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

225

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.



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.



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

235

+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.

236



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

238

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

239

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.

240

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

241

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.

242

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

245

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.

261

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