Formulary 51st Edition - Drug Plan

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Formulary 51st Edition - Drug Plan
Saskatchewan
Health
Formulary
Fifty-First Edition
Drug Plan
July 2001 - July 2002
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) 787-3305
(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 - 2001
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 Now
Published Annually
Quarterly Updates will be provided:
Fall 2001
Winter 2002
Spring 2002
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
22
26
36
42
74
114
118
122
124
134
142
144
146
166
188
192
196
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............................................. .
206
237
268
270
272
277
282
285
287
288
289
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.............. .
294
296
298
315
FORMULARY UPDATES...................................................................................................... .
336
ii
INTRODUCTION
COMMITTEES
SASKATCHEWAN FORMULARY
COMMITTEE
SASKATCHEWAN DRUG QUALITY
ASSESSMENT COMMITTEE
Dr. B.R. Schnell
Chairperson
Dr. John Tuchek
Chairperson
Dr. M. Caughlin
Saskatchewan Medical Association
Ms Barb Evans
College of Pharmacy
Dr. Johann De La Rey Nel
College of Physicians & Surgeons
Dr. Ian Holmes
College of Medicine
Mr. Michael Gaucher
Saskatchewan Association of
Health Care Organizations
Dr. D. Quest
Department of Pharmacology,
College of Medicine
Ms Cintra Kanhai
Saskatchewan Pharmaceutical
Association
Dr. A. Kumar Ramlall
College of Medicine
Dr. B.R. Schnell
Ex-officio
Mr. George Peters
Saskatchewan Health
Dr. Y. Shevchuk
College of Pharmacy
Dr. D. Seibel
Member at Large
Dr. Thomas W. Wilson
Departments of Medicine &
Pharmacology,
College of Medicine
Dr. Y. Shevchuk
College of Pharmacy
University of Saskatchewan
Ms Marilyn Smith
Saskatchewan Registered Nurses
Association
Mr. Roy Dobson
Member at Large
Dr. John Tuchek
College of Medicine
STAFF ASSISTANCE
Ms Gail Bradley
Pharmacist, Drug Plan &
Extended Benefits Branch
Ms Barbara J. Shea
Executive Director, Drug Plan &
Extended Benefits Branch
Dr. L. Davis
Pharmacologist, Drug Plan &
Extended Benefits Branch
Ms Margaret Baker
Acting Director, Pharmaceutical Services
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, pharmacologists, and pharmacists with special
interest in pharmaceutics and pharmaceutical chemistry. The SFC is made up of
representatives of the associations or institutions related to the regulation, education,
delivery and payment of the cost 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.
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 should be submitted with the clinical documentation if
possible, but will be accepted at a later date.
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 test 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.
Market Information
To allow for an accurate projection of the impact of a new product, expected market
share information is requested.
Patent Status
Product patent expiration date is requested to allow for consideration of the potential
long-term economic impact of the product.
Promotion Material
Copies of the initial product launch material, and any subsequent material sent to
physicians and pharmacists, are requested.
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, Acting Director, Pharmaceutical Services Division
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. Drugs
not listed in the Formulary will not be covered by the Drug Plan except when approved for
coverage under the Exception Drug Status Program. See Appendix A for more
information regarding the Exception Drug Status Program.
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, but may be made available on Exception Drug
Status for treatment of selected clinical indications. (See Appendix A)
6.
Oral combination products are required to meet the following additional criteria:
• each component must make a contribution to the claimed effect;
x
• 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;
antineoplastic agents (these are provided to patients through the Saskatchewan
Cancer Agency);
• anti-tuberculosis drugs;
xi
• 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;
• the drug has potential for use in other than approved indications;
• the drug has potential for the development of widespread inappropriate use;
xii
• 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, as well as credits to deductibles, will be based only on the lowest
priced interchangeable brand as listed in the Formulary. 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
1
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 xii).
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.
6
The following symbol: x , to the left of a drug strength and dosage form indicates that the
products listed below are NOT interchangeable.
7
Drug strength and dosage form.
8
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.
9
This product requires Exception Drug Status (EDS) approval (see Appendix A for EDS
criteria).
10
All active ingredients of combination products are listed.
11
Strengths of active ingredients are listed in the same order as the ingredients. This
example indicates that the tablet contains 300mg of acetaminophen and 30mg of codeine.
12
Brand name of drug.
13
Three letter identification code assigned to each manufacturer. The codes are listed in
Index A near the back of the Formulary.
14
The size of vials or ampoules of injectables is listed in brackets.
15
The size of a tube of ophthalmic ointments is listed in brackets.
xvi
1 8
08:00 ANTI-INFECTIVE AGENTS
2 8
08:12.16 ANTIBIOTICS (PENICILLINS)
3 8
AMOXICILLIN (AMOXYCILLIN)
* 250MG CAPSULE
4 8
NU-AMOXI
NOVAMOXIN
APO-AMOXI
LIN-AMOX
PENTA-AMOXICILLIN
GEN-AMOXICILLIN
MED-AMOXICILLIN
AMOXIL-250
NXP
NOP
APX
LIN
PEN
GPM
MED
WYA
$
0.0837 * 7 5
0.1120
0.1120
0.1120
0.1120
0.1120
0.1120
0.2051
00010308
WARFILONE
MSD
$
0.1917
01918354
COUMADIN
DUP
00865567
00406724
00628115
02181487
02229584
02238171
02239761
02041294
WARFARIN
6 8
x
5MG TABLET
0.3150
CIPROFLOXACIN
500MG TABLET
7 8
8 8
10 8
11 8
02155966
CIPRO (EDS) 7 9
BAY
$
2.7188
TCH
$
0.0494
ACETAMINOPHEN/CODEINE
* 300MG/30MG TABLET
00608882
EMTEC-30 7 12
00666130
EMPRACET-30
13
8 GLA
0.0494
FLUPENTHIXOL DECANOATE
20MG/ML INJECTION SOLUTION (10ML) 7 14
02156032
FLUANXOL DEPOT
LUD
$
73.1900
SCH
SAB
$
4.3400
4.3400
GENTAMICIN SO4
* 5MG/G OPHTHALMIC OINTMENT (3.5G)
00028339
02230888
GARAMYCIN
GENTAMICIN SULFATE
xvii
7 15
ANTI-INFECTIVE AGENTS
8:00
08:00 ANTI-INFECTIVE AGENTS
08:04.00 AMEBICIDES
DIIODOHYDROXYQUIN
650MG TABLET
01997750
DIODOQUIN
GLW
$
0.6906
JAN
$
3.1592
RBP
$
0.9700
BAY
$
5.7510
PFC
$
5.9675
PFC
$
1.4322
PFC
$
1.0325
08:08.00 ANTHELMINTICS
MEBENDAZOLE
100MG TABLET
00556734
VERMOX
PIPERAZINE ADIPATE
2G/PKG GRANULES
02100215
ENTACYL
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
2
08:00 ANTI-INFECTIVE AGENTS
08:12.00 ANTIBIOTICS
ANTIBIOTIC ASSOCIATED COLITIS OR PSEUDOMEMBRANOUS ENTEROCOLIT
IS A SEVERE POTENTIALLY FATAL COLITIS WHICH MAY FOLLOW TH
ADMINISTRATION OF ANTIBIOTICS, MOST COMMONLY CLINDAMYCIN
THE SYNDROME IS CAUSED BY A BACTERIAL TOXIN.
PATIENTS FOR WHOM ANTIBIOTICS ARE PRESCRIBED SHOULD BE ADVISE
TO DISCONTINUE THERAPY AND REPORT TO THE PHYSICIAN IF
PERSISTANT DIARRHEA DEVELOPS AND/OR IF BLOOD OR MUCUS APPEAR
IN THE STOOL, AND SHOULD BE ADVISED NOT TO USE ANTIDIARRHEA
PREPARATIONS WHILE ON THESE DRUGS AS THEY MAY EXACERBATE TH
CONDITION.
RECOMMENDED TREATMENT INCLUDES STOPPING ANTIBIOTICS AS SOON A
POSSIBLE, CAREFUL ATTENTION TO FLUIDS AND ELECTROLYTES AND TH
USE OF AN APPROPRIATE ANTIBIOTIC (SUCH AS ORALLY ADMINISTERE
METRONIDAZOLE OR VANCOMYCIN) DIRECTED AGAINST THE TOXI
PRODUCING ORGANISM.
08:12.02 ANTIBIOTICS (AMINOGLYCOSIDES)
GENTAMICIN SO4
* 40MG/ML INJECTION SOLUTION (2ML)
00223824
02145758
GARAMYCIN
GENTAMICIN SULPHATE
SCH
NOP
$
4.3000
4.3000
CCL
$
51.1700
APX
PFI
$
11.0779
15.1868
APX
PFI
$
3.7693
5.0581
APX
PFI
$
6.6867
8.5699
PFI
$
1.0126
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
02141442
APO-FLUCONAZOLE
DIFLUCAN
* 50MG TABLET
02237370
00891800
APO-FLUCONAZOLE (EDS)
DIFLUCAN (EDS)
* 100MG TABLET
02237371
00891819
APO-FLUCONAZOLE (EDS)
DIFLUCAN (EDS)
10MG/ML POWDER FOR ORAL SUSPENSION
02024152
DIFLUCAN P.O.S. (EDS)
3
08:00 ANTI-INFECTIVE AGENTS
08:12.04 ANTIBIOTICS (ANTIFUNGALS)
GRISEOFULVIN (ULTRA-FINE)
250MG TABLET
00028274
FULVICIN U/F
SCH
$
0.2775
SCH
$
0.4697
JAN
$
3.7975
JAN
$
0.8075
NXP
NOP
APX
MCL
$
1.2841
1.2841
1.2841
2.0383
TCH
$
0.0858
DOM
TCH
FTP
TAR
PMS
PPZ
$
0.0534
0.0566
0.0566
0.0638
0.0643
0.1978
APX
PMS
NOP
GPM
NVR
$
2.5574
2.7391
2.7393
2.7393
3.8712
500MG TABLET
00028282
FULVICIN U/F
ITRACONAZOLE
SEE APPENDIX A FOR EDS CRITERIA
100MG CAPSULE
02047454
SPORANOX (EDS)
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
NILSTAT
* 100,000U/ML ORAL SUSPENSION
02125145
02194201
02238544
00779121
00792667
00248169
DOM-NYSTATIN
NILSTAT
FTP-NYSTATIN
NYADERM
PMS-NYSTATIN
MYCOSTATIN
TERBINAFINE HCL
* 250MG TABLET
02239893
02240807
02240346
02242503
02031116
APO-TERBINAFINE
PMS-TERBINAFINE
NOVO-TERBINAFINE
GEN-TERBINAFINE
LAMISIL
4
08:00 ANTI-INFECTIVE AGENTS
08:12.06 ANTIBIOTICS (CEPHALOSPORINS)
CEFACLOR
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
LIL
$
0.0827
0.0827
0.0930
0.1183
PMS
APX
DOM
LIL
$
0.1514
0.1514
0.1702
0.2164
PMS
APX
DOM
LIL
$
0.2181
0.2181
0.2450
0.3117
AVT
$
3.3570
AVT
$
0.3598
BMY
$
1.6601
BMY
$
3.2550
BMY
$
0.1622
BMY
$
0.3245
* 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)
CEFPROZIL
SEE APPENDIX A FOR EDS CRITERIA
250MG TABLET
02163659
CEFZIL (EDS)
500MG TABLET
02163667
CEFZIL (EDS)
25MG/ML ORAL SUSPENSION
02163675
CEFZIL (EDS)
50MG/ML ORAL SUSPENSION
02163683
CEFZIL (EDS)
5
08:00 ANTI-INFECTIVE AGENTS
08:12.06 ANTIBIOTICS (CEPHALOSPORINS)
CEFUROXIME AXETIL
SEE APPENDIX A FOR EDS CRITERIA
250MG TABLET
02212277
CEFTIN (EDS)
GSK
$
1.5705
GSK
$
3.1112
GSK
$
0.1736
NOP
$
0.1620
NOP
$
0.3240
NXP
NOP
APX
PMS
DOM
$
0.1055 *
0.1620
0.1620
0.1620
0.1966
NXP
NOP
APX
PMS
DOM
LIL
$
0.2099 *
0.3240
0.3240
0.3240
0.3871
0.6954
NOP
$
0.0352
NOP
LIL
$
0.0712
0.0980
500MG TABLET
02212285
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
00244392
NU-CEPHALEX
NOVO-LEXIN
APO-CEPHALEX
PMS-CEPHALEXIN
DOM-CEPHALEXIN
KEFLEX
25MG/ML ORAL SUSPENSION
00342106
NOVO-LEXIN
* 50MG/ML ORAL SUSPENSION
00342092
00035645
NOVO-LEXIN
KEFLEX
6
08:00 ANTI-INFECTIVE AGENTS
08:12.12 ANTIBIOTICS (MACROLIDES)
PRESCRIPTIONS FOR SOLID DOSAGE FORMS OF ERYTHROMYCIN SHOULD B
FILLED WITH AN ERYTHROMYCIN BASE PREPARATION OF THE STRENGT
PRESCRIBED; DISPENSE THE STEARATE AND ESTOLATE ONLY WHE
SPECIFICALLY PRESCRIBED
AZITHROMYCIN
SEE APPENDIX A FOR EDS CRITERIA
250MG TABLET
02212021
ZITHROMAX (EDS)
PFI
$
5.1386
PFI
$
12.3326
PFI
$
1.1111
PFI
$
1.5740
ABB
$
1.6048
ABB
$
3.2095
ABB
$
0.2817
ABB
$
0.5137
PFI
$
0.5024
PFI
$
0.5581
NOP
$
0.0297
NOP
$
0.0598
NOP
ABB
$
0.0671
0.0748
NOP
ABB
$
0.0899
0.1133
APX
NXP
$
0.0940
0.0940
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 (EDS)
500MG TABLET
02126710
BIAXIN (EDS)
25MG/ML ORAL SUSPENSION
02146908
BIAXIN (EDS)
ERYTHROMYCIN 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
ERYTHROMYCIN ETHYLSUCCINATE
* 40MG/ML ORAL SUSPENSION
00605859
00000299
NOVO-RYTHRO ETHYLSUCC.
EES 200
* 80MG/ML ORAL SUSPENSION
00652318
00453617
NOVO-RYTHRO ETHYLSUCC.
EES 400
ERYTHROMYCIN STEARATE
* 250MG TABLET
00545678
02051850
APO-ERYTHRO-S
NU-ERYTHROMYCIN-S
7
08:00 ANTI-INFECTIVE AGENTS
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
NXP
NOP
APX
LIN
GPM
MED
$
0.0810 *
0.1120
0.1120
0.1120
0.1120
0.1120
NXP
NOP
APX
LIN
GPM
MED
WYA
$
0.1578 *
0.2181
0.2181
0.2181
0.2181
0.2181
0.4058
NOP
WYA
$
0.2512
0.3138
NOP
$
0.3700
NXP
NOP
APX
LIN
$
0.0157 *
0.0217
0.0217
0.0217
NXP
NOP
APX
LIN
WYA
$
0.0234 *
0.0326
0.0326
0.0326
0.0637
* 500MG CAPSULE
00865575
00406716
00628123
02181495
02238172
02239762
02041308
NU-AMOXI
NOVAMOXIN
APO-AMOXI
LIN-AMOX
GEN-AMOXICILLIN
MED-AMOXICILLIN
AMOXIL
* 125MG CHEWABLE TABLET
02036347
02041685
NOVAMOXIN
AMOXIL
250MG CHEWABLE TABLET
02036355
NOVAMOXIN
* 25MG/ML ORAL SUSPENSION
00865540
00452149
00628131
02181509
NU-AMOXI
NOVAMOXIN
APO-AMOXI
LIN-AMOX
* 50MG/ML ORAL SUSPENSION
00865559
00452130
00628158
02181517
02042592
NU-AMOXI
NOVAMOXIN
APO-AMOXI
LIN-AMOX
AMOXIL-250
AMOXICILLIN TRIHYDRATE/POTASSIUM CLAVULANATE
SEE APPENDIX A FOR EDS CRITERIA
* 250MG/125MG TABLET
02243350
01916866
APO-AMOXI CLAV (EDS)
CLAVULIN-250 (EDS)
APX
GSK
$
0.6631
0.9943
APX
GSK
$
1.0136
1.4915
GSK
$
2.2372
* 500MG/125MG TABLET
02243351
01916858
APO-AMOXI CLAV (EDS)
CLAVULIN-500 (EDS)
875MG/125MG TABLET
02238829
CLAVULIN-875 (EDS)
8
08:00 ANTI-INFECTIVE AGENTS
08:12.16 ANTIBIOTICS (PENICILLINS)
25MG/6.25MG/ML ORAL SUSPENSION
01916882
CLAVULIN-125F (EDS)
GSK
$
0.1179
GSK
$
0.1452
GSK
$
0.1979
GSK
$
0.2712
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
40MG/5.3MG/ML ORAL SUSPENSION
02238831
CLAVULIN-200 (EDS)
50MG/12.5MG/ML ORAL SUSPENSION
01916874
CLAVULIN-250F (EDS)
80MG/11.4MG/ML ORAL SUSPENSION
02238830
CLAVULIN-400 (EDS)
AMPICILLIN
* 250MG CAPSULE
00020877
00603279
00717657
NOVO-AMPICILLIN
APO-AMPI
NU-AMPI
* 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
9
08:00 ANTI-INFECTIVE AGENTS
08:12.16 ANTIBIOTICS (PENICILLINS)
PENICILLIN V (POTASSIUM)
* 300MG TABLET
02232391
00021202
00642215
00717568
PVF-K 500
NOVO-PEN-VK
APO-PEN-VK
NU-PEN-VK
LIH
NOP
APX
NXP
$
0.0388
0.0407
0.0407
0.0407
APX
$
0.0266
LEO
$
0.9203
25MG/ML ORAL SOLUTION
00642223
APO-PEN-VK
PIVMECILLINAM HCL
SEE APPENDIX A FOR EDS CRITERIA
200MG TABLET
00657212
SELEXID (EDS)
08:12.24 ANTIBIOTICS (TETRACYCLINES)
THE USE OF TETRACYCLINES DURING TOOTH DEVELOPMENT (LAST HAL
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 O
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 EFFECTIV
OR ARE CONTRAINDICATED
DOXYCYCLINE
* 100MG CAPSULE
02044668
00740713
00817120
02093103
02140039
00024368
NU-DOXYCYCLINE
APO-DOXY
DOXYCIN
DOXYTEC
ALTI-DOXYCYCLINE
VIBRAMYCIN
NXP
APX
GPM
TCH
ALT
PFI
$
0.4346 *
0.6359
0.6359
0.6359
0.6359
1.7703
NXP
GPM
APX
TCH
ALT
NOP
PFI
$
0.4346 *
0.6359
0.6359
0.6359
0.6359
0.6359
1.7702
* 100MG TABLET
02044676
00860751
00874256
02091232
02142058
02158574
00578452
NU-DOXYCYCLINE
DOXYCIN
APO-DOXY
DOXYTEC
ALTI-DOXYCYCLINE
NOVO-DOXYLIN
VIBRA-TABS
10
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
ALTI-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)
ALT
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
ALT
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
$
0.0326
0.0326
* 100MG CAPSULE
01914146
02084104
02108151
02230736
02237314
02237876
02239239
02239668
02173506
ALTI-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
02130033
02241709
00030570
ALTI-CLINDAMYCIN
NOVO-CLINDAMYCIN
DALACIN C
ALT
NOP
PHU
$
0.5895
0.5895
0.8896
ALT
NOP
PHU
$
1.1791
1.1791
1.7792
* 300MG CAPSULE
02192659
02241710
02182866
ALTI-CLINDAMYCIN
NOVO-CLINDAMYCIN
DALACIN C
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
11
$
0.1197
08:00 ANTI-INFECTIVE AGENTS
08:12.28 ANTIBIOTICS (MISCELLANEOUS ANTIBIOTICS)
VANCOMYCIN HCL
SEE APPENDIX A FOR EDS CRITERIA
125MG CAPSULE
00800430
VANCOCIN (EDS)
LIL
$
7.1133
LIL
$
14.2266
PMS
LIL
$
24.2000
28.4600
PMS
LIL
$
48.3700
55.4500
NXP
TCH
APX
ALT
GPM
GSK
$
0.7734 *
0.9530
0.9530
0.9530
0.9530
1.2706
TCH
NXP
APX
GPM
GSK
$
1.8758
1.8758
1.8758
1.8758
2.5010
NXP
APX
ALT
GPM
TCH
GSK
$
3.0985
3.0985
3.0985
3.0985
3.0986
4.9181
DOM
PMS
END
GPM
MED
DUP
$
0.1722 *
0.5620
0.5620
0.5620
0.5620
1.0703
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
02229707
02242784
00634506
NU-ACYCLOVIR
AVIRAX
APO-ACYCLOVIR
ALTI-ACYCLOVIR
GEN-ACYCLOVIR
ZOVIRAX
* 400MG TABLET
02078635
02197413
02207648
02242463
01911627
AVIRAX
NU-ACYCLOVIR
APO-ACYCLOVIR
GEN-ACYCLOVIR
ZOVIRAX WELLSTAT PAC
* 800MG TABLET
02197421
02207656
02229709
02242464
02078651
01911635
NU-ACYCLOVIR
APO-ACYCLOVIR
ALTI-ACYCLOVIR
GEN-ACYCLOVIR
AVIRAX
ZOVIRAX ZOSTAB PAC
AMANTADINE
* 100MG CAPSULE
02130963
01990403
02034468
02139200
02199289
01914006
DOM-AMANTADINE
PMS-AMANTADINE
ENDANTADINE
GEN-AMANTADINE
MED-AMANTADINE
SYMMETREL
12
08:00 ANTI-INFECTIVE AGENTS
08:18.00 ANTIVIRALS
* 10MG/ML SYRUP
01913999
02022826
02130971
SYMMETREL
PMS-AMANTADINE
DOM-AMANTADINE
DUP
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
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
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
DUP
$
1.2019
DUP
$
2.4033
DUP
$
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)
13
08:00 ANTI-INFECTIVE AGENTS
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
BMY
$
0.4178
BMY
$
0.8365
BMY
$
1.6728
BMY
$
2.5091
BMY
$
73.6100
GSK
$
4.7740
GSK
$
4.7740
GSK
$
0.3184
GSK
$
10.0000
BRI
$
4.1013
BRI
$
4.2641
BRI
$
4.4485
BRI
$
4.6113
20MG/ML ORAL SOLUTION
02240358
ZIAGEN (EDS)
DIDANOSINE
SEE APPENDIX A FOR EDS CITERIA
25MG CHEWABLE TABLET
01940511
VIDEX (EDS)
50MG CHEWABLE TABLET
01940538
VIDEX (EDS)
100MG CHEWABLE TABLET
01940546
VIDEX (EDS)
150MG CHEWABLE TABLET
01940554
VIDEX (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)
STAVUDINE
SEE APPENDIX A FOR EDS CRITERIA
15MG CAPSULE
02216086
ZERIT (EDS)
20MG CAPSULE
02216094
ZERIT (EDS)
30MG CAPSULE
02216108
ZERIT (EDS)
40MG CAPSULE
02216116
ZERIT (EDS)
14
08:00 ANTI-INFECTIVE AGENTS
08:18.08 ANTIRETROVIRAL AGENTS (NUCLEOSIDE REVERSE
TRANSCRIPTASE INHIBITORS)
ZALCITABINE
SEE APPENDIX A FOR EDS CRITERIA
0.375MG TABLET
01990918
HIVID (EDS)
HLR
$
1.8662
HLR
$
2.3328
APX
GSK
$
1.3020
1.8445
GSK
$
0.1962
GSK
$
17.5500
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)
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
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)
15
08:00 ANTI-INFECTIVE AGENTS
08:18.08 ANTIRETROVIRAL AGENTS (PROTEASE INHIBITORS)
SAQUINAVIR
SEE APPENDIX A FOR EDS CRITERIA
200MG CAPSULE
02216965
INVIRASE (EDS)
HLR
$
1.9312
HLR
$
1.1067
NOP
SAW
$
0.0865
0.3481
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
200MG SOFT GELATIN CAPSULE
02239083
FORTOVASE (EDS)
08:20.00 ANTIMALARIAL AGENTS
CHLOROQUINE PHOSPHATE
* 250MG TABLET
00021261
02017539
NOVO-CHLOROQUINE
ARALEN
HYDROXYCHLOROQUINE SO4
200MG TABLET
02017709
PLAQUENIL
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)
16
08:00 ANTI-INFECTIVE AGENTS
08:22.00 QUINOLONES
LEVOFLOXACIN
SEE APPENDIX A FOR EDS CRITERIA
250MG TABLET
02236841
LEVAQUIN (EDS)
JAN
$
4.8174
JAN
$
5.4359
BAY
$
5.4359
APX
NOP
MSD
$
1.6554
1.6554
2.4120
WYA
$
0.2496
PFR
$
21.7000
PFI
$
0.1825
NOP
ALZ
$
0.2470
0.3771
APX
$
0.0879
APX
$
0.1270
500MG TABLET
02236842
LEVAQUIN (EDS)
MOXIFLOXACIN HCL
SEE APPENDIX A FOR EDS CRITERIA
400MG TABLET
02242965
AVELOX (EDS)
NORFLOXACIN
SEE APPENDIX A FOR EDS CRITERIA
* 400MG TABLET
02229524
02237682
00643025
APO-NORFLOX (EDS)
NOVO-NORFLOXACIN (EDS)
NOROXIN (EDS)
08:26.00 SULFONES
DAPSONE
100MG TABLET
02041510
AVLOSULFON
08:36.00 URINARY ANTI-INFECTIVES
METHENAMINE SALTS ARE EFFECTIVE ONLY IN ACIDIC URINE AN
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
17
08:00 ANTI-INFECTIVE AGENTS
08:36.00 URINARY ANTI-INFECTIVES
NITROFURANTOIN MONOHYDRATE
100MG CAPSULE (MACROCRYSTALS)
02063662
MACROBID
ALZ
$
0.6700
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
PMS
APX
$
0.0353
0.0364
0.0749
NXP
GSK
APX
NOP
$
0.0412 *
0.0523
0.0523
0.0523
NXP
APX
NOP
GSK
$
0.1038 *
0.1325
0.1325
0.1326
TRIMETHOPRIM
* 100MG TABLET
02243116
00675229
APO-TRIMETHOPRIM
PROLOPRIM
* 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
00584339
00545066
NOVO-NIDAZOL
PMS-METRONIDAZOLE
APO-METRONIDAZOLE
SULFAMETHOXAZOLE/TRIMETHOPRIM
(CO-TRIMOXAZOLE)
* 400MG/80MG TABLET
00865710
00270636
00445274
00510637
NU-COTRIMOX
SEPTRA
APO-SULFATRIM
NOVO-TRIMEL
* 800MG/160MG TABLET
00865729
00445282
00510645
00368040
NU-COTRIMOX DS
APO-SULFATRIM DS
NOVO-TRIMEL DS
SEPTRA D.S.
18
08:00 ANTI-INFECTIVE AGENTS
08:40.00 MISCELLANEOUS ANTI-INFECTIVES
100MG/20MG PEDIATRIC TABLET
00445266
APO-SULFATRIM
APX
$
0.0955
NOP
APX
NXP
GSK
$
0.0215
0.0215
0.0215
0.0216
* 40MG/8MG PER ML ORAL SUSPENSION
00726540
00846465
00865753
00270644
NOVO-TRIMEL
APO-SULFATRIM
NU-COTRIMOX
SEPTRA
19
ANTINEOPLASTIC AGENTS
10:00
10:00 ANTINEOPLASTIC AGENTS
10:00.00 ANTINEOPLASTIC AGENTS
CYPROTERONE ACETATE
SEE APPENDIX A FOR EDS CRITERIA
* 50MG TABLET
00704431
02229449
02229723
02232872
ANDROCUR (EDS)
ALTI-CPA (EDS)
GEN-CYPROTERONE (EDS)
NOVO-CYPROTERONE (EDS)
PMS
ALT
GPM
NOP
$
1.6375
1.6375
1.6375
1.6375
PMS
$
79.1100
HLR
$
36.8900
HLR
$
110.6700
HLR
$
221.3400
SCH
$
61.4700
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
5 MILLION IU POWDER FOR INJECTION (ML)
02223414
INTRON-A PREMIX (EDS)
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)
22
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
NXP
LIN
BMY
$
3.9267
3.9350
3.9353
5.8302
BMY
$
1.1653
GSK
$
1.9899
* 160MG TABLET
02195925
02185423
02176106
00731323
APO-MEGESTROL (EDS)
NU-MEGESTROL (EDS)
LIN-MEGESTROL (EDS)
MEGACE (EDS)
40MG/ML ORAL SUSPENSION
02168979
MEGACE OS (EDS)
MERCAPTOPURINE
SEE APPENDIX A FOR EDS CRITERIA
50MG TABLET
00004723
PURINETHOL (EDS)
23
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
$
0.0191 *
0.0586
0.1558
MSD
$
5.1400
AVT
$
0.2013
GSK
PMS
DOM
ICN
$
0.0277
0.0277
0.0291
0.0771
GSK
PMS
$
0.0333
0.0333
* 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
PROCYCLIDINE HCL
* 5MG TABLET
00004758
00587354
02125102
00306290
KEMADRIN
PMS-PROCYCLIDINE
DOM-PROCYCLIDINE
PROCYCLID
* 0.5MG/ML ELIXIR
00004405
00587362
KEMADRIN
PMS-PROCYCLIDINE
26
12:00 AUTONOMIC DRUGS
12:08.04 ANTIPARKINSONIAN AGENTS
TRIHEXYPHENIDYL HCL
2MG TABLET
00545058
APO-TRIHEX
APX
$
0.0228
APO-TRIHEX
APX
$
0.0358
ICN
$
0.0992
AVT
$
0.1149
AVT
$
0.0612
BOE
$
0.2370
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
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
ALT
PMS
BOE
$
0.8200
0.8200
1.4301
ALT
APX
NOP
PMS
GPM
BOE
$
0.6000
0.6000
0.6000
0.6000
0.6000
0.9532
NXP
ALT
GPM
PMS
APX
BOE
$
1.2570 *
1.6390
1.6390
1.6390
1.6390
2.8610
* 0.0125% INHALATION SOLUTION (2ML)
02097176
02231135
02026759
ALTI-IPRATROPIUM UDV
PMS-IPRATROPIUM
ATROVENT
* 0.025% INHALATION SOLUTION
02097141
02126222
02210479
02231136
02239131
00731439
ALTI-IPRATROPIUM
APO-IPRAVENT
NOVO-IPRAMIDE
PMS-IPRATROPIUM
GEN-IPRATROPIUM
ATROVENT
* 0.025% INHALATION SOLUTION (2ML)
02231785
02097168
02216221
02231245
02231494
01950681
NU-IPRATROPIUM
ALTI-IPRATROPIUM UDV
GEN-IPRATROPIUM
PMS-IPRATROPIUM
APO-IPRAVENT
ATROVENT
27
12:00 AUTONOMIC DRUGS
12:08.08 ANTIMUSCARINICS/ANTISPASMODICS
IPRATROPIUM BROMIDE/SALBUTAMOL SO4
NOTE: SALBUTAMOL STRENGTHS ARE EXPRESSED IN TERMS OF SALBUTAMOL
BASE EQUIVALENT.
20UG/100UG INHALER AEROSOL (PACKAGE)
02163721
COMBIVENT
BOE
$
21.2200
BOE
$
1.5930
RBP
$
0.2038
ICN
RBP
$
0.1807
0.2257
0.5MG/2.5MG INHALATION SOLUTION (2.5ML)
02231675
COMBIVENT
PROPANTHELINE BROMIDE
7.5MG TABLET
02030829
PRO-BANTHINE
* 15MG TABLET
00294837
02030837
PROPANTHEL
PRO-BANTHINE
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
AMATINE (EDS)
RBP
$
0.5290
AMATINE (EDS)
RBP
$
0.8935
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)
MIDODRINE HCL
SEE APPENDIX A FOR EDS CRITERIA
2.5MG TABLET
01934392
5MG TABLET
01934406
28
12:00 AUTONOMIC DRUGS
12:12.00 SYMPATHOMIMETIC (ADRENERGIC) AGENTS
ORCIPRENALINE SO4
* 2MG/ML SYRUP
02152568
02236783
00249920
ALTI-ORCIPRENALINE
APO-ORCIPRENALINE
ALUPENT
ALT
APX
BOE
$
0.0415
0.0415
0.0656
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
$
0.1846
GSK
$
1.4764
GSK
$
0.2565
GSK
$
2.0514
GSK
$
0.0738
APX
ALT
NOP
GSK
$
5.0400
5.0400
5.0400
13.3200
MDA
$
5.0500
PMS
ALT
GSK
$
0.4047
0.4047
0.5398
* 4MG TABLET
00620963
02146851
02165376
200UG/AEROSOL POWDER CAPSULE
02212315
VENTOLIN ROTACAPS
200UG/DOSE AEROSOL POWDER DISK (8)
02214997
VENTODISK
400UG/AEROSOL POWDER CAPSULE
02212323
VENTOLIN ROTACAPS
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
ALTI-SALBUTAMOL
NOVO-SALMOL
VENTOLIN
100UG/DOSE INHALER AEROSOL (PACKAGE)
(CFC-FREE)
02232570
AIROMIR
* 0.5MG/ML INHALATION SOLUTION PRESERVATIVE
FREE (2.5ML)
02208245
02239365
02022125
PMS-SALBUTAMOL
ALTI-SALBUTAMOL P.F.
VENTOLIN NEBULES P.F.
29
12:00 AUTONOMIC DRUGS
12:12.00 SYMPATHOMIMETIC (ADRENERGIC) AGENTS
* 1MG/ML INHALATION SOLUTION PRESERVATIVE FREE
(2.5ML)
02231783
01926934
01986864
02084333
02208229
02231430
02231488
02216949
02213419
NU-SALBUTAMOL
GEN-SALBUTAMOL STERINEB
ALTI-SALBUTAMOL SULPHATE
MED-SALBUTAMOL
PMS-SALBUTAMOL
ASMAVENT
APO-SALVENT
DOM-SALBUTAMOL
VENTOLIN NEBULES P.F.
NXP
GPM
ALT
MED
PMS
TCH
APX
DOM
GSK
$
0.3370 *
0.6610
0.6610
0.6610
0.6610
0.6610
0.6610
0.7410
1.0480
GPM
PMS
APX
NXP
ALT
GSK
$
1.2538
1.2538
1.2538
1.2538
1.2538
1.9905
ALT
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
$
54.0400
* 2MG/ML INHALATION SOLUTION PRESERVATIVE FREE
(2.5ML)
02173360
02208237
02231678
02231784
02239366
01945203
GEN-SALBUTAMOL STERINEB
PMS-SALBUTAMOL
APO-SALVENT
NU-SALBUTAMOL
ALTI-SALBUTAMOL P.F.
VENTOLIN NEBULES P.F.
* 5MG/ML INHALATION SOLUTION
00860808
02046741
02069571
02154412
02232987
02139324
02213486
ALTI-SALBUTAMOL RESP.SOL.
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)
GSK
SALMETEROL XINAFOATE/FLUTICASONE PROPIONATE
SEE APPENDIX A FOR EDS CRITERIA
50UG/100UG POWDER FOR INHALATION (PACKAGE)
02240835
ADVAIR DISKUS (EDS)
GSK
$
77.8000
$
93.1000
$
132.1600
$
15.5200
50UG/250UG POWDER FOR INHALATION (PACKAGE)
02240836
ADVAIR DISKUS (EDS)
GSK
50UG/500UG POWDER FOR INHALATION (PACKAGE)
02240837
ADVAIR DISKUS (EDS)
GSK
TERBUTALINE SO4
0.5MG/DOSE POWDER FOR INHALATION (PACKAGE)
00786616
BRICANYL TURBUHALER
30
AST
12:00 AUTONOMIC DRUGS
12:16.00 SYMPATHOLYTIC AGENTS (ANTIMIGRAINE DRUGS)
DIHYDROERGOTAMINE MESYLATE
SEE APPENDIX A FOR EDS CRITERIA
* 1MG/ML INJECTION SOLUTION (1ML)
02241163
00027243
DIHYDROERGOTAMINE MESYL.
DIHYDROERGOTAMINE-SANDOZ
SAB
NVR
$
3.7200
4.5800
NVR
$
9.8200
AVT
$
0.7958
NVR
$
2.3735
PMS
$
0.8229
NVR
$
0.6961
4MG/ML NASAL SPRAY
02228947
MIGRANAL (EDS)
ERGOTAMINE TARTRATE
2MG SUBLINGUAL TABLET
00328952
ERGOMAR
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
PROPRANOLOL
SEE SECTION 24:04.00 (CARDIAC DRUGS)
31
12:00 AUTONOMIC DRUGS
12:16.00 SYMPATHOLYTIC AGENTS (ANTIMIGRAINE 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)
32
12:00 AUTONOMIC DRUGS
12:20.00 SKELETAL MUSCLE RELAXANTS
BACLOFEN
* 10MG TABLET
02138271
02063735
02084449
02088398
02136090
02139332
02236507
02238445
00455881
DOM-BACLOFEN
PMS-BACLOFEN
MED-BACLOFEN
GEN-BACLOFEN
NU-BACLO
APO-BACLOFEN
LIOTEC
FTP-BACLOFEN
LIORESAL
DOM
PMS
MED
GPM
NXP
APX
TCH
FTP
NVR
$
0.0785 *
0.3159
0.3159
0.3159
0.3159
0.3159
0.3159
0.3159
0.5014
DOM
PMS
MED
GPM
NXP
APX
TCH
FTP
NVR
$
0.1535 *
0.6149
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
ALT
APX
PMS
GPM
TCH
MED
DOM
ALZ
$
0.4085
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
02238446
00636576
DOM-BACLOFEN
PMS-BACLOFEN
MED-BACLOFEN
GEN-BACLOFEN
NU-BACLO
APO-BACLOFEN
LIOTEC
FTP-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
02174618
02177145
02212048
02231353
02236506
02237275
02238633
00782742
NOVO-CYCLOPRINE (EDS)
NU-CYCLOBENZAPRINE (EDS)
ALTI-CYCLOBENZAPRINE(EDS)
APO-CYCLOBENZAPRINE (EDS)
PMS-CYCLOBENZAPRINE (EDS)
GEN-CYCLOBENZAPRINE (EDS)
FLEXITEC (EDS)
MED-CYCLOBENZAPRINE (EDS)
DOM-CYCLOBENZAPRINE (EDS)
FLEXERIL (EDS)
DANTROLENE SODIUM
25MG CAPSULE
01997602
DANTRIUM
100MG CAPSULE
01997653
DANTRIUM
33
12:00 AUTONOMIC DRUGS
12:20.00 SKELETAL MUSCLE RELAXANTS
TIZANIDINE HCL
SEE APPENDIX A FOR EDS CRITERIA
4MG TABLET
02239170
ZANAFLEX (EDS)
DPY
34
$
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
AST
$
2.8800
SINTROM
NVR
$
0.1343
SINTROM
NVR
$
0.4221
PHU
$
5.1600
PHU
$
16.2800
PHU
$
37.1100
PHU
$
154.6200
AVT
$
6.5600
AVT
$
21.7000
AVT
$
65.1000
ORG
$
6.0400
IRON SORBITOL
SEE APPENDIX A FOR EDS CRITERIA
50MG/ML INJECTION (2ML)
00001910
JECTOFER (EDS)
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
36
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
COUMADIN
TAR
DUP
$
0.2149
0.3071
TARO-WARFARIN
COUMADIN
TAR
DUP
$
0.2272
0.3247
TARO-WARFARIN
COUMADIN
TAR
DUP
$
0.1821
0.2600
TARO-WARFARIN
COUMADIN
TAR
DUP
$
0.2817
0.4025
TARO-WARFARIN
COUMADIN
TAR
DUP
$
0.2817
0.4026
TARO-WARFARIN
COUMADIN
TAR
DUP
$
0.1823
0.2604
TAR
DUP
$
0.3271
0.4672
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
01918311
* 2MG TABLET
02242681
01918338
* 2.5MG TABLET
02242682
01918346
* 3MG TABLET
02242683
02240205
* 4MG TABLET
02242684
02007959
* 5MG TABLET
02242685
01918354
* 10MG TABLET
02242687
01918362
TARO-WARFARIN
COUMADIN
37
20:00 BLOOD FORMATION AND COAGULATION
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)
JAN
$
15.4700
JAN
$
30.9300
JAN
$
46.3900
JAN
$
61.8500
JAN
$
123.6900
JAN
$
92.7700
JAN
$
138.9500
JAN
$
290.6800
AMG
$
239.4700
SAW
$
2.6057
ALT
APX
NXP
AVT
$
0.4164
0.4164
0.4164
0.6629
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)
FILGRASTIM
SEE APPENDIX A FOR EDS CRITERIA
300UG/ML INJECTION SOLUTION
01968017
NEUPOGEN (EDS)
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
ALBERT PENTOXIFYLLINE
APO-PENTOXIFYLLINE SR
NU-PENTOXIFYLLINE-SR
TRENTAL
38
20:00 BLOOD FORMATION AND COAGULATION
20:24.00 HEMORRHEOLOGIC AGENTS
TICLOPIDINE HCL
SEE APPENDIX A FOR EDS CRITERIA
* 250MG TABLET
02237560
02237701
02194422
02239744
02243327
02162776
NU-TICLOPIDINE (EDS)
APO-TICLOPIDINE (EDS)
ALTI-TICLOPIDINE (EDS)
GEN-TICLOPIDINE (EDS)
PMS-TICLOPIDINE (EDS)
TICLID (EDS)
39
NXP
APX
ALT
GPM
PMS
HLR
$
0.5865 *
0.7471
0.7472
0.7472
0.7472
1.2982
CARDIOVASCULAR DRUGS
24:00
24:00 CARDIOVASCULAR DRUGS
24:04.00 CARDIAC DRUGS
ACEBUTOLOL HCL
* 100MG TABLET
02165546
01910140
02147602
02204517
02237721
02237885
02239754
02239758
01926543
02036290
NU-ACEBUTOLOL
RHOTRAL
APO-ACEBUTOLOL
NOVO-ACEBUTOLOL
GEN-ACEBUTOLOL
GEN-ACEBUTOLOL (TYPE S)
MED-ACEBUTOLOL (TYPE S)
MED-ACEBUTOLOL
SECTRAL
MONITAN
NXP
ROP
APX
NOP
GPM
GPM
MED
MED
AVT
WYA
$
0.0954 *
0.1769
0.1769
0.1769
0.1769
0.1769
0.1769
0.1769
0.2949
0.2949
NXP
ROP
APX
NOP
GPM
GPM
MED
MED
AVT
WYA
$
0.1431 *
0.2648
0.2648
0.2648
0.2648
0.2648
0.2648
0.2648
0.4424
0.4424
ROP
APX
NXP
NOP
GPM
GPM
MED
MED
AVT
WYA
$
0.5260
0.5260
0.5260
0.5260
0.5260
0.5260
0.5260
0.5260
0.8803
0.8803
* 200MG TABLET
02165554
01910159
02147610
02204525
02237722
02237886
02239755
02239759
01926551
02036436
NU-ACEBUTOLOL
RHOTRAL
APO-ACEBUTOLOL
NOVO-ACEBUTOLOL
GEN-ACEBUTOLOL
GEN-ACEBUTOLOL (TYPE S)
MED-ACEBUTOLOL (TYPE S)
MED-ACEBUTOLOL
SECTRAL
MONITAN
* 400MG TABLET
01910167
02147629
02165562
02204533
02237723
02237887
02239756
02239760
01926578
02036444
RHOTRAL
APO-ACEBUTOLOL
NU-ACEBUTOLOL
NOVO-ACEBUTOLOL
GEN-ACEBUTOLOL
GEN-ACEBUTOLOL (TYPE S)
MED-ACEBUTOLOL (TYPE S)
MED-ACEBUTOLOL
SECTRAL
MONITAN
42
24:00 CARDIOVASCULAR DRUGS
24:04.00 CARDIAC DRUGS
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
ALTI-AMIODARONE
CORDARONE
ALT
WYA
$
1.4074
2.4661
PFI
$
1.3333
PFI
$
1.9791
DOM
APX
NXP
NOP
GPM
TCH
MED
RHO
PMS
FTP
AST
$
0.0607 *
0.3814
0.3814
0.3814
0.3814
0.3814
0.3814
0.3814
0.3814
0.3814
0.6054
DOM
APX
NXP
NOP
GPM
TCH
MED
RHO
PMS
FTP
AST
$
0.1094 *
0.6268
0.6268
0.6268
0.6268
0.6268
0.6268
0.6268
0.6268
0.6268
0.9952
AMLODIPINE BESYLATE
5MG TABLET
00878928
NORVASC
10MG TABLET
00878936
NORVASC
ATENOLOL
* 50MG TABLET
02229467
00773689
00886114
01912062
02146894
02171791
02188961
02231731
02237600
02238569
02039532
DOM-ATENOLOL
APO-ATENOL
NU-ATENOL
NOVO-ATENOL
GEN-ATENOLOL
TENOLIN
MED-ATENOLOL
RHOXAL-ATENOLOL
PMS-ATENOLOL
FTP-ATENOLOL
TENORMIN
* 100MG TABLET
02229468
00773697
00886122
01912054
02147432
02171805
02188988
02231733
02237601
02238570
02039540
DOM-ATENOLOL
APO-ATENOL
NU-ATENOL
NOVO-ATENOL
GEN-ATENOLOL
TENOLIN
MED-ATENOLOL
RHOXAL-ATENOLOL
PMS-ATENOLOL
FTP-ATENOLOL
TENORMIN
43
24:00 CARDIOVASCULAR DRUGS
24:04.00 CARDIAC DRUGS
BISOPROLOL FUMARATE
SEE APPENDIX A FOR EDS CRITERIA
5MG TABLET
02241148
MONOCOR (EDS)
BVL
$
0.3798
BVL
$
0.6293
GSK
$
1.3780
GSK
$
1.3780
GSK
$
1.3780
GSK
$
1.3780
VIR
$
0.2164
VIR
$
0.2164
VIR
$
0.2164
VIR
$
0.3539
10MG TABLET
02241149
MONOCOR (EDS)
CAPTOPRIL
SEE SECTION 24:08.00 (HYPOTENSIVE DRUGS)
CARVEDILOL
SEE APPENDIX A FOR EDS CRITERIA
3.125MG TABLET
02229650
COREG (EDS)
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
44
24:00 CARDIOVASCULAR DRUGS
24:04.00 CARDIAC DRUGS
DILTIAZEM HCL
* 30MG TABLET
00886068
00771376
00862924
00888524
02146916
02189038
02097370
NU-DILTIAZ
APO-DILTIAZ
NOVO-DILTAZEM
ALTI-DILTIAZEM
GEN-DILTIAZEM
MED-DILTIAZEM
CARDIZEM
NXP
APX
NOP
ALT
GPM
MED
BVL
$
0.0795 *
0.2252
0.2252
0.2252
0.2252
0.2252
0.4031
NXP
APX
NOP
ALT
GPM
MED
BVL
$
0.1378 *
0.3947
0.3947
0.3947
0.3947
0.3947
0.7070
APX
NOP
GPM
BVL
$
0.3944
0.3944
0.3944
0.7274
APX
NOP
GPM
BVL
$
0.5919
0.5919
0.5919
0.9655
APX
NOP
GPM
BVL
$
0.7888
0.7888
0.7888
1.2807
RHO
ALT
APX
NXP
NOP
BVL
$
0.8703
0.9324
0.9324
0.9324
0.9324
1.3093
BVL
$
0.8773
* 60MG TABLET
00886076
00771384
00862932
00888532
02146924
02189046
02097389
NU-DILTIAZ
APO-DILTIAZ
NOVO-DILTAZEM
ALTI-DILTIAZEM
GEN-DILTIAZEM
MED-DILTIAZEM
CARDIZEM
* 60MG SUSTAINED-RELEASE CAPSULE
02222957
02229406
02231743
02097214
APO-DILTIAZ SR
NOVO-DILTAZEM SR
GEN-DILTIAZEM SR
CARDIZEM-SR
* 90MG SUSTAINED-RELEASE CAPSULE
02222965
02229407
02231744
02097222
APO-DILTIAZ SR
NOVO-DILTAZEM SR
GEN-DILTIAZEM SR
CARDIZEM-SR
* 120MG SUSTAINED-RELEASE CAPSULE
02222973
02229408
02231745
02097230
APO-DILTIAZ SR
NOVO-DILTAZEM SR
GEN-DILTIAZEM SR
CARDIZEM-SR
* 120MG CONTROLLED DELIVERY CAPSULE
02243338
02229781
02230997
02231052
02242538
02097249
RHOXAL-DILTIAZEM CD
ALTI-DILTIAZEM CD
APO-DILTIAZ CD
NU-DILTIAZ-CD
NOVO-DILTAZEM CD
CARDIZEM CD
120MG EXTENDED RELEASE CAPSULE
02231150
TIAZAC
45
24:00 CARDIOVASCULAR DRUGS
24:04.00 CARDIAC DRUGS
* 180MG CONTROLLED DELIVERY CAPSULE
02243339
02229782
02230998
02231053
02242539
02097257
RHOXAL-DILTIAZEM CD
ALTI-DILTIAZEM CD
APO-DILTIAZ CD
NU-DILTIAZ-CD
NOVO-DILTAZEM CD
CARDIZEM CD
RHO
ALT
APX
NXP
NOP
BVL
$
1.1551
1.2377
1.2377
1.2377
1.2377
1.7380
BVL
$
1.1645
RHO
ALT
APX
NXP
NOP
BVL
$
1.5322
1.6416
1.6416
1.6416
1.6416
2.3053
BVL
$
1.5445
RHO
APX
ALT
NOP
BVL
$
1.9153
2.1608
2.1608
2.1608
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
180MG EXTENDED RELEASE CAPSULE
02231151
TIAZAC
* 240MG CONTROLLED DELIVERY CAPSULE
02243340
02229783
02230999
02231054
02242540
02097265
RHOXAL-DILTIAZEM CD
ALTI-DILTIAZEM CD
APO-DILTIAZ CD
NU-DILTIAZ-CD
NOVO-DILTAZEM CD
CARDIZEM CD
240MG EXTENDED RELEASE CAPSULE
02231152
TIAZAC
* 300MG CONTROLLED DELIVERY CAPSULE
02243341
02229526
02229784
02242541
02097273
RHOXAL-DILTIAZEM CD
APO-DILTIAZ CD
ALTI-DILTIAZEM CD
NOVO-DILTAZEM CD
CARDIZEM CD
300MG ENTENDED 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
46
24:00 CARDIOVASCULAR DRUGS
24:04.00 CARDIAC DRUGS
METOPROLOL TARTRATE
* 50MG TABLET
02172550
00618632
00648035
00749354
00842648
00865605
02145413
02174545
02230448
02230803
02239771
02231121
00397423
00402605
DOM-METOPROLOL
APO-METOPROLOL
NOVO-METOPROL
APO-METOPROLOL-TYPE L
NOVO-METOPROL (UNCOATED)
NU-METOP
PMS-METOPROLOL-B
GEN-METOPROLOL (TYPE L)
GEN-METOPROLOL
PMS-METOPROLOL-L
MED-METOPROLOL
DOM-METOPROLOL-L
LOPRESOR
BETALOC
DOM
APX
NOP
APX
NOP
NXP
PMS
GPM
GPM
PMS
MED
DOM
NVR
AST
$
0.0397 *
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
DOM
APX
NOP
APX
NOP
NXP
PMS
GPM
GPM
PMS
MED
DOM
AST
NVR
$
0.0626 *
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
* 100MG TABLET
02172569
00618640
00648043
00751170
00842656
00865613
02145421
02174553
02230449
02230804
02239772
02231122
00402540
00397431
DOM-METOPROLOL
APO-METOPROLOL
NOVO-METOPROL
APO-METOPROLOL-TYPE L
NOVO-METOPROL (UNCOATED)
NU-METOP
PMS-METOPROLOL-B
GEN-METOPROLOL (TYPE L)
GEN-METOPROLOL
PMS-METOPROLOL-L
MED-METOPROLOL
DOM-METOPROLOL-L
BETALOC
LOPRESOR
100MG SUSTAINED RELEASE TABLET
00658855
N
LOPRESOR-SR
200MG SUSTAINED RELEASE TABLET
00497827
00534560
BETALOC DURULES
LOPRESOR-SR
47
24:00 CARDIOVASCULAR DRUGS
24:04.00 CARDIAC DRUGS
MEXILETINE HCL
* 100MG CAPSULE
02230359
00599956
NOVO-MEXILETINE
MEXITIL
NOP
BOE
$
0.3785
0.5407
NOP
BOE
$
0.5068
0.7241
PPZ
APX
ALT
NOP
$
0.2675
0.2675
0.2675
0.2675
PPZ
APX
ALT
NOP
$
0.3814
0.3814
0.3814
0.3814
PPZ
APX
ALT
$
0.7156
0.7156
0.7156
APX
NOP
PMS
$
0.2648
0.2648
0.2648
APX
NOP
NXP
PMS
DOM
$
0.2016
0.2016
0.2016
0.2016
0.2117
APX
NXP
BAY
$
0.2436
0.2436
0.5569
* 200MG CAPSULE
02230360
00599964
NOVO-MEXILETINE
MEXITIL
NADOLOL
* 40MG TABLET
00607126
00782505
00851663
02126753
CORGARD
APO-NADOL
ALTI-NADOLOL
NOVO-NADOLOL
* 80MG TABLET
00463256
00782467
00851671
02126761
CORGARD
APO-NADOL
ALTI-NADOLOL
NOVO-NADOLOL
* 160MG TABLET
00523372
00782475
00851698
CORGARD
APO-NADOL
ALTI-NADOLOL
NIFEDIPINE
* 5MG CAPSULE
00725110
02047462
02235897
APO-NIFED
NOVO-NIFEDIN
PMS-NIFEDIPINE
* 10MG CAPSULE
00755907
00756830
00865591
02235898
02236758
APO-NIFED
NOVO-NIFEDIN
NU-NIFED
PMS-NIFEDIPINE
DOM-NIFEDIPINE
* 10MG SUSTAINED RELEASE TABLET
02197448
02212102
02155885
APO-NIFED PA
NU-NIFEDIPINE-PA
ADALAT PA
48
24:00 CARDIOVASCULAR DRUGS
24:04.00 CARDIAC DRUGS
* 20MG SUSTAINED RELEASE TABLET
02181525
02200937
02155893
APO-NIFED PA
NU-NIFEDIPINE-PA
ADALAT PA
APX
NXP
BAY
$
0.4232
0.4232
0.8708
BAY
$
0.8138
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
$
0.0871 *
0.2477
0.2477
0.2477
0.2477
0.2477
0.2601
0.4492
NXP
APX
NOP
GPM
MED
PMS
DOM
NVR
$
0.1600 *
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
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
* 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
* 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
49
24:00 CARDIOVASCULAR DRUGS
24:04.00 CARDIAC DRUGS
PROCAINAMIDE HCL
* 250MG CAPSULE
00029076
00713325
PRONESTYL
APO-PROCAINAMIDE
SQU
APX
$
0.1913
0.1913
SQU
APX
$
0.2497
0.2497
SQU
APX
$
0.3321
0.3321
PFI
$
0.1628
PFI
SQU
$
0.3255
0.5122
PFI
$
0.4883
APX
KNO
$
0.7395
0.9713
APX
KNO
$
1.3037
1.7121
DOM
APX
PMS
NOP
WYA
$
0.0164 *
0.0209
0.0209
0.0261
0.0883
APX
NOP
NXP
$
0.0376
0.0376
0.0376
* 375MG CAPSULE
00296031
00713333
PRONESTYL
APO-PROCAINAMIDE
* 500MG CAPSULE
00353523
00713341
PRONESTYL
APO-PROCAINAMIDE
250MG SUSTAINED RELEASE TABLET
00638692
N
PROCAN-SR
500MG SUSTAINED RELEASE TABLET
00638676
00639885
PROCAN-SR
PRONESTYL-SR
750MG SUSTAINED RELEASE TABLET
00638684
PROCAN-SR
PROPAFENONE HCL
* 150MG TABLET
02243324
00603708
APO-PROPAFENONE
RYTHMOL
* 300MG TABLET
02243325
00603716
APO-PROPAFENONE
RYTHMOL
PROPRANOLOL
* 10MG TABLET
02137313
00402788
00582255
00496480
02042177
DOM-PROPRANOLOL
APO-PROPRANOLOL
PMS-PROPRANOLOL
NOVO-PRANOL
INDERAL
* 20MG TABLET
00663719
00740675
02044692
APO-PROPRANOLOL
NOVO-PRANOL
NU-PROPRANOLOL
50
24:00 CARDIOVASCULAR DRUGS
24:04.00 CARDIAC DRUGS
* 40MG TABLET
02137321
00402753
00496499
00582263
02044706
02042207
DOM-PROPRANOLOL
APO-PROPRANOLOL
NOVO-PRANOL
PMS-PROPRANOLOL
NU-PROPRANOLOL
INDERAL
DOM
APX
NOP
PMS
NXP
WYA
$
0.0282 *
0.0378
0.0378
0.0378
0.0378
0.1574
APX
NOP
PMS
DOM
WYA
$
0.0635
0.0635
0.0635
0.0667
0.2207
APX
NOP
$
0.1149
0.1149
WYA
$
0.4532
WYA
$
0.6066
WYA
$
0.8685
WYA
$
1.1001
AST
$
0.4449
WYA
$
0.5525
* 80MG TABLET
00402761
00496502
00582271
02137348
02042215
APO-PROPRANOLOL
NOVO-PRANOL
PMS-PROPRANOLOL
DOM-PROPRANOLOL
INDERAL
* 120MG TABLET
00504335
00549657
APO-PROPRANOLOL
NOVO-PRANOL
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
300MG SUSTAINED RELEASE TABLET
02043505
QUINIDEX EXTENTABS
51
24:00 CARDIOVASCULAR DRUGS
24:04.00 CARDIAC DRUGS
SOTALOL HCL
* 80MG TABLET
02238634
00897272
02084228
02170833
02200996
02210428
02229778
02231181
02234008
02237269
02238326
02238417
DOM-SOTALOL
SOTACOR
ALTI-SOTALOL
LINSOTALOL
NU-SOTALOL
APO-SOTALOL
GEN-SOTALOL
NOVO-SOTALOL
RHOXAL-SOTALOL
MED-SOTALOL
PMS-SOTALOL
SOTAMOL
DOM
BRI
ALT
LIN
NXP
APX
GPM
NOP
RHO
MED
PMS
TCH
$
0.1834 *
0.6437
0.6437
0.6437
0.6437
0.6437
0.6437
0.6437
0.6437
0.6437
0.6437
0.6437
DOM
BRI
ALT
NXP
APX
LIN
GPM
NOP
RHO
MED
PMS
TCH
$
0.2423 *
0.7044
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
02238415
DOM-SOTALOL
SOTACOR
ALTI-SOTALOL
NU-SOTALOL
APO-SOTALOL
LINSOTALOL
GEN-SOTALOL
NOVO-SOTALOL
RHOXAL-SOTALOL
MED-SOTALOL
PMS-SOTALOL
SOTAMOL
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)
52
24:00 CARDIOVASCULAR DRUGS
24:06.00 ANTILIPEMIC DRUGS
ATORVASTATIN CALCIUM
10MG TABLET
02230711
LIPITOR
PFI
$
1.7360
PFI
$
2.1700
PFI
$
2.3328
PMS
$
0.6710
HLR
$
1.7360
BAY
$
1.3020
BAY
$
1.5733
BAY
$
1.7360
BAY
$
2.1700
BRI
NOP
PMS
$
0.6952
0.6952
0.6952
PMS
BRI
NOP
$
0.6952
0.6952
0.6952
20MG TABLET
02230713
LIPITOR
40MG TABLET
02230714
LIPITOR
BEZAFIBRATE
SEE APPENDIX A FOR EDS CRITERIA
200MG TABLET
02240331
PMS-BEZAFIBRATE (EDS)
400MG SUSTAINED RELEASE TABLET
02083523
BEZALIP SR (EDS)
CERIVASTATIN SODIUM
0.2MG TABLET
02237325
BAYCOL
0.3MG TABLET
02237326
BAYCOL
0.4MG TABLET
02241466
BAYCOL
0.8MG TABLET
02243223
BAYCOL
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
53
24:00 CARDIOVASCULAR DRUGS
24:06.00 ANTILIPEMIC DRUGS
COLESTIPOL HCL RESIN
5G GRANULES
00642975
COLESTID
PHU
$
0.8880
COLESTID
PHU
$
0.8880
COLESTID
PHU
$
0.2533
NXP
APX
$
0.4693
0.4693
PMS
APX
GPM
DOM
FFR
$
1.3129
1.3129
1.3129
1.3785
1.8771
NVR
$
0.8138
NVR
$
1.1393
DOM
ALT
APX
NXP
GPM
PMS
NOP
PFI
$
0.1533 *
0.3216
0.3216
0.3216
0.3216
0.3216
0.3216
0.5375
7.5G GRANULES
02132699
1G TABLET
02132680
FENOFIBRATE
SEE APPENDIX A FOR EDS CRITERIA
* 100MG CAPSULE
02223600
02225980
NU-FENOFIBRATE (EDS)
APO-FENOFIBRATE (EDS)
* 200MG CAPSULE
02231780
02239864
02240210
02240337
02146959
PMS-FENOFIBR. MICRO (EDS)
APO-FENO-MICRO (EDS)
GEN-FENOFIBR. MICRO (EDS)
DOM-FENOFIBR. MICRO (EDS)
LIPIDIL-MICRO (EDS)
FLUVASTATIN SODIUM
20MG CAPSULE
02061562
LESCOL
40MG CAPSULE
02061570
LESCOL
GEMFIBROZIL
* 300MG CAPSULE
02241608
00851922
01979574
02058456
02185407
02239951
02241704
00599026
DOM-GEMFIBROZIL
GEMFIBROZIL
APO-GEMFIBROZIL
NU-GEMFIBROZIL
GEN-GEMFIBROZIL
PMS-GEMFIBROZIL
NOVO-GEMFIBROZIL
LOPID
54
24:00 CARDIOVASCULAR DRUGS
24:06.00 ANTILIPEMIC DRUGS
* 600MG TABLET
02230580
00851930
01979582
02058464
02142074
02230183
02230476
02237292
00659606
DOM-GEMFIBROZIL
GEMFIBROZIL
APO-GEMFIBROZIL
NU-GEMFIBROZIL
NOVO-GEMFIBROZIL
PMS-GEMFIBROZIL
GEN-GEMFIBROZIL
MED-GEMFIBROZIL
LOPID
DOM
ALT
APX
NXP
NOP
PMS
GPM
MED
PFI
$
0.2131 *
0.8160
0.8160
0.8160
0.8160
0.8160
0.8160
0.8160
1.0760
APX
GPM
MSD
$
1.5028
1.5028
1.8786
APX
GPM
MSD
$
2.7717
2.7719
3.4649
BMI
LIN
SQU
$
0.7219 *
1.1491
1.6421
BMI
LIN
SQU
$
0.9682 *
1.3560
1.9368
BMI
LIN
SQU
$
1.4360 *
1.6330
2.3328
LOVASTATIN
* 20MG TABLET
02220172
02243127
00795860
APO-LOVASTATIN
GEN-LOVASTATIN
MEVACOR
* 40MG TABLET
02220180
02243129
00795852
APO-LOVASTATIN
GEN-LOVASTATIN
MEVACOR
PRAVASTATIN
* 10MG TABLET
02242865
02237373
00893749
BIOPRAVASTATIN
LIN-PRAVASTATIN
PRAVACHOL
* 20MG TABLET
02242866
02237374
00893757
BIOPRAVASTATIN
LIN-PRAVASTATIN
PRAVACHOL
* 40MG TABLET
02242867
02237375
02222051
BIOPRAVASTATIN
LIN-PRAVASTATIN
PRAVACHOL
55
24:00 CARDIOVASCULAR DRUGS
24:06.00 ANTILIPEMIC DRUGS
SIMVASTATIN
5MG TABLET
00884324
ZOCOR
MSD
$
0.9765
MSD
$
1.9313
MSD
$
2.3870
MSD
$
2.3870
MSD
$
2.3870
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 THERAP
OF HYPERTENSION. HYPERTENSION REQUIRES THERAPY TO BE TITRATE
TO THE INDIVIDUAL PATIENT. IF THE FIXED COMBINATIO
REPRESENTS THE DOSAGE SO DETERMINED, ITS USE MAY BE MORE
CONVENIENT IN PATIENT MANAGEMENT. THE TREATMENT O
HYPERTENSION IS NOT STATIC, BUT MUST BE RE-EVALUATED A
CONDITIONS IN EACH PATIENT WARRANT
ACEBUTOLOL HCL
SEE SECTION 24:04.00 (CARDIAC DRUGS)
AMILORIDE HCL/HYDROCHLOROTHIAZIDE
SEE NOTE REGARDING COMBINATION PRODUCTS UNDER
SECTION 24:08.00 (HYPOTENSIVE DRUGS)
* 5MG/50MG TABLET
00886106
00784400
01937219
02174596
00487813
NU-AMILZIDE
APO-AMILZIDE
NOVAMILOR
ALTI-AMILORIDE HCTZ
MODURET
ATENOLOL
SEE SECTION 24:04.00 (CARDIAC DRUGS)
56
NXP
APX
NOP
ALT
MSD
$
0.1458 *
0.2080
0.2080
0.2080
0.3816
24:00 CARDIOVASCULAR DRUGS
24:08.00 HYPOTENSIVE DRUGS
ATENOLOL/CHLORTHALIDONE
SEE NOTE REGARDING COMBINATION PRODUCTS UNDER
SECTION 24:08.00 (HYPOTENSIVE DRUGS)
50MG/25MG TABLET
02049961
TENORETIC
AST
$
0.6732
AST
$
1.1033
NVR
$
0.6239
NVR
$
0.7378
NVR
$
0.8463
AST
$
1.1718
AST
$
1.1718
APX
$
0.1297
DOM
SQU
ALT
APX
NXP
NOP
GPM
MED
PMS
TCH
FTP
ZYP
$
0.0369 *
0.2301
0.2301
0.2301
0.2301
0.2301
0.2301
0.2301
0.2301
0.2301
0.2301
0.2301
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
CAPTOPRIL
6.25MG TABLET
01999559
APO-CAPTO
* 12.5MG TABLET
02238551
00695661
00851639
00893595
01913824
01942964
02163551
02188929
02230203
02237861
02238449
02242788
DOM-CAPTOPRIL
CAPOTEN
ALTI-CAPTOPRIL
APO-CAPTO
NU-CAPTO
NOVO-CAPTORIL
GEN-CAPTOPRIL
MED-CAPTOPRIL
PMS-CAPTOPRIL
CAPTRIL
FTP-CAPTOPRIL
CAPTOPRIL
57
24:00 CARDIOVASCULAR DRUGS
24:08.00 HYPOTENSIVE DRUGS
* 25MG TABLET
02238552
00546283
00851833
00893609
01913832
01942972
02163578
02188937
02230204
02237862
02238450
02242789
DOM-CAPTOPRIL
CAPOTEN
ALTI-CAPTOPRIL
APO-CAPTO
NU-CAPTO
NOVO-CAPTORIL
GEN-CAPTOPRIL
MED-CAPTOPRIL
PMS-CAPTOPRIL
CAPTRIL
FTP-CAPTOPRIL
CAPTOPRIL
DOM
SQU
ALT
APX
NXP
NOP
GPM
MED
PMS
TCH
FTP
ZYP
$
0.0456 *
0.3255
0.3255
0.3255
0.3255
0.3255
0.3255
0.3255
0.3255
0.3255
0.3255
0.3255
DOM
SQU
ALT
APX
NXP
NOP
GPM
MED
PMS
TCH
FTP
ZYP
$
0.0789 *
0.6066
0.6066
0.6066
0.6066
0.6066
0.6066
0.6066
0.6066
0.6066
0.6066
0.6066
CAPOTEN
ALTI-CAPTOPRIL
APO-CAPTO
NU-CAPTO
NOVO-CAPTORIL
GEN-CAPTOPRIL
MED-CAPTOPRIL
PMS-CAPTOPRIL
CAPTOPRIL
DOM-CAPTOPRIL
SQU
ALT
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
* 50MG TABLET
02238553
00546291
00851647
00893617
01913840
01942980
02163586
02188945
02230205
02237863
02238451
02242790
DOM-CAPTOPRIL
CAPOTEN
ALTI-CAPTOPRIL
APO-CAPTO
NU-CAPTO
NOVO-CAPTORIL
GEN-CAPTOPRIL
MED-CAPTOPRIL
PMS-CAPTOPRIL
CAPTRIL
FTP-CAPTOPRIL
CAPTOPRIL
* 100MG TABLET
00546305
00851655
00893625
01913859
01942999
02163594
02188953
02230206
02242791
02238554
CILAZAPRIL
1MG TABLET
01911465
2.5MG TABLET
01911473
5MG TABLET
01911481
58
24:00 CARDIOVASCULAR DRUGS
24:08.00 HYPOTENSIVE DRUGS
CILAZAPRIL/HYDROCHLOROTHIAZIDE
SEE NOTE REGARDING COMBINATION PRODUCTS UNDER
SECTION 24:08.00 (HYPOTENSIVE DRUGS)
5MG/12.5MG TABLET
02181479
INHIBACE PLUS
HLR
$
0.8572
BOE
$
0.2059
BOE
APX
NXP
NOP
$
0.1915
0.1915
0.1915
0.1915
BOE
APX
NXP
NOP
$
0.3417
0.3417
0.3417
0.3417
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)
59
24:00 CARDIOVASCULAR DRUGS
24:08.00 HYPOTENSIVE DRUGS
DOXAZOSIN MESYLATE
* 1MG TABLET
02240498
02240588
02242728
01958100
GEN-DOXAZOSIN
APO-DOXAZOSIN
NOVO-DOXAZOSIN
CARDURA-1
GPM
APX
NOP
AST
$
0.3760
0.3760
0.3760
0.5968
GEN-DOXAZOSIN
APO-DOXAZOSIN
NOVO-DOXAZOSIN
CARDURA-2
GPM
APX
NOP
AST
$
0.4512
0.4512
0.4512
0.7161
GEN-DOXAZOSIN
APO-DOXAZOSIN
NOVO-DOXAZOSIN
CARDURA-4
GPM
APX
NOP
AST
$
0.5865
0.5865
0.5865
0.9310
VASOTEC
MSD
$
0.7327
VASOTEC
MSD
$
0.8666
MSD
$
1.0416
MSD
$
1.2568
MSD
$
1.0416
SLV
$
0.5534
SLV
$
1.1067
* 2MG TABLET
02240499
02240589
02242729
01958097
* 4MG TABLET
02240500
02240590
02242730
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)
10MG/25MG TABLET
00657298
VASERETIC
EPROSARTAN MESYLATE
300MG TABLET
02240431
TEVETEN
400MG TABLET
02240432
TEVETEN
60
24:00 CARDIOVASCULAR DRUGS
24:08.00 HYPOTENSIVE DRUGS
FELODIPINE
* 2.5MG SUSTAINED RELEASE TABLET
02221985
02057778
RENEDIL
PLENDIL
AVT
AST
$
0.5357
0.5359
AST
AVT
$
0.7161
0.7161
AVT
AST
$
1.0706
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
BMY
$
1.1718
BMY
$
1.1718
BMY
$
1.1718
* 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
IRBESARTAN
75MG TABLET
02237923
AVAPRO
150MG TABLET
02237924
AVAPRO
300MG TABLET
02237925
AVAPRO
61
24:00 CARDIOVASCULAR DRUGS
24:08.00 HYPOTENSIVE DRUGS
IRBESARTAN/HYDROCHLOROTHIAZIDE
SEE NOTE REGARDING COMBINATION PRODUCTS UNDER
SECTION 24:08.00 (HYPOTENSIVE DRUGS)
150MG/12.5MG TABLET
02241818
AVALIDE
BMY
$
1.1718
BMY
$
1.1718
RBP
$
0.2553
TRANDATE
RBP
$
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
AST
MSD
$
0.8782
0.8782
MSD
AST
$
1.0551
1.0551
MSD
AST
$
1.0551
1.0551
300MG/12.5MG TABLET
02241819
AVALIDE
LABETALOL HCL
100MG TABLET
02106272
TRANDATE
200MG TABLET
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
LISINOPRIL/HYDROCHLOROTHIAZIDE
SEE NOTE REGARDING COMBINATION PRODUCTS UNDER
SECTION 24:08.00 (HYPOTENSIVE DRUGS)
* 10MG/12.5MG TABLET
02103729
02108194
ZESTORETIC
PRINZIDE
* 20MG/12.5MG TABLET
00884413
02045737
PRINZIDE
ZESTORETIC
* 20MG/25MG TABLET
00884421
02045729
PRINZIDE
ZESTORETIC
62
24:00 CARDIOVASCULAR DRUGS
24:08.00 HYPOTENSIVE DRUGS
LOSARTAN POTASSIUM
25MG TABLET
02182815
COZAAR
MSD
$
1.1940
MSD
$
1.1940
MSD
$
1.1940
MSD
$
1.1940
MSD
$
1.1935
APX
$
0.0641
NXP
APX
$
0.0841
0.1009
NXP
APX
$
0.1601
0.1921
NOP
APX
$
0.0736
0.0736
NOP
APX
$
0.0761
0.0761
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
00717509
00360260
NU-MEDOPA
APO-METHYLDOPA
* 500MG TABLET
00717576
00426830
NU-MEDOPA
APO-METHYLDOPA
METHYLDOPA/HYDROCHLOROTHIAZIDE
SEE NOTE REGARDING COMBINATION PRODUCTS UNDER
SECTION 24:08.00 (HYPOTENSIVE DRUGS)
* 250MG/15MG TABLET
00363642
00441708
NOVO-DOPARIL
APO-METHAZIDE-15
* 250MG/25MG TABLET
00363634
00441716
NOVO-DOPARIL
APO-METHAZIDE-25
METOPROLOL TARTRATE
SEE SECTION 24:04.00 (CARDIAC DRUGS)
63
24:00 CARDIOVASCULAR DRUGS
24:08.00 HYPOTENSIVE 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
64
24:00 CARDIOVASCULAR DRUGS
24:08.00 HYPOTENSIVE DRUGS
PRAZOSIN
* 1MG TABLET
00882801
01913794
01934198
02139979
00560952
APO-PRAZO
NU-PRAZO
NOVO-PRAZIN
ALTI-PRAZOSIN
MINIPRESS
APX
NXP
NOP
ALT
PFI
$
0.1683
0.1683
0.1683
0.1683
0.2960
APO-PRAZO
NU-PRAZO
NOVO-PRAZIN
ALTI-PRAZOSIN
MINIPRESS
APX
NXP
NOP
ALT
PFI
$
0.2275
0.2275
0.2275
0.2275
0.4021
APO-PRAZO
NU-PRAZO
NOVO-PRAZIN
ALTI-PRAZOSIN
MINIPRESS
APX
NXP
NOP
ALT
PFI
$
0.3284
0.3284
0.3284
0.3284
0.5527
WYA
$
0.5672
WYA
$
0.8781
PFI
$
0.8915
PFI
$
0.8915
PFI
$
0.8915
PFI
$
0.8915
* 2MG TABLET
00882828
01913808
01934201
02139987
00560960
* 5MG TABLET
00882836
01913816
01934228
02139995
00560979
PROPRANOLOL
SEE SECTION 24:04.00 (CARDIAC DRUGS)
PROPRANOLOL/HYDROCHLOROTHIAZIDE
SEE NOTE REGARDING COMBINATION PRODUCTS UNDER
SECTION 24:08.00 (HYPOTENSIVE DRUGS)
40MG/25MG TABLET
02042282
INDERIDE-40
80MG/25MG TABLET
02042290
INDERIDE-80
QUINAPRIL HCL
5MG TABLET
01947664
ACCUPRIL
10MG TABLET
01947672
ACCUPRIL
20MG TABLET
01947680
ACCUPRIL
40MG TABLET
01947699
ACCUPRIL
65
24:00 CARDIOVASCULAR DRUGS
24:08.00 HYPOTENSIVE DRUGS
QUINAPRIL HCL/HYDROCHLOROTHIAZIDE
SEE NOTE REGARDING COMBINATION PRODUCTS UNDER
SECTION 24:08.00 (HYPOTENSIVE DRUGS)
10MG/12.5MG TABLET
02237367
ACCURETIC
PFI
$
0.8914
PFI
$
0.8914
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
20MG/12.5MG TABLET
02237368
ACCURETIC
RAMIPRIL
1.25MG CAPSULE
02221829
ALTACE
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
66
24:00 CARDIOVASCULAR DRUGS
24:08.00 HYPOTENSIVE DRUGS
TERAZOSIN HCL
* 1MG TABLET
02218941
02230805
02233047
02234502
02243518
00818658
ALTI-TERAZOSIN
NOVO-TERAZOSIN
NU-TERAZOSIN
APO-TERAZOSIN
PMS-TERAZOSIN
HYTRIN
ALT
NOP
NXP
APX
PMS
ABB
$
0.3787
0.3787
0.3787
0.3787
0.3787
0.6011
ALTI-TERAZOSIN
NOVO-TERAZOSIN
NU-TERAZOSIN
APO-TERAZOSIN
PMS-TERAZOSIN
HYTRIN
ALT
NOP
NXP
APX
PMS
ABB
$
0.4813
0.4813
0.4813
0.4813
0.4813
0.7641
ALTI-TERAZOSIN
NOVO-TERAZOSIN
NU-TERAZOSIN
APO-TERAZOSIN
PMS-TERAZOSIN
HYTRIN
ALT
NOP
NXP
APX
PMS
ABB
$
0.6538
0.6538
0.6538
0.6538
0.6538
1.0377
ALT
NOP
NXP
APX
PMS
ABB
$
0.9570
0.9570
0.9570
0.9570
0.9570
1.5190
ABB
$
24.0900
MSD
$
0.4654
* 2MG TABLET
02218968
02230806
02233048
02234503
02243519
00818682
* 5MG TABLET
02218976
02230807
02233049
02234504
02243520
00818666
* 10MG TABLET
02218984
02230808
02233050
02234505
02243521
00818674
ALTI-TERAZOSIN
NOVO-TERAZOSIN
NU-TERAZOSIN
APO-TERAZOSIN
PMS-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
67
24:00 CARDIOVASCULAR DRUGS
24:08.00 HYPOTENSIVE DRUGS
TRANDOLAPRIL
0.5MG CAPSULE
02231457
MAVIK
KNO
$
0.6727
KNO
$
0.7812
KNO
$
0.8897
NXP
APX
NOP
$
0.0350 *
0.0518
0.0518
NVR
$
1.1393
NVR
$
1.1393
NVR
$
1.1393
NVR
$
1.1393
NXP
APX
NOP
ALT
GPM
MED
KNO
$
0.1655 *
0.2968
0.2968
0.2968
0.2968
0.2968
0.3043
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
00886033
00782483
00812331
00867365
02237921
02239769
00554316
NU-VERAP
APO-VERAP
NOVO-VERAMIL
ALTI-VERAPAMIL
GEN-VERAPAMIL
MED-VERAPAMIL
ISOPTIN
68
24:00 CARDIOVASCULAR DRUGS
24:08.00 HYPOTENSIVE DRUGS
* 120MG TABLET
00886041
00782491
00812358
00867373
02237922
02239770
00554324
NU-VERAP
APO-VERAP
NOVO-VERAMIL
ALTI-VERAPAMIL
GEN-VERAPAMIL
MED-VERAPAMIL
ISOPTIN
NXP
APX
NOP
ALT
GPM
MED
KNO
$
0.2570 *
0.4612
0.4612
0.4612
0.4612
0.4612
0.4728
WYA
$
0.7487
GPM
KNO
$
0.7487
1.1038
PHU
$
0.8463
WYA
$
0.8463
GPM
KNO
$
0.8463
1.2466
PHU
$
0.9462
WYA
$
0.9462
DOM
GPM
NOP
PMS
KNO
$
0.7800 *
0.9462
0.9462
0.9462
1.6624
SLV
$
0.2546
120MG SUSTAINED RELEASE CAPSULE
02100479
VERELAN
* 120MG SUSTAINED RELEASE TABLET
02210347
01907123
GEN-VERAPAMIL SR
ISOPTIN SR
180MG CONTROLLED-ONSET EXTENDED-RELEASE
TABLET
02231676
CHRONOVERA
180MG SUSTAINED RELEASE CAPSULE
02100487
VERELAN
* 180MG SUSTAINED RELEASE TABLET
02210355
01934317
GEN-VERAPAMIL SR
ISOPTIN SR
240MG CONTROLLED-ONSET EXTENDED-RELEASE
TABLET
02231677
CHRONOVERA
240MG SUSTAINED RELEASE CAPSULE
02100495
VERELAN
* 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
69
24:00 CARDIOVASCULAR DRUGS
24:12.00 VASODILATING DRUGS
DIPYRIDAMOLE
SEE APPENDIX A FOR EDS CRITERIA
25MG TABLET
00067385
PERSANTINE (EDS)
BOE
$
0.3008
BOE
$
0.4008
BOE
$
0.5398
BOE
$
0.6325
BOE
$
0.9124
APX
NOP
WYA
$
0.0174
0.0174
0.0565
APX
NOP
WYA
$
0.0375
0.0375
0.1324
APX
WYA
$
0.0363
0.0403
WYA
$
0.5154
AST
$
0.6944
BAY
$
5.7574
50MG TABLET
00067393
PERSANTINE (EDS)
75MG TABLET
00452092
PERSANTINE (EDS)
100MG TABLET
00452106
PERSANTINE (EDS)
DIPYRIDAMOLE/ACETYLSALICYLIC ACID
SEE APPENDIX A FOR EDS CRITERIA
200MG/25MG CAPSULE
02242119
AGGRENOX (EDS)
ISOSORBIDE DINITRATE
* 10MG TABLET
00441686
00458686
02042622
APO-ISDN
NOVO-SORBIDE
ISORDIL
* 30MG TABLET
00441694
00458694
02042614
APO-ISDN
NOVO-SORBIDE
ISORDIL
* 5MG SUBLINGUAL TABLET
00670944
02042606
APO-ISDN
ISORDIL
ISOSORBIDE-5 MONONITRATE
20MG TABLET
02058472
ISMO
60MG EXTENDED-RELEASE TABLET
02126559
IMDUR
NIMODIPINE
SEE APPENDIX A FOR EDS CRITERIA
30MG CAPSULE
02155923
NIMOTOP (EDS)
70
24:00 CARDIOVASCULAR DRUGS
24:12.00 VASODILATING DRUGS
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).
N
0.2MG/HR. TRANSDERMAL THERAPEUTIC SYSTEM
00584223
01911910
02162806
02230732
N
NVR
KEY
MDA
SAW
$
0.6149
0.6149
0.6149
0.6149
$
0.6944
0.6944
0.6944
0.6944
KEY
NVR
MDA
SAW
$
0.6944
0.6944
0.6944
0.6944
KEY
$
1.2044
PFI
$
0.0290
PFI
$
0.0302
PMS
$
0.2105
AVT
$
13.1200
0.4MG/HR. TRANSDERMAL THERAPEUTIC SYSTEM
00852384
01911902
02163527
02230733
N
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
NVR
KEY
MDA
SAW
0.6MG/HR. TRANSDERMAL THERAPEUTIC SYSTEM
01911929
02046156
02163535
02230734
NITRO-DUR 0.6
TRANSDERM-NITRO 0.6
MINITRAN 0.6
TRINIPATCH 0.6
0.8MG/HR. TRANSDERMAL THERAPEUTIC SYSTEM
02011271
NITRO-DUR 0.8
0.3MG SUBLINGUAL TABLET
00037613
NITROSTAT
0.6MG SUBLINGUAL TABLET
00037621
NITROSTAT
2% OINTMENT
01926454
NITROL
0.4MG/DOSE LINGUAL SPRAY (PACKAGE)
02231441
NITROLINGUAL PUMPSPRAY
71
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
JJM
JJM
$
0.0160
0.0160
0.0546
JJM
NOP
JJM
$
0.0263
0.0382
0.0936
PHU
$
0.6782
PHU
$
1.3563
NXP
NOP
APX
PMS
DOM
NVR
$
0.0965 *
0.2064
0.2064
0.2064
0.2293
0.3391
NXP
NOP
APX
PMS
DOM
NVR
$
0.2067 *
0.4272
0.4272
0.4272
0.4585
0.7155
NXP
NOP
APX
PMS
DOM
NVR
$
0.4134 *
0.6191
0.6191
0.6191
0.6877
1.0055
NXP
NOP
APX
PMS
DOM
NVR
$
0.5724 *
0.8544
0.8544
0.8544
0.9169
1.4332
* 650MG ENTERIC TABLET
02046261
00229296
00010340
MSD ENTERIC-COATED ASA
NOVASEN
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
02158582
02162814
02231504
02231664
00782459
NU-DICLO-SR
NOVO-DIFENAC SR
APO-DICLO SR
PMS-DICLOFENAC-SR
DOM-DICLOFENAC SR
VOLTAREN-SR
* 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
74
28:00 CENTRAL NERVOUS SYSTEM DRUGS
28:08.04 NON-STEROIDAL ANTI-INFLAMMATORY AGENTS
* 50MG SUPPOSITORY
02174677
02231506
02237786
02241224
00632724
NOVO-DIFENAC
PMS-DICLOFENAC
DICLOTEC
SAB-DICLOFENAC
VOLTAREN
NOP
PMS
TCH
SAB
NVR
$
0.6768
0.6768
0.6768
0.6768
1.0742
NOP
PMS
TCH
SAB
NVR
$
0.9111
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
GPM
TAR
PGA
$
0.6510
0.6510
0.6510
0.8680
APX
GPM
TAR
PGA
$
0.6510
0.6510
0.6510
0.8680
LIL
$
0.5628
* 100MG SUPPOSITORY
02174685
02231508
02237787
02241225
00632732
NOVO-DIFENAC
PMS-DICLOFENAC
DICLOTEC
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
02239319
02242914
02142023
APO-ETODOLAC (EDS)
GEN-ETODOLAC (EDS)
TARO-ETODOLAC (EDS)
ULTRADOL (EDS)
* 300MG CAPSULE
02232318
02239320
02242915
02142031
APO-ETODOLAC (EDS)
GEN-ETODOLAC (EDS)
TARO-ETODOLAC (EDS)
ULTRADOL (EDS)
FENOPROFEN
600MG TABLET
00345504
NALFON
75
28:00 CENTRAL NERVOUS SYSTEM DRUGS
28:08.04 NON-STEROIDAL ANTI-INFLAMMATORY AGENTS
FLURBIPROFEN
* 50MG TABLET
00675202
01912046
02020661
02100509
00647942
ALTI-FLURBIPROFEN
APO-FLURBIPROFEN
NU-FLURBIPROFEN
NOVO-FLURPROFEN
ANSAID
ALT
APX
NXP
NOP
PHU
$
0.2782
0.2782
0.2782
0.2782
0.5346
ALT
APX
NXP
NOP
PHU
$
0.3807
0.3807
0.3807
0.3807
0.6999
APX
NOP
NXP
MCL
$
0.0309
0.0309
0.0309
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
TCH
FTP
$
0.0945
0.0945
0.0945
0.0945
0.0945
NOP
APX
NXP
TCH
FTP
$
0.1640
0.1640
0.1640
0.1640
0.1640
* 100MG TABLET
00675199
01912038
02020688
02100517
00600792
ALTI-FLURBIPROFEN
APO-FLURBIPROFEN
NU-FLURBIPROFEN
NOVO-FLURPROFEN
ANSAID
IBUPROFEN
* 300MG TABLET
00441651
00629332
02020696
00327794
APO-IBUPROFEN
NOVO-PROFEN
NU-IBUPROFEN
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
02238442
NOVO-METHACIN
APO-INDOMETHACIN
NU-INDO
INDOTEC
FTP-INDOMETHACIN
* 50MG CAPSULE
00337439
00611166
00865869
02143372
02238443
NOVO-METHACIN
APO-INDOMETHACIN
NU-INDO
INDOTEC
FTP-INDOMETHACIN
76
28:00 CENTRAL NERVOUS SYSTEM DRUGS
28:08.04 NON-STEROIDAL ANTI-INFLAMMATORY AGENTS
* 50MG SUPPOSITORY
02146932
02176130
02231799
00594466
RHODACINE
NOVO-METHACIN
SAB-INDOMETHACIN
INDOCID
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
AVT
$
0.3340
0.3340
0.7793
ROP
APX
AVT
$
0.6680
0.6680
1.5864
AVT
$
0.7831
PMS
NOP
TCH
AVT
$
1.0774
1.0774
1.0774
1.5947
APX
NXP
PMS
DOM
PFI
$
0.3590
0.3590
0.3590
0.4484
0.6115
* 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
01926365
RHODIS EC
PMS-KETOPROFEN-EC
ORUDIS-E
* 200MG SUSTAINED RELEASE TABLET
02031175
02172577
01926373
RHODIS SR
APO-KETOPROFEN SR
ORUDIS SR
50MG SUPPOSITORY
01931512
ORUDIS
* 100MG SUPPOSITORY
02015951
02156083
02165481
01926411
PMS-KETOPROFEN
NOVO-KETO
ORAFEN
ORUDIS
MEFENAMIC ACID
* 250MG CAPSULE
02229452
02229569
02231208
02237826
00155225
APO-MEFENAMIC
NU-MEFENAMIC
PMS-MEFENAMIC ACID
DOM-MEFENAMIC ACID
PONSTAN
77
28:00 CENTRAL NERVOUS SYSTEM DRUGS
28:08.04 NON-STEROIDAL ANTI-INFLAMMATORY AGENTS
NABUMETONE
SEE APPENDIX A FOR EDS CRITERIA
* 500MG TABLET
02238639
02240867
02083531
APO-NABUMETONE (EDS)
NOVO-NABUMETONE (EDS)
RELAFEN (EDS)
APX
NOP
GSK
$
0.5453
0.5453
0.7488
NOP
$
0.7406
APX
NOP
NXP
$
0.0590
0.0590
0.0590
NXP
APX
NOP
ALT
HLR
$
0.0958 *
0.1159
0.1159
0.1159
0.4256
NXP
APX
ALT
NOP
HLR
$
0.1306 *
0.1582
0.1582
0.1582
0.5550
NXP
NOP
APX
ALT
HLR
$
0.1888 *
0.2290
0.2290
0.2290
1.0067
APX
NOP
HLR
$
0.8251
0.8251
1.3778
ALT
SAB
PMS
HLR
$
0.8601
0.8601
0.8604
1.1935
HLR
$
0.0622
750MG TABLET
02240868
NOVO-NABUMETONE (EDS)
NAPROXEN
* 125MG TABLET
00522678
00565369
00865621
APO-NAPROXEN
NOVO-NAPROX
NU-NAPROX
* 250MG TABLET
00865648
00522651
00565350
00615315
02162474
NU-NAPROX
APO-NAPROXEN
NOVO-NAPROX
NAXEN
NAPROSYN
* 375MG TABLET
00865656
00600806
00615323
00627097
02162482
NU-NAPROX
APO-NAPROXEN
NAXEN
NOVO-NAPROX
NAPROSYN
* 500MG TABLET
00865664
00589861
00592277
00615331
02162490
NU-NAPROX
NOVO-NAPROX
APO-NAPROXEN
NAXEN
NAPROSYN
* 750MG SUSTAINED RELEASE TABLET
02177072
02231327
02162466
APO-NAPROXEN SR
NOVO-NAPROX SR
NAPROSYN-S.R.
* 500MG SUPPOSITORY
00756814
02230477
02017237
02162458
NAXEN
NAPROXEN
PMS-NAPROXEN
NAPROSYN
25MG/ML SUSPENSION
02162431
NAPROSYN
78
28:00 CENTRAL NERVOUS SYSTEM DRUGS
28:08.04 NON-STEROIDAL ANTI-INFLAMMATORY AGENTS
PHENYLBUTAZONE
100MG TABLET
00312789
APO-PHENYLBUTAZONE
APX
$
0.0358
APX
NOP
PMS
NXP
GPM
PFI
$
0.4500
0.4500
0.4500
0.4500
0.4500
0.9554
APX
NOP
PMS
NXP
ALT
GPM
PFI
$
0.7767
0.7767
0.7767
0.7767
0.7767
0.7767
1.6019
PMS
$
0.8040
PMS
TCH
PFI
$
1.1802
1.1802
1.8634
MSD
$
1.3563
MSD
$
1.3563
MSD
$
0.2713
NOP
APX
NXP
$
0.4149
0.4149
0.4149
NXP
NOP
APX
$
0.4333 *
0.5252
0.5252
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
02139960
02171821
00525618
APO-PIROXICAM
NOVO-PIROCAM
PMS-PIROXICAM
NU-PIROX
ALTI-PIROXICAM
GEN-PIROXICAM
FELDENE
10MG SUPPOSITORY
02154420
PMS-PIROXICAM
* 20MG SUPPOSITORY
02154463
02238028
00632716
PMS-PIROXICAM
FEXICAM
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)
SULINDAC
* 150MG TABLET
00745588
00778354
02042576
NOVO-SUNDAC
APO-SULIN
NU-SULINDAC
* 200MG TABLET
02042584
00745596
00778362
NU-SULINDAC
NOVO-SUNDAC
APO-SULIN
79
28:00 CENTRAL NERVOUS SYSTEM DRUGS
28:08.04 NON-STEROIDAL ANTI-INFLAMMATORY AGENTS
TIAPROFENIC ACID
* 200MG TABLET
01924613
02136112
02179679
02230827
ALBERT-TIAFEN
APO-TIAPROFENIC
NOVO-TIAPROFENIC
PMS-TIAPROFENIC
ALT
APX
NOP
PMS
$
0.3730
0.3730
0.3730
0.3730
NXP
ALT
APX
NOP
PMS
DOM
AVT
$
0.2115 *
0.4453
0.4453
0.4453
0.4453
0.5008
0.7069
JAN
$
0.8722
* 300MG TABLET
02146886
01924621
02136120
02179687
02230828
02231060
02221950
NU-TIAPROFENIC
ALBERT-TIAFEN
APO-TIAPROFENIC
NOVO-TIAPROFENIC
PMS-TIAPROFENIC
DOM-TIAPROFENIC
SURGAM
TOLMETIN
600MG TABLET
00632740
TOLECTIN
28:08.08 OPIATE AGONISTS (NARCOTIC ANALGESICS)
ACETAMINOPHEN/CAFFEINE/CODEINE
* WITH 15MG CODEINE/TABLET
00653241
02163934
00687200
00293504
LENOLTEC NO.2
TYLENOL WITH CODEINE NO.2
NOVO-GESIC C15
ATASOL-15
TCH
JAN
NOP
HOR
$
0.0537
0.0646
0.0835
0.0919
TCH
JAN
NOP
HOR
LIH
$
0.0603
0.0711
0.0867
0.1334
0.1469
TCH
GSK
$
0.0494
0.0494
TCH
JAN
GSK
$
0.1502
0.1502
0.1537
JAN
$
0.0835
* WITH 30MG CODEINE/TABLET
00653276
02163926
00687219
00293512
02232389
LENOLTEC NO.3
TYLENOL WITH CODEINE NO.3
NOVO-GESIC C30
ATASOL-30
EXDOL-30
ACETAMINOPHEN/CODEINE
* 300MG/30MG TABLET
00608882
00666130
EMTEC-30
EMPRACET-30
* 300MG/60MG TABLET
00621463
02163918
00666149
LENOLTEC #4
TYLENOL WITH CODEINE NO.4
EMPRACET-60
32MG/1.6MG/ML ELIXIR
02163942
TYLENOL WITH CODEINE ELX
80
28:00 CENTRAL NERVOUS SYSTEM DRUGS
28:08.08 OPIATE AGONISTS (NARCOTIC ANALGESICS)
ACETYLSALICYLIC ACID/CAFFEINE/CODEINE
375MG/30MG/30MG TABLET
02238645
292
LIH
$
0.1834
PFR
$
0.3051
PFR
$
0.6102
PFR
$
0.9223
PFR
$
1.2207
TCH
$
0.0832
TCH
$
0.1080
ROG
$
0.0266
JAN
$
9.2225
JAN
$
17.3600
JAN
$
24.4125
JAN
$
30.3800
PMS-HYDROMORPHONE
DILAUDID
PMS
KNO
$
0.1226
0.1321
DILAUDID
PMS-HYDROMORPHONE
KNO
PMS
$
0.1538
0.1538
DILAUDID
PMS-HYDROMORPHONE
KNO
PMS
$
0.2431
0.2431
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
CODEINE
30MG TABLET
00593451
CODEINE
5MG/ML SYRUP
00779474
CODEINE
FENTANYL
SEE APPENDIX A FOR EDS CRITERIA
25UG/HR TRANSDERMAL SYSTEM
01937383
DURAGESIC (EDS)
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
00885444
00705438
* 2MG TABLET
00125083
00885436
* 4MG TABLET
00125121
00885401
81
28:00 CENTRAL NERVOUS SYSTEM DRUGS
28:08.08 OPIATE AGONISTS (NARCOTIC ANALGESICS)
* 8MG TABLET
00885428
00786543
PMS-HYDROMORPHONE
DILAUDID
PMS
KNO
$
0.4510
0.4854
PFR
$
0.6510
PFR
$
0.9765
PFR
$
1.6926
PFR
$
3.1248
PFR
$
3.7433
KNO
PMS
$
0.0859
0.0860
KNO
SAB
$
1.2400
1.2500
KNO
SAB
$
3.0300
3.0400
SAB
KNO
$
4.8200
4.8200
KNO
SAB
$
10.8000
10.8000
KNO
$
76.1100
KNO
$
2.3979
SAW
$
0.1285
SAB
ABB
ABB
$
0.6900
0.8300
0.8300
SAB
ABB
ABB
$
0.7300
0.8700
0.8700
3MG CONTROLLED-RELEASE CAPSULE
02125323
HYDROMORPH CONTIN
6MG CONTROLLED RELEASE CAPSULE
02125331
HYDROMORPH CONTIN
12MG CONTROLLED-RELEASE CAPSULE
02125366
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
* 10MG/ML INJECTION SOLUTION (1ML)
00622133
02145928
DILAUDID-HP
HYDROMORPHONE HP 10
* 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
82
28:00 CENTRAL NERVOUS SYSTEM DRUGS
28:08.08 OPIATE AGONISTS (NARCOTIC ANALGESICS)
MORPHINE
ORAL FORMS CONTAIN MORPHINE HYDROCHLORIDE OR SULFATE,
INJECTABLE FORMS CONTAIN MORPHINE SULFATE.
* 5MG TABLET
00594652
02009773
02014203
STATEX
MOS-SULFATE
MSIR
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
PFR
$
0.4206
ICN
$
0.4573
PMS
ICN
$
0.3744
0.3744
ICN
$
0.6349
AVT
$
0.3147
AVT
$
0.3852
PFR
$
0.6460
KNO
$
0.8173
AVT
$
0.6478
ICN
BOE
PFR
$
0.5953
0.7437
0.9755
KNO
$
1.4940
AVT
$
1.1593
* 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
30MG TABLET
02014254
MSIR
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
02015439
MS CONTIN
20MG SUSTAINED-RELEASE CAPSULE
02184435
KADIAN
30MG EXTENDED-RELEASE CAPSULE
02019949
N
M-ESLON
30MG SUSTAINED RELEASE TABLET
00776181
01988727
02014297
M.O.S.-S.R.
ORAMORPH SR
MS CONTIN
50MG SUSTAINED-RELEASE CAPSULE
02184443
KADIAN
60MG EXTENDED-RELEASE CAPSULE
02019957
M-ESLON
83
28:00 CENTRAL NERVOUS SYSTEM DRUGS
28:08.08 OPIATE AGONISTS (NARCOTIC ANALGESICS)
N
60MG SUSTAINED RELEASE TABLET
00776203
01988735
02014300
M.O.S.-S.R.
ORAMORPH SR
MS CONTIN
ICN
BOE
PFR
$
1.0447
1.3056
1.7195
KNO
$
2.6218
AVT
$
2.0724
BOE
PFR
$
2.1806
2.6218
AVT
$
4.1447
PFR
$
4.8739
ICN
PMS
TCH
$
0.0217
0.0217
0.0217
PMS
TCH
ICN
$
0.0873
0.0873
0.0914
ICN
TCH
$
0.1995
0.1995
PMS
TCH
ICN
$
0.5404
0.5404
0.5686
SAB
ABB
$
0.5600
0.6600
SAB
ABB
$
0.5600
0.6700
SAB
$
3.3700
KNO
$
96.5700
PMS
$
1.4485
PMS
ICN
PFR
$
1.6080
1.8988
1.9422
100MG SUSTAINED-RELEASE CAPSULE
02184451
KADIAN
100MG EXTENDED-RELEASE CAPSULE
02019965
N
M-ESLON
100MG SUSTAINED RELEASE TABLET
01988743
02014319
ORAMORPH SR
MS CONTIN
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
MORPHITEC-1
* 5MG/ML ORAL SOLUTION
00591475
00607770
00514217
STATEX
MORPHITEC-5
M.O.S.
* 10MG/ML ORAL SOLUTION
00632503
00690783
M.O.S.
MORPHITEC-10
* 20MG/ML ORAL SOLUTION
00621935
00690791
00632481
STATEX
MORPHITEC-20
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
00624268
02014246
STATEX
M.O.S.
MSIR
84
28:00 CENTRAL NERVOUS SYSTEM DRUGS
28:08.08 OPIATE AGONISTS (NARCOTIC ANALGESICS)
* 20MG SUPPOSITORY
00596965
00624276
02014262
STATEX
M.O.S.
MSIR
PMS
ICN
PFR
$
1.9020
2.2605
2.3274
PMS
ICN
PFR
$
2.1125
2.4865
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
DUP
$
4.3480
* 30MG SUPPOSITORY
00639389
00636681
02014173
STATEX
M.O.S.
MSIR
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
OXYMORPHONE HCL
5MG SUPPOSITORY
01916513
NUMORPHAN
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
85
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
02017628
IDARAC
SAW
$
0.3939
SAW
$
0.6859
SDR
$
0.0063
SDR
$
0.0066
SDR
$
0.0148
SDR
$
0.0199
SDR
$
0.0139
APX
DPY
$
0.0516
0.0632
APX
DPY
$
0.0814
0.1222
400MG TABLET
02017636
IDARAC
28:12.04 ANTICONVULSANTS (BARBITURATES)
PHENOBARBITAL
15MG TABLET
00178799
PHENOBARBITAL
30MG TABLET
00178802
PHENOBARBITAL
60MG TABLET
00178810
PHENOBARBITAL
100MG TABLET
00178829
PHENOBARBITAL
5MG/ML ELIXIR
00645575
PHENOBARBITAL
PRIMIDONE
* 125MG TABLET
00399310
02042363
APO-PRIMIDONE
MYSOLINE
* 250MG TABLET
00396761
02042355
APO-PRIMIDONE
MYSOLINE
86
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
ALTI-CLONAZEPAM
NU-CLONAZEPAM
APO-CLONAZEPAM
PMS-CLONAZEPAM-R
CLONAPAM
GEN-CLONAZEPAM
RHOXAL-CLONAZEPAM
MED-CLONAZEPAM
NOVO-CLONAZEPAM
RIVOTRIL
DOM
DOM
ALT
NXP
APX
PMS
ICN
GPM
RHO
MED
NOP
HLR
$
0.0325 *
0.0325 *
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
ALTI-CLONAZEPAM
NU-CLONAZEPAM
APO-CLONAZEPAM
CLONAPAM
GEN-CLONAZEPAM
RHOXAL-CLONAZEPAM
MED-CLONAZEPAM
NOVO-CLONAZEPAM
RIVOTRIL
DOM
PMS
ALT
NXP
APX
ICN
GPM
RHO
MED
NOP
HLR
$
0.0556 *
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
87
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
NVR
$
0.1327
NXP
APX
NOP
NVR
$
0.0674 *
0.0863
0.0863
0.3164
PMS
TAR
GPM
APX
DOM
NVR
$
0.2048
0.2048
0.2048
0.2048
0.2560
0.3251
GPM
APX
PMS
TAR
DOM
NVR
$
0.4095
0.4095
0.4096
0.4096
0.5121
0.6502
NVR
$
0.0628
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
00369810
TEGRETOL
* 200MG TABLET
02042568
00402699
00782718
00010405
NU-CARBAMAZEPINE
APO-CARBAMAZEPINE
NOVO-CARBAMAZ
TEGRETOL
* 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
02241883
02242909
02231544
02237908
02238223
00755583
GEN-CARBAMAZEPINE CR(EDS)
APO-CARBAMAZEPINE CR(EDS)
PMS-CARBAMAZEPINE CR(EDS)
TARO-CARBAMAZEPINE (EDS)
DOM-CARBAMAZEPINE CR(EDS)
TEGRETOL CR (EDS)
20MG/ML ORAL SUSPENSION
02194333
TEGRETOL
88
28:00 CENTRAL NERVOUS SYSTEM DRUGS
28:12.92 MISCELLANEOUS ANTICONVULSANTS
CLOBAZAM
* 10MG TABLET
02238334
02238797
02221799
NOVO-CLOBAZAM
ALTI-CLOBAZAM
FRISIUM
NOP
ALT
AVT
$
0.2598
0.2598
0.3708
NXP
APX
NOP
ABB
$
0.1660
0.1660
0.1660
0.2372
NXP
APX
NOP
ABB
$
0.2984
0.2984
0.2984
0.4262
NXP
APX
NOP
ABB
$
0.5971
0.5971
0.5971
0.8530
PMS
PFI
$
0.3038
0.4340
PMS
PFI
$
0.7390
1.0557
PMS
PFI
$
0.8807
1.2581
GSK
$
0.1551
GSK
$
0.3597
GSK
$
1.4388
GSK
$
2.1581
DIVALPROEX SODIUM
* 125MG ENTERIC COATED TABLET
02239517
02239698
02239701
00596418
NU-DIVALPROEX
APO-DIVALPROEX
NOVO-DIVALPROEX
EPIVAL
* 250MG ENTERIC COATED TABLET
02239518
02239699
02239702
00596426
NU-DIVALPROEX
APO-DIVALPROEX
NOVO-DIVALPROEX
EPIVAL
* 500MG ENTERIC COATED TABLET
02239519
02239700
02239703
00596434
NU-DIVALPROEX
APO-DIVALPROEX
NOVO-DIVALPROEX
EPIVAL
GABAPENTIN
* 100MG CAPSULE
02243446
02084260
PMS-GABAPENTIN
NEURONTIN
* 300MG CAPSULE
02243447
02084279
PMS-GABAPENTIN
NEURONTIN
* 400MG CAPSULE
02243448
02084287
PMS-GABAPENTIN
NEURONTIN
LAMOTRIGINE
5MG CHEWABLE TABLET
02240115
LAMICTAL
25MG TABLET
02142082
LAMICTAL
100MG TABLET
02142104
LAMICTAL
150MG TABLET
02142112
LAMICTAL
89
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
ALT
PMS
TCH
APX
ABB
$
0.0595
0.0626
0.0626
0.0626
0.0628
0.0995
DOM
NOP
ALT
GPM
TCH
MED
PMS
NXP
APX
FTP
RHO
ABB
$
0.1079 *
0.2804
0.2804
0.2804
0.2804
0.2804
0.2804
0.2804
0.2804
0.2804
0.2804
0.4475
ALT
NOP
PMS
TCH
RHO
ABB
$
0.5639
0.5639
0.5639
0.5639
0.5639
0.8951
AVT
$
0.9624
AVT
$
0.9624
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
ALTI-VALPROIC
PMS-VALPROIC ACID
DEPROIC
APO-VALPROIC
DEPAKENE
VALPROIC ACID
* 250MG CAPSULE
02231030
02100630
02140047
02184648
02217414
02230663
02230768
02237830
02238048
02238448
02239714
00443840
DOM-VALPROIC ACID
NOVO-VALPROIC
ALTI-VALPROIC
GEN-VALPROIC
DEPROIC
MED-VALPROIC
PMS-VALPROIC
NU-VALPROIC
APO-VALPROIC
FTP-VALPROIC ACID
RHOXAL-VALPROIC
DEPAKENE
* 500MG ENTERIC COATED CAPSULE
02140055
02218321
02229628
02231489
02239713
00507989
ALTI-VALPROIC
NOVO-VALPROIC
PMS-VALPROIC ACID E.C.
DEPROIC
RHOXAL-VALPROIC
DEPAKENE
VIGABATRIN
500MG TABLET
02065819
SABRIL
500MG SACHET
02068036
SABRIL
90
28:00 CENTRAL NERVOUS SYSTEM DRUGS
28:16.04 PSYCHOTHERAPEUTIC AGENTS (ANTIDEPRESSANTS)
PHENELZINE AND TRANYLCYPROMINE
MONOAMINE OXIDASE INHIBITORS INTERACT WITH SYMPATHOMIMETI
DRUGS, FOODS AND ALCOHOLIC BEVERAGES CONTAINING TYRAMINE O
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 MANUFACTURER
LITERATURE REGARDING PRECAUTIONS AND CONTRAINDICATION
SHOULD BE CONSULTED PRIOR TO PRESCRIBING THESE DRUGS
AMITRIPTYLINE
* 10MG TABLET
00335053
00016322
APO-AMITRIPTYLINE
ELAVIL
APX
MSD
$
0.0196
0.0787
APX
MSD
$
0.0326
0.1500
APX
MSD
$
0.0586
0.2785
WYA
$
0.3505
WYA
$
0.6865
GSK
$
0.5788
GSK
$
0.8680
LUD
$
1.3563
LUD
$
1.3563
APX
GPM
MED
NOP
NVR
$
0.1765
0.1765
0.1765
0.1765
0.2801
* 25MG TABLET
00335061
00016330
APO-AMITRIPTYLINE
ELAVIL
* 50MG TABLET
00335088
00016349
APO-AMITRIPTYLINE
ELAVIL
AMOXAPINE
50MG TABLET
02169894
ASENDIN
100MG TABLET
02169908
ASENDIN
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
CLOMIPRAMINE HCL
* 10MG TABLET
02040786
02139340
02188996
02230256
00330566
APO-CLOMIPRAMINE
GEN-CLOMIPRAMINE
MED-CLOMIPRAMINE
NOVO-CLOPAMINE
ANAFRANIL
91
28:00 CENTRAL NERVOUS SYSTEM DRUGS
28:16.04 PSYCHOTHERAPEUTIC AGENTS (ANTIDEPRESSANTS)
* 25MG TABLET
02040778
02130165
02139359
02189003
00324019
APO-CLOMIPRAMINE
NOVO-CLOPAMINE
GEN-CLOMIPRAMINE
MED-CLOMIPRAMINE
ANAFRANIL
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
ALT
NXP
APX
NOP
DOM
AVT
$
0.2067
0.2067
0.2067
0.2067
0.2067
0.2395
0.3067
DOM
PMS
ALT
NXP
APX
NOP
AVT
$
0.0859 *
0.2761
0.2761
0.2761
0.2761
0.2761
0.3752
DOM
PMS
ALT
NXP
APX
NOP
AVT
$
0.1349 *
0.4460
0.4460
0.4460
0.4460
0.4460
0.6615
PMS
ALT
NXP
APX
NOP
$
0.6873
0.6873
0.6873
0.6873
0.6873
NXP
APX
$
0.9342
0.9342
* 50MG TABLET
02040751
02130173
02139367
02189011
00402591
APO-CLOMIPRAMINE
NOVO-CLOPAMINE
GEN-CLOMIPRAMINE
MED-CLOMIPRAMINE
ANAFRANIL
DESIPRAMINE HCL
* 10MG TABLET
01946250
01948776
02211939
02216248
02223341
02130084
02103583
PMS-DESIPRAMINE
ALTI-DESIPRAMINE
NU-DESIPRAMINE
APO-DESIPRAMINE
NOVO-DESIPRAMINE
DOM-DESIPRAMINE
NORPRAMIN
* 25MG TABLET
02130092
01946269
01948784
02211947
02216256
02223325
02099128
DOM-DESIPRAMINE
PMS-DESIPRAMINE
ALTI-DESIPRAMINE
NU-DESIPRAMINE
APO-DESIPRAMINE
NOVO-DESIPRAMINE
NORPRAMIN
* 50MG TABLET
02130106
01946277
01948792
02211955
02216264
02223333
02099136
DOM-DESIPRAMINE
PMS-DESIPRAMINE
ALTI-DESIPRAMINE
NU-DESIPRAMINE
APO-DESIPRAMINE
NOVO-DESIPRAMINE
NORPRAMIN
* 75MG TABLET
01946242
01948806
02211963
02216272
02223368
PMS-DESIPRAMINE
ALTI-DESIPRAMINE
NU-DESIPRAMINE
APO-DESIPRAMINE
NOVO-DESIPRAMINE
* 100MG TABLET
02211971
02216280
NU-DESIPRAMINE
APO-DESIPRAMINE
92
28:00 CENTRAL NERVOUS SYSTEM DRUGS
28:16.04 PSYCHOTHERAPEUTIC AGENTS (ANTIDEPRESSANTS)
DOXEPIN HCL
* 10MG CAPSULE
02049996
02140071
00024325
APO-DOXEPIN
ALTI-DOXEPIN
SINEQUAN
APX
ALT
PFI
$
0.1286
0.1286
0.2588
NOP
APX
ALT
PFI
$
0.1552
0.1552
0.1552
0.3174
NOP
APX
ALT
PFI
$
0.2418
0.2418
0.2418
0.5889
NOP
APX
ALT
PFI
$
0.5180
0.5180
0.5180
0.8454
NOP
APX
PFI
$
0.6803
0.6803
1.1137
NOP
APX
$
1.0280
1.0280
DOM
PMS
NXP
APX
NOP
GPM
MED
ALT
RHO
LIL
$
0.4097 *
1.2774
1.2774
1.2774
1.2774
1.2774
1.2774
1.2774
1.2774
1.7035
* 25MG CAPSULE
01913425
02050005
02140098
00024333
NOVO-DOXEPIN
APO-DOXEPIN
ALTI-DOXEPIN
SINEQUAN
* 50MG CAPSULE
01913433
02050013
02140101
00024341
NOVO-DOXEPIN
APO-DOXEPIN
ALTI-DOXEPIN
SINEQUAN
* 75MG CAPSULE
01913441
02050021
02140128
00400750
NOVO-DOXEPIN
APO-DOXEPIN
ALTI-DOXEPIN
SINEQUAN
* 100MG CAPSULE
01913468
02050048
00326925
NOVO-DOXEPIN
APO-DOXEPIN
SINEQUAN
* 150MG CAPSULE
01913476
02050056
NOVO-DOXEPIN
APO-DOXEPIN
FLUOXETINE
* 10MG CAPSULE
02177617
02177579
02192756
02216353
02216582
02237813
02239751
02241371
02243486
02018985
DOM-FLUOXETINE
PMS-FLUOXETINE
NU-FLUOXETINE
APO-FLUOXETINE
NOVO-FLUOXETINE
GEN-FLUOXETINE
MED FLUOXETINE
ALTI-FLUOXETINE
RHOXAL-FLUOXETINE
PROZAC
93
28:00 CENTRAL NERVOUS SYSTEM DRUGS
28:16.04 PSYCHOTHERAPEUTIC AGENTS (ANTIDEPRESSANTS)
* 20MG CAPSULE
02177625
02177587
02192764
02216361
02216590
02237814
02239752
02241374
02243487
00636622
DOM-FLUOXETINE
PMS-FLUOXETINE
NU-FLUOXETINE
APO-FLUOXETINE
NOVO-FLUOXETINE
GEN-FLUOXETINE
MED FLUOXETINE
ALTI-FLUOXETINE
RHOXAL-FLUOXETINE
PROZAC
DOM
PMS
NXP
APX
NOP
GPM
MED
ALT
RHO
LIL
$
0.2412 *
1.0972
1.0972
1.0972
1.0972
1.0972
1.0972
1.0972
1.0972
1.7415
PMS
APX
LIL
$
0.5019
0.5019
0.6692
NXP
ALT
APX
NOP
PMS
GPM
DOM
SLV
$
0.3096 *
0.5373
0.5373
0.5373
0.5373
0.5373
0.5641
0.8529
NXP
ALT
APX
NOP
PMS
GPM
DOM
SLV
$
0.5565 *
0.9659
0.9659
0.9659
0.9659
0.9659
1.0142
1.5331
APX
$
0.0358
APX
NVR
$
0.0613
0.2485
APX
NVR
$
0.0879
0.4619
* 4MG/ML ORAL SOLUTION
02177595
02231328
01917021
PMS-FLUOXETINE
APO-FLUOXETINE
PROZAC
FLUVOXAMINE MALEATE
* 50MG TABLET
02231192
02218453
02231329
02239953
02240682
02240849
02241347
01919342
NU-FLUVOXAMINE
ALTI-FLUVOXAMINE
APO-FLUVOXAMINE
NOVO-FLUVOXAMINE
PMS-FLUVOXAMINE
GEN-FLUVOXAMINE
DOM-FLUVOXAMINE
LUVOX
* 100MG TABLET
02231193
02218461
02231330
02239954
02240683
02240850
02241348
01919369
NU-FLUVOXAMINE
ALTI-FLUVOXAMINE
APO-FLUVOXAMINE
NOVO-FLUVOXAMINE
PMS-FLUVOXAMINE
GEN-FLUVOXAMINE
DOM-FLUVOXAMINE
LUVOX
IMIPRAMINE
10MG TABLET
00360201
APO-IMIPRAMINE
* 25MG TABLET
00312797
00010472
APO-IMIPRAMINE
TOFRANIL
* 50MG TABLET
00326852
00010480
APO-IMIPRAMINE
TOFRANIL
94
28:00 CENTRAL NERVOUS SYSTEM DRUGS
28:16.04 PSYCHOTHERAPEUTIC AGENTS (ANTIDEPRESSANTS)
MAPROTILINE
* 10MG TABLET
02158604
00641855
NOVO-MAPROTILINE
LUDIOMIL
NOP
NVR
$
0.1644
0.2255
NOP
NVR
$
0.2241
0.2992
NOP
NVR
$
0.4243
0.5659
NOP
$
0.5794
APX
NXP
NOP
$
0.2735
0.2735
0.2735
NXP
ALT
APX
NOP
PMS
DOM
HLR
$
0.2905 *
0.3965
0.3965
0.3965
0.3965
0.4164
0.6444
ALT
NOP
APX
PMS
DOM
HLR
$
0.8651
0.8651
0.8651
0.8651
0.9084
1.2655
APX
LIN
$
0.5571
0.5571
LIN
APX
BMY
$
0.6076
0.6076
0.8680
* 25MG TABLET
02158612
00360481
NOVO-MAPROTILINE
LUDIOMIL
* 50MG TABLET
02158620
00360503
NOVO-MAPROTILINE
LUDIOMIL
75MG TABLET
02158639
NOVO-MAPROTILINE
MOCLOBEMIDE
* 100MG TABLET
02232148
02237111
02239746
APO-MOCLOBEMIDE
NU-MOCLOBEMIDE
NOVO-MOCLOBEMIDE
* 150MG TABLET
02237112
02218410
02232150
02239747
02243218
02243348
00899356
NU-MOCLOBEMIDE
ALTI-MOCLOBEMIDE
APO-MOCLOBEMIDE
NOVO-MOCLOBEMIDE
PMS-MOCLOBEMIDE
DOM-MOCLOBEMIDE
MANERIX
* 300MG TABLET
02218429
02239748
02240456
02243219
02243349
02166747
ALTI-MOCLOBEMIDE
NOVO-MOCLOBEMIDE
APO-MOCLOBEMIDE
PMS-MOCLOBEMIDE
DOM-MOCLOBEMIDE
MANERIX
NEFAZODONE
* 50MG TABLET
02242822
02237397
APO-NEFAZODONE
LIN-NEFAZODONE
* 100MG TABLET
02237398
02242823
02087375
LIN-NEFAZODONE
APO-NEFAZODONE
SERZONE
95
28:00 CENTRAL NERVOUS SYSTEM DRUGS
28:16.04 PSYCHOTHERAPEUTIC AGENTS (ANTIDEPRESSANTS)
* 150MG TABLET
02237399
02242824
02087383
LIN-NEFAZODONE
APO-NEFAZODONE
SERZONE
LIN
APX
BMY
$
0.6076
0.6076
0.8680
APX
LIN
BMY
$
0.7090
0.7090
1.0128
NXP
PMS
APX
ICN
GPM
NOP
ALT
DOM
LIL
$
0.1069 *
0.1368
0.1368
0.1368
0.1368
0.1368
0.1368
0.1709
0.2170
NXP
NOP
PMS
APX
ICN
GPM
ALT
DOM
LIL
$
0.2160 *
0.2763
0.2764
0.2764
0.2764
0.2764
0.2764
0.3455
0.4387
GSK
$
1.7771
GSK
$
1.8884
PFI
$
0.3633
* 200MG TABLET
02242825
02237400
02087391
APO-NEFAZODONE
LIN-NEFAZODONE
SERZONE
NORTRIPTYLINE
* 10MG CAPSULE
02223139
02177692
02223511
02230361
02231686
02231781
02240789
02178729
00015229
NU-NORTRIPTYLINE
PMS-NORTRIPTYLINE
APO-NORTRIPTYLINE
NORVENTYL
GEN-NORTRIPTYLINE
NOVO-NORTRIPTYLINE
ALTI-NORTRIPTYLINE
DOM-NORTRIPTYLINE
AVENTYL
* 25MG CAPSULE
02223147
02231782
02177706
02223538
02230362
02231687
02240790
02178737
00015237
NU-NORTRIPTYLINE
NOVO-NORTRIPTYLINE
PMS-NORTRIPTYLINE
APO-NORTRIPTYLINE
NORVENTYL
GEN-NORTRIPTYLINE
ALTI-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
96
28:00 CENTRAL NERVOUS SYSTEM DRUGS
28:16.04 PSYCHOTHERAPEUTIC AGENTS (ANTIDEPRESSANTS)
SERTRALINE HYDROCHLORIDE
* 25MG CAPSULE
02238280
02240485
02242519
02132702
APO-SERTRALINE
NOVO-SERTRALINE
GEN-SERTRALINE
ZOLOFT
APX
NOP
GPM
PFI
$
0.5469
0.5469
0.5469
0.8698
APX
NOP
GPM
PFI
$
1.0937
1.0937
1.0937
1.7395
APX
NOP
GPM
PFI
$
1.1963
1.1963
1.1963
1.8228
GSK
$
0.3734
NXP
BRI
PMS
ALT
NOP
APX
ICN
GPM
DOM
$
0.1103 *
0.2403
0.2403
0.2403
0.2403
0.2403
0.2403
0.2403
0.2792
NXP
BRI
PMS
ALT
NOP
APX
ICN
GPM
DOM
$
0.1929 *
0.4293
0.4293
0.4293
0.4293
0.4293
0.4293
0.4293
0.5093
* 50MG CAPSULE
02238281
02240484
02242520
01962817
APO-SERTRALINE
NOVO-SERTRALINE
GEN-SERTRALINE
ZOLOFT
* 100MG CAPSULE
02238282
02240481
02242521
01962779
APO-SERTRALINE
NOVO-SERTRALINE
GEN-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
ALTI-TRAZODONE
NOVO-TRAZODONE
APO-TRAZODONE
TRAZOREL
GEN-TRAZODONE
DOM-TRAZODONE
* 100MG TABLET
02165392
00579378
01937235
02053195
02144271
02147645
02230285
02231684
02128969
NU-TRAZODONE
DESYREL
PMS-TRAZODONE
ALTI-TRAZODONE
NOVO-TRAZODONE
APO-TRAZODONE
TRAZOREL
GEN-TRAZODONE
DOM-TRAZODONE
97
28:00 CENTRAL NERVOUS SYSTEM DRUGS
28:16.04 PSYCHOTHERAPEUTIC AGENTS (ANTIDEPRESSANTS)
TRIMIPRAMINE
* 75MG CAPSULE
02070987
01926349
APO-TRIMIP
SURMONTIL
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
AVT
$
0.2169
0.2169
0.2169
0.2169
0.6207
APX
ROP
NOP
NXP
AVT
$
0.3709
0.3709
0.3709
0.3709
1.0591
WYA
$
0.8463
WYA
$
1.6926
WYA
$
0.8463
WYA
$
1.6926
WYA
$
1.7903
* 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
01926330
APO-TRIMIP
RHOTRIMINE
NOVO-TRIPRAMINE
NU-TRIMIPRAMINE
SURMONTIL
* 100MG TABLET
00740829
00761648
01940457
02020629
01926284
APO-TRIMIP
RHOTRIMINE
NOVO-TRIPRAMINE
NU-TRIMIPRAMINE
SURMONTIL
VENLAFAXINE HCL
37.5MG TABLET
02103680
EFFEXOR
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
98
28:00 CENTRAL NERVOUS SYSTEM DRUGS
28:16.08 PSYCHOTHERAPEUTIC AGENTS
(ANTIPSYCHOTIC AGENTS)
CHLORPROMAZINE
10MG TABLET
00232157
NOVO-CHLORPROMAZINE
NOP
$
0.0174
NOP
$
0.0364
NOP
$
0.0416
NOP
$
0.0695
RHO
$
0.0259
TCH
RHO
$
0.0376
0.0376
TCH
RHO
$
0.2932
0.2932
SAB
RHO
$
1.0600
1.0600
NVR
$
1.0221
NVR
$
4.0780
LUD
$
73.1900
LUD
$
73.1900
FLUANXOL
LUD
$
0.2528
FLUANXOL
LUD
$
0.5461
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
00580988
01929976
CHLORPROMANYL
LARGACTIL
* 40MG/ML ORAL SOLUTION
00690805
01929992
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)
FLUPENTHIXOL DECANOATE
20MG/ML INJECTION SOLUTION (10ML)
02156032
FLUANXOL DEPOT
100MG/ML INJECTION SOLUTION (2ML)
02156040
FLUANXOL DEPOT
FLUPENTHIXOL DIHYDROCHLORIDE
0.5MG TABLET
02156008
3MG TABLET
02156016
99
28:00 CENTRAL NERVOUS SYSTEM DRUGS
28:16.08 PSYCHOTHERAPEUTIC AGENTS
(ANTIPSYCHOTIC AGENTS)
FLUPHENAZINE DECANOATE
* 25MG/ML INJECTION SOLUTION (5ML)
00349917
02091275
02211157
MODECATE
PMS-FLUPHENAZINE DECAN.
RHO-FLUPHENAZINE
SQU
PMS
ROP
$
25.1300
25.1300
25.1300
SQU
ROP
PMS
$
32.3200
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
NOVO-PERIDOL
APO-HALOPERIDOL
PERIDOL
NOP
APX
TCH
$
0.0391
0.0391
0.0391
NOVO-PERIDOL
APO-HALOPERIDOL
PERIDOL
NOP
APX
TCH
$
0.0667
0.0667
0.0667
NOVO-PERIDOL
APO-HALOPERIDOL
NOP
APX
$
0.1140
0.1140
NOVO-PERIDOL
APO-HALOPERIDOL
PERIDOL
NOP
APX
TCH
$
0.1614
0.1614
0.1614
APX
NOP
$
0.1443
0.1443
* 100MG/ML INJECTION SOLUTION (1ML)
00755575
02211165
02241928
MODECATE CONCENTRATE
RHO-FLUPHENAZINE
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
HALOPERIDOL
* 0.5MG TABLET
00363685
00396796
00552135
* 1MG TABLET
00363677
00396818
00552143
* 2MG TABLET
00363669
00396826
* 5MG TABLET
00363650
00396834
00647969
* 10MG TABLET
00463698
00713449
APO-HALOPERIDOL
NOVO-PERIDOL
100
28:00 CENTRAL NERVOUS SYSTEM DRUGS
28:16.08 PSYCHOTHERAPEUTIC AGENTS
(ANTIPSYCHOTIC AGENTS)
* 2MG/ML ORAL SOLUTION
00552429
00759503
00587702
PERIDOL
PMS-HALOPERIDOL
APO-HALOPERIDOL
TCH
PMS
APX
$
0.1165
0.1165
0.1274
SAB
$
3.4800
SAB
ROP
APX
$
30.4200
30.4200
30.4200
SAB
ROP
APX
$
60.1100
60.1100
60.1100
PMS
NXP
APX
DOM
WYA
$
0.1628
0.1628
0.1628
0.1709
0.2326
PMS
NXP
APX
DOM
WYA
$
0.2711
0.2711
0.2711
0.2846
0.3872
PMS
NXP
APX
DOM
WYA
$
0.4202
0.4202
0.4202
0.4412
0.6002
PMS
NXP
APX
DOM
WYA
$
0.5601
0.5601
0.5601
0.5881
0.8002
NVR
$
0.3950
5MG/ML INJECTION SOLUTION (1ML)
00808652
HALOPERIDOL
HALOPERIDOL DECANOATE
* 50MG/ML INJECTION SOLUTION (5ML)
02130297
02211130
02242361
HALOPERIDOL LA
RHO-HALOPERIDOL
APO-HALOPERIDOL LA
* 100MG/ML INJECTION SOLUTION (5ML)
02130300
02211149
02242362
HALOPERIDOL LA
RHO-HALOPERIDOL
APO-HALOPERIDOL LA
LOXAPINE SUCCINATE
* 5MG TABLET
02230837
02237534
02237651
02239918
02170019
PMS-LOXAPINE
NU-LOXAPINE
APO-LOXAPINE
DOM-LOXAPINE
LOXAPAC
* 10MG TABLET
02230838
02237535
02237652
02239919
02170027
PMS-LOXAPINE
NU-LOXAPINE
APO-LOXAPINE
DOM-LOXAPINE
LOXAPAC
* 25MG TABLET
02230839
02237536
02237653
02239920
02170132
PMS-LOXAPINE
NU-LOXAPINE
APO-LOXAPINE
DOM-LOXAPINE
LOXAPAC
* 50MG TABLET
02230840
02237537
02237654
02239921
02170035
PMS-LOXAPINE
NU-LOXAPINE
APO-LOXAPINE
DOM-LOXAPINE
LOXAPAC
MESORIDAZINE
25MG TABLET
00027456
SERENTIL
101
28:00 CENTRAL NERVOUS SYSTEM DRUGS
28:16.08 PSYCHOTHERAPEUTIC AGENTS
(ANTIPSYCHOTIC AGENTS)
OLANZAPINE
SEE APPENDIX A FOR EDS CRITERIA
2.5MG TABLET
02229250
ZYPREXA (EDS)
LIL
$
1.8310
ZYPREXA (EDS)
LIL
$
3.6619
LIL
$
5.4929
LIL
$
7.2500
LIL
$
3.6619
LIL
$
7.3238
AVT
$
0.1817
AVT
$
0.2796
AVT
$
0.4413
AVT
$
0.3076
APO-PERPHENAZINE
APX
$
0.0239
APO-PERPHENAZINE
APX
$
0.0348
APO-PERPHENAZINE
APX
$
0.0456
APX
$
0.0565
PMS-PERPHENAZINE CONC.
PMS
$
0.1727
ORAP
PMS
$
0.3533
ORAP
PMS
$
0.6411
5MG TABLET
02229269
7.5MG TABLET
02229277
ZYPREXA (EDS)
10MG TABLET
02229285
ZYPREXA (EDS)
5MG ORALLY DISINTEGRATING TABLET
02243086
ZYPREXA ZYDIS (EDS)
10MG ORALLY DISINTEGRATING TABLET
02243087
ZYPREXA ZYDIS (EDS)
PERICYAZINE
5MG CAPSULE
01926780
NEULEPTIL
10MG CAPSULE
01926772
NEULEPTIL
20MG CAPSULE
01926764
NEULEPTIL
10MG/ML ORAL DROPS
01926756
NEULEPTIL
PERPHENAZINE
2MG TABLET
00335134
4MG TABLET
00335126
8MG TABLET
00335118
16MG TABLET
00335096
APO-PERPHENAZINE
3.2MG/ML SYRUP
00751898
PIMOZIDE
2MG TABLET
00313815
4MG TABLET
00313823
102
28:00 CENTRAL NERVOUS SYSTEM DRUGS
28:16.08 PSYCHOTHERAPEUTIC AGENTS
(ANTIPSYCHOTIC AGENTS)
PIPOTIAZINE PALMITATE
25MG/ML INJECTION SOLUTION (1ML)
01926667
PIPORTIL L4
AVT
$
13.1800
AVT
$
42.4300
APX
RHO
NXP
$
0.1145
0.1145
0.1145
APX
RHO
NXP
$
0.1400
0.1400
0.1400
RHO
$
0.0552
SAB
RHO
$
1.0800
1.0800
RHO
$
0.9006
AST
$
0.5208
AST
$
1.3888
AST
$
2.1483
AST
$
2.7885
JAN
$
0.4503
RISPERDAL
JAN
$
0.7541
RISPERDAL
JAN
$
1.0416
RISPERDAL
JAN
$
2.0797
RISPERDAL
JAN
$
3.1194
RISPERDAL
JAN
$
4.1593
JAN
$
1.1979
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
1MG/ML ORAL SOLUTION
01927787
STEMETIL
* 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)
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
103
28:00 CENTRAL NERVOUS SYSTEM DRUGS
28:16.08 PSYCHOTHERAPEUTIC AGENTS
(ANTIPSYCHOTIC AGENTS)
THIORIDAZINE
* 10MG TABLET
00575119
00360228
PMS-THIORIDAZINE
APO-THIORIDAZINE
PMS
APX
$
0.0179
0.0358
PMS
APX
$
0.0353
0.0619
PMS
APX
$
0.0635
0.1009
PMS
APX
$
0.1213
0.1660
PMS
$
0.1133
NVR
$
0.0374
PFI
$
0.2005
PFI
$
0.3447
PFI
$
0.4438
APO-TRIFLUOPERAZINE
APX
$
0.0358
APO-TRIFLUOPERAZINE
APX
$
0.0489
APO-TRIFLUOPERAZINE
APX
$
0.0749
APX
$
0.1140
PMS
$
0.2700
LUD
$
15.1900
LUD
$
151.9000
* 25MG TABLET
00575127
00360198
PMS-THIORIDAZINE
APO-THIORIDAZINE
* 50MG TABLET
00575135
00360236
PMS-THIORIDAZINE
APO-THIORIDAZINE
* 100MG TABLET
00575143
00360244
PMS-THIORIDAZINE
APO-THIORIDAZINE
30MG/ML ORAL SOLUTION
00775320
PMS-THIORIDAZINE
2MG/ML ORAL SUSPENSION
00027375
MELLARIL
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)
104
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
TCH
NVR
$
0.1726
0.1726
0.2831
PMS
TCH
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
RIPHENIDATE
RITALIN
* 20MG TABLET
00585009
02230322
00005614
PMS-METHYLPHENIDATE
RIPHENIDATE
RITALIN
20MG SUSTAINED RELEASE TABLET
00632775
RITALIN SR
MODAFINIL
SEE APPENDIX A FOR EDS CRITERIA
100MG TABLET
02239665
ALERTEC (EDS)
105
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
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
00677485
00865397
01913484
02137534
02237264
00548359
NU-ALPRAZ
ALTI-ALPRAZOLAM
APO-ALPRAZ
NOVO-ALPRAZOL
GEN-ALPRAZOLAM
MED-ALPRAZOLAM
XANAX
NXP
ALT
APX
NOP
GPM
MED
PHU
$
0.0552 *
0.0825
0.0825
0.0825
0.0825
0.0825
0.2540
NXP
ALT
APX
NOP
GPM
MED
PHU
$
0.0663 *
0.0999
0.0999
0.0999
0.0999
0.0999
0.3037
* 0.5MG TABLET
01913247
00677477
00865400
01913492
02137542
02237265
00548367
NU-ALPRAZ
ALTI-ALPRAZOLAM
APO-ALPRAZ
NOVO-ALPRAZOL
GEN-ALPRAZOLAM
MED-ALPRAZOLAM
XANAX
106
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
ALTI-BROMAZEPAM
APO-BROMAZEPAM
GEN-BROMAZEPAM
NOVO-BROMAZEPAM
MED-BROMAZEPAM
LECTOPAM
NXP
ALT
APX
GPM
NOP
MED
HLR
$
0.0635 *
0.0957
0.0957
0.0957
0.0957
0.0957
0.1519
ALTI-BROMAZEPAM
NU-BROMAZEPAM
APO-BROMAZEPAM
GEN-BROMAZEPAM
NOVO-BROMAZEPAM
MED-BROMAZEPAM
LECTOPAM
ALT
NXP
APX
GPM
NOP
MED
HLR
$
0.1398
0.1398
0.1398
0.1398
0.1398
0.1398
0.2219
APX
$
0.0315
APX
$
0.0456
APX
$
0.0575
NOP
APX
ABB
$
0.0753
0.0753
0.1686
NOP
APX
ABB
$
0.1662
0.1662
0.2067
NOP
APX
ABB
$
0.2840
0.2840
0.3722
* 3MG TABLET
02171864
02167816
02177161
02192713
02230584
02230667
00518123
* 6MG TABLET
02167824
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
00264938
NOVO-CLOPATE
APO-CLORAZEPATE
TRANXENE
* 7.5MG CAPSULE
00628204
00860700
00264946
NOVO-CLOPATE
APO-CLORAZEPATE
TRANXENE
* 15MG CAPSULE
00628212
00860697
00264911
NOVO-CLOPATE
APO-CLORAZEPATE
TRANXENE
107
28:00 CENTRAL NERVOUS SYSTEM DRUGS
28:24.08 ANXIOLYTICS,SEDATIVES AND HYPNOTICS
(BENZODIAZEPINES)
DIAZEPAM
2MG TABLET
00405329
APO-DIAZEPAM
APX
$
0.0228
APO-DIAZEPAM
VIVOL
VALIUM
APX
HOR
HLR
$
0.0358
0.0952
0.1552
APX
HOR
$
0.0489
0.1561
DPY
$
72.9700
PMS
APX
ICN
$
0.0479
0.0879
0.1330
PMS
APX
ICN
$
0.0548
0.1009
0.1557
APO-LORAZEPAM
NOVO-LORAZEM
NU-LORAZ
ATIVAN
APX
NOP
NXP
WYA
$
0.0507
0.0507
0.0507
0.0814
NOVO-LORAZEM
APO-LORAZEPAM
NU-LORAZ
ATIVAN
NOP
APX
NXP
WYA
$
0.0517
0.0517
0.0517
0.1009
NOVO-LORAZEM
APO-LORAZEPAM
NU-LORAZ
ATIVAN
NOP
APX
NXP
WYA
$
0.0840
0.0840
0.0840
0.1585
* 5MG TABLET
00362158
00013765
00013285
* 10MG TABLET
00405337
00013773
APO-DIAZEPAM
VIVOL
5MG/ML RECTAL GEL (DELIVERY SYSTEM)
02238162
DIASTAT
FLURAZEPAM HCL
* 15MG CAPSULE
00667102
00521698
00012696
PMS-FLURAZEPAM
APO-FLURAZEPAM
DALMANE
* 30MG CAPSULE
00667099
00521701
00012718
PMS-FLURAZEPAM
APO-FLURAZEPAM
DALMANE
LORAZEPAM
* 0.5MG TABLET
00655740
00711101
00865672
02041413
* 1MG TABLET
00637742
00655759
00865680
02041421
* 2MG TABLET
00637750
00655767
00865699
02041448
108
28:00 CENTRAL NERVOUS SYSTEM DRUGS
28:24.08 ANXIOLYTICS,SEDATIVES AND HYPNOTICS
(BENZODIAZEPINES)
OXAZEPAM
10MG TABLET
00402680
APO-OXAZEPAM
APX
$
0.0228
APX
WYA
$
0.0358
0.0718
APX
WYA
$
0.0489
0.1040
NXP
APX
PMS
NOP
GPM
MED
DOM
NVR
$
0.0467 *
0.1196
0.1196
0.1196
0.1196
0.1196
0.1493
0.1899
NXP
APX
PMS
NOP
GPM
MED
DOM
NVR
$
0.0562 *
0.1439
0.1439
0.1439
0.1439
0.1439
0.1795
0.2284
ALT
APX
GPM
NOP
$
0.0604
0.0604
0.0604
0.0606
APX
NOP
GPM
PHU
$
0.0760
0.0760
0.0760
0.2199
* 15MG TABLET
00402745
02043661
APO-OXAZEPAM
SERAX
* 30MG TABLET
00402737
02043688
APO-OXAZEPAM
SERAX
TEMAZEPAM
* 15MG CAPSULE
02223570
02225964
02229455
02230095
02231615
02237294
02229756
00604453
NU-TEMAZEPAM
APO-TEMAZEPAM
PMS-TEMAZEPAM
NOVO-TEMAZEPAM
GEN-TEMAZEPAM
MED-TEMAZEPAM
DOM-TEMAZEPAM
RESTORIL
* 30MG CAPSULE
02223589
02225972
02229456
02230102
02231616
02237295
02229758
00604461
NU-TEMAZEPAM
APO-TEMAZEPAM
PMS-TEMAZEPAM
NOVO-TEMAZEPAM
GEN-TEMAZEPAM
MED-TEMAZEPAM
DOM-TEMAZEPAM
RESTORIL
TRIAZOLAM
* 0.125MG TABLET
00614351
00808563
01995227
00872423
ALTI-TRIAZOLAM
APO-TRIAZO
GEN-TRIAZOLAM
NOVO-TRIOLAM
* 0.25MG TABLET
00808571
00872431
01913506
00443158
APO-TRIAZO
NOVO-TRIOLAM
GEN-TRIAZOLAM
HALCION
109
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
TCH
FTP
BRI
$
0.1977 *
0.7076
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
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
* 10MG TABLET
02232564
02176122
02207672
02211076
02230874
02230942
02231492
02237268
02237858
02238447
00603821
DOM-BUSPIRONE
LIN-BUSPIRONE
NU-BUSPIRONE
APO-BUSPIRONE
GEN-BUSPIRONE
PMS-BUSPIRONE
NOVO-BUSPIRONE
MED-BUSPIRONE
BUSPIREX
FTP-BUSPIRONE
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
METHOTRIMEPRAZINE
* 2MG TABLET
01927647
02238403
* 5MG TABLET
01927655
01964909
02232903
02238404
110
28:00 CENTRAL NERVOUS SYSTEM DRUGS
28:24.92 MISCELLANEOUS ANXIOLYTICS,SEDATIVES
AND HYPNOTICS
* 25MG TABLET
01927663
01964925
02232904
02238405
NOZINAN
NOVO-MEPRAZINE
PMS-METHOTRIMEPRAZINE
APO-METHOPRAZINE
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
APX
PMS
ICN
$
0.0578
0.0687
0.1238
APX
PMS
ICN
$
0.0606
0.0721
0.1017
PMS
ICN
$
0.1476
0.1845
JAN
$
0.2068
* 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
02242837
02216132
00461733
APO-LITHIUM CARBONATE
PMS-LITHIUM CARBONATE
CARBOLITH
* 300MG CAPSULE
02242838
02216140
00236683
APO-LITHIUM CARBONATE
PMS-LITHIUM CARBONATE
CARBOLITH
* 600MG CAPSULE
02216159
02011239
PMS-LITHIUM CARBONATE
CARBOLITH
300MG SUSTAINED RELEASE TABLET
00590665
DURALITH
111
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
N
STRIP
00950889
00950378
00950408
00950432
00950505
00950894
00950068
00950882
00950300
00950878
00950893
00950459
00950734
00950661
00950883
00950572
NOVO-GLUCOSE
GLUCOFILM
GLUCOSTIX
ACCUTREND
ENCORE
PRECISION XTRA
CHEMSTRIP BG
FASTTAKE
PRECISION PLUS
GLUCOMETER DEX
ONE TOUCH ULTRA
ONE TOUCH
SURESTEP
ADVANTAGE
ADVANTAGE COMFORT
ELITE
NOP
BAY
BAY
BOM
BAY
MDS
BOM
LSN
MDS
BAY
LSN
LSN
LSN
BOM
BOM
BAY
$
0.6011
0.7012
0.7012
0.7324
0.7324
0.7476
0.7834
0.8453
0.8626
0.8626
0.8626
0.8663
0.8663
0.8680
0.8680
0.9388
BAY
$
0.0998
BAY
BAY
$
0.1129
0.1389
BOM
$
0.1389
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
GLUCOSE OXIDASE/PEROXIDASE REAGENT
N
STICK
00035130
00035114
DIASTIX
CLINISTIX
GLUCOSE OXIDASE/PEROXIDASE/SODIUM
NITROFERRICYANIDE/GLYCINE REAGENT
STICK
00950238
CHEMSTRIP UG 5000K
114
36:00 DIAGNOSTIC AGENTS
36:88.00 URINE CONTENTS
GLUCOSE OXIDASE/PEROXIDASE/SODIUM
NITROPRUSSIDE REAGENT
STICK
00035149
KETO DIASTIX
BAY
$
0.1354
KETOSTIX
BAY
$
0.1259
ACETEST
BAY
$
0.1728
SODIUM NITROPRUSSIDE REAGENT
STICK
00035092
TABLET
00035106
115
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
WYA
$
0.1030
APX
NVR
$
0.0489
0.0736
KEY
$
0.2887
PMS
GSK
$
0.0139
0.0157
ABB
$
0.3165
RBP
$
0.5191
SAW
$
0.3031
PMS
$
0.1027
PMS
SAW
$
0.1172
0.1569
PMS
$
14.8000
BURINEX (EDS)
LEO
$
0.4883
BURINEX (EDS)
LEO
$
0.9765
BURINEX (EDS)
LEO
$
1.8627
10MMOL LONG ACTING CAPSULE
02042312
N
MICRO-K 10 EXTENCAPS
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)
40:28.00 DIURETICS
ACETAZOLAMIDE
SEE SECTION 52:10.00 (CARBONIC ANHYDRASE INHIBITORS)
BUMETANIDE
SEE APPENDIX A FOR EDS CRITERIA
1MG TABLET
00728284
2MG TABLET
02176076
5MG TABLET
00728276
118
40:00 ELECTROLYTIC, CALORIC AND WATER BALANCE
40:28.00 DIURETICS
CHLORTHALIDONE
50MG TABLET
00360279
APO-CHLORTHALIDONE
APX
$
0.0619
APX
$
0.0879
MSD
$
0.3440
NOP
APX
AVT
$
0.0158
0.0158
0.0749
NOP
APX
AVT
$
0.0082
0.0082
0.1147
AVT
$
0.2356
NOP
APX
MSD
$
0.0223
0.0223
0.0795
NOP
APX
$
0.0250
0.0250
DOM
PRO
PMS
GPM
SEV
$
0.1752 *
0.2037
0.2037
0.2037
0.3234
DOM
PRO
GPM
NXP
APX
NOP
PMS
SEV
$
0.1957 *
0.3230
0.3230
0.3230
0.3230
0.3230
0.3230
0.5289
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
INDAPAMIDE HEMIHYDRATE
* 1.25MG TABLET
02239913
02227339
02239619
02240067
02179709
DOM-INDAPAMIDE
INDAPAMIDE
PMS-INDAPAMIDE
GEN-INDAPAMIDE
LOZIDE
* 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
119
40:00 ELECTROLYTIC, CALORIC AND WATER BALANCE
40:28.00 DIURETICS
METOLAZONE
2.5MG TABLET
00888400
ZAROXOLYN
AVT
$
0.1585
ZAROXOLYN
AVT
$
0.2024
MSD
$
0.3104
PHU
NOP
$
0.0751
0.0751
PHU
NOP
$
0.2301
0.2301
GSK
$
0.2022
GSK
$
0.2615
ICN
$
0.2045
APX
NXP
$
0.1302
0.1302
NXP
APX
$
0.1791
0.2149
5MG TABLET
00888419
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
TRIAMTERENE
50MG TABLET
01919563
DYRENIUM
100MG TABLET
01919571
DYRENIUM
40:40.00 URICOSURIC DRUGS
PROBENECID
500MG TABLET
00294926
BENURYL
SULFINPYRAZONE
* 100MG TABLET
00441759
02045680
APO-SULFINPYRAZONE
NU-SULFINPYRAZONE
* 200MG TABLET
02045699
00441767
NU-SULFINPYRAZONE
APO-SULFINPYRAZONE
120
COUGH PREPARATIONS
48:00
48:00 COUGH PREPARATIONS
48:24.00 MUCOLYTIC AGENTS
ACETYLCYSTEINE
20% AEROSOL SOLUTION (30ML)
02091526
MUCOMYST
RBP
$
19.1600
HLR
$
36.0000
DORNASE ALFA
SEE APPENDIX A FOR EDS CRITERIA
1MG/ML INHALATION SOLUTION (2.5ML)
02046733
PULMOZYME (EDS)
122
EYE, EAR, NOSE AND THROAT
PREPARATIONS
52:00
52:00 EYE, EAR, NOSE AND THROAT PREPARATIONS
52:04.04 ANTI-INFECTIVES (ANTIBIOTICS)
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
00880191
02229440
02212927
00436771
GARAMYCIN
PMS-GENTAMYCIN
GARATEC
GENTAMICIN SULFATE
GENTAMICIN
ALCOMICIN
SCH
PMS
TCH
SAB
RVX
ALC
$
0.4406
0.4406
0.4406
0.4406
0.4644
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
RVX
NVO
PMS
SAB
ALC
$
1.1371
1.1393
1.1393
1.1393
1.8077
ALC
$
8.9800
POLYMYXIN B SO4/NEOMYCIN SO4/GRAMICIDIN
N
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
TOBRAMYCIN
SEE APPENDIX A FOR EDS CRITERIA
* 0.3% OPHTHALMIC SOLUTION
02239148
02238708
02239577
02241755
00513962
TOBRAMYCIN (EDS)
TOMYCINE (EDS)
PMS-TOBRAMYCIN (EDS)
SAB-TOBRAMYCIN (EDS)
TOBREX (EDS)
0.3% OPHTHALMIC OINTMENT (3.5G)
00614254
TOBREX (EDS)
124
52:00 EYE, EAR, NOSE AND THROAT PREPARATIONS
52:04.06 ANTI-INFECTIVES (ANTIVIRALS)
TRIFLURIDINE
1% OPHTHALMIC SOLUTION (7.5ML)
00687456
VIROPTIC
THM
$
33.4800
AKN
SCH
$
0.0789
0.0876
ALC
$
3.1000
STI
$
0.2279
ALC
$
2.1049
ALC
$
10.5300
MSD
$
1.7686
ALL
$
1.5364
ALT
GPM
MED
NXP
APX
$
13.3100
13.3100
13.3100
13.3100
13.3100
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)
NORFLOXACIN
SEE APPENDIX A FOR EDS CRITERIA
0.3% OPHTHALMIC SOLUTION
01908294
NOROXIN (EDS)
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
ALTI-BECLOMETHASONE AQ.
GEN-BECLO AQ.
MED-BECLOMETHASONE AQ
NU-BECLOMETHASONE
APO-BECLOMETHASONE
125
52:00 EYE, EAR, NOSE AND THROAT PREPARATIONS
52:08.00 ANTI-INFLAMMATORY AGENTS
BETAMETHASONE DISODIUM PHOSPHATE
0.1% OPHTHALMIC/OTIC SOLUTION
02060868
BETNESOL
RBP
$
3.2724
GPM
AST
$
9.1500
10.7700
GPM
$
13.8300
AST
$
23.9300
ALC
$
1.6709
SAB
PMS
RVX
AKN
$
0.7335
0.7335
0.7335
0.9071
ALC
$
9.0600
ALT
PMS
APX
HLR
$
15.0400
15.0400
15.0400
21.4900
ALL
$
2.1939
ALC
$
1.8879
ALL
$
5.0062
GSK
$
24.0500
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
02212978
02023865
DEXAMETHASONE SODIUM PHO
PMS-DEXAMETHASONE SOD PHO
DEXAMETHASONE
DIODEX
0.1% OPHTHALMIC OINTMENT (3.5G)
00042579
MAXIDEX
FLUNISOLIDE
* 0.025% NASAL SOLUTION (PACKAGE)
00878790
01927167
02239288
02162687
ALTI-FLUNISOLIDE
RHINARIS-F
APO-FLUNISOLIDE
RHINALAR
FLUOROMETHOLONE
0.1% OPHTHALMIC SUSPENSION
00247855
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
126
52:00 EYE, EAR, NOSE AND THROAT PREPARATIONS
52:08.00 ANTI-INFLAMMATORY AGENTS
KETOROLAC TROMETHAMINE
SEE APPENDIX A FOR EDS CRITERIA
0.5% OPHTHALMIC SOLUTION
01968300
ACULAR (EDS)
ALL
$
3.4720
SCH
$
22.7400
SAB
ALL
$
1.1501
1.5473
ALT
SAB
AKN
ALL
$
0.6293
0.6293
0.6293
3.7954
NVO
$
1.6731
NVO
RVX
$
1.5190
1.5190
AVT
$
21.7000
AVT
$
23.3900
ALC
$
2.2790
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
OPHTHO-TATE
PREDNISOLONE
DIOPRED
PRED FORTE
PREDNISOLONE SODIUM PHOSPHATE
0.125% OPHTHALMIC SOLUTION
02133296
INFLAMASE MILD
* 1% OPHTHALMIC SOLUTION
02133318
02213079
INFLAMASE FORTE
PREDNISOLONE
TRIAMCINOLONE ACETONIDE
100UG/DOSE NASAL SPRAY (PACKAGE)
01913328
NASACORT
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
01987712
SOFRACORT
AVT
$
1.5190
AVT
$
10.4200
5MG/50UG/0.5MG PER G EYE/EAR OINTMENT (5G)
02224631
SOFRACORT
127
52:00 EYE, EAR, NOSE AND THROAT PREPARATIONS
52:08.00 COMBINATION ANTI-INFECTIVE/
ANTI-INFLAMMATORY AGENTS
GENTAMICIN SO4/BETAMETHASONE SODIUM PHOSPHATE
0.3%/0.1% OPHTHALMIC OINTMENT (3.5G)
00586706
GARASONE
SCH
$
11.0000
SCH
$
1.9872
0.3%/0.1% OTIC/OPHTHALMIC SOLUTION
00682217
GARASONE
IODOCHLORHYDROXYQUIN/FLUMETHASONE PIVALATE
1%/0.02% OTIC SOLUTION
00074454
LOCACORTEN-VIOFORM
NVR
$
1.3346
GSK
$
10.5200
POLYMYXIN B SO4/BACITRACIN (ZINC)/
NEOMYCIN SO4/HYDROCORTISONE
10000U/400U/5MG/10MG PER G OPHTHALMIC
OINTMENT (3.5G)
00701904
CORTISPORIN
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
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)
128
52:00 EYE, EAR, NOSE AND THROAT PREPARATIONS
52:10.00 CARBONIC ANHYDRASE INHIBITORS
ACETAZOLAMIDE
* 250MG TABLET
00545015
02238072
APO-ACETAZOLAMIDE
DIAMOX
APX
WYA
$
0.0586
0.1413
WYA
$
0.7567
ALC
$
3.4069
MSD
$
3.5805
WYA
$
0.4231
ALC
$
0.7307
ALC
$
0.8789
WYA
$
4.9737
WYA
$
5.7006
WYA
$
6.4558
ALC
$
0.3328
NVO
TCH
RVX
ALC
AKN
$
0.1888
0.1888
0.2026
0.2221
0.2221
500MG SUSTAINED RELEASE CAPSULE
02238073
DIAMOX SEQUELS
BRINZOLAMIDE
1% OPHTHALMIC SUSPENSION
02238873
AZOPT
DORZOLAMIDE HCL
2% OPHTHALMIC SOLUTION
02216205
TRUSOPT
METHAZOLAMIDE
50MG TABLET
02238071
NEPTAZANE
52:20.00 MIOTICS
CARBACHOL
1.5% OPHTHALMIC SOLUTION
00000655
ISOPTO CARBACHOL
3% OPHTHALMIC SOLUTION
00000663
ISOPTO CARBACHOL
ECHOTHIOPHATE IODIDE
0.06% OPHTHALMIC SOLUTION
02238075
PHOSPHOLINE IODIDE
0.125% OPHTHALMIC SOLUTION
02238076
PHOSPHOLINE IODIDE
0.25% OPHTHALMIC SOLUTION
02243343
PHOSPHOLINE IODIDE
PILOCARPINE HCL
0.5% OPHTHALMIC SOLUTION
00000833
ISOPTO CARPINE
* 1% OPHTHALMIC SOLUTION
02134861
02229393
02213036
00000841
02023725
MIOCARPINE
PILOCARPINE
PILOCARPINE
ISOPTO CARPINE
DIOCARPINE
129
52:00 EYE, EAR, NOSE AND THROAT PREPARATIONS
52:20.00 MIOTICS
* 2% OPHTHALMIC SOLUTION
02134888
02229394
02213044
00000868
02023741
MIOCARPINE
PILOCARPINE
PILOCARPINE
ISOPTO CARPINE
DIOCARPINE
NVO
TCH
RVX
ALC
AKN
$
0.2099
0.2099
0.2251
0.2561
0.2561
NVO
TCH
RVX
ALC
AKN
$
0.2395
0.2395
0.2561
0.2894
0.2894
NVO
ALC
$
0.3661
0.4883
ALC
$
13.5600
ALC
NVO
NVO
$
0.5100
0.5534
0.6185
ALT
PMS
APX
ALL
$
1.0807
1.0807
1.0807
1.7154
ALC
$
0.6293
ALC
$
0.7487
ALC
$
23.0800
ALC
$
11.9200
* 4% OPHTHALMIC SOLUTION
02134896
02229395
02213052
00000884
02023733
MIOCARPINE
PILOCARPINE
PILOCARPINE
ISOPTO CARPINE
DIOCARPINE
* 6% OPHTHALMIC SOLUTION
02133334
00000892
MIOCARPINE
ISOPTO CARPINE
4% OPHTHALMIC GEL (5G)
00575240
PILOPINE-HS
52:24.00 MYDRIATICS
ATROPINE SO4
* 1% OPHTHALMIC SOLUTION
00035017
02134853
01948598
ISOPTO ATROPINE
ATROPISOL
ATROPINE
DIPIVEFRIN HCL
* 0.1% OPHTHALMIC SOLUTION
02032376
02237868
02242232
00529117
OPHTHO-DIPIVEFRIN
PMS-DIPIVEFRIN
APO-DIPIVEFRIN
PROPINE
HOMATROPINE HYDROBROMIDE
2% OPHTHALMIC SOLUTION
00000779
ISOPTO HOMATROPINE
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
130
52:00 EYE, EAR, NOSE AND THROAT PREPARATIONS
52:36.00 MISCELLANEOUS E.E.N.T. DRUGS
BETAXOLOL HCL
0.25% OPHTHALMIC SUSPENSION
01908448
BETOPTIC S
ALC
$
2.4456
ALL
$
3.5810
NVO
$
2.5715
MSD
$
5.4250
PMS
ALT
DOM
BOE
$
21.0900
21.0900
22.2000
30.2100
PHU
$
28.2100
ALT
NOP
RVX
APX
SAB
ALL
$
1.2760
1.2760
1.2760
1.2760
1.2760
2.3078
PMS
ALT
NOP
RVX
APX
SAB
ALL
$
1.6872
1.6883
1.6883
1.6883
1.6883
1.6883
2.8341
ALL
$
3.2008
BRIMONIDINE TARTRATE
0.2% OPHTHALMIC SOLUTION
02236876
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
ALTI-IPRATROPIUM
DOM-IPRATROPIUM
ATROVENT NASAL SPRAY
LATANOPROST
50UG/ML OPHTHALMIC SOLUTION (2.5ML)
02231493
XALATAN
LEVOBUNOLOL HCL
* 0.25% OPHTHALMIC SOLUTION
02031159
02197456
02231714
02241575
02241715
00751286
OPHTHO-BUNOLOL
NOVO-LEVOBUNOLOL
LEVOBUNOLOL HYDROCHLORIDE
APO-LEVOBUNOLOL
SAB-LEVOBUNOLOL
BETAGAN
* 0.5% OPHTHALMIC SOLUTION
02237991
02031167
02197464
02231715
02241574
02241716
00637661
PMS-LEVOBUNOLOL
OPHTHO-BUNOLOL
NOVO-LEVOBUNOLOL
LEVOBUNOLOL HYDROCHLORIDE
APO-LEVOBUNOLOL
SAB-LEVOBUNOLOL
BETAGAN
LEVOBUNOLOL HCL/DIPIVEFRIN HCL
0.5%/0.1% OPHTHALMIC SOLUTION
02209071
PROBETA
131
52:00 EYE, EAR, NOSE AND THROAT PREPARATIONS
52:36.00 MISCELLANEOUS E.E.N.T. DRUGS
LEVOCABASTINE HYDROCHLORIDE
0.5MG PER ML OPHTHALMIC SUSPENSION (5ML)
02131625
LIVOSTIN
NVO
$
18.8300
ALC
$
1.1122
PMS
APX
$
14.9300
14.9300
APX
GPM
NOP
PMS
MED
SAB
RHO
DOM
$
1.6818
1.6818
1.6818
1.6818
1.6818
1.6818
1.6818
1.7664
APX
GPM
NOP
PMS
MED
SAB
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
LODOXAMIDE TROMETHAMINE
0.1% OPHTHALMIC SOLUTION
00893560
ALOMIDE
SODIUM CROMOGLYCATE
* 2% NASAL METERED DOSE MIST (PACKAGE)
01950541
02231390
CROMOLYN
APO-CROMOLYN
TIMOLOL MALEATE
* 0.25% OPHTHALMIC SOLUTION
00755826
00893773
02048523
02083353
02084317
02166712
02241731
02238770
APO-TIMOP
GEN-TIMOLOL
NOVO-TIMOL
PMS-TIMOLOL
MED-TIMOLOL
TIMOLOL MALEATE
RHOXAL-TIMOLOL
DOM-TIMOLOL
* 0.5% OPHTHALMIC SOLUTION
00755834
00893781
02048515
02083345
02084325
02166720
02241732
02238771
00451207
APO-TIMOP
GEN-TIMOLOL
NOVO-TIMOL
PMS-TIMOLOL
MED-TIMOLOL
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
0.5%/4% OPHTHALMIC SOLUTION
01905090
TIMPILO
132
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
MCL
$
0.2676
0.2676
0.2676
0.2676
0.2676
0.2684
0.7451
PMS
PMS
$
0.0911
0.0912
PMS
TCH
$
0.0158
0.0158
JAN
$
0.3733
JAN
$
0.3727
AXC
$
0.2214
SLV
$
0.1812
ORG
$
0.2670
LOPERAMIDE HCL
* 2MG CAPLET
02132591
02212005
02228343
02228351
02233998
02229552
02183862
NOVO-LOPERAMIDE
APO-LOPERAMIDE
LOPERACAP
PMS-LOPERAMIDE
RHOXAL-LOPERAMIDE
DIARR-EZE
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
N
667MG/ML SYRUP
00703486
00854409
PMS-LACTULOSE (EDS)
ACILAC (EDS)
56:16.00 DIGESTANTS
PANCRELIPASE (LIPASE/AMYLASE/PROTEASE)
4000U/12000U/12000U CAPSULE CONTAINING
ENTERIC COATED PARTICLES
00789445
PANCREASE MT 4
4000U/20000U/25000U CAPSULE CONTAINING
ENTERIC COATED PARTICLES
00591548
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
134
56:00 GASTROINTESTINAL DRUGS
56:16.00 DIGESTANTS
8000U/30000U/30000U CAPSULE CONTAINING
ENTERIC COATED PARTICLES
00502790
COTAZYM ECS 8
ORG
$
0.3662
JAN
$
0.9329
SLV
$
0.2897
AXC
$
0.4275
JAN
$
1.4925
ORG
$
0.9456
AXC
$
0.7503
SLV
$
0.8597
SLV
$
0.9049
AXC
$
0.2303
AXC
$
0.3470
AXC
$
0.4951
APX
NOP
HOR
$
0.0138
0.0408
0.1313
HOR
$
0.0740
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
25000U/74000U/62500U CAPSULE CONTAINING
ENTERIC COATED PARTICLES
01985205
CREON 25
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
135
56:00 GASTROINTESTINAL DRUGS
56:22.00 ANTI-EMETICS
* 50MG/ML INJECTION SOLUTION (5ML)
00392537
00013579
DIMENHYDRINATE IM
GRAVOL
SAB
HOR
$
3.2600
4.4100
HOR
$
0.5100
HOR
$
0.5328
DUI
$
1.3020
PFC
$
2.6040
NVR
$
3.8000
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
56:40.00 MISCELLANEOUS GASTROINTESTINAL DRUGS
BUDESONIDE
SEE APPENDIX A FOR EDS CRITERIA
3MG CONTROLLED ILEAL RELEASE CAPSULE
02229293
ENTOCORT (EDS)
AST
$
1.6058
DOM
APX
TCH
NOP
NXP
GPM
PMS
GSK
$
0.0435 *
0.0934
0.0934
0.0934
0.0934
0.0934
0.0934
0.4003
DOM
TCH
APX
NOP
NXP
GPM
PMS
GSK
$
0.0682 *
0.1465
0.1465
0.1465
0.1465
0.1465
0.1465
0.6548
CIMETIDINE
* 300MG TABLET
02231287
00487872
00546240
00582417
00865818
02227444
02229718
01916815
DOM-CIMETIDINE
APO-CIMETIDINE
PEPTOL
NOVO-CIMETINE
NU-CIMET
GEN-CIMETIDINE
PMS-CIMETIDINE
TAGAMET
* 400MG TABLET
02231288
00568449
00600059
00603678
00865826
02227452
02229719
01916785
DOM-CIMETIDINE
PEPTOL
APO-CIMETIDINE
NOVO-CIMETINE
NU-CIMET
GEN-CIMETIDINE
PMS-CIMETIDINE
TAGAMET
136
56:00 GASTROINTESTINAL DRUGS
56:40.00 MISCELLANEOUS GASTROINTESTINAL DRUGS
* 600MG TABLET
02231290
00584282
00600067
00603686
00865834
02227460
02229720
01916777
DOM-CIMETIDINE
PEPTOL
APO-CIMETIDINE
NOVO-CIMETINE
NU-CIMET
GEN-CIMETIDINE
PMS-CIMETIDINE
TAGAMET
DOM
TCH
APX
NOP
NXP
GPM
PMS
GSK
$
0.0870 *
0.1867
0.1867
0.1867
0.1867
0.1867
0.1867
0.7610
APX
$
0.1220
DOM
ALT
APX
NOP
TCH
NXP
PMS
FTP
JAN
$
0.0627 *
0.1624
0.1624
0.1624
0.1624
0.1624
0.1624
0.1624
0.2578
NXP
APX
NOP
GPM
ICN
RHO
ALT
MSD
$
0.4028 *
0.6398
0.6398
0.6398
0.6398
0.6398
0.6398
1.0153
NXP
APX
NOP
GPM
ICN
RHO
ALT
MSD
$
0.7208 *
1.1514
1.1514
1.1514
1.1514
1.1514
1.1514
1.8461
ABB
$
2.1700
ABB
$
2.1700
60MG/ML ORAL LIQUID
02243085
APO-CIMETIDINE
DOMPERIDONE MALEATE
* 10MG TABLET
02238315
01912070
02103613
02157195
02230473
02231477
02236466
02238444
00855820
DOM-DOMPERIDONE
ALTI-DOMPERIDONE MALEATE
APO-DOMPERIDONE
NOVO-DOMPERIDONE
MOTILIDONE
NU-DOMPERIDONE
PMS-DOMPERIDONE
FTP-DOMPERIDONE MALEATE
MOTILIUM
FAMOTIDINE
* 20MG TABLET
02024195
01953842
02022133
02196018
02237148
02240622
02242327
00710121
NU-FAMOTIDINE
APO-FAMOTIDINE
NOVO-FAMOTIDINE
GEN-FAMOTIDINE
ULCIDINE
RHOXAL-FAMOTIDINE
ALTI-FAMOTIDINE
PEPCID
* 40MG TABLET
02024209
01953834
02022141
02196026
02237149
02240623
02242328
00710113
NU-FAMOTIDINE
APO-FAMOTIDINE
NOVO-FAMOTIDINE
GEN-FAMOTIDINE
ULCIDINE
RHOXAL-FAMOTIDINE
ALTI-FAMOTIDINE
PEPCID
LANSOPRAZOLE
SEE APPENDIX A FOR EDS CRITERIA
15MG DELAYED RELEASE CAPSULE
02165503
PREVACID (EDS)
30MG DELAYED RELEASE CAPSULE
02165511
PREVACID (EDS)
137
56:00 GASTROINTESTINAL DRUGS
56:40.00 MISCELLANEOUS GASTROINTESTINAL DRUGS
LANSOPRAZOLE/CLARITHROMYCIN/AMOXICILLIN
SEE APPENDIX A FOR EDS CRITERIA
30MG/500MG/500MG 7-DAY PACKAGE
02238525
HP-PAC (EDS)
ABB
$
79.8600
PMS
$
0.0604
APX
NXP
PMS
WYA
$
0.0633
0.0633
0.0633
0.1845
PMS
$
0.0291
PHU
$
0.2952
PHU
$
0.4914
PMS
APX
NOP
LIL
$
0.5737
0.5737
0.5737
0.9106
PMS
APX
NOP
LIL
$
1.0395
1.0395
1.0395
1.6499
PHU
$
0.5176
AST
$
1.8988
AST
$
2.3900
METOCLOPRAMIDE HCL
5MG TABLET
02230431
PMS-METOCLOPRAMIDE
* 10MG TABLET
00842834
02143283
02230432
02043521
APO-METOCLOP
NU-METOCLOPRAMIDE
PMS-METOCLOPRAMIDE
REGLAN
1MG/ML ORAL SOLUTION
02230433
PMS-METOCLOPRAMIDE
MISOPROSTOL
100UG TABLET
00813966
CYTOTEC
200UG TABLET
00632600
CYTOTEC
NIZATIDINE
* 150MG CAPSULE
02177714
02220156
02240457
00778338
PMS-NIZATIDINE
APO-NIZATIDINE
NOVO-NIZATIDINE
AXID
* 300MG CAPSULE
02177722
02220164
02240458
00778346
PMS-NIZATIDINE
APO-NIZATIDINE
NOVO-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)
138
56:00 GASTROINTESTINAL DRUGS
56:40.00 MISCELLANEOUS GASTROINTESTINAL DRUGS
PANTOPRAZOLE
SEE APPENDIX A FOR EDS CRITERIA
40MG ENTERIC TABLET
02229453
PANTOLOC (EDS)
SLV
$
2.0615
NXP
APX
NOP
ALT
GPM
MED
PMS
GSK
$
0.1590 *
0.4386
0.4386
0.4386
0.4386
0.4386
0.4386
1.1885
NXP
APX
NOP
ALT
GPM
MED
PMS
GSK
$
0.3074 *
0.8449
0.8449
0.8449
0.8449
0.8449
0.8449
2.2373
GSK
$
0.2023
NXP
NOP
APX
PMS
DOM
AVT
$
0.1484 *
0.3192
0.3192
0.3192
0.3352
0.5578
AVT
$
0.1014
PMS
ALT
PHU
$
0.0907
0.0907
0.2433
PMS
ALT
ICN
PHU
$
0.1177
0.1177
0.2643
0.3832
RANITIDINE
* 150MG TABLET
00865737
00733059
00828564
00828823
02207761
02219077
02242453
02212331
NU-RANIT
APO-RANITIDINE
NOVO-RANIDINE
ALTI-RANITIDINE
GEN-RANITIDINE
MED-RANITIDINE
PMS-RANITIDINE
ZANTAC
* 300MG TABLET
00865745
00733067
00828556
00828688
02207788
02219085
02242454
00641790
NU-RANIT
APO-RANITIDINE
NOVO-RANIDINE
ALTI-RANITIDINE
GEN-RANITIDINE
MED-RANITIDINE
PMS-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
SULFASALAZINE (SALICYLAZOSULFAPYRIDINE)
* 500MG TABLET
00598461
00685933
02064480
PMS-SULFASALAZINE
ALTI-SULFASALAZINE
SALAZOPYRIN
* 500MG ENTERIC TABLET
00598488
00685925
00445126
02064472
PMS-SULFASALAZINE
ALTI-SULFASALAZINE
S.A.S. 500
SALAZOPYRIN
139
56:00 GASTROINTESTINAL DRUGS
56:40.00 MISCELLANEOUS GASTROINTESTINAL DRUGS
5-AMINOSALICYLIC ACID
250MG DELAYED RELEASE TABLET
02099675
N
PENTASA
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
400MG ENTERIC COATED TABLET
02171929
01997580
NOVO-5-ASA
ASACOL
500MG DELAYED RELEASE TABLET
02099683
N
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
N
SALOFALK
1.0G SUPPOSITORY
02242146
02153564
SALOFALK
PENTASA
140
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
$
1.3652
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
142
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
$
8.8700
14.1900
NVR
$
56.9700
MSD
$
0.5315
MSD
$
0.7968
HOR
$
0.6838
2G/VIAL POWDER FOR SOLUTION
01981250
DESFERAL (EDS)
PENICILLAMINE
125MG CAPSULE
00497894
CUPRIMINE
250MG CAPSULE
00016055
CUPRIMINE
250MG TABLET
00511641
DEPEN
144
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
146
68:00 HORMONES AND SUBSTITUTES
68:04.00 ADRENAL CORTICOSTEROIDS
BECLOMETHASONE DIPROPIONATE
* 50UG/INHALATION AEROSOL (PACKAGE)
00374407
00872334
VANCERIL INHALER
ALTI-BECLOMETHASONE
SCH
ALT
$
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
147
68:00 HORMONES AND SUBSTITUTES
68:04.00 ADRENAL CORTICOSTEROIDS
DEXAMETHASONE
* 0.5MG TABLET
00295094
01964976
02240684
DEXASONE
PMS-DEXAMETHASONE
ALTI-DEXAMETHASONE
ICN
PMS
ALT
$
0.2138
0.2138
0.2138
DEXASONE
PMS-DEXAMETHASONE
ALTI-DEXAMETHASONE
ICN
PMS
ALT
$
0.4883
0.4883
0.4883
PMS-DEXAMETHASONE
ALTI-DEXAMETHASONE
DEXASONE
PMS
ALT
ICN
$
0.8326
0.8326
0.8329
SAB
CYT
PMS
$
9.1700
9.1700
16.2800
RBP
$
0.2355
GSK
$
14.3300
GSK
$
23.7700
GSK
$
39.0600
GSK
$
78.1200
$
14.3300
$
23.7700
$
39.0600
GSK
$
78.1200
PHU
$
0.1468
PHU
$
0.2653
* 0.75MG TABLET
00285471
01964968
02240685
* 4MG TABLET
01964070
02240687
00489158
DEXAMETHASONE 21-PHOSPHATE
* 4MG/ML INJECTION SOLUTION (5ML)
00664227
01977547
00751863
DEXAMETHASONE SOD PHO INJ
DEXAMETHASONE SOD PHO INJ
PMS-DEXAMETHASONE SOD PHO
FLUDROCORTISONE ACETATE
0.1MG TABLET
02086026
FLORINEF
FLUTICASONE PROPIONATE
25UG/INHALATION AEROSOL (PACKAGE)
02213583
FLOVENT
50UG/INHALATION AEROSOL (PACKAGE)
02213591
FLOVENT
125UG/INHALATION AEROSOL (PACKAGE)
02213605
FLOVENT
250UG/INHALATION AEROSOL (PACKAGE)
02213613
FLOVENT
50UG/DOSE POWDER FOR INHALATION (PACKAGE)
02237244
FLOVENT DISKUS
GSK
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
HYDROCORTISONE
10MG TABLET
00030910
CORTEF
20MG TABLET
00030929
CORTEF
148
68:00 HORMONES AND SUBSTITUTES
68:04.00 ADRENAL CORTICOSTEROIDS
HYDROCORTISONE SODIUM SUCCINATE
100MG INJECTION POWDER
00030600
SOLU-CORTEF
PHU
$
3.4800
PHU
$
6.0500
PHU
$
0.3529
PHU
$
1.0182
PHU
$
5.1000
PHU
$
9.7700
AVT
$
0.1041
WINPRED
APO-PREDNISONE
ICN
APX
$
0.1123
0.1123
APO-PREDNISONE
NOVO-PREDNISONE
APX
NOP
$
0.0098
0.0162
APX
NOP
$
0.1091
0.1760
ARISTOCORT
STI
$
0.3041
ARISTOCORT
STI
$
0.5246
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
02230619
PEDIAPRED
PREDNISONE
* 1MG TABLET
00271373
00598194
* 5MG TABLET
00312770
00021695
* 50MG TABLET
00550957
00232378
APO-PREDNISONE
NOVO-PREDNISONE
TRIAMCINOLONE
2MG TABLET
02194082
4MG TABLET
02194090
149
68:00 HORMONES AND SUBSTITUTES
68:04.00 ADRENAL CORTICOSTEROIDS
TRIAMCINOLONE ACETONIDE
200UG/DOSE INHALATION AEROSOL (PACKAGE)
01926314
AZMACORT
AVT
$
17.3600
SAB
WSD
$
12.9400
15.9400
CYT
SAB
WSD
$
5.5600
5.8048
7.4000
STI
$
6.7000
SAW
$
0.7733
SAW
$
1.1474
SAW
$
1.8336
CYT
PHU
$
18.4000
25.1900
THM
$
5.3000
ORG
$
1.0199
* 10MG/ML INJECTION SUSPENSION (5ML)
02229540
01999761
TRIAMCINOLONE ACETONIDE
KENALOG 10
* 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
150
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
$
11.7800
12.7300
JAN
ORG
$
11.7800
12.7300
PHU
$
12.2700
PHU
$
13.1200
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
N
0.03MG/0.15MG (21 TABLET)
02042541
02042487
N
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
N
00707600
02043726
N
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
151
68:00 HORMONES AND SUBSTITUTES
68:12.00 CONTRACEPTIVES
ETHINYL ESTRADIOL/NORETHINDRONE
N
0.035MG/0.5MG (21 TABLET)
02187086
00317047
N
BREVICON
ORTHO 0.5/35
PHU
JAN
$
11.2500
11.7800
PHU
JAN
$
11.2500
11.7800
JAN
$
11.7800
JAN
$
11.7800
PHU
$
11.0900
PHU
$
11.0900
PHU
PHU
JAN
$
7.6000
11.2500
11.7800
PHU
PHU
JAN
$
7.6000
11.2500
11.7800
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
N
02197502
02189054
00372846
N
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
152
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
$
11.7800
JAN
$
11.7800
JAN
$
11.7800
JAN
$
11.7800
WYA
$
480.0000
BEX
$
314.6500
JAN
$
11.7800
JAN
$
11.7800
ICN
WYA
$
0.0862
0.1151
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
$
0.3783
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
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
68:16.00 ESTROGENS
CONJUGATED ESTROGENS
N
0.3MG TABLET
02230891
02043394
N
0.625MG TABLET
00587281
00265470
02043408
N
PMS-CONJUGATED ESTROGENS
C.E.S.
PREMARIN
0.9MG TABLET
02230892
02043416
N
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
153
68:00 HORMONES AND SUBSTITUTES
68:16.00 ESTROGENS
CONJUGATED ESTROGENS/MEDROXYPROGESTERONE
ACETATE
0.625MG/2.5MG TABLET (PACKAGE)
02242878
PREMPLUS
WYA
$
7.6000
ESTRACE
RBP
$
0.1113
ESTRACE
RBP
$
0.2149
ESTRACE
RBP
$
0.3792
SCH
$
19.4800
PHU
$
65.1000
$
19.8000
21.1600
$
19.8000
$
21.1600
21.1600
21.1600
21.1600
$
22.7100
$
23.8700
23.8700
23.8700
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
N
ESTRING
25UG TRANSDERMAL THERAPEUTIC SYSTEM (PKG)
00756849
02237807
ESTRADERM (EDS)
OESCLIM (EDS)
NVR
PMS
37.5UG TRANSDERMAL THERAPEUTIC SYSTEM (PKG)
02204401
N
VIVELLE (EDS)
NVR
50UG TRANSDERMAL THERAPEUTIC SYSTEM (PKG)
00756857
02204428
02231509
02237808
ESTRADERM (EDS)
VIVELLE (EDS)
CLIMARA 50 (EDS)
OESCLIM (EDS)
NVR
NVR
BEX
PMS
75UG TRANSDERMAL THERAPEUTIC SYSTEM (PKG)
02204436
N
VIVELLE (EDS)
NVR
100UG TRANSDERMAL THERAPEUTIC SYSTEM (PKG)
00756792
02204444
02231510
ESTRADERM (EDS)
VIVELLE (EDS)
CLIMARA 100 (EDS)
NVR
NVR
BEX
ESTRADIOL & NORETHINDRONE ACETATE/ESTRADIOL
SEE APPENDIX A FOR EDS CRITERIA
50UG & 250UG/50UG TRANSDERMAL THERAPEUTIC
SYSTEM (8)
02108186
ESTRACOMB (EDS)
NVR
$
22.4100
THM
$
17.8600
ESTRADIOL VALERATE
10MG/ML OILY INJECTION SUSPENSION (5ML)
00029238
DELESTROGEN
154
68:00 HORMONES AND SUBSTITUTES
68:16.00 ESTROGENS
ESTRADIOL/NORETHINDRONE ACETATE
SEE APPENDIX A FOR EDS CRITERIA
50UG/140UG TRANSDERMAL THERAPEUTIC SYSTEM (8 )
02241835
ESTALIS (EDS)
NVR
$
23.6600
NVR
$
23.6600
PHU
$
0.1704
PHU
$
0.3043
PHU
$
0.4811
RBP
$
0.2329
STILBESTROL
RBP
$
0.2821
STILBESTROL
RBP
$
0.3069
LIL
$
1.6926
WYA
$
81.3800
SRO
$
55.9900
50UG/250UG TRANSDERMAL THERAPEUTIC SYSTEM (8 )
02241837
ESTALIS (EDS)
ESTROPIPATE (CALCULATED AS SODIUM
ESTRONE SULFATE)
0.625MG TABLET
02089793
OGEN
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 (10ML)
02168936
APL (EDS)
10000IU/VIAL INJECTION
01925679
PROFASI HP (EDS)
155
68:00 HORMONES AND SUBSTITUTES
68:20.08 ANTI-DIABETIC DRUGS (INSULINS-PORK)
INSULIN (ISOPHANE) PORK
100U/ML INJECTION SUSPENSION (10ML)
00514551
NPH ILETIN II PORK
LIL
$
19.7300
LIL
$
19.7300
LIL
$
19.7300
LIL
NOO
$
16.2900
16.8400
NOO
LIL
$
33.6700
33.7700
LIL
NOO
$
16.2900
16.8400
LIL
NOO
$
16.2900
16.8400
NOO
LIL
$
33.6700
33.7700
LIL
$
24.1500
LIL
$
48.3000
INSULIN (LENTE) PORK
100U/ML INJECTION SUSPENSION (10ML)
00514535
LENTE ILETIN II, PORK
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
N
100U/ML INJECTION SUSPENSION (10ML)
00587737
02024225
N
HUMULIN-N
NOVOLIN GE NPH
100U/ML INJECTION SUSPENSION (5X3ML)
02024268
01959239
NOVOLIN GE NPH PENFILL
HUMULIN-N CARTRIDGE
INSULIN (LENTE) HUMAN BIOSYNTHETIC
N
100U/ML INJECTION SUSPENSION (10ML)
00646148
02024241
HUMULIN-L
NOVOLIN GE LENTE
INSULIN (REGULAR) HUMAN BIOSYNTHETIC
N
100U/ML INJECTION SOLUTION (10ML)
00586714
02024233
N
HUMULIN-R
NOVOLIN GE TORONTO
100U/ML INJECTION SOLUTION (5X3ML)
02024284
01959220
NOVOLIN GE TORONTO PENFIL
HUMULIN-R CARTRIDGE
INSULIN (REGULAR) LISPRO
SEE APPENDIX A FOR EDS CRITERIA
100U/ML INJECTION SOLUTION (10ML)
02229704
HUMALOG (EDS)
100U/ML INJECTION SOLUTION (5X3ML)
02229705
HUMALOG CARTRIDGE (EDS)
156
68:00 HORMONES AND SUBSTITUTES
68:20.08 ANTI-DIABETIC DRUGS
(INSULINS-HUMAN BIOSYNTHETIC)
INSULIN (REGULAR/ISOPHANE) HUMAN BIOSYNTHETIC
100U/ML INJECTION SUSPENSION 10%/90%
(5X3ML)
02024292
N
02024306
01962655
N
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
N
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
N
100U/ML INJECTION SUSPENSION (10ML)
00733075
02024276
HUMULIN-U
NOVOLIN GE ULTRALENTE
LIL
NOO
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
100MG TABLET
02190893
PRANDASE
CHLORPROPAMIDE
100MG TABLET
00399302
APO-CHLORPROPAMIDE
* 250MG TABLET
00021350
00312711
NOVO-PROPAMIDE
APO-CHLORPROPAMIDE
157
68:00 HORMONES AND SUBSTITUTES
68:20.20 ANTI-DIABETIC DRUGS (ORAL HYPOGLYCEMICS)
GLYBURIDE
* 2.5MG TABLET
02020734
00720933
00808733
01900927
01913654
01913670
02084341
02236733
02234513
02224550
NU-GLYBURIDE
EUGLUCON
GEN-GLYBE
ALBERT-GLYBURIDE
APO-GLYBURIDE
NOVO-GLYBURIDE
MED-GLYBURIDE
PMS-GLYBURIDE
DOM-GLYBURIDE
DIABETA
NXP
PMS
GPM
ALT
APX
NOP
MED
PMS
DOM
AVT
$
0.0159 *
0.0427
0.0427
0.0427
0.0427
0.0427
0.0427
0.0427
0.0449
0.1144
NU-GLYBURIDE
EUGLUCON
GEN-GLYBE
APO-GLYBURIDE
NOVO-GLYBURIDE
MED-GLYBURIDE
PMS-GLYBURIDE
ALBERT-GLYBURIDE
DOM-GLYBURIDE
DIABETA
NXP
PMS
GPM
APX
NOP
MED
PMS
ALT
DOM
AVT
$
0.0223 *
0.0741
0.0741
0.0741
0.0741
0.0741
0.0741
0.0743
0.0778
0.2051
NXP
NOP
GPM
APX
PMS
ICN
MED
RHO
ZYP
ALT
DOM
AVT
$
0.0530 *
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
ALT
DOM
AVT
$
0.1484 *
0.2268
0.2268
0.2268
0.2268
0.2268
0.2268
0.2382
0.3025
* 5MG TABLET
02020742
00720941
00808741
01913662
01913689
02085887
02236734
01900935
02234514
02224569
METFORMIN
* 500MG TABLET
02162822
02045710
02148765
02167786
02223562
02229516
02230670
02233999
02242794
02242974
02229994
02099233
NU-METFORMIN
NOVO-METFORMIN
GEN-METFORMIN
APO-METFORMIN
PMS-METFORMIN
GLYCON
MED-METFORMIN
RHOXAL-METFORMIN
METFORMIN
ALTI-METFORMIN
DOM-METFORMIN
GLUCOPHAGE
* 850MG TABLET
02229517
02229656
02229785
02230475
02242589
02242793
02242931
02242726
02162849
NU-METFORMIN
GEN-METFORMIN
APO-METFORMIN
NOVO-METFORMIN
PMS-METFORMIN
METFORMIN
ALTI-METFORMIN
DOM-METFORMIN
GLUCOPHAGE
158
68:00 HORMONES AND SUBSTITUTES
68:20.20 ANTI-DIABETIC DRUGS (ORAL HYPOGLYCEMICS)
PIOGLITAZONE HCL
SEE APPENDIX A FOR EDS CRITERIA
15MG TABLET
02242572
ACTOS (EDS)
LIL
$
2.6691
LIL
$
2.9946
LIL
$
4.4834
GLUCONORM (EDS)
NOO
$
0.2713
GLUCONORM (EDS)
NOO
$
0.2821
GLUCONORM (EDS)
NOO
$
0.2930
AVANDIA (EDS)
GSK
$
1.3346
AVANDIA (EDS)
GSK
$
2.6691
AVANDIA (EDS)
GSK
$
2.9946
APX
$
0.0619
FEI
$
4.2500
FEI
$
8.4900
AVT
$
45.2200
NVR
$
26.5900
30MG TABLET
02242573
ACTOS (EDS)
45MG TABLET
02242574
ACTOS (EDS)
REPAGLINIDE
SEE APPENDIX A FOR EDS CRITERIA
0.5MG TABLET
02239924
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 (0.5ML)
01940376
CALTINE 50 (EDS)
100IU/ML INJECTION (1ML)
02007134
CALTINE 100 (EDS)
200IU/ML INJECTION
01926691
CALCIMAR (EDS)
200IU/DOSE NASAL SPRAY (BOTTLE)
02240775
MIACALCIN (EDS)
159
68:00 HORMONES AND SUBSTITUTES
68:28.00 PITUITARY AGENTS
COSYNTROPIN ZINC HYDROXIDE
1MG/ML INJECTION SUSPENSION (1ML)
00253952
SYNACTHEN DEPOT
NVR
$
23.0900
FEI
$
1.4341
FEI
$
2.8681
FEI
$
10.5300
FEI
$
51.2200
$
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
$
590.0400
DESMOPRESSIN
SEE APPENDIX A FOR EDS CRITERIA
0.1MG TABLET
00824305
D.D.A.V.P. (EDS)
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)
APX
FEI
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
N
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)
160
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
02229838
00708917
ALTI-MPA
NOVO-MEDRONE
GEN-MEDROXY
PROVERA
ALT
NOP
GPM
PHU
$
0.0862
0.0862
0.0862
0.1670
ALTI-MPA
NOVO-MEDRONE
GEN-MEDROXY
PROVERA
ALT
NOP
GPM
PHU
$
0.1703
0.1703
0.1703
0.3303
ALT
NOP
GPM
PHU
$
0.3439
0.3439
0.3439
0.6702
PHU
$
25.2400
PHU
$
27.0800
SCH
$
0.5410
* 5MG TABLET
02148560
02221292
02229839
00030937
* 10MG TABLET
02148579
02221306
02229840
00729973
ALTI-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)
161
68:00 HORMONES AND SUBSTITUTES
68:36.04 THYROID AGENTS
LEVOTHYROXINE (SODIUM)
0.025MG TABLET
02172062
SYNTHROID
KNO
$
0.0782
GSK
KNO
$
0.0431
0.0574
KNO
$
0.0843
KNO
$
0.0843
GSK
KNO
$
0.0332
0.0708
KNO
$
0.0890
KNO
$
0.0901
GSK
KNO
$
0.0369
0.0758
KNO
$
0.0966
GSK
KNO
$
0.0391
0.0809
GSK
KNO
$
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
162
68:00 HORMONES AND SUBSTITUTES
68:36.08 ANTITHYROID AGENTS
METHIMAZOLE
5MG TABLET
00015741
TAPAZOLE
LIL
$
0.1243
MSD
$
0.1243
MSD
$
0.1945
PROPYLTHIOURACIL
50MG TABLET
00010200
PROPYL-THYRACIL
100MG TABLET
00010219
PROPYL-THYRACIL
163
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
NEOTOPIC
NEOSPORIN
TCH
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
166
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
$
12.4800
TAR
BCD
$
0.2279
0.3531
BCD
$
0.2132
TAR
BCD
$
0.1899
0.2285
TAR
BCD
$
0.3798
0.4570
BCD
$
12.4800
WSD
$
6.0689
WSD
$
0.4630
MCL
$
0.4915
MCL
$
1.5764
MCL
$
12.6200
SDR
MCL
$
1.7940
3.6782
1% TOPICAL LOTION
02221810
LOPROX
CLOTRIMAZOLE
200MG VAGINAL TABLET
02150921
CANESTEN-3-COMBI-PAK
* 1% TOPICAL CREAM
00812382
02150867
CLOTRIMADERM
CANESTEN
1% TOPICAL SOLUTION
02150875
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
00703974
NIZORAL
MICONAZOLE NITRATE
100MG VAGINAL SUPPOSITORY
02084295
MONISTAT-7
100MG VAGINAL SUPPOSITORY/2% TOPICAL CREAM
(COMBINATION PACKAGE)
02126257
MONISTAT 7 COMBINATION
* 400MG VAGINAL OVULES
02171775
02126605
MICONAZOLE 3 DAY OVULE
MONISTAT-3
167
84:00 SKIN AND MUCOUS MEMBRANE PREPARATIONS
84:04.08 ANTI-INFECTIVES (ANTI-FUNGALS)
400MG VAGINAL OVULES/2% TOPICAL CREAM
(COMBINATION PACKAGE)
02126249
MONISTAT 3 COMBINATION
MCL
$
12.6200
TCH
MCL
$
0.1595
0.3153
MCL
$
0.3523
TCH
$
0.1519
TAR
TCH
PPZ
$
0.0760
0.1269
0.3038
TAR
TCH
PPZ
$
0.1556
0.1556
0.3038
TAR
PPZ
$
0.0534
0.0955
TCH
$
0.2771
WSD
$
0.4022
NVR
$
0.4883
NVR
$
0.4883
JAN
$
6.3364
JAN
$
19.0100
JAN
$
19.0100
JAN
$
19.0100
* 2% VAGINAL CREAM
02219476
02084309
MONAZOLE 7
MONISTAT-7
2% TOPICAL CREAM
02085852
MICATIN
NYSTATIN
100,000U VAGINAL TABLET
02194171
NILSTAT
* 100,000U/G TOPICAL CREAM
00716871
02194236
00029092
NYADERM
NILSTAT
MYCOSTATIN
* 100,000U/G TOPICAL OINTMENT
00716898
02194228
00029556
NYADERM
NILSTAT
MYCOSTATIN
* 25,000U/G VAGINAL CREAM
00716901
00295973
NYADERM
MYCOSTATIN
100,000U/G VAGINAL CREAM
02194163
NILSTAT
100,000U/G TOPICAL POWDER
02195704
CANDISTATIN
TERBINAFINE HCL
1% TOPICAL CREAM
02031094
LAMISIL
1% TOPICAL SPRAY SOLUTION
02238703
LAMISIL
TERCONAZOLE
80MG VAGINAL OVULES
00894710
TERAZOL-3
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
168
84:00 SKIN AND MUCOUS MEMBRANE PREPARATIONS
84:04.12 ANTI-INFECTIVES (SCABICIDES AND PEDICULICIDES)
CROTAMITON
10% TOPICAL CREAM
00623377
EURAX
NVC
$
0.4471
MED
$
17.3600
PMS
$
0.0792
PMS
ODN
$
0.0792
0.0999
RCA
PFC
$
0.1129
1.3528
GSK
$
0.4991
RCA
$
0.2843
RCA
$
0.1027
SAW
$
0.0620
GAC
$
0.6304
GAC
$
0.5354
DER
$
0.5357
RHO
$
0.4796
MDA
$
0.2752
RHO
$
0.2189
ESDEPALLATHRIN/PIPERONYL BUTOXIDE
0.63%/5.04% AEROSOL
02229874
SCABENE
GAMMA-BENZENE HEXACHLORIDE
1% TOPICAL LOTION
00703591
PMS-LINDANE
* 1% SHAMPOO
00703605
00430617
PMS-LINDANE
HEXIT SHAMPOO
PERMETHRIN
* 1% CREME RINSE
02231480
00771368
KWELLADA-P CREME RINSE
NIX 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
84:04.16 MISCELLANEOUS ANTI-INFECTIVES
HEXACHLOROPHENE
3% TOPICAL EMULSION
02017733
PHISOHEX
METRONIDAZOLE
0.75% TOPICAL GEL
02013223
METROGEL
0.75% TOPICAL CREAM
02226839
METROCREAM
1% TOPICAL CREAM
02156091
NORITATE
500MG VAGINAL TABLET
01926888
FLAGYL
0.75% VAGINAL GEL
02125226
NIDAGEL
10% VAGINAL CREAM
01926861
FLAGYL
169
84:00 SKIN AND MUCOUS MEMBRANE PREPARATIONS
84:04.16 MISCELLANEOUS ANTI-INFECTIVES
POVIDONE-IODINE
200MG VAGINAL SUPPOSITORY
00026050
BETADINE
PFR
$
0.7595
PFR
ROG
$
0.1034
0.1177
PFR
$
0.0445
$
0.5074
$
0.3045
* 10% VAGINAL GEL
00026034
00026611
BETADINE
PROVIODINE
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 APPROXIMAT
RELATIVE POTENCIES OF TOPICAL STEROID PREPARATIONS, RELATIV
RATES OF PENETRATION IN DIFFERENT ANATOMICAL SITES AN
SUGGESTED GUIDELINES FOR TOPICAL STEROID THERAPY
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
170
84:00 SKIN AND MUCOUS MEMBRANE PREPARATIONS
84:06.00 ANTI-INFLAMMATORY AGENTS
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
TCH
TAR
$
0.2337
0.2337
0.2337
SCH
TCH
TAR
$
0.2149
0.2149
0.2149
SCH
TCH
$
0.5628
0.5628
SCH
TCH
$
0.5628
0.5628
SCH
TCH
$
0.5083
0.5083
SCH
$
0.7697
SCH
$
0.6507
RBP
$
8.6300
* 0.05% TOPICAL OINTMENT
00344923
00805009
01944436
DIPROSONE
TOPISONE
TARO-SONE
* 0.05% TOPICAL LOTION
00417246
00809187
01944444
DIPROSONE
TOPISONE
TARO-SONE
* 0.05% TOPICAL GLYCOL CREAM
00688622
00849650
DIPROLENE
TOPILENE GLYCOL
* 0.05% TOPICAL GLYCOL OINTMENT
00629367
00849669
DIPROLENE
TOPILENE GLYCOL
* 0.05% TOPICAL GLYCOL LOTION
00862975
01927914
DIPROLENE
TOPILENE GLYCOL
BETAMETHASONE DIPROPIONATE/
SALICYLIC ACID
0.05%/3% TOPICAL OINTMENT
00578436
DIPROSALIC
0.05%/2% TOPICAL LOTION
00578428
DIPROSALIC
BETAMETHASONE DISODIUM PHOSPHATE
5MG/100ML ENEMA (100ML)
02060884
BETNESOL ENEMA
171
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.
172
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.
173
ULTRA
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
HIGH
POTENCY
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
174
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
nd
Therapeutics, 2 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
175
84:00 SKIN AND MUCOUS MEMBRANE PREPARATIONS
84:06.00 ANTI-INFLAMMATORY AGENTS
BETAMETHASONE VALERATE
* 0.05% TOPICAL CREAM
00027898
00535427
00716618
CELESTODERM-V/2
ECTOSONE MILD
BETADERM
SCH
TCH
TAR
$
0.0167
0.0167
0.0167
SCH
TCH
TAR
$
0.0248
0.0248
0.0248
SCH
TAR
$
0.0167
0.0167
SCH
TAR
$
0.0248
0.0248
TCH
$
0.2062
TCH
RBP
$
0.2713
0.3961
SCH
TCH
TAR
$
0.0927
0.0927
0.0927
AST
$
8.3600
TCH
GPM
NOP
PMS
GSK
$
0.4414
0.4414
0.4414
0.4414
0.8131
NOP
GPM
PMS
GSK
$
0.4413
0.4414
0.4414
0.8131
GPM
PMS
TCH
GSK
$
0.3868
0.3868
0.3871
0.7834
* 0.1% TOPICAL CREAM
00027901
00535435
00716626
CELESTODERM-V
ECTOSONE REGULAR
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
ECTOSONE MILD
* 0.1% TOPICAL LOTION
00750050
02100193
ECTOSONE
BETNOVATE
* 0.1% SCALP LOTION
00027944
00653217
00716634
VALISONE
ECTOSONE
BETADERM
BUDESONIDE
0.02MG/ML ENEMA (100ML)
02052431
ENTOCORT
CLOBETASOL PROPIONATE
* 0.05% TOPICAL CREAM
01910272
02024187
02093162
02232191
02213265
DERMASONE
GEN-CLOBETASOL
NOVO-CLOBETASOL
PMS-CLOBETASOL
DERMOVATE
* 0.05% TOPICAL OINTMENT
02126192
02026767
02232193
02213273
NOVO-CLOBETASOL
GEN-CLOBETASOL
PMS-CLOBETASOL
DERMOVATE
* 0.05% SCALP APPLICATION
02216213
02232195
01910299
02213281
GEN-CLOBETASOL
PMS-CLOBETASOL
DERMASONE
DERMOVATE
176
84:00 SKIN AND MUCOUS MEMBRANE PREPARATIONS
84:06.00 ANTI-INFLAMMATORY AGENTS
CLOBETASONE BUTYRATE
0.05% TOPICAL CREAM
02214415
EUMOVATE
GSK
$
0.4774
GSK
$
0.4774
GAC
$
0.3147
GAC
$
0.3147
GAC
$
0.1574
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
0.05% TOPICAL OINTMENT
00456551
EUMOVATE
DESONIDE
0.05% TOPICAL CREAM
02048639
DESOCORT
0.05% TOPICAL OINTMENT
02115522
DESOCORT
0.05% TOPICAL LOTION
02115514
DESOCORT
DESOXIMETASONE
* 0.05% TOPICAL CREAM
02239068
02221918
DESOXI
TOPICORT MILD
* 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
177
84:00 SKIN AND MUCOUS MEMBRANE PREPARATIONS
84:06.00 ANTI-INFLAMMATORY AGENTS
0.01% TOPICAL OIL
00873292
DERMA-SMOOTHE/FS
HDI
$
0.2346
GAC
$
0.2575
OPT
MDC
$
0.5007
0.5010
OPT
MDC
$
0.3711
0.5561
OPT
MDC
$
0.3657
0.5489
MDC
$
0.6041
WSD
$
0.5650
WSD
$
0.5180
WSD
$
0.4356
WSD
$
0.7986
WSD
$
0.7986
SDR
TAR
SCP
$
0.1310
0.1628
0.2301
SCH
TAR
SDR
STI
$
0.0198
0.0198
0.0222
0.1718
STI
$
0.2344
0.01% SHAMPOO
02242738
CAPEX SHAMPOO
FLUOCINONIDE
* 0.05% TOPICAL CREAM
00716863
02161923
LYDERM
LIDEX
* 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
178
84:00 SKIN AND MUCOUS MEMBRANE PREPARATIONS
84:06.00 ANTI-INFLAMMATORY AGENTS
* 0.5% TOPICAL OINTMENT
00716685
00513261
CORTODERM
CORTATE
TAR
SCP
$
0.1628
0.2301
SCH
TAR
$
0.0212
0.0212
SCP
$
0.1817
STI
STI
$
0.0938
0.1587
STI
STI
$
0.1812
0.2099
STI
$
0.1985
ICN
AXC
$
5.5800
6.5700
RCA
$
80.5400
OPT
WSD
$
0.1809
0.2583
OPT
WSD
$
0.1809
0.2583
STI
$
0.1747
STI
$
0.0970
SCH
$
0.6938
SCH
$
0.6938
SCH
$
0.5397
* 1% TOPICAL OINTMENT
00502197
00716693
CORTATE
CORTODERM
0.5% TOPICAL LOTION
00513253
N
00578541
00192600
N
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
02242984
01910124
HYDROVAL
WESTCORT
* 0.2% TOPICAL OINTMENT
02242985
01910132
HYDROVAL
WESTCORT
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
179
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
$
1.2556
1.4122
* 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
SCH
$
0.6706
LEO
$
0.7595
WSD
$
0.5614
TAR
WSD
$
0.4594
0.7943
WSD
$
0.5614
TAR
WSD
$
0.4594
0.7943
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
180
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
STI
DER
JAN
$
0.3082
0.3082
0.3863
STI
DER
JAN
$
0.3082
0.3082
0.3748
* 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 APPROVE
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
TRETINOIN
SEE APPENDIX A FOR EDS CRITERIA
* 0.01% TOPICAL CREAM
00657204
01926497
00897329
STIEVA-A
VITAMIN A ACID
RETIN A
* 0.01% TOPICAL GEL
00587958
01926462
00870013
STIEVA-A
VITAMIN A ACID
RETIN A
181
84:00 SKIN AND MUCOUS MEMBRANE PREPARATIONS
84:16.00 CELL STIMULANTS AND PROLIFERANTS
* 0.025% TOPICAL CREAM
00578576
01926500
00897310
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
$
0.1932
STI
DER
JAN
$
0.3082
0.3082
0.3748
STI
DER
$
0.3082
0.3082
STI
$
0.1932
STI
DER
JAN
$
0.3082
0.3082
0.3863
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
* 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)
84:28.00 KERATOLYTIC AGENTS
BENZOYL PEROXIDE
10% BAR
00527661
PANOXYL
* 10% TOPICAL LOTION
00432938
00370568
OXYDERM
BENOXYL
* 20% TOPICAL LOTION
00187585
00374318
N
10% WASH
01908901
01925199
10% TOPICAL GEL (ACETONE BASE)
00406848
N
ACETOXYL
10% TOPICAL GEL (ALCOHOL BASE)
00263699
02220385
PANOXYL-10
BENZAGEL
182
84:00 SKIN AND MUCOUS MEMBRANE PREPARATIONS
84:28.00 KERATOLYTIC AGENTS
N
10% TOPICAL GEL (AQUEOUS BASE)
01908871
01925997
02223856
01912437
DESQUAM-X
BENZAC-W
PANOXYL AQUAGEL
BENZAC AC
WSD
GAC
STI
GAC
$
0.1068
0.1453
0.1492
0.1519
STI
$
0.1806
STI
$
0.1945
STI
$
0.1945
MED
$
0.2437
MED
$
0.2570
MED
$
0.3038
MED
$
0.3318
MED
$
0.3501
PMS
CDX
$
34.4000
40.1500
15% TOPICAL GEL (ALCOHOL BASE)
00403571
PANOXYL-15
20% TOPICAL GEL (ALCOHOL BASE)
00373036
PANOXYL-20
20% TOPICAL GEL (AQUEOUS BASE)
02223864
PANOXYL AQUAGEL
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
PODOFILOX
N
0.5% TOPICAL SOLUTION (PACKAGE)
02074788
01945149
WARTEC
CONDYLINE
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
DBU
WYA
$
0.7747
1.0908
25MG CAPSULE
02070863
SORIATANE (EDS)
AMETHOPTERIN
* 2.5MG TABLET
02182963
02170698
METHOTREXATE
METHOTREXATE
183
84:00 SKIN AND MUCOUS MEMBRANE PREPARATIONS
84:36.00 MISCELLANEOUS SKIN & MUCOUS MEMBRANE
AGENTS
CALCIPOTRIOL
50UG/G TOPICAL CREAM
02150956
DOVONEX
LEO
$
0.7568
LEO
$
0.7568
LEO
$
0.7568
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
ICN
$
0.4601
HLR
$
1.7903
HLR
$
3.6529
ALL
$
1.3964
ALL
$
1.3964
25MG CAPSULE
00950793
NEORAL (EDS)
50MG CAPSULE
00950807
NEORAL (EDS)
100MG CAPSULE
00950815
NEORAL (EDS)
100MG/ML LIQUID
00950823
NEORAL (EDS)
FLUOROURACIL
5% TOPICAL CREAM
00330582
EFUDEX
ISOTRETINOIN
10MG CAPSULE
00582344
ACCUTANE
40MG CAPSULE
00582352
ACCUTANE
TAZAROTENE
0.05% TOPICAL GEL
02230784
TAZORAC
0.1% TOPICAL GEL
02230785
TAZORAC
184
84:00 SKIN AND MUCOUS MEMBRANE PREPARATIONS
84:50.06 DEPIGMENTING & PIGMENTING AGENTS
(PIGMENTING AGENTS)
METHOXSALEN
SEE APPENDIX A FOR EDS CRITERIA
N
10MG CAPSULE
00252654
00646237
01946374
N
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
185
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
00728179
URISPAS (EDS)
PMS
$
0.5360
NXP
APX
ICN
ALT
NOP
GPM
PMS
DOM
ALZ
$
0.0954 *
0.2697
0.2697
0.2697
0.2697
0.2697
0.2697
0.2831
0.4281
PMS
APX
ALZ
$
0.0675
0.0675
0.0964
DETROL (EDS)
PHU
$
0.9494
DETROL (EDS)
PHU
$
0.9494
OXYBUTYNIN CHLORIDE
* 5MG TABLET
02158590
02163543
02220059
02220067
02230394
02230800
02240550
02241285
01924761
NU-OXYBUTYN
APO-OXYBUTYNIN
OXYBUTYN
ALBERT OXYBUTYNIN
NOVO-OXYBUTYNIN
GEN-OXYBUTYNIN
PMS-OXYBUTYNIN
DOM-OXYBUTYNIN
DITROPAN
* 1MG/ML SYRUP
02223376
02231089
01924753
PMS-OXYBUTYNIN
APO-OXYBUTYNIN
DITROPAN
TOLTERODINE L-TARTRATE
SEE APPENDIX A FOR EDS CRITERIA
1MG TABLET
02239064
2MG TABLET
02239065
86:16.00 RESPIRATORY SMOOTH MUSCLE RELAXANTS
AMINOPHYLLINE
225MG SUSTAINED RELEASE TABLET
02014270
PHYLLOCONTIN
PFR
$
0.2158
PFR
$
0.2751
APX
$
0.0272
APX
$
0.0337
APX
$
0.0345
PFI
$
0.2453
PFI
$
0.2911
350MG SUSTAINED RELEASE TABLET
02014289
PHYLLOCONTIN-350
OXTRIPHYLLINE
100MG TABLET
00441724
APO-OXTRIPHYLLINE
200MG TABLET
00441732
APO-OXTRIPHYLLINE
300MG TABLET
00511692
APO-OXTRIPHYLLINE
400MG SUSTAINED RELEASE TABLET
00503436
CHOLEDYL-SA
600MG SUSTAINED RELEASE TABLET
00536709
CHOLEDYL-SA
188
86:00 SMOOTH MUSCLE RELAXANTS
86:16.00 RESPIRATORY SMOOTH MUSCLE RELAXANTS
10MG/ML SYRUP
00405310
ROUPHYLLINE
ROG
$
0.0112
PMS
PFI
$
0.0249
0.0363
AVT
$
0.1826
AVT
$
0.2048
APX
NOP
AST
$
0.1411
0.1411
0.2073
APX
NOP
RIV
AST
$
0.1465
0.1465
0.1823
0.2404
APX
NOP
MDA
RIV
BRI
AST
$
0.1519
0.1519
0.1747
0.2040
0.2811
0.2892
PFR
$
0.4959
PFR
$
0.6005
TCH
PMS
$
0.0038
0.0038
MDA
$
0.0208
* 20MG/ML ELIXIR
00792942
00476366
PMS-OXTRIPHYLLINE
CHOLEDYL
THEOPHYLLINE (ANHYDROUS)
50MG SUSTAINED RELEASE CAPSULE
01926616
SLO-BID
100MG SUSTAINED RELEASE CAPSULE
01926586
N
00692689
02230085
00460982
N
APO-THEO-LA
NOVO-THEOPHYL SR
THEO-DUR
200MG SUSTAINED RELEASE TABLET
00692697
02230086
00631701
00460990
N
SLO-BID
100MG SUSTAINED RELEASE TABLET
APO-THEO-LA
NOVO-THEOPHYL SR
THEOCHRON
THEO-DUR
300MG SUSTAINED RELEASE TABLET
00692700
02230087
01966278
00599905
00556742
00461008
APO-THEO-LA
NOVO-THEOPHYL SR
THEOLAIR-SR
THEOCHRON
QUIBRON-T/SR
THEO-DUR
400MG SUSTAINED RELEASE TABLET
02014165
UNIPHYL
600MG SUSTAINED RELEASE TABLET
02014181
UNIPHYL
* 5.33MG/ML ELIXIR
00532223
00575151
THEOPHYLLINE
PMS-THEOPHYLLINE
5.33MG/ML SOLUTION
01966219
THEOLAIR LIQUID
189
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
$
0.0196
WYA
$
5.9024
ICN
$
0.0154
ICN
$
0.0317
ODN
ICN
$
0.0429
0.0495
LEA
ICN
ODN
$
0.0234
0.0280
0.0320
LEA
ICN
$
0.0192
0.0620
SAB
ABB
$
13.5700
16.2500
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
THIAMINE HCL
* 50MG TABLET
00610267
00268631
VITAMIN B1
VITAMIN B1
* 100MG/ML INJECTION SOLUTION (10ML)
00816078
02241983
VITAMIN B1
BETAXIN
192
88:00 VITAMINS
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)
LEO
$
0.4438
LEO
$
1.3284
SAW
$
0.4202
HLR
$
0.9538
HLR
$
1.5169
HLR
$
3.0380
MSD
$
0.2177
1.0UG CAPSULE
00474525
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)
VITAMIN D
50,000IU CAPSULE
00009830
OSTOFORTE
193
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
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
ALT
NOP
APX
GSK
$
0.5879
0.5879
0.5879
0.5879
0.9331
ORP
$
1.4046
ALL
$
3.6890
40MG TABLET
02201038
FOSAMAX (EDS)
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
ALTI-AZATHIOPRINE
NOVO-AZATHIOPRINE
APO-AZATHIOPRINE
IMURAN
BETAINE ANHYDROUS
1G/SCOOP POWDER FOR ORAL SOLUTION
02238526
CYSTADANE
BOTULINUM TOXIN TYPE A
SEE APPENDIX A FOR EDS CRITERIA
100IU STERILE LYOPHILIZED POWDER (IU)
01981501
BOTOX (EDS)
196
92:00 UNCLASSIFIED THERAPEUTIC AGENTS
92:00.00 UNCLASSIFIED THERAPEUTIC AGENTS
BROMOCRIPTINE MESYLATE
* 5MG CAPSULE
02230454
02236949
00568643
APO-BROMOCRIPTINE
PMS-BROMOCRIPTINE
PARLODEL
APX
PMS
NVR
$
1.0537
1.0537
1.6726
APX
PMS
NVR
$
0.5917
0.5917
0.9391
AVT
$
101.7200
AVT
$
68.1400
PHU
$
13.7253
COLCHICINE
COLCHICINE-ODAN
ROG
ODN
$
0.0722
0.0722
COLCHICINE
COLCHICINE-ODAN
ROG
ODN
$
0.2051
0.2051
NVR
$
0.6637
NVR
$
1.5426
NVR
$
3.0073
NVR
$
6.0164
NVR
$
5.3480
WYA
$
0.4180
* 2.5MG TABLET
02087324
02231702
00371033
APO-BROMOCRIPTINE
PMS-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
00287873
00572349
* 1MG TABLET
00206032
00621374
CYCLOSPORINE (TRANSPLANT)
SEE APPENDIX A FOR EDS CRITERIA
10MG CAPSULE
02237671
NEORAL (EDS)
25MG CAPSULE
02150689
NEORAL (EDS)
50MG CAPSULE
02150662
NEORAL (EDS)
100MG CAPSULE
02150670
NEORAL (EDS)
100MG/ML LIQUID
02150697
NEORAL (EDS)
DISULFIRAM
250MG TABLET
02041375
ANTABUSE
197
92:00 UNCLASSIFIED THERAPEUTIC AGENTS
92:00.00 UNCLASSIFIED THERAPEUTIC AGENTS
DONEPEZIL HCL
SEE APPENDIX A FOR EDS CRITERIA
5MG TABLET
02232043
ARICEPT (EDS)
PFI
$
4.7849
PFI
$
4.7849
PGA
$
1.4224
PGA
$
39.8200
MSD
$
1.7686
TVM
$
34.6900
LIL
$
35.6500
AST
$
411.7500
$
861.1800
$
861.1800
10MG TABLET
02232044
ARICEPT (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
GLATIRAMER ACETATE
SEE APPENDIX J FOR EDS CRITERIA
20MG INJECTION (VIAL)
02233014
COPAXONE (EDS)
GLUCAGON
1MG INJECTION POWDER
00015377
GLUCAGON
GOSERELIN ACETATE
SEE APPENDIX A FOR EDS CRITERIA
3.6MG/SYRINGE
02049325
ZOLADEX (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
198
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
JAN
$
5.1538
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)
LEVAMISOLE
SEE APPENDIX A FOR EDS CRITERIA
50MG TABLET
00846368
ERGAMISOL (EDS)
199
92:00 UNCLASSIFIED THERAPEUTIC AGENTS
92:00.00 UNCLASSIFIED THERAPEUTIC AGENTS
LEVODOPA/BENZERAZIDE
50MG/12.5MG CAPSULE
00522597
PROLOPA
HLR
$
0.2767
HLR
$
0.4557
HLR
$
0.7650
ALT
NXP
APX
DUP
$
0.2745
0.2745
0.2745
0.4580
ALT
NXP
APX
DUP
$
0.4107
0.4107
0.4107
0.6839
ALT
NXP
APX
DUP
$
0.4585
0.4585
0.4585
0.7634
DUP
$
0.6746
DUP
$
1.2443
MSD
$
1.5190
MSD
$
2.2351
HLR
$
2.2373
HLR
$
4.4746
ICN
$
6.7325
100MG/25MG CAPSULE
00386464
PROLOPA
200MG/50MG CAPSULE
00386472
PROLOPA
LEVODOPA/CARBIDOPA
* 100MG/10MG TABLET
02126176
02182831
02195933
00355658
ENDO-LEVODOPA/CARBIDOPA
NU-LEVOCARB
APO-LEVOCARB
SINEMET
* 100MG/25MG TABLET
02126168
02182823
02195941
00513997
ENDO-LEVODOPA/CARBIDOPA
NU-LEVOCARB
APO-LEVOCARB
SINEMET
* 250MG/25MG TABLET
02126184
02182858
02195968
00328219
ENDO-LEVODOPA/CARBIDOPA
NU-LEVOCARB
APO-LEVOCARB
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
5MG CHEWABLE TABLET
02238216
SINGULAIR (EDS)
10MG TABLET
02238217
SINGULAIR (EDS)
MYCOPHENOLATE MOFETIL
SEE APPENDIX A FOR EDS CRITERIA
250MG CAPSULE
02192748
CELLCEPT (EDS)
500MG TABLET
02237484
CELLCEPT (EDS)
NABILONE
SEE APPENDIX A FOR EDS CRITERIA
1MG CAPSULE
00548375
CESAMET (EDS)
200
92:00 UNCLASSIFIED THERAPEUTIC AGENTS
92:00.00 UNCLASSIFIED THERAPEUTIC AGENTS
NAFARELIN ACETATE
SEE APPENDIX A FOR EDS CRITERIA
2MG/ML NASAL SOLUTION
02188783
SYNAREL (EDS)
FEI
$
303.8000
AVT
$
27.9700
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
ALZ
$
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
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)
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
201
92:00 UNCLASSIFIED THERAPEUTIC AGENTS
92:00.00 UNCLASSIFIED THERAPEUTIC AGENTS
RIFABUTIN
SEE APPENDIX A FOR EDS CRITERIA
150MG CAPSULE
02063786
MYCOBUTIN (EDS)
PHU
$
4.0500
PGA
$
1.8011
PGA
$
11.6638
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
$
0.4028 *
1.3726
1.3726
1.3726
1.3726
1.3726
1.5445
2.1793
RISEDRONATE SODIUM
SEE APPENDIX A FOR EDS CRITERIA
5MG TABLET
02242518
ACTONEL (EDS)
30MG TABLET
02239146
ACTONEL (EDS)
RIVASTIGMINE
SEE APPENDIX A FOR EDS CRITERIA
1.5MG CAPSULE
02242115
EXELON (EDS)
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)
202
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
AVT
PMS
APX
NXP
DOM
$
0.5258
0.5258
0.5258
0.5258
0.6562
AVT
$
42.8600
AVT
$
0.3521
FUJ
$
2.1339
FUJ
$
2.6583
FUJ
$
12.5500
FUJ
$
127.5000
BOE
$
1.0308
LIV
$
2.1700
PANECTYL
AVT
$
0.2256
PANECTYL
AVT
$
0.2805
AVT
$
0.0681
100MG CAPSULE
00500895
NALCROM (EDS)
* 10MG/ML INHALATION SOLUTION (2ML)
00534609
02046113
02231431
02231671
02145448
INTAL NEBULIZER SOLUTION
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
0.5MG/ML ORAL LIQUID
01926446
PANECTYL
203
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)
204
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 and prescribers 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
206
_____________________________________________
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.
Acilac - see lactulose
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 235.
Accolate - see zafirlukast
Actonel - see risedronate sodium
Actos - see pioglitazone HCl
Acular - see ketorolac tromethamine
Advair Diskus - see salmeterol xinafoate/fluticasone propionate
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.
Alertec - see modafinil
alfacalcidol, capsule, 0.25ug, 1ug (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.
Alti-CPA - see cyproterone acetate
Alti-Cyclobenzaprine - see cyclobenzaprine HCl
Alti-Minocycline - see minocycline HCl
Alti-Ticlopidine - see ticlopidine HCl
Amatine - see midodrine HCl
Amerge – see naratriptan HCl
amoxicillin trihydrate/potassium clavulanate, tablet, 875mg/125mg; oral
suspension, 25mg/6.25mg/mL, 50mg/12.5mg/mL, 40mg/5.3mg/mL,
80mg/11.4mg/mL (Clavulin-GSK)
* tablet, 250mg/125mg, 500mg/125mg (Clavulin-GSK) (Apo-Amoxi Clav-APX)
(a) For treatment of infections in patients with underlying lung disease not
responding to first-line antibiotics.
(b) For treatment of infections caused by organisms known to be resistant to
alternative antibiotics.
(c) For step-down care following hospital separation in patients treated with
intravenous 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).
Androcur - see cyproterone acetate
207
APL - see chorionic gonadotropin
Apo-Amoxi Clav - see amoxicillin trihydrate/potassium clavulanate
Apo-Carbamazepine CR - see carbamazepine
Apo-Cefaclor - see cefaclor
Apo-Cyclobenzaprine - see cyclobenzaprine HCl
Apo-Desmopressin - see desmopressin
Apo-Etodolac - see etodolac
Apo-Fenofibrate - see fenofibrate
Apo-Feno-Micro - see fenofibrate (micronized)
Apo-Fluconazole – see fluconazole
Apo-Ketoconazole - see ketoconazole
Apo-Ketotifen - see ketotifen fumarate
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
Aricept - see donepezil HCl
Aristospan - see triamcinolone/hexacetonide
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)
(a) For treatment of infections in patients with underlying lung disease not
responding to first-line antibiotics.
(b) For treatment of infections caused by organisms known to be resistant to
alternative antibiotics.
(c) For treatment of infections in patients allergic 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 treatment of chlamydia trachomatis infections.
(g) For step-down care following hospital separation in patients treated with
intravenous macrolides (guided by culture and sensitivity results).
azithromycin, tablet, 600mg (Zithromax-PFI)
For prevention of disseminated Mycobacterium avium complex (MAC) disease in
patients with advanced HIV infections.
baclofen, injection, 0.05mg/mL, 0.5mg/mL, 2mg/mL (Lioresal Intrathecal-NVR)
For treatment of severe spastic conditions in patients who do not respond or cannot
tolerate oral baclofen.
Betaseron - see Appendix J
208
bezafibrate, tablet, 200mg (pms-Bezafibrate-PMS); sustained release tablet, 400mg
(Bezalip SR-HLR)
For treatment of patients with hyperlipidemia who have failed to respond to
gemfibrozil or have experienced side effects with it.
Bezalip SR - see bezafibrate
Biaxin - 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.
Botox - see botulinum toxin type A
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)
For treatment of hyperprolactinemic disorders in patients not responding to, or
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.
209
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 .
calcitriol, capsule, 0.25ug, 0.5ug (Rocaltrol-HLR)
For management of hypocalcemia and clinical manifestations associated with
postsurgical 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)
(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)
(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).
(g) For treatment of uncomplicated gonorrhea.
210
cefprozil, tablet, 250mg, 500mg; suspension, 25mg/mL, 50mg/mL (Cefzil-BMY)
(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).
Ceftin - see cefuroxime axetil
cefuroxime axetil, tablet, 250mg, 500mg; suspension, 25mg/mL (Ceftin-GSK)
(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).
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) (APL-WYA)
(a) For treatment of habitual abortion.
(b) For treatment of delayed puberty.
Ciloxan - see ciprofloxacin
Cipro - see ciprofloxacin tablet
Cipro HC - see ciprofloxacin/hydrocortisone
211
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)
(a) For treatment of infections caused by pseudomonas aeruginosa.
(b) For treatment of infections in patients allergic to alternative antibiotics.
(c) For treatment of infections with organisms known to be resistant to alternative
antibiotics.
(d) For step-down care following hospital separation in patients treated with
intravenous antibiotics (guided by culture and sensitivity results).
(e) For prophylaxis of infection in immunocompromised patients.
(f) For treatment of genitourinary tract infections unresponsive to first-line antibiotics
or based on culture and sensitivity results.
(g) For treatment of gonorrhea.
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 (Biaxin-ABB)
(a) For treatment of infections in patients with underlying lung disease not
responding to first-line antibiotics.
(b) For treatment of infections caused by organisms known to be resistant to
alternative antibiotics.
(c) For treatment of infections in patients allergic 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 treatment and prophylaxis of Mycobacterium avium complex (MAC) in HIV
positive patients.
(g) For one week for eradication of H. pylori-related infections when used in
combination treatment regimens for the treatment of peptic ulcer disease.
(h) For step-down care following hospital separation in patients treated with
intravenous macrolides (guided by culture and sensitivity results).
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
212
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-MSD) (Apo-Cyclobenzaprine-APX)
(Novo-Cycloprine-NOP) (Nu-Cyclobenzaprine-NXP) (pms-Cyclobenzaprine-PMS)
(Alti-Cyclobenzaprine-ALT) (Gen-Cyclobenzaprine-GPM) (Med-CyclobenzaprineMED) (Flexitec-TCH) (Dom-Cyclobenzaprine-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) (Alti-CPA-ALT) (Gen-Cyproterone-GPM) (NovoCyproterone-NOP)
For treatment of hirsuitism.
213
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 (pms-Deferoxamine)
(Desferal-NVR); 2g/vial (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)
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
dihydroergotamine mesylate, nasal spray, 4mg/mL (Migranal-NVR)
For treatment of migraines where standard therapy such as an analgesic or oral
ergotamine product has failed or cannot be tolerated.
214
dipyridamole, tablet, 25mg, 50mg, 75mg, 100mg (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-Fenofibrate Micro - see fenofibrate (micronized)
Dom-Minocycline - see minocycline HCl
Dom-Selegiline – see selegiline 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.
215
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
Duragesic - see fentanyl
Edecrin - see ethacrynic acid
efavirenz, capsule, 50mg, 100mg, 200mg (Sustiva-DUP)
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
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
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.
Eprex - see epoetin alfa
Ergamisol - see levamisole
Estalis - see estradiol/norethindrone acetate
216
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 (Oesclim-PMS)
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, 50ug
& 250ug/50ug (Estracomb-NVR)
For treatment in patients who are unable to tolerate oral estrogen.
Estrogel – see estradiol
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.
*etodolac, capsule, 200mg, 300mg (Ultradol-PGA) (Apo-Etodolac-APX) (GenEtodolac-GPM) (Taro-Etodolac-TAR)
For treatment of patients with an intolerance to other NSAIDS listed in the Formulary.
Evista - see raloxifene HCl
Exelon - see rivastigmine
*fenofibrate, capsule, 100mg (Apo-Fenofibrate-APX) (Nu-Fenofibrate-NXP)
For treatment of patients with hyperlipidemia who have failed to respond to
gemfibrozil or have experienced side effects with it.
*fenofibrate (micronized), capsule, 200mg (Lipidil Micro-FFR) (Apo-Feno-MicroAPX) (Gen-Fenofibrate Micro-GPM) (pms-Fenofibrate Micro-PMS) (Dom-Fenofibrate
Micro-DOM)
For treatment of patients with hyperlipidemia who have failed to respond to
gemfibrozil or have experienced side effects with it.
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 sustainedrelease morphine, 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.
217
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)
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)
(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
+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 when used in patients on concurrent 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).
Fortovase – see saquinavir
Fosamax - see alendronate sodium
fosfomycin tromethamine, oral powder (sachet), 3g (Monurol-PFR)
(a) For treatment of urinary tract infections with organisms resistant to first line
therapy.
(b) For treatment of urinary tract infections in patients allergic to first line agents.
(c) For treatment of urinary tract infections in pregnancy when first line agents are
inappropriate.
Fragmin – see dalteparin sodium
218
Fraxiparine – see nadroparin calcium
Fraxiparine Forte – see nadroparin calcium
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.
Gen-Carbamazepine CR - see carbamazepine
Gen-Cycloprine - see cyclobenzaprine HCl
Gen-Cyproterone - see cyproterone acetate
Gen-Etodolac – see etodolac
Gen-Fenofibrate Micro - see fenofibrate (micronized)
Gen-Minocycline - see minocycline HCl
Gen-Selegiline - see selegiline HCl
Gen-Ticlopidine – see ticlopidine HCl
glatiramer acetate, injection, 20mg (vial) (Copaxone-TVM)
See Appendix J
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.
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.
Infufer - see iron dextran
Innohep - see tinzaparin sodium
insulin lispro, injection, 100U/mL, vial (10mL), cartridge (5 x 1.5mL, 5 x 3mL)
(Humalog-LIL)
(a) For treatment of patients using insulin pumps.
(b) For treatment of patients with difficult to control diabetes.
219
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 m onths.
(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
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.
iron sorbitol, injection, 50mg/mL (Jectofer-AST)
For treatment of iron deficiency when patients are intolerant to oral iron replacement
products.
220
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.
Jectofer - see iron sorbitol
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 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 (Acilac-TCH) (pms-Lactulose-PMS)
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.
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 H 2 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 H 2 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 H 2 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.
221
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 rheumatoid arthritis in patients who have failed or are intolerant to at
least two other DMARDs (e.g. gold, methotrexate, sulfasalazine, azathioprine).
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
levofloxacin, tablet, 250mg, 500mg (Levaquin-JAN)
(a) For treatment of infections in patients with underlying lung disease not
responding to first-line antibiotics.
(b) For treatment of infections caused by organisms known to be resistant to
alternative antibiotics.
(c) For treatment of infections in patients allergic to alternative antibiotics.
Lin-Megestrol - see megestrol acetate tablet
Lioresal Intrathecal - see baclofen
Lipidil Micro - see fenofibrate (micronized)
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
222
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.
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.
Migranal - see dihydroergotamine mesylate
Minocin - see minocycline HCl
*minocycline HCl, capsule, 50mg (Minocin-WYA) (Apo-Minocycline-APX) (NovoMinocycline-NOP) (Alti-Minocycline-ALT) (Gen-Minocycline-GPM) (MedMinocycline-MED) (Dom-Minocycline-DOM) (Rhoxal-Minocycline-RHO) (pmsMinocycline-PMS); 100mg (Minocin-WYA) (Apo-Minocycline-APX) (NovoMinocycline-NOP) (Alti-Minocycline-ALT) (Gen-Minocycline-GPM) (MedMinocycline-MED) (Dom-Minocycline-DOM) (Rhoxal-Minocycline-RHO)
(pms-Minocycline-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.
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.
223
Monocor - see bisoprolol fumarate
montelukast sodium, chewable tablet, 5mg; tablet, 10mg (Singulair-MSD)
(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.
Monurol - see fosfomycin tromethamine
moxifloxacin HCl, tablet, 400mg (Avelox-BAY)
(a) For treatment of infections in patients with underlying lung disease not
responding to first-line antibiotics.
(b) For treatment of infections caused by organisms known to be resistant to
alternative antibiotics.
(c) For treatment of infections in patients allergic to alternative antibiotics.
Mycobutin - see rifabutin
mycophenolate mofetil, capsule, 250mg; tablet, 500mg (CellCept-HLR)
For prevention of acute rejection in renal and cardiac transplant patients.
nabilone, capsule, 1mg (Cesamet-LIL)
For treatment of nausea and anorexia in AIDS patients.
nabumetone, tablet, 750mg (Novo-Nabumetone-NOP);
*tablet, 500mg (Relafen-GSK) (Apo-Nabumetone-APX) (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 where other standard therapy such as an
analgesic and/or an ergotamine product have failed. 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.
224
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-NorfloxacinNOP)
(a) For treatment of genitourinary tract infections caused by pseudomonas
aeruginosa.
(b) For treatment of genitourinary tract infections in adults with gonoccoccal urethritis
or cervicitis.
(c) For treatment of genitourinary tract infections in patients allergic to alternative
agents.
(d) For treatment of genitourinary tract infections with organisms known to be
resistant to alternative antibiotics.
Noroxin - see norfloxacin
Norvir - see ritonavir
Norvir SEC - ritonavir
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-Fenofibrate - see fenofibrate
Nu-Ketocon – see ketoconazole
Nu-Ketotifen - see ketotifen fumarate
Nu-Megestrol - see megestrol acetate tablet
Nu-Selegiline - see selegiline HCl
Nu-Ticlopidine - see ticlopidine HCl
225
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 (Zyprexa-LIL); orally disintegrating
tablet, 5mg, 10mg (Zyprexa Zydis-LIL)
(a) For treatment of schizophrenia.
(b) For treatment of other 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.
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 H 2 antagonist depending on symptom
resolution.
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 H 2 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 H 2 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 H 2 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.
226
One-Alpha - see alfacalcidol
Oxeze Turbuhaler - see formoterol fumarate
Oxsoralen - see methoxsalen
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 H 2 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 H 2 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 H 2 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.
Pantoloc - see pantoprazole
pentosan polysulfate sodium, capsule, 100mg (Elmiron-ALZ)
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 and sulfonylureas.
pivmecillinam HCl, tablet, 200mg (Selexid-LEO)
(a) For treatment of urinary tract infections with organisms resistant to first line
therapy.
(b) For treatment of urinary tract infections in patients allergic to first line agents.
(c) For treatment of 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-Fenofibrate Micro - see fenofibrate (micronized)
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
227
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)
Protropin - see somatrem
Pulmozyme - see dornase alfa
Purinethol - see mercaptopurine
quetiapine, tablet, 25mg, 100mg, 150mg, 200mg (Seroquel-AST)
(a) For treatment of schizophrenia.
(b) For treatment of other 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.
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.
Rebetron – see interferon alfa-2b/ribavirin
Rebif - see Appendix J
Relafen - see nabumetone
repaglinide, tablet, 0.5mg, 1mg, 2mg (GlucoNorm-NOO)
For treatment of diabetes in patients who are not adequately controlled on or are
intolerant to metformin and sulfonylureas.
Rescriptor – see delavirdine mesylate
Retin A - see tretinoin
Retrovir - see zidovudine
Rhoxal-Minocycline - see minocycline 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 unable to tolerate alendronate sodium
(Fosamax).
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.
228
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.
•
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.
rizatriptan benzoate, tablet, 5mg, 10mg (Maxalt-MSD); wafer, 5mg, 10mg
(Maxalt RPD-MSD)
For treatment of migraine headaches where other standard therapy such as an
analgesic and/or an ergotamine product have failed. 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
229
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 and 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 when used in patients on concurrent 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).
salmeterol xinafoate/fluticasone propionate, powder for inhalation (package),
50ug/100ug, 50ug/250ug, 50ug/500ug (Advair Diskus-GSK)
For treatment of asthma in patients not adequately controlled on steroid therapy. It is
important that these patients also have access to a short-acting beta-2 agonist for
symptomatic relief.
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
230
Sibelium - see flunarizine HCl
Singulair – see montelukast sodium
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.
+somatropin, injection, 3.33mg (Saizen-SRO), 5mg (Humatrope-LIL) (Saizen-SRO),
6mg, 12mg (Humatrope Cartridge-LIL)
For treatment of children who have growth failure due to inadequate secretion of
normal endogenous growth hormone.
+somatropin, injection, 5mg/vial (Nutropin-HLR), 10mg/vial (Nutropin AQ-HLR)
For treatment of children who have growth failure due to inadequate secretion of
normal endogenous growth hormone, and 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
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 where other standard therapy such as an
analgesic and/or an ergotamine product have failed. 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
Synarel - see nafarelin acetate
3TC - see lamivudine
tacrolimus, capsule, 0.5mg, 1mg, 5mg; ampoule, 5mg/mL (Prograf-FUJ)
For prophylaxis of graft rejection.
231
Taro-Carbamazepine CR – see carbamazepine
Taro-Etodolac - see etodolac
Tegretol CR - see carbamazepine
Ticlid - see ticlopidine HCl
*ticlopidine HCl, tablet, 250mg (Ticlid-HLR) (Apo-Ticlopidine-APX) (Nu-TiclopidineNXP) (Gen-Ticlopidine-GPM) (Alti-Ticlopidine-ALT) (pms-Ticlopidine-PMS)
(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) (Tomycine-NVO) (pms-Tobramycin-PMS)
(Tobramycin-RVX) (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.
232
Tobrex - see tobramycin
tolterodine l-tartrate, tablet, 1mg, 2mg (Detrol-PHU)
For treatment of patients unable to tolerate oxybutynin chloride.
Tomycine - see tobramycin
*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.
Ultradol - see etodolac
Ultramop - see methoxsalen
Ultravate - see halobetasol propionate
Urispas - see flavoxate HCl
Urso - see ursodiol
ursodiol, tablet, 250mg (Urso-AXC)
(a) For treatment of radiolucent gallstones.
(b) 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 pseudomembranous colitis for up to two consecutive two week
periods after no response to a course of metronidazole. Repeat approvals will only
be granted with laboratory evidence of c. difficile toxin.
Videx - 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.
Zanaflex - see tizanidine HCl
Zerit - see stavudine
Ziagen - see abacavir SO4
233
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 where other standard therapy such as an
analgesic and/or an ergotamine product have failed. 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
LEGEND:
*These brands of products have been approved as interchangeable.
+These brands of products have NOT been approved as interchangeable.
234
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 sym ptoms.
•
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.
235
APPENDIX B
HOSPITAL BENEFIT DRUG LIST
JULY 1, 2001
NOTIFICATION OF UPDATES TO THE HOSPITAL BENEFIT DRUG LIST
WILL BE PROVIDED IN THE DRUG PLAN QUARTERLY UPDATE
BULLETINS
PLEASE DIRECT INQUIRIES REGARDING THIS LIST TO:
(306) 787- 3224
237
1.
This list of drug benefits under Saskatchewan Health is supplementary to the annual
Saskatchewan Formulary (51st Edition, July 1, 2001). 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 Association of Saskatchewan Health Services
Executives 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 District Health Boards 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 supplem ental 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.
238
4.
Formularies established by health facilities or District Health Boards may not include
all insured items. If an insured drug is not included in a facility or Health District
formulary, its provision will be subject to facility or District Health Board 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 district.
The district 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 district.
Payment Policy Statement:
•
The Drug Plan will reimburse hospital pharmacies the actual acquisition cost
(AAC) of the dose of EprexTM, Iron Dextran or VenuferTM 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 Iron Dextran to the Drug Plan:
•
To ensure consistency in billing for these agents, hospital pharmacy
departments are asked to use specific billing forms to submit clains. Please
contact (306) 787-3315 or toll free 1-800-667-7578 with any questions.
239
TABLE OF CONTENTS
04:00.00
ANTIHISTAMINE DRUGS
244
08:00.00
ANTI INFECTIVE AGENTS
244
8:12.00
ANTIBIOTICS
08:12.02
AMINOGLYCOSIDES
08:12.04
ANTIFUNGALS
08:12.06
CEPHALOSPORINS
08:12.07
MISCELLANEOUS BETA LACTAM ANTIBIOTICS
08:12.08
CHLORAMPHENICOL
08:12.12
ERYTHROMYCINS
08:12.16
PENICILLINS
08:12.28
MISCELLANEOUS ANTIBIOTICS
244
244
244
244
245
245
245
245
246
08:16.00
ANTITUBERCULOSIS AGENTS
246
08:18.00
ANTIVIRALS
246
08:22.00
QUINOLONES
246
08:40.00
MISCELLANEOUS ANTI INFECTIVES
247
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.)
247
12:00.00
247
12:04.00
AUTONOMIC DRUGS
PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS
247
12:08.00
ANTICHOLINERGIC AGENTS
12:08.08
ANTIMUSCARINIC/ANTISPASMODICS
247
247
12:12.00
SYMPATHOMIMETIC (ADRENERGIC) AGENTS
247
12:16.00
SYMPATHOLYTICS
248
12:20.00
SKELETAL MUSCLE RELAXANTS
248
20:00.00
BLOOD FORMATION AND COAGULATION
248
20:04.00
ANTIANEMIA DRUGS
248
20:04.04
IRON PREPARATIONS
248
20:12.00
COAGULANTS AND ANTICOAGULANTS
20:12.04
ANTICOAGULANTS
240
249
249
20:12.08
20:12.16
20:40.00
24:00.00
ANTIHEPARIN AGENTS
HEMOSTATICS
249
249
THROMBOLYTIC AGENTS
CARDIOVASCULAR DRUGS
250
250
24.04.00
CARDIAC DRUG
250
24:08.00
HYPOTENSIVE AGENTS
251
24:12.00
VASODILATING AGENTS
251
28:00.00
28:04.00
CENTRAL NERVOUS SYSTEM AGENTS
GENERAL ANESTHETICS
251
251
28:08.00
ANALGESICS AND ANTIPYRETICS
28:08.04
NON-STEROIDAL ANTI-INFLAMMATORY AGENTS
28:08.08
OPIATE AGONISTS
28:08.12
OPIATE PARTIAL AGONISTS
28:08.92
MISCELLANEOUS ANALGESICS AND ANTIPYRETICS
251
251
252
252
252
28:10.00
OPIATE ANTAGONISTS
252
28:12.00
ANTICONVULSANTS
252
28:16.00
PSYCHOTHERAPEUTIC AGENTS
28:16.08
TRANQUILIZERS
252
252
28:20.00
252
RESPIRATORY AND CEREBRAL STIMULANTS
28:24.00
ANXIOLYTICS, SEDATIVES AND HYPNOTICS
252
28:24.04
BARBITURATES
253
28:24.08
BENZODIAZEPINES
253
28:24.92
MISCELLANEOUS ANXIOLYTICS, SEDATIVES AND HYPNOTICS253
36:00.00
36:56.00
40:00.00
DIAGNOSTIC AGENTS
253
MYASTHENIA GRAVIS
253
ELECTROLYTIC, CALORIC AND WATER BALANCE
253
40:08.00
ALKALINIZING AGENTS
253
40:20.00
CALORIC AGENTS
254
40:28.00
DIURETICS
254
241
44:00.00
ENZYMES
254
48:00.00
ANTITUSSIVES, EXPECTORANTS AND MUCOLYTIC AGENTS
255
48:08.00
ANTITUSSIVES
255
48:16.00
EXPECTORANTS
255
52:00.00
EYE, EAR, NOSE AND THROAT PREPARATIONS
255
52:04.00
ANTI-INFECTIVES
52:04.04
ANTIBIOTICS
255
255
52:16.00
LOCAL ANESTHETICS
255
52:20.00
MIOTICS
255
52:24.00
MYDRIATICS
255
52:32.00
VASOCONSTRICTORS
256
52:36.00
MISCELLANEOUS EYE, EAR, NOSE AND THROAT DRUGS
256
56:00.00
GASTROINTESTINAL DRUGS
256
56:04.00
ANTACIDS AND ADSORBENTS
256
56:08.00
ANTIDIARRHEA AGENTS
256
56:12.00
CATHARTICS AND LAXATIVES
256
56:20.00
EMETICS
257
56:22.00
ANTIEMETICS
257
64:00.00
HEAVY METAL ANTAGONISTS
257
68:00.00
HORMONES AND SYNTHETIC SUBSTITUTES
257
68:04.00
ADRENALS
257
68:08.00
ANDROGENS
257
68:28.00
PITUITARY
257
72:00.00
LOCAL ANESTHETICS
258
76:00.00
OXYTOCICS
258
242
80:00.00
SERUMS, TOXOIDS AND VACCINES
259
80:04.00
SERUMS
259
80:08.00
TOXOIDS
259
80:12.00
VACCINES
259
84:00.00
SKIN AND MUCOUS MEMBRANE AGENTS
260
84:04.00
ANTI INFECTIVES
84:04.04
ANTIBIOTICS
84:04.16
MISCELLANEOUS LOCAL ANTI-INFECTIVES
260
260
260
84:08.00
ANTI PRURITICS AND LOCAL ANESTHETICS
260
84:24.00
EMOLLIENTS, DEMULCENTS ANDPROTECTANTS
261
84:40:00 HEMORRHOID PREPARATIONS
88:00.00
88:16.00
92:00.00
VITAMINS
261
261
VITAMIN D
261
UNCLASSIFIED THERAPEUTIC AGENTS
243
261
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
<25mL/minute or special renal condition (e.g. transplant or single kidney);
•
severe dose-related toxicities which do not resolve with premedication (e.g.
fever, rigors, hypotension).
FLUCONAZOLE
Restricted Coverage: Injection
Injection 2mg/mL
FLUCYTOSINE (HPB – Emergency Drug Release)
Injection 1g, 5g, 10g
Capsules 500mg
08:12.06
CEPHALOSPORINS
CEFAZOLIN
Injection 500mg, 1g
CEFOTAXIME
Restricted Coverage: Benefit status is automatic for first 72 hours in severe
infections. Long term use is covered when supported by sensitivity tests.
Injection 500mg, 1g, 2g
244
CEFOTETAN
Injection 1g, 2g
CEFOXITIN SODIUM
Injection 1g, 2g
CEFTAZIDIME
Restricted Coverage: Benefit status is automatic for first 72 hours in severe
infections. Long term use is covered when supported by sensitivity tests.
Injection 500mg, 1g, 2g
CEFTRIAXONE
Restricted Coverage: Benefit status is automatic for first 72 hours in severe
infections. Long term use is covered when supported by sensitivity tests.
Injection 250mg, 1g, 2g
CEFUROXIME (see Appendix A – Saskatchewan Health Formulary)
Tablet (axetil) 125mg
Injection 750mg, 1.5g
CEPHALOTHIN injection
08:12.07
MISCELLANEOUS BETA LACTAM ANTIBIOTICS
IMIPENEM/CILASTATIN
Restricted Coverage: For the treatment of severe infections on the recommendation
of an infectious disease specialist; internist or medical microbiologist.
Injection 250mg/250mg; 500mg/500mg
08:12.08
CHLORAMPHENICOL
CHLORAMPHENICOL
Injection 1g
08:12.12
ERYTHROMYCINS
AZITHROMYCIN
Restricted Coverage: As per the Exceptional Drug Status (EDS) criteria listed in
Appendix A of the Saskatchewan Formulary when a patient cannot tolerate oral
dosage forms.
Injection
ERYTHROMYCIN
Injection (lactobionate) 500mg, 1g
08:12.16
PENICILLINS
AMPICILLIN
Injection 125mg, 250mg, 500mg, 1g, 2g
PIPERACILLIN
Injection 2g, 3g, 4g
Piperacillin/Tazobactam
Restricted Coverage: For the treatment of severe infections on the
recommendation of an infectious disease specialist; internist or medical
microbiologist.
Injection 2g/0.25g; 3g/0.375g; 4g/0.5g
TICARCILLIN
Injection 3g
245
08:12.28
MISCELLANEOUS ANTIBIOTICS
BACITRACIN STERILE
Vial 50,000 units
POLYMYXIN B SULFATE (injection only) (HPB – Special Access)
QUINUPRISTIN/DALFOPRISTIN (SynercidTM)
Restricted Coverage: Reserved for use against multi-resistant gram positive
organisms, including Methicillin Resistant Staph. Aureus (MRSA) and vancomycin
resistant E.faecium, on the recommendation of an infectious disease specialist.
VANCOMYCIN
Injection
08:16.00
ANTITUBERCULOSIS AGENTS
ETHAMBUTOL
Tablet 100mg, 400mg
ISONIAZID
Tablet 50mg, 100mg, 300mg
Syrup 10mg/mL
PYRAZINAMIDE
Tablet 500mg
RIFAMPIN
Capsule 150mg, 300mg
08:18.00
ANTIVIRALS
ACYCLOVIR
Restricted Coverage:
a) IV form only when used for treatment of initial and recurrent mucosal and
cutaneous herpes simplex infections in immunocompromised patients and;
b) IV form when used for severe initial episodes of herpes simplex infections in
patients who may not be immunocompromised.
Suspension 40mg/mL
Injection 500mg, 1g
FOSCARNET
Injection 24mg/mL
GANCICLOVIR (see Appendix A - Saskatchewan Health Formulary)
Vial 500mg
RIBAVIRIN
Restricted Coverage: When used in a Pediatric Intensive Care Unit,
preferably on the basis of consultation with an infectious disease specialist, and
for proven or seriously ill cases during an outbreak of the Respiratory Syncytial
Virus (RSV).
Powder for inhalation solution 6g
08:22.00
QUINOLONES
CIPROFLOXACIN
Injection 10mg/mL
LEVOFLOXACIN
Injection 5mg/mL, 25mg/mL
246
08:40.00
MISCELLANEOUS ANTI INFECTIVES
PENTAMIDINE ISETHIONATE
Injection 300mg
Oral inhalation solution 300mg
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.)
BLEOMYCIN
Injection 15 unit
CYCLOPHOSPHAMIDE
Tablet 25mg, 50mg
Injection 200mg, 1g
DAUNORUBICIN
Injection 20mg
DOXORUBICIN
Injection 2mg/mL
FLUOROURACIL
Injection 50mg/mL
METHOTREXATE
Injection 10mg/mL (2mL), 25mg/mL (2mL, 4mL, 8mL, 20mL, 40mL,
200mL)
Powder for injection 20mg
12:00.00
AUTONOMIC DRUGS
12:04.00
PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS
EDROPHONIUM
Injection 10mg/mL
NEOSTIGMINE
Injection 0.5mg/mL (1:2000), 1mg/mL (1:1000)
Injection 2.5mg/mL (5mL)
PHYSOSTIGMINE (HPB - Emergency Drug Release)
Injection 1mg/mL
12:08.00
ANTICHOLINERGIC AGENTS
12:08.08
ANTIMUSCARINIC/ANTISPASMODICS
HYOSCINE BUTYLBROMIDE
- Also known as SCOPOLAMINE BUTYLBROMIDE
Injection 20mg/mL
HYOSCINE HYDROBROMIDE
- Also known as SCOPOLAMINE HYDROBROMIDE
Injection 0.4mg/mL, 0.6mg/mL
12:12.00
SYMPATHOMIMETIC (ADRENERGIC) AGENTS
DOBUTAMINE
Injection 12.5mg/mL
247
DOPAMINE
Injection 40mg/mL (20mL)
IV premixed bag 0.8mg/mL (250mL, 500mL) D5W
EPHEDRINE
Injection 50mg/1mL
Tablet 8mg, 15mg, 25mg, 30mg
Capsule 25mg
ISOPROTERENOL
Injection 0.2mg/mL (1:5000)
METHOXAMINE
Aqueous solution 20mg/mL (1mL)
NOREPINEPHRINE
Injection 1mg/mL
PHENYLEPHRINE
Injection 10mg/mL
PSEUDOEPHEDRINE
Tablet 60mg
Syrup 6mg/mL
12:16.00
SYMPATHOLYTICS
PHENTOLAMINE MESYLATE
Injection 5mg vial
12:20.00
SKELETAL MUSCLE RELAXANTS
ATRACURIUM BESYLATE
Injection 10mg/mL (5mL, 10mL)
GALLAMINE TRIETHIODIDE
Injection 20mg/mL (2mL, 5mL)
PANCURONIUM
Injection 2mg/mL
ROCURONIUM
Injection 10mg/mL (10mL)
SUCCINYLCHOLINE
Injection 20mg/mL
TUBOCURARINE
Injection 3mg/mL (5mL)
VECURONIUM
Injection 10mg
20:00.00
BLOOD FORMATION AND COAGULATION
20:04.00
ANTIANEMIA DRUGS
20:04.04
IRON PREPARATIONS
FERROUS FUMARATE
Capsule
FERROUS GLUCONATE
Tablet
248
FERROUS SULPHATE
Tablet
Syrup
Oral drops
Oral solution
IRON DEXTRAN
Injection 50mg elemental iron/mL
IRON-SORBITOL
Injection 50mg iron/mL
20:12.00
COAGULANTS AND ANTICOAGULANTS
20:12.04
ANTICOAGULANTS
ANCROD
Injection 70 IU/mL
DALTEPARIN
Restricted Coverage: For in-hospital treatment of acute coronary syndrome to a
maximum of eight (8) days.
Injection
ENOXAPARIN
Restricted Coverage: For in-hospital treatment of acute coronary syndrome to a
maximum of eight (8) days.
Injection
HEPARIN (not including low molecular weight formulations)
Injection 1,000 IU/mL (1mL, 10mL, 30mL)
Injection (subcutaneous) 25000 IU/mL (0.2mL, 2mL)
Injection (heparin lock flush) 100 IU/mL (2mL, 10mL)
IV premixed bags all strengths mixed in D5W and 0.9% NaCl
NADROPARIN
Restricted Coverage: For in-hospital treatment of acute coronary syndrome to a
maximum of eight (8) days.
Injection
20:12.08
ANTIHEPARIN AGENTS
PROTAMINE SULPHATE
Injection 10mg/mL
20:12.16
HEMOSTATICS
AMINOCAPROIC ACID
Tablet 500mg
Syrup 250mg/mL
Injection 250mg/mL
ANTIHEMOPHILIC FACTOR VIII (HUMAN)
APROTININ
Injection 10,000 Kallikrein Inhibitory Units/mL
FACTOR IX
THROMBIN
Powder 5000 unit, 10000 unit vials
249
20:20.00
SKELETAL MUSCLE RELAXANT
ATRACURIUM BESYLATE
Ampoules 10mg
Injection 10mg/mL (single use 5mL vials)
Injection 10mg/mL (multi-use 10mL vials)
20:40.00
THROMBOLYTIC AGENTS
STREPTOKINASE
Injection 250,000 IU, 750000 IU, 1.5 million IU
TISSUE PLASMINOGEN ACTIVATOR (tPA)
Restricted Coverage: Streptokinase is the drug of choice when thrombolytic
therapy in myocardial infarction is indicated. R-tPA should be used instead of
streptokinase under the following circulstances:
a) patients with larger acute myocardial infarction and presenting within four
(4) hours.
high risk inferior wall myocardial infarctions.
known allergy to streptokinase.
received streptokinase in the past (5 days – 3 years).
patients with significant hypotension or cardiogenic shock.
Injection 50mg, 100mg
b) for the treatment of strokes when all the following circumstances are present:
within three (3) hours of the onset of symptoms;
under the guidance of a neurologist and a neuro-radiologist;
after a CT scan to rule out hemorrhage; and
in conjunction with established treatment protocols.
24:00.00
CARDIOVASCULAR DRUGS
24.04.00
CARDIAC DRUG
ADENOSINE
Restricted Coverage: When used as an antiarrhythmic – for conversion to sinus
rhythm of paroxysmal supraventricular tachycardia, including those associated with
accessory bypass tracts (Wolf-Parkinson-White Syndrome).
Injection 3mg/mL
BRETYLIUM TOSYLATE
Injection 50mg/mL
DIGOXIN
Injection 0.05mg/mL (1mL), 0.25mg/mL (2mL)
DILTIAZEM
Injection 5mg/mL (5mL, 10mL)
ESMOLOL
Restricted Coverage: For use in Operating Room or Critical Care Areas only for: the
perioperative management of tachycardia and hypertension in patients with atrial
fibrillation or atrial flutter in acute situations.
Injection 10mg/mL (10mL)
MILRINONE
Restricted Coverage:
a) When used in the short term management of ventricular dysfunction
unresponsive to digitalis, diuretics and vasodilators or as an aid to weaning off
an intra-aortic balloon pump when other inotropes have failed.
b) Must be administered in a critical care setting capable of invasive cardiac
monitoring including cardiac output, pulmonary capillary wedge
250
pressures and systemic vascular resistance.
Injection 1mg/mL (10mL, 20mL)
PROCAINAMIDE
Injection 100mg/mL (10mL)
24:08.00
HYPOTENSIVE AGENTS
DIAZOXIDE
Injection 15mg/mL (20mL)
LABETALOL
Injection 5mg/mL
SODIUM NITROPRUSSIDE
Injection 50mg
24:12.00
VASODILATING AGENTS
NIMODIPINE
Injection 0.2mg/mL (250mL)
NITROGLYCERIN
Injection 5mg/mL (10mL)
PAPAVERINE
Injection 32.5mg/mL (2mL)
28:00.00
CENTRAL NERVOUS SYSTEM AGENTS
28:04.00
GENERAL ANESTHETICS
DESFLURANE
Inhalation solution 1mL/mL (240mL)
ENFLURANE
Solution 250mL
HALOTHANE
Solution 250mL
ISOFLURANE
Solution 100mL
KETAMINE
Injection 10mg/mL, 50mg/mL
PROPOFOL
Injection 10mg/mL (20mL, 50mL, 100mL)
SEVOFLURANE
Solution 250mL
THIOPENTAL
Injection kit 1g, 2.5g
28:08.00
ANALGESICS AND ANTIPYRETICS
28:08.04
NON-STEROIDAL ANTI-INFLAMMATORY AGENTS
ACETYLSALICYLIC ACID
Tablet
Enteric coated tablet
Suppository
251
28:08.08
OPIATE AGONISTS
ALFENTANIL
Injection 0.05mg/mL, 0.5mg/mL
FENTANYL
Injection 50ug/mL
METHADONE
Powder for oral solution
(Use of methadone is restricted to Health Protection Branch authorized
prescribers)
SUFENTANIL
Injection 50ug/mL
28:08.12
OPIATE PARTIAL AGONISTS
NALBUPHINE
Ampoule 10mg/mL
28:08.92
MISCELLANEOUS ANALGESICS AND ANTIPYRETICS
ACETAMINOPHEN
Tablet (chewable)
Tablet
Oral liquid
Elixir
Suppository
28:10.00
OPIATE ANTAGONISTS
NALOXONE
Injection 0.02mg/mL, 0.4mg/mL
28:12.00
ANTICONVULSANTS
28:12.92
MISCELLANEOUS ANTICONVULSANTS
MAGNESIUM SULFATE
Injection 50mg/mL
28:16.00
PSYCHOTHERAPEUTIC AGENTS
28:16.08
TRANQUILIZERS
LOXAPINE
Oral solution 25mg/mL
28:20.00
RESPIRATORY AND CEREBRAL STIMULANTS
DOXAPRAM
Restricted Coverage: When used for approved indications.
Injection 20mg/mL (20mL)
28:24.00
ANXIOLYTICS, SEDATIVES AND HYPNOTICS
252
28:24.04
BARBITURATES
METHOHEXITAL
Injection 50mg/mL (50mL)
Injection 500mg
28:24.08
BENZODIAZEPINES
MIDAZOLAM
Injection 1mg/mL (2mL, 5mL, 10mL), 5mg/mL (1mL, 2mL, 10mL)
28:24.92
MISCELLANEOUS ANXIOLYTICS, SEDATIVES AND HYPNOTICS
DROPERIDOL
Injection 2.5mg/mL
PARALDEHYDE
Injection 5mL ampoule (1mL is equivalent to approximately 1g)
36:00.00
DIAGNOSTIC AGENTS
36:56.00
MYASTHENIA GRAVIS
EDROPHONIUM
Injection 10mg/mL
40:00.00
ELECTROLYTIC, CALORIC AND WATER BALANCE
40:08.00
ALKALINIZING AGENTS
SODIUM BICARBONATE injectable preparations
Injection 0.5mEq/mL (4.2%), 1mEq/mL (8.4%) pre-load syringe
Injection 5g/100mL (5%) (500mL)
Injection 75mg/mL (7.5%)
Injection 1mEq/mL (8.4%)
TROMETHAMINE injection
Injection 36mg/mL (0.3 Molar)
40:12.00
ELECTROLYTE AND FLUID REPLACEMENT
CALCIUM CHLORIDE
Injection 10% - 100mg/mL (27mg elemental calcium/mL)
CALCIUM GLUCONATE
Injection 10% - 100mg/mL (9mg elemental calcium/mL)
CALCIUM ORAL DOSAGE FORMS
Note:
500mg elemental calcium = 12.5mmol or 25mEq elemental calcium
DEXTRAN 40
Solution 10% in D5W 500mL
Solution 10% in Saline 0.9% 500mL
DEXTRAN 70
Solution 32% in D10W 100mL
Solution 6% in D5W 500mL
253
Solution 6% in Saline 0.9% 500mL
MAGNESIUM ORAL DOSAGE FORMS
MAGNESIUM SULPHATE
Injection 50% - 500mg/mL (50mg elemental magnesium/mL)
Note:
5mg elemental magnesium = 0.2mmol or 0.4mEq elemental magnesium
PHOSPHATE
Injection potassium phosphate dibasic 236mg/mL
Injection potassium phosphate monobasic 224mg/mL
Effervescent tablet 500mg
POTASSIUM ACETATE
Injection 392mg/mL
POTASSIUM CHLORIDE
Injection 2mEq elemental potassium/mL
POTASSIUM PHOSPHATE
Vial 3mmol/mL
SODIUM CHLORIDE
Injection 2.5mEq/mL
Injection 4mEq/mL
SODIUM PHOSPHATE
Injection 3 mmol/mL
ZINC ORAL DOSAGE FORMS
40:20.00
CALORIC AGENTS
ABSOLUTE ALCOHOL INJECTION (dehydrated alcohol)
Injection 100% (10mL)
AMINO ACIDS SOLUTIONS (with or without electrolytes)
Includes all single substrate formulations
AMINO ACIDS / DEXTROSE SOLUTIONS (with or without electrolytes)
Includes all multisubstrate formulations
DEXTROSE
Injection 5%, 10%, 50%
FAT EMULSION PREPARATIONS
Injection 10%, 20%, 30%
40:28.00
DIURETICS
MANNITOL
Injection 10% (1000mL)
Injection 20% (500mL)
Injection 25% (50mL)
44:00.00
ENZYMES
CHYMOPAPAIN
Restricted Coverage: When recommended by an authorized orthopaedic surgeon or
neurosurgeon.
Injection, intradiscal 4NKAT Units/2mL
HYALURONIDASE
Injection 150 USP units/mL (1mL, 10mL)
254
48:00.00
ANTITUSSIVES, EXPECTORANTS AND MUCOLYTIC AGENTS
48:08.00
ANTITUSSIVES
DEXTROMETHORPHAN
Syrup 3mg/mL
48:16.00
EXPECTORANTS
GUAIFENESIN
Oral solution 20mg/mL
48:24.00
MUCOLYTIC AGENTS
ACETYLCYSTEINE INJECTION
Antidote for acetaminophen poisoning
20% solution
52:00.00
EYE, EAR, NOSE AND THROAT PREPARATIONS
52:04.00
ANTI-INFECTIVES
52:04.04
ANTIBIOTICS
POLYMYXIN B/GRAMICIDIN or BACITRACIN
Ophthalmic/otic solution, each mL: 10,000 units/0.25mg (gramicidin)
Ophthalmic ointment, each g: 10,000 units/500 units (bacitacin)
52:16.00
LOCAL ANESTHETICS
BENZOCAINE
Gel, topical 7.5%
Spray, 20%
Gel, topical 20%
COCAINE
Topical solution 100mg/mL: 4% (4mL), 10% (5mL)
LIDOCAINE (except for lozenges and suppositories)
Aerosol, endotracheal
Liquid (viscous), topical 2%
PROPARACAINE
Ophthalmic solution 0.5%
TETRACAINE
Ophthalmic solution 0.5%
Ophthalmic solution minums 0.5%
Aerosol 754 mg / 65g (oral)
52:20.00
MIOTICS
ACETYLCHOLINE
Solution, intraocular irrigation 10mg/mL
52:24.00
MYDRIATICS
255
PHENYLEPHRINE
Ophthalmic solution 2.5%
Ophthalmic solution minums 10%
TROPICAMIDE
Ophthalmic solution 0.5%, 1%
Ophthalmic solution minums 1%
52:32.00
VASOCONSTRICTORS
NAPHAZOLINE
Ophthalmic solution 0.1%
XYLOMETAZOLINE
Nasal spray 0.05%, 0.1%
Nasal solution 0.05%, 0.1%
52:36.00
MISCELLANEOUS EYE, EAR, NOSE AND THROAT DRUGS
ALUMINUM ACETATE
Solution, otic 0.5%
ARTIFICIAL TEARS
Ophthalmic solution
FLUORESCEIN SODIUM
Ophthalmic solution 2%, 10%
Ophthalmic solution minums 2%
Strip, ophthalmic 1mg
Injection 100mg/mL, 250mg/mL
56:00.00
GASTROINTESTINAL DRUGS
56:04.00
ANTACIDS AND ADSORBENTS
ACTIVATED CHARCOAL
Suspension (aqueous), oral - 200mg/mL
Suspension (in sorbitol), oral - 200mg/mL
56:08.00
ANTIDIARRHEA AGENTS
ATTAPULGITE
Tablet 300mg, 600mg, 750mg
Suspension 40mg/mL, 50mg/mL
56:12.00
CATHARTICS AND LAXATIVES
CASTOR OIL
36.4% (115mL)
FLEET
Enema with monobasic sodium phosphate 16g/100mL, dibasic sodium
phosphate 6g/100mL
Enema with monobasic sodium phosphate 16g/100mL, dibasic sodium
phosphate 6g/100mL, & mineral oil
FLEET PHOSPHO - SODA BUFFERED SALINE
Oral solution with sodium biphosphate 900mg/5mL, sodium phosphate
monobasic 2.4g/5mL
GLYCERIN
Suppository - infant 1.63g, adult 2.67g
256
SENNOSIDES (Standardized)
Liquid 119mg/70mL
Powder 157.5mg/21g pouch
Tablet 8.6mg, 12mg, 15mg, 25mg
Granules 15mg/3g=1tsp
Syrup 1.7mg/mL (70mL, 100mL, 250mL, 500mL)
Suppository 30mg
56:20.00
EMETICS
IPECAC
Syrup
56:22.00
ANTIEMETICS
DROPERIDOL
Injection 2.5mg/mL
64:00.00
HEAVY METAL ANTAGONISTS
CALCIUM DISODIUM EDETATE
Restricted Coverage: Used in the treatment of lead poisonings and other select
heavy metal poisonings (zinc, manganese, nickel, chromium and certain
radioisotopes). (Coverage not provided for chelation therapy.)
Injection 200mg/mL
DEFEROXAMINE MESYLATE
Injection 500mg, 2g vial
DIMERCAPROL
Injection 100mg/mL
68:00.00
HORMONES AND SYNTHETIC SUBSTITUTES
68:04.00
ADRENALS
METHYLPREDNISOLONE
Plain
Injection 40mg, 50mg, 125mg, 500mg, 1g
Injection (depot) 20mg/mL, 40mg/mL, 80mg/mL (5mL)
With Lidocaine
Injection 10mg/mL, 40mg/mL (1mL, 2mL, 5mL)
68:08.00
ANDROGENS
FLUOXYMESTERONE
Tablet 5mg
68:28.00
PITUITARY
ACTH (adrenocorticotropic hormone / corticotropin)
Jelly 80 unit/mL (5mL)
Powder 80 unit
VASOPRESSIN
Injection (aqueous) 20 units/mL
257
68:36.00 THYROID AND ANTITHYROID AGENTS
POTASSIUM IODIDE
Tablet 130mg
72:00.00
LOCAL ANESTHETICS
ARTICAINE
Cartridge 4% (5ug/mL epinephrine) (1.7mL)
BUPIVACAINE
Injection 0.25%, 0.5%, 0.75%
Injection 0.25% with epinephrine 1:200,000
Injection 0.5% with epinephrine 1:200,000
Injection, spinal 0.75% with dextrose 8.25% (2mL)
CHLOROPROCAINE
Injection, caudal-epidural 2%, 3%
LIDOCAINE (with the exception of lozenges or suppositories)
Injection 0.5%, 1%, 2%
Injection 0.5% with epinephrine 1:100,000
Injection 0.5% with epinephrine 1:200,000
Injection 1% with epinephrine 1:100,000
Injection 1% with epinephrine 1:200,000
Injection 2% with epinephrine 1:100,000
Injection, epidural 1.5%, 2%
Injection, epidural 1.5% with epinephrine 1:200,000
Injection, epidural 2% with carbon dioxide
Injection, spinal 5% with glucose 7.5% - 2mL vial
MEPIVACAINE
Injection 1%
Injection, caudal-epidural 1%, 2%
PRILOCAINE
Solution 4%
PROCAINE
Vial 2%
TETRACAINE
Injection 20mg ampoule
76:00.00
OXYTOCICS
ALPROSTADIL
Injection 0.5mg/mL
CARBOPROST
Injection 250mg/mL
DINOPROSTONE
Tablet 0.5mg
Gel 0.5mg/2.5mL, 1mg/2.5mL, 2mg/2.5mL syringe
Vaginal insert 10mg
DINOPROST TROMETHAMINE
Injection 5mg/mL
ERGOMETRINE MALEATE
Injection 0.25mg/mL
OXYTOCIN
Injection 10 units/mL
258
80:00.00
SERUMS, TOXOIDS AND VACCINES
Note:
* indicates the product is supplied to health districts by Saskatchewan Health
**indicates the product is supplied to health districts by the Canadian Blood Services
80:04.00
SERUMS
DIGOXIN IMMUNE FAB
Restricted Coverage:
a) When used for the treatment of severe, life threatening digoxin toxicity as
defined by: (1) severe ventricular tachy or bradyarrhythmias and/or (2)
progressive hyperkalemia of greater then 5mmol/L in the setting of severe
digoxin toxicity.
b) It is recommended one of the following medical specialties be consulted before
this agent is administered: cardiologist; internist; or pediatrician.
Injection 38mg
DIPHTHERIA ANTITOXIN*
Injection 20,000 IU vial
HEPATITIS B IMMUNE GLOBULIN (HUMAN)**
IMMUNE GLOBULIN (HUMAN IV)**
Injection 0.5%, 10% solution
IMMUNE SERUM GLOBULIN (HUMAN IM)
Injection 18%
TETANUS IMMUNE GLOBULIN (HUMAN)
Injection 250 unit
80:08.00
TOXOIDS
DIPHTHERIA TOXOID*
50Lf/mL (1mL, 10mL)
DIPHTHERIA TETANUS TOXOIDS*
Injection (2Lf / 0.5mL diphtheria toxoid and 5Lf/0.5mL tetanus toxoid)
(5mL – adult adsorbed)
Injection (25Lf/0.5mL diphtheria toxoid and 5Lf/0.5mL tetanus toxoid) (0.5mL,
5mL)
DIPHTHERIA TOXOID/PERTUSSIS VACCINE/TETANUS TOXOID (DPT
Adsorbed)*
Injection (diphtheria toxoid 25Lf/0.5mL, tetanus toxoid 5Lf/0.5mL, pertussis
vaccine 4 to 12 PU/0.5mL)
TETANUS DIPHTHERIA TOXOIDS/POLIOMYELITIS VACCINE*
Injection (diphtheria toxoid 2Lf/0.5mL, poliamyelitis vaccine (inactivated)
NIL/0.5mL, tetanus toxoid
5Lf/0.5mL)
DIPHTHERIA TOXOID/PERTUSSIS/TETANUS/POLIOVIRUS VACCINE/
HAEMOPHILUS INFLUENZA TYPE B (PENTA VACCINE)
80:12.00
VACCINES
HEPATITIS B IMMUNE GLOBULIN**
Injection 217 IU/mL
HEPATITIS B VACCINE*
Injection 20ug/mL
INFLUENZA VIRUS VACCINE*
Injection 5mL
259
MEASLES/MUMPS/RUBELLA VACCINE*
Injection NIL/0.5mL
PNEUMOCOCCAL VACCINE*
Injection 50ug/0.5mL
POLIOMYELITIIS VACCINE*
Injection 0.5mL
RUBELLA VIRUS VACCINE*
Injection 31000 TCID 50/0.5mL
BCG VACCINE*
Injection 0.1mg/0.1mL
HAEMOPHILUS INFLUENZAE TYPE B VACCINE*
84:00.00
SKIN AND MUCOUS MEMBRANE AGENTS
84:04.00
ANTI INFECTIVES
84:04.04
ANTIBIOTICS
BACITRACIN
Ointment 500 IU/g
84:04.08
ANTIFUNGALS
TOLNAFTATE
Aerosol liquid 0.72mg/g (70g)
Aerosol powder 10mg/g
Cream 10mg/g
Powder 10mg/g
Solution 10mg/mL
84:04.16MISCELLANEOUS LOCAL ANTI-INFECTIVES
CHLORHEXIDINE
Alcoholic scrub
Cleanser 4%
Gauze 0.5%
Jelly 2%, 4%
Liquid 2%, 4%, 20%
Ointment 1%
Soap 2%
MAFENIDE
Cream 8.5%
SILVER SULFADIAZINE
Cream 1% w/w
Cream 1% with chlorhexidine 0.2%
84:08.00
ANTI PRURITICS AND LOCAL ANESTHETICS
CALCIUM FOLINATE (folinic acid)
Powder 50mg, 350mg
Tablets 5mg
Injection 10mg/mL
260
DIBUCAINE
Cream 0.5% (30g)
Ointment 1% (30g)
LIDOCAINE/PRILOCAINE
Topical cream 2.5%/2.5%
Patch
LIDOCAINE (except lozenges and suppositories)
Jelly 2%
Jelly (urojet) 2%
Ointment 5%
Topical solution 4%
PRAMOXINE
Cream, rectal 1%
84:24.00
EMOLLIENTS, DEMULCENTS AND PROTECTANTS
84:24.12
BASIC CREAMS, OINTMENTS AND PROTECTANTS
ZINC OXIDE
Ointment 15%
84:24.16
BASIC POWDERS AND DEMULCENTS
GELATIN, PECTIN, SODIUM CARBOXYMETHYLCELLULOSE
Paste 13.3% gelatin, 13.3% pectin, 13.3% sodium carboxymethylcellulose
84:40:00
HEMORRHOID PREPARATIONS
PRAMOXINE
Ointment, rectal 1%, with zinc sulphate 0.5%
Suppository 20MG, with zinc sulphate 10mg
88:00.00
VITAMINS
88:16.00
VITAMIN D
CALCITRIOL
-also known as 1,25-DIHYDROXYCHOLECALCIFEROL
Injection 1ug/mL
DIHYDROTACHYSTEROL
Capsule 0.125mg
92:00.00
UNCLASSIFIED THERAPEUTIC AGENTS
ABCIXMAB INJECTION
Restricted Coverage: For use in high risk angioplasties carried out in a cardiac
catheterization laboratory as per approved health district protocols.
Injection 2 mg/mL (5mL)
ACTHAR GEL 80IU/5mL (Emergency Drug Release from HPB for infantile spasms)
BASILIXIMAB
Restricted Coverage: For prophylaxis of acute rejection in renal transplant patients.
Injection
261
BERACTANT
Restricted Coverage: When administered in a Neonatal Intensive Care Unit.
Powder (reconstituted) 25mg phospholipids/mL
CLIMACTERON
Restricted Coverage: When used in hospital for post-hysterectomy patients.
Injection
COLFOSCERIL PALMITATE
Restricted Coverage: When administered in a Neonatal Intensive Care Unit.
Powder for tracheal suspension
CYANIDE ANTIDOTE KIT
With sodium nitrate injection 30mg/mL (2 x 10mL ampoules), sodium thiosulfate
injection 250mg/mL (2 x 50mL ampoules), amyl nitrate inhalant solution (12 x
0.3mL crushable ampoules)
CYCLOSPORINE (see Appendix A - Saskatchewan Health Formulary)
Restricted Coverage: Injection
Injection 50mg/mL
DACLIZUMAB
Restricted Coverage: For prophylaxis of acute rejection in renal transplant patients.
Injection
DIMETHYL SULFOXIDE
Solution 500mg/g (50mL)
LEVOCARNITINE
Restricted Coverage: For the treatment of metabolic disorders with carnitine
deficiency and neonates who will be on long term Total Parenteral Nutrition (greater
than 14 days).
Injection 200mg/mL
Oral solution 100mg/mL
Tablet 330mg
OCTREOTIDE
Restricted Coverage:
a) For the treatment of acute variceal bleeds in patients with acute portal
hypertension.
b) For the prevention of fistulas following pancreatic resection to a maximum of 7
days.
Injection 50ug, 100ug, 500ug (1mL)
Injection 200ug (5mL)
Injection 10mg, 20mg, 30mg (powder for injection)
PRALIDOXIME CHLORIDE
Injection, 1g vial
SOMATOSTATIN
Restricted Coverage: For the treatment of acute variceal bleeds.
Powder 205ug, 3mg
TRACE ELEMENTS
Chromium 4ug/mL
Copper 0.4mg/mL
Manganese 0.1mg/mL, 0.5mg/mL
Selenium 40ug/mL
Zinc 1mg/mL, 5mg/mL
Note: May come as cocktails.
(M.T.E.-4 contains: 4.0ug/mL chromium, 0.4mg/mL copper, 0.1mg/mL
manganese, and 1.0mg/mL zinc)
(Micro 5 contains: 10ug/mL chromium, 1mg/mL copper, 0.5mg/mL manganese,
60ug/mL selenium, 5mg/mL zinc)
262
APPENDIX I: Products included in the Hospital Benefit List, and as referred to in 3
(a), (b), and (c) are approved for use and are benefits only when manufactured by
approved suppliers as listed in the Saskatchewan Formulary or included below:
Adria
Anaquest
Cutter
IMS
Johnson & Johnson-Merck
Lyphomed
Mallinkrodt
Metapharma
Smith & Nephew
APPENDIX II: PROCEDURES FOR OBTAINING DRUGS PROVIDED UNDER
PROVINCIAL PROGRAMS
Drugs Used for the Treatment of Tuberculosis:
The following drugs can be obtained for use in the treatment of tuberculosis by contacting
the Clinical Director for Tuberculosis Control (933-6166). The drugs will be sent from the
TB Pharmacy in Ellis Hall at the Royal University Hospital in Saskatoon.
Amikacin injection 500mg/2mL
Cycloserine capsules 250mg
Ethambutol tablets, 100mg, 400mg
Ethionamide tablets 250mg
Isoniazide syrup 10mg/mL, tablets 100mg, 300mg
Pyrazinamide tablet 500mg
Rifabutin capsule 150mg
Rifampin capsule 150mg, 300mg, suspension 25mg/mL
Streptomycin injection 1 gram/2.5mL
Drugs Used for the Treatment of Sexually Transmitted Diseases:
•
The following drugs can be obtained from Saskatchewan Health – Communicable
Disease Control at (306) 787-7104 for the treatment of sexually transmitted
diseases:
Azithromycin 1g
Erythromycin PCE 333mg or 250mg
Cefixime 400mg
•
The following medication/vaccines are available on special request from
Saskatchewan Health – Communicable Disease Control (306) 787-1460:
Benzathine Penicillin 2.4 MU IM injection
Ciprofloxacin 500mg
263
INDEX
1,25-DIHYDROXYCHOLECALCIFEROL ....................261
ACEBUTOLOL .....................................250
ACETAMINOPHEN.............................252
ACETYLCHOLINE ..............................255
ACETYLSALICYLIC ACID .................251
ACTIVASE ............................................250
ACTIVATED CHARCOAL ..................256
ACYCLOVIR.........................................246
ADENOCARD ......................................250
ADENOSINE ........................................250
ADRENALS..........................................257
ADRIAMYCIN.......................................247
ALCAINE...............................................255
ALCOHOL (ETHYL) DRESSING......260
ALFENTA..............................................252
ALFENTANIL........................................252
ALKALINIZING AGENTS..................253
ALPROSTADIL ....................................258
ALUMINUM ACETATE.......................256
AMICAR ................................................249
AMIKACIN.............................................244
AMIKIN ..................................................244
AMINOCAPROIC ACID ......................249
AMINOGLYCOSIDES ........................244
AMPHOTERICIN B..............................244
AMPHOTERICIN B LIPID COMPLEX
INJECTION ......................................244
AMPICILLIN..........................................245
ANALGESICS AND ANTIPYRETICS
...........................................................251
ANCEF ..................................................244
ANCROD ..............................................249
ANDROGENS ......................................257
ANECTINE............................................248
ANTACIDS AND ADSORBENTS ....256
ANTIANEMIA DRUGS .......................248
ANTICHOLINERGIC AGENTS.........247
ANTICOAGULANTS ..........................249
ANTICONVULSANTS ........................252
ANTIDIARRHEA AGENTS................256
ANTIEMETICS .....................................257
ANTIFUNGALS ...................................244
ANTIHEMOPHILIC FACTOR VIII .....249
ANTIHEPARIN AGENTS...................249
ANTIHISTAMINE DRUGS.................244
ANTILIRIUM.........................................247
ANTIMUSCARINIC/
ANTISPASMODICS .......................247
ANTINEOPLASTIC AGENTS...........247
ANTIPRURITICS AND LOCAL
ANESTHETICS ......................260, 261
ANTITUBERCULOSIS AGENTS .....246
ANTITUSSIVES ...................................255
ANTIVIRALS........................................246
ANUSOL ...............................................261
ANXIOLYTICS, SEDATIVES AND
HYPNOTICS ....................................252
ARVIN....................................................249
ASA........................................................251
ATTAPULGITE.....................................256
AZITHROMYCIN .................................245
BACIGUENT.........................................260
BACITRACIN........................................260
BACITRACIN STERILE......................246
BAL IN OIL............................................257
BARBITURATES ................................253
BASILIXIMAB .......................................261
BENADRYL ..........................................244
BENYLIN DM........................................255
BENZOCAINE......................................255
BENZODIAZEPINES ..........................253
BERACTANT........................................262
BETA LACTAM ANTIBIOTICS ........245
BLENOXANE .......................................247
BLEOMYCIN ........................................247
BRETYLIUM.........................................250
BREVIBLOC .........................................250
BRIETAL ...............................................253
BUPIVACAINE.....................................258
BURO SOL ...........................................256
CALCITRIOL ........................................261
CALCIUM CHLORIDE........................253
CALCIUM DISODIUM EDETATE .....257
CALCIUM GLUCONATE....................253
CALORIC AGENTS............................254
CARBOCAINE .....................................258
CARDIZEM...........................................250
CARNITOR ...........................................262
CATHARTICS AND LAXATIVES.....256
CEFAZOLIN .........................................244
CEFOTAXIME ......................................244
CEFOTETAN........................................245
CEFOXITIN...........................................245
CEFTAZIDIME .....................................245
CEFTIN .................................................245
CEFTRIAXONE ...................................245
CEFUROXIME .....................................245
CEPHALOSPORINS...........................244
CHLORAMPHENICOL .......................245
CHLORHEXIDINE...............................260
CHLOROMYCETIN.............................245
CHLOROPROCAINE..........................258
CHOLINERGIC AGENTS ..................247
CIPRO...................................................246
CIPROFLOXACIN ...............................246
CLAFORAN ..........................................244
CLIMACTERON...................................262
264
COCAINE..............................................255
COLFOSCERIL PALMITATE ............262
CYANIDE ANTIDOTE KIT..................262
CYCLOPHOSPHAMIDE.....................247
CYCLOSPORINE................................262
CYPROHEPTADINE...........................244
CYTOXAN.............................................247
DACLIZUMAB ......................................262
DALTEPARIN.......................................249
DEFEROXAMINE................................257
DEPO MEDROL ..................................257
DESFERAL...........................................257
DEXTRAN 40.......................................253
DEXTRAN 70.......................................253
DEXTROMETHORPHAN...................255
DEXTROSE..........................................254
DIAGNOSTIC AGENTS.....................253
DIAZOXIDE ..........................................251
DIFLUCAN............................................244
DIGIBIND..............................................259
DIGOXIN ...............................................250
DIGOXIN IMMUNE FAB .....................259
DILTIAZEM...........................................250
DIMERCAPROL...................................257
DINOPROSTONE ...............................258
DIPHENHYDRAMINE.........................244
DIPHTHERIA ANTITOXIN .................259
DIPHTHERIA TETANUS TOXOIDS.259
DIURETICS ..........................................254
DOBUTAMINE .....................................247
DOBUTREX..........................................247
DOPAMINE...........................................248
DOPRAM..............................................252
DOXAPRAM.........................................252
DOXORUBICIN....................................247
DROPERIDOL ............................253, 257
DT ADSORBED...................................259
DURAGESIC ........................................252
EDROPHONIUM........................247, 253
EFUDEX................................................247
ELECTROLYTE AND FLUID
REPLACEMENT .............................253
EMETICS..............................................257
ENLON..................................................253
ENOXAPARIN......................................249
ENTROPHEN ......................................251
ENZYMES.............................................254
ERGOMETRINE MALEATE ..............258
ERGONOVINE.....................................258
ERYTHROMYCIN ...............................245
ESMOLOL HYDROCHLORIDE........250
ETHAMBUTOL.....................................246
EXOSURF.............................................262
EXPECTORANTS...............................255
EYE, EAR, NOSE AND THROAT
PREPARATIONS ............................255
FACTOR IX COMPLEX......................249
FENTANYL ...........................................252
FERGON...............................................248
FERROUS GLUCONATE ..................248
FERROUS SULPHATE......................249
FLAMAZINE .........................................260
FLAMAZINE-C.....................................260
FLEET ...................................................256
FLEET PHOSPHO SODA BUFFERED
SALINE .............................................256
FLUCONAZOLE ..................................244
FLUOR I STRIP ...................................256
FLUORESCEIN SODIUM..................256
FLUORESCITE....................................256
FLUOROURACIL ................................247
FLUOXYMESTERONE.......................257
FORTAZ ................................................245
FUNGIZONE ........................................244
GENERAL ANESTHETICS ...............251
GLYCERIN ...........................................256
GUAIFENESIN.....................................255
HALOTESTIN.......................................257
HEAVY METAL ANTAGONISTS.....257
HEMORRHOID PREPARATIONS ...261
HEMOSTATICS ...................................249
HEPARIN ..............................................249
HEPATITIS B IMMUNE GLOBULIN.259
HEPATITIS B VACCINE ....................259
HIBITANE .............................................260
HORMONES AND SYNTHETIC
SUBSTITUTES ................................257
HYALURONIDASE..............................254
HYDROCONTIN ..................................252
HYOSCINE BUTYLBROMIDE ..........247
HYOSCINE HYDROBROMIDE.........247
HYPERSTAT ........................................251
HYPOTENSIVE AGENTS..................251
HYSKON ...............................................253
IMIPENEM CILASTATIN ....................245
IMMUNE GLOBULIN ..........................259
IMMUNE SERUM GLOBULIN...........259
INAPSINE ....................................253, 257
INFLUENZA VIRUS VACCINE .........259
INH.........................................................246
INTROPIN.............................................248
IPECAC .................................................257
IRON PREPARATIONS .....................248
ISOFLURANE ......................................251
ISONIAZID ............................................246
ISOPROTERENOL .............................248
ISUPREL ..............................................248
KAOPECTATE.....................................256
KEFZOL ................................................244
LABETALOL .........................................251
LANOXIN ..............................................250
LEVARTERENOL................................248
265
LEVOCARNITINE................................262
LEVOPHED..........................................248
LIDOCAINE ........................255, 258, 261
LOCAL ANESTHETICS ............255, 258
LOXAPAC .............................................252
LOXAPINE............................................252
M M R II.................................................260
MAFENIDE ...........................................260
MAGNESIUM SULPHATE.................254
MANNITOL ...........................................254
MARCAINE...........................................258
MCT OIL................................................254
MEASLES/MUMPS/RUBELLA
VACCINE..........................................260
MEDIUM CHAIN TRIGLYCERIDES
OIL .....................................................254
MEFOXIN..............................................245
MEPIVACAINE.....................................258
METHADONE ......................................252
METHOHEXITAL.................................253
METHOTREXATE...............................247
METHYLPREDNISOLONE
ACETATE .........................................257
MIDAZOLAM........................................253
MIOCHOL .............................................255
MIOTICS ...............................................255
MYAMBUTOL.......................................246
MYDFRIN..............................................256
MYDRIACYL.........................................256
MYDRIATICS .......................................255
NADROPARIN .....................................249
NALBUPHINE......................................252
NALOXONE..........................................252
NAPHAZOLINE....................................256
NARCAN ...............................................252
NEO SYNEPHRINE............................248
NEOSTIGMINE....................................247
NESACAINE CE..................................258
NIPRIDE ...............................................251
NITROGLYCERIN ...............................251
NITROPRUSSIDE...............................251
NON STEROIDAL ANTI
INFLAMMATORY AGENTS .........251
NORCURON........................................248
NOREPINEPHRINE ...........................248
NOVOCAINE........................................258
NUBAIN.................................................252
OPIATE AGONISTS...........................252
OPIATE ANTAGONISTS...................252
OPIATE PARTIAL AGONISTS.........252
ORAJEL ................................................255
OTRIVIN................................................256
OXYTOCICS ........................................258
OXYTOCIN ...........................................258
PANCURONIUM..................................248
PAPAVERINE ......................................251
PARALDEHYDE..................................253
PAVULON.............................................248
PENBRITIN ..........................................245
PENICILLINS .......................................245
PENTACARINAT.................................247
PENTAMIDINE ISETHIONATE.........247
PERIACTIN...........................................244
PHENERGAN ......................................244
PHENTOLAMINE ................................248
PHENYLEPHRINE.....................248, 256
PHOSPHATE .......................................254
PHOSPHATE SANDOZ......................254
PHYSOSTIGMINE...............................247
PIPERACILLIN.....................................245
PIPRACIL..............................................245
PITRESSIN...........................................257
PITUITARY...........................................257
PNEUMOCOCCAL VACCINE...........260
PNEUMOVAX 23.................................260
POLYSPORIN ......................................255
PONTOCAINE ............................255, 258
POTASSIUM ACETATE.....................254
POTASSIUM CHLORIDE ..................254
POTASSIUM PHOSPHATE...............254
PRALIDOXIME CHLORIDE...............262
PRAMOXINE........................................261
PRIMAXIN.............................................245
PROCAINAMIDE.................................251
PROCAINE...........................................258
PROMETHAZINE................................244
PRONESTYL........................................251
PROPARACAINE................................255
PROSTIN E2........................................258
PROSTIN VR .......................................258
PROTAMINE SULPHATE..................249
PROTOPAM.........................................262
PSEUDOEPHEDRINE.......................248
QUINOLONES .....................................246
QUINUPRISTIN/DALFOPRISTIN
(SynercidTM).....................................246
RESPIRATORY AND CEREBRAL
STIMULANTS..................................252
RHEOMACRODEX.............................253
RIBAVIRIN ............................................246
RIFADIN ................................................246
RIFAMPIN.............................................246
RIMSO...................................................261
ROCALTROL .......................................261
ROCEPHIN ..........................................245
ROGITINE.............................................248
SCOPOLAMINE BUTYLBROMIDE..247
SCOPOLAMINE HYDROBROMIDE 247
SENSORCAINE...................................258
SERUMS...............................................259
SILVER SULFADIAZINE....................260
266
SKELETAL MUSCLE RELAXANTS
...........................................................248
SKIN AND MUCOUS MEMBRANE
AGENTS...........................................260
SLOW-K................................................254
SODAMINT...........................................253
SODIUM BICARBONATE ..................253
SODIUM CHLORIDE..........................254
SODIUM PHOSPHATE ......................254
STREPTOKINASE ..............................250
SUBLIMAZE .........................................252
SUCCINYLCHOLINE .........................248
SUDAFED.............................................248
SUFENTA.............................................252
SUFENTANIL .......................................252
SULFAMYLON.....................................260
SURVANTA..........................................262
SYMPATHOLYTICS ...........................248
SYNTOCINON .....................................258
TAZOCIN ..............................................245
TENSILON...................................247, 253
TETANUS DIPHTHERIA TOXOIDS/
POLIOMYELITIS VACCINE..........259
TETANUS IMMUNE GLOBULIN ......259
TETRACAINE..............................255, 258
THROMBIN TOPICAL ........................249
THROMBOLYTIC AGENTS..............250
THROMBOSTAT .................................249
TICAR ....................................................245
TICARCILLIN .......................................245
TISSUE PLASMINOGEN
ACTIVATOR (tPA)...........................250
TOBRAMYCIN .....................................244
TOXOIDS ..............................................259
TRANQUILIZERS................................252
TRASYLOL ...........................................249
TRIMETHOPRIM.................................246
TROMETHAMINE ...............................253
TRONOTHANE....................................261
TROPICAMIDE....................................256
TYLENOL..............................................252
VACCINES ...........................................259
VASOCON ............................................256
VASOCONSTRICTORS.....................256
VASODILATING AGENTS................251
VASOPRESSIN ...................................257
VECURONIUM.....................................248
VERSED ...............................................253
VIRAZOLE............................................246
VITAMIN D............................................261
WYDASE...............................................254
X PREP .................................................257
XYLOCAINE.........................................258
XYLOMETAZOLINE............................256
ZINACEF...............................................245
ZINC OXIDE.........................................261
ZINCOFAX............................................261
ZOVIRAX..............................................246
267
APPENDIX C
TIPS ON PRESCRIPTION WRITING
(Adapted from "Tips on Prescription Writing", a pamphlet available from the
Saskatchewan Pharmaceutical Association.)
Properly issued prescriptions are in the best interest of the patient, the pharmacist and
the prescriber. This information is designed to assist prescribers to issue prescriptions
most effectively. These guidelines will help to reduce the time involved in the prescription
process, increase patient safety and maximize patient compliance.
PRESCRIPTION CONTENT
Prescriptions need to be issued clearly and completely to minimize errors.
pronunciation or legible writing with accurate spelling is essential.
Clear
The prescription may be written, or verbal for certain classes of drugs, (refer to chart on
pages 270 and 271) and must include the following information:
§
§
§
§
§
§
§
§
§
§
§
date
physician's name and signature
patient's name
full name of the medication
medication concentration where appropriate
medication strength where appropriate
dosage
amount prescribed or the duration of treatment
administration route if other than oral
explicit instructions for patient usage of the medication
number of refills where refills are authorized
The prescriber's name, address and telephone number should be preprinted on the
prescription form, or hand printed beneath the signature.
VERBAL PRESCRIPTIONS
Federal and Provincial legislation states that a verbal prescription or refill authority must
be given by a medical practitioner, duly qualified optometrist, dentist or veterinary
surgeon directly to a pharmacist. Having a receptionist or nurse assume this
responsibility is contrary to the law.
Direct prescriber/pharmacist communication is necessary to provide the best quality of
care for the patient. The pharmacist may wish to discuss an aspect of the drug therapy
prior to dispensing the medication. As well, the prescriber may wish to ask the
pharmacist about a particular medication, or a patient's medication history, compliance,
or pattern of drug use. Both the professionals and the patient will benefit from this direct
communication.
MEDICATION DIRECTIONS
Pharmacists maintain patient profiles which contain information concerning prescriptions
dispensed, directions for use, drug allergies, medical conditions, and other pertinent
information. These profiles are used to monitor the patient's drug usage and compliance,
and drug interactions. Thus, it is very important that directions on the prescription be
consistent with verbal instructions given to the patient. Clear directions enable the
pharmacist to effectively counsel the patient and reinforce the prescriber's instructions.
268
Prescriptions with closing instructions written "As Directed" create problems for the
patient, particularly the elderly or those assisting them. Patients taking more than one
medication may become confused if all instructions read "As Directed". Such labelling
also makes it impossible for pharmacists to monitor compliance, or assist patients with
medication concerns.
It is helpful for a patient taking more than one medication, or for the caregiver, to know
what the medication is used for. The prescriber may wish to indicate the use of the
medication on the prescription (e.g. for heart), to enable the pharmacist to include this
information on the label.
REFILLS
When a patient is stabilized on medication, refills, where permitted by law, should be
indicated on the prescription. Authorization should allow for sufficient refills until the
patient's next appointment, to a maximum of one year. If refills are not properly indicated
on the prescription, the pharmacist must by law, contact the prescriber for refill
authorization.
Specific regulations apply to various categories of prescription drugs. Your pharmacist
would be pleased to review the regulations with you. Please refer to the following chart
for a summary of requirements.
SUBSTITUTION
Unless the prescriber directs otherwise, the pharmacist may select and dispense an
interchangeable pharmaceutical product, other than the one prescribed, according to the
Saskatchewan Prescription Drug Plan Formulary. An interchangeable pharmaceutical
product is a product containing a drug or drugs in the same amounts, of the same active
ingredients, in the same dosage form as that directed by the prescription. Those which
conform to the criteria for interchangeability determined by the Saskatchewan Formulary
Committee are designated as "interchangeable" in the Saskatchewan Formulary Listing.
A prescriber may request that a specific brand of a drug be dispensed by indicating in his
own handwriting at the time of issuing a written prescription, or verbally at the time of
giving a verbal prescription, No Substitution, No Sub, or N/S. In most cases, the patient
is responsible for the incremental cost of "No Sub" prescriptions.
TRANSFER OF PRESCRIPTIONS
Schedule F drugs may be transferred from one pharmacist to another at the request of a
patient. Prescriptions for benzodiazepines and other targeted substances may be
transferred. Prescriptions for Schedule 2 and 3 drugs and Narcotic and Controlled
Drugs may NOT be transferred.
When a prescription is transferred, the original prescription shall remain on file, and on it
shall be entered:
1. the date of the transfer;
2. an indication that no further sales nor transfers may be made under the prescription
(i.e. the word "VOID");
3. the name of the pharmacy and pharmacist to whom the prescription was transferred;
4. the patient profile, manual or electronic, must also indicate the prescription is "VOID".
The pharmacist receiving the transferred prescription shall indicate:
1.
2.
3.
4.
the name of the pharmacist transferring the prescription;
the name and address of the pharmacy transferring the prescription;
the number of authorized repeats remaining, if any;
the date of the last fill or refill.
269
Saskatchewan Pharmaceutical Association
PRESCRIPTION REGULATIONS
A synopsis* of Federal and Provincial Acts and Regulations
governing the Distribution of Drugs by Prescription in Saskatchewan
CLASS
NARCOTIC DRUG**
Examples: Codeine, Demerol, Morphine,
Novahistex DH, Percodan, Tussionex, Tylenol
#4, Lomotil, Darvon-N, Talwin, 642's, etc.
DESCRIPTION
REQUIREMENTS
All straight narcotics, all narcotic drugs or compounds for
parenteral use. Compounds containing more than one
narcotic or compounds with less than two non-narcotic
ingredients. All products containing diacetylmorphine,
oxycodone, hydrocodone, methadone, or pentazocine.
Written prescription signed and dated by a
practitioner.
**Refer to Triplicate Prescription Program.
Refer to the Schedule to the Narcotic Control Regulations.
VERBAL PRESCRIPTION NARCOTIC**
Examples: A.C. with Codeine 15, 30, 60 mg,
Fiorinal C 1/4, C1/2, Tylenol #2 and #3,
Darvon-N Compound, 692's, 292's, etc.
A combination product not intended for parenteral use,
containing one narcotic (only) and two or more non-narcotic
drugs in therapeutic dose, except products containing
diacetylmorphine, oxycodone, hydrocodone, methadone, or
pentazocine.
Refer to the Schedule to the Narcotic Control Regulations.
CONTROLLED DRUGS - LEVEL I**
Examples: Dexedrine, Ritalin, Seconal,
Tuinal, etc.
Those drugs listed in Part I of the Schedule to Part G of the
Food and Drug Regulations and Schedule III of the
Controlled Drugs and Substances Act. They include
amphetamines, methaqualone, methylphenidate,
phendimetrazine, phenmetrazine, pentobarbital and
secobarbital.
Written or verbal prescription** from a
practitioner. Verbal prescription must be reduced
to writing by a pharmacist showing:
- name and address of patient;
- name, initials and address of prescriber;
- name, quantity, and form of drug(s);
- directions for use;
- date;
- prescription number;
- name or initials of pharmacist
**Refer to Triplicate Prescription Program
CONTROLLED DRUG PREPARATION LEVEL I**
Examples: Carbrital, Mandrax, etc.
A combination containing a controlled drug - Level I - as
described above, and one or more active medicinal
ingredients, in a recognized therapeutic dose, other than a
narcotic or controlled drug.
CONTROLLED DRUGS - LEVEL II**
Examples: Phenobarb, Amytal, Butisol,
Tenuate, Ionamin, Anabolic Steroids, etc.
Those drugs listed in Parts II & III of the Schedule to Part G
of the Food and Drug Regulations and Schedule IV of the
Controlled Drugs and Substances Act. They include:
barbituric acid and its salts and derivatives (except
secobarbital and pentobarbital), butorphanol,
chlorphentermine, diethylpropion, nalbuphine, phentermine,
thiobarbituric acid.
CONTROLLED DRUG PREPARATION LEVEL II
Examples: Donnatal, Fiorinal**, Tedral,
Anabolic Steroids, etc.
A combination containing a controlled drug - Level II - as
described above, and one or more active medicinal
ingredients, in a recognized therapeutic dose, other than a
narcotic or controlled drug.
TARGETED DRUGS
Examples: Benzodiazepines (except for
Flunitrazepam, Clozapine & Olanzapine),
Clotiazepam, Ethchlorvynol, Ethinamate,
Fencamamin, Mazindol, Mefernorex,
Meprobamate, Methnprylon, Pipradol
Those drugs listed in Schedule I of the Benzodiazepines
and Other Targeted Substances Regulations.
Written or verbal prescription from practitioner.
Verbal prescriptions must be reduced to writing by
a pharmacist showing date, prescription number,
patient's name and address, name and quantity of
drug(s), directions for use, prescriber's name,
name and initials of pharmacist, and number of
refills (if any).
PRESCRIPTION DRUGS
Those drugs listed in Schedule I of the Bylaws to the
Pharmacy Act, 1996, including drugs listed in Schedule F to
the Food and Drug Regulations.
Written or verbal prescription from practitioner.
Verbal prescriptions must be reduced to writing by
a pharmacist showing date, prescription number,
patient's name and address, name and quantity of
drug(s), directions for use, prescriber's name,
name and initials of pharmacist, and number of
refills (if any).
TRANSFER OF PRESCRIPTIONS
Only prescriptions for Schedule I and
Targeted drugs may be transferred from one
pharmacist to another at the request of a
patient. Prescriptions for Narcotic and
Controlled Drugs may NOT be transferred.
270
As immediately above, plus, in the case of verbal
prescriptions:
- number and frequency of refills (if any)
authorized.
The pharmacist receiving the transferred prescription shall indicate:
1. the name of the pharmacist transferring the prescription;
2. the name and address of the pharmacy transferring the prescription;
3. the number of authorized repeats remaining, if any;
4. the date of the last fill or refill.
* This synopsis is a condensation of some of the pertinent Acts and Regulations. Users of the chart are reminded that it has been compiled for convenient
reference only and that the official legislation should always be consulted for the purposes of interpreting and applying the laws.
** Triplicate Prescription Program: Effective August 1, 1988, a specially designed prescription form must be used by a prescriber to write a prescription for any
of the medications on the panel of monitored drugs. Pharmacists may not fill a prescription for any of these drugs written on any other form. Verbal prescriptions
may not be accepted for any of the drugs listed on this panel of drugs. Please refer to the Triplicate Prescription Program Newsletter for details.
*** RECORDS - Narcotic Register includes either the approved manual or electronic (i.e. pharmacy computer) version.
SOURCE: Saskatchewan Pharmaceutical
Association
REPEATS
RECORDS***
No Repeats.
All re-orders must be new, written prescriptions. However, a
prescription may be dispensed in divided portions, subject to
professional discretion.
All receipts and all sales (except prescription sales of dextropropoxyphene) entered in
Narcotic Register. Prescriptions filed in order of date and number in a special file
designated for Narcotics and Controlled Drugs. If a part-fill is made, all records, including
the prescription itself, and the Narcotic Register, must reflect the actual amount dispensed.
Further part-fills must be documented and cross-referenced to the original prescription.
No Repeats.
All orders must be new, written prescriptions, however,
a prescription may be dispensed in divided portions,
subject to professional discretion.
Receipts - entry required in Narcotic Register.
Sales - no entry required for sales pursuant to prescriptions, but emergency supplies
provided to another pharmacist and returns to licensed dealers must be recorded in sales
portion of Register. Prescriptions filed in order of date and number in a special file
designated for Narcotics and Controlled Drugs.
No repeats are allowed if original prescription is verbal. If
written, the original prescription may be repeated if the
prescriber has indicated in writing the number and
frequency of repeats.
All receipts and all sales entered in Narcotic Register.
Prescriptions filed in order of date and number in a special file designated for Narcotics and
Controlled Drugs.
**Refer to the Triplicate Prescription Program.
Receipts - entry required in Narcotic Register.
Sales - no entry required in Narcotic Register for sales pursuant to prescriptions, but emergency
supplies provided to another pharmacist and returns to licensed dealers must be recorded in sales
portion of Register. Prescriptions filed in order of date and number in a special file designated for
Narcotics and Controlled Drugs.
Repeats may be authorized on original prescription whether
written or verbal, but authorization must indicate number
and frequency of repeats.
Receipts - entry required in Narcotic Register or invoices must be available to substantiate
receipt.
Sales - no entry required in Narcotic Register for sales pursuant to prescriptions, but
emergency supplies provided to another pharmacist and returns to licensed dealers must be
recorded in sales portion of Register. Prescriptions filed in order of date and number in
special file designated for Narcotics and Controlled Drugs.
Repeats may be authorized on original prescription whether
written or verbal, but authorization must be for a specific
number of refills. Refills are permitted only if less than 1 year
has elapsed since the date on which the prescription was
issued.
Receipts - entry required in Narcotic Register or invoices must be available to substantiate
receipt.
Prescriptions filed in the regular Schedule I file and must be retained for at least two years
from the date of the last fill or refill.
"PRN" is not valid authority for repeats.
Repeats may be authorized on original prescription whether
written or verbal, but authorization must be for a specific
number of refills.
No entries required in Narcotic Register. Prescriptions filed in regular file and must be
retained for at least two years from date of last fill or refill.
"PRN" is not valid authority for repeats.
When a prescription is transferred, the original prescription shall remain on file, and on it shall be entered:
1. the date of the transfer;
2. an indication that no further sales nor transfers may be made under the prescription (i.e. the word "VOID");
3. the name of the pharmacy and pharmacist to whom the prescription was transferred;
4. the patient profile, manual or electronic, must also indicate the prescription is "VOID".
271
APPENDIX D
GUIDELINES FOR REPORTING ADVERSE DRUG REACTIONS
DEFINITION OF AN ADVERSE DRUG REACTION (ADR):
"Any undesirable patient effect suspected to be associated with drug use."
WHICH ADVERSE DRUG REACTIONS SHOULD BE REPORTED?
Proof a drug caused an undesirable patient effect (causality) is NOT a requirement for
reporting an adverse drug reaction. If an adverse event is suspected of being drugrelated, particularly if the event is unusual in the context of the illness, it should be
reported.
Practitioners should report to SaskADR:
•
all suspected adverse drug reactions which are unexpected. An unexpected
adverse drug reaction is an undesirable patient effect which is not consistent with
product information or labelling;
•
all suspected adverse drug reactions which are serious. A serious adverse drug
reaction is an undesirable patient effect which contributes to significant disability or
illness. All adverse drug reactions which result in, or prolong hospitalization or
require significant medical intervention should be considered serious;
•
all suspected adverse reactions to recently marketed drugs regardless of their
nature or severity. A recently marketed drug is considered to be commercially
available for 5 (five) years or less.
HOW TO REPORT A SUSPECTED ADVERSE DRUG REACTION TO SaskADR:
Adverse drug reaction reports from Saskatchewan practitioners should be sent to the
Saskatchewan Adverse Drug Reaction Reporting Centre (SaskADR) located at the Dial
Access Drug Information Service, College of Pharmacy, University of Saskatchewan.
Please report suspected adverse drug reactions as soon as possible after detection
even if all details are not known at the time of the report. Staff at SaskADR will follow-up
for further information if required.
•
Complete a written ADR report form (next page). Record all information that is
available and mail to SaskADR. Information may be attached to the report form if
insufficient space is available for complete documentation. Additional forms may be
obtained from SaskADR at the following address:
SaskADR Centre
Dial Access Drug Information Service
College of Pharmacy & Nutrition
110 Science Place
University of Saskatchewan
Saskatoon, S7N 5C9
Fax: (306) 966-6377
OR
•
provide a verbal report to SaskADR by phoning Dial Access Drug Information at tollfree 1-800-667-3425 or (in Saskatoon) at 966-6340 or 966-6329. Office hours are
9:00 a.m. to 5:00 p.m., Monday to Friday, excluding statutory holidays.
272
Health
Canada
l
l
Santé
Canada
Canadian Adverse Drug Reaction Monitoring Program
See reverse for return address.
La version française de ce document
est disponible sur demande. Voir au
verso pour connaître le centre à contacter.
A. Patient Information
1. Patient identifier
Chart Number
DD
2. Age at time of
reaction
__________ or
Date of birth
MM
YYYY
3. Sex
Male
Female
4. Height
5. Weight
_____ feet
_____ lbs
or
or
_____ cm
_____ kgs
B. Adverse Reaction
1. Outcome attributed to adverse reaction (check all that apply)
Death ____________ (dd / mm / yyyy)
Disability
Life-threatening
Congenital malformation
Hospitalization
Hospitalization - prolonged
2.
Date and time of reaction
DD
MM
YYYY
Required intervention to prevent
damage / permanent impairment
Other: ____________________
3.
DD
Therapeutic
Products
Programme
Report of suspected adverse reaction
due to drug products marketed in Canada
(Vaccines excluded)
Date of this report
MM
YYYY
PROTECTED
C. Suspected drug product(s)
(See "How to report" section on reverse)
1. Name (give labelled strength & manufacturer, if known).
#1
____________________________________________________________________
#2
____________________________________________________________________
2. Dose, frequency & route used
#1
3. Therapy dates (if unknown, give duration)
#1 From (dd / mm / yyyy) - To (dd / mm / yyyy)
#2
#2
4. Indication for use of suspected drug
product
#1
5. Reaction abated after use
stopped or dose reduced
#1
Yes
No
Doesn't apply
#2
Yes
No
Doesn't apply
#2
4. Describe reaction or problem
6. Lot # (if known)
#1
_______________
#2
7. Exp. date (if known) 8. Reaction reappeared after
reintroduction
#1 (dd / mm / yyyy)
_______________
#1
Yes
No
Doesn't apply
#2
#2
Yes
No
Doesn't apply
9. Concomitant drugs (name, dose, frequency and route used) and therapy dates
(dd / mm / yyyy) (exclude treatment of reaction)
10. Treatment of adverse reaction (drugs and / or therapy), including dates
(dd / mm / yyyy)
5. Relevant tests / laboratory data (including dates (dd / mm / yyyy)
D. Reporter
(See "Confidentiality" section on reverse)
1. Name, address & phone number.
6. Other relevant history, including preexisting medical conditions
(e.g. allergies, pregnancy, smoking and alcohol use, hepatic / renal dysfunction)
2. Health professional? 3.Occupation
Yes
Submission of a report does not constitute an admission that medical
personnel or the product caused or contributed to the adverse reaction.
HC/SC 4016 (12-98)
No
For TPP use only
4. Also reported to
manufacturer?
Yes
No
Return this form to the address listed for your region
ADVERSE DRUG REACTION REPORTING GUIDELINES
What to report?
An adverse drug reaction (ADR) is a noxious and unintended response to a drug which occurs with use or testing for the diagnosis, treatment or prevention of a disease or the
modification of an organic function. This includes any undesirable patient effect suspected to be associated with drug use. ADRs as a result of prescription, non-prescription,
biological (including blood products), complementary medicines (including herbals) and radiopharmaceutical drug products are monitored. Drug abuse, drug overdoses, drug
interactions and unusual lack of therapeutic efficacy are also considered to be reportable as ADRs.
ADR reports are, for the most part, only suspected associations. A temporal or possible association is sufficient for a report to be made. Reporting an ADR does not imply a
causal link.
ADRs that should be reported include all suspected adverse drug reactions which are:
"
unexpected, regardless of their severity i.e. not consistent with product information or labelling; or
"
serious, whether expected or not; or
"
reactions to recently marketed drugs (on the market for less than five years) regardless of their nature or severity.
The Canadian Regulations pertaining to reporting ADRs for marketed drug products define a serious adverse drug reaction as "a noxious and unintended response to a drug,
which occurs at any dose and requires in-patient hospitalization or prolongation of existing hospitalization, causes congenital malformation, results in persistent or significant
disability or incapacity, is life-threatening or results in death".
Confidentiality of ADR Information
Any information related to the reporter and patient identifiers is kept confidential.
How to report?
To report a suspected ADR for drug products marketed in Canada, health professionals should complete a copy of the ADR Reporting Form (Report of suspected adverse
reaction due to drug products marketed in Canada (Vaccines excluded) (HC/SC 4016 (12-98)). This form may be obtained from your Regional Centre or from the
National ADR Unit (see addresses below), and is included in the Canadian Compendium of Pharmaceuticals and Specialities (CPS).
Fill in the sections that apply to the report as completely as possible, using a separate form for each patient. Additional pages may be attached if additional space is required.
The success of the program depends on the quality and accuracy of the information sent in by the reporter.
Up to two (2) suspected drug products may be reported on one form (#1 = first suspected drug product, #2 = second suspected drug product). Attach an additional form if
there are more than two suspected drug products for the reported adverse reaction.
How to deal with follow-up information for an ADR that has already been reported?
Any follow-up information for an ADR that has already been reported can be sent on another ADR form, or it can be communicated by telephone, fax or e-mail if convenient to
the appropriate address for your region (see addresses below). So that this information can be matched with the original report, indicate that it is follow-up information, the
date of the original report and the report case number if known. It is very important that follow-up reports are identified and linked to the original report.
What about reporting ADRs to the Manufacturer?
Health professionals may also report ADRs to the manufacturer. Indicate on your ADR report sent to Health Canada if a case was also reported to the manufacturer.
For more information on the ADR monitoring program, additional copies of ADR reporting forms or to report an ADR, physicians, pharmacists and other health professionals
are invited to contact the addresses listed for your region.
British Columbia
Ontario
BC Regional ADR Centre
c/o BC Drug and Poison Information Centre
1081 Burrard St.
Vancouver, British Columbia V6Z 1Y6
Tel: (604) 631-5625
Fax: (604) 631-5262
[email protected]
Ontario Regional ADR Centre
LonDIS Drug Information Centre
London Health Sciences Centre
339 Windermere Road
London, Ontario N6A 5A5
Tel: (519) 663-8801 Fax: (519) 663-2968
[email protected]
Saskatchewan
Québec
All other provinces and territories
Sask ADR Regional Centre
Dial Access Drug Information Service
College of Pharmacy and Nutrition
University of Saskatchewan
110 Science Place
Saskatoon, Saskatchewan S7N 5C9
Tel: (306) 966-6340 or (800) 667-3425
Fax: (306) 966-6377
[email protected]
Québec Regional ADR Centre
Drug Information Centre
Hôpital du Sacré-Coeur de Montréal
5400, boul. Gouin ouest
Montréal, Québec H4J 1C5
Tel: (514) 338-2961 or (888) 265-7692
Fax: (514) 338-3670
[email protected]
National ADR Unit
Continuing Assessment Division
Bureau of Drug Surveillance
Therapeutic Products Programme
Finance Building
Tunney's Pasture
AL 0201C2
Ottawa, Ontario K1A 1B9
Tel: (613) 957-0337 Fax: (613) 957-0335
[email protected]
For Therapeutic Products Programme Use Only
New Brunswick, Nova Scotia
Prince Edward Island and Newfoundland
Atlantic Regional ADR Centre
c/o Queen Elizabeth II Health Sciences Centre
Drug Information Centre
1796 Summer Street, Rm 2421
Halifax, Nova Scotia B3H 3A7
Tel: (902) 473-7171 Fax: (902) 473-8612
[email protected]
Health
Canada
l
l
Santé
Canada
Canadian Adverse Drug Reaction Monitoring Program
See reverse for return address.
La version française de ce document
est disponible sur demande. Voir au
verso pour connaître le centre à contacter.
A. Patient Information
1. Patient identifier
Chart Number
DD
2. Age at time of
reaction
__________ or
Date of birth
MM
YYYY
3. Sex
Male
Female
4. Height
5. Weight
_____ feet
_____ lbs
or
or
_____ cm
_____ kgs
B. Adverse Reaction
1. Outcome attributed to adverse reaction (check all that apply)
Death ____________ (dd / mm / yyyy)
Disability
Life-threatening
Congenital malformation
Hospitalization
Hospitalization - prolonged
2.
Date and time of reaction
DD
MM
YYYY
Required intervention to prevent
damage / permanent impairment
Other: ____________________
3.
DD
Therapeutic
Products
Programme
Report of suspected adverse reaction
due to drug products marketed in Canada
(Vaccines excluded)
Date of this report
MM
YYYY
PROTECTED
C. Suspected drug product(s)
(See "How to report" section on reverse)
1. Name (give labelled strength & manufacturer, if known).
#1
____________________________________________________________________
#2
____________________________________________________________________
2. Dose, frequency & route used
#1
3. Therapy dates (if unknown, give duration)
#1 From (dd / mm / yyyy) - To (dd / mm / yyyy)
#2
#2
4. Indication for use of suspected drug
product
#1
5. Reaction abated after use
stopped or dose reduced
#1
Yes
No
Doesn't apply
#2
Yes
No
Doesn't apply
#2
4. Describe reaction or problem
6. Lot # (if known)
#1
_______________
#2
7. Exp. date (if known) 8. Reaction reappeared after
reintroduction
#1 (dd / mm / yyyy)
_______________
#1
Yes
No
Doesn't apply
#2
#2
Yes
No
Doesn't apply
9. Concomitant drugs (name, dose, frequency and route used) and therapy dates
(dd / mm / yyyy) (exclude treatment of reaction)
10. Treatment of adverse reaction (drugs and / or therapy), including dates
(dd / mm / yyyy)
5. Relevant tests / laboratory data (including dates (dd / mm / yyyy)
D. Reporter
(See "Confidentiality" section on reverse)
1. Name, address & phone number.
6. Other relevant history, including preexisting medical conditions
(e.g. allergies, pregnancy, smoking and alcohol use, hepatic / renal dysfunction)
2. Health professional? 3.Occupation
Yes
Submission of a report does not constitute an admission that medical
personnel or the product caused or contributed to the adverse reaction.
HC/SC 4016 (12-98)
No
For TPP use only
4. Also reported to
manufacturer?
Yes
No
Return this form to the address listed for your region
ADVERSE DRUG REACTION REPORTING GUIDELINES
What to report?
An adverse drug reaction (ADR) is a noxious and unintended response to a drug which occurs with use or testing for the diagnosis, treatment or prevention of a disease or the
modification of an organic function. This includes any undesirable patient effect suspected to be associated with drug use. ADRs as a result of prescription, non-prescription,
biological (including blood products), complementary medicines (including herbals) and radiopharmaceutical drug products are monitored. Drug abuse, drug overdoses, drug
interactions and unusual lack of therapeutic efficacy are also considered to be reportable as ADRs.
ADR reports are, for the most part, only suspected associations. A temporal or possible association is sufficient for a report to be made. Reporting an ADR does not imply a
causal link.
ADRs that should be reported include all suspected adverse drug reactions which are:
"
unexpected, regardless of their severity i.e. not consistent with product information or labelling; or
"
serious, whether expected or not; or
"
reactions to recently marketed drugs (on the market for less than five years) regardless of their nature or severity.
The Canadian Regulations pertaining to reporting ADRs for marketed drug products define a serious adverse drug reaction as "a noxious and unintended response to a drug,
which occurs at any dose and requires in-patient hospitalization or prolongation of existing hospitalization, causes congenital malformation, results in persistent or significant
disability or incapacity, is life-threatening or results in death".
Confidentiality of ADR Information
Any information related to the reporter and patient identifiers is kept confidential.
How to report?
To report a suspected ADR for drug products marketed in Canada, health professionals should complete a copy of the ADR Reporting Form (Report of suspected adverse
reaction due to drug products marketed in Canada (Vaccines excluded) (HC/SC 4016 (12-98)). This form may be obtained from your Regional Centre or from the
National ADR Unit (see addresses below), and is included in the Canadian Compendium of Pharmaceuticals and Specialities (CPS).
Fill in the sections that apply to the report as completely as possible, using a separate form for each patient. Additional pages may be attached if additional space is required.
The success of the program depends on the quality and accuracy of the information sent in by the reporter.
Up to two (2) suspected drug products may be reported on one form (#1 = first suspected drug product, #2 = second suspected drug product). Attach an additional form if
there are more than two suspected drug products for the reported adverse reaction.
How to deal with follow-up information for an ADR that has already been reported?
Any follow-up information for an ADR that has already been reported can be sent on another ADR form, or it can be communicated by telephone, fax or e-mail if convenient to
the appropriate address for your region (see addresses below). So that this information can be matched with the original report, indicate that it is follow-up information, the
date of the original report and the report case number if known. It is very important that follow-up reports are identified and linked to the original report.
What about reporting ADRs to the Manufacturer?
Health professionals may also report ADRs to the manufacturer. Indicate on your ADR report sent to Health Canada if a case was also reported to the manufacturer.
For more information on the ADR monitoring program, additional copies of ADR reporting forms or to report an ADR, physicians, pharmacists and other health professionals
are invited to contact the addresses listed for your region.
British Columbia
Ontario
BC Regional ADR Centre
c/o BC Drug and Poison Information Centre
1081 Burrard St.
Vancouver, British Columbia V6Z 1Y6
Tel: (604) 631-5625
Fax: (604) 631-5262
[email protected]
Ontario Regional ADR Centre
LonDIS Drug Information Centre
London Health Sciences Centre
339 Windermere Road
London, Ontario N6A 5A5
Tel: (519) 663-8801 Fax: (519) 663-2968
[email protected]
Saskatchewan
Québec
All other provinces and territories
Sask ADR Regional Centre
Dial Access Drug Information Service
College of Pharmacy and Nutrition
University of Saskatchewan
110 Science Place
Saskatoon, Saskatchewan S7N 5C9
Tel: (306) 966-6340 or (800) 667-3425
Fax: (306) 966-6377
[email protected]
Québec Regional ADR Centre
Drug Information Centre
Hôpital du Sacré-Coeur de Montréal
5400, boul. Gouin ouest
Montréal, Québec H4J 1C5
Tel: (514) 338-2961 or (888) 265-7692
Fax: (514) 338-3670
[email protected]
National ADR Unit
Continuing Assessment Division
Bureau of Drug Surveillance
Therapeutic Products Programme
Finance Building
Tunney's Pasture
AL 0201C2
Ottawa, Ontario K1A 1B9
Tel: (613) 957-0337 Fax: (613) 957-0335
[email protected]
For Therapeutic Products Programme Use Only
New Brunswick, Nova Scotia
Prince Edward Island and Newfoundland
Atlantic Regional ADR Centre
c/o Queen Elizabeth II Health Sciences Centre
Drug Information Centre
1796 Summer Street, Rm 2421
Halifax, Nova Scotia B3H 3A7
Tel: (902) 473-7171 Fax: (902) 473-8612
[email protected]
APPENDIX E
SPECIAL COVERAGES
SPECIAL SUPPORT PROGRAM
An expanded safety net program, called the Special Support Program, has been
designed to help those whose benefit drug costs are high in relation to their income.
Based on the information provided on the application form along with Drug Plan records,
the Drug Plan may lower the deductible and give the consumer a lower co-payment to
reduce the consumer's share of drug costs.
Benefits are determined by family income (adjusted for number of dependents) and
actual benefit drug costs. Residents must apply for Special Support annually.
Residents can call the Drug Plan at 787-3317 (in Regina) or toll-free at 1-800-667-7581
and request an application form be sent to them or they may pick up a form at their
community pharmacy. Coverage will be backdated 30 days from the date the application
is received by the Drug Plan.
If the family income or medication costs change during the coverage period, the
consumer may wish to contact the Drug Plan for a reassessment of coverage.
Income Supplement Recipients
Families receiving Family Health Benefits, and seniors receiving the Saskatchewan
Income Plan supplement (S.I.P.) or receiving the federal Guaranteed Income Supplement
(G.I.S.) and residing in a special care home will pay a $100 semi-annual deductible.
Other seniors receiving G.I.S. (ie. living in the community) have a $200 semi-annual
deductible. (If these patients have high drug costs they may also apply for Special
Support.) Other seniors are treated the same as non-seniors, based on their income and
drug cost.
Children under 18 years of age of families receiving Family Health Benefits are eligible
for the same benefits as Supplementary Health beneficiaries with Plan Two coverage.
This means all covered drugs will be provided at no charge. Also certain dental services,
medical supplies and appliances, optical services, chiropractic services, and emergency
medical transportation costs will be covered.
Adults receiving Family Health Benefits are eligible for chiropractic services and an eye
examination every two years.
Inquiries regarding benefits, contact the Supplementary Health Program:
Regina: 787-3125
Toll-free: 1-800-266-0695
Inquiries regarding prescription drugs should be directed to the Drug Plan:
Regina: 787-3317
Toll-free: 1-800-667-7581
277
SUMMARY OF FAMILY HEALTH BENEFITS FOR FAMILIES RECEIVING
SASKATCHEWAN CHILD BENEFIT AND/OR
SASKATCHEWAN EMPLOYMENT SUPPLEMENT
HEALTH BENEFITS
CHILDREN
PARENTS OR
GUARDIANS
Dental Coverage
Coverage of most services
Coverage not provided
Optometric Services
Eye examinations once a
year
Eye examinations covered
once every two years
Basic Eyeglasses
Emergency Ambulance
Covered
Coverage not provided
Medical Supplies
Basic coverage, some
items require prior approval
Coverage not provided
Chiropractic Services
Covered
Covered
Drug Coverage
No charge for Formulary
drugs
$100 semi-annual family
deductible; 35% consumer
co-payment there after
Drug Plan Special Support
Program available if
provides better coverage
(Consumer must apply)
EMERGENCY ASSISTANCE
Eligibility
Residents who require immediate treatment with covered prescription drugs and are
unable to cover their share of the cost, may access emergency assistance. An eligible
beneficiary may obtain a limited supply of covered prescription drug(s) at a reduced cost.
The level of assistance provided will be in accordance with the consumer's ability to pay.
Request Process
During regular office hours, the patient's pharmacy may call the Drug Plan at 787-3317
(Regina) or toll-free at 1-800-667-7578 to provide the information needed to support the
request, as follows:
•
•
•
patient identification (health services number);
pharmacy identification (name, number);
name and cost of the drug(s) required immediately;
278
•
reason for the request, including evidence that other sources of credit or assistance
have been explored and are not available.
Following approval by the Drug Plan, the claims may be submitted via the on-line system.
The patient may obtain up to a one month supply of covered drug product(s) included in
the request. A completed "Request for Special Support" form must be submitted for
future assistance.
Outside regular office hours, the pharmacy may provide up to a four day supply of
benefit drug products in an emergency situation. The paper claim will be honoured by
the Drug Plan at the rate of payment specified by the pharmacist. A completed "Request
for Special Support" form must be submitted for future assistance.
EXCEPTION DRUG STATUS PROGRAM
Please refer to Appendix A for detailed information and criteria for coverage of
medications under the Exception Drug Status Program. For general information
regarding Exception Drug Status, see "Notes Concerning the Formulary".
PALLIATIVE CARE COVERAGE
Definition of Palliative Care
Patients who are in the late stages of a terminal illness, where life expectancy is
measured in months, and for whom treatment aimed at cure or prolongation of life is no
longer deemed appropriate, but for whom care is aimed at improving or maintaining the
quality of remaining life (eg. management of symptoms such as pain, nausea and stress),
will be eligible for Drug Plan Palliative Care drug benefits. The patient's physician must
submit a completed Drug Plan" Request for Palliative Care Coverage" form to the Drug
Plan in order to register a patient for this program.
Drug Benefits under Palliative Care
A palliative care patient who is registered with the Drug Plan is entitled to receive
prescription drugs listed in the Saskatchewan Formulary at no charge to them. The
patient's pharmacy will bill the Drug Plan for 100% of the cost of benefit medications.
Coverage is also provided for some commonly used laxatives, on prescription request, to
patients registered under this program.
Exception Drug Status Drugs for Palliative Care Patients
Drugs listed under the Exception Drug Status program still require a separate physician
request on behalf of the patient. To be eligible for approval of Exception Drug Status
drugs, palliative care patients must meet the criteria as outlined in Appendix A of the
current Saskatchewan Formulary. The Drug Plan must be provided with all relevant
information to determine if the patient meets the criteria for the Exception Drug Status
drug being requested on the patient's behalf.
Provisional Approval of Palliative Care Coverage
Provisional approval may be granted in response to a telephoned request from the
pharmacy, the physician or social worker involved in the patient's care. At the time of the
request, the pharmacy or social worker must be in possession of a signed Palliative Care
form. After provisional coverage has been granted, the pharmacy or social worker must
forward the signed form to the Drug Plan. Provisional approval may be withheld by the
Drug Plan if the pharmacy or social worker is not in receipt of a signed form. All
279
physicians requesting provisional approval must provide the Drug Plan with a signed form
on the patient's behalf in a timely manner.
For provisional approval of Palliative Care, please contact the Drug Plan at 787-8744 to
arrange coverage.
Notification of Physician and Patient
Upon receipt of a signed Palliative Care form, notification letters are generated by the
Drug Plan, to the patient and the requesting physician.
Backdating of Palliative Care Coverage
Palliative Care coverage is routinely backdated 30 days from the date the form is
received by the Drug Plan. In certain cases where a patient is eligible for coverage but
application is inadvertently not made, the Drug Plan will consider backdating at the
physician's request, beyond this period.
Palliative Care Benefits under Health Districts
Patients, pharmacists or physicians should contact the home care office in their health
district to inquire about coverage provided by the district for dietary supplements and
other basic supplies.
"NO SUB" PRESCRIPTION DRUG COVERAGE
It is recognized that extremely rare cases may exist in which a person is not able to use a
particular brand of product. In such cases, the prescriber may request exemption from
full payment of incremental cost when a specific brand of drug in an interchangeable
category is found to be essential for a particular patient. There is no provision for
"blanket" exemptions. Each request must be patient and product specific.
The request may be submitted in writing or by telephone (787-8744 or toll-free
1-800-667-2549) and must provide sufficient details to permit thorough, objective
assessment.
S.A.I.L. COVERAGE (SASKATCHEWAN AIDS TO INDEPENDENT LIVING)
S.A.I.L. beneficiaries include persons with cystic fibrosis, chronic end-stage renal disease
and paraplegics. S.A.I.L. provides coverage for Formulary and non-Formulary diseaserelated drugs used by these beneficiaries. For general inquiries regarding this program,
telephone (306) 787-7121. For drug inquiries, telephone (306) 787-3314.
SASKATCHEWAN CANCER AGENCY
Prescriptions for drugs covered by the Saskatchewan Cancer Agency are provided free
of charge to registered cancer patients by either the Allan Blair Cancer Centre Pharmacy
in Regina (telephone: (306) 766-2816) or the Saskatoon Cancer Centre Pharmacy
(telephone: (306) 655-2680). These drugs would be provided when requested by a
clinic oncologist or a physician working in association with the Cancer Agency. These
drugs are not covered by the Drug Plan. Examples are flutamide, cyproterone and
ondansetron. Please note that dexamethasone 4mg when used in the treatment of
registered cancer patients would be provided by the Saskatchewan Cancer Agency
through the 2 cancer centre pharmacies. When dexamethasone 4mg is used for control
of symptoms in the palliative patient, the cost is covered by the Drug Plan, when the
patient has been registered under the Drug Plan Palliative Care program.
280
SOCIAL ASSISTANCE BENEFICIARIES
Plan One Drug Coverage
Holders of Supplementary Health cards designated as "Plan One" may obtain
prescriptions for Formulary drugs at a nominal consumer charge, currently no more than
$2.00 per prescription. In addition, they may obtain the following prescribed drugs
without charge:
insulin, oral hypoglycemics, injectable Vitamin B12, oral contraceptives, allergenic
extracts, and products used in megavitamin therapy.
Beneficiaries under the age of 18 may obtain Formulary drugs or approved Exception
Drug Status drugs without charge.
Cost of allergenic extracts and products used in megavitamin therapy are covered by the
Supplementary Health Program of Saskatchewan Health. All of the other products listed
above are covered and processed through the Drug Plan.
Plan Two Drug Coverage
Beneficiaries requiring several Formulary drugs on a regular basis can be considered for
"Plan Two" drug coverage. Plan Two coverage may be initiated by contacting the Drug
Plan at 787-8744 or (toll-free) 1-800-667-7581. The request can be made by the patient
or a health professional (ie. physician, social worker).
Holders of Supplementary Health cards designated as "Plan Two" may obtain the
products available under "Plan One" together with any Formulary drugs or approved
Exception Drug Status drugs, without charge.
Plan Three Drug Coverage
Holders of Supplementary Health cards designated as "Plan Three" may obtain, in
addition to drugs available under the Drug Plan, certain other prescribed drugs at no
charge. The cost of such drugs is covered by the Supplementary Health Program of
Saskatchewan Health. All pharmacy claims are processed by the Drug Plan.
Pharmacies may contact the Drug Plan at 787-3314 (Regina) or
1-800-667-7578 with inquires regarding Plan Three drug coverage.
(toll-free)
Special Drug Authorization
In addition to Formulary and Exception Drug Status benefits, Social Assistance
beneficiaries (Plan One and Plan Two) may be eligible for coverage of a selected panel
of products under the Supplementary Health Program through the Special Drug
Authorization process. Selected over-the-counter (OTC) products which are currently
benefits for Plan Three beneficiaries could be considered for coverage for Plan One and
Plan Two beneficiaries on a case-by-case basis. The prescriber must submit a request
on the patient's behalf. Requests may be submitted in writing or by telephone at
(306) 787-8744 or (toll-free) 1-800-667-2549.
281
APPENDIX F
TRIPLICATE PRESCRIPTION PROGRAM
PARTICIPANTS:
• Saskatchewan Pharmaceutical Association
• College of Physicians & Surgeons of Saskatchewan
• College of Dental Surgeons of Saskatchewan
OBJECTIVE:
To reduce the abuse and diversion of a select panel of prescription drugs.
PROGRAM CAPABILITY
The Triplicate Prescription program provides the College of Physicians & Surgeons with
the ability to:
•
•
•
•
•
•
identify patients who may be double doctoring or drug shopping;
upon request from the prescriber or pharmacist, provide accurate and up-to-date
prescribing information;
detect changing trends among the drug shopping patient population;
observe the prescribing practices of physicians and dentists and the dispensing
activities of pharmacies and provide advice to prevent serious problems from
developing;
generate prescriber, patient and pharmacy profiles relevant to the panel of monitored
drugs;
generate statistics and reports relevant to the panel of monitored drugs.
PROCESS
A specially designed prescription form must be used to write a prescription for any of the
medications included on the appended list. Pharmacists cannot fill a prescription for any
of these drugs written on any other form. Verbal prescriptions cannot be accepted for
any of these products. Faxed prescriptions are acceptable if done according to published
guidelines for faxing prescriptions.
PRESCRIBER PARTICIPATION
Physicians and dentists who wish to prescribe any of the medications on the panel of
monitored drugs must subscribe to the program by ordering their triplicate prescription
forms from the College of Physicians & Surgeons. Prescribers without these forms
cannot prescribe the monitored drugs.
GENERAL INFORMATION
The prescriber will complete the prescription form according to instructions. The patient
will receive the original prescription plus one copy. The patient will present the original
and copy to the pharmacist for dispensing. Upon receiving the medication, the patient or
the patient's agent will sign the form in the space provided. The pharmacist completes
the lower portion of the forms and retains the original. The network will receive and store
the information on the existing panel of formulary drugs for Drug Plan beneficiaries only.
Pharmacists are asked to continue to mail the College copy for all other beneficiaries and
drugs. This is done at least once per week. (The Saskatchewan Pharmaceutical
Association distributes self-addressed envelopes for this purpose.)
Upon receipt of the prescription copy, the College of Physicians & Surgeons enters the
information into their computer system.
282
DISPENSING INFORMATION
Prescriptions for the listed drugs must be written on a triplicate prescription form.
Prescriptions that are issued incompletely or inaccurately or are issued in any manner
which is contrary to the requirements of the Triplicate Prescription Program are rejected.
The following information must be complete on the prescription presented at the
pharmacy:
•
•
•
•
date (the prescription is valid for only 3 days from date of issue);
patient's name and address;
personal health number;
printed name of the prescriber.
The pharmacist enters the following information before sending the copy to the College:
•
•
•
•
•
prescription number;
date of filling the prescription;
price charged (optional);
dispensing pharmacist's signature or initials;
dispensing pharmacist's certificate (i.e. membership) number.
The prescription form must be signed by the patient (or agent) upon receipt of the
dispensed prescription. The signature must appear on the College copy.
ADDITIONAL INFORMATION
The Triplicate Prescription Program does not apply to orders issued in licensed special
care homes.
Only those products included in the panel of monitored drugs can be prescribed on the
triplicate form, and only one of those medications can be prescribed per form.
Refills are not allowed.
Part-fills are not encouraged but are acceptable subject to the usual legal and recordkeeping requirement. Under the program, every part-fill must be documented with the
original prescription number and the form number (upper right hand corner). The College
copy of the original prescription must be sent to the College of Physicians & Surgeons
immediately after the first fill. No subsequent refill information is required by the College.
Triplicate prescription pads are assigned numerically for the individual prescriber's use
and cannot be exchanged between practitioners. The prescriber is expected to print his
name, address and prescriber number on the form.
If a prescriber or pharmacist is concerned about a patient's drug history, he/she may
contact the College personally for confidential information at (306) 244-8778.
Prescriptions written at hospital emergency outpatient departments must be written on a
triplicate form if one of the monitored products is prescribed for an outpatient.
If a patient does not have the personal health number available and cannot readily obtain
it, the prescriber is expected to ask for identification and accurately fill in the remaining
identifiers on the form. Under these circumstances the pharmacist may fill the
prescription if this number is absent, but the remaining identifiers are in place.
283
DRUGS ON THE TRIPLICATE PRESCRIPTION PROGRAM:
NOTE: Trade names are included as examples only. Any brands or dosage forms of products
within a particular category are subject to the program. The list is subject to change from time to
time. Prescribers and pharmacists will be advised directly of the effective date of any additions or
deletions. Questions should be directed to the College of Physicians & Surgeons at (306) 244-8778,
or to the Saskatchewan Pharmaceutical Association at (306) 584-2292.
THE TRIPLICATE PRESCRIPTION PROGRAM PANEL OF DRUGS
(by product categories with examples)
ACETAMINOPHEN WITH CODEINE-in all dosage forms except
those containing 8mg or less of codeine (for example*)
Atasol 15, 30
Empracet 30, 60
Emtec-30
Exdol 15, 30
Lenoltec with Codeine #2, #3, #4
Novogesic C-15, C-30
Tylenol with Codeine #2, #3, #4
Tylenol with Codeine Elixir
ACETYLSALICYLIC ACID (ASA) WITH CODEINE- in all
dosage forms except those containing 8mg of codeine (for
example*)
282, 292, 293
Anacasal 15, 30
Phenaphen #2, #3, #4
282 Meps
Robaxisal C¼, C½
HYDROCODONE-DIHYDROCODEINONE-continued
Robidone
Triaminic Expectorant DH
Tussaminic DH Forte
Tussaminic DH Pediatric
Tussionex Suspension, Tablets
HYDROMORPHONE-DIHYDROMORPHINONE-in all dosage
forms (for example*)
Dilaudid, all strengths
Dilaudid HP Parenteral
Hydromorphone, all strengths
LEVORPHANOL-in all dosage forms (for example*)
Levo-Dromoran
MEPERIDINE-PETHIDINE-in all dosage forms (for example*)
Demerol Injectable, Tablets
Meperidine HCl Injectable
ANILERIDINE-in all dosage forms (for example*)
Leritine
METHADONE-in all dosage forms
METHYLPHENIDATE-in all dosage forms (for example*)
Ritalin
Ritalin SR
BUTALBITAL -in all dosage forms (for example*)
Fiorinal Plain
Tecnal
MORPHINE- in all dosage forms (for example*)
M.O.S., all strengths
Morphine Injectable
Morphine HP
Morphine LP
Morphitec, all strengths
MS Contin, all strengths
MSIR, all strengths
Oramorph SR, all strengths
Statex, all strengths
BUTALBITAL WITH CODEINE-in all dosage forms (for
example*)
Fiorinal C¼, C½
Tecnal C¼, C½
BUTORPHANOL
Stadol Nasal Spray
COCAINE-in all dosage forms
CODEINE- as the single active ingredient, or in combination with
other active ingredients in all dosage forms except those
containing 20mg per 30mL or less of codeine in liquid for oral
administration (for example*)
Codeine Tablets, all strengths
Codeine Syrup, all strengths
Codeine Injectable, all strengths
Co-Actifed Syrup, Tablets
CoSudafed Syrup, Tablets
CoSudafed Expectorant
Cotridine
Novahistex C
Omni-Tuss
Pentuss
Robitussin AC
Tussaminic C Forte and C Pediatric
NORMETHADONE-P-HYDROXYEPHEDRINE-in all dosage
forms (for example*)
Cophylac
Cophylac Expectorant
DEXTROAMPHETAMINE-in all dosage forms (for example*)
Dexedrine
PANTOPON-in all dosage forms
DIETHYLPROPION-in all dosage forms (for example*)
Tenuate
Tenuate Dospan
FENTANYL-transdermal system (for example*)
Duragesic, all strengths
HYDROCODONE-DIHYDROCODEINONE-in all dosage forms
(for example*)
Dimetane Expectorant-C
Hycodan Syrup, Tablets
Hycomine Syrup
Hycomine-S Pediatric Syrup
Mercodol with Decapryn
Novahistex DH
Novahistex DH Expectorant
Novahistine DH
OXYCODONE-as a single active ingredient, or in combination
with other active ingredients in all dosage forms (for example*)
Endocet
Endodan
Oxyc ocet
Ocyocodan
Oxycontin, all strengths
Percocet
Percocet-Demi
Percodan
Percodan-Demi
PENTAZOCINE-in all dosage forms (for example*)
Talwin
Talwin Compound-50
PHENTERMINE-in all dosage forms (for example*)
Fastin
Ionamin
PROPOXYPHENE-in all dosage forms (for example*)
642, 692
Darvon-N
Darvon-N Compound
Darvon-N with ASA
Novo-Proxyphene
Novo-Proxyphene Compound
*DISCLAIMER-The product names listed with each drug
category are for example only, and are not intended to be
inclusive.
284
APPENDIX G
CODES FOR PHARMACY ON-LINE CLAIMS PROCESSING
The following is a list of error and warning codes that may appear when processing
claims on the on-line system. The error codes are highlighted.
CODE
DESCRIPTION
AA
AI
AR
CA
CB
CC
CD
CE
CF
CO
CP
CR
CS
CT
FC
GA
GB
GC
GE
GG
GH
GI
GJ
GK
GL
GM
GN
GO
GP
GQ
GR
GT
GU
GW
GX
GY
GZ
HA
HB
HSN not on file
Registered Indian
HSN no coverage
Prescription number required
Prescriber ineligible
Prescriber required
Prescriber inactive
Prescriber not on file
Prescriber inactive
Pharmacy not on file
Dispensing date no contract
Dispensing date over 62 days
Dispensing date invalid
Invalid prescription number
Formulary Clearance
Possible duplicate same pharmacy
Possible duplicate same pharmacy
Verify quantity & unit cost
Unit drug cost exceeded
Non-formulary drug cost exceeded
Non-formulary drug cost exceeded
Dispense SOC for payment
Verify quantity & unit cost & possible duplicate
Total prescription cost exceeded(memory claim)
Patient paid exceeded(memory claim)
Verify quantity & possible duplicate
Verify unit cost & possible duplicate
Dispensing fee exceeds maximum
Possible duplicate different pharmacy
Possible duplicate different pharmacy
Age inconsistent with drug
Total prescription cost invalid(memory claim)
Patient paid invalid(mem ory claim)
Verify compound unit cost and compound fee
Compound quantity must be 1
Verify compound unit cost
Verify compound fee
Non-benefit DIN
DIN not on file
285
CODE
DESCRIPTION
HC
HD
HE
HF
HG
HH
HI
HJ
IP
IS
IT
MA
MB
NA
RC
RD
RE
SA
SF
TA
TB
TC
TD
TE
TF
TG
TH
TJ
TK
TL
TM
TN
TP
TQ
YI
YK
YL
YM
Three month supply exceeded
Three month supply exceeded; another pharmacy
Possible benefit under Exception Drug Status
Three submissions exceeded for Palliative Care
Three submissions exceeded for Palliative Care; another pharmacy
Verify quantity & three submissions exceeded for Palliative Care
Verify unit cost & three submissions exceeded for Palliative Care
Verify quantity & unit cost & three submissions exceeded for Palliative Care
Alternative Reimbursement not allowed
Alternative Reimbursement Fee exceeds maximum allowable
Alternative Reimbursement Type (Quantity) invalid
Mark-up percentage exceeds the maximum allowable
Discount percentage exceeds 100% (PC interfaced)
Transmission error - re-send
Void - original claim not found
Void - original claim already voided
Void not allowed - claim paid to family
Not authorized for PC interface - contact the Drug Plan Help Desk
File error - contact the Drug Plan Help Desk
Trial/Remainder/Alternative Reimbursement prior to April 1, 1996
Product not eligible for Trial Prescription Program
Trial not allowed - not a new medication
Trial not allowed - not a new medication; another pharmacy
Duplicate Trial prescription same pharmacy
Duplicate Trial prescription different pharmacy
Remainder not allowed - trial not found
Duplicate Remainder prescription same pharmacy
Remainder not allowed - dispensed to soon after trial
Remainder not allowed - regular prescription found same pharmacy
Remainder not allowed - regular prescription found different pharmacy
Dispensing Fee not allowed on Remainder
Regular prescription not allowed - trial found
Alternative Reimbursement not allowed - trial not found
Duplicate Alternative Reimbursement
Quantity exceeds maximum
Quantity exceeds the recommended quantity
Quantity exceeds the authorized limit
Quantity lower than minimum
286
APPENDIX H
MAINTENANCE DRUG SCHEDULE
The following lists of drugs are appended to the contract between Saskatchewan Health
and each Saskatchewan pharmacy. Prescribing and dispensing should be in these
quantities once the medical therapy of a patient is in the maintenance stage, unless there
are unusual circumstances that require these quantities not be dispensed.
100 DAY LIST (by product categories)
DIGITALIS PREPARATIONS
digoxin
PHENOBARBITAL
phenobarbital
ANTICONVULSANTS
carbamazepine
clobazam
clonazepam
divalproex sodium
ethosuximide
gabapentin
lamotrigine
methsuximide
nitrazepam
phenytoin
primidone
topiramate
valproate sodium
valproic acid
vigabatrin
ORAL HYPOGLYCEMICS
acarbose
chlorpropamide
glyburide
metformin
pioglitazone HCl
rosiglitazone maleate
repaglinide
tolbutamide
THYROID PREPARATIONS
thyroid
levothyroxine (sodium)
ANTI-THYROIDS
methimazole
propylthiouracil
TWO MONTH DRUG LIST (by product categories)
ORAL CONTRACEPTIVES
ESTROGENS
conjugated estrogens
estradiol
estropipate
ethinyl estradiol
piperazine estrone sulfate
stilboestrol
stilboestrol sodium diphosphate
287
APPENDIX I
TRIAL PRESCRIPTION PROGRAM MEDICATION LIST
A trial prescription provides a patient with a 7 or 10 day supply of new medication to
determine if it will be tolerated.
The following list of drugs is appended to the contract between Saskatchewan Health and
each Saskatchewan pharmacy. These medications are eligible for reimbursement under
the Trial Prescription Program.
ALPHA ADRENERGIC BLOCKERS
doxazosin
prazosin
terazosin
ANTIDEPRESSANT AGENTS
fluoxetine
fluvoxamine
moclobemide
nefazodone
paroxetine
sertraline
ANTILIPEMIC AGENTS
cholestyramine
colestipol
gemfibrozil
CALCIUM CHANNEL BLOCKERS
amlodipine
diltiazem
felodipine
nifedipine
verapamil
GASTROINTESTINAL AGENTS
misoprostol
HEMORRHELOGIC AGENTS
pentoxifylline
NONSTEROIDAL ANTI-INFLAMMATORY AGENTS
diclofenac
diclofenac/misoprostol
flurbiprofen
indomethacin
ketoprofen
piroxicam
sulindac
tiaprofenic acid
tolmetin
288
APPENDIX J
SASKATCHEWAN MS DRUGS PROGRAM
CRITERIA FOR COVERAGE OF MS DRUGS
Approval for coverage will be given to patients who are assessed and meet the following
criteria:
•
have clinical definite relapsing and remitting multiple sclerosis;
•
have had at least two attacks of MS during the previous two years (an attack is
defined as the appearance of new symptoms or worsening of old symptoms, lasting
at least 24 hours in the absence of fever, preceded by stability for at least one
month);
•
are fully ambulatory 100 meters without aids (canes, walkers or wheelchairs)Extended Disability Status Scale (EDSS) 5.5 or less;
•
are age 18 or older.
Contraindications to Treatment
•
concurrent illness likely to alter compliance or substantially reduce life expectancy;
•
pregnancy is planned or occurs;
•
nursing women;
•
active, severe depression.
Physicians should also forward the following information:
•
documentation of attacks, date of onset, date of diagnosis;
•
neurological findings, Extended Disability Status Scale (EDSS)-if known;
•
MRI reports or other significant information;
•
list of current medications.
PROCEDURE FOR OBTAINING COVERAGE OF MS DRUGS UNDER DRUG PLAN
•
Requests are initiated by a physician. The patient and physician complete the
application form and the physician forwards any relevant information to the
Saskatchewan MS Drugs Program. A copy of the application form appears in this
appendix.
•
The MS Drug Advisory Panel reviews the application form and relevant
documentation and renders a decision. Note: A patient's eligibility for coverage
is determined by the MS Drug Advisory Panel. The Drug Plan is notified of the
decision and communicates the results to the patient and the physician.
•
Questions regarding eligibility should be directed to:
Saskatchewan MS Drugs Program
Suite 7703-7th Floor
Saskatoon City Hospital
Saskatoon, S7K 0M7
Telephone: (306) 655-8400
FAX:
(306) 655-8404
•
Upon approval of coverage, patients are encouraged to apply for assistance with
the cost of these medications under the Drug Plan Special Support Program. For
more detailed information regarding this program, see Appendix E.
289
MS DRUG APPROVAL PROCESS
Fax #: (306) 655-8404
Physician
EDS
Application
(Patient consent)
MS Drug
Advisory
Panel
Not
Approved
Approved
Patient
Education
Schedule
Response to
Physician
&
Patient
Drug Plan
On-line Update
Physician
Letter
(Special Support Approval)
Patient
Letter
Follow-up
On-going
Assessment
MS Drug
Advisory
Panel
290
Saskatchewan
Health
Drug Plan &
Extended Benefits
Branch
MS DRUGS EXCEPTION DRUG STATUS APPLICATION
DATE: ___________________________
NAME: _______________________________________________ B/D: ______________________
(D/M/Y)
ADDRESS: _______________________________________________________________________
______________________________________________________ PHONE: __________________
NEUROLOGIST: __________________________________________________________________
DATE OF LAST CONSULTATION: ______________________
FAMILY PHYSICIAN: __________________________________ HSN: ____________________
Drug Requested:
Betaseron
Copaxone
Rebif
Avonex
Exception Drug Status approval will be given to patients who are assessed and meet the following
criteria:
Yes
No
1. Have clinical definite relapsing and remitting multiple sclerosis
2. Have had at least two attacks of MS during the previous two
years (an attack is defined as the appearance of new symptoms
or worsening of old symptoms, lasting at least 24 hours in the
absence of fever, preceded by stability for at least one month)
3. Are fully ambulatory 100 meters without aids (canes, walkers
or wheelchairs) – EDSS 5.5 or less
4. Are age 18 or older
Contraindications to Treatment
1. Concurrent illness likely to alter compliance or substantially
reduce life expectancy
2. Pregnancy is planned or occurs, nursing women
3. Active, severe depression
I, (patient signature) ____________________________________________, give my permission for any
health care provider involved in my care to release to the Advisory Panel any information that may be deemed
necessary in assessing my application for coverage and subsequent monitoring.
MD Signature: ___________________________ Address: ____________________________________
Telephone: ______________________________ Fax: _________________________________
Please Forward:
- clinical history including:
a) documentation of attacks, date of onset, date of diagnosis
b) neurological findings, Extended Disability Status Scale (EDSS) - if known
c) MRI reports or other significant information
d) list current medications
Mail to:
Saskatchewan MS Drugs Program
Suite 7703 - 7th Floor
Saskatoon City Hospital
SASKATOON, Saskatchewan S7K 0M7
OR
Fax:
(306) 655-8404
For clinical program information: Phone (306) 655-8400 For reimbursement information: Phone 1-800-667-7578.
291
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
INDEX A
PHARMACEUTICAL MANUFACTURERS LIST
ABB
AGR
AKN
ALC
ALL
ALT
ALZ
AMG
APX
AST
AVT
AXC
BAY
BCD
BEX
BGN
BMI
BMY
BOE
BOM
BRI
BVL
CCL
CDX
CYT
DBU
DER
DOM
DPY
DUI
DUP
END
FEI
FFR
FTP
FUJ
GAC
GLW
GPM
GSK
HDI
HLR
HOR
ICN
JAN
JJM
KEY
KNO
LEA
LEO
LIH
Abbott Laboratories Ltd.
Agouron Pharmaceuticals Canada Inc.
Dioptic Laboratories, Division of Akorn Pharmaceuticals Canada Ltd.
Alcon Canada Inc.
Allergan Inc.
Altimed Pharmaceutical Company
Alza Canada
Amgen Canada Inc.
Apotex Inc.
AstraZeneca
Aventis Pharma Inc.
Axcan Pharma
Bayer Inc.-Healthcare Division
Bayer Inc.-Consumer Care Division
Berlex Canada Inc.
Biogen Canada Inc.
Bioenhance Medicines Inc.
Bristol-Myers Squibb Canada Inc.
Boehringer Ingelheim (Canada) Ltd.
Roche Diagnostics, Division of Hoffmann-LaRoche Limited
Bristol Pharmaceutical Products - Bristol-Myers Squibb
Crystaal, Division of Biovail Corporation
Chiron Canada Ltd.
Canderm Pharma Inc.
Cytex Pharmaceuticals Inc.
Faulding (Canada) Inc.
Dermik Laboratories Canada Inc.
Dominion Pharmacal
Draxis Health Inc.
Duchesnay Inc.
DuPont Pharma Inc.
Endo Canada Inc., Subsidiary of DuPont Pharma
Ferring Inc.
Fournier Pharma Inc.
FTP Pharmacal Inc.
Fujisawa Canada Inc.
Galderma Canada Inc.
Glenwood Laboratories Canada Ltd.
Genpharm Inc.
GlaxoSmithKline
Hill Dermaceuticals, Inc.
Hoffmann-LaRoche Ltd.
Carter-Horner Inc.
ICN Canada Ltd.
Janssen-Ortho Inc.
Johnson & Johnson - Merck
Key, Division of Schering Canada Inc.
Knoll Pharma Inc.
Lee-Adams Laboratories, Division of Pharmascience Inc.
Leo Pharma Inc.
Lioh Inc.
294
LIL
LIN
LIV
LSN
LUD
MCL
MDA
MDC
MDS
MED
MSD
NOO
NOP
NVC
NVO
NVR
NXP
ODN
OPT
ORG
ORP
PFC
PFI
PFR
PGA
PHU
PMS
PPZ
PRO
RBP
RCA
RHO
RIV
ROG
ROP
RVX
SAB
SAW
SCH
SCP
SDR
SEV
SLV
SQU
SRO
STI
TAR
TCH
THM
TVM
VIR
WSD
WYA
ZYP
Eli Lilly Canada Inc.
Linson Pharma Inc.
Lynden International Logistics
Lifescan Canada Ltd.
Lundbeck Canada Inc
McNeil Consumer Healthcare
3M Pharmaceuticals, 3M Canada Company
Medicis Canada Ltd.
Medisense Canada Inc.
Medican Pharma Inc.
Merck Frosst Canada & Co.
Novo Nordisk Canada Inc.
Novopharm Ltd.
Novartis Consumer Health Canada Inc.
Novartis Ophthalmics, Novartis Pharmaceuticals Canada Inc.
Novartis Pharmaceuticals Canada Inc.
Nu-Pharm Inc.
Odan Laboratories Limited
OptimaPharma, Division of Taro Pharmaceuticals Inc.
Organon Canada Ltd.
Orphan Medical Inc.
Pfizer Canada Inc.-Consumer Health Care Division
Pfizer Canada Inc.
Purdue Pharma
Procter & Gamble Pharm. Canada, Inc.
Pharmacia Canada Inc.
Pharmascience Inc.
Princeton Pharmaceutical Products - Bristol-Myers Squibb
Proval Pharma Inc.
Shire Canada Inc.
Reed & Carnrick, Division of Block Drug Company (Canada) Ltd.
Rhoxalpharma Inc.
Riva Laboratories Ltd.
Rougier Pharma Inc., Division of Technilab
Rhodiapharm
Rivex Pharma Inc.
Sabex Inc.
Sanofi-Synthelabo Canada Inc.
Schering Canada Inc.
Schering-Plough Healthcare Products
Vita Health Products
Servier Canada Inc.
Solvay Pharma Inc.
Squibb Pharmaceutical Products - Bristol-Myers Squibb
Serono Canada Inc.
Stiefel Canada Inc.
Taro Pharmaceuticals Inc.
Technilab Inc.
Theramed Corporation
Teva Marion Partners Canada
Virco Pharmaceuticals (Canada), Inc.
Westwood Squibb Canada
Wyeth-Ayerst Inc.
Zymcan Pharmaceuticals Inc.
295
INDEX B
THERAPEUTIC CLASSIFICATION LIST
08:00 ANTI-INFECTIVE AGENTS................................................................................................... .
08:04.00 AMEBICIDES................................................................................................................ .
08:08.00 ANTHELMINTICS......................................................................................................... .
08:12.00 ANTIBIOTICS................................................................................................................ .
08:12.02 ANTIBIOTICS (AMINOGLYCOSIDES)......................................................................... .
08:12.04 ANTIBIOTICS (ANTIFUNGALS)................................................................................... .
08:12.06 ANTIBIOTICS (CEPHALOSPORINS)........................................................................... .
08:12.12 ANTIBIOTICS (MACROLIDES)..................................................................................... .
08:12.16 ANTIBIOTICS (PENICILLINS)...................................................................................... .
08:12.24 ANTIBIOTICS (TETRACYCLINES)............................................................................... .
08:12.28 ANTIBIOTICS (MISCELLANEOUS ANTIBIOTICS)...................................................... .
08:18.00 ANTIVIRALS................................................................................................................. .
08:18.08 ANTIRETROVIRAL AGENTS (NONNUCLEOSIDE REVERSE
TRANSCRIPTASE INHIBITORS)....................................................................... .
08:18.08 ANTIRETROVIRAL AGENTS (NUCLEOSIDE REVERSE
TRANSCRIPTASE INHIBITORS)....................................................................... .
08:18.08 ANTIRETROVIRAL AGENTS (PROTEASE INHIBITORS)........................................... .
08:20.00 ANTIMALARIAL AGENTS............................................................................................. .
08:22.00 QUINOLONES.............................................................................................................. .
08:26.00 SULFONES................................................................................................................... .
08:36.00 URINARY ANTI-INFECTIVES....................................................................................... .
08:40.00 MISCELLANEOUS ANTI-INFECTIVES........................................................................ .
10:00 ANTINEOPLASTIC AGENTS................................................................................................ .
10:00.00 ANTINEOPLASTIC AGENTS........................................................................................ .
12:00 AUTONOMIC DRUGS........................................................................................................... .
12:04.00 PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS............................................. .
12:08.04 ANTIPARKINSONIAN AGENTS................................................................................... .
12:08.08 ANTIMUSCARINICS/ANTISPASMODICS.................................................................... .
12:12.00 SYMPATHOMIMETIC (ADRENERGIC) AGENTS........................................................ .
12:16.00 SYMPATHOLYTIC AGENTS (ANTIMIGRAINE DRUGS)............................................. .
12:20.00 SKELETAL MUSCLE RELAXANTS.............................................................................. .
20:00 BLOOD FORMATION AND COAGULATION....................................................................... .
20:04.04 IRON PREPARATIONS................................................................................................ .
20:12.04 ANTICOAGULANTS..................................................................................................... .
20:12.20 ANTIPLATELET DRUGS.............................................................................................. .
20:16.00 HEMATOPOIETIC AGENTS......................................................................................... .
20:24.00 HEMORRHEOLOGIC AGENTS.................................................................................... .
24:00 CARDIOVASCULAR DRUGS............................................................................................... .
24:04.00 CARDIAC DRUGS........................................................................................................ .
24:06.00 ANTILIPEMIC DRUGS.................................................................................................. .
24:08.00 HYPOTENSIVE DRUGS............................................................................................... .
24:12.00 VASODILATING DRUGS.............................................................................................. .
28:00 CENTRAL NERVOUS SYSTEM DRUGS............................................................................. .
28:08.04 NON-STEROIDAL ANTI-INFLAMMATORY AGENTS.................................................. .
28:08.08 OPIATE AGONISTS (NARCOTIC ANALGESICS)....................................................... .
28:08.12 OPIATE PARTIAL AGONISTS...................................................................................... .
28:08.92 MISCELLANEOUS ANALGESICS AND ANTIPYRETICS............................................ .
28:12.04 ANTICONVULSANTS (BARBITURATES).................................................................... .
28:12.08 ANTICONVULSANTS (BENZODIAZEPINES).............................................................. .
28:12.12 ANTICONVULSANTS (HYDANTOINS)........................................................................ .
28:12.20 ANTICONVULSANTS (SUCCINIMIDES)...................................................................... .
28:12.92 MISCELLANEOUS ANTICONVULSANTS.................................................................... .
28:16.04 PSYCHOTHERAPEUTIC AGENTS (ANTIDEPRESSANTS)........................................ .
28:16.08 PSYCHOTHERAPEUTIC AGENTS (ANTIPSYCHOTIC AGENTS).............................. .
28:20.00 RESPIRATORY AND CEREBRAL STIMULANTS........................................................ .
28:24.04 ANXIOLYTICS,SEDATIVES AND HYPNOTICS (BARBITURATES)............................ .
28:24.08 ANXIOLYTICS,SEDATIVES AND HYPNOTICS (BENZODIAZEPINES)...................... .
28:24.92 MISCELLANEOUS ANXIOLYTICS,SEDATIVES AND HYPNOTICS........................... .
28:28.00 ANTIMANIC AGENTS................................................................................................... .
36:00 DIAGNOSTIC AGENTS......................................................................................................... .
36:04.00 ADRENAL INSUFFICIENCY......................................................................................... .
36:26.00 DIABETES MELLITUS.................................................................................................. .
36:88.00 URINE CONTENTS...................................................................................................... .
296
2
2
2
3
3
3
5
7
8
10
11
12
13
14
15
16
16
17
17
18
22
22
26
26
26
27
28
31
33
36
36
36
38
38
38
42
42
53
56
69
74
74
80
86
86
86
87
88
88
88
91
99
105
106
106
110
111
114
114
114
114
40:00 ELECTROLYTIC, CALORIC AND WATER BALANCE........................................................ .
40:12.00 REPLACEMENT AGENTS............................................................................................ .
40:18.00 POTASSIUM-REMOVING RESINS.............................................................................. .
40:28.00 DIURETICS................................................................................................................... .
40:28.10 POTASSIUM SPARING DIURETICS............................................................................ .
40:40.00 URICOSURIC DRUGS.................................................................................................. .
48:00 COUGH PREPARATIONS.................................................................................................... .
48:24.00 MUCOLYTIC AGENTS................................................................................................. .
52:00 EYE, EAR, NOSE AND THROAT PREPARATIONS............................................................ .
52:04.04 ANTI-INFECTIVES (ANTIBIOTICS).............................................................................. .
52:04.06 ANTI-INFECTIVES (ANTIVIRALS)............................................................................... .
52:04.08 ANTI-INFECTIVES (SULFONAMIDES)........................................................................ .
52:04.12 ANTI-INFECTIVES (MISCELLANEOUS)...................................................................... .
52:08.00 ANTI-INFLAMMATORY AGENTS................................................................................. .
52:08.00 COMBINATION ANTI-INFECTIVE/ ANTI-INFLAMMATORY AGENTS........................ .
52:10.00 CARBONIC ANHYDRASE INHIBITORS...................................................................... .
52:20.00 MIOTICS....................................................................................................................... .
52:24.00 MYDRIATICS................................................................................................................ .
52:36.00 MISCELLANEOUS E.E.N.T. DRUGS........................................................................... .
56:00 GASTROINTESTINAL DRUGS............................................................................................. .
56:08.00 ANTIDIARRHEA AGENTS............................................................................................ .
56:12.00 CATHARTICS AND LAXATIVES.................................................................................. .
56:16.00 DIGESTANTS............................................................................................................... .
56:22.00 ANTI-EMETICS............................................................................................................. .
56:40.00 MISCELLANEOUS GASTROINTESTINAL DRUGS..................................................... .
60:00 GOLD COMPOUNDS............................................................................................................ .
60:00.00 GOLD COMPOUNDS................................................................................................... .
64:00 METAL ANTAGONISTS........................................................................................................ .
64:00.00 METAL ANTAGONISTS................................................................................................ .
68:00 HORMONES AND SUBSTITUTES....................................................................................... .
68:04.00 ADRENAL CORTICOSTEROIDS................................................................................. .
68:08.00 ANDROGENS............................................................................................................... .
68:12.00 CONTRACEPTIVES..................................................................................................... .
68:16.00 ESTROGENS................................................................................................................ .
68:16.12 ESTROGEN AGONIST-ANTAGONISTS...................................................................... .
68:18.00 GONADOTROPINS...................................................................................................... .
68:20.08 ANTI-DIABETIC DRUGS (INSULINS-PORK)............................................................... .
68:20.08 ANTI-DIABETIC DRUGS (INSULINS-HUMAN BIOSYNTHETIC)................................ .
68:20.20 ANTI-DIABETIC DRUGS (ORAL HYPOGLYCEMICS)................................................. .
68:24.00 PARATHYROID............................................................................................................ .
68:28.00 PITUITARY AGENTS.................................................................................................... .
68:32.00 PROGESTINS............................................................................................................... .
68:36.04 THYROID AGENTS...................................................................................................... .
68:36.08 ANTITHYROID AGENTS.............................................................................................. .
84:00 SKIN AND MUCOUS MEMBRANE PREPARATIONS......................................................... .
84:04.04 ANTI-INFECTIVES (ANTIBIOTICS).............................................................................. .
84:04.08 ANTI-INFECTIVES (ANTI-FUNGALS).......................................................................... .
84:04.12 ANTI-INFECTIVES (SCABICIDES AND PEDICULICIDES)......................................... .
84:04.16 MISCELLANEOUS ANTI-INFECTIVES........................................................................ .
84:06.00 ANTI-INFLAMMATORY AGENTS................................................................................. .
84:06.00 COMBINATION ANTI-INFECTIVE/ ANTI-INFLAMMATORY AGENTS........................ .
84:08.00 ANTIPRURITICS AND LOCAL ANAESTHETICS......................................................... .
84:12.00 ASTRINGENTS............................................................................................................. .
84:16.00 CELL STIMULANTS AND PROLIFERANTS................................................................ .
84:28.00 KERATOLYTIC AGENTS.............................................................................................. .
84:36.00 MISCELLANEOUS SKIN & MUCOUS MEMBRANE AGENTS.................................... .
84:50.06 DEPIGMENTING & PIGMENTING AGENTS (PIGMENTING AGENTS)...................... .
86:00 SMOOTH MUSCLE RELAXANTS........................................................................................ .
86:12.00 GENITOURINARY SMOOTH MUSCLE RELAXANTS................................................. .
86:16.00 RESPIRATORY SMOOTH MUSCLE RELAXANTS..................................................... .
88:00 VITAMINS.............................................................................................................................. .
88:04.00 VITAMIN A.................................................................................................................... .
88:08.00 VITAMINS B.................................................................................................................. .
88:16.00 VITAMIN D.................................................................................................................... .
92:00 UNCLASSIFIED THERAPEUTIC AGENTS.......................................................................... .
92:00.00 UNCLASSIFIED THERAPEUTIC AGENTS.................................................................. .
297
118
118
118
118
120
120
122
122
124
124
125
125
125
125
127
129
129
130
130
134
134
134
134
135
136
142
142
144
144
146
147
150
151
153
155
155
156
156
157
159
160
161
162
163
166
166
167
169
169
170
180
181
181
181
182
183
185
188
188
188
192
192
192
193
196
196
INDEX C
NUMERICAL LIST OF DRUG IDENTIFICATION NUMBERS
DIN
00000086
00000299
00000655
00000663
00000779
00000787
00000833
00000841
00000868
00000884
00000892
00001910
00004405
00004588
00004596
00004723
00004758
00004774
00005525
00005533
00005541
00005606
00005614
00009830
00010081
00010200
00010219
00010332
00010340
00010383
00010391
00010405
00010472
00010480
00012696
00012718
00013285
00013579
00013595
00013609
00013765
00013773
00013803
00015148
00015156
00015229
00015237
00015288
00015377
00015423
00015741
00016055
00016128
00016233
00016322
00016330
00016349
00016357
00016438
00016446
00016497
00016500
00020877
PAGE
106
7
129
129
130
130
129
129
130
130
130
36
26
196
196
23
26
16
61
61
61
105
105
193
85
163
163
74
74
36
36
88
94
94
108
108
108
136
136
136
108
108
135
106
106
96
96
106
198
12
163
144
26
77
91
91
91
26
147
147
119
119
9
DIN
PAGE
00020885
00021008
00021016
00021067
00021075
00021172
00021202
00021261
00021350
00021423
00021474
00021482
00021555
00021695
00022608
00022772
00022780
00022799
00022802
00023442
00023450
00023485
00023698
00023949
00023957
00023965
00024325
00024333
00024341
00024368
00024430
00024449
00024457
00024694
00026034
00026050
00026093
00026611
00027243
00027375
00027456
00027499
00027898
00027901
00027944
00028053
00028096
00028274
00028282
00028339
00028355
00028363
00028606
00029076
00029092
00029173
00029238
00029246
00029556
00030570
00030600
00030619
00030759
298
9
16
16
192
192
7
10
16
157
135
119
119
18
149
153
88
88
88
88
88
88
88
88
162
162
162
93
93
93
10
104
104
104
110
170
170
170
170
31
104
101
31
176
176
176
125
147
4
4
124
176
176
120
50
168
100
154
150
168
11
149
149
149
DIN
00030767
00030783
00030848
00030910
00030929
00030937
00030988
00035017
00035092
00035106
00035114
00035122
00035130
00035149
00035645
00036129
00036323
00037605
00037613
00037621
00042560
00042579
00042676
00067385
00067393
00074225
00074454
00125083
00125105
00125121
00155225
00155357
00176214
00178799
00178802
00178810
00178829
00180408
00187585
00192597
00192600
00206032
00216666
00220442
00223824
00225851
00228079
00228087
00229296
00230197
00230316
00232157
00232378
00232475
00232807
00232823
00232831
00236683
00244392
00247855
00248169
00249580
00249920
PAGE
149
150
161
148
148
161
149
130
115
115
114
114
114
115
6
149
134
153
71
71
126
126
128
70
70
118
128
81
82
81
77
28
31
86
86
86
86
66
182
178
179
197
74
136
3
11
178
178
74
135
179
99
149
192
99
99
99
111
6
126
4
51
29
DIN
00252522
00252654
00253952
00259527
00261238
00261432
00262595
00263699
00263818
00264911
00264938
00264946
00265470
00265489
00268585
00268593
00268607
00268631
00270636
00270644
00271373
00271489
00280437
00285455
00285471
00287873
00291889
00293504
00293512
00294322
00294837
00294926
00294950
00295094
00295973
00296031
00297143
00299405
00301175
00306290
00307246
00312711
00312738
00312746
00312754
00312762
00312770
00312789
00312797
00312800
00313815
00313823
00315966
00317047
00319511
00323071
00324019
00326836
00326844
00326852
00326925
00327794
00328219
00328952
00329320
00330566
00330582
00335053
PAGE
125
185
160
59
203
85
7
182
134
107
107
107
153
153
192
192
192
192
18
19
149
181
147
120
148
197
59
80
80
196
28
120
192
148
168
50
152
127
127
26
128
157
17
104
104
159
149
79
94
119
102
102
152
152
17
171
92
104
119
94
93
76
200
31
31
91
184
91
DIN
PAGE
00335061
00335088
00335096
00335118
00335126
00335134
00337420
00337439
00337730
00337749
00337757
00337765
00337773
00340731
00342084
00342092
00342106
00342114
00343838
00344923
00345504
00345539
00349739
00349917
00353027
00353523
00355658
00358177
00360198
00360201
00360228
00360236
00360244
00360252
00360260
00360279
00360287
00360481
00360503
00361933
00362158
00362166
00363634
00363642
00363650
00363669
00363677
00363685
00363693
00363766
00363812
00364142
00364282
00368040
00369810
00370568
00371033
00372838
00372846
00373036
00374318
00374407
00382825
00382841
00386391
00386464
00386472
00392537
299
91
91
102
102
102
102
76
76
119
119
9
9
9
152
6
6
6
6
152
171
75
104
26
100
152
50
200
128
104
94
104
104
104
63
63
119
119
95
95
27
108
119
63
63
100
100
100
100
196
135
27
76
196
18
88
182
197
152
152
183
182
147
87
87
23
200
200
136
DIN
00392561
00392588
00396761
00396788
00396796
00396818
00396826
00396834
00397423
00397431
00399302
00399310
00400750
00402516
00402540
00402575
00402583
00402591
00402605
00402680
00402699
00402737
00402745
00402753
00402761
00402788
00402796
00402818
00403571
00405310
00405329
00405337
00405345
00405361
00406716
00406724
00406848
00410632
00417246
00417270
00417289
00426830
00426849
00426857
00430617
00432938
00436771
00441619
00441627
00441635
00441651
00441686
00441694
00441708
00441716
00441724
00441732
00441759
00441767
00441775
00443158
00443174
00443794
00443816
00443832
00443840
00445126
00445266
PAGE
84
84
86
119
100
100
100
100
47
47
157
86
93
160
47
64
64
92
47
109
88
109
109
51
51
50
196
196
183
189
108
108
100
100
8
8
182
100
171
49
49
63
192
26
169
182
124
61
61
61
76
70
70
63
63
188
188
120
120
68
109
49
182
182
90
90
139
19
DIN
00445274
00445282
00451207
00452092
00452106
00452130
00452149
00453617
00454583
00455881
00456551
00458686
00458694
00460982
00460990
00461008
00461733
00463256
00463698
00464880
00465208
00465216
00469327
00471526
00474517
00474525
00476366
00476552
00476714
00476722
00479799
00481211
00481815
00481823
00483923
00484911
00486582
00487805
00487813
00487872
00489158
00496480
00496499
00496502
00497452
00497479
00497827
00497894
00499013
00500895
00502197
00502200
00502790
00503134
00503436
00504335
00506052
00506370
00507989
00509353
00510637
00510645
00511528
00511536
00511552
00511641
00511692
00512184
PAGE
18
18
132
70
70
8
8
7
181
33
177
70
70
189
189
189
111
48
100
53
5
5
151
151
193
193
189
96
181
181
196
118
193
193
52
76
84
120
56
136
148
50
51
51
82
82
47
144
17
203
179
178
135
179
188
51
76
196
90
67
18
18
87
87
31
144
188
124
DIN
PAGE
00512192
00513253
00513261
00513288
00513644
00513962
00513997
00514004
00514012
00514217
00514497
00514500
00514535
00514551
00518123
00518131
00518174
00518182
00519251
00521515
00521698
00521701
00522597
00522651
00522678
00522724
00522988
00522996
00523372
00525596
00525618
00527661
00529117
00532223
00532657
00534560
00534579
00534587
00534609
00535427
00535435
00536709
00537594
00537608
00541389
00545015
00545058
00545066
00545074
00545678
00546240
00546283
00546291
00546305
00548359
00548367
00548375
00549657
00550094
00550957
00552135
00552143
00552429
00554316
00554324
00555649
00556734
00556742
300
124
179
179
178
156
124
200
74
74
84
64
64
156
156
107
107
182
182
59
192
108
108
200
78
78
107
107
107
48
79
79
182
130
189
68
47
64
64
203
176
176
188
183
183
28
129
27
18
27
7
136
58
58
58
106
106
200
51
136
149
100
100
101
68
69
203
2
189
DIN
00560022
00560952
00560960
00560979
00564966
00565342
00565350
00565369
00566748
00566756
00568449
00568627
00568635
00568643
00572349
00575119
00575127
00575135
00575143
00575151
00575240
00576158
00577308
00578428
00578436
00578452
00578541
00578568
00578576
00579335
00579351
00579378
00579947
00580929
00580988
00582255
00582263
00582271
00582301
00582344
00582352
00582417
00582514
00583405
00583413
00583421
00584223
00584282
00584339
00584991
00585009
00585092
00585114
00586668
00586676
00586706
00586714
00587265
00587281
00587303
00587354
00587362
00587702
00587737
00587818
00587826
00587834
00587958
PAGE
179
65
65
65
119
196
78
78
183
183
136
64
64
197
197
104
104
104
104
189
130
27
199
171
171
10
179
182
182
179
97
97
181
11
99
50
51
51
166
184
184
136
100
18
6
6
71
137
18
105
105
161
76
166
166
128
156
26
153
153
26
26
101
156
177
177
177
181
DIN
00587966
00589861
00590665
00590827
00591467
00591475
00591548
00592277
00593435
00593451
00594377
00594466
00594636
00594644
00594652
00595799
00595802
00596418
00596426
00596434
00596965
00598194
00598461
00598488
00599026
00599905
00599956
00599964
00600059
00600067
00600784
00600792
00600806
00602884
00602957
00602965
00603260
00603279
00603287
00603295
00603678
00603686
00603708
00603716
00603821
00604453
00604461
00605859
00607126
00607142
00607762
00607770
00608882
00609129
00610267
00611158
00611166
00611174
00613215
00613223
00613231
00614254
00614351
00615315
00615323
00615331
00617288
00618284
PAGE
182
78
111
74
84
84
134
78
81
81
66
77
83
83
83
178
179
89
89
89
85
149
139
139
54
189
48
48
136
137
199
76
78
118
152
152
9
9
9
9
136
137
50
50
110
109
109
7
48
7
84
84
80
136
192
76
76
180
120
120
66
124
109
78
78
78
84
9
DIN
PAGE
00618292
00618632
00618640
00620955
00620963
00621374
00621463
00621935
00622133
00623377
00624268
00624276
00627097
00627100
00628115
00628123
00628131
00628158
00628190
00628204
00628212
00629332
00629340
00629359
00629367
00631701
00632201
00632228
00632481
00632503
00632600
00632716
00632724
00632732
00632740
00632775
00633836
00634506
00636576
00636622
00636681
00637661
00637742
00637750
00638676
00638684
00638692
00639389
00639885
00641154
00641790
00641855
00641863
00642215
00642223
00642886
00642894
00642975
00643025
00644633
00645575
00646016
00646024
00646059
00646148
00646237
00647942
00647969
301
9
47
47
29
29
197
80
84
82
169
84
85
78
82
8
8
8
8
107
107
107
76
76
76
171
189
84
84
84
84
138
79
75
75
80
105
4
12
33
94
85
131
108
108
50
50
50
85
50
179
139
95
182
10
10
79
79
54
17
9
86
110
110
110
156
185
76
100
DIN
00648035
00648043
00652318
00653209
00653217
00653241
00653268
00653276
00655740
00655759
00655767
00657182
00657204
00657212
00657298
00658855
00659606
00662348
00663719
00664227
00666122
00666130
00666149
00666203
00666246
00667099
00667102
00670901
00670928
00670944
00674222
00675199
00675202
00675229
00675962
00677477
00677485
00677590
00682217
00682314
00685925
00685933
00687200
00687219
00687456
00688622
00690198
00690201
00690228
00690244
00690783
00690791
00690805
00692689
00692697
00692700
00694371
00694398
00695351
00695440
00695459
00695661
00695696
00695718
00698059
00700401
00701904
00703486
PAGE
47
47
7
176
176
80
166
80
108
108
108
66
181
10
60
47
55
182
50
148
166
80
80
166
181
108
108
60
60
70
125
76
76
18
83
106
106
18
128
107
139
139
80
80
125
171
83
83
83
83
84
84
99
189
189
189
124
124
183
16
16
57
79
79
185
127
128
134
DIN
00703591
00703605
00703974
00704423
00704431
00705438
00707503
00707600
00708879
00708917
00710113
00710121
00711101
00713325
00713333
00713341
00713376
00713449
00716618
00716626
00716634
00716642
00716650
00716685
00716693
00716782
00716790
00716812
00716820
00716839
00716863
00716871
00716898
00716901
00716952
00716960
00716987
00717002
00717029
00717495
00717509
00717568
00717576
00717584
00717592
00717606
00717630
00717649
00717657
00717673
00720933
00720941
00722146
00725110
00725749
00725765
00726540
00728179
00728276
00728284
00729973
00731323
00731439
00733059
00733067
00733075
00738824
00738832
PAGE
169
169
167
22
22
81
151
151
60
161
137
137
108
50
50
50
118
100
176
176
176
176
176
179
179
177
177
177
178
178
178
168
168
168
180
180
180
180
180
9
63
10
63
9
9
11
9
9
9
9
158
158
12
48
82
82
19
188
118
118
161
23
27
139
139
157
110
110
DIN
PAGE
00738840
00739839
00740497
00740675
00740713
00740799
00740802
00740810
00740829
00741817
00742554
00743518
00745588
00745596
00745626
00749354
00750050
00751170
00751286
00751863
00751871
00751898
00755338
00755575
00755583
00755826
00755834
00755842
00755850
00755869
00755877
00755885
00755893
00755907
00756784
00756792
00756814
00756830
00756849
00756857
00759465
00759473
00759481
00759503
00761605
00761613
00761621
00761648
00761672
00761680
00766046
00768715
00768723
00769533
00769541
00769991
00771368
00771376
00771384
00773611
00773689
00773697
00775320
00776181
00776203
00776521
00778338
00778346
302
110
126
36
50
10
98
98
98
98
110
69
99
79
79
160
47
176
47
131
148
104
102
118
100
88
132
132
52
52
52
49
49
49
48
126
154
78
48
154
154
61
61
61
101
98
98
98
98
77
77
126
6
6
118
118
7
169
45
45
88
43
43
104
83
84
124
138
138
DIN
00778354
00778362
00778907
00778915
00779121
00779474
00782327
00782459
00782467
00782475
00782483
00782491
00782505
00782718
00782742
00783137
00784338
00784400
00785261
00786535
00786543
00786616
00788716
00789429
00789437
00789445
00789747
00790419
00790427
00792659
00792667
00792942
00795852
00795860
00795879
00800430
00805009
00807435
00808539
00808547
00808563
00808571
00808652
00808733
00808741
00809187
00812331
00812358
00812366
00812374
00812382
00813966
00816078
00817120
00818658
00818666
00818674
00818682
00821373
00824143
00824291
00824305
00828556
00828564
00828688
00828823
00832804
00836230
PAGE
79
79
128
128
4
81
150
74
48
48
68
69
48
88
33
18
181
56
126
82
82
30
12
135
135
134
103
29
77
110
4
189
55
55
157
12
171
124
74
74
109
109
101
158
158
171
68
69
167
167
167
138
192
10
67
67
67
67
135
160
193
160
139
139
139
139
5
79
DIN
00836249
00836273
00836362
00839175
00839183
00839191
00839205
00839213
00839388
00839396
00839418
00842648
00842656
00842834
00846341
00846368
00846465
00849650
00849669
00850322
00850330
00851639
00851647
00851655
00851663
00851671
00851698
00851736
00851744
00851752
00851760
00851779
00851787
00851795
00851833
00851841
00851922
00851930
00852074
00852384
00854409
00855774
00855820
00856711
00860689
00860697
00860700
00860751
00860808
00862924
00862932
00862975
00865397
00865400
00865532
00865540
00865559
00865567
00865575
00865591
00865605
00865613
00865621
00865648
00865656
00865664
00865672
00865680
PAGE
79
199
160
74
74
201
201
201
62
62
62
47
47
138
31
199
19
171
171
84
84
57
58
58
48
48
48
179
179
147
147
61
61
60
58
29
54
55
147
71
134
142
137
179
107
107
107
10
30
45
45
171
106
106
68
8
8
8
8
48
47
47
78
78
78
78
108
108
DIN
PAGE
00865699
00865710
00865729
00865737
00865745
00865753
00865761
00865788
00865818
00865826
00865834
00865850
00865869
00865877
00865885
00867365
00867373
00868949
00868957
00869007
00869015
00869023
00869945
00869953
00869961
00870013
00870021
00870935
00871095
00872318
00872334
00872423
00872431
00873292
00873454
00873993
00874086
00874256
00878790
00878928
00878936
00880191
00882801
00882828
00882836
00884324
00884332
00884340
00884359
00884413
00884421
00884502
00885401
00885428
00885436
00885444
00885835
00885843
00885851
00886009
00886017
00886025
00886033
00886041
00886068
00886076
00886106
00886114
303
108
18
18
139
139
19
79
79
136
136
137
76
76
6
6
68
69
59
59
49
49
49
26
26
26
181
182
200
179
125
147
109
109
178
7
160
29
10
126
43
43
124
65
65
65
56
56
56
56
62
62
199
81
82
81
81
57
57
57
49
74
74
68
69
45
45
56
43
DIN
00886122
00886130
00886149
00886432
00886440
00888354
00888400
00888419
00888524
00888532
00890960
00891800
00891819
00893560
00893595
00893609
00893617
00893625
00893749
00893757
00893773
00893781
00894710
00894729
00894737
00894745
00897272
00897310
00897329
00899356
00950068
00950238
00950300
00950378
00950408
00950432
00950459
00950505
00950572
00950661
00950734
00950792
00950793
00950807
00950815
00950823
00950878
00950882
00950883
00950889
00950893
00950894
01900927
01900935
01902628
01902644
01902652
01902660
01905082
01905090
01907107
01907115
01907123
01907476
01908294
01908448
01908871
01908901
PAGE
43
49
49
103
103
130
120
120
45
45
53
3
3
132
57
58
58
58
55
55
132
132
168
168
99
99
52
182
181
95
114
114
114
114
114
114
114
114
114
114
114
184
184
184
184
184
114
114
114
114
114
114
158
158
166
15
15
15
132
132
61
61
69
185
125
131
183
182
DIN
01910086
01910124
01910132
01910140
01910159
01910167
01910272
01910299
01911465
01911473
01911481
01911627
01911635
01911902
01911910
01911929
01912038
01912046
01912054
01912062
01912070
01912437
01912828
01913204
01913220
01913239
01913247
01913328
01913425
01913433
01913441
01913468
01913476
01913484
01913492
01913506
01913654
01913662
01913670
01913689
01913786
01913794
01913808
01913816
01913824
01913832
01913840
01913859
01913999
01914006
01914030
01914138
01914146
01916181
01916203
01916386
01916513
01916777
01916785
01916815
01916823
01916858
01916866
01916874
01916882
01916947
01917021
01917056
PAGE
166
179
179
42
42
42
176
176
58
58
58
12
12
71
71
71
76
76
43
43
137
183
128
61
59
106
106
127
93
93
93
93
93
106
106
109
158
158
158
158
59
65
65
65
57
58
58
58
13
12
140
11
11
127
127
82
85
137
136
136
142
8
8
9
9
166
94
75
DIN
PAGE
01918303
01918311
01918338
01918346
01918354
01918362
01918486
01919342
01919369
01919458
01919466
01919563
01919571
01919598
01924516
01924559
01924567
01924613
01924621
01924753
01924761
01925199
01925350
01925679
01925997
01926284
01926292
01926306
01926314
01926322
01926330
01926349
01926357
01926365
01926373
01926381
01926403
01926411
01926446
01926454
01926462
01926470
01926489
01926497
01926500
01926519
01926527
01926543
01926551
01926578
01926586
01926616
01926667
01926675
01926691
01926756
01926764
01926772
01926780
01926853
01926861
01926888
01926934
01927167
01927604
01927612
01927620
01927647
304
118
37
37
37
37
37
53
94
94
162
162
120
120
97
105
105
105
80
80
188
188
182
171
155
183
98
203
203
150
98
98
98
98
77
77
77
77
77
203
71
181
182
182
181
182
182
182
42
42
42
189
189
103
103
159
102
102
102
102
18
169
169
30
126
142
142
142
110
DIN
01927655
01927663
01927671
01927701
01927728
01927744
01927752
01927760
01927779
01927787
01927795
01927914
01929968
01929976
01929984
01929992
01931512
01934155
01934198
01934201
01934228
01934317
01934392
01934406
01937219
01937227
01937235
01937383
01937391
01937405
01937413
01939130
01940376
01940414
01940430
01940449
01940457
01940473
01940481
01940511
01940538
01940546
01940554
01940635
01942964
01942972
01942980
01942999
01943200
01944355
01944363
01944436
01944444
01945149
01945203
01945270
01946242
01946250
01946269
01946277
01946323
01946374
01947664
01947672
01947680
01947699
01947796
01947818
PAGE
110
111
111
111
111
26
103
103
103
103
103
171
99
99
99
99
77
168
65
65
65
69
28
28
56
97
97
81
81
81
81
192
159
131
98
98
98
96
96
14
14
14
14
14
57
58
58
58
192
2
2
171
171
183
30
125
92
92
92
92
15
185
65
65
65
65
52
52
DIN
01947826
01947923
01947931
01947958
01948598
01948776
01948784
01948792
01948806
01950541
01950681
01953834
01953842
01958097
01958100
01958119
01959212
01959220
01959239
01962655
01962701
01962728
01962779
01962817
01964054
01964070
01964399
01964402
01964909
01964925
01964933
01964968
01964976
01966197
01966200
01966219
01966278
01968017
01968300
01968432
01968440
01976133
01977547
01977563
01977601
01978918
01978926
01979574
01979582
01981242
01981250
01981501
01984853
01985205
01986864
01987003
01987682
01987712
01988727
01988735
01988743
01988840
01989553
01989561
01990403
01990896
01990918
01992872
PAGE
52
26
26
26
130
92
92
92
92
132
27
137
137
60
60
60
157
156
156
157
178
178
97
97
180
148
103
103
110
111
111
148
148
46
46
189
189
38
127
38
153
184
148
150
150
147
147
54
55
144
144
196
7
135
30
192
166
127
83
84
84
166
46
46
12
15
15
153
DIN
PAGE
01995227
01997580
01997602
01997629
01997637
01997653
01997750
01999559
01999761
01999788
01999796
01999818
01999826
01999834
01999842
01999850
01999869
02004828
02004836
02006383
02007134
02007959
02009706
02009749
02009765
02009773
02010267
02010283
02010291
02010909
02011239
02011271
02011921
02011948
02011956
02012472
02013223
02014165
02014173
02014181
02014203
02014211
02014238
02014246
02014254
02014262
02014270
02014289
02014297
02014300
02014319
02014327
02015439
02015951
02016095
02017237
02017539
02017598
02017628
02017636
02017709
02017733
02017741
02018144
02018152
02018160
02018985
02019809
305
109
140
33
198
17
33
2
57
150
180
180
180
180
180
180
180
150
61
61
28
159
37
83
83
83
83
167
178
178
198
111
71
178
167
124
36
169
189
85
189
83
83
83
84
83
85
188
188
83
84
84
84
83
77
134
78
16
193
86
86
16
169
118
150
150
150
93
2
DIN
02019930
02019949
02019957
02019965
02020599
02020602
02020610
02020629
02020661
02020688
02020696
02020718
02020726
02020734
02020742
02022125
02022133
02022141
02022826
02023725
02023733
02023741
02023768
02023814
02023830
02023865
02024152
02024187
02024195
02024209
02024217
02024225
02024233
02024241
02024268
02024276
02024284
02024292
02024306
02024314
02024322
02025248
02025280
02025299
02025302
02025310
02025736
02026759
02026767
02026961
02028700
02028786
02029421
02029448
02030810
02030829
02030837
02031094
02031116
02031159
02031167
02031175
02032376
02034468
02035324
02036282
02036290
02036347
PAGE
83
83
83
84
98
98
98
98
76
76
76
76
76
158
158
29
137
137
13
129
130
130
127
128
125
126
3
176
137
137
157
156
156
156
156
157
156
157
157
157
157
157
103
103
103
103
128
27
176
118
153
200
153
201
46
28
28
168
4
131
131
77
130
12
126
43
42
8
DIN
02036355
02036436
02036444
02039486
02039494
02039532
02039540
02040751
02040778
02040786
02041308
02041375
02041413
02041421
02041448
02041510
02041685
02042177
02042207
02042215
02042231
02042258
02042266
02042274
02042282
02042290
02042304
02042312
02042320
02042339
02042355
02042363
02042479
02042487
02042533
02042541
02042568
02042576
02042584
02042592
02042606
02042614
02042622
02043033
02043041
02043394
02043408
02043416
02043424
02043440
02043505
02043521
02043661
02043688
02043726
02043734
02044609
02044617
02044668
02044676
02044692
02044706
02045680
02045699
02045702
02045710
02045729
02045737
PAGE
8
42
42
75
75
43
43
92
92
91
8
197
108
108
108
17
8
50
51
51
51
51
51
51
65
65
118
118
151
151
86
86
151
151
151
151
88
79
79
8
70
70
70
151
151
153
153
153
153
153
51
138
109
109
151
151
52
52
10
10
50
51
120
120
139
158
62
62
DIN
PAGE
02045834
02045869
02046113
02046121
02046148
02046156
02046253
02046261
02046733
02046741
02047454
02047462
02047799
02047802
02048493
02048507
02048515
02048523
02048639
02048698
02048728
02048736
02049325
02049333
02049341
02049376
02049384
02049392
02049961
02049988
02049996
02050005
02050013
02050021
02050048
02050056
02051850
02052431
02052717
02053187
02053195
02056704
02056712
02057778
02057808
02057816
02057824
02058413
02058456
02058464
02058472
02060590
02060868
02060884
02061562
02061570
02063662
02063735
02063743
02063786
02063808
02064472
02064480
02065819
02068036
02068087
02069571
02070847
306
135
135
203
59
59
71
74
74
122
30
4
48
166
166
75
75
132
132
177
74
87
87
198
62
119
62
62
201
57
57
93
93
93
93
93
93
7
176
192
97
97
28
28
61
49
49
49
75
54
55
70
153
126
171
54
54
18
33
33
202
138
139
139
90
90
202
30
183
DIN
02070863
02070987
02074788
02076306
02078627
02078635
02078651
02080052
02083345
02083353
02083523
02083531
02084090
02084104
02084228
02084236
02084260
02084279
02084287
02084295
02084309
02084317
02084325
02084333
02084341
02084376
02084384
02084392
02084449
02084457
02085852
02085887
02085895
02086026
02087324
02087375
02087383
02087391
02088398
02088401
02089580
02089602
02089610
02089769
02089777
02089793
02091194
02091232
02091275
02091461
02091488
02091526
02093103
02093162
02097141
02097168
02097176
02097214
02097222
02097230
02097249
02097257
02097265
02097273
02097370
02097389
02099128
02099136
PAGE
183
98
183
130
12
12
12
33
132
132
53
78
11
11
52
52
89
89
89
167
168
132
132
30
158
49
49
49
33
33
168
158
82
148
197
95
96
96
33
33
118
170
170
155
155
155
74
10
100
155
155
122
10
176
27
27
27
45
45
45
45
46
46
46
45
45
92
92
DIN
02099225
02099233
02099675
02099683
02100193
02100215
02100304
02100479
02100487
02100495
02100509
02100517
02100622
02100630
02102978
02103036
02103095
02103567
02103583
02103613
02103656
02103680
02103702
02103729
02103737
02106272
02106280
02108143
02108151
02108186
02108194
02112736
02112752
02112760
02112787
02112795
02112809
02115514
02115522
02122197
02123274
02123282
02123312
02123320
02123339
02123347
02125102
02125145
02125226
02125250
02125323
02125331
02125366
02125382
02125390
02125447
02126168
02126176
02126184
02126192
02126222
02126249
02126257
02126559
02126605
02126710
02126753
02126761
PAGE
203
158
140
140
176
2
155
69
69
69
76
76
139
90
27
170
27
139
92
137
87
98
98
62
87
62
62
11
11
154
62
179
140
140
140
140
140
177
177
4
64
64
202
201
201
201
26
4
169
139
82
82
82
82
82
169
200
200
200
176
27
168
167
70
167
7
48
48
DIN
PAGE
02128950
02128969
02130033
02130084
02130092
02130106
02130165
02130173
02130297
02130300
02130874
02130963
02130971
02130998
02131013
02131048
02131056
02131064
02131625
02132591
02132621
02132648
02132664
02132680
02132699
02132702
02133296
02133318
02133334
02133342
02134829
02134853
02134861
02134888
02134896
02136090
02136104
02136112
02136120
02137267
02137313
02137321
02137348
02137534
02137542
02137984
02138018
02138271
02138298
02139189
02139197
02139200
02139324
02139332
02139340
02139359
02139367
02139391
02139960
02139979
02139987
02139995
02140039
02140047
02140055
02140063
02140071
02140098
307
97
97
11
92
92
92
92
92
101
101
168
12
13
87
87
33
33
33
132
134
36
36
36
54
54
97
127
127
130
128
139
130
129
130
130
33
33
80
80
84
50
51
51
106
106
86
82
33
33
53
53
12
30
33
91
92
92
33
79
65
65
65
10
90
90
90
93
93
DIN
02140101
02140128
02141442
02142023
02142031
02142058
02142074
02142082
02142104
02142112
02143283
02143291
02143364
02143372
02144263
02144271
02145413
02145421
02145448
02145758
02145863
02145901
02145928
02145936
02145944
02145952
02145960
02146118
02146126
02146827
02146843
02146851
02146886
02146894
02146908
02146916
02146924
02146932
02146940
02146959
02147432
02147602
02147610
02147629
02147637
02147645
02148552
02148560
02148579
02148587
02148595
02148749
02148765
02150662
02150670
02150689
02150697
02150808
02150816
02150824
02150867
02150875
02150891
02150905
02150921
02150948
02150956
02152568
PAGE
93
93
3
75
75
10
55
89
89
89
138
125
76
76
97
97
47
47
203
3
82
82
82
82
85
85
85
82
82
85
29
29
80
43
7
45
45
77
77
54
43
42
42
42
97
97
161
161
161
154
154
181
158
197
197
197
197
77
77
77
167
167
167
167
167
167
184
29
DIN
02153483
02153521
02153548
02153556
02153564
02154412
02154420
02154463
02155885
02155893
02155907
02155923
02155958
02155966
02155974
02155990
02156008
02156016
02156032
02156040
02156083
02156091
02157195
02158574
02158582
02158590
02158604
02158612
02158620
02158639
02161923
02161966
02161974
02162431
02162458
02162466
02162474
02162482
02162490
02162504
02162512
02162687
02162776
02162806
02162814
02162822
02162849
02163152
02163527
02163535
02163543
02163551
02163578
02163586
02163594
02163659
02163667
02163675
02163683
02163705
02163721
02163748
02163772
02163780
02163799
02163918
02163926
02163934
PAGE
119
140
140
140
140
30
79
79
48
49
49
70
16
16
16
49
99
99
99
99
77
169
137
10
74
188
95
95
95
95
178
178
178
78
78
78
78
78
78
177
177
126
39
71
74
158
158
178
71
71
188
57
58
58
58
5
5
5
5
131
28
81
52
81
81
80
80
80
DIN
PAGE
02163942
02165376
02165384
02165392
02165481
02165503
02165511
02165546
02165554
02165562
02166704
02166712
02166720
02166747
02167786
02167794
02167816
02167824
02167840
02168898
02168936
02168979
02169649
02169894
02169908
02170019
02170027
02170035
02170132
02170493
02170698
02170833
02170841
02171228
02171775
02171791
02171805
02171813
02171821
02171848
02171858
02171864
02171872
02171880
02171899
02171929
02172062
02172070
02172089
02172097
02172100
02172119
02172127
02172135
02172143
02172151
02172550
02172569
02172577
02172712
02173344
02173352
02173360
02173506
02173514
02174545
02174553
02174596
308
80
29
97
97
77
137
137
42
42
42
161
132
132
95
158
52
107
107
37
154
155
23
199
91
91
101
101
101
101
192
183
52
52
162
167
43
43
79
79
33
107
107
107
132
132
140
162
162
162
162
162
162
162
162
162
162
47
47
77
125
87
87
30
11
11
47
47
56
DIN
02174618
02174677
02174685
02175983
02175991
02176009
02176017
02176076
02176084
02176092
02176106
02176122
02176130
02176149
02177072
02177102
02177145
02177153
02177161
02177188
02177579
02177587
02177595
02177617
02177625
02177633
02177641
02177668
02177676
02177684
02177692
02177706
02177714
02177722
02177749
02177757
02177781
02177803
02177846
02177854
02177889
02177897
02178729
02178737
02179679
02179687
02179709
02181479
02181487
02181495
02181509
02181517
02181525
02182815
02182823
02182831
02182858
02182866
02182874
02182882
02182963
02183862
02184435
02184443
02184451
02184648
02185407
02185415
PAGE
33
75
75
203
203
203
198
118
199
23
23
110
77
77
78
13
33
107
107
107
93
94
94
93
94
5
5
5
5
5
96
96
138
138
83
84
6
6
6
6
87
87
96
96
80
80
119
59
8
8
8
8
49
63
200
200
200
11
63
63
183
134
83
83
84
90
54
23
DIN
02185423
02185830
02185849
02185857
02185865
02185873
02186802
02187086
02187094
02187108
02187116
02187876
02188783
02188929
02188937
02188945
02188953
02188961
02188988
02188996
02189003
02189011
02189038
02189046
02189054
02189062
02190885
02190893
02190915
02192268
02192276
02192284
02192659
02192667
02192683
02192691
02192705
02192713
02192721
02192748
02192756
02192764
02194031
02194058
02194082
02194090
02194155
02194163
02194171
02194198
02194201
02194228
02194236
02194333
02194341
02194422
02195704
02195917
02195925
02195933
02195941
02195968
02195984
02195992
02196018
02196026
02197405
02197413
PAGE
23
5
5
5
5
5
13
152
152
152
152
67
201
57
58
58
58
43
43
91
92
92
45
45
152
152
157
157
138
170
170
170
11
134
14
14
107
107
107
200
93
94
180
180
149
149
150
168
168
4
4
168
168
88
184
39
168
23
23
200
200
200
5
5
137
137
12
12
DIN
PAGE
02197421
02197448
02197456
02197464
02197502
02199270
02199289
02199297
02200104
02200864
02200937
02200996
02201011
02201038
02202441
02202468
02202476
02202484
02203324
02204401
02204428
02204436
02204444
02204517
02204525
02204533
02204576
02204584
02206072
02207621
02207648
02207656
02207672
02207761
02207788
02207818
02208229
02208237
02208245
02209071
02210320
02210347
02210355
02210363
02210428
02210479
02211076
02211130
02211149
02211157
02211165
02211742
02211920
02211939
02211947
02211955
02211963
02211971
02212005
02212021
02212048
02212102
02212153
02212161
02212188
02212277
02212285
02212307
309
12
48
131
131
152
203
12
152
135
125
49
52
196
196
85
85
85
85
134
154
154
154
154
42
42
42
160
160
38
12
12
12
110
139
139
87
30
30
29
131
53
69
69
69
52
27
110
101
101
100
100
30
69
92
92
92
92
92
134
7
33
48
32
32
32
6
6
6
DIN
02212315
02212323
02212331
02212374
02212390
02212927
02212978
02213036
02213044
02213052
02213079
02213192
02213206
02213214
02213222
02213230
02213265
02213273
02213281
02213419
02213478
02213486
02213583
02213591
02213605
02213613
02213672
02213834
02214261
02214415
02214997
02215004
02215136
02216086
02216094
02216108
02216116
02216132
02216140
02216159
02216183
02216205
02216213
02216221
02216248
02216256
02216264
02216272
02216280
02216353
02216361
02216582
02216590
02216949
02216965
02217015
02217058
02217066
02217414
02217422
02217481
02217503
02217511
02218305
02218321
02218410
02218429
02218453
PAGE
29
29
139
139
29
124
126
129
130
130
127
162
162
162
162
162
176
176
176
30
29
30
148
148
148
148
126
127
30
177
29
29
160
14
14
14
14
111
111
111
160
129
176
27
92
92
92
92
92
93
94
93
94
30
16
22
22
22
90
18
62
62
62
199
90
95
95
94
DIN
02218461
02218941
02218968
02218976
02218984
02219077
02219085
02219476
02219492
02219905
02220059
02220067
02220156
02220164
02220172
02220180
02220385
02220407
02221284
02221292
02221306
02221330
02221780
02221799
02221802
02221810
02221829
02221837
02221845
02221853
02221896
02221918
02221926
02221934
02221950
02221977
02221985
02221993
02222000
02222051
02222957
02222965
02222973
02223139
02223147
02223325
02223333
02223341
02223368
02223376
02223406
02223414
02223511
02223538
02223562
02223570
02223589
02223597
02223600
02223678
02223716
02223724
02223856
02223864
02224100
02224550
02224569
02224631
PAGE
94
67
67
67
67
139
139
168
13
169
188
188
138
138
55
55
182
170
161
161
161
199
36
89
167
167
66
66
66
66
177
177
177
177
80
38
61
61
61
55
45
45
45
96
96
92
92
92
92
188
22
22
96
96
158
109
109
119
54
119
7
7
183
183
87
158
158
127
DIN
PAGE
02224690
02224704
02224720
02224836
02225158
02225166
02225190
02225964
02225972
02225980
02226839
02227339
02227444
02227452
02227460
02228203
02228211
02228343
02228351
02228947
02229099
02229110
02229129
02229145
02229161
02229196
02229250
02229269
02229277
02229285
02229293
02229393
02229394
02229395
02229406
02229407
02229408
02229440
02229441
02229449
02229452
02229453
02229455
02229456
02229467
02229468
02229515
02229516
02229517
02229524
02229526
02229540
02229550
02229552
02229569
02229617
02229628
02229650
02229651
02229652
02229653
02229654
02229655
02229656
02229704
02229705
02229707
02229709
310
119
119
119
46
197
197
154
109
109
54
169
119
136
136
137
74
74
134
134
31
147
13
13
15
15
15
102
102
102
102
136
129
130
130
45
45
45
124
124
22
77
139
109
109
43
43
37
158
158
17
46
150
150
134
77
9
90
44
44
44
44
87
87
158
156
156
12
12
DIN
02229718
02229719
02229720
02229722
02229723
02229755
02229756
02229758
02229778
02229779
02229781
02229782
02229783
02229784
02229785
02229837
02229838
02229839
02229840
02229874
02229994
02230019
02230020
02230047
02230085
02230086
02230087
02230090
02230095
02230102
02230183
02230203
02230204
02230205
02230206
02230256
02230263
02230264
02230284
02230285
02230302
02230321
02230322
02230359
02230360
02230361
02230362
02230366
02230368
02230369
02230386
02230394
02230401
02230402
02230403
02230404
02230405
02230406
02230418
02230420
02230431
02230432
02230433
02230448
02230449
02230454
02230473
02230475
PAGE
136
136
137
160
22
37
109
109
52
52
45
46
46
46
158
75
161
161
161
169
158
135
135
63
189
189
189
38
109
109
55
57
58
58
58
91
5
5
97
97
81
105
105
48
48
96
96
87
87
87
128
188
38
105
105
105
104
104
32
32
138
138
138
47
47
197
137
158
DIN
02230476
02230477
02230543
02230580
02230584
02230585
02230619
02230641
02230648
02230663
02230666
02230667
02230668
02230670
02230711
02230713
02230714
02230717
02230730
02230732
02230733
02230734
02230735
02230736
02230737
02230768
02230784
02230785
02230800
02230803
02230804
02230805
02230806
02230807
02230808
02230827
02230828
02230837
02230838
02230839
02230840
02230874
02230888
02230889
02230891
02230892
02230893
02230894
02230896
02230897
02230898
02230941
02230942
02230950
02230951
02230997
02230998
02230999
02231015
02231030
02231036
02231052
02231053
02231054
02231060
02231061
02231089
02231121
PAGE
55
78
201
55
107
107
149
202
126
90
107
107
107
158
53
53
53
202
199
71
71
71
11
11
138
90
184
184
188
47
47
67
67
67
67
80
80
101
101
101
101
110
124
124
153
153
90
90
90
2
28
110
110
87
87
45
46
46
17
90
202
45
46
46
80
4
188
47
DIN
PAGE
02231122
02231129
02231135
02231136
02231143
02231150
02231151
02231152
02231154
02231155
02231171
02231181
02231182
02231184
02231192
02231193
02231208
02231245
02231287
02231288
02231290
02231327
02231328
02231329
02231330
02231347
02231348
02231353
02231390
02231430
02231431
02231432
02231433
02231441
02231457
02231459
02231460
02231477
02231478
02231480
02231488
02231489
02231491
02231492
02231493
02231494
02231502
02231503
02231504
02231505
02231506
02231508
02231509
02231510
02231536
02231537
02231539
02231543
02231544
02231583
02231584
02231585
02231586
02231587
02231592
02231615
02231616
02231650
311
47
30
27
27
7
45
46
46
46
46
36
52
52
119
94
94
77
27
136
136
137
78
94
94
94
4
169
33
132
30
203
5
5
71
68
68
68
137
37
169
30
90
196
110
131
27
74
74
74
74
75
75
154
154
49
49
49
88
88
38
38
38
38
38
181
109
109
49
DIN
02231662
02231663
02231664
02231665
02231671
02231675
02231676
02231677
02231678
02231679
02231680
02231683
02231684
02231686
02231687
02231691
02231693
02231702
02231714
02231715
02231731
02231733
02231743
02231744
02231745
02231780
02231781
02231782
02231783
02231784
02231785
02231799
02231800
02231923
02231934
02232043
02232044
02232148
02232150
02232191
02232193
02232195
02232317
02232318
02232389
02232391
02232564
02232565
02232567
02232568
02232569
02232570
02232872
02232903
02232904
02232905
02232987
02233014
02233047
02233048
02233049
02233050
02233960
02233982
02233985
02233998
02233999
02234003
PAGE
74
74
74
74
203
28
69
69
30
199
199
97
97
96
96
5
5
197
131
131
43
43
45
45
45
54
96
96
30
30
27
77
77
126
85
198
198
95
95
176
176
176
75
75
80
10
110
202
202
202
202
29
22
110
111
111
30
198
67
67
67
67
87
87
87
134
158
87
DIN
02234007
02234008
02234013
02234502
02234503
02234504
02234505
02234513
02234514
02234749
02235897
02235898
02236466
02236506
02236507
02236508
02236564
02236606
02236733
02236734
02236758
02236783
02236799
02236807
02236808
02236809
02236819
02236841
02236842
02236859
02236876
02236883
02236913
02236949
02236950
02236951
02236952
02236953
02236974
02236975
02236996
02236997
02237111
02237112
02237145
02237146
02237147
02237148
02237149
02237224
02237225
02237235
02237244
02237245
02237246
02237247
02237264
02237265
02237268
02237269
02237270
02237275
02237277
02237278
02237279
02237280
02237282
02237289
PAGE
87
52
52
67
67
67
67
158
158
105
48
48
137
33
33
33
36
204
158
158
48
29
196
90
68
68
196
17
17
196
131
36
37
197
103
103
103
103
151
151
178
178
95
95
201
201
201
137
137
28
28
4
148
148
148
148
106
106
110
52
52
33
87
87
98
98
98
202
DIN
PAGE
02237292
02237294
02237295
02237313
02237314
02237319
02237320
02237325
02237326
02237367
02237368
02237370
02237371
02237373
02237374
02237375
02237379
02237397
02237398
02237399
02237400
02237484
02237500
02237501
02237502
02237514
02237534
02237535
02237536
02237537
02237560
02237600
02237601
02237618
02237651
02237652
02237653
02237654
02237671
02237682
02237701
02237721
02237722
02237723
02237770
02237786
02237787
02237791
02237807
02237808
02237813
02237814
02237820
02237821
02237824
02237825
02237826
02237830
02237835
02237858
02237860
02237861
02237862
02237863
02237868
02237875
02237876
02237885
312
55
109
109
11
11
199
199
53
53
66
66
3
3
55
55
55
125
95
95
96
96
200
5
5
5
16
101
101
101
101
39
43
43
49
101
101
101
101
197
17
39
42
42
42
199
75
75
69
154
154
93
94
31
31
91
91
77
90
147
110
160
57
58
58
130
11
11
42
DIN
02237886
02237887
02237907
02237908
02237921
02237922
02237923
02237924
02237925
02237971
02237991
02238028
02238042
02238046
02238047
02238048
02238071
02238072
02238073
02238075
02238076
02238102
02238123
02238162
02238171
02238172
02238209
02238216
02238217
02238222
02238223
02238280
02238281
02238282
02238315
02238326
02238327
02238334
02238340
02238348
02238370
02238403
02238404
02238405
02238406
02238415
02238417
02238442
02238443
02238444
02238445
02238446
02238447
02238448
02238449
02238450
02238451
02238465
02238525
02238526
02238544
02238551
02238552
02238553
02238554
02238569
02238570
02238577
PAGE
42
42
88
88
68
69
61
61
61
160
131
79
90
49
49
90
129
129
129
129
129
202
203
108
8
8
139
200
200
88
88
97
97
97
137
52
52
89
202
13
90
110
110
111
111
52
52
76
76
137
33
33
110
90
57
58
58
127
138
196
4
57
58
58
58
43
43
125
DIN
02238578
02238604
02238617
02238618
02238633
02238634
02238635
02238639
02238645
02238660
02238674
02238675
02238682
02238703
02238704
02238708
02238748
02238770
02238771
02238796
02238797
02238817
02238829
02238830
02238831
02238873
02238984
02239007
02239008
02239024
02239025
02239028
02239064
02239065
02239068
02239069
02239083
02239091
02239092
02239131
02239146
02239148
02239170
02239193
02239213
02239238
02239239
02239288
02239319
02239320
02239323
02239324
02239325
02239365
02239366
02239517
02239518
02239519
02239577
02239607
02239608
02239619
02239620
02239627
02239630
02239665
02239667
02239668
PAGE
180
118
15
15
33
52
52
78
81
32
22
22
38
168
154
124
13
132
132
125
89
90
8
9
9
129
204
134
135
87
87
155
188
188
177
177
16
57
57
27
202
124
34
14
14
11
11
126
75
75
201
201
201
29
30
89
89
89
124
91
91
119
119
131
3
105
11
11
DIN
PAGE
02239698
02239699
02239700
02239701
02239702
02239703
02239713
02239714
02239730
02239738
02239744
02239746
02239747
02239748
02239751
02239752
02239754
02239755
02239756
02239757
02239758
02239759
02239760
02239761
02239762
02239769
02239770
02239771
02239772
02239834
02239864
02239886
02239887
02239888
02239893
02239907
02239908
02239912
02239913
02239917
02239918
02239919
02239920
02239921
02239924
02239925
02239926
02239941
02239942
02239951
02239953
02239954
02240035
02240067
02240071
02240072
02240113
02240114
02240115
02240131
02240132
02240205
02240210
02240294
02240321
02240331
02240332
02240335
313
89
89
89
89
89
89
90
90
198
32
39
95
95
95
93
94
42
42
42
166
42
42
42
8
8
68
69
47
47
199
54
13
13
13
4
90
90
139
119
119
101
101
101
101
159
159
159
74
74
54
94
94
127
119
43
131
131
37
89
85
85
37
54
157
69
53
56
17
DIN
02240337
02240346
02240357
02240358
02240362
02240363
02240431
02240432
02240456
02240457
02240458
02240481
02240484
02240485
02240498
02240499
02240500
02240508
02240518
02240519
02240520
02240521
02240550
02240551
02240552
02240588
02240589
02240590
02240601
02240622
02240623
02240682
02240683
02240684
02240685
02240687
02240693
02240694
02240695
02240769
02240770
02240775
02240789
02240790
02240807
02240835
02240836
02240837
02240849
02240850
02240862
02240867
02240868
02241003
02241007
02241107
02241108
02241109
02241112
02241113
02241114
02241148
02241149
02241159
02241163
02241224
02241225
02241285
PAGE
54
4
14
14
13
124
60
60
95
138
138
97
97
97
60
60
60
131
32
32
32
32
188
103
103
60
60
60
69
137
137
94
94
148
148
148
22
22
22
66
66
159
96
96
4
30
30
30
94
94
103
78
78
126
63
79
79
79
159
159
159
44
44
198
31
75
75
188
DIN
02241347
02241348
02241371
02241374
02241466
02241480
02241574
02241575
02241594
02241608
02241704
02241709
02241710
02241715
02241716
02241731
02241732
02241755
02241818
02241819
02241820
02241821
02241835
02241837
02241882
02241883
02241887
02241888
02241889
02241895
02241900
02241901
02241928
02241933
02241983
02242003
02242005
02242029
02242030
02242055
02242115
02242116
02242117
02242118
02242119
02242146
02242232
02242320
02242321
02242322
02242323
02242327
02242328
02242361
02242362
02242453
02242454
02242463
02242464
02242465
02242471
02242503
02242518
02242519
02242520
02242521
02242538
02242539
PAGE
94
94
93
94
53
15
131
131
201
54
54
11
11
131
131
132
132
124
62
62
12
12
155
155
88
88
177
199
199
3
68
68
100
135
192
82
82
147
147
144
202
202
202
202
70
140
130
44
44
44
44
137
137
101
101
139
139
12
12
160
197
4
202
97
97
97
45
46
DIN
PAGE
02242540
02242541
02242572
02242573
02242574
02242589
02242680
02242681
02242682
02242683
02242684
02242685
02242687
02242726
02242728
02242729
02242730
02242738
02242784
02242788
02242789
02242790
02242791
02242793
02242794
02242822
02242823
02242824
02242825
02242837
02242838
02242865
02242866
02242867
02242878
02242907
02242908
02242909
02242914
02242915
02242931
02242965
02242974
02242984
02242985
02243005
02243045
02243077
02243078
02243085
02243086
02243087
02243116
02243117
02243127
02243129
02243144
02243218
02243219
02243223
02243324
02243325
02243327
02243338
02243339
02243340
02243341
02243343
314
46
46
159
159
159
158
37
37
37
37
37
37
37
158
60
60
60
178
12
57
58
58
58
158
158
95
95
96
96
111
111
55
55
55
154
196
88
88
75
75
158
17
158
179
179
153
32
160
160
137
102
102
18
18
55
55
203
95
95
53
50
50
39
45
46
46
46
129
DIN
02243348
02243349
02243350
02243351
02243401
02243403
02243446
02243447
02243448
02243486
02243487
02243518
02243519
02243520
02243521
02243643
02243644
PAGE
95
95
8
8
38
38
89
89
89
93
94
67
67
67
67
15
15
INDEX D
ALPHABETICAL LIST OF PHARMACEUTICAL PRODUCT NAMES
PRODUCT NAME
292
3TC (EDS)
5-AMINOSALICYLIC ACID
642
ABACAVIR SO4
ACARBOSE
ACCOLATE (EDS)
ACCUPRIL
ACCURETIC
ACCUTANE
ACCUTREND
ACEBUTOLOL HCL
"
ACENOCOUMAROL
ACETAMINOPHEN/CAFFEINE/
CODEINE
ACETAMINOPHEN/CODEINE
ACETAZOLAMIDE
"
ACETEST
ACETOXYL
ACETYLCYSTEINE
ACETYLSALICYLIC ACID
ACETYLSALICYLIC ACID/
CAFFEINE/CODEINE
ACILAC (EDS)
ACITRETIN
ACTONEL (EDS)
ACTOS (EDS)
ACULAR (EDS)
ACYCLOVIR
ADALAT PA
"
ADALAT XL
ADAPALENE
ADRENALIN
ADVAIR DISKUS (EDS)
ADVANTAGE
ADVANTAGE COMFORT
AGGRENOX (EDS)
AGRYLIN
AIROMIR
ALBERT OXYBUTYNIN
ALBERT PENTOXIFYLLINE
ALBERT-GLYBURIDE
ALBERT-TIAFEN
ALCOMICIN
ALDACTAZIDE-25
ALDACTAZIDE-50
ALDACTONE
ALENDRONATE SODIUM
ALERTEC (EDS)
ALESSE
ALFACALCIDOL
ALLOPURINOL
ALOMIDE
ALPHAGAN
ALPRAZOLAM
ALTACE
ALTI-ACYCLOVIR
ALTI-ALPRAZOLAM
ALTI-AMILORIDE HCTZ
ALTI-AMIODARONE
Page
81
14
140
85
14
157
204
65
66
184
114
42
56
36
80
80
118
129
115
182
122
74
81
134
183
202
159
127
12
48
49
49
181
28
30
114
114
70
196
29
188
38
158
80
124
66
66
120
196
105
151
193
196
132
131
106
66
12
106
56
43
315
PRODUCT NAME
ALTI-AZATHIOPRINE
ALTI-BECLOMETHASONE
ALTI-BECLOMETHASONE AQ.
ALTI-BROMAZEPAM
ALTI-CAPTOPRIL
"
ALTI-CLINDAMYCIN
ALTI-CLOBAZAM
ALTI-CLONAZEPAM
ALTI-CPA (EDS)
ALTI-CYCLOBENZAPRINE(EDS)
ALTI-DESIPRAMINE
ALTI-DEXAMETHASONE
ALTI-DILTIAZEM
ALTI-DILTIAZEM CD
"
ALTI-DOMPERIDONE MALEATE
ALTI-DOXEPIN
ALTI-DOXYCYCLINE
ALTI-FAMOTIDINE
ALTI-FLUNISOLIDE
ALTI-FLUOXETINE
"
ALTI-FLURBIPROFEN
ALTI-FLUVOXAMINE
ALTI-IPRATROPIUM
"
ALTI-IPRATROPIUM UDV
ALTI-METFORMIN
ALTI-MINOCYCLINE (EDS)
ALTI-MOCLOBEMIDE
ALTI-MPA
ALTI-NADOLOL
ALTI-NORTRIPTYLINE
ALTI-ORCIPRENALINE
ALTI-PIROXICAM
ALTI-PRAZOSIN
ALTI-RANITIDINE
ALTI-SALBUTAMOL
ALTI-SALBUTAMOL P.F.
"
ALTI-SALBUTAMOL RESP.SOL.
ALTI-SALBUTAMOL SULPHATE
ALTI-SOTALOL
ALTI-SULFASALAZINE
ALTI-TERAZOSIN
ALTI-TICLOPIDINE (EDS)
ALTI-TRAZODONE
ALTI-TRIAZOLAM
ALTI-VALPROIC
ALTI-VERAPAMIL
"
ALUMINUM ACETATE/
BENZETHONIUM CHLORIDE
"
ALUPENT
AMANTADINE
AMATINE (EDS)
AMCINONIDE
AMERGE (EDS)
AMETHOPTERIN
AMILORIDE HCL
AMILORIDE HCL/
Page
196
147
125
107
57
58
11
89
87
22
33
92
148
45
45
46
137
93
10
137
126
93
94
76
94
27
131
27
158
11
95
161
48
96
29
79
65
139
29
29
30
30
30
52
139
67
39
97
109
90
68
69
125
181
29
12
28
170
31
183
120
PRODUCT NAME
HYDROCHLOROTHIAZIDE
AMINOPHYLLINE
AMIODARONE
AMITRIPTYLINE
AMLODIPINE BESYLATE
AMOBARBITAL SODIUM
AMOXAPINE
AMOXICILLIN (AMOXYCILLIN)
AMOXICILLIN TRIHYDRATE/
POTASSIUM CLAVULANATE
AMOXIL
AMOXIL-250
AMPICILLIN
AMYTAL SODIUM
ANAFRANIL
"
ANAGRELIDE HCL
ANDRIOL
ANDROCUR (EDS)
ANSAID
ANTABUSE
ANTHRAFORTE-1
ANTHRAFORTE-2
ANTHRANOL
ANTHRASCALP
APL (EDS)
APO-ACEBUTOLOL
APO-ACETAZOLAMIDE
APO-ACYCLOVIR
APO-ALLOPURINOL
APO-ALPRAZ
APO-AMILZIDE
APO-AMITRIPTYLINE
APO-AMOXI
APO-AMOXI CLAV (EDS)
APO-AMPI
APO-ATENOL
APO-AZATHIOPRINE
APO-BACLOFEN
APO-BECLOMETHASONE
APO-BENZTROPINE
APO-BROMAZEPAM
APO-BROMOCRIPTINE
APO-BUSPIRONE
APO-CAPTO
"
APO-CARBAMAZEPINE
APO-CARBAMAZEPINE CR(EDS)
APO-CEFACLOR (EDS)
APO-CEPHALEX
APO-CHLORDIAZEPOXIDE
APO-CHLORPROPAMIDE
APO-CHLORTHALIDONE
APO-CIMETIDINE
"
APO-CLOMIPRAMINE
"
APO-CLONAZEPAM
APO-CLONIDINE
APO-CLORAZEPATE
APO-CLOXI
APO-CROMOLYN
"
APO-CYCLOBENZAPRINE (EDS)
APO-DESIPRAMINE
APO-DESMOPRESSIN (EDS)
APO-DIAZEPAM
APO-DICLO
Page
56
188
43
91
43
106
91
8
8
8
8
9
106
91
92
196
150
22
76
197
183
183
183
183
155
42
129
12
196
106
56
91
8
8
9
43
196
33
125
26
107
197
110
57
58
88
88
5
6
107
157
119
136
137
91
92
87
59
107
9
132
203
33
92
160
108
74
316
PRODUCT NAME
APO-DICLO SR
APO-DIFLUNISAL
APO-DILTIAZ
APO-DILTIAZ CD
"
APO-DILTIAZ SR
APO-DIMENHYDRINATE
APO-DIPIVEFRIN
APO-DIVALPROEX
APO-DOMPERIDONE
APO-DOXAZOSIN
APO-DOXEPIN
APO-DOXY
APO-ERYTHRO-S
APO-ETODOLAC (EDS)
APO-FAMOTIDINE
APO-FENOFIBRATE (EDS)
APO-FENO-MICRO (EDS)
APO-FLUCONAZOLE
APO-FLUCONAZOLE (EDS)
APO-FLUNISOLIDE
APO-FLUOXETINE
"
APO-FLUPHENAZINE
APO-FLURAZEPAM
APO-FLURBIPROFEN
APO-FLUVOXAMINE
APO-FOLIC
APO-FUROSEMIDE
APO-GEMFIBROZIL
"
APO-GLYBURIDE
APO-HALOPERIDOL
"
APO-HALOPERIDOL LA
APO-HYDRALAZINE
APO-HYDRO
APO-HYDROXYZINE
APO-IBUPROFEN
APO-IMIPRAMINE
APO-INDAPAMIDE
APO-INDOMETHACIN
APO-IPRAVENT
APO-ISDN
APO-K
APO-KETO
APO-KETOCONAZOLE (EDS)
APO-KETOPROFEN SR
APO-KETOTIFEN (EDS)
APO-LEVOBUNOLOL
APO-LEVOCARB
APO-LISINOPRIL
APO-LITHIUM CARBONATE
APO-LOPERAMIDE
APO-LORAZEPAM
APO-LOVASTATIN
APO-LOXAPINE
APO-MEFENAMIC
APO-MEGESTROL (EDS)
APO-METFORMIN
APO-METHAZIDE-15
APO-METHAZIDE-25
APO-METHOPRAZINE
"
APO-METHYLDOPA
APO-METOCLOP
APO-METOPROLOL
APO-METOPROLOL-TYPE L
Page
74
75
45
45
46
45
135
130
89
137
60
93
10
7
75
137
54
54
3
3
126
93
94
100
108
76
94
192
119
54
55
158
100
101
101
61
119
110
76
94
119
76
27
70
118
77
4
77
199
131
200
62
111
134
108
55
101
77
23
158
63
63
110
111
63
138
47
47
PRODUCT NAME
APO-METRONIDAZOLE
APO-MINOCYCLINE (EDS)
APO-MOCLOBEMIDE
APO-NABUMETONE (EDS)
APO-NADOL
APO-NAPROXEN
APO-NAPROXEN SR
APO-NEFAZODONE
"
APO-NIFED
APO-NIFED PA
"
APO-NITROFURANTOIN
APO-NIZATIDINE
APO-NORFLOX (EDS)
APO-NORTRIPTYLINE
APO-ORCIPRENALINE
APO-OXAZEPAM
APO-OXTRIPHYLLINE
APO-OXYBUTYNIN
APO-PENTOXIFYLLINE SR
APO-PEN-VK
APO-PERPHENAZINE
APO-PHENYLBUTAZONE
APO-PINDOL
APO-PIROXICAM
APO-PRAZO
APO-PREDNISONE
APO-PRIMIDONE
APO-PROCAINAMIDE
APO-PROCHLORAZINE
APO-PROPAFENONE
APO-PROPRANOLOL
"
APO-RANITIDINE
APO-SALVENT
"
APO-SELEGILINE (EDS)
APO-SERTRALINE
APO-SOTALOL
APO-SUCRALFATE
APO-SULFATRIM
"
APO-SULFATRIM DS
APO-SULFINPYRAZONE
APO-SULIN
APO-TEMAZEPAM
APO-TERAZOSIN
APO-TERBINAFINE
APO-TETRA
APO-THEO-LA
APO-THIORIDAZINE
APO-TIAPROFENIC
APO-TICLOPIDINE (EDS)
APO-TIMOL
APO-TIMOP
APO-TOLBUTAMIDE
APO-TRAZODONE
APO-TRIAZIDE
APO-TRIAZO
APO-TRIFLUOPERAZINE
APO-TRIHEX
APO-TRIMETHOPRIM
APO-TRIMIP
APO-VALPROIC
APO-VERAP
"
APO-ZIDOVUDINE (EDS)
Page
18
11
95
78
48
78
78
95
96
48
48
49
17
138
17
96
29
109
188
188
38
10
102
79
49
79
65
149
86
50
103
50
50
51
139
29
30
202
97
52
139
18
19
18
120
79
109
67
4
11
189
104
80
39
52
132
159
97
68
109
104
27
18
98
90
68
69
15
317
PRODUCT NAME
APRACLONIDINE HCL
APRESOLINE
ARALEN
ARAVA (EDS)
ARICEPT (EDS)
ARISTOCORT
ARISTOCORT R
ARISTOSPAN (EDS)
ARTHROTEC
ARTHROTEC 75
ASACOL
ASENDIN
ASMAVENT
ATACAND
ATARAX
ATASOL-15
ATASOL-30
ATENOLOL
"
ATENOLOL/CHLORTHALIDONE
ATIVAN
ATORVASTATIN CALCIUM
ATOVAQUONE
ATROPINE
ATROPINE SO4
ATROPISOL
ATROVENT
ATROVENT NASAL SPRAY
AURANOFIN
AUROTHIOGLUCOSE
AVALIDE
AVANDIA (EDS)
AVAPRO
AVC
AVELOX (EDS)
AVENTYL
AVIRAX
AVLOSULFON
AVONEX (EDS)
AXID
AZATHIOPRINE
AZITHROMYCIN
AZMACORT
AZOPT
BACLOFEN
BACTROBAN
BAYCOL
BECLOMETHASONE
DIPROPIONATE
"
"
BENAZEPRIL HCL
BENOXYL
BENTYLOL
BENURYL
BENZAC AC
BENZAC W
BENZAC-W
BENZAGEL
BENZOYL PEROXIDE
BENZTROPINE MESYLATE
BEROTEC
BEROTEC UDV
BETADERM
BETADINE
BETAGAN
BETAHISTINE HCL
BETAINE ANHYDROUS
Page
130
61
16
199
198
149
180
150
75
75
140
91
30
57
110
80
80
43
56
57
108
53
18
130
130
130
27
131
142
142
62
159
61
170
17
96
12
17
199
138
196
7
150
129
33
166
53
125
147
170
57
182
27
120
183
182
183
182
182
26
28
28
176
170
131
69
196
PRODUCT NAME
BETAJECT
BETALOC
BETALOC DURULES
BETAMETHASONE ACETATE/
BETAMETHASONE SODIUM
PHOSPHATE
BETAMETHASONE
DIPROPIONATE
BETAMETHASONE
DIPROPIONATE/
SALICYLIC ACID
BETAMETHASONE
DIPROPIONATE/CLOTRIMAZOLE
BETAMETHASONE DISODIUM
PHOSPHATE
"
BETAMETHASONE VALERATE
BETASERON (EDS)
BETAXIN
BETAXOLOL HCL
BETHANECHOL CHLORIDE
BETNESOL
BETNESOL ENEMA
BETNOVATE
BETOPTIC S
BEZAFIBRATE
BEZALIP SR (EDS)
BIAXIN (EDS)
BILTRICIDE
BIOPRAVASTATIN
BIQUIN DURULES
BISOPROLOL FUMARATE
BLEPHAMIDE S.O.P.
BONAMINE
BOTOX (EDS)
BOTULINUM TOXIN TYPE A
BREVICON
BREVICON 1/35
BRICANYL TURBUHALER
BRIMONIDINE TARTRATE
BRINZOLAMIDE
BROMAZEPAM
BROMOCRIPTINE MESYLATE
BUDESONIDE
"
"
"
BUMETANIDE
BUPROPION HCL
BURINEX (EDS)
BURO-SOL
BURO-SOL-OTIC
BUSCOPAN
BUSERELIN ACETATE
BUSPAR
BUSPIREX
BUSPIRONE
C.E.S.
CABERGOLINE
CAFERGOT-PB
CALCIFEROL
CALCIMAR (EDS)
CALCIPOTRIOL
CALCITONIN SALMON
CALCITRIOL
CALCIUM POLYSTYRENE
SULFONATE
CALTINE 100 (EDS)
Page
147
47
47
147
171
171
180
126
171
176
199
192
131
26
126
171
176
131
53
53
7
2
55
51
44
128
136
196
196
152
152
30
131
129
107
197
126
136
147
176
118
91
118
181
125
27
197
110
110
110
153
197
31
193
159
184
159
193
118
159
318
PRODUCT NAME
CALTINE 50 (EDS)
CANDESARTAN CILEXETIL
CANDISTATIN
CANESTEN
CANESTEN-1-COMBI-PAK
CANESTEN-3
CANESTEN-3-COMBI-PAK
CANESTEN-6
CAPEX SHAMPOO
CAPOTEN
"
CAPTOPRIL
"
CAPTOPRIL
"
CAPTRIL
"
CARBACHOL
CARBAMAZEPINE
CARBOLITH
CARDIZEM
CARDIZEM CD
"
CARDIZEM-SR
CARDURA-1
CARDURA-2
CARDURA-4
CARVEDILOL
CATAPRES
CECLOR (EDS)
CECLOR BID (EDS)
CEFACLOR
CEFIXIME
CEFPROZIL
CEFTIN (EDS)
CEFUROXIME AXETIL
CEFZIL (EDS)
CELEBREX (EDS)
CELECOXIB
CELESTODERM-V
CELESTODERM-V/2
CELESTONE SOLUSPAN
CELEXA
CELLCEPT (EDS)
CELONTIN
CEPHALEXIN MONOHYDRATE
CERIVASTATIN SODIUM
CESAMET (EDS)
CETAMIDE
CHEMSTRIP BG
CHEMSTRIP UG 5000K
CHLORAL HYDRATE
CHLORDIAZEPOXIDE
CHLOROQUINE PHOSPHATE
CHLORPROMANYL
CHLORPROMANYL-40
CHLORPROMAZINE
CHLORPROMAZINE
CHLORPROPAMIDE
CHLORTHALIDONE
CHOLEDYL
CHOLEDYL-SA
CHOLESTYRAMINE RESIN
CHORIONIC GONADOTROPIN
CHRONOVERA
CICLOPIROX OLAMINE
CILAZAPRIL
CILAZAPRIL/
Page
159
57
168
167
167
167
167
167
178
57
58
44
57
57
58
57
58
129
88
111
45
45
46
45
60
60
60
44
59
5
5
5
5
5
6
6
5
74
74
176
176
147
91
200
88
6
53
200
125
114
114
110
107
16
99
99
99
99
157
119
189
188
53
155
69
167
58
PRODUCT NAME
HYDROCHLOROTHIAZIDE
CILOXAN (EDS)
CIMETIDINE
CIPRO (EDS)
CIPRO HC (EDS)
CIPROFLOXACIN
"
CIPROFLOXACIN/
HYDROCORTISONE
CITALOPRAM HYDROBROMIDE
CLARITHROMYCIN
CLAVULIN-125F (EDS)
CLAVULIN-200 (EDS)
CLAVULIN-250 (EDS)
CLAVULIN-250F (EDS)
CLAVULIN-400 (EDS)
CLAVULIN-500 (EDS)
CLAVULIN-875 (EDS)
CLIMARA 100 (EDS)
CLIMARA 50 (EDS)
CLINDAMYCIN HCL
CLINDAMYCIN PALMITATE HCL
CLINDAMYCIN PHOSPHATE
CLINISTIX
CLINITEST
CLOBAZAM
CLOBETASOL PROPIONATE
CLOBETASONE BUTYRATE
CLOMIPRAMINE HCL
CLONAPAM
CLONAZEPAM
CLONIDINE HCL
CLOPIDOGREL BISULFATE
CLOPIXOL (EDS)
CLOPIXOL ACUPHASE (EDS)
CLOPIXOL DEPOT (EDS)
CLORAZEPATE DIPOTASSIUM
CLOTRIMADERM
CLOTRIMAZOLE
CLOXACILLIN
CLOZAPINE
CLOZARIL (EDS)
CODEINE
CODEINE
CODEINE CONTIN (EDS)
CODEINE PHOSPHATE
COGENTIN
COLCHICINE
COLCHICINE
COLCHICINE-ODAN
COLESTID
COLESTIPOL HCL RESIN
COMBANTRIN
COMBIVENT
COMBIVIR (EDS)
CONDYLINE
CONJUGATED ESTROGENS
CONJUGATED ESTROGENS/
MEDROXYPROGESTERONE
ACETATE
"
COPAXONE (EDS)
CORDARONE
COREG (EDS)
CORGARD
CORTATE
"
CORTEF
Page
59
125
136
16
127
16
125
127
91
7
9
9
8
9
9
8
8
154
154
11
11
166
114
114
89
176
177
91
87
87
59
38
105
104
104
107
167
167
9
99
99
81
81
81
81
26
197
197
197
54
54
2
28
14
183
153
154
161
198
43
44
48
178
179
148
319
PRODUCT NAME
CORTENEMA
CORTIFOAM
CORTIMYXIN
CORTISONE
CORTISONE ACETATE
CORTISPORIN
"
CORTODERM
CORTONE
COSOPT
COSYNTROPIN ZINC
HYDROXIDE
"
COTAZYM
COTAZYM ECS 20
COTAZYM ECS 8
COUMADIN
COVERSYL
COZAAR
CREON 10
CREON 20
CREON 25
CREON 5
CRIXIVAN (EDS)
CROMOLYN
CROTAMITON
CUPRIC SO4 REAGENT
CUPRIMINE
CYANOCOBALAMIN
CYANOCOBALAMIN
CYCLEN
CYCLOBENZAPRINE HCL
CYCLOCORT
CYCLOMEN
CYCLOSPORINE
CYCLOSPORINE (TRANSPLANT)
CYPROTERONE ACETATE
CYSTADANE
CYTOMEL
CYTOTEC
CYTOVENE (EDS)
D.D.A.V.P. (EDS)
DALACIN C
DALACIN T
DALMANE
DALTEPARIN SODIUM
DANAZOL
DANTRIUM
DANTROLENE SODIUM
DAPSONE
DARAPRIM
DARVON-N
DEFEROXAMINE MESYLATE
DELATESTRYL
DELAVIRDINE MESYLATE
DELESTROGEN
DEMEROL
DEMULEN 30
DEPAKENE
DEPEN
DEPO-MEDROL
DEPO-PROVERA
DEPO-TESTOSTERONE
DEPROIC
DERMA-SMOOTHE/FS
DERMASONE
DERMOVATE
DESFERAL (EDS)
Page
179
179
128
147
147
128
181
179
147
131
114
160
134
135
135
37
64
63
135
135
135
134
15
132
169
114
144
192
192
153
33
170
150
184
197
22
196
162
138
13
160
11
166
108
36
150
33
33
17
16
85
144
150
13
154
82
151
90
144
149
161
150
90
178
176
176
144
PRODUCT NAME
DESIPRAMINE HCL
DESMOPRESSIN
DESOCORT
DESONIDE
DESOXI
DESOXIMETASONE
DESQUAM-X
"
DESYREL
DETROL (EDS)
DEXAMETHASONE
"
DEXAMETHASONE
DEXAMETHASONE
21-PHOSPHATE
DEXAMETHASONE SOD PHO INJ
DEXAMETHASONE SODIUM PHO
DEXASONE
DEXEDRINE
DEXTROAMPHETAMINE SO4
DIABETA
DIAMOX
DIAMOX SEQUELS
DIARR-EZE
DIASTAT
DIASTIX
DIAZEPAM
DICLECTIN
DICLOFENAC SODIUM
"
DICLOFENAC SODIUM/
MISOPROSTOL
DICLOTEC
DICYCLOMINE HCL
DIDANOSINE
DIDROCAL
DIDRONEL (EDS)
DIFFERIN
DIFLUCAN
DIFLUCAN (EDS)
DIFLUCAN P.O.S. (EDS)
DIFLUCORTOLONE VALERATE
DIFLUNISAL
DIGOXIN
DIHYDROERGOTAMINE MESYL.
DIHYDROERGOTAMINE
MESYLATE
DIHYDROERGOTAMINE-SANDOZ
DIIODOHYDROXYQUIN
DILANTIN
DILAUDID
"
DILAUDID HP-PLUS
DILAUDID-HP
DILAUDID-XP
DILTIAZEM HCL
"
DIMENHYDRINATE
DIMENHYDRINATE IM
DIOCARPINE
"
DIODEX
DIODOQUIN
DIOPRED
DIOPTIMYD
DIOSULF
DIOVAN
DIOVAN-HCT
Page
92
160
177
177
177
177
182
183
97
188
126
148
126
148
148
126
148
105
105
158
129
129
134
108
114
108
136
74
131
75
75
27
14
198
198
181
3
3
3
177
75
44
31
31
31
2
88
81
82
82
82
82
45
59
135
136
129
130
126
2
127
128
125
68
68
320
PRODUCT NAME
DIPENTUM
DIPHENOXYLATE HCL
DIPIVEFRIN HCL
DIPROLENE
DIPROSALIC
DIPROSONE
DIPYRIDAMOLE
DIPYRIDAMOLE/
ACETYLSALICYLIC ACID
DISOPYRAMIDE
DISULFIRAM
DITHRANOL
DITROPAN
DIVALPROEX SODIUM
DIXARIT (EDS)
DOM-AMANTADINE
"
DOM-ATENOLOL
DOM-BACLOFEN
DOM-BUSPIRONE
DOM-CAPTOPRIL
"
DOM-CARBAMAZEPINE CR(EDS)
DOM-CEFACLOR (EDS)
DOM-CEPHALEXIN
DOM-CIMETIDINE
"
DOM-CLONAZEPAM
DOM-CLONAZEPAM-R
DOM-CYCLOBENZAPRINE (EDS)
DOM-DESIPRAMINE
DOM-DICLOFENAC
DOM-DICLOFENAC SR
DOM-DOMPERIDONE
DOM-FENOFIBR. MICRO (EDS)
DOM-FLUOXETINE
"
DOM-FLUVOXAMINE
DOM-GEMFIBROZIL
"
DOM-GLYBURIDE
DOM-INDAPAMIDE
DOM-IPRATROPIUM
DOM-LOXAPINE
DOM-MEFENAMIC ACID
DOM-METFORMIN
DOM-METOPROLOL
DOM-METOPROLOL-L
DOM-MINOCYCLINE (EDS)
DOM-MOCLOBEMIDE
DOM-NIFEDIPINE
DOM-NORTRIPTYLINE
DOM-NYSTATIN
DOM-OXYBUTYNIN
DOMPERIDONE MALEATE
DOM-PINDOLOL
DOM-PROCYCLIDINE
DOM-PROPRANOLOL
"
DOM-SALBUTAMOL
DOM-SALBUTAMOL RESPIR.SOL
DOM-SELEGILINE (EDS)
DOM-SODIUM CROMOGLYCATE
DOM-SOTALOL
DOM-SUCRALFATE
DOM-TEMAZEPAM
DOM-TIAPROFENIC
DOM-TIMOLOL
Page
138
134
130
171
171
171
70
70
46
197
183
188
89
59
12
13
43
33
110
57
58
88
5
6
136
137
87
87
33
92
74
74
137
54
93
94
94
54
55
158
119
131
101
77
158
47
47
11
95
48
96
4
188
137
49
26
50
51
30
30
202
203
52
139
109
80
132
PRODUCT NAME
DOM-TRAZODONE
DOM-VALPROIC ACID
DOM-VERAPAMIL SR
DONEPEZIL HCL
DORNASE ALFA
DORZOLAMIDE HCL
DORZOLAMIDE HCL/TIMOLOL
MALEATE
DOSTINEX (EDS)
DOVONEX
DOXAZOSIN MESYLATE
DOXEPIN HCL
DOXYCIN
DOXYCYCLINE
DOXYLAMINE SUCCINATE/
PYRIDOXINE HCL
DOXYTEC
DRISDOL
DURAGESIC (EDS)
DURALITH
DUVOID
DYRENIUM
ECHOTHIOPHATE IODIDE
ECONAZOLE NITRATE
ECOSTATIN
ECTOSONE
ECTOSONE MILD
ECTOSONE REGULAR
EDECRIN (EDS)
EES 200
EES 400
EFAVIRENZ
EFFEXOR
EFFEXOR XR
EFUDEX
ELAVIL
ELDEPRYL (EDS)
ELITE
ELMIRON (EDS)
ELOCOM
ELTROXIN
EMO-CORT
"
EMPRACET-30
EMPRACET-60
EMTEC-30
ENALAPRIL MALEATE
ENALAPRIL MALEATE/
HYDROCHLOROTHIAZIDE
ENCORE
ENDANTADINE
ENDO-LEVODOPA/CARBIDOPA
ENOXAPARIN
ENTACYL
ENTOCORT
ENTOCORT (EDS)
ENTROPHEN
EPINEPHRINE HCL
EPIVAL
EPOETIN ALFA
EPREX (EDS)
EPROSARTAN MESYLATE
ERGAMISOL (EDS)
ERGOMAR
ERGOTAMINE TARTRATE
ERGOTAMINE TARTRATE/
CAFFEINE/
BELLADONNA ALKALOIDS/
Page
97
90
69
198
122
129
131
197
184
60
93
10
10
136
10
193
81
111
26
120
129
167
167
176
176
176
119
7
7
13
98
98
184
91
202
114
201
179
162
178
179
80
80
80
60
60
114
12
200
36
2
176
136
74
28
89
38
38
60
199
31
31
321
PRODUCT NAME
PENTOBARBITAL
ERYC
ERYTHROMYCIN BASE
ERYTHROMYCIN ESTOLATE
ERYTHROMYCIN
ETHYLSUCCINATE
ERYTHROMYCIN
ETHYLSUCCINATE/
SULFISOXAZOLE ACETATE
ERYTHROMYCIN STEARATE
ERYTHROMYCIN/ETHYL
ALCOHOL
ESDEPALLATHRIN/PIPERONYL
BUTOXIDE
ESTALIS (EDS)
ESTRACE
ESTRACOMB (EDS)
ESTRADERM (EDS)
ESTRADIOL
ESTRADIOL & NORETHINDRONE
ACETATE/ESTRADIOL
"
ESTRADIOL VALERATE
ESTRADIOL/NORETHINDRONE
ACETATE
"
ESTRING
ESTROGEL (EDS)
ESTROPIPATE
ETHACRYNIC ACID
ETHINYL ESTRADIOL/
DESOGESTREL
ETHINYL ESTRADIOL/
D-NORGESTREL
ETHINYL ESTRADIOL/
ETHYNODIOL DIACETATE
ETHINYL ESTRADIOL/
L-NORGESTREL
ETHINYL ESTRADIOL/
NORETHINDRONE
ETHINYL ESTRADIOL/
NORETHINDRONE ACETATE
ETHINYL ESTRADIOL/
NORGESTIMATE
ETHOPROPAZINE
ETHOSUXIMIDE
ETIDRONATE DISODIUM
ETIDRONATE DISODIUM/
CALCIUM CARBONATE
ETODOLAC
EUGLUCON
EUMOVATE
EURAX
EVISTA (EDS)
EXDOL-30
EXELON (EDS)
FAMCICLOVIR
FAMOTIDINE
FAMVIR
FASTTAKE
FELDENE
FELODIPINE
FENOFIBRATE
FENOPROFEN
FENOTEROL HYDROBROMIDE
FENTANYL
FEXICAM
FILGRASTIM
Page
31
7
7
7
7
18
7
166
169
155
154
154
154
154
154
161
154
155
161
154
154
155
119
151
151
151
151
152
152
153
26
88
198
198
75
158
177
169
155
80
202
13
137
13
114
79
61
54
75
28
81
79
38
PRODUCT NAME
FINASTERIDE
FLAGYL
"
FLAREX
FLAVOXATE HCL
FLECAINIDE ACETATE
FLEXERIL (EDS)
FLEXITEC (EDS)
FLOCTAFENINE
FLOMAX
FLONASE
FLORINEF
FLOVENT
FLOVENT DISKUS
FLUANXOL
FLUANXOL DEPOT
FLUCONAZOLE
FLUDROCORTISONE ACETATE
FLUNARIZINE HCL
FLUNISOLIDE
FLUOCINOLONE ACETONIDE
FLUOCINONIDE
FLUODERM
FLUOROMETHOLONE
FLUOROMETHOLONE ACETATE
FLUOROURACIL
FLUOTIC
FLUOXETINE
FLUPENTHIXOL DECANOATE
FLUPENTHIXOL
DIHYDROCHLORIDE
FLUPHENAZINE DECANOATE
FLUPHENAZINE ENANTHATE
FLUPHENAZINE HCL
FLURAZEPAM HCL
FLURBIPROFEN
FLURBIPROFEN SODIUM
FLUTICASONE PROPIONATE
"
FLUVASTATIN SODIUM
FLUVOXAMINE MALEATE
FML
FOLIC ACID
FORADIL (EDS)
FORMOTEROL FUMARATE
FORMULEX
FORTOVASE (EDS)
FOSAMAX (EDS)
FOSFOMYCIN TROMETHAMINE
FOSINOPRIL
FRAGMIN (EDS)
FRAMYCETIN SO4
FRAMYCETIN SO4/GRAMICIDIN/
DEXAMETHASONE BASE
FRAXIPARINE (EDS)
FRAXIPARINE FORTE (EDS)
FRISIUM
FTP-ATENOLOL
FTP-BACLOFEN
FTP-BUSPIRONE
FTP-CAPTOPRIL
"
FTP-DOMPERIDONE MALEATE
FTP-INDOMETHACIN
FTP-NYSTATIN
FTP-VALPROIC ACID
FUCIDIN
FUCIDIN H
Page
198
18
169
126
188
46
33
33
86
203
126
148
148
148
99
99
3
148
31
126
177
178
177
126
126
184
203
93
99
99
100
100
100
108
76
126
126
148
54
94
126
192
28
28
27
16
196
17
61
36
166
127
37
37
89
43
33
110
57
58
137
76
4
90
166
180
322
PRODUCT NAME
FULVICIN U/F
FUROSEMIDE
FUSIDIC ACID
FUSIDIC ACID/
HYDROCORTISONE ACETATE
GABAPENTIN
GAMMA-BENZENE
HEXACHLORIDE
GANCICLOVIR SO4
GARAMYCIN
"
GARASONE
GARATEC
GEMFIBROZIL
GEMFIBROZIL
"
GEN-ACEBUTOLOL
GEN-ACEBUTOLOL (TYPE S)
GEN-ACYCLOVIR
GEN-ALPRAZOLAM
GEN-AMANTADINE
GEN-AMOXICILLIN
GEN-ATENOLOL
GEN-AZATHIOPRINE
GEN-BACLOFEN
GEN-BECLO AQ.
GEN-BROMAZEPAM
GEN-BUDESONIDE AQ
GEN-BUSPIRONE
GEN-CAPTOPRIL
"
GEN-CARBAMAZEPINE CR(EDS)
GEN-CIMETIDINE
"
GEN-CLOBETASOL
GEN-CLOMIPRAMINE
"
GEN-CLONAZEPAM
GEN-CYCLOBENZAPRINE (EDS)
GEN-CYPROTERONE (EDS)
GEN-DILTIAZEM
GEN-DILTIAZEM SR
GEN-DOXAZOSIN
GEN-ETODOLAC (EDS)
GEN-FAMOTIDINE
GEN-FENOFIBR. MICRO (EDS)
GEN-FLUOXETINE
"
GEN-FLUVOXAMINE
GEN-GEMFIBROZIL
"
GEN-GLYBE
GEN-INDAPAMIDE
GEN-IPRATROPIUM
GEN-LOVASTATIN
GEN-MEDROXY
GEN-METFORMIN
GEN-METOPROLOL
GEN-METOPROLOL (TYPE L)
GEN-MINOCYCLINE (EDS)
GEN-NORTRIPTYLINE
GEN-OXYBUTYNIN
GEN-PINDOLOL
GEN-PIROXICAM
GEN-RANITIDINE
GEN-SALBUTAMOL RESPIR.SOL
GEN-SALBUTAMOL STERINEB
GEN-SELEGILINE (EDS)
Page
4
119
166
180
89
169
13
3
124
128
124
54
54
55
42
42
12
106
12
8
43
196
33
125
107
126
110
57
58
88
136
137
176
91
92
87
33
22
45
45
60
75
137
54
93
94
94
54
55
158
119
27
55
161
158
47
47
11
96
188
49
79
139
30
30
202
PRODUCT NAME
GEN-SERTRALINE
GEN-SOTALOL
GENTAMICIN
GENTAMICIN SO4
"
GENTAMICIN SO4
GENTAMICIN SO4/
BETAMETHASONE SODIUM
PHOSPHATE
GENTAMICIN SULFATE
GENTAMICIN SULPHATE
GEN-TEMAZEPAM
GEN-TERBINAFINE
GEN-TICLOPIDINE (EDS)
GEN-TIMOLOL
GEN-TRAZODONE
GEN-TRIAZOLAM
GEN-VALPROIC
GEN-VERAPAMIL
"
GEN-VERAPAMIL SR
GLATIRAMER ACETATE
GLUCAGON
GLUCAGON
GLUCOFILM
GLUCOMETER DEX
GLUCONORM (EDS)
GLUCOPHAGE
GLUCOSE OXIDASE/
PEROXIDASE REAGENT
GLUCOSE OXIDASE/
PEROXIDASE/SODIUM
NITROFERRICYANIDE/
GLYCINE REAGENT
GLUCOSE OXIDASE/
PEROXIDASE/SODIUM
NITROPRUSSIDE REAGENT
GLUCOSTIX
GLYBURIDE
GLYCON
GOSERELIN ACETATE
GRAVOL
"
GRISEOFULVIN (ULTRA-FINE)
HALCINONIDE
HALCION
HALOBETASOL PROPIONATE
HALOG
HALOPERIDOL
HALOPERIDOL
HALOPERIDOL DECANOATE
HALOPERIDOL LA
HEPALEAN
HEPARIN
HEPTOVIR (EDS)
HEXACHLOROPHENE
HEXIT SHAMPOO
HIVID (EDS)
HOMATROPINE HYDROBROMIDE
HP-PAC (EDS)
HUMALOG (EDS)
HUMALOG CARTRIDGE (EDS)
HUMALOG MIX25 (EDS)
HUMATROPE (EDS)
HUMATROPE CARTRIDGE (EDS)
HUMULIN 20/80 CARTRIDGE
HUMULIN 30/70
HUMULIN 30/70 CARTRIDGE
Page
97
52
124
3
124
124
128
124
3
109
4
39
132
97
109
90
68
69
69
198
198
198
114
114
159
158
114
114
115
114
158
158
198
135
136
4
178
109
178
178
100
101
101
101
36
36
14
169
169
15
130
138
156
156
157
160
160
157
157
157
323
PRODUCT NAME
HUMULIN-L
HUMULIN-N
HUMULIN-N CARTRIDGE
HUMULIN-R
HUMULIN-R CARTRIDGE
HUMULIN-U
HYCORT
HYDERM
HYDRALAZINE HCL
HYDROCHLOROTHIAZIDE
HYDROCORTISONE
"
HYDROCORTISONE ACETATE
HYDROCORTISONE CREAM
HYDROCORTISONE SODIUM
SUCCINATE
HYDROCORTISONE VALERATE
HYDROCORTISONE/UREA
HYDRODIURIL
HYDROMORPH CONTIN
HYDROMORPHONE HCL
HYDROMORPHONE HCL
HYDROMORPHONE HP 10
HYDROMORPHONE HP 20
HYDROMORPHONE HP 50
HYDROVAL
HYDROXYCHLOROQUINE SO4
HYDROXYZINE
HYOSCINE BUTYLBROMIDE
HYTRIN
HYTRIN STARTER PACK
HYZAAR
HYZAAR DS
IBUPROFEN
IDARAC
IMDUR
IMIPRAMINE
IMITREX (EDS)
IMODIUM
IMURAN
INDAPAMIDE
INDAPAMIDE HEMIHYDRATE
INDERAL
"
INDERAL-LA
INDERIDE-40
INDERIDE-80
INDINAVIR SO4
INDOCID
INDOMETHACIN
INDOTEC
INFLAMASE FORTE
INFLAMASE MILD
INFUFER (EDS)
INHIBACE
INHIBACE PLUS
INNOHEP (EDS)
INSULIN (ISOPHANE) HUMAN
BIOSYNTHETIC
INSULIN (ISOPHANE) PORK
INSULIN (LENTE) HUMAN
BIOSYNTHETIC
INSULIN (LENTE) PORK
INSULIN (REGULAR) HUMAN
BIOSYNTHETIC
INSULIN (REGULAR) LISPRO
INSULIN (REGULAR) PORK
INSULIN (REGULAR/ISOPHANE
Page
156
156
156
156
156
157
179
178
61
119
148
178
179
178
149
179
179
119
82
81
82
82
82
82
179
16
110
27
67
67
63
63
76
86
70
94
32
134
196
119
119
50
51
51
65
65
15
77
76
76
127
127
36
58
59
37
156
156
156
156
156
156
156
PRODUCT NAME
HUMAN BIOSYNTHETIC
INSULIN (REGULAR/
PROTAMINE) LISPRO
INSULIN (ULTRALENTE)
HUMAN BIOSYNTHETIC
INTAL
INTAL NEBULIZER SOLUTION
INTAL SPINCAPS
INTERFERON ALFA-2A
INTERFERON ALFA-2B
INTERFERON ALFA-2B/
RIBAVIRIN
INTERFERON BETA-1A
INTERFERON BETA-1B
INTRON-A (EDS)
INTRON-A PREMIX (EDS)
INVIRASE (EDS)
IODOCHLORHYDROXYQUIN/
FLUMETHASONE PIVALATE
IOPIDINE
IPRATROPIUM BROMIDE
"
IPRATROPIUM BROMIDE/
SALBUTAMOL SO4
IRBESARTAN
IRBESARTAN/
HYDROCHLOROTHIAZIDE
IRON DEXTRAN
IRON SORBITOL
ISMO
ISOPTIN
"
ISOPTIN SR
ISOPTO ATROPINE
ISOPTO CARBACHOL
ISOPTO CARPINE
"
ISOPTO HOMATROPINE
ISORDIL
ISOSORBIDE DINITRATE
ISOSORBIDE-5 MONONITRATE
ISOTRETINOIN
"
ISOTREX
ITRACONAZOLE
JECTOFER (EDS)
K-10
KADIAN
"
KALETRA (EDS)
KAYEXALATE
K-DUR
KEFLEX
KEMADRIN
KENACOMB
KENACOMB MILD
KENALOG
KENALOG 10
KENALOG 40
KENALOG-ORABASE
KETO DIASTIX
KETOCONAZOLE
"
KETOPROFEN
KETOROLAC TROMETHAMINE
KETOSTIX
KETOTIFEN FUMARATE
K-LOR
Page
157
157
157
203
203
203
22
22
198
199
199
22
22
16
128
130
27
131
28
61
62
36
36
70
68
69
69
130
129
129
130
130
70
70
70
181
184
181
4
36
118
83
84
15
118
118
6
26
180
180
180
150
150
180
115
4
167
77
127
115
199
118
324
PRODUCT NAME
K-LYTE/CL
KWELLADA-P CREME RINSE
KWELLADA-P LOTION
LABETALOL HCL
LACTULOSE
LAMICTAL
LAMISIL
"
LAMIVUDINE
LAMIVUDINE/ZIDOVUDINE
LAMOTRIGINE
LANOXIN
LANSOPRAZOLE
LANSOPRAZOLE/
CLARITHROMYCIN/AMOXICILLIN
LARGACTIL
LASIX
LATANOPROST
LECTOPAM
LEFLUNOMIDE
LENOLTEC #4
LENOLTEC NO.2
LENOLTEC NO.3
LENTE ILETIN II, PORK
LESCOL
LEUCOVORIN (EDS)
LEUCOVORIN CALCIUM
(FOLINIC ACID)
LEUPROLIDE ACETATE
LEVAMISOLE
LEVAQUIN (EDS)
LEVOBUNOLOL HCL
LEVOBUNOLOL HCL/
DIPIVEFRIN HCL
LEVOBUNOLOL HYDROCHLORIDE
LEVOCABASTINE
HYDROCHLORIDE
LEVODOPA/BENZERAZIDE
LEVODOPA/CARBIDOPA
LEVOFLOXACIN
LEVONORGESTREL
LEVOTHYROXINE (SODIUM)
LIDEMOL
LIDEX
LIN-AMOX
LIN-BUSPIRONE
LIN-MEGESTROL (EDS)
LIN-NEFAZODONE
"
LIN-PRAVASTATIN
LINSOTALOL
LIORESAL
LIORESAL INTRATHECAL(EDS)
LIORESAL-DS
LIOTEC
LIOTHYRONINE (SODIUM)
LIPIDIL-MICRO (EDS)
LIPITOR
LISINOPRIL
LISINOPRIL/
HYDROCHLOROTHIAZIDE
LITHIUM CARBONATE
LIVOSTIN
LOCACORTEN-VIOFORM
LODOXAMIDE TROMETHAMINE
LOESTRIN 1.5/30
LOMOTIL
LONITEN (EDS)
Page
118
169
169
62
134
89
4
168
14
14
89
44
137
138
99
119
131
107
199
80
80
80
156
54
192
192
199
199
17
131
131
131
132
200
200
17
153
162
178
178
8
110
23
95
96
55
52
33
33
33
33
162
54
53
62
62
111
132
128
132
152
134
64
PRODUCT NAME
LOPERACAP
LOPERAMIDE HCL
LOPID
"
LOPINAVIR/RITONAVIR
LOPRESOR
LOPRESOR-SR
LOPROX
LORAZEPAM
LOSARTAN POTASSIUM
LOSARTAN POTASSIUM/
HYDROCHLOROTHIAZIDE
LOSEC (EDS)
LOTENSIN
LOTRIDERM
LOVASTATIN
LOVENOX (EDS)
LOXAPAC
LOXAPINE SUCCINATE
LOZIDE
LUDIOMIL
LUPRON DEPOT (EDS)
LUVOX
LYDERM
M.O.S.
"
"
M.O.S.-S.R.
"
MACROBID
MACRODANTIN
MANDELAMINE
MANERIX
MAPROTILINE
MARVELON
MAVIK
MAXALT (EDS)
MAXALT RPD (EDS)
MAXIDEX
MAXITROL
MEBENDAZOLE
MECLIZINE HCL
MED FLUOXETINE
"
MED-ACEBUTOLOL
MED-ACEBUTOLOL (TYPE S)
MED-ALPRAZOLAM
MED-AMANTADINE
MED-AMOXICILLIN
MED-ATENOLOL
MED-BACLOFEN
MED-BECLOMETHASONE AQ
MED-BROMAZEPAM
MED-BUSPIRONE
MED-CAPTOPRIL
"
MED-CLOMIPRAMINE
"
MED-CLONAZEPAM
MED-CYCLOBENZAPRINE (EDS)
MED-DILTIAZEM
MED-GEMFIBROZIL
MED-GLYBURIDE
MED-METFORMIN
MED-METOPROLOL
MED-MINOCYCLINE (EDS)
MED-PINDOLOL
MED-RANITIDINE
Page
134
134
54
55
15
47
47
167
108
63
63
138
57
180
55
36
101
101
119
95
199
94
178
83
84
85
83
84
18
17
17
95
95
151
68
32
32
126
128
2
136
93
94
42
42
106
12
8
43
33
125
107
110
57
58
91
92
87
33
45
55
158
158
47
11
49
139
325
PRODUCT NAME
MEDROL
MEDROXYPROGESTERONE
ACETATE
MED-SALBUTAMOL
MED-SELEGILINE (EDS)
MED-SOTALOL
MED-TEMAZEPAM
MED-TIMOLOL
MED-VALPROIC
MED-VERAPAMIL
"
MEFENAMIC ACID
MEGACE (EDS)
MEGACE OS (EDS)
MEGESTROL
MELLARIL
MEPERIDINE HCL
MEPERIDINE HYDROCHLORIDE
MEPRON (EDS)
MERCAPTOPURINE
MESASAL
M-ESLON
"
MESORIDAZINE
MESTINON
MESTRANOL/NORETHINDRONE
METFORMIN
METFORMIN
METHAZOLAMIDE
METHENAMINE MANDELATE
METHIMAZOLE
METHOTREXATE
METHOTRIMEPRAZINE
METHOXSALEN
METHSUXIMIDE
METHYLDOPA
METHYLDOPA/
HYDROCHLOROTHIAZIDE
METHYLPHENIDATE HCL
METHYLPREDNISOLONE
METHYLPREDNISOLONE
ACETATE
METHYSERGIDE MALEATE
METOCLOPRAMIDE HCL
METOLAZONE
METOPROLOL TARTRATE
"
METROCREAM
METROGEL
METRONIDAZOLE
"
MEVACOR
MEXILETINE HCL
MEXITIL
MIACALCIN (EDS)
MICARDIS
MICATIN
MICONAZOLE 3 DAY OVULE
MICONAZOLE NITRATE
MICRO-K 10 EXTENCAPS
MICRO-K EXTENCAPS
MICRONOR
MIDAMOR
MIDODRINE HCL
MIGRANAL (EDS)
MINESTRIN 1/20
MINIPRESS
MINITRAN 0.2
Page
149
161
30
202
52
109
132
90
68
69
77
23
23
23
104
82
82
18
23
140
83
84
101
26
153
158
158
129
17
163
183
110
185
88
63
63
105
149
149
31
138
120
47
63
169
169
18
169
55
48
48
159
66
168
167
167
118
118
153
120
28
31
152
65
71
PRODUCT NAME
MINITRAN 0.4
MINITRAN 0.6
MINOCIN (EDS)
MINOCYCLINE HCL
MIN-OVRAL
MINOXIDIL
MIOCARPINE
"
MIRAPEX
MIRENA
MISOPROSTOL
MOCLOBEMIDE
MODAFINIL
MODECATE
MODECATE CONCENTRATE
MODITEN
MODITEN ENANTHATE
MODURET
MOGADON
MOMETASONE FUROATE
MOMETASONE FUROATE
MONOHYDRATE
MONAZOLE 7
MONISTAT 3 COMBINATION
MONISTAT 7 COMBINATION
MONISTAT-3
MONISTAT-7
"
MONITAN
MONOCOR (EDS)
MONOPRIL
MONTELUKAST SODIUM
MONUROL (EDS)
MORPHINE
MORPHINE HP 50
MORPHINE SO4
MORPHINE SULPHATE
MORPHITEC-1
MORPHITEC-10
MORPHITEC-20
MORPHITEC-5
MOS-SULFATE
MOTILIDONE
MOTILIUM
MOTRIN
MOXIFLOXACIN HCL
MS CONTIN
"
"
MSD ENTERIC-COATED ASA
MSIR
"
"
MUCOMYST
MUPIROCIN
MYCOBUTIN (EDS)
MYCOPHENOLATE MOFETIL
MYCOSTATIN
"
MYOCHRYSINE
MYSOLINE
NABILONE
NABUMETONE
NADOLOL
"
NADROPARIN CALCIUM
NAFARELIN ACETATE
NALCROM (EDS)
Page
71
71
11
11
151
64
129
130
201
153
138
95
105
100
100
100
100
56
87
179
127
168
168
167
167
167
168
42
44
61
200
17
83
84
84
84
84
84
84
84
83
137
137
76
17
83
84
85
74
83
84
85
122
166
202
200
4
168
142
86
200
78
48
64
37
201
203
326
PRODUCT NAME
NALFON
NAPROSYN
NAPROSYN-S.R.
NAPROXEN
NAPROXEN
NARATRIPTAN HCL
NARDIL
NASACORT
NASACORT AQ
NASONEX
NAVANE
NAXEN
NEDOCROMIL SO4
NEFAZODONE
NELFINAVIR MESYLATE
NEMBUTAL
NEOMYCIN/
GRAMICIDIN/NYSTATIN/
TRIAMCINOLONE ACETONIDE
NEORAL (EDS)
"
NEOSPORIN
"
NEOSTIGMINE BROMIDE
NEOTOPIC
NEPTAZANE
NERISONE
NEULEPTIL
NEUPOGEN (EDS)
NEURONTIN
NEVIRAPINE
NIACIN
NIACIN
NIDAGEL
NIFEDIPINE
"
NILSTAT
"
NIMODIPINE
NIMOTOP (EDS)
NITOMAN
NITRAZADON
NITRAZEPAM
NITRO-DUR 0.2
NITRO-DUR 0.4
NITRO-DUR 0.6
NITRO-DUR 0.8
NITROFURANTOIN
NITROFURANTOIN
MONOHYDRATE
NITROGLYCERIN
NITROL
NITROLINGUAL PUMPSPRAY
NITROSTAT
NIX CREME RINSE
NIX DERMAL CREAM
NIZATIDINE
NIZORAL
NIZORAL (EDS)
NORETHINDRONE
NORFLOXACIN
"
NORITATE
NOROXIN (EDS)
"
NORPACE-CR
NORPLANT
NORPRAMIN
Page
75
78
78
78
78
31
96
127
127
127
104
78
201
95
15
106
180
184
197
124
166
26
166
129
177
102
38
89
13
192
192
169
48
64
4
168
70
70
203
87
87
71
71
71
71
17
18
71
71
71
71
169
169
138
167
4
153
17
125
169
17
125
46
153
92
PRODUCT NAME
NORTRIPTYLINE
NORVASC
NORVENTYL
NORVIR (EDS)
NORVIR SEC (EDS)
NOVAMILOR
NOVAMOXIN
NOVASEN
NOVO-5-ASA
NOVO-ACEBUTOLOL
NOVO-ALPRAZOL
NOVO-AMPICILLIN
NOVO-ATENOL
NOVO-AZATHIOPRINE
NOVO-BROMAZEPAM
NOVO-BUSPIRONE
NOVO-CAPTORIL
"
NOVO-CARBAMAZ
NOVO-CEFACLOR (EDS)
NOVO-CHLOROQUINE
NOVO-CHLORPROMAZINE
NOVO-CHOLAMINE
NOVO-CHOLAMINE LIGHT
NOVO-CIMETINE
"
NOVO-CLINDAMYCIN
NOVO-CLOBAZAM
NOVO-CLOBETASOL
NOVO-CLONAZEPAM
NOVO-CLONIDINE
NOVO-CLOPAMINE
"
NOVO-CLOPATE
NOVO-CLOXIN
NOVO-CYCLOPRINE (EDS)
NOVO-CYPROTERONE (EDS)
NOVO-DESIPRAMINE
NOVO-DIFENAC
"
NOVO-DIFENAC SR
NOVO-DIFLUNISAL
NOVO-DILTAZEM
NOVO-DILTAZEM CD
"
NOVO-DILTAZEM SR
NOVO-DIMENATE
NOVO-DIVALPROEX
NOVO-DOMPERIDONE
NOVO-DOPARIL
NOVO-DOXAZOSIN
NOVO-DOXEPIN
NOVO-DOXYLIN
NOVO-FAMOTIDINE
NOVO-FLUOXETINE
"
NOVO-FLURPROFEN
NOVO-FLUVOXAMINE
NOVO-FURANTOIN
NOVO-GEMFIBROZIL
"
NOVO-GESIC C15
NOVO-GESIC C30
NOVO-GLUCOSE
NOVO-GLYBURIDE
NOVO-HYDRAZIDE
NOVO-HYDROXYZIN
NOVO-HYLAZIN
Page
96
43
96
15
15
56
8
74
140
42
106
9
43
196
107
110
57
58
88
5
16
99
53
53
136
137
11
89
176
87
59
91
92
107
9
33
22
92
74
75
74
75
45
45
46
45
135
89
137
63
60
93
10
137
93
94
76
94
17
54
55
80
80
114
158
119
110
61
327
PRODUCT NAME
NOVO-INDAPAMIDE
NOVO-IPRAMIDE
NOVO-KETO
NOVO-KETOCONAZOLE (EDS)
NOVO-KETOTIFEN (EDS)
NOVO-LEVOBUNOLOL
NOVO-LEXIN
NOVOLIN GE 10/90 PENFILL
NOVOLIN GE 20/80 PENFILL
NOVOLIN GE 30/70
NOVOLIN GE 30/70 PENFILL
NOVOLIN GE 40/60 PENFILL
NOVOLIN GE 50/50 PENFILL
NOVOLIN GE LENTE
NOVOLIN GE NPH
NOVOLIN GE NPH PENFILL
NOVOLIN GE TORONTO
NOVOLIN GE TORONTO PENFIL
NOVOLIN GE ULTRALENTE
NOVO-LOPERAMIDE
NOVO-LORAZEM
NOVO-MAPROTILINE
NOVO-MEDRONE
NOVO-MEPRAZINE
"
NOVO-METFORMIN
NOVO-METHACIN
"
NOVO-METOPROL
NOVO-METOPROL (UNCOATED)
NOVO-MEXILETINE
NOVO-MINOCYCLINE (EDS)
NOVO-MOCLOBEMIDE
NOVO-NABUMETONE (EDS)
NOVO-NADOLOL
NOVO-NAPROX
NOVO-NAPROX SR
NOVO-NIDAZOL
NOVO-NIFEDIN
NOVO-NIZATIDINE
NOVO-NORFLOXACIN (EDS)
NOVO-NORTRIPTYLINE
NOVO-OXYBUTYNIN
NOVO-PEN-VK
NOVO-PERIDOL
NOVO-PINDOL
NOVO-PIROCAM
NOVO-PRANOL
"
NOVO-PRAZIN
NOVO-PREDNISONE
NOVO-PROFEN
NOVO-PROPAMIDE
NOVO-PUROL
NOVO-QUININE
NOVO-RANIDINE
NOVO-RYTHRO ESTOLATE
NOVO-RYTHRO ETHYLSUCC.
NOVO-SALMOL
NOVO-SELEGILINE (EDS)
NOVO-SEMIDE
NOVO-SERTRALINE
NOVO-SORBIDE
NOVO-SOTALOL
NOVO-SPIROTON
NOVO-SPIROZINE
NOVO-SUCRALATE
NOVO-SUNDAC
Page
119
27
77
4
199
131
6
157
157
157
157
157
157
156
156
156
156
156
157
134
108
95
161
110
111
158
76
77
47
47
48
11
95
78
48
78
78
18
48
138
17
96
188
10
100
49
79
50
51
65
149
76
157
196
16
139
7
7
29
202
119
97
70
52
120
66
139
79
PRODUCT NAME
NOVO-TEMAZEPAM
NOVO-TERAZOSIN
NOVO-TERBINAFINE
NOVO-THEOPHYL SR
NOVO-TIAPROFENIC
NOVO-TIMOL
"
NOVO-TRAZODONE
NOVO-TRIAMZIDE
NOVO-TRIMEL
"
NOVO-TRIMEL DS
NOVO-TRIOLAM
NOVO-TRIPRAMINE
NOVO-VALPROIC
NOVO-VERAMIL
"
NOVO-VERAMIL SR
NOZINAN
"
NPH ILETIN II PORK
NU-ACEBUTOLOL
NU-ACYCLOVIR
NU-ALPRAZ
NU-AMILZIDE
NU-AMOXI
NU-AMPI
NU-ATENOL
NU-BACLO
NU-BECLOMETHASONE
NU-BROMAZEPAM
NU-BUSPIRONE
NU-CAPTO
"
NU-CARBAMAZEPINE
NU-CEFACLOR (EDS)
NU-CEPHALEX
NU-CIMET
"
NU-CLONAZEPAM
NU-CLONIDINE
NU-CLOXI
NU-COTRIMOX
"
NU-COTRIMOX DS
NU-CROMOLYN
NU-CYCLOBENZAPRINE (EDS)
NU-DESIPRAMINE
NU-DICLO
NU-DICLO-SR
NU-DIFLUNISAL
NU-DILTIAZ
NU-DILTIAZ-CD
"
NU-DIVALPROEX
NU-DOMPERIDONE
NU-DOXYCYCLINE
NU-ERYTHROMYCIN-S
NU-FAMOTIDINE
NU-FENOFIBRATE (EDS)
NU-FLUOXETINE
"
NU-FLURBIPROFEN
NU-FLUVOXAMINE
NU-GEMFIBROZIL
"
NU-GLYBURIDE
NU-HYDRAL
Page
109
67
4
189
80
52
132
97
68
18
19
18
109
98
90
68
69
69
110
111
156
42
12
106
56
8
9
43
33
125
107
110
57
58
88
5
6
136
137
87
59
9
18
19
18
203
33
92
74
74
75
45
45
46
89
137
10
7
137
54
93
94
76
94
54
55
158
61
328
PRODUCT NAME
NU-IBUPROFEN
NU-INDAPAMIDE
NU-INDO
NU-IPRATROPIUM
NU-KETOCON (EDS)
NU-KETOTIFEN (EDS)
NU-LEVOCARB
NU-LORAZ
NU-LOXAPINE
NU-MEDOPA
NU-MEFENAMIC
NU-MEGESTROL (EDS)
NU-METFORMIN
NU-METOCLOPRAMIDE
NU-METOP
NU-MOCLOBEMIDE
NUMORPHAN
NU-NAPROX
NU-NIFED
NU-NIFEDIPINE-PA
"
NU-NORTRIPTYLINE
NU-OXYBUTYN
NU-PENTOXIFYLLINE-SR
NU-PEN-VK
NU-PINDOL
NU-PIROX
NU-PRAZO
NU-PROCHLOR
NU-PROPRANOLOL
"
NU-RANIT
NU-SALBUTAMOL
"
NU-SELEGILINE (EDS)
NU-SOTALOL
NU-SUCRALFATE
NU-SULFINPYRAZONE
NU-SULINDAC
NU-TEMAZEPAM
NU-TERAZOSIN
NU-TETRA
NU-TIAPROFENIC
NU-TICLOPIDINE (EDS)
NU-TIMOLOL
NU-TRAZODONE
NU-TRIAZIDE
NU-TRIMIPRAMINE
NUTROPIN (EDS)
NUTROPIN AQ (EDS)
NU-VALPROIC
NU-VERAP
"
NYADERM
"
NYSTATIN
"
OCTOSTIM (EDS)
OCTREOTIDE
OCUFEN (EDS)
OCUFLOX (EDS)
OESCLIM (EDS)
OFLOXACIN
OGEN
OLANZAPINE
OLSALAZINE SODIUM
OMEPRAZOLE
ONE ALPHA (EDS)
Page
76
119
76
27
4
199
200
108
101
63
77
23
158
138
47
95
85
78
48
48
49
96
188
38
10
49
79
65
103
50
51
139
29
30
202
52
139
120
79
109
67
11
80
39
52
97
68
98
160
160
90
68
69
4
168
4
168
160
201
126
125
154
125
155
102
138
138
193
PRODUCT NAME
ONE TOUCH
ONE TOUCH ULTRA
ONE-ALPHA (EDS)
OPHTHO-BUNOLOL
OPHTHO-DIPIVEFRIN
OPHTHO-TATE
OPTIMYXIN PLUS
ORACORT DENTAL PASTE
ORAFEN
ORAMORPH SR
"
ORAP
ORCIPRENALINE SO4
ORTHO 0.5/35
ORTHO 1/35
ORTHO 7/7/7
ORTHO-CEPT
ORTHO-NOVUM 1/50
ORUDIS
ORUDIS SR
ORUDIS-E
OSTOFORTE
OVRAL
OXAZEPAM
OXEZE TURBUHALER (EDS)
OXPRENOLOL HCL
OXSORALEN (EDS)
OXSORALEN ULTRA (EDS)
OXTRIPHYLLINE
OXYBUTYN
OXYBUTYNIN CHLORIDE
OXYCODONE HCL
OXYCONTIN
OXYDERM
OXY-IR
OXYMORPHONE HCL
PANCREASE
PANCREASE MT 10
PANCREASE MT 16
PANCREASE MT 4
PANCRELIPASE (LIPASE/
AMYLASE/PROTEASE)
PANECTYL
PANOXYL
PANOXYL AQUAGEL
PANOXYL-10
PANOXYL-15
PANOXYL-20
PANTOLOC (EDS)
PANTOPRAZOLE
PARLODEL
PARNATE
PAROXETINE HCL
PARSITAN
PAXIL
PCE
PEDIAPRED
PEDIAZOLE
PENICILLAMINE
PENICILLIN V (BENZATHINE)
PENICILLIN V (POTASSIUM)
PENTASA
PENTAZOCINE
PENTOBARBITAL SODIUM
PENTOSAN POLYSULFATE SO4
PENTOXIFYLLINE
PEN-VEE
PEPCID
Page
114
114
193
131
130
127
124
180
77
83
84
102
29
152
152
152
151
153
77
77
77
193
151
109
28
64
185
185
188
188
188
85
85
182
85
85
134
135
135
134
134
203
182
183
182
183
183
139
139
197
97
96
26
96
7
149
18
144
9
10
140
86
106
201
38
9
137
329
PRODUCT NAME
PEPTOL
"
PERGOLIDE MESYLATE
PERICYAZINE
PERIDOL
"
PERINDOPRIL ERBUMINE
PERMAX
PERMETHRIN
PERPHENAZINE
PERSANTINE (EDS)
PETHIDINE
PHENAZO
PHENAZOPYRIDINE
PHENELZINE SO4
PHENOBARBITAL
"
PHENOBARBITAL
PHENYLBUTAZONE
PHENYTOIN
PHISOHEX
PHOSPHOLINE IODIDE
PHYLLOCONTIN
PHYLLOCONTIN-350
PILOCARPINE
"
PILOCARPINE HCL
PILOPINE-HS
PIMOZIDE
PINDOLOL
"
PINDOLOL/
HYDROCHLOROTHIAZIDE
PIOGLITAZONE HCL
PIPERAZINE ADIPATE
PIPORTIL L4
PIPOTIAZINE PALMITATE
PIROXICAM
PIVMECILLINAM HCL
PIZOTYLINE HYDROGEN
MALATE
PLAQUENIL
PLAVIX (EDS)
PLENDIL
PMS-AMANTADINE
"
PMS-ATENOLOL
PMS-BACLOFEN
PMS-BENZTROPINE
PMS-BEZAFIBRATE (EDS)
PMS-BROMOCRIPTINE
PMS-BUSPIRONE
PMS-CAPTOPRIL
"
PMS-CARBAMAZEPINE CR(EDS)
PMS-CEFACLOR (EDS)
PMS-CEPHALEXIN
PMS-CHLORAL HYDRATE SYRUP
PMS-CHOLESTYRAMINE
PMS-CHOLESTYRAMINE LIGHT
PMS-CIMETIDINE
"
PMS-CLOBETASOL
PMS-CLONAZEPAM
PMS-CLONAZEPAM-R
PMS-CONJUGATED ESTROGENS
PMS-CYCLOBENZAPRINE (EDS)
PMS-DEFEROXAMINE (EDS)
Page
136
137
201
102
100
101
64
201
169
102
70
82
181
181
96
86
106
86
79
88
169
129
188
188
129
130
129
130
102
49
64
64
159
2
103
103
79
10
31
16
38
61
12
13
43
33
26
53
197
110
57
58
88
5
6
110
53
53
136
137
176
87
87
153
33
144
PRODUCT NAME
PMS-DESIPRAMINE
PMS-DEXAMETHASONE
PMS-DEXAMETHASONE SOD PHO
"
PMS-DICLOFENAC
"
PMS-DICLOFENAC-SR
PMS-DIPIVEFRIN
PMS-DOMPERIDONE
PMS-FENOFIBR. MICRO (EDS)
PMS-FLUOXETINE
"
PMS-FLUPHENAZINE DECAN.
PMS-FLURAZEPAM
PMS-FLUVOXAMINE
PMS-GABAPENTIN
PMS-GEMFIBROZIL
"
PMS-GENTAMICIN
PMS-GENTAMYCIN
PMS-GLYBURIDE
PMS-HALOPERIDOL
PMS-HYDROMORPHONE
"
PMS-HYDROXYZINE
PMS-INDAPAMIDE
PMS-IPRATROPIUM
"
PMS-KETOPROFEN
PMS-KETOPROFEN-EC
PMS-KETOTIFEN (EDS)
PMS-LACTULOSE (EDS)
PMS-LEVOBUNOLOL
PMS-LINDANE
PMS-LITHIUM CARBONATE
PMS-LOPERAMIDE
PMS-LOPERAMIDE HCL
PMS-LOXAPINE
PMS-MEFENAMIC ACID
PMS-METFORMIN
PMS-METHOTRIMEPRAZINE
"
PMS-METHYLPHENIDATE
PMS-METOCLOPRAMIDE
PMS-METOPROLOL-B
PMS-METOPROLOL-L
PMS-METRONIDAZOLE
PMS-MINOCYCLINE (EDS)
PMS-MOCLOBEMIDE
PMS-NAPROXEN
PMS-NIFEDIPINE
PMS-NIZATIDINE
PMS-NORTRIPTYLINE
PMS-NYSTATIN
PMS-OXTRIPHYLLINE
PMS-OXYBUTYNIN
PMS-PERPHENAZINE CONC.
PMS-PINDOLOL
PMS-PIROXICAM
PMS-POLYTRIMETHOPRIM
PMS-POTASSIUM CHLORIDE
PMS-PROCYCLIDINE
PMS-PROPRANOLOL
"
PMS-RANITIDINE
PMS-SALBUTAMOL
"
PMS-SALBUTAMOL RESPIR.SOL
Page
92
148
126
148
74
75
74
130
137
54
93
94
100
108
94
89
54
55
124
124
158
101
81
82
110
119
27
131
77
77
199
134
131
169
111
134
134
101
77
158
110
111
105
138
47
47
18
11
95
78
48
138
96
4
189
188
102
49
79
124
118
26
50
51
139
29
30
30
330
PRODUCT NAME
PMS-SELEGILINE (EDS)
PMS-SOD POLY SULF (120ML)
PMS-SOD POLYSTYRENE SULF
PMS-SODIUM CROMOGLYCATE
PMS-SOTALOL
PMS-SUCRALFATE
PMS-SULFASALAZINE
PMS-TEMAZEPAM
PMS-TERAZOSIN
PMS-TERBINAFINE
PMS-THEOPHYLLINE
PMS-THIORIDAZINE
PMS-TIAPROFENIC
PMS-TICLOPIDINE (EDS)
PMS-TIMOLOL
PMS-TOBRAMYCIN (EDS)
PMS-TRAZODONE
PMS-TRIFLUOPERAZINE
PMS-VALPROIC
PMS-VALPROIC ACID
PMS-VALPROIC ACID E.C.
PMS-VANCOMYCIN (EDS)
PMS-VERAPAMIL SR
PODOFILOX
POLYMYXIN B SO4/
BACITRACIN (ZINC)/
NEOMYCIN SO4/
HYDROCORTISONE
"
POLYMYXIN B SO4/NEOMYCIN
SO4/BACITRACIN(ZINC)
"
POLYMYXIN B SO4/NEOMYCIN
SO4/DEXAMETHASONE
POLYMYXIN B SO4/NEOMYCIN
SO4/GRAMICIDIN
"
POLYMYXIN B SO4/NEOMYCIN
SO4/HYDROCORTISONE
POLYMYXIN B SO4/
TRIMETHOPRIM SO4
POLYTRIM
PONSTAN
POTASSIUM CHLORIDE
POVIDONE-IODINE
PRAMIPEXOLE
DIHYDROCHLORIDE
PRANDASE
PRAVACHOL
PRAVASTATIN
PRAZIQUANTEL
PRAZOSIN
PRECISION PLUS
PRECISION XTRA
PRED FORTE
PRED MILD
PREDNISOLONE
PREDNISOLONE ACETATE
PREDNISOLONE SODIUM
PHOSPHATE
"
PREDNISONE
PREMARIN
PREMPLUS
PREVACID (EDS)
PRIMIDONE
PRINIVIL
PRINZIDE
Page
202
118
118
203
52
139
139
109
67
4
189
104
80
39
132
124
97
104
90
90
90
12
69
183
128
181
124
166
128
124
166
128
124
124
77
118
170
201
157
55
55
2
65
114
114
127
127
127
127
127
149
149
153
154
137
86
62
62
PRODUCT NAME
PRO-BANTHINE
PROBENECID
PROBETA
PROCAINAMIDE HCL
PROCAN-SR
PROCHLORPERAZINE
PROCHLORPERAZINE MESYLATE
PROCYCLID
PROCYCLIDINE HCL
PROFASI HP (EDS)
PROGESTERONE (MICRONIZED)
PROGRAF (EDS)
PROLOPA
PROLOPRIM
PROMETRIUM (EDS)
PRONESTYL
PRONESTYL-SR
PROPADERM
PROPAFENONE HCL
PROPANTHEL
PROPANTHELINE BROMIDE
PROPINE
PROPOXYPHENE
PROPRANOLOL
"
"
PROPRANOLOL/
HYDROCHLOROTHIAZIDE
PROPYLTHIOURACIL
PROPYL-THYRACIL
PROSCAR
PROSTIGMIN
PROTROPIN (EDS)
PROVERA
PROVIODINE
PROZAC
"
PULMICORT NEBUAMP
PULMICORT TURBUHALER
PULMOZYME (EDS)
PURINETHOL (EDS)
PVF-K 500
PYRANTEL PAMOATE
PYRETHINS/PIPERONYL
BUTOXIDE/
PETROLEUM DISTILLATE
PYRIDIUM
PYRIDOSTIGMINE BROMIDE
PYRIDOXINE HCL
PYRIDOXINE HCL
PYRIMETHAMINE
PYRVINIUM PAMOATE
QUESTRAN
QUESTRAN LIGHT
QUETIAPINE
QUIBRON-T/SR
QUINAPRIL HCL
QUINAPRIL HCL/
HYDROCHLOROTHIAZIDE
QUINIDEX EXTENTABS
QUINIDINE BISULFATE
QUINIDINE SO4
QUININE SO4
QUININE-ODAN
QVAR
R&C SHAMPOO/CONDITIONER
RALOXIFENE HCL
RAMIPRIL
Page
28
120
131
50
50
103
103
26
26
155
161
203
200
18
161
50
50
170
50
28
28
130
85
31
50
65
65
163
163
198
26
160
161
170
93
94
147
147
122
23
10
2
169
181
26
192
192
16
2
53
53
103
189
65
66
51
51
51
16
16
147
169
155
66
331
PRODUCT NAME
RANITIDINE
REBETRON (EDS)
REBIF (EDS)
REGLAN
REGULAR ILETIN II, PORK
RELAFEN (EDS)
RENEDIL
REPAGLINIDE
REQUIP
RESCRIPTOR (EDS)
RESONIUM CALCIUM
RESTORIL
RETIN A
"
RETIN A (EDS)
RETROVIR (EDS)
RHINALAR
RHINARIS-F
RHINOCORT AQUA
RHINOCORT TURBUHALER
RHODACINE
RHODIS EC
RHODIS SR
RHO-FLUPHENAZINE
RHO-HALOPERIDOL
RHOTRAL
RHOTRIMINE
RHOXAL-ATENOLOL
RHOXAL-CLONAZEPAM
RHOXAL-DILTIAZEM CD
"
RHOXAL-FAMOTIDINE
RHOXAL-FLUOXETINE
"
RHOXAL-LOPERAMIDE
RHOXAL-METFORMIN
RHOXAL-MINOCYCLINE (EDS)
RHOXAL-NITRAZEPAM
RHOXAL-SALBUTAMOL RES.SOL
RHOXAL-SOTALOL
RHOXAL-TIMOLOL
RHOXAL-VALPROIC
RIDAURA
RIFABUTIN
RIPHENIDATE
RISEDRONATE SODIUM
RISPERDAL
RISPERIDONE
RITALIN
RITALIN SR
RITONAVIR
RIVASTIGMINE
RIVOTRIL
RIZATRIPTAN BENZOATE
ROCALTROL (EDS)
ROFECOXIB
ROFERON-A (EDS)
ROPINIROLE HCL
ROSIGLITAZONE MALEATE
ROUPHYLLINE
RYTHMODAN
RYTHMODAN-LA
RYTHMOL
S.A.S. 500
SAB-DICLOFENAC
SAB-INDOMETHACIN
SAB-LEVOBUNOLOL
SABRIL
Page
139
198
199
138
156
78
61
159
202
13
118
109
181
182
182
15
126
126
126
126
77
77
77
100
101
42
98
43
87
45
46
137
93
94
134
158
11
87
30
52
132
90
142
202
105
202
103
103
105
105
15
202
87
32
193
79
22
202
159
189
46
46
50
139
75
77
131
90
PRODUCT NAME
SAB-TOBRAMYCIN (EDS)
SAIZEN (EDS)
SALAZOPYRIN
SALBUTAMOL SO4
SALMETEROL XINAFOATE
SALMETEROL XINAFOATE/
FLUTICASONE PROPIONATE
SALOFALK
SALOFALK RETENTION ENEMA
SANDOMIGRAN
SANDOMIGRAN DS
SANDOSTATIN (EDS)
SANDOSTATIN LAR (EDS)
SANS-ACNE
SANSERT (EDS)
SAQUINAVIR
SARNA HC
SCABENE
SCOPOLAMINE
SECOBARBITAL SODIUM
SECONAL
SECTRAL
SELECT 1/35
SELEGILINE HCL
SELEXID (EDS)
SEPTRA
"
SEPTRA D.S.
SERAX
SERC
SERENTIL
SEREVENT (EDS)
SEREVENT DISKUS (EDS)
SEROQUEL (EDS)
SERTRALINE HYDROCHLORIDE
SERZONE
"
SIBELIUM (EDS)
SIMVASTATIN
SINEMET
SINEMET CR
SINEQUAN
SINGULAIR (EDS)
SINTROM
SLO-BID
SLOW TRASICOR
SLOW-K
SODIUM AUROTHIOMALATE
SODIUM CROMOGLYCATE
"
SODIUM FLUORIDE
SODIUM FUSIDATE
SODIUM NITROPRUSSIDE
REAGENT
SODIUM POLYSTYRENE
SULFONATE
SODIUM SULAMYD
SOFRACORT
SOFRA-TULLE
SOLGANAL
SOLU-CORTEF
SOMATREM
SOMATROPIN
SORIATANE (EDS)
SOTACOR
SOTALOL HCL
SOTAMOL
SPIRONOLACTONE
Page
124
160
139
29
30
30
140
140
31
31
201
201
166
31
16
179
169
136
106
106
42
152
202
10
18
19
18
109
69
101
30
30
103
97
95
96
31
56
200
200
93
200
36
189
64
118
142
132
203
203
166
115
118
125
127
166
142
149
160
160
183
52
52
52
120
332
PRODUCT NAME
SPIRONOLACTONE/
HYDROCHLOROTHIAZIDE
SPORANOX (EDS)
STATEX
"
"
STATICIN
STAVUDINE
STEMETIL
STIEVA-A
"
STIEVA-A FORTE (EDS)
STILBESTROL
STILBOESTROL
SUCRALFATE
SULCRATE
SULCRATE SUSPENSION PLUS
SULFACETAMIDE (SODIUM)
SULFACETAMIDE (SODIUM)/
COLLOIDAL SULPHUR
SULFACETAMIDE SODIUM/
PREDNISOLONE ACETATE
SULFACET-R
SULFAMETHOXAZOLE/
TRIMETHOPRIM
SULFANILAMIDE/AMINACRINE
HCL/ALLANTOIN
SULFASALAZINE
(SALICYLAZOSULFAPYRIDINE)
SULFINPYRAZONE
"
SULINDAC
SUMATRIPTAN
SUPRAX (EDS)
SUPREFACT (EDS)
SURESTEP
SURGAM
SURMONTIL
SUSTIVA (EDS)
SYMMETREL
"
SYNACTHEN DEPOT
SYNALAR
SYNALAR REGULAR
SYNAREL (EDS)
SYNPHASIC
SYNTHROID
TACROLIMUS
TAGAMET
"
TALWIN
TAMBOCOR
TAMSULOSIN HCL
TAPAZOLE
TARO-CARBAMAZEPINE (EDS)
TARO-ETODOLAC (EDS)
TARO-SONE
TARO-WARFARIN
TAZAROTENE
TAZORAC
TEGRETOL
TEGRETOL CR (EDS)
TELMISARTAN
TEMAZEPAM
TENOLIN
TENORETIC
TENORMIN
TERAZOL-3
Page
66
4
83
84
85
166
14
103
181
182
182
155
155
139
139
139
125
170
128
170
18
170
139
38
120
79
32
5
197
114
80
98
13
12
13
160
177
177
201
152
162
203
136
137
86
46
203
163
88
75
171
37
184
184
88
88
66
109
43
57
43
168
PRODUCT NAME
TERAZOL-3 DUAL-PAK
TERAZOL-7
TERAZOSIN HCL
TERBINAFINE HCL
"
TERBUTALINE SO4
TERCONAZOLE
TESTOSTERONE CYPIONATE
TESTOSTERONE CYPIONATE
TESTOSTERONE ENANTHATE
TESTOSTERONE UNDECANOATE
TETRABENAZINE
TETRACYCLINE
TEVETEN
THEOCHRON
THEO-DUR
THEOLAIR LIQUID
THEOLAIR-SR
THEOPHYLLINE
THEOPHYLLINE (ANHYDROUS)
THIAMINE HCL
THIORIDAZINE
THIOTHIXENE
THYROID
THYROID
TIAPROFENIC ACID
TIAZAC
"
TICLID (EDS)
TICLOPIDINE HCL
TILADE
TIMOLIDE
TIMOLOL MALEATE
"
"
TIMOLOL MALEATE
TIMOLOL MALEATE/
PILOCARPINE
HYDROCHLORIDE
TIMOLOL/
HYDROCHLOROTHIAZIDE
TIMOPTIC
TIMOPTIC-XE
TIMPILO
TINZAPARIN SODIUM
TIZANIDINE HCL
TOBI (EDS)
TOBRADEX (EDS)
TOBRAMYCIN
"
TOBRAMYCIN (EDS)
TOBRAMYCIN/DEXAMETHASONE
TOBREX (EDS)
TOFRANIL
TOLBUTAMIDE
TOLECTIN
TOLMETIN
TOLTERODINE L-TARTRATE
TOMYCINE (EDS)
TOPAMAX
TOPICORT
TOPICORT MILD
TOPILENE GLYCOL
TOPIRAMATE
TOPISONE
TOPSYN
TRANDATE
TRANDOLAPRIL
Page
168
168
67
4
168
30
168
150
150
150
150
203
11
60
189
189
189
189
189
189
192
104
104
162
162
80
45
46
39
39
201
67
52
67
132
132
132
67
132
132
132
37
34
3
128
3
124
124
128
124
94
159
80
80
188
124
90
177
177
171
90
171
178
62
68
333
PRODUCT NAME
TRANSDERM-NITRO 0.2
TRANSDERM-NITRO 0.4
TRANSDERM-NITRO 0.6
TRANSDERM-V
TRANXENE
TRANYLCYPROMINE SO4
TRASICOR
TRAZODONE
TRAZOREL
TRENTAL
TRETINOIN
TRIADERM
TRIAMCINOLONE
TRIAMCINOLONE ACETONIDE
"
"
TRIAMCINOLONE ACETONIDE
TRIAMCINOLONE
HEXACETONIDE
TRIAMTERENE
TRIAMTERENE/
HYDROCHLOROTHIAZIDE
TRIAZOLAM
TRI-CYCLEN
TRIFLUOPERAZINE
TRIFLURIDINE
TRIHEXYPHENIDYL HCL
TRIKACIDE
TRIMEPRAZINE TARTRATE
TRIMETHOPRIM
TRIMIPRAMINE
TRINIPATCH 0.2
TRINIPATCH 0.4
TRINIPATCH 0.6
TRIPHASIL
TRIQUILAR
TRUSOPT
T-STAT
TYLENOL WITH CODEINE ELX
TYLENOL WITH CODEINE NO.2
TYLENOL WITH CODEINE NO.3
TYLENOL WITH CODEINE NO.4
ULCIDINE
ULTRADOL (EDS)
ULTRAMOP (EDS)
ULTRASE MS4
ULTRASE MT12
ULTRASE MT20
ULTRAVATE (EDS)
UNIPHYL
URECHOLINE
UREMOL-HC
URISPAS (EDS)
URSO (EDS)
URSODIOL
VALACYCLOVIR
VALISONE
VALIUM
VALPROATE SODIUM
VALPROIC ACID
VALSARTAN
VALSARTAN/
HYDROCHLOROTHIAZIDE
VALTREX
VANCERIL INHALER
VANCOCIN (EDS)
VANCOMYCIN HCL
VANQUIN
Page
71
71
71
136
107
97
64
97
97
38
181
180
149
127
150
180
150
150
120
68
109
153
104
125
27
18
203
18
98
71
71
71
151
151
129
166
80
80
80
80
137
75
185
134
135
135
178
189
26
179
188
204
204
13
176
108
90
90
68
68
13
147
12
12
2
PRODUCT NAME
VASERETIC
VASOCIDIN
VASOTEC
VENLAFAXINE HCL
VENTODISK
VENTOLIN
VENTOLIN NEBULES P.F.
"
VENTOLIN RESPIRATOR SOLN.
VENTOLIN ROTACAPS
VERAPAMIL HCL
"
VERELAN
VERMOX
VIADERM-KC
VIBRAMYCIN
VIBRA-TABS
VIDEX (EDS)
VIGABATRIN
VIOKASE
VIOXX (EDS)
VIRACEPT (EDS)
VIRAMUNE (EDS)
VIROPTIC
VISKAZIDE
VISKEN
VITAMIN A
VITAMIN A
VITAMIN A ACID
"
VITAMIN A ACID (EDS)
VITAMIN B1
VITAMIN B12
VITAMIN B6
VITAMIN D
VIVELLE (EDS)
VIVOL
VOLTAREN
"
VOLTAREN OPHTHA (EDS)
VOLTAREN-SR
WARFARIN
WARTEC
WELLBUTRIN SR (EDS)
WESTCORT
WINPRED
XALATAN
XANAX
ZADITEN (EDS)
ZAFIRLUKAST
ZALCITABINE
ZANAFLEX (EDS)
ZANTAC
ZARONTIN
ZAROXOLYN
ZERIT (EDS)
ZESTORETIC
ZESTRIL
ZIAGEN (EDS)
ZIDOVUDINE
ZITHROMAX (EDS)
ZOCOR
ZOLADEX (EDS)
ZOLMITRIPTAN
ZOLOFT
ZOMIG (EDS)
ZOMIG RAPIMELT (EDS)
ZOVIRAX
Page
60
128
60
98
29
29
29
30
30
29
52
68
69
2
180
10
10
14
90
135
79
15
13
125
64
49
192
192
181
182
182
192
192
192
193
154
108
74
75
131
74
37
183
91
179
149
131
106
199
204
15
34
139
88
120
14
62
62
14
15
7
56
198
32
97
32
32
12
334
PRODUCT NAME
ZOVIRAX WELLSTAT PAC
ZOVIRAX ZOSTAB PAC
ZUCLOPENTHIXOL ACETATE
ZUCLOPENTHIXOL DECANOATE
ZUCLOPENTHIXOL
DIHYDROCHLORIDE
ZYLOPRIM
ZYPREXA (EDS)
ZYPREXA ZYDIS (EDS)
Page
12
12
104
104
105
196
102
102
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10
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