Formulary 54th Edition - Drug Plan

Transcription

Saskatchewan
Health
Formulary
Fifty-Fourth Edition
July 2004 – June 2005
Updated quarterly
Inquiries should be directed to:
Pharmaceutical Services Division
Drug Plan & Extended Benefits Branch
Saskatchewan Health
2nd Floor, 3475 Albert Street
Regina, Saskatchewan
S4S 6X6
Website Address: http://formulary.drugplan.health.gov.sk.ca/
Telephone inquiries should be directed as follows:
Consumer Inquiries………………..……………Toll Free……..
…………………………………………….……...Regina….…..
Pharmacy Inquiries………………………………Toll Free…….
………………………………………………..……Regina………
Special Support Program Inquiries……………Toll Free……..
…………………………………………….……....Regina….…...
EDS, Palliative Care, "No Substitution" Inquiries…….……….
EDS Requests (24-hour message system)…..Toll Free……..
Profile Release Program………………………………………...
Pricing, Contract Inquiries……………………………………….
Product Submission Inquiries………………………….………..
Research and Utilization Inquiries……………………………...
Hospital Benefit List Inquiries………………………….………..
1-800-667-7581
(306) 787-3317
1-800-667-7578
(306) 787-3315
1-800-667-7581
(306) 787-3317
(306) 787-8744
1-800-667-2549
(306) 787-1661
(306) 787-3420
(306) 933-5599
(306) 787-3307
(306) 787-6823
Facsimile numbers:
EDS Unit Fax (EDS requests, Palliative Care forms and "No
Substitution" requests only)…………………….
General Fax ………………………………………..…..………...
(306) 798-1089
(306) 787-8679
Copyright - 2004
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.
54th EDITION
TABLE OF CONTENTS
FORMULARY AND DRUG PLAN
PROGRAMS
The Saskatchewan Formulary is
Published Annually
Updates will be provided:
Fall 2004
Winter 2004
Spring 2005
Please insert sticker updates in the section
provided at the back of the Formulary.
TABLE OF CONTENTS
(FORMULARY & DRUG PLAN PROGRAMS)
MEMBERSHIP OF SASKATCHEWAN FORMULARY COMMITTEE.................................... .
MEMBERSHIP OF SASKATCHEWAN DRUG QUALITY ASSESSMENT COMMITTEE ..... .
PREFACE.............................................................................................................................. .
NOTES CONCERNING THE FORMULARY......................................................................... .
LEGEND................................................................................................................................ .
iv
iv
v
xii
xx
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 AGENTS............................................................. .
36:00 DIAGNOSTIC AGENTS.......................................................................................... .
40:00 ELECTROLYTIC, CALORIC AND WATER BALANCE........................................... .
48:00 ANTITUSSIVES, EXPECTORANTS AND MUCOLYTIC AGENTS......................... .
52:00 EYE, EAR, NOSE AND THROAT PREPARATIONS.............................................. .
56:00 GASTROINTESTINAL DRUGS............................................................................... .
60:00 GOLD COMPOUNDS.............................................................................................. .
64:00 HEAVY METAL ANTAGONISTS............................................................................. .
68:00 HORMONES AND SYNTHETIC SUBSTITUTES.................................................... .
84:00 SKIN AND MUCOUS MEMBRANE AGENTS......................................................... .
86:00 SMOOTH MUSCLE RELAXANTS.......................................................................... .
88:00 VITAMINS................................................................................................................ .
92:00 UNCLASSIFIED THERAPEUTIC AGENTS............................................................ .
94:00 DIABETIC SUPPLIES...............................................................................………… .
2
22
26
36
42
74
118
122
128
130
142
152
154
156
176
198
202
206
220
APPENDICES
APPENDIX A - EXCEPTION DRUG STATUS PROGRAM................................................ .
APPENDIX B - SPECIAL COVERAGES............................................................................ .
APPENDIX C - CODES FOR PHARMACY ON-LINE CLAIMS PROCESSING................. .
APPENDIX D - MAINTENANCE DRUG SCHEDULE........................................................ .
APPENDIX E - TRIAL PRESCRIPTION PROGRAM MEDICATION LIST......................... .
APPENDIX F - SASKATCHEWAN MS DRUGS PROGRAM............................................. .
APPENDIX G - PHARMACEUTICAL MANUFACTURERS LIST....................................... .
224
261
267
270
271
272
274
INDICES
INDEX A - THERAPEUTIC CLASSIFICATION LIST......................................................... . 278
INDEX B - NUMERICAL LIST OF DRUG IDENTIFICATION NUMBERS.......................... . 280
INDEX C - ALPHABETICAL LIST OF PHARMACEUTICAL PRODUCT NAMES.............. . 299
FORMULARY UPDATES...................................................................................................... . 324
UPDATE INDEX.......…………………………………............................................................... . 346
NOTE: A section of supplementary Information regarding non-Drug Plan programs can be
found following the Update Index. See the Table of Contents for this section following the
Update Index.
ii
INTRODUCTION
COMMITTEES
SASKATCHEWAN FORMULARY
COMMITTEE (SFC)
SASKATCHEWAN DRUG QUALITY
ASSESSMENT COMMITTEE (DQAC)
Dr. B.R. Schnell
Chairperson
Dr. D. Quest
Chairperson
Dr. M. Caughlin
Saskatchewan Medical Association
Ms B. Evans
College of Pharmacy & Nutrition
Ms S. Chow
Saskatchewan Registered Nurses
Association
Dr. A. Paus-Jenssen
College of Medicine
Dr. A. K. Ramlall
College of Medicine
Dr. R. Dobson
Member at Large
Dr. B.R. Schnell
Chair, SFC
Not available at time of print
Saskatchewan Association of
Health Organizations
Dr. Y. Shevchuk
Ms C. Kanhai
Saskatchewan College of Pharmacists
Dr. J. Sibley
Department of Medicine,
College of Medicine
Dr. J. de la Rey Nel
College of Physicians & Surgeons
Dr. J. Tuchek
Department of Pharmacology,
College of Medicine
Mr. G. Peters
Saskatchewan Health
Dr. D. Quest
Chair, DQAC
Dr. T. W. Wilson
Departments of Medicine &
Pharmacology,
College of Medicine
Dr. D. Seibel
Member at Large
Dr. Y. Shevchuk
Mr. Kevin Wilson
Acting Executive Director,
STAFF ASSISTANCE
Ms Gail Bradley
Pharmacist, Pharmaceutical Services
Ms Margaret Baker
Acting Director, Pharmaceutical Services
Dr. Lorne Davis
Pharmacologist, Pharmaceutical Services
Ms Anne Champagne
Pharmacist, Pharmaceutical Services
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
Saskatchewan is participating in the Common Drug Review (CDR). The CDR
provides participating federal, provincial and territorial drug benefit plans with a
systematic review of the available clinical evidence, a critique of manufacturersubmitted pharmacoeconomic studies and a formulary listing recommendation
made by the Canadian Expert Drug Advisory Committee (CEDAC). For more
information about the CDR and CEDAC, visit http://www.ccohta.ca.
Note: The Drug Review process described below is in transition and will be
changing to reflect the CDR process.
When a 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 ensures that the products meet accepted standards for interchangeability.
v
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 xii - xiv).
The membership on the two Committees reflects its unique but complementary
mandate. The DQAC is composed of clinical specialists in internal medicine and/or
pharmacology, clinical pharmacists and pharmacologists. The SFC is made up of
representatives of the associations or institutions related to the regulation, education,
delivery and payment of drug therapy in Saskatchewan.
vi
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.
* The Product Submission Process is in transition and will be changing to reflect the Common Drug
Review (CDR) and the recommendations of the Canadian Expert Drug Advisory Committee (CEDAC).
For more information on the CDR and CEDAC visit http://www.ccohta.ca
vii
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 (interchangeable
products) 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
New Chemical Entities and New Combination Products
Saskatchewan is participating in the Common Drug Review (CDR) process. As a
consequence, submissions for new chemical entities and new combination products
should be made directly to CDR Directorate in accordance to the CDR Submission
Guidelines as posted on the Canadian Co-ordinating Office for Health Technology
Assessment (CCOHTA) website http://www.ccohta.ca.
The Budget Impact Analysis for Saskatchewan Health should be prepared in accordance
to the Economic Template at http://formulary.drugplan.health.gov.sk.ca, under Product
Submission Process. See Appendix III.
Single Source Products That Do Not Contain New Chemical Entities
Saskatchewan Health will accept submissions of single source products that do not
contain new chemical entities or new combinations and that will not fall under the
jurisdiction of the CDR process; however, the same submission requirements as per
CDR guidelines will apply to this category of products.
Line Extension Products
The following submission requirements pertain to new strengths and formulations or
reformulations of drug products that are currently listed in the Saskatchewan Formulary.
1. Copy of NOC
2. Copy of completed Drug Identification Number (DIN) notification form
3. Copy of approved Product Monograph
4. Justification of the need for the Line Extension
5. Copy of Comprehensive Summary (“Clinical Studies” section only) or other
document accepted by Health Canada and copies of critical studies that
address key clinical issues relevant to the new strength, formulation or
reformulation or evidence of formulation proportionality or bioequivalence data;
and evidence of a similar dissolution profile.
Changes to Benefit Status of Listed Single Source Drug Products to a New Indication
The following submission requirements pertain to single source drug products currently
listed in the Saskatchewan Formulary that have received a new indication from the
Therapeutic Product Directorate (TPD) and where the manufacturer wishes to request
expansion of the coverage criteria or a change in benefit status due to the new
indication.
viii
1.
2.
3.
4.
5.
Copy of NOC
Copy of completed Drug Identification Number (DIN) notification form
Copy of approved Product Monograph
Justification for the Expanded Coverage Criteria or Change in Benefits Status
Copy of Comprehensive Summary (Clinical Studies section only) or other
document accepted by Health Canada and copies of critical studies that
address key clinical issues relevant to the new indication.
Interchangeable Product Submissions
The following submission requirements pertain to multi-source products submitted for
listing in an interchangeable grouping in the Saskatchewan Formulary.
A.
Drug products in solid oral dosage forms reviewed by the TPD according to the
guidelines, “Conduct and Analysis of Bioavailability and Bioequivalence Studies
- Part A and B” and have a Canadian Reference Product on the Notice of
Compliance.
1. Copy of NOC
Note: (Bio) studies may be requested on a case-by-case basis.
B.
Drug products in solid oral dosage forms reviewed by the TPD according to the
guidelines “Conduct and Analysis of Bioavailability and Bioequivalence Studies
- Report C.
1.
2.
3.
4.
Copy of NOC
Executive summary of comparative bioavailability studies with the
reference drug product, including tables of calculated pharmacokinetic
(PK) parameters, ratios of geometric means for relevant PK parameters
and relative 90% CI, or 95% CI where appropriate, for the measured and
for the potency corrected data, mean plasma concentrations vs. time
curves (linear and log-transformed) or executive summary of comparative
pharmacodynamic studies.
C. Drug Products that are cross-referenced
1.
2.
3.
4.
Copy of NOC
Copy of completed Drug Identification Number (DIN)
Letters from both the manufacturer of the submitted product and the
manufacturer of the cross-licensed product, confirming that the two
products are identical in all aspects, except for embossing and labelling.
D. Drug products in Aqueous Solutions (e.g. oral, ophthalmics, inhalation,
injections) that have a Canadian Reference Product on the Notice of
Compliance.
1. Copy of NOC
Note: Comparative (Bio) studies may be requested on a case-by-case basis.
ix
E.
Drug products in semi-solid formulations (e.g. creams, ointments)
1.
2.
3.
4.
Copy of NOC
Executive summary of comparative bioavailability studies with reference
drug products, including tables of calculated pharmacokinetic (PK)
parameters, ratios of geometric means for relevant PK parameters and
relative 90% CI or 95% CI where appropriate for the measured and for the
potency corrected data, mean plasma concentrations vs. time curves
(linear and log-transformed) or surrogate comparisons with the reference
drug product (i.e. in vivo or in vitro test methods or a pharmacodynamic or
therapeutic equivalence study).
Drug Products Without a Canadian Reference Product
The following submission requirements pertain to products submitted for listing in an
interchangeable grouping where the active ingredient is designated as an “old drug” by
the TPD and the drug product is approved on the basis of DIN application (i.e. an NOC
is not issued) or is issued a Notice of Compliance without a Canadian Reference
Product.
A.
Drug products in solid dosage forms
1.
2.
3.
B.
Copy of approved Product Monograph or Prescribing Information
Executive
summary
of
comparative
bioavailablity
study
or
pharmacodynamic study or studies conducted in accordance with the TPD
guidelines, “Conduct and Analysis of Bioavailablity and Bioequivalence
studies - Part A and B and Report C.
Drug Products Not in Solid Oral Dosage Form
1.
2.
3.
Copy of approved Product Monograph or Prescribing Information
Executive
summary
of
comparative
Bioavailablity
study
or
pharmacodynamic study or studies conducted in accordance with the TPD
guidelines or surrogate comparisons with the reference drug product (i.e. in
vivo or vitro test methods or a pharmacodynamic or therapeutic
equivalence study).
C. Drug Products That Are Cross-Referenced
1.
2.
3.
Copy of approved product monograph or prescribing information
Letters from both the manufacturer of the submitted product and the
manufacturer of the cross-licensed product, confirming that the two
products are identical in all aspects, except for embossing and labelling.
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 submission as quickly as
possible upon receipt. Details of the criteria for product listings are published in each
edition of the Formulary and in the quarterly updates to the Formulary.
x
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.
Manufacturing Documentation
A copy of completed and approved Certified Product Information Document (C.P.I.D.)
should be submitted with the clinical documentation if possible, but will be accepted at a
later date.
Economic Evaluation
Price information including catalogue or estimated prices should be provided at the time
of product submission.
Submission of pharmacoeconomic analyses are encouraged.
The National
Pharmacoeconomic Guidelines serve as a guide. The Formulary Committee will
routinely consider direct “medical” costs such as:
•
•
•
•
•
impact on laboratory tests for monitoring, evaluation or diagnosis
impact on physician office visits
impact on hospitalization or institutionalization
impact on surgical procedures
increased or decreased incidence and severity of side effects.
The availability of quality-of-life analyses is encouraged.
Additional Documentation Required:
• A letter authorizing unrestricted communication regarding the drug product between
the Saskatchewan Prescription Drug Plan and:
1. Participating federal/provincial/territorial (F/P/T) drug plans
2. F/P/T governments, including their agencies and departments
3. F/P/T health authorities (including regional authorities and related facilities)
4. Health Canada
5. Patented Medicine Prices Review Board (PMPRB)
6. Canadian Coordinating Office for Health Technology Assessment (CCOHTA)
• Expected market share information is requested to allow for an accurate projection of
the impact of a new product.
• Product patent expiration date is requested to allow for consideration of the potential
long-term economic impact of the product.
• Copies of the initial product launch material, and any subsequent promotional material
sent to physicians and pharmacists.
• Ability to supply product.
xi
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
Drug Plan and Extended Benefits Branch, Saskatchewan Health
Regina, Saskatchewan S4S 6X6
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, urine-testing agents, syringes, needles, lancets and swabs
used by diabetic patients. Certain drugs are covered under the Exception Drug Status
Program (EDS) and require that specific medical criteria are met before coverage is
granted. See Appendix A for more information regarding EDS.
Eligibility
With a few exceptions, all Saskatchewan residents with a valid Saskatchewan Health
Services card are eligible for coverage under the Drug Plan. The exceptions include
those who have prescription costs paid by another agency. For example:
!
!
!
!
!
!
Health Canada; First Nations and Inuit Health Branch
Workers' Compensation Board
Veterans Affairs Canada
members of the Royal Canadian Mounted Police
members of the Canadian Forces
inmates of Federal Penitentiaries
Policy for Inclusion of Products in the Saskatchewan Formulary
1. Only products produced by manufacturers approved by Health Canada will be
considered.
2. Only drug products formulated and produced in accordance with sound
manufacturing principles and found to comply with official standards will be
considered.
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.
xii
The medical literature and clinical studies are reviewed and evaluated to determine
if the drug product is therapeutically effective for the treatment of the conditions for
which the drug is indicated.
The clinical literature is also reviewed to determine the therapeutic advantages or
disadvantages in relation to alternative agents, which may or may not be listed in
the Saskatchewan Formulary.
The rate and severity of potential undesirable effects are reviewed and compared
with those for alternative products.
In reviewing products for which suitable alternatives are listed in the Formulary,
consideration will be given to the following additional criteria:
• clinical documentation must clearly demonstrate therapeutic advantages such as:
• more effective for treatment of the condition(s) for which the drug is intended;
• increased safety as shown by reduced toxicity and reduced incidence of
adverse reactions and/or side effects;
• improved dosing schedule;
• reduced potential for abuse or inappropriate use;
OR
• anticipated cost of a product of equivalent therapeutic effectiveness must offer a
potential economic advantage over listed alternatives.
4. The cost of therapy relative to the clinical efficacy is reviewed and compared to the
cost of therapy relative to the clinical efficacy of alternative agents.
An increased cost may be justified if the drug product produces better clinical
results in a significant portion of the patient population, demonstrates fewer or less
severe undesirable effects, or has a dosage regime which improves patient
compliance.
The cost of oral combination products relative to the combined costs of the single
entities, the cost of the various dosage strengths relative to therapeutic
advantages, and the cost of additional dosage forms relative to the therapeutic
advantages will be considered when reviewing such products.
5. Some drug products will not be listed as regular benefits, but may be made
available on Exception Drug Status for treatment of selected clinical indications.
(See Appendix A)
6. Oral combination products are required to meet the following additional criteria:
• each component must make a contribution to the claimed effect;
• the dosage of each component (amount, frequency, duration of therapeutic
effect) must be such that the combination is safe and effective for a significant
patient population, requiring such concurrent therapy as defined in the labelling;
• a component may be added to:
• enhance safety or effectiveness of the principal active ingredient;
• minimize the potential for abuse of the principal active ingredient.
• combination fixed ratio must be "right" for:
xiii
• significant portion of patients;
• significant amount of natural history of disease.
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;
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;
• 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:
xiv
• 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;
• 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.
xv
"No Substitution" Prescriptions
Drug Plan benefits will be based only on the lowest priced interchangeable brand as
listed in the Formulary or sticker updates. Credit towards established deductibles or
thresholds (for income based drug coverage under Special Support) will also be based
on the lowest priced interchangeable brand. Although the Formulary will continue to list
all approved brands, patients will, in addition to their normal share of cost, be
responsible for any incremental cost associated with the selection of a higher cost brand.
It is important to note that both generic and brand name products are manufactured
under the same standards of good manufacturing practice, and that only those brands
which meet the SFC's standards for bioequivalence are accepted as interchangeable in
Saskatchewan.
In cases where a patient experiences problems with a specific brand of a medication, a
prescriber may make application for exemption from the cost of the "no sub" brand.
(See Appendix B for details.)
Adverse Drug Reactions
The Health Protection Branch encourages the reporting of suspected adverse reactions.
In Saskatchewan, prescribers, pharmacists, and other health professionals are
encouraged to participate in the Sask AR Program; see Supplementary Information at
the back of the book.
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.
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.
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.
xvi
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 D. 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
Saskatchewan Health
Regina SK S4S 6X6
FAX: (306) 787-8679
xvii
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 (Standing Offer Contract - SOC) for that product. Pharmacists will dispense these
products except where a prescriber indicates "no substitution" for a product in an
interchangeable category (see page xvi). In cases where contracts have been negotiated with
two suppliers of an interchangeable product, either brand may be used.
6
The price published in the formulary includes a wholesale mark-up, and is the maximum price
accepted (at time of publication) expressed as decimal dollars. Pharmacies are required by
contract to submit their actual acquisition cost of the drug, which may be less than the
published formulary price. For the most up to date information on formulary drug prices refer
to the on-line formulary at http://formulary.drugplan.health.gov.sk.ca.
7
The following symbol:⌧, to the left of a drug strength and dosage form indicates that the
products listed below are NOT interchangeable.
8
Drug strength and dosage form.
9
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. In some cases, as noted in the
formulary, identification numbers are generated by the Drug Plan for billing purposes only.
10 This product requires Exception Drug Status (EDS) approval (see Appendix A for EDS
10
criteria).
11 All active ingredients of combination products are listed.
12
12 Strengths of active ingredients are listed in the same order as the ingredients. This example
indicates that the tablet contains 100mg of levodopa and 25mg of carbidopa.
13 Brand name of drug.
13
14 Three letter identification code assigned to each manufacturer. The codes are listed in
14
Appendix G near the back of the Formulary.
15 The size of vials or ampoules of injectables is listed in brackets.
15
16 The size of a tube of ophthalmic ointments is listed in brackets.
xx
1
08:00 ANTI-INFECTIVE AGENTS
2
08:12.16 ANTIBIOTICS (PENICILLINS)
3
AMOXICILLIN (AMOXYCILLIN)
* 250MG CAPSULE
4
00865567
00406724
00628115
02181487
02230243
02238171
NU-AMOXI
NOVAMOXIN
APO-AMOXI
LIN-AMOX
PMS-AMOXICILLIN
GEN-AMOXICILLIN
NXP
NOP
APX
LIN
PMS
GPM
$
0.0898 *
0.1120
0.1120
0.1120
0.1120
0.1120
PMS
ICN
WYA
$
0.0814
0.1055
0.1319
BMY
$
5.4359
RTP
NXP
APX
NOP
DOM
BMY
$
0.3833
0.3833
0.3833
0.3833
0.4313
0.6839
LUD
$
73.1900
SCH
SAB
$
4.3400
4.3400
5
CONJUGATED ESTROGENS
7
⌧
0.625MG TABLET
00587281
00265470
02043408
PMS-CONJUGATED ESTROGENS
C.E.S.
PREMARIN
GATAFLOXACIN
8
400MG TABLET
9
02243182
11
12
10
TEQUIN (EDS)
LEVODOPA/CARBIDOPA
* 100MG/25MG TABLET
02126168
02182823
02195941
02244495
02247606
00513997
RATIO-LEVODOPA/CARBIDOPA
NU-LEVOCARB
13
APO-LEVOCARB
NOVO-LEVOCARBIDOPA
DOM-LEVO-CARBIDOPA
SINEMET
14
FLUPENTHIXOL DECANOATE
20MG/ML INJECTION SOLUTION (10ML)
02156032
GENTAMICIN SO4
* 5MG/G OPHTHALMIC OINTMENT (3.5G)
00028339
02230888
15
FLUANXOL DEPOT
GARAMYCIN
GENTAMICIN SULFATE
xxi
16
6
ANTI-INFECTIVE AGENTS
8:00
08:04.00 AMEBICIDES
DIIODOHYDROXYQUIN
650MG TABLET
01997750
DIODOQUIN
GLW
$
0.7870
JAN
$
3.2859
BAY
$
5.7510
PFC
$
1.1520
PFC
$
0.2765
PFC
$
0.1899
08:08.00 ANTHELMINTICS
MEBENDAZOLE
100MG TABLET
00556734
VERMOX
PRAZIQUANTEL
600MG TABLET
02230897
BILTRICIDE
PYRANTEL PAMOATE
125MG TABLET
01944363
COMBANTRIN
50MG/ML ORAL SUSPENSION
01944355
COMBANTRIN
PYRVINIUM PAMOATE
02019809
VANQUIN
08:12.00 ANTIBIOTICS
ANTIBIOTIC ASSOCIATED COLITIS OR PSEUDOMEMBRANOUS ENTEROCOLITIS
IS A SEVERE POTENTIALLY FATAL COLITIS WHICH MAY FOLLOW THE
ADMINISTRATION OF ANTIBIOTICS, MOST COMMONLY CLINDAMYCIN.
THE SYNDROME IS CAUSED BY A BACTERIAL TOXIN.
PATIENTS FOR WHOM ANTIBIOTICS ARE PRESCRIBED SHOULD BE ADVISED
TO DISCONTINUE THERAPY AND REPORT TO THE PHYSICIAN IF A
PERSISTANT DIARRHEA DEVELOPS AND/OR IF BLOOD OR MUCUS APPEARS
IN THE STOOL, AND SHOULD BE ADVISED NOT TO USE ANTIDIARRHEAL
PREPARATIONS WHILE ON THESE DRUGS AS THEY MAY EXACERBATE THE
CONDITION.
RECOMMENDED TREATMENT INCLUDES STOPPING ANTIBIOTICS AS SOON AS
POSSIBLE, CAREFUL ATTENTION TO FLUIDS AND ELECTROLYTES AND THE
USE OF AN APPROPRIATE ANTIBIOTIC (SUCH AS ORALLY ADMINISTERED
METRONIDAZOLE OR VANCOMYCIN) DIRECTED AGAINST THE TOXIN
PRODUCING ORGANISM.
2
08:12.02 ANTIBIOTICS (AMINOGLYCOSIDES)
GENTAMICIN SO4
* 40MG/ML INJECTION SOLUTION (2ML)
00223824
02242652
GARAMYCIN
GENTAMICIN
SCH
SAB
$
4.3000
4.3000
CCL
$
51.1700
APX
NOP
GPM
PMS
PFI
$
9.9658
9.9712
9.9712
11.0779
15.7941
NOP
APX
GPM
PMS
DOM
PFI
$
3.3924
3.3924
3.3924
3.3924
3.5621
5.2603
NOP
APX
GPM
PMS
DOM
PFI
$
6.0181
6.0181
6.0181
6.0181
6.3191
9.2008
PFI
$
1.0531
SCH
$
0.2775
SCH
$
0.4697
TOBRAMYCIN
SEE APPENDIX A FOR EDS CRITERIA
60MG/ML INHALATION SOLUTION (5ML)
02239630
TOBI (EDS)
08:12.04 ANTIBIOTICS (ANTIFUNGALS)
FLUCONAZOLE
* 150MG CAPSULE
02241895
02243645
02245697
02246620
02141442
APO-FLUCONAZOLE
NOVO-FLUCONAZOLE
GEN-FLUCONAZOLE
PMS-FLUCONAZOLE
DIFLUCAN
* 50MG TABLET
02236978
02237370
02245292
02245643
02246108
00891800
NOVO-FLUCONAZOLE (EDS)
APO-FLUCONAZOLE (EDS)
GEN-FLUCONAZOLE (EDS)
PMS-FLUCONAZOLE (EDS)
DOM-FLUCONAZOLE (EDS)
DIFLUCAN (EDS)
* 100MG TABLET
02236979
02237371
02245293
02245644
02246109
00891819
DIFLUCAN (EDS)
10MG/ML POWDER FOR ORAL SUSPENSION
02024152
DIFLUCAN P.O.S. (EDS)
GRISEOFULVIN (ULTRA-FINE)
250MG TABLET
00028274
FULVICIN U/F
500MG TABLET
00028282
FULVICIN U/F
3
08:12.04 ANTIBIOTICS (ANTIFUNGALS)
ITRACONAZOLE
100MG CAPSULE
02047454
SPORANOX (EDS)
JAN
$
3.9494
JAN
$
0.8398
NXP
NOP
APX
$
1.2841
1.2841
1.2841
RPH
$
0.0858
RPH
PMS
DOM
$
0.0566
0.0643
0.0674
NXP
APX
PMS
GPM
PRM
NOP
NVR
$
2.1943 *
2.7391
2.7391
2.7391
2.7391
2.7393
3.8712
AVT
$
3.3559
AVT
$
0.3598
10MG/ML ORAL SOLUTION
02231347
SPORANOX (EDS)
KETOCONAZOLE
* 200MG TABLET
02122197
02231061
02237235
NU-KETOCON (EDS)
NOVO-KETOCONAZOLE (EDS)
APO-KETOCONAZOLE (EDS)
NYSTATIN
500,000U TABLET
02194198
RATIO-NYSTATIN
* 100,000U/ML ORAL SUSPENSION
02194201
00792667
02125145
RATIO-NYSTATIN
PMS-NYSTATIN
DOM-NYSTATIN
TERBINAFINE HCL
* 250MG TABLET
02248845
02239893
02240807
02242503
02247530
02240346
02031116
NU-TERBINAFINE
APO-TERBINAFINE
PMS-TERBINAFINE
GEN-TERBINAFINE
PREM-TERBINAFINE
NOVO-TERBINAFINE
LAMISIL
08:12.06 ANTIBIOTICS (CEPHALOSPORINS)
CEFIXIME
400MG TABLET
02195984
SUPRAX (EDS)
02195992
SUPRAX (EDS)
4
08:12.06 ANTIBIOTICS (CEPHALOSPORINS)
CEFPROZIL
250MG TABLET
02163659
CEFZIL (EDS)
BMY
$
1.7149
BMY
$
3.3625
BMY
$
0.1676
BMY
$
0.3351
RPH
APX
GSK
$
1.0994
1.0994
1.6411
RPH
APX
GSK
$
2.1779
2.1779
3.2511
GSK
$
0.1815
NOP
$
0.1620
NOP
$
0.3240
NXP
NOP
APX
PMS
DOM
$
0.1272 *
0.1620
0.1620
0.1620
0.1966
NXP
NOP
APX
PMS
DOM
$
0.2544 *
0.3240
0.3240
0.3240
0.3871
NOP
$
0.0352
NOP
$
0.0712
500MG TABLET
02163667
CEFZIL (EDS)
02163675
CEFZIL (EDS)
02163683
CEFZIL (EDS)
CEFUROXIME AXETIL
* 250MG TABLET
02242656
02244393
02212277
RATIO-CEFUROXIME (EDS)
APO-CEFUROXIME (EDS)
CEFTIN (EDS)
* 500MG TABLET
02242657
02244394
02212285
CEFTIN (EDS)
02212307
CEFTIN (EDS)
CEPHALEXIN MONOHYDRATE
250MG CAPSULE
00342084
NOVO-LEXIN
500MG CAPSULE
00342114
NOVO-LEXIN
* 250MG TABLET
00865877
00583413
00768723
02177781
02177846
NU-CEPHALEX
NOVO-LEXIN
APO-CEPHALEX
PMS-CEPHALEXIN
DOM-CEPHALEXIN
* 500MG TABLET
00865885
00583421
00768715
02177803
02177854
NU-CEPHALEX
NOVO-LEXIN
APO-CEPHALEX
PMS-CEPHALEXIN
DOM-CEPHALEXIN
00342106
NOVO-LEXIN
00342092
NOVO-LEXIN
5
08:12.12 ANTIBIOTICS (MACROLIDES)
PRESCRIPTIONS FOR SOLID DOSAGE FORMS OF ERYTHROMYCIN SHOULD BE
FILLED WITH AN ERYTHROMYCIN BASE PREPARATION OF THE STRENGTH
PRESCRIBED; DISPENSE THE STEARATE AND ESTOLATE ONLY WHEN
SPECIFICALLY PRESCRIBED.
AZITHROMYCIN
250MG TABLET
02212021
ZITHROMAX (EDS)
PFI
$
5.3441
PFI
$
12.8255
PFI
$
1.1552
PFI
$
1.6370
ABB
$
1.6610
ABB
$
3.3218
ABB
$
2.7282
ABB
$
0.2915
ABB
$
0.5830
APX
$
0.1107
ABB
$
0.5496
PFI
$
0.5225
PFI
$
0.5804
NOP
$
0.0297
NOP
$
0.0598
600MG TABLET
02231143
ZITHROMAX (EDS)
02223716
ZITHROMAX (EDS)
02223724
ZITHROMAX (EDS)
CLARITHROMYCIN
250MG TABLET
01984853
BIAXIN BID (EDS)
500MG TABLET
02126710
BIAXIN BID (EDS)
500MG EXTENDED-RELEASE TABLET
02244756
BIAXIN XL (EDS)
02146908
BIAXIN (EDS)
02244641
BIAXIN (EDS)
ERYTHROMYCIN BASE
250MG TABLET
00682020
APO-ERYTHRO-BASE
333MG PARTICLE COATED TABLET
00769991
PCE
250MG CAPSULE (ENTERIC COATED PELLETS)
00607142
ERYC
333MG CAPSULE (ENTERIC COATED PELLETS)
00873454
ERYC
ERYTHROMYCIN ESTOLATE
00021172
NOVO-RYTHRO ESTOLATE
00262595
6
08:12.12 ANTIBIOTICS (MACROLIDES)
ERYTHROMYCIN ETHYLSUCCINATE
* 40MG/ML ORAL SUSPENSION
00605859
00000299
NOVO-RYTHRO ETHYLSUCC.
EES 200
NOP
ABB
$
0.0732
0.0801
NOP
ABB
$
0.1133
0.1213
APX
NXP
$
0.1026
0.1026
NXP
NOP
APX
LIN
PMS
GPM
$
0.0898 *
0.1120
0.1120
0.1120
0.1120
0.1120
NXP
NOP
APX
LIN
PMS
GPM
$
0.1748 *
0.2181
0.2181
0.2181
0.2181
0.2181
NOP
$
0.2512
NOP
$
0.3700
00652318
00453617
EES 400
ERYTHROMYCIN STEARATE
* 250MG TABLET
00545678
02051850
APO-ERYTHRO-S
NU-ERYTHROMYCIN-S
* 250MG CAPSULE
00865567
00406724
00628115
02181487
02230243
02238171
NU-AMOXI
NOVAMOXIN
APO-AMOXI
LIN-AMOX
PMS-AMOXICILLIN
GEN-AMOXICILLIN
* 500MG CAPSULE
00865575
00406716
00628123
02181495
02230244
02238172
NU-AMOXI
NOVAMOXIN
APO-AMOXI
LIN-AMOX
PMS-AMOXICILLIN
GEN-AMOXICILLIN
125MG CHEWABLE TABLET
02036347
NOVAMOXIN
02036355
NOVAMOXIN
7
00865540
00452149
00628131
02181509
02230245
NU-AMOXI
NOVAMOXIN
APO-AMOXI
LIN-AMOX
PMS-AMOXICILLIN
NXP
NOP
APX
LIN
PMS
$
0.0174 *
0.0217
0.0217
0.0217
0.0217
NXP
NOP
APX
LIN
PMS
$
0.0261 *
0.0326
0.0326
0.0326
0.0326
00865559
00452130
00628158
02181517
02230246
NU-AMOXI
NOVAMOXIN
APO-AMOXI
LIN-AMOX
PMS-AMOXICILLIN
AMOXICILLIN TRIHYDRATE/POTASSIUM CLAVULANATE
* 250MG/125MG TABLET
02243350
02243770
01916866
APO-AMOXI CLAV (EDS)
RATIO-ACLAVULANATE (EDS)
CLAVULIN-250 (EDS)
APX
RPH
GSK
$
0.6632
0.6632
0.9943
APX
RPH
GSK
$
1.0136
1.0136
1.4915
RPH
APX
NOP
GSK
$
1.3682
1.3683
1.3683
2.2372
APX
RPH
GSK
$
0.0786
0.0786
0.1179
GSK
$
0.1452
APX
RPH
GSK
$
0.1322
0.1322
0.1979
GSK
$
0.2712
02243351
02243771
01916858
RATIO-ACLAVULANATE(EDS)
CLAVULIN-500 (EDS)
02247021
02245623
02248138
02238829
NOVO-CLAVAMOXIN (EDS)
CLAVULIN-875 (EDS)
* 25MG/6.25MG/ML ORAL SUSPENSION
02243986
02244646
01916882
CLAVULIN-125F (EDS)
40MG/5.3MG/ML ORAL SUSPENSION
02238831
CLAVULIN-200 (EDS)
* 50MG/12.5MG/ML ORAL SUSPENSION
02243987
02244647
01916874
CLAVULIN-250F (EDS)
80MG/11.4MG/ML ORAL SUSPENSION
02238830
CLAVULIN-400 (EDS)
8
AMPICILLIN
* 250MG CAPSULE
00020877
00603279
00717657
NOVO-AMPICILLIN
APO-AMPI
NU-AMPI
NOP
APX
NXP
$
0.0889
0.0889
0.0889
NOP
APX
NXP
$
0.1723
0.1723
0.1723
NXP
$
0.0174
NXP
$
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
PNG
$
0.0380
NOP
APX
NXP
$
0.0407
0.0407
0.0407
APX
$
0.0266
LEO
$
0.9203
* 500MG CAPSULE
00020885
00603295
00717673
NOVO-AMPICILLIN
APO-AMPI
NU-AMPI
00717495
NU-AMPI
00717649
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)
02229617
PEN-VEE
PENICILLIN V (POTASSIUM)
* 300MG TABLET
00021202
00642215
00717568
NOVO-PEN-VK
APO-PEN-VK
NU-PEN-VK
00642223
APO-PEN-VK
PIVMECILLINAM HCL
200MG TABLET
00657212
SELEXID (EDS)
9
08:12.24 ANTIBIOTICS (TETRACYCLINES)
THE USE OF TETRACYCLINES DURING TOOTH DEVELOPMENT (LAST HALF
OF PREGNANCY, INFANCY AND CHILDHOOD TO THE AGE OF 8 YEARS)
MAY CAUSE PERMANENT TOOTH DISCOLORATION (YELLOW-GRAY-BROWN).
THIS REACTION IS MORE COMMON DURING LONG-TERM USE OF
TETRACYCLINES, BUT HAS BEEN OBSERVED FOLLOWING SHORT-TERM
COURSES. ENAMEL HYPOPLASIA HAS ALSO BEEN REPORTED.
TETRACYCLINE DRUGS, THEREFORE, SHOULD NOT BE USED IN THIS
AGE GROUP UNLESS OTHER DRUGS ARE NOT LIKELY TO BE EFFECTIVE
OR ARE CONTRAINDICATED.
DOXYCYCLINE
* 100MG CAPSULE
02044668
00740713
00817120
02093103
00024368
NU-DOXYCYCLINE
APO-DOXY
DOXYCIN
RATIO-DOXYCYCLINE
VIBRAMYCIN
NXP
APX
GPM
RPH
PFI
$
0.5094 *
0.6359
0.6359
0.6359
1.8389
NXP
GPM
APX
RPH
NOP
PFI
$
0.5094 *
0.6359
0.6359
0.6359
0.6359
1.8411
RPH
APX
NOP
GPM
RHO
PMS
DOM
STI
$
0.5805
0.5805
0.5805
0.5805
0.5805
0.5805
0.6131
0.6456
RPH
APX
NOP
GPM
RHO
PMS
DOM
STI
$
1.1211
1.1211
1.1211
1.1211
1.1211
1.1211
1.1769
1.2456
* 100MG TABLET
02044676
00860751
00874256
02091232
02158574
00578452
NU-DOXYCYCLINE
DOXYCIN
APO-DOXY
RATIO-DOXYCYCLINE
NOVO-DOXYLIN
VIBRA-TABS
MINOCYCLINE HCL
* 50MG CAPSULE
01914138
02084090
02108143
02230735
02237313
02239238
02239667
02173514
RATIO-MINOCYCLINE (EDS)
APO-MINOCYCLINE (EDS)
NOVO-MINOCYCLINE (EDS)
GEN-MINOCYCLINE (EDS)
RHOXAL-MINOCYCLINE (EDS)
PMS-MINOCYCLINE (EDS)
DOM-MINOCYCLINE (EDS)
MINOCIN (EDS)
* 100MG CAPSULE
01914146
02084104
02108151
02230736
02237314
02239239
02239668
02173506
MINOCIN (EDS)
10
08:12.24 ANTIBIOTICS (TETRACYCLINES)
TETRACYCLINE
* 250MG CAPSULE
00580929
00717606
APO-TETRA
NU-TETRA
APX
NXP
$
0.0689
0.0689
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
02245232
00030570
RATIO-CLINDAMYCIN
NOVO-CLINDAMYCIN
APO-CLINDAMYCIN
DALACIN C
RPH
NOP
APX
PFI
$
0.5306
0.5306
0.5306
0.9252
RPH
NOP
APX
PFI
$
1.0612
1.0612
1.0612
1.8504
* 300MG CAPSULE
02192659
02241710
02245233
02182866
RATIO-CLINDAMYCIN
NOVO-CLINDAMYCIN
APO-CLINDAMYCIN
DALACIN C
CLINDAMYCIN PALMITATE HCL
SEE NOTE REGARDING ANTIBIOTIC ASSOCIATED COLITIS OR
PSEUDOMEMBRANOUS ENTERCOLITIS UNDER SECTION 08:12.00 (ANTIBIOTICS)
00225851
DALACIN C
PFI
$
0.1245
PFI
$
76.6434
LIL
$
7.1133
LIL
$
14.2266
PMS
$
24.2000
PMS
$
48.3700
LINEZOLID
600MG TABLET
02243684
ZYVOXAM (EDS)
VANCOMYCIN HCL
125MG CAPSULE
00800430
VANCOCIN (EDS)
250MG CAPSULE
00788716
VANCOCIN (EDS)
500MG INJECTION
02241820
PMS-VANCOMYCIN (EDS)
1GM INJECTION
02241821
11
08:18.00 ANTIVIRALS
ACYCLOVIR
* 200MG TABLET
02197405
02078627
02207621
02242784
00634506
NU-ACYCLOVIR
RATIO-ACYCLOVIR
APO-ACYCLOVIR
GEN-ACYCLOVIR
ZOVIRAX
NXP
RPH
APX
GPM
GSK
$
0.7635 *
0.9530
0.9530
0.9530
1.3278
RPH
NXP
APX
GPM
GSK
$
1.8758
1.8758
1.8758
1.8758
2.6136
NXP
APX
GPM
RPH
GSK
$
3.0985
3.0985
3.0985
3.0986
5.1395
DOM
PMS
BMY
GPM
BMY
$
0.3532 *
0.5620
0.5620
0.5620
1.1773
BMY
PMS
DOM
$
0.0879
0.0879
0.0924
NVR
$
2.8829
NVR
$
3.8735
NVR
$
6.8810
* 400MG TABLET
02078635
02197413
02207648
02242463
01911627
RATIO-ACYCLOVIR
NU-ACYCLOVIR
APO-ACYCLOVIR
GEN-ACYCLOVIR
ZOVIRAX WELLSTAT PAC
* 800MG TABLET
02197421
02207656
02242464
02078651
01911635
NU-ACYCLOVIR
APO-ACYCLOVIR
GEN-ACYCLOVIR
RATIO-ACYCLOVIR
ZOVIRAX ZOSTAB PAC
AMANTADINE
* 100MG CAPSULE
02130963
01990403
02034468
02139200
01914006
DOM-AMANTADINE
PMS-AMANTADINE
ENDANTADINE
GEN-AMANTADINE
SYMMETREL
* 10MG/ML SYRUP
01913999
02022826
02130971
SYMMETREL
PMS-AMANTADINE
DOM-AMANTADINE
FAMCICLOVIR
125MG TABLET
02229110
FAMVIR
250MG TABLET
02229129
FAMVIR
500MG TABLET
02177102
FAMVIR
12
08:18.00 ANTIVIRALS
GANCICLOVIR SO4
250MG CAPSULE
02186802
CYTOVENE (EDS)
HLR
$
4.6604
HLR
$
9.3208
GSK
$
3.4243
HLR
$
24.3200
500MG CAPSULE
02240362
CYTOVENE (EDS)
VALACYCLOVIR
500MG CAPLET
02219492
VALTREX
VALGANCICLOVIR HCL
450MG TABLET
02245777
VALCYTE (EDS)
08:18.08 ANTIRETROVIRAL AGENTS (NONNUCLEOSIDE
REVERSE TRANSCRIPTASE INHIBITORS)
DELAVIRDINE MESYLATE
100MG TABLET
02238348
RESCRIPTOR (EDS)
PFI
$
0.9627
BMY
$
1.2417
BMY
$
2.4825
BMY
$
4.9096
BMY
$
14.3954
BOE
$
5.3582
EFAVIRENZ
50MG CAPSULE
02239886
SUSTIVA (EDS)
100MG CAPSULE
02239887
SUSTIVA (EDS)
200MG CAPSULE
02239888
SUSTIVA (EDS)
600MG TABLET
02246045
SUSTIVA (EDS)
NEVIRAPINE
200MG TABLET
02238748
VIRAMUNE (EDS)
13
08:18.08 ANTIRETROVIRAL AGENTS (NUCLEOSIDE REVERSE
TRANSCRIPTASE INHIBITORS)
ABACAVIR SO4
300MG TABLET
02240357
ZIAGEN (EDS)
GSK
$
6.7813
GSK
$
0.4522
GSK
$
17.0888
BMY
$
0.4315
BMY
$
0.8641
BMY
$
1.7279
BMY
$
2.5920
BMY
$
3.3635
BMY
$
5.3816
BMY
$
6.7270
BMY
$
10.7849
BMY
$
73.6100
02240358
ZIAGEN (EDS)
ABACAVIR SO4/LAMIVUDINE/ZIDOVUDINE
300MG/150MG/300MG TABLET
02244757
TRIZIVIR (EDS)
DIDANOSINE
SEE APPENDIX A FOR EDS CITERIA
01940511
VIDEX (EDS)
01940538
VIDEX (EDS)
01940546
VIDEX (EDS)
01940554
VIDEX (EDS)
125MG CAPSULE (ENTERIC COATED BEADLET)
02244596
VIDEX EC (EDS)
02244597
VIDEX EC (EDS)
02244598
VIDEX EC (EDS)
02244599
VIDEX EC (EDS)
4G POWDER FOR ORAL SOLUTION (PACKAGE)
01940635
VIDEX (EDS)
14
TRANSCRIPTASE INHIBITORS)
LAMIVUDINE
100MG TABLET
02239193
HEPTOVIR (EDS)
GSK
$
4.7740
GSK
$
4.7740
GSK
$
9.5480
GSK
$
0.3184
GSK
$
10.3075
BRI
$
4.2366
BRI
$
4.4048
BRI
$
4.5954
BRI
$
4.7636
HLR
$
2.4145
GSK
$
1.8445
GSK
$
0.1962
GSK
$
17.5500
150MG TABLET
02192683
3TC (EDS)
300MG TABLET
02247825
3TC (EDS)
02192691
3TC (EDS)
LAMIVUDINE/ZIDOVUDINE
150MG/300MG TABLET
02239213
COMBIVIR (EDS)
STAVUDINE
15MG CAPSULE
02216086
ZERIT (EDS)
20MG CAPSULE
02216094
ZERIT (EDS)
30MG CAPSULE
02216108
ZERIT (EDS)
40MG CAPSULE
02216116
ZERIT (EDS)
ZALCITABINE
0.75MG TABLET
01990896
HIVID (EDS)
ZIDOVUDINE
100MG CAPSULE
01902660
RETROVIR (EDS)
10MG/ML SOLUTION
01902652
RETROVIR (EDS)
10MG/ML INJECTION SOLUTION
01902644
RETROVIR (EDS)
15
08:18.08 ANTIRETROVIRAL AGENTS (PROTEASE INHIBITORS)
AMPRENAVIR
50MG CAPSULE
02243541
AGENERASE (EDS)
GSK
$
0.6944
GSK
$
2.0450
GSK
$
0.2084
MSD
$
1.4300
MSD
$
2.9224
ABB
$
3.4612
ABB
$
2.1448
PFI
$
1.9747
PFI
$
0.3951
ABB
$
1.5214
ABB
$
1.2170
HLR
$
1.9747
HLR
$
1.1456
150MG CAPSULE
02243542
AGENERASE (EDS)
02243543
AGENERASE (EDS)
INDINAVIR SO4
200MG CAPSULE
02229161
CRIXIVAN (EDS)
400MG CAPSULE
02229196
CRIXIVAN (EDS)
LOPINAVIR/RITONAVIR
133.3MG/33.3MG CAPSULE
02243643
KALETRA (EDS)
80MG/20MG (ML) ORAL SOLUTION
02243644
KALETRA (EDS)
NELFINAVIR MESYLATE
250MG TABLET
02238617
VIRACEPT (EDS)
50MG/G ORAL POWDER
02238618
VIRACEPT (EDS)
RITONAVIR
100MG SOFT ELASTIC CAPSULE
02241480
NORVIR SEC (EDS)
02229145
NORVIR (EDS)
SAQUINAVIR
200MG CAPSULE
02216965
INVIRASE (EDS)
200MG SOFT GELATIN CAPSULE
02239083
FORTOVASE (EDS)
16
08:20.00 ANTIMALARIAL AGENTS
CHLOROQUINE PHOSPHATE
* 250MG TABLET
00021261
02017539
NOVO-CHLOROQUINE
ARALEN
NOP
SAW
$
0.0865
0.3481
APX
SAW
$
0.3980
0.5686
GSK
$
1.3461
NOP
ODN
$
0.2594
0.2594
NOP
ODN
$
0.4069
0.4069
ODN
$
0.3418
NOP
APX
GPM
RPH
COB
PMS
RHO
PRM
DOM
BAY
$
1.6869
1.6869
1.6869
1.6869
1.6869
1.6869
1.6869
1.6869
1.7712
2.6064
HYDROXYCHLOROQUINE SO4
* 200MG TABLET
02246691
02017709
APO-HYDROXYQUINE
PLAQUENIL
PYRIMETHAMINE
25MG TABLET
00004774
DARAPRIM
QUININE SO4
* 200MG CAPSULE
00021008
00695440
NOVO-QUININE
QUININE-ODAN
* 300MG CAPSULE
00021016
00695459
NOVO-QUININE
QUININE-ODAN
300MG TABLET
00695432
QUININE-ODAN
08:22.00 QUINOLONES
CIPROFLOXACIN
* 250MG TABLET
02161737
02229521
02245647
02246825
02247339
02248437
02248756
02249960
02251272
02155958
NOVO-CIPROFLOXACIN (EDS)
APO-CIPROFLOX (EDS)
GEN-CIPROFLOXACIN (EDS)
RATIO-CIPROFLOXACIN (EDS)
CO CIPROFLOXACIN (EDS)
PMS-CIPROFLOXACIN (EDS)
RHOXAL-CIPROFLOXACIN (EDS)
PREM-CIPROFLOXACIN (EDS)
DOM-CIPROFLOXACIN (EDS)
CIPRO (EDS)
17
08:22.00 QUINOLONES
* 500MG TABLET
02229522
02161745
02245648
02246826
02247340
02248438
02248757
02249979
02251280
02155966
APO-CIPROFLOX (EDS)
CIPRO (EDS)
APX
NOP
GPM
RPH
COB
PMS
RHO
PRM
DOM
BAY
$
1.9032
1.9032
1.9032
1.9032
1.9032
1.9032
1.9032
1.9032
1.9984
2.9406
APX
NOP
GPM
RPH
COB
PMS
RHO
PRM
DOM
BAY
$
3.5895
3.5895
3.5895
3.5895
3.5895
3.5895
3.5895
3.5895
3.7690
5.5463
BAY
$
0.5881
BMY
$
5.4359
JAN
$
4.8174
JAN
$
5.4359
BAY
$
5.5986
* 750MG TABLET
02229523
02161753
02245649
02246827
02247341
02248439
02248758
02249987
02251299
02155974
APO-CIPROFLOX (EDS)
CIPRO (EDS)
02237514
CIPRO (EDS)
GATIFLOXACIN
400MG TABLET
02243182
TEQUIN (EDS)
LEVOFLOXACIN
250MG TABLET
02236841
LEVAQUIN (EDS)
500MG TABLET
02236842
LEVAQUIN (EDS)
MOXIFLOXACIN HCL
400MG TABLET
02242965
AVELOX (EDS)
18
08:22.00 QUINOLONES
NORFLOXACIN
* 400MG TABLET
02237682
02246596
02229524
00643025
NOVO-NORFLOXACIN (EDS)
PMS-NORFLOXACIN (EDS)
APO-NORFLOX (EDS)
NOROXIN (EDS)
NOP
PMS
APX
MSD
$
1.4882
1.4882
1.4899
2.4594
JAC
$
0.4261
PFR
$
22.2500
PFI
$
0.1898
NOP
PGA
$
0.3458
0.3771
APX
$
0.1302
APX
$
0.1736
PGA
$
0.6700
08:26.00 SULFONES
DAPSONE
100MG TABLET
02041510
DAPSONE
08:36.00 URINARY ANTI-INFECTIVES
METHENAMINE SALTS ARE EFFECTIVE ONLY IN ACIDIC URINE AND
ACIDIFICATION OF URINE TO PH 5.5 OR LESS IS RECOMMENDED.
FOSFOMYCIN TROMETHAMINE
3G ORAL POWDER (SACHET)
02240335
MONUROL (EDS)
METHENAMINE MANDELATE
500MG ENTERIC TABLET
00499013
MANDELAMINE
NITROFURANTOIN
* 50MG CAPSULE (MACROCRYSTALS)
02231015
01997637
NOVO-FURANTOIN
MACRODANTIN
50MG TABLET
00319511
APO-NITROFURANTOIN
100MG TABLET
00312738
APO-NITROFURANTOIN
NITROFURANTOIN MONOHYDRATE
100MG CAPSULE (MACROCRYSTALS)
02063662
MACROBID
19
08:36.00 URINARY ANTI-INFECTIVES
TRIMETHOPRIM
* 100MG TABLET
02243116
00675229
APO-TRIMETHOPRIM
PROLOPRIM
APX
GSK
$
0.2052
0.3174
APX
GSK
$
0.4216
0.6022
GSK
$
2.5224
ABB
$
0.1216
APX
$
0.0749
NXP
APX
NOP
$
0.0420 *
0.0523
0.0523
NXP
APX
NOP
GSK
$
0.1062 *
0.1325
0.1325
0.1326
APX
$
0.0955
NOP
APX
NXP
$
0.0215
0.0215
0.0215
* 200MG TABLET
02243117
00677590
APO-TRIMETHOPRIM
PROLOPRIM
08:40.00 MISCELLANEOUS ANTI-INFECTIVES
ATOVAQUONE
150MG/ML SUSPENSION
02217422
MEPRON (EDS)
ERYTHROMYCIN ETHYLSUCCINATE/
SULFISOXAZOLE ACETATE
40MG(BASE)/120MG(BASE) PER ML ORAL SOLUTION
00583405
PEDIAZOLE
METRONIDAZOLE
250MG TABLET
00545066
APO-METRONIDAZOLE
SULFAMETHOXAZOLE/TRIMETHOPRIM
(CO-TRIMOXAZOLE)
* 400MG/80MG TABLET
00865710
00445274
00510637
NU-COTRIMOX
APO-SULFATRIM
NOVO-TRIMEL
00865729
00445282
00510645
00368040
NU-COTRIMOX DS
APO-SULFATRIM DS
NOVO-TRIMEL DS
SEPTRA D.S.
100MG/20MG PEDIATRIC TABLET
00445266
APO-SULFATRIM
* 40MG/8MG PER ML ORAL SUSPENSION
00726540
00846465
00865753
NOVO-TRIMEL
APO-SULFATRIM
NU-COTRIMOX
20
ANTINEOPLASTIC AGENTS
10:00
10:00 ANTINEOPLASTIC AGENTS
10:00.00 ANTINEOPLASTIC AGENTS
CYPROTERONE ACETATE
* 50MG TABLET
00704431
02229723
02232872
ANDROCUR (EDS)
GEN-CYPROTERONE (EDS)
NOVO-CYPROTERONE (EDS)
PMS
GPM
NOP
$
1.6375
1.6375
1.6375
PMS
$
79.1100
HLR
$
36.8900
HLR
$
110.6700
HLR
$
221.3400
SCH
$
36.8800
SCH
$
127.2600
SCH
$
122.9400
SCH
$
221.2800
SCH
$
368.8000
SCH
$
709.8000
100MG/ML INJECTION
00704423
ANDROCUR (EDS)
INTERFERON ALFA-2A
3 MILLION IU/1ML INJECTION SOLUTION
ALBUMIN (HUMAN) FREE (1ML)
02217015
ROFERON-A (EDS)
02217058
ROFERON-A (EDS)
02217066
ROFERON-A (EDS)
INTERFERON ALFA-2B
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)
02240694
INTRON-A (EDS)
02240695
INTRON-A (EDS)
22
10:00 ANTINEOPLASTIC AGENTS
10:00.00 ANTINEOPLASTIC AGENTS
MEGESTROL
* 40MG TABLET
02176092
02185415
02195917
LIN-MEGESTROL (EDS)
NU-MEGESTROL (EDS)
APO-MEGESTROL (EDS)
LIN
NXP
APX
$
0.9824
0.9824
0.9824
APX
LIN
NXP
BMY
$
3.9350
3.9350
3.9350
5.8302
BMY
$
1.2702
NOP
$
1.9899
SCH
$
429.5000
SCH
$
429.5000
SCH
$
429.5000
SCH
$
429.5000
* 160MG TABLET
02195925
02176106
02185423
00731323
APO-MEGESTROL (EDS)
LIN-MEGESTROL (EDS)
NU-MEGESTROL (EDS)
MEGACE (EDS)
02168979
MEGACE OS (EDS)
MERCAPTOPURINE
50MG TABLET
00004723
PURINETHOL (EDS)
PEGINTERFERON ALFA-2B
50UG/0.5ML POWDER FOR INJECTION (VIAL)
02242966
UNITRON PEG (EDS)
02242967
UNITRON PEG (EDS)
02242968
UNITRON PEG (EDS)
02242969
UNITRON PEG (EDS)
23
AUTONOMIC DRUGS
12:00
12:00 AUTONOMIC DRUGS
12:04.00 PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS
BETHANECHOL CHLORIDE
10MG TABLET
01947958
DUVOID
RBP
$
0.2688
RBP
$
0.4355
RBP
$
0.5735
ICN
$
0.4742
ICN
$
0.4660
ICN
$
1.0196
PMS
APX
$
0.0586
0.0586
MSD
OMG
$
5.1400
5.5800
ERF
$
0.2013
25MG TABLET
01947931
DUVOID
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
PMS-BENZTROPINE
APO-BENZTROPINE
00016128
02238903
COGENTIN
BENZTROPINE OMEGA
ETHOPROPAZINE
50MG TABLET
01927744
PARSITAN
26
12:08.04 ANTIPARKINSONIAN AGENTS
PROCYCLIDINE HCL
* 5MG TABLET
00587354
02125102
00306290
PMS-PROCYCLIDINE
DOM-PROCYCLIDINE
PROCYCLID
PMS
DOM
ICN
$
0.0277
0.0291
0.0771
PMS
$
0.0333
APO-TRIHEX
APX
$
0.0326
APO-TRIHEX
APX
$
0.0586
ICN
$
0.0992
AVT
$
0.2157
AVT
$
0.0612
BOE
$
0.3212
0.5MG/ML ELIXIR
00587362
PMS-PROCYCLIDINE
TRIHEXYPHENIDYL HCL
2MG TABLET
00545058
5MG TABLET
00545074
12:08.08 ANTIMUSCARINICS/ANTISPASMODICS
DICYCLOMINE HCL
10MG CAPSULE
00361933
FORMULEX
20MG TABLET
02103095
BENTYLOL
2MG/ML SYRUP
02102978
BENTYLOL
HYOSCINE BUTYLBROMIDE
10MG TABLET
00363812
BUSCOPAN
27
12:08.08 ANTIMUSCARINICS/ANTISPASMODICS
IPRATROPIUM BROMIDE
NOTE: WHEN USING THE INHALATION SOLUTION CARE MUST BE TAKEN
TO PREVENT CONTACT WITH EYES. A WELL FITTED NEBULIZER MASK
MUST BE USED.
INHALER AEROSOL (PACKAGE)
00576158
ATROVENT
BOE
$
19.1800
RPH
PMS
APX
BOE
$
0.8200
0.8200
0.8200
1.4301
RPH
APX
NOP
PMS
GPM
BOE
$
0.6000
0.6000
0.6000
0.6000
0.6000
0.9532
NXP
RPH
GPM
PMS
APX
BOE
$
1.3123 *
1.6390
1.6390
1.6390
1.6390
2.8610
* 0.0125% INHALATION SOLUTION (2ML)
02097176
02231135
02243827
02026759
RATIO-IPRATROPIUM UDV
PMS-IPRATROPIUM
APO-IPRAVENT
ATROVENT
* 0.025% INHALATION SOLUTION
02097141
02126222
02210479
02231136
02239131
00731439
RATIO-IPRATROPIUM
APO-IPRAVENT
NOVO-IPRAMIDE
PMS-IPRATROPIUM
GEN-IPRATROPIUM
ATROVENT
* 0.025% INHALATION SOLUTION (2ML)
02231785
02097168
02216221
02231245
02231494
01950681
NU-IPRATROPIUM
GEN-IPRATROPIUM
PMS-IPRATROPIUM
APO-IPRAVENT
ATROVENT
IPRATROPIUM BROMIDE/SALBUTAMOL SO4
NOTE: SALBUTAMOL STRENGTHS ARE EXPRESSED IN TERMS OF SALBUTAMOL
BASE EQUIVALENT.
20UG/100UG INHALER AEROSOL (PACKAGE)
02163721
COMBIVENT
BOE
$
22.4300
RPH
GPM
BOE
$
1.1149
1.1149
1.4310
ICN
$
0.1807
BOE
$
2.2785
* 0.5MG/2.5MG INHALATION SOLUTION (2.5ML)
02243789
02246066
02231675
RATIO-IPRA SAL UDV
GEN-COMBO STERINEBS
COMBIVENT
PROPANTHELINE BROMIDE
15MG TABLET
00294837
PROPANTHEL
TIOTROPIUM BROMIDE MONOHYDRATE
18UG/DOSE INHALATION POWDER CAPSULE
02246793
SPIRIVA (EDS)
28
12:12.00 SYMPATHOMIMETIC (ADRENERGIC) AGENTS
EPINEPHRINE
0.15MG/DOSE INJECTION SOLUTION (PACKAGE)
00578657
EPIPEN JR.
ALX
$
87.8900
ALX
$
87.8900
PFI
$
1.4300
BOE
$
11.3300
BOE
$
0.8100
NVR
$
0.7650
AST
$
35.4800
AST
$
47.2600
0.3MG/DOSE INJECTION SOLUTION (PACKAGE)
00509558
EPIPEN
EPINEPHRINE HCL
00155357
ADRENALIN
FENOTEROL HYDROBROMIDE
100UG INHALER AEROSOL (PACKAGE)
02006383
BEROTEC
0.1% INHALATION SOLUTION
00541389
BEROTEC
FORMOTEROL FUMARATE
12UG/INHALATION POWDER CAPSULE
02230898
FORADIL (EDS)
6UG/DOSE POWDER FOR INHALATION (PACKAGE)
02237225
OXEZE TURBUHALER (EDS)
02237224
FORMOTEROL FUMARATE DIHYDRATE/BUDESONIDE
6UG/100UG POWDER FOR INHALATION (PACKAGE)
02245385
SYMBICORT TURBUHALER(EDS)
AST
$
65.1000
AST
$
84.6300
AMATINE (EDS)
RBP
$
0.5290
AMATINE (EDS)
RBP
$
0.8935
02245386
MIDODRINE HCL
2.5MG TABLET
01934392
5MG TABLET
01934406
29
ORCIPRENALINE SO4
* 2MG/ML SYRUP
02152568
02236783
RATIO-ORCIPRENALINE
APO-ORCIPRENALINE
RPH
APX
$
0.0415
0.0415
SALBUTAMOL SO4
NOTE: PRODUCT STRENGTHS ARE EXPRESSED IN TERMS OF SALBUTAMOL
BASE EQUIVALENT.
2MG TABLET
02146843
APO-SALVENT
APX
$
0.1075
APO-SALVENT
NU-SALBUTAMOL
APX
NXP
$
0.1796
0.1796
GSK
$
1.4764
GSK
$
2.0514
PMS
GSK
$
0.0591
0.0738
RPH
APX
MDA
$
5.0400
5.0400
5.0500
PMS
RPH
APX
GSK
$
0.4047
0.4047
0.4047
0.5398
$
0.5163 *
0.6610
0.6610
0.6610
0.6610
0.7410
1.0480
* 4MG TABLET
02146851
02165376
200UG/DOSE AEROSOL POWDER DISK (8)
02214997
VENTODISK
02215004
VENTODISK
* 0.4MG/ML ORAL LIQUID
02091186
02212390
PMS-SALBUTAMOL
VENTOLIN
* 100UG/DOSE INHALER AEROSOL (PACKAGE)
(CFC-FREE)
02244914
02245669
02232570
RATIO-SALBUTAMOL HFA
APO-SALVENT CFC FREE
AIROMIR
* 0.5MG/ML INHALATION SOLUTION PRESERVATIVE
FREE (2.5ML)
02208245
02239365
02243828
02213400
PMS-SALBUTAMOL
RATIO-SALBUTAMOL P.F.
APO-SALVENT
VENTOLIN NEBULES P.F.
* 1MG/ML INHALATION SOLUTION PRESERVATIVE FREE
(2.5ML)
02231783
01926934
01986864
02208229
02231488
02216949
02213419
NU-SALBUTAMOL
GEN-SALBUTAMOL STERINEB
RATIO-SALBUTAMOL
PMS-SALBUTAMOL
APO-SALVENT
DOM-SALBUTAMOL
30
NXP
GPM
RPH
PMS
APX
DOM
GSK
* 2MG/ML INHALATION SOLUTION PRESERVATIVE FREE
(2.5ML)
02173360
02208237
02231678
02231784
02239366
01945203
PMS-SALBUTAMOL
APO-SALVENT
NU-SALBUTAMOL
GPM
PMS
APX
NXP
RPH
GSK
$
1.2538
1.2538
1.2538
1.2538
1.2538
1.9905
RPH
APX
PMS
RHO
GPM
DOM
GSK
$
0.6402
0.6402
0.6402
0.6402
0.6402
0.7205
1.0167
GSK
$
56.4700
GSK
$
3.7643
GSK
$
56.4700
* 5MG/ML INHALATION SOLUTION
00860808
02046741
02069571
02154412
02232987
02139324
02213486
RATIO-SALBUTAMOL
APO-SALVENT
PMS-SALBUTAMOL RESP. SOL.
RHOXAL-SALBUTAMOL RES.SOL
GEN-SALBUTAMOL RESPIR.SOL
DOM-SALBUTAMOL RESPIR.SOL
VENTOLIN RESPIRATOR SOLN.
SALMETEROL XINAFOATE
25UG/DOSE INHALER AEROSOL (PACKAGE)
02211742
SEREVENT (EDS)
02214261
SEREVENT (EDS)
02231129
SEREVENT DISKUS (EDS)
SALMETEROL XINAFOATE/FLUTICASONE PROPIONATE
02245126
ADVAIR (EDS)
GSK
$
93.1000
GSK
$
132.1600
$
77.8000
$
93.1000
$
132.1600
$
15.9500
02245127
ADVAIR (EDS)
02240835
ADVAIR DISKUS (EDS)
GSK
02240836
ADVAIR DISKUS (EDS)
GSK
02240837
ADVAIR DISKUS (EDS)
GSK
TERBUTALINE SO4
0.5MG/DOSE POWDER FOR INHALATION (PACKAGE)
00786616
BRICANYL TURBUHALER
31
AST
12:16.00 SYMPATHOLYTIC AGENTS (ANTIMIGRAINE DRUGS)
DIHYDROERGOTAMINE MESYLATE
02241163
00027243
DIHYDROERGOTAMINE MESYL.
DIHYDROERGOTAMINE-SANDOZ
SAB
STE
$
3.7200
4.5800
STE
$
9.8200
APX
PMS
$
0.5761
0.5761
NVR
$
0.8353
4MG/ML NASAL SPRAY
02228947
MIGRANAL
FLUNARIZINE HCL
* 5MG CAPSULE
02246082
00846341
APO-FLUNARIZINE (EDS)
SIBELIUM (EDS)
METHYSERGIDE MALEATE
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
$
13.9350
GSK
$
14.7000
SANDOMIGRAN
PAL
$
0.3771
SANDOMIGRAN DS
PAL
$
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)
RIZATRIPTAN BENZOATE
5MG TABLET
02240520
MAXALT (EDS)
MSD
$
14.6133
MAXALT (EDS)
MSD
$
14.6133
MAXALT RPD (EDS)
MSD
$
14.6133
MSD
$
14.6133
10MG TABLET
02240521
5MG WAFER
02240518
10MG WAFER
02240519
MAXALT RPD (EDS)
32
12:16.00 SYMPATHOLYTIC AGENTS (ANTIMIGRAINE DRUGS)
SUMATRIPTAN
25MG TABLET
02239738
IMITREX (EDS)
GSK
$
13.9347
GSK
$
14.6833
GSK
$
16.1752
GSK
$
43.6200
GSK
$
13.9500
GSK
$
14.7000
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
2.5MG TABLET
02238660
ZOMIG (EDS)
AST
$
14.4740
AST
$
14.4740
DOM
PMS
GPM
NXP
APX
RPH
NVR
$
2.5MG ORALLY DISPERSIBLE TABLET
02243045
ZOMIG RAPIMELT (EDS)
12:20.00 SKELETAL MUSCLE RELAXANTS
BACLOFEN
* 10MG TABLET
02138271
02063735
02088398
02136090
02139332
02236507
00455881
DOM-BACLOFEN
PMS-BACLOFEN
GEN-BACLOFEN
NU-BACLO
APO-BACLOFEN
RATIO-BACLOFEN
LIORESAL
33
0.2078 *
0.3159
0.3159
0.3159
0.3159
0.3159
0.5265
12:20.00 SKELETAL MUSCLE RELAXANTS
* 20MG TABLET
02138298
02063743
02088401
02136104
02139391
02236508
00636576
DOM-BACLOFEN
PMS-BACLOFEN
GEN-BACLOFEN
NU-BACLO
APO-BACLOFEN
RATIO-BACLOFEN
LIORESAL-DS
DOM
PMS
GPM
NXP
APX
RPH
NVR
$
0.4122 *
0.6149
0.6149
0.6149
0.6149
0.6149
1.0248
NVR
$
10.3700
NVR
$
155.3400
NVR
$
155.3400
NOP
NXP
APX
PMS
GPM
RPH
DOM
JAN
$
0.4085
0.4085
0.4085
0.4085
0.4085
0.4085
0.4289
0.6405
PGA
$
0.3762
PGA
$
0.7650
RBP
$
0.7387
0.05MG/ML INJECTION (1ML)
02131048
LIORESAL INTRATHECAL(EDS)
0.5MG/ML INJECTION (20ML)
02131056
2MG/ML INJECTION (5ML)
02131064
CYCLOBENZAPRINE HCL
* 10MG TABLET
02080052
02171848
02177145
02212048
02231353
02236506
02238633
00782742
NOVO-CYCLOPRINE (EDS)
NU-CYCLOBENZAPRINE (EDS)
APO-CYCLOBENZAPRINE (EDS)
PMS-CYCLOBENZAPRINE (EDS)
GEN-CYCLOBENZAPRINE (EDS)
RATIO-CYCLOBENZAPRINE(EDS)
DOM-CYCLOBENZAPRINE (EDS)
FLEXERIL (EDS)
DANTROLENE SODIUM
25MG CAPSULE
01997602
DANTRIUM
100MG CAPSULE
01997653
DANTRIUM
TIZANIDINE HCL
4MG TABLET
02239170
ZANAFLEX (EDS)
34
BLOOD FORMATION AND COAGULATION
20:00
20:00 BLOOD FORMATION AND COAGULATION
20:04.04 IRON PREPARATIONS
IRON DEXTRAN
02221780
02205963
INFUFER (EDS)
DEXIRON (EDS)
SAB
GPM
$
27.5100
29.8400
GPM
$
53.0000
SINTROM
PAL
$
0.5101
SINTROM
PAL
$
1.6039
PFI
$
5.3600
PFI
$
16.9300
PFI
$
38.6000
PFI
$
160.8000
AVT
$
6.5600
AVT
$
21.7000
AVT
$
65.1000
AVT
$
32.5500
IRON SUCROSE
02243716
VENOFER (EDS)
20:12.04 ANTICOAGULANTS
ACENOCOUMAROL
1MG TABLET
00010383
4MG TABLET
00010391
DALTEPARIN SODIUM
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
30MG/0.3ML SYRINGE (0.3ML)
02012472
LOVENOX (EDS)
100MG/ML SYRINGE (0.4ML, 0.6ML, 0.8ML, 1ML)
02236883
LOVENOX (EDS)
02236564
LOVENOX (EDS)
150MG/ML PRE-FILLED SYRINGE (0.8ML, 1ML)
02242692
LOVENOX HP (EDS)
36
HEPARIN
10,000 USP U/ML INJECTION SOLUTION (5ML)
00740497
HEPALEAN
ORG
$
6.4000
SAW
$
9.7200
SAW
$
19.4300
LEO
$
34.7200
LEO
$
7.8800
LEO
$
69.4400
INNOHEP (EDS)
LEO
$
31.2500
TARO-WARFARIN
APO-WARFARIN
GEN-WARFARIN
COUMADIN
TAR
APX
GPM
BMY
$
0.1934
0.1934
0.1934
0.3137
TARO-WARFARIN
APO-WARFARIN
GEN-WARFARIN
COUMADIN
TAR
APX
GPM
BMY
$
0.2046
0.2046
0.2046
0.3318
TARO-WARFARIN
APO-WARFARIN
GEN-WARFARIN
COUMADIN
TAR
APX
GPM
BMY
$
0.1638
0.1638
0.1638
0.2656
TARO-WARFARIN
APO-WARFARIN
COUMADIN
TAR
APX
BMY
$
0.2536
0.2536
0.4114
NADROPARIN CALCIUM
9,500IU/ML SYRINGE (0.3ML, 0.4ML, 0.6ML,
0.8ML, 1ML)
02236913
FRAXIPARINE (EDS)
19,000IU/ML SYRINGE (0.6ML, 0.8ML, 1ML)
02240114
FRAXIPARINE FORTE (EDS)
TINZAPARIN SODIUM
02167840
INNOHEP (EDS)
10,000IU/ML SYRINGE (0.35ML, 0.45ML)
02229755
INNOHEP (EDS)
02229515
INNOHEP (EDS)
20,000IU/ML SYRINGE (0.5ML, 0.7ML, 0.9ML)
02231478
WARFARIN
* 1MG TABLET
02242680
02242924
02244462
01918311
* 2MG TABLET
02242681
02242925
02244463
01918338
* 2.5MG TABLET
02242682
02242926
02244464
01918346
* 3MG TABLET
02242683
02245618
02240205
37
* 4MG TABLET
02242684
02242927
02244465
02007959
TARO-WARFARIN
APO-WARFARIN
GEN-WARFARIN
COUMADIN
TAR
APX
GPM
BMY
$
0.2536
0.2536
0.2536
0.4114
TARO-WARFARIN
APO-WARFARIN
GEN-WARFARIN
COUMADIN
TAR
APX
GPM
BMY
$
0.1641
0.1641
0.1641
0.2662
TAR
APX
GPM
BMY
$
0.2944
0.2944
0.2944
0.4775
AMG
$
29.0800
AMG
$
58.1600
AMG
$
141.5000
AMG
$
275.5000
AMG
$
409.5000
JAN
$
15.4700
JAN
$
30.9300
* 5MG TABLET
02242685
02242928
02244466
01918354
* 10MG TABLET
02242687
02242929
02244467
01918362
TARO-WARFARIN
APO-WARFARIN
GEN-WARFARIN
COUMADIN
20:12.20 ANTIPLATELET DRUGS
SULFINPYRAZONE
SEE SECTION 40:40:00 (URICOSURIC DRUGS)
DARBEPOETIN ALFA
25UG/ML PRE-FILLED SYRINGE (0.4ML)
02246354
ARANESP (EDS)
02246355
ARANESP (EDS)
100UG/ML PRE-FILLED SYRINGE
(0.3ML, 0.4ML, 0.5ML)
02246357
ARANESP (EDS)
200UG/ML PRE-FILLED SYRINGE
(0.3ML, 0.4ML, 0.5ML)
02246358
ARANESP (EDS)
02246360
ARANESP (EDS)
20:16.00 HEMATOPOIETIC AGENTS
EPOETIN ALFA
1000IU/0.5ML PRE-FILLED SYRINGE
02231583
EPREX (EDS)
02231584
EPREX (EDS)
38
20:16.00 HEMATOPOIETIC AGENTS
02231585
EPREX (EDS)
JAN
$
46.3900
JAN
$
61.8500
JAN
$
90.5000
JAN
$
119.0000
JAN
$
147.5000
JAN
$
290.6800
AMG
$
266.3400
BMY
$
2.6916
RPH
APX
NXP
AVT
$
0.4164
0.4164
0.4164
0.6629
NXP
NOP
APX
GPM
PMS
RHO
DOM
HLR
$
0.5985 *
0.7471
0.7471
0.7472
0.7472
0.7472
0.7844
1.3633
02231586
EPREX (EDS)
02243401
EPREX (EDS)
02243403
EPREX (EDS)
10000IU/ML PRE-FILLED SYRINGE
02231587
EPREX (EDS)
20000IU STERILE SOLUTION FOR INJECTION
02206072
EPREX (EDS)
FILGRASTIM
300UG/ML INJECTION SOLUTION
01968017
NEUPOGEN (EDS)
20:24.00 HEMORRHEOLOGIC AGENTS
CLOPIDOGREL BISULFATE
75MG TABLET
02238682
PLAVIX (EDS)
PENTOXIFYLLINE
* 400MG SUSTAINED RELEASE TABLET
01968432
02230090
02230401
02221977
RATIO-PENTOXIFYLLINE
APO-PENTOXIFYLLINE SR
NU-PENTOXIFYLLINE-SR
TRENTAL
TICLOPIDINE HCL
* 250MG TABLET
02237560
02236848
02237701
02239744
02243327
02243587
02243808
02162776
NU-TICLOPIDINE (EDS)
NOVO-TICLOPIDINE (EDS)
APO-TICLOPIDINE (EDS)
GEN-TICLOPIDINE (EDS)
PMS-TICLOPIDINE (EDS)
RHOXAL-TICLOPIDINE (EDS)
DOM-TICLOPIDINE (EDS)
TICLID (EDS)
39
CARDIOVASCULAR DRUGS
24:00
24:00 CARDIOVASCULAR DRUGS
24:04.00 CARDIAC DRUGS
ACEBUTOLOL HCL
* 100MG TABLET
02165546
01910140
02036290
02147602
02204517
02237721
02237885
01926543
NU-ACEBUTOLOL
RHOTRAL
MONITAN
APO-ACEBUTOLOL
NOVO-ACEBUTOLOL
GEN-ACEBUTOLOL
GEN-ACEBUTOLOL (TYPE S)
SECTRAL
NXP
ROP
WYA
APX
NOP
GPM
GPM
AVT
$
0.1418 *
0.1769
0.1769
0.1769
0.1769
0.1769
0.1769
0.2949
NXP
ROP
WYA
APX
NOP
GPM
GPM
AVT
$
0.2122 *
0.2648
0.2648
0.2648
0.2648
0.2648
0.2648
0.4424
NXP
ROP
WYA
APX
NOP
GPM
GPM
$
0.4214 *
0.5260
0.5260
0.5260
0.5260
0.5260
0.5260
* 200MG TABLET
02165554
01910159
02036436
02147610
02204525
02237722
02237886
01926551
NU-ACEBUTOLOL
RHOTRAL
MONITAN
APO-ACEBUTOLOL
NOVO-ACEBUTOLOL
GEN-ACEBUTOLOL
SECTRAL
* 400MG TABLET
02165562
01910167
02036444
02147629
02204533
02237723
02237887
NU-ACEBUTOLOL
RHOTRAL
MONITAN
APO-ACEBUTOLOL
NOVO-ACEBUTOLOL
GEN-ACEBUTOLOL
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
02239835
02240071
02240604
02242472
02243836
02246194
02036282
NOVO-AMIODARONE
RATIO-AMIODARONE
GEN-AMIODARONE
PMS-AMIODARONE
RHOXAL-AMIODARONE
APO-AMIODARONE
CORDARONE
42
NOP
RPH
GPM
PMS
RHO
APX
WYA
$
1.4074
1.4074
1.4074
1.4074
1.4074
1.4074
2.2339
AMLODIPINE BESYLATE
5MG TABLET
00878928
NORVASC
PFI
$
1.3866
PFI
$
2.0582
PMS
$
0.1908
DOM
APX
NXP
NOP
GPM
RPH
PRM
RHO
PMS
AST
$
0.2211 *
0.3814
0.3814
0.3814
0.3814
0.3814
0.3814
0.3814
0.3814
0.6236
DOM
APX
NXP
NOP
GPM
RPH
PRM
RHO
PMS
AST
$
0.3769 *
0.6268
0.6268
0.6268
0.6268
0.6268
0.6268
0.6268
0.6268
1.0250
RHO
BVL
$
0.2659
0.3798
RHO
BVL
$
0.4406
0.6293
10MG TABLET
00878936
NORVASC
ATENOLOL
25MG TABLET
02246581
PMS-ATENOLOL
* 50MG TABLET
02229467
00773689
00886114
01912062
02146894
02171791
02230076
02231731
02237600
02039532
DOM-ATENOLOL
APO-ATENOL
NU-ATENOL
NOVO-ATENOL
GEN-ATENOLOL
RATIO-ATENOLOL
PREM-ATENOLOL
RHOXAL-ATENOLOL
PMS-ATENOLOL
TENORMIN
* 100MG TABLET
02229468
00773697
00886122
01912054
02147432
02171805
02230077
02231733
02237601
02039540
DOM-ATENOLOL
APO-ATENOL
NU-ATENOL
NOVO-ATENOL
GEN-ATENOLOL
RATIO-ATENOLOL
PREM-ATENOLOL
RHOXAL-ATENOLOL
PMS-ATENOLOL
TENORMIN
BISOPROLOL FUMARATE
* 5MG TABLET
02247439
02241148
RHOXAL-BISOPROLOL (EDS)
MONOCOR (EDS)
* 10MG TABLET
02247440
02241149
MONOCOR (EDS)
CAPTOPRIL
SEE SECTION 24:08.00 (HYPOTENSIVE DRUGS)
43
CARVEDILOL
* 3.125MG TABLET
02248748
02245914
02246529
02247933
02248715
02229650
DOM-CARVEDILOL (EDS)
PMS-CARVEDILOL (EDS)
NOVO-CARVEDILOL (EDS)
APO-CARVEDILOL (EDS)
NU-CARVEDILOL (EDS)
COREG (EDS)
DOM
PMS
NOP
APX
NXP
GSK
$
0.7728 *
0.9646
0.9646
0.9646
0.9646
1.4401
DOM
PMS
NOP
APX
NXP
GSK
$
0.7728 *
0.9646
0.9646
0.9646
0.9646
1.4401
DOM
PMS
NOP
APX
NXP
GSK
$
0.7728 *
0.9646
0.9646
0.9646
0.9646
1.4401
DOM
PMS
NOP
APX
NXP
GSK
$
0.7728 *
0.9646
0.9646
0.9646
0.9646
1.4401
VIR
$
0.2251
VIR
$
0.2251
VIR
$
0.2251
VIR
$
0.3681
* 6.25MG TABLET
02248749
02245915
02246530
02247934
02248716
02229651
NU-CARVEDILOL (EDS)
COREG (EDS)
* 12.5MG TABLET
02248750
02245916
02246531
02247935
02248717
02229652
NU-CARVEDILOL (EDS)
COREG (EDS)
* 25MG TABLET
02248751
02245917
02246532
02247936
02248718
02229653
NU-CARVEDILOL (EDS)
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
DILTIAZEM HCL
* 30MG TABLET
00886068
00771376
00862924
02146916
02097370
NU-DILTIAZ
APO-DILTIAZ
NOVO-DILTAZEM
GEN-DILTIAZEM
CARDIZEM
NXP
APX
NOP
GPM
BVL
$
0.1760 *
0.2252
0.2252
0.2252
0.4031
NXP
APX
NOP
GPM
BVL
$
0.3085 *
0.3947
0.3947
0.3947
0.7070
APX
NOP
BVL
$
0.3944
0.3944
0.7274
APX
NOP
BVL
$
0.5919
0.5919
0.9655
APX
NOP
BVL
$
0.7888
0.7888
1.2807
APX
NXP
NOP
RHO
RPH
BVL
$
0.8703
0.8703
0.8703
0.8703
0.8703
1.3093
BVL
$
0.8773
RPH
APX
NXP
NOP
RHO
BVL
$
1.1551
1.1551
1.1551
1.1551
1.1551
1.7380
BVL
$
1.1645
* 60MG TABLET
00886076
00771384
00862932
02146924
02097389
NU-DILTIAZ
APO-DILTIAZ
NOVO-DILTAZEM
GEN-DILTIAZEM
CARDIZEM
* 60MG SUSTAINED-RELEASE CAPSULE
02222957
02229406
02097214
APO-DILTIAZ SR
NOVO-DILTAZEM SR
CARDIZEM-SR
02222965
02229407
02097222
APO-DILTIAZ SR
NOVO-DILTAZEM SR
CARDIZEM-SR
02222973
02229408
02097230
APO-DILTIAZ SR
NOVO-DILTAZEM SR
CARDIZEM-SR
* 120MG CONTROLLED DELIVERY CAPSULE
02230997
02231052
02242538
02243338
02229781
02097249
APO-DILTIAZ CD
NU-DILTIAZ-CD
NOVO-DILTAZEM CD
RHOXAL-DILTIAZEM CD
RATIO-DILTIAZEM CD
CARDIZEM CD
120MG EXTENDED RELEASE CAPSULE
02231150
TIAZAC
02229782
02230998
02231053
02242539
02243339
02097257
RATIO-DILTIAZEM CD
APO-DILTIAZ CD
NU-DILTIAZ-CD
NOVO-DILTAZEM CD
RHOXAL-DILTIAZEM CD
CARDIZEM CD
02231151
TIAZAC
45
02230999
02231054
02242540
02243340
02229783
02097265
APO-DILTIAZ CD
NU-DILTIAZ-CD
NOVO-DILTAZEM CD
RHOXAL-DILTIAZEM CD
RATIO-DILTIAZEM CD
CARDIZEM CD
APX
NXP
NOP
RHO
RPH
BVL
$
1.5322
1.5322
1.5322
1.5322
1.5322
2.3053
BVL
$
1.5445
APX
RPH
NOP
RHO
BVL
$
1.9153
1.9153
1.9153
1.9153
2.8816
BVL
$
1.9307
BVL
$
2.3289
AVT
$
0.2273
AVT
$
0.3212
RBP
$
0.5787
AVT
$
0.7617
MDA
$
0.5344
MDA
$
1.0688
APX
$
0.0698
02231152
TIAZAC
02229526
02229784
02242541
02243341
02097273
APO-DILTIAZ CD
RATIO-DILTIAZEM CD
NOVO-DILTAZEM CD
RHOXAL-DILTIAZEM CD
CARDIZEM CD
02231154
TIAZAC
02231155
TIAZAC
DISOPYRAMIDE
100MG CAPSULE
02224801
RYTHMODAN
150MG CAPSULE
02224828
RYTHMODAN
150MG CONTROLLED RELEASE TABLET
02030810
NORPACE-CR
250MG SUSTAINED RELEASE TABLET
02224836
RYTHMODAN-LA
FLECAINIDE ACETATE
50MG TABLET
01966197
TAMBOCOR
100MG TABLET
01966200
TAMBOCOR
METOPROLOL TARTRATE
25MG TABLET
02246010
APO-METOPROLOL
46
* 50MG TABLET
02231121
00618632
00648035
00749354
00842648
00865605
02145413
02174545
02230803
02247875
02172550
00397423
00402605
DOM-METOPROLOL-L
APO-METOPROLOL
NOVO-METOPROL
APO-METOPROLOL-TYPE L
NOVO-METOPROL (UNCOATED)
NU-METOP
PMS-METOPROLOL-B
GEN-METOPROLOL (TYPE L)
PMS-METOPROLOL-L
RHOXAL-METOPROLOL L
DOM-METOPROLOL
LOPRESOR
BETALOC
DOM
APX
NOP
APX
NOP
NXP
PMS
GPM
PMS
RHO
DOM
NVR
AST
$
0.0716 *
0.1330
0.1330
0.1330
0.1330
0.1330
0.1330
0.1330
0.1330
0.1330
0.1397
0.2232
0.2512
* 100MG TABLET
02231122
00618640
00648043
00751170
00842656
00865613
02145421
02174553
02230804
02247876
02172569
00402540
00397431
DOM-METOPROLOL-L
APO-METOPROLOL
NOVO-METOPROL
NU-METOP
PMS-METOPROLOL-B
PMS-METOPROLOL-L
RHOXAL-METOPROLOL L
DOM-METOPROLOL
BETALOC
LOPRESOR
DOM
APX
NOP
APX
NOP
NXP
PMS
GPM
PMS
RHO
DOM
AST
NVR
$
0.1314 *
0.2412
0.2412
0.2412
0.2412
0.2412
0.2412
0.2412
0.2412
0.2412
0.2533
0.4302
0.4579
00658855
⌧
LOPRESOR-SR
NVR
$
0.2659
NVR
AST
$
0.4824
0.4964
NOP
$
0.8856
NOP
$
1.1859
PPZ
APX
RPH
NOP
$
0.2675
0.2675
0.2675
0.2675
00534560
00497827
LOPRESOR-SR
BETALOC DURULES
MEXILETINE HCL
100MG CAPSULE
02230359
NOVO-MEXILETINE
200MG CAPSULE
02230360
NOVO-MEXILETINE
NADOLOL
* 40MG TABLET
00607126
00782505
00851663
02126753
CORGARD
APO-NADOL
RATIO-NADOLOL
NOVO-NADOLOL
47
* 80MG TABLET
00463256
00782467
00851671
02126761
CORGARD
APO-NADOL
RATIO-NADOLOL
NOVO-NADOLOL
PPZ
APX
RPH
NOP
$
0.3814
0.3814
0.3814
0.3814
PPZ
APX
RPH
$
0.7156
0.7156
0.7156
APX
NOP
$
0.2648
0.2648
APX
NOP
NXP
$
0.2016
0.2016
0.2016
APX
NXP
$
0.2436
0.2436
APX
NXP
$
0.4232
0.4232
BAY
$
0.8140
BAY
$
1.0600
ADALAT XL
BAY
$
1.6628
NU-PINDOL
APO-PINDOL
NOVO-PINDOL
GEN-PINDOLOL
PMS-PINDOLOL
DOM-PINDOLOL
VISKEN
NXP
APX
NOP
GPM
PMS
DOM
NVR
$
0.1840 *
0.2477
0.2477
0.2477
0.2477
0.2601
0.4492
* 160MG TABLET
00523372
00782475
00851698
CORGARD
APO-NADOL
RATIO-NADOLOL
NIFEDIPINE
* 5MG CAPSULE
00725110
02047462
APO-NIFED
NOVO-NIFEDIN
* 10MG CAPSULE
00755907
00756830
00865591
APO-NIFED
NOVO-NIFEDIN
NU-NIFED
02197448
02212102
APO-NIFED PA
NU-NIFEDIPINE-PA
02181525
02200937
APO-NIFED PA
NU-NIFEDIPINE-PA
02237618
ADALAT XL
02155907
ADALAT XL
02155990
PINDOLOL
* 5MG TABLET
00886149
00755877
00869007
02057808
02231536
02231650
00417270
48
* 10MG TABLET
00886009
00755885
00869015
02057816
02231537
02238046
00443174
NU-PINDOL
APO-PINDOL
NOVO-PINDOL
GEN-PINDOLOL
PMS-PINDOLOL
DOM-PINDOLOL
VISKEN
NXP
APX
NOP
GPM
PMS
DOM
NVR
$
0.3278 *
0.4302
0.4302
0.4302
0.4302
0.4517
0.7671
APX
NOP
NXP
GPM
PMS
DOM
NVR
$
0.6321
0.6321
0.6321
0.6321
0.6321
0.6636
1.1127
APX
$
0.1913
APX
$
0.2497
APX
$
0.3321
PFI
$
0.1693
PFI
SQU
$
0.3386
0.5122
PFI
$
0.5078
APX
PMS
GPM
NXP
ABB
$
0.4639
0.4639
0.4639
0.4639
1.0394
* 15MG TABLET
00755893
00869023
00886130
02057824
02231539
02238047
00417289
APO-PINDOL
NOVO-PINDOL
NU-PINDOL
GEN-PINDOLOL
PMS-PINDOLOL
DOM-PINDOLOL
VISKEN
PROCAINAMIDE HCL
250MG CAPSULE
00713325
APO-PROCAINAMIDE
375MG CAPSULE
00713333
APO-PROCAINAMIDE
500MG CAPSULE
00713341
APO-PROCAINAMIDE
00638692
⌧
PROCAN-SR
00638676
00639885
PROCAN-SR
PRONESTYL-SR
00638684
PROCAN-SR
PROPAFENONE HCL
* 150MG TABLET
02243324
02243727
02245372
02249480
00603708
APO-PROPAFENONE
PMS-PROPAFENONE
GEN-PROPAFENONE
NU-PROPAFENONE
RYTHMOL
49
* 300MG TABLET
02243325
02243728
02245373
00603716
APO-PROPAFENONE
PMS-PROPAFENONE
GEN-PROPAFENONE
RYTHMOL
APX
PMS
GPM
ABB
$
0.8178
0.8178
0.8178
1.8320
DOM
APX
PMS
NOP
WYA
$
0.0175 *
0.0209
0.0209
0.0261
0.0748
APX
NOP
NXP
$
0.0376
0.0376
0.0376
DOM
APX
NOP
PMS
NXP
$
0.0332 *
0.0378
0.0378
0.0378
0.0378
APX
NOP
PMS
DOM
$
0.0635
0.0635
0.0635
0.0667
APX
$
0.1149
WYA
$
0.4532
WYA
$
0.5112
WYA
$
0.7870
WYA
$
0.9309
AST
$
0.4579
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
* 40MG TABLET
02137321
00402753
00496499
00582263
02044706
DOM-PROPRANOLOL
APO-PROPRANOLOL
NOVO-PRANOL
PMS-PROPRANOLOL
NU-PROPRANOLOL
* 80MG TABLET
00402761
00496502
00582271
02137348
APO-PROPRANOLOL
NOVO-PRANOL
PMS-PROPRANOLOL
DOM-PROPRANOLOL
120MG TABLET
00504335
APO-PROPRANOLOL
60MG LONG ACTING CAPSULE
02042231
INDERAL-LA
02042258
INDERAL-LA
02042266
INDERAL-LA
02042274
INDERAL-LA
QUINIDINE BISULFATE
00249580
BIQUIN DURULES
50
QUINIDINE SO4
200MG TABLET
00441740
APO-QUINIDINE
APX
$
0.1194
DOM
BRI
RPH
LIN
NXP
APX
GPM
PRM
NOP
RHO
PMS
$
0.4684 *
0.6437
0.6437
0.6437
0.6437
0.6437
0.6437
0.6437
0.6437
0.6437
0.6437
DOM
BRI
RPH
NXP
APX
LIN
GPM
PRM
NOP
RHO
PMS
$
0.5091 *
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
SOTALOL HCL
* 80MG TABLET
02238634
00897272
02084228
02170833
02200996
02210428
02229778
02230068
02231181
02234008
02238326
DOM-SOTALOL
SOTACOR
RATIO-SOTALOL
LINSOTALOL
NU-SOTALOL
APO-SOTALOL
GEN-SOTALOL
PREM-SOTOLOL
NOVO-SOTALOL
RHOXAL-SOTALOL
PMS-SOTALOL
* 160MG TABLET
02238635
00483923
02084236
02163772
02167794
02170841
02229779
02230069
02231182
02234013
02238327
DOM-SOTALOL
SOTACOR
RATIO-SOTALOL
NU-SOTALOL
APO-SOTALOL
LINSOTALOL
GEN-SOTALOL
PREM-SOTALOL
NOVO-SOTALOL
RHOXAL-SOTALOL
PMS-SOTALOL
TIMOLOL MALEATE
* 5MG TABLET
00755842
01947796
02044609
APO-TIMOL
NOVO-TIMOL
NU-TIMOLOL
* 10MG TABLET
00755850
01947818
02044617
APO-TIMOL
NOVO-TIMOL
NU-TIMOLOL
* 20MG TABLET
00755869
01947826
APO-TIMOL
NOVO-TIMOL
VERAPAMIL HCL
SEE SECTION 24:08.00 (HYPOTENSIVE DRUGS)
51
24:06.00 ANTILIPEMIC DRUGS
ATORVASTATIN CALCIUM
10MG TABLET
02230711
LIPITOR
PFI
$
1.8055
PFI
$
2.2568
PFI
$
2.4261
PFI
$
2.4261
PMS
$
0.9585
HLR
$
1.7360
BRI
NOP
PMS
$
0.6952
0.6952
0.6952
PMS
BRI
NOP
$
0.6952
0.6952
0.6952
PFI
$
0.9234
COLESTID
PFI
$
0.9234
COLESTID
PFI
$
0.2634
MSD
$
1.7143
20MG TABLET
02230713
LIPITOR
40MG TABLET
02230714
LIPITOR
80MG TABLET
02243097
LIPITOR
BEZAFIBRATE
200MG TABLET
02240331
PMS-BEZAFIBRATE (EDS)
02083523
BEZALIP SR (EDS)
CHOLESTYRAMINE RESIN
* 444MG/G ORAL POWDER (9G)
00464880
02139189
02210320
QUESTRAN
NOVO-CHOLAMINE
PMS-CHOLESTYRAMINE
* 800MG/G ORAL POWDER (5G)
00890960
01918486
02139197
PMS-CHOLESTYRAMINE LIGHT
QUESTRAN LIGHT
NOVO-CHOLAMINE LIGHT
COLESTIPOL HCL RESIN
5G GRANULES
00642975
COLESTID
7.5G GRANULES
02132699
1G TABLET
02132680
EZETIMIBE
10MG TABLET
02247521
EZETROL
52
FENOFIBRATE
* 200MG CAPSULE
02231780
02239864
02240210
02243552
02249715
02240337
02146959
PMS-FENOFIBR. MICRO
APO-FENO-MICRO
GEN-FENOFIBR. MICRO
NOVO-FENOFIB. MICRO
NU-FENO-MICRO
DOM-FENOFIBR. MICRO
LIPIDIL-MICRO
PMS
APX
GPM
NOP
NXP
DOM
FFR
$
1.1816
1.1816
1.1816
1.1816
1.1816
1.3785
1.8771
NVR
$
0.8341
NVR
$
1.1677
DOM
RPH
APX
NXP
GPM
PMS
NOP
PFI
$
0.2095 *
0.3216
0.3216
0.3216
0.3216
0.3216
0.3216
0.5590
DOM
RPH
APX
NXP
NOP
PMS
GPM
PFI
$
0.5313 *
0.8160
0.8160
0.8160
0.8160
0.8160
0.8160
1.1190
FLUVASTATIN SODIUM
20MG CAPSULE
02061562
LESCOL
40MG CAPSULE
02061570
LESCOL
GEMFIBROZIL
* 300MG CAPSULE
02241608
00851922
01979574
02058456
02185407
02239951
02241704
00599026
DOM-GEMFIBROZIL
RATIO-GEMFIBROZIL
APO-GEMFIBROZIL
NU-GEMFIBROZIL
GEN-GEMFIBROZIL
PMS-GEMFIBROZIL
NOVO-GEMFIBROZIL
LOPID
* 600MG TABLET
02230580
00851930
01979582
02058464
02142074
02230183
02230476
00659606
DOM-GEMFIBROZIL
RATIO-GEMFIBROZIL
APO-GEMFIBROZIL
NU-GEMFIBROZIL
NOVO-GEMFIBROZIL
PMS-GEMFIBROZIL
GEN-GEMFIBROZIL
LOPID
53
LOVASTATIN
* 20MG TABLET
02231434
02220172
02245822
02246013
02246542
02247056
02247536
02243127
02247231
00795860
NU-LOVASTATIN
APO-LOVASTATIN
RATIO-LOVASTATIN
PMS-LOVASTATIN
NOVO-LOVASTATIN
RHOXAL-LOVASTATIN
PREM-LOVASTATIN
GEN-LOVASTATIN
DOM-LOVASTATIN
MEVACOR
NXP
APX
RPH
PMS
NOP
RHO
PRM
GPM
DOM
MSD
$
0.8104 *
1.1834
1.1834
1.1834
1.1834
1.1834
1.1834
1.1834
1.2426
1.9538
APX
NXP
GPM
RPH
PMS
NOP
RHO
PRM
DOM
MSD
$
2.1828
2.1828
2.1828
2.1828
2.1828
2.1828
2.1828
2.1828
2.2920
3.6033
NXP
APX
RPH
NOP
PMS
RHO
COB
LIN
DOM
SQU
$
0.7879 *
1.0340
1.0340
1.0340
1.0340
1.0340
1.0340
1.0345
1.0862
1.6963
* 40MG TABLET
02220180
02231435
02243129
02245823
02246014
02246543
02247057
02247537
02247232
00795852
APO-LOVASTATIN
NU-LOVASTATIN
GEN-LOVASTATIN
RATIO-LOVASTATIN
PMS-LOVASTATIN
NOVO-LOVASTATIN
RHOXAL-LOVASTATIN
PREM-LOVASTATIN
DOM-LOVASTATIN
MEVACOR
PRAVASTATIN
* 10MG TABLET
02244350
02243506
02246930
02247008
02247655
02247856
02248182
02237373
02249723
00893749
NU-PRAVASTATIN
APO-PRAVASTATIN
RATIO-PRAVASTATIN
NOVO-PRAVASTATIN
PMS-PRAVASTATIN
RHOXAL-PRAVASTATIN
CO PRAVASTATIN
LIN-PRAVASTATIN
DOM-PRAVASTATIN
PRAVACHOL
54
* 20MG TABLET
02244351
02237374
02243507
02246931
02247009
02247656
02247857
02248183
02249731
00893757
NU-PRAVASTATIN
LIN-PRAVASTATIN
APO-PRAVASTATIN
RATIO-PRAVASTATIN
NOVO-PRAVASTATIN
PMS-PRAVASTATIN
RHOXAL-PRAVASTATIN
CO PRAVASTATIN
DOM-PRAVASTATIN
PRAVACHOL
NXP
LIN
APX
RPH
NOP
PMS
RHO
COB
DOM
SQU
$
0.9297 *
1.2200
1.2200
1.2200
1.2200
1.2200
1.2200
1.2200
1.2810
2.0008
NXP
RPH
NOP
PMS
RHO
COB
LIN
APX
DOM
SQU
$
1.1198 *
1.4695
1.4695
1.4695
1.4695
1.4695
1.4696
1.4696
1.5429
2.4098
AST
$
1.4756
AST
$
1.8445
AST
$
2.1592
NXP
GPM
APX
RPH
PRM
RHO
COB
NOP
MSD
$
0.4809 *
0.6152
0.6152
0.6152
0.6152
0.6152
0.6152
0.6152
1.0156
* 40MG TABLET
02244352
02246932
02247010
02247657
02247858
02248184
02237375
02243508
02249758
02222051
NU-PRAVASTATIN
RATIO-PRAVASTATIN
NOVO-PRAVASTATIN
PMS-PRAVASTATIN
RHOXAL-PRAVASTATIN
CO PRAVASTATIN
LIN-PRAVASTATIN
APO-PRAVASTATIN
DOM-PRAVASTATIN
PRAVACHOL
ROSUVASTATIN CALCIUM
10MG TABLET
02247162
CRESTOR
20MG TABLET
02247163
CRESTOR
40MG TABLET
02247164
CRESTOR
SIMVASTATIN
* 5MG TABLET
02247072
02246582
02247011
02247067
02247531
02247827
02248103
02250144
00884324
NU-SIMVASTATIN
GEN-SIMVASTATIN
APO-SIMVASTATIN
RATIO-SIMVASTATIN
PREM-SIMVASTATIN
RHOXAL-SIMVASTATIN
CO SIMVASTATIN
NOVO-SIMVASTATIN
ZOCOR
55
* 10MG TABLET
02247075
02246583
02247012
02247068
02247532
02247828
02248104
02250152
00884332
NU-SIMVASTATIN
GEN-SIMVASTATIN
APO-SIMVASTATIN
RATIO-SIMVASTATIN
PREM-SIMVASTATIN
RHOXAL-SIMVASTATIN
CO SIMVASTATIN
NOVO-SIMVASTATIN
ZOCOR
NXP
GPM
APX
RPH
PRM
RHO
COB
NOP
MSD
$
0.9510 *
1.2168
1.2168
1.2168
1.2168
1.2168
1.2168
1.2168
2.0088
NXP
GPM
APX
RPH
PRM
RHO
COB
NOP
MSD
$
1.1754 *
1.5039
1.5039
1.5039
1.5039
1.5039
1.5039
1.5039
2.4825
NXP
GPM
APX
RPH
PRM
RHO
COB
NOP
MSD
$
1.1754 *
1.5039
1.5039
1.5039
1.5039
1.5039
1.5039
1.5039
2.4825
NXP
GPM
APX
RPH
PRM
RHO
COB
NOP
MSD
$
1.1754 *
1.5039
1.5039
1.5039
1.5039
1.5039
1.5039
1.5039
2.4825
* 20MG TABLET
02247076
02246737
02247013
02247069
02247533
02247830
02248105
02250160
00884340
NU-SIMVASTATIN
GEN-SIMVASTATIN
APO-SIMVASTATIN
RATIO-SIMVASTATIN
PREM-SIMVASTATIN
RHOXAL-SIMVASTATIN
CO SIMVASTATIN
NOVO-SIMVASTATIN
ZOCOR
* 40MG TABLET
02247077
02246584
02247014
02247070
02247534
02247831
02248106
02250179
00884359
NU-SIMVASTATIN
GEN-SIMVASTATIN
APO-SIMVASTATIN
RATIO-SIMVASTATIN
PREM-SIMVASTATIN
RHOXAL-SIMVASTATIN
CO SIMVASTATIN
NOVO-SIMVASTATIN
ZOCOR
* 80MG TABLET
02247078
02246585
02247015
02247071
02247535
02247833
02248107
02250187
02240332
NU-SIMVASTATIN
GEN-SIMVASTATIN
APO-SIMVASTATIN
RATIO-SIMVASTATIN
PREM-SIMVASTATIN
RHOXAL-SIMVASTATIN
CO SIMVASTATIN
NOVO-SIMVASTATIN
ZOCOR
56
24:08.00 HYPOTENSIVE DRUGS
ANTIHYPERTENSIVE COMBINATION PRODUCTS:
FIXED COMBINATION DRUGS ARE NOT INDICATED FOR INITIAL THERAPY
OF HYPERTENSION. HYPERTENSION REQUIRES THERAPY TO BE TITRATED
TO THE INDIVIDUAL PATIENT. IF THE FIXED COMBINATION
REPRESENTS THE DOSAGE SO DETERMINED, ITS USE MAY BE MORE
CONVENIENT IN PATIENT MANAGEMENT. THE TREATMENT OF
HYPERTENSION IS NOT STATIC, BUT MUST BE RE-EVALUATED AS
CONDITIONS IN EACH PATIENT WARRANT.
ACEBUTOLOL HCL
AMILORIDE HCL/HYDROCHLOROTHIAZIDE
SEE NOTE REGARDING COMBINATION PRODUCTS UNDER
SECTION 24:08.00 (HYPOTENSIVE DRUGS)
* 5MG/50MG TABLET
00886106
00784400
01937219
00487813
NU-AMILZIDE
APO-AMILZIDE
NOVAMILOR
MODURET
NXP
APX
NOP
MSD
$
0.1667 *
0.2080
0.2080
0.3816
AST
$
0.6934
AST
$
1.1033
NVR
$
0.6445
NVR
$
0.7623
NVR
$
0.8743
ATENOLOL
ATENOLOL/CHLORTHALIDONE
50MG/25MG TABLET
02049961
TENORETIC
100MG/25MG TABLET
02049988
TENORETIC
BENAZEPRIL HCL
5MG TABLET
00885835
LOTENSIN
10MG TABLET
00885843
LOTENSIN
20MG TABLET
00885851
LOTENSIN
57
CANDESARTAN CILEXETIL
8MG TABLET
02239091
ATACAND
AST
$
1.2070
AST
$
1.2070
16MG TABLET
02239092
ATACAND
CANDESARTAN CILEXETIL/HYDROCHLOROTHIAZIDE
16MG/12.5MG TABLET
02244021
ATACAND PLUS
AST
$
1.2062
APX
$
0.1297
DOM
SQU
RPH
APX
NXP
NOP
GPM
PMS
ZYP
$
0.1740 *
0.2301
0.2301
0.2301
0.2301
0.2301
0.2301
0.2301
0.2301
DOM
SQU
RPH
APX
NXP
NOP
GPM
PMS
ZYP
$
0.2462 *
0.3255
0.3255
0.3255
0.3255
0.3255
0.3255
0.3255
0.3255
CAPTOPRIL
6.25MG TABLET
01999559
APO-CAPTO
* 12.5MG TABLET
02238551
00695661
00851639
00893595
01913824
01942964
02163551
02230203
02242788
DOM-CAPTOPRIL
CAPOTEN
RATIO-CAPTOPRIL
APO-CAPTO
NU-CAPTO
NOVO-CAPTORIL
GEN-CAPTOPRIL
PMS-CAPTOPRIL
CAPTOPRIL
* 25MG TABLET
02238552
00546283
00851833
00893609
01913832
01942972
02163578
02230204
02242789
DOM-CAPTOPRIL
CAPOTEN
RATIO-CAPTOPRIL
APO-CAPTO
NU-CAPTO
NOVO-CAPTORIL
GEN-CAPTOPRIL
PMS-CAPTOPRIL
CAPTOPRIL
58
* 50MG TABLET
02238553
00546291
00851647
00893617
01913840
01942980
02163586
02230205
02242790
DOM-CAPTOPRIL
CAPOTEN
RATIO-CAPTOPRIL
APO-CAPTO
NU-CAPTO
NOVO-CAPTORIL
GEN-CAPTOPRIL
PMS-CAPTOPRIL
CAPTOPRIL
DOM
SQU
RPH
APX
NXP
NOP
GPM
PMS
ZYP
$
0.4586 *
0.6066
0.6066
0.6066
0.6066
0.6066
0.6066
0.6066
0.6066
CAPOTEN
RATIO-CAPTOPRIL
APO-CAPTO
NU-CAPTO
NOVO-CAPTORIL
GEN-CAPTOPRIL
PMS-CAPTOPRIL
CAPTOPRIL
DOM-CAPTOPRIL
SQU
RPH
APX
NXP
NOP
GPM
PMS
ZYP
DOM
$
1.1279
1.1279
1.1279
1.1279
1.1279
1.1279
1.1279
1.1279
1.1843
INHIBACE
HLR
$
0.6626
INHIBACE
HLR
$
0.7637
INHIBACE
HLR
$
0.8872
HLR
$
0.8870
BOE
$
0.2791
* 100MG TABLET
00546305
00851655
00893625
01913859
01942999
02163594
02230206
02242791
02238554
CILAZAPRIL
1MG TABLET
01911465
2.5MG TABLET
01911473
5MG TABLET
01911481
CILAZAPRIL/HYDROCHLOROTHIAZIDE
5MG/12.5MG TABLET
02181479
INHIBACE PLUS
CLONIDINE HCL
0.025MG TABLET
00519251
DIXARIT (EDS)
59
* 0.1MG TABLET
00259527
00868949
01913786
02046121
02247607
CATAPRES
APO-CLONIDINE
NU-CLONIDINE
NOVO-CLONIDINE
DOM-CLONIDINE
BOE
APX
NXP
NOP
DOM
$
0.1915
0.1915
0.1915
0.1915
0.2011
BOE
APX
NXP
NOP
DOM
$
0.3417
0.3417
0.3417
0.3417
0.3587
* 0.2MG TABLET
00291889
00868957
01913220
02046148
02247608
CATAPRES
APO-CLONIDINE
NU-CLONIDINE
NOVO-CLONIDINE
DOM-CLONIDINE
DILTIAZEM HCL
NOTE: THE SUSTAINED RELEASE DOSAGE FORMS ARE APPROVED AS
ANTIHYPERTENSIVE AGENTS
(SEE SECTION 24:04.00)
DOXAZOSIN MESYLATE
* 1MG TABLET
02240498
02240588
02242728
02243215
02244527
01958100
GEN-DOXAZOSIN
APO-DOXAZOSIN
NOVO-DOXAZOSIN
RATIO-DOXAZOSIN
PMS-DOXAZOSIN
CARDURA-1
GPM
APX
NOP
RPH
PMS
AST
$
0.3760
0.3760
0.3760
0.3760
0.3760
0.6147
GEN-DOXAZOSIN
APO-DOXAZOSIN
NOVO-DOXAZOSIN
RATIO-DOXAZOSIN
PMS-DOXAZOSIN
CARDURA-2
GPM
APX
NOP
RPH
PMS
AST
$
0.4512
0.4512
0.4512
0.4512
0.4512
0.7373
GEN-DOXAZOSIN
APO-DOXAZOSIN
NOVO-DOXAZOSIN
RATIO-DOXAZOSIN
PMS-DOXAZOSIN
CARDURA-4
GPM
APX
NOP
RPH
PMS
AST
$
0.5865
0.5865
0.5865
0.5865
0.5865
0.9586
* 2MG TABLET
02240499
02240589
02242729
02243216
02244528
01958097
* 4MG TABLET
02240500
02240590
02242730
02243217
02244529
01958119
60
ENALAPRIL MALEATE
2.5MG TABLET
00851795
VASOTEC
MSD
$
0.7620
VASOTEC
MSD
$
0.9013
MSD
$
1.0833
MSD
$
1.3070
MSD
$
0.9013
MSD
$
1.0833
SLV
$
1.2298
SLV
$
1.1067
AVT
AST
$
0.5357
0.5520
AVT
AST
$
0.7161
0.7375
AVT
AST
$
1.0735
1.1064
LIN
NOP
BMY
$
0.6000
0.6000
0.8854
LIN
NOP
BMY
$
0.7216
0.7216
1.0649
5MG TABLET
00708879
10MG TABLET
00670901
VASOTEC
20MG TABLET
00670928
VASOTEC
ENALAPRIL MALEATE/HYDROCHLOROTHIAZIDE
5MG/12.5MG TABLET
02242826
VASERETIC
10MG/25MG TABLET
00657298
VASERETIC
EPROSARTAN MESYLATE
400MG TABLET
02240432
TEVETEN
600MG TABLET
02243942
TEVETEN
FELODIPINE
* 2.5MG SUSTAINED RELEASE TABLET
02221985
02057778
RENEDIL
PLENDIL
02221993
00851779
RENEDIL
PLENDIL
02222000
00851787
RENEDIL
PLENDIL
FOSINOPRIL
* 10MG TABLET
02242733
02247802
01907107
LIN-FOSINOPRIL
NOVO-FOSINOPRIL
MONOPRIL
* 20MG TABLET
02242734
02247803
01907115
LIN-FOSINOPRIL
NOVO-FOSINOPRIL
MONOPRIL
61
HYDRALAZINE HCL
* 10MG TABLET
00441619
00759465
01913204
APO-HYDRALAZINE
NOVO-HYLAZIN
NU-HYDRAL
APX
NOP
NXP
$
0.1001
0.1001
0.1001
APX
NOP
NXP
$
0.1784
0.1784
0.1784
APX
NOP
NXP
$
0.2742
0.2742
0.2742
BMY
$
1.1930
BMY
$
1.1930
BMY
$
1.1930
BMY
$
1.1930
BMY
$
1.1930
APX
RBP
$
0.1787
0.2553
APX
RBP
$
0.3161
0.4515
* 25MG TABLET
00441627
00759473
02004828
APO-HYDRALAZINE
NOVO-HYLAZIN
NU-HYDRAL
* 50MG TABLET
00441635
00759481
02004836
APO-HYDRALAZINE
NOVO-HYLAZIN
NU-HYDRAL
IRBESARTAN
75MG TABLET
02237923
AVAPRO
150MG TABLET
02237924
AVAPRO
300MG TABLET
02237925
AVAPRO
IRBESARTAN/HYDROCHLOROTHIAZIDE
150MG/12.5MG TABLET
02241818
AVALIDE
300MG/12.5MG TABLET
02241819
AVALIDE
LABETALOL HCL
* 100MG TABLET
02243538
02106272
APO-LABETALOL
TRANDATE
* 200MG TABLET
02243539
02106280
APO-LABETALOL
TRANDATE
62
LISINOPRIL
* 5MG TABLET
00839388
02217481
02049333
PRINIVIL
APO-LISINOPRIL
ZESTRIL
MSD
APX
AST
$
0.5845
0.6576
0.7530
MSD
APX
AST
$
0.7025
0.8246
0.9044
MSD
APX
AST
$
0.8442
0.9917
1.0868
MSD
AST
$
0.7025
0.9046
MSD
AST
$
0.8441
1.0869
MSD
AST
$
0.8441
1.0869
MSD
$
1.2420
MSD
$
1.2420
MSD
$
1.2420
MSD
$
1.2420
MSD
$
1.2420
* 10MG TABLET
00839396
02217503
02049376
PRINIVIL
APO-LISINOPRIL
ZESTRIL
* 20MG TABLET
00839418
02217511
02049384
PRINIVIL
APO-LISINOPRIL
ZESTRIL
LISINOPRIL/HYDROCHLOROTHIAZIDE
* 10MG/12.5MG TABLET
02108194
02103729
PRINZIDE
ZESTORETIC
* 20MG/12.5MG TABLET
00884413
02045737
PRINZIDE
ZESTORETIC
* 20MG/25MG TABLET
00884421
02045729
PRINZIDE
ZESTORETIC
LOSARTAN POTASSIUM
25MG TABLET
02182815
COZAAR
50MG TABLET
02182874
COZAAR
100MG TABLET
02182882
COZAAR
LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE
50MG/12.5MG TABLET
02230047
HYZAAR
100MG/25MG TABLET
02241007
HYZAAR DS
63
METHYLDOPA
125MG TABLET
00360252
APO-METHYLDOPA
APX
$
0.0641
APX
$
0.1519
APX
$
0.2306
APX
$
0.1823
APX
$
0.1991
PFI
$
0.3568
PFI
$
0.7867
NVR
$
0.2804
NVR
$
0.4249
NVR
$
0.4248
NVR
$
0.8496
250MG TABLET
00360260
APO-METHYLDOPA
500MG TABLET
00426830
APO-METHYLDOPA
METHYLDOPA/HYDROCHLOROTHIAZIDE
250MG/15MG TABLET
00441708
APO-METHAZIDE-15
250MG/25MG TABLET
00441716
APO-METHAZIDE-25
METOPROLOL TARTRATE
MINOXIDIL
2.5MG TABLET
00514497
LONITEN (EDS)
10MG TABLET
00514500
LONITEN (EDS)
NADOLOL
NIFEDIPINE
OXPRENOLOL HCL
40MG TABLET
00402575
TRASICOR
80MG TABLET
00402583
TRASICOR
80MG SLOW RELEASE TABLET
00534579
SLOW TRASICOR
160MG SLOW RELEASE TABLET
00534587
SLOW TRASICOR
64
PERINDOPRIL ERBUMINE
2MG TABLET
02123274
COVERSYL
SEV
$
0.6510
COVERSYL
SEV
$
0.8138
COVERSYL
SEV
$
1.1393
SEV
$
1.0199
NVR
$
0.7513
VISKAZIDE
NVR
$
0.7513
APO-PRAZO
NU-PRAZO
NOVO-PRAZIN
MINIPRESS
APX
NXP
NOP
PFI
$
0.1683
0.1683
0.1683
0.3079
APO-PRAZO
NU-PRAZO
NOVO-PRAZIN
MINIPRESS
APX
NXP
NOP
PFI
$
0.2275
0.2275
0.2275
0.4182
APO-PRAZO
NU-PRAZO
NOVO-PRAZIN
MINIPRESS
APX
NXP
NOP
PFI
$
0.3284
0.3284
0.3284
0.5749
4MG TABLET
02123282
8MG TABLET
02246624
PERINDOPRIL ERBUMINE/INDAPAMIDE
4MG/1.25MG TABLET
02246569
COVERSYL PLUS
PINDOLOL
PINDOLOL/HYDROCHLOROTHIAZIDE
10MG/25MG TABLET
00568627
VISKAZIDE
10MG/50MG TABLET
00568635
PRAZOSIN
* 1MG TABLET
00882801
01913794
01934198
00560952
* 2MG TABLET
00882828
01913808
01934201
00560960
* 5MG TABLET
00882836
01913816
01934228
00560979
PROPRANOLOL
65
QUINAPRIL HCL
5MG TABLET
01947664
ACCUPRIL
PFI
$
0.9271
PFI
$
0.9271
PFI
$
0.9271
PFI
$
0.9271
PFI
$
0.9270
PFI
$
0.9270
PFI
$
0.8914
AVT
$
0.7053
AVT
$
0.8138
AVT
$
0.8138
AVT
$
1.0308
NOP
PFI
$
0.0932
0.0970
NOP
PFI
$
0.2426
0.2523
BOE
$
1.1610
BOE
$
1.1610
10MG TABLET
01947672
ACCUPRIL
20MG TABLET
01947680
ACCUPRIL
40MG TABLET
01947699
ACCUPRIL
QUINAPRIL HCL/HYDROCHLOROTHIAZIDE
10MG/12.5MG TABLET
02237367
ACCURETIC
20MG/12.5MG TABLET
02237368
ACCURETIC
20MG/25MG TABLET
02237369
ACCURETIC
RAMIPRIL
1.25MG CAPSULE
02221829
ALTACE
2.5MG CAPSULE
02221837
ALTACE
5MG CAPSULE
02221845
ALTACE
10MG CAPSULE
02221853
ALTACE
SPIRONOLACTONE/HYDROCHLOROTHIAZIDE
* 25MG/25MG TABLET
00613231
00180408
NOVO-SPIROZINE
ALDACTAZIDE-25
* 50MG/50MG TABLET
00657182
00594377
NOVO-SPIROZINE
ALDACTAZIDE-50
TELMISARTAN
40MG TABLET
02240769
MICARDIS
80MG TABLET
02240770
MICARDIS
66
TELMISARTAN/HYDROCHLOROTHIAZIDE
80MG/12.5MG TABLET
02244344
MICARDIS PLUS
BOE
$
1.1610
DOM-TERAZOSIN
RATIO-TERAZOSIN
NOVO-TERAZOSIN
NU-TERAZOSIN
APO-TERAZOSIN
PMS-TERAZOSIN
HYTRIN
DOM
RPH
NOP
NXP
APX
PMS
ABB
$
0.2764 *
0.3787
0.3787
0.3787
0.3787
0.3787
0.6432
DOM-TERAZOSIN
RATIO-TERAZOSIN
NOVO-TERAZOSIN
NU-TERAZOSIN
APO-TERAZOSIN
PMS-TERAZOSIN
HYTRIN
DOM
RPH
NOP
NXP
APX
PMS
ABB
$
0.3513 *
0.4813
0.4813
0.4813
0.4813
0.4813
0.8176
DOM-TERAZOSIN
RATIO-TERAZOSIN
NOVO-TERAZOSIN
NU-TERAZOSIN
APO-TERAZOSIN
PMS-TERAZOSIN
HYTRIN
DOM
RPH
NOP
NXP
APX
PMS
ABB
$
0.4771 *
0.6538
0.6538
0.6538
0.6538
0.6538
1.1103
RPH
NOP
NXP
APX
PMS
DOM
ABB
$
0.9570
0.9570
0.9570
0.9570
0.9570
1.0049
1.6254
ABB
$
24.0900
TERAZOSIN HCL
* 1MG TABLET
02243746
02218941
02230805
02233047
02234502
02243518
00818658
* 2MG TABLET
02243747
02218968
02230806
02233048
02234503
02243519
00818682
* 5MG TABLET
02243748
02218976
02230807
02233049
02234504
02243520
00818666
* 10MG TABLET
02218984
02230808
02233050
02234505
02243521
02243749
00818674
RATIO-TERAZOSIN
NOVO-TERAZOSIN
NU-TERAZOSIN
APO-TERAZOSIN
PMS-TERAZOSIN
DOM-TERAZOSIN
HYTRIN
1MG TABLET (7) 2MG TABLET (7) 5MG TABLET (14 )
(PACKAGE)
02187876
HYTRIN STARTER PACK
TIMOLOL MALEATE
67
TRANDOLAPRIL
0.5MG CAPSULE
02231457
MAVIK
ABB
$
0.6727
ABB
$
0.7270
ABB
$
0.8355
ABB
$
1.0308
NXP
APX
NOP
$
0.0416 *
0.0518
0.0518
NVR
$
1.1393
NVR
$
1.1393
NVR
$
1.1393
NVR
$
1.1393
NVR
$
1.1393
NVR
$
1.1393
NVR
$
1.1393
1MG CAPSULE
02231459
MAVIK
2MG CAPSULE
02231460
MAVIK
4MG CAPSULE
02239267
MAVIK
TRIAMTERENE/HYDROCHLOROTHIAZIDE
* 50MG/25MG TABLET
00865532
00441775
00532657
NU-TRIAZIDE
APO-TRIAZIDE
NOVO-TRIAMZIDE
VALSARTAN
80MG CAPSULE
02236808
DIOVAN
80MG TABLET
02244781
DIOVAN
160MG CAPSULE
02236809
DIOVAN
160MG TABLET
02244782
DIOVAN
VALSARTAN/HYDROCHLOROTHIAZIDE
80MG/12.5MG TABLET
02241900
DIOVAN-HCT
160MG/12.5MG TABLET
02241901
DIOVAN-HCT
160MG/25MG TABLET
02246955
DIOVAN-HCT
68
VERAPAMIL HCL
* 80MG TABLET
00886033
00782483
02237921
NU-VERAP
APO-VERAP
GEN-VERAPAMIL
NXP
APX
GPM
$
0.2378 *
0.2968
0.2968
APX
NXP
GPM
ABB
$
0.4612
0.4612
0.4612
0.4728
GPM
APX
ABB
$
0.7487
0.7487
1.1811
PFI
$
0.8802
GPM
APX
ABB
$
0.7116
0.7116
1.3338
PFI
$
0.9840
NXP
GPM
NOP
PMS
APX
DOM
ABB
$
0.7211 *
0.9462
0.9462
0.9462
0.9462
0.9935
1.7787
* 120MG TABLET
00782491
00886041
02237922
00554324
APO-VERAP
NU-VERAP
GEN-VERAPAMIL
ISOPTIN
02210347
02246893
01907123
GEN-VERAPAMIL SR
APO-VERAP SR
ISOPTIN SR
180MG CONTROLLED-ONSET EXTENDED-RELEASE
TABLET
02231676
CHRONOVERA
02210355
02246894
01934317
GEN-VERAPAMIL SR
APO-VERAP SR
ISOPTIN SR
240MG CONTROLLED-ONSET EXTENDED-RELEASE
TABLET
02231677
CHRONOVERA
02249812
02210363
02211920
02237791
02246895
02240321
00742554
NU-VERAP SR
GEN-VERAPAMIL SR
NOVO-VERAMIL SR
PMS-VERAPAMIL SR
APO-VERAP SR
DOM-VERAPAMIL SR
ISOPTIN SR
69
24:12.00 VASODILATING DRUGS
BETAHISTINE DIHYDROCHLORIDE
8MG TABLET
02240601
SERC
SLV
$
0.2546
SLV
$
0.4557
SLV
$
0.6836
BOE
$
0.4008
BOE
$
0.5398
BOE
$
0.8930
APX
NOP
$
0.0174
0.0174
APX
NOP
$
0.0375
0.0375
APX
$
0.0651
AST
$
0.7154
BAY
$
6.0303
16MG TABLET
02243878
SERC
24MG TABLET
02247998
SERC
DIPYRIDAMOLE
50MG TABLET
00067393
PERSANTINE (EDS)
75MG TABLET
00452092
PERSANTINE (EDS)
DIPYRIDAMOLE/ACETYLSALICYLIC ACID
200MG/25MG CAPSULE
02242119
AGGRENOX (EDS)
ISOSORBIDE DINITRATE
* 10MG TABLET
00441686
00458686
APO-ISDN
NOVO-SORBIDE
* 30MG TABLET
00441694
00458694
APO-ISDN
NOVO-SORBIDE
5MG SUBLINGUAL TABLET
00670944
APO-ISDN
ISOSORBIDE-5 MONONITRATE
02126559
IMDUR
NIMODIPINE
30MG CAPSULE
02155923
NIMOTOP (EDS)
70
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).
⌧
0.2MG/HR. TRANSDERMAL THERAPEUTIC SYSTEM
00584223
01911910
02162806
02230732
⌧
NVR
KEY
MDA
SAW
$
0.6150
0.6150
0.6150
0.6150
$
0.6944
0.6944
0.6944
0.6944
KEY
NVR
MDA
SAW
$
0.6944
0.6944
0.6944
0.6944
KEY
$
1.2044
PFI
$
0.0302
PFI
$
0.0314
PAL
$
0.3662
ROP
GPM
AVT
$
9.1800
9.1800
13.1200
00852384
01911902
02163527
02230733
⌧
TRANSDERM-NITRO 0.2
NITRO-DUR 0.2
MINITRAN 0.2
TRINIPATCH 0.2
TRANSDERM-NITRO 0.4
NITRO-DUR 0.4
MINITRAN 0.4
TRINIPATCH 0.4
NVR
KEY
MDA
SAW
01911929
02046156
02163535
02230734
NITRO-DUR 0.6
TRANSDERM-NITRO 0.6
MINITRAN 0.6
TRINIPATCH 0.6
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)
02238998
02243588
02231441
RHO-NITRO PUMPSPRAY
GEN-NITRO SL SPRAY
NITROLINGUAL PUMPSPRAY
71
CENTRAL NERVOUS SYSTEM AGENTS
28:00
28:00 CENTRAL NERVOUS SYSTEM AGENTS
28:08.04 NON-STEROIDAL ANTI-INFLAMMATORY AGENTS
ACETYLSALICYLIC ACID
* 325MG ENTERIC TABLET
02046253
00216666
00010332
ASADOL
NOVASEN
ENTROPHEN
PNG
NOP
PNG
$
0.0136
0.0160
0.0546
PNG
NOP
PNG
$
0.0241
0.0382
0.0936
PFI
$
0.7053
PFI
$
1.4105
NOP
APX
NXP
PMS
DOM
$
0.2064
0.2064
0.2064
0.2064
0.2167
NXP
NOP
APX
PMS
DOM
NVR
$
0.3339 *
0.4272
0.4272
0.4272
0.4486
0.7155
NXP
NOP
APX
PMS
DOM
NVR
$
0.4839 *
0.6191
0.6191
0.6191
0.6501
1.0055
02046261
00229296
00010340
ASADOL
NOVASEN
ENTROPHEN
CELECOXIB
100MG CAPSULE
02239941
CELEBREX (EDS)
200MG CAPSULE
02239942
CELEBREX (EDS)
DICLOFENAC SODIUM
00808539
00839175
00886017
02231502
02231662
NOVO-DIFENAC
APO-DICLO
NU-DICLO
PMS-DICLOFENAC
DOM-DICLOFENAC
00886025
00808547
00839183
02231503
02231663
00514012
NU-DICLO
NOVO-DIFENAC
APO-DICLO
PMS-DICLOFENAC
DOM-DICLOFENAC
VOLTAREN
02228203
02158582
02162814
02231504
02231664
00782459
NU-DICLO-SR
NOVO-DIFENAC SR
APO-DICLO SR
PMS-DICLOFENAC-SR
DOM-DICLOFENAC SR
VOLTAREN-SR
74
02228211
02048698
02091194
02231505
02231665
00590827
NU-DICLO-SR
NOVO-DIFENAC SR
APO-DICLO SR
PMS-DICLOFENAC-SR
DOM-DICLOFENAC SR
VOLTAREN-SR
NXP
NOP
APX
PMS
DOM
NVR
$
0.6677 *
0.8544
0.8544
0.8544
0.8971
1.4332
NOP
PMS
SAB
NVR
$
0.6768
0.6768
0.6768
1.0742
NOP
PMS
SAB
NVR
$
0.9111
0.9111
0.9111
1.4463
PFI
$
0.6252
PFI
$
0.8509
APX
NOP
$
0.4595
0.4595
APX
NOP
NXP
$
0.5621
0.5621
0.5621
APX
$
0.6510
APX
PGA
$
0.6510
0.8680
* 50MG SUPPOSITORY
02174677
02231506
02241224
00632724
NOVO-DIFENAC
PMS-DICLOFENAC
SAB-DICLOFENAC
VOLTAREN
* 100MG SUPPOSITORY
02174685
02231508
02241225
00632732
NOVO-DIFENAC
PMS-DICLOFENAC
SAB-DICLOFENAC
VOLTAREN
DICLOFENAC SODIUM/MISOPROSTOL
50MG/200UG ENTERIC TABLET
01917056
ARTHROTEC
75MG/200UG ENTERIC TABLET
02229837
ARTHROTEC 75
DIFLUNISAL
* 250MG TABLET
02039486
02048493
APO-DIFLUNISAL
NOVO-DIFLUNISAL
* 500MG TABLET
02039494
02048507
02058413
APO-DIFLUNISAL
NOVO-DIFLUNISAL
NU-DIFLUNISAL
ETODOLAC
200MG CAPSULE
02232317
APO-ETODOLAC (EDS)
* 300MG CAPSULE
02232318
02142031
APO-ETODOLAC (EDS)
ULTRADOL (EDS)
75
FLURBIPROFEN
* 50MG TABLET
01912046
02020661
02100509
00647942
APO-FLURBIPROFEN
NU-FLURBIPROFEN
NOVO-FLURPROFEN
ANSAID
APX
NXP
NOP
PFI
$
0.2782
0.2782
0.2782
0.5560
RPH
APX
NXP
NOP
PFI
$
0.3807
0.3807
0.3807
0.3807
0.7279
APX
NXP
MCL
$
0.0608
0.0608
0.1326
APX
NXP
MCL
$
0.1096
0.1096
0.1723
APX
NOP
NXP
$
0.0505
0.0505
0.0505
NOP
APX
NXP
RPH
$
0.0945
0.0945
0.0945
0.0945
NOP
APX
NXP
RPH
$
0.1640
0.1640
0.1640
0.1640
* 100MG TABLET
00675199
01912038
02020688
02100517
00600792
RATIO-FLURBIPROFEN
APO-FLURBIPROFEN
NU-FLURBIPROFEN
NOVO-FLURPROFEN
ANSAID
IBUPROFEN
* 300MG TABLET
00441651
02020696
00327794
APO-IBUPROFEN
NU-IBUPROFEN
MOTRIN
* 400MG TABLET
00506052
02020718
00364142
APO-IBUPROFEN
NU-IBUPROFEN
MOTRIN
* 600MG TABLET
00585114
00629359
02020726
APO-IBUPROFEN
NOVO-PROFEN
NU-IBUPROFEN
INDOMETHACIN
* 25MG CAPSULE
00337420
00611158
00865850
02143364
NOVO-METHACIN
APO-INDOMETHACIN
NU-INDO
RATIO-INDOMETHACIN
* 50MG CAPSULE
00337439
00611166
00865869
02143372
NOVO-METHACIN
APO-INDOMETHACIN
NU-INDO
RATIO-INDOMETHACIN
76
* 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
$
0.1804
0.1804
ROP
PMS
$
0.1804
0.1804
ROP
PMS
$
0.3340
0.3340
APX
$
0.6680
PMS
$
0.8536
PMS
NOP
$
1.0774
1.0774
APX
NXP
PMS
DOM
$
0.3590
0.3590
0.3590
0.3769
* 100MG SUPPOSITORY
02146940
02176149
02231800
00016233
RHODACINE
NOVO-METHACIN
SAB-INDOMETHACIN
INDOCID
KETOPROFEN
* 50MG CAPSULE
00790427
02150808
APO-KETO
PMS-KETOPROFEN
* 50MG ENTERIC COATED TABLET
00761672
02150816
RHODIS EC
PMS-KETOPROFEN-EC
00761680
02150824
RHODIS EC
PMS-KETOPROFEN-EC
02172577
APO-KETOPROFEN SR
50MG SUPPOSITORY
02148773
PMS-KETOPROFEN
* 100MG SUPPOSITORY
02015951
02156083
PMS-KETOPROFEN
NOVO-KETO
MEFENAMIC ACID
* 250MG CAPSULE
02229452
02229569
02231208
02237826
APO-MEFENAMIC
NU-MEFENAMIC
PMS-MEFENAMIC ACID
DOM-MEFENAMIC ACID
77
MELOXICAM
* 7.5MG TABLET
02247889
02248267
02248973
02248605
02242785
RATIO-MELOXICAM (EDS)
PMS-MELOXICAM (EDS)
APO-MELOXICAM (EDS)
DOM-MELOXICAM (EDS)
MOBICOX (EDS)
RPH
PMS
APX
DOM
BOE
$
0.5925
0.5925
0.5925
0.6221
0.8463
RPH
PMS
APX
DOM
BOE
$
0.6836
0.6836
0.6836
0.7178
0.9765
APX
NOP
RHO
GPM
GSK
$
0.5453
0.5453
0.5453
0.5453
0.7488
NOP
GSK
$
0.7406
1.0170
APX
NXP
$
0.0590
0.0590
NXP
APX
NOP
RPH
$
0.0929 *
0.1159
0.1159
0.1159
NXP
APX
NOP
$
0.1268 *
0.1582
0.1582
* 15MG TABLET
02248031
02248268
02248974
02248606
02242786
PMS-MELOXICAM (EDS)
APO-MELOXICAM (EDS)
DOM-MELOXICAM (EDS)
MOBICOX (EDS)
NABUMETONE
* 500MG TABLET
02238639
02240867
02242912
02244563
02083531
APO-NABUMETONE (EDS)
NOVO-NABUMETONE (EDS)
RHOXAL-NABUMETONE (EDS)
GEN-NABUMETONE (EDS)
RELAFEN (EDS)
* 750MG TABLET
02240868
02083558
RELAFEN (EDS)
NAPROXEN
* 125MG TABLET
00522678
00865621
APO-NAPROXEN
NU-NAPROX
* 250MG TABLET
00865648
00522651
00565350
00615315
NU-NAPROX
APO-NAPROXEN
NOVO-NAPROX
RATIO-NAPROXEN
* 375MG TABLET
00865656
00600806
00627097
NU-NAPROX
APO-NAPROXEN
NOVO-NAPROX
78
* 500MG TABLET
00865664
00589861
00592277
NU-NAPROX
NOVO-NAPROX
APO-NAPROXEN
NXP
NOP
APX
$
0.1834 *
0.2290
0.2290
APX
NOP
HLR
$
0.8251
0.8251
1.3778
SAB
PMS
$
0.8601
0.8604
HLR
$
0.0654
APX
$
0.0814
APX
NOP
PMS
NXP
GPM
$
0.4500
0.4500
0.4500
0.4500
0.4500
APX
NOP
PMS
NXP
GPM
$
0.7767
0.7767
0.7767
0.7767
0.7767
PMS
$
0.8040
PMS
$
1.7860
MSD
$
1.3563
MSD
$
1.3563
MSD
$
0.2713
02177072
02231327
02162466
APO-NAPROXEN SR
NOVO-NAPROX SR
NAPROSYN-S.R.
* 500MG SUPPOSITORY
02230477
02017237
SAB-NAPROXEN
PMS-NAPROXEN
25MG/ML SUSPENSION
02162431
NAPROSYN
PHENYLBUTAZONE
100MG TABLET
00312789
APO-PHENYLBUTAZONE
PIROXICAM
* 10MG CAPSULE
00642886
00695718
00836249
00865761
02171813
APO-PIROXICAM
NOVO-PIROCAM
PMS-PIROXICAM
NU-PIROX
GEN-PIROXICAM
* 20MG CAPSULE
00642894
00695696
00836230
00865788
02171821
APO-PIROXICAM
NOVO-PIROCAM
PMS-PIROXICAM
NU-PIROX
GEN-PIROXICAM
10MG SUPPOSITORY
02154420
PMS-PIROXICAM
20MG SUPPOSITORY
02154463
PMS-PIROXICAM
ROFECOXIB
12.5MG TABLET
02241107
VIOXX (EDS)
25MG TABLET
02241108
VIOXX (EDS)
2.5MG/ML ORAL SUSPENSION
02241109
VIOXX (EDS)
79
SULINDAC
* 150MG TABLET
00745588
00778354
02042576
NOVO-SUNDAC
APO-SULIN
NU-SULINDAC
NOP
APX
NXP
$
0.4149
0.4149
0.4149
NOP
APX
NXP
$
0.5252
0.5252
0.5252
APX
NOP
PMS
$
0.3730
0.3730
0.3730
APX
NXP
NOP
PMS
DOM
AVT
$
0.4453
0.4453
0.4453
0.4453
0.5008
0.7069
PFI
$
1.3563
PFI
$
1.3563
* 200MG TABLET
00745596
00778362
02042584
NOVO-SUNDAC
APO-SULIN
NU-SULINDAC
TIAPROFENIC ACID
* 200MG TABLET
02136112
02179679
02230827
APO-TIAPROFENIC
NOVO-TIAPROFENIC
PMS-TIAPROFENIC
* 300MG TABLET
02136120
02146886
02179687
02230828
02231060
02221950
APO-TIAPROFENIC
NU-TIAPROFENIC
NOVO-TIAPROFENIC
PMS-TIAPROFENIC
DOM-TIAPROFENIC
SURGAM
VALDECOXIB
10MG TABLET
02246621
BEXTRA (EDS)
20MG TABLET
02246622
BEXTRA (EDS)
80
28:08.08 OPIATE AGONISTS (NARCOTIC ANALGESICS)
ACETAMINOPHEN/CAFFEINE/CODEINE
* 300MG ACETAMINOPHEN & 15MG CODEINE/TABLET
00653241
02163934
RATIO-LENOLTEC NO.2
TYLENOL WITH CODEINE NO.2
RPH
JAN
$
0.0646
0.0672
$
0.0597
$
0.0711
0.0740
0.1730
HOR
$
0.0651
RPH
$
0.1411
RPH
JAN
$
0.1502
0.1562
JAN
$
0.0868
PNG
$
0.1845
PFR
$
0.3051
PFR
$
0.6102
PFR
$
0.9223
PFR
$
1.2207
RPH
$
0.0832
RPH
$
0.1080
RPH
$
0.0266
325MG ACETAMINOPHEN & 15MG CODEINE/TABLET
00293504
ATASOL-15
HOR
* 300MG ACETAMINOPHEN & 30MG CODEINE/TABLET
00653276
02163926
02232389
RATIO-LENOLTEC NO.3
EXDOL-30
RPH
JAN
PNG
325MG ACETAMINOPHEN & 30MG CODEINE/TABLET
00293512
ATASOL-30
ACETAMINOPHEN/CODEINE
300MG/30MG TABLET
00608882
RATIO-EMTEC
* 300MG/60MG TABLET
00621463
02163918
RATIO-LENOLTEC #4
32MG/1.6MG/ML ELIXIR
02163942
TYLENOL WITH CODEINE ELX
ACETYLSALICYLIC ACID/CAFFEINE/CODEINE
375MG/30MG/30MG TABLET
02238645
292
CODEINE
02230302
CODEINE CONTIN (EDS)
02163748
02163780
02163799
CODEINE PHOSPHATE
15MG TABLET
00593435
RATIO-CODEINE
30MG TABLET
00593451
RATIO-CODEINE
5MG/ML SYRUP
00779474
RATIO-CODEINE
81
FENTANYL
25UG/HR TRANSDERMAL SYSTEM
01937383
DURAGESIC (EDS)
JAN
$
9.5914
JAN
$
18.0544
JAN
$
25.3890
JAN
$
31.5952
DILAUDID
PMS-HYDROMORPHONE
ABB
PMS
$
0.1041
0.1041
DILAUDID
PMS-HYDROMORPHONE
ABB
PMS
$
0.1538
0.1538
DILAUDID
PMS-HYDROMORPHONE
ABB
PMS
$
0.2431
0.2431
DILAUDID
PMS-HYDROMORPHONE
ABB
PMS
$
0.3828
0.3828
PFR
$
0.6510
PFR
$
0.9765
PFR
$
1.6926
PFR
$
2.4413
PFR
$
3.1248
PFR
$
3.7433
ABB
PMS
$
0.0860
0.0860
ABB
SAB
$
1.2400
1.2400
01937391
DURAGESIC (EDS)
01937405
DURAGESIC (EDS)
01937413
DURAGESIC (EDS)
HYDROMORPHONE HCL
* 1MG TABLET
00705438
00885444
* 2MG TABLET
00125083
00885436
* 4MG TABLET
00125121
00885401
* 8MG TABLET
00786543
00885428
3MG CONTROLLED-RELEASE CAPSULE
02125323
HYDROMORPH CONTIN
6MG CONTROLLED RELEASE CAPSULE
02125331
HYDROMORPH CONTIN
02125366
HYDROMORPH CONTIN
02243562
HYDROMORPH CONTIN
02125382
HYDROMORPH CONTIN
02125390
HYDROMORPH CONTIN
00786535
01916386
DILAUDID
PMS-HYDROMORPHONE
00627100
02145901
DILAUDID
HYDROMORPHONE HCL
82
00622133
02145928
DILAUDID-HP
HYDROMORPHONE HP 10
ABB
SAB
$
3.0300
3.0300
SAB
ABB
$
4.8200
4.8200
ABB
SAB
$
10.8000
10.8000
ABB
$
76.1100
ABB
$
2.3979
SAW
$
0.1285
SAB
ABB
ABB
$
0.7600
0.8300
0.8300
SAB
ABB
ABB
$
0.8000
0.8700
0.8700
02145936
02146118
HYDROMORPHONE HP 20
DILAUDID HP-PLUS
02145863
02146126
DILAUDID-XP
HYDROMORPHONE HP 50
250MG STERILE POWDER
02085895
DILAUDID
3MG SUPPOSITORY
00125105
DILAUDID
MEPERIDINE HCL
50MG TABLET
02138018
DEMEROL
00725765
00497452
02242003
MEPERIDINE HYDROCHLORIDE
PETHIDINE
DEMEROL
00725749
00497479
02242005
PETHIDINE
DEMEROL
METHADONE HCL
COVERAGE RESTRICTED TO DRUG PLAN REGISTERED PALLIATIVE CARE
PATIENTS ONLY. EDS IS NOT REQUIRED FOR THESE PATIENTS.
1MG TABLET
02247698
METADOL (PALL CARE)
PMS
$
0.1628
METADOL (PALL CARE)
PMS
$
0.5425
PMS
$
0.8680
PMS
$
1.6275
PMS
$
0.0912
5MG TABLET
02247699
10MG TABLET
02247700
METADOL (PALL CARE)
25MG TABLET
02247701
METADOL (PALL CARE)
02247694
METADOL (PALL CARE)
83
MORPHINE
ORAL FORMS CONTAIN MORPHINE HYDROCHLORIDE OR SULFATE,
INJECTABLE FORMS CONTAIN MORPHINE SULFATE.
* 5MG TABLET
00594652
02009773
02014203
STATEX
MOS-SULFATE
MSIR
PAL
ICN
PFR
$
0.1194
0.1194
0.1224
PAL
ICN
ICN
PFR
$
0.1845
0.1845
0.1845
0.1901
PFR
ICN
$
0.3357
0.3519
PAL
ICN
$
0.2442
0.2442
PFR
$
0.4310
ICN
$
0.4573
PAL
ICN
$
0.3744
0.3744
ICN
$
0.6349
AVT
$
0.3147
AVT
$
0.3852
RPH
PMS
PFR
$
0.4070
0.4071
0.6621
ABB
$
0.8173
AVT
$
0.5859
RPH
PMS
PFR
$
0.6146
0.6146
0.9998
* 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
02177749
M-ESLON
02244790
02245284
02015439
RATIO-MORPHINE SR
PMS-MORPHINE SULFATE SR
MS CONTIN
20MG SUSTAINED-RELEASE CAPSULE
02184435
KADIAN
02019949
M-ESLON
02244791
02245285
02014297
RATIO-MORPHINE SR
MS CONTIN
84
30MG SUSTAINED-RELEASE TABLET
00776181
M.O.S.-S.R.
ICN
$
0.5953
ABB
$
1.4940
AVT
$
1.0286
RPH
PMS
PFR
$
1.0833
1.0833
1.7625
ICN
$
1.0447
ABB
$
2.6218
AVT
$
2.0724
PFR
$
2.6874
AVT
$
4.1447
PFR
$
4.9958
ICN
PAL
RPH
$
0.0217
0.0217
0.0217
PAL
RPH
ICN
$
0.0873
0.0873
0.0914
ICN
RPH
$
0.1995
0.1995
PAL
RPH
ICN
$
0.5404
0.5404
0.5686
SAB
ABB
$
0.6000
0.6600
SAB
ABB
$
0.6100
0.6700
02184443
KADIAN
02019957
M-ESLON
02244792
02245286
02014300
RATIO-MORPHINE SR
MS CONTIN
60MG SUSTAINED-RELEASE TABLET
00776203
M.O.S.-S.R.
02184451
KADIAN
02019965
M-ESLON
02014319
MS CONTIN
02177757
M-ESLON
02014327
MS CONTIN
* 1MG/ML ORAL SOLUTION
00486582
00591467
00607762
M.O.S.
STATEX
RATIO-MORPHINE
00591475
00607770
00514217
STATEX
RATIO-MORPHINE
M.O.S.
00632503
00690783
M.O.S.
RATIO-MORPHINE
00621935
00690791
00632481
STATEX
RATIO-MORPHINE
M.O.S.
00392588
00850322
MORPHINE SO4
MORPHINE SO4
00392561
00850330
MORPHINE SO4
MORPHINE SO4
85
00617288
MORPHINE HP 50
SAB
$
3.4900
ABB
$
96.5700
PAL
$
1.8109
PAL
$
2.0225
PAL
$
2.4077
PAL
$
2.6409
PFR
$
0.2626
PFR
$
0.3872
PFR
$
0.6719
PFR
$
0.8680
PFR
$
1.3020
PFR
$
2.2568
PFR
$
4.1664
50MG/ML INJECTION SOLUTION (50ML SYRINGE)
02137267
MORPHINE SULPHATE
5MG SUPPOSITORY
00632228
STATEX
10MG SUPPOSITORY
00632201
STATEX
20MG SUPPOSITORY
00596965
STATEX
30MG SUPPOSITORY
00639389
STATEX
OXYCODONE HCL
5MG IMMEDIATE RELEASE TABLET
02231934
OXY-IR
02240131
OXY-IR
02240132
OXY-IR
02202441
OXYCONTIN
02202468
OXYCONTIN
02202476
OXYCONTIN
02202484
OXYCONTIN
PROPOXYPHENE
SEVERE TOXIC INTERACTION BETWEEN PROPOXYPHENE AND CENTRAL
NERVOUS SYSTEM DEPRESSANTS, PARTICULARLY ALCOHOL AND DIAZEPAM,
HAS BEEN NOTED. IT IS RECOMMENDED THAT ALL PRODUCTS WHICH
CONTAIN PROPOXYPHENE SHOULD BE USED ONLY WITH EXTREME CAUTION
AND WITH FULL PATIENT AWARENESS OF THE SERIOUS POTENTIAL FOR
INTERACTION.
PROPOXYPHENE NAPSYLATE 100MG IS EQUIVALENT IN ANALGESIC
ACTIVITY TO PROPOXYPHENE HCL 65MG.
65MG TABLET
00010081
642
PNG
$
0.1155
LIL
$
0.2332
100MG CAPSULE
00261432
DARVON-N
86
28:08.12 OPIATE PARTIAL AGONISTS
PENTAZOCINE
50MG TABLET
02137984
TALWIN
SAW
$
0.3708
28:08.92 MISCELLANEOUS ANALGESICS AND ANTIPYRETICS
FLOCTAFENINE
* 200MG TABLET
02244680
02017628
APO-FLOCTAFENINE
IDARAC
APX
SAW
$
0.2757
0.3939
APX
SAW
$
0.4802
0.6859
PMS
$
0.0651
PMS
$
0.0775
PMS
$
0.1050
PMS
$
0.1437
PMS
$
0.0868
APX
$
0.0516
APX
DPY
$
0.0814
0.1222
* 400MG TABLET
02244681
02017636
APO-FLOCTAFENINE
IDARAC
28:12.04 ANTICONVULSANTS (BARBITURATES)
PHENOBARBITAL
15MG TABLET
00178799
PMS-PHENOBARBITAL
30MG TABLET
00178802
PMS-PHENOBARBITAL
60MG TABLET
00178810
PMS-PHENOBARBITAL
100MG TABLET
00178829
PMS-PHENOBARBITAL
5MG/ML ELIXIR
00645575
PMS-PHENOBARBITAL
PRIMIDONE
125MG TABLET
00399310
APO-PRIMIDONE
* 250MG TABLET
00396761
02042355
APO-PRIMIDONE
MYSOLINE
87
28:12.08 ANTICONVULSANTS (BENZODIAZEPINES)
CLONAZEPAM
* 0.5MG TABLET
02130998
02224100
02103656
02173344
02177889
02207818
02230366
02230950
02233960
02239024
00382825
DOM-CLONAZEPAM
DOM-CLONAZEPAM-R
RATIO-CLONAZEPAM
NU-CLONAZEPAM
APO-CLONAZEPAM
PMS-CLONAZEPAM-R
CLONAPAM
GEN-CLONAZEPAM
RHOXAL-CLONAZEPAM
NOVO-CLONAZEPAM
RIVOTRIL
DOM
DOM
RPH
NXP
APX
PMS
ICN
GPM
RHO
NOP
HLR
$
0.0865 *
0.0865 *
0.1266
0.1266
0.1266
0.1266
0.1266
0.1266
0.1266
0.1266
0.2109
PMS-CLONAZEPAM
CLONAPAM
RHOXAL-CLONAZEPAM
PMS
ICN
RHO
$
0.2019
0.2019
0.2019
DOM-CLONAZEPAM
PMS-CLONAZEPAM
RATIO-CLONAZEPAM
NU-CLONAZEPAM
APO-CLONAZEPAM
CLONAPAM
GEN-CLONAZEPAM
RHOXAL-CLONAZEPAM
NOVO-CLONAZEPAM
RIVOTRIL
DOM
PMS
RPH
NXP
APX
ICN
GPM
RHO
NOP
HLR
$
0.1364 *
0.2181
0.2181
0.2181
0.2181
0.2181
0.2181
0.2181
0.2181
0.3635
ICN
RHO
APX
ICN
$
0.0930
0.0930
0.0930
0.1550
ICN
RHO
APX
ICN
$
0.1391
0.1391
0.1391
0.2319
* 1MG TABLET
02048728
02230368
02233982
* 2MG TABLET
02131013
02048736
02103737
02173352
02177897
02230369
02230951
02233985
02239025
00382841
NITRAZEPAM
* 5MG TABLET
02229654
02234003
02245230
00511528
NITRAZADON
RHOXAL-NITRAZEPAM
APO-NITRAZEPAM
MOGADON
* 10MG TABLET
02229655
02234007
02245231
00511536
NITRAZADON
RHOXAL-NITRAZEPAM
APO-NITRAZEPAM
MOGADON
88
28:12.12 ANTICONVULSANTS (HYDANTOINS)
PHENYTOIN
30MG CAPSULE
00022772
DILANTIN
PFI
$
0.0561
PFI
$
0.0701
PFI
$
0.0770
PFI
$
0.0425
PFI
$
0.0502
PFI
$
0.3173
PFI
$
0.0635
PFI
$
0.3509
$
0.0929
0.0929
0.1327
100MG CAPSULE
00022780
DILANTIN
50MG TABLET
00023698
DILANTIN
00023442
DILANTIN
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
* 100MG CHEWABLE TABLET
02231542
02244403
00369810
PMS-CARBAMAZEPINE CHEWTAB
TARO-CARBAMAZEPINE
TEGRETOL
89
PMS
TAR
NVR
* 200MG TABLET
00402699
00782718
02042568
00010405
APO-CARBAMAZEPINE
NOVO-CARBAMAZ
NU-CARBAMAZEPINE
TEGRETOL
APX
NOP
NXP
NVR
$
0.0863
0.0863
0.0863
0.3164
PMS
TAR
GPM
APX
DOM
NVR
$
0.2048
0.2048
0.2048
0.2048
0.2560
0.3251
PMS
GPM
APX
TAR
DOM
NVR
$
0.4095
0.4095
0.4095
0.4096
0.5121
0.6502
NVR
$
0.0628
DOM
APX
NOP
RPH
PMS
AVT
$
0.1961 *
0.2337
0.2337
0.2337
0.2337
0.3708
NXP
APX
NOP
PMS
DOM
ABB
$
0.1197 *
0.1494
0.1494
0.1494
0.1744
0.2538
* 200MG CONTROLLED RELEASE TABLET
02231543
02237907
02241882
02242908
02238222
00773611
PMS-CARBAMAZEPINE CR(EDS)
TARO-CARBAMAZEPINE (EDS)
GEN-CARBAMAZEPINE CR(EDS)
APO-CARBAMAZEPINE CR(EDS)
DOM-CARBAMAZEPINE CR(EDS)
TEGRETOL CR (EDS)
* 400MG CONTROLLED RELEASE TABLET
02231544
02241883
02242909
02237908
02238223
00755583
TEGRETOL CR (EDS)
02194333
TEGRETOL
CLOBAZAM
* 10MG TABLET
02247230
02244638
02238334
02238797
02244474
02221799
DOM-CLOBAZAM
APO-CLOBAZAM
NOVO-CLOBAZAM
RATIO-CLOBAZAM
PMS-CLOBAZAM
FRISIUM
DIVALPROEX SODIUM
02239517
02239698
02239701
02244138
02245751
00596418
NU-DIVALPROEX
APO-DIVALPROEX
NOVO-DIVALPROEX
PMS-DIVALPROEX
DOM-DIVALPROEX
EPIVAL
90
02239518
02239699
02239702
02244139
02245752
00596426
NU-DIVALPROEX
APO-DIVALPROEX
NOVO-DIVALPROEX
PMS-DIVALPROEX
DOM-DIVALPROEX
EPIVAL
NXP
APX
NOP
PMS
DOM
ABB
$
0.2152 *
0.2686
0.2686
0.2686
0.3134
0.4561
NXP
APX
NOP
PMS
DOM
ABB
$
0.4305 *
0.5373
0.5373
0.5373
0.6270
0.9126
DOM
PMS
APX
NOP
NXP
GPM
PRM
PFI
$
0.2111 *
0.2735
0.2735
0.2735
0.2735
0.2735
0.2735
0.4514
DOM
PMS
APX
NOP
NXP
GPM
PRM
PFI
$
0.5004 *
0.6651
0.6651
0.6651
0.6651
0.6651
0.6651
1.0980
DOM
PMS
APX
NOP
NXP
GPM
PRM
PFI
$
0.6118 *
0.7926
0.7926
0.7926
0.7926
0.7926
0.7926
1.3084
02239519
02239700
02239703
02244140
02245753
00596434
NU-DIVALPROEX
APO-DIVALPROEX
NOVO-DIVALPROEX
PMS-DIVALPROEX
DOM-DIVALPROEX
EPIVAL
GABAPENTIN
* 100MG CAPSULE
02243743
02243446
02244304
02244513
02246742
02248259
02249367
02084260
DOM-GABAPENTIN
PMS-GABAPENTIN
APO-GABAPENTIN
NOVO-GABAPENTIN
NU-GABAPENTIN
GEN-GABAPENTIN
PREM-GABAPENTIN
NEURONTIN
* 300MG CAPSULE
02243744
02243447
02244305
02244514
02246743
02248260
02249375
02084279
DOM-GABAPENTIN
PMS-GABAPENTIN
APO-GABAPENTIN
NOVO-GABAPENTIN
NU-GABAPENTIN
GEN-GABAPENTIN
PREM-GABAPENTIN
NEURONTIN
* 400MG CAPSULE
02243745
02243448
02244306
02244515
02246744
02248261
02249383
02084287
DOM-GABAPENTIN
PMS-GABAPENTIN
APO-GABAPENTIN
NOVO-GABAPENTIN
NU-GABAPENTIN
GEN-GABAPENTIN
PREM-GABAPENTIN
NEURONTIN
91
LAMOTRIGINE
5MG CHEWABLE TABLET
02240115
LAMICTAL
GSK
$
0.1620
RPH
APX
PMS
NOP
GSK
$
0.2266
0.2266
0.2266
0.2266
0.3759
RPH
APX
PMS
NOP
GSK
$
0.9064
0.9064
0.9064
0.9064
1.5037
APX
PMS
NOP
RPH
GSK
$
1.3597
1.3597
1.3597
1.3597
2.2552
LUD
$
1.6167
LUD
$
1.9747
LUD
$
2.8102
NVR
$
0.8138
NVR
$
1.6275
NVR
$
3.2550
NVR
$
0.3255
* 25MG TABLET
02243352
02245208
02246897
02248232
02142082
RATIO-LAMOTRIGINE
APO-LAMOTRIGINE
PMS-LAMOTRIGINE
NOVO-LAMOTRIGINE
LAMICTAL
* 100MG TABLET
02243353
02245209
02246898
02248233
02142104
RATIO-LAMOTRIGINE
APO-LAMOTRIGINE
PMS-LAMOTRIGINE
NOVO-LAMOTRIGINE
LAMICTAL
* 150MG TABLET
02245210
02246899
02248234
02246963
02142112
APO-LAMOTRIGINE
PMS-LAMOTRIGINE
NOVO-LAMOTRIGINE
RATIO-LAMOTRIGINE
LAMICTAL
LEVETIRACETAM
250MG TABLET
02247027
KEPPRA
500MG TABLET
02247028
KEPPRA
750MG TABLET
02247029
KEPPRA
OXCARBAZEPINE
150MG TABLET
02242067
TRILEPTAL (EDS)
300MG TABLET
02242068
TRILEPTAL (EDS)
600MG TABLET
02242069
TRILEPTAL (EDS)
02244673
TRILEPTAL (EDS)
92
TOPIRAMATE
25MG TABLET
02230893
TOPAMAX
JAN
$
1.1849
JAN
$
2.2437
JAN
$
3.5545
JAN
$
1.1284
JAN
$
1.1849
RPH
PMS
APX
DOM
ABB
$
0.0626
0.0626
0.0628
0.0658
0.1065
NOP
RPH
GPM
PMS
NXP
APX
RHO
DOM
ABB
$
0.2804
0.2804
0.2804
0.2804
0.2804
0.2804
0.2804
0.2944
0.4789
RPH
NOP
PMS
RHO
ABB
$
0.5639
0.5639
0.5639
0.5639
0.9577
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
02140063
02236807
02238370
02238817
00443832
RATIO-VALPROIC
PMS-VALPROIC ACID
APO-VALPROIC
DOM-VALPROIC ACID
DEPAKENE
VALPROIC ACID
* 250MG CAPSULE
02100630
02140047
02184648
02230768
02237830
02238048
02239714
02231030
00443840
NOVO-VALPROIC
RATIO-VALPROIC
GEN-VALPROIC
PMS-VALPROIC
NU-VALPROIC
APO-VALPROIC
RHOXAL-VALPROIC
DOM-VALPROIC ACID
DEPAKENE
* 500MG ENTERIC COATED CAPSULE
02140055
02218321
02229628
02239713
00507989
RATIO-VALPROIC
NOVO-VALPROIC
PMS-VALPROIC ACID E.C.
RHOXAL-VALPROIC
DEPAKENE
VIGABATRIN
500MG TABLET
02065819
SABRIL
500MG SACHET
02068036
SABRIL
93
28:16.04 PSYCHOTHERAPEUTIC AGENTS (ANTIDEPRESSANTS)
PHENELZINE AND TRANYLCYPROMINE:
MONOAMINE OXIDASE INHIBITORS INTERACT WITH SYMPATHOMIMETIC
DRUGS, FOODS AND ALCOHOLIC BEVERAGES CONTAINING TYRAMINE OR
OTHER PRESSOR AMINES (EG. CHEESE, HERRING, CHICKEN LIVERS,
BROAD BEANS, CHIANTI WINE, ETC.) AND MAY EVOKE HYPERTENSION.
THESE DRUGS ARE CONTRAINDICATED IN PATIENTS WITH
CEREBROVASCULAR AND CARDIOVASCULAR DISEASE. THE MANUFACTURERS'
LITERATURE REGARDING PRECAUTIONS AND CONTRAINDICATIONS
SHOULD BE CONSULTED PRIOR TO PRESCRIBING THESE DRUGS.
AMITRIPTYLINE
* 10MG TABLET
00335053
02248131
APO-AMITRIPTYLINE
DOM-AMITRIPTYLINE
APX
DOM
$
0.0565
0.0594
APX
DOM
$
0.1080
0.1134
APX
DOM
$
0.2008
0.2109
BVL
$
0.5990
BVL
$
0.8984
DOM
APX
GPM
PMS
COB
RHO
NXP
NOP
LUD
$
0.6661 *
0.9494
0.9494
0.9494
0.9494
0.9494
0.9494
0.9494
1.3563
* 25MG TABLET
00335061
02248132
APO-AMITRIPTYLINE
DOM-AMITRIPTYLINE
* 50MG TABLET
00335088
02248133
APO-AMITRIPTYLINE
DOM-AMITRIPTYLINE
BUPROPION HCL
100MG TABLET
02237824
WELLBUTRIN SR (EDS)
150MG TABLET
02237825
WELLBUTRIN SR (EDS)
CITALOPRAM HYDROBROMIDE
* 20MG TABLET
02248942
02246056
02246594
02248010
02248050
02248170
02248996
02251558
02239607
DOM-CITALOPRAM
APO-CITALOPRAM
GEN-CITALOPRAM
PMS-CITALOPRAM
CO CITALOPRAM
RHOXAL-CITALOPRAM
NU-CITALOPRAM
NOVO-CITALOPRAM
CELEXA
94
* 40MG TABLET
02248943
02246057
02246595
02248011
02248051
02248171
02248997
02251566
02239608
DOM-CITALOPRAM
APO-CITALOPRAM
GEN-CITALOPRAM
PMS-CITALOPRAM
CO CITALOPRAM
RHOXAL-CITALOPRAM
NU-CITALOPRAM
NOVO-CITALOPRAM
CELEXA
DOM
APX
GPM
PMS
COB
RHO
NXP
NOP
LUD
$
0.6661 *
0.9494
0.9494
0.9494
0.9494
0.9494
0.9494
0.9494
1.3563
APX
GPM
COB
ORX
$
0.1765
0.1765
0.1765
0.2801
APX
GPM
COB
ORX
$
0.2404
0.2404
0.2404
0.3815
APX
GPM
COB
ORX
$
0.4425
0.4425
0.4425
0.7025
PMS
NXP
APX
DOM
$
0.2067
0.2067
0.2067
0.2170
DOM
PMS
RPH
NXP
APX
AVT
$
0.2136 *
0.2761
0.2761
0.2761
0.2761
0.3752
CLOMIPRAMINE HCL
* 10MG TABLET
02040786
02139340
02244816
00330566
APO-CLOMIPRAMINE
GEN-CLOMIPRAMINE
CO-CLOMIPRAMINE
ANAFRANIL
* 25MG TABLET
02040778
02139359
02244817
00324019
APO-CLOMIPRAMINE
GEN-CLOMIPRAMINE
CO-CLOMIPRAMINE
ANAFRANIL
* 50MG TABLET
02040751
02139367
02244818
00402591
APO-CLOMIPRAMINE
GEN-CLOMIPRAMINE
CO-CLOMIPRAMINE
ANAFRANIL
DESIPRAMINE HCL
* 10MG TABLET
01946250
02211939
02216248
02130084
PMS-DESIPRAMINE
NU-DESIPRAMINE
APO-DESIPRAMINE
DOM-DESIPRAMINE
* 25MG TABLET
02130092
01946269
01948784
02211947
02216256
02099128
DOM-DESIPRAMINE
PMS-DESIPRAMINE
RATIO-DESIPRAMINE
NU-DESIPRAMINE
APO-DESIPRAMINE
NORPRAMIN
95
* 50MG TABLET
02130106
01946277
01948792
02211955
02216264
02099136
DOM-DESIPRAMINE
PMS-DESIPRAMINE
RATIO-DESIPRAMINE
NU-DESIPRAMINE
APO-DESIPRAMINE
NORPRAMIN
DOM
PMS
RPH
NXP
APX
AVT
$
0.3451 *
0.4460
0.4460
0.4460
0.4460
0.6615
PMS
NXP
APX
$
0.6873
0.6873
0.6873
NXP
APX
$
0.9342
0.9342
APX
PFI
$
0.1286
0.2691
NOP
APX
PFI
$
0.1552
0.1552
0.3301
NOP
APX
RPH
PFI
$
0.2418
0.2418
0.2418
0.6124
NOP
APX
PFI
$
0.5180
0.5180
0.8792
NOP
APX
PFI
$
0.6803
0.6803
1.1583
NOP
APX
$
1.0280
1.0280
* 75MG TABLET
01946242
02211963
02216272
PMS-DESIPRAMINE
NU-DESIPRAMINE
APO-DESIPRAMINE
* 100MG TABLET
02211971
02216280
NU-DESIPRAMINE
APO-DESIPRAMINE
DOXEPIN HCL
* 10MG CAPSULE
02049996
00024325
APO-DOXEPIN
SINEQUAN
* 25MG CAPSULE
01913425
02050005
00024333
NOVO-DOXEPIN
APO-DOXEPIN
SINEQUAN
* 50MG CAPSULE
01913433
02050013
02140101
00024341
NOVO-DOXEPIN
APO-DOXEPIN
RATIO-DOXEPIN
SINEQUAN
* 75MG CAPSULE
01913441
02050021
00400750
NOVO-DOXEPIN
APO-DOXEPIN
SINEQUAN
* 100MG CAPSULE
01913468
02050048
00326925
NOVO-DOXEPIN
APO-DOXEPIN
SINEQUAN
* 150MG CAPSULE
01913476
02050056
NOVO-DOXEPIN
APO-DOXEPIN
96
FLUOXETINE
* 10MG CAPSULE
02177617
02177579
02192756
02216353
02216582
02237813
02241371
02242177
02243486
02247528
02018985
DOM-FLUOXETINE
PMS-FLUOXETINE
NU-FLUOXETINE
APO-FLUOXETINE
NOVO-FLUOXETINE
GEN-FLUOXETINE
RATIO-FLUOXETINE
CO FLUOXETINE
RHOXAL-FLUOXETINE
PREM-FLUOXETINE
PROZAC
DOM
PMS
NXP
APX
NOP
GPM
RPH
COB
RHO
PRM
LIL
$
1.0234 *
1.2774
1.2774
1.2774
1.2774
1.2774
1.2774
1.2774
1.2774
1.2774
1.7989
DOM
PMS
NXP
APX
NOP
GPM
RPH
COB
RHO
PRM
LIL
$
0.6299 *
1.0972
1.0972
1.0972
1.0972
1.0972
1.0972
1.0972
1.0972
1.0972
1.8390
PMS
APX
LIL
$
0.5019
0.5019
0.6692
NXP
RPH
APX
NOP
PMS
RHO
DOM
SLV
$
0.4305 *
0.5373
0.5373
0.5373
0.5373
0.5373
0.5641
0.8529
* 20MG CAPSULE
02177625
02177587
02192764
02216361
02216590
02237814
02241374
02242178
02243487
02247529
00636622
DOM-FLUOXETINE
PMS-FLUOXETINE
NU-FLUOXETINE
APO-FLUOXETINE
NOVO-FLUOXETINE
GEN-FLUOXETINE
RATIO-FLUOXETINE
CO FLUOXETINE
RHOXAL-FLUOXETINE
PREM-FLUOXETINE
PROZAC
02177595
02231328
01917021
PMS-FLUOXETINE
APO-FLUOXETINE
PROZAC
FLUVOXAMINE MALEATE
* 50MG TABLET
02231192
02218453
02231329
02239953
02240682
02247054
02241347
01919342
NU-FLUVOXAMINE
RATIO-FLUVOXAMINE
APO-FLUVOXAMINE
NOVO-FLUVOXAMINE
PMS-FLUVOXAMINE
RHOXAL-FLUVOXAMINE
DOM-FLUVOXAMINE
LUVOX
97
* 100MG TABLET
02231193
02218461
02231330
02239954
02240683
02247055
02241348
01919369
NU-FLUVOXAMINE
RATIO-FLUVOXAMINE
APO-FLUVOXAMINE
NOVO-FLUVOXAMINE
PMS-FLUVOXAMINE
RHOXAL-FLUVOXAMINE
DOM-FLUVOXAMINE
LUVOX
NXP
RPH
APX
NOP
PMS
RHO
DOM
SLV
$
0.7738 *
0.9659
0.9659
0.9659
0.9659
0.9659
1.0142
1.5331
APX
$
0.1126
APX
NVR
$
0.1791
0.2485
APX
NVR
$
0.3326
0.4619
NOP
$
0.5960
NOP
$
1.1285
NOP
$
1.5412
RHO
$
0.4709
RHO
PMS
ORG
$
0.9418
1.0764
1.3454
APX
NXP
NOP
$
0.2735
0.2735
0.2735
IMIPRAMINE
10MG TABLET
00360201
APO-IMIPRAMINE
* 25MG TABLET
00312797
00010472
APO-IMIPRAMINE
TOFRANIL
* 50MG TABLET
00326852
00010480
APO-IMIPRAMINE
TOFRANIL
MAPROTILINE
25MG TABLET
02158612
NOVO-MAPROTILINE
50MG TABLET
02158620
NOVO-MAPROTILINE
75MG TABLET
02158639
NOVO-MAPROTILINE
MIRTAZAPINE
15MG TABLET
02250594
RHOXAL-MIRTAZAPINE
* 30MG TABLET
02250608
02248762
02243910
RHOXAL-MIRTAZAPINE
PMS-MIRTAZAPINE
REMERON
MOCLOBEMIDE
* 100MG TABLET
02232148
02237111
02239746
APO-MOCLOBEMIDE
NU-MOCLOBEMIDE
NOVO-MOCLOBEMIDE
98
* 150MG TABLET
02237112
02218410
02232150
02239747
02243218
02243348
00899356
NU-MOCLOBEMIDE
RATIO-MOCLOBEMIDE
APO-MOCLOBEMIDE
NOVO-MOCLOBEMIDE
PMS-MOCLOBEMIDE
DOM-MOCLOBEMIDE
MANERIX
NXP
RPH
APX
NOP
PMS
DOM
HLR
$
0.2916 *
0.3965
0.3965
0.3965
0.3965
0.4164
0.6444
NOP
APX
PMS
DOM
HLR
$
0.7786
0.7786
0.7786
0.9084
1.2655
DOM
PMS
NXP
APX
GPM
NOP
RPH
PML
$
0.0939 *
0.1368
0.1368
0.1368
0.1368
0.1368
0.1368
0.2170
DOM
NOP
PMS
NXP
APX
GPM
RPH
PML
$
0.1896 *
0.2764
0.2764
0.2764
0.2764
0.2764
0.2764
0.4387
PMS
NXP
$
1.1317
1.1317
DOM
APX
PMS
GPM
NOP
NXP
RPH
GSK
$
0.7530 *
1.2076
1.2076
1.2076
1.2076
1.2076
1.2076
1.8036
* 300MG TABLET
02239748
02240456
02243219
02243349
02166747
NOVO-MOCLOBEMIDE
APO-MOCLOBEMIDE
PMS-MOCLOBEMIDE
DOM-MOCLOBEMIDE
MANERIX
NORTRIPTYLINE
* 10MG CAPSULE
02178729
02177692
02223139
02223511
02231686
02231781
02240789
00015229
DOM-NORTRIPTYLINE
PMS-NORTRIPTYLINE
NU-NORTRIPTYLINE
APO-NORTRIPTYLINE
GEN-NORTRIPTYLINE
NOVO-NORTRIPTYLINE
RATIO-NORTRIPTYLINE
AVENTYL
* 25MG CAPSULE
02178737
02231782
02177706
02223147
02223538
02231687
02240790
00015237
DOM-NORTRIPTYLINE
NOVO-NORTRIPTYLINE
PMS-NORTRIPTYLINE
NU-NORTRIPTYLINE
APO-NORTRIPTYLINE
GEN-NORTRIPTYLINE
RATIO-NORTRIPTYLINE
AVENTYL
PAROXETINE HCL
* 10MG TABLET
02247750
02248719
PMS-PAROXETINE
NU-PAROXETINE
* 20MG TABLET
02248448
02240908
02247751
02248013
02248557
02248720
02247811
01940481
DOM-PAROXETINE
APO-PAROXETINE
PMS-PAROXETINE
GEN-PAROXETINE
NOVO-PAROXETINE
NU-PAROXETINE
RATIO-PAROXETINE
PAXIL
99
* 30MG TABLET
02248449
02240909
02247752
02247812
02248014
02248558
02248721
01940473
DOM-PAROXETINE
APO-PAROXETINE
PMS-PAROXETINE
RATIO-PAROXETINE
GEN-PAROXETINE
NOVO-PAROXETINE
NU-PAROXETINE
PAXIL
DOM
APX
PMS
RPH
GPM
NOP
NXP
GSK
$
0.7973 *
1.2836
1.2836
1.2836
1.2836
1.2836
1.2836
1.9166
PFI
$
0.3778
NXP
APX
NOP
GPM
PMS
RHO
RPH
DOM
PFI
$
0.3745 *
0.5469
0.5469
0.5469
0.5469
0.5469
0.5469
0.5742
0.8698
NXP
APX
NOP
GPM
PMS
RHO
RPH
DOM
PFI
$
0.7490 *
1.0937
1.0937
1.0937
1.0937
1.0937
1.0937
1.1484
1.7395
NXP
APX
NOP
GPM
PMS
RHO
RPH
DOM
PFI
$
0.8193 *
1.1963
1.1963
1.1963
1.1963
1.1963
1.1963
1.2560
1.8228
PHENELZINE SO4
SEE NOTE REGARDING MONOAMINE OXIDASE INHIBITORS
UNDER SECTION 28:16.04
15MG TABLET
00476552
NARDIL
SERTRALINE HYDROCHLORIDE
* 25MG CAPSULE
02247047
02238280
02240485
02242519
02244838
02245159
02245787
02245748
02132702
NU-SERTRALINE
APO-SERTRALINE
NOVO-SERTRALINE
GEN-SERTRALINE
PMS-SERTRALINE
RHOXAL-SERTRALINE
RATIO-SERTRALINE
DOM-SERTRALINE
ZOLOFT
* 50MG CAPSULE
02247048
02238281
02240484
02242520
02244839
02245160
02245788
02245749
01962817
NU-SERTRALINE
APO-SERTRALINE
NOVO-SERTRALINE
GEN-SERTRALINE
PMS-SERTRALINE
RHOXAL-SERTRALINE
RATIO-SERTRALINE
DOM-SERTRALINE
ZOLOFT
* 100MG CAPSULE
02247050
02238282
02240481
02242521
02244840
02245161
02245789
02245750
01962779
NU-SERTRALINE
APO-SERTRALINE
NOVO-SERTRALINE
GEN-SERTRALINE
PMS-SERTRALINE
RHOXAL-SERTRALINE
RATIO-SERTRALINE
DOM-SERTRALINE
ZOLOFT
100
TRANYLCYPROMINE SO4
SEE NOTE REGARDING MONOAMINE OXIDASE INHIBITORS
UNDER SECTION 28:16.04
10MG TABLET
01919598
PARNATE
GSK
$
0.3734
DOM
BRI
PMS
RPH
NOP
APX
NXP
ICN
GPM
$
0.1732 *
0.2403
0.2403
0.2403
0.2403
0.2403
0.2403
0.2403
0.2403
DOM
BRI
PMS
RPH
NOP
APX
NXP
ICN
GPM
$
0.3096 *
0.4293
0.4293
0.4293
0.4293
0.4293
0.4293
0.4293
0.4293
APX
AVT
$
0.5639
0.8354
APX
ROP
NXP
AVT
$
0.0890
0.0890
0.0890
0.2462
APX
ROP
NXP
$
0.1129
0.1129
0.1129
APX
ROP
NXP
$
0.2169
0.2169
0.2169
TRAZODONE
* 50MG TABLET
02128950
00579351
01937227
02053187
02144263
02147637
02165384
02230284
02231683
DOM-TRAZODONE
DESYREL
PMS-TRAZODONE
RATIO-TRAZODONE
NOVO-TRAZODONE
APO-TRAZODONE
NU-TRAZODONE
TRAZOREL
GEN-TRAZODONE
* 100MG TABLET
02128969
00579378
01937235
02053195
02144271
02147645
02165392
02230285
02231684
DOM-TRAZODONE
DESYREL
PMS-TRAZODONE
RATIO-TRAZODONE
NOVO-TRAZODONE
APO-TRAZODONE
NU-TRAZODONE
TRAZOREL
GEN-TRAZODONE
TRIMIPRAMINE
* 75MG CAPSULE
02070987
01926349
APO-TRIMIP
SURMONTIL
* 12.5MG TABLET
00740799
00761605
02020599
01926357
APO-TRIMIP
RHOTRIMINE
NU-TRIMIPRAMINE
SURMONTIL
* 25MG TABLET
00740802
00761613
02020602
APO-TRIMIP
RHOTRIMINE
NU-TRIMIPRAMINE
* 50MG TABLET
00740810
00761621
02020610
APO-TRIMIP
RHOTRIMINE
NU-TRIMIPRAMINE
101
* 100MG TABLET
00740829
00761648
02020629
APO-TRIMIP
RHOTRIMINE
NU-TRIMIPRAMINE
APX
ROP
NXP
$
0.3709
0.3709
0.3709
WYA
$
0.8463
WYA
$
1.6926
WYA
$
0.8789
WYA
$
1.7577
WYA
$
1.8559
NOP
$
0.1818
NOP
$
0.2078
NOP
$
0.3472
ROP
$
0.0376
RPH
ROP
$
0.2932
0.2932
SAB
$
1.0600
NVR
$
1.0221
NVR
$
4.0780
LUD
$
73.1900
LUD
$
73.1900
VENLAFAXINE HCL
37.5MG TABLET
02103680
EFFEXOR
75MG TABLET
02103702
EFFEXOR
37.5MG EXTENDED-RELEASE CAPSULE
02237279
EFFEXOR XR
02237280
EFFEXOR XR
02237282
EFFEXOR XR
28:16.08 PSYCHOTHERAPEUTIC AGENTS
(ANTIPSYCHOTIC AGENTS)
CHLORPROMAZINE
25MG TABLET
00232823
NOVO-CHLORPROMAZINE
50MG TABLET
00232807
NOVO-CHLORPROMAZINE
100MG TABLET
00232831
NOVO-CHLORPROMAZINE
01929976
LARGACTIL
00690805
01929992
RATIO-CHLORPROMANYL-40
LARGACTIL
00743518
CHLORPROMAZINE
CLOZAPINE
25MG TABLET
00894737
CLOZARIL (EDS)
100MG TABLET
00894745
CLOZARIL (EDS)
02156032
FLUANXOL DEPOT
02156040
FLUANXOL DEPOT
102
FLUPENTHIXOL DIHYDROCHLORIDE
0.5MG TABLET
02156008
FLUANXOL
LUD
$
0.2528
FLUANXOL
LUD
$
0.5461
SQU
PMS
APX
$
25.1300
25.1300
25.1300
SQU
PMS
$
32.3200
32.3200
APO-FLUPHENAZINE
APX
$
0.1823
APO-FLUPHENAZINE
APX
$
0.2214
APO-FLUPHENAZINE
APX
$
0.2735
NOVO-PERIDOL
APO-HALOPERIDOL
RATIO-HALOPERIDOL
NOP
APX
RPH
$
0.0391
0.0391
0.0391
NOVO-PERIDOL
APO-HALOPERIDOL
RATIO-HALOPERIDOL
NOP
APX
RPH
$
0.0667
0.0667
0.0667
NOVO-PERIDOL
APO-HALOPERIDOL
NOP
APX
$
0.1140
0.1140
NOVO-PERIDOL
APO-HALOPERIDOL
NOP
APX
$
0.1614
0.1614
3MG TABLET
02156016
FLUPHENAZINE DECANOATE
00349917
02091275
02244166
MODECATE
PMS-FLUPHENAZINE DECAN.
APO-FLUPHENAZINE
00755575
02241928
MODECATE CONCENTRATE
FLUPHENAZINE HCL
1MG TABLET
00405345
2MG TABLET
00410632
5MG TABLET
00405361
HALOPERIDOL
* 0.5MG TABLET
00363685
00396796
00552135
* 1MG TABLET
00363677
00396818
00552143
* 2MG TABLET
00363669
00396826
* 5MG TABLET
00363650
00396834
103
* 10MG TABLET
00463698
00713449
APO-HALOPERIDOL
NOVO-PERIDOL
APX
NOP
$
0.1443
0.1443
RPH
PMS
APX
$
0.1165
0.1165
0.1274
SAB
$
3.7400
SAB
NOP
APX
$
30.4200
30.4200
30.4200
SAB
APX
NOP
$
60.1100
60.1100
60.1100
PMS
NXP
APX
DOM
$
0.1628
0.1628
0.1628
0.1709
PMS
NXP
APX
DOM
$
0.2711
0.2711
0.2711
0.2846
PMS
NXP
APX
DOM
$
0.4202
0.4202
0.4202
0.4412
PMS
NXP
APX
DOM
$
0.5601
0.5601
0.5601
0.5881
00552429
00759503
00587702
RATIO-HALOPERIDOL
PMS-HALOPERIDOL
APO-HALOPERIDOL
00808652
HALOPERIDOL
HALOPERIDOL DECANOATE
02130297
02236866
02242361
HALOPERIDOL LA
HALOPERIDOL LONG ACTING
APO-HALOPERIDOL LA
02130300
02242362
02242631
HALOPERIDOL LA
APO-HALOPERIDOL LA
LOXAPINE SUCCINATE
* 5MG TABLET
02230837
02237534
02237651
02239918
PMS-LOXAPINE
NU-LOXAPINE
APO-LOXAPINE
DOM-LOXAPINE
* 10MG TABLET
02230838
02237535
02237652
02239919
PMS-LOXAPINE
NU-LOXAPINE
APO-LOXAPINE
DOM-LOXAPINE
* 25MG TABLET
02230839
02237536
02237653
02239920
PMS-LOXAPINE
NU-LOXAPINE
APO-LOXAPINE
DOM-LOXAPINE
* 50MG TABLET
02230840
02237537
02237654
02239921
PMS-LOXAPINE
NU-LOXAPINE
APO-LOXAPINE
DOM-LOXAPINE
104
OLANZAPINE
2.5MG TABLET
02229250
ZYPREXA (EDS)
LIL
$
1.8310
ZYPREXA (EDS)
LIL
$
3.6619
LIL
$
5.4929
LIL
$
7.3238
LIL
$
10.9857
LIL
$
3.6619
LIL
$
7.3238
LIL
$
10.9857
ERF
$
0.1817
ERF
$
0.2796
ERF
$
0.4413
ERF
$
0.3076
APO-PERPHENAZINE
APX
$
0.0239
APO-PERPHENAZINE
APX
$
0.0348
APO-PERPHENAZINE
APX
$
0.0456
APX
$
0.0565
5MG TABLET
02229269
7.5MG TABLET
02229277
ZYPREXA (EDS)
10MG TABLET
02229285
ZYPREXA (EDS)
15MG TABLET
02238850
ZYPREXA (EDS)
5MG ORALLY DISINTEGRATING TABLET
02243086
ZYPREXA ZYDIS (EDS)
02243087
ZYPREXA ZYDIS (EDS)
02243088
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
105
PIMOZIDE
* 2MG TABLET
00313815
02245432
ORAP
APO-PIMOZIDE
PML
APX
$
0.2473
0.2473
ORAP
APO-PIMOZIDE
PML
APX
$
0.4488
0.4488
AVT
$
13.1800
AVT
$
42.4300
APX
NXP
$
0.1145
0.1145
APX
NXP
$
0.1400
0.1400
SAB
$
1.0800
SAB
$
0.9010
AST
$
0.5362
AST
$
1.4305
AST
$
2.2124
AST
$
2.8717
AST
$
4.1625
* 4MG TABLET
00313823
02245433
PIPOTIAZINE PALMITATE
01926667
PIPORTIL L4
01926675
PIPORTIL L4
PROCHLORPERAZINE
* 5MG TABLET
00886440
01964399
APO-PROCHLORAZINE
NU-PROCHLOR
* 10MG TABLET
00886432
01964402
APO-PROCHLORAZINE
NU-PROCHLOR
00789747
PROCHLORPERAZINE MESYLATE
10MG SUPPOSITORY
00789720
SAB-PROCHLOPERAZINE
QUETIAPINE
25MG TABLET
02236951
SEROQUEL
100MG TABLET
02236952
SEROQUEL
150MG TABLET
02240862
SEROQUEL
200MG TABLET
02236953
SEROQUEL
300MG TABLET
02244107
SEROQUEL
106
RISPERIDONE
0.25MG TABLET
02240551
RISPERDAL
JAN
$
0.5034
JAN
$
0.8431
RISPERDAL M-TAB
JAN
$
0.7541
RISPERDAL
JAN
$
1.1683
RISPERDAL M-TAB
JAN
$
1.0416
RISPERDAL
JAN
$
2.3252
RISPERDAL M-TAB
JAN
$
2.0796
RISPERDAL
JAN
$
3.4877
RISPERDAL
JAN
$
4.6500
JAN
$
1.3389
APX
$
0.0923
APX
$
0.1107
APX
$
0.1313
APX
$
0.2577
PMS
$
0.1627
PFI
$
0.2089
PFI
$
0.3585
PFI
$
0.4616
0.5MG TABLET
02240552
RISPERDAL
0.5MG ORALLY DISINTEGRATING TABLET
02247704
1MG TABLET
02025280
02247705
2MG TABLET
02025299
02247706
3MG TABLET
02025302
4MG TABLET
02025310
02236950
RISPERDAL
THIORIDAZINE
10MG TABLET
00360228
APO-THIORIDAZINE
25MG TABLET
00360198
APO-THIORIDAZINE
50MG TABLET
00360236
APO-THIORIDAZINE
100MG TABLET
00360244
APO-THIORIDAZINE
00775320
PMS-THIORIDAZINE
THIOTHIXENE
2MG CAPSULE
00024430
NAVANE
5MG CAPSULE
00024449
NAVANE
10MG CAPSULE
00024457
NAVANE
107
TRIFLUOPERAZINE
1MG TABLET
00345539
APO-TRIFLUOPERAZINE
APX
$
0.1102
APO-TRIFLUOPERAZINE
APX
$
0.1443
APO-TRIFLUOPERAZINE
APX
$
0.1915
APX
$
0.2295
PMS
$
0.2700
LUD
$
15.1900
LUD
$
151.9000
LUD
$
0.3906
LUD
$
0.9765
2MG TABLET
00312754
5MG TABLET
00312746
10MG TABLET
00326836
APO-TRIFLUOPERAZINE
00751871
PMS-TRIFLUOPERAZINE
ZUCLOPENTHIXOL ACETATE
02230405
CLOPIXOL ACUPHASE (EDS)
ZUCLOPENTHIXOL DECANOATE
02230406
CLOPIXOL DEPOT (EDS)
ZUCLOPENTHIXOL DIHYDROCHLORIDE
10MG TABLET
02230402
CLOPIXOL (EDS)
25MG TABLET
02230403
CLOPIXOL (EDS)
28:20.00 RESPIRATORY AND CEREBRAL STIMULANTS
DEXTROAMPHETAMINE SO4
5MG TABLET
01924516
DEXEDRINE
GSK
$
0.4623
GSK
$
0.6631
GSK
$
0.8108
10MG SPANSULE CAPSULE
01924559
DEXEDRINE
15MG SPANSULE CAPSULE
01924567
DEXEDRINE
108
28:20.00 RESPIRATORY AND CEREBRAL STIMULANTS
METHYLPHENIDATE HCL
* 5MG TABLET
02234749
02247364
PMS-METHYLPHENIDATE
RATIO-METHYLPHENIDATE
PMS
RPH
$
0.1028
0.1028
PMS
RPH
NVR
$
0.1726
0.1726
0.2924
PMS
RPH
NVR
$
0.3837
0.3958
0.5111
NVR
$
0.5387
RBP
$
1.3020
* 10MG TABLET
00584991
02230321
00005606
PMS-METHYLPHENIDATE
RITALIN
* 20MG TABLET
00585009
02230322
00005614
PMS-METHYLPHENIDATE
RITALIN
00632775
RITALIN SR
MODAFINIL
100MG TABLET
02239665
ALERTEC (EDS)
28:24.04 ANXIOLYTICS,SEDATIVES AND HYPNOTICS
(BARBITURATES)
AMOBARBITAL SODIUM
60MG CAPSULE
00015148
AMYTAL SODIUM
PMS
$
0.1042
PMS
$
0.2294
PMS
$
0.1160
200MG CAPSULE
00015156
AMYTAL SODIUM
PHENOBARBITAL
SEE SECTION 28:12.04 (ANTICONVULSANTS)
SECOBARBITAL SODIUM
100MG CAPSULE
00015288
SECONAL
109
(BENZODIAZEPINES)
ALPRAZOLAM
* 0.25MG TABLET
00677485
00865397
01913239
01913484
02137534
00548359
RATIO-ALPRAZOLAM
APO-ALPRAZ
NU-ALPRAZ
NOVO-ALPRAZOL
GEN-ALPRAZOLAM
XANAX
RPH
APX
NXP
NOP
GPM
PFI
$
0.0825
0.0825
0.0825
0.0825
0.0825
0.2642
RPH
APX
NXP
NOP
GPM
PFI
$
0.0999
0.0999
0.0999
0.0999
0.0999
0.3159
NU-BROMAZEPAM
APO-BROMAZEPAM
GEN-BROMAZEPAM
LECTOPAM
NXP
APX
GPM
HLR
$
0.0752
0.0752
0.0752
0.1174
NU-BROMAZEPAM
APO-BROMAZEPAM
GEN-BROMAZEPAM
NOVO-BROMAZEPAM
LECTOPAM
NXP
APX
GPM
NOP
HLR
$
0.0957
0.0957
0.0957
0.0957
0.1595
NU-BROMAZEPAM
APO-BROMAZEPAM
GEN-BROMAZEPAM
NOVO-BROMAZEPAM
LECTOPAM
NXP
APX
GPM
NOP
HLR
$
0.1398
0.1398
0.1398
0.1398
0.2330
APX
$
0.0527
APX
$
0.0830
APX
$
0.1286
* 0.5MG TABLET
00677477
00865400
01913247
01913492
02137542
00548367
RATIO-ALPRAZOLAM
APO-ALPRAZ
NU-ALPRAZ
NOVO-ALPRAZOL
GEN-ALPRAZOLAM
XANAX
BROMAZEPAM
* 1.5MG TABLET
02171856
02177153
02192705
00682314
* 3MG TABLET
02171864
02177161
02192713
02230584
00518123
* 6MG TABLET
02171872
02177188
02192721
02230585
00518131
CHLORDIAZEPOXIDE
5MG CAPSULE
00522724
APO-CHLORDIAZEPOXIDE
10MG CAPSULE
00522988
25MG CAPSULE
00522996
110
(BENZODIAZEPINES)
CLORAZEPATE DIPOTASSIUM
* 3.75MG CAPSULE
00628190
00860689
NOVO-CLOPATE
APO-CLORAZEPATE
NOP
APX
$
0.0753
0.0753
NOP
APX
$
0.1662
0.1662
NOVO-CLOPATE
APO-CLORAZEPATE
NOP
APX
$
0.2840
0.2840
APO-DIAZEPAM
BIO-DIAZEPAM
APX
BMD
$
0.0662
0.0662
VIVOL
APO-DIAZEPAM
BIO-DIAZEPAM
VALIUM
AXX
APX
BMD
HLR
$
0.0841
0.0977
0.0977
0.1630
AXX
APX
BMD
$
0.0868
0.1129
0.1130
RBP
$
72.9700
APX
ICN
$
0.0879
0.1396
APX
ICN
$
0.1009
0.1635
* 7.5MG CAPSULE
00628204
00860700
NOVO-CLOPATE
APO-CLORAZEPATE
* 15MG CAPSULE
00628212
00860697
DIAZEPAM
* 2MG TABLET
00405329
02247173
* 5MG TABLET
00013765
00362158
02247174
00013285
* 10MG TABLET
00013773
00405337
02247176
VIVOL
APO-DIAZEPAM
BIO-DIAZEPAM
5MG/ML RECTAL GEL (DELIVERY SYSTEM)
02238162
DIASTAT
FLURAZEPAM HCL
* 15MG CAPSULE
00521698
00012696
APO-FLURAZEPAM
DALMANE
* 30MG CAPSULE
00521701
00012718
APO-FLURAZEPAM
DALMANE
111
(BENZODIAZEPINES)
LORAZEPAM
* 0.5MG TABLET
02245784
00655740
00711101
00728187
00865672
02041413
DOM-LORAZEPAM
APO-LORAZEPAM
NOVO-LORAZEM
PMS-LORAZEPAM
NU-LORAZ
ATIVAN
DOM
APX
NOP
PMS
NXP
WYA
$
0.0317 *
0.0390
0.0390
0.0390
0.0390
0.0814
DOM-LORAZEPAM
NOVO-LORAZEM
APO-LORAZEPAM
PMS-LORAZEPAM
NU-LORAZ
ATIVAN
DOM
NOP
APX
PMS
NXP
WYA
$
0.0395 *
0.0485
0.0485
0.0485
0.0485
0.1009
DOM-LORAZEPAM
NOVO-LORAZEM
APO-LORAZEPAM
PMS-LORAZEPAM
NU-LORAZ
ATIVAN
DOM
NOP
APX
PMS
NXP
WYA
$
0.0613 *
0.0759
0.0759
0.0759
0.0759
0.1585
APX
$
0.0456
APX
$
0.0717
APX
$
0.0977
* 1MG TABLET
02245785
00637742
00655759
00728195
00865680
02041421
* 2MG TABLET
02245786
00637750
00655767
00728209
00865699
02041448
OXAZEPAM
10MG TABLET
00402680
APO-OXAZEPAM
15MG TABLET
00402745
APO-OXAZEPAM
30MG TABLET
00402737
APO-OXAZEPAM
112
(BENZODIAZEPINES)
TEMAZEPAM
* 15MG CAPSULE
02223570
02225964
02229455
02230095
02231615
02243023
02244814
02247526
02229756
00604453
NU-TEMAZEPAM
APO-TEMAZEPAM
PMS-TEMAZEPAM
NOVO-TEMAZEPAM
GEN-TEMAZEPAM
RATIO-TEMAZEPAM
CO-TEMAZEPAM
PREM-TEMAZEPAM
DOM-TEMAZEPAM
RESTORIL
NXP
APX
PMS
NOP
GPM
RPH
COB
PRM
DOM
ORX
$
0.1196
0.1196
0.1196
0.1196
0.1196
0.1196
0.1196
0.1196
0.1493
0.1899
NXP
APX
PMS
NOP
GPM
RPH
COB
PRM
DOM
ORX
$
0.1439
0.1439
0.1439
0.1439
0.1439
0.1439
0.1439
0.1439
0.1795
0.2284
APX
GPM
$
0.0604
0.0604
APX
GPM
PFI
$
0.0760
0.0760
0.2288
* 30MG CAPSULE
02223589
02225972
02229456
02230102
02231616
02243024
02244815
02247527
02229758
00604461
NU-TEMAZEPAM
APO-TEMAZEPAM
PMS-TEMAZEPAM
NOVO-TEMAZEPAM
GEN-TEMAZEPAM
RATIO-TEMAZEPAM
CO-TEMAZEPAM
PREM-TEMAZEPAM
DOM-TEMAZEPAM
RESTORIL
TRIAZOLAM
* 0.125MG TABLET
00808563
01995227
APO-TRIAZO
GEN-TRIAZOLAM
* 0.25MG TABLET
00808571
01913506
00443158
APO-TRIAZO
GEN-TRIAZOLAM
HALCION
113
28:24.92 MISCELLANEOUS ANXIOLYTICS,SEDATIVES
AND HYPNOTICS
BUSPIRONE
5MG TABLET
02230941
PMS-BUSPIRONE
PMS
$
0.4323
DOM
LIN
NXP
APX
GPM
PMS
NOP
RPH
BRI
$
0.4674 *
0.7076
0.7076
0.7076
0.7076
0.7076
0.7076
0.7076
1.0844
PMS
ODN
$
0.0471
0.0471
APX
NOP
$
0.0361
0.0361
APX
NOP
$
0.0584
0.0584
APX
NOP
$
0.0814
0.0814
PMS
PFI
$
0.0422
0.0515
* 10MG TABLET
02232564
02176122
02207672
02211076
02230874
02230942
02231492
02237858
00603821
DOM-BUSPIRONE
LIN-BUSPIRONE
NU-BUSPIRONE
APO-BUSPIRONE
GEN-BUSPIRONE
PMS-BUSPIRONE
NOVO-BUSPIRONE
RATIO-BUSPIREX
BUSPAR
CHLORAL HYDRATE
* 100MG/ML SYRUP
00792659
02247621
PMS-CHLORAL HYDRATE SYRUP
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
114
28:24.92 MISCELLANEOUS ANXIOLYTICS,SEDATIVES
AND HYPNOTICS
METHOTRIMEPRAZINE
2MG TABLET
02238403
APO-METHOPRAZINE
APX
$
0.0548
NOZINAN
PMS-METHOTRIMEPRAZINE
APO-METHOPRAZINE
ROP
PMS
APX
$
0.0573
0.0573
0.0573
ROP
PMS
APX
$
0.1228
0.1228
0.1228
ROP
NOP
PMS
APX
$
0.1672
0.1672
0.1672
0.1672
ROP
$
0.0609
PMS
APX
ICN
$
0.0578
0.0578
0.1238
PMS
APX
ICN
$
0.0606
0.0606
0.1017
PMS
ICN
$
0.1476
0.1845
JAN
$
0.2151
* 5MG TABLET
01927655
02232903
02238404
* 25MG TABLET
01927663
02232904
02238405
NOZINAN
APO-METHOPRAZINE
* 50MG TABLET
01927671
01964933
02232905
02238406
NOZINAN
NOVO-MEPRAZINE
APO-METHOPRAZINE
01927728
NOZINAN
28:28.00 ANTIMANIC AGENTS
LITHIUM CARBONATE
* 150MG CAPSULE
02216132
02242837
00461733
PMS-LITHIUM CARBONATE
APO-LITHIUM CARBONATE
CARBOLITH
* 300MG CAPSULE
02216140
02242838
00236683
CARBOLITH
* 600MG CAPSULE
02216159
02011239
CARBOLITH
00590665
DURALITH
115
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.
BLOOD GLUCOSE TEST STRIP
⌧
STRIP
00950378
00950831
00950432
00950505
00950068
00950911
00950459
00950734
00950907
00950882
00950300
00950878
00950893
00950894
00950902
00950912
00950883
00950900
00950924
00950926
00950572
GLUCOFILM
PRESTIGE
ACCUTREND
ENCORE
CHEMSTRIP BG
BD LATITUDE STRIP
ONE TOUCH
SURESTEP
FREESTYLE
FASTTAKE
PRECISION PLUS
ASCENSIA DEX
ONE TOUCH ULTRA
PRECISION XTRA
SOF-TACT
PRECISION EASY
ADVANTAGE COMFORT
ACCU-CHEK COMPACT
ASCENSIA MICROFILL
ACCU-CHEK ADVANTAGE
ELITE
BAY
THR
BOM
BAY
BOM
BDC
LSN
LSN
THS
LSN
MDS
BAY
LSN
MDS
MDS
ABB
BOM
BOM
BAY
BOM
BAY
$
0.6661
0.6793
0.7324
0.7324
0.7474
0.7822
0.8029
0.8029
0.8029
0.8453
0.8626
0.8626
0.8626
0.8626
0.8626
0.8626
0.8680
0.8680
0.8680
0.8680
0.9388
MDS
$
1.6344
HYDROXYBUTYRATE DEHYDROGENASE
BLOOD KETONE TEST STRIP
00950896
PRECISION XTRA KETONE
118
36:00 DIAGNOSTIC AGENTS
36:88.00 URINE CONTENTS
NOTE: THE IDENTIFICATION NUMBERS LISTED IN THIS SECTION
HAVE BEEN GENERATED BY THE PRESCRIPTION DRUG PLAN FOR
BILLING PURPOSES ONLY.
CUPRIC SO4 REAGENT
TABLET
00035122
CLINITEST
BAY
$
0.0998
BAY
$
0.1129
BOM
$
0.1389
BAY
$
0.1354
KETOSTIX
BAY
$
0.1259
ACETEST
BAY
$
0.1728
GLUCOSE OXIDASE/PEROXIDASE REAGENT
STICK
00035130
DIASTIX
GLUCOSE OXIDASE/PEROXIDASE/SODIUM
NITROFERRICYANIDE/GLYCINE REAGENT
STICK
00950238
CHEMSTRIP UG 5000K
GLUCOSE OXIDASE/PEROXIDASE/SODIUM
NITROPRUSSIDE REAGENT
STICK
00035149
KETO DIASTIX
SODIUM NITROPRUSSIDE REAGENT
STICK
00035092
TABLET
00035106
119
ELECTROLYTIC, CALORIC AND
WATER BALANCE
40:00
40:00 ELECTROLYTIC, CALORIC AND WATER BALANCE
40:12.00 REPLACEMENT AGENTS
POTASSIUM CHLORIDE
8MMOL LONG ACTING CAPSULE
02042304
⌧
MICRO-K EXTENCAPS
WYA
$
0.0971
APX
NVR
$
0.0623
0.1160
KEY
$
0.2165
PMS
GSK
$
0.0139
0.0157
ABB
$
0.3165
WEL
$
0.5191
SAW
$
0.3031
PMS
$
0.1027
PMS
SAW
$
0.1554
0.1569
PMS
$
14.8000
8MMOL LONG ACTING TABLET
00602884
00074225
APO-K
SLOW-K
20MMOL LONG ACTING TABLET
00713376
K-DUR
* 1.33MMOL/ML ORAL SOLUTION
02238604
01918303
PMS-POTASSIUM CHLORIDE
K-10
20MMOL/PACKAGE POWDER (3G)
00481211
K-LOR
25MMOL/PACKAGE POWDER (7.8G)
02089580
K-LYTE/CL
40:18.00 POTASSIUM-REMOVING RESINS
CALCIUM POLYSTYRENE SULFONATE
POWDER (1G BINDS WITH APPROX. 1.6MMOL. K)
02017741
RESONIUM CALCIUM
SODIUM POLYSTYRENE SULFONATE
00769541
PMS-SOD POLYSTYRENE SULF
* POWDER (1G BINDS WITH APPROX.1MMOL K IN VIVO)
00755338
02026961
KAYEXALATE
250MG/ML RETENTION ENEMA
00769533
PMS-SOD POLY SULF (120ML)
122
40:28.00 DIURETICS
ACETAZOLAMIDE
SEE SECTION 52:10.00 (CARBONIC ANHYDRASE INHIBITORS)
BUMETANIDE
1MG TABLET
00728284
BURINEX (EDS)
LEO
$
0.7324
BURINEX (EDS)
LEO
$
1.4648
BURINEX (EDS)
LEO
$
2.7939
APX
$
0.0852
APX
$
0.1020
NXP
NOP
APX
BMD
DOM
AVT
$
0.0336 *
0.0483
0.0483
0.0483
0.0507
0.0749
NXP
NOP
APX
BMD
DOM
AVT
$
0.0503 *
0.0727
0.0727
0.0727
0.0764
0.1147
AVT
$
0.2356
2MG TABLET
02176076
5MG TABLET
00728276
CHLORTHALIDONE
50MG TABLET
00360279
APO-CHLORTHALIDONE
100MG TABLET
00360287
APO-CHLORTHALIDONE
FUROSEMIDE
* 20MG TABLET
02239224
00337730
00396788
02247371
02248124
02224690
NU-FUROSEMIDE
NOVO-SEMIDE
APO-FUROSEMIDE
BIO-FUROSEMIDE
DOM-FUROSEMIDE
LASIX
* 40MG TABLET
02239225
00337749
00362166
02247372
02248125
02224704
NU-FUROSEMIDE
NOVO-SEMIDE
APO-FUROSEMIDE
BIO-FUROSEMIDE
DOM-FUROSEMIDE
LASIX
02224720
LASIX
123
40:28.00 DIURETICS
HYDROCHLOROTHIAZIDE
* 25MG TABLET
02250659
00021474
00326844
02247170
02248134
NU-HYDRO
NOVO-HYDRAZIDE
APO-HYDRO
BIO-HYDROCHLOROTHIAZIDE
DOM-HYDROCHLOROTHIAZIDE
NXP
NOP
APX
BMD
DOM
$
0.0357 *
0.0516
0.0516
0.0516
0.0543
NXP
NOP
APX
BMD
DOM
$
0.0517 *
0.0706
0.0706
0.0706
0.0743
DOM
PRO
PMS
GPM
APX
SEV
$
0.1752 *
0.2037
0.2037
0.2037
0.2037
0.3234
DOM
PRO
GPM
NXP
APX
NOP
PMS
SEV
$
0.2500 *
0.3190
0.3230
0.3230
0.3230
0.3230
0.3230
0.5289
AVT
$
0.1585
MSD
$
0.3259
* 50MG TABLET
02250667
00021482
00312800
02247171
02248135
NU-HYDRO
NOVO-HYDRAZIDE
APO-HYDRO
INDAPAMIDE HEMIHYDRATE
* 1.25MG TABLET
02239913
02227339
02239619
02240067
02245246
02179709
DOM-INDAPAMIDE
INDAPAMIDE
PMS-INDAPAMIDE
GEN-INDAPAMIDE
APO-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
METOLAZONE
2.5MG TABLET
00888400
ZAROXOLYN
40:28.10 POTASSIUM SPARING DIURETICS
AMILORIDE HCL
5MG TABLET
00487805
MIDAMOR
124
40:28.10 POTASSIUM SPARING DIURETICS
SPIRONOLACTONE
* 25MG TABLET
00613215
00028606
NOVO-SPIROTON
ALDACTONE
NOP
PFI
$
0.0751
0.0782
NOP
PFI
$
0.2301
0.2393
ICN
$
0.2045
APX
NXP
$
0.1519
0.1519
APX
NXP
$
0.2149
0.2149
* 100MG TABLET
00613223
00285455
NOVO-SPIROTON
ALDACTONE
40:40.00 URICOSURIC DRUGS
PROBENECID
500MG TABLET
00294926
BENURYL
SULFINPYRAZONE
* 100MG TABLET
00441759
02045680
APO-SULFINPYRAZONE
NU-SULFINPYRAZONE
* 200MG TABLET
00441767
02045699
APO-SULFINPYRAZONE
NU-SULFINPYRAZONE
125
ANTITUSSIVES, EXPECTORANTS AND
MUCOLYTIC AGENTS
48:00
48:00 ANTITUSSIVES, EXPECTORANTS AND
MUCOLYTIC AGENTS
48:24.00 MUCOLYTIC AGENTS
ACETYLCYSTEINE
* 20% SOLUTION (30ML)
02243098
02091526
ACETYLCYSTEINE SOLUTION
MUCOMYST
SAB
WEL
$
16.5200
19.1600
HLR
$
36.0000
DORNASE ALFA
1MG/ML INHALATION SOLUTION (2.5ML)
02046733
PULMOZYME (EDS)
128
EYE, EAR, NOSE AND THROAT
PREPARATIONS
52:00
52:00 EYE, EAR, NOSE AND THROAT PREPARATIONS
52:04.04 ANTI-INFECTIVES (ANTIBIOTICS)
FUSIDIC ACID
1% OPHTHALMIC DROPS (PRESERVATIVE FREE)
02243861
FUCITHALMIC (EDS)
LEO
$
0.8190
LEO
$
1.7630
1% OPHTHALMIC DROPS (G)
02243862
FUCITHALMIC (EDS)
GENTAMICIN SO4
TOPICAL GENTAMICIN SHOULD BE RESERVED FOR THERAPY OF SERIOUS
INFECTIONS INSUSCEPTIBLE TO OTHER AGENTS SINCE RESISTANT
ORGANISMS CAN DEVELOP.
GENTAMICIN SO4 5MG/ML IS EQUIVALENT TO 3MG/ML GENTAMICIN BASE.
* 5MG/ML OPHTHALMIC SOLUTION
00512192
00776521
02229440
00436771
GARAMYCIN
PMS-GENTAMYCIN
SAB-GENTAMICIN
ALCOMICIN
SCH
PMS
SAB
ALC
$
0.4406
0.4406
0.4406
0.5187
SAB
PMS
SCH
$
1.1198
1.1198
1.1970
SCH
SAB
$
4.3400
4.3400
SAB
GSK
$
0.6250
0.8333
PMS
ALL
$
0.7194
2.7516
* 5MG/ML OTIC SOLUTION
02229441
02230889
00512184
SAB-GENTAMICIN
PMS-GENTAMICIN
GARAMYCIN
* 5MG/G OPHTHALMIC OINTMENT (3.5G)
00028339
02230888
GARAMYCIN
GENTAMICIN SULFATE
POLYMYXIN B SO4/NEOMYCIN SO4/GRAMICIDIN
* 10,000U/2.5MG/0.025MG PER ML EYE/EAR SOLUTION
00807435
00694371
OPTIMYXIN PLUS
NEOSPORIN
POLYMYXIN B SO4/TRIMETHOPRIM SO4
* 10,000U/1MG PER ML OPHTHALMIC SOLUTION
02240363
02011956
PMS-POLYTRIMETHOPRIM
POLYTRIM
130
TOBRAMYCIN
* 0.3% OPHTHALMIC SOLUTION
02239577
02241755
02245698
00513962
PMS-TOBRAMYCIN (EDS)
SAB-TOBRAMYCIN (EDS)
APO-TOBRAMYCIN (EDS)
TOBREX (EDS)
PMS
SAB
APX
ALC
$
1.1371
1.1371
1.1371
1.8077
ALC
$
8.9800
THM
$
33.4800
SCH
$
0.0876
ALC
$
3.1000
STI
$
0.2604
ALC
$
2.1049
ALC
$
10.5300
0.3% OPHTHALMIC OINTMENT (3.5G)
00614254
TOBREX (EDS)
52:04.06 ANTI-INFECTIVES (ANTIVIRALS)
TRIFLURIDINE
1% OPHTHALMIC SOLUTION (7.5ML)
00687456
VIROPTIC
52:04.08 ANTI-INFECTIVES (SULFONAMIDES)
SULFACETAMIDE (SODIUM)
10% OPHTHALMIC SOLUTION
00028053
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
0.3% OPHTHALMIC SOLUTION
01945270
CILOXAN (EDS)
02200864
CILOXAN (EDS)
131
52:04.12 ANTI-INFECTIVES (MISCELLANEOUS)
OFLOXACIN
02248398
02143291
APO-OFLOXACIN (EDS)
OCUFLOX (EDS)
APX
ALL
$
1.0764
2.2113
RPH
GPM
NXP
APX
$
13.3100
13.3100
13.3100
13.3100
GPM
AST
$
9.1500
11.0700
GPM
$
13.8300
AST
$
24.6300
ALC
$
1.6709
SAB
PMS
$
0.7335
0.7335
ALC
$
9.0600
RPH
PMS
APX
HLR
$
15.0400
15.0400
15.0400
21.4900
52:08.00 ANTI-INFLAMMATORY AGENTS
BECLOMETHASONE DIPROPIONATE
* 50UG/DOSE AQUEOUS NASAL SPRAY (PACKAGE)
00872318
02172712
02238577
02238796
RATIO-BECLOMETHASONE AQ.
GEN-BECLO AQ.
NU-BECLOMETHASONE
APO-BECLOMETHASONE
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
SAB-DEXAMETHASONE
PMS-DEXAMETHASONE SOD PHO
00042579
MAXIDEX
FLUNISOLIDE
* 0.025% NASAL SOLUTION (PACKAGE)
00878790
01927167
02239288
02162687
RATIO-FLUNISOLIDE
RHINARIS-F
APO-FLUNISOLIDE
RHINALAR
132
FLUOROMETHOLONE
* 0.1% OPHTHALMIC SUSPENSION
02238568
00247855
PMS-FLUOROMETHOLONE
FML
PMS
ALL
$
1.7556
2.3046
ALC
$
1.8879
ALL
$
5.2558
GSK
$
25.1300
APX
RPH
ALL
$
2.4304
2.4304
3.6456
SCH
$
26.5200
SAB
ALL
$
1.1501
1.6243
RPH
SAB
ALL
$
0.6293
0.6293
3.9842
NVO
$
1.5190
AVT
$
23.3900
FLUOROMETHOLONE ACETATE
00756784
FLAREX
FLURBIPROFEN SODIUM
00766046
OCUFEN (EDS)
FLUTICASONE PROPIONATE
50UG/DOSE AQUEOUS NASAL SPRAY (PACKAGE)
02213672
FLONASE
KETOROLAC TROMETHAMINE
02245821
02247461
01968300
APO-KETOROLAC (EDS)
RATIO-KETOROLAC (EDS)
ACULAR (EDS)
MOMETASONE FUROATE MONOHYDRATE
0.05% AQUEOUS NASAL SPRAY
02238465
NASONEX
PREDNISOLONE ACETATE
01916181
00299405
SAB-PREDNISOLONE
PRED MILD
00700401
01916203
00301175
RATIO-PREDNISOLONE
SAB-PREDNISOLONE
PRED FORTE
PREDNISOLONE SODIUM PHOSPHATE
02133318
INFLAMASE FORTE
TRIAMCINOLONE ACETONIDE
AQUEOUS NASAL SPRAY (PACKAGE)
02213834
NASACORT AQ
133
52:08.00 COMBINATION ANTI-INFECTIVE/
ANTI-INFLAMMATORY AGENTS
CIPROFLOXACIN/HYDROCORTISONE
0.2%/1% OTIC SUSPENSION
02240035
CIPRO HC (EDS)
ALC
$
2.2790
FRAMYCETIN SO4/GRAMICIDIN/DEXAMETHASONE BASE
* 5MG/50UG/0.5MG PER ML EYE/EAR SOLUTION
02247920
02224623
SAB-OPTICORT
SOFRACORT
SAB
AVT
$
1.2194
1.5190
AVT
$
10.4200
5MG/50UG/0.5MG PER G EYE/EAR OINTMENT (5G)
02224631
SOFRACORT
GENTAMICIN SO4/BETAMETHASONE SODIUM PHOSPHATE
0.3%/0.1% OPHTHALMIC OINTMENT (3.5G)
00586706
GARASONE
SCH
$
11.0000
SCH
SAB
$
1.3904
1.3904
* 0.3%/0.1% OTIC/OPHTHALMIC SOLUTION
00682217
02244999
GARASONE
SAB-PENTASONE
IODOCHLORHYDROXYQUIN/FLUMETHASONE PIVALATE
1%/0.02% OTIC SOLUTION
00074454
LOCACORTEN-VIOFORM
PAL
$
1.4398
SAB
$
8.9700
POLYMYXIN B SO4/BACITRACIN (ZINC)/
NEOMYCIN SO4/HYDROCORTISONE
10000U/400U/5MG/10MG PER G OPHTHALMIC
OINTMENT (3.5G)
02242485
SAB-CORTIMYXIN
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
$
1.2988
SAB
GSK
$
0.9223
1.2988
* 10,000U/5MG/10MG PER ML OTIC SOLUTION
02230386
01912828
SAB-CORTIMYXIN
CORTISPORIN
134
SULFACETAMIDE SODIUM/PREDNISOLONE ACETATE
100MG/2.5MG PER ML OPHTHALMIC SOLUTION
02133342
VASOCIDIN
NVO
$
2.2460
ALL
$
12.9400
ALC
$
2.1353
ALC
$
11.0700
APX
$
0.1015
WYA
$
0.7567
ALC
$
3.4069
MSD
$
3.7238
APX
$
0.3385
100MG/2MG PER G OPHTHALMIC OINTMENT
(3.5G)
00307246
BLEPHAMIDE S.O.P.
TOBRAMYCIN/DEXAMETHASONE
0.3%/0.1% OPHTHALMIC SUSPENSION
00778907
TOBRADEX (EDS)
0.3%/0.1% OPHTHALMIC OINTMENT (3.5G)
00778915
TOBRADEX (EDS)
52:10.00 CARBONIC ANHYDRASE INHIBITORS
ACETAZOLAMIDE
250MG TABLET
00545015
APO-ACETAZOLAMIDE
500MG SUSTAINED RELEASE CAPSULE
02238073
DIAMOX SEQUELS
BRINZOLAMIDE
1% OPHTHALMIC SUSPENSION
02238873
AZOPT
DORZOLAMIDE HCL
02216205
TRUSOPT
METHAZOLAMIDE
50MG TABLET
02245882
APO-METHAZOLAMIDE
135
52:20.00 MIOTICS
CARBACHOL
00000655
ISOPTO CARBACHOL
ALC
$
0.7307
ALC
$
0.8800
ALC
$
0.2221
ALC
$
0.2561
ALC
$
0.2894
ALC
$
13.5600
ALC
$
0.5100
RPH
PMS
ALL
$
1.0807
1.0807
1.8011
ALC
$
0.6293
ALC
$
0.7487
00000663
ISOPTO CARBACHOL
PILOCARPINE HCL
00000841
ISOPTO CARPINE
00000868
ISOPTO CARPINE
00000884
ISOPTO CARPINE
4% OPHTHALMIC GEL (5G)
00575240
PILOPINE-HS
52:24.00 MYDRIATICS
ATROPINE SO4
00035017
ISOPTO ATROPINE
DIPIVEFRIN HCL
02032376
02237868
00529117
RATIO-DIPIVEFRIN
PMS-DIPIVEFRIN
PROPINE
HOMATROPINE HYDROBROMIDE
00000779
ISOPTO HOMATROPINE
00000787
ISOPTO HOMATROPINE
136
52:36.00 MISCELLANEOUS E.E.N.T. DRUGS
APRACLONIDINE HCL
0.5% OPHTHALMIC SOLUTION (5ML)
02076306
IOPIDINE
ALC
$
23.0800
ALC
$
11.9200
ALC
$
2.4456
ALL
$
11.7400
ALL
$
3.5805
RPH
PMS
ALL
$
2.5064
2.5064
3.5810
NVO
$
2.5715
MSD
$
5.6420
APX
PMS
RPH
DOM
BOE
$
19.0400
21.0900
21.0900
22.2000
30.2100
PFI
$
29.3400
1% OPHTHALMIC SOLUTION (1 TREATMENT)
00888354
IOPIDINE
BETAXOLOL HCL
01908448
BETOPTIC S
BIMATOPROST
02245860
LUMIGAN
BRIMONIDINE TARTRATE
02248151
ALPHAGAN P (EDS)
02243026
02246284
02236876
RATIO-BRIMONIDINE
PMS-BRIMONIDINE
ALPHAGAN
DICLOFENAC SODIUM
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)
02246083
02239627
02240072
02240508
02163705
APO-IPRAVENT
PMS-IPRATROPIUM
RATIO-IPRATROPIUM
DOM-IPRATROPIUM
ATROVENT NASAL SPRAY
LATANOPROST
50UG/ML OPHTHALMIC SOLUTION (2.5ML)
02231493
XALATAN
137
LATANOPROST/TIMOLOL MALEATE
50UG/5MG PER ML OPHTHALMIC SOLUTION (2.5ML)
02246619
XALACOM
PFI
$
33.2100
RPH
NOP
APX
SAB
$
1.2760
1.2760
1.2760
1.2760
SAB
PMS
RPH
NOP
APX
ALL
$
1.6861
1.6872
1.6883
1.6883
1.6883
2.9751
ALL
$
3.2008
NVO
$
23.5400
ALC
$
1.1122
PMS
APX
$
14.9300
14.9300
LEVOBUNOLOL HCL
02031159
02197456
02241575
02241715
RATIO-LEVOBUNOLOL
NOVO-LEVOBUNOLOL
APO-LEVOBUNOLOL
SAB-LEVOBUNOLOL
02241716
02237991
02031167
02197464
02241574
00637661
SAB-LEVOBUNOLOL
PMS-LEVOBUNOLOL
RATIO-LEVOBUNOLOL
NOVO-LEVOBUNOLOL
APO-LEVOBUNOLOL
BETAGAN
LEVOBUNOLOL HCL/DIPIVEFRIN HCL
0.5%/0.1% OPHTHALMIC SOLUTION
02209071
PROBETA
LEVOCABASTINE HYDROCHLORIDE
0.5MG PER ML OPHTHALMIC SUSPENSION (5ML)
02131625
LIVOSTIN
LODOXAMIDE TROMETHAMINE
00893560
ALOMIDE
SODIUM CROMOGLYCATE
* 2% NASAL METERED DOSE MIST (PACKAGE)
01950541
02231390
CROMOLYN
APO-CROMOLYN
138
TIMOLOL MALEATE
00755826
00893773
02083353
02166712
02241731
02238770
APO-TIMOP
GEN-TIMOLOL
PMS-TIMOLOL
SAB-TIMOLOL
RHOXAL-TIMOLOL
DOM-TIMOLOL
APX
GPM
PMS
SAB
RHO
DOM
$
1.6818
1.6818
1.6818
1.6818
1.6818
1.7664
APX
GPM
PMS
SAB
RPH
RHO
DOM
MSD
$
2.0181
2.0181
2.0181
2.0181
2.0181
2.0181
2.1190
3.4460
MSD
$
3.5371
MSD
$
4.2315
00755834
00893781
02083345
02166720
02240249
02241732
02238771
00451207
APO-TIMOP
GEN-TIMOLOL
PMS-TIMOLOL
SAB-TIMOLOL
RATIO-TIMOLOL MALEATE
RHOXAL-TIMOLOL
DOM-TIMOLOL
TIMOPTIC
0.25% OPHTHALMIC GELLAN SOLUTION
02171880
TIMOPTIC-XE
0.5% OPHTHALMIC GELLAN SOLUTION
02171899
TIMOPTIC-XE
TIMOLOL MALEATE/PILOCARPINE HYDROCHLORIDE
0.5%/2% OPHTHALMIC SOLUTION
01905082
TIMPILO
MSD
$
3.5567
MSD
$
3.5567
ALC
$
28.7600
0.5%/4% OPHTHALMIC SOLUTION
01905090
TIMPILO
TRAVOPROST
0.004% OPHTHALMIC SOLUTION (2.5ML)
02244896
TRAVATAN
139
GASTROINTESTINAL DRUGS
56:00
56:00 GASTROINTESTINAL DRUGS
56:08.00 ANTIDIARRHEA AGENTS
DIPHENOXYLATE HCL
2.5MG TABLET
00036323
LOMOTIL
PFI
$
0.4729
NOP
APX
ICN
PMS
RHO
DOM
PMS
MCL
$
0.2676
0.2676
0.2676
0.2676
0.2676
0.2809
0.3545
0.8229
PMS
PMS
$
0.0912
0.1058
PMS
$
0.0158
RPH
APX
$
0.0158
0.0158
JAN
$
0.3883
JAN
$
0.3876
AXC
$
0.2214
LOPERAMIDE HCL
* 2MG CAPLET
02132591
02212005
02228343
02228351
02233998
02239535
02229552
02183862
NOVO-LOPERAMIDE
APO-LOPERAMIDE
LOPERACAP
PMS-LOPERAMIDE
RHOXAL-LOPERAMIDE
DOM-LOPERAMIDE
DIARR-EZE
IMODIUM
* 0.2MG/ML ORAL SOLUTION
02016095
02192667
PMS-LOPERAMIDE HCL
DIARR-EZE
56:12.00 CATHARTICS AND LAXATIVES
LACTULOSE
667MG/ML SYRUP
00703486
PMS-LACTULOSE (EDS)
* 667MG/ML SOLUTION
00854409
02242814
RATIO-LACTULOSE (EDS)
APO-LACTULOSE (EDS)
56:16.00 DIGESTANTS
PANCRELIPASE (LIPASE/AMYLASE/PROTEASE)
4000U/12000U/12000U CAPSULE CONTAINING
ENTERIC COATED PARTICLES
00789445 PANCREASE MT 4
02242374 PANCREASE
02203324 ULTRASE MS4
142
56:16.00 DIGESTANTS
02239007 CREON 5
8000U/30000U/30000U CAPSULE
00263818 COTAZYM
00502790 COTAZYM ECS 8
02200104 CREON 10
02045834 ULTRASE MT12
00821373 COTAZYM ECS 20
02045869 ULTRASE MT20
02239008 CREON 20
01985205 CREON 25
8000U/30000U/30000U TABLET
02230019 VIOKASE
16000U/60000U/60000U TABLET
02241933 VIOKASE
24000U/100000U/100000U POWDER
02230020 VIOKASE
143
SLV
$
0.1812
ORG
$
0.2670
ORG
$
0.3662
JAN
$
0.9702
SLV
$
0.2897
AXC
$
0.4330
JAN
$
1.5521
ORG
$
0.9456
AXC
$
0.7503
SLV
$
0.8597
SLV
$
0.9049
AXC
$
0.2303
AXC
$
0.3470
AXC
$
0.4951
56:22.00 ANTI-EMETICS
DIMENHYDRINATE
* 50MG TABLET
00363766
00013803
00021423
APO-DIMENHYDRINATE
GRAVOL
NOVO-DIMENATE
APX
HOR
NOP
$
0.0147
0.0217
0.0408
HOR
$
0.0724
HOR
SAB
$
2.8600
3.0100
HOR
$
0.4850
HOR
$
0.5067
DUI
$
1.3020
PFC
$
0.5035
PMS
$
4.1800
3MG/ML ORAL LIQUID
00230197
GRAVOL
00013579
00392537
GRAVOL
DIMENHYDRINATE IM
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
3MG CONTROLLED ILEAL RELEASE CAPSULE
02229293
ENTOCORT (EDS)
AST
$
1.6536
NXP
APX
RPH
GPM
PMS
DOM
$
0.0722 *
0.0934
0.0934
0.0934
0.0934
0.0980
CIMETIDINE
* 300MG TABLET
00865818
00487872
00546240
02227444
02229718
02231287
NU-CIMET
APO-CIMETIDINE
RATIO-PEPTOL
GEN-CIMETIDINE
PMS-CIMETIDINE
DOM-CIMETIDINE
144
* 400MG TABLET
00865826
00568449
00600059
02227452
02229719
02231288
NU-CIMET
RATIO-PEPTOL
APO-CIMETIDINE
GEN-CIMETIDINE
PMS-CIMETIDINE
DOM-CIMETIDINE
NXP
RPH
APX
GPM
PMS
DOM
$
0.1134 *
0.1465
0.1465
0.1465
0.1465
0.1539
NXP
RPH
APX
NOP
GPM
PMS
DOM
$
0.1444 *
0.1867
0.1867
0.1867
0.1867
0.1867
0.1960
APX
$
0.1220
FTP
RPH
APX
NOP
NXP
PMS
DOM
$
0.1269 *
0.1624
0.1624
0.1624
0.1624
0.1624
0.1705
AST
$
2.2785
AST
$
2.2785
* 600MG TABLET
00865834
00584282
00600067
00603686
02227460
02229720
02231290
NU-CIMET
RATIO-PEPTOL
APO-CIMETIDINE
NOVO-CIMETINE
GEN-CIMETIDINE
PMS-CIMETIDINE
DOM-CIMETIDINE
60MG/ML ORAL LIQUID
02243085
APO-CIMETIDINE
DOMPERIDONE MALEATE
* 10MG TABLET
02238444
01912070
02103613
02157195
02231477
02236466
02238315
FTP-DOMPERIDONE MALEATE
RATIO-DOMPERIDONE
APO-DOMPERIDONE
NOVO-DOMPERIDONE
NU-DOMPERIDONE
PMS-DOMPERIDONE
DOM-DOMPERIDONE
ESOMEPRAZOLE MAGNESIUM TRIHYDRATE
20MG DELAYED RELEASE TABLET
02244521
NEXIUM (EDS)
02244522
NEXIUM (EDS)
145
FAMOTIDINE
* 20MG TABLET
02024195
01953842
02022133
02196018
02240622
02242327
00710121
NU-FAMOTIDINE
APO-FAMOTIDINE
NOVO-FAMOTIDINE
GEN-FAMOTIDINE
RHOXAL-FAMOTIDINE
RATIO-FAMOTIDINE
PEPCID
NXP
APX
NOP
GPM
RHO
RPH
MSD
$
0.5000 *
0.6398
0.6398
0.6398
0.6398
0.6398
1.0557
NXP
APX
NOP
GPM
RHO
RPH
MSD
$
0.9000 *
1.1514
1.1514
1.1514
1.1514
1.1514
1.9198
ABB
$
2.1700
ABB
$
2.1700
ABB
$
82.6600
PMS
$
0.0604
APX
NXP
PMS
$
0.0633
0.0633
0.0633
PMS
$
0.0318
* 40MG TABLET
02024209
01953834
02022141
02196026
02240623
02242328
00710113
NU-FAMOTIDINE
APO-FAMOTIDINE
NOVO-FAMOTIDINE
GEN-FAMOTIDINE
RHOXAL-FAMOTIDINE
RATIO-FAMOTIDINE
PEPCID
LANSOPRAZOLE
15MG DELAYED RELEASE CAPSULE
02165503
PREVACID (EDS)
30MG DELAYED RELEASE CAPSULE
02165511
PREVACID (EDS)
LANSOPRAZOLE/CLARITHROMYCIN/AMOXICILLIN
30MG/500MG/500MG 7-DAY PACKAGE
02238525
HP-PAC (EDS)
METOCLOPRAMIDE HCL
5MG TABLET
02230431
PMS-METOCLOPRAMIDE
* 10MG TABLET
00842834
02143283
02230432
APO-METOCLOP
NU-METOCLOPRAMIDE
PMS-METOCLOPRAMIDE
02230433
PMS-METOCLOPRAMIDE
146
MISOPROSTOL
* 100UG TABLET
02240754
02244022
00813966
NOVO-MISOPROSTOL
APO-MISOPROSTOL
CYTOTEC
NOP
APX
PFI
$
0.1860
0.1860
0.3070
APX
PMS
PFI
$
0.3096
0.3440
0.5111
DOM
PMS
APX
NOP
GPM
NXP
PML
$
0.4820 *
0.5737
0.5737
0.5737
0.5737
0.5737
0.9106
PMS
APX
NOP
GPM
NXP
PML
$
1.0395
1.0395
1.0395
1.0395
1.0395
1.6499
PFI
$
0.5383
APX
$
1.3563
AST
$
1.8988
AST
$
2.3900
* 200UG TABLET
02244023
02244125
00632600
APO-MISOPROSTOL
PMS-MISOPROSTOL
CYTOTEC
NIZATIDINE
* 150MG CAPSULE
02185814
02177714
02220156
02240457
02246046
02247051
00778338
DOM-NIZATIDINE
PMS-NIZATIDINE
APO-NIZATIDINE
NOVO-NIZATIDINE
GEN-NIZATIDINE
NU-NIZATIDINE
AXID
* 300MG CAPSULE
02177722
02220164
02240458
02246047
02247052
00778346
PMS-NIZATIDINE
APO-NIZATIDINE
NOVO-NIZATIDINE
GEN-NIZATIDINE
NU-NIZATIDINE
AXID
OLSALAZINE SODIUM
250MG CAPSULE
02063808
DIPENTUM
OMEPRAZOLE
2OMG CAPSULE
02245058
APO-OMEPRAZOLE (EDS)
OMEPRAZOLE MAGNESIUM
02230737
LOSEC (EDS)
02190915
LOSEC (EDS)
147
PANTOPRAZOLE
40MG ENTERIC TABLET
02229453
PANTOLOC (EDS)
SLV
$
2.0615
JAN
$
0.7053
NXP
APX
NOP
RPH
GPM
PRM
PMS
RHO
COB
DOM
GSK
$
0.3003 *
0.4386
0.4386
0.4386
0.4386
0.4386
0.4386
0.4386
0.4386
0.4605
1.2420
NXP
APX
NOP
RPH
GPM
PRM
PMS
RHO
COB
DOM
GSK
$
0.5787 *
0.8449
0.8449
0.8449
0.8449
0.8449
0.8449
0.8449
0.8449
0.8871
2.3379
GSK
$
0.2114
RABEPRAZOLE SODIUM
10MG TABLET
02243796
PARIET (EDS)
RANITIDINE
* 150MG TABLET
00865737
00733059
00828564
00828823
02207761
02230003
02242453
02243229
02248570
02243038
02212331
NU-RANIT
APO-RANITIDINE
NOVO-RANIDINE
RATIO-RANITIDINE
GEN-RANITIDINE
PREM-RANITIDINE
PMS-RANITIDINE
RHOXAL-RANITIDINE
CO RANITIDINE
DOM-RANITIDINE
ZANTAC
* 300MG TABLET
00865745
00733067
00828556
00828688
02207788
02230004
02242454
02243230
02248571
02243039
00641790
NU-RANIT
APO-RANITIDINE
NOVO-RANIDINE
RATIO-RANITIDINE
GEN-RANITIDINE
PREM-RANITIDINE
PMS-RANITIDINE
RHOXAL-RANITIDINE
CO RANITIDINE
DOM-RANITIDINE
ZANTAC
02212374
ZANTAC
148
SUCRALFATE
* 1G TABLET
02134829
02045702
02125250
02238209
02239912
02100622
NU-SUCRALFATE
NOVO-SUCRALATE
APO-SUCRALFATE
PMS-SUCRALFATE
DOM-SUCRALFATE
SULCRATE
NXP
NOP
APX
PMS
DOM
AVT
$
0.2557 *
0.3192
0.3192
0.3192
0.3352
0.5578
AVT
$
0.1014
PMS
RPH
PFI
$
0.0907
0.0907
0.2531
PMS
RPH
PFI
$
0.1177
0.1177
0.3985
NOP
PGA
$
0.4297
0.5371
FEI
$
0.6043
AXC
GSK
$
0.5252
0.5934
FEI
$
4.0300
AXC
$
3.8100
AXC
$
6.4700
FEI
$
4.8400
AXC
$
0.8348
AXC
$
1.1820
AXC
FEI
$
1.7360
1.7686
02103567
SULCRATE SUSPENSION PLUS
SULFASALAZINE (SALICYLAZOSULFAPYRIDINE)
* 500MG TABLET
00598461
00685933
02064480
PMS-SULFASALAZINE
RATIO-SULFASALAZINE
SALAZOPYRIN
00598488
00685925
02064472
PMS-SULFASALAZINE
RATIO-SULFASALAZINE
SALAZOPYRIN
5-AMINOSALICYLIC ACID
⌧
400MG ENTERIC COATED TABLET
02171929
01997580
NOVO-5-ASA
ASACOL
02099683
⌧
PENTASA
500MG ENTERIC COATED TABLET
02112787
01914030
SALOFALK
MESASAL
1.0G/100ML RETENTION ENEMA
02153521
PENTASA
2.0G/60G RETENTION ENEMA
02112795
SALOFALK RETENTION ENEMA
4.0G/60G RETENTION ENEMA
02112809
4.0G/100ML RETENTION ENEMA
02153556
PENTASA
250MG SUPPOSITORY
02112752
SALOFALK
500MG SUPPOSITORY
02112760
⌧
SALOFALK
1.0G SUPPOSITORY
02242146
02153564
SALOFALK
PENTASA
149
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
PAL
$
1.5597
SAB
AVT
$
8.1200
9.7800
SAB
AVT
$
9.8500
11.8700
SAB
AVT
$
15.2900
18.4400
SODIUM AUROTHIOMALATE
02245456
01927620
MYOCHRYSINE
02245457
01927612
MYOCHRYSINE
02245458
01927604
MYOCHRYSINE
152
HEAVY METAL ANTAGONISTS
64:00
64:00 HEAVY METAL ANTAGONISTS
64:00.00 HEAVY METAL ANTAGONISTS
DEFEROXAMINE MESYLATE
* 500MG/VIAL POWDER FOR SOLUTION
02242055
01981242
PMS-DEFEROXAMINE (EDS)
DESFERAL (EDS)
PMS
NVR
$
8.8800
14.1900
PMS
NVR
$
45.5700
56.9700
MSD
$
0.5581
MSD
$
0.8366
* 2G/VIAL POWDER FOR SOLUTION
02243450
01981250
DESFERAL (EDS)
PENICILLAMINE
125MG CAPSULE
00497894
CUPRIMINE
250MG CAPSULE
00016055
CUPRIMINE
154
HORMONES AND SYNTHETIC
SUBSTITUTES
68:00
68:00 HORMONES AND SYNTHETIC SUBSTITUTES
68:04.00 ADRENAL CORTICOSTEROIDS
COMPARABLE ANTI-INFLAMMATORY ACTIVITY OF ORAL
CORTICOSTEROIDS
(MINERALCORTICOID ACTIVITY NOT COMPARABLE)
DURATION OF
ACTION
SHORT ACTING
PRODUCT
COMPARABLE
ANTI-INFLAMMATORY
DOSE
- CORTISONE
- HYDROCORTISONE
- PREDNISONE
- METHYLPREDNISOLONE
25 mg
20 mg
5 mg
4 mg
INTERMEDIATE ACTING - TRIAMCINOLONE
LONG ACTING
- DEXAMETHASONE
- BETAMETHASONE
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
156
50UG/INHALATION AEROSOL (PACKAGE)
(CFC-FREE)
02242029
QVAR
MDA
$
30.7600
MDA
$
61.5200
SAB
SCH
$
3.9500
4.2900
AST
$
0.4476
AST
$
0.8952
AST
$
1.7903
AST
$
33.0300
AST
$
66.0300
AST
$
118.8100
ICN
$
0.3327
(CFC-FREE)
02242030
QVAR
BETAMETHASONE ACETATE/
BETAMETHASONE SODIUM PHOSPHATE
* 3MG/3MG PER ML INJECTION SUSPENSION (1ML)
02237835
00028096
BETAJECT
CELESTONE SOLUSPAN
BUDESONIDE
0.125MG/ML INHALATION SOLUTION (2ML)
02229099
PULMICORT NEBUAMP
01978918
PULMICORT NEBUAMP
01978926
PULMICORT NEBUAMP
00852074
PULMICORT TURBUHALER
00851752
00851760
CORTISONE ACETATE
25MG TABLET
00280437
CORTISONE
157
DEXAMETHASONE
* 0.5MG TABLET
00295094
01964976
02240684
DEXASONE
PMS-DEXAMETHASONE
RATIO-DEXAMETHASONE
ICN
PMS
RPH
$
0.2138
0.2138
0.2138
DEXASONE
PMS-DEXAMETHASONE
RATIO-DEXAMETHASONE
ICN
PMS
RPH
$
0.4883
0.4883
0.4883
PMS-DEXAMETHASONE
RATIO-DEXAMETHASONE
DEXASONE
APO-DEXAMETHASONE
PMS
RPH
ICN
APX
$
0.8326
0.8326
0.8329
0.8329
SAB
CYT
$
9.1700
9.1700
RBP
$
0.2355
GSK
$
24.8400
GSK
$
40.8200
GSK
$
81.6400
$
14.9700
$
24.8400
$
40.8200
$
81.6400
* 0.75MG TABLET
00285471
01964968
02240685
* 4MG TABLET
01964070
02240687
00489158
02250055
DEXAMETHASONE 21-PHOSPHATE
00664227
01977547
DEXAMETHASONE SOD PHO INJ
FLUDROCORTISONE ACETATE
0.1MG TABLET
02086026
FLORINEF
02244291
FLOVENT HFA
02244292
FLOVENT HFA
02244293
FLOVENT HFA
02237244
FLOVENT DISKUS
GSK
02237245
FLOVENT DISKUS
GSK
02237246
FLOVENT DISKUS
GSK
02237247
FLOVENT DISKUS
GSK
158
HYDROCORTISONE
10MG TABLET
00030910
CORTEF
PFI
$
0.1527
PFI
$
0.2760
PFI
$
3.4800
PFI
$
6.0500
PFI
$
0.3529
PFI
$
1.0182
SAB
PFI
$
3.8843
5.1000
SAB
PFI
$
4.1800
9.7700
PMS
AVT
$
0.0832
0.1041
WINPRED
APO-PREDNISONE
ICN
APX
$
0.1123
0.1123
NOVO-PREDNISONE
APO-PREDNISONE
NOP
APX
$
0.0283
0.0283
NOP
APX
$
0.1188
0.1188
20MG TABLET
00030929
CORTEF
HYDROCORTISONE SODIUM SUCCINATE
100MG INJECTION POWDER
00030600
SOLU-CORTEF
250MG INJECTION POWDER
00030619
SOLU-CORTEF
METHYLPREDNISOLONE
4MG TABLET
00030988
MEDROL
16MG TABLET
00036129
MEDROL
METHYLPREDNISOLONE ACETATE
* 40MG/ML INJECTION SUSPENSION (1ML)
02245400
00030759
DEPO-MEDROL
02245406
00030767
DEPO-MEDROL
PREDNISOLONE SODIUM PHOSPHATE
02245532
02230619
PMS-PREDNISOLONE
PEDIAPRED
PREDNISONE
* 1MG TABLET
00271373
00598194
* 5MG TABLET
00021695
00312770
* 50MG TABLET
00232378
00550957
NOVO-PREDNISONE
APO-PREDNISONE
159
02229540
01999761
KENALOG 10
SAB
WSD
$
12.9300
16.2900
CYT
SAB
WSD
$
5.9700
5.9700
7.5700
STI
$
27.1300
SAW
$
0.7733
SAW
$
1.1474
SAW
$
1.8336
CYT
SAB
PFI
$
19.4800
19.4800
26.2000
THM
$
5.3210
ORG
$
1.0199
01977563
02229550
01999869
KENALOG 40
TRIAMCINOLONE HEXACETONIDE
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
02246063
00030783
DEPO-TESTOSTERONE
TESTOSTERONE ENANTHATE
200MG/ML OILY INJECTION SOLUTION (ML)
00029246
DELATESTRYL
TESTOSTERONE UNDECANOATE
40MG CAPSULE
00782327
ANDRIOL
160
68:12.00 CONTRACEPTIVES
ETHINYL ESTRADIOL/D-NORGESTREL
0.05MG/0.25MG (21 TABLET)
02043033
OVRAL
WYA
$
12.6900
WYA
$
12.6900
ORG
JAN
$
12.7300
12.9800
ORG
JAN
$
12.7300
12.9800
PFI
$
13.1700
PFI
$
14.0900
WYA
$
12.7000
WYA
$
12.7000
BEX
WYA
$
11.7000
12.7000
BEX
WYA
$
11.7000
12.7000
WYA
$
12.7000
WYA
$
12.7000
02043041
OVRAL
ETHINYL ESTRADIOL/DESOGESTREL
⌧
02042487
02042541
⌧
MARVELON
ORTHO-CEPT
02042479
02042533
MARVELON
ORTHO-CEPT
ETHINYL ESTRADIOL/ETHYNODIOL DIACETATE
0.03MG/2MG (21 TABLET)
00469327
DEMULEN 30
00471526
DEMULEN 30
ETHINYL ESTRADIOL/L-NORGESTREL
02236974
ALESSE
02236975
⌧
00707600
02043726
⌧
ALESSE
0.03MG/0.05MG(6)0.04MG/0.075MG(5)
0.03MG/0.125MG(10) (21 TABLET)
TRIQUILAR
TRIPHASIL
0.03MG/0.05MG(6)0.04MG/0.075MG(5)
0.03MG/0.125MG(10) INERT TABLETS (7)
(28 TABLET)
00707503
02043734
TRIQUILAR
TRIPHASIL
02042320
MIN-OVRAL
02042339
MIN-OVRAL
161
ETHINYL ESTRADIOL/NORETHINDRONE
⌧
02187086
00317047
⌧
BREVICON
ORTHO 0.5/35
PFI
JAN
$
12.0700
12.9800
PFI
JAN
$
12.0700
12.9800
JAN
$
12.9800
JAN
$
12.9800
PFI
$
11.0900
PFI
$
11.0900
PFI
PFI
JAN
$
8.1500
12.0700
12.9800
PFI
PFI
JAN
$
8.1500
12.0700
12.9800
PFI
$
12.6800
PFI
$
12.6800
PFI
$
12.6800
PFI
$
12.6800
02187094
00340731
BREVICON
ORTHO 0.5/35
0.035MG/0.5MG (7) 0.035MG/0.75MG (7)
0.035/1.0MG (7) (21 TABLET)
00602957
ORTHO 7/7/7
0.035MG/0.5MG (7) 0.035MG/0.75MG (7)
0.035MG/1.0MG (7) INERT TABLETS (7)
(28 TABLET)
00602965
ORTHO 7/7/7
0.035MG/0.5MG(7)0.035MG/1.0MG(9)
0.035MG/0.5MG(5) (21 TABLET)
02187108
SYNPHASIC
0.035MG/0.5MG(7)0.035MG/1.0MG(9)
0.035MG/0.5MG(5) INERT TABLETS (7)
(28 TABLET)
02187116
⌧
02197502
02189054
00372846
⌧
SYNPHASIC
SELECT 1/35
BREVICON 1/35
ORTHO 1/35
02199297
02189062
00372838
SELECT 1/35
BREVICON 1/35
ORTHO 1/35
ETHINYL ESTRADIOL/NORETHINDRONE ACETATE
00315966
MINESTRIN 1/20
00343838
MINESTRIN 1/20
00297143
LOESTRIN 1.5/30
00353027
LOESTRIN 1.5/30
162
ETHINYL ESTRADIOL/NORGESTIMATE
0.035MG/0.18MG (7) 0.035MG/0.215MG (7)
0.035MG/0.25MG (7) (21 TABLET)
02028700
TRI-CYCLEN
JAN
$
12.9800
JAN
$
12.9800
JAN
$
12.9800
JAN
$
12.9800
PAL
$
8.6600
BEX
$
314.6500
JAN
$
12.9800
JAN
$
12.9800
ICN
WYA
$
0.0862
0.1151
PMS
ICN
WYA
$
0.0814
0.1055
0.1319
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
0.75MG TABLET
02241674
PLAN B
52MG EXTENDED RELEASE INTRAUTERINE INSERT
02243005
MIRENA
MESTRANOL/NORETHINDRONE
00022608
ORTHO-NOVUM 1/50
NORETHINDRONE
0.35MG (28 TABLET)
00037605
MICRONOR
68:16.00 ESTROGENS
⌧
0.3MG TABLET
02230891
02043394
⌧
0.625MG TABLET
00587281
00265470
02043408
⌧
C.E.S.
PREMARIN
0.9MG TABLET
02230892
02043416
⌧
C.E.S.
PREMARIN
C.E.S.
PREMARIN
1.25MG TABLET
00587303
00265489
02043424
C.E.S.
PREMARIN
0.625MG/G VAGINAL CREAM
02043440
PREMARIN
163
68:16.00 ESTROGENS
CONJUGATED ESTROGENS/MEDROXYPROGESTERONE
ACETATE
0.625MG/2.5MG TABLET (PACKAGE)
02242878
PREMPLUS
WYA
$
7.6000
WYA
$
7.6000
ESTRACE
RBP
$
0.1224
ESTRACE
RBP
$
0.2364
ESTRACE
RBP
$
0.4172
SCH
$
21.1600
PAL
$
65.1000
NOO
$
2.5100
$
19.8000
21.1600
21.7700
NVR
$
19.8000
RHO
$
14.8000
BEX
PAL
NVR
NVR
$
21.1600
21.1600
21.1600
23.2800
RHO
$
15.8900
NVR
$
22.7100
RHO
$
16.7100
$
23.8700
23.8700
26.2600
0.625MG/5MG TABLET (PACKAGE)
02242879
PREMPLUS
ESTRADIOL
0.5MG TABLET
02225190
1MG TABLET
02148587
2MG TABLET
02148595
0.06% TRANSDERMAL GEL SPRAY (PACKAGE)
02238704
ESTROGEL (EDS)
2MG VAGINAL RING (7.5UG/24 HOURS)
02168898
ESTRING
25UG VAGINAL TABLET
02241332
⌧
VAGIFEM
25UG TRANSDERMAL THERAPEUTIC SYSTEM (PKG)
02245676
02243722
00756849
ESTRADOT (EDS)
OESCLIM (EDS)
ESTRADERM (EDS)
NVR
PAL
NVR
37.5UG TRANSDERMAL THERAPEUTIC SYSTEM (PKG)
02243999
ESTRADOT (EDS)
50UG TRANSDERMAL PATCH (PKG)
02246967
⌧
RHOXAL-ESTRADIOL DERM(EDS)
02231509
02243724
02244000
00756857
CLIMARA 50 (EDS)
OESCLIM (EDS)
ESTRADOT (EDS)
ESTRADERM (EDS)
02246968
02244001
ESTRADOT (EDS)
02246969
⌧
02231510
02244002
00756792
CLIMARA 100 (EDS)
ESTRADOT (EDS)
ESTRADERM (EDS)
BEX
NVR
NVR
164
68:16.00 ESTROGENS
ESTRADIOL & NORETHINDRONE ACETATE/ESTRADIOL
50UG & 140UG/50UG TRANSDERMAL THERAPEUTIC
SYSTEM (8)
02243529
⌧
ESTALIS-SEQUI (EDS)
NVR
$
22.4100
NVR
NVR
$
22.4100
23.1500
THM
$
17.8600
$
23.6600
NVR
$
23.6600
PFI
$
0.1704
PFI
$
0.3043
PFI
$
0.4811
LIL
$
1.7740
SRO
$
55.9900
50UG & 250UG/50UG TRANSDERMAL THERAPEUTIC
SYSTEM (8)
02243530
02108186
ESTALIS-SEQUI (EDS)
ESTRACOMB (EDS)
ESTRADIOL VALERATE
10MG/ML OILY INJECTION SUSPENSION (5ML)
00029238
DELESTROGEN
ESTRADIOL/NORETHINDRONE ACETATE
50UG/140UG TRANSDERMAL THERAPEUTIC SYSTEM (8 )
02241835
ESTALIS (EDS)
NVR
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
68:16.12 ESTROGEN AGONIST-ANTAGONISTS
RALOXIFENE HCL
60MG TABLET
02239028
EVISTA (EDS)
68:18.00 GONADOTROPINS
CHORIONIC GONADOTROPIN
10000IU/VIAL INJECTION
01925679
PROFASI HP (EDS)
165
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
$
17.2000
18.3400
LIL
$
35.6600
LIL
$
17.2000
NOO
$
25.3300
NOO
$
50.6900
LIL
NOO
$
17.2000
18.3400
LIL
$
35.6600
LIL
$
25.6400
INSULIN (LENTE) PORK
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
⌧
00587737
02024225
HUMULIN-N
NOVOLIN GE NPH
100U/ML INJECTION SUSPENSION (5X3ML)
01959239
HUMULIN-N CARTRIDGE
INSULIN (LENTE) HUMAN BIOSYNTHETIC
00646148
HUMULIN-L
INSULIN (REGULAR) ASPART
02245397
NOVORAPID (EDS)
100U/ML INJECTION SOLUTION (5X3ML)
02244353
NOVORAPID (EDS)
INSULIN (REGULAR) HUMAN BIOSYNTHETIC
⌧
00586714
02024233
HUMULIN-R
NOVOLIN GE TORONTO
100U/ML INJECTION SOLUTION (5X3ML)
01959220
HUMULIN-R CARTRIDGE
INSULIN (REGULAR) LISPRO
02229704
HUMALOG (EDS)
166
INSULIN (REGULAR/ISOPHANE) HUMAN BIOSYNTHETIC
100U/ML INJECTION SUSPENSION 10%/90%
(5X3ML)
02024292 NOVOLIN GE 10/90 PENFILL
(5X3ML)
⌧ 100U/ML INJECTION SUSPENSION 30%/70% (10ML)
00795879 HUMULIN 30/70
02024217 NOVOLIN GE 30/70
(5X3ML)
01959212 HUMULIN 30/70 CARTRIDGE
(5X3ML)
(5X3ML)
NOO
$
36.6700
NOO
$
36.6700
LIL
NOO
$
17.2000
18.3400
LIL
$
35.6600
NOO
$
36.6700
NOO
$
36.6700
LIL
$
51.2700
$
17.2000
INSULIN (REGULAR/PROTAMINE) LISPRO
(5X3ML)
02240294 HUMALOG MIX25 (EDS)
INSULIN (ULTRALENTE) HUMAN BIOSYNTHETIC
00733075 HUMULIN-U
LIL
68:20.20 ANTI-DIABETIC DRUGS (ORAL HYPOGLYCEMICS)
ACARBOSE
50MG TABLET
02190885
PRANDASE
BAY
$
0.2575
BAY
$
0.3559
100MG TABLET
02190893
PRANDASE
167
CHLORPROPAMIDE
100MG TABLET
00399302
APO-CHLORPROPAMIDE
APX
$
0.0782
NOP
APX
$
0.0454
0.1075
NU-GLYBURIDE
EUGLUCON
GEN-GLYBE
RATIO-GLYBURIDE
APO-GLYBURIDE
NOVO-GLYBURIDE
PMS-GLYBURIDE
RHOXAL-GLYBURIDE
PREM-GLYBURIDE
DOM-GLYBURIDE
DIABETA
NXP
PMS
GPM
RPH
APX
NOP
PMS
RHO
PRM
DOM
AVT
$
0.0333 *
0.0427
0.0427
0.0427
0.0427
0.0427
0.0427
0.0427
0.0427
0.0449
0.1144
NU-GLYBURIDE
PREM-GLYBURIDE
EUGLUCON
GEN-GLYBE
RATIO-GLYBURIDE
APO-GLYBURIDE
NOVO-GLYBURIDE
PMS-GLYBURIDE
RHOXAL-GLYBURIDE
DOM-GLYBURIDE
DIABETA
NXP
PRM
PMS
GPM
RPH
APX
NOP
PMS
RHO
DOM
AVT
$
0.0580 *
0.0741
0.0741
0.0741
0.0741
0.0741
0.0741
0.0741
0.0741
0.0778
0.2051
ICN
NOP
GPM
NXP
APX
PMS
PRM
ZYP
RPH
RHO
DOM
AVT
$
0.0684 *
0.1320
0.1320
0.1320
0.1320
0.1320
0.1320
0.1320
0.1320
0.1320
0.1504
0.2094
* 250MG TABLET
00021350
00312711
NOVO-PROPAMIDE
APO-CHLORPROPAMIDE
GLYBURIDE
* 2.5MG TABLET
02020734
00720933
00808733
01900927
01913654
01913670
02236733
02248008
02230036
02234513
02224550
* 5MG TABLET
02020742
02230037
00720941
00808741
01900935
01913662
01913689
02236734
02248009
02234514
02224569
METFORMIN
* 500MG TABLET
02229516
02045710
02148765
02162822
02167786
02223562
02230026
02242794
02242974
02246820
02229994
02099233
GLYCON
NOVO-METFORMIN
GEN-METFORMIN
NU-METFORMIN
APO-METFORMIN
PMS-METFORMIN
PREM-METFORMIN
METFORMIN
RATIO-METFORMIN
RHOXAL-METFORMIN FC
DOM-METFORMIN
GLUCOPHAGE
168
* 850MG TABLET
02229517
02229656
02229785
02230027
02230475
02242589
02242793
02242931
02246821
02242726
02162849
NU-METFORMIN
GEN-METFORMIN
APO-METFORMIN
PREM-METFORMIN
NOVO-METFORMIN
PMS-METFORMIN
METFORMIN
RATIO-METFORMIN
RHOXAL-METFORMIN FC
DOM-METFORMIN
GLUCOPHAGE
NXP
GPM
APX
PRM
NOP
PMS
ZYP
RPH
RHO
DOM
AVT
$
0.1773 *
0.2268
0.2268
0.2268
0.2268
0.2268
0.2268
0.2268
0.2268
0.2382
0.3025
NVR
$
0.5859
NVR
$
0.5859
NVR
$
0.5859
LIL
$
2.1375
LIL
$
2.9946
LIL
$
4.4834
GLUCONORM (EDS)
NOO
$
0.2849
GLUCONORM (EDS)
NOO
$
0.2962
GLUCONORM (EDS)
NOO
$
0.3076
AVANDIA (EDS)
GSK
$
1.3346
AVANDIA (EDS)
GSK
$
2.0941
AVANDIA (EDS)
GSK
$
2.9946
NATEGLINIDE
60MG TABLET
02245438
STARLIX (EDS)
120MG TABLET
02245439
STARLIX (EDS)
180MG TABLET
02245440
STARLIX (EDS)
PIOGLITAZONE HCL
15MG TABLET
02242572
ACTOS (EDS)
30MG TABLET
02242573
ACTOS (EDS)
45MG TABLET
02242574
ACTOS (EDS)
REPAGLINIDE
0.5MG TABLET
02239924
1MG TABLET
02239925
2MG TABLET
02239926
ROSIGLITAZONE MALEATE
2MG TABLET
02241112
4MG TABLET
02241113
8MG TABLET
02241114
169
TOLBUTAMIDE
500MG TABLET
00312762
APO-TOLBUTAMIDE
APX
$
0.0896
FEI
$
8.4900
APX
AVT
$
31.6500
45.2200
APX
NVR
$
21.2700
26.5900
NVR
$
25.4000
FEI
$
1.4341
FEI
$
2.8681
FEI
$
11.5100
FEI
$
51.2200
$
71.7000
102.4300
$
416.0000
68:24.00 PARATHYROID
CALCITONIN SALMON
100IU/ML INJECTION (1ML)
02007134
CALTINE 100 (EDS)
* 200IU/ML INJECTION (2ML)
02246058
01926691
APO-CALCITONIN (EDS)
CALCIMAR (EDS)
* 200IU/DOSE NASAL SPRAY (BOTTLE)
02247585
02240775
MIACALCIN (EDS)
68:28.00 PITUITARY AGENTS
COSYNTROPIN ZINC HYDROXIDE
1MG/ML INJECTION SUSPENSION (1ML)
00253952
SYNACTHEN DEPOT
DESMOPRESSIN
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)
FEI
170
68:28.00 PITUITARY AGENTS
SOMATREM
5MG INJECTION (VIAL)
02204584
PROTROPIN (EDS)
HLR
$
205.9000
SRO
$
136.7100
HLR
SRO
LIL
$
195.9000
205.2300
238.3500
LIL
$
303.8300
HLR
HLR
$
386.8000
411.8000
LIL
$
590.2400
SOMATROPIN
3.33MG INJECTION (VIAL)
02215136
⌧
SAIZEN (EDS)
02216183
02237971
00745626
NUTROPIN (EDS)
SAIZEN (EDS)
HUMATROPE (EDS)
6MG INJECTION (CARTRIDGE)
02243077
⌧
HUMATROPE CARTRIDGE (EDS)
02229722
02216191
NUTROPIN AQ (EDS)
NUTROPIN (EDS)
12MG INJECTION (CARTRIDGE)
02243078
68:32.00 PROGESTINS
CONJUGATED ESTROGENS/MEDROXYPROGESTERONE
ACETATE
SEE SECTION 68:16.00 (ESTROGENS)
ESTRADIOL & NORETHINDRONE ACETATE/ESTRADIOL
ESTRADIOL/NORETHINDRONE ACETATE
171
68:32.00 PROGESTINS
MEDROXYPROGESTERONE ACETATE
* 2.5MG TABLET
02148552
02221284
02229838
02244726
02246627
02247581
00708917
RATIO-MPA
NOVO-MEDRONE
GEN-MEDROXY
APO-MEDROXY
PMS-MEDROXYPROGESTERONE
DOM-MEDROXYPROGESTERONE
PROVERA
RPH
NOP
GPM
APX
PMS
DOM
PFI
$
0.0862
0.0862
0.0862
0.0862
0.0862
0.0905
0.1737
RATIO-MPA
NOVO-MEDRONE
GEN-MEDROXY
APO-MEDROXY
PROVERA
RPH
NOP
GPM
APX
PMS
DOM
PFI
$
0.1703
0.1703
0.1703
0.1703
0.1703
0.1788
0.3436
RPH
NOP
GPM
PMS
DOM
PFI
$
0.3439
0.3439
0.3439
0.3439
0.3611
0.6970
PFI
$
26.2500
PFI
$
28.1600
SCH
$
0.8900
* 5MG TABLET
02148560
02221292
02229839
02244727
02246628
02247582
00030937
* 10MG TABLET
02148579
02221306
02229840
02246629
02247583
00729973
RATIO-MPA
NOVO-MEDRONE
GEN-MEDROXY
PROVERA
00030848
DEPO-PROVERA
00585092
DEPO-PROVERA
PROGESTERONE (MICRONIZED)
100MG CAPSULE
02166704
PROMETRIUM (EDS)
172
68:36.04 THYROID AGENTS
LEVOTHYROXINE (SODIUM)
0.025MG TABLET
02172062
SYNTHROID
ABB
$
0.0836
GSK
ABB
$
0.0431
0.0574
ABB
$
0.0902
ABB
$
0.0902
GSK
ABB
$
0.0332
0.0708
ABB
$
0.0952
ABB
$
0.0964
GSK
ABB
$
0.0369
0.0758
ABB
$
0.1033
GSK
ABB
$
0.0391
0.0809
GSK
ABB
$
0.0934
0.1116
THM
$
0.1047
THM
$
0.1270
PFI
$
0.0401
PFI
$
0.0497
PFI
$
0.0634
* 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
173
68:36.08 ANTITHYROID AGENTS
METHIMAZOLE
5MG TABLET
00015741
TAPAZOLE
PAL
$
0.2510
PAL
$
0.1311
PAL
$
0.2051
PROPYLTHIOURACIL
50MG TABLET
00010200
PROPYL-THYRACIL
100MG TABLET
00010219
PROPYL-THYRACIL
174
SKIN AND MUCOUS MEMBRANE
AGENTS
84:00
84:00 SKIN AND MUCOUS MEMBRANE AGENTS
CLINDAMYCIN PHOSPHATE
1% TOPICAL SOLUTION
00582301
DALACIN T
PFI
$
0.3190
WSD
$
0.1741
GAC
$
0.1549
WSD
$
0.1872
WSD
$
0.1872
ERF
$
1.0254
ERF
$
3.0869
FUCIDIN
LEO
$
0.6260
BACTROBAN
GCH
$
0.5512
GCH
$
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
00666122
NEOSPORIN
GSK
$
0.4652
GSK
$
0.4652
LEO
$
0.6260
POLYMYXIN B SO4/NEOMYCIN SO4/GRAMICIDIN
10,000U/5MG/0.25MG PER G TOPICAL CREAM
00666203
NEOSPORIN
SODIUM FUSIDATE
2% TOPICAL OINTMENT
00586676
FUCIDIN
176
84:04.08 ANTI-INFECTIVES (ANTI-FUNGALS)
CICLOPIROX OLAMINE
1% TOPICAL CREAM
02221802
LOPROX
AVT
$
0.5968
AVT
$
0.5498
BCD
$
13.1100
TAR
BCD
$
0.2308
0.3705
TAR
BCD
$
0.1899
0.2400
TAR
BCD
$
0.3798
0.4800
BCD
$
13.1100
WSD
$
6.0689
WSD
$
0.4630
OPT
MCL
$
0.3437
0.5162
1% TOPICAL LOTION
02221810
LOPROX
CLOTRIMAZOLE
200MG VAGINAL TABLET
02150921
CANESTEN-3-COMBI-PAK
* 1% TOPICAL CREAM
00812382
02150867
CLOTRIMADERM
CANESTEN
* 1% VAGINAL CREAM
00812366
02150891
CLOTRIMADERM
CANESTEN-6
* 2% VAGINAL CREAM
00812374
02150905
CLOTRIMADERM
CANESTEN-3
500MG VAGINAL SUPPOSITORY/1% TOPICAL CREAM
(COMBINATION PACKAGE)
02150948
ECONAZOLE NITRATE
150MG VAGINAL SUPPOSITORY
02010267
ECOSTATIN
1% TOPICAL CREAM
02011948
ECOSTATIN
KETOCONAZOLE
* 2% TOPICAL CREAM
02245662
00703974
KETODERM
NIZORAL
177
MICONAZOLE NITRATE
02084295
MONISTAT-7
MCL
$
1.7222
MCL
$
13.8000
MCL
$
4.0182
MCL
$
13.8000
MCL
$
0.3445
MCL
$
0.3849
RPH
$
0.1519
TAR
RPH
PPZ
$
0.0760
0.0760
0.3038
TAR
RPH
$
0.1556
0.1556
TAR
PPZ
$
0.0534
0.0955
RPH
$
0.2771
WSD
$
0.4109
NVR
$
0.5046
NVR
$
0.5046
100MG VAGINAL SUPPOSITORY/2% TOPICAL CREAM
02126257
MONISTAT 7 COMBINATION
400MG VAGINAL OVULES
02126605
MONISTAT-3
400MG VAGINAL OVULES/2% TOPICAL CREAM
02126249
2% VAGINAL CREAM
02084309
MONISTAT-7
2% TOPICAL CREAM
02085852
MICATIN
NYSTATIN
100,000U VAGINAL TABLET
02194171
RATIO-NYSTATIN
* 100,000U/G TOPICAL CREAM
00716871
02194236
00029092
NYADERM
RATIO-NYSTATIN
MYCOSTATIN
* 100,000U/G TOPICAL OINTMENT
00716898
02194228
NYADERM
RATIO-NYSTATIN
* 25,000U/G VAGINAL CREAM
00716901
00295973
NYADERM
MYCOSTATIN
100,000U/G VAGINAL CREAM
02194163
RATIO-NYSTATIN
100,000U/G TOPICAL POWDER
02195704
CANDISTATIN
TERBINAFINE HCL
1% TOPICAL CREAM
02031094
LAMISIL
1% TOPICAL SPRAY SOLUTION
02238703
LAMISIL
178
TERCONAZOLE
80MG VAGINAL OVULES
00894710
TERAZOL-3
JAN
$
6.5897
JAN
$
19.7700
JAN
$
19.7700
JAN
$
19.7700
80MG VAGINAL OVULES/0.8% CREAM (DUAL-PAK)
02130874
TERAZOL-3 DUAL-PAK
0.4% VAGINAL CREAM (PKG)
00894729
TERAZOL-7
0.8% VAGINAL CREAM (PKG)
01934155
TERAZOL-3
84:04.12 ANTI-INFECTIVES (SCABICIDES AND PEDICULICIDES)
CROTAMITON
10% TOPICAL CREAM
00623377
EURAX
CLC
$
0.3854
PMS
$
0.1270
ODN
PMS
$
0.1216
0.1270
GCH
IPC
$
0.1129
0.1185
GCH
$
0.4991
GCH
$
0.2843
GCH
$
0.1027
GAMMA-BENZENE HEXACHLORIDE
1% TOPICAL LOTION
00703591
PMS-LINDANE
* 1% SHAMPOO
00430617
00703605
HEXIT SHAMPOO
PMS-LINDANE
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
179
84:04.16 MISCELLANEOUS ANTI-INFECTIVES
HEXACHLOROPHENE
3% TOPICAL EMULSION
02017733
PHISOHEX
SAW
$
0.0620
GAC
$
0.7064
GAC
$
0.5354
DER
$
0.5357
STI
$
0.5357
MDA
$
0.2752
ROP
$
0.2189
PFR
$
0.7945
PFR
$
0.0468
$
0.5074
METRONIDAZOLE
0.75% TOPICAL GEL
02092832
METROGEL
0.75% TOPICAL CREAM
02226839
METROCREAM
1% TOPICAL CREAM
02156091
NORITATE
1% TOPICAL CREAM (WITH SUNSCREEN)
02242919
ROSASOL
0.75% VAGINAL GEL
02125226
NIDAGEL
10% VAGINAL CREAM
01926861
FLAGYL
POVIDONE-IODINE
00026050
BETADINE
10% VAGINAL SOLUTION
00026093
BETADINE
SULFACETAMIDE (SODIUM)/COLLOIDAL SULPHUR
02220407
SULFACET-R
DER
SEE INSERT THIS SECTION FOR TABLES SHOWING APPROXIMATE
RELATIVE POTENCIES OF TOPICAL STEROID PREPARATIONS, RELATIVE
RATES OF PENETRATION IN DIFFERENT ANATOMICAL SITES AND
SUGGESTED GUIDELINES FOR TOPICAL STEROID THERAPY
180
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.
181
APPROXIMATE
RELATIVE POTENCIES
of
TOPICAL STEROID
PREPARATIONS
The classification of products in this table is based on The Rx Files Topical Corticosteroids: Comparison Chart July 2003. Available from:
http://www.rxfiles.ca/acrobat/CHT-SteroidClassPotencyCOLOR.pdf
(Access verified May 20, 2004)
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.
182
ULTRA
HIGH
POTENCY
HIGH
POTENCY
GROUP
I
Betamethasone dipropionate 0.05% glycol cream, ointment,
lotion
Betamethasone dipropionate 0.05%/salicylic acid 3%
ointment
Clobetasol propionate 0.05% cream, ointment, scalp lotion
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
Triamcinolone acetonide 0.1% ointment
Mometasone furoate 0.1%, ointment
GROUP
IV
Amcinonide 0.1% cream, lotion
Beclomethasone dipropionate 0.025% cream, lotion
Clobetasone butyrate, 0.05% cream, ointment
Desoximetasone 0.05% cream
Diflucortolone valerate,0.1%, cream, ointment
Fluocinolone acetonide 0.025% ointment
Hydrocortisone valerate 0.2% ointment
Mometasone furoate 0.1% cream,, lotion
Triamcinolone acetonide 0.1% cream
MID
POTENCY
GROUP
V
GROUP
VI
LOW
POTENCY
GROUP
VII
Betamethasone valerate 0.1% cream, lotion
Betamethasone valerate 0.05% cream, ointment, lotion
Fluocinolone acetonide 0.01% cream, solution, shampoo
Fluocinolone acetonide 0.025% cream
Hydrocortisone valerate 0.2% cream
Triamcinolone acetonide 0.025% cream
Desonide 0.05% cream, ointment, lotion
Hydrocortisone/Urea 1%/10%, cream, lotion
Hydrocortisone
2.5% cream, lotion, scalp solution
1% cream, ointment, lotion
0.5% lotion
183
RELATIVE RATES OF PERCUTANEOUS PENETRATION IN
DIFFERENT ANATOMICAL SITES
(Based on hydrocortisone/forearm = 1)
RELATIVE
PENETRATION
0.14
0.83
1.0
1.7
3.5
6.0
13.0
42.0
SITE
Foot (plantar)
Palm
Forearm
Back
Scalp
Forehead
Jaw angle/cheeks
Scrotum
Arndt, K.A., Manual of Dermatological
Therapeutics, 2nd Edition, p. 293
GUIDE TO TOPICAL QUANTITIES IN DERMATOLOGY
Amount used three times daily for one week, average adult.
SITE
% BODY
SURFACE
VANISHING
CREAM
GREASE
BASE
SHAKE
LOTION
THIN
(NON SHAKE
LOTION)
PROPYLENE
GLYCOL
ONE WHOLE
HAND or
FOOT
2%
7.5g
10g
20mL
5mL
15mL
ONE WHOLE
ARM
9%
30g
45g
90mL
24mL
60mL
TRUNK
36%
120g
180g
360mL
90mL
240mL
GENITAL
AREA
1%
7.5g
5g
not used
here
5mL
7.5mL
ONE TOTAL
LEG
18%
60g
90g
180mL
45mL
120mL
TOTAL FACE
4.5%
15g
20g
40mL
10mL
30mL
BODY
100%
375g
500g
1000mL
240mL
750mL
184
AMCINONIDE
* 0.1% TOPICAL CREAM
02246714
02247098
02192284
AMCORT
RATIO-AMCINONIDE
CYCLOCORT
OPT
RPH
STI
$
0.2973
0.2973
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
0.025% TOPICAL CREAM
02089602
PROPADERM
0.025% TOPICAL LOTION
02089610
PROPADERM
BETAMETHASONE DIPROPIONATE
PENETRATION OF ACTIVE DRUG THROUGH THE EPIDERMIS IS ENHANCED
BY THE PROPYLENE GLYCOL BASE, RESULTING IN INCREASED POTENCY,
BECAUSE OF THE DIFFERENCE IN POTENCY YET SIMILARITY OF THE NAMES
(DIPROSONE-DIPROLENE) EXTRA CAUTION IS ADVISED.
00323071
01925350
DIPROSONE
TARO-SONE
PMS
TAR
$
0.2222
0.2222
PMS
RPH
$
0.2337
0.2337
SCH
RPH
TAR
$
0.2149
0.2149
0.2149
SCH
RPH
$
0.5628
0.5628
SCH
RPH
$
0.5628
0.5628
SCH
RPH
$
0.5083
0.5083
* 0.05% TOPICAL OINTMENT
00344923
00805009
DIPROSONE
RATIO-TOPISONE
* 0.05% TOPICAL LOTION
00417246
00809187
01944444
DIPROSONE
RATIO-TOPISONE
TARO-SONE
* 0.05% TOPICAL GLYCOL CREAM
00688622
00849650
DIPROLENE
RATIO-TOPILENE
* 0.05% TOPICAL GLYCOL OINTMENT
00629367
00849669
DIPROLENE
RATIO-TOPILENE
* 0.05% TOPICAL GLYCOL LOTION
00862975
01927914
DIPROLENE
RATIO-TOPILENE
185
BETAMETHASONE DIPROPIONATE/
SALICYLIC ACID
0.05%/3% TOPICAL OINTMENT
00578436
DIPROSALIC
SCH
$
0.7697
SCH
RPH
$
0.3824
0.3824
RBP
$
9.2600
RPH
SCH
TAR
$
0.0167
0.0167
0.0167
PMS
RPH
TAR
$
0.0248
0.0248
0.0248
SCH
$
0.0167
SCH
$
0.0248
RPH
$
0.2062
RPH
$
0.2713
SCH
RPH
TAR
$
0.0927
0.0927
0.0927
AST
$
8.6100
RPH
GPM
NOP
PMS
TAR
OPT
$
0.4414
0.4414
0.4414
0.4414
0.4414
0.8131
* 0.05%/2% TOPICAL LOTION
00578428
02245688
DIPROSALIC
RATIO-TOPISALIC
BETAMETHASONE DISODIUM PHOSPHATE
5MG/100ML ENEMA (100ML)
02060884
BETNESOL ENEMA
BETAMETHASONE VALERATE
00535427
00027898
00716618
RATIO-ECTOSONE
CELESTODERM-V/2
BETADERM
00027901
00535435
00716626
CELESTODERM-V
RATIO-ECTOSONE
BETADERM
00028355
CELESTODERM-V/2
00028363
CELESTODERM-V
00653209
RATIO-ECTOSONE MILD
0.1% TOPICAL LOTION
00750050
RATIO-ECTOSONE
* 0.1% SCALP LOTION
00027944
00653217
00716634
VALISONE
RATIO-ECTOSONE
BETADERM
BUDESONIDE
0.02MG/ML ENEMA (100ML)
02052431
ENTOCORT
CLOBETASOL PROPIONATE
01910272
02024187
02093162
02232191
02245523
02213265
RATIO-CLOBETASOL
GEN-CLOBETASOL
NOVO-CLOBETASOL
PMS-CLOBETASOL
DERMOVATE
186
02026767
02126192
02232193
02245524
02213273
GEN-CLOBETASOL
NOVO-CLOBETASOL
PMS-CLOBETASOL
DERMOVATE
GPM
NOP
PMS
TAR
OPT
$
0.4414
0.4414
0.4414
0.4414
0.8131
GPM
PMS
TAR
RPH
OPT
$
0.3868
0.3868
0.3868
0.3871
0.7834
GCH
$
0.4774
GCH
$
0.4774
PMS
GAC
PMS
$
0.2837
0.3147
0.4210
PMS
GAC
PMS
$
0.2837
0.3147
0.4196
GAC
$
0.1574
AVT
$
0.4530
AVT
$
0.6538
AVT
$
0.5371
AVT
$
0.6538
STI
$
0.3943
STI
$
0.3943
STI
$
0.3943
* 0.05% SCALP APPLICATION
02216213
02232195
02245522
01910299
02213281
GEN-CLOBETASOL
PMS-CLOBETASOL
RATIO-CLOBETASOL
DERMOVATE
CLOBETASONE BUTYRATE
0.05% TOPICAL CREAM
02214415
EUMOVATE
02214423
EUMOVATE
DESONIDE
02229315
02048639
02154862
PMS-DESONIDE
DESOCORT
TRIDESILON
02229323
02115522
02154870
PMS-DESONIDE
DESOCORT
TRIDESILON
02115514
DESOCORT
DESOXIMETASONE
0.05% TOPICAL CREAM
02221918
TOPICORT MILD
0.25% TOPICAL CREAM
02221896
TOPICORT
0.05% TOPICAL GEL
02221926
TOPICORT
02221934
TOPICORT
DIFLUCORTOLONE VALERATE
0.1% TOPICAL CREAM
00587826
NERISONE
0.1% TOPICAL OILY CREAM
00587818
NERISONE
00587834
NERISONE
187
FLUOCINOLONE ACETONIDE
0.01% TOPICAL CREAM
00716782
FLUODERM
TAR
$
0.0703
TAR
$
0.3364
TAR
MDC
$
0.0965
0.4676
MDC
$
0.4440
HDI
$
0.2681
GAC
$
0.2704
OPT
MDC
$
0.5007
0.5010
OPT
MDC
$
0.3711
0.5561
OPT
MDC
$
0.3657
0.5525
MDC
$
0.6041
WSD
$
0.5773
WSD
$
0.5295
WSD
$
0.4451
WSD
$
0.8160
WSD
$
0.8160
00716790
FLUODERM
00716812
02162512
FLUODERM
SYNALAR REGULAR
0.01% TOPICAL SOLUTION
02162504
SYNALAR
0.01% TOPICAL OIL
00873292
DERMA-SMOOTHE/FS
0.01% SHAMPOO
02242738
CAPEX SHAMPOO
FLUOCINONIDE
00716863
02161923
LYDERM
LIDEX
* 0.05% TOPICAL GEL
02236997
02161974
LYDERM
TOPSYN
02236996
02161966
LYDERM
LIDEX
0.05% IN EMOLLIENT BASE
02163152
LIDEMOL
HALCINONIDE
0.1% TOPICAL CREAM
02011921
HALOG
02010283
HALOG
02010291
HALOG
HALOBETASOL PROPIONATE
0.05% CREAM
01962701
ULTRAVATE (EDS)
0.05% OINTMENT
01962728
ULTRAVATE (EDS)
188
HYDROCORTISONE
00513288
00716820
CORTATE
HYDERM
SCP
TAR
$
0.1448
0.1809
PMS
TAR
STI
$
0.0198
0.0198
0.1718
STI
$
0.2344
SCP
TAR
$
0.1448
0.1809
SCH
TAR
$
0.0212
0.0212
SCP
$
0.1177
STI
STI
$
0.0938
0.1587
STI
STI
$
0.1812
0.2099
STI
$
0.1985
ICN
AXC
$
5.5800
6.5700
PAL
$
92.3000
WSD
OPT
$
0.1809
0.1809
WSD
OPT
$
0.1809
0.1809
* 1% TOPICAL CREAM
00502200
00716839
00192597
CORTATE
HYDERM
EMO-CORT
2.5% TOPICAL CREAM
00595799
EMO-CORT
00513261
00716685
CORTATE
CORTODERM
* 1% TOPICAL OINTMENT
00502197
00716693
CORTATE
CORTODERM
0.5% TOPICAL LOTION
00513253
⌧
00578541
00192600
⌧
CORTATE
1% TOPICAL LOTION
SARNA HC
EMO-CORT
2.5% TOPICAL LOTION
00856711
00595802
SARNA HC
EMO-CORT
2.5% SCALP SOLUTION
00641154
EMO-CORT
* 100MG/60ML ENEMA (60ML)
00230316
02112736
HYCORT
CORTENEMA
HYDROCORTISONE ACETATE
10% RECTAL AEROSOL FOAM (15G)
00579335
CORTIFOAM
HYDROCORTISONE VALERATE
01910124
02242984
WESTCORT
HYDROVAL
01910132
02242985
WESTCORT
HYDROVAL
189
HYDROCORTISONE/UREA
1%/10% TOPICAL CREAM
00503134
UREMOL-HC
STI
$
0.1747
STI
$
0.0970
SCH
$
0.6940
PMS
RPH
SCH
$
0.4209
0.4209
0.6940
SCH
$
0.5397
TAR
$
0.0504
TAR
STI
WSD
$
0.1411
0.1411
0.3664
TAR
STI
WSD
$
0.1411
0.1411
0.3664
TAR
WSD
$
1.1718
1.4431
00560022
UREMOL-HC
MOMETASONE FUROATE
0.1% TOPICAL CREAM
00851744
ELOCOM
02244769
02248130
00851736
PMS-MOMETASONE
RATIO-MOMETASONE
ELOCOM
0.1% TOPICAL LOTION
00871095
ELOCOM
00716952
TRIADERM
00716960
02194058
01999818
TRIADERM
ARISTOCORT R
KENALOG
00716987
02194031
01999796
TRIADERM
ARISTOCORT R
KENALOG
* 0.1% ORAL TOPICAL OINTMENT
01964054
01999788
ORACORT DENTAL PASTE
KENALOG-ORABASE
BETAMETHASONE DIPROPIONATE/CLOTRIMAZOLE
0.05%/1% TOPICAL CREAM
00611174
LOTRIDERM
SCH
$
0.6706
LEO
$
1.0446
FUSIDIC ACID/HYDROCORTISONE ACETATE
2%/1% TOPICAL CREAM
02238578
FUCIDIN H
190
NEOMYCIN/GRAMICIDIN/NYSTATIN/
2.5MG/0.25MG/100,000U/0.25MG PER G
TOPICAL CREAM
01999842
KENACOMB MILD
WSD
$
0.6312
TAR
WSD
$
0.4594
0.8934
WSD
$
0.6312
TAR
WSD
$
0.4594
0.8934
GSK
$
0.7828
* 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
POLYMYXIN B SO4/BACITRACIN (ZINC)/
5000U/400U/5MG/10MG PER G TOPICAL OINTMENT
00666246
CORTISPORIN
84:08.00 ANTIPRURITICS AND LOCAL ANAESTHETICS
PHENAZOPYRIDINE
100MG TABLET
00271489
PHENAZO
ICN
$
0.1281
ICN
$
0.1598
$
0.7487
200MG TABLET
00454583
PHENAZO
84:12.00 ASTRINGENTS
ALUMINUM ACETATE/BENZETHONIUM CHLORIDE
0.35%/0.023% POWDER (2.36G PACKAGE)
00579947
BURO-SOL
STI
191
84:16.00 CELL STIMULANTS AND PROLIFERANTS
CONDITIONS OTHER THAN ACNE VULGARIS ARE NOT APPROVED
INDICATIONS FOR THE USE OF TOPICAL RETINOIDS.
ADAPALENE
0.1% TOPICAL CREAM
02231592
DIFFERIN
GAC
$
0.6610
GAC
$
0.6610
STI
DER
JAN
$
0.3082
0.3082
0.4019
STI
DER
JAN
$
0.3082
0.3082
0.3896
STI
DER
JAN
$
0.3082
0.3082
0.4019
STI
DER
JAN
$
0.3082
0.3082
0.3896
STI
$
0.1932
STI
DER
JAN
$
0.3090
0.3090
0.3896
STI
DER
$
0.3082
0.3082
STI
$
0.1932
STI
DER
JAN
$
0.3082
0.3082
0.4019
0.1% TOPICAL GEL
02148749
DIFFERIN
TRETINOIN
00657204
01926497
00897329
STIEVA-A
VITAMIN A ACID
RETIN A
* 0.01% TOPICAL GEL
00587958
01926462
00870013
STIEVA-A
VITAMIN A ACID
RETIN A
00578576
01926500
00897310
STIEVA-A
VITAMIN A ACID
RETIN A
* 0.025% TOPICAL GEL
00587966
01926470
00443816
STIEVA-A
VITAMIN A ACID
RETIN A
00578568
STIEVA-A
00518182
01926519
00443794
STIEVA-A
VITAMIN A ACID
RETIN A
* 0.05% TOPICAL GEL
00641863
01926489
STIEVA-A
VITAMIN A ACID
00518174
STIEVA-A
00662348
01926527
00870021
STIEVA-A FORTE (EDS)
VITAMIN A ACID (EDS)
RETIN A (EDS)
192
84:28.00 KERATOLYTIC AGENTS
BENZOYL PEROXIDE
10% BAR
00527661
PANOXYL
STI
$
9.1400
ICN
STI
$
0.1677
0.1910
BENOXYL
OXYDERM
STI
ICN
$
0.2122
0.2176
DESQUAM-X
BENZAC W
WSD
GAC
$
0.0554
0.0573
VAL
$
0.1492
STI
DER
$
0.1492
0.1511
WSD
GAC
GAC
$
0.1091
0.1525
0.1525
STI
$
0.1806
STI
$
0.1945
STI
$
0.9353
MTI
$
0.6094
MTI
$
0.6424
MTI
$
0.7595
MTI
$
0.8296
MTI
$
0.8752
* 10% TOPICAL LOTION
00432938
00370568
OXYDERM
BENOXYL
* 20% TOPICAL LOTION
00187585
00374318
⌧
10% WASH
01908901
01925199
10% TOPICAL GEL (ACETONE BASE)
00406848
⌧
00263699
02220385
⌧
ACETOXYL
10% TOPICAL GEL (ALCOHOL BASE)
PANOXYL-10
BENZAGEL
10% TOPICAL GEL (AQUEOUS BASE)
01908871
01912437
01925997
DESQUAM-X
BENZAC AC
BENZAC-W
00403571
PANOXYL-15
00373036
PANOXYL-20
CLINDAMYCIN PHOSPHATE/BENZOYL PEROXIDE
1%5% TOPICAL GEL
02243158
CLINDOXYL GEL
DITHRANOL
0.1% TOPICAL CREAM
00537594
ANTHRANOL
0.2% TOPICAL CREAM
00537608
ANTHRANOL
0.4% TOPICAL LOTION
00695351
ANTHRASCALP
1% TOPICAL OINTMENT
00566756
ANTHRAFORTE-1
2% TOPICAL OINTMENT
00566748
ANTHRAFORTE-2
193
84:28.00 KERATOLYTIC AGENTS
ERYTHROMYCIN/BENZOYL PEROXIDE
3%/5% TOPICAL GEL
02225271
BENZAMYCIN
DER
$
0.9389
CDX
PAL
$
40.1500
41.6300
PODOFILOX
⌧
0.5% TOPICAL SOLUTION (PACKAGE)
01945149
02074788
CONDYLINE
WARTEC
84:36.00 MISCELLANEOUS SKIN & MUCOUS MEMBRANE
AGENTS
ACITRETIN
10MG CAPSULE
02070847
SORIATANE (EDS)
HLR
$
1.6782
HLR
$
3.0952
WYA
DBU
RPH
$
0.6863
0.6863
0.6863
LEO
$
0.7568
LEO
$
0.7568
LEO
$
0.7568
25MG CAPSULE
02070863
SORIATANE (EDS)
AMETHOPTERIN
* 2.5MG TABLET
02170698
02182963
02244798
METHOTREXATE
APO-METHOTREXATE
RATIO-METHOTREXATE
CALCIPOTRIOL
50UG/G TOPICAL CREAM
02150956
DOVONEX
50UG/G TOPICAL OINTMENT
01976133
DOVONEX
50UG/ML SCALP SOLUTION
02194341
DOVONEX
194
AGENTS
CYCLOSPORINE
NOTE: THE IDENTIFICATION NUMBERS LISTED FOR THIS PRODUCT HAVE
BEEN GENERATED BY THE PRESCRIPTION DRUG PLAN FOR BILLING
PURPOSES ONLY.
10MG CAPSULE
00950792
NEORAL (EDS)
NVR
$
0.6637
NVR
$
1.5426
NVR
$
3.0073
NVR
$
6.0164
NVR
$
5.3480
ICN
$
0.8680
HLR
$
1.8529
HLR
$
3.7809
NVR
$
2.1266
FUJ
$
2.3330
FUJ
$
2.4960
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
PIMECROLIMUS
1% TOPICAL CREAM
02247238
ELIDEL (EDS)
TACROLIMUS
02244149
PROTOPIC (EDS)
02244148
PROTOPIC (EDS)
195
AGENTS
TAZAROTENE
0.05% TOPICAL CREAM
02243894
TAZORAC
ALL
$
1.3961
ALL
$
1.3961
ALL
$
1.3961
ALL
$
1.3961
0.05% TOPICAL GEL
02230784
TAZORAC
0.1% TOPICAL CREAM
02243895
TAZORAC
0.1% TOPICAL GEL
02230785
TAZORAC
84:50.06 DEPIGMENTING & PIGMENTING AGENTS
(PIGMENTING AGENTS)
METHOXSALEN
⌧
10MG CAPSULE
00252654
00646237
01946374
⌧
OXSORALEN ULTRA (EDS)
ULTRAMOP (EDS)
OXSORALEN (EDS)
ICN
CDX
ICN
$
0.4666
0.5160
0.8181
ULTRAMOP (EDS)
OXSORALEN (EDS)
CDX
ICN
$
1.1198
1.5939
1% LOTION
00698059
01907476
196
SMOOTH MUSCLE RELAXANTS
86:00
86:00 SMOOTH MUSCLE RELAXANTS
86:12.00 GENITOURINARY SMOOTH MUSCLE RELAXANTS
FLAVOXATE HCL
* 200MG TABLET
02244842
02245480
00728179
APO-FLAVOXATE (EDS)
PMS-FLAVOXATE (EDS)
URISPAS (EDS)
APX
PMS
PAL
$
0.3377
0.3377
0.5360
DOM
NXP
APX
ICN
NOP
GPM
PMS
JAN
$
0.1662 *
0.2697
0.2697
0.2697
0.2697
0.2697
0.2697
0.4452
PMS
APX
JAN
$
0.0675
0.0675
0.0964
PFI
$
1.9747
PFI
$
1.9747
OXYBUTYNIN CHLORIDE
* 5MG TABLET
02241285
02158590
02163543
02220059
02230394
02230800
02240550
01924761
DOM-OXYBUTYNIN
NU-OXYBUTYN
APO-OXYBUTYNIN
OXYBUTYN
NOVO-OXYBUTYNIN
GEN-OXYBUTYNIN
PMS-OXYBUTYNIN
DITROPAN
* 1MG/ML SYRUP
02223376
02231089
01924753
PMS-OXYBUTYNIN
APO-OXYBUTYNIN
DITROPAN
TOLTERODINE L-TARTRATE
02244612
UNIDET (EDS)
02244613
UNIDET (EDS)
86:16.00 RESPIRATORY SMOOTH MUSCLE RELAXANTS
AMINOPHYLLINE
02014270
PHYLLOCONTIN
PFR
$
0.2213
PFR
$
0.2819
02014289
PHYLLOCONTIN-350
198
86:00 SMOOTH MUSCLE RELAXANTS
86:16.00 RESPIRATORY SMOOTH MUSCLE RELAXANTS
OXTRIPHYLLINE
100MG TABLET
00441724
APO-OXTRIPHYLLINE
APX
$
0.0516
APX
$
0.0733
APX
$
0.1031
PMS
PFI
$
0.0249
0.0378
APX
NOP
$
0.1411
0.1411
APX
NOP
$
0.1465
0.1465
APX
NOP
RIV
BRI
$
0.1519
0.1519
0.2214
0.2811
PFR
$
0.5083
PFR
$
0.6155
PMS
$
0.0114
MDA
$
0.0208
200MG TABLET
00441732
APO-OXTRIPHYLLINE
300MG TABLET
00511692
APO-OXTRIPHYLLINE
* 20MG/ML ELIXIR
00792942
00476366
PMS-OXTRIPHYLLINE
CHOLEDYL
THEOPHYLLINE (ANHYDROUS)
⌧
00692689
02230085
⌧
00692697
02230086
⌧
APO-THEO-LA
NOVO-THEOPHYL SR
APO-THEO-LA
NOVO-THEOPHYL SR
00692700
02230087
00599905
00556742
APO-THEO-LA
NOVO-THEOPHYL SR
THEOCHRON
QUIBRON-T/SR
02014165
UNIPHYL
02014181
UNIPHYL
5.33MG/ML ELIXIR
00575151
PMS-THEOPHYLLINE
5.33MG/ML SOLUTION
01966219
THEOLAIR LIQUID
199
VITAMINS
88:00
88:00 VITAMINS
88:04.00 VITAMIN A
VITAMIN A IS TOXIC IN EXCESSIVE DOSES.
VITAMIN A
50,000IU CAPSULE
00021075
VITAMIN A
NOP
$
0.0961
VITAMIN B12
CYANOCOBALAMIN
CYANOCOBALAMIN
SAB
CYT
TAR
$
3.3700
3.3700
3.3700
APO-FOLIC
APX
$
0.0255
WYA
$
5.9024
ICN
$
0.0154
ICN
$
0.0317
ODN
ICN
$
0.0489
0.0495
LEA
ICN
ODN
$
0.0266
0.0280
0.0320
88:08.00 VITAMINS B
CYANOCOBALAMIN
00521515
01987003
02052717
FOLIC ACID
5MG TABLET
00426849
LEUCOVORIN CALCIUM (FOLINIC ACID)
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
VITAMIN B6
VITAMIN B6
VITAMIN B6
202
88:00 VITAMINS
88:08.00 VITAMINS B
THIAMINE HCL
50MG TABLET
00268631
VITAMIN B1
ICN
$
0.0620
SAB
OMG
ABB
$
12.8900
12.8900
14.9800
LEO
$
0.4438
LEO
$
1.3284
LEO
$
5.0746
SAW
$
0.4202
HLR
$
0.9872
HLR
$
1.5699
HLR
$
3.1444
RBP
$
1.8445
MSD
$
0.2285
00816078
02193221
02241983
VITAMIN B1
THIAMIJECT
BETAXIN
88:16.00 VITAMIN D
VITAMIN D IS TOXIC IN EXCESSIVE DOSES.
ALFACALCIDOL
0.25UG CAPSULE
00474517
ONE-ALPHA (EDS)
1.0UG CAPSULE
00474525
ONE-ALPHA (EDS)
2UG/ML ORAL DROPS (ML)
02240329
ONE-ALPHA (EDS)
CALCIFEROL
8,288IU/ML ORAL SOLUTION
02017598
DRISDOL
CALCITRIOL
0.25UG CAPSULE
00481823
ROCALTROL (EDS)
0.5UG CAPSULE
00481815
ROCALTROL (EDS)
1UG/ML ORAL SOLUTION
00824291
ROCALTROL (EDS)
DOXERCALCIFEROL
2.5UG CAPSULE
02243790
HECTOROL (EDS)
VITAMIN D
50,000IU CAPSULE
00009830
OSTOFORTE
203
UNCLASSIFIED THERAPEUTIC AGENTS
92:00
92:00 UNCLASSIFIED THERAPEUTIC AGENTS
92:00.00 UNCLASSIFIED THERAPEUTIC AGENTS
ALENDRONATE SODIUM
* 10MG TABLET
02247373
02201011
NOVO-ALENDRONATE (EDS)
FOSAMAX (EDS)
NOP
MSD
$
1.3330
1.9042
MSD
$
3.8898
MSD
$
9.6030
SAW
$
1.0308
NOP
APX
GSK
$
0.0207
0.0207
0.1152
APX
NOP
GSK
$
0.0363
0.0363
0.1911
NOP
APX
GSK
$
0.0446
0.0446
0.3123
RBP
$
5.0845
AMG
$
46.0700
40MG TABLET
02201038
FOSAMAX (EDS)
70MG TABLET
02245329
FOSAMAX (EDS)
ALFUZOSIN
10MG PROLONGED-RELEASE TABLET
02245565
XATRAL
ALLOPURINOL
* 100MG TABLET
00364282
00402818
00004588
NOVO-PUROL
APO-ALLOPURINOL
ZYLOPRIM
* 200MG TABLET
00479799
00565342
00506370
APO-ALLOPURINOL
NOVO-PUROL
ZYLOPRIM
* 300MG TABLET
00363693
00402796
00294322
NOVO-PUROL
APO-ALLOPURINOL
ZYLOPRIM
ANAGRELIDE HCL
0.5MG CAPSULE
02236859
AGRYLIN
ANAKINRA
100MG/0.67ML PRE-FILLED SYRINGE
02245913
KINERET (EDS)
206
AZATHIOPRINE
* 50MG TABLET
02231491
02236799
02236819
02242907
02248843
00004596
GEN-AZATHIOPRINE
RATIO-AZATHIOPRINE
NOVO-AZATHIOPRINE
APO-AZATHIOPRINE
NU-AZATHIOPRINE
IMURAN
GPM
RPH
NOP
APX
NXP
GSK
$
0.5879
0.5879
0.5879
0.5879
0.5879
0.9751
ORP
$
1.4046
ACT
$
64.7143
ACT
$
64.7143
ALL
$
3.8735
APX
PMS
NVR
$
1.0537
1.0537
1.8399
DOM
APX
PMS
NVR
$
0.5087 *
0.5917
0.5917
1.0331
AVT
$
101.7200
AVT
$
68.1400
BETAINE ANHYDROUS
1G/SCOOP POWDER FOR ORAL SOLUTION
02238526
CYSTADANE
BOSENTAN
62.5MG TABLET
02244981
TRACLEER (EDS)
125MG TABLET
02244982
TRACLEER (EDS)
BOTULINUM TOXIN TYPE A
100IU STERILE LYOPHILIZED POWDER (IU)
01981501
BOTOX (EDS)
BROMOCRIPTINE MESYLATE
* 5MG CAPSULE
02230454
02236949
00568643
APO-BROMOCRIPTINE
PMS-BROMOCRIPTINE
PARLODEL
* 2.5MG TABLET
02238636
02087324
02231702
00371033
DOM-BROMOCRIPTINE
APO-BROMOCRIPTINE
PMS-BROMOCRIPTINE
PARLODEL
BUSERELIN ACETATE
1.05MG/ML INJECTION (2)
02225166
SUPREFACT (EDS)
1.05MG/ML INTRANASAL SOLUTION
02225158
SUPREFACT (EDS)
207
CABERGOLINE
0.5MG TABLET
02242471
DOSTINEX (EDS)
PAL
$
13.7253
COLCHICINE-ODAN
ODN
$
0.2382
COLCHICINE-ODAN
ODN
$
0.4747
NVR
$
0.6637
NVR
$
1.5426
NVR
$
3.0073
NVR
$
6.0164
NVR
$
5.3480
PFI
$
4.9770
PFI
$
4.9770
NVR
$
1.5190
AMG
$
177.9500
GPM
PGA
$
0.9957
1.4224
$
39.8200
COLCHICINE
0.6MG TABLET
00572349
1MG TABLET
00621374
CYCLOSPORINE (TRANSPLANT)
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)
DONEPEZIL HCL
5MG TABLET
02232043
ARICEPT (EDS)
10MG TABLET
02232044
ARICEPT (EDS)
ENTACAPONE
200MG TABLET
02243763
COMTAN
ETANERCEPT
25MG/VIAL POWDER FOR INJECTION (VIAL)
02242903
ENBREL (EDS)
ETIDRONATE DISODIUM
* 200MG TABLET
02245330
01997629
GEN-ETIDRONATE
DIDRONEL
ETIDRONATE DISODIUM/CALCIUM CARBONATE
400MG/1250MG TABLET (PACKAGE)
02176017
DIDROCAL
PGA
208
FINASTERIDE
5MG TABLET
02010909
PROSCAR
MSD
$
1.7686
REMINYL (EDS)
JAN
$
2.5898
REMINYL (EDS)
JAN
$
2.5898
JAN
$
2.5898
TVM
$
44.2000
LIL
$
89.1800
AST
$
414.2000
GALANTAMINE HYDROBROMIDE
4MG TABLET
02244298
8MG TABLET
02244299
12MG TABLET
02244300
REMINYL (EDS)
GLATIRAMER ACETATE
SEE APPENDIX J FOR EDS CRITERIA
20MG INJECTION (PRE-FILLED SYRINGE)
02245619
COPAXONE (EDS)
GLUCAGON
1MG INJECTION POWDER (RDNA ORIGIN)
02243297
GLUCAGON
GOSERELIN ACETATE
3.6MG/SYRINGE
02049325
ZOLADEX (EDS)
INFLIXIMAB
WHEN BILLING, SUBMIT QUANTITY IN TERMS OF MILLIGRAMS.
NOTE: THE IDENTIFICATION NUMBER LISTED FOR THIS PRODUCT HAS
BEEN GENERATED BY THE PRESCRIPTION DRUG PLAN FOR BILLING
PURPOSES ONLY.
100MG/VIAL INJECTION (MG) (CROHN'S DISEASE)
00950899
REMICADE (EDS)
SCH
$
9.7000
SCH
$
9.7000
$
861.1800
100MG/VIAL INJECTION (MG) (RHEUMATOID
ARTHRITIS)
02244016
REMICADE (EDS)
INTERFERON ALFA-2B/RIBAVIRIN
15 MILLION IU/ML MULTI-DOSE PEN
ALBUMIN (HUMAN) FREE/200MG CAPSULE (PACKAGE)
02241159
REBETRON (EDS)
SCH
209
INTERFERON BETA-1A
22UG (6 MILLION IU) PRE-FILLED SYRINGE
02237319 REBIF (EDS)
44UG (12 MILLION IU) PRE-FILLED SYRINGE
02237320 REBIF (EDS)
30UG POWDER FOR IM INJECTION (VIAL)
02237770 AVONEX (EDS)
SRO
$
118.2700
SRO
$
145.0000
BGN
$
337.4100
BEX
$
101.9900
NOP
PMS
PAL
$
0.6874
0.6874
0.8594
NOP
NXP
APX
PMS
PAL
$
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
INTERFERON BETA-1B
0.3MG POWDER FOR INJECTION (3ML)
02169649 BETASERON (EDS)
KETOTIFEN FUMARATE
* 1MG TABLET
02230730
02231680
00577308
NOVO-KETOTIFEN (EDS)
PMS-KETOTIFEN (EDS)
ZADITEN (EDS)
* 0.2MG/ML SYRUP
02176084
02218305
02221330
02231679
00600784
NU-KETOTIFEN (EDS)
APO-KETOTIFEN (EDS)
PMS-KETOTIFEN (EDS)
ZADITEN (EDS)
LEFLUNOMIDE
10MG TABLET
02241888
ARAVA (EDS)
20MG TABLET
02241889
ARAVA (EDS)
LEUPROLIDE ACETATE
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)
210
LEVODOPA/BENZERAZIDE
50MG/12.5MG CAPSULE
00522597
PROLOPA
HLR
$
0.2906
HLR
$
0.4785
HLR
$
0.8033
RPH
NXP
APX
NOP
BMY
$
0.2566
0.2566
0.2566
0.2566
0.4580
RPH
NXP
APX
NOP
DOM
BMY
$
0.3833
0.3833
0.3833
0.3833
0.4313
0.6839
RPH
NXP
APX
NOP
BMY
$
0.4279
0.4279
0.4279
0.4279
0.7634
BMY
$
0.6968
APX
BMY
$
0.8711
1.2853
MSD
$
1.4308
MSD
$
1.5798
MSD
$
2.3245
100MG/25MG CAPSULE
00386464
PROLOPA
200MG/50MG CAPSULE
00386472
PROLOPA
LEVODOPA/CARBIDOPA
* 100MG/10MG TABLET
02126176
02182831
02195933
02244494
00355658
NU-LEVOCARB
APO-LEVOCARB
NOVO-LEVOCARBIDOPA
SINEMET
* 100MG/25MG TABLET
02126168
02182823
02195941
02244495
02247606
00513997
NU-LEVOCARB
APO-LEVOCARB
NOVO-LEVOCARBIDOPA
DOM-LEVO-CARBIDOPA
SINEMET
* 250MG/25MG TABLET
02126184
02182858
02195968
02244496
00328219
NU-LEVOCARB
APO-LEVOCARB
NOVO-LEVOCARBIDOPA
SINEMET
100MG/25MG CONTROLLED RELEASE TABLET
02028786
SINEMET CR
* 200MG/50MG CONTROLLED RELEASE TABLET
02245211
00870935
APO-LEVOCARB CR
SINEMET CR
MONTELUKAST SODIUM
4MG CHEWABLE TABLET
02243602
SINGULAIR (EDS)
5MG CHEWABLE TABLET
02238216
SINGULAIR (EDS)
10MG TABLET
02238217
SINGULAIR (EDS)
211
MYCOPHENOLATE MOFETIL
250MG CAPSULE
02192748
CELLCEPT (EDS)
HLR
$
2.2373
HLR
$
4.4746
ICN
$
6.7325
FEI
$
303.8000
AVT
$
27.9700
500MG TABLET
02237484
CELLCEPT (EDS)
NABILONE
1MG CAPSULE
00548375
CESAMET (EDS)
NAFARELIN ACETATE
2MG/ML NASAL SOLUTION
02188783
SYNAREL (EDS)
NEDOCROMIL SO4
2MG/DOSE INHALATION AEROSOL (PACKAGE)
02230543
TILADE
OCTREOTIDE
WHEN BILLING LAR FORM, SUBMIT QUANTITY IN TERMS OF MILLIGRAMS.
* 50UG INJECTION (1ML)
02248639
00839191
OCTREOTIDE ACETATE (EDS)
SANDOSTATIN (EDS)
OMG
NVR
$
4.3300
5.4200
OMG
NVR
$
8.1900
10.2300
OMG
NVR
$
78.6500
98.3100
OMG
NVR
$
38.4400
48.0400
NVR
$
119.8200
NVR
$
79.4100
NVR
$
66.0200
02248640
00839205
SANDOSTATIN (EDS)
* 200UG/ML INJECTION (5ML)
02248642
02049392
SANDOSTATIN (EDS)
02248641
00839213
SANDOSTATIN (EDS)
10MG/VIAL POWDER FOR INJECTION (MG)
02239323
SANDOSTATIN LAR (EDS)
02239324
02239325
212
PAMIDRONATE DISODIUM
* 30MG INJECTION
02244550
02245998
02059762
PAMIDRONATE DISODIUM (EDS)
PMS-PAMIDRONATE (EDS)
AREDIA (EDS)
DBU
PMS
NVR
$
100.9100
108.4800
170.8900
DBU
$
201.8100
DBU
PMS
NVR
$
302.7200
325.4300
502.5000
$
782.2400
$
782.2000
$
782.2000
$
861.1800
$
861.1800
JAN
$
1.3428
RBP
$
0.2696
PERMAX
RBP
$
0.9883
PERMAX
RBP
$
3.3690
60MG INJECTION
02244551
* 90MG INJECTION
02244552
02245999
02059789
AREDIA (EDS)
PEGINTERFERON ALFA-2B/RIBAVIRIN
50UG/0.5ML POWDER FOR SOLUTION/200MG CAPSULE
02246026 PEGETRON (EDS)
SCH
SCH
SCH
SCH
SCH
PENTOSAN POLYSULFATE SO4
100MG CAPSULE
02029448
ELMIRON (EDS)
PERGOLIDE MESYLATE
0.05MG TABLET
02123320
PERMAX
0.25MG TABLET
02123339
1MG TABLET
02123347
213
PRAMIPEXOLE DIHYDROCHLORIDE
0.25MG TABLET
02237145
MIRAPEX
BOE
$
1.1408
MIRAPEX
BOE
$
2.2816
MIRAPEX
BOE
$
2.2816
BOE
$
2.2816
PFI
$
4.2000
PGA
$
1.8011
PGA
$
11.6638
PGA
$
9.6023
NVR
$
2.5898
NVR
$
2.5898
NVR
$
2.5898
NVR
$
2.5898
NVR
$
1.3823
0.5MG TABLET
02241594
1MG TABLET
02237146
1.5MG TABLET
02237147
MIRAPEX
RIFABUTIN
150MG CAPSULE
02063786
MYCOBUTIN (EDS)
RISEDRONATE SODIUM
5MG TABLET
02242518
ACTONEL (EDS)
30MG TABLET
02239146
ACTONEL (EDS)
35MG TABLET
02246896
ACTONEL (EDS)
RIVASTIGMINE
1.5MG CAPSULE
02242115
EXELON (EDS)
3MG CAPSULE
02242116
EXELON (EDS)
4.5MG CAPSULE
02242117
EXELON (EDS)
6MG CAPSULE
02242118
EXELON (EDS)
02245240
EXELON (EDS)
214
ROPINIROLE HCL
0.25MG TABLET
02232565
REQUIP
GSK
$
0.2794
REQUIP
GSK
$
1.1176
REQUIP
GSK
$
1.2293
REQUIP
GSK
$
3.4644
DOM
NOP
APX
NXP
GPM
PMS
DPY
$
1.0728 *
1.3726
1.3726
1.3726
1.3726
1.4449
2.1793
GZY
$
0.7704
GZY
$
1.5407
RAPAMUNE (EDS)
WYA
$
7.3889
RAPAMUNE (EDS)
WYA
$
7.3889
1MG TABLET
02232567
2MG TABLET
02232568
5MG TABLET
02232569
SELEGILINE HCL
* 5MG TABLET
02238340
02068087
02230641
02230717
02231036
02238102
02123312
DOM-SELEGILINE (EDS)
NOVO-SELEGILINE (EDS)
APO-SELEGILINE (EDS)
NU-SELEGILINE (EDS)
GEN-SELEGILINE (EDS)
PMS-SELEGILINE (EDS)
ELDEPRYL (EDS)
SEVELAMER HCL
400MG TABLET
02244309
RENAGEL (EDS)
800MG TABLET
02244310
RENAGEL (EDS)
SIROLIMUS
02243237
1MG TABLET
02247111
215
SODIUM CROMOGLYCATE
20MG/CAPSULE AEROSOL POWDER
00261238
INTAL SPINCAPS
AVT
$
0.5007
AVT
$
1.1621
PMS
APX
NXP
DOM
$
0.5258
0.5258
0.5258
0.6562
AVT
$
42.8600
AVT
$
0.3521
FUJ
$
2.1375
FUJ
$
2.6583
FUJ
$
12.5500
FUJ
$
127.5000
BOE
$
1.0308
RBP
$
2.1700
PANECTYL
ERF
$
0.2256
PANECTYL
ERF
$
0.2805
100MG CAPSULE
00500895
NALCROM (EDS)
* 10MG/ML INHALATION SOLUTION (2ML)
02046113
02231431
02231671
02145448
PMS-SODIUM CROMOGLYCATE
APO-CROMOLYN
NU-CROMOLYN
DOM-SODIUM CROMOGLYCATE
1MG/DOSE PRESSURIZED AEROSOL (PACKAGE)
00555649
INTAL
SODIUM FLUORIDE
20MG TABLET
02099225
FLUOTIC
TACROLIMUS
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
216
URSODIOL
250MG TABLET
02238984
URSO (EDS)
AXC
$
1.3385
AXC
$
2.5389
AST
$
0.7822
500MG TABLET
02245894
URSO DS (EDS)
ZAFIRLUKAST
20MG TABLET
02236606
ACCOLATE (EDS)
217
DIABETIC SUPPLIES
94:00
94:00 DIABETIC SUPPLIES
94:00.00 DIABETIC SUPPLIES
NOTE: SOME OF THE IDENTIFICATION NUMBERS LISTED IN THIS
SECTION HAVE BEEN GENERATED BY THE PRESCRIPTION DRUG PLAN
FOR BILLING PURPOSES ONLY.
ISOPROPYL ALCOHOL
⌧
70% SWAB
00795232
99438102
00480452
02240759
WEBCOL ALCOHOL PREP
MONOJECT ALCOHOL SWAB
ALCOHOL PREP
BD ALCOHOL SWAB
TYC
TYC
PFD
BDC
$
0.0087
0.0173
0.0231
0.0288
MEDISENSE THIN
MONOLET THIN
COMFORT TOUCH
AMES
MONOLET ORIGINAL
EQUATE THIN
PRECISION THIN
EQUATE ULTRATHIN
MICROLET
ONE TOUCH ULTRA SOFT
LIFESCAN FINE POINT
BD ULTRA FINE II
SOFTCLIX
BD LATITUDE
GLUCOLET FINGERSTIX
SOFTCLIX PRO
SAFE-T-PRO
FREESTYLE
ABB
TYC
ABB
BAY
TYC
MPD
MDS
MPD
BAY
LSN
LSN
BDC
BOM
BDC
BAY
BOM
BOM
THS
$
0.0472
0.0487
0.0488
0.0528
0.0580
0.0593
0.0608
0.0649
0.0670
0.0706
0.0706
0.0733
0.0836
0.1084
0.1337
0.1411
0.1953
0.7487
NOVOFINE 12MM
NOO
$
0.1944
ACM
BDC
$
0.1732
0.2512
NOO
NOO
$
0.2401
0.2472
ACM
ACM
BDC
$
0.1953
0.1953
0.2519
LANCET
⌧
LANCET
00950921
99401055
00977051
00930610
00977543
00950913
00906190
00950914
00906239
00901359
00977853
00977659
00000165
99401068
00995965
00950915
00905916
99401063
NEEDLE
28G NEEDLE
99221028
⌧
29G NEEDLE
00964344
00977101
⌧
30G NEEDLE
00908169
99117796
⌧
UNIFINE
BD ULTRA FINE 12MM
NOVOFINE 8MM
NOVOFINE 6MM
31G NEEDLE
00964220
00964271
00977011
UNIFINE
UNIFINE
BD ULTRAFINE 5MM, 8MM
220
94:00 DIABETIC SUPPLIES
94:00.00 DIABETIC SUPPLIES
SYRINGE
⌧
0.3CC SYRINGE
00964018
00964174
99254011
00977951
00920169
00920193
00977977
⌧
ACM
ACM
TYC
TYC
BDC
BDC
BDC
$
0.2041
0.2144
0.2300
0.2386
0.2551
0.2458
0.2512
ACM
ACM
TYC
TYC
BDC
BDC
BDC
$
0.2041
0.2144
0.2300
0.2300
0.2551
0.2458
0.2512
ACM
ACM
TYC
TYC
BDC
BDC
BDC
BDC
$
0.2041
0.2144
0.2300
0.2577
0.2551
0.2551
0.2704
0.2704
0.5CC SYRINGE
00963941
00964115
00920355
99432799
00920177
00920207
00977985
⌧
ULTICARE 29G
ULTICARE 30G
MONOJECT ULTRA COMFORT
MONOJECT PLUS 29G
BD MICROFINE 29G
BD ULTRA FINE
BD ULTRAFINE II SHORT
ULTICARE 29G
ULTICARE 30G
MONOJECT PLUS 29G
BD MICROFINE 28G
BD ULTRA FINE 29G
BD ULTRA FINE II SHORT
1CC SYRINGE
00963895
00964069
00920045
99433383
00950917
99767467
00920215
00909238
ULTICARE 29G
ULTICARE 30G
MONOJECT PLUS 29G
BD MICROFINE 1V
BD MICROFINE 28G
BD ULTRA FINE
221
APPENDICES
APPENDIX A - EXCEPTION DRUG STATUS PROGRAM
APPENDIX B - SPECIAL COVERAGES
APPENDIX C - CODES FOR PHARMACY ON-LINE CLAIMS
PROCESSING
APPENDIX D - MAINTENANCE DRUG SCHEDULE
APPENDIX E - TRIAL PRESCRIPTION PROGRAM
MEDICATION LIST
APPENDIX F - SASKATCHEWAN MS DRUGS PROGRAM
APPENDIX G - PHARMACEUTICAL MANUFACTURERS LIST
APPENDIX A
EXCEPTION DRUG STATUS PROGRAM
NOTES REGARDING THE EXCEPTION DRUG STATUS (EDS) PROGRAM
• Physicians, dentists, duly qualified optometrists (or authorized office staff), nurse
•
•
•
•
•
•
•
practitioners 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.
Patients are notified by letter if coverage has been approved and the time period for
which coverage has been approved.
If a request has been denied, letters are sent to the patient and prescriber notifying
them of the reason for the denial. In most cases, the Drug Plan requires more
information to determine the patient's eligibility for coverage, and will reconsider
coverage at such time as further information is received.
If the drug requested is not a benefit under the Drug Plan, the patient and prescriber
are notified. Payment for the medication is the responsibility of the patient in these
cases. It is important to note that not all medications currently available on the
market in Canada are benefits under the Saskatchewan Drug Plan or under the
Exception Drug Status Program of the Drug Plan.
The majority of EDS requests are routinely backdated 30 days from the time the Drug
Plan receives the request. Provision can be made for further backdating of EDS
coverage on a case-by-case basis by staff in Pharmaceutical Services Division.
However, there is no provision or backdating further than one year from the current
date. Requests for backdating can be made by a health professional or the patient.
Patients are expected to meet EDS criteria within the dates requested.
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-xvii for additional general
information regarding Exception Drug Status coverage.
CRITERIA FOR COVERAGE UNDER EXCEPTION DRUG STATUS
Following are the criteria for coverage of certain drugs under Exception Drug Status.
Coverage may be provided for other products in certain instances. Further information
can be provided by professional staff at the Drug Plan.
Certain products may be granted Exception Drug Status for non-approved indications.
This is the case only when the Saskatchewan Formulary Committee has reviewed
evidence to demonstrate safety and efficacy and the prescriber is aware the drug is being
prescribed for a non-approved indication.
The following information is required to process all Exception Drug Status
requests:
•
patient name; patient Health Services Number (9 digits); name of drug;
diagnosis* relevant to use of drug; prescriber name and phone number.
*For pharmacist-initiated EDS requests:
The diagnosis, which must be obtained from the physician or physician's agent, is to be
consistently documented within the pharmacy, whether the documentation is on the
original prescription, computer file, or EDS fax form.
224
abacavir SO4, oral solution, 20mg/mL; tablet, 300mg (Ziagen-GSK)
For management of HIV disease. This drug, as with other antivirals in the treatment
of HIV, should be used under the direction of an infectious disease specialist.
abacavir SO4/lamivudine/zidovudine, tablet, 300mg/150mg/300mg (Trizivir-GSK)
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 259.
Accolate - see zafirlukast
Actonel - see risedronate sodium
Actos - see pioglitazone HCl
Acular - see ketorolac tromethamine
Advair - see salmeterol xinafoate/fluticasone propionate
Advair Diskus - see salmeterol xinafoate/fluticasone propionate
Agenerase - see amprenavir
Aggrenox - see dipyridamole/acetylsalicylic acid
*alendronate sodium, tablet, 10mg (Fosamax-MSD) (Novo-Alendronate-NOP);
tablet, 70mg (Fosamax-MSD)
(a) For treatment of osteoporosis in patients who do not respond to etidronate
disodium/calcium (Didrocal) after receiving it for one year.
(b) For treatment of osteoporosis in patients unable to tolerate etidronate
disodium/calcium (Didrocal).
(c) For treatment of osteoporosis in patients who have pre-existing and/or recent
fractures.
(d) For treatment of glucocorticoid-induced osteoporosis in patients who have
received systemic glucocorticoid treatment for at least 3 months.
alendronate sodium, tablet, 40mg (Fosamax-MSD)
For treatment of symptomatic Paget’s Disease of the bone.
Alertec - see modafinil
alfacalcidol, capsule, 0.25ug, 1ug; oral drops, 2ug/mL (One-Alpha-LEO)
For management of hypocalcemia and osteodystrophy in chronic renal disease
patients prior to initiation of dialysis. Note: Coverage for dialysis patients is provided
under the Saskatchewan Aids to Independent Living (S.A.I.L.) Program. Exception
Drug Status coverage is not required for S.A.I.L. patients.
Alphagan P - see brimonidine tartrate
Amatine - see midodrine HCl
Amerge - see naratriptan HCl
amoxicillin trihydrate/potassium clavulanate, oral suspension, 40mg/5.3mg/mL,
80mg/11.4mg/mL (Clavulin-GSK);
*oral suspension, 25mg/6.25mg/mL, 50mg/12.5mg/mL (Clavulin-GSK)
(Apo-Amoxi Clav-APX) (ratio-Aclavulanate-RPH);
*tablet, 250mg/125mg, 500mg/125mg (Clavulin-GSK) (Apo-Amoxi Clav-APX)
(ratio-Aclavulanate-RPH);
*tablet, 875mg/125mg (Clavulin-GSK) (Apo-Amoxi Clav-APX) (Novo-ClavamoxinNOP) (ratio-Aclavulante-RPH)
For treatment of:
(a) Upper and lower respiratory tract infections in patients not responding to first-line
antibiotics.
(b) Infections caused by organisms known to be resistant to or not responding to
225
alternative antibiotics.
(c) Respiratory tract infections in nursing home patients.
(d) Pneumonia in patients in the community with comorbidity eg. chronic underlying
lung disease (excluding asthma), diabetes mellitus, renal insufficiency, heart
failure, stroke.
(e) Infection in patients with neutropenia.
(f) Pneumonia caused by aspiration.
(g) For human, cat and dog bites.
(h) Diabetic foot infections, and:
(i) For completion of treatment initiated in hospital.
amprenavir, capsule, 50mg, 150mg; oral solution, 15mg/mL (Agenerase-GSK)
For management of HIV disease in patients who have failed other protease inhibitor
combinations. This drug, as with other antivirals in the treatment of HIV, should be
used under the direction of an infectious disease specialist.
anakinra, subcutaneous injection (pre-filled syringe), 100mg/0.67mL (Kineret-AMG)
For treatment of patients with active rheumatoid arthritis who have failed or are intolerant
to methotrexate and leflunomide. (Note - exceptions can be considered in cases where
methotrexate or leflunomide are contraindicated). This product should be used in
consultation with a specialist in this area.
Note: Coverage will not be provided when used in combination with TNF blocking agents
(i.e. infliximab and etanercept) due to the significantly higher risk of adverse events.
Androcur - see cyproterone acetate
Apo-Amoxi Clav - see amoxicillin trihydrate/potassium clavulanate
Apo-Calcitonin - see calcitonin salmon
Apo-Carbamazepine CR - see carbamazepine
Apo-Carvedilol - see carvedilol
Apo-Cefuroxime - see cefuroxime axetil
Apo-Ciproflox - see ciprofloxacin
Apo-Cyclobenzaprine - see cyclobenzaprine HCl
Apo-Desmopressin - see desmopressin
Apo-Etodolac - see etodolac
Apo-Flavoxate - see flavoxate
Apo-Fluconazole - see fluconazole
Apo-Flunarizine - see flunarizine
Apo-Ketoconazole - see ketoconazole
Apo-Ketorolac - see ketorolac tromethamine
Apo-Ketotifen - see ketotifen fumarate
Apo-Lactulose - see lactulose
Apo-Megestrol - see megestrol acetate tablet
Apo-Meloxicam - see meloxicam
Apo-Minocycline - see minocycline HCl
Apo-Nabumetone - see nabumetone
Apo-Norflox - see norfloxacin
Apo-Ofloxacin - see ofloxacin
Apo-Omeprazole - see omeprazole
Apo-Selegiline - see selegiline HCl
Apo-Ticlopidine - see ticlopidine HCl
Apo-Tobramycin - see tobramycin
Aranesp - see darbepoetin alfa
Arava - see leflunomide
Aredia - see pamidronate
Aricept - see donepezil HCl
Aristospan - see triamcinolone/hexacetonide
226
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 F
azithromycin, tablet, 250mg; oral suspension, 20mg/mL, 40mg/mL (Zithromax-PFI)
For treatment of:
(a) Pneumonia.
(b) Upper and lower respiratory tract bacterial infections known to be resistant to or
not responding to alternative antibiotics.
(c) Infections in patients allergic to alternative antibiotics.
(d) Non-tuberculous Mycobacterium infections (and prophylaxis).
(e) Chlamydia trachomatis infections, and:
(f) For completion of treatment initiated in hospital with macrolides or quinolones.
(g) For patients intolerant to erythromycin and/or other antibiotics.
azithromycin, tablet, 600mg (Zithromax-PFI)
For prophylaxis and treatment of non-tuberculous Mycobacterium infections.
baclofen, injection, 0.05mg/mL, 0.5mg/mL, 2mg/mL (Lioresal Intrathecal-NVR)
(a) For treatment of severe spastic conditions in patients who do not respond to oral
baclofen.
(b) For treatment of severe spastic conditions in patients who cannot tolerate oral
baclofen.
Betaseron - see Appendix F
Bextra - see valdecoxib
bezafibrate, tablet, 200mg (pms-Bezafibrate-PMS); sustained release tablet, 400mg
(Bezalip SR-HLR)
(a) For treatment of patients with hyperlipidemia who have failed to respond to
gemfibrozil or fenofibrate.
(b) For treatment of patients with hyperlipidemia who have experienced side effects
with gemfibrozil or fenofibrate.
Bezalip SR - see bezafibrate
Biaxin - see clarithromycin
Biaxin XL - see clarithromycin
*bisoprolol fumarate, tablet, 5mg, 10mg (Monocor-BVL) (Rhoxal-Bisoprolol-RHO)
For treatment of patients with stable symptomatic congestive heart failure, who are
taking an ACE inhibitor. Coverage will also be provided for patients with stable
symptomatic congestive heart failure who are intolerant to an ACE inhibitor.
bosentan, tablet, 62.5mg, 125mg (Tracleer-ACT)
For patients with pulmonary arterial hypertension on the recommendation of a
specialist.
Botox - see botulinum toxin type A
botulinum toxin type A, sterile lyophilized powder, 100IU (Botox-ALL)
(a) For treatment of eye dystonias, that is, blepharospasm and strabismus.
227
(b) For treatment of cervical dystonia, that is, torticollis.
(c) For treatment of other forms of severe spasticity.
brimonidine tartrate, ophthalmic solution, 0.15% (Alphagan P-ALL)
For patients intolerant to benzalkonium chloride.
budesonide, controlled ileal release capsule, 3mg (Entocort-AST)
(a) For treatment of patients with mild to moderate Crohn's Disease affecting the
ileum and/or ascending colon. Coverage will be provided for up to 8 weeks.
(b) Maintenance treatment will be approved for patients unresponsive or intolerant to
other agents.
bumetanide, tablet, 2mg (Burinex-LEO)
For treatment of patients unable to tolerate furosemide.
bupropion HCl, tablet, 100mg, 150mg (Wellbutrin SR-GSK)
For treatment of depression.
Burinex - see bumetanide
buserelin acetate, intranasal solution, 1.05mg/mL; injection, 1.05mg/mL (SuprefactHRU)
(a) For treatment of endometriosis, for a maximum of 6 months. Coverage may be
repeated after a six month lapse, for another 6 month course.
(b) For pre-treatment of uterine fibroids prior to surgical removal, for a maximum of 6
months.
(c) For treatment of menorrhagia in preparation for endometrial ablation, for a
maximum of 6 months.
cabergoline, tablet, 0.5mg (Dostinex-PHU)
(a) For treatment of hyperprolactinemic disorders in patients not responding to
bromocriptine.
(b) For treatment of hyperprolactinemic disorders in patients intolerant to
bromocriptine.
Calcimar - see calcitonin salmon
calcitonin salmon, injection, 100IU/mL (Caltine-FEI);
*injection, 200IU/mL (Calcimar-AVT) (Apo-Calcitonin-APX)
(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
(c) For treatment of osteogenesis imperfecta.
*calcitonin salmon, nasal spray, 200IU/dose (Miacalcin-NVR) (Apo-Calcitonin-APX)
(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; oral solution, 1ug/mL (Rocaltrol-HLR)
(a) For management of hypocalcemia and osteodystrophy in patients with chronic
renal failure undergoing renal dialysis. Note: Coverage for dialysis patients is
provided under the Saskatchewan Aids to Independent Living (SAIL) Program.
Exception Drug Status coverage is NOT required for SAIL patients.
228
(b) For management of hypocalcemia and clinical manifestations associated with
post-surgical hypoparathyroidism, idiopathic hypoparathyroidism,
pseudohypoparathyroidism, or vitamin D resistant rickets.
Caltine - see calcitonin salmon
*carbamazepine, controlled release tablet, 200mg, 400mg (Tegretol CR-NVR)
(pms-Carbamazepine-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)
(Apo-Carvedilol-APX) (pms-Carvedilol-PMS) (Novo-Carvedilol-NOP)
(Nu-Carvedilol-NXP) (Dom-Carvedilol-DOM
For treatment of patients with stable symptomatic congestive heart failure, who are
taking an ACE inhibitor. Coverage will also be provided for patients with stable
symptomatic congestive heart failure who are intolerant to an ACE inhibitor.
cefixime, tablet, 400mg (Suprax-AVT)
For treatment of:
(a) Infections in patients allergic to alternative antibiotics. (Note: patients who have
had an anaphylactic reaction to penicillin should not receive cephalosporins.)
(b) Infections caused by organisms known to be resistant to or not responding to
(c) Uncomplicated gonorrhea.
cefprozil, tablet, 250mg, 500mg; suspension, 25mg/mL, 50mg/mL (Cefzil-BMY)
For treatment of:
antibiotics.
(b) Infections caused by organisms known to be resistant or not responding to
(c) Infections in patients allergic to alternative antibiotics. (Note: patients who have
(d) Respiratory tract infections in nursing home patients.
(e) Pneumonia in patients in the community with comorbidity eg. chronic underlying
failure, stroke, and:
(f) For completion of antibiotic treatment initiated in hospital.
Ceftin - see cefuroxime axetil
cefuroxime axetil, suspension, 25mg/mL (Ceftin-GSK)
*tablet, 250mg, 500mg (Ceftin-GSK) (ratio-Cefuroxime-RPH) (Apo-Cefuroxime-APX)
For treatment of:
antibiotics.
(b) Infections caused by organisms known to be resistant or not responding to
(c) Infections in patients allergic to alternative antibiotics. (Note: patients who have
(d) Respiratory tract infections in nursing home patients.
(e) Pneumonia in patients in the community with comorbidity ie. chronic underlying
failure, stroke, and:
229
(f)
For completion of antibiotic treatment initiated in hospital.
Cefzil - see cefprozil
Celebrex - see celecoxib
celecoxib, capsule, 100mg, 200mg (Celebrex-PHU)
(a) For treatment in patients age 65 and over (approved automatically through the
on-line computer system).
(b) For treatment of rheumatoid arthritis and osteoarthritis in patients who have one
of the following factors:
•
past history of ulcers;
•
concurrent prednisone therapy;
•
concurrent warfarin therapy.
(c) For treatment of patients with an intolerance to other NSAIDs listed in the
Formulary.
(d) For treatment of familial adenomatous polyposis.
CellCept - see mycophenolate mofetil
Cesamet - see nabilone
chorionic gonadotropin, injection, 10,000IU/vial (Profasi HP-SRO)
(a) For treatment of habitual abortion.
(b) For treatment of delayed puberty.
Ciloxan - see ciprofloxacin
Cipro - see ciprofloxacin tablet
Cipro HC - see ciprofloxacin/hydrocortisone
ciprofloxacin, ophthalmic solution, 0.3%; ophthalmic ointment, 0.3% (Ciloxan-ALC)
For treatment of ophthalmic infections caused by gram-negative organisms or those
not responding to alternative agents.
*ciprofloxacin, tablet, 250mg, 500mg, 750mg (Apo-Ciproflox-APX) (CO Ciprofloxacin-COB)
(Gen-Ciprofloxacin-GPM) (Novo-Ciprofloxacin-NOP) (pms-Ciprofloxacin-PMS)
(ratio-Ciprofloxacin-RPH) (Rhoxal-Ciprofloxacin-RHO) (Dom-Ciprofloxacin-DOM)
(Prem-Ciprofloxacin-PRM); oral suspension, 100mg/mL (Cipro-BAY)
For treatment of:
(a) Infections caused by Pseudomonas aeruginosa.
(b) Infections in patients allergic to two or more alternative antibiotics.
(c) Infections known to be resistant to alternative antibiotics. Resistance must be
determined by culture and sensitivity testing (C&S).
(d) Patients with severe diabetic foot infections in combination with other antibiotics.
(e) Infection (and prophylaxis) in patients with prolonged neutropenia.
(f) Genitourinary tract infections in patients allergic or not responding to alternative
antibiotics.
(g) Patients with bronchiectasis or cystic fibrosis.
(h) Gonorrhea, and:
(i) For completion of antibiotic treatment initiated in hospital when alternatives are
not appropriate.
ciprofloxacin/hydrocortisone, otic suspension, 0.2%/1% (Cipro HC-ALC)
(a) For treatment of otitis externa in patients who have failed previous treatment with
listed combination anti-infective/anti-inflammatory agents.
(b) For treatment of patients with perforation of the tympanic membrane.
clarithromycin, tablet, 250mg, 500mg; oral suspension, 25mg/mL, 50mg/mL (Biaxin-ABB);
extended-release tablet, 500mg (Biaxin XL-ABB)
For treatment of:
230
(a) Pneumonia.
(b) Upper and lower respiratory tract bacterial infections known to be resistant to or
not responding to alternative antibiotics.
(c) Infections in patients allergic to alternative antibiotics.
(d) Non-tuberculous Mycobacterium infections (and prophylaxis), and:
(e) For one week for eradication of H. pylori-related infections when used in
combination treatment regimens for the treatment of peptic ulcer disease.
(f) For completion of treatment initiated in hospital with macrolides or quinolones.
(g) For patients intolerant to erythromycin and/or other antibiotics.
Clavulin - see amoxicillin trihydrate/potassium clavulanate
Climara - see estradiol
clonidine HCl, tablet, 0.025mg (Dixarit-BOE)
(a) For treatment of menopausal flushing.
(b) For treatment of Attention Deficit Hyperactivity Disorder.
clopidogrel bisulfate, tablet, 75mg (Plavix-SAW)
(a) For treatment of patients who have experienced a transient ischemic attack,
stroke, or a myocardial infarction while on acetylsalicylic acid.
(b) For treatment of patients who have experienced a transient ischemic attack,
stroke, or who have had a myocardial infarction and have a clearly
demonstrated allergy to acetylsalicylic acid (manifested by asthma or nasal
polyps).
(c) For treatment of patients who have experienced a transient ischemic attack,
stroke or have had a myocardial infarction 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 1 year. In patients intolerant or allergic to ASA coverage
may be renewed.
(e) For reduction of atherothrombotic events in patients with acute coronary
syndrome (i.e. unstable angina or non-Q-wave myocardial infarction without ST
segment elevation) concurrently with acetylsalicylic acid. Coverage will also be
considered for patients intolerant or allergic to acetylsalicylic acid. Coverage will
be provided for a period of 1 year. In patients intolerant or allergic to ASA
coverage may be renewed.
Clopixol - see zuclopenthixol
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
CO Ciprofloxacin - see ciprofloxacin
codeine, controlled release tablet, 50mg, 100mg, 150mg, 200mg
(Codeine Contin-PFR)
(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 F
231
Coreg - see carvedilol
Crixivan - see indinavir SO4
*cyclobenzaprine HCl, tablet, 10mg (Flexeril-JAN) (Apo-Cyclobenzaprine-APX)
(Novo-Cycloprine-NOP) (Nu-Cyclobenzaprine-NXP) (pms-Cyclobenzaprine-PMS)
(Gen-Cyclobenzaprine-GPM) (Med-Cyclobenzaprine-MED) (Flexitec-TCH) (DomCyclobenzaprine-DOM)
As an adjunct to rest and physical therapy for relief of muscle spasm associated with
acute, painful musculoskeletal conditions not responding or experiencing severe
adverse reactions to alternative therapy. Coverage will be provided for up to a 3 week
period. Coverage can be renewed for a 3 week period every 3 months.
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 (where applicable)
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
(where applicable) does not apply.
cyproterone acetate, injection, 100mg/mL (Androcur Depot-PMS);
*tablet, 50mg (Androcur-PMS) (Gen-Cyproterone-GPM) (Novo-Cyproterone-NOP)
For treatment of hirsuitism.
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.
darbepoetin alfa, pre-filled syringe, 25ug/mL (0.4mL), 40ug/mL (0.5mL), 100ug/mL (0.3mL,
0.4mL, 0.5mL), 200ug/mL (0.3mL, 0.4mL, 0.5mL), 500ug/mL (0.3mL) (Aranesp-AMG)
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.
DDAVP - see desmopressin acetate
232
delavirdine mesylate, tablet, 100mg (Rescriptor-PHU)
For management of HIV disease. This drug, as with other antivirals in the treatment of
HIV, should be used under the direction of an infectious disease specialist.
*deferoxamine mesylate, powder for solution, 500mg/vial, 2g/vial
(pms-Deferoxamine-PMS) (Desferal-NVR)
For treatment of iron overload in patients with transfusion-dependent anemias.
Desferal - see deferoxamine mesylate
desmopressin, tablet, 0.1mg, 0.2mg (DDAVP-FEI)
*intranasal solution, 10ug/dose (DDAVP-FEI) (Apo-Desmopressin-APX)
(a) For treatment of diabetes insipidus.
(b) For treatment of enuresis in children over 5 years of age refractory to bed-wetting
alarms or alternative agents listed in the Formulary.
desmopressin, injection, 4ug/mL (DDAVP-FEI); intranasal solution, 150ug/dose
(Octostim-FEI)
For prophylaxis of mild hemophilia A and mild von Willebrand's Disease.
DexIron - see iron dextran
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 (Videx-BMY); chewable tablet,
25mg, 50mg, 100mg, 150mg (Videx-BMY); capsule (enteric coated beadlet), 125mg,
200mg, 250mg, 400mg (Videx EC-BMY)
Diflucan - see fluconazole
dipyridamole, tablet, 50mg, 75mg (Persantine-BOE)
(a) Following transluminal angioplasty, for a maximum of 6 months.
(b) Following bypass surgery, for a maximum of 12 months.
(c) Following prosthetic heart valve replacement, for 12 months. This is renewable
on a yearly basis.
dipyridamole/acetylsalicylic acid, capsule, 200mg/25mg (Aggrenox-BOE)
For treatment of patients who have had a stroke or transient ischemic attack while on
acetylsalicylic acid.
Dixarit - see clonidine HCl
Dom-Carbamazepine CR - see carbamazepine
Dom-Carvedilol - see carvedilol
Dom-Ciprofloxacin - see ciprofloxacin
Dom-Cyclobenzaprine - see cyclobenzaprine HCl
Dom-Fluconazole - see fluconazole
Dom-Meloxicam - see meloxicam
Dom-Minocycline - see minocycline HCl
Dom-Selegiline - see selegiline HCl
Dom-Ticlopidine - see ticlopidine HCl
233
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 or nurse practitioner.
(c) A Functional Activities Questionnaire (FAQ) must be completed within 60 days
prior to initial application for coverage by a clinician or nurse practitioner.
(d) Patients must discontinue all drugs with anticholinergic activity at least 14 days
before the MMSE and FAQ are administered. Drugs with anticholinergic activity
are not to be used concurrently with donepezil therapy. List all current
medications patient was taking at the time of assessment.
(e) Patients intolerant to one drug may be switched to another drug in this class.
Intolerance should be observed within the first month of treatment.
•
•
Eligible patients currently taking donepezil would require assessment at 6
month intervals. To continue receiving donepezil, patients must not have both a
greater than 2 point reduction in MMSE and a 1 point increase in FAQ in a 6
month evaluation period. Scores are compared to the most recent test results.
Eligible new patients will enter a 3 month treatment period with donepezil.
During the 3 month trial, patients must exhibit an improvement from the initial
MMSE or FAQ to continue treatment with donepezil. The improvement must be
at least 2 MMSE points or -1 FAQ. Patients who meet these requirements will be
re-evaluated at 6 month intervals. To continue receiving donepezil, patients must
not have both a greater than 2 point reduction in MMSE and a 1 point increase in
FAQ in a 6 month evaluation period. Scores are compared to the most recent
test results.
•
The MMSE score must remain at 10 or greater at all times to be eligible for
coverage.
•
Patients who do not meet criteria to continue donepezil can be re-evaluated
within 3 months to confirm deterioration before coverage is discontinued.
•
Donepezil does not need to be discontinued prior to MMSE or FAQ testing.
•
A patient intolerant of one drug and switching to a second will be considered a
"new" patient and will be assessed as such.
•
Coverage will not be considered for patients who have failed on other drugs in
this class.
Applications for EDS for donepezil (Aricept) will only be accepted from physicians on
the Aricept/Exelon/Reminyl EDS application form. This form is available on-line at
http://formulary.drugplan.health.gov.sk.ca or by calling the Drug Plan.
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
234
doxercalciferol, capsule, 2.5ug (Hectorol-DPY)
For the management of hypocalcemia, osteodystrophy and secondary
hyperparathyroidism in chronic renal disease patients prior to initiation of dialysis.
Note: Coverage for dialysis patients is provided under the Saskatchewan Aids to
Independent Living (SAIL) Program. Exception Drug Status coverage is NOT
required for SAIL patients.
Duragesic - see fentanyl
efavirenz, capsule, 50mg, 100mg, 200mg; tablet, 600mg (Sustiva-BMY)
For management of HIV disease. This drug, as with other antivirals in treatment of
Eldepryl - see selegiline HCl
Elidel - see pimecrolimus
Elmiron - see pentosan polysulfate sodium
Enbrel - see etanercept
enoxaparin, syringe, 100mg/mL (0.3mL, 0.4mL, 0.6mL, 0.8mL, 1mL); injection
solution, 100mg/mL (3mL) (Lovenox-AVT); 150mg/mL (0.8mL, 1mL)
(Lovenox HP-AVT)
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.
(c) For treatment of anemia in transplant patients.
Eprex - see epoetin alfa
esomeprazole magnesium trihydrate, delayed release tablet, 20mg, 40mg
(Nexium-AST)
(a) For a maximum of 8 weeks in treatment of peptic ulcer disease, which includes
gastric and duodenal ulcers, in patients not responding or experiencing unusual
or severe adverse reactions to a reasonable trial with H2 blockers, sucralfate or
misoprostol. Coverage for a repeat treatment will be approved only after a 3-6
month period of no treatment or prophylaxis with an H2 blocker, sucralfate or
misoprostol.
(b) For treatment of symptoms of gastroesophageal reflux disease (GERD). It was
noted that patients with non-erosive GERD could potentially be reduced to stop235
down therapy with an H2 antagonist depending on symptom resolution.
(c) For treatment of severe erosive esophagitis and Zollinger-Ellison Syndrome.
(d) For one week for eradication of H. pylori-related infections in individuals with
peptic ulcer disease. Provision will be made for additional coverage in treatment
failures.
(e) For first-line prevention of gastroduodenal hemorrhage in high risk patients with
prior history of gastroduodenal bleeds for whom anticoagulant,glucocorticosteroid
or NSAID therapy cannot be avoided. Coverage is renewable on a yearly basis
for patients in dicontinuation of offending agents or replacement with less
damaging alternatives is not feasible.
(f) For a maximum of 8 weeks in patients discharged from hospital, on a proton
pump inhibitor, following a gastroduodenal bleed.
Estalis - see estradiol/norethindrone acetate
Estalis-Sequi - see estradiol & norethindrone acetate/estradiol
Estracomb - see estradiol & norethindrone acetate/estradiol
Estraderm - see estradiol
estradiol, transdermal gel (metered dose pump), 0.06% (Estrogel-SCH);
+transdermal therapeutic system, 25ug, 50ug, 100ug (Estraderm-NVR), 37.5ug
50ug, 100ug (Climara-BEX), 25ug, 50ug (Oesclim-PAL), 25ug, 37.5ug, 50ug, 75ug,
100ug (Estradot-NVR); transdermal patch, 50ug, 75ug, 100ug
(Rhoxal-Estradiol Derm-RHO),
(a) For treatment in patients who are unable to tolerate oral estrogen.
(b) For treatment of patients with a fasting plasma triglyceride level of 4.5 mmol/L or
more.
estradiol/norethindrone acetate, transdermal therapeutic system (8), 50ug/140ug,
50ug/250ug (Estalis-NVR)
(a) For treatment in patients who are unable to tolerate oral hormone replacement
therapy (either estrogen or progesterone).
more.
estradiol & norethindrone acetate/estradiol, transdermal therapeutic system (8),
50ug & 140ug/50ug (Estalis-Sequi-NVR)
+50ug & 250ug/50ug (Estracomb-NVR) (Estalis-Sequi-NVR)
(a) For treatment in patients who are unable to tolerate oral hormone replacement
therapy (either estrogen or progesterone).
more.
Estradot - see estradiol
Estrogel - see estradiol
etanercept, powder for injection (vial), 25mg/vial (Enbrel-WYA)
(a) For treatment of patients with active rheumatoid arthritis who have failed or are
intolerant to methotrexate and leflunomide.
(b) For treatment of paediatric patients with active juvenile rheumatoid arthritis who
have failed one DMARD.
This product should be used in consultation with a specialist in this area.
Note: Exceptions can be considered in cases where methotrexate or leflunomide are
contraindicated.
etodolac, capsule, 200mg (Apo-Etodolac-APX);
*capsule, 300mg (Ultradol-PGA) (Apo-Etodolac-APX)
For treatment of patients with an intolerance to other NSAIDs listed in the Formulary.
236
Evista - see raloxifene HCl
Exelon - see rivastigmine
fentanyl, transdermal system, 25ug/hr, 50ug/hr, 75ug/hr, 100ug/hr
(Duragesic-JAN)
For treatment of patients who cannot tolerate, or are unable to take, oral sustainedrelease strong opioids, or as an alternative to subcutaneous narcotic infusion therapy.
filgrastim, injection solution, 300ug/mL (Neupogen-AMG)
(a) For treatment of patients with congenital, cyclic or idiopathic neutropenia with
absolute neutrophil counts of less than or equal to 500.
(b) For treatment of non-cancer patients who have undergone bone marrow
transplantation.
(c) For treatment of AIDS patients with absolute neutrophil counts of less than 500.
*flavoxate HCl, tablet, 200mg (Urispas-PMS) (Apo-Flavoxate-APX)
(pms-Flavoxate-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) (Gen-FluconazoleGPM) (pms-Fluconazole-PMS) (Novo-Fluconazole-NOP) (Dom-Fluconazole-DOM)
(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) (Apo-Flunarizine-APX)
For prophylaxis of migraines in cases where alternative prophylactic agents have not
been effective.
flurbiprofen sodium, ophthalmic solution, 0.03% (Ocufen-ALL)
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 uncontrolled on concurrent inhaled steroid therapy. It is
important that these patients also have access to a short-acting beta-2 agonist for
symptomatic relief.
(b) For treatment of patients with COPD not responding to short-acting beta agonists
or short-acting anticholinergic bronchodilators.
formoterol fumarate dihydrate/budesonide, powder for inhalation (package),
6ug/100ug, 6ug/200ug (Symbicort Turbuhaler-AST)
237
(a) For treatment of asthma in patients not adequately controlled on inhaled steroid
therapy. It is important that these patients also have access to a short-acting
beta-2 agonist for symptomatic relief.
(b) For treatment of chronic obstructive pulmonary disease (COPD) in patients who
are not adequately controlled on a long-acting beta-2 agonist alone.
Fortovase - see saquinavir
Fosamax - see alendronate sodium
fosfomycin tromethamine, oral powder (sachet), 3g (Monurol-PFR)
For treatment of:
(a) Urinary tract infections with organisms resistant to first line therapy.
(b) Urinary tract infections in patients allergic to first line agents.
(c) Urinary tract infections in pregnancy when first line agents are inappropriate.
Fragmin - see dalteparin sodium
Fraxiparine - see nadroparin calcium
Fraxiparine Forte - see nadroparin calcium
Fucithalmic - see fusidic acid
fusidic acid, ophthalmic drops (preservative free), 1%; ophthalmic drops 1%
(Fucithalmic-LEO)
For patients not responding to listed alternatives.
galantamine hydrobromide, tablet, 4mg, 8mg, 12mg (Reminyl-JAN)
(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 within 60 days
prior to initial application for coverage by a clinician.
are not to be used concurrently with galantamine hydrobromide therapy. List all
current medications patient was taking at the time of assessment.
•
Eligible patients currently taking galantamine hydrobromide would require
assessment at 6 month intervals. To continue receiving galantamine
hydrobromide, patients must not have both a greater than 2 point reduction in
MMSE and a 1 point increase in FAQ in a 6 month evaluation period. Scores are
compared to the most recent test results.
•
Eligible new patients will enter a 3 month treatment period with galantamine
hydrobromide. During the 3 month trial, patients must exhibit an improvement
from the initial MMSE or FAQ to continue treatment with galantamine
hydrobromide. The improvement must be at least 2 MMSE points or -1 FAQ.
Patients who meet these requirements will be re-evaluated at 6 month intervals.
To continue receiving galantamine hydrobromide, patients must not have both a
greater than 2 point reduction in MMSE and a 1 point increase in FAQ in a 6
•
coverage.
•
Patients who do not meet criteria to continue galantamine hydrobromide can be
re-evaluated within 3 months to confirm deterioration before coverage is
discontinued.
238
•
Galantamine hydrobromide does not need to be discontinued prior to MMSE or
FAQ testing.
•
•
this class.
Applications for EDS for galantamine (Reminyl) will only be accepted from
physicians on the Aricept/Exelon/Reminyl EDS application form. This form is
available on-line at http://formulary.drugplan.health.gov.sk.ca or by calling the
Drug Plan.
ganciclovir sodium, capsule, 250mg, 500mg (Cytovene-HLR)
(a) For treatment of CMV retinitis and other CMV infections in immunocompromised
patients.
(b) For prevention of CMV in solid organ transplant recipients who are considered at
risk of developing CMV disease. Coverage will be granted for a period of 3
months.
gatifloxacin, tablet, 400mg (Tequin-BMY)
For treatment of:
(a) Pneumonia in patients with underlying lung disease (excluding asthma) and
pneumonia in nursing home patients.
(b) Infections caused by organisms known to be resistant to alternative antibiotics.
determined by C & S. Where a C & S cannot be obtained coverage will be
approved when a patient has failed at least 2 other classes of antibiotics.
(d) For completion of antibiotic treatment initiated in hospital when alternatives are
not appropriate.
Gen-Carbamazepine CR - see carbamazepine
Gen-Ciprofloxacin - see ciprofloxacin
Gen-Cycloprine - see cyclobenzaprine HCl
Gen-Cyproterone - see cyproterone acetate
Gen-Fluconazole - see fluconazole
Gen-Minocycline - see minocycline HCl
Gen-Nabumetone - see nabumetone
Gen-Selegiline - see selegiline HCl
Gen-Ticlopidine - see ticlopidine HCl
glatiramer acetate, injection, 20mg (pre-filled syringe) (Copaxone-TVM)
See Appendix F
GlucoNorm - see repaglinide
goserelin acetate, 3.6mg/syringe (Zoladex-AST)
months.
halobetasol propionate, cream, 0.05%; ointment, 0.05% (Ultravate-WSD)
For treatment of patients refractory to or intolerant of other listed products.
239
Hectorol - see doxercalciferol
Heptovir - see lamivudine
Hivid - see zalcitabine
Hp-PAC - see lansoprazole/clarithromycin/amoxicillin
Humalog - see insulin lispro
Humalog Mix25 - see insulin (regular/protamine) lispro
Humatrope - see somatropin
Imitrex - see sumatriptan
indinavir SO4, capsule, 200mg, 400mg (Crixivan-MSD)
infliximab, injection (mg),100mg/vial (Remicade-SCH)
Crohn's Disease:
(a) Moderate to severe Crohn's Disease:
•
For treatment of patients who demonstrate continuing symptoms despite the
use of optimal conventional therapies such as 5-ASA agents, glucocorticoids
and immunosuppressive therapy.
•
For treatment of patients who are unable to tolerate conventional therapy
including 5-ASA agents, glucocorticoids and immunosuppressive therapy.
(b) Fistulizing Crohn's Disease:
•
For treatment of patients with symptomatic enterocutaneous or perineal
fistulae, enterovaginal fistulae or enterovesical fistulae (i.e. any type of
fistulizing Crohn’s Disease).
Note: This product should be used in consultation with a specialist in this area.
Pharmacies note: claims on behalf of Crohn's Disease patients must use the
following identifying number (not the DIN):
00950899
Rheumatoid Arthritis:
For treatment of patients with active rheumatoid arthritis who have failed or are
intolerant to methotrexate and leflunomide.
Treatment should be combined with an immunosuppressant. This product should be
used in consultation with a specialist in this area.
Note: Exceptions can be considered in cases where methotrexate or leflunomide are
contraindicated.
Infufer - see iron dextran
Innohep - see tinzaparin sodium
insulin aspart, injection solution, 100U/ml (5x3ml) (10ml) (NovoRapid-NOO)
For treatment of difficult to control diabetes.
insulin lispro, injection solution, 100U/mL (5 x 1.5mL, 5 x 3mL) (Humalog-LIL)
(a) For treatment of patients using insulin pumps.
(b) For treatment of patients with difficult to control diabetes.
insulin (regular/protamine) lispro, injection suspension, 100U/mL, 25%/75%
(5x3mL) (Humalog Mix25-LIL)
For treatment of patients with difficult to control diabetes.
interferon alfa-2a, injection solution albumin (human) free, 3 million IU/1mL,
9 million IU/1mL, 18 million IU/3mL (Roferon-A-HLR)
240
(a) For treatment of chronic active hepatitis B for a period of up to 6 months.
(b) For treatment of chronic active hepatitis C. Coverage will be provided for an initial
6 month period with potential renewal for 2 additional 6 month periods.
Note: Interferons are not interchangeable. Pharmacists should dispense the product
specified by the physician.
interferon alfa-2b, powder for injection, 10 million IU; injection solution albumin
(human) free, 6 million IU/mL (0.5mL), 10 million IU/mL (0.5mL, 1mL); multi-dose
pen (kit) albumin (human) free, 18 million IU/pen, 30 million IU/pen, 60 million
IU/pen (Intron-A-SCH)
(a) For treatment of chronic active hepatitis B for a period of up to 6 months.
(b) For treatment of chronic active hepatitis C. Coverage will be provided for an initial
6 month period with potential renewal for 2 additional 6 month periods.
Note: Interferons are not interchangeable. Pharmacists should dispense the product
specified by the physician.
interferon alfa-2b/Ribavirin, 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 F
interferon beta-1a, pre-filled syringe, 22ug (6 million IU), 44ug (12 million IU)
(Rebif-SRO)
See Appendix F
interferon beta-1b, powder for injection, 0.3mg (3mL) (Betaseron-BEX)
See Appendix F
Intron A - see interferon alfa-2b
Invirase - see saquinavir
iron sucrose, injection, 20mg/mL (Venofer-GPM)
For treatment of iron deficiency when patients are intolerant to oral iron replacement
products and intravenous iron dextran.
*iron dextran, injection, 50mg/mL (Infufer-SAB) (DexIron-GPM)
For treatment of iron deficiency when patients are intolerant to oral iron replacement
products. Note: Coverage for dialysis patients is provided under the Saskatchewan
Aids to Independent Living (S.A.I.L.) Program. Exception Drug Status coverage is not
required for S.A.I.L. patients.
itraconazole, capsule, 100mg; oral solution, 10mg/mL (Sporanox-JAN)
(a) For treatment of severe or life-threatening fungal infections.
(b) For treatment of severe dermatophytoses not responding to other forms of
therapy.
(c) For treatment of onychomycosis.
Kaletra - see lopinavir/ritonavir
*ketoconazole, tablet, 200mg (Apo-Ketoconazole-APX) (Nu-Ketocon-NXP)
(Novo-Ketoconazole-NOP)
(a) For treatment of severe or life-threatening fungal infections.
241
(b) For treatment of severe dermatophytoses.
(c) For treatment of dermatophytoses not responding to other forms of therapy.
*ketorolac tromethamine, ophthalmic solution, 0.5% (Acular-ALL)
(Apo-Ketoralac-APX) (ratio-Ketorolac-RPH)
cataract surgery.
(c) For treatment of long-term inflammatory conditions not responding to shorttopical steroids.
+ketotifen fumarate, tablet, 1mg (Zaditen-NVR) (Novo-Ketotifen-NOP)
(pms-Ketotifen-PMS); syrup, 0.2mg/mL (Zaditen-NVR) (Novo-Ketotifen-NOP)
(Nu-Ketotifen-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.
Kineret - see anakinra
lactulose, syrup, 667mg/mL (pms-Lactulose-PMS);
*solution, 667mg/mL (ratio-Lactulose-RPH) (Apo-Lactulose-APX)
For treatment of portal systemic encephalopathy.
lamivudine, tablet, 100mg (Heptovir-GSK)
For management of hepatitis B.
lamivudine, tablet, 150mg, 300mg; oral solution, 10mg/mL (3TC-GSK)
lamivudine/zidovudine, tablet, 150mg/300mg (Combivir-GSK)
lansoprazole, delayed release capsule, 15mg, 30mg (Prevacid-ABB)
misoprostol.
noted that patients with non-erosive GERD could potentially be reduced to stepdown therapy with an H2 antagonist depending on symptom resolution.
failures.
prior history of gastroduodenal bleeds for whom anticoagulant,
glucocorticosteroid or NSAID therapy cannot be avoided. Coverage is renewable
on a yearly basis for patients if discontinuation of offending agents or
replacement with less damaging alternatives is not feasible.
(f) For a maximum of 8 weeks in patients discharged from hospital, on a
proton pump inhibitor, following a gastroduodenal bleed.
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.
242
leflunomide, tablet, 10mg, 20mg (Arava-AVT)
For treatment of patients with active rheumatoid arthritis who have failed or are
intolerant to methotrexate and at least one other DMARD (e.g. sulfasalazine,
azathioprine or hydroxychloroquine).
Note: Leflunomide is contraindicated in patients with pre-existing impairment of liver
function.
Leucovorin - see leucovorin calcium
leucovorin calcium, tablet, 5mg (Leucovorin-WYA)
For treatment of folic acid deficiency in patients who have been on long-term therapy
with trimethoprim/sulfamethoxazole.
leuprolide acetate, injection, 3.75mg/mL, 7.5mg/mL; depot injection, 11.25mg
(3-month SR) (Lupron Depot-ABB)
months.
Levaquin - see levofloxacin
levofloxacin, tablet, 250mg, 500mg (Levaquin-JAN)
For treatment of:
determined by C & S. Where C & S cannot be obtained coverage will be
not appropriate.
Lin-Megestrol - see megestrol acetate tablet
linezolid, tablet, 600mg (Zyvoxam-PHU)
Following consultation with an infectious disease specialist for:
(a) Treatment of gram-positive infections resistant to vancomycin.
(b) Treatment of gram-positive infections in patients unable to tolerate or who are
experiencing severe adverse effects from vancomycin.
(c) For completion of therapy initiated in hospital with intravenous vancomycin,
quinupristin/dalfopristin or linezolid for patients who can be discharged on oral
therapy.
Lioresal Intrathecal - see baclofen
Loniten - see minoxidil
lopinavir/ritonavir, capsule, 133.3mg/33.3mg; oral solution, 80mg/20mg(mL)
(Kaletra-ABB)
Losec - see omeprazole magnesium
Lovenox - see enoxaparin
243
Lovenox HP - see enoxaparin
Lupron Depot - see leuprolide acetate
Maxalt - see rizatriptan benzoate
Maxalt RPD - see rizatriptan benzoate
Med-Cyclobenzaprine - see cyclobenzaprine HCl
Med-Minocycline - see minocycline HCl
Med-Selegiline - see selegiline HCl
Megace - see megestrol acetate tablet
Megace OS - see megestrol acetate oral suspension
*megestrol acetate, tablet, 40mg, 160mg (Lin-Megestrol-LIN) (Apo-Megestrol-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, 40mg/mL (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.
*meloxicam, tablet, 7.5mg, 15mg (Mobicox-BOE) (pms-Meloxicam-PMS)
(ratio-Meloxicam-RPH) (Apo-Meloxicam-APX) (Dom-Meloxicam-DOM)
For treatment of patients with an intolerance to other NSAIDs listed in the formulary.
Mepron - see atovaquone
mercaptopurine, tablet, 50mg (Purinethol-GSK)
(a) For treatment of Crohn's Disease.
(b) For treatment of rheumatoid arthritis.
+methoxsalen, capsule, 10mg (Oxsoralen-ICN) (Oxsoralen Ultra-ICN)
(Ultramop-CDX); lotion, 1% (Oxsoralen-ICN) (Ultramop-CDX)
For treatment of psoriasis, for use prior to PUVA therapy.
methysergide maleate, tablet, 2mg (Sansert-NVR)
For prophylaxis of recurrent vascular headaches. Coverage will be provided for up to
6 months at a time with a 3-4 week medication free interval between courses of
therapy.
Miacalcin - see calcitonin salmon nasal spray
midodrine HCl, tablet, 2.5mg, 5mg (Amatine-RBP)
For treatment of orthostatic hypotension.
Minocin - see minocycline HCl
* minocycline HCl, capsule, 50mg, 100mg (Minocin-WYA) (Apo-Minocycline-APX)
(Novo-Minocycline-NOP) (ratio-Minocycline-RPH) (Gen-Minocycline-GPM)
(Med-Minocycline-MED) (Dom-Minocycline-DOM) (Rhoxal-Minocycline-RHO) (pmsMinocycline-PMS)
For treatment of acne unresponsive to tetracycline.
minoxidil, tablet, 2.5mg, 10mg (Loniten-PHU)
For control of hypertension unresponsive to all other listed therapeutic agents.
Mobicox - see meloxicam
244
modafinil, tablet, 100mg (Alertec-DPY)
For treatment of:
(a) patients with sleep laboratory-confirmed diagnosis of narcolepsy.
(b) patients with sleep laboratory confirmed diagnosis of idiopathic CNS
hypersomnia.
Monocor - see bisoprolol fumarate
montelukast sodium, chewable tablet, 4mg, 5mg; tablet, 10mg (Singulair-MSD)
For adjunctive treatment of asthma in patients not well controlled on inhaled
corticosteroids.
Monurol - see fosfomycin tromethamine
moxifloxacin HCl, tablet, 400mg (Avelox-BAY)
For treatment of:
determined by C & S. Where a C & S cannot be obtained coverage will be
not appropriate.
Mycobutin - see rifabutin
mycophenolate mofetil, capsule, 250mg; tablet, 500mg (CellCept-HLR)
For prevention of acute rejection in transplant patients.
nabilone, capsule, 1mg (Cesamet-LIL)
For treatment of nausea and anorexia in AIDS patients.
*nabumetone, tablet, 500mg (Relafen-GSK) (Apo-Nabumetone-APX)
(Gen-Nabumetone-GPM) (Novo-Nabumetone-NOP) (Rhoxal-Nabumetone-RHO);
750mg (Relafen-GSK) (Novo-Nabumetone-NOP)
For treatment of patients with an intolerance to other NSAIDs listed in the Formulary.
nadroparin calcium, syringe, 9,500IU/mL (0.3mL, 0.4mL, 0.6mL, 0.8mL, 1.0mL)
(Fraxiparine-SAW); syringe, 19,000IU/mL (0.6mL, 0.8mL, 1mL)
(Fraxiparine Forte-SAW)
syndrome.
nafarelin acetate, intranasal solution, 2mg/mL (Synarel-HLR)
months.
Nalcrom - see sodium cromoglycate
245
naratriptan HCl, tablet, 1mg, 2.5mg (Amerge-GSK)
For treatment of migraine headaches. Eligibility will be restricted to beneficiaries over
18 and under 65 years of age.
The maximum quantity that can be claimed through the Drug Plan is limited to 6
doses per 30 days within a 60 day period. Patients requiring more than 12 doses in
a consecutive 60 day period should be considered for migraine prophylaxis therapy if
they are not already receiving such therapy.
nateglinide, tablet, 60mg, 120mg, 180mg (Starlix-NVR)
For treatment of diabetes in patients who are not adequately controlled on or are
intolerant to sulfonylureas.
nelfinavir mesylate, tablet, 250mg; oral powder, 50mg/g (Viracept-AGR)
Neoral - see cyclosporine
Neupogen - see filgrastim
nevirapine, tablet, 200mg (Viramune-BOE)
Nexium - see esomeprazole magnesium trihydrate
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, tablet, 400mg (Noroxin-MSD) (Apo-Norflox-APX)
(Novo-Norfloxacin-NOP) (pms-Norfloxacin-PMS)
For treatment of:
(a) Genitourinary tract infections caused by Pseudomonas aeruginosa.
(b) Adults with gonoccoccal urethritis or cervicitis.
(c) Genitourinary tract infections in patients allergic to alternative agents.
(d) Genitourinary tract infections with organisms known to be resistant to alternative
antibiotics.
Noroxin - see norfloxacin
Norvir - see ritonavir
Norvir SEC - see ritonavir
NovoRapid - see insulin aspart
Novo-Carvedilol - see carvedilol
Novo-Ciprofloxacin - see ciprofloxacin
Novo-Clavamoxin - see amoxicillin trihydrate/potassium clavulanate
Novo-Cycloprine - see cyclobenzaprine HCl
Novo-Cyproterone - see cyproterone acetate
Novo-Fluconazole - see fluconazole
Novo-Ketoconazole - see ketoconazole
Novo-Ketotifen - see ketotifen fumarate
Novo-Minocycline - see minocycline HCl
Novo-Nabumetone - see nabumetone
246
Novo-Norfloxacin - see norfloxacin
Novo-Selegiline - see selegiline HCl
Novo-Ticlopidine - see ticlopidine
Nu-Carvedilol - see carvedilol
Nu-Cyclobenzaprine - see cyclobenzaprine HCl
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
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) (Octreotide Acetate-OMG);
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.
Octreotide Acetate - see octreotide
Ocufen - see flurbiprofen sodium
Ocuflox - see ofloxacin ophthalmic solution
Oesclim - see estradiol
*ofloxacin, ophthalmic solution, 0.3% (Ocuflox-ALL) (Apo-Ofloxacin-APX)
(a) For treatment of ophthalmic infections caused by gram-negative organisms or
those not responding to alternative agents.
(b) For treatment of infiltrative corneal infections.
olanzapine, tablet, 2.5mg, 5mg, 7.5mg, 10mg, 15mg (Zyprexa-LIL); orally
disintegrating tablet, 5mg, 10mg, 15mg (Zyprexa Zydis-LIL)
(a) For treatment of schizophrenia.
(b) For treatment of other psychotic conditions where there has been treatment
failure or intolerance to other atypical anti-psychotic agents.
(c) For treatment of patients with acute mania or bi-polar affective disorder for an
additional 4 weeks following hospital discharge.
omeprazole, capsule, 20mg (Apo-Omeprazole-APX)
misoprostol.
(b) For one year in treatment of symptoms of gastroesophageal reflux disease
(GERD). It was noted that patients with non-erosive GERD could potentially be
reduced to step-down therapy with an H2 antagonist depending on symptom
resolution.
(c) For one year in treatment of severe erosive esophagitis and Zollinger-Ellison
Syndrome.
247
failures.
omeprazole magnesium, delayed release tablet, 10mg (Losec-AST)
(a) For maintenance therapy of healed reflux esophagitis. This is renewable on a
yearly basis.
(c) For treatment of severe erosive esophagitis and Zollinger-Ellison syndrome. This
is renewable on a yearly basis.
omeprazole magnesium, delayed release tablet, 20mg (Losec-AST)
misoprostol.
(b) For one year in treatment of symptoms of gastroesophageal reflux disease
(GERD). It was noted that patients with non-erosive GERD could potentially be
reduced to step-down therapy with an H2 antagonist depending on symptom
resolution.
(c) For one year in treatment of severe erosive esophagitis and Zollinger-Ellison
Syndrome.
failures.
One-Alpha - see alfacalcidol
oxcarbazepine, tablet, 150mg, 300mg, 600mg; oral suspension, 60mg/mL
(Trileptil-NVR)
For treatment of partial seizures in patients intolerant to carbamazepine.
Oxeze Turbuhaler - see formoterol fumarate
Oxsoralen - see methoxsalen
*pamidronate disodium injection, 30mg, 90mg (Aredia-NVR) (Pamidronate
Disodium Injection-DBU) (pms-Pamidronate-PMS);
60mg (Pamidronate Disodium Injection-DBU)
For treatment of osteoporosis in patients unable to tolerate oral bisphosphonates.
248
pantoprazole, enteric coated tablet, 40mg (Pantoloc-SLV)
misoprostol.
failures.
Pantoloc - see pantoprazole
Pariet - see rabeprazole sodium
Pegetron - see peginterferon alfa-2b/ribavirin
peginterferon alfa-2b, powder for injection (vial), 50ug/0.5mL, 80ug/0.5mL,
120ug/0.5mL, 150ug/0.5mL (Unitron PEG-SCH)
For treatment of chronic active hepatitis C. Coverage will be provided for an initial 6
month period with potential renewal for 2 additional 6 month periods.
peginterferon alfa-2b/ribavirin, powder for solution/capsule, 50ug/200mg,
80ug/200mg, 100ug/200mg, 120ug/200mg, 150ug/200mg (Pegetron-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.
pentosan polysulfate sodium, capsule, 100mg (Elmiron-JAN)
For treatment of interstitial cystitis where other treatments have failed.
Persantine - see dipyridamole
pimecrolimus, topical cream, 1% (Elidel-NVR)
For treatment of atopic dermatitis in patients unresponsive or intolerant to topical
steroids within the last 3 months.
pioglitazone HCl, tablet, 15mg, 30mg, 45mg (Actos-LIL)
intolerant to metformin or sulfonylureas.
pivmecillinam HCl, tablet, 200mg (Selexid-LEO)
For treatment of:
(a) Urinary tract infections with organisms resistant to first line therapy.
(b) Urinary tract infections in patients allergic to first line agents.
(c) Urinary tract infections in pregnancy when first line agents are inappropriate.
Plavix - see clopidogrel bisulfate
249
pms-Bezafibrate - see bezafibrate
pms-Carbamazepine-CR - see carbamazepine
pms-Carvedilol - see carvedilol
pms-Ciprofloxacin - see ciprofloxacin
pms-Cyclobenzaprine - see cyclobenzaprine HCl
pms-Deferoxamine - see deferoxamine mesylate
pms-Flavoxate - see flavoxate HCl
pms-Fluconazole - see fluconazole
pms-Ketotifen - see ketotifen
pms-Lactulose - see lactulose
pms-Meloxicam - see meloxicam
pms-Minocycline - see minocycline HCl
pms-Norfloxacin - see norfloxacin
pms-Ticlopidine - see ticlopidine HCl
pms-Tobramycin - see tobramycin
pms-Vancomycin - see vancomycin HCl
Prem-Ciprofloxacin - see ciprofloxacin
Prevacid - see lansoprazole
Profasi HP - see chorionic gonadotropin
progesterone (micronized), capsule, 100mg (Prometrium-SCH)
(a) For treatment of patients unable to tolerate medroxyprogesterone acetate
(Provera).
(b) For treatment of patients having low high-density lipoproteins.
Prograf - see tacrolimus
Prometrium - see progesterone (micronized)
Protopic - see tacrolimus
Protropin - see somatrem
Pulmozyme - see dornase alfa
Purinethol - see mercaptopurine
rabeprazole sodium, tablet, 10mg (Pariet-JAN)
misoprostol.
failures.
(e) First-line prevention of gastroduodenal hemorrhage in high risk patients with prior
history of gastroduodenal bleeds for whom anticoagulant, glucocorticosteroid or
NSAID therapy cannot be avoided. Coverage is renewable on a yearly basis for
patients if discontinuation of offending agents or replacement with less damaging
alternatives is not feasible.
raloxifene HCl, tablet, 60mg (Evista-LIL)
250
disodium/calcium (Didrocal) after receiving it for 1 year.
Rapamune - see sirolimus
ratio-Aclavulanate - see amoxicillin trihydrate/potassium clavulanate
ratio-Cefuroxime - see cefuroxime axetil
ratio-Ciprofloxacin - see ciprofloxacin
ratio-Ketorolac - see ketorolac tromethamine
ratio-Lactulose - see lactulose
ratio-Meloxicam - see meloxicam
ratio-Minocycline - see minocycline HCl
Rebetron - see interferon alfa-2b/ribavirin
Rebif - see Appendix F
Relafen - see nabumetone
Remicade - see infliximab
Reminyl - see galantamine hydrobromide
Renagel - see sevelamer HCl
repaglinide, tablet, 0.5mg, 1mg, 2mg (GlucoNorm-NOO)
intolerant to sulfonylureas.
Rescriptor - see delavirdine mesylate
Retin A - see tretinoin
Retrovir - see zidovudine
Rhoxal-Ciprofloxacin - see ciprofloxacin
Rhoxal-Minocycline - see minocycline HCl
Rhoxal-Nabumetone - see nabumetone
Rhoxal-Ticlopidine - see ticlopidine HCl
rifabutin, capsule, 150mg (Mycobutin-PHU)
For prevention of disseminated Mycobacterium avium complex (MAC) disease in
patients with advanced human immunodeficiency virus (HIV) infection.
risedronate sodium, tablet, 5mg, 35mg (Actonel-PGA)
disodium/calcium (Didrocal) after receiving it for one year.
(c) For treatment of osteoporosis in patients who have pre-existing and/or recent
fractures.
(d) For treatment of glucocorticoid-induced osteoporosis in patients who have
received systemic glucocorticoid treatment for at least 3 months.
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)
rivastigmine, capsule, 1.5mg, 3mg, 4.5mg, 6mg; oral solution, 2mg/mL
(Exelon-NVR)
(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.
251
are not to be used concurrently with rivastigmine therapy. List all current
medications patient was taking at the time of assessment.
•
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
•
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.
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.
•
•
this class.
Applications for EDS for rivastigmine (Exelon) will only be accepted from physicians
on the Aricept/Exelon/Reminyl EDS application form. This form is available on-line at
http://formulary.drugplan.health.gov.sk.ca or by calling the Drug Plan.
rizatriptan benzoate, tablet, 5mg, 10mg (Maxalt-MSD); wafer, 5mg, 10mg
(Maxalt RPD-MSD)
Rocaltrol - see calcitriol
rofecoxib, tablet, 12.5mg, 25mg; oral suspension, 2.5mg/mL (Vioxx-MSD)
on-line computer system).
•
252
•
•
(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)
intolerant to metformin or sulfonylureas.
SAB-Tobramycin - see tobramycin ophthalmic solution
Saizen - see somatropin
salmeterol xinafoate, metered dose inhaler, 25ug/actuation; powder disk,
50ug/blister (Serevent-GSK); powder for inhalation (package), 50ug/dose
(Serevent Diskus-GSK)
(a) For treatment of asthma uncontrolled on concurrent inhaled steroid therapy.
It is important that these patients also have access to a short-acting beta-2
agonist for symptomatic relief
(b) For treatment of patients with COPD not responding to short-acting beta agonists
or short-acting anticholinergic bronchodilators.
salmeterol xinafoate/fluticasone propionate, metered dose inhaler (package),
25ug/125ug, 25ug/250ug (Advair-GSK); powder for inhalation (package),
50ug/100ug, 50ug/250ug, 50ug/500ug (Advair Diskus-GSK)
(a) For treatment of asthma in patients not adequately controlled on inhaled steroid
therapy. It is important that these patients also have access to a short-acting
beta-2 agonist for symptomatic relief.
(b) For treatment of chronic obstructive pulmonary disease (COPD) in patients who
are not adequately controlled on long-acting beta-2 agonists alone.
Sandostatin - see octreotide
Sandostatin LAR - see octreotide
Sansert - see methysergide maleate
saquinavir, capsule, 200mg (Invirase-HLR); soft gelatin capsule, 200mg
(Fortovase-HLR)
*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
sevelamer HCl, tablet, 400mg, 800mg (Renagel-GZY)
(a) For treatment of patients in endstage renal disease with intolerance to aluminum
or calcium containing phosphate binding agents.
(b) For treatment of patients in endstage renal disease where aluminum or calcium
253
containing phosphate binding agents are inappropriate.
Sibelium - see flunarizine HCl
Singulair - see montelukast sodium
sirolimus, tablet, 1mg; oral solution, 1mg/mL (Rapamune-WYA)
For prophylaxis of graft rejection in transplant patients.
sodium cromoglycate, capsule, 100mg (Nalcrom-AVT)
(a) For treatment of patients who experience severe reactions to foods which cannot
be avoided.
(b) For treatment of patients with Crohn's Disease or ulcerative colitis not responding
to traditional therapy.
somatrem, injection, 5mg, (Protropin-HLR)
For treatment of children who have growth failure due to inadequate secretion of
normal endogenous growth hormone.
+somatropin, injection, 5mg (Humatrope-LIL), 6mg, 12mg
(Humatrope Cartridge-LIL)
normal endogenous growth hormone.
+somatropin, injection, 3.33mg (Saizen-SRO), 5mg (Nutropin-HLR) (Saizen-SRO),
10mg (Nutropin AQ-HLR) (Nutropin-HLR)
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 Saskatchewan Aids to Independent
Living (S.A.I.L.) Program.
Soriatane - see acitretin
Spiriva - see tiotropium bromide monohydrate
Sporanox - see itraconazole
Starlix - see nateglinide
stavudine, capsule, 15mg, 20mg, 30mg, 40mg (Zerit-BRI)
Stieva-A Forte - see tretinoin
sumatriptan, tablet, 25mg, 50mg, 100mg; injection solution, 6mg/0.5mL;
nasal spray, 5mg, 20mg (Imitrex-GSK)
Suprax - see cefixime
Suprefact - see buserelin acetate
Sustiva - see efavirenz
Symbicort Turbuhaler - see formoterol fumarate dihydrate/budesonide
254
Synarel - see nafarelin acetate
3TC - see lamivudine
tacrolimus, capsule, 0.5mg, 1mg, 5mg; ampoule, 5mg/mL (Prograf-FUJ)
For prophylaxis of graft rejection.
tacrolimus, topical ointment, 0.03%, 0.1% (Protopic-FUJ)
For treatment atopic dermatitis in patients unresponsive or intolerant to topical
steroids within the last three months.
Taro-Carbamazepine CR - see carbamazepine
Tequin - see gatifloxacin
Tegretol CR - see carbamazepine
Ticlid - see ticlopidine HCl
*ticlopidine HCl, tablet, 250mg (Ticlid-HLR) (Apo-Ticlopidine-APX)
(Nu-Ticlopidine-NXP) (Gen-Ticlopidine-GPM) (pms-Ticlopidine-PMS)
(Dom-Ticlopidine-DOM) (Rhoxal-Ticlopidine-RHO) (Novo-Ticlopidine-NOP)
(a) For treatment of patients who have experienced a transient ischemic attack,
stroke, or myocardial infarction while on acetylsalicylic acid.
(b) For treatment of patients who have experienced a transient ischemic attack,
stroke or myocardial infarction and have clearly demonstrated allergy to
acetylsalicylic acid (manifested by asthma or nasal polyps).
(c) For treatment of patients who have experienced a transient ischemic attack,
stroke or a myocardial infarction and are intolerant of acetylsalicylic acid
(manifested by gastrointestinal hemorrhage).
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)
(Innohep-LEO)
syndrome.
tiotropium bromide monohydrate, powder capsule, 18ug/dose (Spiriva-BOE)
For the treatment of patients with COPD not responding to short-acting beta agonists
or short-acting anticholinergic bronchodialators.
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.
255
tobramycin, ophthalmic ointment, 0.3% (Tobrex-ALC);
*ophthalmic solution, 0.3% (Tobrex-ALC) (pms-Tobramycin-PMS)
(SAB-Tobramycin-SAB) (Apo-Tobramycin-APX)
For treatment of ophthalmic infections in cases not responding to gentamicin
ophthalmic.
tobramycin/dexamethasone, ophthalmic suspension, 0.3%/0.1%; ophthalmic
ointment, 0.3%/0.1% (Tobradex-ALC)
(a) For treatment of ophthalmic infections in cases not responding to therapeutic
alternatives.
(b) For post-operative long-term (>7days) use.
Tobrex - see tobramycin
tolterodine l-tartrate, extended-release capsule, 2mg, 4mg (Unidet-PHU)
For treatment of patients unable to tolerate oxybutynin chloride.
Tracleer - see bosentan
*tretinoin, cream, 0.1% (Stieva-A Forte-STI) (Retin A-JAN) (Vitamin A Acid-DER)
For treatment of acne not responding to alternative topical therapy.
triamcinolone hexacetonide, injection suspension, 20mg/mL (Aristospan-STI)
For intra-articular injection in the management of pediatric chronic inflammatory
arthropathies.
Trileptal - see oxcarbazepine
Trizivir - see abacavir SO4/lamivudine/zidovudine
Ultradol - see etodolac
Ultramop - see methoxsalen
Ultravate - see halobetasol propionate
Unidet - see tolterodine l-tartrate
Unitron PEG - see peginterferon alfa-2b
Urispas - see flavoxate HCl
Urso - see ursodiol
ursodiol, tablet, 250mg (Urso-AXC), 500mg (Urso DS-AXC)
For management of cholestatic liver diseases such as primary biliary cirrhosis.
Valcyte - see valganciclovir HCl
valdecoxib, tablet, 10mg, 20mg (Bextra-PFI)
on-line computer system.)
•
•
•
(c) For treatment of patients with an intolerance to other NSAIDS listed in the
Formulary.
valganciclovir HCl, tablet, 450mg (Valcyte-HLR)
(a) For treatment of retinitis arising from CMV infection in patients with HIV infection.
(b) For prophylaxis and treatment of CMV infection in solid organ transplant patients.
Coverage will be approved for a three month period.
256
Vancocin - see vancomycin HCl
vancomycin HCl, capsule, 125mg, 250mg (Vancocin-LIL);
injection, 500mg, 1g (pms-Vancomycin-PMS)
For treatment of:
Clostridium difficile infections for up to two consecutive two week periods after no
response, allergies or intolerance to a course of metronidazole. Repeat approvals will
only be granted with laboratory evidence of C. difficile toxin.
Venofer - see iron sucrose
Videx - see didanosine
Videx EC - see didanosine
Vioxx - see rofecoxib
Viracept - see nelfinavir mesylate
Viramune - see nevirapine
Vitamin A Acid - see tretinoin
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, 0.750mg (Hivid-HLR)
Zanaflex - see tizanidine HCl
Zerit - see stavudine
Ziagen - see abacavir SO4
zidovudine, syrup, 10mg/mL; injection, 10mg/mL (Retrovir-GSK)
*capsule, 100mg (Retrovir-GSK)
Zithromax - see azithromycin
Zoladex - see goserelin acetate
zolmitriptan, tablet, 2.5mg (Zomig-AST); orally dispersible tablet, 2.5mg
(Zomig Rapimelt-AST)
Zomig - see zolmitriptan
Zomig Rapimelt - see zolmitriptan
257
zuclopenthixol, acetate injection, 50mg/mL (Clopixol-Acuphase-AVT); decanoate
injection, 200mg/mL (Clopixol-Depot-AVT); dihydrochloride tablet, 10mg, 25mg,
(Clopixol-AVT)
For treatment of patients with schizophrenia not responding to other neuroleptic
medications.
Zyprexa - see olanzapine
Zyprexa Zydis - see olanzapine
Zyvoxam - see linezolid
LEGEND:
*These brands of products have been approved as interchangeable.
+These brands of products have NOT been approved as interchangeable.
258
SORIATANE
Important Information for Female Patients:
Soriatane can cause deformed babies if it is taken by a female before or during
pregnancy.
•
Do not take Soriatane if you are or may become pregnant during treatment or for an
undetermined period of time* after treatment has stopped.
•
You must avoid becoming pregnant while you are taking Soriatane and for an
undetermined period of time* after you stop taking Soriatane.
•
You must discuss effective birth control with your doctor before beginning treatment
and you must use effective birth control: for at least 1 month before you start
Soriatane; while you are taking Soriatane; and for an undetermined period of time*
after you stop taking Soriatane, bearing in mind that any method of birth control can
fail.
•
It is recommended that you either abstain from sexual intercourse or use 2 reliable
methods of birth control at the same time.
•
Do not take Soriatane until you are sure that you are not pregnant: you must have a
serum pregnancy test within 2 weeks before you start Soriatane; you must wait until
the second or third day of your next menstrual period before you start Soriatane.
•
Contact your doctor immediately if you do become pregnant while taking Soriatane or
after treatment has stopped. You should discuss with your doctor the serious risk of
your baby having severe birth deformities because you are taking or have taken
Soriatane. You should also discuss the desirability of continuing your pregnancy.
•
Do not breast feed while taking Soriatane or for an extended period of time after
treatment has stopped.
*
Soriatane remains in your body for prolonged periods of time after you have
stopped treatment. It is not known exactly how long you must avoid pregnancy
after Soriatane is stopped. The drug has been found in the blood of some
patients for at least 2 years following treatment. Discuss this with your doctor.
Talk with your doctor before you stop birth control.
Important Information for All Patients:
Soriatane can cause deformed babies if taken by a female before or during
pregnancy.
•
Do not give Soriatane to anyone else who has similar symptoms.
•
Do not donate blood, while you are taking Soriatane or for an extended period of time
after treatment has stopped. This is because your blood should not be given to a
pregnant female.
•
Do not consume alcohol while taking Soriatane.
259
APPENDIX B
SPECIAL COVERAGES
INCOME BASED DRUG BENEFITS - SPECIAL SUPPORT PROGRAM
An income based program was implemented on July 1, 2002. Families pay the full cost
of their prescriptions unless they apply to the income based program, the Special Support
Program.
What is Special Support?
The Special Support Program is designed to help those whose benefit drug costs are
high in relation to their income. Based on the income information provided on the
application form (with photocopies of income tax) along with Drug Plan records, the Drug
Plan will calculate a family threshold deductible and may establish a consumer copayment 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.
How does a person apply?
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. The benefit period is January 1 to December 31.
There
are
two
application
forms
available
on
the
health
website:
www.health.gov.sk.ca/health_forms.html. The differences include:
1) CCRA Application/Consent form:
one time completion of application form
must sign “CONSENT to Canada Customs and Revenue Agency” section
must forward documentation of income initially; subsequent years the
coverage will automatically be renewed as long as the applicant and
spouse both file individual income tax to CCRA
2) Annual Application:
must re-apply annually by October 1
must sign “CONSENT and DECLARATION” section
must forward document of income each year, such as the Notice of
Assessment or pages 1 and 2 of their income tax forms.
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:
1. changes in income must be made in writing with supporting documentation;
2. a request to review the assessment should be made in writing; or
3. the pharmacist may telephone requesting the coverage be reviewed because of new
drugs.
Income Supplement Recipients
Adults in 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 semiannual 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 will have coverage based on their income and
drug cost it they apply for special support.
*MAC & LCA policies apply.
261
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 also eligible for chiropractic services and an
eye examination every two years.
Inquiries regarding benefits, contact the Supplementary Health Program:
Regina: 787-3124
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
SUMMARY OF FAMILY HEALTH BENEFITS
HEALTH BENEFITS
CHILDREN
PARENTS OR
GUARDIANS
Dental Coverage
Covers the majority of the
cost 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
Medical Supplies
Basic coverage, some
items require prior approval
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)
262
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.
Generally, this is a one-time assistance for no more than a month’s supply. The level of
assistance provided will be in accordance with the consumer's ability to pay. A Special
Support Application must be completed for future assistance.
Request Process
During regular office hours, the patient's pharmacy may call the Drug Plan at 787-3315
(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;
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. For future assistance, complete and submit a "Special Support" form.
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.
263
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
pharmacist, the physician or social worker involved in the patient's care. At the time of
the request, the pharmacist or social worker must be in possession of a signed Palliative
Care form. After provisional coverage has been granted, the pharmacist or social worker
must forward the signed form to the Drug Plan. Provisional approval may be withheld by
the Drug Plan if the pharmacist or social worker is not in receipt of a signed form. All
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 Regions
Patients, pharmacists or physicians should contact the home care office in their health
region to inquire about coverage provided by the region for dietary supplements and
other basic supplies.
264
"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 or
maximum allowable cost 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)
Beneficiaries include persons with cystic fibrosis, chronic end-stage renal disease and
paraplegics who have been approved by Saskatchewan Health. Saskatchewan Health
(S.A.I.L. Program) provides coverage for Formulary and non-Formulary disease-related
drugs used by these beneficiaries. For general inquiries regarding this program,
telephone (306) 787-7121. For drug inquiries, telephone (306) 787-3315 or 1-800-6677578 (press #1).
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.
SUPPLEMENTARY HEALTH (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.
265
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 select over-thecounter (OTC) products and 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 787-3315 (Regina) or (toll-free) 1-800-6677578 with inquires regarding Plan Three drug coverage.
Special Drug Authorization
In addition to Formulary and Exception Drug Status benefits, beneficiaries with Plan One
and Plan Two coverage may be eligible for a selected panel of products under the
Supplementary Health Program through the Special Drug Authorization process.
Selected OTC products which are currently benefits for Plan Three beneficiaries could be
considered for coverage when prescribed 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.
266
APPENDIX C
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
HSN not on file
AI
Registered Indian
AR
HSN no coverage
CA
Prescription number required
CB
Prescriber ineligible
CC
Prescriber required
CD
Prescriber inactive
CE
Prescriber not on file
CF
Prescriber inactive
CO
Pharmacy not on file
CP
Dispensing date no contract
CR
Dispensing date over 62 days
CS
Dispensing date invalid
CT
Invalid prescription number
EC
ECP fee not allowed as EC prescription not found
ED
Duplicate submission of the ECP fee
EF
Maximum ECP fee exceeded
FC
Formulary Clearance
GA
Possible duplicate same pharmacy - same pharmacy/same prescriber
GB
Possible duplicate same pharmacy - same pharmacy/different prescriber
GC
Verify quantity & unit cost
GE
Unit drug cost exceeded
GG
Non-formulary drug cost exceeded
GH
Non-formulary drug cost exceeded
GI
Dispense SOC for payment
GJ
Verify quantity & unit cost & possible duplicate
GK
Total prescription cost exceeded (memory claim)
GL
Patient paid exceeded (memory claim)
267
CODE
DESCRIPTION
GM
Verify quantity & possible duplicate
GN
Verify unit cost & possible duplicate
GO
Dispensing fee exceeds maximum
GP
Possible duplicate different pharmacy - different pharmacy/same prescriber
GQ
Possible duplicate different pharmacy - different pharmacy/different prescriber
GR
Age inconsistent with drug
GT
Total prescription cost invalid(memory claim)
GU
Patient paid invalid(memory claim)
GW
Verify compound unit cost and compound fee
GX
Compound quantity must be 1
GY
Verify compound unit cost
GZ
Verify compound fee
HA
Non-benefit DIN
HB
DIN not on file
HC
Three month supply exceeded
HD
Three month supply exceeded; another pharmacy
HE
Possible benefit under Exception Drug Status
HF
Three submissions exceeded for Palliative Care
HG
Three submissions exceeded for Palliative Care; another pharmacy
HH
Verify quantity & three submissions exceeded for Palliative Care
HI
Verify unit cost & three submissions exceeded for Palliative Care
HJ
Verify quantity & unit cost & three submissions exceeded for Palliative Care
IP
Alternative Reimbursement not allowed
IS
Alternative Reimbursement Fee exceeds maximum allowable
IT
Alternative Reimbursement Type (Quantity) invalid
MA
Mark-up percentage exceeds the maximum allowable
MB
Discount percentage exceeds 100% (PC interfaced)
NA
Transmission error - re-send
RC
Void - original claim not found
RD
Void - original claim already voided
RE
Void not allowed - claim paid to family
SA
Not authorized for PC interface - contact the Drug Plan Help Desk
SF
File error - contact the Drug Plan Help Desk
268
CODE
DESCRIPTION
TA
Trial/Remainder/Alternative Reimbursement prior to April 1, 1996
TB
Product not eligible for Trial Prescription Program
TC
Trial not allowed - not a new medication
TD
Trial not allowed - not a new medication; another pharmacy
TE
Duplicate Trial prescription same pharmacy
TF
Duplicate Trial prescription different pharmacy
TG
Remainder not allowed - trial not found
TH
Duplicate Remainder prescription same pharmacy
TJ
Remainder not allowed - dispensed too soon after trial
TK
Remainder not allowed - regular prescription found same pharmacy
TL
Remainder not allowed - regular prescription found different pharmacy
TM
Dispensing Fee not allowed on Remainder
TN
Regular prescription not allowed - trial found
TP
Alternative Reimbursement not allowed - trial not found
TQ
Duplicate Alternative Reimbursement
YI
Quantity exceeds maximum
YK
Quantity exceeds the recommended quantity
YL
Quantity exceeds the authorized limit
YM
Quantity lower than minimum
269
APPENDIX D
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)
ANTICONVULSANTS
carbamazepine
clobazam
clonazepam
divalproex sodium
ethosuximide
gabapentin
lamotrigine
levetiracetam
methsuximide
nitrazepam
oxcarbazepine
phenytoin
primidone
topiramate
valproate sodium
valproic acid
vigabatrin
DIURETICS
amiloride HCl
amiloride HCl/hydrochlorothiazide
chlothalidone
furosemide
hydrochlorothiazide
indapamide
metolazone
spironolactone
spironolactone/hydrochlorothiazide
triamterene/hydrochlorothiazide
ANTI-THYROIDS
methimazole
propylthiouracil
ORAL HYPOGLYCEMICS
acarbose
chlorpropamide
glyburide
metformin
nateglinide
pioglitazone HCl
repaglinide
rosiglitazone maleate
tolbutamide
DIGITALIS PREPARATIONS
digoxin
PHENOBARBITAL
phenobarbital
THYROID PREPARATIONS
thyroid
levothyroxine (sodium)
TWO MONTH DRUG LIST (by product categories)
ESTROGENS
conjugated estrogens
estradiol
estropipate
ethinyl estradiol
piperazine estrone sulfate
stilboestrol
stilboestrol sodium diphosphate
ORAL CONTRACEPTIVES
270
APPENDIX E
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
271
APPENDIX F
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. For a copy of the application form please refer
to the website at: http://formulary.drugplan.health.gov.sk.ca/
•
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 B.
272
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
273
Appendix G
PHARMACEUTICAL MANUFACTURERS LIST
ABB
ACM
ACT
ALC
ALL
ALX
AMG
APX
AST
AVT
AXC
AXX
BAY
BCD
BDC
BEX
BGN
BMD
BMY
BOE
BOM
BRI
BVL
CCL
CDX
CLC
COB
CYT
DBU
DER
DOM
DPY
DUI
ERF
FEI
FFR
FTP
FUJ
GAC
GCH
GLW
GPM
GSK
GZY
HDI
HLR
HOR
ICN
IPC
JAC
JAN
KEY
LEA
LEO
LIL
LIN
Abbott Laboratories Ltd.
AutoControl Medical
Actelion Pharmaceutiques Canada
Alcon Canada Inc.
Allergan Inc.
Allerex Laboratory Ltd.
Amgen Canada Inc.
Apotex Inc.
AstraZeneca
Aventis Pharma Inc.
Axcan Pharma
Axxess Pharma
Bayer Inc.-Healthcare Division
Bayer Inc.-Consumer Care Division
Becton-Dickinson Canada Inc.
Berlex Canada Inc.
Biogen Canada Inc.
BioMed 2002 Inc.
Bristol-Myers Squibb Canada Co.
Boehringer Ingelheim (Canada) Ltd.
Roche Diagnostics, Division of Hoffmann-LaRoche Limited
Bristol Pharmaceutical Products - Bristol-Myers Squibb
Biovail Pharmaceuticals
Chiron Canada ULC.
Canderm Pharma Inc.
Columbia Laboratories Canada Inc.
Cobalt Pharmaceuticals Inc.
Cytex Pharmaceuticals Inc.
Mayne Pharma (Canada) Inc.
Dermik Laboratories Canada Inc.
Dominion Pharmacal
Draxis Health Inc.
Duchesnay Inc.
Erfa Canada Inc.
Ferring Inc.
Fournier Pharma Inc.
FTP Pharmacal Inc.
Fujisawa Canada Inc.
Galderma Canada Inc.
GlaxoSmithKline Consumer Healthcare Inc.
Glenwood Laboratories Canada Ltd.
Genpharm Inc.
GlaxoSmithKline
Genzyme Canada Inc.
Hill Dermaceuticals, Inc.
Hoffmann-LaRoche Ltd.
Carter-Horner Corp.
ICN Canada Ltd.
Insight Pharmaceuticals Corp.
Jacobus Pharma Inc.
Janssen-Ortho Inc.
Key, Division of Schering Canada Inc.
Lee-Adams Laboratories, Division of Pharmascience Inc.
Leo Pharma Inc.
Eli Lilly Canada Inc.
Linson Pharma Co.
274
LSN
LUD
MCL
MDA
MDC
MDS
MPD
MSD
MTI
NOO
NOP
NVO
NVR
NXP
ODN
OMG
OPT
ORG
ORP
ORX
PAL
PFC
PFD
PFI
PFR
PGA
PML
PMS
PNG
PPZ
PRM
PRO
RBP
RHO
RIV
ROP
RPH
SAB
SAW
SCH
SCP
SEV
SLV
SQU
SRO
STE
STI
TAR
THM
THR
THS
TVM
TYC
VAL
VIR
WEL
WSD
WYA
ZYP
Lifescan Canada Ltd.
Lundbeck Canada Inc
McNeil Consumer Healthcare
3M Pharmaceuticals, 3M Canada Company
Medicis Canada Ltd.
Medisense Canada Inc.
Medical Plastic Devices Inc.
Merck Frosst Canada Ltd.
Medican Technologies Inc.
Novo Nordisk Canada Inc.
Novopharm Ltd.
Novartis Ophthalmics, Novartis Pharmaceuticals Canada Inc.
Novartis Pharmaceuticals Canada Inc.
Nu-Pharm Inc.
Odan Laboratories Limited
Omega Laboratories Ltd.
TaroPharma, Division of Taro Pharmaceuticals Inc.
Organon Canada Ltd.
Orphan Medical Inc.
Oryx Pharmaceuticals Inc.
Paladin Labs Inc.
Pfizer Canada Inc.-Consumer Health Care Division
Professional Disposables Inc.
Pfizer Canada Inc.
Purdue Pharma
Procter & Gamble Pharm. Canada, Inc.
PharmMel Inc.
Pharmascience Inc.
PanGeo Pharma Inc.
Princeton Pharmaceutical Products - Bristol-Myers Squibb
PremPharm Inc.
Proval Pharma Inc.
Shire BioChem Inc.
Rhoxalpharma Inc.
Riva Laboratories Ltd.
Rhodiapharm
Ratiopharm Inc.
Sabex 2002 Inc.
Sanofi-Synthelabo Canada Inc.
Schering Canada Inc.
Schering-Plough Healthcare Products
Servier Canada Inc.
Solvay Pharma Inc.
Squibb Pharmaceutical Products - Bristol-Myers Squibb
Serono Canada Inc.
SteriMax Inc.
Stiefel Canada Inc.
Taro Pharmaceuticals Inc.
Theramed Corporation
Thermor Ltd.
Therasense Canada
Teva Marion Partners Canada
Tyco Healthcare
Valeo Pharma Inc.
Virco Pharmaceuticals (Canada), Inc.
Wellspring Pharmaceutical Canada Corp.
Westwood Squibb Canada
Wyeth Pharmaceuticals
Zymcan Pharmaceuticals Inc.
275
INDICES
INDEX A - THERAPEUTIC CLASSIFICATION LIST
INDEX B - NUMERICAL LIST OF DRUG IDENTIFICATION
NUMBERS
INDEX C - ALPHABETICAL LIST OF PHARMACEUTICAL
PRODUCT NAMES
INDEX A
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)....................................................................... .
TRANSCRIPTASE INHIBITORS)....................................................................... .
08:18.08 ANTIRETROVIRAL AGENTS (PROTEASE INHIBITORS)........................................... .
08:20.00 ANTIMALARIAL AGENTS............................................................................................. .
08:22.00 QUINOLONES.............................................................................................................. .
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 AGENTS........................................................................... .
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...................................................................................................... .
278
2
2
2
2
3
3
4
6
7
10
11
12
13
14
16
17
17
19
20
22
22
26
26
26
27
29
32
33
36
36
36
38
38
39
42
42
52
57
70
74
74
81
87
87
87
88
89
89
89
94
102
109
109
110
114
115
118
118
118
119
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 ANTITUSSIVES, EXPECTORANTS AND MUCOLYTIC AGENTS...................................... .
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 HEAVY METAL ANTAGONISTS.......................................................................................... .
64:00.00 METAL ANTAGONISTS................................................................................................ .
68:00 HORMONES AND SYNTHETIC 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 AGENTS....................................................................... .
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.................................................................. .
94:00 DIABETIC SUPPLIES........................................................................................................... .
92:00.00 DIABETIC SUPPLIES................................................................................................... .
279
122
122
122
123
124
125
128
128
130
130
131
131
131
132
134
135
136
136
137
142
142
142
142
144
144
152
152
154
154
156
156
160
160
163
165
165
166
166
167
170
170
171
173
174
176
176
177
179
180
180
190
191
191
192
193
194
196
198
198
198
202
202
202
203
206
206
220
220
INDEX B
NUMERICAL LIST OF DRUG IDENTIFICATION NUMBERS
DIN
00000165
00000299
00000655
00000663
00000779
00000787
00000841
00000868
00000884
00004588
00004596
00004723
00004774
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
00015741
00016055
00016128
00016233
00020877
00020885
00021008
00021016
00021075
00021172
00021202
00021261
00021350
00021423
00021474
00021482
00021695
00022608
00022772
00022780
00022799
00022802
00023442
PAGE
220
7
136
136
136
136
136
136
136
206
207
23
17
109
109
203
86
174
174
74
74
36
36
90
98
98
111
111
111
144
144
144
111
111
144
109
109
99
99
109
174
154
26
77
9
9
17
17
202
6
9
17
168
144
124
124
159
163
89
89
89
89
89
DIN
PAGE
00023450
00023485
00023698
00023949
00023957
00023965
00024325
00024333
00024341
00024368
00024430
00024449
00024457
00024694
00026050
00026093
00027243
00027499
00027898
00027901
00027944
00028053
00028096
00028274
00028282
00028339
00028355
00028363
00028606
00029092
00029238
00029246
00030570
00030600
00030619
00030759
00030767
00030783
00030848
00030910
00030929
00030937
00030988
00035017
00035092
00035106
00035122
00035130
00035149
00036129
00036323
00037605
00037613
00037621
00042560
00042579
00042676
00067393
00074225
00074454
00125083
00125105
00125121
280
89
89
89
173
173
173
96
96
96
10
107
107
107
114
180
180
32
32
186
186
186
131
157
3
3
130
186
186
125
178
165
160
11
159
159
159
159
160
172
159
159
172
159
136
119
119
119
119
119
159
142
163
71
71
132
132
134
70
122
134
82
83
82
DIN
00155357
00178799
00178802
00178810
00178829
00180408
00187585
00192597
00192600
00216666
00220442
00223824
00225851
00229296
00230197
00230316
00232378
00232475
00232807
00232823
00232831
00236683
00247855
00249580
00252522
00252654
00253952
00259527
00261238
00261432
00262595
00263699
00263818
00265470
00265489
00268585
00268593
00268607
00268631
00271373
00271489
00280437
00285455
00285471
00291889
00293504
00293512
00294322
00294837
00294926
00294950
00295094
00295973
00297143
00299405
00301175
00306290
00307246
00312711
00312738
00312746
00312754
00312762
PAGE
29
87
87
87
87
66
193
189
189
74
144
3
11
74
144
189
159
202
102
102
102
115
133
50
131
196
170
60
216
86
6
193
143
163
163
202
202
202
203
159
191
157
125
158
60
81
81
206
28
125
202
158
178
162
133
133
27
135
168
19
108
108
170
DIN
00312770
00312789
00312797
00312800
00313815
00313823
00315966
00317047
00319511
00323071
00324019
00326836
00326844
00326852
00326925
00327794
00328219
00329320
00330566
00330582
00335053
00335061
00335088
00335096
00335118
00335126
00335134
00337420
00337439
00337730
00337749
00337757
00337765
00337773
00340731
00342084
00342092
00342106
00342114
00343838
00344923
00345539
00349917
00353027
00355658
00358177
00360198
00360201
00360228
00360236
00360244
00360252
00360260
00360279
00360287
00361933
00362158
00362166
00363650
00363669
00363677
00363685
00363693
00363766
00363812
00364142
00364282
00368040
PAGE
159
79
98
124
106
106
162
162
19
185
95
108
124
98
96
76
211
32
95
195
94
94
94
105
105
105
105
76
76
123
123
9
9
9
162
5
5
5
5
162
185
108
103
162
211
134
107
98
107
107
107
64
64
123
123
27
111
123
103
103
103
103
206
144
27
76
206
20
DIN
PAGE
00369810
00370568
00371033
00372838
00372846
00373036
00374318
00382825
00382841
00386464
00386472
00392537
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
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
281
89
193
207
162
162
193
193
88
88
211
211
144
85
85
87
123
103
103
103
103
47
47
168
87
96
170
47
64
64
95
47
112
90
112
112
50
50
50
206
206
193
111
111
103
103
7
7
193
103
185
48
49
64
202
26
179
193
130
62
62
62
76
70
70
64
64
199
199
DIN
00441740
00441759
00441767
00441775
00443158
00443174
00443794
00443816
00443832
00443840
00445266
00445274
00445282
00451207
00452092
00452130
00452149
00453617
00454583
00455881
00458686
00458694
00461733
00463256
00463698
00464880
00469327
00471526
00474517
00474525
00476366
00476552
00479799
00480452
00481211
00481815
00481823
00483923
00486582
00487805
00487813
00487872
00489158
00496480
00496499
00496502
00497452
00497479
00497827
00497894
00499013
00500895
00502197
00502200
00502790
00503134
00504335
00506052
00506370
00507989
00509558
00510637
00510645
00511528
00511536
00511552
00511692
00512184
PAGE
51
125
125
68
113
49
192
192
93
93
20
20
20
139
70
8
8
7
191
33
70
70
115
48
104
52
161
161
203
203
199
100
206
220
122
203
203
51
85
124
57
144
158
50
50
50
83
83
47
154
19
216
189
189
143
190
50
76
206
93
29
20
20
88
88
32
199
130
DIN
00512192
00513253
00513261
00513288
00513644
00513962
00513997
00514012
00514217
00514497
00514500
00514535
00514551
00518123
00518131
00518174
00518182
00519251
00521515
00521698
00521701
00522597
00522651
00522678
00522724
00522988
00522996
00523372
00527661
00529117
00532657
00534560
00534579
00534587
00535427
00535435
00537594
00537608
00541389
00545015
00545058
00545066
00545074
00545678
00546240
00546283
00546291
00546305
00548359
00548367
00548375
00550094
00550957
00552135
00552143
00552429
00554324
00555649
00556734
00556742
00560022
00560952
00560960
00560979
00564966
00565342
00565350
00566748
PAGE
130
189
189
189
166
131
211
74
85
64
64
166
166
110
110
192
192
59
202
111
111
211
78
78
110
110
110
48
193
136
68
47
64
64
186
186
193
193
29
135
27
20
27
7
144
58
59
59
110
110
212
144
159
103
103
104
69
216
2
199
190
65
65
65
124
206
78
193
DIN
PAGE
00566756
00568449
00568627
00568635
00568643
00572349
00575151
00575240
00576158
00577308
00578428
00578436
00578452
00578541
00578568
00578576
00578657
00579335
00579351
00579378
00579947
00580929
00582255
00582263
00582271
00582301
00582344
00582352
00583405
00583413
00583421
00584223
00584282
00584991
00585009
00585092
00585114
00586668
00586676
00586706
00586714
00587265
00587281
00587303
00587354
00587362
00587702
00587737
00587818
00587826
00587834
00587958
00587966
00589861
00590665
00590827
00591467
00591475
00592277
00593435
00593451
00594377
00594466
00594636
00594644
00594652
00595799
00595802
282
193
145
65
65
207
208
199
136
28
210
186
186
10
189
192
192
29
189
101
101
191
11
50
50
50
176
195
195
20
5
5
71
145
109
109
172
76
176
176
134
166
26
163
163
27
27
104
166
187
187
187
192
192
79
115
75
85
85
79
81
81
66
77
84
84
84
189
189
DIN
00596418
00596426
00596434
00596965
00598194
00598461
00598488
00599026
00599905
00600059
00600067
00600784
00600792
00600806
00602884
00602957
00602965
00603279
00603295
00603686
00603708
00603716
00603821
00604453
00604461
00605859
00607126
00607142
00607762
00607770
00608882
00609129
00611158
00611166
00611174
00613215
00613223
00613231
00614254
00615315
00617288
00618284
00618292
00618632
00618640
00621374
00621463
00621935
00622133
00623377
00627097
00627100
00628115
00628123
00628131
00628158
00628190
00628204
00628212
00629359
00629367
00632201
00632228
00632481
00632503
00632600
00632724
00632732
PAGE
90
91
91
86
159
149
149
53
199
145
145
210
76
78
122
162
162
9
9
145
49
50
114
113
113
7
47
6
85
85
81
144
76
76
190
125
125
66
131
78
86
9
9
47
47
208
81
85
83
179
78
82
7
7
8
8
111
111
111
76
185
86
86
85
85
147
75
75
DIN
00632775
00634506
00636576
00636622
00637661
00637742
00637750
00638676
00638684
00638692
00639389
00639885
00641154
00641790
00641863
00642215
00642223
00642886
00642894
00642975
00643025
00644633
00645575
00646016
00646024
00646059
00646148
00646237
00647942
00648035
00648043
00652318
00653209
00653217
00653241
00653276
00655740
00655759
00655767
00657182
00657204
00657212
00657298
00658855
00659606
00662348
00663719
00664227
00666122
00666203
00666246
00670901
00670928
00670944
00674222
00675199
00675229
00675962
00677477
00677485
00677590
00682020
00682217
00682314
00685925
00685933
00687456
00688622
PAGE
109
12
34
97
138
112
112
49
49
49
86
49
189
148
192
9
9
79
79
52
19
9
87
114
114
114
166
196
76
47
47
7
186
186
81
81
112
112
112
66
192
9
61
47
53
192
50
158
176
176
191
61
61
70
131
76
20
84
110
110
20
6
134
110
149
149
131
185
DIN
PAGE
00690198
00690201
00690228
00690244
00690783
00690791
00690805
00692689
00692697
00692700
00694371
00695351
00695432
00695440
00695459
00695661
00695696
00695718
00698059
00700401
00703486
00703591
00703605
00703974
00704423
00704431
00705438
00707503
00707600
00708879
00708917
00710113
00710121
00711101
00713325
00713333
00713341
00713376
00713449
00716618
00716626
00716634
00716685
00716693
00716782
00716790
00716812
00716820
00716839
00716863
00716871
00716898
00716901
00716952
00716960
00716987
00717002
00717029
00717495
00717568
00717584
00717592
00717606
00717630
00717649
00717657
00717673
00720933
283
84
84
84
84
85
85
102
199
199
199
130
193
17
17
17
58
79
79
196
133
142
179
179
177
22
22
82
161
161
61
172
146
146
112
49
49
49
122
104
186
186
186
189
189
188
188
188
189
189
188
178
178
178
190
190
190
191
191
9
9
9
9
11
9
9
9
9
168
DIN
00720941
00725110
00725749
00725765
00726540
00728179
00728187
00728195
00728209
00728276
00728284
00729973
00731323
00731439
00733059
00733067
00733075
00738824
00738832
00738840
00739839
00740497
00740675
00740713
00740799
00740802
00740810
00740829
00741817
00742554
00743518
00745588
00745596
00745626
00749354
00750050
00751170
00751871
00755338
00755575
00755583
00755826
00755834
00755842
00755850
00755869
00755877
00755885
00755893
00755907
00756784
00756792
00756830
00756849
00756857
00759465
00759473
00759481
00759503
00761605
00761613
00761621
00761648
00761672
00761680
00766046
00768715
00768723
PAGE
168
48
83
83
20
198
112
112
112
123
123
172
23
28
148
148
167
114
114
114
132
37
50
10
101
101
101
102
114
69
102
80
80
171
47
186
47
108
122
103
90
139
139
51
51
51
48
49
49
48
133
164
48
164
164
62
62
62
104
101
101
101
102
77
77
133
5
5
DIN
00769533
00769541
00769991
00771368
00771376
00771384
00773611
00773689
00773697
00775320
00776181
00776203
00776521
00778338
00778346
00778354
00778362
00778907
00778915
00779474
00782327
00782459
00782467
00782475
00782483
00782491
00782505
00782718
00782742
00784400
00785261
00786535
00786543
00786616
00788716
00789429
00789437
00789445
00789720
00789747
00790427
00792659
00792667
00792942
00795232
00795852
00795860
00795879
00800430
00805009
00807435
00808539
00808547
00808563
00808571
00808652
00808733
00808741
00809187
00812366
00812374
00812382
00813966
00816078
00817120
00818658
00818666
00818674
PAGE
122
122
6
179
45
45
90
43
43
107
85
85
130
147
147
80
80
135
135
81
160
74
48
48
69
69
47
90
34
57
132
82
82
31
11
143
143
142
106
106
77
114
4
199
220
54
54
167
11
185
130
74
74
113
113
104
168
168
185
177
177
177
147
203
10
67
67
67
DIN
PAGE
00818682
00821373
00824143
00824291
00824305
00828556
00828564
00828688
00828823
00836230
00836249
00836273
00836362
00839175
00839183
00839191
00839205
00839213
00839388
00839396
00839418
00842648
00842656
00842834
00846341
00846465
00849650
00849669
00850322
00850330
00851639
00851647
00851655
00851663
00851671
00851698
00851736
00851744
00851752
00851760
00851779
00851787
00851795
00851833
00851922
00851930
00852074
00852384
00854409
00856711
00860689
00860697
00860700
00860751
00860808
00862924
00862932
00862975
00865397
00865400
00865532
00865540
00865559
00865567
00865575
00865591
00865605
00865613
284
67
143
170
203
170
148
148
148
148
79
79
210
170
74
74
212
212
212
63
63
63
47
47
146
32
20
185
185
85
85
58
59
59
47
48
48
190
190
157
157
61
61
61
58
53
53
157
71
142
189
111
111
111
10
31
45
45
185
110
110
68
8
8
7
7
48
47
47
DIN
00865621
00865648
00865656
00865664
00865672
00865680
00865699
00865710
00865729
00865737
00865745
00865753
00865761
00865788
00865818
00865826
00865834
00865850
00865869
00865877
00865885
00868949
00868957
00869007
00869015
00869023
00869945
00869953
00869961
00870013
00870021
00870935
00871095
00872318
00873292
00873454
00873993
00874256
00878790
00878928
00878936
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
00886122
PAGE
78
78
78
79
112
112
112
20
20
148
148
20
79
79
144
145
145
76
76
5
5
60
60
48
49
49
26
26
26
192
192
211
190
132
188
6
170
10
132
43
43
65
65
65
55
56
56
56
63
63
210
82
82
82
82
57
57
57
49
74
74
69
69
45
45
57
43
43
DIN
00886130
00886149
00886432
00886440
00888354
00888400
00890960
00891800
00891819
00893560
00893595
00893609
00893617
00893625
00893749
00893757
00893773
00893781
00894710
00894729
00894737
00894745
00897272
00897310
00897329
00899356
00901359
00905916
00906190
00906239
00908169
00909238
00920045
00920169
00920177
00920193
00920207
00920215
00920355
00930610
00950068
00950238
00950300
00950378
00950432
00950459
00950505
00950572
00950734
00950792
00950793
00950807
00950815
00950823
00950831
00950878
00950882
00950883
00950893
00950894
00950896
00950899
00950900
00950902
00950907
00950911
00950912
00950913
PAGE
49
48
106
106
137
124
52
3
3
138
58
58
59
59
54
55
139
139
179
179
102
102
51
192
192
99
220
220
220
220
220
221
221
221
221
221
221
221
221
220
118
119
118
118
118
118
118
118
118
195
195
195
195
195
118
118
118
118
118
118
118
209
118
118
118
118
118
220
DIN
PAGE
00950914
00950915
00950917
00950921
00950924
00950926
00963895
00963941
00964018
00964069
00964115
00964174
00964220
00964271
00964344
00977011
00977051
00977101
00977543
00977659
00977853
00977951
00977977
00977985
00995965
01900927
01900935
01902628
01902644
01902652
01902660
01905082
01905090
01907107
01907115
01907123
01907476
01908448
01908871
01908901
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
01913425
285
220
220
221
220
118
118
221
221
221
221
221
221
220
220
220
220
220
220
220
220
220
221
221
221
220
168
168
176
15
15
15
139
139
61
61
69
196
137
193
193
176
189
189
42
42
42
186
187
59
59
59
12
12
71
71
71
76
76
43
43
145
193
134
62
60
110
110
96
DIN
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
01916823
01916858
01916866
01916874
01916882
01916947
01917021
01917056
01918303
01918311
01918338
01918346
01918354
01918362
01918486
01919342
01919369
01919458
01919466
01919598
01924516
01924559
01924567
01924753
01924761
01925199
01925350
01925679
01925997
01926292
01926306
01926349
01926357
01926454
01926462
01926470
01926489
01926497
01926500
01926519
01926527
PAGE
96
96
96
96
110
110
113
168
168
168
168
60
65
65
65
58
58
59
59
12
12
149
10
10
133
133
82
152
8
8
8
8
176
97
75
122
37
37
37
38
38
52
97
98
173
173
101
108
108
108
198
198
193
185
165
193
216
216
101
101
71
192
192
192
192
192
192
192
DIN
01926543
01926551
01926667
01926675
01926691
01926756
01926764
01926772
01926780
01926861
01926934
01927167
01927604
01927612
01927620
01927655
01927663
01927671
01927728
01927744
01927914
01929976
01929992
01934155
01934198
01934201
01934228
01934317
01934392
01934406
01937219
01937227
01937235
01937383
01937391
01937405
01937413
01939130
01940414
01940473
01940481
01940511
01940538
01940546
01940554
01940635
01942964
01942972
01942980
01942999
01943200
01944355
01944363
01944444
01945149
01945203
01945270
01946242
01946250
01946269
01946277
01946374
01947664
01947672
01947680
01947699
01947796
01947818
PAGE
42
42
106
106
170
105
105
105
105
180
30
132
152
152
152
115
115
115
115
26
185
102
102
179
65
65
65
69
29
29
57
101
101
82
82
82
82
202
137
100
99
14
14
14
14
14
58
58
59
59
202
2
2
185
194
31
131
96
95
95
96
196
66
66
66
66
51
51
DIN
PAGE
01947826
01947923
01947931
01947958
01948784
01948792
01950541
01950681
01953834
01953842
01958097
01958100
01958119
01959212
01959220
01959239
01962701
01962728
01962779
01962817
01964054
01964070
01964399
01964402
01964933
01964968
01964976
01966197
01966200
01966219
01968017
01968300
01968432
01968440
01976133
01977547
01977563
01977601
01978918
01978926
01979574
01979582
01981242
01981250
01981501
01984853
01985205
01986864
01987003
01987682
01988840
01990403
01990896
01992872
01995227
01997580
01997602
01997629
01997637
01997653
01997750
01999559
01999761
01999788
01999796
01999818
01999826
01999834
286
51
26
26
26
95
96
138
28
146
146
60
60
60
167
166
166
188
188
100
100
190
158
106
106
115
158
158
46
46
199
39
133
39
163
194
158
160
160
157
157
53
53
154
154
207
6
143
30
202
176
176
12
15
163
113
149
34
208
19
34
2
58
160
190
190
190
191
191
DIN
01999842
01999850
01999869
02004828
02004836
02006383
02007134
02007959
02009706
02009749
02009765
02009773
02010267
02010283
02010291
02010909
02011239
02011271
02011921
02011948
02011956
02012472
02014165
02014181
02014203
02014211
02014238
02014254
02014270
02014289
02014297
02014300
02014319
02014327
02015439
02015951
02016095
02017237
02017539
02017598
02017628
02017636
02017709
02017733
02017741
02018144
02018152
02018160
02018985
02019809
02019930
02019949
02019957
02019965
02020599
02020602
02020610
02020629
02020661
02020688
02020696
02020718
02020726
02020734
02020742
02022133
02022141
02022826
PAGE
191
191
160
62
62
29
170
38
84
84
84
84
177
188
188
209
115
71
188
177
130
36
199
199
84
84
84
84
198
198
84
85
85
85
84
77
142
79
17
203
87
87
17
180
122
160
160
160
97
2
84
84
85
85
101
101
101
102
76
76
76
76
76
168
168
146
146
12
DIN
02024152
02024187
02024195
02024209
02024217
02024225
02024233
02024292
02024306
02024314
02024322
02025280
02025299
02025302
02025310
02025736
02026759
02026767
02026961
02028700
02028786
02029421
02029448
02030810
02031094
02031116
02031159
02031167
02032376
02034468
02035324
02036282
02036290
02036347
02036355
02036436
02036444
02039486
02039494
02039532
02039540
02040751
02040778
02040786
02041413
02041421
02041448
02041510
02042177
02042231
02042258
02042266
02042274
02042304
02042320
02042339
02042355
02042479
02042487
02042533
02042541
02042568
02042576
02042584
02043033
02043041
02043394
02043408
PAGE
3
186
146
146
167
166
166
167
167
167
167
107
107
107
107
134
28
187
122
163
211
163
213
46
178
4
138
138
136
12
132
42
42
7
7
42
42
75
75
43
43
95
95
95
112
112
112
19
50
50
50
50
50
122
161
161
87
161
161
161
161
90
80
80
161
161
163
163
DIN
PAGE
02043416
02043424
02043440
02043726
02043734
02044609
02044617
02044668
02044676
02044692
02044706
02045680
02045699
02045702
02045710
02045729
02045737
02045834
02045869
02046113
02046121
02046148
02046156
02046253
02046261
02046733
02046741
02047454
02047462
02047799
02047802
02048493
02048507
02048639
02048698
02048728
02048736
02049325
02049333
02049341
02049376
02049384
02049392
02049961
02049988
02049996
02050005
02050013
02050021
02050048
02050056
02051850
02052431
02052717
02053187
02053195
02057778
02057808
02057816
02057824
02058413
02058456
02058464
02059762
02059789
02060884
02061562
02061570
287
163
163
163
161
161
51
51
10
10
50
50
125
125
149
168
63
63
143
143
216
60
60
71
74
74
128
31
4
48
176
176
75
75
187
75
88
88
209
63
124
63
63
212
57
57
96
96
96
96
96
96
7
186
202
101
101
61
48
49
49
75
53
53
213
213
186
53
53
DIN
02063662
02063735
02063743
02063786
02063808
02064472
02064480
02065819
02068036
02068087
02069571
02070847
02070863
02070987
02074788
02076306
02078627
02078635
02078651
02080052
02083345
02083353
02083523
02083531
02083558
02084090
02084104
02084228
02084236
02084260
02084279
02084287
02084295
02084309
02085852
02085895
02086026
02087324
02088398
02088401
02089580
02089602
02089610
02089769
02089777
02089793
02091186
02091194
02091232
02091275
02091526
02092832
02093103
02093162
02097141
02097168
02097176
02097214
02097222
02097230
02097249
02097257
02097265
02097273
02097370
02097389
02099128
02099136
PAGE
19
33
34
214
147
149
149
93
93
215
31
194
194
101
194
137
12
12
12
34
139
139
52
78
78
10
10
51
51
91
91
91
178
178
178
83
158
207
33
34
122
185
185
165
165
165
30
75
10
103
128
180
10
186
28
28
28
45
45
45
45
45
46
46
45
45
95
96
DIN
02099225
02099233
02099683
02100509
02100517
02100622
02100630
02102978
02103095
02103567
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
02128950
02128969
02130033
02130084
02130092
02130106
02130297
02130300
02130874
PAGE
216
168
149
76
76
149
93
27
27
149
145
88
102
102
63
88
62
62
10
10
165
63
189
149
149
149
149
149
187
187
4
65
65
215
213
213
213
27
4
180
149
82
82
82
82
82
179
211
211
211
187
28
178
178
70
178
6
47
48
101
101
11
95
95
96
104
104
179
DIN
PAGE
02130963
02130971
02130998
02131013
02131048
02131056
02131064
02131625
02132591
02132621
02132648
02132664
02132680
02132699
02132702
02133318
02133342
02134829
02136090
02136104
02136112
02136120
02137267
02137313
02137321
02137348
02137534
02137542
02137984
02138018
02138271
02138298
02139189
02139197
02139200
02139324
02139332
02139340
02139359
02139367
02139391
02140047
02140055
02140063
02140101
02141442
02142031
02142074
02142082
02142104
02142112
02143283
02143291
02143364
02143372
02144263
02144271
02145413
02145421
02145448
02145863
02145901
02145928
02145936
02146118
02146126
02146843
02146851
288
12
12
88
88
34
34
34
138
142
36
36
36
52
52
100
133
135
149
33
34
80
80
86
50
50
50
110
110
87
83
33
34
52
52
12
31
33
95
95
95
34
93
93
93
96
3
75
53
92
92
92
146
132
76
76
101
101
47
47
216
83
82
83
83
83
83
30
30
DIN
02146886
02146894
02146908
02146916
02146924
02146932
02146940
02146959
02147432
02147602
02147610
02147629
02147637
02147645
02148552
02148560
02148579
02148587
02148595
02148749
02148765
02148773
02150662
02150670
02150689
02150697
02150808
02150816
02150824
02150867
02150891
02150905
02150921
02150948
02150956
02152568
02153483
02153521
02153556
02153564
02154412
02154420
02154463
02154862
02154870
02155907
02155923
02155958
02155966
02155974
02155990
02156008
02156016
02156032
02156040
02156083
02156091
02157195
02158574
02158582
02158590
02158612
02158620
02158639
02161737
02161745
02161753
02161923
PAGE
80
43
6
45
45
77
77
53
43
42
42
42
101
101
172
172
172
164
164
192
168
77
208
208
208
208
77
77
77
177
177
177
177
177
194
30
124
149
149
149
31
79
79
187
187
48
70
17
18
18
48
103
103
102
102
77
180
145
10
74
198
98
98
98
17
18
18
188
DIN
02161966
02161974
02162431
02162466
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
02163942
02165376
02165384
02165392
02165503
02165511
02165546
02165554
02165562
02166704
02166712
02166720
02166747
02167786
02167794
02167840
02168898
02168979
02169649
02170493
02170698
02170833
02170841
02171228
02171791
02171805
02171813
02171821
02171848
02171856
02171864
02171872
02171880
02171899
02171929
PAGE
188
188
79
79
188
188
132
39
71
74
168
169
188
71
71
198
58
58
59
59
5
5
5
5
137
28
81
51
81
81
81
81
81
81
30
101
101
146
146
42
42
42
172
139
139
99
168
51
37
164
23
210
202
194
51
51
173
43
43
79
79
34
110
110
110
139
139
149
DIN
PAGE
02172062
02172070
02172089
02172097
02172100
02172119
02172127
02172135
02172143
02172151
02172550
02172569
02172577
02172712
02173344
02173352
02173360
02173506
02173514
02174545
02174553
02174677
02174685
02175983
02175991
02176009
02176017
02176076
02176084
02176092
02176106
02176122
02176130
02176149
02177072
02177102
02177145
02177153
02177161
02177188
02177579
02177587
02177595
02177617
02177625
02177692
02177706
02177714
02177722
02177749
02177757
02177781
02177803
02177846
02177854
02177889
02177897
02178729
02178737
02179679
02179687
02179709
02181479
02181487
02181495
02181509
02181517
02181525
289
173
173
173
173
173
173
173
173
173
173
47
47
77
132
88
88
31
10
10
47
47
75
75
216
216
216
208
123
210
23
23
114
77
77
79
12
34
110
110
110
97
97
97
97
97
99
99
147
147
84
85
5
5
5
5
88
88
99
99
80
80
124
59
7
7
8
8
48
DIN
02182815
02182823
02182831
02182858
02182866
02182874
02182882
02182963
02183862
02184435
02184443
02184451
02184648
02185407
02185415
02185423
02185814
02186802
02187086
02187094
02187108
02187116
02187876
02188783
02189054
02189062
02190885
02190893
02190915
02192268
02192276
02192284
02192659
02192667
02192683
02192691
02192705
02192713
02192721
02192748
02192756
02192764
02193221
02194031
02194058
02194155
02194163
02194171
02194198
02194201
02194228
02194236
02194333
02194341
02195704
02195917
02195925
02195933
02195941
02195968
02195984
02195992
02196018
02196026
02197405
02197413
02197421
02197448
PAGE
63
211
211
211
11
63
63
194
142
84
85
85
93
53
23
23
147
13
162
162
162
162
67
212
162
162
167
167
147
185
185
185
11
142
15
15
110
110
110
212
97
97
203
190
190
160
178
178
4
4
178
178
90
194
178
23
23
211
211
211
4
4
146
146
12
12
12
48
DIN
02197456
02197464
02197502
02199270
02199297
02200104
02200864
02200937
02200996
02201011
02201038
02202441
02202468
02202476
02202484
02203324
02204517
02204525
02204533
02204584
02205963
02206072
02207621
02207648
02207656
02207672
02207761
02207788
02207818
02208229
02208237
02208245
02209071
02210320
02210347
02210355
02210363
02210428
02210479
02211076
02211742
02211920
02211939
02211947
02211955
02211963
02211971
02212005
02212021
02212048
02212102
02212153
02212161
02212188
02212277
02212285
02212307
02212331
02212374
02212390
02213192
02213206
02213214
02213222
02213230
02213265
02213273
02213281
PAGE
138
138
162
216
162
143
131
48
51
206
206
86
86
86
86
142
42
42
42
171
36
39
12
12
12
114
148
148
88
30
31
30
138
52
69
69
69
51
28
114
31
69
95
95
96
96
96
142
6
34
48
33
33
33
5
5
5
148
148
30
173
173
173
173
173
186
187
187
DIN
PAGE
02213400
02213419
02213486
02213672
02213834
02214261
02214415
02214423
02214997
02215004
02215136
02216086
02216094
02216108
02216116
02216132
02216140
02216159
02216183
02216191
02216205
02216213
02216221
02216248
02216256
02216264
02216272
02216280
02216353
02216361
02216582
02216590
02216949
02216965
02217015
02217058
02217066
02217422
02217481
02217503
02217511
02218305
02218321
02218410
02218453
02218461
02218941
02218968
02218976
02218984
02219492
02219905
02220059
02220156
02220164
02220172
02220180
02220385
02220407
02221284
02221292
02221306
02221330
02221780
02221799
02221802
02221810
02221829
290
30
30
31
133
133
31
187
187
30
30
171
15
15
15
15
115
115
115
171
171
135
187
28
95
95
96
96
96
97
97
97
97
30
16
22
22
22
20
63
63
63
210
93
99
97
98
67
67
67
67
13
179
198
147
147
54
54
193
180
172
172
172
210
36
90
177
177
66
DIN
02221837
02221845
02221853
02221896
02221918
02221926
02221934
02221950
02221977
02221985
02221993
02222000
02222051
02222957
02222965
02222973
02223139
02223147
02223376
02223406
02223511
02223538
02223562
02223570
02223589
02223597
02223678
02223716
02223724
02224100
02224550
02224569
02224623
02224631
02224690
02224704
02224720
02224801
02224828
02224836
02225158
02225166
02225190
02225271
02225964
02225972
02226839
02227339
02227444
02227452
02227460
02228203
02228211
02228343
02228351
02228947
02229099
02229110
02229129
02229145
02229161
02229196
02229250
02229269
02229277
02229285
02229293
02229315
PAGE
66
66
66
187
187
187
187
80
39
61
61
61
55
45
45
45
99
99
198
22
99
99
168
113
113
124
124
6
6
88
168
168
134
134
123
123
123
46
46
46
207
207
164
194
113
113
180
124
144
145
145
74
75
142
142
32
157
12
12
16
16
16
105
105
105
105
144
187
DIN
02229323
02229406
02229407
02229408
02229440
02229441
02229452
02229453
02229455
02229456
02229467
02229468
02229515
02229516
02229517
02229521
02229522
02229523
02229524
02229526
02229540
02229550
02229552
02229569
02229617
02229628
02229650
02229651
02229652
02229653
02229654
02229655
02229656
02229704
02229718
02229719
02229720
02229722
02229723
02229755
02229756
02229758
02229778
02229779
02229781
02229782
02229783
02229784
02229785
02229837
02229838
02229839
02229840
02229994
02230003
02230004
02230019
02230020
02230026
02230027
02230036
02230037
02230047
02230068
02230069
02230076
02230077
02230085
PAGE
187
45
45
45
130
130
77
148
113
113
43
43
37
168
169
17
18
18
19
46
160
160
142
77
9
93
44
44
44
44
88
88
169
166
144
145
145
171
22
37
113
113
51
51
45
45
46
46
169
75
172
172
172
168
148
148
143
143
168
169
168
168
63
51
51
43
43
199
DIN
PAGE
02230086
02230087
02230090
02230095
02230102
02230183
02230203
02230204
02230205
02230206
02230243
02230244
02230245
02230246
02230284
02230285
02230302
02230321
02230322
02230359
02230360
02230366
02230368
02230369
02230386
02230394
02230401
02230402
02230403
02230405
02230406
02230418
02230420
02230431
02230432
02230433
02230454
02230475
02230476
02230477
02230543
02230580
02230584
02230585
02230619
02230641
02230648
02230711
02230713
02230714
02230717
02230730
02230732
02230733
02230734
02230735
02230736
02230737
02230768
02230784
02230785
02230800
02230803
02230804
02230805
02230806
02230807
02230808
291
199
199
39
113
113
53
58
58
59
59
7
7
8
8
101
101
81
109
109
47
47
88
88
88
134
198
39
108
108
108
108
33
33
146
146
146
207
169
53
79
212
53
110
110
159
215
132
52
52
52
215
210
71
71
71
10
10
147
93
196
196
198
47
47
67
67
67
67
DIN
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
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
02231431
02231434
02231435
02231441
02231457
02231459
PAGE
80
80
104
104
104
104
114
130
130
163
163
93
93
93
2
29
114
114
88
88
45
45
46
19
93
215
45
45
46
80
4
198
47
47
31
28
28
6
45
45
46
46
46
36
51
51
124
97
98
77
28
144
145
145
79
97
97
98
4
179
34
138
216
54
54
71
68
68
DIN
02231460
02231477
02231478
02231480
02231488
02231491
02231492
02231493
02231494
02231502
02231503
02231504
02231505
02231506
02231508
02231509
02231510
02231536
02231537
02231539
02231542
02231543
02231544
02231583
02231584
02231585
02231586
02231587
02231592
02231615
02231616
02231650
02231662
02231663
02231664
02231665
02231671
02231675
02231676
02231677
02231678
02231679
02231680
02231683
02231684
02231686
02231687
02231702
02231731
02231733
02231780
02231781
02231782
02231783
02231784
02231785
02231799
02231800
02231923
02231934
02232043
02232044
02232148
02232150
02232191
02232193
02232195
02232317
PAGE
68
145
37
179
30
207
114
137
28
74
74
74
75
75
75
164
164
48
49
49
89
90
90
38
38
39
39
39
192
113
113
48
74
74
74
75
216
28
69
69
31
210
210
101
101
99
99
207
43
43
53
99
99
30
31
28
77
77
132
86
208
208
98
99
186
187
187
75
DIN
PAGE
02232318
02232389
02232564
02232565
02232567
02232568
02232569
02232570
02232872
02232903
02232904
02232905
02232987
02233047
02233048
02233049
02233050
02233960
02233982
02233985
02233998
02234003
02234007
02234008
02234013
02234502
02234503
02234504
02234505
02234513
02234514
02234749
02236466
02236506
02236507
02236508
02236564
02236606
02236733
02236734
02236783
02236799
02236807
02236808
02236809
02236819
02236841
02236842
02236848
02236859
02236866
02236876
02236883
02236913
02236949
02236950
02236951
02236952
02236953
02236974
02236975
02236978
02236979
02236996
02236997
02237111
02237112
02237145
292
75
81
114
215
215
215
215
30
22
115
115
115
31
67
67
67
67
88
88
88
142
88
88
51
51
67
67
67
67
168
168
109
145
34
33
34
36
217
168
168
30
207
93
68
68
207
18
18
39
206
104
137
36
37
207
107
106
106
106
161
161
3
3
188
188
98
99
214
DIN
02237146
02237147
02237224
02237225
02237235
02237244
02237245
02237246
02237247
02237279
02237280
02237282
02237313
02237314
02237319
02237320
02237367
02237368
02237369
02237370
02237371
02237373
02237374
02237375
02237484
02237514
02237534
02237535
02237536
02237537
02237560
02237600
02237601
02237618
02237651
02237652
02237653
02237654
02237671
02237682
02237701
02237721
02237722
02237723
02237770
02237791
02237813
02237814
02237820
02237821
02237824
02237825
02237826
02237830
02237835
02237858
02237860
02237868
02237885
02237886
02237887
02237907
02237908
02237921
02237922
02237923
02237924
02237925
PAGE
214
214
29
29
4
158
158
158
158
102
102
102
10
10
210
210
66
66
66
3
3
54
55
55
212
18
104
104
104
104
39
43
43
48
104
104
104
104
208
19
39
42
42
42
210
69
97
97
32
32
94
94
77
93
157
114
170
136
42
42
42
90
90
69
69
62
62
62
DIN
02237971
02237991
02238046
02238047
02238048
02238073
02238102
02238123
02238162
02238171
02238172
02238209
02238216
02238217
02238222
02238223
02238280
02238281
02238282
02238315
02238326
02238327
02238334
02238340
02238348
02238370
02238403
02238404
02238405
02238406
02238444
02238465
02238525
02238526
02238551
02238552
02238553
02238554
02238568
02238577
02238578
02238604
02238617
02238618
02238633
02238634
02238635
02238636
02238639
02238645
02238660
02238674
02238675
02238682
02238703
02238704
02238748
02238770
02238771
02238796
02238797
02238817
02238829
02238830
02238831
02238850
02238873
02238903
PAGE
171
138
49
49
93
135
215
216
111
7
7
149
211
211
90
90
100
100
100
145
51
51
90
215
13
93
115
115
115
115
145
133
146
207
58
58
59
59
133
132
190
122
16
16
34
51
51
207
78
81
33
22
22
39
178
164
13
139
139
132
90
93
8
8
8
105
135
26
DIN
PAGE
02238984
02238998
02239007
02239008
02239024
02239025
02239028
02239083
02239091
02239092
02239131
02239146
02239170
02239193
02239213
02239224
02239225
02239238
02239239
02239267
02239288
02239323
02239324
02239325
02239365
02239366
02239517
02239518
02239519
02239535
02239577
02239607
02239608
02239619
02239620
02239627
02239630
02239665
02239667
02239668
02239698
02239699
02239700
02239701
02239702
02239703
02239713
02239714
02239738
02239744
02239746
02239747
02239748
02239757
02239834
02239835
02239864
02239886
02239887
02239888
02239893
02239907
02239908
02239912
02239913
02239917
02239918
02239919
293
217
71
143
143
88
88
165
16
58
58
28
214
34
15
15
123
123
10
10
68
132
212
212
212
30
31
90
91
91
142
131
94
95
124
124
137
3
109
10
10
90
91
91
90
91
91
93
93
33
39
98
99
99
176
210
42
53
13
13
13
4
93
93
149
124
124
104
104
DIN
02239920
02239921
02239924
02239925
02239926
02239941
02239942
02239951
02239953
02239954
02240035
02240067
02240071
02240072
02240113
02240114
02240115
02240131
02240132
02240205
02240210
02240249
02240294
02240321
02240329
02240331
02240332
02240335
02240337
02240346
02240357
02240358
02240362
02240363
02240432
02240456
02240457
02240458
02240481
02240484
02240485
02240498
02240499
02240500
02240508
02240518
02240519
02240520
02240521
02240550
02240551
02240552
02240588
02240589
02240590
02240601
02240604
02240622
02240623
02240682
02240683
02240684
02240685
02240687
02240693
02240694
02240695
02240754
PAGE
104
104
169
169
169
74
74
53
97
98
134
124
42
137
137
37
92
86
86
37
53
139
167
69
203
52
56
19
53
4
14
14
13
130
61
99
147
147
100
100
100
60
60
60
137
32
32
32
32
198
107
107
60
60
60
70
42
146
146
97
98
158
158
158
22
22
22
147
DIN
02240759
02240769
02240770
02240775
02240789
02240790
02240807
02240835
02240836
02240837
02240862
02240867
02240868
02240908
02240909
02241003
02241007
02241107
02241108
02241109
02241112
02241113
02241114
02241148
02241149
02241159
02241163
02241224
02241225
02241285
02241332
02241347
02241348
02241371
02241374
02241480
02241574
02241575
02241594
02241608
02241674
02241704
02241709
02241710
02241715
02241716
02241731
02241732
02241755
02241818
02241819
02241820
02241821
02241835
02241837
02241882
02241883
02241888
02241889
02241895
02241900
02241901
02241928
02241933
02241983
02242003
02242005
02242029
PAGE
220
66
66
170
99
99
4
31
31
31
106
78
78
99
100
132
63
79
79
79
169
169
169
43
43
209
32
75
75
198
164
97
98
97
97
16
138
138
214
53
163
53
11
11
138
138
139
139
131
62
62
11
11
165
165
90
90
210
210
3
68
68
103
143
203
83
83
157
DIN
PAGE
02242030
02242055
02242067
02242068
02242069
02242115
02242116
02242117
02242118
02242119
02242146
02242177
02242178
02242320
02242321
02242322
02242323
02242327
02242328
02242361
02242362
02242374
02242453
02242454
02242463
02242464
02242465
02242471
02242472
02242485
02242503
02242518
02242519
02242520
02242521
02242538
02242539
02242540
02242541
02242572
02242573
02242574
02242589
02242631
02242652
02242656
02242657
02242680
02242681
02242682
02242683
02242684
02242685
02242687
02242692
02242726
02242728
02242729
02242730
02242733
02242734
02242738
02242784
02242785
02242786
02242788
02242789
02242790
294
157
154
92
92
92
214
214
214
214
70
149
97
97
44
44
44
44
146
146
104
104
142
148
148
12
12
170
208
42
134
4
214
100
100
100
45
45
46
46
169
169
169
169
104
3
5
5
37
37
37
37
38
38
38
36
169
60
60
60
61
61
188
12
78
78
58
58
59
DIN
02242791
02242793
02242794
02242814
02242826
02242837
02242838
02242878
02242879
02242907
02242908
02242909
02242912
02242919
02242924
02242925
02242926
02242927
02242928
02242929
02242931
02242965
02242966
02242967
02242968
02242969
02242974
02242984
02242985
02243005
02243023
02243024
02243026
02243038
02243039
02243045
02243077
02243078
02243085
02243086
02243087
02243088
02243097
02243098
02243116
02243117
02243127
02243129
02243144
02243158
02243182
02243215
02243216
02243217
02243218
02243219
02243229
02243230
02243237
02243297
02243324
02243325
02243327
02243338
02243339
02243340
02243341
02243348
PAGE
59
169
168
142
61
115
115
164
164
207
90
90
78
180
37
37
37
38
38
38
169
18
23
23
23
23
168
189
189
163
113
113
137
148
148
33
171
171
145
105
105
105
52
128
20
20
54
54
216
193
18
60
60
60
99
99
148
148
215
209
49
50
39
45
45
46
46
99
DIN
02243349
02243350
02243351
02243352
02243353
02243401
02243403
02243446
02243447
02243448
02243450
02243486
02243487
02243506
02243507
02243508
02243518
02243519
02243520
02243521
02243529
02243530
02243538
02243539
02243541
02243542
02243543
02243552
02243562
02243587
02243588
02243602
02243643
02243644
02243645
02243684
02243716
02243722
02243724
02243727
02243728
02243743
02243744
02243745
02243746
02243747
02243748
02243749
02243763
02243770
02243771
02243789
02243790
02243796
02243808
02243827
02243828
02243836
02243861
02243862
02243878
02243894
02243895
02243910
02243942
02243986
02243987
02243999
PAGE
99
8
8
92
92
39
39
91
91
91
154
97
97
54
55
55
67
67
67
67
165
165
62
62
16
16
16
53
82
39
71
211
16
16
3
11
36
164
164
49
50
91
91
91
67
67
67
67
208
8
8
28
203
148
39
28
30
42
130
130
70
196
196
98
61
8
8
164
DIN
PAGE
02244000
02244001
02244002
02244016
02244021
02244022
02244023
02244107
02244125
02244138
02244139
02244140
02244148
02244149
02244166
02244291
02244292
02244293
02244298
02244299
02244300
02244304
02244305
02244306
02244309
02244310
02244344
02244350
02244351
02244352
02244353
02244393
02244394
02244403
02244462
02244463
02244464
02244465
02244466
02244467
02244474
02244494
02244495
02244496
02244513
02244514
02244515
02244521
02244522
02244527
02244528
02244529
02244550
02244551
02244552
02244563
02244596
02244597
02244598
02244599
02244612
02244613
02244638
02244641
02244646
02244647
02244673
02244680
295
164
164
164
209
58
147
147
106
147
90
91
91
195
195
103
158
158
158
209
209
209
91
91
91
215
215
67
54
55
55
166
5
5
89
37
37
37
38
38
38
90
211
211
211
91
91
91
145
145
60
60
60
213
213
213
78
14
14
14
14
198
198
90
6
8
8
92
87
DIN
02244681
02244726
02244727
02244756
02244757
02244769
02244781
02244782
02244790
02244791
02244792
02244798
02244814
02244815
02244816
02244817
02244818
02244838
02244839
02244840
02244842
02244896
02244914
02244981
02244982
02244999
02245058
02245126
02245127
02245159
02245160
02245161
02245208
02245209
02245210
02245211
02245230
02245231
02245232
02245233
02245240
02245246
02245284
02245285
02245286
02245292
02245293
02245329
02245330
02245372
02245373
02245385
02245386
02245397
02245400
02245406
02245432
02245433
02245438
02245439
02245440
02245456
02245457
02245458
02245480
02245522
02245523
02245524
PAGE
87
172
172
6
14
190
68
68
84
84
85
194
113
113
95
95
95
100
100
100
198
139
30
207
207
134
147
31
31
100
100
100
92
92
92
211
88
88
11
11
214
124
84
84
85
3
3
206
208
49
50
29
29
166
159
159
106
106
169
169
169
152
152
152
198
187
186
187
DIN
02245532
02245565
02245618
02245619
02245623
02245643
02245644
02245647
02245648
02245649
02245662
02245669
02245676
02245688
02245697
02245698
02245748
02245749
02245750
02245751
02245752
02245753
02245777
02245784
02245785
02245786
02245787
02245788
02245789
02245821
02245822
02245823
02245860
02245882
02245894
02245913
02245914
02245915
02245916
02245917
02245998
02245999
02246010
02246013
02246014
02246026
02246027
02246028
02246029
02246030
02246045
02246046
02246047
02246056
02246057
02246058
02246063
02246066
02246082
02246083
02246108
02246109
02246194
02246284
02246354
02246355
02246357
02246358
PAGE
159
206
37
209
8
3
3
17
18
18
177
30
164
186
3
131
100
100
100
90
91
91
13
112
112
112
100
100
100
133
54
54
137
135
217
206
44
44
44
44
213
213
46
54
54
213
213
213
213
213
13
147
147
94
95
170
160
28
32
137
3
3
42
137
38
38
38
38
DIN
PAGE
02246360
02246529
02246530
02246531
02246532
02246542
02246543
02246569
02246581
02246582
02246583
02246584
02246585
02246594
02246595
02246596
02246619
02246620
02246621
02246622
02246624
02246627
02246628
02246629
02246691
02246714
02246737
02246742
02246743
02246744
02246793
02246820
02246821
02246825
02246826
02246827
02246893
02246894
02246895
02246896
02246897
02246898
02246899
02246930
02246931
02246932
02246955
02246963
02246967
02246968
02246969
02247008
02247009
02247010
02247011
02247012
02247013
02247014
02247015
02247021
02247027
02247028
02247029
02247047
02247048
02247050
02247051
02247052
296
38
44
44
44
44
54
54
65
43
55
56
56
56
94
95
19
138
3
80
80
65
172
172
172
17
185
56
91
91
91
28
168
169
17
18
18
69
69
69
214
92
92
92
54
55
55
68
92
164
164
164
54
55
55
55
56
56
56
56
8
92
92
92
100
100
100
147
147
DIN
02247054
02247055
02247056
02247057
02247067
02247068
02247069
02247070
02247071
02247072
02247075
02247076
02247077
02247078
02247098
02247111
02247162
02247163
02247164
02247170
02247171
02247173
02247174
02247176
02247230
02247231
02247232
02247238
02247339
02247340
02247341
02247364
02247371
02247372
02247373
02247439
02247440
02247461
02247521
02247526
02247527
02247528
02247529
02247530
02247531
02247532
02247533
02247534
02247535
02247536
02247537
02247581
02247582
02247583
02247585
02247606
02247607
02247608
02247621
02247655
02247656
02247657
02247694
02247698
02247699
02247700
02247701
02247704
PAGE
97
98
54
54
55
56
56
56
56
55
56
56
56
56
185
215
55
55
55
124
124
111
111
111
90
54
54
195
17
18
18
109
123
123
206
43
43
133
52
113
113
97
97
4
55
56
56
56
56
54
54
172
172
172
170
211
60
60
114
54
55
55
83
83
83
83
83
107
DIN
02247705
02247706
02247750
02247751
02247752
02247802
02247803
02247811
02247812
02247825
02247827
02247828
02247830
02247831
02247833
02247856
02247857
02247858
02247875
02247876
02247889
02247920
02247933
02247934
02247935
02247936
02247998
02248008
02248009
02248010
02248011
02248013
02248014
02248031
02248050
02248051
02248103
02248104
02248105
02248106
02248107
02248124
02248125
02248130
02248131
02248132
02248133
02248134
02248135
02248138
02248151
02248170
02248171
02248182
02248183
02248184
02248232
02248233
02248234
02248259
02248260
02248261
02248267
02248268
02248398
02248437
02248438
02248439
PAGE
107
107
99
99
100
61
61
99
100
15
55
56
56
56
56
54
55
55
47
47
78
134
44
44
44
44
70
168
168
94
95
99
100
78
94
95
55
56
56
56
56
123
123
190
94
94
94
124
124
8
137
94
95
54
55
55
92
92
92
91
91
91
78
78
132
17
18
18
DIN
PAGE
02248448
02248449
02248557
02248558
02248570
02248571
02248605
02248606
02248639
02248640
02248641
02248642
02248715
02248716
02248717
02248718
02248719
02248720
02248721
02248748
02248749
02248750
02248751
02248756
02248757
02248758
02248762
02248843
02248845
02248942
02248943
02248973
02248974
02248996
02248997
02249367
02249375
02249383
02249480
02249715
02249723
02249731
02249758
02249812
02249960
02249979
02249987
02250055
02250144
02250152
02250160
02250179
02250187
02250594
02250608
02250659
02250667
02251272
02251280
02251299
02251558
02251566
99117796
99221028
99254011
99401055
99401063
99401068
297
99
100
99
100
148
148
78
78
212
212
212
212
44
44
44
44
99
99
100
44
44
44
44
17
18
18
98
207
4
94
95
78
78
94
95
91
91
91
49
53
54
55
55
69
17
18
18
158
55
56
56
56
56
98
98
124
124
17
18
18
94
95
220
220
221
220
220
220
DIN
99432799
99433383
99438102
99767467
PAGE
221
221
220
221
INDEX C
ALPHABETICAL LIST OF PHARMACEUTICAL PRODUCT NAMES
PRODUCT NAME
292
3TC (EDS)
5-AMINOSALICYLIC ACID
642
ABACAVIR SO4
ABACAVIR SO4/
ACARBOSE
ACCOLATE (EDS)
ACCU-CHEK ADVANTAGE
ACCU-CHEK COMPACT
ACCUPRIL
ACCURETIC
ACCUTANE
ACCUTREND
ACEBUTOLOL HCL
"
ACENOCOUMAROL
ACETAMINOPHEN/CAFFEINE/
CODEINE
ACETAMINOPHEN/CODEINE
ACETAZOLAMIDE
"
ACETEST
ACETOXYL
ACETYLCYSTEINE
ACETYLCYSTEINE SOLUTION
ACETYLSALICYLIC ACID/
CAFFEINE/CODEINE
ACITRETIN
ACTONEL (EDS)
ACTOS (EDS)
ACULAR (EDS)
ACYCLOVIR
ADALAT XL
ADAPALENE
ADRENALIN
ADVAIR (EDS)
ADVAIR DISKUS (EDS)
ADVANTAGE COMFORT
AGENERASE (EDS)
AGGRENOX (EDS)
AGRYLIN
AIROMIR
ALCOHOL PREP
ALCOMICIN
ALDACTAZIDE-25
ALDACTAZIDE-50
ALDACTONE
ALENDRONATE SODIUM
ALERTEC (EDS)
ALESSE
ALFACALCIDOL
ALFUZOSIN
ALLOPURINOL
Page
81
15
149
86
14
14
167
217
118
118
66
66
195
118
42
57
36
81
81
123
135
119
193
128
128
74
81
194
214
169
133
12
48
192
29
31
31
118
16
70
206
30
220
130
66
66
125
206
109
161
203
206
206
299
PRODUCT NAME
ALOMIDE
ALPHAGAN
ALPHAGAN P (EDS)
ALPRAZOLAM
ALTACE
ALUMINUM ACETATE/
BENZETHONIUM CHLORIDE
"
AMANTADINE
AMATINE (EDS)
AMCINONIDE
AMCORT
AMERGE (EDS)
AMES
AMETHOPTERIN
AMILORIDE HCL
AMILORIDE HCL/
HYDROCHLOROTHIAZIDE
AMINOPHYLLINE
AMIODARONE
AMITRIPTYLINE
AMLODIPINE BESYLATE
AMOBARBITAL SODIUM
AMOXICILLIN TRIHYDRATE/
POTASSIUM CLAVULANATE
AMPICILLIN
AMPRENAVIR
AMYTAL SODIUM
ANAFRANIL
ANAGRELIDE HCL
ANAKINRA
ANDRIOL
ANDROCUR (EDS)
ANSAID
ANTHRAFORTE-1
ANTHRAFORTE-2
ANTHRANOL
ANTHRASCALP
APO-ACEBUTOLOL
APO-ACETAZOLAMIDE
APO-ACYCLOVIR
APO-ALLOPURINOL
APO-ALPRAZ
APO-AMILZIDE
APO-AMIODARONE
APO-AMITRIPTYLINE
APO-AMOXI
"
APO-AMPI
APO-ATENOL
APO-AZATHIOPRINE
APO-BACLOFEN
"
APO-BECLOMETHASONE
Page
138
137
137
110
66
131
191
12
29
185
185
32
220
194
124
57
198
42
94
43
109
7
8
9
16
109
95
206
206
160
22
76
193
193
193
193
42
135
12
206
110
57
42
94
7
8
8
9
43
207
33
34
132
PRODUCT NAME
APO-BENZTROPINE
APO-BROMAZEPAM
APO-BROMOCRIPTINE
APO-BUSPIRONE
APO-CAPTO
"
APO-CARBAMAZEPINE
APO-CEPHALEX
APO-CHLORPROPAMIDE
APO-CHLORTHALIDONE
APO-CIMETIDINE
"
APO-CIPROFLOX (EDS)
"
APO-CITALOPRAM
"
APO-CLINDAMYCIN
APO-CLOBAZAM
APO-CLOMIPRAMINE
APO-CLONAZEPAM
APO-CLONIDINE
APO-CLORAZEPATE
APO-CLOXI
APO-CROMOLYN
"
APO-CYCLOBENZAPRINE (EDS)
APO-DESIPRAMINE
"
APO-DESMOPRESSIN (EDS)
APO-DEXAMETHASONE
APO-DIAZEPAM
APO-DICLO
APO-DICLO SR
"
APO-DIFLUNISAL
APO-DILTIAZ
APO-DILTIAZ CD
"
APO-DILTIAZ SR
APO-DIMENHYDRINATE
APO-DIVALPROEX
"
APO-DOMPERIDONE
APO-DOXAZOSIN
APO-DOXEPIN
APO-DOXY
APO-ERYTHRO-BASE
APO-ERYTHRO-S
APO-ETODOLAC (EDS)
APO-FAMOTIDINE
APO-FENO-MICRO
APO-FLAVOXATE (EDS)
APO-FLOCTAFENINE
APO-FLUCONAZOLE
APO-FLUNARIZINE (EDS)
Page
26
110
207
114
170
58
59
90
90
44
5
5
110
168
123
144
145
17
18
94
95
11
90
95
88
60
111
9
138
216
34
95
96
170
158
111
74
74
75
75
45
45
46
45
144
90
91
145
60
96
10
6
7
75
146
53
198
87
3
3
32
300
PRODUCT NAME
APO-FLUNISOLIDE
APO-FLUOXETINE
APO-FLUPHENAZINE
APO-FLURAZEPAM
APO-FLURBIPROFEN
APO-FLUVOXAMINE
"
APO-FOLIC
APO-FUROSEMIDE
APO-GABAPENTIN
APO-GEMFIBROZIL
APO-GLYBURIDE
APO-HALOPERIDOL
"
APO-HALOPERIDOL LA
APO-HYDRALAZINE
APO-HYDRO
APO-HYDROXYQUINE
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-KETOROLAC (EDS)
APO-KETOTIFEN (EDS)
APO-LABETALOL
APO-LACTULOSE (EDS)
APO-LAMOTRIGINE
APO-LEVOBUNOLOL
APO-LEVOCARB
APO-LEVOCARB CR
APO-LISINOPRIL
APO-LOPERAMIDE
APO-LORAZEPAM
APO-LOVASTATIN
APO-LOXAPINE
APO-MEDROXY
APO-MEFENAMIC
APO-MEGESTROL (EDS)
APO-MELOXICAM (EDS)
APO-METFORMIN
"
APO-METHAZIDE-15
APO-METHAZIDE-25
APO-METHAZOLAMIDE
APO-METHOPRAZINE
APO-METHOTREXATE
APO-METHYLDOPA
APO-METOCLOP
APO-METOPROLOL
"
APO-METRONIDAZOLE
Page
132
97
103
111
76
97
98
202
123
91
53
168
103
104
104
62
124
17
114
76
98
124
76
28
137
70
122
77
4
77
133
210
62
142
92
138
211
211
63
115
142
112
54
104
172
77
23
78
168
169
64
64
135
115
194
64
146
46
47
47
20
PRODUCT NAME
APO-MISOPROSTOL
APO-MOCLOBEMIDE
"
APO-NABUMETONE (EDS)
APO-NADOL
"
APO-NAPROXEN
"
APO-NAPROXEN SR
APO-NIFED
APO-NIFED PA
APO-NITRAZEPAM
APO-NITROFURANTOIN
APO-NIZATIDINE
APO-NORFLOX (EDS)
APO-NORTRIPTYLINE
APO-OFLOXACIN (EDS)
APO-OMEPRAZOLE (EDS)
APO-ORCIPRENALINE
APO-OXAZEPAM
APO-OXTRIPHYLLINE
APO-OXYBUTYNIN
APO-PAROXETINE
"
APO-PENTOXIFYLLINE SR
APO-PEN-VK
APO-PERPHENAZINE
APO-PHENYLBUTAZONE
APO-PIMOZIDE
APO-PINDOL
"
APO-PIROXICAM
APO-PRAVASTATIN
"
APO-PRAZO
APO-PREDNISONE
APO-PRIMIDONE
APO-PROCAINAMIDE
APO-PROCHLORAZINE
APO-PROPAFENONE
"
APO-PROPRANOLOL
APO-QUINIDINE
APO-RANITIDINE
APO-SALVENT
"
APO-SALVENT CFC FREE
APO-SELEGILINE (EDS)
APO-SERTRALINE
APO-SIMVASTATIN
"
APO-SOTALOL
APO-SUCRALFATE
APO-SULFATRIM
APO-SULFATRIM DS
APO-SULFINPYRAZONE
APO-SULIN
APO-TEMAZEPAM
APO-TERAZOSIN
APO-TERBINAFINE
Page
10
147
98
99
78
47
48
78
79
79
48
48
88
19
147
19
99
132
147
30
112
199
198
99
100
39
9
105
79
106
48
49
79
54
55
65
159
87
49
106
49
50
50
51
148
30
31
30
215
100
55
56
51
149
20
20
125
80
113
67
4
301
PRODUCT NAME
APO-TETRA
APO-THEO-LA
APO-THIORIDAZINE
APO-TIAPROFENIC
APO-TICLOPIDINE (EDS)
APO-TIMOL
APO-TIMOP
APO-TOBRAMYCIN (EDS)
APO-TOLBUTAMIDE
APO-TRAZODONE
APO-TRIAZIDE
APO-TRIAZO
APO-TRIFLUOPERAZINE
APO-TRIHEX
APO-TRIMETHOPRIM
APO-TRIMIP
"
APO-VALPROIC
APO-VERAP
APO-VERAP SR
APO-WARFARIN
"
APRACLONIDINE HCL
ARALEN
ARANESP (EDS)
ARAVA (EDS)
AREDIA (EDS)
ARICEPT (EDS)
ARISTOCORT R
ARISTOSPAN (EDS)
ARTHROTEC
ARTHROTEC 75
ASACOL
ASADOL
ASCENSIA DEX
ASCENSIA MICROFILL
ATACAND
ATACAND PLUS
ATARAX
ATASOL-15
ATASOL-30
ATENOLOL
"
ATENOLOL/CHLORTHALIDONE
ATIVAN
ATORVASTATIN CALCIUM
ATOVAQUONE
ATROPINE SO4
ATROVENT
ATROVENT NASAL SPRAY
AURANOFIN
AVALIDE
AVANDIA (EDS)
AVAPRO
AVELOX (EDS)
AVENTYL
AVONEX (EDS)
AXID
AZATHIOPRINE
AZITHROMYCIN
AZOPT
Page
11
199
107
80
39
51
139
131
170
101
68
113
108
27
20
101
102
93
69
69
37
38
137
17
38
210
213
208
190
160
75
75
149
74
118
118
58
58
114
81
81
43
57
57
112
52
20
136
28
137
152
62
169
62
18
99
210
147
207
6
135
PRODUCT NAME
BACLOFEN
BACTROBAN
BD ALCOHOL SWAB
BD LATITUDE
BD LATITUDE STRIP
BD MICROFINE 1V
BD MICROFINE 28G
BD MICROFINE 29G
BD ULTRA FINE
BD ULTRA FINE 12MM
BD ULTRA FINE 29G
BD ULTRA FINE II
BD ULTRAFINE 5MM, 8MM
BD ULTRAFINE II SHORT
BECLOMETHASONE
DIPROPIONATE
"
"
BENAZEPRIL HCL
BENOXYL
BENTYLOL
BENURYL
BENZAC AC
BENZAC W
BENZAC-W
BENZAGEL
BENZAMYCIN
BENZOYL PEROXIDE
BENZTROPINE MESYLATE
BENZTROPINE OMEGA
BEROTEC
BETADERM
BETADINE
BETAGAN
BETAHISTINE
DIHYDROCHLORIDE
BETAINE ANHYDROUS
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 ENEMA
BETOPTIC S
BEXTRA (EDS)
Page
33
176
220
220
118
221
221
221
221
220
221
220
221
220
221
132
157
185
57
193
27
125
193
193
193
193
194
193
26
26
29
186
180
138
70
207
157
47
47
157
185
186
190
186
186
210
203
137
26
186
137
80
302
PRODUCT NAME
BEZAFIBRATE
BEZALIP SR (EDS)
BIAXIN (EDS)
BIAXIN BID (EDS)
BIAXIN XL (EDS)
BILTRICIDE
BIMATOPROST
BIO-DIAZEPAM
BIO-FUROSEMIDE
BIQUIN DURULES
BISOPROLOL FUMARATE
BLEPHAMIDE S.O.P.
BLOOD GLUCOSE TEST STRIP
BONAMINE
BOSENTAN
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
BUSPIRONE
C.E.S.
CABERGOLINE
CALCIFEROL
CALCIMAR (EDS)
CALCIPOTRIOL
CALCITONIN SALMON
CALCITRIOL
CALCIUM POLYSTYRENE
SULFONATE
CALTINE 100 (EDS)
CANDESARTAN CILEXETIL
CANDESARTAN CILEXETIL/
HYDROCHLOROTHIAZIDE
CANDISTATIN
CANESTEN
CANESTEN-3
CANESTEN-6
CAPEX SHAMPOO
CAPOTEN
"
CAPTOPRIL
Page
52
52
6
6
6
2
137
111
123
124
50
43
135
118
144
207
207
207
162
162
31
137
135
110
207
132
144
157
186
123
94
123
191
131
27
207
114
114
163
208
203
170
194
170
203
122
170
58
58
178
177
177
177
177
177
188
58
59
43
PRODUCT NAME
CAPTOPRIL
CAPTOPRIL
"
CARBACHOL
CARBAMAZEPINE
CARBOLITH
CARDIZEM
CARDIZEM CD
"
CARDIZEM-SR
CARDURA-1
CARDURA-2
CARDURA-4
CARVEDILOL
CATAPRES
CEFIXIME
CEFPROZIL
CEFTIN (EDS)
CEFUROXIME AXETIL
CEFZIL (EDS)
CELEBREX (EDS)
CELECOXIB
CELESTODERM-V
CELESTODERM-V/2
CELESTONE SOLUSPAN
CELEXA
"
CELLCEPT (EDS)
CELONTIN
CEPHALEXIN MONOHYDRATE
CESAMET (EDS)
CETAMIDE
CHEMSTRIP BG
CHEMSTRIP UG 5000K
CHLORAL HYDRATE
CHLORAL HYDRATE SYRUP
CHLORDIAZEPOXIDE
CHLOROQUINE PHOSPHATE
CHLORPROMAZINE
CHLORPROMAZINE
CHLORPROPAMIDE
CHLORTHALIDONE
CHOLEDYL
CHOLESTYRAMINE RESIN
CHORIONIC GONADOTROPIN
CHRONOVERA
CICLOPIROX OLAMINE
CILAZAPRIL
CILAZAPRIL/
HYDROCHLOROTHIAZIDE
CILOXAN (EDS)
CIMETIDINE
CIPRO (EDS)
"
CIPRO HC (EDS)
CIPROFLOXACIN
"
CIPROFLOXACIN/
HYDROCORTISONE
CITALOPRAM HYDROBROMIDE
CLARITHROMYCIN
Page
58
58
59
136
89
115
45
45
46
45
60
60
60
44
60
4
5
5
5
5
74
74
186
186
157
94
95
212
89
5
212
131
118
119
114
114
110
17
102
102
168
123
199
52
165
69
177
59
59
131
144
17
18
134
17
131
134
94
6
303
PRODUCT NAME
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
CLINDAMYCIN PHOSPHATE/
BENZOYL PEROXIDE
CLINDOXYL GEL
CLINITEST
CLOBAZAM
"
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)
"
CO CITALOPRAM
"
CO FLUOXETINE
CO PRAVASTATIN
"
CO RANITIDINE
CO SIMVASTATIN
"
CO-CLOMIPRAMINE
CODEINE
CODEINE PHOSPHATE
COGENTIN
COLCHICINE
COLCHICINE-ODAN
COLESTID
COLESTIPOL HCL RESIN
COMBANTRIN
COMBIVENT
COMBIVIR (EDS)
COMFORT TOUCH
COMTAN
CONDYLINE
Page
8
8
8
8
8
8
8
164
164
11
11
176
193
193
119
90
186
186
187
187
95
88
88
59
39
108
108
108
111
177
177
9
102
102
17
18
94
95
97
54
55
148
55
56
95
81
81
81
26
208
208
52
52
2
28
15
220
208
194
163
PRODUCT NAME
CONJUGATED ESTROGENS/
MEDROXYPROGESTERONE
ACETATE
"
COPAXONE (EDS)
CORDARONE
COREG (EDS)
CORGARD
"
CORTATE
CORTEF
CORTENEMA
CORTIFOAM
CORTISONE
CORTISONE ACETATE
CORTISPORIN
"
CORTODERM
COSOPT
COSYNTROPIN ZINC
HYDROXIDE
"
COTAZYM
COTAZYM ECS 20
COTAZYM ECS 8
CO-TEMAZEPAM
COUMADIN
"
COVERSYL
COVERSYL PLUS
COZAAR
CREON 10
CREON 20
CREON 25
CREON 5
CRESTOR
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
Page
164
171
209
42
44
47
48
189
159
189
189
157
157
134
191
189
137
118
170
143
143
143
113
37
38
65
65
63
143
143
143
143
55
16
138
179
119
154
202
202
163
34
185
160
195
208
22
207
173
147
13
170
11
176
111
36
160
34
304
PRODUCT NAME
DANTROLENE SODIUM
DAPSONE
DAPSONE
DARAPRIM
DARBEPOETIN ALFA
DARVON-N
DELATESTRYL
DELAVIRDINE MESYLATE
DELESTROGEN
DEMEROL
DEMULEN 30
DEPAKENE
DEPO-MEDROL
DEPO-PROVERA
DEPO-TESTOSTERONE
DERMA-SMOOTHE/FS
DERMOVATE
"
DESFERAL (EDS)
DESIPRAMINE HCL
DESMOPRESSIN
DESOCORT
DESONIDE
DESOXIMETASONE
DESQUAM-X
DESYREL
DEXAMETHASONE
"
DEXAMETHASONE
21-PHOSPHATE
DEXASONE
DEXEDRINE
DEXIRON (EDS)
DEXTROAMPHETAMINE SO4
DIABETA
DIAMOX SEQUELS
DIARR-EZE
DIASTAT
DIASTIX
DIAZEPAM
DICLECTIN
DICLOFENAC SODIUM
"
DICLOFENAC SODIUM/
MISOPROSTOL
DICYCLOMINE HCL
DIDANOSINE
DIDROCAL
DIDRONEL
DIFFERIN
DIFLUCAN
DIFLUCAN (EDS)
DIFLUCAN P.O.S. (EDS)
DIFLUCORTOLONE VALERATE
DIFLUNISAL
DIGOXIN
DIHYDROERGOTAMINE MESYL.
DIHYDROERGOTAMINE
MESYLATE
Page
34
19
19
17
38
86
154
160
13
165
83
161
93
159
172
160
188
186
187
154
95
170
187
187
187
193
101
132
158
158
158
158
108
36
108
168
135
142
111
119
111
144
74
137
75
27
14
208
208
192
3
3
3
187
75
44
32
32
PRODUCT NAME
DIHYDROERGOTAMINE-SANDOZ
DIIODOHYDROXYQUIN
DILANTIN
DILAUDID
"
DILAUDID HP-PLUS
DILAUDID-HP
DILAUDID-XP
DILTIAZEM HCL
"
DIMENHYDRINATE
DIMENHYDRINATE IM
DIODOQUIN
DIOVAN
DIOVAN-HCT
DIPENTUM
DIPHENOXYLATE HCL
DIPIVEFRIN HCL
DIPROLENE
DIPROSALIC
DIPROSONE
DIPYRIDAMOLE
DIPYRIDAMOLE/
DISOPYRAMIDE
DITHRANOL
DITROPAN
DIVALPROEX SODIUM
DIXARIT (EDS)
DOM-AMANTADINE
DOM-AMITRIPTYLINE
DOM-ATENOLOL
DOM-BACLOFEN
"
DOM-BROMOCRIPTINE
DOM-BUSPIRONE
DOM-CAPTOPRIL
"
DOM-CEPHALEXIN
DOM-CIMETIDINE
"
"
DOM-CITALOPRAM
"
DOM-CLOBAZAM
DOM-CLONAZEPAM
DOM-CLONAZEPAM-R
DOM-CLONIDINE
DOM-CYCLOBENZAPRINE (EDS)
DOM-DESIPRAMINE
"
DOM-DICLOFENAC
DOM-DICLOFENAC SR
"
DOM-DIVALPROEX
"
DOM-DOMPERIDONE
DOM-FENOFIBR. MICRO
Page
32
2
89
82
83
83
83
83
45
60
144
144
2
68
68
147
142
136
185
186
185
70
70
46
193
198
90
59
12
94
43
33
34
207
114
58
59
90
44
5
144
145
17
18
94
95
90
88
88
60
34
95
96
74
74
75
90
91
145
53
305
PRODUCT NAME
DOM-FLUOXETINE
DOM-FLUVOXAMINE
"
DOM-FUROSEMIDE
DOM-GABAPENTIN
DOM-GEMFIBROZIL
DOM-GLYBURIDE
DOM-INDAPAMIDE
DOM-IPRATROPIUM
DOM-LEVO-CARBIDOPA
DOM-LOPERAMIDE
DOM-LORAZEPAM
DOM-LOVASTATIN
DOM-LOXAPINE
DOM-MEFENAMIC ACID
DOM-MELOXICAM (EDS)
DOM-METFORMIN
"
DOM-METOPROLOL
DOM-METOPROLOL-L
DOM-MOCLOBEMIDE
DOM-NIZATIDINE
DOM-NORTRIPTYLINE
DOM-NYSTATIN
DOM-OXYBUTYNIN
DOM-PAROXETINE
"
DOMPERIDONE MALEATE
DOM-PINDOLOL
"
DOM-PRAVASTATIN
"
DOM-PROCYCLIDINE
DOM-PROPRANOLOL
DOM-RANITIDINE
DOM-SALBUTAMOL
DOM-SALBUTAMOL RESPIR.SOL
DOM-SELEGILINE (EDS)
DOM-SERTRALINE
DOM-SODIUM CROMOGLYCATE
DOM-SOTALOL
DOM-SUCRALFATE
DOM-TEMAZEPAM
DOM-TERAZOSIN
DOM-TIAPROFENIC
DOM-TICLOPIDINE (EDS)
DOM-TIMOLOL
DOM-TRAZODONE
DOM-VALPROIC ACID
DOM-VERAPAMIL SR
DONEPEZIL HCL
DORNASE ALFA
DORZOLAMIDE HCL
DORZOLAMIDE HCL/TIMOLOL
MALEATE
DOSTINEX (EDS)
DOVONEX
Page
3
97
97
98
123
91
53
168
124
124
137
211
142
112
54
104
172
77
78
168
169
47
47
10
99
147
99
4
198
99
100
145
48
49
54
55
27
50
148
30
31
215
100
216
51
149
113
67
80
39
139
101
93
69
208
128
135
137
208
194
PRODUCT NAME
DOXAZOSIN MESYLATE
DOXEPIN HCL
DOXERCALCIFEROL
DOXYCIN
DOXYCYCLINE
DOXYLAMINE SUCCINATE/
PYRIDOXINE HCL
DRISDOL
DURAGESIC (EDS)
DURALITH
DUVOID
ECONAZOLE NITRATE
ECOSTATIN
EES 200
EES 400
EFAVIRENZ
EFFEXOR
EFFEXOR XR
EFUDEX
ELDEPRYL (EDS)
ELIDEL (EDS)
ELITE
ELMIRON (EDS)
ELOCOM
ELTROXIN
EMO-CORT
ENALAPRIL MALEATE
ENALAPRIL MALEATE/
HYDROCHLOROTHIAZIDE
ENCORE
ENDANTADINE
ENOXAPARIN
ENTACAPONE
ENTOCORT
ENTOCORT (EDS)
ENTROPHEN
EPINEPHRINE
EPINEPHRINE HCL
EPIPEN
EPIPEN JR.
EPIVAL
"
EPOETIN ALFA
EPREX (EDS)
"
EPROSARTAN MESYLATE
EQUATE THIN
EQUATE ULTRATHIN
ERYC
ERYTHROMYCIN BASE
ERYTHROMYCIN ESTOLATE
ERYTHROMYCIN
ETHYLSUCCINATE
ERYTHROMYCIN
ETHYLSUCCINATE/
SULFISOXAZOLE ACETATE
ERYTHROMYCIN STEARATE
ERYTHROMYCIN/BENZOYL
PEROXIDE
ERYTHROMYCIN/ETHYL
ALCOHOL
Page
60
96
203
10
10
144
203
82
115
26
177
177
7
7
13
102
102
195
215
195
118
213
190
173
189
61
61
118
12
36
208
186
144
74
29
29
29
29
90
91
38
38
39
61
220
220
6
6
6
7
20
7
194
176
306
PRODUCT NAME
ESOMEPRAZOLE MAGNESIUM
TRIHYDRATE
ESTALIS (EDS)
ESTALIS-SEQUI (EDS)
ESTRACE
ESTRACOMB (EDS)
ESTRADERM (EDS)
ESTRADIOL
ESTRADIOL & NORETHINDRONE
ACETATE/ESTRADIOL
"
ESTRADIOL VALERATE
ESTRADIOL/NORETHINDRONE
ACETATE
"
ESTRADOT (EDS)
ESTRING
ESTROGEL (EDS)
ESTROPIPATE (CALCULATED
AS SODIUM ESTRONE SULFATE)
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)
EZETIMIBE
EZETROL
FAMCICLOVIR
FAMOTIDINE
FAMVIR
FASTTAKE
FELODIPINE
FENOFIBRATE
FENOTEROL HYDROBROMIDE
FENTANYL
FILGRASTIM
FINASTERIDE
FLAGYL
FLAREX
FLAVOXATE HCL
Page
145
165
165
164
165
164
164
165
171
165
165
171
164
164
164
165
161
161
161
161
162
162
163
26
89
208
208
75
168
187
179
165
81
214
52
52
12
146
12
118
61
53
29
82
39
209
180
133
198
PRODUCT NAME
FLECAINIDE ACETATE
FLEXERIL (EDS)
FLOCTAFENINE
FLOMAX
FLONASE
FLORINEF
FLOVENT DISKUS
FLOVENT HFA
FLUANXOL
FLUANXOL DEPOT
FLUCONAZOLE
FLUDROCORTISONE ACETATE
FLUNARIZINE HCL
FLUNISOLIDE
FLUOCINOLONE ACETONIDE
FLUOCINONIDE
FLUODERM
FLUOROMETHOLONE
FLUOROMETHOLONE ACETATE
FLUOROURACIL
FLUOTIC
FLUOXETINE
FLUPENTHIXOL
DIHYDROCHLORIDE
FLUPHENAZINE DECANOATE
FLUPHENAZINE HCL
FLURAZEPAM HCL
FLURBIPROFEN
FLURBIPROFEN SODIUM
"
FLUVASTATIN SODIUM
FLUVOXAMINE MALEATE
FML
FOLIC ACID
FORADIL (EDS)
FORMOTEROL FUMARATE
FORMOTEROL FUMARATE
DIHYDRATE/BUDESONIDE
FORMULEX
FORTOVASE (EDS)
FOSAMAX (EDS)
FOSFOMYCIN TROMETHAMINE
FOSINOPRIL
FRAGMIN (EDS)
FRAMYCETIN SO4
FRAMYCETIN SO4/
GRAMICIDIN/DEXAMETHASONE BASE
FRAXIPARINE (EDS)
FRAXIPARINE FORTE (EDS)
FREESTYLE
"
FRISIUM
FTP-DOMPERIDONE MALEATE
FUCIDIN
FUCIDIN H
FUCITHALMIC (EDS)
FULVICIN U/F
FUROSEMIDE
FUSIDIC ACID
Page
46
34
87
216
133
158
158
158
103
102
3
158
32
132
188
188
188
133
133
195
216
97
102
103
103
103
111
76
133
133
158
53
97
133
202
29
29
29
27
16
206
19
61
36
176
134
37
37
118
220
90
145
176
190
130
3
123
130
307
PRODUCT NAME
FUSIDIC ACID
FUSIDIC ACID/
GABAPENTIN
GALANTAMINE HYDROBROMIDE
GAMMA-BENZENE
HEXACHLORIDE
GANCICLOVIR SO4
GARAMYCIN
"
GARASONE
GATIFLOXACIN
GEMFIBROZIL
GEN-ACEBUTOLOL
GEN-ACYCLOVIR
GEN-ALPRAZOLAM
GEN-AMANTADINE
GEN-AMIODARONE
GEN-AMOXICILLIN
GEN-ATENOLOL
GEN-AZATHIOPRINE
GEN-BACLOFEN
"
GEN-BECLO AQ.
GEN-BROMAZEPAM
GEN-BUDESONIDE AQ
GEN-BUSPIRONE
GEN-CAPTOPRIL
"
GEN-CIMETIDINE
"
"
GEN-CITALOPRAM
"
GEN-CLOBETASOL
"
GEN-CLOMIPRAMINE
GEN-CLONAZEPAM
GEN-COMBO STERINEBS
GEN-CYCLOBENZAPRINE (EDS)
GEN-CYPROTERONE (EDS)
GEN-DILTIAZEM
GEN-DOXAZOSIN
GEN-ETIDRONATE
GEN-FAMOTIDINE
GEN-FENOFIBR. MICRO
GEN-FLUCONAZOLE
GEN-FLUOXETINE
GEN-GABAPENTIN
GEN-GEMFIBROZIL
GEN-GLYBE
GEN-INDAPAMIDE
GEN-IPRATROPIUM
GEN-LOVASTATIN
GEN-MEDROXY
GEN-METFORMIN
"
Page
176
190
91
209
179
13
3
130
134
18
53
42
42
12
110
12
42
7
43
207
33
34
132
110
132
114
58
59
90
144
145
17
18
94
95
186
187
95
88
28
34
22
45
60
208
146
53
3
3
97
91
53
168
124
28
54
172
168
169
PRODUCT NAME
GEN-NABUMETONE (EDS)
GEN-NITRO SL SPRAY
GEN-NIZATIDINE
GEN-NORTRIPTYLINE
GEN-OXYBUTYNIN
GEN-PAROXETINE
"
GEN-PINDOLOL
"
GEN-PIROXICAM
GEN-PROPAFENONE
"
GEN-RANITIDINE
GEN-SALBUTAMOL RESPIR.SOL
"
GEN-SELEGILINE (EDS)
GEN-SERTRALINE
GEN-SIMVASTATIN
"
GEN-SOTALOL
GENTAMICIN
GENTAMICIN SO4
"
GENTAMICIN SO4/
BETAMETHASONE SODIUM
PHOSPHATE
GENTAMICIN SULFATE
GEN-TEMAZEPAM
GEN-TERBINAFINE
GEN-TICLOPIDINE (EDS)
GEN-TIMOLOL
GEN-TRAZODONE
GEN-TRIAZOLAM
GEN-VALPROIC
GEN-VERAPAMIL
GEN-VERAPAMIL SR
GEN-WARFARIN
"
GLATIRAMER ACETATE
GLUCAGON
GLUCAGON
GLUCOFILM
GLUCOLET FINGERSTIX
GLUCONORM (EDS)
GLUCOPHAGE
"
GLUCOSE OXIDASE/
PEROXIDASE REAGENT
GLUCOSE OXIDASE/
PEROXIDASE/SODIUM
NITROFERRICYANIDE/
GLYCINE REAGENT
GLUCOSE OXIDASE/
PEROXIDASE/SODIUM
NITROPRUSSIDE REAGENT
GLYBURIDE
GLYCON
GOSERELIN ACETATE
Page
47
10
78
71
147
99
198
99
100
48
49
79
49
50
148
31
30
31
215
100
55
56
51
3
3
130
134
130
113
4
39
139
101
113
93
69
69
37
38
209
209
209
118
220
169
168
169
119
119
119
168
168
209
308
PRODUCT NAME
GRAVOL
GRISEOFULVIN (ULTRA-FINE)
HALCINONIDE
HALCION
HALOBETASOL PROPIONATE
HALOG
HALOPERIDOL
HALOPERIDOL
HALOPERIDOL DECANOATE
HALOPERIDOL LA
HECTOROL (EDS)
HEPALEAN
HEPARIN
HEPTOVIR (EDS)
HEXACHLOROPHENE
HEXIT SHAMPOO
HIVID (EDS)
HOMATROPINE HYDROBROMIDE
HP-PAC (EDS)
HUMALOG (EDS)
HUMALOG MIX25 (EDS)
HUMATROPE (EDS)
HUMULIN 30/70
HUMULIN 30/70 CARTRIDGE
HUMULIN-L
HUMULIN-N
HUMULIN-N CARTRIDGE
HUMULIN-R
HUMULIN-R CARTRIDGE
HUMULIN-U
HYCORT
HYDERM
HYDRALAZINE HCL
HYDROCHLOROTHIAZIDE
HYDROCORTISONE
"
HYDROCORTISONE SODIUM
SUCCINATE
HYDROCORTISONE VALERATE
HYDROCORTISONE/UREA
HYDROMORPH CONTIN
HYDROMORPHONE HCL
HYDROMORPHONE HCL
HYDROMORPHONE HP 10
HYDROMORPHONE HP 20
HYDROMORPHONE HP 50
HYDROVAL
HYDROXYBUTYRATE
DEHYDROGENASE
HYDROXYCHLOROQUINE SO4
HYDROXYZINE
HYOSCINE BUTYLBROMIDE
HYTRIN
HYTRIN STARTER PACK
HYZAAR
HYZAAR DS
IBUPROFEN
IDARAC
Page
144
3
188
113
188
188
103
104
104
104
104
203
37
37
15
180
179
15
136
146
166
167
171
171
167
167
166
166
166
166
166
167
189
189
62
124
159
189
189
159
189
190
82
82
82
83
83
83
189
118
17
114
27
67
67
63
63
76
87
PRODUCT NAME
IMDUR
IMIPRAMINE
IMITREX (EDS)
IMODIUM
IMURAN
INDAPAMIDE
INDAPAMIDE HEMIHYDRATE
INDERAL
INDERAL-LA
INDINAVIR SO4
INDOCID
INDOMETHACIN
INFLAMASE FORTE
INFLIXIMAB
INFUFER (EDS)
INHIBACE
INHIBACE PLUS
INNOHEP (EDS)
INSULIN (ISOPHANE) HUMAN
BIOSYNTHETIC
INSULIN (ISOPHANE) PORK
INSULIN (LENTE) HUMAN
BIOSYNTHETIC
INSULIN (LENTE) PORK
INSULIN (REGULAR) ASPART
INSULIN (REGULAR) HUMAN
BIOSYNTHETIC
INSULIN (REGULAR) LISPRO
INSULIN (REGULAR) PORK
INSULIN (REGULAR/
ISOPHANE) HUMAN BIOSYNTHETIC
INSULIN (REGULAR/
PROTAMINE) LISPRO
INSULIN (ULTRALENTE)
HUMAN BIOSYNTHETIC
INTAL
INTAL SPINCAPS
INTERFERON ALFA-2A
INTERFERON ALFA-2B
INTERFERON ALFA-2B/
RIBAVIRIN
INTERFERON BETA-1A
INTERFERON BETA-1B
INTRON-A (EDS)
INVIRASE (EDS)
IODOCHLORHYDROXYQUIN/
FLUMETHASONE PIVALATE
IOPIDINE
IPRATROPIUM BROMIDE
"
IPRATROPIUM BROMIDE/
SALBUTAMOL SO4
IRBESARTAN
IRBESARTAN/
HYDROCHLOROTHIAZIDE
IRON DEXTRAN
IRON SUCROSE
ISOPROPYL ALCOHOL
ISOPTIN
ISOPTIN SR
ISOPTO ATROPINE
Page
70
98
33
142
207
124
124
50
50
16
77
76
133
209
36
59
59
37
166
166
166
166
166
166
166
166
167
167
167
216
216
22
22
209
210
210
22
16
134
137
28
137
28
62
62
36
36
220
69
69
136
309
PRODUCT NAME
ISOPTO CARBACHOL
ISOPTO CARPINE
ISOPTO HOMATROPINE
ISOSORBIDE DINITRATE
ISOSORBIDE-5 MONONITRATE
ISOTRETINOIN
ITRACONAZOLE
K-10
KADIAN
"
KALETRA (EDS)
KAYEXALATE
K-DUR
KENACOMB
KENACOMB MILD
KENALOG
KENALOG 10
KENALOG 40
KENALOG-ORABASE
KEPPRA
KETO DIASTIX
KETOCONAZOLE
"
KETODERM
KETOPROFEN
KETOROLAC TROMETHAMINE
KETOSTIX
KETOTIFEN FUMARATE
KINERET (EDS)
K-LOR
K-LYTE/CL
KWELLADA-P CREME RINSE
KWELLADA-P LOTION
LABETALOL HCL
LACTULOSE
LAMICTAL
LAMISIL
"
LAMIVUDINE
LAMOTRIGINE
LANCET
LANOXIN
LANSOPRAZOLE
LANSOPRAZOLE/
CLARITHROMYCIN/AMOXICILLIN
LARGACTIL
LASIX
LATANOPROST
LATANOPROST/TIMOLOL
MALEATE
LECTOPAM
LEFLUNOMIDE
LENTE ILETIN II, PORK
LESCOL
LEUCOVORIN (EDS)
LEUCOVORIN CALCIUM
(FOLINIC ACID)
LEUPROLIDE ACETATE
LEVAQUIN (EDS)
LEVETIRACETAM
Page
136
136
136
70
70
195
4
122
84
85
16
122
122
191
191
190
160
160
190
92
119
4
177
177
77
133
119
210
206
122
122
179
179
62
142
92
4
178
15
15
92
220
44
146
146
102
123
137
138
110
210
166
53
202
202
210
18
92
PRODUCT NAME
LEVOBUNOLOL HCL
LEVOBUNOLOL HCL/DIPIVEFRIN HCL
LEVOCABASTINE HYDROCHLORIDE
LEVODOPA/BENZERAZIDE
LEVODOPA/CARBIDOPA
LEVOFLOXACIN
LEVONORGESTREL
LEVOTHYROXINE (SODIUM)
LIDEMOL
LIDEX
LIFESCAN FINE POINT
LIN-AMOX
"
LIN-BUSPIRONE
LINEZOLID
LIN-FOSINOPRIL
LIN-MEGESTROL (EDS)
LIN-PRAVASTATIN
"
LINSOTALOL
LIORESAL
LIORESAL-DS
LIOTHYRONINE (SODIUM)
LIPIDIL-MICRO
LIPITOR
LISINOPRIL
LISINOPRIL/HYDROCHLOROTHIAZIDE
LITHIUM CARBONATE
LIVOSTIN
LOCACORTEN-VIOFORM
LODOXAMIDE TROMETHAMINE
LOESTRIN 1.5/30
LOMOTIL
LONITEN (EDS)
LOPERACAP
LOPERAMIDE HCL
LOPID
LOPINAVIR/RITONAVIR
LOPRESOR
LOPRESOR-SR
LOPROX
LORAZEPAM
LOSARTAN POTASSIUM
LOSARTAN POTASSIUM/
HYDROCHLOROTHIAZIDE
LOSEC (EDS)
LOTENSIN
LOTRIDERM
LOVASTATIN
LOVENOX (EDS)
LOVENOX HP (EDS)
LOXAPINE SUCCINATE
LOZIDE
LUMIGAN
LUPRON DEPOT (EDS)
LUVOX
"
LYDERM
M.O.S.
"
Page
138
138
138
211
211
18
163
173
188
188
220
7
8
114
11
61
23
54
55
51
33
34
34
173
53
52
63
63
115
138
134
138
162
142
64
142
142
53
16
47
47
177
112
63
63
147
57
190
54
36
36
104
124
137
210
97
98
188
84
85
310
PRODUCT NAME
M.O.S.-S.R.
MACROBID
MACRODANTIN
MANDELAMINE
MANERIX
MAPROTILINE
MARVELON
MAVIK
MAXALT (EDS)
MAXALT RPD (EDS)
MAXIDEX
MAXITROL
MEBENDAZOLE
MECLIZINE HCL
MEDISENSE THIN
MEDROL
MEDROXYPROGESTERONE ACETATE
MEFENAMIC ACID
MEGACE (EDS)
MEGACE OS (EDS)
MEGESTROL
MELOXICAM
MEPERIDINE HCL
MEPRON (EDS)
MERCAPTOPURINE
MESASAL
M-ESLON
"
MESTINON
MESTRANOL/NORETHINDRONE
METADOL (PALL CARE)
METFORMIN
METFORMIN
"
METHADONE HCL
METHAZOLAMIDE
METHENAMINE MANDELATE
METHIMAZOLE
METHOTREXATE
METHOTRIMEPRAZINE
METHOXSALEN
METHSUXIMIDE
METHYLDOPA
METHYLDOPA/
HYDROCHLOROTHIAZIDE
METHYLPHENIDATE HCL
METHYLPREDNISOLONE
METHYSERGIDE MALEATE
METOCLOPRAMIDE HCL
METOLAZONE
METOPROLOL TARTRATE
"
METROCREAM
METROGEL
METRONIDAZOLE
"
MEVACOR
MEXILETINE HCL
MIACALCIN (EDS)
Page
85
19
19
19
99
98
161
68
32
32
132
134
2
144
220
159
172
77
23
23
23
78
83
83
20
23
149
84
85
26
163
83
168
168
169
83
135
19
174
194
115
196
89
64
64
109
159
159
32
146
124
46
64
180
180
20
180
54
47
170
PRODUCT NAME
MICARDIS
MICARDIS PLUS
MICATIN
MICONAZOLE NITRATE
MICRO-K EXTENCAPS
MICROLET
MICRONOR
MIDAMOR
MIDODRINE HCL
MIGRANAL
MINESTRIN 1/20
MINIPRESS
MINITRAN 0.2
MINITRAN 0.4
MINITRAN 0.6
MINOCIN (EDS)
MINOCYCLINE HCL
MIN-OVRAL
MINOXIDIL
MIRAPEX
MIRENA
MIRTAZAPINE
MISOPROSTOL
MOBICOX (EDS)
MOCLOBEMIDE
MODAFINIL
MODECATE
MODECATE CONCENTRATE
MODURET
MOGADON
MOMETASONE FUROATE
MOMETASONE FUROATE
MONOHYDRATE
MONISTAT-3
MONISTAT-7
MONITAN
MONOCOR (EDS)
MONOJECT ALCOHOL SWAB
MONOJECT PLUS 29G
MONOLET ORIGINAL
MONOLET THIN
MONOPRIL
MONTELUKAST SODIUM
MONUROL (EDS)
MORPHINE
MORPHINE HP 50
MORPHINE SO4
MORPHINE SULPHATE
MOS-SULFATE
MOTRIN
MOXIFLOXACIN HCL
MS CONTIN
"
MSIR
MUCOMYST
MUPIROCIN
MYCOBUTIN (EDS)
MYCOPHENOLATE MOFETIL
Page
66
67
178
178
122
220
163
124
29
32
162
65
71
71
71
10
10
161
64
214
163
98
147
78
98
109
103
103
57
88
190
133
178
178
178
178
42
43
220
221
221
220
220
61
211
19
84
86
85
86
84
76
18
84
85
84
128
176
214
212
311
PRODUCT NAME
MYCOSTATIN
MYOCHRYSINE
MYSOLINE
NABILONE
NABUMETONE
NADOLOL
"
NADROPARIN CALCIUM
NAFARELIN ACETATE
NALCROM (EDS)
NAPROSYN
NAPROSYN-S.R.
NAPROXEN
NARATRIPTAN HCL
NARDIL
NASACORT AQ
NASONEX
NATEGLINIDE
NAVANE
NEDOCROMIL SO4
NEEDLE
NELFINAVIR MESYLATE
NEOMYCIN/GRAMICIDIN/NYSTATIN/
NEORAL (EDS)
"
NEOSPORIN
"
NEOSTIGMINE BROMIDE
NERISONE
NEULEPTIL
NEUPOGEN (EDS)
NEURONTIN
NEVIRAPINE
NEXIUM (EDS)
NIACIN
NIACIN
NIDAGEL
NIFEDIPINE
"
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
NORETHINDRONE
Page
178
152
87
212
78
47
64
37
212
216
79
79
78
32
100
133
133
169
107
212
220
16
2
191
195
208
130
176
26
187
105
39
91
13
145
202
202
180
48
64
70
70
216
88
88
71
71
71
71
19
19
71
71
71
71
179
179
147
177
163
PRODUCT NAME
NORFLOXACIN
NORITATE
NOROXIN (EDS)
NORPACE-CR
NORPRAMIN
"
NORTRIPTYLINE
NORVASC
NORVIR (EDS)
NORVIR SEC (EDS)
NOVAMILOR
NOVAMOXIN
"
NOVASEN
NOVO-5-ASA
NOVO-ACEBUTOLOL
NOVO-ALENDRONATE (EDS)
NOVO-ALPRAZOL
NOVO-AMIODARONE
NOVO-AMPICILLIN
NOVO-ATENOL
NOVO-AZATHIOPRINE
NOVO-BROMAZEPAM
NOVO-BUSPIRONE
NOVO-CAPTORIL
"
NOVO-CARBAMAZ
NOVO-CHLOROQUINE
NOVO-CHLORPROMAZINE
NOVO-CHOLAMINE
NOVO-CHOLAMINE LIGHT
NOVO-CIMETINE
"
NOVO-CITALOPRAM
"
NOVO-CLAVAMOXIN (EDS)
NOVO-CLINDAMYCIN
NOVO-CLOBAZAM
NOVO-CLOBETASOL
"
NOVO-CLONAZEPAM
NOVO-CLONIDINE
NOVO-CLOPATE
NOVO-CLOXIN
NOVO-CYCLOPRINE (EDS)
NOVO-CYPROTERONE (EDS)
NOVO-DIFENAC
"
NOVO-DIFENAC SR
"
NOVO-DIFLUNISAL
NOVO-DILTAZEM
NOVO-DILTAZEM CD
"
NOVO-DILTAZEM SR
NOVO-DIMENATE
NOVO-DIVALPROEX
"
NOVO-DOMPERIDONE
Page
19
180
19
46
95
96
99
43
16
16
57
7
8
74
149
42
206
110
42
9
43
207
110
114
58
59
90
44
17
102
52
52
145
17
18
94
95
8
11
90
186
187
88
60
111
9
34
22
74
75
74
75
75
45
45
46
45
144
90
91
145
312
PRODUCT NAME
NOVO-DOXAZOSIN
NOVO-DOXEPIN
NOVO-DOXYLIN
NOVO-FAMOTIDINE
NOVO-FENOFIB. MICRO
NOVOFINE 12MM
NOVOFINE 6MM
NOVOFINE 8MM
NOVO-FLUCONAZOLE
NOVO-FLUOXETINE
NOVO-FLURPROFEN
NOVO-FLUVOXAMINE
"
NOVO-FOSINOPRIL
NOVO-FURANTOIN
NOVO-GABAPENTIN
NOVO-GEMFIBROZIL
NOVO-GLYBURIDE
NOVO-HYDRAZIDE
NOVO-HYDROXYZIN
NOVO-HYLAZIN
NOVO-INDAPAMIDE
NOVO-IPRAMIDE
NOVO-KETO
NOVO-KETOCONAZOLE (EDS)
NOVO-LAMOTRIGINE
NOVO-LEVOBUNOLOL
NOVO-LEVOCARBIDOPA
NOVO-LEXIN
NOVOLIN GE 10/90 PENFILL
NOVOLIN GE 30/70
NOVOLIN GE NPH
NOVOLIN GE TORONTO
NOVO-LOPERAMIDE
NOVO-LORAZEM
NOVO-LOVASTATIN
NOVO-MAPROTILINE
NOVO-MEDRONE
NOVO-MEPRAZINE
NOVO-METFORMIN
"
NOVO-METHACIN
"
NOVO-METOPROL
NOVO-MEXILETINE
NOVO-MISOPROSTOL
NOVO-MOCLOBEMIDE
"
NOVO-NADOLOL
"
NOVO-NAPROX
"
NOVO-NAPROX SR
Page
60
96
10
146
53
220
220
220
3
3
97
76
97
98
61
19
91
53
168
124
114
62
124
28
77
4
210
92
138
211
5
167
167
167
167
167
166
166
142
112
54
98
172
115
168
169
76
77
47
47
47
10
147
98
99
78
47
48
78
79
79
PRODUCT NAME
NOVO-NIFEDIN
NOVO-NIZATIDINE
NOVO-NORFLOXACIN (EDS)
NOVO-NORTRIPTYLINE
NOVO-OXYBUTYNIN
NOVO-PAROXETINE
"
NOVO-PEN-VK
NOVO-PERIDOL
"
NOVO-PINDOL
"
NOVO-PIROCAM
NOVO-PRANOL
NOVO-PRAVASTATIN
"
NOVO-PRAZIN
NOVO-PREDNISONE
NOVO-PROFEN
NOVO-PROPAMIDE
NOVO-PUROL
NOVO-QUININE
NOVO-RANIDINE
NOVORAPID (EDS)
NOVO-SELEGILINE (EDS)
NOVO-SEMIDE
NOVO-SERTRALINE
NOVO-SIMVASTATIN
"
NOVO-SORBIDE
NOVO-SOTALOL
NOVO-SPIROTON
NOVO-SPIROZINE
NOVO-SUCRALATE
NOVO-SUNDAC
NOVO-TEMAZEPAM
NOVO-TERAZOSIN
NOVO-TERBINAFINE
NOVO-THEOPHYL SR
NOVO-TIAPROFENIC
NOVO-TICLOPIDINE (EDS)
NOVO-TIMOL
NOVO-TRAZODONE
NOVO-TRIAMZIDE
NOVO-TRIMEL
NOVO-TRIMEL DS
NOVO-VALPROIC
NOVO-VERAMIL SR
NOZINAN
NPH ILETIN II PORK
NU-ACEBUTOLOL
NU-ACYCLOVIR
NU-ALPRAZ
NU-AMILZIDE
NU-AMOXI
"
NU-AMPI
NU-ATENOL
NU-AZATHIOPRINE
Page
48
147
19
99
198
99
100
9
103
104
48
49
79
50
54
55
65
159
76
168
206
17
148
166
6
7
215
123
100
55
56
70
51
125
66
149
80
113
67
4
199
80
39
51
101
68
20
20
93
69
115
166
42
12
110
57
7
8
9
43
207
313
PRODUCT NAME
NU-BACLO
"
NU-BECLOMETHASONE
NU-BROMAZEPAM
NU-BUSPIRONE
NU-CAPTO
"
NU-CARBAMAZEPINE
NU-CARVEDILOL (EDS)
NU-CEPHALEX
NU-CIMET
"
NU-CITALOPRAM
"
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-FENO-MICRO
NU-FLUOXETINE
NU-FLURBIPROFEN
NU-FLUVOXAMINE
"
NU-FUROSEMIDE
NU-GABAPENTIN
NU-GEMFIBROZIL
NU-GLYBURIDE
NU-HYDRAL
NU-HYDRO
NU-IBUPROFEN
NU-INDAPAMIDE
NU-INDO
NU-IPRATROPIUM
NU-KETOCON (EDS)
NU-KETOTIFEN (EDS)
NU-LEVOCARB
NU-LORAZ
NU-LOVASTATIN
NU-LOXAPINE
NU-MEFENAMIC
NU-MEGESTROL (EDS)
NU-METFORMIN
"
Page
33
34
132
110
114
58
59
90
44
5
144
145
94
95
88
60
9
20
20
216
34
95
96
74
74
75
75
45
45
46
90
91
145
10
7
146
53
97
76
97
98
123
91
53
168
62
124
76
124
76
28
4
210
211
112
54
104
77
23
168
169
PRODUCT NAME
NU-METOCLOPRAMIDE
NU-METOP
NU-MOCLOBEMIDE
"
NU-NAPROX
"
NU-NIFED
NU-NIFEDIPINE-PA
NU-NIZATIDINE
NU-NORTRIPTYLINE
NU-OXYBUTYN
NU-PAROXETINE
"
NU-PENTOXIFYLLINE-SR
NU-PEN-VK
NU-PINDOL
"
NU-PIROX
NU-PRAVASTATIN
"
NU-PRAZO
NU-PROCHLOR
NU-PROPAFENONE
NU-PROPRANOLOL
NU-RANIT
NU-SALBUTAMOL
"
NU-SELEGILINE (EDS)
NU-SERTRALINE
NU-SIMVASTATIN
"
NU-SOTALOL
NU-SUCRALFATE
NU-SULFINPYRAZONE
NU-SULINDAC
NU-TEMAZEPAM
NU-TERAZOSIN
NU-TERBINAFINE
NU-TETRA
NU-TIAPROFENIC
NU-TICLOPIDINE (EDS)
NU-TIMOLOL
NU-TRAZODONE
NU-TRIAZIDE
NU-TRIMIPRAMINE
"
NUTROPIN (EDS)
NUTROPIN AQ (EDS)
NU-VALPROIC
NU-VERAP
NU-VERAP SR
NYADERM
NYSTATIN
"
OCTOSTIM (EDS)
OCTREOTIDE
OCUFEN (EDS)
OCUFLOX (EDS)
OESCLIM (EDS)
OFLOXACIN
Page
146
47
98
99
78
79
48
48
147
99
198
99
100
39
9
48
49
79
54
55
65
106
49
50
148
30
31
215
100
55
56
51
149
125
80
113
67
4
11
80
39
51
101
68
101
102
171
171
93
69
69
178
4
178
170
212
212
133
132
164
132
314
PRODUCT NAME
OGEN
OLANZAPINE
OLSALAZINE SODIUM
OMEPRAZOLE
OMEPRAZOLE MAGNESIUM
ONE TOUCH
ONE TOUCH ULTRA
ONE TOUCH ULTRA SOFT
ONE-ALPHA (EDS)
OPTIMYXIN PLUS
ORACORT DENTAL PASTE
ORAP
ORCIPRENALINE SO4
ORTHO 0.5/35
ORTHO 1/35
ORTHO 7/7/7
ORTHO-CEPT
ORTHO-NOVUM 1/50
OSTOFORTE
OVRAL
OXAZEPAM
OXCARBAZEPINE
OXPRENOLOL HCL
OXSORALEN (EDS)
OXSORALEN ULTRA (EDS)
OXTRIPHYLLINE
OXYBUTYN
OXYBUTYNIN CHLORIDE
OXYCODONE HCL
OXYCONTIN
OXYDERM
OXY-IR
PAMIDRONATE DISODIUM
PANCREASE
PANCREASE MT 10
PANCREASE MT 16
PANCREASE MT 4
PANCRELIPASE (LIPASE/
AMYLASE/PROTEASE)
PANECTYL
PANOXYL
PANOXYL-10
PANOXYL-15
PANOXYL-20
PANTOLOC (EDS)
PANTOPRAZOLE
PARIET (EDS)
PARLODEL
PARNATE
PAROXETINE HCL
PARSITAN
PAXIL
"
PCE
PEDIAPRED
PEDIAZOLE
PEGETRON (EDS)
PEGINTERFERON ALFA-2B
Page
165
105
147
147
147
118
118
220
203
130
190
106
30
162
162
162
161
163
203
161
112
92
29
64
196
196
199
198
198
86
86
193
86
213
213
142
143
143
142
142
216
193
193
193
193
148
148
148
207
101
99
26
99
100
6
159
20
213
23
PRODUCT NAME
PEGINTERFERON ALFA-2B/RIBAVIRIN
PENICILLAMINE
PENICILLIN V (BENZATHINE)
PENICILLIN V (POTASSIUM)
PENTASA
PENTAZOCINE
PENTOSAN POLYSULFATE SO4
PENTOXIFYLLINE
PEN-VEE
PEPCID
PERGOLIDE MESYLATE
PERICYAZINE
PERINDOPRIL ERBUMINE
PERINDOPRIL ERBUMINE/
INDAPAMIDE
PERMAX
PERMETHRIN
PERPHENAZINE
PERSANTINE (EDS)
PETHIDINE
PHENAZO
PHENAZOPYRIDINE
PHENELZINE SO4
PHENOBARBITAL
"
PHENYLBUTAZONE
PHENYTOIN
PHISOHEX
PHYLLOCONTIN
PHYLLOCONTIN-350
PILOCARPINE HCL
PILOPINE-HS
PIMECROLIMUS
PIMOZIDE
PINDOLOL
"
PINDOLOL/HYDROCHLOROTHIAZIDE
PIOGLITAZONE HCL
PIPORTIL L4
PIPOTIAZINE PALMITATE
PIROXICAM
PIVMECILLINAM HCL
PIZOTYLINE HYDROGEN MALATE
PLAN B
PLAQUENIL
PLAVIX (EDS)
PLENDIL
PMS-AMANTADINE
PMS-AMIODARONE
PMS-AMOXICILLIN
"
PMS-ATENOLOL
PMS-BACLOFEN
"
PMS-BENZTROPINE
PMS-BEZAFIBRATE (EDS)
PMS-BRIMONIDINE
PMS-BROMOCRIPTINE
PMS-BUSPIRONE
PMS-CAPTOPRIL
"
Page
213
154
9
9
149
87
213
39
9
146
213
105
65
65
213
179
105
70
83
191
191
100
87
109
79
89
180
198
198
136
136
195
106
48
65
65
169
106
106
79
9
32
163
17
39
61
12
42
7
8
43
33
34
26
52
137
207
114
58
59
315
PRODUCT NAME
PMS-CARBAMAZEPINE CHEWTAB
PMS-CEPHALEXIN
PMS-CHLORAL HYDRATE SYRUP
PMS-CHOLESTYRAMINE
PMS-CHOLESTYRAMINE LIGHT
PMS-CIMETIDINE
"
"
PMS-CITALOPRAM
"
PMS-CLOBAZAM
PMS-CLOBETASOL
"
PMS-CLONAZEPAM
PMS-CLONAZEPAM-R
PMS-CYCLOBENZAPRINE (EDS)
PMS-DESIPRAMINE
"
PMS-DESONIDE
PMS-DEXAMETHASONE
PMS-DEXAMETHASONE SOD PHO
PMS-DICLOFENAC
"
PMS-DICLOFENAC-SR
"
PMS-DIPIVEFRIN
PMS-DIVALPROEX
"
PMS-DOMPERIDONE
PMS-DOXAZOSIN
PMS-FENOFIBR. MICRO
PMS-FLAVOXATE (EDS)
PMS-FLUCONAZOLE
PMS-FLUOROMETHOLONE
PMS-FLUOXETINE
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-LAMOTRIGINE
PMS-LEVOBUNOLOL
Page
89
90
44
5
114
52
52
144
145
17
18
94
95
90
186
187
88
88
163
34
154
95
96
187
158
132
74
75
74
75
136
90
91
145
60
53
198
3
3
133
97
103
97
98
91
53
130
130
168
104
82
114
124
28
137
77
77
210
142
92
138
PRODUCT NAME
PMS-LINDANE
PMS-LOPERAMIDE
PMS-LOPERAMIDE HCL
PMS-LORAZEPAM
PMS-LOVASTATIN
PMS-LOXAPINE
PMS-MEFENAMIC ACID
PMS-MELOXICAM (EDS)
PMS-METFORMIN
"
PMS-METHYLPHENIDATE
PMS-METOCLOPRAMIDE
PMS-METOPROLOL-B
PMS-METOPROLOL-L
PMS-MIRTAZAPINE
PMS-MISOPROSTOL
PMS-MOCLOBEMIDE
PMS-MOMETASONE
"
PMS-NAPROXEN
PMS-NIZATIDINE
PMS-NORFLOXACIN (EDS)
PMS-NORTRIPTYLINE
PMS-NYSTATIN
PMS-OXTRIPHYLLINE
PMS-OXYBUTYNIN
PMS-PAROXETINE
"
PMS-PHENOBARBITAL
PMS-PINDOLOL
"
PMS-PIROXICAM
PMS-POLYTRIMETHOPRIM
PMS-POTASSIUM CHLORIDE
PMS-PRAVASTATIN
"
PMS-PREDNISOLONE
PMS-PROCYCLIDINE
PMS-PROPAFENONE
"
PMS-PROPRANOLOL
PMS-RANITIDINE
PMS-SALBUTAMOL
"
PMS-SALBUTAMOL RESP. SOL.
PMS-SELEGILINE (EDS)
PMS-SERTRALINE
PMS-SOD POLY SULF (120ML)
PMS-SODIUM CROMOGLYCATE
PMS-SOTALOL
PMS-SUCRALFATE
PMS-SULFASALAZINE
PMS-TEMAZEPAM
PMS-TERAZOSIN
Page
179
115
142
142
112
54
104
172
77
78
168
169
115
109
146
47
47
10
98
147
99
190
84
85
79
147
19
99
4
199
198
213
99
100
87
48
49
79
130
122
54
55
159
27
49
50
50
148
30
31
31
215
100
122
122
216
51
149
149
113
67
316
PRODUCT NAME
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-VERAPAMIL SR
PODOFILOX
POLYMYXIN B SO4/
BACITRACIN (ZINC)/NEOMYCIN SO4/
HYDROCORTISONE
"
POLYMYXIN B SO4/NEOMYCIN SO4/
BACITRACIN (ZINC)
DEXAMETHASONE
GRAMICIDIN
"
HYDROCORTISONE
POLYMYXIN B SO4/
TRIMETHOPRIM SO4
POLYTRIM
POTASSIUM CHLORIDE
POVIDONE-IODINE
PRAMIPEXOLE DIHYDROCHLORIDE
PRANDASE
PRAVACHOL
"
PRAVASTATIN
PRAZIQUANTEL
PRAZOSIN
PRECISION EASY
PRECISION PLUS
PRECISION THIN
PRECISION XTRA
PRECISION XTRA KETONE
PRED FORTE
PRED MILD
PREDNISOLONE SODIUM
PHOSPHATE
"
PREDNISONE
PREMARIN
PREM-ATENOLOL
"
PREM-FLUOXETINE
PREM-GABAPENTIN
PREM-GLYBURIDE
PREM-LOVASTATIN
PREM-METFORMIN
Page
4
199
107
80
39
139
131
101
108
93
93
93
11
69
194
134
191
176
134
130
176
134
130
130
122
180
214
167
54
55
54
2
65
118
118
220
118
118
133
133
133
133
159
159
163
43
17
18
97
91
168
54
168
PRODUCT NAME
PREM-METFORMIN
PREMPLUS
PREM-RANITIDINE
PREM-SIMVASTATIN
"
PREM-SOTALOL
PREM-SOTOLOL
PREM-TEMAZEPAM
PREM-TERBINAFINE
PRESTIGE
PREVACID (EDS)
PRIMIDONE
PRINIVIL
PRINZIDE
PROBENECID
PROBETA
PROCAINAMIDE HCL
PROCAN-SR
PROCHLORPERAZINE
PROCHLORPERAZINE MESYLATE
PROCYCLID
PROCYCLIDINE HCL
PROFASI HP (EDS)
PROGESTERONE (MICRONIZED)
PROGRAF (EDS)
PROLOPA
PROLOPRIM
PROMETRIUM (EDS)
PRONESTYL-SR
PROPADERM
PROPAFENONE HCL
PROPANTHEL
PROPANTHELINE BROMIDE
PROPINE
PROPOXYPHENE
PROPRANOLOL
"
"
PROPYLTHIOURACIL
PROPYL-THYRACIL
PROSCAR
PROSTIGMIN
PROTOPIC (EDS)
PROTROPIN (EDS)
PROVERA
PROZAC
PULMICORT NEBUAMP
PULMOZYME (EDS)
PURINETHOL (EDS)
PYRANTEL PAMOATE
PYRETHINS/PIPERONYL BUTOXIDE/
PETROLEUM DISTILLATE
PYRIDOSTIGMINE BROMIDE
PYRIDOXINE HCL
PYRIMETHAMINE
PYRVINIUM PAMOATE
QUESTRAN
QUESTRAN LIGHT
QUETIAPINE
QUIBRON-T/SR
Page
169
164
148
55
56
51
51
113
4
118
146
87
63
63
125
138
49
49
106
106
27
27
165
172
216
211
20
172
49
185
49
28
28
136
86
32
50
65
174
174
209
26
195
171
172
97
157
157
128
23
2
179
26
202
17
2
52
52
106
199
317
PRODUCT NAME
QUINAPRIL HCL
QUINAPRIL HCL/
HYDROCHLOROTHIAZIDE
QUINIDINE BISULFATE
QUINIDINE SO4
QUININE SO4
QUININE-ODAN
QVAR
R&C SHAMPOO/CONDITIONER
RABEPRAZOLE SODIUM
RALOXIFENE HCL
RAMIPRIL
RANITIDINE
RAPAMUNE (EDS)
RATIO-ACLAVULANATE(EDS)
RATIO-ACYCLOVIR
RATIO-ALPRAZOLAM
RATIO-AMCINONIDE
RATIO-AMIODARONE
RATIO-ATENOLOL
RATIO-AZATHIOPRINE
RATIO-BACLOFEN
"
RATIO-BECLOMETHASONE AQ.
RATIO-BRIMONIDINE
RATIO-BUSPIREX
RATIO-CAPTOPRIL
"
RATIO-CHLORPROMANYL-40
"
RATIO-CLINDAMYCIN
RATIO-CLOBAZAM
RATIO-CLOBETASOL
"
RATIO-CLONAZEPAM
RATIO-CODEINE
RATIO-CYCLOBENZAPRINE(EDS)
RATIO-DESIPRAMINE
"
RATIO-DEXAMETHASONE
RATIO-DILTIAZEM CD
"
RATIO-DIPIVEFRIN
RATIO-DOMPERIDONE
RATIO-DOXAZOSIN
RATIO-DOXEPIN
RATIO-DOXYCYCLINE
RATIO-ECTOSONE
RATIO-ECTOSONE MILD
RATIO-EMTEC
RATIO-FAMOTIDINE
RATIO-FLUNISOLIDE
RATIO-FLUOXETINE
RATIO-FLURBIPROFEN
RATIO-FLUVOXAMINE
"
RATIO-GEMFIBROZIL
RATIO-GLYBURIDE
Page
66
66
50
51
17
17
157
179
148
165
66
148
215
8
8
12
110
185
42
43
207
33
34
132
137
114
58
59
5
102
17
18
11
90
186
187
88
81
34
95
96
158
45
46
136
145
60
96
10
186
186
81
146
132
97
76
97
98
53
168
PRODUCT NAME
RATIO-HALOPERIDOL
"
RATIO-INDOMETHACIN
RATIO-IPRA SAL UDV
RATIO-IPRATROPIUM
"
RATIO-KETOROLAC (EDS)
RATIO-LACTULOSE (EDS)
RATIO-LAMOTRIGINE
RATIO-LENOLTEC #4
RATIO-LENOLTEC NO.2
RATIO-LENOLTEC NO.3
RATIO-LEVOBUNOLOL
RATIO-LOVASTATIN
RATIO-METFORMIN
"
RATIO-METHOTREXATE
RATIO-MOCLOBEMIDE
RATIO-MOMETASONE
RATIO-MORPHINE
RATIO-MORPHINE SR
"
RATIO-MPA
RATIO-NADOLOL
"
RATIO-NAPROXEN
RATIO-NORTRIPTYLINE
RATIO-NYSTATIN
"
RATIO-ORCIPRENALINE
RATIO-PAROXETINE
"
RATIO-PENTOXIFYLLINE
RATIO-PEPTOL
"
RATIO-PRAVASTATIN
"
RATIO-PREDNISOLONE
RATIO-RANITIDINE
RATIO-SALBUTAMOL
"
RATIO-SALBUTAMOL HFA
"
RATIO-SERTRALINE
RATIO-SIMVASTATIN
"
RATIO-SOTALOL
RATIO-SULFASALAZINE
RATIO-TEMAZEPAM
RATIO-TERAZOSIN
RATIO-TIMOLOL MALEATE
RATIO-TOPILENE
RATIO-TOPISALIC
RATIO-TOPISONE
RATIO-TRAZODONE
Page
103
104
76
28
28
137
28
133
142
92
81
81
81
138
211
54
78
168
169
194
109
10
99
190
85
84
85
172
47
48
78
99
4
178
30
99
100
39
144
145
54
55
133
148
30
31
30
30
31
100
55
56
51
149
113
67
139
185
186
185
101
318
PRODUCT NAME
RATIO-VALPROIC
REBETRON (EDS)
REBIF (EDS)
REGULAR ILETIN II, PORK
RELAFEN (EDS)
REMERON
REMICADE (EDS)
REMINYL (EDS)
RENAGEL (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
RHO-NITRO PUMPSPRAY
RHOTRAL
RHOTRIMINE
"
RHOXAL-AMIODARONE
RHOXAL-ATENOLOL
"
RHOXAL-CITALOPRAM
"
RHOXAL-CLONAZEPAM
RHOXAL-DILTIAZEM CD
"
RHOXAL-FAMOTIDINE
RHOXAL-FLUOXETINE
RHOXAL-FLUVOXAMINE
"
RHOXAL-GLYBURIDE
RHOXAL-LOPERAMIDE
RHOXAL-LOVASTATIN
RHOXAL-METFORMIN FC
"
RHOXAL-METOPROLOL L
RHOXAL-MIRTAZAPINE
RHOXAL-NABUMETONE (EDS)
RHOXAL-NITRAZEPAM
RHOXAL-PRAVASTATIN
"
RHOXAL-RANITIDINE
RHOXAL-SALBUTAMOL RES.SOL
RHOXAL-SERTRALINE
RHOXAL-SIMVASTATIN
"
RHOXAL-SOTALOL
Page
93
209
210
166
78
98
209
209
215
61
169
215
13
122
113
192
192
15
132
132
132
132
77
77
71
42
101
102
42
43
43
17
18
94
95
88
45
46
164
146
97
97
98
168
142
54
168
169
47
10
98
78
88
54
55
148
31
100
55
56
51
PRODUCT NAME
RHOXAL-TICLOPIDINE (EDS)
RHOXAL-TIMOLOL
RHOXAL-VALPROIC
RIDAURA
RIFABUTIN
RISEDRONATE SODIUM
RISPERDAL
RISPERDAL M-TAB
RISPERIDONE
RITALIN
RITALIN SR
RITONAVIR
RIVASTIGMINE
RIVOTRIL
RIZATRIPTAN BENZOATE
ROCALTROL (EDS)
ROFECOXIB
ROFERON-A (EDS)
ROPINIROLE HCL
ROSASOL
ROSIGLITAZONE MALEATE
ROSUVASTATIN CALCIUM
RYTHMODAN
RYTHMODAN-LA
RYTHMOL
"
SAB-CORTIMYXIN
SAB-DEXAMETHASONE
SAB-DICLOFENAC
SAB-GENTAMICIN
SAB-INDOMETHACIN
SAB-LEVOBUNOLOL
SAB-NAPROXEN
SAB-OPTICORT
SAB-PENTASONE
SAB-PREDNISOLONE
SAB-PROCHLOPERAZINE
SABRIL
SAB-TIMOLOL
SAB-TOBRAMYCIN (EDS)
SAFE-T-PRO
SAIZEN (EDS)
SALAZOPYRIN
SALBUTAMOL SO4
SALMETEROL XINAFOATE
SALMETEROL XINAFOATE/
SALOFALK
SANDOMIGRAN
SANDOMIGRAN DS
SANDOSTATIN (EDS)
SANS-ACNE
SANSERT (EDS)
SAQUINAVIR
SARNA HC
SCOPOLAMINE
SECOBARBITAL SODIUM
SECONAL
SECTRAL
Page
39
139
93
152
214
214
107
107
107
109
109
16
214
88
32
203
79
22
215
180
169
55
46
46
49
50
134
132
75
130
77
138
79
134
134
133
106
93
139
131
220
171
149
30
31
31
149
149
32
32
212
212
176
32
16
189
144
109
109
42
319
PRODUCT NAME
SELECT 1/35
SELEGILINE HCL
SELEXID (EDS)
SEPTRA D.S.
SERC
SEREVENT (EDS)
SEREVENT DISKUS (EDS)
SEROQUEL
SERTRALINE HYDROCHLORIDE
SEVELAMER HCL
SIBELIUM (EDS)
SIMVASTATIN
SINEMET
SINEMET CR
SINEQUAN
SINGULAIR (EDS)
SINTROM
SIROLIMUS
SLOW TRASICOR
SLOW-K
SODIUM CROMOGLYCATE
"
SODIUM FLUORIDE
SODIUM FUSIDATE
SODIUM NITROPRUSSIDE REAGENT
SODIUM POLYSTYRENE SULFONATE
SODIUM SULAMYD
SOFRACORT
SOFRA-TULLE
SOF-TACT
SOFTCLIX
SOFTCLIX PRO
SOLU-CORTEF
SOMATREM
SOMATROPIN
SORIATANE (EDS)
SOTACOR
SOTALOL HCL
SPIRIVA (EDS)
SPIRONOLACTONE
SPIRONOLACTONE/
HYDROCHLOROTHIAZIDE
SPORANOX (EDS)
STARLIX (EDS)
STATEX
"
"
STATICIN
STAVUDINE
STIEVA-A
STIEVA-A FORTE (EDS)
SUCRALFATE
SULCRATE
SULCRATE SUSPENSION PLUS
SULFACETAMIDE (SODIUM)
SULFACETAMIDE (SODIUM)/
COLLOIDAL SULPHUR
SULFACETAMIDE SODIUM/
Page
162
215
9
20
70
31
31
106
100
215
32
55
211
211
96
211
36
215
64
122
152
152
138
216
216
176
119
122
131
134
176
118
220
220
159
171
171
194
51
51
28
125
66
4
169
84
85
86
176
15
192
192
149
149
149
131
180
135
PRODUCT NAME
SULFACET-R
SULFAMETHOXAZOLE/
TRIMETHOPRIM
(CO-TRIMOXAZOLE)
SULFASALAZINE
(SALICYLAZOSULFAPYRIDINE)
SULFINPYRAZONE
"
SULINDAC
SUMATRIPTAN
SUPRAX (EDS)
SUPREFACT (EDS)
SURESTEP
SURGAM
SURMONTIL
SUSTIVA (EDS)
SYMMETREL
SYNACTHEN DEPOT
SYNALAR
SYNALAR REGULAR
SYNAREL (EDS)
SYNPHASIC
SYNTHROID
SYRINGE
TACROLIMUS
"
TALWIN
TAMBOCOR
TAMSULOSIN HCL
TAPAZOLE
TARO-CARBAMAZEPINE
TARO-SONE
TARO-WARFARIN
"
TAZAROTENE
TAZORAC
TEGRETOL
"
TEGRETOL CR (EDS)
TELMISARTAN
TELMISARTAN/
HYDROCHLOROTHIAZIDE
TEMAZEPAM
TENORETIC
TENORMIN
TEQUIN (EDS)
TERAZOL-3
TERAZOL-3 DUAL-PAK
TERAZOL-7
TERAZOSIN HCL
TERBINAFINE HCL
"
TERBUTALINE SO4
TERCONAZOLE
TESTOSTERONE ENANTHATE
TESTOSTERONE UNDECANOATE
TETRABENAZINE
Page
180
20
149
38
125
80
33
4
207
118
80
101
13
29
12
170
188
188
212
162
173
221
195
216
87
46
216
174
89
90
185
37
38
196
196
89
90
90
66
67
113
57
43
18
179
179
179
67
4
178
31
179
160
160
160
160
216
320
PRODUCT NAME
TETRACYCLINE
TEVETEN
THEOCHRON
THEOLAIR LIQUID
THEOPHYLLINE (ANHYDROUS)
THIAMIJECT
THIAMINE HCL
THIORIDAZINE
THIOTHIXENE
THYROID
THYROID
TIAPROFENIC ACID
TIAZAC
"
TICLID (EDS)
TICLOPIDINE HCL
TILADE
TIMOLOL MALEATE
"
"
TIMOLOL MALEATE/
PILOCARPINE HYDROCHLORIDE
TIMOPTIC
TIMOPTIC-XE
TIMPILO
TINZAPARIN SODIUM
TIOTROPIUM BROMIDE
MONOHYDRATE
TIZANIDINE HCL
TOBI (EDS)
TOBRADEX (EDS)
TOBRAMYCIN
"
TOBRAMYCIN/DEXAMETHASONE
TOBREX (EDS)
TOFRANIL
TOLBUTAMIDE
TOLTERODINE L-TARTRATE
TOPAMAX
TOPICORT
TOPICORT MILD
TOPIRAMATE
TOPSYN
TRACLEER (EDS)
TRANDATE
TRANDOLAPRIL
TRANSDERM-NITRO 0.2
TRANSDERM-NITRO 0.4
TRANSDERM-NITRO 0.6
TRANSDERM-V
TRANYLCYPROMINE SO4
TRASICOR
TRAVATAN
TRAVOPROST
TRAZODONE
TRAZOREL
TRENTAL
TRETINOIN
TRIADERM
"
Page
11
61
199
199
199
203
203
107
107
173
173
80
45
46
39
39
212
51
67
139
139
139
139
139
37
28
34
3
135
3
131
135
131
98
170
198
93
187
187
93
188
207
62
68
71
71
71
144
101
64
139
139
101
101
39
192
190
133
160
PRODUCT NAME
TRIAMCINOLONE HEXACETONIDE
TRIAMTERENE/
HYDROCHLOROTHIAZIDE
TRIAZOLAM
TRI-CYCLEN
TRIDESILON
TRIFLUOPERAZINE
TRIFLURIDINE
TRIHEXYPHENIDYL HCL
TRILEPTAL (EDS)
TRIMEPRAZINE TARTRATE
TRIMETHOPRIM
TRIMIPRAMINE
TRINIPATCH 0.2
TRINIPATCH 0.4
TRINIPATCH 0.6
TRIPHASIL
TRIQUILAR
TRIZIVIR (EDS)
TRUSOPT
T-STAT
TYLENOL WITH CODEINE ELX
ULTICARE 29G
ULTICARE 30G
ULTRADOL (EDS)
ULTRAMOP (EDS)
ULTRASE MS4
ULTRASE MT12
ULTRASE MT20
ULTRAVATE (EDS)
UNIDET (EDS)
UNIFINE
UNIPHYL
UNITRON PEG (EDS)
UREMOL-HC
URISPAS (EDS)
URSO (EDS)
URSO DS (EDS)
URSODIOL
VAGIFEM
VALACYCLOVIR
VALCYTE (EDS)
VALDECOXIB
VALGANCICLOVIR HCL
VALISONE
VALIUM
VALPROATE SODIUM
VALPROIC ACID
VALSARTAN
VALSARTAN/
HYDROCHLOROTHIAZIDE
VALTREX
VANCOCIN (EDS)
VANCOMYCIN HCL
VANQUIN
VASERETIC
Page
190
160
160
68
113
163
187
108
131
27
92
216
20
101
71
71
71
161
161
14
135
176
81
81
81
81
221
221
75
196
142
143
143
188
198
220
199
23
190
198
217
217
217
164
13
13
80
13
186
111
93
93
68
68
13
11
11
2
61
321
PRODUCT NAME
VASOCIDIN
VASOTEC
VENLAFAXINE HCL
VENOFER (EDS)
VENTODISK
VENTOLIN
"
VENTOLIN RESPIRATOR SOLN.
VERAPAMIL HCL
"
VERMOX
VIADERM-KC
VIBRAMYCIN
VIBRA-TABS
VIDEX (EDS)
VIDEX EC (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
VIVOL
VOLTAREN
"
VOLTAREN OPHTHA (EDS)
VOLTAREN-SR
"
WARFARIN
WARTEC
WEBCOL ALCOHOL PREP
WELLBUTRIN SR (EDS)
WESTCORT
WINPRED
XALACOM
XALATAN
XANAX
XATRAL
ZADITEN (EDS)
ZAFIRLUKAST
ZALCITABINE
ZANAFLEX (EDS)
ZANTAC
ZARONTIN
ZAROXOLYN
ZERIT (EDS)
ZESTORETIC
ZESTRIL
ZIAGEN (EDS)
Page
135
61
102
36
30
30
30
31
31
51
69
2
191
10
10
14
14
93
143
79
16
13
131
65
48
49
202
202
192
192
203
202
202
203
111
74
75
137
74
75
37
194
220
94
189
159
138
137
110
206
210
217
15
34
148
89
124
15
63
63
14
PRODUCT NAME
ZIDOVUDINE
ZITHROMAX (EDS)
ZOCOR
"
ZOLADEX (EDS)
ZOLMITRIPTAN
ZOLOFT
ZOMIG (EDS)
ZOMIG RAPIMELT (EDS)
ZOVIRAX
ZOVIRAX WELLSTAT PAC
ZOVIRAX ZOSTAB PAC
ZUCLOPENTHIXOL ACETATE
ZUCLOPENTHIXOL DECANOATE
ZUCLOPENTHIXOL
DIHYDROCHLORIDE
ZYLOPRIM
ZYPREXA (EDS)
ZYPREXA ZYDIS (EDS)
ZYVOXAM (EDS)
Page
15
6
55
56
209
33
100
33
33
12
12
12
108
108
108
206
105
105
11
322
FORMULARY UPDATES
Formulary Updates
1
Please place update sticker here
2
324
3
4
325
Formulary Updates
Formulary Updates
5
6
326
7
8
327
Formulary Updates
Formulary Updates
9
10
328
11
12
329
Formulary Updates
Formulary Updates
13
14
330
15
16
331
Formulary Updates
Formulary Updates
17
18
332
19
20
333
Formulary Updates
Formulary Updates
21
22
334
23
24
335
Formulary Updates
Formulary Updates
25
26
336
27
28
337
Formulary Updates
Formulary Updates
29
30
338
31
32
339
Formulary Updates
Formulary Updates
33
34
340
35
36
341
Formulary Updates
Formulary Updates
37
38
342
39
40
343
Formulary Updates
UPDATE INDEX
A
Update Index
B
346
C
Update Index
D
347
E
Update Index
F
348
G
Update Index
H
349
I
Update Index
J
350
K
Update Index
L
351
M
Update Index
N
352
TABLE OF CONTENTS
SUPPLEMENTARY INFORMATION
TABLE OF CONTENTS
(SUPPLEMENTARY INFORMATION)
Note: This section is provided for information purposes only.
Documents contained in this section are not
part of the Formulary or the Drug Plan.
HOSPITAL BENEFIT DRUG LIST..................................................................................... .
TIPS ON PRESCRIPTION WRITING................................................................…………….
PRESCRIPTION REGULATIONS.............................................................. .
GUIDELINES FOR REPORTING ADVERSE REACTIONS.....................................……… .
TRIPLICATE PRESCRIPTION PROGRAM....................................................................... .
ii
2
36
38
42
46
HOSPITAL BENEFIT DRUG LIST
HOSPITAL BENEFIT DRUG LIST
July 2004
NOTIFICATION OF UPDATES TO THE HOSPITAL BENEFIT DRUG LIST
WILL BE PROVIDED IN THE DRUG PLAN UPDATE BULLETINS
PLEASE DIRECT INQUIRIES REGARDING THIS LIST TO:
(306) 787- 6823
2
1.
This list of drug benefits under Saskatchewan Health is supplementary to the annual
th
Saskatchewan Formulary (54 Edition, July 2004). It is intended to expand on the
Formulary as required to meet the special requirements of hospitals and health
centers.
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
Saskatchewan Drug Quality Assessment Committee; the Saskatchewan Association
of Health Organizations and officials from the Department of Health.
3.
In summary, the government is accepting the following items as insured benefits
when administered to patients in hospital and/or health centers. Institutional
formularies put in place by Regional Health Authorities and affiliates may affect the
availability of some insured drugs:
(a)
All products listed in the Saskatchewan Formulary. (Brands other than
those listed are not considered as interchangeable.)
(b)
Unlisted strengths of products included in the Saskatchewan Formulary or
approved for Exception Drug Status coverage (see item 5). [This applies
only to brands manufactured by the same supplier(s).]
(c)
Generally accepted nursing treatments, agents such as antiseptics,
disinfectants, mouthwashes, lozenges, lubricants, soaps and emollients.
(d)
All diagnostic agents.
(e)
All irrigating solutions.
(f)
All radioactive agents.
(g)
All injectable vitamins and injectable multivitamin preparations when used
to maintain or attain nutritional status.
(h)
Alcoholic beverages such as beer, stout, brandy and whiskey.
(i)
All dietary supplements.
(j)
All antacids and laxatives marketed by approved manufacturers.
(k)
All hemostatic agents.
(l)
All agents appearing on the attached supplemental list including all dosage
forms and strengths unless otherwise indicated in the list. Prolonged
release, sustained release, and delayed release dosage forms are benefits
only when specifically listed.
(m) New dosage forms, drug entities and other products released on the
market after the effective date of this list are not insured hospital/health
center benefits. They may be charged to hospital or health center clients
until reviewed and approved as an insured benefit by the Saskatchewan
Formulary Committee or the Advisory Committee on Institutional
Pharmacy Practice.
3
4.
Formularies established by Regional Health Authorities and affiliates may not include
all insured items. If an insured drug is not included in a health region/affiliate
formulary, its provision will be subject to Regional Health Authority/affiliate 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 or health center, 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 or health center, it will be recognized as
an inpatient benefit providing the patient's case meets the eligibility criteria listed in
the Saskatchewan Formulary. The drugs eligible for such coverage and the criteria
for patient eligibility are published in the Saskatchewan Formulary as Appendix A.
7.
Certain products are benefits only when used according to specific criteria. The
usage criteria or restrictions that apply are shown for each product. When these
products are ordered, the ordering physician and/or the pharmacist must determine if
the conditions for coverage have been met. When the conditions are met, the
patient receives the drug as a benefit. The cost is absorbed by the health region or
affiliate. The region/affiliate 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.
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. Toxoids and Vaccines are to be provided by health regions and affiliates according to
supply and guidelines established by Saskatchewan Health and Canadian Blood
Services. Other such products will be reviewed and recommended for approval on a
case by case basis by the health regions and affiliates. Serums are listed in Section
80:00.00.
12. EprexTM, InfuferTM 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, InfuferTM and VenoferTM for
inpatient use is the responsibility of the health region or affiliate.
Payment Policy Statement:
•
The Drug Plan will reimburse hospital pharmacies the actual acquisition cost
TM
TM
TM
(AAC) of the dose of Eprex , Infufer or Venofer that is administered plus a
4
10% mark-up for each month’s supply. The mark-up will be capped at $20.00
per month, unless there are dosage changes.
How to bill the Drug Plan:
•
To ensure consistency in billing for these agents, hospital pharmacy
departments are asked to use specific billing forms to submit claims. Please
contact (306) 787-3315 or toll free 1-800-667-7578 with any questions.
5
TABLE OF CONTENTS
04:00.00
ANTIHISTAMINE AGENTS
10
08:00.00
10
08:12.00
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
MACROLIDES
08:12.16
PENICILLINS
08:12.28
MISCELLANEOUS ANTIBIOTICS
10
10
10
10
11
11
11
11
12
08:16.00
ANTITUBERCULOSIS AGENTS
12
08:18.00
ANTIVIRALS
12
QUINOLONES
13
08:22.00
08:40.00
MISCELLANEOUS ANTI INFECTIVES
13
10:00.00
ANTINEOPLASTIC AGENTS (Agents used for non-cancer indications. See
the Formulary of the Saskatchewan Cancer Foundation for a complete listing
13
of antineoplastic agents.)
12:00.00
AUTONOMIC DRUGS
12:04.00
13
PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS
13
12:08.00
ANTICHOLINERGIC AGENTS
12:08.08
ANTIMUSCARINIC/ANTISPASMODICS
13
13
12:12.00
SYMPATHOMIMETIC (ADRENERGIC) AGENTS
14
12:16.00
SYMPATHOLYTICS
14
12:20.00
SKELETAL MUSCLE RELAXANTS
14
20:00.00
14
20:04.00
ANTIANEMIA DRUGS
20:04.04
IRON PREPARATIONS
14
14
20:12.00
COAGULANTS AND ANTICOAGULANTS
20:12.04
ANTICOAGULANTS
20:12.08
ANTIHEPARIN AGENTS
20:12.16
HEMOSTATICS
15
15
15
15
20:40.00
16
THROMBOLYTIC AGENTS
6
24:00.00
16
24.04.00
CARDIAC DRUGS
16
24:08.00
HYPOTENSIVE AGENTS
17
24:12.00
VASODILATING AGENTS
17
28:00.00
28:04.00
17
17
GENERAL ANESTHETICS
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
17
17
18
18
18
28:10.00
18
OPIATE ANTAGONISTS
28:12.00
ANTICONVULSANTS
28:12.12
HYDANTOINS
28:12.92
MISCELLANEOUS ANTICONVULSANTS
18
18
18
28:16.00
PSYCHOTHERAPEUTIC AGENTS
18
28:20.00
RESPIRATORY AND CEREBRAL STIMULANTS
18
28:24.00
ANXIOLYTICS, SEDATIVES AND HYPNOTICS
28:24.04
BARBITURATES
28:24.08
BENZODIAZEPINES
28:24.92
MISCELLANEOUS ANXIOLYTICS, SEDATIVES, HYPNOTICS
36:00.00
36:56.00
40:00.00
18
19
19
19
19
DIAGNOSTIC AGENTS
19
MYASTHENIA GRAVIS
ELECTROLYTIC, CALORIC AND WATER BALANCE
19
40:08.00
ALKALINIZING AGENTS
19
40:12.00
ELECTROLYTE AND FLUID REPLACEMENT
19
40:20.00
CALORIC AGENTS
20
40:28.00
DIURETICS
20
48:00.00
ANTITUSSIVES, EXPECTORANTS AND MUCOLYTIC AGENTS
20
48:08.00
ANTITUSSIVES
20
48:16.00
EXPECTORANTS
20
48:24.00
MUCOLYTIC AGENTS
20
52:00.00
EYE, EAR, NOSE AND THROAT PREPARATIONS
7
21
52:04.00
ANTI-INFECTIVES
52:04.04
ANTIBIOTICS
21
21
52:16.00
LOCAL ANESTHETICS
21
52:20.00
MIOTICS
21
52:24.00
MYDRIATICS
21
52:32.00
VASOCONSTRICTORS
21
52:36.00
MISCELLANEOUS EYE, EAR, NOSE AND THROAT DRUGS
21
56:00.00
22
56:04.00
ANTACIDS AND ADSORBENTS
22
56:08.00
ANTIDIARRHEA AGENTS
22
56:12.00
CATHARTICS AND LAXATIVES
22
56:20.00
EMETICS
22
56:22.00
ANTIEMETICS
22
56:40.00
MISCELLANEOUS GASTROINTESTINAL DRUGS
23
64:00.00
23
68:00.00
HORMONES AND SYNTHETIC SUBSTITUTES
23
68:04.00
ADRENALS
23
68:08.00
ANDROGENS
23
68:28.00
PITUITARY
23
72:00.00
LOCAL ANESTHETICS
23
76:00.00
OXYTOCICS
24
80:00.00
SERUMS, TOXOIDS AND VACCINES
24
80:04.00
SERUMS
24
80:08.00
TOXOIDS
25
80:12.00
VACCINES
25
84:00.00
SKIN AND MUCOUS MEMBRANE AGENTS
84:04.00
ANTI INFECTIVES
84:04.04
ANTIBIOTICS
84:04.08
ANTIFUNGALS
84:04.16
MISCELLANEOUS LOCAL ANTI-INFECTIVES
8
25
25
25
25
25
84:08.00
ANTIPRURITICS AND LOCAL ANESTHETICS
26
84:24.00
EMOLLIENTS, DEMULCENTS AND PROTECTANTS
84:24.12
BASIC CREAMS, OINTMENTS AND PROTECTANTS
84:24.16
BASIC POWDERS AND DEMULCENTS
26
26
26
84:36.00
MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS
26
84:40:00
HEMORRHOID PREPARATIONS
26
88:00.00
88:16.00
92:00.00
26
VITAMINS
26
VITAMIN D
APPENDIX I: PROCEDURES FOR OBTAINING DRUGS PROVIDED UNDER
PROVINCIAL PROGRAMS
9
27
29
04:00.00
ANTIHISTAMINE AGENTS
CYPROHEPTADINE
Tablet 4mg
Syrup 0.4mg/mL
DIPHENHYDRAMINE (injection only)
Injection 50mg/mL
PROMETHAZINE
Injection 25mg/mL
08:00.00
08:12.00
08:12.02
ANTIBIOTICS
AMINOGLYCOSIDES
AMIKACIN
Injection 250mg/mL
TOBRAMYCIN
Injection 10mg/mL, 40mg/mL
08:12.04
ANTIFUNGALS
AMPHOTERICIN B
Injection 50mg
AMPHOTERICIN B LIPID COMPLEX INJECTION (Abelcet) and
LIPOSOMAL AMPHOTERICIN B (AmBisome)
Restricted Coverage: When used in consultation 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 baseline 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).
CASPOFUNGIN ACETATE
Restricted coverage: when administered in consultation with an infectious disease
specialist.
Injection 50mg, 70mg
FLUCONAZOLE
Restricted Coverage: Injection
Injection 2mg/mL
FLUCYTOSINE (Health Canada - Special Access Programme)
Injection 1g, 5g, 10g
Capsules 500mg
08:12.06
CEPHALOSPORINS
CEFAZOLIN
Injection 500mg, 1g
CEFOTAXIME
10
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
CEFOTETAN
Injection 1g, 2g
CEFOXITIN SODIUM
Injection 1g, 2g
CEFTAZIDIME
CEFTRIAXONE
CEFUROXIME (see Appendix A – Saskatchewan Health Drug Plan Formulary)
Injection 750mg, 1.5g
CEPHALOTHIN
Injection
08:12.07
MISCELLANEOUS BETA LACTAM ANTIBIOTICS
ERTAPENEM
Restricted coverage: For the treatment of severe infections on the recommendation
of an infectious disease specialist, internist or microbiologist.
Injection 1g
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
MEROPENEM
Restricted Coverage: For the treatment of severe infections on the recommendation
of an infectious disease specialist; internist or medical microbiologist.
Injection
08:12.08
CHLORAMPHENICOL
CHLORAMPHENICOL
Injection 1g
08:12.12
MACROLIDES
AZITHROMYCIN (see Appendix A - Saskatchewan Health Drug Plan Formulary)
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
11
recommendation of an infectious disease specialist; internist or medical
microbiologist.
Injection 2g/0.25g; 3g/0.375g; 4g/0.5g
TICARCILLIN
Injection 3g
08:12.28
MISCELLANEOUS ANTIBIOTICS
BACITRACIN STERILE
Vial 50,000 units
POLYMYXIN B SULFATE (injection only) (Health Canada - Special Access
Programme)
TM
QUINUPRISTIN/DALFOPRISTIN (Synercid )
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.
Injection
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 (Health Canada - Special Access Programme)
Injection 24mg/mL
GANCICLOVIR (see Appendix A - Saskatchewan Health Drug Plan 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
12
08:22.00
QUINOLONES (see Appendix A - Saskatchewan Health Drug Plan
Formulary)
CIPROFLOXACIN
Injection 10mg/mL
GATIFLOXACIN
Injection 10 mg/mL
LEVOFLOXACIN
MOXIFLOXACIN
Injection, 400mg
08:40.00
LINEZOLID (see Appendix A - Saskatchewan Health Drug Plan Formulary)
Injection
PENTAMIDINE ISETHIONATE
Injection
Oral inhalation solution 300mg
10:00.00
ANTINEOPLASTIC AGENTS (Agents used for non-cancer indications.
See the 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
12:04.00
AUTONOMIC DRUGS
PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS
EDROPHONIUM
Injection 10mg/mL
NEOSTIGMINE
Injection 0.5mg/mL (1:2000), 1mg/mL (1:1000)
Injection 2.5mg/mL (5mL)
12:08.00
12:08.08
ANTICHOLINERGIC AGENTS
HYOSCINE BUTYLBROMIDE Also known as SCOPOLAMINE BUTYLBROMIDE
13
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
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)
NOREPINEPHRINE
Injection 1mg/mL
PHENYLEPHRINE
Injection 10mg/mL
PSEUDOEPHEDRINE
Tablet 60mg
Syrup 6mg/mL
12:16.00
SYMPATHOLYTICS
PHENTOLAMINE MESYLATE
Injection
12:20.00
SKELETAL MUSCLE RELAXANTS
ATRACURIUM BESYLATE
Injection 10mg/mL (5mL, 10mL)
GALLAMINE TRIETHIODIDE
PANCURONIUM
Injection 2mg/mL
ROCURONIUM
SUCCINYLCHOLINE
Injection 20mg/mL
VECURONIUM
Injection 10mg
20:00.00
20:04.00
20:04.04
ANTIANEMIA DRUGS
IRON PREPARATIONS
FERROUS FUMARATE
Capsule
FERROUS GLUCONATE
Tablet
14
FERROUS SULPHATE
Tablet
Syrup
Oral drops
Oral solution
IRON DEXTRAN
Injection 50mg/mL elemental iron
20:12.00
20:12.04
COAGULANTS AND ANTICOAGULANTS
ANTICOAGULANTS
DALTEPARIN
Restricted Coverage: See Appendix A - Saskatchewan Health Drug Plan Formulary.
For in-hospital treatment of acute coronary syndrome to a maximum of eight (8)
days.
Injection
DANAPAROID
Restricted Coverage: For treatment of heparin-induced thrombocytopenia.
Injection
ENOXAPARIN
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
days.
Injection
20:12.08
ANTIHEPARIN AGENTS
PROTAMINE SULPHATE
Injection 10mg/mL
20:12.16
HEMOSTATICS
AMINOCAPROIC ACID
Tablet 500mg
Injection 250mg/mL
ANTIHEMOPHILIC FACTOR VIII (HUMAN)
APROTININ
Injection 10,000 Kallikrein Inhibitory Units/mL
FACTOR IX
THROMBIN
Powder 5000 unit, 10000 unit vials
TRANEXAMIC ACID
Injection 100mg/mL
15
20:40.00
THROMBOLYTIC AGENTS
STREPTOKINASE
Injection 250,000 IU, 750000 IU, 1.5 million IU
TENECTEPLASE (TNK)
Restricted Coverage: For the treatment of patients with:
larger acute myocardial infarction and presenting within twelve (12) hours;
high risk inferior wall myocardial infarctions;
patients with significant hypotension or cardiogenic shock.
Injection
ALTEPLASE (TISSUE PLASMINOGEN ACTIVATOR or tPA)
a) for the treatment of patients with:
larger acute myocardial infarction and presenting within twelve (12) hours.
high risk inferior wall myocardial infarctions.
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.
c) Injection, powder for solution, 2mg/vial (Cathflo)
For correction of catheter occlusions.
24:00.00
24.04.00
CARDIAC DRUGS
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
AMIODARONE HCl
Injection 50mg/mL
BRETYLIUM TOSYLATE
Injection 50mg/mL
DIGOXIN
Injection 0.05mg/mL (1mL), 0.25mg/mL (2mL)
DILTIAZEM
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.
MILRINONE
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
pressures and systemic vascular resistance.
16
PROCAINAMIDE
24:08.00
HYPOTENSIVE AGENTS
LABETALOL
Injection 5mg/mL
SODIUM NITROPRUSSIDE
Injection 50mg
24:12.00
VASODILATING AGENTS
ALPROSTADIL
Injection 0.5mg/mL
NIMODIPINE
NITROGLYCERIN
PAPAVERINE
28:00.00
28:04.00
GENERAL ANESTHETICS
DESFLURANE
Inhalation solution 1mL/mL (240mL)
ENFLURANE
Solution 250mL
HALOTHANE
Solution 250mL
ISOFLURANE
Solution 100mL
KETAMINE
PROPOFOL
Injection 10mg/mL (20mL, 50mL, 100mL)
SEVOFLURANE
Solution 250mL
THIOPENTAL
Injection kit 1 g kit and 500mg /2.5% kit
28:08.00
28:08.04
ANALGESICS AND ANTIPYRETICS
NON-STEROIDAL ANTI-INFLAMMATORY AGENTS
Tablet
Enteric coated tablet
Suppository
17
28:08.08
OPIATE AGONISTS
ALFENTANIL
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
28:12.00
28:12.12
ANTICONVULSANTS
HYDANTOINS
FOSPHENYTOIN
Restricted coverage: for the treatment of status epilepticus.
Injection 25mg (50 PE)
28:12.92
MISCELLANEOUS ANTICONVULSANTS
MAGNESIUM SULFATE
Injection 50mg/mL
28:16.00
PSYCHOTHERAPEUTIC AGENTS (see the Saskatchewan Formulary)
28:20.00
RESPIRATORY AND CEREBRAL STIMULANTS
DOXAPRAM (FDA – Special Access Program)
Restricted Coverage: When used for approved indications.
28:24.00
ANXIOLYTICS, SEDATIVES AND HYPNOTICS
18
28:24.04
BARBITURATES (see the Saskatchewan Formulary)
28:24.08
BENZODIAZEPINES
MIDAZOLAM
Injection 1mg/mL (2mL, 5mL, 10mL), 5mg/mL (1mL, 2mL, 10mL)
28:24.92
MISCELLANEOUS ANXIOLYTICS, SEDATIVES, HYPNOTICS
DROPERIDOL
Injection 2.5mg/mL
PARALDEHYDE
Injection 5mL ampoule (1mL is equivalent to approximately 1g)
36:00.00
36:56.00
DIAGNOSTIC AGENTS
MYASTHENIA GRAVIS
EDROPHONIUM
Injection 10mg/mL
40:00.00
40:08.00
ELECTROLYTIC, CALORIC AND WATER BALANCE
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 6% in Saline 0.9% 500mL
MAGNESIUM ORAL DOSAGE FORMS
MAGNESIUM SULPHATE
Injection 50% - 500mg/mL (50mg elemental magnesium/mL)
19
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
48:00.00
48:08.00
ANTITUSSIVES, EXPECTORANTS AND MUCOLYTIC AGENTS
ANTITUSSIVES
DEXTROMETHORPHAN
Syrup 3mg/mL
48:16.00
EXPECTORANTS
GUAIFENESIN
Oral solution 20mg/mL
48:24.00
MUCOLYTIC AGENTS
20
ACETYLCYSTEINE
Antidote for acetaminophen poisoning
Injection 20% solution
52:00.00
52:04.00
52:04.04
EYE, EAR, NOSE AND THROAT PREPARATIONS
ANTI-INFECTIVES
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 (bacitracin)
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 minums 0.5%
Aerosol 754 mg / 65g (oral)
52:20.00
MIOTICS
ACETYLCHOLINE
Solution, intraocular irrigation 10mg/mL
52:24.00
MYDRIATICS
PHENYLEPHRINE
Ophthalmic solution minums 10%
TROPICAMIDE
Ophthalmic solution 0.5%, 1%
52:32.00 VASOCONSTRICTORS
NAPHAZOLINE
XYLOMETAZOLINE
Nasal spray 0.05%, 0.1%
Nasal solution 0.05%, 0.1%
52:36.00
MISCELLANEOUS EYE, EAR, NOSE AND THROAT DRUGS
21
ALUMINUM ACETATE
Solution, otic 0.5%
ARTIFICIAL TEARS
Ophthalmic solution
FLUORESCEIN SODIUM
Ophthalmic solution 2%, 10%
Strip, ophthalmic 1mg
SODIUM CHLORIDE
Ophthalmic solution, 5%
56:00.00
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
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
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
22
DROPERIDOL
Injection 2.5mg/mL
56:40.00
MISCELLANEOUS GASTROINTESTINAL DRUGS
PANTOPRAZOLE IV
Restricted Coverage: When ordered in a high dose (80mg IV bolus followed by
8mg/hour x 72 hours) by a gastroenterologist or general surgeon following
endoscopic hemostasis for non-variceal upper gastrointestinal bleeding; or
when ordered as Pantoprazole 40mg IV q24h for patients who are strict NPO (i.e.
not taking any oral medications or oral diet) and have:
a) non-variceal upper GI bleeding not requiring endoscopic hemostatis; or
b) severe erosive esophagitis; or
c) Exception Drug Status (EDS) for a Proton Pump Inhibitor taken prior to
admission.
Injection
64:00.00
CALCIUM DISODIUM EDETATE
Injection (not for chelation therapy)
Injection 500mg, 2g vial
DIMERCAPROL
Injection 100mg/mL
68:00.00
68:04.00
HORMONES AND SYNTHETIC SUBSTITUTES
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
72:00.00
LOCAL ANESTHETICS
ARTICAINE
23
Cartridge 4% (5ug/mL epinephrine) (1.7mL)
BUPIVACAINE
Injection 0.25%, 0.5%, 0.75%
Injection 0.25% 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 1% 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
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
80:00.00
SERUMS, TOXOIDS AND VACCINES
Note:
* indicates the product is supplied to health regions by Saskatchewan Health
**indicates the product is supplied to health regions by the Canadian Blood Services
80:04.00
SERUMS
DIGOXIN IMMUNE FAB
24
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
To be provided according to supply and guidelines by Saskatchewan Health and
Canadian Blood Services. Other such products to be reviewed and approved on a
case by case basis by the health regions.
80:12.00 VACCINES
To be provided according to supply and guidelines by Saskatchewan Health and
Canadian Blood Services. Other such products to be reviewed and approved on a
case by case basis by the health regions.
84:00.00
84:04.00
84:04.04
SKIN AND MUCOUS MEMBRANE AGENTS
ANTI INFECTIVES
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
84:04.16
MISCELLANEOUS LOCAL ANTI-INFECTIVES
CHLORHEXIDINE
Alcoholic scrub
Cleanser 4%
Gauze 0.5%
Jelly 2%, 4%
Liquid 2%, 4%, 20%
Ointment 1%
Soap 2%
25
SILVER SULFADIAZINE
Cream 1% w/w
84:08.00
ANTIPRURITICS AND LOCAL ANESTHETICS
CALCIUM FOLINATE (folinic acid)
Powder 50mg, 350mg
Tablets 5mg
Injection 10mg/mL
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
84:24.12
EMOLLIENTS, DEMULCENTS AND PROTECTANTS
BASIC CREAMS, OINTMENTS AND PROTECTANTS
ZINC OXIDE
Ointment 15%
84:24.16
GELATIN, PECTIN, SODIUM CARBOXYMETHYLCELLULOSE
Paste 13.3% gelatin, 13.3% pectin, 13.3% sodium carboxymethylcellulose
84:36.00
MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS
COLLAGENASE
Ointment, 250U/g of activity
84:40:00
HEMORRHOID PREPARATIONS
PRAMOXINE
Ointment, rectal 1%, with zinc sulphate 0.5%
Suppository 20mg, with zinc sulphate 10mg
88:00.00
88:16.00
VITAMINS
VITAMIN D
ALFACALCIDOL DISODIUM INJECTION
Injection 2ug/mL
CALCITRIOL (also known as 1,25-DIHYDROXYCHOLECALCIFEROL)
Injection 1ug/mL
26
DIHYDROTACHYSTEROL
Capsule 0.125mg
92:00.00
ABCIXMAB INJECTION
Restricted Coverage: For use in high risk angioplasties carried out in a cardiac
catheterization laboratory as per approved health region/affiliate protocols.
Injection 2 mg/mL (5mL)
ACTHAR GEL 80IU/5mL (Health Canada - Special Access Programme for infantile
spasms)
BASILIXIMAB
Restricted Coverage: For prophylaxis of acute rejection in renal transplant patients.
Injection
BERACTANT
Restricted Coverage: When administered in a Neonatal Intensive Care Unit.
Powder (reconstituted) 25mg phospholipids/mL
CLIMACTERON
Restricted Coverage: When used in hospital/health center 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)
Injection 50mg/mL
DACLIZUMAB
Restricted Coverage: For prophylaxis of acute rejection in renal transplant patients.
Injection 5mg/mL
DIMETHYL SULFOXIDE
Solution 500mg/g (50mL)
DROTRECOGIN ALFA
Restricted coverage: for use when administered in a tertiary care facility on the
recommendation of an intensivist.
Injection 5mg, 20mg
EPTIFIBITIDE
Restricted Coverage: When used on the recommendation of a cardiologist for the
treatment of High Risk Unstable Angina and Non-ST Segment Elevation Myocardial
Infarction according to the guidelines of The American College of Cardiology &
American Heart Association, Inc. (Circulation, 2000; 102: 1193-1209)
Injection
ETANERCEPT (see Appendix A - Saskatchewan Health Formulary)
Injection
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
27
OCTREOTIDE
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
TIROFIBAN
Restricted Coverage: When used on the recommendation of a cardiologist for the
treatment of High Risk Unstable Angina and Non-ST Segment Elevation Myocardial
Infarction according to the guidelines of The American College of Cardiology &
American Heart Association, Inc. (Circulation, 2000; 102: 1193-1209)
Injection
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)
28
APPENDIX I: 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 (933-6171). 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
Isoniazid syrup 10mg/mL, tablets 100mg, 300mg
Pyrazinamide tablet 500mg
Rifampin capsule 150mg, 300mg, suspension 25mg/mL
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 1.2 MU IM injection
Ciprofloxacin 500mg
29
INDEX
1,25DIHYDROXYCHOLECALCIFEROL
ANTIFUNGALS ........................... 10, 25
ANTIHEMOPHILIC FACTOR VIII ...... 15
ANTIHEPARIN AGENTS ................... 15
ANTIHISTAMINE AGENTS ............... 10
ANTI-INFECTIVE AGENTS ............... 10
ANTI-INFECTIVES ............................ 21
...................................................... 26
ABCIXMAB INJECTION .................... 27
ABELCET ........................................ 10
ABSOLUTE ALCOHOL INJECTION . 20
ACETAMINOPHEN ........................... 18
ACETYLCHOLINE ............................ 21
ACETYLCYSTEINE .......................... 21
ACETYLSALICYLIC ACID ................ 17
ACTH ................................................ 23
ACTHAR GEL ................................... 27
ACTIVATED CHARCOAL ................. 22
ACYCLOVIR ..................................... 12
ADENOSINE ..................................... 16
ADRENALS ....................................... 23
ADRENERGIC AGENTS .................... 14
...................................................... 13
ANTINEOPLASTIC AGENTS ............. 13
ANTIPRURITICS AND LOCAL
ANESTHETICS .............................. 26
ANTISPASMODICS ........................... 13
ANTITUBERCULOSIS AGENTS ........ 12
ANTITUSSIVES ................................. 20
ANTITUSSIVES, EXPECTORANTS AND
MUCOLYTIC AGENTS .................. 20
ANTIVIRALS ..................................... 12
ANXIOLYTICS .................................. 19
ANXIOLYTICS, SEDATIVES AND
HYPNOTICS .................................. 18
APROTININ ....................................... 15
ARTICAINE ....................................... 23
ARTIFICIAL TEARS .......................... 22
ATRACURIUM BESYLATE ............... 14
ATTAPULGITE .................................. 22
AUTONOMIC DRUGS ....................... 13
AZITHROMYCIN ......................... 11, 29
BACITRACIN..................................... 25
BACITRACIN STERILE ..................... 12
BARBITURATES ............................... 19
BASIC CREAMS, OINTMENTS AND
PROTECTANTS ............................. 26
ADRENOCORTICOTROPIC
HORMONE / CORTICOTROPIN... 23
ALFACALCIDOL DISODIUM
INJECTION ................................... 26
ALFENTANIL .................................... 18
ALKALINIZING AGENTS.................. 19
ALPROSTADIL ................................. 17
ALTEPLASE ...................................... 16
ALUMINUM ACETATE...................... 22
AMBISOME..................................... 10
AMIKACIN ................................... 10, 29
AMINO ACIDS / DEXTROSE
SOLUTIONS ................................. 20
AMINO ACIDS SOLUTIONS ............. 20
AMINOCAPROIC ACID..................... 15
AMINOGLYCOSIDES ........................ 10
AMIODARONE HCl ........................... 16
AMPHOTERICIN B ........................... 10
AMPHOTERICIN B LIPID COMPLEX
INJECTION ................................... 10
AMPICILLIN ...................................... 11
ANALGESICS AND ANTIPYRETICS . 17
ANDROGENS .................................... 23
ANESTHETICS .................................. 17
ANTACIDS AND ADSORBENTS ....... 22
ANTI INFECTIVES ...................... 13, 25
ANTIANEMIA DRUGS ...................... 14
ANTIBIOTICS .................. 10, 12, 21, 25
ANTICHOLINERGIC AGENTS .......... 13
ANTICOAGULANTS ......................... 15
ANTICONVULSANTS ....................... 18
ANTIDIARRHEA AGENTS ................ 22
ANTIEMETICS .................................. 22
...................................................... 26
BASILIXIMAB .................................... 27
BENZATHINE PENICILLIN .......... 29
BENZOCAINE ................................... 21
BENZODIAZEPINES .......................... 19
BERACTANT..................................... 27
BETA LACTAM ANTIBIOTICS.......... 11
BLEOMYCIN ..................................... 13
BLOOD FORMATION AND
COAGULATION ............................ 14
BRETYLIUM TOSYLATE .................. 16
BUPIVACAINE .................................. 24
CALCITRIOL ..................................... 26
CALCIUM CHLORIDE ....................... 19
CALCIUM DISODIUM EDETATE ...... 23
CALCIUM FOLINATE ........................ 26
CALCIUM GLUCONATE ................... 19
30
CALCIUM ORAL DOSAGE FORMS . 19
CALORIC AGENTS ........................... 20
CARBOPROST ................................. 24
CARDIAC DRUGS ............................. 16
CARDIOVASCULAR DRUGS ............ 16
CASPOFUNGIN ACETATE .............. 10
CASTOR OIL .................................... 22
CATHARTICS AND LAXATIVES ...... 22
CEFAZOLIN ...................................... 10
DIBUCAINE ....................................... 26
DIGOXIN ........................................... 16
DIGOXIN IMMUNE FAB .................... 24
DIHYDROTACHYSTEROL ............... 27
DILTIAZEM........................................ 16
DIMERCAPROL ................................ 23
DIMETHYL SULFOXIDE .............. 27
DINOPROST TROMETHAMINE ....... 24
DINOPROSTONE ............................. 24
DIPHENHYDRAMINE ....................... 10
DIPHTHERIA ANTITOXIN................. 25
DIURETICS........................................ 20
DOBUTAMINE .................................. 14
DOPAMINE ....................................... 14
DOXAPRAM ...................................... 18
DOXORUBICIN ................................. 13
DROPERIDOL............................. 19, 23
DROTRECOGIN ALFA .................. 27
EDROPHONIUM ......................... 13, 19
CEFIXIME ....................................... 29
CEFOTAXIME ................................... 10
CEFOTETAN .................................... 11
CEFOXITIN SODIUM ........................ 11
CEFTAZIDIME .................................. 11
CEFTRIAXONE ................................. 11
CEFUROXIME .................................. 11
CENTRAL NERVOUS SYSTEM
AGENTS ........................................ 17
CEPHALOSPORINS ........................... 10
CEPHALOTHIN ................................. 11
CHLORAMPHENICOL....................... 11
CHLORHEXIDINE ............................. 25
CHLOROPROCAINE ........................ 24
CHOLINERGIC AGENTS ................... 13
CHROMIUM ...................................... 28
CIPROFLOXACIN ....................... 13, 29
CLIMACTERON ................................ 27
COAGULANTS AND
ANTICOAGULANTS ..................... 15
COCAINE .......................................... 21
COLFOSCERIL PALMITATE ............ 27
COLLAGENASE ............................... 26
COPPER ........................................... 28
CYANIDE ANTIDOTE KIT................. 27
CYCLOPHOSPHAMIDE ................... 13
ELECTROLYTE AND FLUID
REPLACEMENT ............................ 19
ELECTROLYTIC, CALORIC AND
WATER BALANCE ........................ 19
EMETICS ........................................... 22
EMOLLIENTS, DEMULCENTS AND
PROTECTANTS ............................. 26
ENFLURANE ..................................... 17
ENOXAPARIN ................................... 15
ENZYMES ......................................... 20
EPHEDRINE ..................................... 14
EPTIFIBITIDE.................................... 27
ERGOMETRINE MALEATE .............. 24
ERTAPENEM .................................... 11
ERYTHROMYCIN ....................... 11, 29
ESMOLOL ......................................... 16
ETANERCEPT .................................. 27
ETHAMBUTOL ............................ 12, 29
CYCLOSERINE............................... 29
CYCLOSPORINE .............................. 27
CYPROHEPTADINE ......................... 10
DACLIZUMAB ................................... 27
DALTEPARIN .................................... 15
DANAPAROID .................................. 15
DAUNORUBICIN............................... 13
DEFEROXAMINE MESYLATE ......... 23
DEMULCENTS .................................. 26
DESFLURANE .................................. 17
DEXTRAN 40 .................................... 19
DEXTRAN 70 .................................... 19
DEXTROMETHORPHAN .................. 20
DEXTROSE ...................................... 20
DIAGNOSTIC AGENTS ..................... 19
ETHIONAMIDE .............................. 29
EXPECTORANTS .............................. 20
EYE, EAR, NOSE AND THROAT
PREPARATIONS ............................ 21
FACTOR IX ....................................... 15
FAT EMULSION PREPARATIONS ... 20
FENTANYL........................................ 18
FERROUS FUMARATE .................... 14
FERROUS GLUCONATE.................. 14
FERROUS SULPHATE ..................... 15
FLEET ............................................... 22
FLEET PHOSPHO-SODA BUFFERED
SALINE.......................................... 22
31
MAGNESIUM ORAL DOSAGE FORMS
FLUCONAZOLE ................................ 10
FLUCYTOSINE ................................. 10
FLUORESCEIN SODIUM ................. 22
FLUOROURACIL .............................. 13
FLUOXYMESTERONE ..................... 23
...................................................... 19
MAGNESIUM SULFATE ................... 18
MAGNESIUM SULPHATE ................ 19
MANGANESE ................................... 28
MANNITOL ........................................ 20
MEPIVACAINE .................................. 24
MEROPENEM ................................... 11
METHADONE ................................... 18
METHOTREXATE ............................. 13
METHYLPREDNISOLONE ............... 23
MIDAZOLAM ..................................... 19
MILRINONE ...................................... 16
MIOTICS............................................ 21
MISCELLANEOUS ANALGESICS AND
ANTIPYRETICS ............................. 18
FOSCARNET ................................... 12
FOSPHENYTOIN .............................. 18
GALLAMINE TRIETHIODIDE ........... 14
GANCICLOVIR ................................. 12
GASTROINTESTINAL DRUGS .......... 22
GATIFLOXACIN ................................ 13
GELATIN, PECTIN, SODIUM
CARBOXYMETHYLCELLULOSE . 26
GENERAL ANESTHETICS................. 17
GLYCERIN ........................................ 22
GUAIFENESIN .................................. 20
HALOTHANE .................................... 17
HEAVY METAL ANTAGONISTS....... 23
HEMORRHOID PREPARATIONS ...... 26
HEMOSTATICS ................................. 15
HEPARIN .......................................... 15
HEPATITIS B IMMUNE GLOBULIN .. 25
HORMONES AND SYNTHETIC
SUBSTITUTES ............................... 23
HYDANTOINS ................................... 18
HYOSCINE BUTYLBROMIDE .......... 13
HYOSCINE HYDROBROMIDE ......... 14
HYPNOTICS ...................................... 19
HYPOTENSIVE AGENTS .................. 17
IMIPENEM CILASTATIN ................... 11
IMMUNE GLOBULIN......................... 25
IMMUNE SERUM GLOBULIN ........... 25
IPECAC ............................................. 22
IRON DEXTRAN ............................... 15
IRON PREPARATIONS ...................... 14
ISOFLURANE ................................... 17
ISONIAZID .................................. 12, 29
ISOPROTERENOL ........................... 14
KETAMINE ........................................ 17
LABETALOL...................................... 17
LEVOCARNITINE ............................. 27
LEVOFLOXACIN ............................... 13
LIDOCAINE ........................... 21, 24, 26
LIDOCAINE/PRILOCAINE ................ 26
LINEZOLID ........................................ 13
LIPOSOMAL AMPHOTERICIN B ...... 10
LOCAL ANESTHETICS ............... 21, 23
LOCAL ANTI-INFECTIVES ............... 25
MACROLIDES ................................... 11
...................................................... 13
MISCELLANEOUS ANTIBIOTICS ..... 12
MISCELLANEOUS
ANTICONVULSANTS.................... 18
MISCELLANEOUS ANXIOLYTICS,
SEDATIVES, HYPNOTICS ............. 19
MISCELLANEOUS BETA LACTAM
ANTIBIOTICS ................................ 11
MISCELLANEOUS EYE, EAR, NOSE
AND THROAT DRUGS .................. 21
MISCELLANEOUS
GASTROINTESTINAL DRUGS ...... 23
MISCELLANEOUS LOCAL ANTIINFECTIVES .................................. 25
MISCELLANEOUS SKIN AND
MUCOUS MEMBRANE AGENTS .. 26
MOXIFLOXACIN ............................... 13
MUCOLYTIC AGENTS ...................... 20
MYASTHENIA GRAVIS .................... 19
MYDRIATICS .................................... 21
NADROPARIN .................................. 15
NALBUPHINE ................................... 18
NALOXONE ...................................... 18
NAPHAZOLINE ................................. 21
NEOSTIGMINE ................................. 13
NIMODIPINE ..................................... 17
NITROGLYCERIN ............................. 17
NON-STEROIDAL ANTIINFLAMMATORY AGENTS .......... 17
NOREPINEPHRINE .......................... 14
OCTREOTIDE ................................... 28
OPIATE AGONISTS ........................... 18
OPIATE ANTAGONISTS .................... 18
OPIATE PARTIAL AGONISTS ........... 18
32
OXYTOCICS ...................................... 24
OXYTOCIN ....................................... 24
PANCURONIUM ............................... 14
PANTOPRAZOLE IV ......................... 23
PAPAVERINE ................................... 17
PARALDEHYDE ............................... 19
PARASYMPATHOMIMETIC AGENTS
SERUMS, TOXOIDS AND VACCINES 24
SEVOFLURANE................................ 17
SILVER SULFADIAZINE ................... 26
SKELETAL MUSCLE RELAXANTS ... 14
SKIN AND MUCOUS MEMBRANE
AGENTS ........................................ 25
SODIUM BICARBONATE ................. 19
SODIUM CHLORIDE .................. 20, 22
SODIUM NITROPRUSSIDE.............. 17
SODIUM PHOSPHATE ..................... 20
SOMATOSTATIN .............................. 28
STREPTOKINASE ............................ 16
SUCCINYLCHOLINE ........................ 14
SUFENTANIL .................................... 18
SYMPATHOLYTICS .......................... 14
SYMPATHOMIMETIC (ADRENERGIC)
AGENTS ........................................ 14
TENECTEPLASE (TNK).................... 16
TETANUS IMMUNE GLOBULIN ....... 25
TETRACAINE.............................. 21, 24
THIOPENTAL .................................... 17
THROMBIN ....................................... 15
THROMBOLYTIC AGENTS ............... 16
TICARCILLIN .................................... 12
TIROFIBAN ....................................... 28
TISSUE PLASMINOGEN ACTIVATOR
(tPA) .............................................. 16
TOBRAMYCIN .................................. 10
TOLNAFTATE ................................... 25
TOXOIDS........................................... 25
TRACE ELEMENTS .......................... 28
TRANEXAMIC ACID ......................... 15
TROMETHAMINE ............................. 19
TROPICAMIDE ................................. 21
UNCLASSIFIED THERAPEUTIC
AGENTS ........................................ 27
VACCINES ........................................ 25
VANCOMYCIN .................................. 12
VASOCONSTRICTORS ...................... 21
VASODILATING AGENTS ................ 17
VASOPRESSIN ................................. 23
VECURONIUM .................................. 14
VITAMIN D ....................................... 26
VITAMINS ......................................... 26
XYLOMETAZOLINE .......................... 21
ZINC .................................................. 28
ZINC ORAL DOSAGE FORMS ......... 20
ZINC OXIDE ...................................... 26
...................................................... 13
PENICILLINS .................................... 11
PENTAMIDINE ISETHIONATE ......... 13
PHENTOLAMINE MESYLATE .......... 14
PHENYLEPHRINE ...................... 14, 21
PHOSPHATE .................................... 20
PIPERACILLIN .................................. 11
PIPERACILLIN/TAZOBACTAM ........ 11
PITUITARY ....................................... 23
POLYMYXIN B SULFATE ................. 12
POLYMYXIN B/GRAMICIDIN or
BACITRACIN ................................ 21
POTASSIUM ACETATE.................... 20
POTASSIUM CHLORIDE .................. 20
POTASSIUM PHOSPHATE .............. 20
PRALIDOXIME CHLORIDE .............. 28
PRAMOXINE ..................................... 26
PRILOCAINE .................................... 24
PROCAINAMIDE............................... 17
PROCAINE ....................................... 24
PROMETHAZINE .............................. 10
PROPARACAINE .............................. 21
PROPOFOL ...................................... 17
PROTAMINE SULPHATE ................. 15
PROTECTANTS ................................. 26
PSEUDOEPHEDRINE ...................... 14
PSYCHOTHERAPEUTIC AGENTS ..... 18
PYRAZINAMIDE ......................... 12, 29
QUINOLONES ................................... 13
QUINUPRISTIN/DALFOPRISTIN
TM
(Synercid ) .................................. 12
RESPIRATORY AND CEREBRAL
STIMULANTS ............................... 18
RIBAVIRIN ........................................ 12
RIFAMPIN ................................... 12, 29
ROCURONIUM ................................. 14
SCOPOLAMINE BUTYLBROMIDE ... 13
SCOPOLAMINE HYDROBROMIDE . 14
SEDATIVES ....................................... 19
SELENIUM ........................................ 28
SENNOSIDES ................................... 22
SERUMS ............................................ 24
33
TIPS ON PRESCRIPTION WRITING
(PRESCRIPTION REGULATIONS)
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 38 and 39 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.
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
36
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 once. 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.
37
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 Controlled Drugs and Substances Act and 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, 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 Controlled Drugs and Substances Act and to the
Schedule to the Narcotic Control Regulations
CONTROLLED DRUGS - LEVEL I**
Examples: Dexedrine, Ritalin, Seconal, 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: Cafergot PB, etc.
A combination containing a controlled drug - LeveI 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 (i.e.
Delatestryl), 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: Fiorinal**, Anabolic Steroids,
(i.e. Climacteron), 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.
38
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".
39
GUIDELINES FOR REPORTING
ADVERSE DRUG REACTIONS
GUIDELINES FOR REPORTING ADVERSE REACTIONS
DEFINITION OF AN ADVERSE REACTION (AR):
“A noxious and unintended response to a drug which occurs with use or testing for the
diagnosis, treatment, or prophylaxis of a disease or modification of an organic function.
This includes any undesirable patient effect suspected to be associated with drug use.”
ARs resulting from any prescription, non-prescription, biological (including blood
products), complementary medicines (including herbals), and radiopharmaceutical drug
products are monitored.
WHICH ADVERSE REACTIONS SHOULD BE REPORTED?
AR reports are, for the most part, only SUSPECTED associations. Reporting an AR
DOES NOT imply a causal link.
Practitioners should report the following suspected ARs to the SaskAR Regional Centre:
•
•
•
all suspected adverse reactions that are unexpected. An unexpected adverse
reaction is an undesirable patient effect that is not consistent with product information
or labelling;
all suspected adverse reactions that are serious. A serious adverse reaction is an
undesirable patient effect that contributes to significant disability or illness. All
adverse drug reactions that 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 REACTION TO SASKAR:
Please report suspected adverse reactions as soon as possible after detection, even if
all details are not known at the time. SaskAR staff will follow-up for further information if
required.
Complete a written AR report form (available in the Compendium of Pharmaceuticals and
Specialties (CPS), the SPDP Formulary, or contact the SaskAR Regional Centre.
Information may be attached to the report form if insufficient space is available for
complete documentation. A form may also be downloaded from the Health Canada
website. http://www.hc-sc.gc.ca/hpfb-dgpsa/tpd-dpt/adverse_e.pdf. Click on “Report
(form) of suspected adverse reaction due to drug products marketed in Canada”.
Record all information that is available and mail or fax to SaskAR. Mail or fax to:
SaskAR Regional Centre:
Saskatchewan Drug Information Service
110 Science Place
University of Saskatchewan
Saskatoon SK S7N 5C9
Fax: 1-866-678-6789 or in Saskatoon 966-2286
OR
Telephone report to SaskAR:
1-866-234-2345 or in Saskatoon 966-6329
Office hours are 8:30 a.m. - 4:30 p.m., Monday to Friday, excluding statutory holidays.
42
43
44
TRIPLICATE PRESCRIPTION PROGRAM
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.
46
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.
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 for non-Drug Plan beneficiaries. 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.
47
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
Emtec-30
Lenoltec with Codeine #2, #3, #4
Tylenol with Codeine #2, #3, #4
Tylenol with Codeine Elixir
HYDROMORPHONE-DIHYDROMORPHINONE-in all dosage
forms (for example*)
Dilaudid, all strengths
Dilaudid HP Parenteral
Hydromorphone, all strengths
MEPERIDINE-PETHIDINE-in all dosage forms (for example*)
Demerol Injectable, Tablets
Meperidine HCl Injectable
ACETYLSALICYLIC ACID (ASA) WITH CODEINE- in all
dosage forms except those containing 8mg of codeine (for
example*)
282
Anacasal 15, 30
Phenaphen
282 Meps
Robaxisal C¼, C½
METHADONE-in all dosage forms
METHYLPHENIDATE-in all dosage forms (for example*)
Concerta
Ritalin
Ritalin SR
BUTALBITAL-in all dosage forms (for example*)
Tecnal
MORPHINE- in all dosage forms (for example*)
M.O.S., all strengths
Morphine Injectable
Morphine HP
Morphine LP
MS Contin, all strengths
MSIR, all strengths
Statex, all strengths
BUTALBITAL WITH CODEINE-in all dosage forms (for
example*)
Fiorinal C¼, C½
Tecnal C¼, C½
BUTORPHANOL
Stadol Nasal Spray
OXYCODONE-as a single active ingredient, or in combination
with other active ingredients in all dosage forms (for example*)
Endocet
Endodan
Oxycocet
Oxycontin, all strengths
Percocet
Percocet-Demi
Percodan
Percodan-Demi
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
Omni-Tuss
Robitussin AC
PANTOPON-in all dosage forms
PENTAZOCINE-in all dosage forms (for example*)
Talwin
Talwin Compound-50
DEXTROAMPHETAMINE-in all dosage forms (for example*)
Dexedrine
PHENTERMINE-in all dosage forms (for example*)
Ionamin
DIETHYLPROPION-in all dosage forms (for example*)
Tenuate
Tenuate Dospan
PROPOXYPHENE-in all dosage forms (for example*)
642, 692
Darvon-N
Darvon-N Compound
FENTANYL- transdermal system (for example*)
Duragesic, all strengths
*DISCLAIMER-The product names listed with each drug
category are for example only, and are not intended to be
inclusive.
HYDROCODONE-DIHYDROCODEINONE-in all dosage forms
(for example*)
Dimetane Expectorant-C
Hycodan Syrup, Tablets
Hycomine Syrup
Hycomine-S Pediatric Syrup
Novahistex DH
Novahistex DH Expectorant
Novahistine DH
Tussionex Suspension, Tablets
48

Formulary 54th Edition - Drug Plan

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