6944
BAY
$
5.7574
* 30MG TABLET 00441694 00458694
APO-ISDN NOVO-SORBIDE
5MG SUBLINGUAL TABLET 00670944
APO-ISDN
ISOSORBIDE-5 MONONITRATE 60MG EXTENDED-RELEASE TABLET 02126559
IMDUR
NIMODIPINE SEE APPENDIX A FOR EDS CRITERIA
30MG CAPSULE 02155923
NIMOTOP (EDS)
NITROGLYCERIN NOTE: TO PREVENT DEVELOPMENT OF TOLERANCE, PATCHES SHOULD BE REMOVED AFTER 12-14 HOURS TO PROVIDE DAILY NITRATE-FREE PERIODS OF 10-12 HOURS. THE NITRATE-FREE PERIOD SHOULD BE TIMED TO COINCIDE WITH THE PERIOD IN WHICH ANGINA IS LEAST LIKELY TO OCCUR (USUALLY AT NIGHT). ⌧
0.2MG/HR. TRANSDERMAL THERAPEUTIC SYSTEM 00584223 01911910 02162806 02230732
⌧
NVR KEY MDA SAW
$
0.6149 0.6149 0.6149 0.6149
NVR KEY MDA SAW
$
0.6944 0.6944 0.6944 0.6944
KEY NVR MDA SAW
$
0.6944 0.6944 0.6944 0.6944
0.4MG/HR. TRANSDERMAL THERAPEUTIC SYSTEM 00852384 01911902 02163527 02230733
⌧
TRANSDERM-NITRO 0.2 NITRO-DUR 0.2 MINITRAN 0.2 TRINIPATCH 0.2 TRANSDERM-NITRO 0.4 NITRO-DUR 0.4 MINITRAN 0.4 TRINIPATCH 0.4
0.6MG/HR. TRANSDERMAL THERAPEUTIC SYSTEM 01911929 02046156 02163535 02230734
NITRO-DUR 0.6 TRANSDERM-NITRO 0.6 MINITRAN 0.6 TRINIPATCH 0.6
72
24:00 CARDIOVASCULAR DRUGS 24:12.00 VASODILATING DRUGS 0.8MG/HR. TRANSDERMAL THERAPEUTIC SYSTEM 02011271
NITRO-DUR 0.8
KEY
$
1.2044
PFI
$
0.0290
PFI
$
0.0302
PMS
$
0.2165
RHO GPM AVT
$
9.8500 10.5000 13.1200
0.3MG SUBLINGUAL TABLET 00037613
NITROSTAT
0.6MG SUBLINGUAL TABLET 00037621
NITROSTAT
2% OINTMENT 01926454
NITROL
* 0.4MG/DOSE LINGUAL SPRAY (PACKAGE) 02238998 02243588 02231441
RHO-NITRO PUMPSPRAY GEN-NITRO SL SPRAY NITROLINGUAL PUMPSPRAY
73
CENTRAL NERVOUS SYSTEM DRUGS
28:00
28:00 CENTRAL NERVOUS SYSTEM DRUGS 28:08.04 NON-STEROIDAL ANTI-INFLAMMATORY AGENTS
ACETYLSALICYLIC ACID * 325MG ENTERIC TABLET 00216666 02046253 00010332
NOVASEN MSD ENTERIC-COATED ASA ENTROPHEN
NOP PNG PNG
$
0.0160 0.0160 0.0546
NOP PNG PNG
$
0.0382 0.0382 0.0936
PHU
$
0.6782
PHU
$
1.3563
NXP NOP APX PMS DOM NVR
$
0.1654 * 0.2064 0.2064 0.2064 0.2293 0.3391
NXP NOP APX PMS DOM NVR
$
0.3422 * 0.4272 0.4272 0.4272 0.4585 0.7155
NXP APX PMS NOP DOM NVR
$
0.4960 * 0.6191 0.6191 0.6191 0.6877 1.0055
* 650MG ENTERIC TABLET 00229296 02046261 00010340
NOVASEN MSD ENTERIC-COATED ASA ENTROPHEN
CELECOXIB SEE APPENDIX A FOR EDS CRITERIA
100MG CAPSULE 02239941
CELEBREX (EDS)
200MG CAPSULE 02239942
CELEBREX (EDS)
DICLOFENAC SODIUM * 25MG ENTERIC TABLET 00886017 00808539 00839175 02231502 02231662 00514004
NU-DICLO NOVO-DIFENAC APO-DICLO PMS-DICLOFENAC DOM-DICLOFENAC VOLTAREN
* 50MG ENTERIC TABLET 00886025 00808547 00839183 02231503 02231663 00514012
NU-DICLO NOVO-DIFENAC APO-DICLO PMS-DICLOFENAC DOM-DICLOFENAC VOLTAREN
* 75MG SUSTAINED RELEASE TABLET 02228203 02162814 02231504 02158582 02231664 00782459
NU-DICLO-SR APO-DICLO SR PMS-DICLOFENAC-SR NOVO-DIFENAC SR DOM-DICLOFENAC SR VOLTAREN-SR
76
28:00 CENTRAL NERVOUS SYSTEM DRUGS 28:08.04 NON-STEROIDAL ANTI-INFLAMMATORY AGENTS
* 100MG SUSTAINED RELEASE TABLET 02228211 02048698 02091194 02231505 02231665 00590827
NU-DICLO-SR NOVO-DIFENAC SR APO-DICLO SR PMS-DICLOFENAC-SR DOM-DICLOFENAC SR VOLTAREN-SR
NXP NOP APX PMS DOM NVR
$
0.6845 * 0.8544 0.8544 0.8544 0.9169 1.4332
NOP PMS SAB NVR
$
0.6768 0.6768 0.6768 1.0742
NOP PMS SAB NVR
$
0.9111 0.9111 0.9111 1.4463
PHU
$
0.6011
PHU
$
0.8181
APX NOP
$
0.4595 0.4595
APX NOP NXP
$
0.5621 0.5621 0.5621
APX
$
0.6510
APX PGA
$
0.6510 0.8680
LIL
$
0.5628
* 50MG SUPPOSITORY 02174677 02231506 02241224 00632724
NOVO-DIFENAC PMS-DICLOFENAC SAB-DICLOFENAC VOLTAREN
* 100MG SUPPOSITORY 02174685 02231508 02241225 00632732
NOVO-DIFENAC PMS-DICLOFENAC SAB-DICLOFENAC VOLTAREN
DICLOFENAC SODIUM/MISOPROSTOL 50MG/200UG ENTERIC TABLET 01917056
ARTHROTEC
75MG/200UG ENTERIC TABLET 02229837
ARTHROTEC 75
DIFLUNISAL * 250MG TABLET 02039486 02048493
APO-DIFLUNISAL NOVO-DIFLUNISAL
* 500MG TABLET 02039494 02048507 02058413
APO-DIFLUNISAL NOVO-DIFLUNISAL NU-DIFLUNISAL
ETODOLAC SEE APPENDIX A FOR EDS CRITERIA
200MG CAPSULE 02232317
APO-ETODOLAC (EDS)
* 300MG CAPSULE 02232318 02142031
APO-ETODOLAC (EDS) ULTRADOL (EDS)
FENOPROFEN 600MG TABLET 00345504
NALFON
77
28:00 CENTRAL NERVOUS SYSTEM DRUGS 28:08.04 NON-STEROIDAL ANTI-INFLAMMATORY AGENTS
FLURBIPROFEN * 50MG TABLET 01912046 02020661 02100509 00647942
APO-FLURBIPROFEN NU-FLURBIPROFEN NOVO-FLURPROFEN ANSAID
APX NXP NOP PHU
$
0.2782 0.2782 0.2782 0.5346
RTP APX NXP NOP PHU
$
0.3807 0.3807 0.3807 0.3807 0.6999
APX NXP NOP MCL
$
0.0309 0.0309 0.0316 0.1696
APX NOP NXP MCL
$
0.0404 0.0404 0.0404 0.2169
APX NOP NXP MCL
$
0.0505 0.0505 0.0505 0.3048
NOP APX NXP RTP
$
0.0945 0.0945 0.0945 0.0945
* 100MG TABLET 00675199 01912038 02020688 02100517 00600792
RATIO-FLURBIPROFEN APO-FLURBIPROFEN NU-FLURBIPROFEN NOVO-FLURPROFEN ANSAID
IBUPROFEN * 300MG TABLET 00441651 02020696 00629332 00327794
APO-IBUPROFEN NU-IBUPROFEN NOVO-PROFEN MOTRIN
* 400MG TABLET 00506052 00629340 02020718 00364142
APO-IBUPROFEN NOVO-PROFEN NU-IBUPROFEN MOTRIN
* 600MG TABLET 00585114 00629359 02020726 00484911
APO-IBUPROFEN NOVO-PROFEN NU-IBUPROFEN MOTRIN
INDOMETHACIN * 25MG CAPSULE 00337420 00611158 00865850 02143364
NOVO-METHACIN APO-INDOMETHACIN NU-INDO RATIO-INDOMETHACIN
78
28:00 CENTRAL NERVOUS SYSTEM DRUGS 28:08.04 NON-STEROIDAL ANTI-INFLAMMATORY AGENTS
* 50MG CAPSULE 00337439 00611166 00865869 02143372
NOVO-METHACIN APO-INDOMETHACIN NU-INDO RATIO-INDOMETHACIN
NOP APX NXP RTP
$
0.1640 0.1640 0.1640 0.1640
RHO NOP SAB MSD
$
0.7194 0.7194 0.7194 1.1430
RHO NOP SAB MSD
$
0.9668 0.9668 0.9668 1.5361
APX PMS AVT
$
0.1804 0.1804 0.3853
ROP PMS AVT
$
0.1804 0.1804 0.3853
ROP PMS
$
0.3340 0.3340
ROP APX AVT
$
0.6680 0.6680 1.5864
PMS
$
0.9513
PMS NOP
$
1.0774 1.0774
DOM APX PMS NXP PFI
$
0.2981 * 0.3590 0.3590 0.3590 0.6115
* 50MG SUPPOSITORY 02146932 02176130 02231799 00594466
RHODACINE NOVO-METHACIN SAB-INDOMETHACIN INDOCID
* 100MG SUPPOSITORY 02146940 02176149 02231800 00016233
RHODACINE NOVO-METHACIN SAB-INDOMETHACIN INDOCID
KETOPROFEN * 50MG CAPSULE 00790427 02150808 01926403
APO-KETO PMS-KETOPROFEN ORUDIS
* 50MG ENTERIC COATED TABLET 00761672 02150816 01926381
RHODIS EC PMS-KETOPROFEN-EC ORUDIS-E
* 100MG ENTERIC COATED TABLET 00761680 02150824
RHODIS EC PMS-KETOPROFEN-EC
* 200MG SUSTAINED RELEASE TABLET 02031175 02172577 01926373
RHODIS SR APO-KETOPROFEN SR ORUDIS SR
50MG SUPPOSITORY 02148773
PMS-KETOPROFEN
* 100MG SUPPOSITORY 02015951 02156083
PMS-KETOPROFEN NOVO-KETO
MEFENAMIC ACID * 250MG CAPSULE 02237826 02229452 02231208 02229569 00155225
DOM-MEFENAMIC ACID APO-MEFENAMIC PMS-MEFENAMIC ACID NU-MEFENAMIC PONSTAN 79
28:00 CENTRAL NERVOUS SYSTEM DRUGS 28:08.04 NON-STEROIDAL ANTI-INFLAMMATORY AGENTS
MELOXICAM SEE APPENDIX A FOR EDS CRITERIA
7.5MG TABLET 02242785
MOBICOX (EDS)
BOE
$
0.8463
BOE
$
0.9765
APX NOP RHO GPM GSK
$
0.5453 0.5453 0.5453 0.5453 0.7488
NOP GSK
$
0.7406 1.0170
APX NXP
$
0.0590 0.0590
NXP APX NOP RTP
$
0.0929 * 0.1159 0.1159 0.1159
NXP APX RTP NOP
$
0.1268 * 0.1582 0.1582 0.1582
NXP NOP APX RTP
$
0.1834 * 0.2290 0.2290 0.2290
APX NOP HLR
$
0.8251 0.8251 1.3778
15MG TABLET 02242786
MOBICOX (EDS)
NABUMETONE SEE APPENDIX A FOR EDS CRITERIA
* 500MG TABLET 02238639 02240867 02242912 02244563 02083531
APO-NABUMETONE (EDS) NOVO-NABUMETONE (EDS) RHOXAL-NABUMETONE (EDS) GEN-NABUMETONE (EDS) RELAFEN (EDS)
* 750MG TABLET 02240868 02083558
NOVO-NABUMETONE (EDS) RELAFEN (EDS)
NAPROXEN * 125MG TABLET 00522678 00865621
APO-NAPROXEN NU-NAPROX
* 250MG TABLET 00865648 00522651 00565350 00615315
NU-NAPROX APO-NAPROXEN NOVO-NAPROX RATIO-NAPROXEN
* 375MG TABLET 00865656 00600806 00615323 00627097
NU-NAPROX APO-NAPROXEN RATIO-NAPROXEN NOVO-NAPROX
* 500MG TABLET 00865664 00589861 00592277 00615331
NU-NAPROX NOVO-NAPROX APO-NAPROXEN RATIO-NAPROXEN
* 750MG SUSTAINED RELEASE TABLET 02177072 02231327 02162466
APO-NAPROXEN SR NOVO-NAPROX SR NAPROSYN-S.R.
80
28:00 CENTRAL NERVOUS SYSTEM DRUGS 28:08.04 NON-STEROIDAL ANTI-INFLAMMATORY AGENTS
* 500MG SUPPOSITORY 00756814 02230477 02017237 02162458
RATIO-NAPROXEN NAPROXEN PMS-NAPROXEN NAPROSYN
RTP SAB PMS HLR
$
0.8601 0.8601 0.8604 1.1935
HLR
$
0.0622
APX
$
0.0814
APX NOP PMS NXP GPM PFI
$
0.4500 0.4500 0.4500 0.4500 0.4500 0.9952
APX NOP PMS NXP GPM PFI
$
0.7767 0.7767 0.7767 0.7767 0.7767 1.6687
PMS
$
0.8040
PMS PFI
$
1.1802 1.9411
MSD
$
1.3563
MSD
$
1.3563
MSD
$
0.2713
25MG/ML SUSPENSION 02162431
NAPROSYN
PHENYLBUTAZONE 100MG TABLET 00312789
APO-PHENYLBUTAZONE
PIROXICAM * 10MG CAPSULE 00642886 00695718 00836249 00865761 02171813 00525596
APO-PIROXICAM NOVO-PIROCAM PMS-PIROXICAM NU-PIROX GEN-PIROXICAM FELDENE
* 20MG CAPSULE 00642894 00695696 00836230 00865788 02171821 00525618
APO-PIROXICAM NOVO-PIROCAM PMS-PIROXICAM NU-PIROX GEN-PIROXICAM FELDENE
10MG SUPPOSITORY 02154420
PMS-PIROXICAM
* 20MG SUPPOSITORY 02154463 00632716
PMS-PIROXICAM FELDENE
ROFECOXIB SEE APPENDIX A FOR EDS CRITERIA
12.5MG TABLET 02241107
VIOXX (EDS)
25MG TABLET 02241108
VIOXX (EDS)
2.5MG/ML ORAL SUSPENSION 02241109
VIOXX (EDS)
81
28:00 CENTRAL NERVOUS SYSTEM DRUGS 28:08.04 NON-STEROIDAL ANTI-INFLAMMATORY AGENTS
SULINDAC * 150MG TABLET 00745588 00778354 02042576
NOVO-SUNDAC APO-SULIN NU-SULINDAC
NOP APX NXP
$
0.4149 0.4149 0.4149
NOP APX NXP
$
0.5252 0.5252 0.5252
APX NOP PMS RTP
$
0.3730 0.3730 0.3730 0.4055
RTP APX NXP NOP PMS DOM AVT
$
0.4453 0.4453 0.4453 0.4453 0.4453 0.5008 0.7069
* 200MG TABLET 00745596 00778362 02042584
NOVO-SUNDAC APO-SULIN NU-SULINDAC
TIAPROFENIC ACID * 200MG TABLET 02136112 02179679 02230827 01924613
APO-TIAPROFENIC NOVO-TIAPROFENIC PMS-TIAPROFENIC RATIO-TIAFEN
* 300MG TABLET 01924621 02136120 02146886 02179687 02230828 02231060 02221950
RATIO-TIAFEN APO-TIAPROFENIC NU-TIAPROFENIC NOVO-TIAPROFENIC PMS-TIAPROFENIC DOM-TIAPROFENIC SURGAM
28:08.08 OPIATE AGONISTS (NARCOTIC ANALGESICS)
ACETAMINOPHEN/CAFFEINE/CODEINE * WITH 15MG CODEINE/TABLET 00653241 02163934 00687200 00293504
RATIO-LENOLTEC NO.2 TYLENOL WITH CODEINE NO.2 NOVO-GESIC C15 ATASOL-15
RTP JAN NOP HOR
$
0.0537 0.0646 0.0835 0.0919
RTP JAN NOP HOR LIH
$
0.0603 0.0711 0.0867 0.1334 0.1469
* WITH 30MG CODEINE/TABLET 00653276 02163926 00687219 00293512 02232389
RATIO-LENOLTEC NO.3 TYLENOL WITH CODEINE NO.3 NOVO-GESIC C30 ATASOL-30 EXDOL-30
82
28:00 CENTRAL NERVOUS SYSTEM DRUGS 28:08.08 OPIATE AGONISTS (NARCOTIC ANALGESICS)
ACETAMINOPHEN/CODEINE 300MG/30MG TABLET 00608882
RATIO-EMTEC
RTP
$
0.0494
RTP JAN
$
0.1502 0.1502
JAN
$
0.0835
LIH
$
0.1834
PFR
$
0.3051
PFR
$
0.6102
PFR
$
0.9223
PFR
$
1.2207
RTP
$
0.0832
RTP
$
0.1080
RTP
$
0.0266
* 300MG/60MG TABLET 00621463 02163918
RATIO-LENOLTEC #4 TYLENOL WITH CODEINE NO.4
32MG/1.6MG/ML ELIXIR 02163942
TYLENOL WITH CODEINE ELX
ACETYLSALICYLIC ACID/CAFFEINE/CODEINE 375MG/30MG/30MG TABLET 02238645
292
CODEINE SEE APPENDIX A FOR EDS CRITERIA
50MG CONTROLLED RELEASE TABLET 02230302
CODEINE CONTIN (EDS)
100MG CONTROLLED RELEASE TABLET 02163748
CODEINE CONTIN (EDS)
150MG CONTROLLED RELEASE TABLET 02163780
CODEINE CONTIN (EDS)
200MG CONTROLLED RELEASE TABLET 02163799
CODEINE CONTIN (EDS)
CODEINE PHOSPHATE 15MG TABLET 00593435
RATIO-CODEINE
30MG TABLET 00593451
RATIO-CODEINE
5MG/ML SYRUP 00779474
RATIO-CODEINE
83
28:00 CENTRAL NERVOUS SYSTEM DRUGS 28:08.08 OPIATE AGONISTS (NARCOTIC ANALGESICS)
FENTANYL SEE APPENDIX A FOR EDS CRITERIA
25UG/HR TRANSDERMAL SYSTEM 01937383
DURAGESIC (EDS)
JAN
$
9.2225
JAN
$
17.3600
JAN
$
24.4125
JAN
$
30.3800
DILAUDID PMS-HYDROMORPHONE
ABB PMS
$
0.1041 0.1041
DILAUDID PMS-HYDROMORPHONE
ABB PMS
$
0.1538 0.1538
DILAUDID PMS-HYDROMORPHONE
ABB PMS
$
0.2431 0.2431
DILAUDID PMS-HYDROMORPHONE
ABB PMS
$
0.3828 0.3828
PFR
$
0.6510
PFR
$
0.9765
PFR
$
1.6926
PFR
$
2.4413
PFR
$
3.1248
PFR
$
3.7433
ABB PMS
$
0.0859 0.0860
ABB SAB
$
1.2400 1.2400
50UG/HR TRANSDERMAL SYSTEM 01937391
DURAGESIC (EDS)
75UG/HR TRANSDERMAL SYSTEM 01937405
DURAGESIC (EDS)
100UG/HR TRANSDERMAL SYSTEM 01937413
DURAGESIC (EDS)
HYDROMORPHONE HCL * 1MG TABLET 00705438 00885444
* 2MG TABLET 00125083 00885436
* 4MG TABLET 00125121 00885401
* 8MG TABLET 00786543 00885428
3MG CONTROLLED-RELEASE CAPSULE 02125323
HYDROMORPH CONTIN
6MG CONTROLLED RELEASE CAPSULE 02125331
HYDROMORPH CONTIN
12MG CONTROLLED-RELEASE CAPSULE 02125366
HYDROMORPH CONTIN
18MG CONTROLLED-RELEASE CAPSULE 02243562
HYDROMORPH CONTIN
24MG CONTROLLED-RELEASE CAPSULE 02125382
HYDROMORPH CONTIN
30MG CONTROLLED-RELEASE CAPSULE 02125390
HYDROMORPH CONTIN
* 1MG/ML ORAL LIQUID 00786535 01916386
DILAUDID PMS-HYDROMORPHONE
* 2MG/ML INJECTION SOLUTION (1ML) 00627100 02145901
DILAUDID HYDROMORPHONE HCL
84
28:00 CENTRAL NERVOUS SYSTEM DRUGS 28:08.08 OPIATE AGONISTS (NARCOTIC ANALGESICS)
* 10MG/ML INJECTION SOLUTION (1ML) 00622133 02145928
DILAUDID-HP HYDROMORPHONE HP 10
ABB SAB
$
3.0300 3.0300
SAB ABB
$
4.8200 4.8200
ABB SAB
$
10.8000 13.1500
ABB
$
76.1100
ABB
$
2.3979
SAW
$
0.1285
SAB ABB ABB
$
0.6900 0.8300 0.8300
SAB ABB ABB
$
0.7300 0.8700 0.8700
PMS ICN PFR
$
0.1194 0.1194 0.1194
PMS ICN ICN PFR
$
0.1845 0.1845 0.1845 0.1856
PFR ICN
$
0.3275 0.3519
PMS ICN
$
0.2442 0.2442
* 20MG/ML INJECTION SOLUTION (1ML) 02145936 02146118
HYDROMORPHONE HP 20 DILAUDID HP-PLUS
* 50MG/ML INJECTION SOLUTION (1ML) 02145863 02146126
DILAUDID-XP HYDROMORPHONE HP 50
250MG STERILE POWDER 02085895
DILAUDID
3MG SUPPOSITORY 00125105
DILAUDID
MEPERIDINE HCL 50MG TABLET 02138018
DEMEROL
* 50MG/ML INJECTION SOLUTION (1ML) 00725765 00497452 02242003
MEPERIDINE HYDROCHLORIDE PETHIDINE DEMEROL
* 100MG/ML INJECTION SOLUTION (1ML) 00725749 00497479 02242005
MEPERIDINE HYDROCHLORIDE PETHIDINE DEMEROL
MORPHINE ORAL FORMS CONTAIN MORPHINE HYDROCHLORIDE OR SULFATE, INJECTABLE FORMS CONTAIN MORPHINE SULFATE.
* 5MG TABLET 00594652 02009773 02014203
STATEX MOS-SULFATE MSIR
* 10MG TABLET 00594644 00690198 02009765 02014211
STATEX M.O.S. MOS-SULFATE MSIR
* 20MG TABLET 02014238 00690201
MSIR M.O.S.
* 25MG TABLET 00594636 02009749
STATEX MOS-SULFATE
85
28:00 CENTRAL NERVOUS SYSTEM DRUGS 28:08.08 OPIATE AGONISTS (NARCOTIC ANALGESICS) 30MG TABLET 02014254
MSIR
PFR
$
0.4206
ICN
$
0.4573
PMS ICN
$
0.3744 0.3744
ICN
$
0.6349
AVT
$
0.3147
AVT
$
0.3852
RTP PMS PFR
$
0.4523 0.4523 0.6460
ABB
$
0.8173
AVT
$
0.5859
RTP PMS PFR
$
0.6828 0.6828 0.9755
ICN
$
0.5953
ABB
$
1.4940
AVT
$
1.0286
RTP PMS PFR
$
1.2037 1.2037 1.7195
ICN
$
1.0447
ABB
$
2.6218
AVT
$
2.0724
40MG TABLET 00690228
M.O.S.
* 50MG TABLET 00675962 02009706
STATEX MOS-SULFATE
60MG TABLET 00690244
M.O.S.
10MG EXTENDED-RELEASE CAPSULE 02019930
M-ESLON
15MG EXTENDED-RELEASE CAPSULE 02177749
M-ESLON
* 15MG SUSTAINED RELEASE TABLET 02244790 02245284 02015439
RATIO-MORPHINE SR PMS-MORPHINE SULFATE SR MS CONTIN
20MG SUSTAINED-RELEASE CAPSULE 02184435
KADIAN
30MG EXTENDED-RELEASE CAPSULE 02019949
M-ESLON
* 30MG SUSTAINED RELEASE TABLET 02244791 02245285 02014297
RATIO-MORPHINE SR PMS-MORPHINE SULFATE SR MS CONTIN
30MG SUSTAINED-RELEASE TABLET 00776181
M.O.S.-S.R.
50MG SUSTAINED-RELEASE CAPSULE 02184443
KADIAN
60MG EXTENDED-RELEASE CAPSULE 02019957
M-ESLON
* 60MG SUSTAINED RELEASE TABLET 02244792 02245286 02014300
RATIO-MORPHINE SR PMS-MORPHINE SULFATE SR MS CONTIN
60MG SUSTAINED-RELEASE TABLET 00776203
M.O.S.-S.R.
100MG SUSTAINED-RELEASE CAPSULE 02184451
KADIAN
100MG EXTENDED-RELEASE CAPSULE 02019965
M-ESLON
86
28:00 CENTRAL NERVOUS SYSTEM DRUGS 28:08.08 OPIATE AGONISTS (NARCOTIC ANALGESICS) 100MG SUSTAINED RELEASE TABLET 02014319
MS CONTIN
PFR
$
2.6218
AVT
$
4.1447
PFR
$
4.8739
ICN PMS RTP
$
0.0217 0.0217 0.0217
PMS RTP ICN
$
0.0873 0.0873 0.0914
ICN RTP
$
0.1995 0.1995
PMS RTP ICN
$
0.5404 0.5404 0.5686
SAB ABB
$
0.5600 0.6600
SAB ABB
$
0.5600 0.6700
SAB
$
3.3700
ABB
$
96.5700
PMS
$
1.4485
PMS PFR
$
1.6080 1.9422
PMS PFR
$
1.9020 2.3274
200MG EXTENDED-RELEASE CAPSULE 02177757
M-ESLON
200MG SUSTAINED RELEASE TABLET 02014327
MS CONTIN
* 1MG/ML ORAL SOLUTION 00486582 00591467 00607762
M.O.S. STATEX RATIO-MORPHINE
* 5MG/ML ORAL SOLUTION 00591475 00607770 00514217
STATEX RATIO-MORPHINE M.O.S.
* 10MG/ML ORAL SOLUTION 00632503 00690783
M.O.S. RATIO-MORPHINE
* 20MG/ML ORAL SOLUTION 00621935 00690791 00632481
STATEX RATIO-MORPHINE M.O.S.
* 10MG/ML INJECTION SOLUTION (1ML) 00392588 00850322
MORPHINE SO4 MORPHINE SO4
* 15MG/ML INJECTION SOLUTION (1ML) 00392561 00850330
MORPHINE SO4 MORPHINE SO4
50MG/ML INJECTION SOLUTION (1ML) 00617288
MORPHINE HP 50
50MG/ML INJECTION SOLUTION (50ML SYRINGE) 02137267
MORPHINE SULPHATE
5MG SUPPOSITORY 00632228
STATEX
* 10MG SUPPOSITORY 00632201 02014246
STATEX MSIR
* 20MG SUPPOSITORY 00596965 02014262
STATEX MSIR
87
28:00 CENTRAL NERVOUS SYSTEM DRUGS 28:08.08 OPIATE AGONISTS (NARCOTIC ANALGESICS)
* 30MG SUPPOSITORY 00639389 02014173
STATEX MSIR
PMS PFR
$
2.1125 2.5796
PFR
$
2.5823
PFR
$
3.2659
PFR
$
4.1773
PFR
$
6.4558
PFR
$
0.2561
PFR
$
0.3776
PFR
$
0.6554
PFR
$
0.8680
PFR
$
1.3020
PFR
$
2.2568
PFR
$
4.1664
30MG SUSTAINED RELEASE SUPPOSITORY 02146827
MS CONTIN
60MG SUSTAINED RELEASE SUPPOSITORY 02145944
MS CONTIN
100MG SUSTAINED RELEASE SUPPOSITORY 02145952
MS CONTIN
200MG SUSTAINED RELEASE SUPPOSITORY 02145960
MS CONTIN
OXYCODONE HCL 5MG IMMEDIATE RELEASE TABLET 02231934
OXY-IR
10MG IMMEDIATE RELEASE TABLET 02240131
OXY-IR
20MG IMMEDIATE RELEASE TABLET 02240132
OXY-IR
10MG CONTROLLED RELEASE TABLET 02202441
OXYCONTIN
20MG CONTROLLED RELEASE TABLET 02202468
OXYCONTIN
40MG CONTROLLED RELEASE TABLET 02202476
OXYCONTIN
80MG CONTROLLED RELEASE TABLET 02202484
OXYCONTIN
PROPOXYPHENE SEVERE TOXIC INTERACTION BETWEEN PROPOXYPHENE AND CENTRAL NERVOUS SYSTEM DEPRESSANTS, PARTICULARLY ALCOHOL AND DIAZEPAM, HAS BEEN NOTED. IT IS RECOMMENDED THAT ALL PRODUCTS WHICH CONTAIN PROPOXYPHENE SHOULD BE USED ONLY WITH EXTREME CAUTION AND WITH FULL PATIENT AWARENESS OF THE SERIOUS POTENTIAL FOR INTERACTION. PROPOXYPHENE NAPSYLATE 100MG IS EQUIVALENT IN ANALGESIC ACTIVITY TO PROPOXYPHENE HCL 65MG.
CAPSULE 00261432
DARVON-N
LIL
$
0.2332
LIH
$
0.1155
65MG TABLET 00010081
642
88
28:00 CENTRAL NERVOUS SYSTEM DRUGS 28:08.12 OPIATE PARTIAL AGONISTS
PENTAZOCINE 50MG TABLET 02137984
TALWIN
SAW
$
0.3708
28:08.92 MISCELLANEOUS ANALGESICS AND ANTIPYRETICS
FLOCTAFENINE * 200MG TABLET 02244680 02017628
APO-FLOCTAFENINE IDARAC
APX SAW
$
0.3151 0.3939
APX SAW
$
0.5487 0.6859
PMS
$
0.0651
PMS
$
0.0775
PMS
$
0.1050
PMS
$
0.1437
PMS
$
0.0868
APX
$
0.0516
APX DPY
$
0.0814 0.1222
* 400MG TABLET 02244681 02017636
APO-FLOCTAFENINE IDARAC
28:12.04 ANTICONVULSANTS (BARBITURATES)
PHENOBARBITAL 15MG TABLET 00178799
PMS-PHENOBARBITAL
30MG TABLET 00178802
PMS-PHENOBARBITAL
60MG TABLET 00178810
PMS-PHENOBARBITAL
100MG TABLET 00178829
PMS-PHENOBARBITAL
5MG/ML ELIXIR 00645575
PMS-PHENOBARBITAL
PRIMIDONE 125MG TABLET 00399310
APO-PRIMIDONE
* 250MG TABLET 00396761 02042355
APO-PRIMIDONE MYSOLINE
89
28:00 CENTRAL NERVOUS SYSTEM DRUGS 28:12.08 ANTICONVULSANTS (BENZODIAZEPINES)
CLONAZEPAM * 0.5MG TABLET 02130998 02224100 02103656 02173344 02177889 02207818 02230366 02230950 02233960 02237277 02239024 00382825
DOM-CLONAZEPAM DOM-CLONAZEPAM-R RATIO-CLONAZEPAM NU-CLONAZEPAM APO-CLONAZEPAM PMS-CLONAZEPAM-R CLONAPAM GEN-CLONAZEPAM RHOXAL-CLONAZEPAM MED-CLONAZEPAM NOVO-CLONAZEPAM RIVOTRIL
DOM DOM RTP NXP APX PMS ICN GPM RHO MED NOP HLR
$
0.0854 * 0.0854 * 0.1266 0.1266 0.1266 0.1266 0.1266 0.1266 0.1266 0.1266 0.1266 0.2008
PMS-CLONAZEPAM CLONAPAM RHOXAL-CLONAZEPAM
PMS ICN RHO
$
0.2019 0.2019 0.2019
DOM-CLONAZEPAM PMS-CLONAZEPAM RATIO-CLONAZEPAM NU-CLONAZEPAM APO-CLONAZEPAM CLONAPAM GEN-CLONAZEPAM RHOXAL-CLONAZEPAM MED-CLONAZEPAM NOVO-CLONAZEPAM RIVOTRIL
DOM PMS RTP NXP APX ICN GPM RHO MED NOP HLR
$
0.1790 * 0.2181 0.2181 0.2181 0.2181 0.2181 0.2181 0.2181 0.2181 0.2181 0.3462
ICN RHO ICN
$
0.0996 0.0996 0.1476
ICN RHO ICN
$
0.1490 0.1490 0.2208
* 1MG TABLET 02048728 02230368 02233982
* 2MG TABLET 02131013 02048736 02103737 02173352 02177897 02230369 02230951 02233985 02237278 02239025 00382841
NITRAZEPAM * 5MG TABLET 02229654 02234003 00511528
NITRAZADON RHOXAL-NITRAZEPAM MOGADON
* 10MG TABLET 02229655 02234007 00511536
NITRAZADON RHOXAL-NITRAZEPAM MOGADON
90
28:00 CENTRAL NERVOUS SYSTEM DRUGS 28:12.12 ANTICONVULSANTS (HYDANTOINS)
PHENYTOIN 30MG CAPSULE 00022772
DILANTIN
PFI
$
0.0540
PFI
$
0.0674
PFI
$
0.0740
PFI
$
0.0408
PFI
$
0.0482
PFI
$
0.3051
PFI
$
0.0610
PFI
$
0.3375
$
0.0929 0.1327
100MG CAPSULE 00022780
DILANTIN
50MG TABLET 00023698
DILANTIN
6MG/ML ORAL SUSPENSION 00023442
DILANTIN
25MG/ML ORAL SUSPENSION 00023450
DILANTIN
28:12.20 ANTICONVULSANTS (SUCCINIMIDES)
ETHOSUXIMIDE 250MG CAPSULE 00022799
ZARONTIN
50MG/ML ORAL SYRUP 00023485
ZARONTIN
METHSUXIMIDE 300MG CAPSULE 00022802
CELONTIN
28:12.92 MISCELLANEOUS ANTICONVULSANTS
CARBAMAZEPINE SEE APPENDIX A FOR EDS CRITERIA
* 100MG CHEWABLE TABLET 02244403 00369810
TARO-CARBAMAZEPINE TEGRETOL
91
TAR NVR
28:00 CENTRAL NERVOUS SYSTEM DRUGS 28:12.92 MISCELLANEOUS ANTICONVULSANTS
* 200MG TABLET 02042568 00402699 00782718 00010405
NU-CARBAMAZEPINE APO-CARBAMAZEPINE NOVO-CARBAMAZ TEGRETOL
NXP APX NOP NVR
$
0.0692 * 0.0863 0.0863 0.3164
PMS TAR GPM APX DOM NVR
$
0.2048 0.2048 0.2048 0.2048 0.2560 0.3251
PMS GPM APX TAR DOM NVR
$
0.4095 0.4095 0.4095 0.4096 0.5121 0.6502
NVR
$
0.0628
NOP RTP APX AVT
$
0.2598 0.2598 0.2598 0.3708
NXP APX NOP PMS DOM ABB
$
0.1660 0.1660 0.1660 0.1660 0.1744 0.2372
NXP APX NOP PMS DOM ABB
$
0.2984 0.2984 0.2984 0.2984 0.3134 0.4262
* 200MG CONTROLLED RELEASE TABLET 02231543 02237907 02241882 02242908 02238222 00773611
PMS-CARBAMAZEPINE CR(EDS) TARO-CARBAMAZEPINE (EDS) GEN-CARBAMAZEPINE CR(EDS) APO-CARBAMAZEPINE CR(EDS) DOM-CARBAMAZEPINE CR(EDS) TEGRETOL CR (EDS)
* 400MG CONTROLLED RELEASE TABLET 02231544 02241883 02242909 02237908 02238223 00755583
PMS-CARBAMAZEPINE CR(EDS) GEN-CARBAMAZEPINE CR(EDS) APO-CARBAMAZEPINE CR(EDS) TARO-CARBAMAZEPINE (EDS) DOM-CARBAMAZEPINE CR(EDS) TEGRETOL CR (EDS)
20MG/ML ORAL SUSPENSION 02194333
TEGRETOL
CLOBAZAM * 10MG TABLET 02238334 02238797 02244638 02221799
NOVO-CLOBAZAM RATIO-CLOBAZAM APO-CLOBAZAM FRISIUM
DIVALPROEX SODIUM * 125MG ENTERIC COATED TABLET 02239517 02239698 02239701 02244138 02245751 00596418
NU-DIVALPROEX APO-DIVALPROEX NOVO-DIVALPROEX PMS-DIVALPROEX DOM-DIVALPROEX EPIVAL
* 250MG ENTERIC COATED TABLET 02239518 02239699 02239702 02244139 02245752 00596426
NU-DIVALPROEX APO-DIVALPROEX NOVO-DIVALPROEX PMS-DIVALPROEX DOM-DIVALPOREX EPIVAL
92
28:00 CENTRAL NERVOUS SYSTEM DRUGS 28:12.92 MISCELLANEOUS ANTICONVULSANTS
* 500MG ENTERIC COATED TABLET 02239519 02239700 02239703 02244140 02245753 00596434
NU-DIVALPROEX APO-DIVALPROEX NOVO-DIVALPROEX PMS-DIVALPROEX DOM-DIVALPROEX EPIVAL
NXP APX NOP PMS DOM ABB
$
0.5971 0.5971 0.5971 0.5971 0.6270 0.8530
PMS APX NOP DOM PFI
$
0.3038 0.3038 0.3038 0.3190 0.4340
PMS APX NOP DOM PFI
$
0.7390 0.7390 0.7390 0.7760 1.0557
PMS APX NOP DOM PFI
$
0.8807 0.8807 0.8807 0.9248 1.2581
GSK
$
0.1551
APX GSK
$
0.2519 0.3597
APX GSK
$
1.0071 1.4388
APX GSK
$
1.5107 2.1581
GABAPENTIN * 100MG CAPSULE 02243446 02244304 02244513 02243743 02084260
PMS-GABAPENTIN APO-GABAPENTIN NOVO-GABAPENTIN DOM-GABAPENTIN NEURONTIN
* 300MG CAPSULE 02243447 02244305 02244514 02243744 02084279
PMS-GABAPENTIN APO-GABAPENTIN NOVO-GABAPENTIN DOM-GABAPENTIN NEURONTIN
* 400MG CAPSULE 02243448 02244306 02244515 02243745 02084287
PMS-GABAPENTIN APO-GABAPENTIN NOVO-GABAPENTIN DOM-GABAPENTIN NEURONTIN
LAMOTRIGINE 5MG CHEWABLE TABLET 02240115
LAMICTAL
* 25MG TABLET 02245208 02142082
APO-LAMOTRIGINE LAMICTAL
* 100MG TABLET 02245209 02142104
APO-LAMOTRIGINE LAMICTAL
* 150MG TABLET 02245210 02142112
APO-LAMOTRIGINE LAMICTAL
93
28:00 CENTRAL NERVOUS SYSTEM DRUGS 28:12.92 MISCELLANEOUS ANTICONVULSANTS
TOPIRAMATE 25MG TABLET 02230893
TOPAMAX
JAN
$
1.1393
JAN
$
2.1592
JAN
$
3.4178
JAN
$
1.0850
JAN
$
1.1393
DOM RTP PMS RTP APX ABB
$
0.0595 0.0626 0.0626 0.0626 0.0628 0.0995
DOM NOP RTP GPM MED PMS NXP APX RHO ABB
$
0.2328 * 0.2804 0.2804 0.2804 0.2804 0.2804 0.2804 0.2804 0.2804 0.4475
RTP NOP PMS RHO ABB
$
0.5639 0.5639 0.5639 0.5639 0.8951
100MG TABLET 02230894
TOPAMAX
200MG TABLET 02230896
TOPAMAX
15MG SPRINKLE CAPSULE 02239907
TOPAMAX
25MG SPRINKLE CAPSULE 02239908
TOPAMAX
VALPROATE SODIUM * 50MG/ML ORAL SYRUP 02238817 02140063 02236807 02238042 02238370 00443832
DOM-VALPROIC ACID RATIO-VALPROIC PMS-VALPROIC ACID RATIO-DEPROIC APO-VALPROIC DEPAKENE
VALPROIC ACID * 250MG CAPSULE 02231030 02100630 02140047 02184648 02230663 02230768 02237830 02238048 02239714 00443840
DOM-VALPROIC ACID NOVO-VALPROIC RATIO-VALPROIC GEN-VALPROIC MED-VALPROIC PMS-VALPROIC NU-VALPROIC APO-VALPROIC RHOXAL-VALPROIC DEPAKENE
* 500MG ENTERIC COATED CAPSULE 02140055 02218321 02229628 02239713 00507989
RATIO-VALPROIC NOVO-VALPROIC PMS-VALPROIC ACID E.C. RHOXAL-VALPROIC DEPAKENE
94
28:00 CENTRAL NERVOUS SYSTEM DRUGS 28:12.92 MISCELLANEOUS ANTICONVULSANTS
VIGABATRIN 500MG TABLET 02065819
SABRIL
AVT
$
0.9624
AVT
$
0.9624
500MG SACHET 02068036
SABRIL
28:16.04 PSYCHOTHERAPEUTIC AGENTS (ANTIDEPRESSANTS) PHENELZINE AND TRANYLCYPROMINE: MONOAMINE OXIDASE INHIBITORS INTERACT WITH SYMPATHOMIMETIC DRUGS, FOODS AND ALCOHOLIC BEVERAGES CONTAINING TYRAMINE OR OTHER PRESSOR AMINES (EG. CHEESE, HERRING, CHICKEN LIVERS, BROAD BEANS, CHIANTI WINE, ETC.) AND MAY EVOKE HYPERTENSION. THESE DRUGS ARE CONTRAINDICATED IN PATIENTS WITH CEREBROVASCULAR AND CARDIOVASCULAR DISEASE. THE MANUFACTURERS' LITERATURE REGARDING PRECAUTIONS AND CONTRAINDICATIONS SHOULD BE CONSULTED PRIOR TO PRESCRIBING THESE DRUGS.
AMITRIPTYLINE * 10MG TABLET 00335053 00016322
APO-AMITRIPTYLINE ELAVIL
APX MSD
$
0.0565 0.0787
APX MSD
$
0.1080 0.1500
APX MSD
$
0.2008 0.2785
GSK
$
0.5788
GSK
$
0.8680
LUD
$
1.3563
LUD
$
1.3563
* 25MG TABLET 00335061 00016330
APO-AMITRIPTYLINE ELAVIL
* 50MG TABLET 00335088 00016349
APO-AMITRIPTYLINE ELAVIL
BUPROPION HCL SEE APPENDIX A FOR EDS CRITERIA
100MG TABLET 02237824
WELLBUTRIN SR (EDS)
150MG TABLET 02237825
WELLBUTRIN SR (EDS)
CITALOPRAM HYDROBROMIDE 20MG TABLET 02239607
CELEXA
40MG TABLET 02239608
CELEXA
95
28:00 CENTRAL NERVOUS SYSTEM DRUGS 28:16.04 PSYCHOTHERAPEUTIC AGENTS (ANTIDEPRESSANTS)
CLOMIPRAMINE HCL * 10MG TABLET 02040786 02139340 02188996 02230256 00330566
APO-CLOMIPRAMINE GEN-CLOMIPRAMINE MED-CLOMIPRAMINE NOVO-CLOPAMINE ANAFRANIL
APX GPM MED NOP NVR
$
0.1765 0.1765 0.1765 0.1765 0.2801
APX NOP GPM MED NVR
$
0.2404 0.2404 0.2404 0.2404 0.3815
APX NOP GPM MED NVR
$
0.4425 0.4425 0.4425 0.4425 0.7025
PMS NXP APX NOP DOM
$
0.2067 0.2067 0.2067 0.2067 0.2395
DOM PMS RTP NXP APX NOP AVT
$
0.2266 * 0.2761 0.2761 0.2761 0.2761 0.2761 0.3752
* 25MG TABLET 02040778 02130165 02139359 02189003 00324019
APO-CLOMIPRAMINE NOVO-CLOPAMINE GEN-CLOMIPRAMINE MED-CLOMIPRAMINE ANAFRANIL
* 50MG TABLET 02040751 02130173 02139367 02189011 00402591
APO-CLOMIPRAMINE NOVO-CLOPAMINE GEN-CLOMIPRAMINE MED-CLOMIPRAMINE ANAFRANIL
DESIPRAMINE HCL * 10MG TABLET 01946250 02211939 02216248 02223341 02130084
PMS-DESIPRAMINE NU-DESIPRAMINE APO-DESIPRAMINE NOVO-DESIPRAMINE DOM-DESIPRAMINE
* 25MG TABLET 02130092 01946269 01948784 02211947 02216256 02223325 02099128
DOM-DESIPRAMINE PMS-DESIPRAMINE RATIO-DESIPRAMINE NU-DESIPRAMINE APO-DESIPRAMINE NOVO-DESIPRAMINE NORPRAMIN
96
28:00 CENTRAL NERVOUS SYSTEM DRUGS 28:16.04 PSYCHOTHERAPEUTIC AGENTS (ANTIDEPRESSANTS)
* 50MG TABLET 02130106 01946277 01948792 02211955 02216264 02223333 02099136
DOM-DESIPRAMINE PMS-DESIPRAMINE RATIO-DESIPRAMINE NU-DESIPRAMINE APO-DESIPRAMINE NOVO-DESIPRAMINE NORPRAMIN
DOM PMS RTP NXP APX NOP AVT
$
0.3660 * 0.4460 0.4460 0.4460 0.4460 0.4460 0.6615
PMS RTP NXP APX NOP
$
0.6873 0.6873 0.6873 0.6873 0.6873
NXP APX
$
0.9342 0.9342
APX PFI
$
0.1286 0.2696
NOP APX PFI
$
0.1552 0.1552 0.3306
NOP APX PFI
$
0.2418 0.2418 0.6134
NOP APX RTP PFI
$
0.5180 0.5180 0.5180 0.8806
NOP APX PFI
$
0.6803 0.6803 1.1601
NOP APX
$
1.0280 1.0280
* 75MG TABLET 01946242 01948806 02211963 02216272 02223368
PMS-DESIPRAMINE RATIO-DESIPRAMINE NU-DESIPRAMINE APO-DESIPRAMINE NOVO-DESIPRAMINE
* 100MG TABLET 02211971 02216280
NU-DESIPRAMINE APO-DESIPRAMINE
DOXEPIN HCL * 10MG CAPSULE 02049996 00024325
APO-DOXEPIN SINEQUAN
* 25MG CAPSULE 01913425 02050005 00024333
NOVO-DOXEPIN APO-DOXEPIN SINEQUAN
* 50MG CAPSULE 01913433 02050013 00024341
NOVO-DOXEPIN APO-DOXEPIN SINEQUAN
* 75MG CAPSULE 01913441 02050021 02140128 00400750
NOVO-DOXEPIN APO-DOXEPIN RATIO-DOXEPIN SINEQUAN
* 100MG CAPSULE 01913468 02050048 00326925
NOVO-DOXEPIN APO-DOXEPIN SINEQUAN
* 150MG CAPSULE 01913476 02050056
NOVO-DOXEPIN APO-DOXEPIN
97
28:00 CENTRAL NERVOUS SYSTEM DRUGS 28:16.04 PSYCHOTHERAPEUTIC AGENTS (ANTIDEPRESSANTS)
FLUOXETINE * 10MG CAPSULE 02177617 02177579 02192756 02216353 02216582 02237813 02239751 02241371 02242177 02243486 02018985
DOM-FLUOXETINE PMS-FLUOXETINE NU-FLUOXETINE APO-FLUOXETINE NOVO-FLUOXETINE GEN-FLUOXETINE MED FLUOXETINE RATIO-FLUOXETINE CO FLUOXETINE RHOXAL-FLUOXETINE PROZAC
DOM PMS NXP APX NOP GPM MED RTP COB RHO LIL
$
1.0234 * 1.2774 1.2774 1.2774 1.2774 1.2774 1.2774 1.2774 1.2774 1.2774 1.7035
NXP PMS APX NOP GPM MED RTP COB RHO DOM LIL
$
0.8162 * 1.0972 1.0972 1.0972 1.0972 1.0972 1.0972 1.0972 1.0972 1.4802 1.7415
PMS APX LIL
$
0.5019 0.5019 0.6692
NXP RTP APX NOP PMS DOM SLV
$
0.4305 * 0.5373 0.5373 0.5373 0.5373 0.5641 0.8529
* 20MG CAPSULE 02192764 02177587 02216361 02216590 02237814 02239752 02241374 02242178 02243487 02177625 00636622
NU-FLUOXETINE PMS-FLUOXETINE APO-FLUOXETINE NOVO-FLUOXETINE GEN-FLUOXETINE MED FLUOXETINE RATIO-FLUOXETINE CO FLUOXETINE RHOXAL-FLUOXETINE DOM-FLUOXETINE PROZAC
* 4MG/ML ORAL SOLUTION 02177595 02231328 01917021
PMS-FLUOXETINE APO-FLUOXETINE PROZAC
FLUVOXAMINE MALEATE * 50MG TABLET 02231192 02218453 02231329 02239953 02240682 02241347 01919342
NU-FLUVOXAMINE RATIO-FLUVOXAMINE APO-FLUVOXAMINE NOVO-FLUVOXAMINE PMS-FLUVOXAMINE DOM-FLUVOXAMINE LUVOX
98
28:00 CENTRAL NERVOUS SYSTEM DRUGS 28:16.04 PSYCHOTHERAPEUTIC AGENTS (ANTIDEPRESSANTS)
* 100MG TABLET 02231193 02218461 02231330 02239954 02240683 02241348 01919369
NU-FLUVOXAMINE RATIO-FLUVOXAMINE APO-FLUVOXAMINE NOVO-FLUVOXAMINE PMS-FLUVOXAMINE DOM-FLUVOXAMINE LUVOX
NXP RTP APX NOP PMS DOM SLV
$
0.7738 * 0.9659 0.9659 0.9659 0.9659 1.0142 1.5331
APX
$
0.1126
APX NVR
$
0.1791 0.2485
APX NVR
$
0.3326 0.4619
NOP
$
0.1644
NOP
$
0.2241
NOP
$
0.4243
NOP
$
0.5794
ORG
$
1.3454
APX NXP NOP
$
0.2735 0.2735 0.2735
IMIPRAMINE 10MG TABLET 00360201
APO-IMIPRAMINE
* 25MG TABLET 00312797 00010472
APO-IMIPRAMINE TOFRANIL
* 50MG TABLET 00326852 00010480
APO-IMIPRAMINE TOFRANIL
MAPROTILINE 10MG TABLET 02158604
NOVO-MAPROTILINE
25MG TABLET 02158612
NOVO-MAPROTILINE
50MG TABLET 02158620
NOVO-MAPROTILINE
75MG TABLET 02158639
NOVO-MAPROTILINE
MIRTAZAPINE 30MG TABLET 02243910
REMERON
MOCLOBEMIDE * 100MG TABLET 02232148 02237111 02239746
APO-MOCLOBEMIDE NU-MOCLOBEMIDE NOVO-MOCLOBEMIDE
99
28:00 CENTRAL NERVOUS SYSTEM DRUGS 28:16.04 PSYCHOTHERAPEUTIC AGENTS (ANTIDEPRESSANTS)
* 150MG TABLET 02237112 02218410 02232150 02239747 02243218 02243348 00899356
NU-MOCLOBEMIDE RATIO-MOCLOBEMIDE APO-MOCLOBEMIDE NOVO-MOCLOBEMIDE PMS-MOCLOBEMIDE DOM-MOCLOBEMIDE MANERIX
NXP RTP APX NOP PMS DOM HLR
$
0.3176 * 0.3965 0.3965 0.3965 0.3965 0.4164 0.6444
NOP APX PMS DOM HLR
$
0.7786 0.7786 0.7786 0.9084 1.2655
APX PMS GPM LIN DOM
$
0.5570 0.5570 0.5570 0.5571 0.5849
DOM PMS LIN APX GPM BMY
$
0.4809 * 0.6076 0.6076 0.6076 0.6076 0.8680
DOM PMS LIN APX GPM BMY
$
0.4809 * 0.6076 0.6076 0.6076 0.6076 0.8680
DOM PMS APX GPM LIN BMY
$
0.5610 * 0.7089 0.7089 0.7089 0.7090 1.0128
* 300MG TABLET 02239748 02240456 02243219 02243349 02166747
NOVO-MOCLOBEMIDE APO-MOCLOBEMIDE PMS-MOCLOBEMIDE DOM-MOCLOBEMIDE MANERIX
NEFAZODONE * 50MG TABLET 02242822 02245101 02245202 02237397 02245754
APO-NEFAZODONE PMS-NEFAZODONE GEN-NEFAZODONE LIN-NEFAZODONE DOM-NEFAZODONE
* 100MG TABLET 02245755 02245102 02237398 02242823 02245203 02087375
DOM-NEFAZODONE PMS-NEFAZODONE LIN-NEFAZODONE APO-NEFAZODONE GEN-NEFAZODONE SERZONE
* 150MG TABLET 02245756 02245103 02237399 02242824 02245204 02087383
DOM-NEFAZODONE PMS-NEFAZODONE LIN-NEFAZODONE APO-NEFAZODONE GEN-NEFAZODONE SERZONE
* 200MG TABLET 02245757 02245111 02242825 02245205 02237400 02087391
DOM-NEFAZODONE PMS-NEFAZODONE APO-NEFAZODONE GEN-NEFAZODONE LIN-NEFAZODONE SERZONE
100
28:00 CENTRAL NERVOUS SYSTEM DRUGS 28:16.04 PSYCHOTHERAPEUTIC AGENTS (ANTIDEPRESSANTS)
NORTRIPTYLINE * 10MG CAPSULE 02223139 02177692 02223511 02231686 02231781 02240789 02178729 00015229
NU-NORTRIPTYLINE PMS-NORTRIPTYLINE APO-NORTRIPTYLINE GEN-NORTRIPTYLINE NOVO-NORTRIPTYLINE RATIO-NORTRIPTYLINE DOM-NORTRIPTYLINE AVENTYL
NXP PMS APX GPM NOP RTP DOM PMS
$
0.1095 * 0.1368 0.1368 0.1368 0.1368 0.1368 0.1709 0.2170
NXP NOP PMS APX GPM RTP DOM PMS
$
0.2215 * 0.2763 0.2764 0.2764 0.2764 0.2764 0.3455 0.4387
GSK
$
1.7771
GSK
$
1.8884
PFI
$
0.3633
* 25MG CAPSULE 02223147 02231782 02177706 02223538 02231687 02240790 02178737 00015237
NU-NORTRIPTYLINE NOVO-NORTRIPTYLINE PMS-NORTRIPTYLINE APO-NORTRIPTYLINE GEN-NORTRIPTYLINE RATIO-NORTRIPTYLINE DOM-NORTRIPTYLINE AVENTYL
PAROXETINE HCL 20MG TABLET 01940481
PAXIL
30MG TABLET 01940473
PAXIL
PHENELZINE SO4 SEE NOTE REGARDING MONOAMINE OXIDASE INHIBITORS UNDER SECTION 28:16.04
15MG TABLET 00476552
NARDIL
101
28:00 CENTRAL NERVOUS SYSTEM DRUGS 28:16.04 PSYCHOTHERAPEUTIC AGENTS (ANTIDEPRESSANTS)
SERTRALINE HYDROCHLORIDE * 25MG CAPSULE 02245748 02245159 02238280 02240485 02242519 02244838 02245787 02132702
DOM-SERTRALINE RHOXAL-SERTRALINE APO-SERTRALINE NOVO-SERTRALINE GEN-SERTRALINE PMS-SERTRALINE RATIO-SERTRALINE ZOLOFT
DOM RHO APX NOP GPM PMS RTP PFI
$
0.4327 * 0.5469 0.5469 0.5469 0.5469 0.5469 0.5469 0.9060
DOM APX NOP GPM PMS RHO RTP PFI
$
0.8655 * 1.0937 1.0937 1.0937 1.0937 1.0937 1.0937 1.8120
DOM APX NOP GPM PMS RHO RTP PFI
$
0.9466 * 1.1963 1.1963 1.1963 1.1963 1.1963 1.1963 1.8988
GSK
$
0.3734
NXP BRI PMS RTP NOP APX ICN GPM DOM
$
0.1924 * 0.2403 0.2403 0.2403 0.2403 0.2403 0.2403 0.2403 0.2792
* 50MG CAPSULE 02245749 02238281 02240484 02242520 02244839 02245160 02245788 01962817
DOM-SERTRALINE APO-SERTRALINE NOVO-SERTRALINE GEN-SERTRALINE PMS-SERTRALINE RHOXAL-SERTRALINE RATIO-SERTRALINE ZOLOFT
* 100MG CAPSULE 02245750 02238282 02240481 02242521 02244840 02245161 02245789 01962779
DOM-SERTRALINE APO-SERTRALINE NOVO-SERTRALINE GEN-SERTRALINE PMS-SERTRALINE RHOXAL-SERTRALINE RATIO-SERTRALINE ZOLOFT
TRANYLCYPROMINE SO4 SEE NOTE REGARDING MONOAMINE OXIDASE INHIBITORS UNDER SECTION 28:16.04
10MG TABLET 01919598
PARNATE
TRAZODONE * 50MG TABLET 02165384 00579351 01937227 02053187 02144263 02147637 02230284 02231683 02128950
NU-TRAZODONE DESYREL PMS-TRAZODONE RATIO-TRAZODONE NOVO-TRAZODONE APO-TRAZODONE TRAZOREL GEN-TRAZODONE DOM-TRAZODONE 102
28:00 CENTRAL NERVOUS SYSTEM DRUGS 28:16.04 PSYCHOTHERAPEUTIC AGENTS (ANTIDEPRESSANTS)
* 100MG TABLET 02165392 02147645 00579378 01937235 02053195 02144271 02230285 02231684 02128969
NU-TRAZODONE APO-TRAZODONE DESYREL PMS-TRAZODONE RATIO-TRAZODONE NOVO-TRAZODONE TRAZOREL GEN-TRAZODONE DOM-TRAZODONE
NXP APX BRI PMS RTP NOP ICN GPM DOM
$
0.3439 * 0.4293 0.4293 0.4293 0.4293 0.4293 0.4293 0.4293 0.5093
APX AVT
$
0.5639 0.8354
APX ROP NXP AVT
$
0.0890 0.0890 0.0890 0.2462
APX ROP NOP NXP AVT
$
0.1129 0.1129 0.1129 0.1129 0.3171
APX ROP NOP NXP
$
0.2169 0.2169 0.2169 0.2169
APX ROP NOP NXP AVT
$
0.3709 0.3709 0.3709 0.3709 1.0591
TRIMIPRAMINE * 75MG CAPSULE 02070987 01926349
APO-TRIMIP SURMONTIL
* 12.5MG TABLET 00740799 00761605 02020599 01926357
APO-TRIMIP RHOTRIMINE NU-TRIMIPRAMINE SURMONTIL
* 25MG TABLET 00740802 00761613 01940430 02020602 01926322
APO-TRIMIP RHOTRIMINE NOVO-TRIPRAMINE NU-TRIMIPRAMINE SURMONTIL
* 50MG TABLET 00740810 00761621 01940449 02020610
APO-TRIMIP RHOTRIMINE NOVO-TRIPRAMINE NU-TRIMIPRAMINE
* 100MG TABLET 00740829 00761648 01940457 02020629 01926284
APO-TRIMIP RHOTRIMINE NOVO-TRIPRAMINE NU-TRIMIPRAMINE SURMONTIL
103
28:00 CENTRAL NERVOUS SYSTEM DRUGS 28:16.04 PSYCHOTHERAPEUTIC AGENTS (ANTIDEPRESSANTS)
VENLAFAXINE HCL 37.5MG TABLET 02103680
EFFEXOR
WYA
$
0.8463
WYA
$
1.6926
WYA
$
0.8463
WYA
$
1.6926
WYA
$
1.7903
NOP
$
0.0174
NOP
$
0.0364
NOP
$
0.0416
NOP
$
0.0695
RHO
$
0.0259
RHO
$
0.0376
RTP RHO
$
0.2932 0.2932
SAB RHO
$
1.0600 1.0600
NVR
$
1.0221
NVR
$
4.0780
75MG TABLET 02103702
EFFEXOR
37.5MG EXTENDED-RELEASE CAPSULE 02237279
EFFEXOR XR
75MG EXTENDED-RELEASE CAPSULE 02237280
EFFEXOR XR
150MG EXTENDED-RELEASE CAPSULE 02237282
EFFEXOR XR
28:16.08 PSYCHOTHERAPEUTIC AGENTS (ANTIPSYCHOTIC AGENTS) CHLORPROMAZINE 10MG TABLET 00232157
NOVO-CHLORPROMAZINE
25MG TABLET 00232823
NOVO-CHLORPROMAZINE
50MG TABLET 00232807
NOVO-CHLORPROMAZINE
100MG TABLET 00232831
NOVO-CHLORPROMAZINE
5MG/ML ORAL SOLUTION 01929968
LARGACTIL
20MG/ML ORAL SOLUTION 01929976
LARGACTIL
* 40MG/ML ORAL SOLUTION 00690805 01929992
RATIO-CHLORPROMANYL-40 LARGACTIL
* 25MG/ML INJECTION SOLUTION (2ML) 00743518 01929984
CHLORPROMAZINE LARGACTIL
CLOZAPINE SEE APPENDIX A FOR EDS CRITERIA
25MG TABLET 00894737
CLOZARIL (EDS)
100MG TABLET 00894745
CLOZARIL (EDS)
104
28:00 CENTRAL NERVOUS SYSTEM DRUGS 28:16.08 PSYCHOTHERAPEUTIC AGENTS (ANTIPSYCHOTIC AGENTS)
FLUPENTHIXOL DECANOATE 20MG/ML INJECTION SOLUTION (10ML) 02156032
FLUANXOL DEPOT
LUD
$
73.1900
LUD
$
73.1900
FLUANXOL
LUD
$
0.2528
FLUANXOL
LUD
$
0.5461
SQU PMS APX
$
25.1300 25.1300 25.1300
SQU PMS
$
32.3200 32.3200
SQU
$
47.2600
APO-FLUPHENAZINE
APX
$
0.1823
APO-FLUPHENAZINE
APX
$
0.2214
APO-FLUPHENAZINE
APX
$
0.2735
SQU
$
0.9559
100MG/ML INJECTION SOLUTION (2ML) 02156040
FLUANXOL DEPOT
FLUPENTHIXOL DIHYDROCHLORIDE 0.5MG TABLET 02156008
3MG TABLET 02156016
FLUPHENAZINE DECANOATE * 25MG/ML INJECTION SOLUTION (5ML) 00349917 02091275 02244166
MODECATE PMS-FLUPHENAZINE DECAN. APO-FLUPHENAZINE
* 100MG/ML INJECTION SOLUTION (1ML) 00755575 02241928
MODECATE CONCENTRATE PMS-FLUPHENAZINE DECAN.
FLUPHENAZINE ENANTHATE 25MG/ML INJECTION SOLUTION (5ML) 00029173
MODITEN ENANTHATE
FLUPHENAZINE HCL 1MG TABLET 00405345
2MG TABLET 00410632
5MG TABLET 00405361
10MG TABLET 00582514
MODITEN
105
28:00 CENTRAL NERVOUS SYSTEM DRUGS 28:16.08 PSYCHOTHERAPEUTIC AGENTS (ANTIPSYCHOTIC AGENTS)
HALOPERIDOL * 0.5MG TABLET 00363685 00396796 00552135
NOVO-PERIDOL APO-HALOPERIDOL RATIO-HALOPERIDOL
NOP APX RTP
$
0.0391 0.0391 0.0391
NOVO-PERIDOL APO-HALOPERIDOL RATIO-HALOPERIDOL
NOP APX RTP
$
0.0667 0.0667 0.0667
NOVO-PERIDOL APO-HALOPERIDOL
NOP APX
$
0.1140 0.1140
NOVO-PERIDOL APO-HALOPERIDOL RATIO-HALOPERIDOL
NOP APX RTP
$
0.1614 0.1614 0.1614
APX NOP
$
0.1443 0.1443
RTP PMS APX
$
0.1165 0.1165 0.1274
SAB
$
3.5700
SAB ROP NOP APX
$
30.4200 30.4200 30.4200 30.4200
SAB ROP APX NOP
$
60.1100 60.1100 60.1100 60.1100
* 1MG TABLET 00363677 00396818 00552143
* 2MG TABLET 00363669 00396826
* 5MG TABLET 00363650 00396834 00647969
* 10MG TABLET 00463698 00713449
APO-HALOPERIDOL NOVO-PERIDOL
* 2MG/ML ORAL SOLUTION 00552429 00759503 00587702
RATIO-HALOPERIDOL PMS-HALOPERIDOL APO-HALOPERIDOL
5MG/ML INJECTION SOLUTION (1ML) 00808652
HALOPERIDOL
HALOPERIDOL DECANOATE * 50MG/ML INJECTION SOLUTION (5ML) 02130297 02211130 02236866 02242361
HALOPERIDOL LA RHO-HALOPERIDOL HALOPERIDOL LONG ACTING APO-HALOPERIDOL LA
* 100MG/ML INJECTION SOLUTION (5ML) 02130300 02211149 02242362 02242631
HALOPERIDOL LA RHO-HALOPERIDOL APO-HALOPERIDOL LA HALOPERIDOL LONG ACTING
106
28:00 CENTRAL NERVOUS SYSTEM DRUGS 28:16.08 PSYCHOTHERAPEUTIC AGENTS (ANTIPSYCHOTIC AGENTS)
LOXAPINE SUCCINATE * 5MG TABLET 02230837 02237534 02237651 02239918
PMS-LOXAPINE NU-LOXAPINE APO-LOXAPINE DOM-LOXAPINE
PMS NXP APX DOM
$
0.1628 0.1628 0.1628 0.1709
PMS NXP APX DOM
$
0.2711 0.2711 0.2711 0.2846
PMS NXP APX DOM
$
0.4202 0.4202 0.4202 0.4412
PMS NXP APX DOM
$
0.5601 0.5601 0.5601 0.5881
ZYPREXA (EDS)
LIL
$
1.8310
ZYPREXA (EDS)
LIL
$
3.6619
LIL
$
5.4929
LIL
$
7.2500
LIL
$
10.6250
LIL
$
3.6619
LIL
$
7.3238
* 10MG TABLET 02230838 02237535 02237652 02239919
PMS-LOXAPINE NU-LOXAPINE APO-LOXAPINE DOM-LOXAPINE
* 25MG TABLET 02230839 02237536 02237653 02239920
PMS-LOXAPINE NU-LOXAPINE APO-LOXAPINE DOM-LOXAPINE
* 50MG TABLET 02230840 02237537 02237654 02239921
PMS-LOXAPINE NU-LOXAPINE APO-LOXAPINE DOM-LOXAPINE
OLANZAPINE SEE APPENDIX A FOR EDS CRITERIA
2.5MG TABLET 02229250
5MG TABLET 02229269
7.5MG TABLET 02229277
ZYPREXA (EDS)
10MG TABLET 02229285
ZYPREXA (EDS)
15MG TABLET 02238850
ZYPREXA (EDS)
5MG ORALLY DISINTEGRATING TABLET 02243086
ZYPREXA ZYDIS (EDS)
10MG ORALLY DISINTEGRATING TABLET 02243087
ZYPREXA ZYDIS (EDS)
107
28:00 CENTRAL NERVOUS SYSTEM DRUGS 28:16.08 PSYCHOTHERAPEUTIC AGENTS (ANTIPSYCHOTIC AGENTS)
PERICYAZINE 5MG CAPSULE 01926780
NEULEPTIL
AVT
$
0.1817
AVT
$
0.4413
AVT
$
0.3076
APO-PERPHENAZINE
APX
$
0.0239
APO-PERPHENAZINE
APX
$
0.0348
APO-PERPHENAZINE
APX
$
0.0456
APO-PERPHENAZINE
APX
$
0.0565
ORAP
PMS
$
0.3851
ORAP
PMS
$
0.6988
AVT
$
13.1800
AVT
$
42.4300
APX RHO NXP
$
0.1145 0.1145 0.1145
APX RHO NXP
$
0.1400 0.1400 0.1400
20MG CAPSULE 01926764
NEULEPTIL
10MG/ML ORAL DROPS 01926756
NEULEPTIL
PERPHENAZINE 2MG TABLET 00335134
4MG TABLET 00335126
8MG TABLET 00335118
16MG TABLET 00335096
PIMOZIDE 2MG TABLET 00313815
4MG TABLET 00313823
PIPOTIAZINE PALMITATE 25MG/ML INJECTION SOLUTION (1ML) 01926667
PIPORTIL L4
50MG/ML INJECTION SOLUTION (2ML) 01926675
PIPORTIL L4
PROCHLORPERAZINE * 5MG TABLET 00886440 01927752 01964399
APO-PROCHLORAZINE STEMETIL NU-PROCHLOR
* 10MG TABLET 00886432 01927760 01964402
APO-PROCHLORAZINE STEMETIL NU-PROCHLOR
108
28:00 CENTRAL NERVOUS SYSTEM DRUGS 28:16.08 PSYCHOTHERAPEUTIC AGENTS (ANTIPSYCHOTIC AGENTS) 1MG/ML ORAL SOLUTION 01927787
STEMETIL
RHO
$
0.0552
SAB RHO
$
1.0800 1.0800
RHO
$
0.9006
AST
$
0.5208
AST
$
1.3888
AST
$
2.1483
AST
$
2.7885
AST
$
4.0500
JAN
$
0.4842
RISPERDAL
JAN
$
0.8108
RISPERDAL
JAN
$
1.1198
RISPERDAL
JAN
$
2.2357
RISPERDAL
JAN
$
3.3534
RISPERDAL
JAN
$
4.4712
JAN
$
1.2876
* 5MG/ML INJECTION SOLUTION (2ML) 00789747 01927779
PROCHLORPERAZINE MESYLATE STEMETIL
10MG SUPPOSITORY 01927795
STEMETIL
QUETIAPINE SEE APPENDIX A FOR EDS CRITERIA
25MG TABLET 02236951
SEROQUEL (EDS)
100MG TABLET 02236952
SEROQUEL (EDS)
150MG TABLET 02240862
SEROQUEL (EDS)
200MG TABLET 02236953
SEROQUEL (EDS)
300MG TABLET 02244107
SEROQUEL (EDS)
RISPERIDONE 0.25MG TABLET 02240551
RISPERDAL
0.5MG TABLET 02240552
1MG TABLET 02025280
2MG TABLET 02025299
3MG TABLET 02025302
4MG TABLET 02025310
1MG/ML ORAL SOLUTION 02236950
RISPERDAL
109
28:00 CENTRAL NERVOUS SYSTEM DRUGS 28:16.08 PSYCHOTHERAPEUTIC AGENTS (ANTIPSYCHOTIC AGENTS)
THIORIDAZINE 10MG TABLET 00360228
APO-THIORIDAZINE
APX
$
0.0923
APX
$
0.1107
APX
$
0.1313
APX
$
0.2577
PMS
$
0.1133
PFI
$
0.2089
PFI
$
0.3591
PFI
$
0.4623
APO-TRIFLUOPERAZINE
APX
$
0.1102
APO-TRIFLUOPERAZINE
APX
$
0.1443
APO-TRIFLUOPERAZINE
APX
$
0.1915
APX
$
0.2295
PMS
$
0.2700
LUD
$
15.1900
LUD
$
151.9000
25MG TABLET 00360198
APO-THIORIDAZINE
50MG TABLET 00360236
APO-THIORIDAZINE
100MG TABLET 00360244
APO-THIORIDAZINE
30MG/ML ORAL SOLUTION 00775320
PMS-THIORIDAZINE
THIOTHIXENE 2MG CAPSULE 00024430
NAVANE
5MG CAPSULE 00024449
NAVANE
10MG CAPSULE 00024457
NAVANE
TRIFLUOPERAZINE 1MG TABLET 00345539
2MG TABLET 00312754
5MG TABLET 00312746
10MG TABLET 00326836
APO-TRIFLUOPERAZINE
10MG/ML ORAL SOLUTION 00751871
PMS-TRIFLUOPERAZINE
ZUCLOPENTHIXOL ACETATE SEE APPENDIX A FOR EDS CRITERIA
50MG/ML INJECTION (1ML) 02230405
CLOPIXOL ACUPHASE (EDS)
ZUCLOPENTHIXOL DECANOATE SEE APPENDIX A FOR EDS CRITERIA
200MG/ML INJECTION (10ML) 02230406
CLOPIXOL DEPOT (EDS)
110
28:00 CENTRAL NERVOUS SYSTEM DRUGS 28:16.08 PSYCHOTHERAPEUTIC AGENTS (ANTIPSYCHOTIC AGENTS)
ZUCLOPENTHIXOL DIHYDROCHLORIDE SEE APPENDIX A FOR EDS CRITERIA
10MG TABLET 02230402
CLOPIXOL (EDS)
LUD
$
0.3906
LUD
$
0.9765
LUD
$
1.5624
25MG TABLET 02230403
CLOPIXOL (EDS)
40MG TABLET 02230404
CLOPIXOL (EDS)
28:20.00 RESPIRATORY AND CEREBRAL STIMULANTS
DEXTROAMPHETAMINE SO4 5MG TABLET 01924516
DEXEDRINE
GSK
$
0.3082
GSK
$
0.4421
GSK
$
0.5405
PMS
$
0.1028
PMS RTP NVR
$
0.1726 0.1726 0.2831
PMS RTP NVR
$
0.3958 0.3958 0.4948
NVR
$
0.5215
DPY
$
1.3020
10MG SPANSULE CAPSULE 01924559
DEXEDRINE
15MG SPANSULE CAPSULE 01924567
DEXEDRINE
METHYLPHENIDATE HCL 5MG TABLET 02234749
PMS-METHYLPHENIDATE
* 10MG TABLET 00584991 02230321 00005606
PMS-METHYLPHENIDATE RATIO-METHYLPHENIDATE RITALIN
* 20MG TABLET 00585009 02230322 00005614
PMS-METHYLPHENIDATE RATIO-METHYLPHENIDATE RITALIN
20MG SUSTAINED RELEASE TABLET 00632775
RITALIN SR
MODAFINIL SEE APPENDIX A FOR EDS CRITERIA
100MG TABLET 02239665
ALERTEC (EDS)
111
28:00 CENTRAL NERVOUS SYSTEM DRUGS 28:24.04 ANXIOLYTICS,SEDATIVES AND HYPNOTICS (BARBITURATES)
AMOBARBITAL SODIUM 60MG CAPSULE 00015148
AMYTAL SODIUM
PMS
$
0.1042
PMS
$
0.2294
ABB
$
0.2212
PMS
$
0.1160
NXP APX RTP NOP GPM MED PHU
$
0.0661 * 0.0825 0.0825 0.0825 0.0825 0.0825 0.2540
NXP RTP APX NOP GPM MED PHU
$
0.0800 * 0.0999 0.0999 0.0999 0.0999 0.0999 0.3037
200MG CAPSULE 00015156
AMYTAL SODIUM
PENTOBARBITAL SODIUM 100MG CAPSULE 00000086
NEMBUTAL
PHENOBARBITAL SEE SECTION 28:12.04 (ANTICONVULSANTS)
SECOBARBITAL SODIUM 100MG CAPSULE 00015288
SECONAL
28:24.08 ANXIOLYTICS,SEDATIVES AND HYPNOTICS (BENZODIAZEPINES)
ALPRAZOLAM * 0.25MG TABLET 01913239 00865397 00677485 01913484 02137534 02237264 00548359
NU-ALPRAZ APO-ALPRAZ RATIO-ALPRAZOLAM NOVO-ALPRAZOL GEN-ALPRAZOLAM MED-ALPRAZOLAM XANAX
* 0.5MG TABLET 01913247 00677477 00865400 01913492 02137542 02237265 00548367
NU-ALPRAZ RATIO-ALPRAZOLAM APO-ALPRAZ NOVO-ALPRAZOL GEN-ALPRAZOLAM MED-ALPRAZOLAM XANAX
112
28:00 CENTRAL NERVOUS SYSTEM DRUGS 28:24.08 ANXIOLYTICS,SEDATIVES AND HYPNOTICS (BENZODIAZEPINES)
BROMAZEPAM * 1.5MG TABLET 02171858 02177153 02192705 02230666 00682314
NU-BROMAZEPAM APO-BROMAZEPAM GEN-BROMAZEPAM MED-BROMAZEPAM LECTOPAM
NXP APX GPM MED HLR
$
0.0752 0.0752 0.0752 0.0752 0.1118
NU-BROMAZEPAM APO-BROMAZEPAM GEN-BROMAZEPAM NOVO-BROMAZEPAM MED-BROMAZEPAM LECTOPAM
NXP APX GPM NOP MED HLR
$
0.0767 * 0.0957 0.0957 0.0957 0.0957 0.1519
NU-BROMAZEPAM APO-BROMAZEPAM GEN-BROMAZEPAM NOVO-BROMAZEPAM MED-BROMAZEPAM LECTOPAM
NXP APX GPM NOP MED HLR
$
0.1398 0.1398 0.1398 0.1398 0.1398 0.2219
APX
$
0.0527
APX
$
0.0830
APX
$
0.1286
NOP APX
$
0.0753 0.0753
NOP APX
$
0.1662 0.1662
NOP APX
$
0.2840 0.2840
* 3MG TABLET 02171864 02177161 02192713 02230584 02230667 00518123
* 6MG TABLET 02171872 02177188 02192721 02230585 02230668 00518131
CHLORDIAZEPOXIDE 5MG CAPSULE 00522724
APO-CHLORDIAZEPOXIDE
10MG CAPSULE 00522988
APO-CHLORDIAZEPOXIDE
25MG CAPSULE 00522996
APO-CHLORDIAZEPOXIDE
CLORAZEPATE DIPOTASSIUM * 3.75MG CAPSULE 00628190 00860689
NOVO-CLOPATE APO-CLORAZEPATE
* 7.5MG CAPSULE 00628204 00860700
NOVO-CLOPATE APO-CLORAZEPATE
* 15MG CAPSULE 00628212 00860697
NOVO-CLOPATE APO-CLORAZEPATE
113
28:00 CENTRAL NERVOUS SYSTEM DRUGS 28:24.08 ANXIOLYTICS,SEDATIVES AND HYPNOTICS (BENZODIAZEPINES)
DIAZEPAM 2MG TABLET 00405329
APO-DIAZEPAM
APX
$
0.0662
VIVOL APO-DIAZEPAM VALIUM
HOR APX HLR
$
0.0952 0.0977 0.1552
APX HOR
$
0.1129 0.1561
DPY
$
72.9700
APX ICN
$
0.0879 0.1330
APX ICN
$
0.1009 0.1557
APO-LORAZEPAM NOVO-LORAZEM PMS-LORAZEPAM NU-LORAZ DOM-LORAZEPAM ATIVAN
APX NOP PMS NXP DOM WYA
$
0.0390 0.0390 0.0390 0.0390 0.0409 0.0814
NOVO-LORAZEM APO-LORAZEPAM PMS-LORAZEPAM NU-LORAZ DOM-LORAZEPAM ATIVAN
NOP APX PMS NXP DOM WYA
$
0.0485 0.0485 0.0485 0.0485 0.0509 0.1009
NOVO-LORAZEM APO-LORAZEPAM PMS-LORAZEPAM NU-LORAZ DOM-LORAZEPAM ATIVAN
NOP APX PMS NXP DOM WYA
$
0.0759 0.0759 0.0759 0.0759 0.0797 0.1585
* 5MG TABLET 00013765 00362158 00013285
* 10MG TABLET 00405337 00013773
APO-DIAZEPAM VIVOL
5MG/ML RECTAL GEL (DELIVERY SYSTEM) 02238162
DIASTAT
FLURAZEPAM HCL * 15MG CAPSULE 00521698 00012696
APO-FLURAZEPAM DALMANE
* 30MG CAPSULE 00521701 00012718
APO-FLURAZEPAM DALMANE
LORAZEPAM * 0.5MG TABLET 00655740 00711101 00728187 00865672 02245784 02041413
* 1MG TABLET 00637742 00655759 00728195 00865680 02245785 02041421
* 2MG TABLET 00637750 00655767 00728209 00865699 02245786 02041448
114
28:00 CENTRAL NERVOUS SYSTEM DRUGS 28:24.08 ANXIOLYTICS,SEDATIVES AND HYPNOTICS (BENZODIAZEPINES)
OXAZEPAM 10MG TABLET 00402680
APO-OXAZEPAM
APX
$
0.0456
APX
$
0.0717
APX
$
0.0977
NXP APX PMS NOP GPM MED RTP DOM NVR
$
0.0959 * 0.1196 0.1196 0.1196 0.1196 0.1196 0.1196 0.1493 0.1899
NXP APX NOP PMS GPM MED RTP DOM NVR
$
0.1153 * 0.1439 0.1439 0.1439 0.1439 0.1439 0.1439 0.1795 0.2284
APX GPM NOP
$
0.0604 0.0604 0.0606
APX NOP GPM PHU
$
0.0760 0.0760 0.0760 0.2199
15MG TABLET 00402745
APO-OXAZEPAM
30MG TABLET 00402737
APO-OXAZEPAM
TEMAZEPAM * 15MG CAPSULE 02223570 02225964 02229455 02230095 02231615 02237294 02243023 02229756 00604453
NU-TEMAZEPAM APO-TEMAZEPAM PMS-TEMAZEPAM NOVO-TEMAZEPAM GEN-TEMAZEPAM MED-TEMAZEPAM RATIO-TEMAZEPAM DOM-TEMAZEPAM RESTORIL
* 30MG CAPSULE 02223589 02225972 02230102 02229456 02231616 02237295 02243024 02229758 00604461
NU-TEMAZEPAM APO-TEMAZEPAM NOVO-TEMAZEPAM PMS-TEMAZEPAM GEN-TEMAZEPAM MED-TEMAZEPAM RATIO-TEMAZEPAM DOM-TEMAZEPAM RESTORIL
TRIAZOLAM * 0.125MG TABLET 00808563 01995227 00872423
APO-TRIAZO GEN-TRIAZOLAM NOVO-TRIOLAM
* 0.25MG TABLET 00808571 00872431 01913506 00443158
APO-TRIAZO NOVO-TRIOLAM GEN-TRIAZOLAM HALCION
115
28:00 CENTRAL NERVOUS SYSTEM DRUGS 28:24.92 MISCELLANEOUS ANXIOLYTICS,SEDATIVES AND HYPNOTICS
BUSPIRONE 5MG TABLET 02230941
PMS-BUSPIRONE
PMS
$
0.4323
DOM LIN NXP APX GPM PMS NOP MED RTP BRI
$
0.5531 * 0.7076 0.7076 0.7076 0.7076 0.7076 0.7076 0.7076 0.7076 1.0498
PMS
$
0.0471
APX NOP
$
0.0361 0.0361
APX NOP
$
0.0584 0.0584
APX NOP
$
0.0814 0.0814
PMS PFI
$
0.0422 0.0515
* 10MG TABLET 02232564 02176122 02207672 02211076 02230874 02230942 02231492 02237268 02237858 00603821
DOM-BUSPIRONE LIN-BUSPIRONE NU-BUSPIRONE APO-BUSPIRONE GEN-BUSPIRONE PMS-BUSPIRONE NOVO-BUSPIRONE MED-BUSPIRONE RATIO-BUSPIREX BUSPAR
CHLORAL HYDRATE 100MG/ML SYRUP 00792659
PMS-CHLORAL HYDRATE SYRUP
HYDROXYZINE * 10MG CAPSULE 00646059 00738824
APO-HYDROXYZINE NOVO-HYDROXYZIN
* 25MG CAPSULE 00646024 00738832
APO-HYDROXYZINE NOVO-HYDROXYZIN
* 50MG CAPSULE 00646016 00738840
APO-HYDROXYZINE NOVO-HYDROXYZIN
* 2MG/ML ORAL SYRUP 00741817 00024694
PMS-HYDROXYZINE ATARAX
116
28:00 CENTRAL NERVOUS SYSTEM DRUGS 28:24.92 MISCELLANEOUS ANXIOLYTICS,SEDATIVES AND HYPNOTICS
METHOTRIMEPRAZINE * 2MG TABLET 01927647 02238403
NOZINAN APO-METHOPRAZINE
RHO APX
$
0.0548 0.0548
NOZINAN NOVO-MEPRAZINE PMS-METHOTRIMEPRAZINE APO-METHOPRAZINE
RHO NOP PMS APX
$
0.0573 0.0573 0.0573 0.0573
RHO NOP PMS APX
$
0.1228 0.1228 0.1228 0.1228
RHO NOP PMS APX
$
0.1672 0.1672 0.1672 0.1672
RHO
$
0.0609
RHO
$
0.4451
PMS APX ICN
$
0.0578 0.0578 0.1238
PMS APX ICN
$
0.0606 0.0606 0.1017
PMS ICN
$
0.1476 0.1845
JAN
$
0.2068
* 5MG TABLET 01927655 01964909 02232903 02238404
* 25MG TABLET 01927663 01964925 02232904 02238405
NOZINAN NOVO-MEPRAZINE PMS-METHOTRIMEPRAZINE APO-METHOPRAZINE
* 50MG TABLET 01927671 01964933 02232905 02238406
NOZINAN NOVO-MEPRAZINE PMS-METHOTRIMEPRAZINE APO-METHOPRAZINE
5MG/ML ORAL SOLUTION 01927728
NOZINAN
40MG/ML ORAL SOLUTION 01927701
NOZINAN
28:28.00 ANTIMANIC AGENTS
LITHIUM CARBONATE * 150MG CAPSULE 02216132 02242837 00461733
PMS-LITHIUM CARBONATE APO-LITHIUM CARBONATE CARBOLITH
* 300MG CAPSULE 02216140 02242838 00236683
PMS-LITHIUM CARBONATE APO-LITHIUM CARBONATE CARBOLITH
* 600MG CAPSULE 02216159 02011239
PMS-LITHIUM CARBONATE CARBOLITH
300MG SUSTAINED RELEASE TABLET 00590665
DURALITH
117
DIAGNOSTIC AGENTS
36:00
36:00 DIAGNOSTIC AGENTS 36:04.00 ADRENAL INSUFFICIENCY
COSYNTROPIN ZINC HYDROXIDE SEE SECTION 68:28.00 (PITUITARY AGENTS)
36:26.00 DIABETES MELLITUS NOTE: THE IDENTIFICATION NUMBERS LISTED IN THIS SECTION HAVE BEEN GENERATED BY THE PRESCRIPTION DRUG PLAN FOR BILLING PURPOSES ONLY.
GLUCOSE OXIDASE/PEROXIDASE REAGENT ⌧
STRIP 00950889 00950831 00950378 00950408 00950432 00950505 00950068 00950907 00950300 00950878 00950893 00950894 00950902 00950459 00950734 00950883 00950900 00950572 00950882
NOVO-GLUCOSE PRESTIGE GLUCOFILM GLUCOSTIX ACCUTREND ENCORE CHEMSTRIP BG FREESTYLE PRECISION PLUS ASCENSIA DEX ONE TOUCH ULTRA PRECISION XTRA SOF-TACT ONE TOUCH SURESTEP ADVANTAGE COMFORT ACCU-CHEK COMPACT ELITE FASTTAKE
NOP THR BAY BAY BOM BAY BOM THS MDS BAY LSN MDS MDS LSN LSN BOM BOM BAY LSN
$
0.6011 0.6270 0.7012 0.7012 0.7324 0.7324 0.7834 0.8029 0.8626 0.8626 0.8626 0.8626 0.8626 0.8663 0.8663 0.8680 0.8680 0.9388 0.9388
MDS
$
1.6344
HYDROXYBUTYRATE DEHYDROGENASE BLOOD KETONE TEST STRIP 00950896
PRECISION XTRA KETONE
120
36:00 DIAGNOSTIC AGENTS 36:88.00 URINE CONTENTS NOTE: THE IDENTIFICATION NUMBERS LISTED IN THIS SECTION HAVE BEEN GENERATED BY THE PRESCRIPTION DRUG PLAN FOR BILLING PURPOSES ONLY.
CUPRIC SO4 REAGENT TABLET 00035122
CLINITEST
BAY
$
0.0998
BAY
$
0.1129
BOM
$
0.1389
BAY
$
0.1354
KETOSTIX
BAY
$
0.1259
ACETEST
BAY
$
0.1728
GLUCOSE OXIDASE/PEROXIDASE REAGENT STICK 00035130
DIASTIX
GLUCOSE OXIDASE/PEROXIDASE/SODIUM NITROFERRICYANIDE/GLYCINE REAGENT STICK 00950238
CHEMSTRIP UG 5000K
GLUCOSE OXIDASE/PEROXIDASE/SODIUM NITROPRUSSIDE REAGENT STICK 00035149
KETO DIASTIX
SODIUM NITROPRUSSIDE REAGENT STICK 00035092
TABLET 00035106
121
ELECTROLYTIC, CALORIC AND WATER BALANCE
40:00
40:00 ELECTROLYTIC, CALORIC AND WATER BALANCE 40:12.00 REPLACEMENT AGENTS
POTASSIUM CHLORIDE 8MMOL LONG ACTING CAPSULE 02042304 ⌧
MICRO-K EXTENCAPS
WYA
$
0.0971
APX NVR
$
0.0586 0.1040
KEY
$
0.2165
PMS GSK
$
0.0139 0.0157
ABB
$
0.3165
WEL
$
0.5191
SAW
$
0.3031
PMS
$
0.1027
PMS SAW
$
0.1172 0.1569
PMS
$
14.8000
8MMOL LONG ACTING TABLET 00602884 00074225
APO-K SLOW-K
20MMOL LONG ACTING TABLET 00713376
K-DUR
* 1.33MMOL/ML ORAL SOLUTION 02238604 01918303
PMS-POTASSIUM CHLORIDE K-10
20MMOL/PACKAGE POWDER (3G) 00481211
K-LOR
25MMOL/PACKAGE POWDER (7.8G) 02089580
K-LYTE/CL
40:18.00 POTASSIUM-REMOVING RESINS
CALCIUM POLYSTYRENE SULFONATE POWDER (1G BINDS WITH APPROX. 1.6MMOL. K) 02017741
RESONIUM CALCIUM
SODIUM POLYSTYRENE SULFONATE 250MG/ML ORAL SUSPENSION 00769541
PMS-SOD POLYSTYRENE SULF
* POWDER (1G BINDS WITH APPROX.1MMOL K IN VIVO) 00755338 02026961
PMS-SOD POLYSTYRENE SULF KAYEXALATE
250MG/ML RETENTION ENEMA 00769533
PMS-SOD POLY SULF (120ML)
124
40:00 ELECTROLYTIC, CALORIC AND WATER BALANCE 40:28.00 DIURETICS
ACETAZOLAMIDE SEE SECTION 52:10.00 (CARBONIC ANHYDRASE INHIBITORS)
BUMETANIDE SEE APPENDIX A FOR EDS CRITERIA
1MG TABLET 00728284
BURINEX (EDS)
LEO
$
0.7324
BURINEX (EDS)
LEO
$
1.4648
BURINEX (EDS)
LEO
$
2.7939
APX
$
0.0852
APX
$
0.1020
MSD
$
0.3440
NOP APX AVT
$
0.0483 0.0483 0.0749
NOP APX AVT
$
0.0727 0.0727 0.1147
AVT
$
0.2356
NOP APX MSD
$
0.0516 0.0516 0.0795
NOP APX
$
0.0706 0.0706
2MG TABLET 02176076
5MG TABLET 00728276
CHLORTHALIDONE 50MG TABLET 00360279
APO-CHLORTHALIDONE
100MG TABLET 00360287
APO-CHLORTHALIDONE
ETHACRYNIC ACID SEE APPENDIX A FOR EDS CRITERIA
50MG TABLET 00016497
EDECRIN (EDS)
FUROSEMIDE * 20MG TABLET 00337730 00396788 02224690
NOVO-SEMIDE APO-FUROSEMIDE LASIX
* 40MG TABLET 00337749 00362166 02224704
NOVO-SEMIDE APO-FUROSEMIDE LASIX
10MG/ML ORAL SOLUTION 02224720
LASIX
HYDROCHLOROTHIAZIDE * 25MG TABLET 00021474 00326844 00016500
NOVO-HYDRAZIDE APO-HYDRO HYDRODIURIL
* 50MG TABLET 00021482 00312800
NOVO-HYDRAZIDE APO-HYDRO
125
40:00 ELECTROLYTIC, CALORIC AND WATER BALANCE 40:28.00 DIURETICS
INDAPAMIDE HEMIHYDRATE * 1.25MG TABLET 02239913 02227339 02239619 02240067 02179709
DOM-INDAPAMIDE INDAPAMIDE PMS-INDAPAMIDE GEN-INDAPAMIDE LOZIDE
DOM PRO PMS GPM SEV
$
0.1672 * 0.2037 0.2037 0.2037 0.3254
DOM PRO GPM NXP APX NOP PMS SEV
$
0.2652 * 0.3230 0.3230 0.3230 0.3230 0.3230 0.3230 0.5289
AVT
$
0.1585
MSD
$
0.3104
PHU NOP
$
0.0751 0.0751
PHU NOP
$
0.2301 0.2301
* 2.5MG TABLET 02239917 02049341 02153483 02223597 02223678 02231184 02239620 00564966
DOM-INDAPAMIDE INDAPAMIDE GEN-INDAPAMIDE NU-INDAPAMIDE APO-INDAPAMIDE NOVO-INDAPAMIDE PMS-INDAPAMIDE LOZIDE
METOLAZONE 2.5MG TABLET 00888400
ZAROXOLYN
40:28.10 POTASSIUM SPARING DIURETICS
AMILORIDE HCL 5MG TABLET 00487805
MIDAMOR
SPIRONOLACTONE * 25MG TABLET 00028606 00613215
ALDACTONE NOVO-SPIROTON
* 100MG TABLET 00285455 00613223
ALDACTONE NOVO-SPIROTON
126
40:00 ELECTROLYTIC, CALORIC AND WATER BALANCE 40:40.00 URICOSURIC DRUGS
PROBENECID 500MG TABLET 00294926
BENURYL
ICN
$
0.2045
APX NXP
$
0.1519 0.1519
APX NXP
$
0.2149 0.2149
SULFINPYRAZONE * 100MG TABLET 00441759 02045680
APO-SULFINPYRAZONE NU-SULFINPYRAZONE
* 200MG TABLET 00441767 02045699
APO-SULFINPYRAZONE NU-SULFINPYRAZONE
127
COUGH PREPARATIONS
48:00
48:00 COUGH PREPARATIONS 48:24.00 MUCOLYTIC AGENTS
ACETYLCYSTEINE * 20% SOLUTION (30ML) 02243098 02091526
ACETYLCYSTEINE SOLUTION MUCOMYST
SAB WEL
$
15.8600 19.1600
HLR
$
36.0000
DORNASE ALFA SEE APPENDIX A FOR EDS CRITERIA
1MG/ML INHALATION SOLUTION (2.5ML) 02046733
PULMOZYME (EDS)
130
EYE, EAR, NOSE AND THROAT PREPARATIONS
52:00
52:00 EYE, EAR, NOSE AND THROAT PREPARATIONS 52:04.04 ANTI-INFECTIVES (ANTIBIOTICS)
FUSIDIC ACID SEE APPENDIX A FOR EDS CRITERIA
1% OPHTHALMIC DROPS (PRESERVATIVE FREE) 02243861
FUCITHALMIC (EDS)
LEO
$
0.8190
LEO
$
1.7620
1% OPHTHALMIC DROPS (G) 02243862
FUCITHALMIC (EDS)
GENTAMICIN SO4 TOPICAL GENTAMICIN SHOULD BE RESERVED FOR THERAPY OF SERIOUS INFECTIONS INSUSCEPTIBLE TO OTHER AGENTS SINCE RESISTANT ORGANISMS CAN DEVELOP. GENTAMICIN SO4 5MG/ML IS EQUIVALENT TO 3MG/ML GENTAMICIN BASE.
* 5MG/ML OPHTHALMIC SOLUTION 00512192 00776521 02229440 00436771
GARAMYCIN PMS-GENTAMYCIN GENTAMICIN SULFATE ALCOMICIN
SCH PMS SAB ALC
$
0.4406 0.4406 0.4406 0.5187
SAB PMS SCH
$
1.1192 1.1198 1.1998
SCH SAB
$
4.3400 4.3400
* 5MG/ML OTIC SOLUTION 02229441 02230889 00512184
GENTAMICIN SO4 PMS-GENTAMICIN GARAMYCIN
* 5MG/G OPHTHALMIC OINTMENT (3.5G) 00028339 02230888
GARAMYCIN GENTAMICIN SULFATE
POLYMYXIN B SO4/NEOMYCIN SO4/BACITRACIN(ZINC) 10,000U/5MG/400U PER G OPHTHALMIC OINTMENT (3.5G) 00694398
NEOSPORIN
GSK
$
8.1400
SAB GSK
$
0.6782 0.7975
PMS ALL
$
0.7194 2.6203
POLYMYXIN B SO4/NEOMYCIN SO4/GRAMICIDIN * 10,000U/2.5MG/0.025MG PER ML EYE/EAR SOLUTION 00807435 00694371
OPTIMYXIN PLUS NEOSPORIN
POLYMYXIN B SO4/TRIMETHOPRIM SO4 * 10,000U/1MG PER ML OPHTHALMIC SOLUTION 02240363 02011956
PMS-POLYTRIMETHOPRIM POLYTRIM
132
52:00 EYE, EAR, NOSE AND THROAT PREPARATIONS 52:04.04 ANTI-INFECTIVES (ANTIBIOTICS)
TOBRAMYCIN SEE APPENDIX A FOR EDS CRITERIA
* 0.3% OPHTHALMIC SOLUTION 02239577 02241755 00513962
PMS-TOBRAMYCIN (EDS) SAB-TOBRAMYCIN (EDS) TOBREX (EDS)
PMS SAB ALC
$
1.1371 1.1371 1.8077
ALC
$
8.9800
THM
$
33.4800
AKN SCH
$
0.0789 0.0876
ALC
$
3.1000
STI
$
0.2387
ALC
$
2.1049
ALC
$
10.5300
0.3% OPHTHALMIC OINTMENT (3.5G) 00614254
TOBREX (EDS)
52:04.06 ANTI-INFECTIVES (ANTIVIRALS)
TRIFLURIDINE 1% OPHTHALMIC SOLUTION (7.5ML) 00687456
VIROPTIC
52:04.08 ANTI-INFECTIVES (SULFONAMIDES)
SULFACETAMIDE (SODIUM) * 10% OPHTHALMIC SOLUTION 02023830 00028053
DIOSULF SODIUM SULAMYD
10% OPHTHALMIC OINTMENT (3.5G) 00252522
CETAMIDE
52:04.12 ANTI-INFECTIVES (MISCELLANEOUS)
ALUMINUM ACETATE/BENZETHONIUM CHLORIDE 0.5%/0.03% OTIC SOLUTION 00674222
BURO-SOL-OTIC
CIPROFLOXACIN SEE APPENDIX A FOR EDS CRITERIA
0.3% OPHTHALMIC SOLUTION 01945270
CILOXAN (EDS)
0.3% OPHTHALMIC OINTMENT (3.5G) 02200864
CILOXAN (EDS)
133
52:00 EYE, EAR, NOSE AND THROAT PREPARATIONS 52:04.12 ANTI-INFECTIVES (MISCELLANEOUS)
NORFLOXACIN SEE APPENDIX A FOR EDS CRITERIA
0.3% OPHTHALMIC SOLUTION 01908294
NOROXIN (EDS)
MSD
$
1.7686
ALL
$
2.1049
RTP GPM MED NXP APX
$
13.3100 13.3100 13.3100 13.3100 13.3100
RBP
$
3.2724
GPM AST
$
9.1500 10.7700
GPM
$
13.8300
AST
$
23.9300
ALC
$
1.6709
SAB PMS AKN
$
0.7335 0.7335 0.9071
ALC
$
9.0600
OFLOXACIN SEE APPENDIX A FOR EDS CRITERIA
0.3% OPHTHALMIC SOLUTION 02143291
OCUFLOX (EDS)
52:08.00 ANTI-INFLAMMATORY AGENTS
BECLOMETHASONE DIPROPIONATE * 50UG/DOSE AQUEOUS NASAL SPRAY (PACKAGE) 00872318 02172712 02237379 02238577 02238796
RATIO-BECLOMETHASONE AQ. GEN-BECLO AQ. MED-BECLOMETHASONE AQ NU-BECLOMETHASONE APO-BECLOMETHASONE
BETAMETHASONE DISODIUM PHOSPHATE 0.1% OPHTHALMIC/OTIC SOLUTION 02060868
BETNESOL
BUDESONIDE * 64UG/DOSE NASAL SPRAY (PACKAGE) 02241003 02231923
GEN-BUDESONIDE AQ RHINOCORT AQUA
100UG/DOSE NASAL SPRAY (PACKAGE) 02230648
GEN-BUDESONIDE AQ
100UG POWDER FOR INHALATION (PACKAGE) 02035324
RHINOCORT TURBUHALER
DEXAMETHASONE 0.1% OPHTHALMIC SUSPENSION 00042560
MAXIDEX
* 0.1% OPHTHALMIC/OTIC SOLUTION 00739839 00785261 02023865
DEXAMETHASONE SODIUM PHO PMS-DEXAMETHASONE SOD PHO DIODEX
0.1% OPHTHALMIC OINTMENT (3.5G) 00042579
MAXIDEX
134
52:00 EYE, EAR, NOSE AND THROAT PREPARATIONS 52:08.00 ANTI-INFLAMMATORY AGENTS
FLUNISOLIDE * 0.025% NASAL SOLUTION (PACKAGE) 00878790 01927167 02239288 02162687
RATIO-FLUNISOLIDE RHINARIS-F APO-FLUNISOLIDE RHINALAR
RTP PMS APX HLR
$
15.0400 15.0400 15.0400 21.4900
PMS ALL
$
1.7556 2.1939
ALC
$
1.8879
ALL
$
5.0062
GSK
$
24.0500
ALL
$
3.4720
SCH
$
26.5200
SAB ALL
$
1.1501 1.5473
RTP SAB AKN ALL
$
0.6293 0.6293 0.6293 3.7954
FLUOROMETHOLONE * 0.1% OPHTHALMIC SUSPENSION 02238568 00247855
PMS-FLUOROMETHOLONE FML
FLUOROMETHOLONE ACETATE 0.1% OPHTHALMIC SUSPENSION 00756784
FLAREX
FLURBIPROFEN SODIUM SEE APPENDIX A FOR EDS CRITERIA
0.03% OPHTHALMIC SOLUTION 00766046
OCUFEN (EDS)
FLUTICASONE PROPIONATE 50UG/DOSE AQUEOUS NASAL SPRAY (PACKAGE) 02213672
FLONASE
KETOROLAC TROMETHAMINE SEE APPENDIX A FOR EDS CRITERIA
0.5% OPHTHALMIC SOLUTION 01968300
ACULAR (EDS)
MOMETASONE FUROATE MONOHYDRATE 0.05% AQUEOUS NASAL SPRAY 02238465
NASONEX
PREDNISOLONE ACETATE * 0.12% OPHTHALMIC SUSPENSION 01916181 00299405
PREDNISOLONE PRED MILD
* 1.0% OPHTHALMIC SUSPENSION 00700401 01916203 02023768 00301175
RATIO-PREDNISOLONE PREDNISOLONE DIOPRED PRED FORTE
135
52:00 EYE, EAR, NOSE AND THROAT PREPARATIONS 52:08.00 ANTI-INFLAMMATORY AGENTS
PREDNISOLONE SODIUM PHOSPHATE 0.125% OPHTHALMIC SOLUTION 02133296
INFLAMASE MILD
NVO
$
1.6731
NVO
$
1.5190
AVT
$
23.3800
ALC
$
2.2790
1% OPHTHALMIC SOLUTION 02133318
INFLAMASE FORTE
TRIAMCINOLONE ACETONIDE AQUEOUS NASAL SPRAY (PACKAGE) 02213834
NASACORT AQ
52:08.00 COMBINATION ANTI-INFECTIVE/ ANTI-INFLAMMATORY AGENTS
CIPROFLOXACIN/HYDROCORTISONE SEE APPENDIX A FOR EDS CRITERIA
0.2%/1% OTIC SUSPENSION 02240035
CIPRO HC (EDS)
FRAMYCETIN SO4/GRAMICIDIN/DEXAMETHASONE BASE 5MG/50UG/0.5MG PER ML EYE/EAR SOLUTION 02224623
SOFRACORT
AVT
$
1.5190
AVT
$
10.4200
5MG/50UG/0.5MG PER G EYE/EAR OINTMENT (5G) 02224631
SOFRACORT
GENTAMICIN SO4/BETAMETHASONE SODIUM PHOSPHATE 0.3%/0.1% OPHTHALMIC OINTMENT (3.5G) 00586706
GARASONE
SCH
$
11.0000
SAB SCH
$
1.5904 1.9872
* 0.3%/0.1% OTIC/OPHTHALMIC SOLUTION 02244999 00682217
SAB-PENTASONE GARASONE
IODOCHLORHYDROXYQUIN/FLUMETHASONE PIVALATE 1%/0.02% OTIC SOLUTION 00074454
LOCACORTEN-VIOFORM
PAL
$
1.3715
GSK
$
10.5200
POLYMYXIN B SO4/BACITRACIN (ZINC)/ NEOMYCIN SO4/HYDROCORTISONE 10000U/400U/5MG/10MG PER G OPHTHALMIC OINTMENT (3.5G) 00701904
CORTISPORIN
136
52:00 EYE, EAR, NOSE AND THROAT PREPARATIONS 52:08.00 COMBINATION ANTI-INFECTIVE/ ANTI-INFLAMMATORY AGENTS
POLYMYXIN B SO4/NEOMYCIN SO4/DEXAMETHASONE 6,000U/5MG/1MG PER ML OPHTHALMIC SOLUTION 00042676
MAXITROL
ALC
$
2.0659
ALC
$
10.0800
6,000U/5MG/1MG PER G OPHTHALMIC OINTMENT (3.5G) 00358177
MAXITROL
POLYMYXIN B SO4/NEOMYCIN SO4/HYDROCORTISONE 10,000U/5MG/10MG PER ML EYE/EAR SUSPENSION 02025736
CORTISPORIN
GSK
$
1.2424
SAB GSK
$
1.0004 1.2424
* 10,000U/5MG/10MG PER ML OTIC SOLUTION 02230386 01912828
CORTIMYXIN CORTISPORIN
SULFACETAMIDE SODIUM/PREDNISOLONE ACETATE 100MG/2.5MG PER ML OPHTHALMIC SOLUTION 02133342
VASOCIDIN
NVO
$
2.2460
AKN
$
1.2478
ALL
$
12.3200
ALC
$
2.1353
ALC
$
11.0700
APX
$
0.1015
WYA
$
0.7567
ALC
$
3.4069
100MG/5MG PER ML OPHTHALMIC SUSPENSION 02023814
DIOPTIMYD
100MG/2MG PER G OPHTHALMIC OINTMENT (3.5G) 00307246
BLEPHAMIDE S.O.P.
TOBRAMYCIN/DEXAMETHASONE SEE APPENDIX A FOR EDS CRITERIA
0.3%/0.1% OPHTHALMIC SUSPENSION 00778907
TOBRADEX (EDS)
0.3%/0.1% OPHTHALMIC OINTMENT (3.5G) 00778915
TOBRADEX (EDS)
52:10.00 CARBONIC ANHYDRASE INHIBITORS
ACETAZOLAMIDE 250MG TABLET 00545015
APO-ACETAZOLAMIDE
500MG SUSTAINED RELEASE CAPSULE 02238073
DIAMOX SEQUELS
BRINZOLAMIDE 1% OPHTHALMIC SUSPENSION 02238873
AZOPT
137
52:00 EYE, EAR, NOSE AND THROAT PREPARATIONS 52:10.00 CARBONIC ANHYDRASE INHIBITORS
DORZOLAMIDE HCL 2% OPHTHALMIC SOLUTION 02216205
TRUSOPT
MSD
$
3.5805
ALC
$
0.7307
ALC
$
0.8789
ALC AKN
$
0.2221 0.2221
ALC AKN
$
0.2561 0.2561
NVO ALC AKN
$
0.2395 0.2894 0.2894
ALC
$
13.5600
ALC NVO
$
0.5100 0.6185
RTP PMS APX ALL
$
1.0807 1.0807 1.0807 1.7154
52:20.00 MIOTICS
CARBACHOL 1.5% OPHTHALMIC SOLUTION 00000655
ISOPTO CARBACHOL
3% OPHTHALMIC SOLUTION 00000663
ISOPTO CARBACHOL
PILOCARPINE HCL * 1% OPHTHALMIC SOLUTION 00000841 02023725
ISOPTO CARPINE DIOCARPINE
* 2% OPHTHALMIC SOLUTION 00000868 02023741
ISOPTO CARPINE DIOCARPINE
* 4% OPHTHALMIC SOLUTION 02134896 00000884 02023733
MIOCARPINE ISOPTO CARPINE DIOCARPINE
4% OPHTHALMIC GEL (5G) 00575240
PILOPINE-HS
52:24.00 MYDRIATICS
ATROPINE SO4 * 1% OPHTHALMIC SOLUTION 00035017 01948598
ISOPTO ATROPINE ATROPINE
DIPIVEFRIN HCL * 0.1% OPHTHALMIC SOLUTION 02032376 02237868 02242232 00529117
RATIO-DIPIVEFRIN PMS-DIPIVEFRIN APO-DIPIVEFRIN PROPINE
138
52:00 EYE, EAR, NOSE AND THROAT PREPARATIONS 52:24.00 MYDRIATICS
HOMATROPINE HYDROBROMIDE 2% OPHTHALMIC SOLUTION 00000779
ISOPTO HOMATROPINE
ALC
$
0.6293
ALC
$
0.7487
ALC
$
23.0800
ALC
$
11.9200
ALC
$
2.4456
RTP ALL
$
2.5064 3.5810
NVO
$
2.5715
MSD
$
5.4250
PMS RTP DOM BOE
$
21.0900 21.0900 22.2000 30.2100
PHU
$
28.2100
5% OPHTHALMIC SOLUTION 00000787
ISOPTO HOMATROPINE
52:36.00 MISCELLANEOUS E.E.N.T. DRUGS
APRACLONIDINE HCL 0.5% OPHTHALMIC SOLUTION (5ML) 02076306
IOPIDINE
1% OPHTHALMIC SOLUTION (1 TREATMENT) 00888354
IOPIDINE
BETAXOLOL HCL 0.25% OPHTHALMIC SUSPENSION 01908448
BETOPTIC S
BRIMONIDINE TARTRATE * 0.2% OPHTHALMIC SOLUTION 02243026 02236876
RATIO-BRIMONIDINE ALPHAGAN
DICLOFENAC SODIUM SEE APPENDIX A FOR EDS CRITERIA
0.1% OPHTHALMIC SOLUTION (ML) 01940414
VOLTAREN OPHTHA (EDS)
DORZOLAMIDE HCL/TIMOLOL MALEATE 2%/0.5% OPHTHALMIC SOLUTION 02240113
COSOPT
IPRATROPIUM BROMIDE * 21UG/DOSE NASAL SPRAY (PACKAGE) 02239627 02240072 02240508 02163705
PMS-IPRATROPIUM RATIO-IPRATROPIUM DOM-IPRATROPIUM ATROVENT NASAL SPRAY
LATANOPROST 50UG/ML OPHTHALMIC SOLUTION (2.5ML) 02231493
XALATAN
139
52:00 EYE, EAR, NOSE AND THROAT PREPARATIONS 52:36.00 MISCELLANEOUS E.E.N.T. DRUGS
LEVOBUNOLOL HCL * 0.25% OPHTHALMIC SOLUTION 02031159 02197456 02241575 02241715 00751286
RATIO-LEVOBUNOLOL NOVO-LEVOBUNOLOL APO-LEVOBUNOLOL SAB-LEVOBUNOLOL BETAGAN
RTP NOP APX SAB ALL
$
1.2760 1.2760 1.2760 1.2760 2.3078
SAB PMS RTP NOP APX ALL
$
1.6861 1.6872 1.6883 1.6883 1.6883 2.8341
ALL
$
3.2008
NVO
$
18.8300
ALC
$
1.1122
PMS APX
$
14.9300 14.9300
* 0.5% OPHTHALMIC SOLUTION 02241716 02237991 02031167 02197464 02241574 00637661
SAB-LEVOBUNOLOL PMS-LEVOBUNOLOL RATIO-LEVOBUNOLOL NOVO-LEVOBUNOLOL APO-LEVOBUNOLOL BETAGAN
LEVOBUNOLOL HCL/DIPIVEFRIN HCL 0.5%/0.1% OPHTHALMIC SOLUTION 02209071
PROBETA
LEVOCABASTINE HYDROCHLORIDE 0.5MG PER ML OPHTHALMIC SUSPENSION (5ML) 02131625
LIVOSTIN
LODOXAMIDE TROMETHAMINE 0.1% OPHTHALMIC SOLUTION 00893560
ALOMIDE
SODIUM CROMOGLYCATE * 2% NASAL METERED DOSE MIST (PACKAGE) 01950541 02231390
CROMOLYN APO-CROMOLYN
140
52:00 EYE, EAR, NOSE AND THROAT PREPARATIONS 52:36.00 MISCELLANEOUS E.E.N.T. DRUGS
TIMOLOL MALEATE * 0.25% OPHTHALMIC SOLUTION 00755826 00893773 02048523 02083353 02084317 02166712 02240248 02241731 02238770
APO-TIMOP GEN-TIMOLOL NOVO-TIMOL PMS-TIMOLOL MED-TIMOLOL TIMOLOL MALEATE RATIO-TIMOLOL MALEATE RHOXAL-TIMOLOL DOM-TIMOLOL
APX GPM NOP PMS MED SAB RTP RHO DOM
$
1.6818 1.6818 1.6818 1.6818 1.6818 1.6818 1.6818 1.6818 1.7664
APX GPM PMS MED SAB RTP RHO DOM MSD
$
2.0181 2.0181 2.0181 2.0181 2.0181 2.0181 2.0181 2.1190 3.3874
MSD
$
3.5371
MSD
$
4.2315
* 0.5% OPHTHALMIC SOLUTION 00755834 00893781 02083345 02084325 02166720 02240249 02241732 02238771 00451207
APO-TIMOP GEN-TIMOLOL PMS-TIMOLOL MED-TIMOLOL TIMOLOL MALEATE RATIO-TIMOLOL MALEATE RHOXAL-TIMOLOL DOM-TIMOLOL TIMOPTIC
0.25% OPHTHALMIC GELLAN SOLUTION 02171880
TIMOPTIC-XE
0.5% OPHTHALMIC GELLAN SOLUTION 02171899
TIMOPTIC-XE
TIMOLOL MALEATE/PILOCARPINE HYDROCHLORIDE 0.5%/2% OPHTHALMIC SOLUTION 01905082
TIMPILO
MSD
$
3.3874
MSD
$
3.3874
ALC
$
28.7600
0.5%/4% OPHTHALMIC SOLUTION 01905090
TIMPILO
TRAVOPROST 0.004% OPHTHALMIC SOLUTION (2.5ML) 02244896
TRAVATAN
141
GASTROINTESTINAL DRUGS
56:00
56:00 GASTROINTESTINAL DRUGS 56:08.00 ANTIDIARRHEA AGENTS
DIPHENOXYLATE HCL 2.5MG TABLET 00036323
LOMOTIL
PHU
$
0.4548
NOP APX ICN PMS RHO PMS DOM MCL
$
0.2676 0.2676 0.2676 0.2676 0.2676 0.2684 0.2809 0.7758
PMS PMS
$
0.0911 0.0912
PMS
$
0.0158
RTP APX
$
0.0158 0.0158
LOPERAMIDE HCL * 2MG CAPLET 02132591 02212005 02228343 02228351 02233998 02229552 02239535 02183862
NOVO-LOPERAMIDE APO-LOPERAMIDE LOPERACAP PMS-LOPERAMIDE RHOXAL-LOPERAMIDE DIARR-EZE DOM-LOPERAMIDE IMODIUM
* 0.2MG/ML ORAL SOLUTION 02192667 02016095
DIARR-EZE PMS-LOPERAMIDE HCL
56:12.00 CATHARTICS AND LAXATIVES
LACTULOSE SEE APPENDIX A FOR EDS CRITERIA
667MG/ML SYRUP 00703486
PMS-LACTULOSE (EDS)
* 667MG/ML SOLUTION 00854409 02242814
RATIO-LACTULOSE (EDS) APO-LACTULOSE (EDS)
144
56:00 GASTROINTESTINAL DRUGS 56:16.00 DIGESTANTS
PANCRELIPASE (LIPASE/AMYLASE/PROTEASE) 4000U/12000U/12000U CAPSULE CONTAINING ENTERIC COATED PARTICLES 00789445
PANCREASE MT 4
JAN
$
0.3733
JAN
$
0.3727
AXC
$
0.2214
SLV
$
0.1812
ORG
$
0.2670
ORG
$
0.3662
JAN
$
0.9329
SLV
$
0.2897
AXC
$
0.4330
JAN
$
1.4925
ORG
$
0.9456
AXC
$
0.7503
SLV
$
0.8597
4000U/20000U/25000U CAPSULE CONTAINING ENTERIC COATED PARTICLES 02242374
PANCREASE
4500U/20000U/25000U CAPSULE CONTAINING ENTERIC COATED PARTICLES 02203324
ULTRASE MS4
5000U/16600U/18750U CAPSULE CONTAINING ENTERIC COATED PARTICLES 02239007
CREON 5
8000U/30000U/30000U CAPSULE 00263818
COTAZYM
8000U/30000U/30000U CAPSULE CONTAINING ENTERIC COATED PARTICLES 00502790
COTAZYM ECS 8
10000U/30000U/30000U CAPSULE CONTAINING ENTERIC COATED PARTICLES 00789437
PANCREASE MT 10
10000U/33200U/37500U CAPSULE CONTAINING ENTERIC COATED PARTICLES 02200104
CREON 10
12000U/39000U/39000U CAPSULE CONTAINING ENTERIC COATED PARTICLES 02045834
ULTRASE MT12
16000U/48000U/48000U CAPSULE CONTAINING ENTERIC COATED PARTICLES 00789429
PANCREASE MT 16
20000U/55000U/55000U CAPSULE CONTAINING ENTERIC COATED PARTICLES 00821373
COTAZYM ECS 20
20000U/65000U/65000U CAPSULE CONTAINING ENTERIC COATED PARTICLES 02045869
ULTRASE MT20
20000U/66400U/75000U CAPSULE CONTAINING ENTERIC COATED PARTICLES 02239008
CREON 20
145
56:00 GASTROINTESTINAL DRUGS 56:16.00 DIGESTANTS 25000U/74000U/62500U CAPSULE CONTAINING ENTERIC COATED PARTICLES 01985205
CREON 25
SLV
$
0.9049
AXC
$
0.2303
AXC
$
0.3470
AXC
$
0.4951
APX NOP HOR
$
0.0147 0.0408 0.1313
HOR
$
0.0740
SAB HOR
$
3.2600 4.4100
HOR
$
0.5100
HOR
$
0.5328
DUI
$
1.3020
PFC
$
0.4557
NVR
$
4.1800
8000U/30000U/30000U TABLET 02230019
VIOKASE
16000U/60000U/60000U TABLET 02241933
VIOKASE
24000U/100000U/100000U POWDER 02230020
VIOKASE
56:22.00 ANTI-EMETICS
DIMENHYDRINATE * 50MG TABLET 00363766 00021423 00013803
APO-DIMENHYDRINATE NOVO-DIMENATE GRAVOL
3MG/ML ORAL LIQUID 00230197
GRAVOL
* 50MG/ML INJECTION SOLUTION (5ML) 00392537 00013579
DIMENHYDRINATE IM GRAVOL
50MG SUPPOSITORY 00013595
GRAVOL
100MG SUPPOSITORY 00013609
GRAVOL
DOXYLAMINE SUCCINATE/PYRIDOXINE HCL 10MG/10MG DELAYED RELEASE TABLET 00609129
DICLECTIN
MECLIZINE HCL 25MG TABLET 00220442
BONAMINE
SCOPOLAMINE 1.5MG TRANSDERMAL THERAPEUTIC SYSTEM 00550094
TRANSDERM-V
146
56:00 GASTROINTESTINAL DRUGS 56:40.00 MISCELLANEOUS GASTROINTESTINAL DRUGS
BUDESONIDE SEE APPENDIX A FOR EDS CRITERIA
3MG CONTROLLED ILEAL RELEASE CAPSULE 02229293
ENTOCORT (EDS)
AST
$
1.6058
NXP APX RTP NOP GPM PMS DOM
$
0.0722 * 0.0934 0.0934 0.0934 0.0934 0.0934 0.0980
NXP RTP APX NOP GPM PMS DOM
$
0.1134 * 0.1465 0.1465 0.1465 0.1465 0.1465 0.1539
NXP RTP APX NOP GPM PMS DOM
$
0.1444 * 0.1867 0.1867 0.1867 0.1867 0.1867 0.1960
APX
$
0.1220
DOM RTP APX NOP NXP PMS
$
0.1333 * 0.1624 0.1624 0.1624 0.1624 0.1624
CIMETIDINE * 300MG TABLET 00865818 00487872 00546240 00582417 02227444 02229718 02231287
NU-CIMET APO-CIMETIDINE RATIO-PEPTOL NOVO-CIMETINE GEN-CIMETIDINE PMS-CIMETIDINE DOM-CIMETIDINE
* 400MG TABLET 00865826 00568449 00600059 00603678 02227452 02229719 02231288
NU-CIMET RATIO-PEPTOL APO-CIMETIDINE NOVO-CIMETINE GEN-CIMETIDINE PMS-CIMETIDINE DOM-CIMETIDINE
* 600MG TABLET 00865834 00584282 00600067 00603686 02227460 02229720 02231290
NU-CIMET RATIO-PEPTOL APO-CIMETIDINE NOVO-CIMETINE GEN-CIMETIDINE PMS-CIMETIDINE DOM-CIMETIDINE
60MG/ML ORAL LIQUID 02243085
APO-CIMETIDINE
DOMPERIDONE MALEATE * 10MG TABLET 02238315 01912070 02103613 02157195 02231477 02236466
DOM-DOMPERIDONE RATIO-DOMPERIDONE APO-DOMPERIDONE NOVO-DOMPERIDONE NU-DOMPERIDONE PMS-DOMPERIDONE
147
56:00 GASTROINTESTINAL DRUGS 56:40.00 MISCELLANEOUS GASTROINTESTINAL DRUGS
FAMOTIDINE * 20MG TABLET 02024195 01953842 02242327 02022133 02196018 02237148 02240622 00710121
NU-FAMOTIDINE APO-FAMOTIDINE RATIO-FAMOTIDINE NOVO-FAMOTIDINE GEN-FAMOTIDINE ULCIDINE RHOXAL-FAMOTIDINE PEPCID
NXP APX RTP NOP GPM ICN RHO MSD
$
0.5126 * 0.6398 0.6398 0.6398 0.6398 0.6398 0.6398 1.0153
NXP APX NOP GPM ICN RHO RTP MSD
$
0.9225 * 1.1514 1.1514 1.1514 1.1514 1.1514 1.1514 1.8461
ABB
$
2.1700
ABB
$
2.1700
ABB
$
79.8600
PMS
$
0.0604
APX NXP PMS
$
0.0633 0.0633 0.0633
PMS
$
0.0291
* 40MG TABLET 02024209 01953834 02022141 02196026 02237149 02240623 02242328 00710113
NU-FAMOTIDINE APO-FAMOTIDINE NOVO-FAMOTIDINE GEN-FAMOTIDINE ULCIDINE RHOXAL-FAMOTIDINE RATIO-FAMOTIDINE PEPCID
LANSOPRAZOLE SEE APPENDIX A FOR EDS CRITERIA
15MG DELAYED RELEASE CAPSULE 02165503
PREVACID (EDS)
30MG DELAYED RELEASE CAPSULE 02165511
PREVACID (EDS)
LANSOPRAZOLE/CLARITHROMYCIN/AMOXICILLIN SEE APPENDIX A FOR EDS CRITERIA
30MG/500MG/500MG 7-DAY PACKAGE 02238525
HP-PAC (EDS)
METOCLOPRAMIDE HCL 5MG TABLET 02230431
PMS-METOCLOPRAMIDE
* 10MG TABLET 00842834 02143283 02230432
APO-METOCLOP NU-METOCLOPRAMIDE PMS-METOCLOPRAMIDE
1MG/ML ORAL SOLUTION 02230433
PMS-METOCLOPRAMIDE
148
56:00 GASTROINTESTINAL DRUGS 56:40.00 MISCELLANEOUS GASTROINTESTINAL DRUGS
MISOPROSTOL * 100UG TABLET 02240754 02244022 00813966
NOVO-MISOPROSTOL APO-MISOPROSTOL CYTOTEC
NOP APX PHU
$
0.2066 0.2066 0.2952
NOP APX PMS PHU
$
0.3440 0.3440 0.3440 0.4914
DOM PMS APX NOP GPM PMS
$
0.4764 * 0.5737 0.5737 0.5737 0.5737 0.9106
PMS APX NOP GPM PMS
$
1.0395 1.0395 1.0395 1.0395 1.6499
PHU
$
0.5176
AST
$
1.8988
AST
$
2.3900
SLV
$
2.0615
JAN
$
0.7053
* 200UG TABLET 02240755 02244023 02244125 00632600
NOVO-MISOPROSTOL APO-MISOPROSTOL PMS-MISOPROSTOL CYTOTEC
NIZATIDINE * 150MG CAPSULE 02185814 02177714 02220156 02240457 02246046 00778338
DOM-NIZATIDINE PMS-NIZATIDINE APO-NIZATIDINE NOVO-NIZATIDINE GEN-NIZATIDINE AXID
* 300MG CAPSULE 02177722 02220164 02240458 02246047 00778346
PMS-NIZATIDINE APO-NIZATIDINE NOVO-NIZATIDINE GEN-NIZATIDINE AXID
OLSALAZINE SODIUM 250MG CAPSULE 02063808
DIPENTUM
OMEPRAZOLE SEE APPENDIX A FOR EDS CRITERIA
10MG DELAYED RELEASE TABLET 02230737
LOSEC (EDS)
20MG DELAYED RELEASE TABLET 02190915
LOSEC (EDS)
PANTOPRAZOLE SEE APPENDIX A FOR EDS CRITERIA
40MG ENTERIC TABLET 02229453
PANTOLOC (EDS)
RABEPRAZOLE SODIUM SEE APPENDIX A FOR EDS CRITERIA
10MG TABLET 02243796
PARIET (EDS) 149
56:00 GASTROINTESTINAL DRUGS 56:40.00 MISCELLANEOUS GASTROINTESTINAL DRUGS
RANITIDINE * 150MG TABLET 00865737 00733059 00828564 00828823 02207761 02219077 02242453 02243229 02243038 02212331
NU-RANIT APO-RANITIDINE NOVO-RANIDINE RATIO-RANITIDINE GEN-RANITIDINE MED-RANITIDINE PMS-RANITIDINE RHOXAL-RANITIDINE DOM-RANITIDINE ZANTAC
NXP APX NOP RTP GPM MED PMS RHO DOM GSK
$
0.3513 * 0.4386 0.4386 0.4386 0.4386 0.4386 0.4386 0.4386 0.4605 1.1885
NXP APX NOP RTP GPM MED PMS RHO DOM GSK
$
0.6769 * 0.8449 0.8449 0.8449 0.8449 0.8449 0.8449 0.8449 0.8871 2.2373
GSK
$
0.2023
NXP NOP APX PMS DOM AVT
$
0.2557 * 0.3192 0.3192 0.3192 0.3352 0.5578
AVT
$
0.1014
* 300MG TABLET 00865745 00733067 00828556 00828688 02207788 02219085 02242454 02243230 02243039 00641790
NU-RANIT APO-RANITIDINE NOVO-RANIDINE RATIO-RANITIDINE GEN-RANITIDINE MED-RANITIDINE PMS-RANITIDINE RHOXAL-RANITIDINE DOM-RANITIDINE ZANTAC
15MG/ML ORAL SOLUTION 02212374
ZANTAC
SUCRALFATE * 1G TABLET 02134829 02045702 02125250 02238209 02239912 02100622
NU-SUCRALFATE NOVO-SUCRALATE APO-SUCRALFATE PMS-SUCRALFATE DOM-SUCRALFATE SULCRATE
200MG/ML ORAL SUSPENSION 02103567
SULCRATE SUSPENSION PLUS
150
56:00 GASTROINTESTINAL DRUGS 56:40.00 MISCELLANEOUS GASTROINTESTINAL DRUGS
SULFASALAZINE (SALICYLAZOSULFAPYRIDINE) * 500MG TABLET 00598461 00685933 02064480
PMS-SULFASALAZINE RATIO-SULFASALAZINE SALAZOPYRIN
PMS RTP PHU
$
0.0907 0.0907 0.2433
PMS RTP ICN PHU
$
0.1177 0.1177 0.2643 0.3832
FEI
$
0.3339
NOP PGA
$
0.4297 0.5371
FEI
$
0.6043
AXC GSK
$
0.5252 0.5934
FEI
$
4.0300
AXC
$
3.8100
FEI
$
4.4200
AXC
$
6.4700
FEI
$
4.8400
AXC
$
0.8348
AXC
$
1.1820
AXC FEI
$
1.7360 1.7686
* 500MG ENTERIC TABLET 00598488 00685925 00445126 02064472
PMS-SULFASALAZINE RATIO-SULFASALAZINE S.A.S. 500 SALAZOPYRIN
5-AMINOSALICYLIC ACID 250MG DELAYED RELEASE TABLET 02099675 ⌧
PENTASA
400MG ENTERIC COATED TABLET 02171929 01997580
NOVO-5-ASA ASACOL
500MG DELAYED RELEASE TABLET 02099683 ⌧
PENTASA
500MG ENTERIC COATED TABLET 02112787 01914030
SALOFALK MESASAL
1.0G/100ML RETENTION ENEMA 02153521
PENTASA
2.0G/60G RETENTION ENEMA 02112795
SALOFALK RETENTION ENEMA
2.0G/100ML RETENTION ENEMA 02153548
PENTASA
4.0G/60G RETENTION ENEMA 02112809
SALOFALK RETENTION ENEMA
4.0G/100ML RETENTION ENEMA 02153556
PENTASA
250MG SUPPOSITORY 02112752
SALOFALK
500MG SUPPOSITORY 02112760 ⌧
SALOFALK
1.0G SUPPOSITORY 02242146 02153564
SALOFALK PENTASA
151
GOLD COMPOUNDS
60:00
60:00 GOLD COMPOUNDS 60:00.00 GOLD COMPOUNDS
AURANOFIN AURANOFIN SHOULD BE CONSIDERED ONLY WHEN SALICYLATES OR OTHER NON-STEROIDAL ANTI-INFLAMMATORY DRUGS, AND, WHEN APPROPRIATE, STEROIDS, HAVE PROVEN TO BE INADEQUATE FOR CONTROLLING THE SYMPTOMS OF RHEUMATOID ARTHRITIS. PHYSICIANS PLANNING TO USE AURANOFIN SHOULD BE EXPERIENCED WITH CHRYSOTHERAPY AND SHOULD THOROUGHLY FAMILIARIZE THEMSELVES WITH THE TOXICITY AND BENEFITS OF AURANOFIN. ADVERSE REACTIONS WERE REPORTED IN 62% OF 4,784 PATIENTS TREATED WITH AURANOFIN. MOST COMMON WERE DIARRHEA (47%), RASH (24%), PRURITIS (17%), ABDOMINAL PAIN (14%), AND STOMATITIS (13%). POTENTIALLY SERIOUS ADVERSE REACTIONS WERE ANEMIA (1.6%), LEUKOPENIA (1.9%), THROMBOCYTOPENIA (0.9%) AND PROTEINUREA (5.0%).
3MG CAPSULE 01916823
RIDAURA
PMS
$
1.4034
SAW
$
116.2100
AVT
$
9.7800
AVT
$
11.8700
AVT
$
18.4400
AUROTHIOGLUCOSE 50MG/ML INJECTION SUSPENSION (10ML) 00855774
SOLGANAL
SODIUM AUROTHIOMALATE 10MG/ML INJECTION SOLUTION (1ML) 01927620
MYOCHRYSINE
25MG/ML INJECTION SOLUTION (1ML) 01927612
MYOCHRYSINE
50MG/ML INJECTION SOLUTION (1ML) 01927604
MYOCHRYSINE
154
METAL ANTAGONISTS
64:00
64:00 METAL ANTAGONISTS 64:00.00 METAL ANTAGONISTS
DEFEROXAMINE MESYLATE SEE APPENDIX A FOR EDS CRITERIA
* 500MG/VIAL POWDER FOR SOLUTION 02242055 01981242
PMS-DEFEROXAMINE (EDS) DESFERAL (EDS)
PMS NVR
$
8.8800 14.1900
PMS NVR
$
45.5700 56.9700
MSD
$
0.5315
MSD
$
0.7968
HOR
$
0.6838
* 2G/VIAL POWDER FOR SOLUTION 02243450 01981250
PMS-DEFEROXAMINE (EDS) DESFERAL (EDS)
PENICILLAMINE 125MG CAPSULE 00497894
CUPRIMINE
250MG CAPSULE 00016055
CUPRIMINE
250MG TABLET 00511641
DEPEN
156
HORMONES AND SUBSTITUTES
68:00
68:00 HORMONES AND SUBSTITUTES 68:04.00 ADRENAL CORTICOSTEROIDS COMPARABLE ANTI-INFLAMMATORY ACTIVITY OF ORAL CORTICOSTEROIDS (MINERALCORTICOID ACTIVITY NOT COMPARABLE)
DURATION OF ACTION
PRODUCT
COMPARABLE ANTI-INFLAMMATORY DOSE
SHORT ACTING
- CORTISONE - HYDROCORTISONE - PREDNISONE - METHYLPREDNISOLONE
INTERMEDIATE ACTING
- TRIAMCINOLONE
LONG ACTING
- DEXAMETHASONE - BETAMETHASONE
25 mg 20 mg 5 mg 4 mg 4 mg 0.75 mg 0.60 mg
THESE CLASSIFICATIONS ARE IMPORTANT CONSIDERATIONS IN ALTERNATE DAY STEROID THERAPY.
COMPARABLE ANTI-INFLAMMATORY ACTIVITY OF SOLUBLE INJECTABLE CORTICOSTEROIDS
PRODUCT
% ACTIVE BASE
COMPARABLE ANTI-INFLAMMATORY DOSE
HYDROCORTISONE SODIUM SUCCINATE
74.8
100 mg
DEXAMETHASONE 21 PHOSPHATE
76.1
4 mg
158
68:00 HORMONES AND SUBSTITUTES 68:04.00 ADRENAL CORTICOSTEROIDS
BECLOMETHASONE DIPROPIONATE * 50UG/INHALATION AEROSOL (PACKAGE) 00374407 00872334
VANCERIL INHALER RATIO-BECLOMETHASONE
SCH RTP
$
8.1400 8.1400
MDA
$
30.7600
MDA
$
61.5200
SCH SAB
$
4.2900 4.2900
AST
$
0.4340
AST
$
0.8680
AST
$
1.7360
AST
$
32.0700
AST
$
64.1300
AST
$
115.3900
MSD
$
0.1220
ICN MSD
$
0.3327 0.4557
50UG/INHALATION AEROSOL (PACKAGE) (CFC-FREE) 02242029
QVAR
100UG/INHALATION AEROSOL (PACKAGE) (CFC-FREE) 02242030
QVAR
BETAMETHASONE ACETATE/ BETAMETHASONE SODIUM PHOSPHATE * 3MG/3MG PER ML INJECTION SUSPENSION (1ML) 00028096 02237835
CELESTONE SOLUSPAN BETAJECT
BUDESONIDE 0.125MG/ML INHALATION SOLUTION (2ML) 02229099
PULMICORT NEBUAMP
0.25MG/ML INHALATION SOLUTION (2ML) 01978918
PULMICORT NEBUAMP
0.5MG/ML INHALATION SOLUTION (2ML) 01978926
PULMICORT NEBUAMP
100UG POWDER FOR INHALATION (PACKAGE) 00852074
PULMICORT TURBUHALER
200UG POWDER FOR INHALATION (PACKAGE) 00851752
PULMICORT TURBUHALER
400UG POWDER FOR INHALATION (PACKAGE) 00851760
PULMICORT TURBUHALER
CORTISONE ACETATE 5MG TABLET 00016438
CORTONE
* 25MG TABLET 00280437 00016446
CORTISONE CORTONE
159
68:00 HORMONES AND SUBSTITUTES 68:04.00 ADRENAL CORTICOSTEROIDS
DEXAMETHASONE * 0.5MG TABLET 00295094 01964976 02240684
DEXASONE PMS-DEXAMETHASONE RATIO-DEXAMETHASONE
ICN PMS RTP
$
0.2138 0.2138 0.2138
DEXASONE PMS-DEXAMETHASONE RATIO-DEXAMETHASONE
ICN PMS RTP
$
0.4883 0.4883 0.4883
PMS-DEXAMETHASONE RATIO-DEXAMETHASONE DEXASONE
PMS RTP ICN
$
0.8326 0.8326 0.8329
SAB CYT
$
9.1700 9.1700
RBP
$
0.2355
GSK
$
14.3300
GSK GSK
$
23.7700 23.7700
GSK GSK
$
39.0600 39.0600
GSK GSK
$
78.1200 78.1200
GSK
$
14.3300
$
23.7700
$
39.0600
$
78.1200
* 0.75MG TABLET 00285471 01964968 02240685
* 4MG TABLET 01964070 02240687 00489158
DEXAMETHASONE 21-PHOSPHATE * 4MG/ML INJECTION SOLUTION (5ML) 00664227 01977547
DEXAMETHASONE SOD PHO INJ DEXAMETHASONE SOD PHO INJ
FLUDROCORTISONE ACETATE 0.1MG TABLET 02086026
FLORINEF
FLUTICASONE PROPIONATE 25UG/INHALATION AEROSOL (PACKAGE) 02213583 ⌧
02213591 02244291 ⌧
FLOVENT FLOVENT HFA
125UG/INHALATION AEROSOL (PACKAGE) 02213605 02244292
⌧
FLOVENT
50UG/INHALATION AEROSOL (PACKAGE)
FLOVENT FLOVENT HFA
250UG/INHALATION AEROSOL (PACKAGE) 02213613 02244293
FLOVENT FLOVENT HFA
50UG/DOSE POWDER FOR INHALATION (PACKAGE) 02237244
FLOVENT DISKUS
100UG/DOSE POWDER FOR INHALATION (PACKAGE) 02237245
FLOVENT DISKUS
GSK
250UG/DOSE POWDER FOR INHALATION (PACKAGE) 02237246
FLOVENT DISKUS
GSK
500UG/DOSE POWDER FOR INHALATION (PACKAGE) 02237247
FLOVENT DISKUS
GSK
160
68:00 HORMONES AND SUBSTITUTES 68:04.00 ADRENAL CORTICOSTEROIDS
HYDROCORTISONE 10MG TABLET 00030910
CORTEF
PHU
$
0.1468
PHU
$
0.2653
PHU
$
3.4800
PHU
$
6.0500
PHU
$
0.3529
PHU
$
1.0182
PHU
$
5.1000
PHU
$
9.7700
PMS AVT
$
0.0832 0.1041
WINPRED APO-PREDNISONE
ICN APX
$
0.1123 0.1123
NOVO-PREDNISONE APO-PREDNISONE
NOP APX
$
0.0283 0.0283
NOP APX
$
0.1188 0.1188
STI
$
0.5246
20MG TABLET 00030929
CORTEF
HYDROCORTISONE SODIUM SUCCINATE 100MG INJECTION POWDER 00030600
SOLU-CORTEF
250MG INJECTION POWDER 00030619
SOLU-CORTEF
METHYLPREDNISOLONE 4MG TABLET 00030988
MEDROL
16MG TABLET 00036129
MEDROL
METHYLPREDNISOLONE ACETATE 40MG/ML INJECTION SUSPENSION (1ML) 00030759
DEPO-MEDROL
80MG/ML INJECTION SUSPENSION (1ML) 00030767
DEPO-MEDROL
PREDNISOLONE SODIUM PHOSPHATE * 1MG/ML ORAL LIQUID 02245532 02230619
PMS-PREDNISOLONE PEDIAPRED
PREDNISONE * 1MG TABLET 00271373 00598194
* 5MG TABLET 00021695 00312770
* 50MG TABLET 00232378 00550957
NOVO-PREDNISONE APO-PREDNISONE
TRIAMCINOLONE 4MG TABLET 02194090
ARISTOCORT
161
68:00 HORMONES AND SUBSTITUTES 68:04.00 ADRENAL CORTICOSTEROIDS
TRIAMCINOLONE ACETONIDE * 10MG/ML INJECTION SUSPENSION (5ML) 02229540 01999761
TRIAMCINOLONE ACETONIDE KENALOG 10
SAB WSD
$
12.9400 15.9400
CYT SAB WSD
$
5.9700 5.9700 7.4000
STI
$
6.7000
SAW
$
0.7733
SAW
$
1.1474
SAW
$
1.8336
CYT PHU
$
19.4800 25.1900
THM
$
5.3000
ORG
$
1.0199
* 40MG/ML INJECTION SUSPENSION (1ML) 01977563 02229550 01999869
TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE KENALOG 40
TRIAMCINOLONE HEXACETONIDE SEE APPENDIX A FOR EDS CRITERIA
20MG/ML INJECTION SUSPENSION 02194155
ARISTOSPAN (EDS)
68:08.00 ANDROGENS
DANAZOL 50MG CAPSULE 02018144
CYCLOMEN
100MG CAPSULE 02018152
CYCLOMEN
200MG CAPSULE 02018160
CYCLOMEN
TESTOSTERONE CYPIONATE * 100MG/ML OILY INJECTION SOLUTION (10ML) 01977601 00030783
TESTOSTERONE CYPIONATE DEPO-TESTOSTERONE
TESTOSTERONE ENANTHATE 200MG/ML OILY INJECTION SOLUTION (ML) 00029246
DELATESTRYL
TESTOSTERONE UNDECANOATE 40MG CAPSULE 00782327
ANDRIOL
162
68:00 HORMONES AND SUBSTITUTES 68:12.00 CONTRACEPTIVES
ETHINYL ESTRADIOL/D-NORGESTREL 0.05MG/0.25MG (21 TABLET) 02043033
OVRAL
WYA
$
12.6900
WYA
$
12.6900
JAN ORG
$
12.5300 12.7300
JAN ORG
$
12.5300 12.7300
PHU
$
12.6600
PHU
$
13.5500
WYA
$
12.4800
WYA
$
12.4800
BEX WYA
$
11.7000 12.4200
BEX WYA
$
11.7000 12.4200
WYA
$
12.3600
WYA
$
12.3600
0.05MG/0.25MG (28 TABLET) 02043041
OVRAL
ETHINYL ESTRADIOL/DESOGESTREL ⌧
0.03MG/0.15MG (21 TABLET) 02042541 02042487
⌧
ORTHO-CEPT MARVELON
0.03MG/0.15MG (28 TABLET) 02042533 02042479
ORTHO-CEPT MARVELON
ETHINYL ESTRADIOL/ETHYNODIOL DIACETATE 0.03MG/2MG (21 TABLET) 00469327
DEMULEN 30
0.03MG/2MG (28 TABLET) 00471526
DEMULEN 30
ETHINYL ESTRADIOL/L-NORGESTREL 0.02MG/0.1MG (21 TABLET) 02236974
ALESSE
0.02MG/0.1MG (28 TABLET) 02236975 ⌧
00707600 02043726 ⌧
ALESSE
0.03MG/0.05MG(6)0.04MG/0.075MG(5) 0.03MG/0.125MG(10) (21 TABLET) TRIQUILAR TRIPHASIL
0.03MG/0.05MG(6)0.04MG/0.075MG(5) 0.03MG/0.125MG(10) INERT TABLETS (7) (28 TABLET) 00707503 02043734
TRIQUILAR TRIPHASIL
0.03MG/0.15MG (21 TABLET) 02042320
MIN-OVRAL
0.03MG/0.15MG (28 TABLET) 02042339
MIN-OVRAL
163
68:00 HORMONES AND SUBSTITUTES 68:12.00 CONTRACEPTIVES
ETHINYL ESTRADIOL/NORETHINDRONE ⌧
0.035MG/0.5MG (21 TABLET) 02187086 00317047
⌧
BREVICON ORTHO 0.5/35
PHU JAN
$
11.6000 12.5300
PHU JAN
$
11.6000 12.5300
JAN
$
12.5300
JAN
$
12.5300
PHU
$
11.0900
PHU
$
11.0900
PHU PHU JAN
$
7.8400 11.6000 12.5300
PHU PHU JAN
$
7.8400 11.6000 12.5300
PFI
$
12.6800
PFI
$
12.6800
PFI
$
12.6800
PFI
$
12.6800
0.035MG/0.5MG (28 TABLET) 02187094 00340731
BREVICON ORTHO 0.5/35
0.035MG/0.5MG (7) 0.035MG/0.75MG (7) 0.035/1.0MG (7) (21 TABLET) 00602957
ORTHO 7/7/7
0.035MG/0.5MG (7) 0.035MG/0.75MG (7) 0.035MG/1.0MG (7) INERT TABLETS (7) (28 TABLET) 00602965
ORTHO 7/7/7
0.035MG/0.5MG(7)0.035MG/1.0MG(9) 0.035MG/0.5MG(5) (21 TABLET) 02187108
SYNPHASIC
0.035MG/0.5MG(7)0.035MG/1.0MG(9) 0.035MG/0.5MG(5) INERT TABLETS (7) (28 TABLET) 02187116 ⌧
02197502 02189054 00372846 ⌧
SYNPHASIC
0.035MG/1MG (21 TABLET) SELECT 1/35 BREVICON 1/35 ORTHO 1/35
0.035MG/1MG (28 TABLET) 02199297 02189062 00372838
SELECT 1/35 BREVICON 1/35 ORTHO 1/35
ETHINYL ESTRADIOL/NORETHINDRONE ACETATE 0.02MG/1MG (21 TABLET) 00315966
MINESTRIN 1/20
0.02MG/1MG (28 TABLET) 00343838
MINESTRIN 1/20
0.03MG/1.5MG (21 TABLET) 00297143
LOESTRIN 1.5/30
0.03MG/1.5MG (28 TABLET) 00353027
LOESTRIN 1.5/30
164
68:00 HORMONES AND SUBSTITUTES 68:12.00 CONTRACEPTIVES
ETHINYL ESTRADIOL/NORGESTIMATE 0.035MG/0.18MG (7) 0.035MG/0.215MG (7) 0.035MG/0.25MG (7) (21 TABLET) 02028700
TRI-CYCLEN
JAN
$
12.5300
JAN
$
12.5300
JAN
$
12.5300
JAN
$
12.5300
PAL
$
8.6600
WYA
$
480.0000
BEX
$
314.6500
JAN
$
12.5300
JAN
$
12.5300
0.035MG/0.18MG (7) 0.035MG/0.215MG (7) 0.035MG/0.25MG (7) (28 TABLET) 02029421
TRI-CYCLEN
0.035MG/0.25MG (21 TABLET) 01968440
CYCLEN
0.035MG/0.25MG (28 TABLET) 01992872
CYCLEN
LEVONORGESTREL 0.75MG TABLET 02241674
PLAN B
36MG SUBDERMAL IMPLANTS 02060590
NORPLANT
52MG EXTENDED RELEASE INTRAUTERINE INSERT 02243005
MIRENA
MESTRANOL/NORETHINDRONE 0.05MG/1MG (21 TABLET) 00022608
ORTHO-NOVUM 1/50
NORETHINDRONE 0.35MG (28 TABLET) 00037605
MICRONOR
165
68:00 HORMONES AND SUBSTITUTES 68:16.00 ESTROGENS
CONJUGATED ESTROGENS ⌧
0.3MG TABLET 02230891 02043394
⌧
$
0.0862 0.1151
PMS-CONJUGATED ESTROGENS C.E.S. PREMARIN
PMS ICN WYA
$
0.0814 0.1055 0.1321
ICN WYA
$
0.2061 0.2750
PMS ICN WYA
$
0.1384 0.1877 0.2348
WYA
$
0.3738
0.9MG TABLET 02230892 02043416
⌧
ICN WYA
0.625MG TABLET 00587281 00265470 02043408
⌧
C.E.S. PREMARIN
C.E.S. PREMARIN
1.25MG TABLET 00587303 00265489 02043424
PMS-CONJUGATED ESTROGENS C.E.S. PREMARIN
0.625MG/G VAGINAL CREAM 02043440
PREMARIN
CONJUGATED ESTROGENS/MEDROXYPROGESTERONE ACETATE 0.625MG/2.5MG TABLET (PACKAGE) 02242878
PREMPLUS
WYA
$
7.6000
WYA
$
7.6000
ESTRACE
RBP
$
0.1113
ESTRACE
RBP
$
0.2149
ESTRACE
RBP
$
0.3792
SCH
$
19.4800
PHU
$
65.1000
NOO
$
2.3900
0.625MG/5MG TABLET (PACKAGE) 02242879
PREMPLUS
ESTRADIOL SEE APPENDIX A FOR EDS CRITERIA
0.5MG TABLET 02225190
1MG TABLET 02148587
2MG TABLET 02148595
0.06% TRANSDERMAL GEL SPRAY (PACKAGE) 02238704
ESTROGEL (EDS)
2MG VAGINAL RING (7.5UG/24 HOURS) 02168898
ESTRING
25UG VAGINAL TABLET 02241332
VAGIFEM
166
68:00 HORMONES AND SUBSTITUTES 68:16.00 ESTROGENS ⌧
25UG TRANSDERMAL THERAPEUTIC SYSTEM (PKG) 00756849 02243722
⌧
19.8000 21.1600
VIVELLE (EDS) ESTRADOT (EDS)
NVR NVR
$
19.8000 19.8000
ESTRADERM (EDS) VIVELLE (EDS) CLIMARA 50 (EDS) OESCLIM (EDS) ESTRADOT (EDS)
NVR NVR BEX PAL NVR
$
21.1600 21.1600 21.1600 21.1600 21.1600
$
22.7100 22.7100
$
23.8700 23.8700 23.8700 23.8700
75UG TRANSDERMAL THERAPEUTIC SYSTEM (PKG) 02204436 02244001
⌧
$
50UG TRANSDERMAL THERAPEUTIC SYSTEM (PKG) 00756857 02204428 02231509 02243724 02244000
⌧
NVR PAL
37.5UG TRANSDERMAL THERAPEUTIC SYSTEM (PKG) 02204401 02243999
⌧
ESTRADERM (EDS) OESCLIM (EDS)
VIVELLE (EDS) ESTRADOT (EDS)
NVR NVR
100UG TRANSDERMAL THERAPEUTIC SYSTEM (PKG) 00756792 02204444 02231510 02244002
ESTRADERM (EDS) VIVELLE (EDS) CLIMARA 100 (EDS) ESTRADOT (EDS)
NVR NVR BEX NVR
ESTRADIOL & NORETHINDRONE ACETATE/ESTRADIOL SEE APPENDIX A FOR EDS CRITERIA
50UG & 140UG/50UG TRANSDERMAL THERAPEUTIC SYSTEM (8) 02243529 ⌧
ESTALIS-SEQUI (EDS)
NVR
$
22.4100
NVR NVR
$
22.4100 22.4100
THM
$
17.8600
$
23.6600
$
23.6600
50UG & 250UG/50UG TRANSDERMAL THERAPEUTIC SYSTEM (8) 02108186 02243530
ESTRACOMB (EDS) ESTALIS-SEQUI (EDS)
ESTRADIOL VALERATE 10MG/ML OILY INJECTION SUSPENSION (5ML) 00029238
DELESTROGEN
ESTRADIOL/NORETHINDRONE ACETATE SEE APPENDIX A FOR EDS CRITERIA
50UG/140UG TRANSDERMAL THERAPEUTIC SYSTEM (8 ) 02241835
ESTALIS (EDS)
NVR
50UG/250UG TRANSDERMAL THERAPEUTIC SYSTEM (8 ) 02241837
ESTALIS (EDS)
NVR
167
68:00 HORMONES AND SUBSTITUTES 68:16.00 ESTROGENS
ESTROPIPATE (CALCULATED AS SODIUM ESTRONE SULFATE) 0.625MG TABLET 02089793
OGEN
PHU
$
0.1704
PHU
$
0.3043
PHU
$
0.4811
WEL
$
0.2329
STILBESTROL
WEL
$
0.2821
STILBESTROL
WEL
$
0.3069
LIL
$
1.6926
SRO
$
55.9900
$
19.7300
1.25MG TABLET 02089769
OGEN
2.5MG TABLET 02089777
OGEN
STILBOESTROL 0.1MG TABLET 02091488
STILBESTROL
0.5MG TABLET 02100304
1MG TABLET 02091461
68:16.12 ESTROGEN AGONIST-ANTAGONISTS
RALOXIFENE HCL SEE APPENDIX A FOR EDS CRITERIA
60MG TABLET 02239028
EVISTA (EDS)
68:18.00 GONADOTROPINS
CHORIONIC GONADOTROPIN SEE APPENDIX A FOR EDS CRITERIA
10000IU/VIAL INJECTION 01925679
PROFASI HP (EDS)
68:20.08 ANTI-DIABETIC DRUGS (INSULINS-PORK)
INSULIN (ISOPHANE) PORK 100U/ML INJECTION SUSPENSION (10ML) 00514551
NPH ILETIN II PORK
LIL
168
68:00 HORMONES AND SUBSTITUTES 68:20.08 ANTI-DIABETIC DRUGS (INSULINS-PORK)
INSULIN (LENTE) PORK 100U/ML INJECTION SUSPENSION (10ML) 00514535
LENTE ILETIN II, PORK
LIL
$
19.7300
LIL
$
19.7300
LIL NOO
$
16.2900 16.8400
NOO LIL
$
33.6700 33.7700
LIL NOO
$
16.2900 16.8400
NOO
$
24.1200
NOO
$
48.2700
LIL NOO
$
16.2900 16.8400
NOO LIL
$
33.6700 33.7700
INSULIN (REGULAR) PORK 100U/ML INJECTION SOLUTION (10ML) 00513644
REGULAR ILETIN II, PORK
68:20.08 ANTI-DIABETIC DRUGS (INSULINS-HUMAN BIOSYNTHETIC)
INSULIN (ISOPHANE) HUMAN BIOSYNTHETIC ⌧
100U/ML INJECTION SUSPENSION (10ML) 00587737 02024225
⌧
HUMULIN-N NOVOLIN GE NPH
100U/ML INJECTION SUSPENSION (5X3ML) 02024268 01959239
NOVOLIN GE NPH PENFILL HUMULIN-N CARTRIDGE
INSULIN (LENTE) HUMAN BIOSYNTHETIC ⌧
100U/ML INJECTION SUSPENSION (10ML) 00646148 02024241
HUMULIN-L NOVOLIN GE LENTE
INSULIN (REGULAR) ASPART SEE APPENDIX A FOR EDS CRITERIA
100U/ML INJECTION SOLUTION (10ML) 02245397
NOVORAPID (EDS)
100U/ML INJECTION SOLUTION (5X3ML) 02244353
NOVORAPID (EDS)
INSULIN (REGULAR) HUMAN BIOSYNTHETIC ⌧
100U/ML INJECTION SOLUTION (10ML) 00586714 02024233
⌧
HUMULIN-R NOVOLIN GE TORONTO
100U/ML INJECTION SOLUTION (5X3ML) 02024284 01959220
NOVOLIN GE TORONTO PENFIL HUMULIN-R CARTRIDGE
169
68:00 HORMONES AND SUBSTITUTES 68:20.08 ANTI-DIABETIC DRUGS (INSULINS-HUMAN BIOSYNTHETIC)
INSULIN (REGULAR) LISPRO SEE APPENDIX A FOR EDS CRITERIA
100U/ML INJECTION SOLUTION (10ML) 02229704
HUMALOG (EDS)
LIL
$
24.1500
LIL
$
48.3000
100U/ML INJECTION SOLUTION (5X3ML) 02229705
HUMALOG CARTRIDGE (EDS)
INSULIN (REGULAR/ISOPHANE) HUMAN BIOSYNTHETIC 100U/ML INJECTION SUSPENSION 10%/90% (5X3ML) 02024292 ⌧
02024306 01962655 ⌧
NOO
$
33.6700
NOVOLIN GE 20/80 PENFILL HUMULIN 20/80 CARTRIDGE
NOO LIL
$
33.6700 33.7700
LIL NOO
$
16.2900 16.8400
NOO LIL
$
33.6700 33.7700
NOO
$
33.6700
NOO
$
33.6700
LIL
$
48.3000
$
16.2900 16.8400
100U/ML INJECTION SUSPENSION 30%/70% (10ML) 00795879 02024217
⌧
NOVOLIN GE 10/90 PENFILL
100U/ML INJECTION SUSPENSION 20%/80% (5X3ML)
HUMULIN 30/70 NOVOLIN GE 30/70
100U/ML INJECTION SUSPENSION 30%/70% (5X3ML) 02025248 01959212
NOVOLIN GE 30/70 PENFILL HUMULIN 30/70 CARTRIDGE
100U/ML INJECTION SUSPENSION 40%/60% (5X3ML) 02024314
NOVOLIN GE 40/60 PENFILL
100U/ML INJECTION SUSPENSION 50%/50% (5X3ML) 02024322
NOVOLIN GE 50/50 PENFILL
INSULIN (REGULAR/PROTAMINE) LISPRO SEE APPENDIX A FOR EDS CRITERIA
100U/ML INJECTION SUSPENSION 25%/75% (5X3ML) 02240294
HUMALOG MIX25 (EDS)
INSULIN (ULTRALENTE) HUMAN BIOSYNTHETIC ⌧
100U/ML INJECTION SUSPENSION (10ML) 00733075 02024276
HUMULIN-U NOVOLIN GE ULTRALENTE
170
LIL NOO
68:00 HORMONES AND SUBSTITUTES 68:20.20 ANTI-DIABETIC DRUGS (ORAL HYPOGLYCEMICS)
ACARBOSE 50MG TABLET 02190885
PRANDASE
BAY
$
0.2453
BAY
$
0.3390
APX
$
0.0782
NOP APX
$
0.0454 0.1075
NU-GLYBURIDE EUGLUCON GEN-GLYBE RATIO-GLYBURIDE APO-GLYBURIDE NOVO-GLYBURIDE MED-GLYBURIDE PMS-GLYBURIDE DOM-GLYBURIDE DIABETA
NXP PMS GPM RTP APX NOP MED PMS DOM AVT
$
0.0342 * 0.0427 0.0427 0.0427 0.0427 0.0427 0.0427 0.0427 0.0449 0.1144
NU-GLYBURIDE APO-GLYBURIDE EUGLUCON GEN-GLYBE NOVO-GLYBURIDE MED-GLYBURIDE PMS-GLYBURIDE RATIO-GLYBURIDE DOM-GLYBURIDE DIABETA
NXP APX PMS GPM NOP MED PMS RTP DOM AVT
$
0.0594 * 0.0741 0.0741 0.0741 0.0741 0.0741 0.0741 0.0743 0.0778 0.2051
100MG TABLET 02190893
PRANDASE
CHLORPROPAMIDE 100MG TABLET 00399302
APO-CHLORPROPAMIDE
* 250MG TABLET 00021350 00312711
NOVO-PROPAMIDE APO-CHLORPROPAMIDE
GLYBURIDE * 2.5MG TABLET 02020734 00720933 00808733 01900927 01913654 01913670 02084341 02236733 02234513 02224550
* 5MG TABLET 02020742 01913662 00720941 00808741 01913689 02085887 02236734 01900935 02234514 02224569
171
68:00 HORMONES AND SUBSTITUTES 68:20.20 ANTI-DIABETIC DRUGS (ORAL HYPOGLYCEMICS)
METFORMIN * 500MG TABLET 02162822 02167786 02045710 02148765 02223562 02229516 02230670 02233999 02242794 02242974 02229994 02099233
NU-METFORMIN APO-METFORMIN NOVO-METFORMIN GEN-METFORMIN PMS-METFORMIN GLYCON MED-METFORMIN RHOXAL-METFORMIN METFORMIN RATIO-METFORMIN DOM-METFORMIN GLUCOPHAGE
NXP APX NOP GPM PMS ICN MED RHO ZYP RTP DOM AVT
$
0.1034 * 0.1320 0.1320 0.1320 0.1320 0.1320 0.1320 0.1320 0.1320 0.1320 0.1504 0.2387
NXP GPM APX NOP PMS ZYP DOM AVT
$
0.1817 * 0.2268 0.2268 0.2268 0.2268 0.2268 0.2382 0.3025
NVR
$
0.5859
NVR
$
0.5859
NVR
$
0.5859
LIL
$
2.1375
LIL
$
2.9946
LIL
$
4.4834
* 850MG TABLET 02229517 02229656 02229785 02230475 02242589 02242793 02242726 02162849
NU-METFORMIN GEN-METFORMIN APO-METFORMIN NOVO-METFORMIN PMS-METFORMIN METFORMIN DOM-METFORMIN GLUCOPHAGE
NATEGLINIDE SEE APPENDIX A FOR EDS CRITERIA
60MG TABLET 02245438
STARLIX (EDS)
120MG TABLET 02245439
STARLIX (EDS)
180MG TABLET 02245440
STARLIX (EDS)
PIOGLITAZONE HCL SEE APPENDIX A FOR EDS CRITERIA
15MG TABLET 02242572
ACTOS (EDS)
30MG TABLET 02242573
ACTOS (EDS)
45MG TABLET 02242574
ACTOS (EDS)
172
68:00 HORMONES AND SUBSTITUTES 68:20.20 ANTI-DIABETIC DRUGS (ORAL HYPOGLYCEMICS)
REPAGLINIDE SEE APPENDIX A FOR EDS CRITERIA
0.5MG TABLET 02239924
GLUCONORM (EDS)
NOO
$
0.2713
GLUCONORM (EDS)
NOO
$
0.2821
GLUCONORM (EDS)
NOO
$
0.2930
AVANDIA (EDS)
GSK
$
1.3346
AVANDIA (EDS)
GSK
$
2.0941
AVANDIA (EDS)
GSK
$
2.9946
APX
$
0.0896
FEI
$
8.4900
AVT
$
45.2200
NVR
$
26.5900
NVR
$
23.0900
1MG TABLET 02239925
2MG TABLET 02239926
ROSIGLITAZONE MALEATE SEE APPENDIX A FOR EDS CRITERIA
2MG TABLET 02241112
4MG TABLET 02241113
8MG TABLET 02241114
TOLBUTAMIDE 500MG TABLET 00312762
APO-TOLBUTAMIDE
68:24.00 PARATHYROID
CALCITONIN SALMON SEE APPENDIX A FOR EDS CRITERIA
100IU/ML INJECTION (1ML) 02007134
CALTINE 100 (EDS)
200IU/ML INJECTION 01926691
CALCIMAR (EDS)
200IU/DOSE NASAL SPRAY (BOTTLE) 02240775
MIACALCIN (EDS)
68:28.00 PITUITARY AGENTS
COSYNTROPIN ZINC HYDROXIDE 1MG/ML INJECTION SUSPENSION (1ML) 00253952
SYNACTHEN DEPOT
173
68:00 HORMONES AND SUBSTITUTES 68:28.00 PITUITARY AGENTS
DESMOPRESSIN SEE APPENDIX A FOR EDS CRITERIA
0.1MG TABLET 00824305
D.D.A.V.P. (EDS)
FEI
$
1.4341
FEI
$
2.8681
FEI
$
10.5300
FEI
$
51.2200
APX FEI
$
71.7000 102.4300
FEI
$
416.0000
HLR
$
205.9000
HLR
$
396.8000
SRO
$
136.7100
HLR SRO LIL
$
195.9000 205.2300 238.3500
LIL
$
303.8300
HLR
$
386.8000
LIL
$
590.2400
0.2MG TABLET 00824143
D.D.A.V.P. (EDS)
4UG/ML INJECTION (1ML) 00873993
D.D.A.V.P. (EDS)
10UG/DOSE INTRANASAL SOLUTION 00402516
D.D.A.V.P. (EDS)
* 10UG/DOSE INTRANASAL SOLUTION (SPRAY PUMP) 02242465 00836362
APO-DESMOPRESSIN (EDS) D.D.A.V.P. (EDS)
150UG/DOSE INTRANASAL SOLUTION (SPRAY PUMP) 02237860
OCTOSTIM (EDS)
SOMATREM SEE APPENDIX A FOR EDS CRITERIA
5MG INJECTION (VIAL) 02204584
PROTROPIN (EDS)
10MG INJECTION (VIAL) 02204576
PROTROPIN (EDS)
SOMATROPIN SEE APPENDIX A FOR EDS CRITERIA
3.33MG INJECTION (VIAL) 02215136 ⌧
SAIZEN (EDS)
5MG INJECTION (VIAL) 02216183 02237971 00745626
NUTROPIN (EDS) SAIZEN (EDS) HUMATROPE (EDS)
6MG INJECTION (CARTRIDGE) 02243077
HUMATROPE CARTRIDGE (EDS)
10MG INJECTION (VIAL) 02229722
NUTROPIN AQ (EDS)
12MG INJECTION (CARTRIDGE) 02243078
HUMATROPE CARTRIDGE (EDS)
174
68:00 HORMONES AND SUBSTITUTES 68:32.00 PROGESTINS
CONJUGATED ESTROGENS/MEDROXYPROGESTERONE ACETATE SEE SECTION 68:16.00 (ESTROGENS)
ESTRADIOL & NORETHINDRONE ACETATE/ESTRADIOL SEE SECTION 68:16.00 (ESTROGENS)
ESTRADIOL/NORETHINDRONE ACETATE SEE SECTION 68:16.00 (ESTROGENS)
MEDROXYPROGESTERONE ACETATE * 2.5MG TABLET 02148552 02221284 02244726 02229838 00708917
RATIO-MPA NOVO-MEDRONE APO-MEDROXY GEN-MEDROXY PROVERA
RTP NOP APX GPM PHU
$
0.0862 0.0862 0.0862 0.0889 0.1670
RATIO-MPA NOVO-MEDRONE APO-MEDROXY GEN-MEDROXY PROVERA
RTP NOP APX GPM PHU
$
0.1703 0.1703 0.1703 0.1758 0.3303
RTP NOP GPM PHU
$
0.3439 0.3439 0.3548 0.6702
PHU
$
25.2400
PHU
$
27.0800
SCH
$
0.6970
* 5MG TABLET 02148560 02221292 02244727 02229839 00030937
* 10MG TABLET 02148579 02221306 02229840 00729973
RATIO-MPA NOVO-MEDRONE GEN-MEDROXY PROVERA
50MG/ML INJECTION SUSPENSION (5ML) 00030848
DEPO-PROVERA
150MG/ML INJECTION SUSPENSION (1ML) 00585092
DEPO-PROVERA
PROGESTERONE (MICRONIZED) SEE APPENDIX A FOR EDS CRITERIA
100MG CAPSULE 02166704
PROMETRIUM (EDS)
175
68:00 HORMONES AND SUBSTITUTES 68:36.04 THYROID AGENTS
LEVOTHYROXINE (SODIUM) 0.025MG TABLET 02172062
SYNTHROID
ABB
$
0.0782
GSK ABB
$
0.0431 0.0574
ABB
$
0.0843
ABB
$
0.0843
GSK ABB
$
0.0332 0.0708
ABB
$
0.0890
ABB
$
0.0901
GSK ABB
$
0.0369 0.0758
ABB
$
0.0966
GSK ABB
$
0.0391 0.0809
GSK ABB
$
0.0934 0.1116
THM
$
0.1047
THM
$
0.1270
PFI
$
0.0384
PFI
$
0.0478
PFI
$
0.0609
* 0.05MG TABLET 02213192 02172070
ELTROXIN SYNTHROID
0.075MG TABLET 02172089
SYNTHROID
0.088MG TABLET 02172097
SYNTHROID
* 0.1MG TABLET 02213206 02172100
ELTROXIN SYNTHROID
0.112MG TABLET 02171228
SYNTHROID
0.125MG TABLET 02172119
SYNTHROID
* 0.15MG TABLET 02213214 02172127
ELTROXIN SYNTHROID
0.175MG TABLET 02172135
SYNTHROID
* 0.2MG TABLET 02213222 02172143
ELTROXIN SYNTHROID
* 0.3MG TABLET 02213230 02172151
ELTROXIN SYNTHROID
LIOTHYRONINE (SODIUM) 5UG TABLET 01919458
CYTOMEL
25UG TABLET 01919466
CYTOMEL
THYROID 30MG TABLET 00023949
THYROID
60MG TABLET 00023957
THYROID
125MG TABLET 00023965
THYROID
176
68:00 HORMONES AND SUBSTITUTES 68:36.08 ANTITHYROID AGENTS
METHIMAZOLE 5MG TABLET 00015741
TAPAZOLE
PMS
$
0.1305
PMS
$
0.1277
PMS
$
0.1999
PROPYLTHIOURACIL 50MG TABLET 00010200
PROPYL-THYRACIL
100MG TABLET 00010219
PROPYL-THYRACIL
177
SKIN AND MUCOUS MEMBRANE PREPARATIONS
84:00
84:00 SKIN AND MUCOUS MEMBRANE PREPARATIONS 84:04.04 ANTI-INFECTIVES (ANTIBIOTICS)
CLINDAMYCIN PHOSPHATE 1% TOPICAL SOLUTION 00582301
DALACIN T
PHU
$
0.3068
WSD
$
0.1666
GAC
$
0.1549
WSD
$
0.1666
WSD
$
0.1666
AVT
$
1.0254
AVT
$
2.9784
FUCIDIN
LEO
$
0.6258
BACTROBAN
GSK
$
0.5512
GSK
$
0.5512
ERYTHROMYCIN/ETHYL ALCOHOL 1.5%/55% TOPICAL LOTION 01910086
STATICIN
2%/44% TOPICAL LOTION 01902628
SANS-ACNE
2%/71.2% TOPICAL LOTION 02047802
T-STAT
2%/71.2% TOPICAL LOTION/PRE-MOISTENED PADS 02047799
T-STAT
FRAMYCETIN SO4 1% GAUZE (10CM X 10CM) 01988840
SOFRA-TULLE
1% GAUZE (30CM X 10CM) 01987682
SOFRA-TULLE
FUSIDIC ACID 2% TOPICAL CREAM 00586668
MUPIROCIN 2% CREAM 02239757
2% OINTMENT 01916947
BACTROBAN
POLYMYXIN B SO4/NEOMYCIN SO4/BACITRACIN(ZINC) * 5,000U/5MG/400U PER G TOPICAL OINTMENT 00653268 00666122
RATIO-NEOTOPIC NEOSPORIN
RTP GSK
$
0.3502 0.4449
GSK
$
0.4449
LEO
$
0.6258
POLYMYXIN B SO4/NEOMYCIN SO4/GRAMICIDIN 10,000U/5MG/0.25MG PER G TOPICAL CREAM 00666203
NEOSPORIN
SODIUM FUSIDATE 2% TOPICAL OINTMENT 00586676
FUCIDIN
180
84:00 SKIN AND MUCOUS MEMBRANE PREPARATIONS 84:04.08 ANTI-INFECTIVES (ANTI-FUNGALS)
CICLOPIROX OLAMINE 1% TOPICAL CREAM 02221802
LOPROX
AVT
$
0.5968
AVT
$
0.5498
BCD
$
12.7300
TAR BCD
$
0.2279 0.3596
TAR BCD
$
0.1899 0.2331
TAR BCD
$
0.3798 0.4662
BCD
$
12.7300
WSD
$
6.0689
WSD
$
0.4630
OPT MCL
$
0.3437 0.4915
1% TOPICAL LOTION 02221810
LOPROX
CLOTRIMAZOLE 200MG VAGINAL TABLET 02150921
CANESTEN-3-COMBI-PAK
* 1% TOPICAL CREAM 00812382 02150867
CLOTRIMADERM CANESTEN
* 1% VAGINAL CREAM 00812366 02150891
CLOTRIMADERM CANESTEN-6
* 2% VAGINAL CREAM 00812374 02150905
CLOTRIMADERM CANESTEN-3
500MG VAGINAL SUPPOSITORY/1% TOPICAL CREAM (COMBINATION PACKAGE) 02150948
CANESTEN-1-COMBI-PAK
ECONAZOLE NITRATE 150MG VAGINAL SUPPOSITORY 02010267
ECOSTATIN
1% TOPICAL CREAM 02011948
ECOSTATIN
KETOCONAZOLE * 2% TOPICAL CREAM 02245662 00703974
KETODERM NIZORAL
181
84:00 SKIN AND MUCOUS MEMBRANE PREPARATIONS 84:04.08 ANTI-INFECTIVES (ANTI-FUNGALS)
MICONAZOLE NITRATE 100MG VAGINAL SUPPOSITORY 02084295
MONISTAT-7
MCL
$
1.6400
MCL
$
13.1300
VTH MCL
$
2.0398 3.8265
MCL
$
13.1300
MCL
$
0.3280
MCL
$
0.3668
RTP
$
0.1519
TAR RTP PPZ
$
0.0760 0.1269 0.3038
TAR RTP
$
0.1556 0.1556
TAR PPZ
$
0.0534 0.0955
RTP
$
0.2774
WSD
$
0.4022
NVR
$
0.4883
NVR
$
0.4883
100MG VAGINAL SUPPOSITORY/2% TOPICAL CREAM (COMBINATION PACKAGE) 02126257
MONISTAT 7 COMBINATION
* 400MG VAGINAL OVULES 02171775 02126605
MICONAZOLE 3 DAY OVULE MONISTAT-3
400MG VAGINAL OVULES/2% TOPICAL CREAM (COMBINATION PACKAGE) 02126249
MONISTAT 3 COMBINATION
2% VAGINAL CREAM 02084309
MONISTAT-7
2% TOPICAL CREAM 02085852
MICATIN
NYSTATIN 100,000U VAGINAL TABLET 02194171
RATIO-NYSTATIN
* 100,000U/G TOPICAL CREAM 00716871 02194236 00029092
NYADERM RATIO-NYSTATIN MYCOSTATIN
* 100,000U/G TOPICAL OINTMENT 00716898 02194228
NYADERM RATIO-NYSTATIN
* 25,000U/G VAGINAL CREAM 00716901 00295973
NYADERM MYCOSTATIN
100,000U/G VAGINAL CREAM 02194163
RATIO-NYSTATIN
100,000U/G TOPICAL POWDER 02195704
CANDISTATIN
TERBINAFINE HCL 1% TOPICAL CREAM 02031094
LAMISIL
1% TOPICAL SPRAY SOLUTION 02238703
LAMISIL
182
84:00 SKIN AND MUCOUS MEMBRANE PREPARATIONS 84:04.08 ANTI-INFECTIVES (ANTI-FUNGALS)
TERCONAZOLE 80MG VAGINAL OVULES 00894710
TERAZOL-3
JAN
$
6.3364
JAN
$
19.0100
JAN
$
19.0100
JAN
$
19.0100
80MG VAGINAL OVULES/0.8% CREAM (DUAL-PAK) 02130874
TERAZOL-3 DUAL-PAK
0.4% VAGINAL CREAM (PKG) 00894729
TERAZOL-7
0.8% VAGINAL CREAM (PKG) 01934155
TERAZOL-3
84:04.12 ANTI-INFECTIVES (SCABICIDES AND PEDICULICIDES)
CROTAMITON 10% TOPICAL CREAM 00623377
EURAX
CLC
$
0.4471
MED
$
17.3600
PMS
$
0.0999
ODN PMS
$
0.0999 0.0999
PFC GCH
$
0.1129 0.1129
GSK
$
0.4991
GCH
$
0.2843
GCH
$
0.1027
ESDEPALLATHRIN/PIPERONYL BUTOXIDE 0.63%/5.04% AEROSOL 02229874
SCABENE
GAMMA-BENZENE HEXACHLORIDE 1% TOPICAL LOTION 00703591
PMS-LINDANE
* 1% SHAMPOO 00430617 00703605
HEXIT SHAMPOO PMS-LINDANE
PERMETHRIN * 1% CREME RINSE 00771368 02231480
NIX CREME RINSE KWELLADA-P CREME RINSE
5% TOPICAL CREAM 02219905
NIX DERMAL CREAM
5% TOPICAL LOTION 02231348
KWELLADA-P LOTION
PYRETHINS/PIPERONYL BUTOXIDE/ PETROLEUM DISTILLATE 0.33%/3.0%/1.2% SHAMPOO/CONDITIONER 02125447
R&C SHAMPOO/CONDITIONER
183
84:00 SKIN AND MUCOUS MEMBRANE PREPARATIONS 84:04.16 MISCELLANEOUS ANTI-INFECTIVES
HEXACHLOROPHENE 3% TOPICAL EMULSION 02017733
PHISOHEX
SAW
$
0.0620
GAC
$
0.6304
GAC
$
0.5354
DER
$
0.5357
STI
$
0.5357
MDA
$
0.2752
RHO
$
0.2189
PFR
$
0.7751
PFR
$
0.1054
PFR
$
0.0456
$
0.5074
$
0.3045
METRONIDAZOLE 0.75% TOPICAL GEL 02092832
METROGEL
0.75% TOPICAL CREAM 02226839
METROCREAM
1% TOPICAL CREAM 02156091
NORITATE
1% TOPICAL CREAM (WITH SUNSCREEN) 02242919
ROSASOL
0.75% VAGINAL GEL 02125226
NIDAGEL
10% VAGINAL CREAM 01926861
FLAGYL
POVIDONE-IODINE 200MG VAGINAL SUPPOSITORY 00026050
BETADINE
10% VAGINAL GEL 00026034
BETADINE
10% VAGINAL SOLUTION 00026093
BETADINE
SULFACETAMIDE (SODIUM)/COLLOIDAL SULPHUR 10%/5% TOPICAL LOTION 02220407
SULFACET-R
DER
SULFANILAMIDE/AMINACRINE HCL/ALLANTOIN 15%/0.2%/2% VAGINAL CREAM 02103036
AVC
THM
84:06.00 ANTI-INFLAMMATORY AGENTS SEE INSERT THIS SECTION FOR TABLES SHOWING APPROXIMATE RELATIVE POTENCIES OF TOPICAL STEROID PREPARATIONS, RELATIVE RATES OF PENETRATION IN DIFFERENT ANATOMICAL SITES AND SUGGESTED GUIDELINES FOR TOPICAL STEROID THERAPY
184
GUIDELINES FOR TOPICAL STEROID THERAPY 1.
Apply an appropriately potent compound to bring the condition under control.
2.
Continue treatment, with a less potent preparation after control is achieved.
3.
Reduce the frequency of application.
4.
If required, continue application with the weakest preparation that will control the condition.
5.
Once healed, "tail off" treatment.
6.
Use special care in treating children, the elderly, and in certain anatomical sites (e.g. face and flexures).
7.
Use combination products (those containing antiinfective agents) only for short periods of time.
185
APPROXIMATE RELATIVE POTENCIES of TOPICAL STEROID PREPARATIONS
The classification of products in this table is based on 'WHO Model Prescribing Information: Drugs Used in Dermatology (1995)'. Comments from Saskatchewan Dermatologists have been incorporated. In general, ointments, as a result of their more occlusive property, tend to exhibit higher potency than creams of the same strength. Cream formulations, in turn, appear to be more potent than lotions containing the same concentration of the same anti-inflammatory agent.
186
ULTRA HIGH POTENCY
HIGH POTENCY
GROUP I
Betamethasone dipropionate 0.05% glycol cream, ointment, lotion Betamethasone dipropionate 0.05%/salicylic acid 3% ointment Clobetasol propionate 0.05% cream, ointment, scalp lotion Diflorasone diacetate 0.05% ointment Halobetasol propionate 0.05% ointment
GROUP II
Amcinonide 0.1% ointment Betamethasone dipropionate 0.05% ointment Desoximetasone 0.25% cream, ointment Desoximetasone 0.5% gel Fluocinonide 0.05% cream, ointment, gel, emollient base Halcinonide 0.1% cream, ointment, solution Halobetasol propionate 0.05% cream
GROUP III
Betamethasone dipropionate 0.05% cream Betamethasone valerate 0.1% ointment Diflorasone diacetate 0.05% cream Triamcinolone acetonide 0.1% ointment
GROUP IV MID POTENCY
GROUP V
GROUP VI LOW POTENCY GROUP VII
Amcinonide 0.1% cream, lotion Beclomethasone dipropionate 0.025% cream, lotion Desoximetasone 0.05% cream Fluocinolone acetonide 0.025% ointment Hydrocortisone valerate 0.2% ointment Mometasone furoate 0.1% cream, ointment, lotion Triamcinolone acetonide 0.1% cream
Betamethasone benzoate 0.025% gel Betamethasone valerate 0.1% cream, lotion Betamethasone valerate 0.05% cream, ointment, lotion Fluocinolone acetonide 0.01% cream, ointment, solution Fluocinolone acetonide 0.025% cream Hydrocortisone valerate 0.2% cream Triamcinolone acetonide 0.025% cream, ointment
Desonide 0.05% cream, ointment, lotion
Hydrocortisone 0.5% lotion 1% cream, ointment, lotion 2.5% cream, lotion, scalp solution Methylprednisolone 0.25% ointment
187
RELATIVE RATES OF PERCUTANEOUS PENETRATION IN DIFFERENT ANATOMICAL SITES (Based on hydrocortisone/forearm = 1) RELATIVE PENETRATION 0.14 0.83 1.0 1.7 3.5 6.0 13.0 42.0
SITE Foot (plantar) Palm Forearm Back Scalp Forehead Jaw angle/cheeks Scrotum
Arndt, K.A., Manual of Dermatological Therapeutics, 2nd Edition, p. 293
GUIDE TO TOPICAL QUANTITIES IN DERMATOLOGY Amount used three times daily for one week, average adult. SITE
% BODY SURFACE
VANISHING CREAM
GREASE BASE
SHAKE LOTION
THIN (NON SHAKE LOTION)
PROPYLENE GLYCOL
ONE WHOLE HAND or FOOT
2%
7.5g
10g
20mL
5mL
15mL
ONE WHOLE ARM
9%
30g
45g
90mL
24mL
60mL
TRUNK
36%
120g
180g
360mL
90mL
240mL
GENITAL AREA
1%
7.5g
5g
not used here
5mL
7.5mL
ONE TOTAL LEG
18%
60g
90g
180mL
45mL
120mL
TOTAL FACE
4.5%
15g
20g
40mL
10mL
30mL
BODY
100%
375g
500g
1000mL
240mL
750mL
188
84:00 SKIN AND MUCOUS MEMBRANE PREPARATIONS 84:06.00 ANTI-INFLAMMATORY AGENTS
AMCINONIDE 0.1% TOPICAL CREAM 02192284
CYCLOCORT
STI
$
0.5585
STI
$
0.5585
STI
$
0.4693
RBP
$
0.6431
RBP
$
0.3961
0.1% TOPICAL OINTMENT 02192268
CYCLOCORT
0.1% TOPICAL LOTION 02192276
CYCLOCORT
BECLOMETHASONE DIPROPIONATE 0.025% TOPICAL CREAM 02089602
PROPADERM
0.025% TOPICAL LOTION 02089610
PROPADERM
BETAMETHASONE DIPROPIONATE PENETRATION OF ACTIVE DRUG THROUGH THE EPIDERMIS IS ENHANCED BY THE PROPYLENE GLYCOL BASE, RESULTING IN INCREASED POTENCY, BECAUSE OF THE DIFFERENCE IN POTENCY YET SIMILARITY OF THE NAMES (DIPROSONE-DIPROLENE) EXTRA CAUTION IS ADVISED.
* 0.05% TOPICAL CREAM 00323071 01925350
DIPROSONE TARO-SONE
SCH TAR
$
0.2337 0.2337
SCH RTP
$
0.2337 0.2337
SCH RTP TAR
$
0.2149 0.2149 0.2149
SCH RTP
$
0.5628 0.5628
SCH RTP
$
0.5628 0.5628
SCH RTP
$
0.5083 0.5083
* 0.05% TOPICAL OINTMENT 00344923 00805009
DIPROSONE RATIO-TOPISONE
* 0.05% TOPICAL LOTION 00417246 00809187 01944444
DIPROSONE RATIO-TOPISONE TARO-SONE
* 0.05% TOPICAL GLYCOL CREAM 00688622 00849650
DIPROLENE RATIO-TOPILENE
* 0.05% TOPICAL GLYCOL OINTMENT 00629367 00849669
DIPROLENE RATIO-TOPILENE
* 0.05% TOPICAL GLYCOL LOTION 00862975 01927914
DIPROLENE RATIO-TOPILENE
189
84:00 SKIN AND MUCOUS MEMBRANE PREPARATIONS 84:06.00 ANTI-INFLAMMATORY AGENTS
BETAMETHASONE DIPROPIONATE/ SALICYLIC ACID 0.05%/3% TOPICAL OINTMENT 00578436
DIPROSALIC
SCH
$
0.7697
RTP SCH
$
0.3824 0.6507
RBP
$
8.6300
SCH RTP TAR
$
0.0167 0.0167 0.0167
SCH RTP TAR
$
0.0248 0.0248 0.0248
SCH TAR
$
0.0167 0.0167
SCH TAR
$
0.0248 0.0248
RTP
$
0.2062
RTP
$
0.2713
SCH RTP TAR
$
0.0927 0.0927 0.0927
AST
$
8.3600
* 0.05%/2% TOPICAL LOTION 02245688 00578428
RATIO-TOPISALIC DIPROSALIC
BETAMETHASONE DISODIUM PHOSPHATE 5MG/100ML ENEMA (100ML) 02060884
BETNESOL ENEMA
BETAMETHASONE VALERATE * 0.05% TOPICAL CREAM 00027898 00535427 00716618
CELESTODERM-V/2 RATIO-ECTOSONE BETADERM
* 0.1% TOPICAL CREAM 00027901 00535435 00716626
CELESTODERM-V RATIO-ECTOSONE BETADERM
* 0.05% TOPICAL OINTMENT 00028355 00716642
CELESTODERM-V/2 BETADERM
* 0.1% TOPICAL OINTMENT 00028363 00716650
CELESTODERM-V BETADERM
0.05% TOPICAL LOTION 00653209
RATIO-ECTOSONE MILD
0.1% TOPICAL LOTION 00750050
RATIO-ECTOSONE
* 0.1% SCALP LOTION 00027944 00653217 00716634
VALISONE RATIO-ECTOSONE BETADERM
BUDESONIDE 0.02MG/ML ENEMA (100ML) 02052431
ENTOCORT
190
84:00 SKIN AND MUCOUS MEMBRANE PREPARATIONS 84:06.00 ANTI-INFLAMMATORY AGENTS
CLOBETASOL PROPIONATE * 0.05% TOPICAL CREAM 01910272 02024187 02093162 02232191 02245523 02213265
RATIO-CLOBETASOL GEN-CLOBETASOL NOVO-CLOBETASOL PMS-CLOBETASOL CLOBETASOL PROPIONATE DERMOVATE
RTP GPM NOP PMS TAR OPT
$
0.4414 0.4414 0.4414 0.4414 0.4414 0.8131
GPM NOP PMS TAR OPT
$
0.4414 0.4414 0.4414 0.4414 0.8131
GPM PMS TAR RTP OPT
$
0.3868 0.3868 0.3868 0.3871 0.7834
GCH
$
0.4774
GCH
$
0.4774
PMS GAC PMS
$
0.2837 0.3147 0.4210
PMS GAC PMS
$
0.2837 0.3147 0.4196
GAC
$
0.1574
* 0.05% TOPICAL OINTMENT 02026767 02126192 02232193 02245524 02213273
GEN-CLOBETASOL NOVO-CLOBETASOL PMS-CLOBETASOL CLOBETASOL PROPIONATE DERMOVATE
* 0.05% SCALP APPLICATION 02216213 02232195 02245522 01910299 02213281
GEN-CLOBETASOL PMS-CLOBETASOL CLOBETASOL PROPIONATE RATIO-CLOBETASOL DERMOVATE
CLOBETASONE BUTYRATE 0.05% TOPICAL CREAM 02214415
EUMOVATE
0.05% TOPICAL OINTMENT 02214423
EUMOVATE
DESONIDE * 0.05% TOPICAL CREAM 02229315 02048639 02154862
PMS-DESONIDE DESOCORT TRIDESILON
* 0.05% TOPICAL OINTMENT 02229323 02115522 02154870
PMS-DESONIDE DESOCORT TRIDESILON
0.05% TOPICAL LOTION 02115514
DESOCORT
191
84:00 SKIN AND MUCOUS MEMBRANE PREPARATIONS 84:06.00 ANTI-INFLAMMATORY AGENTS
DESOXIMETASONE * 0.05% TOPICAL CREAM 02239068 02221918
DESOXI TOPICORT MILD
OPT AVT
$
0.3022 0.4530
OPT AVT
$
0.4549 0.6538
OPT AVT
$
0.3350 0.5371
AVT
$
0.6538
STI
$
0.3943
STI
$
0.3943
STI
$
0.3943
TAR
$
0.0703
TAR
$
0.3364
TAR MDC
$
0.4676 0.4676
MDC
$
0.4440
HDI
$
0.2681
GAC
$
0.2575
* 0.25% TOPICAL CREAM 02239069 02221896
DESOXI TOPICORT
* 0.05% TOPICAL GEL 02241887 02221926
DESOXI TOPICORT
0.25% TOPICAL OINTMENT 02221934
TOPICORT
DIFLUCORTOLONE VALERATE 0.1% TOPICAL CREAM 00587826
NERISONE
0.1% TOPICAL OILY CREAM 00587818
NERISONE
0.1% TOPICAL OINTMENT 00587834
NERISONE
FLUOCINOLONE ACETONIDE 0.01% TOPICAL CREAM 00716782
FLUODERM
0.025% TOPICAL CREAM 00716790
FLUODERM
* 0.025% TOPICAL OINTMENT 00716812 02162512
FLUODERM SYNALAR REGULAR
0.01% TOPICAL SOLUTION 02162504
SYNALAR
0.01% TOPICAL OIL 00873292
DERMA-SMOOTHE/FS
0.01% SHAMPOO 02242738
CAPEX SHAMPOO
192
84:00 SKIN AND MUCOUS MEMBRANE PREPARATIONS 84:06.00 ANTI-INFLAMMATORY AGENTS
FLUOCINONIDE * 0.05% TOPICAL CREAM 00716863 02161923
LYDERM LIDEX
OPT MDC
$
0.5007 0.5010
OPT MDC
$
0.3711 0.5561
OPT MDC
$
0.3657 0.5544
MDC
$
0.6041
WSD
$
0.5650
WSD
$
0.5180
WSD
$
0.4356
WSD
$
0.7986
WSD
$
0.7986
VTH TAR SCP
$
0.1541 0.1628 0.2438
SCH TAR VTH STI
$
0.0198 0.0198 0.0226 0.1718
STI
$
0.2344
TAR SCP
$
0.1628 0.2438
* 0.05% TOPICAL GEL 02236997 02161974
LYDERM TOPSYN
* 0.05% TOPICAL OINTMENT 02236996 02161966
LYDERM LIDEX
0.05% IN EMOLLIENT BASE 02163152
LIDEMOL
HALCINONIDE 0.1% TOPICAL CREAM 02011921
HALOG
0.1% TOPICAL OINTMENT 02010283
HALOG
0.1% TOPICAL SOLUTION 02010291
HALOG
HALOBETASOL PROPIONATE SEE APPENDIX A FOR EDS CRITERIA
0.05% CREAM 01962701
ULTRAVATE (EDS)
0.05% OINTMENT 01962728
ULTRAVATE (EDS)
HYDROCORTISONE * 0.5% TOPICAL CREAM 00228079 00716820 00513288
HYDROCORTISONE CREAM HYDERM CORTATE
* 1% TOPICAL CREAM 00502200 00716839 00228087 00192597
CORTATE HYDERM HYDROCORTISONE CREAM EMO-CORT
2.5% TOPICAL CREAM 00595799
EMO-CORT
* 0.5% TOPICAL OINTMENT 00716685 00513261
CORTODERM CORTATE
193
84:00 SKIN AND MUCOUS MEMBRANE PREPARATIONS 84:06.00 ANTI-INFLAMMATORY AGENTS
* 1% TOPICAL OINTMENT 00502197 00716693
CORTATE CORTODERM
SCH TAR
$
0.0212 0.0212
SCP
$
0.1925
STI STI
$
0.0938 0.1587
STI STI
$
0.1812 0.2099
STI
$
0.1985
ICN AXC
$
5.5800 6.5700
GCH
$
80.5400
WSD OPT
$
0.1809 0.1809
WSD OPT
$
0.1809 0.1809
STI
$
0.1747
STI
$
0.0970
SCH
$
0.6938
SCH
$
0.6938
SCH
$
0.5397
0.5% TOPICAL LOTION 00513253 ⌧
00578541 00192600 ⌧
CORTATE
1% TOPICAL LOTION SARNA HC EMO-CORT
2.5% TOPICAL LOTION 00856711 00595802
SARNA HC EMO-CORT
2.5% SCALP SOLUTION 00641154
EMO-CORT
* 100MG/60ML ENEMA (60ML) 00230316 02112736
HYCORT CORTENEMA
HYDROCORTISONE ACETATE 10% RECTAL AEROSOL FOAM (15G) 00579335
CORTIFOAM
HYDROCORTISONE VALERATE * 0.2% TOPICAL CREAM 01910124 02242984
WESTCORT HYDROVAL
* 0.2% TOPICAL OINTMENT 01910132 02242985
WESTCORT HYDROVAL
HYDROCORTISONE/UREA 1%/10% TOPICAL CREAM 00503134
UREMOL-HC
1%/10% TOPICAL LOTION 00560022
UREMOL-HC
MOMETASONE FUROATE 0.1% TOPICAL CREAM 00851744
ELOCOM
0.1% TOPICAL OINTMENT 00851736
ELOCOM
0.1% TOPICAL LOTION 00871095
ELOCOM
194
84:00 SKIN AND MUCOUS MEMBRANE PREPARATIONS 84:06.00 ANTI-INFLAMMATORY AGENTS
TRIAMCINOLONE ACETONIDE 0.025% TOPICAL CREAM 00716952
TRIADERM
TAR
$
0.0504
TAR STI WSD
$
0.1411 0.1411 0.3260
TAR STI WSD
$
0.1411 0.1411 0.3260
TAR WSD
$
1.1718 1.3180
SCH
$
0.6706
LEO
$
0.9494
WSD
$
0.5614
TAR WSD
$
0.4594 0.7943
WSD
$
0.5614
TAR WSD
$
0.4594 0.7943
* 0.1% TOPICAL CREAM 00716960 02194058 01999818
TRIADERM ARISTOCORT R KENALOG
* 0.1% TOPICAL OINTMENT 00716987 02194031 01999796
TRIADERM ARISTOCORT R KENALOG
* 0.1% ORAL TOPICAL OINTMENT 01964054 01999788
ORACORT DENTAL PASTE KENALOG-ORABASE
84:06.00 COMBINATION ANTI-INFECTIVE/ ANTI-INFLAMMATORY AGENTS
BETAMETHASONE DIPROPIONATE/CLOTRIMAZOLE 0.05%/1% TOPICAL CREAM 00611174
LOTRIDERM
FUSIDIC ACID/HYDROCORTISONE ACETATE 2%/1% TOPICAL CREAM 02238578
FUCIDIN H
NEOMYCIN/GRAMICIDIN/NYSTATIN/ TRIAMCINOLONE ACETONIDE 2.5MG/0.25MG/100,000U/0.25MG PER G TOPICAL CREAM 01999842
KENACOMB MILD
* 2.5MG/0.25MG/100,000U/1MG PER G TOPICAL CREAM 00717002 01999850
VIADERM-KC KENACOMB
2.5MG/0.25MG/100,000U/0.25MG PER G TOPICAL OINTMENT 01999834
KENACOMB MILD
* 2.5MG/0.25MG/100,000U/1MG PER G TOPICAL OINTMENT 00717029 01999826
VIADERM-KC KENACOMB
195
84:00 SKIN AND MUCOUS MEMBRANE PREPARATIONS 84:06.00 COMBINATION ANTI-INFECTIVE/ ANTI-INFLAMMATORY AGENTS
POLYMYXIN B SO4/BACITRACIN (ZINC)/ NEOMYCIN SO4/HYDROCORTISONE 5000U/400U/5MG/10MG PER G TOPICAL OINTMENT 00666246
CORTISPORIN
GSK
$
0.7487
84:08.00 ANTIPRURITICS AND LOCAL ANAESTHETICS
PHENAZOPYRIDINE * 100MG TABLET 00271489 00476714
PHENAZO PYRIDIUM
ICN PFI
$
0.1281 0.1281
ICN PFI
$
0.1598 0.1775
$
0.7216
GAC
$
0.6272
GAC
$
0.6272
STI
$
0.5968
* 200MG TABLET 00454583 00476722
PHENAZO PYRIDIUM
84:12.00 ASTRINGENTS
ALUMINUM ACETATE/BENZETHONIUM CHLORIDE 0.35%/0.023% POWDER (2.36G PACKAGE) 00579947
BURO-SOL
STI
84:16.00 CELL STIMULANTS AND PROLIFERANTS CONDITIONS OTHER THAN ACNE VULGARIS ARE NOT APPROVED INDICATIONS FOR THE USE OF TOPICAL RETINOIDS.
ADAPALENE 0.1% TOPICAL CREAM 02231592
DIFFERIN
0.1% TOPICAL GEL 02148749
DIFFERIN
ISOTRETINOIN 0.05% TOPICAL GEL 00784338
ISOTREX
196
84:00 SKIN AND MUCOUS MEMBRANE PREPARATIONS 84:16.00 CELL STIMULANTS AND PROLIFERANTS
TRETINOIN SEE APPENDIX A FOR EDS CRITERIA
* 0.01% TOPICAL CREAM 00657204 01926497 00897329
STIEVA-A VITAMIN A ACID RETIN A
STI DER JAN
$
0.3082 0.3082 0.3863
STI DER JAN
$
0.3082 0.3082 0.3748
STI DER JAN
$
0.3082 0.3082 0.3863
STI DER JAN
$
0.3082 0.3082 0.3748
STI
$
0.1932
STI DER JAN
$
0.3090 0.3090 0.3748
STI DER
$
0.3082 0.3082
STI
$
0.1932
STI DER JAN
$
0.3082 0.3082 0.3863
* 0.01% TOPICAL GEL 00587958 01926462 00870013
STIEVA-A VITAMIN A ACID RETIN A
* 0.025% TOPICAL CREAM 00578576 01926500 00897310
STIEVA-A VITAMIN A ACID RETIN A
* 0.025% TOPICAL GEL 00587966 01926470 00443816
STIEVA-A VITAMIN A ACID RETIN A
0.025% TOPICAL SOLUTION 00578568
STIEVA-A
* 0.05% TOPICAL CREAM 00518182 01926519 00443794
STIEVA-A VITAMIN A ACID RETIN A
* 0.05% TOPICAL GEL 00641863 01926489
STIEVA-A VITAMIN A ACID
0.05% TOPICAL SOLUTION 00518174
STIEVA-A
* 0.1% TOPICAL CREAM 00662348 01926527 00870021
STIEVA-A FORTE (EDS) VITAMIN A ACID (EDS) RETIN A (EDS)
197
84:00 SKIN AND MUCOUS MEMBRANE PREPARATIONS 84:28.00 KERATOLYTIC AGENTS
BENZOYL PEROXIDE 10% BAR 00527661
PANOXYL
STI
$
9.1400
ICN STI
$
0.1677 0.1910
BENOXYL OXYDERM
STI ICN
$
0.2122 0.2176
DESQUAM-X BENZAC W
WSD GAC
$
0.0543 0.0547
STI
$
0.1492
STI DER
$
0.1492 0.1511
WSD GAC STI GAC
$
0.1068 0.1453 0.1492 0.1519
STI
$
0.1806
STI
$
0.1945
STI
$
0.1945
STI
$
0.9353
MED
$
0.2437
MED
$
0.2570
MED
$
0.3038
MED
$
0.3318
MED
$
0.3501
* 10% TOPICAL LOTION 00432938 00370568
OXYDERM BENOXYL
* 20% TOPICAL LOTION 00187585 00374318 ⌧
10% WASH 01908901 01925199
10% TOPICAL GEL (ACETONE BASE) 00406848 ⌧
00263699 02220385 ⌧
ACETOXYL
10% TOPICAL GEL (ALCOHOL BASE) PANOXYL-10 BENZAGEL
10% TOPICAL GEL (AQUEOUS BASE) 01908871 01925997 02223856 01912437
DESQUAM-X BENZAC-W PANOXYL AQUAGEL BENZAC AC
15% TOPICAL GEL (ALCOHOL BASE) 00403571
PANOXYL-15
20% TOPICAL GEL (ALCOHOL BASE) 00373036
PANOXYL-20
20% TOPICAL GEL (AQUEOUS BASE) 02223864
PANOXYL AQUAGEL
CLINDAMYCIN PHOSPHATE/BENZOYL PEROXIDE 1%5% TOPICAL GEL 02243158
CLINDOXYL GEL
DITHRANOL 0.1% TOPICAL CREAM 00537594
ANTHRANOL
0.2% TOPICAL CREAM 00537608
ANTHRANOL
0.4% TOPICAL LOTION 00695351
ANTHRASCALP
1% TOPICAL OINTMENT 00566756
ANTHRAFORTE-1
2% TOPICAL OINTMENT 00566748
ANTHRAFORTE-2
198
84:00 SKIN AND MUCOUS MEMBRANE PREPARATIONS 84:28.00 KERATOLYTIC AGENTS
PODOFILOX ⌧
0.5% TOPICAL SOLUTION (PACKAGE) 02074788 01945149
WARTEC CONDYLINE
PMS CDX
$
37.8400 40.1500
84:36.00 MISCELLANEOUS SKIN & MUCOUS MEMBRANE AGENTS
ACITRETIN SEE APPENDIX A FOR EDS CRITERIA
10MG CAPSULE 02070847
SORIATANE (EDS)
HLR
$
1.6782
HLR
$
2.9477
WYA RTP DBU
$
0.7636 0.7636 0.7747
LEO
$
0.7568
LEO
$
0.7568
LEO
$
0.7568
25MG CAPSULE 02070863
SORIATANE (EDS)
AMETHOPTERIN * 2.5MG TABLET 02170698 02244798 02182963
METHOTREXATE RATIO-METHOTREXATE METHOTREXATE
CALCIPOTRIOL 50UG/G TOPICAL CREAM 02150956
DOVONEX
50UG/G TOPICAL OINTMENT 01976133
DOVONEX
50UG/ML SCALP SOLUTION 02194341
DOVONEX
CYCLOSPORINE NOTE: THE IDENTIFICATION NUMBERS LISTED FOR THIS PRODUCT HAVE BEEN GENERATED BY THE PRESCRIPTION DRUG PLAN FOR BILLING PURPOSES ONLY. SEE APPENDIX A FOR EDS CRITERIA.
10MG CAPSULE 00950792
NEORAL (EDS)
NVR
$
0.6637
NVR
$
1.5426
NVR
$
3.0073
NVR
$
6.0164
NVR
$
5.3480
25MG CAPSULE 00950793
NEORAL (EDS)
50MG CAPSULE 00950807
NEORAL (EDS)
100MG CAPSULE 00950815
NEORAL (EDS)
100MG/ML LIQUID 00950823
NEORAL (EDS)
199
84:00 SKIN AND MUCOUS MEMBRANE PREPARATIONS 84:36.00 MISCELLANEOUS SKIN & MUCOUS MEMBRANE AGENTS
FLUOROURACIL 5% TOPICAL CREAM 00330582
EFUDEX
ICN
$
0.4601
HLR
$
1.7903
HLR
$
3.6529
FUJ
$
2.3330
FUJ
$
2.4960
ALL
$
1.3961
ALL
$
1.3961
ALL
$
1.3961
ALL
$
1.3961
ISOTRETINOIN 10MG CAPSULE 00582344
ACCUTANE
40MG CAPSULE 00582352
ACCUTANE
TACROLIMUS SEE APPENDIX A FOR EDS CRITERIA
0.03% TOPICAL OINTMENT 02244149
PROTOPIC (EDS)
0.1% TOPICAL OINTMENT 02244148
PROTOPIC (EDS)
TAZAROTENE 0.05% TOPICAL CREAM 02243894
TAZORAC
0.05% TOPICAL GEL 02230784
TAZORAC
0.1% TOPICAL CREAM 02243895
TAZORAC
0.1% TOPICAL GEL 02230785
TAZORAC
84:50.06 DEPIGMENTING & PIGMENTING AGENTS (PIGMENTING AGENTS)
METHOXSALEN SEE APPENDIX A FOR EDS CRITERIA ⌧
10MG CAPSULE 00252654 00646237 01946374
⌧
OXSORALEN ULTRA (EDS) ULTRAMOP (EDS) OXSORALEN (EDS)
ICN CDX ICN
$
0.4666 0.5160 0.8181
ULTRAMOP (EDS) OXSORALEN (EDS)
CDX ICN
$
1.1198 1.5939
1% LOTION 00698059 01907476
200
SMOOTH MUSCLE RELAXANTS
86:00
86:00 SMOOTH MUSCLE RELAXANTS 86:12.00 GENITOURINARY SMOOTH MUSCLE RELAXANTS
FLAVOXATE HCL SEE APPENDIX A FOR EDS CRITERIA
* 200MG TABLET 02244842 00728179
APO-FLAVOXATE (EDS) URISPAS (EDS)
APX PMS
$
0.3752 0.5360
NXP APX NOP ICN GPM PMS DOM JAN
$
0.2067 * 0.2697 0.2697 0.2697 0.2697 0.2697 0.2831 0.4281
PMS APX JAN
$
0.0675 0.0675 0.0964
OXYBUTYNIN CHLORIDE * 5MG TABLET 02158590 02163543 02230394 02220059 02230800 02240550 02241285 01924761
NU-OXYBUTYN APO-OXYBUTYNIN NOVO-OXYBUTYNIN OXYBUTYN GEN-OXYBUTYNIN PMS-OXYBUTYNIN DOM-OXYBUTYNIN DITROPAN
* 1MG/ML SYRUP 02223376 02231089 01924753
PMS-OXYBUTYNIN APO-OXYBUTYNIN DITROPAN
TOLTERODINE L-TARTRATE Note: Both strengths of Detrol are scheduled to be delisted from the Saskatchewan Formulary effective April 1, 2003. SEE APPENDIX A FOR EDS CRITERIA
1MG TABLET 02239064
DETROL (EDS)
PHU
$
0.9494
DETROL (EDS)
PHU
$
0.9494
PHU
$
1.8988
PHU
$
1.8988
2MG TABLET 02239065
2MG EXTENDED-RELEASE CAPSULE 02244612
UNIDET (EDS)
4MG EXTENDED-RELEASE CAPSULE 02244613
UNIDET (EDS)
86:16.00 RESPIRATORY SMOOTH MUSCLE RELAXANTS
AMINOPHYLLINE 225MG SUSTAINED RELEASE TABLET 02014270
PHYLLOCONTIN
PFR
$
0.2158
PFR
$
0.2751
350MG SUSTAINED RELEASE TABLET 02014289
PHYLLOCONTIN-350
202
86:00 SMOOTH MUSCLE RELAXANTS 86:16.00 RESPIRATORY SMOOTH MUSCLE RELAXANTS
OXTRIPHYLLINE 100MG TABLET 00441724
APO-OXTRIPHYLLINE
APX
$
0.0516
APX
$
0.0733
APX
$
0.1031
PFI
$
0.2453
PFI
$
0.2911
PMS PFI
$
0.0249 0.0363
APX NOP
$
0.1411 0.1411
APX NOP RIV AST
$
0.1465 0.1465 0.1978 0.2404
APX NOP RIV BRI AST
$
0.1519 0.1519 0.2214 0.2811 0.2892
PFR
$
0.4959
PFR
$
0.6005
PMS
$
0.0038
MDA
$
0.0208
200MG TABLET 00441732
APO-OXTRIPHYLLINE
300MG TABLET 00511692
APO-OXTRIPHYLLINE
400MG SUSTAINED RELEASE TABLET 00503436
CHOLEDYL-SA
600MG SUSTAINED RELEASE TABLET 00536709
CHOLEDYL-SA
* 20MG/ML ELIXIR 00792942 00476366
PMS-OXTRIPHYLLINE CHOLEDYL
THEOPHYLLINE (ANHYDROUS) ⌧
100MG SUSTAINED RELEASE TABLET 00692689 02230085
⌧
200MG SUSTAINED RELEASE TABLET 00692697 02230086 00631701 00460990
⌧
APO-THEO-LA NOVO-THEOPHYL SR APO-THEO-LA NOVO-THEOPHYL SR THEOCHRON THEO-DUR
300MG SUSTAINED RELEASE TABLET 00692700 02230087 00599905 00556742 00461008
APO-THEO-LA NOVO-THEOPHYL SR THEOCHRON QUIBRON-T/SR THEO-DUR
400MG SUSTAINED RELEASE TABLET 02014165
UNIPHYL
600MG SUSTAINED RELEASE TABLET 02014181
UNIPHYL
5.33MG/ML ELIXIR 00575151
PMS-THEOPHYLLINE
5.33MG/ML SOLUTION 01966219
THEOLAIR LIQUID
203
VITAMINS
88:00
88:00 VITAMINS 88:04.00 VITAMIN A VITAMIN A IS TOXIC IN EXCESSIVE DOSES
VITAMIN A 25,000IU CAPSULE 00021067
VITAMIN A
NOP
$
0.0586
NOP
$
0.0961
VITAMIN B12 CYANOCOBALAMIN CYANOCOBALAMIN
SAB CYT TAR
$
3.3700 3.3700 3.3700
APO-FOLIC
APX
$
0.0255
WYA
$
5.9024
ICN
$
0.0154
ICN
$
0.0317
ODN ICN
$
0.0429 0.0495
LEA ICN ODN
$
0.0234 0.0280 0.0320
50,000IU CAPSULE 00021075
VITAMIN A
88:08.00 VITAMINS B
CYANOCOBALAMIN * 1MG/ML INJECTION SOLUTION (10ML) 00521515 01987003 02052717
FOLIC ACID 5MG TABLET 00426849
LEUCOVORIN CALCIUM (FOLINIC ACID) SEE APPENDIX A FOR EDS CRITERIA
5MG TABLET 02170493
LEUCOVORIN (EDS)
NIACIN 50MG TABLET 00268593
NIACIN
100MG TABLET 00268585
NIACIN
* 500MG TABLET 01939130 00294950
NIACIN NIACIN
PYRIDOXINE HCL * 25MG TABLET 00232475 00268607 01943200
PYRIDOXINE HCL VITAMIN B6 VITAMIN B6
206
88:00 VITAMINS 88:08.00 VITAMINS B
THIAMINE HCL * 50MG TABLET 00610267 00268631
VITAMIN B1 VITAMIN B1
LEA ICN
$
0.0192 0.0620
SAB ABB
$
13.5700 16.2500
LEO
$
0.4438
LEO
$
1.3284
LEO
$
5.0746
SAW
$
0.4202
HLR
$
0.9538
HLR
$
1.5169
HLR
$
3.0380
DPY
$
1.8445
MSD
$
0.2177
* 100MG/ML INJECTION SOLUTION (10ML) 00816078 02241983
VITAMIN B1 BETAXIN
88:16.00 VITAMIN D VITAMIN D IS TOXIC IN EXCESSIVE DOSES
ALFACALCIDOL SEE APPENDIX A FOR EDS CRITERIA
0.25UG CAPSULE 00474517
ONE-ALPHA (EDS)
1.0UG CAPSULE 00474525
ONE-ALPHA (EDS)
2UG/ML ORAL DROPS (ML) 02240329
ONE-ALPHA (EDS)
CALCIFEROL 8,288IU/ML ORAL SOLUTION 02017598
DRISDOL
CALCITRIOL SEE APPENDIX A FOR EDS CRITERIA
0.25UG CAPSULE 00481823
ROCALTROL (EDS)
0.5UG CAPSULE 00481815
ROCALTROL (EDS)
1UG/ML ORAL SOLUTION 00824291
ROCALTROL (EDS)
DOXERCALCIFEROL SEE APPENDIX A FOR EDS CRITERIA
2.5UG CAPSULE 02243790
HECTOROL (EDS)
VITAMIN D 50,000IU CAPSULE 00009830
OSTOFORTE
207
UNCLASSIFIED THERAPEUTIC AGENTS
92:00
92:00 UNCLASSIFIED THERAPEUTIC AGENTS 92:00.00 UNCLASSIFIED THERAPEUTIC AGENTS
ALENDRONATE SODIUM SEE APPENDIX A FOR EDS CRITERIA
10MG TABLET 02201011
FOSAMAX (EDS)
MSD
$
1.9042
MSD
$
3.8898
MSD
$
9.6030
SAW
$
1.0308
NOP APX GSK
$
0.0207 0.0207 0.1102
APX NOP GSK
$
0.0363 0.0363 0.1829
NOP APX GSK
$
0.0446 0.0446 0.2988
RBP
$
5.0845
GPM RTP NOP APX GSK
$
0.5879 0.5879 0.5879 0.5879 0.9331
ORP
$
1.4046
40MG TABLET 02201038
FOSAMAX (EDS)
70MG TABLET 02245329
FOSAMAX (EDS)
ALFUZOSIN 10MG PROLONGED-RELEASE TABLET 02245565
XATRAL
ALLOPURINOL * 100MG TABLET 00364282 00402818 00004588
NOVO-PUROL APO-ALLOPURINOL ZYLOPRIM
* 200MG TABLET 00479799 00565342 00506370
APO-ALLOPURINOL NOVO-PUROL ZYLOPRIM
* 300MG TABLET 00363693 00402796 00294322
NOVO-PUROL APO-ALLOPURINOL ZYLOPRIM
ANAGRELIDE HCL 0.5MG CAPSULE 02236859
AGRYLIN
AZATHIOPRINE * 50MG TABLET 02231491 02236799 02236819 02242907 00004596
GEN-AZATHIOPRINE RATIO-AZATHIOPRINE NOVO-AZATHIOPRINE APO-AZATHIOPRINE IMURAN
BETAINE ANHYDROUS 1G/SCOOP POWDER FOR ORAL SOLUTION 02238526
CYSTADANE
210
92:00 UNCLASSIFIED THERAPEUTIC AGENTS 92:00.00 UNCLASSIFIED THERAPEUTIC AGENTS
BOSENTAN SEE APPENDIX A FOR EDS CRITERIA
62.5MG TABLET 02244981
TRACLEER (EDS)
ACT
$
60.4000
ACT
$
60.4000
ALL
$
3.6890
APX PMS NVR
$
1.0537 1.0537 1.6726
APX PMS DOM NVR
$
0.5917 0.5917 0.6213 0.9391
AVT
$
101.7200
AVT
$
68.1400
PHU
$
13.7253
COLCHICINE-ODAN
ODN
$
0.2116
COLCHICINE-ODAN
ODN
$
0.4102
125MG TABLET 02244982
TRACLEER (EDS)
BOTULINUM TOXIN TYPE A SEE APPENDIX A FOR EDS CRITERIA
100IU STERILE LYOPHILIZED POWDER (IU) 01981501
BOTOX (EDS)
BROMOCRIPTINE MESYLATE * 5MG CAPSULE 02230454 02236949 00568643
APO-BROMOCRIPTINE PMS-BROMOCRIPTINE PARLODEL
* 2.5MG TABLET 02087324 02231702 02238636 00371033
APO-BROMOCRIPTINE PMS-BROMOCRIPTINE DOM-BROMOCRIPTINE PARLODEL
BUSERELIN ACETATE SEE APPENDIX A FOR EDS CRITERIA
1.05MG/ML INJECTION (2) 02225166
SUPREFACT (EDS)
1.05MG/ML INTRANASAL SOLUTION 02225158
SUPREFACT (EDS)
CABERGOLINE SEE APPENDIX A FOR EDS CRITERIA
0.5MG TABLET 02242471
DOSTINEX (EDS)
COLCHICINE 0.6MG TABLET 00572349
1MG TABLET 00621374
211
92:00 UNCLASSIFIED THERAPEUTIC AGENTS 92:00.00 UNCLASSIFIED THERAPEUTIC AGENTS
CYCLOSPORINE (TRANSPLANT) SEE APPENDIX A FOR EDS CRITERIA
10MG CAPSULE 02237671
NEORAL (EDS)
NVR
$
0.6637
NVR
$
1.5426
NVR
$
3.0073
NVR
$
6.0164
NVR
$
5.3480
PFI
$
4.7849
PFI
$
4.7849
NVR
$
1.5190
WYA
$
172.5000
PGA
$
1.4224
PGA
$
39.8200
MSD
$
1.7686
25MG CAPSULE 02150689
NEORAL (EDS)
50MG CAPSULE 02150662
NEORAL (EDS)
100MG CAPSULE 02150670
NEORAL (EDS)
100MG/ML LIQUID 02150697
NEORAL (EDS)
DONEPEZIL HCL SEE APPENDIX A FOR EDS CRITERIA
5MG TABLET 02232043
ARICEPT (EDS)
10MG TABLET 02232044
ARICEPT (EDS)
ENTACAPONE 200MG TABLET 02243763
COMTAN
ETANERCEPT SEE APPENDIX A FOR EDS CRITERIA
25MG/VIAL POWDER FOR INJECTION (VIAL) 02242903
ENBREL (EDS)
ETIDRONATE DISODIUM SEE APPENDIX A FOR EDS CRITERIA
200MG TABLET 01997629
DIDRONEL (EDS)
ETIDRONATE DISODIUM/CALCIUM CARBONATE 400MG/1250MG TABLET (PACKAGE) 02176017
DIDROCAL
FINASTERIDE 5MG TABLET 02010909
PROSCAR
212
92:00 UNCLASSIFIED THERAPEUTIC AGENTS 92:00.00 UNCLASSIFIED THERAPEUTIC AGENTS
GALANTAMINE HYDROBROMIDE SEE APPENDIX A FOR EDS CRITERIA
4MG TABLET 02244298
REMINYL (EDS)
JAN
$
2.4901
REMINYL (EDS)
JAN
$
2.4901
JAN
$
2.4901
TVM
$
34.6900
TVM
$
37.0000
LIL
$
35.6500
LIL
$
89.1800
AST
$
411.7500
8MG TABLET 02244299
12MG TABLET 02244300
REMINYL (EDS)
GLATIRAMER ACETATE SEE APPENDIX J FOR EDS CRITERIA
20MG INJECTION (VIAL) 02233014
COPAXONE (EDS)
20MG INJECTION (PRE-FILLED SYRINGE) 02245619
COPAXONE (EDS)
GLUCAGON 1MG INJECTION POWDER 00015377
GLUCAGON
1MG INJECTION POWDER (RDNA ORIGIN) 02243297
GLUCAGON
GOSERELIN ACETATE SEE APPENDIX A FOR EDS CRITERIA
3.6MG/SYRINGE 02049325
ZOLADEX (EDS)
INFLIXIMAB WHEN BILLING, SUBMIT QUANTITY IN TERMS OF MILLIGRAMS. NOTE: THE IDENTIFICATION NUMBER LISTED FOR THIS PRODUCT HAS BEEN GENERATED BY THE PRESCRIPTION DRUG PLAN FOR BILLING PURPOSES ONLY. SEE APPENDIX A FOR EDS CRITERIA.
100MG/VIAL INJECTION (MG) (CROHN'S DISEASE) 00950899
REMICADE (EDS)
SCH
$
11.8000
SCH
$
11.8000
$
861.1800
$
861.1800
100MG/VIAL INJECTION (MG) (RHEUMATOID ARTHRITIS) 02244016
REMICADE (EDS)
INTERFERON ALFA-2B/RIBAVIRIN SEE APPENDIX A FOR EDS CRITERIA
6 MILLION IU/ML (0.5ML) INJECTION SOLUTION ALBUMIN (HUMAN) FREE/200MG CAPSULE (PACKAGE) 02239730
REBETRON (EDS)
SCH
15 MILLION IU/ML MULTI-DOSE PEN ALBUMIN (HUMAN) FREE/200MG CAPSULE (PACKAGE) 02241159
REBETRON (EDS)
SCH 213
92:00 UNCLASSIFIED THERAPEUTIC AGENTS 92:00.00 UNCLASSIFIED THERAPEUTIC AGENTS
INTERFERON BETA-1A SEE APPENDIX J FOR EDS CRITERIA
22UG (6 MILLION IU) PRE-FILLED SYRINGE 02237319
REBIF (EDS)
SRO
$
118.2700
SRO
$
145.0000
BGN
$
330.5800
BEX
$
96.0000
NOP PMS NVR
$
0.6874 0.6874 0.8594
NOP NXP APX PMS NVR
$
0.1443 0.1443 0.1443 0.1443 0.1925
AVT
$
10.4052
AVT
$
10.4052
ABB
$
330.3900
ABB
$
417.9700
ABB
$
943.5000
44UG (12 MILLION IU) PRE-FILLED SYRINGE 02237320
REBIF (EDS)
30UG POWDER FOR IM INJECTION (VIAL) 02237770
AVONEX (EDS)
INTERFERON BETA-1B SEE APPENDIX J FOR EDS CRITERIA
0.3MG POWDER FOR INJECTION (3ML) 02169649
BETASERON (EDS)
KETOTIFEN FUMARATE SEE APPENDIX A FOR EDS CRITERIA
* 1MG TABLET 02230730 02231680 00577308
NOVO-KETOTIFEN (EDS) PMS-KETOTIFEN (EDS) ZADITEN (EDS)
* 0.2MG/ML SYRUP 02176084 02218305 02221330 02231679 00600784
NOVO-KETOTIFEN (EDS) NU-KETOTIFEN (EDS) APO-KETOTIFEN (EDS) PMS-KETOTIFEN (EDS) ZADITEN (EDS)
LEFLUNOMIDE SEE APPENDIX A FOR EDS CRITERIA
10MG TABLET 02241888
ARAVA (EDS)
20MG TABLET 02241889
ARAVA (EDS)
LEUPROLIDE ACETATE SEE APPENDIX A FOR EDS CRITERIA
3.75MG/ML INJECTION 00884502
LUPRON DEPOT (EDS)
7.5MG/ML INJECTION 00836273
LUPRON DEPOT (EDS)
11.25MG (3-MONTH SR) DEPOT INJECTION 02239834
LUPRON DEPOT (EDS)
214
92:00 UNCLASSIFIED THERAPEUTIC AGENTS 92:00.00 UNCLASSIFIED THERAPEUTIC AGENTS
LEVAMISOLE SEE APPENDIX A FOR EDS CRITERIA
50MG TABLET 00846368
ERGAMISOL (EDS)
JAN
$
5.1538
HLR
$
0.2767
HLR
$
0.4557
HLR
$
0.7650
RTP NXP APX NOP BMY
$
0.2745 0.2745 0.2745 0.2745 0.4580
RTP NXP APX NOP BMY
$
0.4107 0.4107 0.4107 0.4107 0.6839
RTP NXP APX NOP BMY
$
0.4585 0.4585 0.4585 0.4585 0.7634
BMY
$
0.6746
BMY
$
1.2443
MSD
$
1.3758
MSD
$
1.5190
MSD
$
2.2351
LEVODOPA/BENZERAZIDE 50MG/12.5MG CAPSULE 00522597
PROLOPA
100MG/25MG CAPSULE 00386464
PROLOPA
200MG/50MG CAPSULE 00386472
PROLOPA
LEVODOPA/CARBIDOPA * 100MG/10MG TABLET 02126176 02182831 02195933 02244494 00355658
RATIO-LEVODOPA/CARBIDOPA NU-LEVOCARB APO-LEVOCARB NOVO-LEVOCARBIDOPA SINEMET
* 100MG/25MG TABLET 02126168 02182823 02195941 02244495 00513997
RATIO-LEVODOPA/CARBIDOPA NU-LEVOCARB APO-LEVOCARB NOVO-LEVOCARBIDOPA SINEMET
* 250MG/25MG TABLET 02126184 02182858 02195968 02244496 00328219
RATIO-LEVODOPA/CARBIDOPA NU-LEVOCARB APO-LEVOCARB NOVO-LEVOCARBIDOPA SINEMET
100MG/25MG CONTROLLED RELEASE TABLET 02028786
SINEMET CR
200MG/50MG CONTROLLED RELEASE TABLET 00870935
SINEMET CR
MONTELUKAST SODIUM SEE APPENDIX A FOR EDS CRITERIA
4MG CHEWABLE TABLET 02243602
SINGULAIR (EDS)
5MG CHEWABLE TABLET 02238216
SINGULAIR (EDS)
10MG TABLET 02238217
SINGULAIR (EDS)
215
92:00 UNCLASSIFIED THERAPEUTIC AGENTS 92:00.00 UNCLASSIFIED THERAPEUTIC AGENTS
MYCOPHENOLATE MOFETIL SEE APPENDIX A FOR EDS CRITERIA
250MG CAPSULE 02192748
CELLCEPT (EDS)
HLR
$
2.2373
HLR
$
4.4746
ICN
$
6.7325
FEI
$
303.8000
AVT
$
27.9700
500MG TABLET 02237484
CELLCEPT (EDS)
NABILONE SEE APPENDIX A FOR EDS CRITERIA
1MG CAPSULE 00548375
CESAMET (EDS)
NAFARELIN ACETATE SEE APPENDIX A FOR EDS CRITERIA
2MG/ML NASAL SOLUTION 02188783
SYNAREL (EDS)
NEDOCROMIL SO4 2MG/DOSE INHALATION AEROSOL (PACKAGE) 02230543
TILADE
OCTREOTIDE WHEN BILLING LAR FORM, SUBMIT QUANTITY IN TERMS OF MILLIGRAMS. SEE APPENDIX A FOR EDS CRITERIA
50UG INJECTION (1ML) 00839191
SANDOSTATIN (EDS)
NVR
$
5.4200
NVR
$
10.2300
NVR
$
98.3100
NVR
$
48.0400
NVR
$
113.2000
NVR
$
75.0000
NVR
$
62.3400
100UG INJECTION (1ML) 00839205
SANDOSTATIN (EDS)
200UG/ML INJECTION (5ML) 02049392
SANDOSTATIN (EDS)
500UG INJECTION (1ML) 00839213
SANDOSTATIN (EDS)
10MG/VIAL POWDER FOR INJECTION (MG) 02239323
SANDOSTATIN LAR (EDS)
20MG/VIAL POWDER FOR INJECTION (MG) 02239324
SANDOSTATIN LAR (EDS)
30MG/VIAL POWDER FOR INJECTION (MG) 02239325
SANDOSTATIN LAR (EDS)
216
92:00 UNCLASSIFIED THERAPEUTIC AGENTS 92:00.00 UNCLASSIFIED THERAPEUTIC AGENTS
PAMIDRONATE DISODIUM SEE APPENDIX A FOR EDS CRITERIA
* 30MG INJECTION 02244550 02059762
PAMIDRONATE DISODIUM(EDS) AREDIA (EDS)
DBU NVR
$
108.4800 170.8900
DBU
$
216.9500
DBU NVR
$
325.4300 502.5000
JAN
$
1.2912
DPY
$
0.2696
PERMAX
DPY
$
0.9883
PERMAX
DPY
$
3.3690
BOE
$
1.0742
MIRAPEX
BOE
$
2.1483
MIRAPEX
BOE
$
2.1483
BOE
$
2.1483
PHU
$
4.0500
PGA
$
1.8011
PGA
$
11.6638
60MG INJECTION 02244551
PAMIDRONATE DISODIUM(EDS)
* 90MG INJECTION 02244552 02059789
PAMIDRONATE DISODIUM(EDS) AREDIA (EDS)
PENTOSAN POLYSULFATE SO4 SEE APPENDIX A FOR EDS CRITERIA
100MG CAPSULE 02029448
ELMIRON (EDS)
PERGOLIDE MESYLATE 0.05MG TABLET 02123320
PERMAX
0.25MG TABLET 02123339
1MG TABLET 02123347
PRAMIPEXOLE DIHYDROCHLORIDE 0.25MG TABLET 02237145
MIRAPEX
0.5MG TABLET 02241594
1MG TABLET 02237146
1.5MG TABLET 02237147
MIRAPEX
RIFABUTIN SEE APPENDIX A FOR EDS CRITERIA
150MG CAPSULE 02063786
MYCOBUTIN (EDS)
RISEDRONATE SODIUM SEE APPENDIX A FOR EDS CRITERIA
5MG TABLET 02242518
ACTONEL (EDS)
30MG TABLET 02239146
ACTONEL (EDS)
217
92:00 UNCLASSIFIED THERAPEUTIC AGENTS 92:00.00 UNCLASSIFIED THERAPEUTIC AGENTS
RIVASTIGMINE SEE APPENDIX A FOR EDS CRITERIA
1.5MG CAPSULE 02242115
EXELON (EDS)
NVR
$
2.4901
NVR
$
2.4901
NVR
$
2.4901
NVR
$
2.4901
REQUIP
GSK
$
0.2794
REQUIP
GSK
$
1.1176
REQUIP
GSK
$
1.2293
REQUIP
GSK
$
3.4644
NXP NOP APX GPM MED PMS DOM DPY
$
1.0996 * 1.3726 1.3726 1.3726 1.3726 1.3726 1.5445 2.1793
GZY
$
0.7704
GZY
$
1.5407
WYA
$
7.3889
3MG CAPSULE 02242116
EXELON (EDS)
4.5MG CAPSULE 02242117
EXELON (EDS)
6MG CAPSULE 02242118
EXELON (EDS)
ROPINIROLE HCL 0.25MG TABLET 02232565
1MG TABLET 02232567
2MG TABLET 02232568
5MG TABLET 02232569
SELEGILINE HCL SEE APPENDIX A FOR EDS CRITERIA
* 5MG TABLET 02230717 02068087 02230641 02231036 02237289 02238102 02238340 02123312
NU-SELEGILINE (EDS) NOVO-SELEGILINE (EDS) APO-SELEGILINE (EDS) GEN-SELEGILINE (EDS) MED-SELEGILINE (EDS) PMS-SELEGILINE (EDS) DOM-SELEGILINE (EDS) ELDEPRYL (EDS)
SEVELAMER HCL SEE APPENDIX A FOR EDS CRITERIA
400MG TABLET 02244309
RENAGEL (EDS)
800MG TABLET 02244310
RENAGEL (EDS)
SIROLIMUS SEE APPENDIX A FOR EDS CRITERIA
1MG/ML ORAL SOLUTION 02243237
RAPAMUNE (EDS)
218
92:00 UNCLASSIFIED THERAPEUTIC AGENTS 92:00.00 UNCLASSIFIED THERAPEUTIC AGENTS
SODIUM CROMOGLYCATE SEE APPENDIX A FOR EDS CRITERIA
20MG/CAPSULE AEROSOL POWDER 00261238
INTAL SPINCAPS
AVT
$
0.5007
AVT
$
1.1621
PMS APX NXP DOM
$
0.5258 0.5258 0.5258 0.6562
AVT
$
42.8600
AVT
$
0.3521
FUJ
$
2.1375
FUJ
$
2.6583
FUJ
$
12.5500
FUJ
$
127.5000
BOE
$
1.0308
RBP
$
2.1700
PANECTYL
AVT
$
0.2256
PANECTYL
AVT
$
0.2805
100MG CAPSULE 00500895
NALCROM (EDS)
* 10MG/ML INHALATION SOLUTION (2ML) 02046113 02231431 02231671 02145448
PMS-SODIUM CROMOGLYCATE APO-CROMOLYN NU-CROMOLYN DOM-SODIUM CROMOGLYCATE
1MG/DOSE PRESSURIZED AEROSOL (PACKAGE) 00555649
INTAL
SODIUM FLUORIDE 20MG TABLET 02099225
FLUOTIC
TACROLIMUS SEE APPENDIX A FOR EDS CRITERIA
0.5MG CAPSULE 02243144
PROGRAF (EDS)
1MG CAPSULE 02175991
PROGRAF (EDS)
5MG CAPSULE 02175983
PROGRAF (EDS)
5MG/ML AMPOULE 02176009
PROGRAF (EDS)
TAMSULOSIN HCL 0.4MG SUSTAINED RELEASE CAPSULE 02238123
FLOMAX
TETRABENAZINE 25MG TABLET 02199270
NITOMAN
TRIMEPRAZINE TARTRATE 2.5MG TABLET 01926306
5MG TABLET 01926292
219
92:00 UNCLASSIFIED THERAPEUTIC AGENTS 92:00.00 UNCLASSIFIED THERAPEUTIC AGENTS
URSODIOL SEE APPENDIX A FOR EDS CRITERIA
250MG TABLET 02238984
URSO (EDS)
AXC
$
1.3385
AST
$
0.7595
ZAFIRLUKAST SEE APPENDIX A FOR EDS CRITERIA
20MG TABLET 02236606
ACCOLATE (EDS)
220
APPENDICES APPENDIX A - EXCEPTION DRUG STATUS PROGRAM APPENDIX B - HOSPITAL BENEFIT DRUG LIST APPENDIX C - TIPS ON PRESCRIPTION WRITING AND PRESCRIPTION REGULATIONS APPENDIX D - GUIDELINES FOR REPORTING ADVERSE DRUG REACTIONS APPENDIX E - SPECIAL COVERAGES APPENDIX F - TRIPLICATE PRESCRIPTION PROGRAM APPENDIX G - CODES FOR PHARMACY ON-LINE CLAIMS PROCESSING APPENDIX H - MAINTENANCE DRUG SCHEDULE APPENDIX I - TRIAL PRESCRIPTION PROGRAM MEDICATION LIST APPENDIX J - SASKATCHEWAN MS DRUGS PROGRAM
APPENDIX A EXCEPTION DRUG STATUS PROGRAM NOTES REGARDING THE EXCEPTION DRUG STATUS (EDS) PROGRAM • Physicians, dentists, duly qualified optometrists (or authorized office staff) and •
• • •
•
•
•
•
pharmacists may apply for EDS. Requests can be submitted by telephone, by mail or by fax. A toll-free line with an electronic message system is available exclusively for requests on a 24-hour basis. The telephone number to access this line is 1-800-667-2549, the Drug Plan EDS Unit fax number is (306) 798-1089. Requests are processed daily on a continuous basis. Please allow Drug Plan staff 24 hours to process requests. Patients are notified by letter if coverage has been approved and the time period for which coverage has been approved. If a request has been denied, letters are sent to the patient and prescriber notifying them of the reason for the denial. In most cases, the Drug Plan requires more information to determine the patient's eligibility for coverage, and will reconsider coverage at such time as further information is received. If the drug requested is not a benefit under the Drug Plan, the patient and prescriber are notified. Payment for the medication is the responsibility of the patient in these cases. It is important to note that not all medications currently available on the market in Canada are benefits under the Saskatchewan Drug Plan or under the Exception Drug Status Program of the Drug Plan. The majority of EDS requests are routinely backdated 30 days from the time the Drug Plan receives the request. Provision can be made for further backdating of EDS coverage on a case-by-case basis. However, the Drug Plan cannot backdate further than one year from the current date. Saskatchewan Prescription Drug Plan policy does not allow a fee to be charged to clients for Exception Drug Status applications made to the Drug Plan on the client's behalf. See NOTES CONCERNING THE FORMULARY, pages xii-xiii for additional general information regarding Exception Drug Status coverage
CRITERIA FOR COVERAGE UNDER EXCEPTION DRUG STATUS Following are the criteria for coverage of certain drugs under Exception Drug Status. Coverage may be provided for other products in certain instances. Further information can be provided by professional staff at the Drug Plan. Certain products may be granted Exception Drug Status for non-approved indications. This is the case only when the Saskatchewan Formulary Committee has reviewed evidence to demonstrate safety and efficacy and the prescriber is aware the drug is being prescribed for a non-approved indication. The following information is required to process all Exception Drug Status requests: • patient name; patient Health Services Number (9 digits); name of drug; diagnosis* relevant to use of drug; prescriber name and phone number. *For pharmacist-initiated EDS requests: The diagnosis, which must be obtained from the physician or physician's agent, is to be consistently documented within the pharmacy, whether the documentation is on the original prescription, computer file, or EDS fax form. 222
____________________________________________ abacavir SO4, oral solution, 20mg/mL; tablet, 300mg (Ziagen-GSK) For management of HIV disease. This drug, as with other antivirals in treatment of HIV, should be used under the direction of an infectious disease specialist. abacavir SO4/lamivudine/zidovudine, tablet, 300mg/150mg/300mg (Trizivir-GSK) For management of HIV disease. This drug, as with other antivirals in the treatment of HIV, should be used under the direction of an infectious disease specialist. acitretin, capsule, 10mg, 25mg (Soriatane-HLR) For treatment of severe intractable psoriasis, Darier's Disease, ichthyosiform dermatoses, palmoplantar pustulosis and other disorders of keratinization. For detailed patient information see page 257. Accolate - see zafirlukast Actonel - see risedronate sodium Actos - see pioglitazone HCl Acular - see ketorolac tromethamine Advair - see salmeterol xinafoate/fluticasone propionate Advair Diskus - see salmeterol xinafoate/fluticasone propionate Agenerase - see amprenavir Aggrenox - see dipyridamole/acetylsalicylic acid alendronate sodium, tablet, 10mg (Fosamax-MSD) (a) For treatment of osteoporosis in patients who do not respond to etidronate disodium/calcium (Didrocal) after receiving it for one year. (b) For treatment of osteoporosis in patients unable to tolerate etidronate disodium/calcium (Didrocal). (c) For treatment of osteoporosis in patients who have fresh fractures. alendronate sodium, tablet, 40mg (Fosamax-MSD) For treatment of symptomatic Paget’s Disease of the bone. alendronate sodium, tablet, 70mg (Fosamax-MSD) (a) For treatment of osteoporosis in patients who do not respond to etidronate disodium /calcium (Didrocal) after receiving it for one year. (b) For treatment of osteoporosis in patients unable to tolerate etidronate disodium/calcium (Didrocal). Alertec - see modafinil alfacalcidol, capsule, 0.25ug, 1ug; oral drops, 2ug/mL (One-Alpha-LEO) For management of hypocalcemia and osteodystrophy in chronic renal disease patients prior to initiation of dialysis. Note: Coverage for dialysis patients is provided under the Saskatchewan Aids to Independent Living (S.A.I.L.) Program. Exception Drug Status coverage is not required for S.A.I.L. patients. Amatine - see midodrine HCl Amerge – see naratriptan HCl
223
amoxicillin trihydrate/potassium clavulanate, tablet, 875mg/125mg; oral suspension, 40mg/5.3mg/mL, 80mg/11.4mg/mL (Clavulin-GSK); * oral suspension, 25mg/6.25mg/mL, 50mg/12.5mg/mL (Clavulin-GSK) (Apo-Amoxi Clav-APX) (ratio-Amoxi Clav-RTP) * tablet, 250mg/125mg, 500mg/125mg (Clavulin-GSK) (Apo-Amoxi Clav-APX) (ratioAmoxi Clav-RTP) For treatment of: (a) Upper and lower respiratory tract infections in patients not responding to first-line antibiotics. (b) Infections caused by organisms known to be resistant to or not responding to alternative antibiotics. (c) Respiratory tract infections in nursing home patients. (d) Pneumonia in patients in the community with comorbidity eg. chronic underlying lung disease (excluding asthma), diabetes mellitus, renal insufficiency, heart failure, stroke. (e) Infection in patients with neutropenia. (f) Pneumonia caused by aspiration. (g) For human, cat and dog bites. (h) Diabetic foot infections, and: (i) For completion of treatment initiated in hospital. amprenavir, capsule, 50mg, 150mg; oral solution, 15mg/mL (Agenerase-GSK) For management of HIV disease in patients who have failed other protease inhibitor combinations. This drug, as with other antivirals in treatment of HIV, should be used under the direction of an infectious disease specialist. Androcur - see cyproterone acetate Apo-Amoxi Clav - see amoxicillin trihydrate/potassium clavulanate Apo-Carbamazepine CR - see carbamazepine Apo-Cefaclor - see cefaclor Apo-Cefuroxime - see cefuroxime axetil Apo-Cyclobenzaprine - see cyclobenzaprine HCl Apo-Desmopressin - see desmopressin Apo-Etodolac - see etodolac Apo-Flavoxate - see flavoxate Apo-Fluconazole - see fluconazole Apo-Ketoconazole - see ketoconazole Apo-Ketotifen - see ketotifen fumarate Apo-Lactulose - see lactulose Apo-Megestrol - see megestrol acetate tablet Apo-Minocycline - see minocycline HCl Apo-Nabumetone - see nabumetone Apo-Norflox - see norfloxacin Apo-Selegiline - see selegiline HCl Apo-Ticlopidine - see ticlopidine HCl Apo-Zidovudine - see zidovudine Arava - see leflunomide Aredia - see pamidronate Aricept - see donepezil HCl Aristospan - see triamcinolone/hexacetonide
224
atovaquone, suspension, 150mg/mL (Mepron-GSK) For treatment of pneumocystis carinii pneumonia (PCP) in patients who are intolerant to trimethoprim/sulfamethoxazole. Avandia - see rosiglitazone maleate Avelox - see moxifloxacin HCl Avonex – see Appendix J azithromycin, tablet, 250mg; oral suspension, 20mg/mL, 40mg/mL (Zithromax-PFI) For treatment of: (a) Pneumonia. (b) Upper and lower respiratory tract bacterial infections known to be resistant to or not responding to alternative antibiotics. (c) Infections in patients allergic to alternative antibiotics. (d) Non-tuberculous Mycobacterium infections (and prophylaxis). (e) Chlamydia trachomatis infections, and: (f) For completion of treatment initiated in hospital with macrolides or quinolones. (g) For patients intolerant to erythromycin and/or other antibiotics. azithromycin, tablet, 600mg (Zithromax-PFI) For prophylaxis and treatment of non-tuberculous Mycobacterium infections. baclofen, injection, 0.05mg/mL, 0.5mg/mL, 2mg/mL (Lioresal Intrathecal-NVR) (a) For treatment of severe spastic conditions in patients who do not respond to oral baclofen. (b) For treatment of severe spastic conditions in patients who cannot tolerate oral baclofen. Betaseron - see Appendix J bezafibrate, tablet, 200mg (pms-Bezafibrate-PMS); sustained release tablet, 400mg (Bezalip SR-HLR) (a) For treatment of patients with hyperlipidemia who have failed to respond to gemfibrozil or fenofibrate. (b) For treatment of patients with hyperlipidemia who have experienced side effects with gemfibrozil or fenofibrate. Bezalip SR - see bezafibrate Biaxin - see clarithromycin Biaxin XL - see clarithromycin bisoprolol fumarate, tablet, 5mg, 10mg (Monocor-BVL) For treatment of patients with stable symptomatic congestive heart failure taking diuretics and ACE inhibitors, with or without digoxin. bosentan, tablet, 62.5mg, 125mg (Tracleer-ACT) For patients with pulmonary arterial hypertension on the recommendation of a specialist. Botox - see botulinum toxin type A
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botulinum toxin type A, sterile lyophilized powder, 100IU (Botox-ALL) (a) For treatment of eye dystonias, that is, blepharospasm and strabismus. (b) For treatment of cervical dystonia, that is, torticollis. (c) For treatment of other forms of severe spasticity. budesonide, controlled ileal release capsule, 3mg (Entocort-AST) (a) For treatment of patients with mild to moderate Crohn's Disease affecting the ileum and/or ascending colon. Coverage will be provided for up to 8 weeks. (b) Maintenance treatment will be approved for patients unresponsive or intolerant to other agents. bumetanide, tablet, 2mg (Burinex-LEO) For treatment of patients unable to tolerate furosemide. bupropion HCl, tablet, 100mg, 150mg (Wellbutrin SR-GSK) For treatment of depression. Burinex - see bumetanide buserelin acetate, intranasal solution, 1.05mg/mL; injection, 1.05mg/mL (SuprefactHRU) (a) For treatment of endometriosis, for a maximum of 6 months. Coverage may be repeated after a six month lapse, for another 6 month course. (b) For pre-treatment of uterine fibroids prior to surgical removal, for a maximum of 6 months. (c) For treatment of menorrhagia in preparation for endometrial ablation, for a maximum of 6 months. cabergoline, tablet, 0.5mg (Dostinex-PHU) (a) For treatment of hyperprolactinemic disorders in patients not responding to bromocriptine. (b) For treatment of hyperprolactinemic disorders in patients intolerant to bromocriptine. Calcimar - see calcitonin salmon +calcitonin salmon, injection, 100IU/mL (Caltine-FEI), 200IU/mL (Calcimar-AVT) (a) For symptomatic treatment of Paget's Disease of the bone. (b) For treatment of crush fracture with bone pain. Coverage will be provided for a maximum of 3 months. (c) For treatment of osteogenesis imperfecta. calcitonin salmon, nasal spray, 200IU/dose (Miacalcin-NVR) (a) For treatment of osteoporosis in patients unable to tolerate listed bisphosphonates. (b) For treatment of osteoporosis in patients not responding to listed bisphosphonates after treatment for one year. (c) For treatment of crush fracture with bone pain. Coverage will be provided for a maximum of 3 months as an alternative to the subcutaneous dosage form.
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calcitriol, capsule, 0.25ug, 0.5ug; oral solution, 1ug/mL (Rocaltrol-HLR) (a) For management of hypocalcemia and osteodystrophy in patients with chronic renal failure undergoing renal dialysis. Note: Coverage for dialysis patients is provided under the Saskatchewan Aids to Independent Living (SAIL) Program. Exception Drug Status coverage is NOT required for SAIL patients. (b) For management of hypocalcemia and clinical manifestations associated with post-surgical hypoparathyroidism, idiopathic hypoparathyroidism, pseudohypoparathyroidism, or vitamin D resistant rickets. Caltine - see calcitonin salmon *carbamazepine, controlled release tablet, 200mg, 400mg (Tegretol CR-NVR) (pmsCarbamazepine-CR-PMS) (Dom-Carbamazepine CR-DOM) (Taro-Carbamazepine CR-TAR) (Gen-Carbamazepine CR-GPM) (Apo-Carbamazepine CR-APX) For treatment in patients experiencing inadequate control or occurrence of unacceptable adverse reactions using the regular tablet dosage form. carvedilol, tablet, 3.125mg, 6.25mg, 12.5mg, 25mg (Coreg-GSK) For treatment of patients with stable symptomatic congestive heart failure taking diuretics and ACE inhibitors, with or without digoxin. Ceclor - see cefaclor *cefaclor, suspension, 25mg/mL, 50mg/mL, 75mg/mL (Ceclor-LIL) (Apo-CefaclorAPX) (Dom-Cefaclor-DOM) (pms-Cefaclor-PMS); capsule, 250mg, 500mg (pmsCefaclor-PMS) (Apo-Cefaclor-APX) (Dom-Cefaclor-DOM) (Nu-Cefaclor-NXP) (Novo-Cefaclor-NOP) Note: All forms and strengths of cefaclor are scheduled to be delisted from the Saskatchewan Formulary effective April 1, 2003. (a) For treatment of infections in patients with underlying lung disease not responding to first-line antibiotics. (b) For treatment of infections in patients allergic to alternative antibiotics. (Note: patients with immediate hypersensitivity to penicillin should not receive cephalosporins.) (c) For treatment of infections caused by organisms known to be resistant to alternative antibiotics. (d) For treatment of respiratory tract infections in nursing home patients. (e) For treatment of pneumonia in patients in the community with comorbidity (ie. COPD, diabetes mellitus, renal insufficiency, heart failure). (f) For step-down care following hospital separation in patients treated with intravenous antibiotics (guided by culture and sensitivity results). cefixime, tablet, 400mg; oral suspension, 20mg/mL (Suprax-AVT) For treatment of: (a) Infections in patients allergic to alternative antibiotics. (Note: patients who have had an anaphylactic reaction to penicillin should not receive cephalosporins.) (b) Infections caused by organisms known to be resistant to or not responding to alternative antibiotics. (c) Uncomplicated gonorrhea.
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cefprozil, tablet, 250mg, 500mg; suspension, 25mg/mL, 50mg/mL (Cefzil-BMY) For treatment of: (a) Upper and lower respiratory tract infections in patients not responding to first-line antibiotics. (b) Infections caused by organisms known to be resistant or not responding to alternative antibiotics. (c) Infections in patients allergic to alternative antibiotics. (Note: patients who have had an anaphylactic reaction to penicillin should not receive cephalosporins.) (d) Respiratory tract infections in nursing home patients. (e) Pneumonia in patients in the community with comorbidity eg. chronic underlying lung disease (excluding asthma), diabetes mellitus, renal insufficiency, heart failure, stroke, and: (f) For completion of antibiotic treatment initiated in hospital. Ceftin - see cefuroxime axetil cefuroxime axetil, suspension, 25mg/mL (Ceftin-GSK) *tablet, 250mg, 500mg (Ceftin-GSK) (ratio-Cefuroxime-RTP) (Apo-Cefuroxime-APX) For treatment of: (a) Upper and lower respiratory tract infections in patients not responding to first-line antibiotics. (b) Infections caused by organisms known to be resistant or not responding to alternative antibiotics. (c) Infections in patients allergic to alternative antibiotics. (Note: patients who have had an anaphylactic reaction to penicillin should not receive cephalosporins.) (d) Respiratory tract infections in nursing home patients. (e) Pneumonia in patients in the community with comorbidity ie. chronic underlying lung disease (excluding asthma), diabetes mellitus, renal insufficiency, heart failure, stroke, and: (f) For completion of antibiotic treatment initiated in hospital. Cefzil - see cefprozil Celebrex - see celecoxib celecoxib, capsule, 100mg, 200mg (Celebrex-PHU) (a) For treatment in patients age 65 and over (approved automatically through the on-line computer system). (b) For treatment of rheumatoid arthritis and osteoarthritis in patients who have one of the following factors: • past history of ulcers; • concurrent prednisone therapy; • concurrent warfarin therapy. (c) For treatment of patients with an intolerance to other NSAIDs listed in the Formulary. CellCept - see mycophenolate mofetil Cesamet - see nabilone chorionic gonadotropin, injection, 10,000IU/vial (Profasi HP-SRO) (a) For treatment of habitual abortion. (b) For treatment of delayed puberty. Ciloxan - see ciprofloxacin Cipro - see ciprofloxacin tablet 228
Cipro HC - see ciprofloxacin/hydrocortisone ciprofloxacin, ophthalmic solution, 0.3%; ophthalmic ointment, 0.3% (Ciloxan-ALC) For treatment of ophthalmic infections caused by gram-negative organisms or those not responding to alternative agents. ciprofloxacin, tablet, 250mg, 500mg, 750mg; oral suspension, 100mg/mL (Cipro-BAY) For treatment of: (a) Infections caused by Pseudomonas aeruginosa. (b) Infections in patients allergic to two or more alternative antibiotics. (c) Infections known to be resistant to alternative antibiotics. (d) Patients with severe diabetic foot infections in combination with other antibiotics. (e) Infection (and prophylaxis) in patients with prolonged neutropenia. (f) Genitourinary tract infections in patients allergic or not responding to alternative antibiotics. (g) Patients with bronchiectasis or cystic fibrosis. (h) Gonorrhea, and: (i) For completion of antibiotic treatment initiated in hospital when alternatives are not appropriate. ciprofloxacin/hydrocortisone, otic suspension, 0.2%/1% (Cipro HC-ALC) (a) For treatment of otitis externa in patients who have failed previous treatment with listed combination anti-infective/anti-inflammatory agents. (b) For treatment of patients with perforation of the tympanic membrane. clarithromycin, tablet, 250mg, 500mg; oral suspension, 25mg/mL, 50mg/mL (Biaxin-ABB); extended-release tablet, 500mg (Biaxin XL-ABB) For treatment of: (a) Pneumonia. (b) Upper and lower respiratory tract bacterial infections known to be resistant to or not responding to alternative antibiotics. (c) Infections in patients allergic to alternative antibiotics. (d) Non-tuberculous Mycobacterium infections (and prophylaxis), and: (e) For one week for eradication of H. pylori-related infections when used in combination treatment regimens for the treatment of peptic ulcer disease. (f) For completion of treatment initiated in hospital with macrolides or quinolones. (g) For patients intolerant to erythromycin and/or other antibiotics. Clavulin - see amoxicillin trihydrate/potassium clavulanate Climara - see estradiol clonidine HCl, tablet, 0.025mg (Dixarit-BOE) (a) For treatment of menopausal flushing in patients unable to tolerate estrogen therapy. (b) For treatment of Attention Deficit Disorder. clopidogrel bisulfate, tablet, 75mg (Plavix-SAW) (a) For treatment of patients who have experienced a recurrent vascular episode while on acetylsalicylic acid. (b) For treatment of patients who have experienced a recurrent vascular episode and have a clearly demonstrated allergy to acetylsalicylic acid (manifested by asthma or nasal polyps). (c) For treatment of patients who have experienced a recurrent vascular episode and are intolerant of acetylsalicylic acid (manifested by gastrointestinal hemorrhage). (d) When prescribed following intracoronary stent placement. Coverage will be provided for a period of 4 weeks. Clopixol - see zuclopenthixol 229
clozapine, tablet, 25mg, 100mg (Clozaril-NVR) For treatment of patients with schizophrenia who are either treatment resistant or treatment intolerant and have no other medical contraindications. Clozaril - see clozapine codeine, controlled release tablet, 50mg, 100mg, 150mg, 200mg (Codeine ContinPFR) (a) For treatment of palliative and chronic pain patients as an alternative to ASA/codeine combination products or acetaminophen/codeine combination products. (b) For treatment of palliative and chronic pain patients as an alternative to the regular release tablet when large doses are required. In non-palliative patients, coverage will only be approved for a 6 month course of therapy, subject to review. Codeine Contin - see codeine Combivir – see lamivudine/zidovudine Copaxone - see Appendix J Coreg - see carvedilol Crixivan - see indinavir SO4 *cyclobenzaprine HCl, tablet, 10mg (Flexeril-JAN) (Apo-Cyclobenzaprine-APX) (Novo-Cycloprine-NOP) (Nu-Cyclobenzaprine-NXP) (pms-Cyclobenzaprine-PMS) (Gen-Cyclobenzaprine-GPM) (Med-Cyclobenzaprine-MED) (Flexitec-TCH) (DomCyclobenzaprine-DOM) As an adjunct to rest and physical therapy for relief of muscle spasm associated with acute, painful musculoskeletal conditions not responding or experiencing severe adverse reactions to alternative therapy. Coverage will be provided for up to a 3 week period. cyclosporine, capsule, 10mg, 25mg, 50mg, 100mg; liquid, 100mg/mL (Neoral-NVR) (a) For induction and maintenance of remission of severe psoriasis in patients for whom conventional therapy is ineffective or inappropriate. (b) For treatment of patients with severe active rheumatoid arthritis for whom classical slow-acting anti-rheumatic agents are inappropriate or ineffective. (c) For treatment of nephrotic syndrome. For the above indications prescriptions are subject to deductible and co-payment as for other drugs covered under the Drug Plan. Pharmacies note: claims on behalf of these patients must use the following identifying numbers (not the DIN): 10mg – 00950792 100mg – 00950815 25mg – 00950793 100mg/mL - 00950823 50mg – 00950807 cyclosporine, capsule, 10mg, 25mg, 50mg, 100mg; liquid, 100mg/mL (Neoral-NVR) For prophylaxis of graft rejection following solid organ transplant and bone marrow transplant procedures. In such cases, the cost is covered at 100% and the deductible does not apply. cyproterone acetate, injection, 100mg/mL (Androcur Depot-PMS); *tablet, 50mg (Androcur-PMS) (Gen-Cyproterone-GPM) (Novo-Cyproterone-NOP) For treatment of hirsuitism. 230
Cytovene - see ganciclovir sodium dalteparin sodium, syringe, 2,500IU (0.2mL), 5,000IU (0.2mL); injection solution, 10,000IU/mL (1mL), 25,000IU/mL (3.8mL) (Fragmin-PHU) (a) For treatment of venous thromboembolism for up to 10 days. (b) For prophylaxis following total knee arthroplasty and major orthopedic trauma for up to 10 days (treatment duration may be reassessed). (c) For longterm outpatient prophylaxis in patients who are pregnant. (d) For longterm outpatient prophylaxis in patients who are intolerant to, or have failed, warfarin therapy. (e) For longterm outpatient prophylaxis in patients who have lupus anticoagulant syndrome. DDAVP - see desmopressin acetate delavirdine mesylate, tablet, 100mg (Rescriptor-PHU) For management of HIV disease. This drug, as with other antivirals in treatment of HIV, should be used under the direction of an infectious disease specialist. *deferoxamine mesylate, powder for solution, 500mg/vial, 2g/vial (pms-Deferoxamine-PMS) (Desferal-NVR) For treatment of iron overload in patients with transfusion-dependent anemias. Desferal - see deferoxamine mesylate desmopressin, tablet, 0.1mg, 0.2mg (DDAVP-FEI) *intranasal solution, 10ug/dose (DDAVP-FEI) (Apo-Desmopressin-APX) (a) For treatment of diabetes insipidus. (b) For treatment of enuresis in children over 5 years of age refractory to bed-wetting alarms or alternative agents listed in the Formulary. desmopressin, injection, 4ug/mL (DDAVP-FEI); intranasal solution, 150ug/dose (Octostim-FEI) For prophylaxis of mild hemophilia A and mild von Willebrand's Disease. Detrol - see tolterodine l-tartrate diclofenac sodium, ophthalmic solution, 0.1% (Voltaren Ophtha-NVO) (a) For treatment of post-operative ocular inflammation in patients undergoing cataract surgery. (b) For prophylaxis of aphakic macular edema following cataract surgery. (c) For treatment of long-term inflammatory conditions not responding to short-term topical steroids. didanosine, powder for oral solution (package), 4g; chewable tablet, 25mg, 50mg, 100mg, 150mg (Videx-BMY); capsule (enteric coated beadlet), 125mg, 200mg, 250mg, 400mg (Videx EC-BMY) For management of HIV disease. This drug, as with other antivirals in treatment of HIV, should be used under the direction of an infectious disease specialist. Didronel - see etidronate disodium Diflucan - see fluconazole
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dipyridamole, tablet, 25mg, 50mg, 75mg (Persantine-BOE) (a) Following transluminal angioplasty, for a maximum of 6 months. (b) Following bypass surgery, for a maximum of 12 months. (c) Following prosthetic heart valve replacement, for 12 months. This is renewable on a yearly basis. dipyridamole/acetylsalicylic acid, capsule, 200mg/25mg (Aggrenox-BOE) For treatment of patients who have had a stroke or transient ischemic attack while on acetylsalicylic acid. Dixarit - see clonidine HCl Dom-Carbamazepine CR – see carbamazepine Dom-Cefaclor - see cefaclor Dom-Cyclobenzaprine – see cyclobenzaprine HCl Dom-Minocycline - see minocycline HCl Dom-Selegiline – see selegiline HCl Dom-Ticlopidine - see ticlopidine HCl donepezil HCl, tablet, 5mg, 10mg (Aricept-PFI) (a) A diagnosis of probable Alzheimer's Disease as per DSM-IV criteria. (b) A mild to moderate stage of the disease with a MMSE score of 10-26 established within 60 days prior to application for coverage by a clinician. (c) A Functional Activities Questionnaire (FAQ) must be completed. (d) Patients must discontinue all drugs with anticholinergic activity at least 14 days before the MMSE and FAQ are administered. Drugs with anticholinergic activity are not to be used concurrently with donepezil therapy. List all current medications patient was taking at the time of assessment. (e) Patients intolerant to one drug may be switched to another drug in this class. Intolerance should be observed within the first month of treatment. •
Eligible patients currently taking donepezil would require assessment at 6 month intervals. To continue receiving donepezil, patients must not have both a greater than 2 point reduction in MMSE and a 1 point increase in FAQ in a 6 month evaluation period. Scores are compared to the most recent test results.
•
Eligible new patients will enter a 3 month treatment period with donepezil. During the 3 month trial, patients must exhibit an improvement from the initial MMSE or FAQ to continue treatment with donepezil. The improvement must be at least 2 MMSE points or -1 FAQ. Patients who meet these requirements will be re-evaluated at 6 month intervals. To continue receiving donepezil, patients must not have both a greater than 2 point reduction in MMSE and a 1 point increase in FAQ in a 6 month evaluation period. Scores are compared to the most recent test results.
•
The MMSE score must remain at 10 or greater at all times to be eligible for coverage.
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Patients who do not meet criteria to continue donepezil can be re-evaluated within 3 months to confirm deterioration before coverage is discontinued.
•
Donepezil does not need to be discontinued prior to MMSE or FAQ testing.
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A patient intolerant of one drug and switching to a second will be considered a "new" patient and will be assessed as such.
•
Coverage will not be considered for patients who have failed on other drugs in this class.
Applications for EDS for donepezil (Aricept) will only be accepted from physicians on the Aricept/Exelon/Reminyl EDS application form. This form is available on-line at http://formulary.drugplan.health.gov.sk.ca or by calling the Drug Plan. 232
dornase alfa, inhalation solution, 1mg/mL (Pulmozyme-HLR) For treatment of cystic fibrosis patients who meet the following criteria: (a) at least 5 years of age (b) Lung function greater than 40% (as measured by FVC) (c) Physicians will be requested to provide evidence of the beneficial effect of this drug in their patients after 6 months of therapy before additional coverage is granted. Renewal of coverage will be provided for a 6 month period if any of the following criteria are met: (a) FEV1 has improved by 10% from pre-treatment value (b) decreased antibiotic utilization (c) decreased hospitalizations (d) decreased absenteeism from school or work (e) if the individual deteriorates upon discontinuation of Pulmozyme therapy. Physicians must provide appropriate documentation to establish benefit. Dostinex - see cabergoline doxercalciferol, capsule, 2.5ug (Hectorol-DPY) For the management of hypocalcemia, osteodystrophy and secondary hyperparathyroidism in chronic renal disease patients prior to initiation of dialysis. Note: Coverage for dialysis patients is provided under the Saskatchewan Aids to Independent Living (SAIL) Program. Exception Drug Status coverage is NOT required for SAIL patients. Duragesic - see fentanyl Edecrin - see ethacrynic acid efavirenz, capsule, 50mg, 100mg, 200mg (Sustiva-BMY) For management of HIV disease. This drug, as with other antivirals in treatment of HIV, should be used under the direction of an infectious disease specialist. Eldepryl - see selegiline HCl Elmiron - see pentosan polysulfate sodium Enbrel - see etanercept enoxaparin, syringe, 100mg/mL (0.3mL, 0.4mL, 0.6mL, 0.8mL, 1mL); injection solution, 100mg/mL (3mL) (Lovenox-AVT) (a) For treatment of venous thromboembolism for up to 10 days. (b) For prophylaxis following total knee arthroplasty and major orthopedic trauma for up to 10 days (treatment duration may be reassessed). (c) For longterm outpatient prophylaxis in patients who are pregnant. (d) For longterm outpatient prophylaxis in patients who are intolerant to, or have failed, warfarin therapy. (e) For longterm outpatient prophylaxis in patients who have lupus anticoagulant syndrome. (f) For treatment of pediatric patients where anticoagulant therapy is required and warfarin cannot be administered. Entocort - see budesonide
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epoetin alfa, pre-filled syringe, 1,000 IU/0.5mL, 2,000IU/0.5mL, 3,000IU/0.3mL, 4,000IU/0.4mL, 6,000IU/0.6mL, 8,000IU/0.8mL, 10,000IU/mL; sterile solution for injection, 20,000IU (Eprex-JAN) (a) For treatment of anemia in chronic renal disease patients prior to initiation of dialysis. Note: Coverage for dialysis patients is provided under the Saskatchewan Aids to Independent Living (S.A.I.L.) Program. Exception Drug Status coverage is not required for S.A.I.L. patients. (b) For treatment of anemia in AIDS patients. (c) For treatment of anemia in transplant patients. Eprex - see epoetin alfa Ergamisol - see levamisole Estalis - see estradiol/norethindrone acetate Estalis-Sequi - see estradiol & norethindrone acetate/estradiol Estracomb - see estradiol & norethindrone acetate/estradiol Estraderm - see estradiol estradiol, transdermal gel (metered dose pump), 0.06% (Estrogel-SCH); +transdermal therapeutic system, 25ug, 50ug, 100ug (Estraderm-NVR), 37.5ug, 50ug, 75ug, 100ug (Vivelle-NVR), 50ug, 100ug (Climara-BEX), 25ug, 50ug (OesclimPAL), 37.5ug, 50ug, 75ug, 100ug (Estradot-NVR) For treatment in patients who are unable to tolerate oral estrogen. estradiol/norethindrone acetate, transdermal therapeutic system (8), 50ug/140ug, 50ug/250ug (Estalis-NVR) For treatment in patients who are unable to tolerate oral hormone replacement therapy (either estrogen or progesterone). estradiol & norethindrone acetate/estradiol, transdermal therapeutic system (8), 50ug & 140ug/50ug (Estalis-Sequi-NVR) +50ug & 250ug/50ug (Estracomb-NVR) (Estalis-Sequi-NVR) For treatment in patients who are unable to tolerate oral hormone replacement therapy (either estrogen or progesterone). Estradot – see estradiol Estrogel – see estradiol etanercept, powder for injection (vial), 25mg/vial (Enbrel-WYA) For treatment of patients with active rheumatoid arthritis who have failed or are intolerant to methotrexate, leflunomide and at least one other DMARD. This product should be used in consultation with a specialist in this area. ethacrynic acid, tablet, 50mg (Edecrin-MSD) For treatment of patients refractory to furosemide. etidronate disodium, tablet, 200mg (Didronel-PGA) (a) For treatment of symptomatic Paget's Disease of the bone for a 6 month period. Coverage can be renewed after a drug holiday of at least 90 days. (b) For treatment of heterotopic calcification. (c) For symptomatic management of bone pain due to cancer in the palliative care patient. (d) For treatment of osteoporosis in patients who are intolerant to the calcium in Didrocal. 234
etodolac, capsule, 200mg (Apo-Etodolac-APX); *capsule, 300mg (Ultradol-PGA) (Apo-Etodolac-APX) For treatment of patients with an intolerance to other NSAIDS listed in the Formulary. Evista - see raloxifene HCl Exelon - see rivastigmine fentanyl, transdermal system, 25ug/hr., 50ug/hr., 75ug/hr., 100ug/hr. (DuragesicJAN) For treatment of patients who cannot tolerate, or are unable to take, oral sustainedreleased strong opioids, or as an alternative to subcutaneous narcotic infusion therapy. In non-palliative patients, coverage will only be approved for a 6-month course of therapy. filgrastim, injection solution, 300ug/mL (Neupogen-AMG) (a) For treatment of patients with congenital, cyclic or idiopathic neutropenia with absolute neutrophil counts of less than or equal to 500. (b) For treatment of non-cancer patients who have undergone bone marrow transplantation. (c) For treatment of AIDS patients with absolute neutrophil counts of less than 500. *flavoxate HCl, tablet, 200mg (Urispas-PMS) (Apo-Flavoxate-APX) For treatment of spasms in the urinary tract in patients unresponsive or intolerant to listed alternatives. Flexeril - see cyclobenzaprine HCl Flexitec - see cyclobenzaprine HCl fluconazole, powder for oral suspension, 10mg/mL (Diflucan-PFI); *tablet, 50mg, 100mg (Diflucan-PFI) (Apo-Fluconazole-APX) (Gen-FluconazoleGPM) (pms-Fluconazole-PMS) (a) For treatment of fungal meningitis in immunocompromised patients. (b) For treatment of severe or life-threatening fungal infections. (c) For treatment of severe dermatophytoses not responding to other forms of therapy including ketoconazole. Note: the 150mg capsule form of fluconazole is listed in the Saskatchewan Formulary. flunarizine HCl, capsule, 5mg (Sibelium-JAN) For prophylaxis of migraines in cases where alternative prophylactic agents have not been effective. flurbiprofen sodium, ophthalmic solution, 0.03% (Ocufen-ALL) (a) For treatment of post-operative ocular inflammation in patients undergoing cataract surgery. (b) For prophylaxis of aphakic macular edema following cataract surgery. (c) For treatment of long-term inflammatory conditions not responding to short-term topical steroids. Foradil - see formoterol fumarate
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+formoterol fumarate, powder for inhalation (capsule), 12ug (Foradil-NVR); powder for inhalation (package), 6ug/dose, 12ug/dose (Oxeze Turbuhaler-AST) (a) For treatment of asthma uncontrolled on concurrent inhaled steroid therapy. It is important that these patients also have access to a short-acting beta-2 agonist for symptomatic relief. (b) For treatment of Chronic Obstructive Pulmonary Disease (COPD). formoterol fumarate dihydrate/budesonide, powder for inhalation (package), 6ug/100ug, 6ug/200ug (Symbicort Turbuhaler-AST) (a) For treatment of asthma in patients not adequately controlled on inhaled steroid therapy. It is important that these patients also have access to a short-acting beta-2 agonist for symptomatic relief. (b) For treatment of chronic obstructive pulmonary disease (COPD) in patients who are not adequately controlled on a long-acting beta-2 agonist alone. Fortovase – see saquinavir Fosamax - see alendronate sodium fosfomycin tromethamine, oral powder (sachet), 3g (Monurol-PFR) For treatment of: (a) Urinary tract infections with organisms resistant to first line therapy. (b) Urinary tract infections in patients allergic to first line agents. (c) Urinary tract infections in pregnancy when first line agents are inappropriate. Fragmin – see dalteparin sodium Fraxiparine – see nadroparin calcium Fraxiparine Forte – see nadroparin calcium Fucithalmic - see fusidic acid fusidic acid, ophthalmic drops (preservative free), 1%; ophthalmic drops 1% (Fucithalmic-LEO) For patients not responding to listed alternatives. galantamine hydrobromide, tablet, 4mg, 8mg, 12mg (Reminyl-JAN) (a) A diagnosis of probable Alzheimer's Disease as per DSM-IV criteria. (b) A mild to moderate stage of the disease with a MMSE score of 10-26 established within 60 days prior to application for coverage by a clinician. (c) A Functional Activities Questionnaire (FAQ) must be completed. (d) Patients must discontinue all drugs with anticholinergic activity at least 14 days before the MMSE and FAQ are administered. Drugs with anticholinergic activity are not to be used concurrently with galantamine hydrobromide therapy. List all current medications patient was taking at the time of assessment. (e) Patients intolerant to one drug may be switched to another drug in this class. Intolerance should be observed within the first month of treatment. •
Eligible patients currently taking galantamine hydrobromide would require assessment at 6 month intervals. To continue receiving galantamine hydrobromide, patients must not have both a greater than 2 point reduction in MMSE and a 1 point increase in FAQ in a 6 month evaluation period. Scores are compared to the most recent test results.
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•
Eligible new patients will enter a 3 month treatment period with galantamine hydrobromide. During the 3 month trial, patients must exhibit an improvement from the initial MMSE or FAQ to continue treatment with galantamine hydrobromide. The improvement must be at least 2 MMSE points or -1 FAQ. Patients who meet these requirements will be re-evaluated at 6 month intervals. To continue receiving galantamine hydrobromide, patients must not have both a greater than 2 point reduction in MMSE and a 1 point increase in FAQ in a 6 month evaluation period. Scores are compared to the most recent test results.
•
The MMSE score must remain at 10 or greater at all times to be eligible for coverage.
•
Patients who do not meet criteria to continue galantamine hydrobromide can be re-evaluated within 3 months to confirm deterioration before coverage is discontinued.
•
Galantamine hydrobromide does not need to be discontinued prior to MMSE or FAQ testing.
•
A patient intolerant of one drug and switching to a second will be considered a "new" patient and will be assessed as such.
•
Coverage will not be considered for patients who have failed on other drugs in this class.
Applications for EDS for galantamine (Reminyl) will only be accepted from physicians on the Aricept/Exelon/Reminyl EDS application form. This form is available on-line at http://formulary.drugplan.health.gov.sk.ca or by calling the Drug Plan. ganciclovir sodium, capsule, 250mg, 500mg (Cytovene-HLR) (a) For treatment of CMV retinitis and other CMV infections in immunocompromised patients. (b) For prevention of CMV in solid organ transplant recipients who are considered at risk of developing CMV disease. Coverage will be granted for a period of 3 months. gatifloxacin, tablet, 400mg (Tequin-BMY) For treatment of: (a) Pneumonia in patients with underlying lung disease (excluding asthma) and pneumonia in nursing home patients. (b) Infections caused by organisms known to be resistant to alternative antibiotics. (c) Infections in patients allergic to two or more alternative antibiotics, and: (d) For completion of antibiotic treatment initiated in hospital when alternatives are not appropriate. Gen-Carbamazepine CR - see carbamazepine Gen-Cycloprine - see cyclobenzaprine HCl Gen-Cyproterone - see cyproterone acetate Gen-Fluconazole - see fluconazole Gen-Minocycline - see minocycline HCl Gen-Nabumetone - see nabumetone Gen-Selegiline - see selegiline HCl Gen-Ticlopidine - see ticlopidine HCl glatiramer acetate, injection, 20mg (vial); 20mg (pre-filled syringe) (Copaxone-TVM) See Appendix J 237
GlucoNorm - see repaglinide goserelin acetate, 3.6mg/syringe (Zoladex-AST) (a) For treatment of endometriosis, for a maximum of 6 months. Coverage may be repeated after a six month lapse, for another 6 month course. (b) For pre-treatment of uterine fibroids prior to surgical removal, for a maximum of 6 months. (c) For treatment of menorrhagia in preparation for endometrial ablation, for a maximum of 6 months. halobetasol propionate, cream, 0.05%; ointment, 0.05% (Ultravate-WSD) For treatment of patients refractory to or intolerant of other listed products. Hectorol - see doxercalciferol Heptovir – see lamivudine Hivid - see zalcitabine Hp-PAC – see lansoprazole/clarithromycin/amoxicillin Humalog - see insulin lispro Humalog Mix25 - see insulin (regular/protamine) lispro Humatrope - see somatropin Imitrex - see sumatriptan indinavir SO4, capsule, 200mg, 400mg (Crixivan-MSD) For management of HIV disease. This drug, as with other antivirals in treatment of HIV, should be used under the direction of an infectious disease specialist. infliximab, injection (mg),100mg/vial (Remicade-SCH) Crohn's Disease: (a) Moderate to severe Crohn's Disease: • For treatment of patients who demonstrate continuing symptoms despite the use of optimal conventional therapies such as 5-ASA agents, glucocorticoids and immunosuppressive therapy. • For treatment of patients who are unable to tolerate conventional therapy including 5-ASA agents, glucocorticoids and immunosuppressive therapy. (b) Fistulizing Crohn's Disease: • For treatment of patients with symptomatic enterocutaneous or perineal fistulae, enterovaginal fistulae or enterovesical fistulae (i.e. any type of fistulizing Crohn’s Disease). Note: This product should be used in consultation with a specialist in this area. Pharmacies note: claims on behalf of Crohn's Disease patients must use the following identifying number (not the DIN): 00950899 Rheumatoid Arthritis: For treatment of patients with active rheumatoid arthritis who have failed or are intolerant to methotrexate, leflunomide and at least one other DMARD. Treatment should be combined with an immunosuppressant. This product should be used in consultation with a specialist in this area. Infufer - see iron dextran Innohep - see tinzaparin sodium
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insulin aspart, injection solution, 100U/ml (5x3ml) (10ml) (NovoRapid-NOO) For treatment of difficult to control diabetes. insulin lispro, injection solution, 100U/mL (5 x 1.5mL, 5 x 3mL) (10mL) (HumalogLIL) (a) For treatment of patients using insulin pumps. (b) For treatment of patients with difficult to control diabetes. insulin (regular/protamine) lispro, injection suspension, 100U/mL, 25%/75% (5x3mL) (Humalog Mix25-LIL) For treatment of patients with difficult to control diabetes. interferon alfa-2a, injection solution albumin (human) free, 3 million IU/1mL, 9 million IU/1mL, 18 million IU/3mL (Roferon-A-HLR) (a) For treatment of chronic active hepatitis B for a period of up to 6 months. (b) For treatment of chronic active hepatitis C. Coverage will be provided for an initial 6 month period with potential renewal for 2 additional 6 month periods. Note: Interferons are not interchangeable. Pharmacists should dispense the product specified by the physician. interferon alfa-2b, powder for injection, 10 million IU; injection solution albumin (human) free, 6 million IU/mL (0.5mL), 10 million IU/mL (0.5mL, 1mL); multi-dose pen (kit) albumin (human) free, 18 million IU/pen, 30 million IU/pen, 60 million IU/pen (Intron-A-SCH) (a) For treatment of chronic active hepatitis B for a period of up to 6 months. (b) For treatment of chronic active hepatitis C. Coverage will be provided for an initial 6 month period with potential renewal for 2 additional 6 month periods. Note: Interferons are not interchangeable. Pharmacists should dispense the product specified by the physician. interferon alfa-2b/Ribavirin, injection solution albumin (human) free/capsule (package), 6 million IU/mL(0.5mL)/200mg; multi-dose pen albumin (human) free/capsule (package), 15 million IU/mL/200mg (Rebetron-SCH) For treatment of hepatitis C. Coverage will be provided for an initial 6 month period with potential renewal for 2 additional 6 month periods. Intron A - see interferon alfa-2b interferon beta-1a, powder for im injection, 30ug (Avonex-BGN) See Appendix J interferon beta-1a, pre-filled syringe, 22ug (6 million IU), 44ug (12 million IU) (RebifSRO) See Appendix J interferon beta-1b, powder for injection, 0.3ng (3mL) (Betaseron-BEX) See Appendix J Intron A - see interferon alfa-2b Invirase - see saquinavir
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iron dextran, injection, 50mg/mL (Infufer-SAB) For treatment of iron deficiency when patients are intolerant to oral iron replacement products. Note: Coverage for dialysis patients is provided under the Saskatchewan Aids to Independent Living (S.A.I.L.) Program. Exception Drug Status coverage is not required for S.A.I.L. patients. itraconazole, capsule, 100mg; oral solution, 10mg/mL (Sporanox-JAN) (a) For treatment of severe or life-threatening fungal infections. (b) For treatment of severe dermatophytoses not responding to other forms of therapy. (c) For treatment of onychomycosis. Kaletra - see lopinavir/ritonavir *ketoconazole, tablet, 200mg (Nizoral-MCL) (Apo-Ketoconazole-APX) (Nu-KetoconNXP) (Novo-Ketoconazole-NOP) (a) For treatment of severe or life-threatening fungal infections. (b) For treatment of severe dermatophytoses. (c) For treatment of dermatophytoses not responding to other forms of therapy. ketorolac tromethamine, ophthalmic solution, 0.5% (Acular-ALL) (a) For treatment of post-operative ocular inflammation in patients undergoing cataract surgery. (b) For prophylaxis of aphakic macular edema following cataract surgery. (c) For treatment of long-term inflammatory conditions not responding to short-term topical steroids. *ketotifen fumarate, tablet, 1mg (Zaditen-NVR) (Novo-Ketotifen-NOP) (pmsKetotifen-PMS); syrup, 0.2mg/mL (Zaditen-NVR) (Novo-Ketotifen-NOP) (NuKetotifen-NXP) (Apo-Ketotifen-APX) (pms-Ketotifen-PMS) For treatment of pediatric patients with asthma who are unresponsive to or unable to administer alternative prophylactic agents listed in the Formulary. lactulose, syrup, 667mg/mL (pms-Lactulose-PMS); *solution, 667mg/mL (ratio-Lactulose-RTP) (Apo-Lactulose-APX) For treatment of portal systemic encephalopathy. lamivudine, tablet, 100mg (Heptovir-GSK) For management of hepatitis B. lamivudine, tablet, 150mg; oral solution, 10mg/mL (3TC-GSK) For management of HIV disease. This drug, as with other antivirals in treatment of HIV, should be used under the direction of an infectious disease specialist. lamivudine/zidovudine, tablet, 150mg/300mg (Combivir-GSK) For management of HIV disease. This drug, as with other antivirals in treatment of HIV, should be used under the direction of an infectious disease specialist.
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lansoprazole, delayed release capsule, 15mg, 30mg (Prevacid-ABB) (a) For a maximum of 8 weeks in treatment of peptic ulcer disease, which includes gastric and duodenal ulcers, in patients not responding or experiencing unusual or severe adverse reactions to a reasonable trial with H2 blockers, sucralfate or misoprostol. Coverage for a repeat treatment will be approved only after a 3-6 month period of no treatment or prophylaxis with an H2 blocker, sucralfate or misoprostol. (b) For one year in treatment of symptoms of gastroesophageal reflux disease (GERD). It was noted that patients with non-erosive GERD could potentially be reduced to step-down therapy with an H2 antagonist depending on symptom resolution. (c) For one year in treatment of severe erosive esophagitis and Zollinger-Ellison Syndrome. This is renewable on a yearly basis. (d) For one week for eradication of H. pylori-related infections in individuals with peptic ulcer disease. Provision will be made for additional coverage in treatment failures. (e) For first-line prevention of gastroduodenal hemorrhage in high risk patients with prior history of gastroduodenal bleeds for whom anticoagulant, glucocorticosteroid or NSAID therapy cannot be avoided. Coverage is renewable on a yearly basis for patients if discontinuation of offending agents or replacement with less damaging alternatives is not feasible. lansoprazole/clarithromycin/amoxicillin, 7 day package, 30mg/500mg/500mg (HpPAC-ABB) For one week for eradication of H. pylori-related infections in individuals with peptic ulcer disease. Provision will be made for additional coverage in treatment failures. leflunomide, tablet, 10mg, 20mg (Arava-AVT) For treatment of patients with active rheumatoid arthritis who have failed or are intolerant to methotrexate and at least one other DMARD (e.g. sulfasalazine, azathioprine or hydroxychloroquine). Note: Leflunomide is contraindicated in patients with pre-existing impairment of liver function. Leucovorin - see leucovorin calcium leucovorin calcium, tablet, 5mg (Leucovorin-WYA) For treatment of folic acid deficiency in patients who have been on long-term therapy with trimethoprim/sulfamethoxazole. leuprolide acetate, injection, 3.75mg/mL, 7.5mg/mL; depot injection, 11.25mg (3month SR) (Lupron Depot-ABB) (a) For treatment of endometriosis, for a maximum of 6 months. Coverage may be repeated after a six month lapse, for another 6 month course. (b) For pre-treatment of uterine fibroids prior to surgical removal, for a maximum of 6 months. (c) For treatment of menorrhagia in preparation for endometrial ablation, for a maximum of 6 months. levamisole, tablet, 50mg (Ergamisol-JAN) For treatment of high-dose steroid-dependent nephrotic syndrome in children as adjunct therapy following relapse on corticosteroids. Levaquin – see levofloxacin
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levofloxacin, tablet, 250mg, 500mg (Levaquin-JAN) For treatment of: (a) Pneumonia in patients with underlying lung disease (excluding asthma) and pneumonia in nursing home patients. (b) Infections caused by organisms known to be resistant to alternative antibiotics. (c) Infections in patients allergic to two or more alternative antibiotics, and: (d) For completion of antibiotic treatment initiated in hospital when alternatives are not appropriate. Lin-Megestrol - see megestrol acetate tablet linezolid, tablet, 600mg (Zyvoxam-PHU) Following consultation with an infectious disease specialist for: (a) Treatment of gram-positive infections resistant to vancomycin. (b) Treatment of gram-positive infections in patients unable to tolerate or who are experiencing severe adverse effects from vancomycin. (c) For completion of therapy initiated in hospital with intravenous vancomycin, quinupristin/dalfopristin or linezolid for patients who can be discharged on oral therapy. Lioresal Intrathecal - see baclofen Loniten - see minoxidil lopinavir/ritonavir, capsule, 133.3mg/33.3mg; oral solution, 80mg/20mg(mL) (Kaletra-ABB) For management of HIV disease. This drug, as with other antivirals in treatment of HIV, should be used under the direction of an infectious disease specialist. Losec - see omeprazole Lovenox - see enoxaparin Lupron Depot - see leuprolide acetate Maxalt - see rizatriptan benzoate Maxalt RPD - see rizatriptan benzoate Med-Cyclobenzaprine - see cyclobenzaprine HCl Med-Minocycline - see minocycline HCl Med-Selegiline - see selegiline HCl Megace - see megestrol acetate tablet Megace OS - see megestrol acetate oral suspension *megestrol acetate, tablet, 40mg, 160mg (Megace-BRI) (Lin-Megestrol-LIN) (ApoMegestrol-APX) (Nu-Megestrol-NXP) For treatment of anorexia, cachexia or an unexplained weight loss in patients with a diagnosis of acquired immunodeficiency (AIDS). megestrol acetate, oral suspension (Megace OS-BRI) For treatment of anorexia, cachexia or an unexplained weight loss in patients with a diagnosis of acquired immunodeficiency syndrome (AIDS) who are unable to tolerate tablets.
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meloxicam, tablet, 7.5mg, 15mg (Mobicox-BOE) (a) For treatment in patients age 65 and over (approved automatically through the on-line computer system). (b) For treatment of rheumatoid arthritis and osteoarthritis in patients who have one of the following factors: • past history of ulcers; • concurrent prednisone therapy; • concurrent warfarin therapy. (c) For treatment of patients with an intolerance to other NSAIDs listed in the Formulary. Mepron - see atovaquone mercaptopurine, tablet, 50mg (Purinethol-GSK) (a) For treatment of Crohn's Disease. (b) For treatment of rheumatoid arthritis. +methoxsalen, capsule, 10mg (Oxsoralen-ICN) (Oxsoralen Ultra-ICN) (UltramopCDX); lotion, 1% (Oxsoralen-ICN) (Ultramop-CDX) For treatment of psoriasis, for use prior to PUVA therapy. methysergide maleate, tablet, 2mg (Sansert-NVR) For prophylaxis of recurrent vascular headaches. Coverage will be provided for up to 6 months at a time with a 3-4 week medication free interval between courses of therapy. Miacalcin - see calcitonin salmon nasal spray midodrine HCl, tablet, 2.5mg, 5mg (Amatine-RBP) For treatment of orthostatic hypotension. Minocin - see minocycline HCl * minocycline HCl, capsule, 50mg, 100mg (Minocin-WYA) (Apo-Minocycline-APX) (Novo-Minocycline-NOP) (ratio-Minocycline-RTP) (Gen-Minocycline-GPM) (Med-Minocycline-MED) (Dom-Minocycline-DOM) (Rhoxal-Minocycline-RHO) (pmsMinocycline-PMS) For treatment of acne unresponsive to tetracycline. minoxidil, tablet, 2.5mg, 10mg (Loniten-PHU) For control of hypertension unresponsive to all other listed therapeutic agents. Mobicox – see meloxicam modafinil, tablet, 100mg (Alertec-DPY) For treatment of narcolepsy and idiopathic CNS hypersomnia in patients whose symptoms of daytime sleepiness are not controlled on methylphenidate or dextroamphetamine. Monocor - see bisoprolol fumarate montelukast sodium, chewable tablet, 4mg, 5mg; tablet, 10mg (Singulair-MSD) For adjunctive treatment of asthma in patients not well controlled on inhaled corticosteroids. 243
Monurol - see fosfomycin tromethamine moxifloxacin HCl, tablet, 400mg (Avelox-BAY) For treatment of: (a) Pneumonia in patients with underlying lung disease (excluding asthma) and pneumonia in nursing home patients. (b) Infections caused by organisms known to be resistant to alternative antibiotics. (c) Infections in patients allergic to two or more alternative antibiotics, and: (d) For completion of antibiotic treatment initiated in hospital when alternatives are not appropriate. Mycobutin - see rifabutin mycophenolate mofetil, capsule, 250mg; tablet, 500mg (CellCept-HLR) For prevention of acute rejection in transplant patients. nabilone, capsule, 1mg (Cesamet-LIL) For treatment of nausea and anorexia in AIDS patients. *nabumetone, tablet, 500mg (Relafen-GSK) (Apo-Nabumetone-APX) (GenNabumetone-GPM) (Novo-Nabumetone-NOP) (Rhoxal-Nabumetone-RHO); 750mg (Relafen-GSK) (Novo-Nabumetone-NOP) For treatment of patients with an intolerance to other NSAIDs listed in the Formulary. nadroparin calcium, syringe, 9,500IU/mL (0.3mL, 0.4mL, 0.6mL, 0.8mL, 1.0mL) (Fraxiparine-SAW); syringe, 19,000IU/mL (0.6mL, 0.8mL, 1mL) (Fraxiparine ForteSAW) (a) For treatment of venous thromboembolism for up to 10 days. (b) For prophylaxis following total knee arthroplasty and major orthopedic trauma for up to 10 days (treatment duration may be reassessed). (c) For longterm outpatient prophylaxis in patients who are pregnant. (d) For longterm outpatient prophylaxis in patients who are intolerant to, or have failed, warfarin therapy. (e) For longterm outpatient prophylaxis in patients who have lupus anticoagulant syndrome. nafarelin acetate, intranasal solution, 2mg/mL (Synarel-HLR) (a) For treatment of endometriosis, for a maximum of 6 months. Coverage may be repeated after a six month lapse, for another 6 month course. (b) For pre-treatment of uterine fibroids prior to surgical removal, for a maximum of 6 months. (c) For treatment of menorrhagia in preparation for endometrial ablation, for a maximum of 6 months. Nalcrom - see sodium cromoglycate naratriptan HCl, tablet, 1mg, 2.5mg (Amerge-GSK) For treatment of migraine headaches. Eligibility will be restricted to beneficiaries over 18 and under 65 years of age. The maximum quantity that can be claimed through the Drug Plan is limited to 6 doses per 30 days within a 60 day period. Patients requiring more than 12 doses in a consecutive 60 day period should be considered for migraine prophylaxis therapy if they are not already receiving such therapy. nateglinide, tablet, 60mg, 120mg, 180mg (Starlix-NVR) For treatment of diabetes in patients who are not adequately controlled on or are intolerant to sulfonylureas. 244
nelfinavir mesylate, tablet, 250mg; oral powder, 50mg/g (Viracept-AGR) For management of HIV disease. This drug, as with other antivirals in treatment of HIV, should be used under the direction of an infectious disease specialist. Neoral - see cyclosporine Neupogen - see filgrastim nevirapine, tablet, 200mg (Viramune-BOE) For management of HIV disease. This drug, as with other antivirals in treatment of HIV, should be used under the direction of an infectious disease specialist. nimodipine, capsule, 30mg (Nimotop-BAY) For treatment of subarachnoid hemorrhage to complete a 3 week course of treatment in cases where a patient is discharged from hospital before completion of the treatment period. Nimotop - see nimodipine Nizoral - see ketoconazole norfloxacin, ophthalmic solution, 0.3% (Noroxin Ophthalmic Solution-MSD) For treatment of ophthalmic infections caused by gram-negative organisms or those not responding to alternative agents. * norfloxacin, tablet, 400mg (Noroxin-MSD) (Apo-Norflox-APX) (Novo-Norfloxacin-NOP) For treatment of: (a) Genitourinary tract infections caused by Pseudomonas aeruginosa. (b) Adults with gonoccoccal urethritis or cervicitis. (c) Genitourinary tract infections in patients allergic to alternative agents. (d) Genitourinary tract infections with organisms known to be resistant to alternative antibiotics. Noroxin - see norfloxacin Norvir - see ritonavir Norvir SEC - see ritonavir NovoRapid - see insulin aspart Novo-Cefaclor - see cefaclor Novo-Cycloprine - see cyclobenzaprine HCl Novo-Cyproterone - see cyproterone acetate Novo-Ketoconazole - see ketoconazole Novo-Ketotifen - see ketotifen fumarate Novo-Minocycline - see minocycline HCl Novo-Nabumetone - see nabumetone Novo-Norfloxacin - see norfloxacin Novo-Selegiline - see selegiline HCl Nu-Cefaclor - see cefaclor Nu-Cyclobenzaprine - see cyclobenzaprine HCl Nu-Ketocon - see ketoconazole Nu-Ketotifen - see ketotifen fumarate
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Nu-Megestrol - see megestrol acetate tablet Nu-Selegiline - see selegiline HCl Nu-Ticlopidine - see ticlopidine HCl Nutropin - see somatropin Nutropin AQ - see somatropin Octostim – see desmopressin octreotide, injection, 50ug/mL (1mL), 100ug/mL (1mL), 200ug/mL (5mL), 500ug/mL (1mL) (Sandostatin-NVR); powder for injection, 10mg/vial, 20mg/vial, 30mg/vial (Sandostatin LAR-NVR) (a) For management of terminal malignant bowel obstruction in palliative patients. (b) For treatment of acromegaly. Note: Coverage for federally approved cancer indications is provided under the Saskatchewan Cancer Foundation according to their guidelines. Ocufen - see flurbiprofen sodium Ocuflox - see ofloxacin ophthalmic solution Oesclim - see estradiol ofloxacin, ophthalmic solution, 0.3% (Ocuflox-ALL) (a) For treatment of ophthalmic infections caused by gram-negative organisms or those not responding to alternative agents. (b) For treatment of infiltrative corneal infections. olanzapine, tablet, 2.5mg, 5mg, 7.5mg, 10mg, 15mg (Zyprexa-LIL); orally disintegrating tablet, 5mg, 10mg (Zyprexa Zydis-LIL) (a) For treatment of schizophrenia. (b) For treatment of other psychotic conditions where there has been treatment failure or intolerance to other atypical anti-psychotic agents. omeprazole, delayed release tablet, 10mg (Losec-AST) (a) For maintenance therapy of healed reflux esophagitis. This is renewable on a yearly basis. (b) For one year in treatment of symptoms of gastroesophageal reflux disease (GERD). It was noted that patients with non-erosive GERD could potentially be reduced to step-down therapy with an H2 antagonist depending on symptom resolution. (c) For first-line prevention of gastroduodenal hemorrhage in high risk patients with prior history of gastroduodenal bleeds for whom anticoagulant, glucocorticosteroid or NSAID therapy cannot be avoided. Coverage is renewable on a yearly basis for patients if discontinuation of offending agents or replacement with less damaging alternatives is not feasible.
246
omeprazole, enteric coated tablet, 20mg (Losec-AST) (a) For a maximum of 8 weeks in treatment of peptic ulcer disease, which includes gastric and duodenal ulcers, in patients not responding or experiencing unusual or severe adverse reactions to a reasonable trial with H2 blockers, sucralfate or misoprostol. Coverage for a repeat treatment will be approved only after a 3-6 month period of no treatment or prophylaxis with an H2 blocker, sucralfate or misoprostol. (b) For one year in treatment of symptoms of gastroesophageal reflux disease (GERD). It was noted that patients with non-erosive GERD could potentially be reduced to step-down therapy with an H2 antagonist depending on symptom resolution. (c) For one year in treatment of severe erosive esophagitis and Zollinger-Ellison Syndrome. This is renewable on a yearly basis. (d) For one week for eradication of H. pylori-related infections in individuals with peptic ulcer disease. Provision will be made for additional coverage in treatment failures. (e) For first-line prevention of gastroduodenal hemorrhage in high risk patients with prior history of gastroduodenal bleeds for whom anticoagulant, glucocorticosteroid or NSAID therapy cannot be avoided. Coverage is renewable on a yearly basis for patients if discontinuation of offending agents or replacement with less damaging alternatives is not feasible. One-Alpha - see alfacalcidol Oxeze Turbuhaler - see formoterol fumarate Oxsoralen - see methoxsalen *pamidronate disodium injection, 30mg, 90mg (Aredia-NVR) (Pamidronate Disodium Injection-DBU); 60mg (Pamidronate Disodium Injection-DBU) For treatment of osteoporosis in patients unable to tolerate oral bisphosphonates. pantoprazole, enteric coated tablet, 40mg (Pantoloc-SLV) (a) For a maximum of 8 weeks in treatment of peptic ulcer disease, which includes gastric and duodenal ulcers, in patients not responding or experiencing unusual or severe adverse reactions to a reasonable trial with H2 blockers, sucralfate or misoprostol. Coverage for a repeat treatment will be approved only after a 3-6 month period of no treatment or prophylaxis with an H2 blocker, sucralfate or misoprostol. (b) For one year in treatment of symptoms of gastroesophageal reflux disease (GERD). It was noted that patients with non-erosive GERD could potentially be reduced to step-down therapy with an H2 antagonist depending on symptom resolution. (c) For one year in treatment of severe erosive esophagitis and Zollinger-Ellison Syndrome. This is renewable on a yearly basis. (d) For one week for eradication of H. pylori-related infections in individuals with peptic ulcer disease. Provision will be made for additional coverage in treatment failures. (e) For first-line prevention of gastroduodenal hemorrhage in high risk patients with prior history of gastroduodenal bleeds for whom anticoagulant, glucocorticosteroid or NSAID therapy cannot be avoided. Coverage is renewable on a yearly basis for patients if discontinuation of offending agents or replacement with less damaging alternatives is not feasible. Pantoloc - see pantoprazole 247
Pariet - see rabeprazole sodium PEG-Intron - see peginterferon alfa-2b peginterferon alfa-2b, powder for injection (vial), 50ug/0.5mL, 80ug/0.5mL, 120ug/0.5mL, 150ug/0.5mL (PEG-Intron-SCH) For treatment of chronic active hepatitis C. Coverage will be provided for an initial 6 month period with potential renewal for 2 additional 6 month periods. pentosan polysulfate sodium, capsule, 100mg (Elmiron-JAN) For treatment of interstitial cystitis where other treatments have failed. Persantine - see dipyridamole pioglitazone HCl, tablet, 15mg, 30mg, 45mg (Actos-LIL) For treatment of diabetes in patients who are not adequately controlled on or are intolerant to metformin or sulfonylureas. pivmecillinam HCl, tablet, 200mg (Selexid-LEO) For treatment of: (a) Urinary tract infections with organisms resistant to first line therapy. (b) Urinary tract infections in patients allergic to first line agents. (c) Urinary tract infections in pregnancy when first line agents are inappropriate. Plavix - see clopidogrel bisulfate pms-Bezafibrate - see bezafibrate pms-Carbamazepine-CR - see carbamazepine pms-Cefaclor - see cefaclor pms-Cyclobenzaprine - see cyclobenzaprine HCl pms-Deferoxamine - see deferoxamine mesylate pms-Fluconazole - see fluconazole pms-Ketotifen - see ketotifen pms-Lactulose - see lactulose pms-Minocycline - see minocycline HCl pms-Ticlopidine - see ticlopidine HCl pms-Tobramycin – see tobramycin pms-Vancomycin - see vancomycin HCl Prevacid - see lansoprazole Profasi HP - see chorionic gonadotropin progesterone (micronized), capsule, 100mg (Prometrium-SCH) (a) For treatment of patients unable to tolerate medroxyprogesterone acetate (Provera). (b) For treatment of patients having low high-density lipoproteins. Prograf - see tacrolimus Prometrium - see progesterone (micronized) Protopic - see tacrolimus Protropin - see somatrem Pulmozyme - see dornase alfa Purinethol - see mercaptopurine
248
quetiapine, tablet, 25mg, 100mg, 150mg, 200mg, 300mg (Seroquel-AST) (a) For treatment of schizophrenia. (b) For treatment of other psychotic conditions where there has been treatment failure or intolerance to other atypical anti-psychotic agents. (c) For treatment of psychosis caused by drugs used in the treatment of Parkinson's Disease. rabeprazole sodium, tablet, 10mg (Pariet-JAN) (a) For a maximum of 8 weeks in treatment of peptic ulcer disease, which includes gastric and duodenal ulcers, in patients not responding or experiencing unusual or severe adverse reactions to a reasonable trial with H2 blockers, sucralfate or misoprostol. Coverage for a repeat treatment with be approved only after a 3-6 month period of no treatment or prophylaxis with an H2 blocker, sucralfate or misoprostol. (b) For one year in treatment of symptoms of gastroesophageal reflux disease (GERD). It was noted that patients with non-erosive GERD could potentially be reduced to step-down therapy with an H2 antagonist depending on symptom resolution. (c) For one year in treatment of severe erosive esophagitis and Zollinger-Ellison Syndrome. This is renewable on a yearly basis. (d) For one week for eradication of H. pylori-related infections in individuals with peptic ulcer disease. Provision will be made for additional coverage in treatment failures. (e) First-line prevention of gastroduodenal hemorrhage in high risk patients with prior history of gastroduodenal bleeds for whom anticoagulant, glucocorticosteroid or NSAID therapy cannot be avoided. Coverage is renewable on a yearly basis for patients if discontinuation of offending agents or replacement with less damaging alternatives is not feasible. raloxifene HCl, tablet, 60mg (Evista-LIL) (a) For treatment of osteoporosis in women unable to tolerate listed bisphosphonates. (b) For treatment of osteoporosis in women who do not respond to listed bisphosphonates after receiving treatment for one year. Rapamune - see sirolimus ratio-Amoxi Clav - see amoxicillin trihydrate/potassium clavulanate ratio-Cefuroxime - see cefuroxime axetil ratio-Lactulose - see lactulose ratio-Minocycline - see minocycline HCl Rebetron - see interferon alfa-2b/ribavirin Rebif - see Appendix J Relafen - see nabumetone Remicade - see infliximab Reminyl - see galantamine hydrobromide Renagel - see sevelamer HCl repaglinide, tablet, 0.5mg, 1mg, 2mg (GlucoNorm-NOO) For treatment of diabetes in patients who are not adequately controlled on or are Intolerant to sulfonylureas. Rescriptor - see delavirdine mesylate Retin A - see tretinoin Retrovir - see zidovudine 249
Rhoxal-Minocycline - see minocycline HCl Rhoxal-Nabumetone - see nabumetone Rhoxal-Ticlopidine - see ticlopidine HCl rifabutin, capsule, 150mg (Mycobutin-PHU) For prevention of disseminated Mycobacterium avium complex (MAC) disease in patients with advanced human immunodeficiency virus (HIV) infection. risedronate sodium, tablet, 5mg (Actonel-PGA) (a) For treatment of osteoporosis in patients who do not respond to etidronate disodium/calcium (Didrocal) after receiving it for one year. (b) For treatment of osteoporosis in patients unable to tolerate etidronate disodium/calcium (Didrocal). (c) For treatment of osteoporosis in patients who have fresh fractures. risedronate sodium, tablet, 30mg (Actonel-PGA) For treatment of symptomatic Paget's Disease of the bone. ritonavir, oral solution, 80mg/mL (Norvir-ABB); soft elastic capsule, 100mg (Norvir SEC-ABB) For management of HIV disease. This drug, as with other antivirals in treatment of HIV, should be used under the direction of an infectious disease specialist. rivastigmine, capsule, 1.5mg, 3mg, 4.5mg, 6mg (Exelon-NVR) (a) A diagnosis of probable Alzheimer's Disease as per DSM-IV criteria. (b) A mild to moderate stage of the disease with a MMSE score of 10-26 established within 60 days prior to application for coverage by a clinician. (c) A Functional Activities Questionnaire (FAQ) must be completed. (d) Patients must discontinue all drugs with anticholinergic activity at least 14 days before the MMSE and FAQ are administered. Drugs with anticholinergic activity are not to be used concurrently with rivastigmine therapy. List all current medications patient was taking at the time of assessment. (e) Patients intolerant to one drug may be switched to another drug in this class. Intolerance should be observed within the first month of treatment. •
Eligible patients currently taking rivastigmine would require assessment at 6 month intervals. To continue receiving rivastigmine, patients must not have both a greater than 2 point reduction in MMSE and a 1 point increase in FAQ in a 6 month evaluation period. Scores are compared to the most recent test results.
•
Eligible new patients will enter a 3 month treatment period with rivastigmine. During the 3 month trial, patients must exhibit an improvement from the initial MMSE or FAQ to continue treatment with rivastigmine. The improvement must be at least 2 MMSE points or -1 FAQ. Patients who meet these requirements will be re-evaluated at 6 month intervals. To continue receiving rivastigmine, patients must not have both a greater than 2 point reduction in MMSE and a 1 point increase in FAQ in a 6 month evaluation period. Scores are compared to the most recent test results.
•
The MMSE score must remain at 10 or greater at all times to be eligible for coverage.
•
Patients who do not meet criteria to continue rivastigmine can be re-evaluated within 3 months to confirm deterioration before coverage is discontinued.
•
Rivastigmine does not need to be discontinued prior to MMSE or FAQ testing. 250
•
A patient intolerant of one drug and switching to a second will be considered a "new" patient and will be assessed as such.
•
Coverage will not be considered for patients who have failed on other drugs in this class.
Applications for EDS for rivastigmine (Exelon) will only be accepted from physicians on the Aricept/Exelon/Reminyl EDS application form. This form is available on-line at http://formulary.drugplan.health.gov.sk.ca or by calling the Drug Plan. rizatriptan benzoate, tablet, 5mg, 10mg (Maxalt-MSD); wafer, 5mg, 10mg (Maxalt RPD-MSD) For treatment of migraine headaches. Eligibility will be restricted to beneficiaries over 18 and under 65 years of age. The maximum quantity that can be claimed through the Drug Plan is limited to 6 doses per 30 days within a 60 day period. Patients requiring more than 12 doses in a consecutive 60 day period should be considered for migraine prophylaxis therapy if they are not already receiving such therapy. Rocaltrol - see calcitriol rofecoxib, tablet, 12.5mg, 25mg; oral suspension, 2.5mg/mL (Vioxx-MSD) (a) For treatment in patients age 65 and over (approved automatically through the on-line computer system). (b) For treatment of rheumatoid arthritis and osteoarthritis in patients who have one of the following factors: • past history of ulcers; • concurrent prednisone therapy; • concurrent warfarin therapy. (c) For treatment of patients with an intolerance to other NSAIDs listed in the Formulary. Roferon-A - see interferon alfa-2a rosiglitazone maleate, tablet, 2mg, 4mg, 8mg (Avandia-GSK) For treatment of diabetes in patients who are not adequately controlled on or are intolerant to metformin or sulfonylureas. SAB-Tobramycin - see tobramycin ophthalmic solution Saizen - see somatropin salmeterol xinafoate, metered dose inhaler, 25ug/actuation; powder disk, 50ug/blister (Serevent-GSK); powder for inhalation (package), 50ug/dose (Serevent Diskus-GSK) (a) For treatment of asthma uncontrolled on concurrent inhaled steroid therapy. It is important that these patients also have access to a short-acting beta-2 agonist for symptomatic relief. (b) For treatment of Chronic Obstructive Pulmonary Disease (COPD).
251
salmeterol xinafoate/fluticasone propionate, metered dose inhaler (package), 25ug/125ug, 25ug/250ug (Advair-GSK); powder for inhalation (package), 50ug/100ug, 50ug/250ug, 50ug/500ug (Advair Diskus-GSK) (a) For treatment of asthma in patients not adequately controlled on inhaled steroid therapy. It is important that these patients also have access to a short-acting beta-2 agonist for symptomatic relief. (b) For treatment of chronic obstructive pulmonary disease (COPD) in patients who are not adequately controlled on long-acting beta-2 agonists alone. Sandostatin - see octreotide Sandostatin LAR - see octreotide Sansert - see methysergide maleate saquinavir, capsule, 200mg (Invirase-HLR); soft gelatin capsule, 200mg (Fortovase-HLR) For management of HIV disease. This drug, as with other antivirals in treatment of HIV, should be used under the direction of an infectious disease specialist. *selegiline HCl, tablet, 5mg (Eldepryl-DPY) (Novo-Selegiline-NOP) (Apo-Selegiline-APX) (Gen-Selegiline-GPM) (Med-Selegiline-MED) (Nu-Selegiline-NXP) (Dom-Selegiline-DOM) (a) For use as an adjunct in cases of Parkinson's Disease being treated with levodopa, levodopa/benzerazide, levodopa/carbidopa, or bromocriptine. (b) For prophylaxis in early Parkinsonism. Selexid - see pivmecillinam HCl Serevent - see salmeterol xinafoate Serevent Diskus - see salmeterol xinafoate Seroquel – see quetiapine sevelamer HCl, tablet, 400mg, 800mg (Renagel-GZY) (a) For treatment of patients in endstage renal disease with intolerance to aluminum or calcium containing phosphate binding agents. (b) For treatment of patients in endstage renal disease where aluminum or calcium containing phosphate binding agents are inappropriate. Sibelium - see flunarizine HCl Singulair – see montelukast sodium sirolimus, oral solution, 1mg/mL (Rapamune-WYA) For prophylaxis of graft rejection in transplant patients. sodium cromoglycate, capsule, 100mg (Nalcrom-AVT) (a) For treatment of patients who experience severe reactions to foods which cannot be avoided. (b) For treatment of patients with Crohn's Disease or ulcerative colitis not responding to traditional therapy. somatrem, injection, 5mg, 10mg (Protropin-HLR) For treatment of children who have growth failure due to inadequate secretion of normal endogenous growth hormone.
252
+somatropin, injection, 5mg (Humatrope-LIL), 6mg, 12mg (Humatrope CartridgeLIL) For treatment of children who have growth failure due to inadequate secretion of normal endogenous growth hormone. +somatropin, injection, 3.33mg (Saizen-SRO), 5mg (Nutropin-HLR) (Saizen-SRO), 10mg (Nutropin AQ-HLR) For treatment of children who have growth failure due to inadequate secretion of normal endogenous growth hormone, or who have growth failure associated with chronic renal insufficiency. Note: Exception Drug Status coverage is not required for S.A.I.L. patients, coverage is provided under the Saskatchewan Aids to Independent Living (S.A.I.L.) Program. Soriatane - see acitretin Sporanox - see itraconazole Starlix - see nateglinide stavudine, capsule, 15mg, 20mg, 30mg, 40mg (Zerit-BRI) For management of HIV disease. This drug, as with other antivirals in treatment of HIV, should be used under the direction of an infectious disease specialist. Stieva-A Forte - see tretinoin sumatriptan, tablet, 25mg, 50mg, 100mg; injection solution, 6mg/0.5mL; nasal spray, 5mg, 20mg (Imitrex-GSK) For treatment of migraine headaches. Eligibility will be restricted to beneficiaries over 18 and under 65 years of age. The maximum quantity that can be claimed through the Drug Plan is limited to 6 doses per 30 days within a 60 day period. Patients requiring more than 12 doses in a consecutive 60 day period should be considered for migraine prophylaxis therapy if they are not already receiving such therapy. Suprax - see cefixime Suprefact - see buserelin acetate Sustiva - see efavirenz Symbicort Turbuhaler - see formoterol fumarate dihydrate/budesonide Synarel - see nafarelin acetate 3TC - see lamivudine tacrolimus, capsule, 0.5mg, 1mg, 5mg; ampoule, 5mg/mL (Prograf-FUJ) For prophylaxis of graft rejection. tacrolimus, topical ointment, 0.03%, 0.1% (Protopic-FUJ) For treatment of moderate to severe atopic dermatitis in patients who are unresponsive or intolerant to topical steroids. Taro-Carbamazepine CR – see carbamazepine Tequin - see gatifloxacin Tegretol CR - see carbamazepine Ticlid - see ticlopidine HCl
253
*ticlopidine HCl, tablet, 250mg (Ticlid-HLR) (Apo-Ticlopidine-APX) (Nu-TiclopidineNXP) (Gen-Ticlopidine-GPM) (pms-Ticlopidine-PMS) (Dom-Ticlopidine-DOM) (Rhoxal-Ticlopidine-RHO) (a) For treatment of patients who have experienced a recurrent vascular episode while on acetylsalicylic acid. (b) For treatment of patients who have experienced a recurrent vascular episode and have a clearly demonstrated allergy to acetylsalicylic acid (manifested by asthma or nasal polyps). (c) For treatment of patients who have experienced a recurrent vascular episode and are intolerant of acetylsalicylic acid (manifested by gastrointestinal hemorrhage). (d) When prescribed following intracoronary stent placement. Coverage will be provided for a period of 4 weeks. tinzaparin sodium, syringe, 10,000IU/mL (0.35mL, 0.45mL), 20,000IU/mL (0.5mL, 0.7mL, 0.9mL); injection solution, 10,000IU/mL (2mL), 20,000IU/mL (2mL) (InnohepLEO) (a) For treatment of venous thromboembolism for up to 10 days. (b) For prophylaxis following total knee arthroplasty and major orthopedic trauma for up to 10 days (treatment duration may be reassessed). (c) For longterm outpatient prophylaxis in patients who are pregnant. (d) For longterm outpatient prophylaxis in patients who are intolerant to, or have failed, warfarin therapy. (e) For longterm outpatient prophylaxis in patients who have lupus anticoagulant syndrome. tizanidine HCl, tablet, 4mg (Zanaflex-DPY) For treatment of patients with severe spasticity who are unresponsive or intolerant to baclofen or benzodiazepines. TOBI - see tobramycin inhalation solution Tobradex - see tobramycin/dexamethasone Tobramycin - see tobramycin ophthalmic solution tobramycin, inhalation solution, 60mg/mL (TOBI-PCL) For treatment of cystic fibrosis patients who do not tolerate injectable tobramycin when used for inhalation. tobramycin, ophthalmic ointment, 0.3% (Tobrex-ALC); *ophthalmic solution, 0.3% (Tobrex-ALC) (pms-Tobramycin-PMS) (TobramycinRVX) (SAB-Tobramycin-SAB) For treatment of ophthalmic infections in cases not responding to gentamicin ophthalmic. tobramycin/dexamethasone, ophthalmic suspension, 0.3%/0.1%; ophthalmic ointment, 0.3%/0.1% (Tobradex-ALC) (a) For treatment of ophthalmic infections in cases not responding to therapeutic alternatives. (b) For post-operative long-term (>7days) use. Tobrex - see tobramycin tolterodine l-tartrate, extended-release capsule, 2mg, 4mg (Unidet-PHU) For treatment of patients unable to tolerate oxybutynin chloride. 254
tolterodine l-tartrate, tablet, 1mg, 2mg (Detrol-PHU) Note: Detrol is scheduled to be delisted from the Saskatchewan Formulary effective April 1, 2003. For treatment of patients unable to tolerate oxybutynin chloride. Tracleer - see bosentan *tretinoin, cream, 0.1% (Stieva-A Forte-STI) (Retin A-JAN) (Vitamin A Acid-DER) For treatment of acne not responding to alternative topical therapy. triamcinolone hexacetonide, injection suspension, 20mg/mL (Aristospan-STI) For intra-articular injection in the management of pediatric chronic inflammatory arthropathies. Trizivir - see abacavir SO4/lamivudine/zidovudine Ultradol - see etodolac Ultramop - see methoxsalen Ultravate - see halobetasol propionate Unidet - see tolterodine l-tartrate Urispas - see flavoxate HCl Urso - see ursodiol ursodiol, tablet, 250mg (Urso-AXC) For management of cholestatic liver diseases such as primary biliary cirrhosis. Vancocin - see vancomycin HCl vancomycin HCl, capsule, 125mg, 250mg, (Vancocin-LIL) * injection, 500mg, 1g (Vancocin-LIL) (pms-Vancomycin-PMS) For treatment of: Clostridium difficile infections for up to two consecutive two week periods after noresponse, allergies or intolerance to a course of metronidazole. Repeat approvals will only be granted with laboratory evidence of C. difficile toxin. Videx - see didanosine Videx EC - see didanosine Vioxx - see rofecoxib Viracept – see nelfinavir mesylate Viramune – see nevirapine Vitamin A Acid - see tretinoin Vivelle - see estradiol Voltaren Ophtha - see diclofenac sodium Wellbutrin SR – see bupropion HCl Zaditen - see ketotifen fumarate zafirlukast, tablet, 20mg (Accolate-AST) (a) For treatment of asthma when used in patients on concurrent steroid therapy. (b) For treatment of asthma in patients not well controlled with inhaled corticosteroids. zalcitabine, tablet, 0.375mg, 0.750mg (Hivid-HLR) For management of HIV disease. This drug, as with other antivirals in treatment of HIV, should be used under the direction of an infectious disease specialist. 255
Zanaflex - see tizanidine HCl Zerit - see stavudine Ziagen - see abacavir SO4 zidovudine, syrup, 10mg/mL; injection, 10mg/mL (Retrovir-GSK) *capsule, 100mg (Retrovir-GSK) (Apo-Zidovudine-APX) For management of HIV disease. This drug, as with other antivirals in treatment of HIV, should be used under the direction of an infectious disease specialist. Zithromax - see azithromycin Zoladex - see goserelin acetate zolmitriptan, tablet, 2.5mg (Zomig-AST); orally dispersible tablet, 2.5mg (Zomig Rapimelt-AST) For treatment of migraine headaches. Eligibility will be restricted to beneficiaries over 18 and under 65 years of age. The maximum quantity that can be claimed through the Drug Plan is limited to 6 doses per 30 days within a 60 day period. Patients requiring more than 12 doses in a consecutive 60 day period should be considered for migraine prophylaxis therapy if they are not already receiving such therapy. Zomig - see zolmitriptan Zomig Rapimelt - see zolmitriptan zuclopenthixol, acetate injection, 50mg/mL (Clopixol-Acuphase-AVT); decanoate injection, 200mg/mL (Clopixol-Depot-AVT); dihydrochloride tablet, 10mg, 25mg, 40mg (Clopixol-AVT) For treatment of patients with schizophrenia not responding to other neuroleptic medications. Zyprexa - see olanzapine Zyprexa Zydis - see olanzapine Zyvoxam - see linezolid
LEGEND: *These brands of products have been approved as interchangeable. +These brands of products have NOT been approved as interchangeable.
256
SORIATANE Important Information for Female Patients: Soriatane can cause deformed babies if it is taken by a female before or during pregnancy. •
Do not take Soriatane if you are or may become pregnant during treatment or for an undetermined period of time* after treatment has stopped.
•
You must avoid becoming pregnant while you are taking Soriatane and for an undetermined period of time* after you stop taking Soriatane.
•
You must discuss effective birth control with your doctor before beginning treatment and you must use effective birth control: for at least 1 month before you start Soriatane; while you are taking Soriatane; and for an undetermined period of time* after you stop taking Soriatane, bearing in mind that any method of birth control can fail.
•
It is recommended that you either abstain from sexual intercourse or use 2 reliable methods of birth control at the same time.
•
Do not take Soriatane until you are sure that you are not pregnant: you must have a serum pregnancy test within 2 weeks before you start Soriatane; you must wait until the second or third day of your next menstrual period before you start Soriatane.
•
Contact your doctor immediately if you do become pregnant while taking Soriatane or after treatment has stopped. You should discuss with your doctor the serious risk of your baby having severe birth deformities because you are taking or have taken Soriatane. You should also discuss the desirability of continuing your pregnancy.
•
Do not breast feed while taking Soriatane or for an extended period of time after treatment has stopped.
*
Soriatane remains in your body for prolonged periods of time after you have stopped treatment. It is not known exactly how long you must avoid pregnancy after Soriatane is stopped. The drug has been found in the blood of some patients for at least 2 years following treatment. Discuss this with your doctor. Talk with your doctor before you stop birth control.
Important Information for All Patients: Soriatane can cause deformed babies if taken by a female before or during pregnancy. •
Do not give Soriatane to anyone else who has similar symptoms.
•
Do not donate blood, while you are taking Soriatane or for an extended period of time after treatment has stopped. This is because your blood should not be given to a pregnant female.
•
Do not consume alcohol while taking Soriatane.
257
APPENDIX B HOSPITAL BENEFIT DRUG LIST
OCTOBER 2002
NOTIFICATION OF UPDATES TO THE HOSPITAL BENEFIT DRUG LIST WILL BE PROVIDED IN THE DRUG PLAN UPDATE BULLETINS
PLEASE DIRECT INQUIRIES REGARDING THIS LIST TO: (306) 787- 3224
259
1.
This list of drug benefits under Saskatchewan Health is supplementary to the annual nd Saskatchewan Formulary (52 Edition, October 2002). It is intended to expand on the Formulary as required to meet the special requirements of hospitals.
2.
The Benefit Drug List is updated semi-annually by the Advisory Committee on Institutional Pharmacy Practice. This committee is composed of representatives of: the Canadian Society of Hospital Pharmacists (Saskatchewan Branch); the Drug Quality Assessment Committee; the Saskatchewan Association of Health Organizations and officials of the Department of Health. The new additions to the list are presented in bold type.
3.
In summary, the government is accepting the following items as insured benefits under The Saskatchewan Hospitalization Act when administered to patients in hospital. Institutional formularies put in place by Regional Health Authorities may affect the availability of some insured drugs: (a)
"All products listed in the Saskatchewan Formulary." (Brands other than those listed are not considered as interchangeable.)
(b)
Unlisted strengths of products included in the Saskatchewan Formulary or approved for Exception Drug Status coverage (see item 5). [This applies only to brands manufactured by the same supplier(s).]
(c)
Generally accepted nursing treatments, agents such as antiseptics, disinfectants, mouthwashes, lozenges, lubricants, soaps and emollients.
(d)
All diagnostic agents.
(e)
All irrigating solutions.
(f)
All radioactive agents.
(g)
All injectable vitamins and injectable multivitamin preparations when used to maintain or attain nutritional status.
(h)
Alcoholic beverages such as beer, stout, brandy and whiskey.
(i)
All dietary supplements.
(j)
All antacids and laxatives marketed by approved manufacturers.
(k)
All hemostatic agents.
(l)
All agents appearing on the attached supplemental list including all dosage forms and strengths unless otherwise indicated in the list. Prolonged release, sustained release, and delayed release dosage forms are benefits only when specifically listed.
(m) New dosage forms, drug entities and other products released on the market after the effective date of this list are not insured hospital benefits. They may be charged to hospital clients until reviewed and approved as an insured benefit by the Saskatchewan Formulary Committee or the Advisory Committee on Institutional Pharmacy Practice. 4.
Formularies established by health facilities or Regional Health Authorities may not include all insured items. If an insured drug is not included in a facility or health 260
region formulary, its provision will be subject to facility or Regional Health Authority policy. 5.
Only drugs listed in the Saskatchewan Formulary, and not those on the Benefit Drug List, are an insured benefit when dispensed to ambulatory patients, i.e. through retail pharmacies or an organized hospital dispensing service.
6.
For certain patients, the Prescription Drug Services Branch may approve/has approved Exception Drug Status coverage, on an outpatient basis, for certain products which are not listed in the Saskatchewan Formulary or the Benefit Drug List. Patients with such coverage have been issued a letter of authorization which, upon presentation in a hospital, also entitles the beneficiary to receive the specified drug as an inpatient benefit (notwithstanding Statement 4 above). In cases where treatment with a product known to be eligible for Exception Drug Status Coverage is initiated in the hospital, it will be recognized as an inpatient benefit providing the patient's case meets the eligibility criteria listed in the Saskatchewan Formulary. The drugs eligible for such coverage and the criteria for patient eligibility are published in the Saskatchewan Formulary as Appendix A.
7.
Certain products are benefits only when used according to specific criteria. The usage criteria or restrictions that apply are shown for each product. When these products are ordered, the ordering physician and/or the pharmacist must determine if the conditions for coverage have been met. When the conditions are met, the patient receives the drug as a benefit. The cost is absorbed by the health region. The region may choose to charge the patient for administration of drugs in this section that fails to meet the criteria/restrictions listed.
8.
Combination products are only benefits if they are specifically included in the Benefit Drug List. Listing of one ingredient included in a combination product does not make that product a benefit.
9.
Products that are not listed in either the Saskatchewan Formulary or this supplementary benefit drug list, or which have not received special approval, are not insured and therefore chargeable to a patient in accordance with instructions included in Statement 137.
10. Certain products may be granted Restricted Coverage status for non-approved indications. This is the case only when the Advisory Committee for Institutional Pharmacy Practice has reviewed evidence to demonstrate safety and efficacy and the prescriber is aware the drug is being prescribed for a non-approved indication. 11. EprexTM, Iron Dextran and VenoferTM may be billed to the Drug Plan when used for the treatment of anemia of renal disease if patients receive these drugs in an institution’s dialysis unit as an outpatient. The cost of EprexTM, Iron Dextran and VenoferTM for inpatient use is the responsibility of the health region. Payment Policy Statement: • The Drug Plan will reimburse hospital pharmacies the actual acquisition cost (AAC) of the dose of EprexTM, Iron Dextran or VenoferTM that is administered plus a 10% mark-up for each month’s supply. The mark-up will be capped at $20.00 per month, unless there are dosage changes. How to bill the Drug Plan: • To ensure consistency in billing for these agents, hospital pharmacy departments are asked to use specific billing forms to submit claims. Please contact (306) 787-3315 or toll free 1-800-667-7578 with any questions.
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TABLE OF CONTENTS 04:00.00
ANTIHISTAMINE DRUGS
266
08:00.00
ANTI INFECTIVE AGENTS
266
8:12.00
ANTIBIOTICS
08:12.02 08:12.04 08:12.06 08:12.07 08:12.08 08:12.12 08:12.28
266
AMINOGLYCOSIDES ANTIFUNGALS CEPHALOSPORINS MISCELLANEOUS BETA LACTAM ANTIBIOTICS CHLORAMPHENICOL ERYTHROMYCINS MISCELLANEOUS ANTIBIOTICS
266 266 266 267 267 267 268
08:16.00
ANTITUBERCULOSIS AGENTS
268
08:18.00
ANTIVIRALS
268
08:22.00
QUINOLONES
268
08:40.00
MISCELLANEOUS ANTI INFECTIVES
269
10:00.00 ANTINEOPLASTIC AGENTS (AGENTS USED FOR NON-CANCER INDICATIONS. SEE FORMULARY OF THE SASKATCHEWAN CANCER FOUNDATION FOR A COMPLETE LISTING OF ANTINEOPLASTIC AGENTS.)
269
12:00.00
AUTONOMIC DRUGS
269
12:04.00
PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS
269
12:08.00
ANTICHOLINERGIC AGENTS
12:08.08
269
ANTIMUSCARINIC/ANTISPASMODICS
269
12:12.00
SYMPATHOMIMETIC (ADRENERGIC) AGENTS
270
12:16.00
SYMPATHOLYTICS
270
12:20.00
SKELETAL MUSCLE RELAXANTS
270
20:00.00
BLOOD FORMATION AND COAGULATION
270
20:04.00
ANTIANEMIA DRUGS
270
20:04.04
IRON PREPARATIONS
270
20:12.00
COAGULANTS AND ANTICOAGULANTS
271
262
20:12.04 20:12.08 20:12.16 20:40.00 24:00.00
ANTICOAGULANTS ANTIHEPARIN AGENTS HEMOSTATICS THROMBOLYTIC AGENTS
CARDIOVASCULAR DRUGS
271 271 271 272 272
24.04.00
CARDIAC DRUG
272
24:08.00
HYPOTENSIVE AGENTS
273
24:12.00
VASODILATING AGENTS
273
28:00.00
CENTRAL NERVOUS SYSTEM AGENTS
28:04.00
GENERAL ANESTHETICS
28:08.00
ANALGESICS AND ANTIPYRETICS
28:08.04 28:08.08 28:08.12 28:08.92
NON-STEROIDAL ANTI-INFLAMMATORY AGENTS OPIATE AGONISTS OPIATE PARTIAL AGONISTS MISCELLANEOUS ANALGESICS AND ANTIPYRETICS
273 273 273
274 274 274 274
28:10.00
OPIATE ANTAGONISTS
274
28:12.00
ANTICONVULSANTS
274
28:16.00
PSYCHOTHERAPEUTIC AGENTS
28:16.08 28:24.00
TRANQUILIZERS ANXIOLYTICS, SEDATIVES AND HYPNOTICS
28:24.04 BARBITURATES 28:24.08 BENZODIAZEPINES 28:24.92 MISCELLANEOUS ANXIOLYTICS, SEDATIVES AND HYPNOTICS 36:00.00 36:56.00 40:00.00
274
274
DIAGNOSTIC AGENTS
275
275 275 275 275
MYASTHENIA GRAVIS
275
ELECTROLYTIC, CALORIC AND WATER BALANCE
275
40:08.00
ALKALINIZING AGENTS
275
40:20.00
CALORIC AGENTS
276
40:28.00
DIURETICS
276
263
44:00.00
ENZYMES
276
48:00.00
ANTITUSSIVES, EXPECTORANTS AND MUCOLYTIC AGENTS
276
48:08.00
ANTITUSSIVES
277
48:16.00
EXPECTORANTS
277
52:00.00
EYE, EAR, NOSE AND THROAT PREPARATIONS
52:04.00
ANTI-INFECTIVES
52:04.04
277 277
ANTIBIOTICS
277
52:16.00
LOCAL ANESTHETICS
277
52:20.00
MIOTICS
277
52:24.00
MYDRIATICS
277
52:32.00
VASOCONSTRICTORS
278
52:36.00
MISCELLANEOUS EYE, EAR, NOSE AND THROAT DRUGS
278
56:08.00
ANTIDIARRHEA AGENTS
278
56:12.00
CATHARTICS AND LAXATIVES
278
56:20.00
EMETICS
279
56:22.00
ANTIEMETICS
279
56:40.00
MISCELLANEOUS GASTROINTESTINAL DRUGS
279
64:00.00
HEAVY METAL ANTAGONISTS
279
68:00.00
HORMONES AND SYNTHETIC SUBSTITUTES
279
68:04.00
ADRENALS
279
68:08.00
ANDROGENS
280
68:28.00
PITUITARY
280
72:00.00
LOCAL ANESTHETICS
280
72:00.00
OXYTOCICS
280
80:00.00
SERUMS, TOXOIDS AND VACCINES
281
264
80:04.00
SERUMS
281
80:08.00
TOXOIDS
281
80:12.00
VACCINES
282
84:00.00
SKIN AND MUCOUS MEMBRANE AGENTS
84:04.00
ANTI INFECTIVES
84:04.04 84:04.16
282 282
ANTIBIOTICS MISCELLANEOUS LOCAL ANTI-INFECTIVES
282 282
84:08.00
ANTI PRURITICS AND LOCAL ANESTHETICS
283
84:24.00
EMOLLIENTS, DEMULCENTS AND PROTECTANTS
283
84:40:00
HEMORRHOID PREPARATIONS
283
88:00.00 88:16.00 92:00.00
VITAMINS
283
VITAMIN D
283
UNCLASSIFIED THERAPEUTIC AGENTS
265
284
04:00.00
ANTIHISTAMINE DRUGS
CYPROHEPTADINE Tablet 4mg Syrup 0.4mg/mL DIPHENHYDRAMINE (injection only) Injection 50mg/mL PROMETHAZINE Injection 25mg/mL
08:00.00
ANTI INFECTIVE AGENTS
8:12.00
ANTIBIOTICS
08:12.02
AMINOGLYCOSIDES
AMIKACIN Injection 250mg/mL TOBRAMYCIN Injection 10mg/mL, 40mg/mL Powder 1.2g 08:12.04
ANTIFUNGALS
AMPHOTERICIN B Injection 50mg AMPHOTERICIN B LIPID COMPLEX INJECTION Restricted Coverage: When used in sonsultation with an infectious disease specialist under the following guidelines: • failure of Amphotericin B deoxycholate. For adults, this is normally defined as poor clinical response to >500mg cumulative doses; • nephrotoxicity due to conventional Amphotericin B therapy as evidenced by doubling of baseine serum creatinine or a significant rise from baseline plus concomitant use of other potential nephrotoxins; • significant pre-existing renal failure – creatinine >220umol/L or CrCl