DRUG FORMULARY (MAY 2014) [EFFECTIVE ON MAY 2014]
Transcription
DRUG FORMULARY (MAY 2014) [EFFECTIVE ON MAY 2014]
DRUG FORMULARY (MAY 2014) [EFFECTIVE ON MAY 2014] ITEM DRUG DESCRIPTION GENERIC NAME UNIT PRICE PK UNIT NO. ($) Disclaimer: Please note that this list is not exhaustive and contains certain drugs that may not be covered under the Cathay Pacific Medical Scheme, e.g. drugs use for psychological conditions, drugs use for management of fertility and contraception. Should you prescribe item that is not included here or have any queries, please call the CPA Provider Hotline at 2851-3870 or email [email protected] . ANTACIDS & ANTIULCERANTS TAC018 TAI010 TAX010 MBA008 TBU020 TCY040 TDE040 TDE080 TDE081 TGA010 MGA010 MGE016 TGE010 TLO041 TLO042 TLO040 TMA010 MMA010 TMI036 TMU010 MMU010 TMY020 MMY020 TNE050 TNE052 MNE010 TPA044 TPA045 TPA046 ACTAL AIR-X CHEWABLE 80mg AXID 150mg BABCON 20mg/mL BUWECON 0.125mg CYTOTEC 200mcg DENOL DEXILANT [DEXLANSOPRAZOLE] MR DEXILANT [DEXLANSOPRAZOLE] MR GAVISCON GAVISCON ADVANCE GELUMAG SUSPENSION GELUSIL LOSEC CAP 20mg (GE) LOSEC MUPS 10mg LOSEC MUPS 20mg MAALOX PLUS MAALOX SUSPENSION (GE) 200mg MILID MUCAINE (GE) MUCAINE SUSPENSION (GE) MYLANTA (GE) MYLANTA SUSPENSION (GE) NEXIUM 20mg NEXIUM 40mg NEXIUM GRANULES 10mg PANTOLOC 20mg (GE) PANTALOC [PANTOPRAZOLE] PANTOLOC 40mg PANTALOC 40mg (GE) TPA047 [PANTOPRAZOLE] TPA055 GLUCOPHAGE TPA056 PARIET 20mg CPA094 PEPCIDINE 20mg TPE040 PEPCIDINE 20mg (GE) CPA098 PEPCIDINE 40mg TPY008 SUCRATE PYLORID 400mg GEL 1G/5mL MSU020 SACHETS TTA010 TAGAMET 200mg (GE) TTA012 TAGAMET 400mg (GE) TTA020 TAKEPRON 30mg TTA021 TAKEPRON OD 30mg NA POLYHYDROXYALUMINIUM MONOCA SIMETHICONE NIZATIDINE 150mg DIMETHYLPOLYSILOXANE 20mg HYOSCINE/SCOPOLAMINE MISOPROSTOL 200mcg COLLOIDAL BISMUTH SUBCITRATE DEXLANSOPRAZOLE DEXLANSOPRAZOLE ALGINIC ACID, AL HYDROXIDE... SODIUM ALGINATE AND POTASSIUM BICARBONATE ALUMINIUM HYDROXIDE GEL MG TRISILICATE, AL HYDROXIDE OMEPRAZOLE 20mg OMEPRAZOLE 10mg OMEPRAZOLE 20mg AL & MG HYDROXIDE, SIMETHICONE AL HYDROXIDE, DIMETHICONE PROGLUMIDE 200mg ALUMINA, MGCO3, OXETHAZINE OXETHAZAINE, AL HYDROXIDE... AL & MG HYDROXIDE, DIMETHICONE AL HYDROXIDE, MG HYDROXIDE... ESOMEPRAZOLE 20mg ESOMEPRAZOLE 40mg ESOMEPRAZOLE PANTOPRAZOLE SODIUM 20mg PANTOPRAZOLE PANTOPRAZOLE SODIUM 40mg 1.50 1.00 7.00 0.50 0.700 9.00 6.00 16.50 25.00 4.10 1.00 0.00 0.60 10.00 17.50 21.20 0.70 0.17 2.00 0.60 0.18 0.60 0.22 22.90 32.60 22.70 15.50 10.60 22.90 PANTOPRAZOLE RABEPRAZOLE SODIUM 10mg RABEPRAZOLE SODIUM 20mg FAMOTIDINE FAMOTIDINE FAMOTIDINE RANITIDINE BISMUTH CITRATE 400mg SUCRALFATE CIMETIDINE 200mg CIMETIDINE 400mg LANSOPRAZOLE 30mg LANSOPRAZOLE 30mg 15.50 8.30 11.00 6.00 2.40 10.00 15.00 5.00 2.00 4.00 22.00 25.10 TAB TAB TAB TAB TAB TAB SACH TAB TAB CAP TAB CPA109 LANSOPRAZOLE 15mg 9.00 TAB TAKEPRON OD 15mg TAB TAB TAB ML TAB TAB TAB CAP CAP TAB ML ML TAB CAP TAB TAB TAB ML TAB TAB ML TAB ML TAB TAB SACH TAB TAB TAB TAB TUL010 ULSANIC 500 mg SUCRALFATE 500mg TUL012 ULSANIC 500mg (GE) SUCRALFATE 500mg MUL010 ULSANIC GRANULES 1g SUCRALFATE 1g IZA010 ZANTAC [ranitidine] RANTIDINE 25mg/mL INJ TZA030 ZANTAC 150 mg RANITIDINE HCL 150mg TZA032 ZANTAC 150mg 300 mg(GE)RANITIDINE HCL 300mg TZA034 [RANITIDINE] RANITIDINE HCL 150mg CPA041 ZANTAC SYRUP RANITIDINE HCL GIT REGULATORS,ANTIFLATULENTS & ANTI-INFLAMMATORIS TAS010 ASACOL 400mg MESALAZINE 400mg PAS010 ASACOL SUPP 500mg MESALAZINE TCE052 CEREKINON 100mg TRIMEBUTINE MALEATE TCH010 CHARCOAL 300mg CHARCOAL 300mg TCH012 CHARCOAL 200mg CHARCOAL 200mg TDI102 DIPENTUM 250mg OLSALAZINE SODIUM 250mg TDI106 DISFLATYL 40mg DIMETHICONE/SILICON DIOXIDE TEU020 ENTOCORT 3mg BUDESONIDE 3mg PEN010 ENTOCORT ENEMA BUDESONIDE DIMETHYLPOLYSILOXANE, 2mg/100mL TGA008 GASTEEL ALUMINIUM HYDROXIDE MGA004 GASCON DROP 20mg/mL DIMETHYLPOLYSILOXANE 300mL TMA022 MAGESTO PRECIPITATED CA CARBONATE 200mg/MYLASE 37.5mg/NA CPA097 MOTILIUM 10mg DOMPERIDONE TMO040 MOTILIUM 10mg (GE) DOMPERIDONE PMO010 MOTILIUM SUPP 10mg (GE) DOMPERIDONE PMO012 MOTILIUM SUPP 30mg (GE) DOMPERIDONE MMO010 MOTILIUM SYRUP 1mg/mL DOMPERIDONE 1mg TMY030 MYLICON (GASTEEL) DIMETHICONE 40mg TPE030 PENTASA 500mg MESALAZINE 500mg PPE010 PENTASA 1g 2g MESALAZINE PENTASASUPP SACHET 2.00 1.40 3.70 46.40 7.60 17.80 4.50 0.85 TAB TAB SACH AMP TAB TAB TAB ML 5.90 20.00 2.00 0.60 0.800 4.50 1.90 27.40 200.00 1.50 2.00 0.60 4.00 1.70 6.00 9.50 1.80 1.00 7.80 26.00 MPE016 (60's/BOX) MESALAZINE 2g 37.00 TAB SUPP TAB TAB TAB TAB TAB CAP TUB TAB ML TAB TAB TAB SUPP SUPP ML TAB TAB SUPP SACH MPE017 TPR060 TPR062 TSA030 TSA032 PSA010 MESALAZINE 1g CISAPRIDE 5mg CISAPRIDE 10mg MESALAZINE 250mg MESALAZINE 500mg Page 1 of 28 MESALAZINE, 5-AMINOSAL. ACID 18.50 3.00 5.30 13.00 15.00 55.00 SACH TAB TAB TAB CAP SUPP PENTASA SCAHET 1g PREPULSID 5mg PREPULSID 10mg SALOFALK 250mg SALOFALK 500mg SALOFALK SUPP 250mg DRUG FORMULARY (MAY 2014) [EFFECTIVE ON MAY 2014] ITEM DRUG DESCRIPTION GENERIC NAME NO. PSA012 SALOFALK GRANULES SUPP 500mg MESALAZINE, 5-AMINOSAL. ACID MSA008 500mg MESALAZINE 500mg MSA010 SALOFALK GRANULES 1G POLYMIGEL MESALAZINE244mg, 1G OXETHAZAINE TST036 STROCAIN 5mg ANTISPASMODICS TBU010 BUSCOPAN 10mg (GE) HYOSCINE-N-BUTYLBROMIDE 10mg IBU010 BUSCOPAN INJ 20mg/mL HYOSCINE BUTYLBROMIDE IBU012 BUSCOPAN INJ 20mg/mL HYOSCINE BUTYLBROMIDE 10mL MBU010 BUSCOPAN LIQUID HYOSCINE-N-BUTYLBROMIDE 1mg/mL (GE) TDA040 DARICON 5mg OXYPHENCYCLIMINE HCL 5mg MDO010 DONNATAL SYRUP PHENOBARBITONE, HYOSCYAMINE.. TDU020 DUSPATALIN 135 mg MEBEVERINE HCL 135mg TDU021 DUSPATALIN RETARD MEBEVERINE HCL 200mg 200mg THO010 HOLOPON 1mg (GE) SCOPOLAMINE METHYLBROMIDE 1mg MIN010 INFACOL SUSPENSION DIMETHICONE MIN012 (GE) INFACOL WIND DROPS DIMETHICONE TLE016 LEVSIN SL 125mcg HYOSCYAMINE SULFATE 125mcg TLI010 LIBRAX (GE) CHLORDIAZEPOXIDE, CLIDINIUM TLI020 LIBRIUM 5mg (GE) CHLORDIAZEPOXIDE TPR084 PROBANTHINE 15mg (GE) PROPANTHELINE BROMIDE 15mg TSP012 SPASMOMEN 40mg OTILONIUM BROMIDE TSP010 SPASMONAL 60mg (GE) ALVERINE CITRATE CPA096 SPASMONAL CAP 60MG ALVERINE CITRATE TUR020 URISPAS 100mg FLAVOXATE HCL 100mg TUR022 URISPAS 200mg FLAVOXATE HCL 200mg TZE007 ZELMAC 6mg TEGASEROD 6mg ANTIDIARRHEALS TAN020 ANTIDIA 200mg NIFUROXAZIDE 200mg TER020 ERCEFURYL 200mg (GE) NIFUROXAZIDE 200mg HIDRASEC 10mg SACHET MHI010 (INFANTS) HIDRASEC 30mg SACHET RACECADOTRIL MHI012 (CHILDREN) RACECADOTRIL TIM028 IMODIUM 2mg LOPERAMIDE HCL 2mg TIM030 IMODIUM 2mg (G.E.) LOPERAMIDE HCL 2mg MIM012 IMODIUM DROPS 2mg/mL LOPERAMIDE HCL (GE) MIM010 IMODIUM SYRUP 2mg/5mL LOPERAMIDE HCL (GE) MKA010 KAOPECTATE (GE) LIGHT KAOLIN, PECTIN TLO010 LOMOTIL DIPHENOXYLATE HCL, ATROPINE TLO011 LOMOTIL (GE) DIPHENOXYLATE HCL, ATROPINE MLO010 LOMOTIL SYRUP DIPHENOXYLATE, ATROPINE 2.5mg/5mL3g(GE) MSM010 SMECTA DIOCTAHEDRAL SMECTITE LAXATIVES, PURGATIVES MAG008 AGAROL SUSPENSION LIQUID PARAFFIN MAG010 AGAROL SUSPENSION LIQUID PARAFFIN (GE) MAG015 AGIOCUR GRANULES 250g PLANTAGO SEED, ISPAGHULA HUSKS MAG020 AGIOLAX 100g PLANTAGO SEED, SENNA PODS... PBA012 BANDI-ENEMA ADULT GLYCERIN, MG SULFATE, NACL PBA010 BANDI-ENEMA PAED GLYCERIN, MG SULFATE, NACL MBI008 BISACODYL IN BISACODYL, POLYETHYLENE POLYETHYLENE LIQUID GLYCOL TDO006 DOCUSATE SODIUM 100mg DOCUSATE Na TDU010 DULCOLAX 5mg (GE) BISACODYL 5mg PDU010 DULCOLAX SUPP 10mg BISACODYL MDU010 (GE) DUPHALAC SYRUP LACTULOSE 10g/15mL PFL020 FLEET ENEMA NA BIPHOSPHATE, NA PHOSPHATE PFL010 FLEET ENEMA NA BIPHOSPHATE, NA PHOSPHATE (CHILDREN) MFL006 FLEET PHOSPHO-SODA MONOBASIC Na PHOSPHATE/DIBASIC MF0010 FORLAX MACROGOL 4000 MFY010 FYBOGEL ISPAGHULA HUSK PGL010 GLYCERINE SUPP GLYCERIN (ADULT) (GE)SUPP (PAED) GLYCERIN PGL012 GLYCERINE (GE) MKL020 KLEAN-PREP POLYETHYLENE GLYCOL,KCL,NA2CO3 MME010 METAMUCIL POWDER PSYLLIUM HYDROPHILIC 100g MUCILLOIDHYDROPHILIC MME012 METAMUCIL POWDER PSYLLIUM 336g MUCILLOIDHYDROPHILIC MME013 METAMUCIL POWDER PSYLLIUM 504g MUCILLOIDHYDROPHILIC MME015 METAMUCIL POWDER PSYLLIUM 528g (ORANGE) MUCILLOIDHYDROPHILIC MME014 METAMUCIL POWDER 6g PSYLLIUM MUCILLOID PMI010 MICROLAX ENEMA NA CITRATE+LAURYL SULFOACETATE MMU040 MUCOFALK ORANGE 5g ISPAGHULA HUSK 5g MNA010 NATURLAX POWDER 368g PSYLLIUM HYDROPHILIC MUCILLOID 62% MNO010 NORMACOL STERCULIA MNO020 NORMACOL PLUS STERCULIA 62%, FRANGULA 8% MPA020 PARAFFIN LIQUID (GE) PARAFFIN LIQUID MPE005 PEGLYTE POWDER POLYETHYLENE GLYCOL, ELECTROLYTES MPH040 PHOSPHATE SOLUTION SODIUM PHOSPHATE NA PICOSULFATE 10mg,MG OXIDE 45mL MPI006 PICOLAX ORAL SOLUTION 3.5g//CITRIC ACID 12g MPI008 PICOLAX POWDER 10mg SODIUM PICOSULFATE TSE030 SENOKOT SENNOSIDES B 7.5mg PSA008 SALOFALK ENEMAS MESALAZINE, 5-AMINOSAL. ACID 4G/60mL DIGESTIVES PANCREATIN, ENZYME TCO054 COMBIZYM CONCENTRATE TCR010 CREON PANCREATIN/AMYLASE/LIPASE/PRO T TEN030 ENZYPLEX AMYLASE,PROTEASE,LIPASE... TPA040 PANKREOFLAT PANCREATIN, SIMETHICONE CHOLAGOGUES, CHOLELITHOLYTICS & HEPATIC Page PROTECTORS 2 of 28 TBI008 BILSAN CHOLINE, DEHYDROCHOLIC ACID, INOSITOL… UNIT PRICE ($) 80.00 13.00 26.60 0.95 PK UNIT 0.80 38.00 20.00 0.40 1.10 0.27 5.00 6.80 1.10 0.26 2.30 2.70 1.50 1.00 0.60 4.40 2.20 4.00 1.50 2.70 8.00 TAB AMP ML ML TAB ML TAB CAP TAB ML ML TAB TAB TAB TAB TAB TAB CAP TAB TAB TAB 0.80 0.65 4.00 6.00 7.00 1.90 1.00 1.00 0.18 1.00 0.70 0.28 4.40 CAP CAP SACH SACH CAP TAB ML ML ML TAB TAB ML SACH 0.20 0.17 130.00 0.60 3.00 2.50 0.25 1.80 0.80 4.60 0.45 25.00 26.00 0.80 4.70 4.00 6.00 4.20 27.00 0.40 0.45 0.60 0.55 4.00 10.50 5.70 0.40 9.20 9.20 0.30 45.00 0.40 56.00 40.00 0.70 280.00 ML ML BOT g TUB TUB ML CAP TAB SUPP ML BOT BOT ML SACH SACH SUPP SUPP SACH g g g g SACH BOT SACH g SACH SACH ML SACH ML SACH SACH TAB PC 2.10 4.70 1.30 2.20 TAB CAP TAB TAB 1.90 TAB SUPP SACH SACH TAB DRUG FORMULARY (MAY 2014) [EFFECTIVE ON MAY 2014] ITEM NO. TCH020 TLE006 TLE008 CPA088 TUR028 DRUG DESCRIPTION CHENOFALK 250mg LEGALON 35mg LEGALON 70mg LEGALON 140mg URSOFALK 250mg 250mg (GE)URSOFALK GENERIC NAME CHENODEOXYCHOLIC ACID 250mg SILYMARIN 35mg SILYMARIN 70mg SILYMARIN 140mg URSODEOXYCHOLIC ACID TUR029 [URSODEOXYCHOLIC] URSODEOXYCHOLIC ACID TUR030 URSOLVAN 200mg URSODEOXYCHOLIC ACID 200mg CARDIAC DRUGS IAD012 ADRENALINE INJ 1:10,000 ADRENALINE 10mL TCO070 CORDARONE 200 mg AMIODARONE HCL 200mg ICO015 CORDARONE INJ AMIODARONE HCL 150mg 150mg/3mLINJ (GE) IDI010 DIGOXIN 0.5mg/2mL DIGOXIN TKI010 KINIDIN DURULE 200mg QUINIDINE BISULFATE 200mg TLA040 LANITOP 0.1mg METILDIGOXIN 0.1mg TLA050 LANOXIN PG 0.0625mg DIGOXIN 0.0625mg TLA052 LANOXIN 0.25mg DIGOXIN 0.25mg TMU035 MULTAQ FILM-COATED DRONEDARONE HC1 400 mg TNO060 NORPACE 100mg DISOPYRAMIDE PHOSPHATE 100mg TNO070 NORPACE RETARD 150mg DISOPYRAMIDE PHOSPHATE 150mg TRY010 RYTMONORM 150mg PROPAFENONE HCL 150mg TRY012 <propafenone> 150mg [APOPROPAFENONE TSL020 SLOW K 600mg POTASSIUM CHLORIDE 600mg TSL030 SLOW K 600mg (GE) POTASSIUM CHLORIDE 600mg TTA022 TAMBOCOR 100mg FLECAINIDE ACETATE 100mg IXY030 XYLOCARD INJ 100mg/5mL LIDOCAINE HCl ANTI-ANGINAL DRUGS TCO069 CORALAN 5mg IVABRADINE TEL010 ELANTAN 20mg ISOSORBIDE MONONITRATE 20mg TIM010 IMDUR 60mg ISOSORBIDE-5-MONONITRATE 60mg TIS008 ISO MACK RETARD 40mg ISOSORBIDE DINITRATE 40mg SIS010 ISOMACK SPRAY ISOSORBIDE DINITRATE TIS040 ISORDIL 10mg ISOSORBIDE DINITRATE 10mg TIS050 ISORDIL SUBLINGUAL 5mg ISOSORBIDE DINITRATE TIS060 ISORDIL TEMBIDS 40mg ISOSORBIDE DINITRATE 40mg (GE) CPA150 LOMAKLINE 5 mg AMLODIPINE BESILATE CPA151 LOMAKLINE 10 mg AMLODIPINE BESILATE ANI020 NITRODERM TTS-10 50mg NITROGLYCERIN TNI030 NITRODISC 5mg NITROGLYCERIN SNI010 NITROLINGUAL SPRAY NITROGLYCERIN 0.4mg 0.4mg TNI040 NITROSTAT 500mcg GLYCERYL TRINITRATE 500mcg (ANGISED) 25mg (GE) TPE070 PERSANTIN DIPYRIDAMOLE 25mg TPE073 PERSANTIN 75mg DIPYRIDAMOLE 75mg TPE072 PERSANTIN 75mg (GE) DIPYRIDAMOLE 75mg TPE074 PERSANTIN PLUS DIPYRIDAMOLE/ACETYSALICYLIC ACID TVA030 VASTAREL 20mg TRIMETAZIDINE DIHCL 20mg TVA032 VASTAREL MR TRIMETAZIDINE DIHYDROCHLORIDE 35mg TIS042 ISORDIL 10mg (GE) ISOSORBIDE DINITRATE 10mg ANGIOTENSIN II ANTAGONIST TCO101 COZAAR <Losartan> 50mg LOSARTAN 50mg (GE) TCO111 COZAAR 100mg (GE)-[LOSARTAN] LOSARTAN 100mg TCO112 COZAAR [Losartan] 100mg [LOSACOR] LOSARTAN THY023 HYZAAR (GE) LOSARTAN, THY024 HYZAAR [LOSACOR HCT HYDROCHLOROTHIAZIDE , 50 mg-12.5mg] LOSARTAN POTASSIUM TMI007 MICARDIS PLUS 80mg TELMISARTAN/HYDROCHLOROTHIA ZIDE 12.5mg MEDOXOMIL 40mg TOL029 OLMETEC 40mg OLMESARTAN TOL030 OLMETEC 20mg OLMESARTAN MEDOXOMIL OLMESARTAN, TOL031 OLMETEC PLUS 10mg OLMESARTAN TOL032 20mg/12.5mg HYDROCHLOROTHIAZIDE ANTIHYPERTENSIVE DRUGS TAC008 ACCUPRIL 10mg QUINAPRIL HCL 10mg TAC007 ACCUPRIL 20mg QUINAPRIL HCL 20mg TAC006 ACCUPRIL 5mg QUINAPRIL HCL 5mg TAC012 ACERTIL 2mg PERINDOPRIL 2mg TAC010 ACERTIL 4mg PERINDOPRIL 4mg CPA081 ACERTIL PLUS FILMPERINDOPRIL ARGININE COATED 5mg TAC011 ACERTIL AR 5mg PERINDOPRIL ARGININE TAL018 ALDOMET 125mg (GE) METHYLDOPA 125mg TAL020 ALDOMET 250mg (GE) METHYLDOPA 250mg TAP010 APRESOLINE 10mg HYDRALAZINE HCL 10mg TAP012 APRESOLINE 25mg HYDRALAZINE HCL 25mg TAP020 APRESOLINE 50mg (GE) HYDRALAZINE HCL 50mg TAP040 APROVEL 150mg IRBESARTAN 150mg TAP042 APROVEL 300mg IRBESARTAN 300mg TBL023 BLOPRESS Plus16mg CANDESARTAN CILEXETIL 16mg CANDESARTAN CILEXETIL 8mg TBL021 BLOPRESS Plus 8mg TBL022 BLOPRESS 16mg CANDESARTAN CILEXETIL 16mg TBL020 TCA050 TCA052 TCA056 TCA054 TCA060 TCA062 TCA064 BLOPRESS 8mg CAPOTEN 12.5mg CAPOTEN 25mg (GE) CAPOTEN 50mg CAPOTEN 50mg (GE) CARDURA 1mg CARDURA 2mg CARDURA XL 4mg CANDESARTAN CILEXETIL 8mg CAPTOPRIL 12.5mg CAPTOPRIL 25mg CAPTOPRIL 50mg CAPTOPRIL 50mg DOXAZOSIN MESYLATE 1mg DOXAZOSIN MESYLATE Page 3 of2mg 28 DOXAZOSIN MESYLATE 4mg UNIT PRICE ($) 11.60 3.30 4.40 5.00 16.00 PK UNIT 10.50 6.00 CAP TAB TAB TAB CAP CAP TAB 70.00 8.80 85.00 120.00 3.80 1.50 1.20 1.70 17.50 4.40 5.00 11.00 11.000 1.50 0.90 17.00 150.00 AMP TAB AMP AMP TAB TAB TAB TAB TAB CAP TAB TAB TAB TAB TAB TAB AMP 11.00 7.00 7.10 2.50 130.00 1.00 1.20 2.00 7.00 7.00 30.00 14.30 220.00 1.90 0.80 2.70 2.00 3.50 5.30 9.00 0.60 TAB TAB TAB TAB BOT TAB TAB TAB TAB TAB PC DISC PC TAB TAB TAB TAB CAP TAB TAB TAB 7.50 8.50 1.26 8.50 9.90 16.00 13.70 11.70 9.00 11.00 TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB 7.00 10.00 4.60 3.80 6.70 4.50 7.50 1.10 1.60 1.50 2.00 2.00 8.50 14.00 16.00 9.60 16.00 TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB 9.60 2.60 2.00 7.70 3.50 6.40 10.30 8.90 TAB TAB TAB TAB TAB TAB TAB TAB DRUG FORMULARY (MAY 2014) [EFFECTIVE ON MAY 2014] ITEM DRUG DESCRIPTION GENERIC NAME UNIT PRICE NO. ($) TCA066 CARDURA XL 8mg DOXAZOSIN MESYLATE 8mg 11.80 ICA030 CATAPRES INJ 150mcg/mL CLONIDINE HCL 50.00 TAP043 CO-APROVEL IRBESARTAN 8.50 150mg/12.5mg 150mg/HYDROCHLOROTHIAZIDE TAP044 CO-APROVEL IRBESARTAN 14.00 300mg/12.5mg 300/25 mg tab 300mg/25mg 300mg/HYDROCHLOROTHIAZIDE CPA125 CO-APROVEL IRBESARTAN 300mg / 14.00 HCTZ 25mg TCO015 CO-DIOVAN 160mg/12.5mg VALSARTAN 15.00 160mg/HYDROCHLOROTHIAZIDE 7.00 TCO016 CO-DIOVAN 80mg/12.5mg (GE)-[VALSARTAN VALSARTAN, HYDROCHLOROTHIAZIDE + HCT] 10.00 TCO017 CO-DIOVAN 160mg/12.5mg (GE)-[VALSARTAN VALSARTAN, HYDROCHLOROTHIAZIDE + HCT] TCO013 CO-DIOVAN 80mg/12.5mg VALSARTAN 10.70 80mg/HYDROCHLOROTHIAZIDE TRE018 CO-RENITEC ENALAPRIL 8.50 20mg/HYDROCHLOROTHIAZIDE TCO110 COZAAR 100mg LOSARTAN POTASSIUM 100mg 10.00 TCO100 COZAAR 50mg LOSARTAN POTASSIUM 50mg 9.90 TDI050 DIBENYLINE 10mg PHENOXYBENZAMINE 10mg 8.00 TDI101 DIOVAN 160mg VALSARTAN 160mg 15.00 6.50 TDI103 DIOVAN 80mg (GE)-[VALSARTAN] VALSARTAN 9.50 TDI104 DIOVAN 160mg (GE)-[VALSARTAN] VALSARTAN TDI100 DIOVAN 80mg VALSARTAN 80mg 10.70 TDI099 DIOVAN 320mg VALSARTAN 20.00 TDY020 DYNACIRC 2.5mg ISRADIPINE 2.5mg 3.50 THY020 HYZAAR LOSARTAN 9.90 50mg/HYDROCHLOROTHIAZIDE THY022 HYZAAR FORTE LOSARTAN 11.50 100mg/HYDROCHLOROTHIAZIDE 25 THY021 HYZAAR PLUS LOSARTAN, 10.00 HYDROCHLOROTHIAZIDE TIN060 INHIBACE 2.5mg CLIAZAPRIL 2.5mg 4.40 TMI005 MICARDIS 40mg TELMISARTAN 40mg 10.60 TMI006 MICARDIS 80mg TELMISARTAN 80mg 16.80 TMI004 MICARDIS PLUS TELMISARTAN 10.00 40mg/12.5mg1mg (GE) 40mg/HYDROCHLOROTHIAZIDE TMI050 MINIPRESS PRAZOSIN HCL 1mg 1.50 TMI052 MINIPRESS 2mg (GE) PRAZOSIN HCL 2mg 2.00 TMI054 MINIPRESS 5mg PRAZOSIN HCL 5mg 8.60 TMI053 MINIPRESS 5mg (GE) PRAZOSIN HCL 5mg 5.00 TMO030 MONOPRIL 10mg FOSINOPRIL SODIUM 10mg 4.50 TNA020 NATRILIX 2.5mg (GE) INDAPAMIDE 2.5mg 2.00 TNA021 NATRILIX SR 1.5mg INDAPAMIDE 1.5mg 5.20 TNI026 NIFTEN ATENOLOL 50mg/NIFEDIPINE SR 11.90 20mg TPR026 PREDONIUM PERINDOPRIL 2mg/INDAPAMIDE 5.00 0.625mg TPR082 PRINIVIL 5mg LISINOPRIL 5mg 3.50 ALISKIREN 150mg TRA005 RASILEZ 150mg 16.00 TRA006 RASILEZ 300mg 20.00 ALISKIREN 300mg 16.000 TRA007 RASILEZ HCT ALISKIREN 150mg, HCT 12.5mg 20.000 TRA008 RASILEZ HCT ALISKIREN 300mg, HCT 12.5mg TRE020 RENITEC 10mg ENALAPRIL MALEATE 10mg 5.30 TRE021 RENITEC 10mg (GE) ENALAPRIL MALEATE 10mg 3.20 TRE026 RENITEC 2.5mg ENALAPRIL MALEATE 2.5mg 3.00 TRE022 RENITEC 20mg ENALAPRIL MALEATE 20mg 7.00 TRE023 RENITEC 20mg (GE) ENALAPRIL MALEATE 20mg 4.20 TRE024 RENITEC 5mg ENALAPRIL MALEATE 5mg 3.70 TRE025 RENITEC 5mg (GE) ENALAPRIL MALEATE 5mg 2.10 TTA025 TANATRIL 10mg IMIDAPRIL 10mg 4.00 TTA060 TARKA VERAPAMIL,TRANDOLAPRIL 7.20 TTE030 TENORET 50mg ATENOLOL 50mg/CHLORTHALIDONE 7.50 12.5mg TTE040 TENORETIC ATENOLOL 10.90 100mg/CHLORTHALIDONE 25mg TTE042 TENORETIC (GE) ATENOLOL 5.00 100mg/CHLORTHALIDONE 25mg TTE080 TEVETEN 600mg EPROSARTAN 600mg 15.00 TTR010 TRANDATE 100mg LABETALOL HCL 100mg 7.00 TTR068 TRITACE 2.5mg RAMIPRIL 2.5mg 2.40 TTR070 TRITACE 5mg RAMIPRIL 5mg 3.50 TZE010 ZESTORETIC LISINOPRIL 11.30 20mg/HYDROCHLOROTHIAZIDE TZE020 ZESTRIL 10mg LISINOPRIL DIHYDRATE 10mg 7.20 TZE021 ZESTRIL 10mg (GE) LISINOPRIL DIHYDRATE 10mg 3.50 TZE022 ZESTRIL 20mg LISINOPRIL DIHYDRATE 20mg 9.90 TZE023 ZESTRIL 20mg (GE) LISINOPRIL DIHYDRATE 20mg 5.00 TZE024 ZESTRIL 5mg LISINOPRIL DIHYDRATE 5mg 4.30 TZE025 ZESTRIL 5mg (GE) LISINOPRIL DIHYDRATE 5mg 2.00 ANTIGLAUCOMA PREPARATION DAZ006 AZARGA EYE DROPS BRINZOLAMIDE 10mg,TIMOLOL 5mg 230 DTA004 TAFLOTAN EYE DROPS TAFLUPROST 250 2.5mL DGA008 GANFORT EYE DROPS BIMATOPROST,TIMOLOL 320.00 BETA-BLOCKERS 6.20 TBE028 BETALOC 100mg METOPROLOL 100mg TBE033 BETALOC 50mg METOPROLOL TARTRATE 50mg 3.70 TBE032 BETALOC 50mg (GE) METOPROLOL TARTRATE 50mg 1.50 TBE030 BETALOC 100mg (GE) METOPROLOL TARTRATE 100mg 2.90 TBE040 BETALOC DURULE 200mg METOPROLOL TARTRATE 200mg 5.50 TBE046 BETALOC ZOK 25mg METOPROLOL SUCCINATE 25mg 3.80 TBE048 BETALOC ZOK 50mg METOPROLOL SUCCINATE 50mg 3.70 TBE049 BETALOC ZOK 50mg (GE) METOPROLOL SUCCINATE 50mg 2.00 TBE050 BETALOC ZOK 100mg METOPROLOL SUCCINATE 100mg 5.90 TBE052 BETALOC ZOK 200mg METOPROLOL SUCCINATE 200mg 12.50 TBE034 BETALOC COMP 100mg METOPROLOL 5.40 100mg/HYDROCHLORTHIAZIDE 12.5mg IBE012 BETALOC INJ 1mg/Ml METOPROLOL SUCCINATE 401.30 TBL010 BLOCADREN 10mg TIMOLOL MALEATE 10mg 3.50 TCO062 CONCOR 2.5mg BISOPROLOL FUMARATE 2.5mg 3.50 Page 4 of 28 TCO060 CONCOR 5mg BISOPROLOL FUMARATE 5mg 4.00 PK UNIT TAB AMP TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB CAP TAB TAB TAB CAP TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB CAP TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB CAP TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB BOT BOT BOT TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB AMP TAB TAB TAB DRUG FORMULARY (MAY 2014) [EFFECTIVE ON MAY 2014] ITEM DRUG DESCRIPTION NO. TCO080 CORGARD 80mg TDI075 DILATREND 6.25mg TDI076 DILATREND 12.5mg TDI077 DILATREND 25mg TIN020 INDERAL 10mg (GE) CPA148 INDERAL TABLET 10mg CPA124 INDERAL 20mg (GE) TIN022 INDERAL 40mg (GE) TIN030 INDERAL LA 80mg TIN032 INDERAL LA 160 mg IIN010 INDERAL INJ 1mg/mL TLO013 LOGIMAX TLO006 LODOZ 2.5mg/6.25mg TLO007 LODOZ 5mg/6.25mg TSE010 SECTRAL 100mg TSE012 SECTRAL 200mg TSE018 SELECTOL 200mg TSO020 SOTACOR 80mg (GE)TSO022 [SOTALOL] TTE055 TENORMIN 25mg (GE) TTE052 TENORMIN 50mg TTE054 TENORMIN 50mg (GE) TTE050 TENORMIN 100mg TTE056 TENORMIN 100mg (GE) CALCIUM ANTAGONISTS TAC013 ACERYCAL 5mg/5mg TAC014 ACERYCAL 5mg/10mg TAC016 ACERYCAL 10mg/10mg TAC017 ACERYCAL 10mg/5mg TAD012 ADALAT 5mg (GE) TAD010 ADALAT 10mg (GE) TAD020 ADALAT GITS 30mg TAD021 ADALAT GITS 30mg (GE) TAD022 ADALAT GITS 60mg TAD028 ADALAT RETARD TAB TAD030 20MG ADALAT RETARD 20mg (GE) TAZ010 AZOREN 20mg/5mg TAZ012 AZOREN 40mg/5mg TBA010 BAYPRESS 10mg TBA020 BAYPRESS 20mg TEX022 EXFORGE 5mg/160mg TEX020 EXFORGE 5mg/80mg EXFORGE HCT TEX023 5mg/160mg/12.5mg TEX024 EXFORGE 10mg/160mg HCT TEX025 EXFORGE 10mg/160mg/12.5mg HCT TEX026 10mg/160mg/25mg TEX027 EXFORGE HCT 10mg/320mg/25mg CPA085 EXFORGE HCT(5mg/160mg/12.5mg) THE018 HERBESSER 30mg THE020 HERBESSER 30mg (GE) THE022 HERBESSER 60mg (GE) THE024 HERBESSER 60mg THE034 HERBESSER SR 90mg THE030 HERBESSER SR 120mg (GE) THE032 HERBESSER SR 180mg GENERIC NAME NADOLOL 80mg CARVEDILOL 6.25mg CARVEDILOL 12.5mg CARVEDILOL 25mg PROPRANOLOL HCL 10mg PROPRANOLOL HYDROCHLORIDE PROPRANOLOL HCL 20mg PROPRANOLOL HCL 40mg PROPRANOLOL HCL 80mg PROPRANOLOL HCL 160mg PROPRANOLOL HCL FELODIPINE 5mg,METOPROLOL 50mg BISOPROLOL FUMARATE/HYDROCHLOROTHIAZID BISOPROLOL FUMARATE/HYDROCHLOROTHIAZID ACEBUTOLOL HCL 100mg ACEBUTOLOL HCL 200mg CELIPROLOL HCL 200mg SOTALOL HCL 80mg SOTALOL ATENOLOL 25mg ATENOLOL 50mg ATENOLOL 50mg ATENOLOL 100mg ATENOLOL 100mg PERINDOPRIL 5mg, AMLODIPINE 5mg PERINDOPRIL 5mg, AMLODIPINE 10mg PERINDOPRIL, AMLODIPINE PERINDOPRIL, AMLODIPINE NIFEDIPINE 5mg NIFEDIPINE 10mg NIFEDIPINE 30mg NIFEDIPINE 30mg NIFEDIPINE 60mg NIFEDIPINE MODIFIED RELEASE NIFEDIPINE 20mg OLMESARTAN 20mg, AMLODIPINE 5mg OLMESARTAN 40mg, AMLODIPINE 5mg NITRENDIPINE 10mg NITRENDIPINE 20mg AMLODIPINE BESYLATE VALSARTANABESYLATE AMLODIPINE VALSARTANA5mg, VALSARTAN AMLODIPINE 160mg, HYDROCHLOROTHIAZIDE AMLODIPINE BESYLATE 10mg, VALSARTAN VALSARTANA 160mg, HYDROCHLOROTHIAZIDE AMLODIPINE 10mg, VALSARTAN 160mg, HYDROCHLOROTHIAZIDE AMLODIPINE 10mg, VALSARTAN 320mg, HYDROCHLOROTHIAZIDE AMLODIPINE, VALSARTANA, HYDROCHLOROTHIAZIDE DILTIAZEM DILTIAZEM HCL 30mg DILTIAZEM HCL 60mg DILTIAZEM HCL 60mg DILTIAZEM HCL 90mg DILTIAZEM HCL 120mg DILTIAZEM HCL 180mg UNIT PRICE ($) 5.00 4.00 5.10 5.60 1.00 1.50 1.30 1.50 4.50 6.70 80.00 21.50 3.30 3.30 2.35 4.16 6.00 5.00 2.50 2.00 3.00 2.00 4.00 2.80 PK UNIT 9 12.5 14.3 12.5 2.00 3.00 10.80 5.50 15.90 10.00 4.30 9.90 12.30 8.80 11.00 17.00 14.00 TAB TAB TAB TAB CAP CAP TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB AMP TAB TAB TAB TAB AMP TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB THE033 HERBESSER R 100mg DILTIAZEM HCL 100mg CPA077 IHE050 TIS018 TIS020 TIS022 TIS030 IIS010 TLA018 TLA020 TNO080 TNO081 TNO082 TNO083 TPL022 TPL024 TPL025 TPL020 TTW010 TTW012 TTW014 TTW016 TZA025 DIURET ICS TAL012 TAL010 TAL008 TAM018 HERBESSER SR 200mg HERBESSER INJ 50mg ISOPTIN 40mg ISOPTIN 40mg (GE) ISOPTIN 80mg (GE) ISOPTIN SR 240mg ISOPTIN INJ 5mg/2mL LACIPIL 2mg LACIPIL 4mg NORVASC 5mg NORVASC 5mg [ACTAPIN] NORVASC 10mg NORVASC 10mg [ACTAPIN] PLENDIL 2.5mg PLENDIL 5mg PLENDIL 5mg (GE) PLENDIL 10mg TWYNSTA 40mg/5mg TWYNSTA 40mg/10mg TWYNSTA 80mg/5mg TWYNSTA 80mg/10mg ZANIDIP 10mg DILTIAZEM HCL 200mg DILTIAZEM VERAPAMIL HCL 40mg VERAPAMIL HCL 40mg VERAPAMIL HCL 80mg VERAPAMIL HCL 240mg VERAPAMIL HCL LACIDIPINE 2mg LACIDIPINE 4mg AMLODIPINE BESYLATE 5mg AMLODIPINE BESYLATE 5mg AMLODIPINE BESYLATE 10mg AMLODIPINE BESYLATE 10mg FELODIPINE 2.5mg FELODIPINE 5mg FELODIPINE FELODIPINE 10mg TELMISARTAN 40mg, AMLODIPINE 5mg TELMISARTAN 40mg, AMLODIPINE 10mg TELMISARTAN 80mg, AMLODIPINE 5mg TELMISARTAN 80mg, AMLODIPINE 10mg LERCANIDIPINE HCl 10mg 17.00 20.00 20.00 20.00 21.7 17.60 2.50 1.50 3.00 3.20 5.00 5.50 7.00 4.50 11.00 90.00 3.60 2.50 4.00 12.30 90.00 5.10 7.70 6.50 4.00 11.70 7.50 4.40 6.80 4.00 12.40 11.00 12.00 17.00 18.00 7.20 ALDACTONE 100mg ALDACTONE 25mg ALDACTONE 25mg (GE) AMILORIDE 5mg SPIRONOLACTONE 25mg SPIRONOLACTONE 100mg SPIRONOLACTONE 25mg AMILORIDE 5mg Page 5 of 28 13.00 5.80 3.70 0.70 TAB TAB TAB TAB TAB TAB TAB TAB CAP CAP AMP TAB TAB TAB CAP CAP TAB TAB TAB TAB TAB TAB TAB TAB DRUG FORMULARY (MAY 2014) [EFFECTIVE ON MAY 2014] ITEM DRUG DESCRIPTION GENERIC NAME NO. TDI030 DIAMOX 250mg (GE) ACETAZOLAMIDE 250mg IDI006 DIAMOX INJ 500mg (GE) ACETAZOLAMIDE TDY008 DYAZIDE TRIAMTERENE 50mg/HYDROCHLOROTHIAZIDE 25mg TDY010 DYAZIDE (GE) TRIAMTERENE 50mg/HYDROCHLOROTHIAZIDE 25mg TEN020 ENDURON 5mg METHYCLOTHIAZIDE 5mg TFR010 FRUMIL FRUSEMIDE 40mg/AMILORIDE 5mg THY006 HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE 25mg 25mg THY008 HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE 50mg 50mg 40mg TLA078 LASIX FRUSEMIDE 40mg TLA080 LASIX 40mg (GE) FRUSEMIDE 40mg ILA012 LASIX INJ 20mg/2mL FRUSEMIDE TLA090 LASIX SPECIAL TAB 500mg FRUSEMIDE 500mg TMI028 MIDAMOR 5mg AMILORIDE 5mg TMO008 MODURETIC AMILORIDE 5mg/HYDROCHLOROTHIAZIDE 50mg TMO010 MODURETIC (GE) AMILORIDE 5mg/HYDROCHLOROTHIAZIDE 50mg TNA030 NAVISPARE CYCLOPENTHIAZIDE 0.25mg/AMILORIDE 2.5mg TZA050 ZAROXOLYN 5mg METOLZAONE CPA076 ZAROXOLYN METOLAZONE ANTIDIURETICS TMI059 MINIRIN 0.1mg DESMOPRESSION TMI060 MINIRIN 0.2mg DESMOPRESSION TMI061 MINIRIN MELT 60mcg DESMOPRESSIN ORAL LYOPHILISATES ACETATE 60mcg TMI062 MINIRIN MELT 120mcg DESMOPRESSIN 120mcg DMI010 MINIRIN DDAVP NASAL DESMOPRESSION ACETATE SPRAY 0.01% PERIPHERAL VASODILATORS & CEREBRAL ACTIVATORS IAT006 ATP INJ 20mg/2mL ATP TDO062 DOXIUM 500mg CA DOBESILATE TDU030 DUXARIL AOLMITRINE 30mg,RAUBASINE 10mg TME040 MERISLON 6mg BETAHISTINE MESILATE 6mg TSE056 SERMION 10mg NICERGOLINE 10mg CPA101 SERMION 30mg NICERGOLINE 30mg CPA078 STUGERON 25mg (JASSEN) CINNARIZINE TST040 STUGERON 25mg (GE) CINNARIZINE 25mg MIGRAI NE TCA010 CAFERGOT ERGOTAMINE TARTRATE 1mg/CAFFEINE 100mg TDI120 DIXARIT 0.025mg CLONIDINE HCL 0.025mg TGR006 GRAVERGOL ERGOTAMINE,DIMENHYDRINATE,C AFFEINE TIM018 IMIGRAN 50mg SUMATRIPTAN SUCCINATE 50mg IIM010 IMIGRAN INJ 6mg/0.5mL SUMATRIPTAN SUCCINATE (REFILL) TMI030 MIGRIL ERGOTAMINE,CYCLIZINE,CAFFEINE TSA040 SANDOMIGRAN 0.5mg PIZOTIFEN 0.5mg TSI010 SIBELIUM 5mg (GE) FLUNARIZINE 5mg TZO024 ZOMIG 2.5mg ZOLMITRIPTAN 2.5mg TZO025 ZOMIG RAPIMELT 2.5mg ZOLMITRIPTAN 2.5mg HAEMOSTATICS TTR020 TRANSAMIN 250mg TRANEXAMIC ACID 250mg TTR022 TRANSAMIN 500mg TRANEXAMIC ACID 500mg ITR020 TRANSAMIN 5% IV INJ TRANEXAMIC ACID (250mg/5mL) 10% IM INJ ITR010 TRANSAMIN TRANEXAMIC ACID (250mg/2.5mL) TRE050 REVOLADE 25mg ELTROMBOPAG OLAMINE TVI060 VITAMIN K-3 10mg VITAMIN K-3 10mg ANTICOAGULANTS, ANTITHROMBOTICS & FIBRINOLYTICS TAG010 AGGRENOX DIPYRIDAMOLE,ASPIRIN TBR024 BRILINTA 90mg TICAGRELOR TCA070 CARTIA 100mg ASPIRIN 100mg ICL010 CLEXANE 40mg/0.4mL ENOXAPARIN 40mg ICL012 CLEXANE 60mg/0.6mL ENOXAPARIN 60mg ICL013 CLEXANE 80mg/0.8mL ENOXAPARIN 80mg TCO067 CO-PLAVIX CLOPIDOGREL, ASPIRIN TCO094 COUMADIN 2mg WARFARIN 2mg TEL015 ELIQUIS 5mg APIXABAN IFR010 FRAGMIN INJ 5,000 IU/2mL DALTEPARIN Na IFR019 FRAXIPRARINE 2850 AXa NADROPARIN Ca iu/0.3mL IFR020 FRAXIPARINE 3,800 AXa NADROPARIN Ca IU/0.4mL INJ IIN018 INNOHEP 20,000 IU/mL TINZAPARIN TXA014 2X0.5mL XARELTO 10mg RIVAROXABAN TXA015 XARELTO 20mg RIVAROXABAN 20mg TPR005 PRADAXA 75mg DABIGATRAN 75mg TPR006 PRADAXA 110mg DABIGATRAN TPR007 PRADAXA 150mg DABIGATRAN 150mg TPL014 PLAVIX 75mg CLOPIDOGREL 75mg TPL015 PLAVIX 75mg (GE) CLOPIDOGREL TPL028 PLETAAL 50mg CILOSTAZOL 50mg TTI010 TICLID 250mg TICLOPIDINE 250mg TWA010 WARFARIN 1mg WARFARIN 1mg TWA012 WARFARIN 3mg WARFARIN 3mg TWA014 WARFARIN 5mg WARFARIN 5mg HAEMORRHOIDAL, PHLEBITIS & VARICOSE PREPARATIONS CAN028 ANUSOL OINTMENT 25g BISMUTH SUBGALLATE CAN030 ANUSOL OINTMENT (GE) BISMUTH SUBGALLATE 30g PAN010 ANUSOL SUPP BALSAM PERU, BISMUTH OXIDE... CAN040 ANUSOL-HC OINTMENT HYDROCORTISONE, ZINC SULFATE (GE) 15g PAN018 ANUSOL-HC SUPP BISMUTH OXIDE,Page ZINC OXIDE.... 6 of 28 PAN020 ANUSOL-HC SUPP (GE) BISMUTH OXIDE, ZINC OXIDE.... UNIT PRICE ($) 2.50 480.00 2.00 1.40 2.00 3.60 0.30 0.50 3.00 1.60 42.00 23.00 1.70 2.20 1.40 3.30 8.40 4.95 PK UNIT 13.50 20.00 12.18 30.00 540.00 TAB TAB TAB TAB BOT 25.00 6.30 8.90 1.20 12.50 33.00 2.70 1.20 AMP CAP TAB TAB TAB TAB TAB TAB 7.00 2.80 1.65 96.00 440.00 5.50 3.20 3.00 102.40 89.00 TAB TAB CAP TAB AMP TAB TAB CAP TAB TAB 2.30 3.00 80.00 110.00 400.00 1.10 CAP TAB AMP AMP TAB TAB 6.90 25.00 1.70 100.00 120.00 150.00 20.00 1.50 17.00 94.00 160.00 156.00 190.00 38.00 40.00 20.00 20.00 20.00 20.00 14.00 6.80 19.50 1.10 1.60 2.00 CAP TAB TAB AMP AMP AMP TAB TAB TAB AMP AMP AMP AMP TAB TAB CAP CAP CAP CAP TAB TAB TAB TAB TAB TAB 2.50 1.00 4.60 2.00 6.00 6.00 g g SUPP g SUPP SUPP TAB TAB AMP TAB TAB TAB TAB TAB TAB TAB TAB AMP TAB TAB TAB TAB TAB TAB DRUG FORMULARY (MAY 2014) [EFFECTIVE ON MAY 2014] ITEM DRUG DESCRIPTION GENERIC NAME NO. TDA010 DAFLON 500mg DIOSMIN 450mg, HESPERIDIN 50mg CFA010 FAKTU OINTMENT 20g POLICRESULEN, CINCHOCAINE HCL PFA010 FAKTU SUPP POLICRESULEN, CINCHOCAINE HCL CHI031 HIRUDOID CREAM 5g (GE) MUCOPOLYSACCHARIDE POLYSULFATE CHI030 HIRUDOID CREAM 14g MUCOPOLYSACCHARIDE POLYSULFATE CHI040 HIRUDOID CREAM 40g MUCOPOLYSACCHARIDE CHI032 HIRUDOID FORTE CREAM POLYSULFATE MUCOPOLYSACCHARIDE 14g POLYSULFATE IPH020 PHENOL IN ALMOND OIL PHENOL INJ 250mg/5mL CPH013 PHENOL 5% IN ALMOND PHENOL OIL CPR008 PREMARIN VAGINAL CONJUGATED ESTROGENS CREAM 14g CPR014 PROCTOSEDYL HYDROCORTISONE, CINCHOCAINE... OINTMENT 15g SUPP PRO010 PROCTOSEDYL HYDROCORTISONE,CINCHOCAINE HCL TRE027 REPARIL 20mg AESCIN ISO072 SODIUM TETRADECYL SODIUM TETRADECYL SULPHATE SULPHATE (FIBRO-VEIN) ITR040 TROMBOVAR 3% INJ SODIUM TETRADECYL SULFATE CUL010 ULTRAPROCT OINTMENT FLUOCORTOLONE, CINCHOCAINE 10g CUL012 ULTRAPROCT-N CREAM FLUOCORTOLONE PIVALATE 10g PUL010 ULTRAPROCT SUPP FLUOCORTOLONE, CINCHOCAINE HCL TVE020 VENORUTON 300mg TRIHYDROXYETHYLRUTOSIDE 300mg CXY030 XYLOPROCT OINTMENT LIDOCAINE, HYDROCORTISONE PXY010 20g XYLOPROCT SUPP LIDOCAINE, HYDROCORTISONE CZI020 ZINC OXIDE OINTMENT ZINE OXIDE 15% HAEMATOPOIETIC AGENTS CPA112 ARANESP 20 mcg/0.5 mL DARBEPOETIN α CPA113 ARANESP 40 mcg/0.4 Ml DARBEPOETIN α CPA114 ARANESP 100 mcg/0.5 mL DARBEPOETIN α IAR001 ARANESP [darbepoetin] DARBEPOETIN 40mcg/0.4ml PRE-FILLED ILE010 LEUCOMAX INJ 150mcg MOLGRAMOSTIM ILE012 LEUCOMAX INJ 300mcg MOLGRAMOSTIM INE005 NEULASTIM 6 mg/0.6 mL PEGFILGRASTIM NEUPOGEN 300mcg/0.5mL INE006 PRE-FILLED FILGRASTIM IRE010 RECORMON INJ 5,000IU ERYTHROPOIETIN OTHER CARDIOVASCULAR ADENOSCAN INJ DRUGS ADENOSINE IAD005 30mg/10mL CPA156 EDARBI 40 mg AZILSARTAN MEDOXOMIL CPA149 EDARBI 80mg AZILSARTAN MEDOXOMIL TEF020 EFFIENT 10mg PRASUGREL 10mg CPA045 EIQUINON 10mg UBIDECARENONE (COENZYME Q10) TGU010 GUTRON 2.5mg MIDRODINE HYDROCHOLORIDE TIM019 IMIGRAN 50mg (GE) SUMATRIPTAN SUCCINATE 50mg TIN080 INSPRA 25mg EPLERENONE 25mg TIN082 INSPRA 50mg EPLERENONE 50mg TPR017 PRAXILENE 100mg NAFTIDROFURYL 100mg TTR030 TRENTAL 400mg PENTOXIFYLLINE 400mg ANTIASTHMATIC PREPARATIONS IAD010 ADRENALINE INJ 1:1,000 ADRENALINE IM (GE) METERED-DOSE CICLESONIDE CPA074 ALVESCO INHALER MDI 160 CPA144 ALVESCO CICLESONIDE IAM020 mcg/actuation AMINOPHYLLINE INJ AMINOPHYLLINE 250mg/10mL IV IAM010 AMINOPHYLLINE INJ AMINOPHYLLINE 250mg/2mL IM SAT018 ATROVENT INHALER IPRATROPIUM BROMIDE 20mcg/puff (200 Doses) ANHYDROUS BROMIDE SAT010 ATROVENT NEB IPRATROPIUM SOLUTION10mg 0.25mg/mL ANHYDROUS HYDROCHLORIDE TBA004 BAMBEC BAMBUTEROL MBA010 BAMBEC SYR.1mg/1ml BAMBUTEROL HYDROCHLORIDE SBE006 BECLAZONE INHALER BECLOMETHASONE DIPROPIONATE 100mcg SBE010 BECLOFORTE BECLOMETHASONE DIPROPIONATE INHALER (200 Doses) SBE011 250mcg/puff (GE) BECLOMETHASONE DIPROPIONATE SBE020 BECODISK 100mcg x 8 BECLOMETHASONE DIPROPIONATE Doses SBE022 BECODISK 200mcg x 8 BECLOMETHASONE DIPROPIONATE Doses SBE060 BECOTIDE DISKHALER BECODISK DISKHALER SBE070 BECOTIDE INHALER BECLOMETHASONE DIPROPIONATE 50mcg/puff (200 Doses) SBE071 BECOTIDE INHALER BECLOMETHASONE DIPROPIONATE 50mcg/puff 2.5mg (GE) TBE020 BEROTEC FENOTEROL HBr 2.5mg SBE080 BEROTEC INHALER FENOTEROL HBr 0.2mg/puff 300 puffs TBR010 BRICANYL 2.5mg TERBUTALINE SULFATE 2.5mg TBR012 BRICANYL 2.5mg (GE) TERBUTALINE SULFATE 2.5mg TBR020 BRICANYL DURULE 5mg TERBUTALINE SULFATE 5mg TBR022 BRICANYL DURULE 7.5mg TERBUTALINE SULFATE 7.5mg MBR010 BRICANYL SYRUP TERBUTALINE SULFATE 1.5mg/5mL (GE) IBR010 BRICANYL INJ 0.5mg/mL TERBUTALINE SULFATE SBR010 BRICANYL INHALER TERBUTALINE SULPHATE 250mcg/puff NEB (400 Doses) SBR020 BRICANYL SOLUTION TERBUTALINE SULFATE 10mg/mL 50mL/BOT SBR026 BRICANYL SPACER TERBUTALINE SULFATE INHALER 250mcg/puff 400 TERBUTALINE SULFATE SBR030 BRICANYL TURBUHALER 0.5mg/dose (200 Doses) SBR024 BRINCANYL RESPULE TERBUTALINE SULFATE SCO020 0.5mg/2mL COMBIVENT INHALER IPRATROPIUM, SALBUTAMOL TDA070 DAXAS 500mcg ROFLUMILAST SCO010 COMBIVENT IPRATROPIUM Br NEB.SOLU.2.5ml/vial ANHYDROUS/SALBU CPA137 COMBIVENT NEBULE IPRATROPIUM BR ANHYDROUS 0.5mg, SALBUTAMOL 2.5mg MDI020 DIPROPHYLLINE DIPROPHYLLINE 100mg/5mL IEP002 EPIPEN AUTO-INJECTOR ADRENALINE 1:1000 SFL024 FLIXOTIDE ACCUHALER FLUTICASONE PROPIONATE 50mcg Page 7 of 28 SFL026 FLIXOTIDE INHALER FLUTICASONE PROPIONATE 25mcg/puff ( 60 DOSE) UNIT PRICE ($) 6.00 4.30 6.00 2.30 3.80 2.80 4.64 100.00 3.40 84.00 3.40 4.60 1.75 400.00 60.00 9.00 8.60 9.20 6.00 3.20 5.80 0.80 PK UNIT 500 880 1700 1314 680.00 1280.00 14520.00 1300.00 760.00 AMP AMP AMP SYR VIA VIA AMP AMP VIA 210 7.30 8.50 28.00 2.30 3.00 50.00 32.10 51.00 3.70 6.40 AMP TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB 70.00 238.00 375.00 50.00 32.00 220.00 150.00 3.50 0.60 255.00 360.00 120.00 18.00 30.00 55.00 110.00 70.00 1.00 120.00 1.00 1.20 2.60 4.20 0.17 77.30 132.00 160.00 130.00 258.00 9.00 200.00 20.500 12.00 9.00 0.17 1500.00 400.00 50.00 AMP PC PC AMP AMP PC BOT TAB ML PC PC PC DISC DISC PC PC PC TAB PC TAB TAB TAB TAB ML AMP PC BOT PC PC AMP PC TAB VIA NEB ML AMP PC PC TAB g SUPP g g g g VIA ML TUB g SUPP TAB AMP VIA g g SUPP CAP g SUPP g DRUG FORMULARY (MAY 2014) [EFFECTIVE ON MAY 2014] ITEM NO. SFL028 SFL029 SFL030 SFL032 SFL033 SFL025 CPA138 SIN010 SIN012 SIN030 SIN040 TNU010 TNU012 MNU010 CPA145 CPA146 SOX010 SOX011 SPU012 SPU010 SPU011 SPU040 SPU042 SPU060 SPU062 SPU064 SPU030 SRE010 SSE020 SSE009 SSE022 SSE006 SSE007 SSE008 CPA079 SSE012 SSE010 SSE016 TSI058 TSI060 TSI062 MSI020 TSL012 TSL010 TSL011 TSL014 TSL016 SSP020 CPA089 CPA087 SSY010 SSY012 SSY008 TTE006 TTH010 TTH012 STI010 CPA147 SVE010 SVE020 SVE022 TVE030 TVE032 MVE012 MVE010 IVE010 SVE050 SVE052 SVE030 SVE040 SVE060 SVE070 TVO010 TVO011 TVO012 AVO012 TZA018 TZA020 MZA020 MZA030 DIN010 DRUG DESCRIPTION GENERIC NAME FLIXOTIDE INHALER 50mcg/puff (60 Doses) FLIXOTIDE INHALER 50mcg/puff (120 Doses) FLIXOTIDE INHALER 125mcg/puff INHALER (60 Doses) FLIXOTIDE 250mcg/puff INHALER (120 Doses) FLIXOTIDE 250mcg/puff ACCUHALER (60 Doses) FLIXOTIDE 250mcg FLIXOTIDE NEBULES 0.5 mg/2 mL INTAL INHALER 1mg/puff (200 Doses) INTAL INHALER 5mg/puff (112 Doses) INTAL NEB SOLUTION 20mg/2mL INTAL SPINCAP 20mg NUELIN SR 200mg NUELIN SR 300mg NUELIN SYRUP 80mg/15mL 60mL ONBREZ BREEZHALER 150 mcg INHALATION POWD CAP ONBREZ BREEZHALER 300 mcg INHALATION POWD CAP OXIS TURBUHALER FLUTICASONE PROPIONATE FLUTICASONE PROPIONATE FLUTICASONE PROPIONATE FLUTICASONE PROPIONATE FLUTICASONE PROPIONATE FLUTICASONE PROPIONATE FLUTICASONE PROPIONATE SODIUM CROMOGLYCATE SODIUM CROMOGLYCATE SODIUM CROMOGLYCATE SODIUM CROMOGLYCATE ANHYDROUS THEOPHYLLINE 200mg ANHYDROUS THEOPHYLLINE 300mg THEOPHYLLINE INDACATEROL MALEATE 4.5mcg/dose (60 Doses) OXIS TURBUHALER 9mcg/dose (60 INHALER Doses) PULMICORT 50mcg/puff (200 Doses) PULMICORT INHALER (100 Dose) Doses) 200mcg/puff (120 PULMICORT SPACE INHALER 200mcg/puff PULMICORT SPACE (100 INHALER 50mcg/puff (200 PULMICORT TURBUHALER PULMICORT 100mcg/dose TURBUHALER 200mcg/dose PULMICORT TURBUHALER 400mcg/dose PULMICORT RESPULE 0.5mg/2mL AUTO-HALER RESPOLIN 100mcg/puffINHALER (400 Doses) SERETIDE 25mcg/125mcg SERETIDE INHALER 25mcg/50mcg SERETIDE INHALER 25mcg/250mcg SERETIDE ACCUHALER 50mcg/100mcg (60 Doses) SERETIDE ACCUHALER 50mcg/500mcg (60 Doses) SERETIDE ACCUHALER 50mcg/250mcg (60 Doses) SERETIDE ACCUHALER 500mcg SEREVENT INHALER 25mcg/puff (120 Doses) SEREVENT INHALER 25mcg/puff (60 Doses) SEREVENT ACCUHALER 50mcg/dose (60 Doses) SINGULAIR 4mg SINGULAIR 5mg SINGULAIR 10mg SINGULAIR ORAL GRANULES 4mg SLO-BID 50mg SLO-BID 100mg SLO-BID 200mg SLO-THEO 50mg SLO-THEO 100mg SPIRIVA 18mcg CAPSULES FOR INHALATION SPIRIVA RESPIMAT SOLUTION FOR SPIRIVA TURBUHALER 18mcg SYMBICORT TURBUHALER 160/4.5mcg 320/9mcg/dose (60 doses) SYMBICORT TURBUHALER TEDRAL SA THEODUR 200mg THEODUR 300mg TILADE STANDARD INHALER 2mg/puff, 112MDI VANNAIR 160/4.5 mcg VENTIDE INHALER (200 Doses) VENTODISK 200mcg x 8 Doses VENTODISK 400mcg x 8 Doses VENTOLIN 2mg (GE) VENTOLIN 4mg (GE) VENTOLIN EXPECTORANT (G.E) VENTOLIN SYRUP 2mg/5mL (GE) VENTOLIN INJ 0.5mg/mL VENTOLIN INHALER 100mcg/puff INHALER (200 Doses) VENTOLIN 100mcg/puff ACCUHALER (GE) VENTOLIN 200mcg VENTOLIN DISKHALER VENTOLIN NEBULE 2.5mg/2.5mLRESP VENTOLIN SOLUTION4mg 5mg/mL VOLMAX VOLMAX {Salbutamol} 4mg (GE) VOLMAX 8mg VOLUMATIC SOFT (GLAXO) 1mg ZADITEN ZADITEN 1mg (GE) ZADITEN SYRUP 1mg/5mL ZANTAC 150mg/10mL INHALANT 30mL/BOT (GE) UNIT PRICE ($) 105.00 322.00 340.00 605.00 336.00 442.00 25.00 204.00 170.00 3.00 3.00 1.30 1.60 0.22 384.00 PK UNIT INDACATEROL MALEATE 637.00 PC FORMOTEROL FUMARATE 4.5mcg FORMOTEROL FUMARATE 9 mcg BUDESONIDE BUDESONIDE BUDESONIDE BUDESONIDE BUDESONIDE BUDESONIDE BUDESONIDE BUDESONIDE BUDESONIDE SALBUTAMOL SULFATE SALMETEROL, FLUTICASONE SALMETEROL, FLUTICASONE SALMETEROL, FLUTICASONE SALMETEROL, FLUTICASONE SALMETEROL, FLUTICASONE SALMETEROL, FLUTICASONE SALMETEROL, FLUTICASONE SALMETEROL XINAFOATE SALMETEROL XINAFOATE SALMETEROL XINAFOATE ZINCAPS MONTELUKAST SODIUM 5mg MONTELUKAST SODIUM 10mg MONTELUKAST SODIUM 4mg THEOPHYLLINE 50mg THEOPHYLLINE 100mg THEOPHYLLINE 200mg ANHYDROUS THEOPHYLLINE 50mg ANHYDROUS THEOPHYLLINE 100mg TIOTROPIUM 18 mcg TIOTROPIUM BR TIOTROPIUM 18 mcg BUDESONIDE/FORMOTEROL FUMARATE BUDESONIDE 320mcg,FORMOTEROL FUMARATE DIHYDRATE 9mcg BUDESONIDE/FORMOTEROL FUMARATE THEOPHYLLINE, EPHEDRINE... ANHYDROUS THEOPHYLLINE 200mg ANHYDROUS THEOPHYLLINE 300mg NEDOCROMIL Na BUDESONIDE, FORMOTEROL FUMARATE DIHYDRATE SALBUTAMOL, BECLOMETHASONE SALBUTAMOL SULPHATE SALBUTAMOL SULPHATE SALBUTAMOL 2mg SALBUTAMOL 4mg SALBUTAMOL SULPHATE SALBUTAMOL SULPHATE SALBUTAMOL SULPHATE SALBUTAMOL SULPHATE SALBUTAMOL SULPHATE SALBUTAMOL SULPHATE SALBUTAMOL SULPHATE SALBUTAMOL SULPHATE SALBUTAMOL SULPHATE SALBUTAMOL SULPHATE 4mg SALBUTAMOL SULPHATE 4mg SALBUTAMOL SULPHATE 8mg 173.00 318.00 140.00 210.00 295.00 210.00 140.00 472.00 795.00 1210.00 58.30 260.00 595.00 360.00 825.00 462.00 905.00 755.00 820.00 455.00 275.00 629.00 14.30 14.30 14.30 14.30 0.80 0.70 0.50 0.70 0.90 19.00 600.00 400.00 416.00 PC PC PC PC PC PC PC PC PC PC AMP PC PC PC PC PC PC PC PC PC PC PC TAB TAB TAB SACH CAP CAP CAP CAP CAP CAP PC PC PC PC KETOTIFEN HYDROGEN FUMARATE 1mg KETOTIFEN 1mg KETOTIFEN HYDROGEN FUMATATE RANITIDINE HCLPage 8 of 28 MENTHOL, EUCALYPTUSE 705 285.00 1.10 1.20 1.50 230.00 820.00 200.00 16.00 20.00 0.80 1.30 0.17 0.19 30.00 115.00 56.00 215.00 58.00 6.70 137.00 2.70 2.70 4.50 171.00 5.00 2.60 1.50 2.20 0.33 PC PC PC PC PC PC NEB PC PC AMP CAP TAB TAB ML PC PC TAB TAB TAB PES PC PC DISC DISC TAB TAB ML ML AMP PC PC PC PC AMP BOT TAB TAB TAB PC TAB TAB ML ML ML DRUG FORMULARY (MAY 2014) [EFFECTIVE ON MAY 2014] ITEM DRUG DESCRIPTION NO. MME005 MEPTIN SYRUP 5mcg/mL COUGH & COLD REMEDIES TAC020 ACTIFED (GE) MAC008 ACTIFED COMPOUND LINCTUS CO SYRUP (GE) MAC010 ACTIFED MAC012 ACTIFED CO SYRUP (1/2 MAC014 STRENGTH) ACTIFED CO "UNI-FEDRA COMPOUND" SYRUP MAC020 ACTIFED SYRUP (GE) MBE020 BENADRYL EXPECTORANT (GE) TBI020 BISOLVON 8mg (GE) MBI020 BISOLVON SYRUP 4mg/5mL (GE) MBI022 BISOLVON SYRUP 8mg/5mL (GE) MBI010 BISOLVON CO ELIXIR (GE) TCP010 C.P.P. MCH010 CHRISTOLIN SYRUP TCL010 CLARINASE TCL012 CLARINASE EXTENDED RELEASE MCO010 COCILLANA CO MIXTURE (GE) MCO012 COCILLANA CO MIXTURE WITH CODEINE CPA104 CODAPANE FORTE CPA157 CO-CODAMOL MCO020 CODEINE LINCTUS 12.5mg/5mL (1/2 MCO022 CODEINE LINCTUS 25mg/5mL PHOSPHATE (FULL TCO010 CODEINE 15mg TCO012 CODEINE PHOSPHATE 30mg TCO014 CODIPRONT TCO020 CODOPLEX TCO022 CODOPLEX JUNIOR MCO030 CODOPLEX SYRUP TCO030 COFREL MCO060 COSYR TDA026 DANZEN 5mg MDE010 DEC SYRUP MDE050 DEXTROCILLA SYRUP MDE060 DEXTROMETHORPHAN 15mg/5mL SYRUP CPA099 DURO-TUSS FORT MEX008 EXPECT STIM MIXTURE (120mL) STIM MIXTURE MEX010 EXPECT (3600mL) MFL020 FLUIMUCIL 100mg MFL022 FLUIMUCIL 200mg MFL021 FLUIMUCIL A 100mg MFL023 FLUIMUCIL A 200mg CPA090 FLUIMUCIL A 600mg TFL050 EFFERVESCENT FLU-OFF TFL040 FLUCOR DAY MGE010 GEE'S LINCTUS (GE) TGE008 GELOMYRTOL FORTE MGL010 GLYCERYL GUAIACOLATE100mg/5mL 100mg MGU010 GUAIFENESIN TLO012 LOGICIN FLU STRENGTH CPA111 LOGICIN RAPID RELIEF LOZ MME020 METHORSEDYL SYRUP IME005 TMU020 TMU030 CPA039 MMU024 MMU026 TPA019 TPA034 MPH012 MPH020 TPH026 MPH030 MPI010 MPR030 METHON-S (50'S/BOX) MUCODYNE 375mg (GE) MUCOSOLVAN 30mg (GE) MUCOSOLVAN 30mg MUCOSPECT SYRUP 100mg/5mL SYRUP MUCOSPECT 250mg/5mL EXTEND 665mg PANADOL PANADOL COLD & FLU PHENEXPECT SYRUP PHENSEDYL SYRUP (GE) PHENSEDYL TAB (GE) PHOLCODINE SYRUP 5mg/5mL EXPECTORANT PIRITON (GE) PRODEX COUGH SYRUP GENERIC NAME PROCATEROL HYDROCHLORIDE TRIPROLIDINE, PSEUDOEPHEDRINE CODEINE PSEUDOEPHEDRINE TRIPROLIDINE CODEINE, PSEUDOEPHEDRINE.... CODEINE, PSEUDOEPHEDRINE.... TRIPROLIDINE, CODEINE, PSEUDOEPHEDRINE TRIPROLIDINE, PSEUDOEPHEDRINE DIPHENHYDRAMINE, AMMONIUM CL.. BROMHEXINE 8mg BROMHEXINE HCL BROMHEXINE HCL BROMHEXINE,CODEINE CHLORPHENIRAMINE,PHENYLEHRI NE EPHEDRINE/AMMONIUM CHLORDIE/PO LORATADINE, PSEUDOEPHEDRINE LORATADINE, PSEUDOEPHEDRINE COCILLANA, SENEGA, EUPHORBIA… COCILLANA, CONDEINE, SENEGA, EUPHORBIA… CODEINE PARACETAMOL, PHOSPHATE PARACETAMOL, CODEINE PHOSPHATE CODEINE PHOSPHATE CODEINE PHOSPHATE CODEINE PHOSPHATE 15mg CODEINE PHOSPHATE 30mg CODEINE, PHENYLTOLOXAMINE CODEINE, CHLORPHENIRAMINE... CODEINE, CHLORPHENIRAMINE... CODEINE, CHLORPHENIRAMINE... BENPROPERINE 20mg DEXTROMETHORPHAN/CHLORPHEN IRAM SERRAPEPTASE CODEINE,EPHEDRINE,DEXCHLORPH ENIRAMINE DEXTROMETHORPHAN,COCILLANA … DEXTROMETHORPHAN PHOLCODINE AMMONIUM CO3, IPECAUANHA TINCT AMMONIUM CO3, IPECAUAUHA TINCT ACETYLCYSTEINE ACETYLCYSTEINE ACETYLCYSTEINE ACETYLCYSTEINE ACETYLCYSTEINE PARACETAMOL, CHLORPHENIRAMINE… PSEUDOEPHEDRINE, OPIUM TINCT, SQUIL LIQ EXTRACT MYRTOL 300mg GLYCERYL GUAIACOLATE 100mG GUAIFENESIN 100mg PARACETAMOL, PSEUDOEPHEDRINE LIGNOCAINE HCI, BENZYDAMINE HCI, DICHLOROBENZYL ALCOHOL 1.2 mg DEXTROMETHORPHAN,PROMETHAZ CHLORPHENIRAMINE,DEXTROMETHOR INE PHAN,GUAIPHENESIN,METHOXPHENAM CARBOCISTEINE AMBROXOL HCL 30mg AMBROXOL HCL 30mg CARBOCYSTEINE CARBOCYSTEINE ACETAMINOPHEN ACETAMINOPHEN/PHENYLEPHRINE DIPHENHYDRAMINE/AMMON CL/NA CI PROMEHTAZINE,CODEINE,EPHEDRI NE PROMETHAZINE,CODEINE,EPHEDRI NE PHOLCODINE CHLORPHENIRAMINE, AMMONIUM CL DEXTROMETHORPHAN HBR/ EPHEDRINE HCL/PROMETHAZINE HCL MRH008 RHINATHIOL INFANT CARBOCISTEINE SYRUP TRO050 ROMILAR 15mg DEXTROMETHORPHAN 15mg (DEXTROMETHORPHAN) TRO052 ROMILAR 25mg DEXTROMETHORPHAN 25mg (DEXTROMETHORPHAN) TSU010 SUDAFED 60mg (GE) PSEUDOEPHEDRINE 60mg MSU010 SUDAFED SYRUP PSEUDOEPHEDRINE HCL 30mg/5mL (GE) MCO052 CORYAID SYRUP (1/2 CHLORPEHNIRAMINE,CODEINE,EPH STRENGTH) (GE) (GE) ED MCO050 CORYAID SYRUP CHLORPEHNIRAMINE,CODEINE,EPH ED TCO090 CORYZAC (GE) CAFFEINE,CHLORPHENIRAMINE,PPA MDI010 DIMETAPP ELIXIR (GE) BROMPHENIRAMINE,PPA,PHENYLEP HR MMU050 MUCOFLUX D,L-trans-1 methyl-4-cyclohex-1,2-2n-6-ol 80mg, 60% sucrose syrup TNE020 NEOZEP PARACETAMOL,PPA,SALICYLAMIDE. . MRH010 RHINOPRONT SYRUP PPA, CARBINOXAMINE MTI010 TIXYLIX SYRUP (GE) PPA, PHOLCODINE, PROMETHAZINE TCO008 CODAEWON DIHYDROCODEINE, GUAIFENESIN, DECONGESTANTS & OTHER NASALCHLORPHENIRAMINE, PREPARATIONS Page 9 of 28 SAF012 AFRIN (PAED) NOSE OXYMETAZOLINE HCL DROPS/SPRAY 0.025% UNIT PRICE ($) 0.79 PK UNIT 2.00 60.00 0.40 0.17 0.32 0.30 0.20 0.85 0.17 0.17 0.17 0.50 0.17 5.50 10.20 0.18 0.42 8.00 2.00 0.23 0.32 1.00 1.50 5.50 1.80 0.50 0.30 2.10 0.17 1.20 0.40 0.22 0.22 0.50 0.17 0.25 2.00 2.50 2.60 3.20 4.00 1.20 2.000 0.18 3.70 0.17 0.17 1.85 1.50 TAB BOT ML ML ML ML ML TAB ML ML ML TAB ML TAB TAB ML ML TAB TAB ML ML TAB TAB CAP TAB TAB ML TAB ML TAB ML ML ML ML ML ML SACH SACH SACH SACH TAB CAP CAP ML TAB ML ML TAB TAB ML 0.25 ML 35.00 1.50 1.20 1.50 0.23 0.27 1.00 2.00 0.17 0.40 2.00 0.20 0.17 0.20 AMP TAB TAB TAB ML ML TAB TAB ML ML TAB ML ML ML 0.24 1.10 1.50 2.00 0.30 0.18 0.18 0.60 0.18 1.00 1.20 0.40 0.19 1.20 ML TAB TAB TAB ML ML ML CAP ML ML TAB ML ML TAB 45.00 BOT DRUG FORMULARY (MAY 2014) [EFFECTIVE ON MAY 2014] ITEM DRUG DESCRIPTION NO. SAF010 AFRIN (ADULT) NASAL SPRAY 0.05% 15mL/BOT CPA059 AVAMYS NASAL SPRAY SAV010 AVAMYS NASAL SPRAY 27.5mcg 120 Doses SBE050 BECONASE NASAL SPRAY 50mcg SBE040 BECONASE AQUEOUS NASAL SPRAY 50mcg DCR020 CROMOLYN NASAL TDR010 SOLUTION DRIXORAL 2% (GE) DEP010 EPHEDRINE NASAL DROPS 0.5% NASAL 15mL/BOT DEP012 EPHEDRINE DROPS 1% 15AQUEOUS mL/BOT SFL010 FLIXONASE NASAL SPRAY CPA105 MAR PLUS NASAL SPRAY (140 SPRAYS) 10NASAL mg/1 mL x SNA006 NASACORT AQ SPRAY SNA010 NASONEX NASAL SPRAY 0.05% 140 Doses SNA012 NASONEX NASAL SPRAY 0.05% 60OINTMENT Doses CNI006 NISITA 20g SNI004 NISITA NASAL SPRAY CPA103 OMNARIS NASAL SPRAY 50MCG CHILDREN SOT010 OTRIVIN NASAL DROPS SOT030 OTRIVIN ADULTS NASAL DROPS SRH010 RHINOCORT NASAL 50mcgAQUA (GE) NASAL SRH008 SPRAY RHINOCORT SPRAY 50mcgAQUA NASAL SRH009 RHINOCORT SPRAY 64mcg SRH012 RHINOCORT TURBUHALER 100mcg/dose SST010 STERIMAR MICROSPRAY 50ml SRY010 RYNACROM M NASAL SPRAY 2% ADULTS DSI020 SINOMARIN 125mL DSI022 SINOMARIN CHILDREN/ENFANTS CVI010 VIBROCIL GEL 12g DXY010 XYLOMA NASAL DROPS 0.1% ANTI-INFLAMMATORY ENZYMES TBR030 BROTASE 20mg TNE040 NEUZYM 30mg TNE042 NEUZYM 30mg (GE) TNE044 NEUZYM 60mg (GE) TPA042 PAPASE TPA043 PAPASE (GE) ANALGESICS & ANTIPYRETICS UNIT PRICE ($) 60.00 120.00 200.00 92.00 175.00 90.00 2.00 0.36 0.45 128.00 30.00 255.00 168.00 135.00 2.00 120.00 315.00 38.00 60 100.00 145.00 147.90 421.80 60.00 70.00 83.00 64.00 3.75 23.00 PK UNIT BROMELAIN LYSOZYME HCL 30mg LYSOZYME HCL 30mg LYSOZYME HCL 60mg PROLASE 10,000U PROLASE 10,000U 0.800 1.00 0.70 0.60 0.70 0.80 TAB TAB TAB TAB TAB TAB TAS050 ASTRIX 100mg ASPIRIN TAS034 TAS030 TAS032 TAS033 TAS040 TBE061 MCA010 TDF010 TDI108 TDO020 TDO030 TDO040 TDO038 TDO050 PEP012 PEP010 IFE020 IMO012 IMO030 MMO008 TOX012 TOX013 TOX006 TOX008 CPA043 TPA020 TPA028 TPA018 TPA030 TPA052 PPA010 PPA012 MPA014 MPA010 MPA012 IPE020 IPE022 TPH030 TPO018 TPO020 TPO022 TPO024 TTE028 ITE008 ANO003 ASPIRIN 80mg ASPIRIN 300mg ASPIRIN 75mg ASPIRIN 80mg ASPIRIN SOLUBLE 300mg VALDECOXIB 20mg PARACETAMOL DIHYDROCODEINE TARTRATE 30mg ASPIRIN 300mg DIFLUNISAL 250mg DEXTROPROPOXYPHENE,PARACET AMOL DEXTROPROPOXYPHENE DEXTROPROPOXYPHENE DEXTROPROPOXYPHENE,ASA,CAFF EIN PARACETAMOL,PROPYPHENAZONE … PARACETAMOL,PROPYPHENAZONE … FENTANYL MORPHINE MORPHINE MORPHINE OXYCODONE 5mg OXYCODONE 10mg OXYCODONE HYDROCHLORIDE OXYCODONE HYDROCHLORIDE PARACETAMOL, CODEINE PARACETAMOL, CODEINE (500/8mg) PARACETAMOL 250mg PARACETAMOL 500mg PARACETAMOL 500mg CODEINE PARACETAMOL PARACETAMOL PARACETAMOL PARACETAMOL PARACETAMOL PARACETAMOL PETHIDINE PETHIDINE METHADONE HCL 5mg MEFENAMIC ACID 250mg MEFENAMIC ACID 250mg MEFENAMIC ACID 500mg MEFENAMIC ACID 500mg BUPRENORPHINE HCL 0.2mg BUPRENORPHINE HCL BUPRENORPHINE Page 10 of 28 1.85 0.50 0.60 0.50 0.70 0.60 10.00 0.25 5.50 1.70 3.20 1.20 2.00 1.00 2.00 5.00 4.80 92.00 50.00 50.00 0.67 26.00 33.00 43.00 54.00 1.60 2.00 0.30 2.00 0.60 3.00 2.80 2.90 0.22 0.17 0.20 60.00 50.00 10.00 1.30 1.05 1.60 1.30 6.20 50.00 820.00 TAB TAB TAB TAB TAB TAB TAB ML TAB TAB CAP TAB CAP CAP CAP SUPP SUPP AMP AMP AMP ML CAP CAP TAB TAB TAB TAB TAB TAB TAB TAB SUPP SUPP ML ML ML AMP AMP TAB CAP CAP CAP TAB TAB AMP BOX ASPILETS ASPIRIN 300mg (GE) ASPIRIN 75mg (GE) ASPIRIN 80mg (GE) ASPIRIN SOLUBLE 300mg (GE) BEXTRA 20mg CALPOL SUSPENSION 120mg/5mL DF 118 30mg DISPRIN 300mg DOLOBID 250mg DOLOGESIC (GE) DOLOXENE 32mg DOLOXENE 32mg (GE) DOLOXENE CO (GE) EPIZON CHILD RECTOCAP EPIZON INFANT RECTOCAP INJ 0.05mg/2mL FENTANYL MORPHINE INJ 10mg/mL MORPHINE INJ 15mg/mL MORPHINE SYRUP 10mg/5mL [OXYCODONE] OXYNORM 5mg OXYNORM [OXYCODONE] 10mg OXYCONTIN 5mg OXYCONTIN 10mg PANADEINE PANADEINE (GE) PANADOL 250mg (GE) PANADOL 500mg PANADOL 500mg (GE) PARCOTEN TAB PANADOL SUPP 125mg (GE) PANADOL SUPP 250mg (GE) PANADOL SUSPENSION 250mg/5mL SYRUP (GE) PANADOL 120mg/5mL SYRUP (GE) PANADOL 250mg/5mL (GE) PETHIDINE INJ 100mg/2mL PETHIDINE INJ 50mg/mL PHYSEPTONE 5mg PONSTAN 250mg PONSTAN 250mg (GE) PONSTAN 500mg PONSTAN 500mg (GE) TEMGESIC 0.2mg TEMGESIC INJ 0.3mg/mL NORSPAN [BUPRENORPHINE] TRANSDERMAL PATCH 5 GENERIC NAME OXYMETAZOLINE HCL FLUTICASONE FUROATE FLUTICASONE FUROATE BECLOMETHASONE DIPROPIONATE BECLOMETHASONE DIPROPIONATE SODIUM CROMOGLYCATE DEXBROMPHENIRAMINE, PSEUDOEPHEDRINE EPHEDRINE 0.5% EPHEDRINE 1% FLUTICASONE PROPIONATE DEXPANTHENOAL 10MG, SEAWATER 250 mg.ACETONIDE TRIAMICINOLONE 55mcg MOMETASONE FUROATE MOMETASONE FUROATE Na Iodide, Na Bromide, Na Cl.. Na IODIDE, Na BROMIDE, NaCl CICLESONIDE XYLOMETAZOLINE HCL 0.05% XYLOMETAZOLINE HCL 0.1% BUDESONIDE BUDESONIDE BUDESONIDE BUDESONIDE PHYSIOLOGICAL SEA WATER SODIUM CROMOGLYCATE SEA WATER SOLUTION HYPERTONIC SEA WATER DIMETHINDENE, PHENYLEPHRINE XYLOMETAZOLINE HCl BOT PC PC BOT BOT BOT TAB ML ML BOT PC BOT BOT BOT g BOT PC BOT BOT BOT BOT BOT PC BOT BOT BOT BOT g BOT DRUG FORMULARY (MAY 2014) [EFFECTIVE ON MAY 2014] ITEM DRUG DESCRIPTION GENERIC NAME NO. ANO004 NORSPAN BUPRENORPHINE [BUPRENORPHINE] TRANSDERMAL PATCH 10 TTR006 TRAMAL 50mg TRAMADOL HCL 50mg <TRAMADOL> TTR007 50mg [MABRON] TRAMADOL ITR006 TRAMAL <TRAMADOL> INJ 50mg TRAMADOL ITR007 INJ 100mg/2mL TRAMADOL TTR008 TRAMAL RETARD 100mg TRAMADOL HCL 100mg TUL030 ULTRACET TRAMADOL 37.5mg/ACETAMINOPHEN 325mg ANTIRHEUMATICS, ANTIINFLAMMATORY ANALGESICS TAF010 AFLOXAN 150mg PROGLUMETACIN 150mg TAR044 ARCOXIA 120mg ETORICOXIB 120mg TAR040 ARCOXIA 60mg ETORICOXIB 60mg TAR042 ARCOXIA 90mg ETORICOXIB 90mg CPA086 ARCOXIA 30mg ETORICOXIB 30mg TAR025 ARTRODAR 50mg DIACEREIN TAR020 ARTHROTEC DICLOFENAC NA, MISOPROSTOL TAS020 ASCRIPTIN A/D AL & MG HYDROXIDE, ASPIRIN TBE060 BEXTRA 10mg VALDECOXIB 10mg TBE062 BEXTRA 40mg VALDECOXIB 40mg TBR120 BRUFEN 200mg (GE) IBUPROFEN 200mg TBR122 BRUFEN 400mg IBUPROFEN TCA080 CATAFLAM 25mg DICLOFENAC POTASSIUM 25mg TCA082 CATAFLAM 50mg DICLOFENAC POTASSIUM 50mg TCE034 CELEBREX 100mg CELECOXIB 100mg TCE036 CELEBREX 200mg CELECOXIB 200mg CPA046 CELEBREX 400mg CELECOXIB 400mg CPA054 CLINORIL 200mg SULINDAC 200mg TCU010 CUPRIMINE 250mg PENICILLAMINE 250mg IDY010 DYNASTAT INJ 40mg PARECOXIB 40 mg TEC010 ECOTRIN 650mg ASPIRIN 650mg IEN020 ENBREL 25mg ETANERCEPT 25mg TFE010 FELDENE 10mg (GE) PIROXICAM 10mg IFE010 FELDENE INJ PIROXICAM TIN040 INDOCID 25mg (GE) INDOMETHACIN 25mg TLO008 LODINE 200mg ETODOLAC 200mg TME048 MESULID 100mg NIMESULIDE 100mg TMO005 MOBIC 15mg MELOXICAM 10mg TMO004 MOBIC 7.5mg MELOXICAM 7.5mg AMO010 MOHRUS PATCH KETOPROFEN IMY010 MYOCRISIN INJ 20mg NA AUROTHIOMALATE TNA010 NAPROSYN 250mg (GE) NAPROXEN 250mg TNI024 NIDOL 100mg NIMESULIDE 100mg MBR020 BRUFEN SUSPENSION IBUPROFEN 100MG/5MLSYRUP 90ml MNU020 NUROFEN IBUPROFEN 100mg/5mL100mg 60mL (GE) TOR020 ORUVAIL KETOPROFEN 100mg TOR030 ORUVAIL 200mg KETOPROFEN 200mg TPL010 PLAQUENIL 200mg HYDROXYCHLOROQUINE 200mg MPO020 PONSTAN SUSPENSION MEFENAMIC ACID 50mg/5mL (GE) MPO022 250mg/5mL MEFENAMIC ACID TRE010 RELIFEX 500mg NABUMETONE 500mg TRI008 RIDAURA 3mg AURANOFIN 3mg TSA020 SALAZOPYRIN EN 500mg SULFASALAZINE 500mg CPA110 SIMPONI 50mg/0.5 mL GOLIMUMAB TSY010 TTI020 TVI028 TVI029 TVO020 TVO022 TVO021 IVO010 TVO028 TVO031 TVO030 TVO032 TVO034 PVO010 PVO004 PVO006 AVO005 AVO006 GOUT PREPAR TBE010 TCO040 SYNFLEX 275mg TILCOTIL 20mg (GE) VIOXX 25mg VIOXX 50mg VOLTAREN 25mg (GE) VOLTAREN 50mg VOLTAREN 50mg (GE) VOLTAREN INJ 75mg (GE) VOLTAREN SR 100mg VOLTAREN SR 100mg CAP (GE) VOLTAREN SR 100mg TAB (GE) VOLTAREN SR 75mg VOLTAREN SR 75mg (GE) VOLTAREN SUPP 100mg (GE) VOLTAREN SUPP 12.5mg VOLTAREN SUPP 25mg VOLTAREN PATCH 15mg 5's VOLTAREN PATCH LARGE 30mg 7's BENEMID 500mg (GE) COLCHICINE 0.5mg (GE) UNIT PRICE ($) 1320.00 PK UNIT 5.00 2.70 40.00 40.00 9.20 5.30 CAP CAP AMP AMP TAB TAB 2.50 11.80 10.50 10.40 8.50 10.00 6.30 0.50 10.00 17.00 0.85 1.700 3.50 5.80 8.00 9.20 15.00 4.00 6.50 340.00 1.00 1586.00 3.50 35.00 1.00 6.25 3.00 10.00 7.00 84.00 60.00 2.30 2.80 65.00 0.50 3.30 5.50 14.00 0.17 0.17 8.00 14.00 4.10 12000.00 CAP TAB TAB TAB TAB CAP TAB TAB TAB TAB TAB TAB TAB TAB CAP CAP CAP TAB TAB VIA TAB AMP CAP AMP CAP CAP TAB TAB TAB BOX AMP TAB TAB BOT ML CAP CAP TAB ML ML TAB TAB TAB UNIT NAPROXEN SODIUM 275mg TENOXICAM 20mg ROFECOXIB 25mg ROFECOXIB 50mg DICLOFENAC SODIUM 25mg DICLOFENAC SODIUM 50mg DICLOFENAC SODIUM 50mg DICLOFENAC SODIUM DICLOFENAC SODIUM 100mg DICLOFENAC SODIUM 100mg DICLOFENAC SODIUM 100mg DICLOFENAC SODIUM 75mg DICLOFENAC SODIUM 75mg DICLOFENAC SODIUM DICLOFENAC SODIUM DICLOFENAC SODIUM DICLOFENAC SODIUM DICLOFENAC SODIUM 2.50 2.50 6.50 9.50 2.00 7.00 4.00 58.00 10.00 4.50 5.00 7.40 4.50 14.00 5.40 7.90 55.00 101.50 TAB TAB TAB TAB TAB TAB TAB AMP TAB CAP TAB TAB TAB SUPP SUPP SUPP BOX BOX PROBENECID 500mg COLCHICINE 0.5mg TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TFE004 FEBURIC 80mg FEBUXOSTAT 80mg TZY010 ZYLORIC 100mg (GE) TZY012 ZYLORIC 300mg (GE) TZY014 ZYLORIC 300mg MINOR TRANQUILLISERS TAT020 ATIVAN 0.5mg TAT022 ATIVAN 1mg TLE032 LEXOTAN 1.5mg TLE030 LEXOTAN 1.5mg (GE) ALLOPURINOL 100mg ALLOPURINOL 300mg ALLOPURINOL 300mg 3.80 1.00 20.30 1.00 2.80 7.00 LORAZEPAM 0.5mg LORAZEPAM 1mg BROMAZEPAM 1.5mg Page 11 of 28 BROMAZEPAM 1.5mg 2.00 3.00 3.00 3.00 BOX DRUG FORMULARY (MAY 2014) [EFFECTIVE ON MAY 2014] ITEM DRUG DESCRIPTION NO. TLE034 LEXOTAN 3mg TVA010 VALIUM 2mg (GE) TVA012 VALIUM 5mg (GE) IVA010 VALIUM INJ 10mg/2mL PVA012 VALIUM RECTAL TUBE 5mg (GE) RECTAL TUBE PVA010 VALIUM 10mg (GE) MAJOR TRANQUILLISERS TLA060 LARGACTIL 25mg TLA061 LARGACTIL 25mg (GE) TST008 STELAZINE 2mg (GE) TST010 STELAZINE 5mg (GE) HYPNOTICS & SEDATIVES TDO070 DORMICUM 7.5mg TDO080 DORMICUM 15mg IDO010 DORMICUM INJ 5mg/mL IDO011 DORMICUM INJ 5mg/5mL IDO012 DORMICUM INJ 15mg/3ml IGA010 GARDENAL INJ 200mg/mL (PHENOBARBITONE) THA010 HALCION 0.25mg THE010 HEMINEVRIN 300mg TLO034 LORAMET 1mg TMO020 MOGADON 5mg (GE) IPA010 PARALDEHYDE INJ TRO040 ROHYPNOL 2mg (GE) TST030 STILNOX 10mg TST031 STILNOX 10mg (GE) ANTICONVULSANTS TDI070 DILANTIN 100mg TDI072 DILANTIN 30mg TEP010 EPILIM 200mg TEP030 EPILIM CHRONO 200mg TEP028 EPILIM CHRONO 300mg TEP020 EPILIM CHRONO 500mg MEP010 EPILIM SF LIQUID 200mg/5mL 300mL TKE028 KEPPRA 250mg TKE030 KEPPRA 500mg TKE032 KEPPRA 1000mg CPA050 KEPPRA SYRUP 100mg/ml 5 LAMICTAL DISPERSIBLE CPA132 mg TLA024 LAMICTAL 50mg TLA026 LAMICTAL 100mg TLY008 LYRICA 25mg TLY009 LYRICA 50mg GENERIC NAME UNIT PRICE ($) 5.00 1.50 2.00 60.00 80.00 100.00 PK UNIT CHLORPROMAZINE 25mg CHLORPROMAZINE 25mg TRIFLUOPERAZINE 2mg TRIFLUOPERAZINE 5mg 1.70 1.20 1.50 2.00 TAB TAB TAB TAB MIDAZOLAM 7.5mg MIDAZOLAM 15mg MIDAZOLAM MIDAZOLAM MIDAZOLAM PHENOBARBITONE TRIAZOLAM 0.25mg CLOMETHIAZOLE 300mg LORMETAZEPAM 1mg NITRAZEPAM 5mg PARALDEHYDE FLUNITRAZEPAM 2mg ZOLPIDEM 10mg ZOLPIDEM TARTRATE 10mg 4.50 8.00 55.00 55.00 90.00 30.00 5.40 4.30 5.50 4.10 50.00 8.00 4.30 3.10 TAB TAB AMP AMP AMP AMP TAB CAP TAB TAB AMP TAB TAB TAB PHENYTOIN SODIUM 100mg PHENYTOIN SODIUM 30mg SODIUM VALPROATE 200mg SODIUM VALPROATE 250mg SODIUM VALPROATE 300mg SODIUM VALPROATE 500mg SODIUM VALPROATE LEVETIRACETAM LEVETIRACETAM LEVETIRACETAM LEVETIRACETAM 100mg LAMOTRIGINE 5mg LAMOTRIGINE 50mg LAMOTRIGINE 100mg PREGABALIN 25mg 4.40 4.40 3.50 3.50 4.40 7.00 1.10 11.60 21.30 48.00 4.10 3.80 11.80 19.40 13.20 13.50 13.60 21.90 8.80 5.00 10.50 7.00 1.00 1.50 0.30 2.00 2.00 5.50 0.56 8.00 19.00 12.60 33.50 5.60 19.00 35.00 52.00 CAP CAP TAB TAB TAB TAB ML TAB TAB TAB ML TAB TAB TAB CAP CAP CAP TAB CAP CAP CAP CAP TAB TAB ML TAB TAB TAB ML TAB TAB TAB TAB TAB TAB TAB TAB 4.20 5.00 3.40 2.00 8.20 2.50 4.00 TAB TAB TAB CAP TAB CAP CAP 0.80 1.00 1.00 0.40 25.00 28.00 TAB TAB TAB ML ML ML 5.60 121.00 4.40 SUPP AMP TAB BROMAZEPAM DIAZEPAM 2mg DIAZEPAM 5mg DIAZEPAM DIAZEPAM DIAZEPAM PREGABALIN 50mg TLY010 LYRICA 75mg PREGABALIN 75mg TLY011 LYRICA 150mg PREGABALIN 150mg TNE034 NEURONTIN 100mg (GE)- GABAPENTIN 100mg TNE035 [GABAPENTIN] GABAPENTIN 100mg TNE036 NEURONTIN 300mg GABAPENTIN 300mg TNE037 NEURONTIN 300mg (GE) GABAPENTIN 300mg TPH020 PHENOBARBITONE 15mg PHENOBARBITONE SODIUM 15mg TPH022 PHENOBARBITONE 30mg PHENOBARBITONE SODIUM 30mg MPH014 PHENOBARBITONE SYRUP PHENOBARBITONE 15mg/5mL 0.5mg TRI050 RIVOTRIL CLONAZEPAM 0.5mg TTE010 TEGRETOL 200mg (GE) CARBAMAZEPINE 200mg TTE020 TEGRETOL CR 200mg CARBAMAZEPINE 200mg MTE020 TEGRETOL SYRUP 2% CARBAMAZEPINE CPA073 250mL TEGRETOL CR 400MG CARBAMAZEPINE CPA056 TOPAMAX 50mg TOPIRAMATE TTO030 TOPAMAX 25mg TOPIRAMATE TTO032 TOPAMAX 100mg TOPIRAMATE 100mg TTR036 TRILEPTAL 300mg OXCARBAZEPINE 300mg VIMPAT FILM-COATED CPA129 VIMPAT TAB 50 mg LACOSAMIDE 50mg FILM-COATED CPA130 VIMPAT FILM-COATED TAB 100 mg LACOSAMIDE 100mg LACOSAMIDE 150mg CPA131 TAB 150 mg NOOTROPICS & NEUROTONICS TAR004 ARCALION 200 SULBUTIAMINE 200mg TME062 METHYCOBAL 500mcg MECOBALAMIN 500mcg TME054 METHYCOBAL 500mg MECOBALAMIN 500mg TNO030 NOOTROPIL 400mg (GE) PIRACETAM 400mg TNO032 NOOTROPIL 800mg PIRACETAM 800mg TNO033 NOOTROPIL 800mg (GE) PIRACETAM [VICK-TROPIL] CPA100 PIRACETAM (GE) 1200mg PIRACETAM ANTIEMETICS & ANTIVERTIGO DRUGS TAV010 AVOMINE 25mg PROMETHAZINE THEOCLATE 25mg TGR012 GRAVOL 50mg DIMENHYDRINATE 50mg TGR010 GRAVOL 50mg (GE) DIMENHYDRINATE 50mg MGR010 GRAVOL SYRUP 15mg/5mL DIMENHYDRINATE (GE) IGR010 GRAVOL INJ 50mg/mL DIMENHYDRINATE IGR011 GRAVOL DIMENHYDRINATE <DIMENHYDRINATE> INJ 50mg/mL10mL PGR010 GRAVOL SUPP (PAED) DIMENHYDRINATE 50mg (GE) IKY010 KYTRIL [GRANISETRON] GRANISETRON Page 12 of 28 1mg/mL INJ50mg TMA034 MARZINE CYCLIZINE HCL 50mg TAB TAB TAB AMP TUB TUB DRUG FORMULARY (MAY 2014) [EFFECTIVE ON MAY 2014] ITEM DRUG DESCRIPTION GENERIC NAME NO. TMA048 MAXOLON 5mg METOCLOPRAMIDE 5mg TMA050 MAXOLON 10mg (GE) METOCLOPRAMIDE 10mg MMA020 MAXOLON SYRUP METOCLOPRAMIDE 5mg/5mL (GE) IMA020 MAXOLON INJ 10mg/2mL METOCLOPRAMIDE TNA026 NAVIDOXINE MECLIZINE HCL, PYRIDOXINE HCL TNA036 NAVOBAN 5mg TROPISETRON 5mg INA010 NAVOBAN INJ 5mg/5mL TROPISETRON TST020 STEMETIL 5mg (GE) PROCHLORPERAZINE 5mg IST010 STEMETIL INJ 12.5mg/mL PROCHLORPERAZINE TZO017 ZOFRAN 4mg ONDANSETRON HCL DIHYDRATE 4mg TZO018 ZOFRAN 8mg ONDANSETRON HCL DIHYDRATE 8mg IZO004 ZOFRAN [ondansetron] 4mg ONDANSETRON INJECTION IZO006 ZOFRAN [ondansetron] 8mg ONDANSETRON INJECTION NEURODEGENERATIVE DISEASE DRUGS TAR006 ARICEPT 5mg DONEPEZIL 5mg TEB010 EBIXA 10mg MEMANTINE HCL 10mg ANTIPARKINSONIAN DRUGS TAM010 AMANTADINE SULFATE AMANTADINE SULFATE 100mg 100mg 2mg (GE) TAR010 ARTANE TRIHEXYPHENIDYL HCL 2mg TAZ004 AZILECT 1mg RASAGILINE TCO055 COMTAN 200mg ENTACAPONE ICO008 COGENTIN INJ 2mg/2mL BENZTROPINE MESYLATE TJU012 JUMEX SELEGILINE HCL 5mg TJU010 JUMEX 5mg (GE) SELEGILINE HCL 5mg TLE017 LEVOMED 100/25mg LEVODOPA 100mg TMA020 MADOPAR 250mg LEVODOPA, BENSERAZIDE TMA018 MADOPAR DISPERSIBLE LEVODOPA, BENSERAZIDE 125mg TMA019 MADOPAR HBS 125mg LEVODOPA, BENSERAZIDE ANE060 NEUPRO PATCH 2mg ROTIGOTINE ANE062 NEUPRO PATCH 4mg ROTIGOTINE ANE064 NEUPRO PATCH 6mg ROTIGOTINE ANE066 NEUPRO PATCH 8mg ROTIGOTINE TPA060 PARLODEL 2.5mg (GE) BROMOCRIPTINE MESYLATE 2.5mg TRE028 REQUIP 0.25mg AMORPHOUS AESCIN TRE029 REQUIP 1mg ROPINIROLE TRE030 REQUIP 2mg ROPINIROLE TRE032 REQUIP PD 2mg ROPINIROLE 2mg TRE033 REQUIP PD 4mg ROPINIROLE 4 mg TSI032 SINEMET 25/100 CARBIDOPA. LEVODOPA (25/100mg) TSI030 SINEMET 25/250 CARBIDOPA, LEVODOPA (25/250mg) TSI034 SINEMET CR 50/200 CARBIDOPA, LEVODOPA (50/200mg) NEUROMUSCULAR DISORDER DRUGS TME044 MESTINON 10mg PYRIDOSTIGMINE BROMIDE 10mg TME046 MESTINON 60mg PYRIDOSTIGMINE BROMIDE 60mg TNO040 PYRIDOSTIGMINE> NORGESIC (GE) 10mg ORPHENADRINE, PARACETAMOL TME045 [JM-PYRIDOSTIGMINE] PYRIDOSTIGMINE ITE010 TENSILON INJ 10mg/mL EDROPHONIUM CHLORIDE TRI032 RILUTEK 50mg RILUZOLE 50mg TUB010 UBRETID 5mg DISTIGMINE BROMIDE 5mg MUSCLE RELAXANTS TBA002 BACLOFEN 10mg BACLOFEN 10mg TCA069 CARISOPRODOL 125mg TLI024 LIORESAL 10mg (GE) BACOLFEN 10mg TMY018 MYDOCALM 50mg TOLPERISONE HYDROCHLORIDE 50mg TQU010 QUININE BISULPHATE 300 QUININE BISULPHATE 300mg mg TQU020 QUININE SULPHATE 200mg QUININIE SULPHATE 200mg TRO020 ROBAXIN 500mg METHOCARBAMOL 500mg ANDROGENS & RELATED SYNTHETIC DRUGS TAN013 ANDRIOL TESTOCAP 40mg TESTOSTERONE UNDECANOATE TESTOSTERONE CAN018 ANDROGEL 50mg TDA020 DANOCRINE 200mg DANAZOL 200mg TDA022 DANOCRINE 200mg (GE) DANAZOL 200mg INE004 NEBIDO 25% 1000mg/4mL INJ TESTOSTERONE UNDECANOATE TPR140 PROVIRON 25mg MESTEROLONE 25mg ISU010 SUSTANON INJ 250mg/mL TESTOSTERONE PROPIONATE 30mg, DECABIATE 100mg ITE012 TESTOSTERONE IMPLANT TESTOSTERONE 100mg ITE020 TESTOVIRON INJ 250mg TESTOSTERONE OESTROGEN & PROGESTERONES & RELATED SYNTHETIC DRUGS TAC024 ACTIVELLE 28's ESTRADIOL, NORETHISTERONE TAN014 ANDROCUR 50mg CYPROTERONE ACETATE TAN016 ANGELIQ 28's ESTRADIOL 1mg, DROSPIRENONE 2mg TCL024 CLIMEN 28's ESTRADIOL VALERATE PCY010 CYCLOGEST PESSARY PROGESTERONE 200mg PCY012 CYCLOGEST PESSARY PROGESTERONE 400mg TCY030 CYCLO-PROGYNOVA 2mg OESTRADIOL 21's VALERATE,NORGESTREL TDI074 DILENA 21's ESTRADIOL, CPA127 DEPO PROVERA MEDROXYPROGESTERONE 150MG/ML SUSP., ACETATE TDO056 DOSTINEX 0.5mg 1ML/ CABERGOLINE TDU018 DUPHASTON 10mg DYDROGESTERONE 10mg TES020 ESTRACOMB TTS 50 ESTRADIOL, NORETHISTERONE TES030 ESTRADERM TTS 25 6'S 17 BETA-ESTRADIOL 2mg TES032 ESTRADERM TTS 50 17 BETA-ESTRADIOL 4mg TES034 ESTRADERM TTS 100 (6 17 BETA-ESTRADIOL 8mg Page 13 of 28 PCs) CES010 ESTREVA GEL 0.1% 50g NATURAL ESTRADIOL 0.1% UNIT PRICE ($) 1.00 1.00 0.23 30.00 1.50 270.00 350.00 0.50 25.00 52.00 214.00 192.50 140.00 PK UNIT 29.00 15.80 TAB TAB 5.00 1.50 37.00 14.50 75.00 13.20 6.00 2.20 8.20 5.90 5.70 47.00 51.00 58.50 73.50 6.00 6.80 12.50 14.30 21.70 38.00 5.20 8.90 7.40 TAB TAB TAB TAB AMP TAB TAB TAB TAB TAB CAP PC PC PC PC TAB TAB TAB TAB TAB TAB TAB TAB TAB 2.60 11.00 1.10 2.30 50.00 100.00 7.90 TAB TAB TAB TAB AMP TAB TAB 2.50 0.60 2.00 1.60 2.50 2.70 3.00 TAB TAB TAB TAB TAB TAB TAB 12.00 25.00 13.00 10.00 1700.00 12.00 205.00 250.00 270.00 CAP TAB CAP CAP AMP TAB AMP AMP VIA 5.00 29.00 15.00 3.00 20.00 38.00 5.30 5.00 190.00 132.00 11.00 245.00 170.00 160.00 200.00 2.70 TAB TAB TAB TAB PES PES TAB TAB AMP TAB TAB BOX BOX BOX BOX g TAB TAB ML AMP TAB TAB AMP TAB AMP TAB TAB AMP AMP DRUG FORMULARY (MAY 2014) [EFFECTIVE ON MAY 2014] ITEM NO. TES040 TFE012 DRUG DESCRIPTION GENERIC NAME ESTROFEM 28's FEMARA 2.5mg OESTRADIOL 2mg LETROZOLE TFE013 FEMOSTON 2/10 28'S OESTRADIOL + CPA091 KLIOGEST ESTRADIOL, NORETHISTERONE TLI050 LIVIAL 2.5mg 30's TIBOLONE 2.5mg TLU010 LUTENYL 5mg NOMEGESTROL ACETATE 5mg CPA064 NORCOLUT 5mg NORETHISTERONE ESTRADIOL 1mg,NORETHISTERONE TNO085 NOVOFEM ACETATE 1mg IOE012 OESTRADIOL IMPLANT OESTRADIOL 50mg IOF010 OESTRADIOL IMPLANT OESTRADIOL 100mg COE010 OESTROGEL 0.06% 80g NATURAL 17B-ESTRADIOL 0.06% TOV008 OVESTIN 1mg 30's ESTRIOL 1mg TPR030 PREMARIN 0.3mg CONJUGATED OESTROGENS 0.3mg TPR032 PREMARIN 0.625mg CONJUGATED OESTROGENS 0.625mg TPR034 PREMARIN 1.25mg CONJUGATED OESTROGENS 1.25mg TPR036 PREMELLE 0.625mg/2.5mg MEDROXYPROGESTERONE, 28's OESTROGEN TPR038 PREMELLE CYCLE 28's MEDROXYPROGESTERONE, OESTROGEN TPR040 PREMPAK 0.625mg 31's MEDROGESTONE, OESTROGENS TPR050 PREMPAK-C 0.625mg 40's NORGESTREL, OESTROGENS TPR052 PREMPAK-C 1.25mg 40's NORGESTREL, OESTROGENS TPR080 PRIMOLUT-N 5mg (GE) NORETHISTERONE 5mg IPR038 PROGESTERONE INJ 50mg PROGESTERONE IPR040 PROGESTERONE INJ 50mg PROGESTERONE/ESTRADIOL +ESTRADIOL BENZOATE TPR094 PROGYNOVA 2mg 28's ESTRADIOL VALERATE 2mg IPR054 PROLUTON DEPOT INJ HYDROXYPROGESTERONE 250mg TPR130 PROVERA 5mg MEDROXYPROGESTERONE ACETATE TPR132 PROVERA 10mg MEDROXYPROGESTERONE ACETATE TST022 STILBOESTROL 1mg DIETHYLSTILBOESTROL TST024 STILBOESTROL 5mg DIETHYLSTILBOESTROL TTR060 TRISEQUENS 28's ESTRADIOL, NORETHISTERONE TUT010 UTROGESTAN 100mg PROGESTERONE MICRONISED 100mg CPA153 VAGIFEM VAGINAL TAB ESTRADIOL 10mcg PVA020 VAGIFEM VAGINAL TAB ESTRADIOL 25mcg PVA021 VAGIFEM VAGINAL TAB ESTRADIOL 10mcg 18'S HORMONES CORTICOSTEROID CPA093 COLIFOAM ENEMA HYDROCORTISONE TCO084 CORTONE 25mg CORTISONE ACETATE 25mg TCO095 CORTEF 20mg HYDROCORTISONE 20mg TDE020 DECADRON 0.5mg (GE) DEXAMETHASONE 0.5mg TDE070 DEXAMETHASONE 4mg DEXAMETHASONE 4mg IDE010 DEPO-MEDROL INJ 40 METHYLPREDNISOLONE ACETATE mg/mL IDE030 DEPOMETHYLPREDNISOLONE, MEDROL+LIDOCAINE LIDOCAINE IDE038 DEXAMETHASONE INJINJ DEXAMETHASONE SODIUM 4mg/mL PHOSPHATE IDE040 DEXAMETHASONE INJ DEXAMETHASONE SODIUM 50mg/10mL PHOSPHATE CPA155 DEXAMETHASONEDEXAMETHASONE NA PHOSPHATE HOSPIRA INJINJ 8 mg/2 IDI020 DIPROSPAN 1mLmL BETAMETHASONE DIPROPIONATE... TFL020 FLORINEF 0.1mg FLUDROCORTISONE ACETATE 0.1mg IHY010 HYDROCORTISONE INJ HYDROCORTISONE 100mg/2mL THY005 HYDROCORTISONE 20mg HYDROCORTISONE 20mg IKE020 KENACORT-A IA/ID INJ TRIAMCINOLONE ACETONIDE 10mg/mL 5mL IM INJ 40 IKE010 KENACORT-A TRIAMCINOLONE ACETONIDE mg/mL IKE011 KENACORT-A IM INJ 40 TRIAMCINOLONE ACETONIDE mg/mL (GE) IKE021 KENACORT-A TRIAMICINOLONE ACETONIDE {Triamicinolone} TME010 MEDROL 4mg IA/ID INJ METHYLPREDNISOLONE 4mg TPR018 PREDNISOLONE 1mg PREDNISOLONE 1mg TPR020 PREDNISOLONE 0.5% 5mg (GE) PREDNISOLONE 5mg DPR014 MINIMS (20'S/BOX) PREDNISOLONE MPR010 PREDNISOLONE PREDNISOLONE SUSPENSION 10mg/5mL IPR010 PREDNISOLONE INJ PREDNISOLONE 25mg/mL 20mL CPA108 REDIPRED (RASPBERRY PREDNISOLONE NA FLAVOUR) ORAL 5 mg/1LIQUID mL x 30 PREDNISOLONE MRE020 REDIPRED 5mg/ml ISO080 SOLU-MEDROL 500mg METHYLPREDNISOLONE NA SUCCINATE DRUGS TROPHIC HORMONES & RELATED SYNTHETIC CAC020 ACTHAR GEL 40 UNITS ADRENOCORTICOTROPIC HORMONE ICO020 CORTROSYN DEPOT INJ TETRACOSACTIDE HEXAACETATE 1mg/mL IDE006 DECAPEPTYL CR INJ TRIPTORELIN IDE005 DECAPEPTYL INJ 0.1mg TRIPTORELIN IDI016 DIPHERELINE PR INJ TRIPTORELIN 3.75mg IEN012 ENANTONE INJ 11.25mg LEUPRORELIN ACETATE IEN010 ENANTONE INJ 3.75mg LEUPRORELIN ACETATE IGO012 GONAL-F 150IU/mL FOLLITROPIN ALFA IGO010 GONAL-F 1050IU/1.75mL FOLLITROPIN ALFA AMI010 MIRENA LEVONORGESTREL AMO020 Mona Lisa CU 375 IUD 375 IPR036 PROFASI INJ 10,000IU HUMAN CHORIONIC GONADOTROPHIN IPR034 PROFASI INJ 5,000 IU HUMAN CHORIONIC GONADOTROPHIN SSU010 SUPRECUR NASAL SPRAY BUSERELIN ACETATE SSY020 SYNAREL NASAL SPRAY NAFARELIN ACETATE 2mg/mL IZO010 ZOLADEX DEPOT INJ GOSERELIN ACETATE 3.6mg 3.6mg IZO012 ZOLADEX LA DEPOT INJ GOSERELIN ACETATE 10.8mg IZO030 10.8mg ZOMACTON SOMATROPIN [SOMATROPIN] 4MG IPR015 PREGNYL INJ 5,000iu/mL HUMAN CHORIONIC GONADOTROPHIN CEPHA Page 14 of 28 LOSPOR TCE008 CECLOR 250mg (GE) CEFACLOR MONOPHYDRATE UNIT PRICE ($) 2.60 61.00 155.00 4.50 14.50 6.00 2.70 4.00 320.00 520.00 1.80 3.80 3.40 4.80 3.50 5.70 3.30 2.74 4.00 4.00 2.90 50.00 110.00 2.70 130.00 3.90 5.70 0.20 0.30 4.80 5.00 18.00 22.00 16.00 PK UNIT 500.00 2.80 3.90 1.20 2.00 145.00 155.00 25.00 25.00 70.00 90.00 2.70 125.00 2.00 37.00 150.00 70.00 57 2.75 0.50 1.20 26.50 0.28 25.00 90.00 100.00 520.00 PC TAB TAB TAB TAB VIA VIA AMP ML AMP AMP TAB VIA TAB ML AMP AMP ML TAB TAB TAB PC ML ML BOT BOT VIA 330.00 330.00 1350.00 150.00 1740.00 5240.00 2050.00 700.00 3200.00 2555.00 220.00 280.00 150.00 690.00 2100.00 2500.00 6040.00 1000.00 165.00 VIA VIA VIA VIA VIA VIA VIA VIA VIA SET PIE AMP AMP BOT BOT AMP AMP AMP AMP 4.30 CAP TAB TAB PK TAB TAB TAB TAB TAB AMP AMP g TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB AMP AMP TAB AMP TAB TAB TAB TAB TAB TAB TAB TAB PES DRUG FORMULARY (MAY 2014) [EFFECTIVE ON MAY 2014] ITEM NO. TCE009 DRUG DESCRIPTION GENERIC NAME UNIT PRICE ($) 7.50 PK UNIT CEFACLOR MONOHYDRATE 375mg CEFACLOR MONOHYDRATE CEFACLOR MONOHYDRATE CEFTIBUTEN DIHYDRATE 200mg CEFTIBUTEN DIHYDRATE CEFOPERAZONE SODIUM CLOXACILLIN SODIUM 250mg CEFADROXIL MONOHYDRATE 250mg CEFADROXIL 500mg CEPHALEXIN MONOHYDRATE 262.5mg CEPHALEXIN MONOHYDRATE 575mg CEPHALEXIN CEPHALEXIN CEFEPIME HCI LIGNOCAINE CEFTRIAXONE CEFTRIAXONE DISODIUM CEFTRIAXONE DISODIUM CEFTRIAXONE DISODIUM CEFTRIAXONE DISODIUM CEFTRIAXONE DISODIUM CEPHRADINE 250mg CEPHRADINE NA CEFUROXIME AXETIL 125mg CEFUROXIME AXETIL 250mg CEFUROXIME AXETIL 500mg CEFUROXIME AXETIL 13.00 1.20 1.10 25.50 4.50 440.00 2.50 3.50 4.00 3.00 5.00 0.90 0.70 350.00 150.00 120.00 105.00 185.00 380.00 330.00 5.90 150.00 9.80 18.00 59.00 2.10 TAB ML ML CAP ML VIA CAP CAP CAP CAP CAP ML ML VIA AMP VIA VIA VIA VIA VIA CAP AMP TAB TAB TAB ML ERYTHROMYCIN 250mg ERYTHROMYCIN ETHYLSUCCINATE ERYTHROMYCIN CLARITHROMYCIN 250mg CLARITHROMYCIN 250mg CLARITHROMYCIN 500mg CLARITHROMYCIN 250mg CLARITHROMYCIN CLARITHROMYCIN ROXITHROMYCIN 150mg AZITHROMYCIN DIHYDRATE 250mg AZITHROMYCIN AZITHROMYCIN DIHYDRATE 1.50 0.50 0.33 12.20 6.00 25.00 22.60 1.70 6.50 13.70 22.50 14.00 6.20 TAB ML ML TAB TAB TAB TAB ML SACH TAB TAB TAB ML DEXAMETHASONE DOXORUBICIN OXALIPLATINE OXALIPLATINE CYCLOPHOSPHAMIDE CARBOPLATIN 6-MERCAPTOPURINE 50mg DOCETAXEL 65.00 983.40 2750.00 5200.00 567.60 1080.00 70.00 2664.000 VIA VIA VIA VIA VIA VIA TAB VIA DOCETAXEL 9526.000 VIA CAPECITABINE CAPECITABINE 11.00 37.00 TAB TAB BICALUTAMIDE FLUTAMIDE 283.00 11.50 TAB TAB 8976.00 25740.00 357.00 895.00 435.00 1166.00 VIA VIA TAB TAB TAB CAP AMOXYCILLIN 250mg AMOXYCILLIN 500mg AMOXYCILLIN TRIHYDRATE AMOXYCILLIN 2.20 3.50 0.42 0.49 CAP CAP ML ML AMPICILLIN 250mg AMPICILLIN 500mg AMPICILLIN AMPICILLIN AMPICILLIN, CLOXACILLIN AMPICILLIN, CLOXACILLIN AMOXYCILLIN, CLAVULANATE K AMOXYCILLIN, CLAVULANATE K 1.50 2.00 0.25 45.00 4.00 0.50 8.00 CAP CAP ML VIA CAP ML TAB TAB CECLOR 500mg (GE)[CEFALOR PLUS] TCE010 CECLOR MR 375mg MCE012 CECLOR SUSPENSION 125mg/5mL (GE) MCE010 CECLOR SUSPENSION 125mg/5mL 60mL TCE020 CEDAX 200mg MCE020 CEDAX SUSPENSION 180mg/5mLINJ 30mL ICE010 CEFOBID 1g TCL040 CLOXACILLIN TDU019 DURACEF 250mg CPA047 CEFADROXIL 500mg (GE) TKE010 KEFLEX 250mg (GE) TKE020 KEFLEX 500mg (GE) MKE010 KEFLEX SUSPENSION 125 mg/5mL 60mL MKE012 KEFLEX SUSPENSION 125mg/5mL 60mL CPA084 MAXIPIME IM/IV (GE) 1g IRO013 ROCEPHIN IM 500g (GE) IRO014 ROCEPHIN INJ 250mg IRO015 ROCEPHIN INJ 250mg (GE) IRO012 ROCEPHIN INJ 500mg IRO010 ROCEPHIN INJ 1g IRO011 ROCEPHIN INJ 1g (GE) TVE010 VELOSEF 250mg IZI010 ZINACEF 250mg INJ TZI010 ZINNAT 125mg TZI012 ZINNAT 250mg TZI014 ZINNAT 500mg MZI006 ZINNAT 125mg/5mL MACRO SUSPENSION LIDES TER010 ERYTHROMYCIN 250mg MER010 ERYTHROMYCIN GRANULES 200mg/5mL MER020 ERYTHROMYCIN SUSPENSION 125mg/5mL TKL010 KLACID 250mg TKL013 KLACID 250mg (GE) TKL011 KLACID 500mg TKL012 KLACID MR 500mg MKL010 KLACID SUSPENSION 125mg/5mL 60mL MKL012 KLACID SUSPENSION 125mg (GE) SACHET TRU010 RULID 150mg TZI020 ZITHROMAX 250mg TZI021 ZITHROMAX 250mg (GE) MZI010 ZITHROMAX SUSPENSION 200MG/5ML 15ML CYTOTOXIC CHEMOTHERAPY IDE042 DEXAMETHASONE 8mg/2mL INJ IDO020 DOXORUBICIN-EBEWE INJ 50MG/25ML IEL001 ELOXATIN [OXALIPLATINE] 50mg INJ IEL002 ELOXATIN [OXALIPLATINE] IEN030 ENDOXAN INJ 1G100mg IPA020 PARAPLATIN INJ 150mg/15mL 50mg TPU010 PURI-NETHOL ITA010 TAXOTERE CONC FOR INF 20mg/0.5ml ITA012 TAXOTERE CONC FOR INF. 80mg/2ml TXE005 XELODA [capecitabine] 150mg TXE006 XELODA [capecitabine] 500mg HORMONAL CHEMOTHERAPY TCA075 CASODEX [bicalutamide] 150mg TFL060 FLUTAMIDE 250mg(G.E) TARGETED CANCER THERAPY IHE060 HERCEPTIN 150mg IHE062 HERCEPTIN 440mg TJA002 JAKAVI [ruxolitinib] 5mg TJA003 JAKAVI [ruxolitinib] 20mg TSP030 SPRYCEL[dasatinib] 50mg TXA013 XALKORI 250mg 60's PENICIL LINS TAM020 AMOXIL 250mg (GE) TAM022 AMOXIL 500mg (GE) MAM010 AMOXIL SYRUP 125mg/5mL (GE) MAM012 AMOXIL SYRUP 125mg/5mL 60mL- NEO TAM030 CHEM AMPICILLIN 250mg TAM032 AMPICILLIN 500mg MAM020 AMPICILLIN SYRUP 125mg/5mL (GE) IAM030 AMPICILLIN INJ 500mg TAM040 AMPICLOX 500mg (GE) MAM030 AMPICLOX SYRUP 250mg/5mL (GE) TAU010 AUGMENTIN 375mg TAU011 AUGMENTIN 375mg (GE)[AMOXYCILLIN, CLAVULANIC625mg ACID] CPA126 AUGMENTIN CEFACLOR AMPICILLIN, CLOXACILLIN 6.000 8.00 TAB TAU012 AUGMENTIN 1g TAU014 AUGMENTIN 1g (GE) AMOXYCILLIN, CLAVULANIC ACID Page 15 of 28 AMOXYCILLIN CLAVULANIC ACID 11.00 8.00 TAB TAB TRASTUZUMAB TRASTUZUMAB RUXOLITINIB RUXOLITINIB DASATINIB CRIZOTNIB 250mg CAP DRUG FORMULARY (MAY 2014) [EFFECTIVE ON MAY 2014] ITEM DRUG DESCRIPTION NO. MAU010 AUGMENTIN SYRUP 156mg/5mL (60mL) MAU020 AUGMENTIN BD SYRUP SYRUP 457mg/5mL, 35mL MAU011 CURAM 156.25mg/5mL 100mLmL (GE)156.25mg/5 CPA133 CURAM ORAL SUSP, 60mL xmL 1's 312.5mg/5 CPA134 CURAM ORAL SUSP, 60mL x 1's 457mg/5 mL ORAL CPA135 SUSP, 35mL x 1's CPA142 CURAM 375 mg CPA143 CURAM 1,000 mg MFL012 FLUCLOXACILLIN ELIXIR 125mg/5mL250mg (GE) TOR010 ORBENIN MOR010 ORBENIN SYRUP 125mg/5mL 100mL (GE) IPE010 PENADUR LA INJ 1.2MU 4mL TPE020 PENGLOBE 400mg IPE016 PENICILLIN G INJ 600mg IPE017 PENICILLIN G INJ 1M IU MPE010 PENICILLIN V SUSPENSION 125mg/5mL TPE010 PEN-V K 250 mg (GE) IPR030 PROCAINE PENICILLIN G QUINOL INJ ONES TAV008 AVELOX 400mg TCI010 CIPROXIN 250mg TCI008 CIPROXIN 250mg (GE) TCI009 CIPROXIN 500mg (GE) TCR006 CRAVIT 100mg TCR007 CRAVIT 250mg TCR008 CRAVIT EYE 500mg DROPS (GE)DCR011 [LEVOFLOXACIN] TLE020 LEXINOR 100mg TLE021 LEXINOR 400mg TAB TTA030 TARIVID 100mg TTA036 TARIVID 100mg (GE) TTA032 TARIVID 200mg TTA034 TARIVID 200mg (GE) TUR026 UROTRACTIN TWI012 WINTOMYLON 500mg TWI010 WINTOMYLON 500mg (GE) TETRACYCLINES TMI072 MINOCIN 50mg TMI074 MINOCIN 50mg (GE) TMI070 MINOCIN 100mg TMI080 MINOCIN MR 100mg TMI076 MINOCIN 100mg (GE) TOX010 OXY-TETRACYCLINE 250 TTE060 mg TETRACYCLINE 250 mg TTE070 TETRALYSAL 300 CAP TVI018 VIBRAMYCIN 50mg TVI020 VIBRAMYCIN 100mg (GE) CPA139 VIBRAMYCIN FILMCOATED TAB 100 mg ANTIFUNGALS CPA063 CLOZOLE PESSARY 500MG TDI058 DIFLUCAN 50mg TDI059 DIFLUCAN 50mg (GE) TDI060 DIFLUCAN 150mg TDI062 DIFLUCAN 150mg (GE) MDI006 DIFLUCAN SUSPENSION 50mg/5mL TGR030 GRISEOSTATIN 330mg TGR020 GRISOVIN 125mg TGR021 GRISOVIN 125mg (GE) TGR022 GRISOVIN 500mg TGR023 GRISOVIN 500mg (GE) TLA030 LAMISIL 250mg TLA031 LAMISIL 250mg (GE) TMY016 MYCOSTATIN 500,000U (GE) MMY010 MYCOSTATIN DROPS 100,000 unit/mL TNI060 NIZORAL 200mg(GE) TNI062 NIZORAL 200mg (GE) TSE040 SEPTRIN (GE) MSE010 SEPTRIN SUSPENSION (GE) TSP020 SPORANOX 100mg TSP022 SPORANOX 100mg (GE) OTHER ANTIBIOTICS IAR003 ARANESP [darbepoetin] 100mcg/0.5ml PRE-FILLED TDA018 DALACIN C 150mg TDA019 DALACIN C 300mg TDA034 DAPSONE 100mg TFL010 FLAGYL 200mg (GE) CPA 079 FLAGYL 200mg (BRANDED)SUSPENSION MFL010 FLAGYL-S 200mg/5mL 100mL TFL011 FLAGYL 250mg(G.E) TFL012 FLAGYL 400mg TFU010 FURADANTIN 50mg (GE) IGE010 GENTAMYCIN INJ 80mg/mL INJ + LIDOCAINE 1% IIN080 INVANZ 1g ILI020 LINCOCIN INJ 3g/10mL GENERIC NAME UNIT PRICE ($) 1.05 2.90 1.00 30.00 50.00 70.00 6.00 11.00 0.50 2.50 0.45 110.00 4.00 35.00 60.00 0.25 1.00 40.00 PK UNIT MOXIFLOXACIN HCl 400mg CIPROFLOXACIN 250mg CIPROFLOXACIN 250mg CIPROFLOXACIN 500mg LEVOFLOXACIN 100mg LEVOFLOXACIN 250mg LEVOFLOXACIN 500mg LEVOFLOXACIN NORFLOXACIN 100mg NORFLOXACIN 400mg OFLOXACIN 100mg OFLOXACIN 100mg OFLOXACIN 200mg OFLOXACIN 200mg PIPEMIDIC ACID 400mg NALIDIXIC ACID 500mg NALIDIXIC ACID 500mg 45.00 11.60 7.70 11.27 8.10 16.00 29.00 40.00 4.50 15.00 6.00 4.20 11.00 8.60 8.50 3.10 2.50 TAB TAB TAB CAP TAB TAB TAB BOT TAB TAB TAB TAB TAB TAB CAP TAB TAB MINOCYCLINE HCL 50mg MINOCYCLINE HCL 50mg MINOCYCLINE HCL 100mg MINOCYCLINE HCL 100mg MINOCYCLINE HCL 100mg OXYTETRACYCLINE HCL 250mg TETRACYCLINE 250mg TETRALYSAL 300 CAP DOXYCYCLINE HYCLATE 50mg DOXYCYCLINE HYCLATE 100mg DOXYCYXLINE 5.00 3.50 10.00 13.00 6.00 0.70 0.90 10.00 4.00 3.00 9.00 CAP CAP CAP CAP CAP CAP CAP CAP TAB TAB TAB CLOTRIMAZOLE FLUCONAZOLE 50mg FLUCONAZOLE 50mg FLUCONAZOLE 150mg FLUCONAZOLE 150mg FLUCONAZOLE GRISEOFULVIN ULTRAMICROSIZE GRISEOFULVIN 125mg GRISEOFULVIN 125mg GRISEOFULVIN 500mg GRISEOFULVIN 500mg TERBINAFINE 250mg TERBINAFINE 250mg NYSTATIN 500,000U NYSTATIN KETOCONAZOLE 200mg KETOCONAZOLE 200mg TRIMETHOPRIM, SULFAMETHOXAZOLE TRIMETHOPRIM, SULFAMETHOXAZOLE ITRACONAZOLE 100mg ITRACONAZOLE 100mg 5.00 85.00 40.00 180.00 105.00 16.50 4.30 1.20 1.20 3.00 2.80 21.00 14.00 1.30 4.00 26.00 7.00 1.50 0.27 28.00 17.00 TAB TAB CAP CAP CAP ML TAB TAB TAB TAB TAB TAB TAB TAB ML TAB TAB TAB ML CAP CAP DARBEPOETIN 100mcg CLINDAMYCIN 150mg CLINDAMYCIN 300mg DAPSONE 100mg METRONIDAZOLE 200mg METRONIDAZOLE 200mg METRONIDAZOLE METRONIDAZOLE METRONIDAZOLE NITROFURANTOIN 50mg GENTAMICIN, LIDOCAINE ERTAPENEM 1g Page 16 of 28 LINCOMYCIN 1892.00 7.60 10.50 1.50 1.70 3.00 1.80 2.50 7.00 1.30 70.00 525.00 100.00 SYR CAP CAP TAB TAB TAB ML TAB TAB TAB VIA VIA VIA AMOXYCILLIN, CLAVULANATE K AMOXYCILLIN, CLAVULANIC ACID AMOXYCILLIN, CLAVULANIC ACID AMOXYCILLIN, CLAVULANATE K AMOXYCILLIN, CLAVULANATE K AMOXYCILLIN, CLAVULANATE K POTASSIUM AMOXYCILLIN, CLAVULANATE POTASSIUM FLUCLOXACILLIN CLOXACILLIN CLOXACILLIN BENZATHINE PENICILLIN G BACAMPICILLIN 400mg BENZYLPENICILLIN SODIUM BENZYLPENICILLIN SODIUM PHENOXYMETHYLPENICILLIN PHENOXYMETHYLPENICILLIN 250mg PROCAINE PENICILLIN ML ML ML BOT BOT BOT TAB TAB ML CAP ML VIA TAB VIA VIA ML TAB VIA DRUG FORMULARY (MAY 2014) [EFFECTIVE ON MAY 2014] ITEM DRUG DESCRIPTION GENERIC NAME NO. TLO030 LORABID 200mg LORACARBEF 200mg MMO006 MONUROL 3g FOSFOMYCIN TROMETAMOL IST020 STREPTOMYCIN INJ 1g STREPTOMYCIN CPA 081 TRIMETHOPRIM HCI TRIMETHOPRIM HCI ITR030 TROBICIN INJ 2g SPECTINOMYCIN HCL IGE008 GENTAMYCIN INJ GENTAMICIN CPA057 80mg/2mL UNASYN 375mg AMPICILLIN SODIUM / SULBACTAM SODIUM CPA100 ZYVOX 600mg LINZOLID TZY060 ZYVOX [linezolid] 600mg LINEZOLID ANTITUBERCULOUS AGENTS TIS010 ISONIAZID 100mg (GE) ISONIAZID 100mg TIS012 ISONIAZID 50mg (GE) ISONIAZID 50mg MRI010 MPR050 100mg/5mL RIFAMPICIN TMY010 MYAMBUTOL 100mg ETHAMBUTOL 100mg TMY012 MYAMBUTOL 400mg ETHAMBUTOL 400mg TMY013 MYAMBUTOL 400mg (GE) ETHAMBUTOL 400mg TPY010 PYRAMIDE 500mg (GE) PYRAZINAMIDE 500mg TRI010 RIFADIN 150mg (GE) RIFAMPICIN 150mg TRI012 RIFADIN 300mg (GE) RIFAMPICIN 300mg TRI030 RIFADIN 450mg (GE) RIFAMPICIN 450mg TRI014 RIFATER RIFAMPICIN/INH/PYRAZINAMIDE TRI018 RIFINAH 150mg RIFAMPICIN,ISONIAZID 150/100mg TRI020 RIFINAH 300mg RIFAMPICIN,ISONIAZID 300/150mg ANTIAMOEBICS TFA020 FASIGYN 500mg (GE) TINIDAZOLE 500mg ANTHELMINTICS TBI010 BILTRICIDE 600mg PRAZIQUANTEL 600mg TCO050 COMBANTRIN 125mg PYRANTEL PAMOATE 125mg TCO051 COMBANTRIN 125mg (GE) PYRANTEL PAMOATE 125mg MCO040 COMBANTRIN PYRANTEL PAMOATE SUSPENSION 125mg/5mL MCO042 COMBANTRIN PYRANTEL PAMOATE SUSPENSION 250mg/5mL TDE030 DECARIS 50mg LEVAMISOLE 50mg TVE040 VERMOX 100mg MEBENDAZOLE 100mg TVE041 VERMOX 100mg (GE) MEBENDAZOLE 100mg CPA080 VERMOX 500mg MEBENDAZOLE 100mg (BRANDED) MVE020 VERMOX SUSPENSION MEBENDAZOLE 100mg/5mL 30mL ANTIVIRALS MAC005 ACICLOVIR SUSPENSION ACICLOVIR CAL030 100mg/5mL ALDARA CREAM 5% IMIQUIMOD 5% CREAM TBA007 BARACLUDE 0.5mg ENTECAVIR TCO066 COPEGUS (RIBAVIRIN) RIBAVIRIN 200mg 200mg 125mg TFA010 FAMVIR FAMCICLOVIR 125mg TFA012 FAMVIR 250mg (GE)FAMCICLOVIR 250mg TFA013 [FAMCICLOVIR] FAMCICLOVIR THE016 HEPSERA 10mg ADEFOVIR DIPIVOXIL 10mg IPE006 PEG-INTRON REDIPEN INJ RECOMBINANT ALPHA-2B INTERFERON IPE004 80mcg PEGASYS INJ INTERFERON ALPHA-2A IPE005 PEGASYS INJ 180mcg/0.5mL ITERFERON ALPHA-2A IPE007 PEG-INTRON INJ 120mcg ALPHA-2B INTERFERON (C.U.) IPE008 PEG-INTRON REDIPEN INJ ALPHA-2B INTERFERON 100mcg SRE006 RELENZA INHALER ZANAMIVIR TSE005 SEBIVO 600mg TELBIVUDINE 600mg TTA023 TAMIFLU 75mg OSELTAMIVIR PHOSPHATE 75mg MTA010 TAMIFLU SUSPENSION OSELTAMIVIR 12mg/mL x 500mg 62mL TVA020 VALTREX VALACICLOVIR 500mg TENOFOVIR DISOPROXIL TVI027 VIREAD 300mg FUMARATE TZE004 ZEFFIX 100mg LAMIVUDINE 100mg TZO030 ZOVIRAX 200mg ACYCLOVIR 200mg TZO031 ZOVIRAX 200mg (GE) ACYCLOVIR 200mg TZO032 ZOVIRAX 400mg ACYCLOVIR 400mg TZO033 ZOVIRAX 400mg (GE) ACYCLOVIR 400mg TZO034 ZOVIRAX 800mg ACYCLOVIR 800mg TZO035 ZOVIRAX 800mg (GE) ACYCLOVIR 800mg MZO010 ZOVIRAX SUSPENSION ACYCLOVIR 200mg/5mL 125mL ANTINEOPLASTICS TAR030 ARIMIDEX 1mg ANASTROZOLE TCA072 CASODEX BICALUTAMIDE CEF022 EFUDIX CREAM 5% 20g 5-FLUORO-URACIL CEF020 EFUDIX OINTMENT 5% 20g 5-FLUORO-URACIL TEN010 ENDOXAN 50mg CYCLOPHOSPHAMIDE 50mg IFL010 FLUORO-URACIL INJ 5-FLUOROURACIL 250mg/5mL THY004 HYDREA 500mg HYDROXYUREA 500mg IIN020 INTRON-A INJ 3MIU + INTERFERON ALPHA-2b RIBARIVARIN 200mg TAB METHOTREXATE 2.5mg TME050 METHOTREXATE 2.5mg IME007 METHOTREXATE 10mg INJ METHOTREXATE 10mg IME009 METHOTREXATE 25mg/mLMETHOTREXATE INJ IMI005 MITOMYCIN-C 2mg MITOMYCIN TNO010 NOLVADEX 10mg (GE) TAMOXIFEN CITRATE 10mg TNO020 NOLVADEX-D 20mg TAMOXIFEN CITRATE 20mg TNO022 NOLVADEX-D 20mg (GE) TAMOXIFEN CITRATE 20mg IRO016 ROFERON-A INJ 3MIU INTERFERON ALPHA 2A ANTIMALARIALS TLA070 LARIAM 250mg (GE) MEFLOQUINE 250mg Page 17 of 28 TMA025 MALARONE ATOVAQUONE, PROGUANIL HCL UNIT PRICE ($) 32.00 82.50 40.00 1.50 205.00 50.00 8.60 540.00 517.00 PK UNIT 0.50 0.40 2.00 2.20 4.80 4.40 2.00 4.50 7.00 10.00 7.50 8.60 19.00 TAB TAB ML TAB TAB TAB TAB CAP CAP TAB TAB TAB TAB 12.00 TAB 160.00 6.00 3.00 2.00 5.50 10.00 6.50 4.50 48.00 3.00 TAB TAB TAB ML ML TAB TAB TAB TAB ML 0.25 720.00 90.00 0.00 35.00 38.00 30.00 75.00 1700.00 1680.00 1750.00 450.00 1700.00 320.00 56.50 32.00 5.00 22.00 110.00 35.00 27.60 7.00 16.40 10.00 20.50 13.00 5.40 ML BOX TAB TAB TAB TAB TAB TAB PEN SYR SYR VIA PEN BOX TAB CAP ML TAB TAB TAB TAB TAB TAB TAB TAB TAB ML 82.00 151.00 12.50 12.50 13.50 80.00 11.80 580.00 8.80 40.00 160.00 130.00 3.50 28.10 6.50 500.00 TAB TAB g g TAB VIA CAP VIA TAB AMP VIA AMP TAB TAB TAB VIA 41.00 73.50 TAB TAB CAP SACH VIA ML VIA AMP TAB TAB TAB DRUG FORMULARY (MAY 2014) [EFFECTIVE ON MAY 2014] ITEM DRUG DESCRIPTION GENERIC NAME NO. TNI050 NIVAQUIN 200mg (GE) CHLOROQUINE PHOSPHATE 200mg PREPARATIONS FOR VAGINAL CONDITIONS PAL010 ALBOTHYL VAGINAL POLICRESULEN SUPP 90mg PESSARY PBE010 BETADINE POVIDONE IODINE 200mg PCA010 CANESTEN PESSARY CLOTRIMAZOLE 100mg 6'S VAGINAL TAB CLOTRIMAZOLE PCA011 CANESTEN PCA012 500MG CANESTEN PESSARY 500 CLOTRIMAZOLE mg 1's (GE) PESSARY 500 CLOTRIMAZOLE CPA154 CANESTEN mg PCO010 COLPOSEPTINE PESSARY PROMESTRIENE, CHLORQUINALDOL CDI006 DIENOESTROL CREAM DIENOESTROL 0.01% 0.01% 78g PESSARY PGI010 GINETRIS CHLORAMPHENICOL/MYRALACT//C LOP PGY020 GYNE-LOTREMIN CHLORAMPHENICOL/MYRALACT//C PESSARY 100mg PESSARY ECONAZOLE LOP PGY016 GYNO-PEVARYL NITRATE 150mg PGY010 GYNO-TRAVOGEN ISOCONAZOLE NITRATE PESSARY 300mg PGY030 GYNOPHILUS GYNO-TROSYD PESSARY TIOCONAZOLE CASEI V. VAG CAP LACTOBACILLUS CPA140 341 341 mg RHAMNOSUS DODERLEIN (LCR35) PMY010 MYCOSTATIN PESSARY NYSTATIN 100,000U (GE) CPR010 PREMARIN VAGINAL CONJUGATED ESTROGENS CREAM 42.5g CPA117 PREMARIN VAGINAL CONJUGATED ESTROGENS 0.625 mg/1 gOVULE x 14 g TETRACYCLINE, AMPHOTERICIN B PTA010 CREAM TALSUTIN PESSARY ZALAIN VAGINAL PZA010 300mg SERTACONAZOLE URINARY ANTISEPTICS MCI010 CITRAVESCENT SODIUM BICARBONATE, CITRIC GRANULES ACID… TUR024 UROCIT-K POTASSIUM CITRATE MMI010 MIST POTASSIUM POTASSIUM CITRATE CITRATE DRUGS FOR BLADDER & PROSTATE DISORDERS TAV009 AVODART 0.5mg DUTASTERIDE THA032 HARNAL D 0.2mg TAMSULOSIN HCl UNIT PRICE ($) 1.00 PK UNIT 14.50 5.00 17.00 120.00 43.00 85.00 7.00 1.92 7.80 11.00 40.00 35.00 36.00 8.60 3.20 6.00 PES PES PES PES PES PES PES g PES PES PES PES PES CAP PES g 70.00 TUB 4.50 75.00 PES PES 2.50 6.50 0.40 PK TAB ML 14.70 15.00 CAP TAB OTHER DRUGS ACTING ON GENITO-URINARY SYSTEM TCE050 CETIPRIN NOVUM 200mg EMEPRONIUM CARRAGEENATE 4.10 200mg CPA044 DETRUSITOL 1mg TOLTERODINE I-TARTRATE 1mg 9.10 TDE044 DETRUSITOL 2mg TOLTERODINE I-TARTRATE 2mg 10.60 TDI110 DITROPAN 5mg (GE) OXYBUTYNIN CHLORIDE 5mg 2.00 THA030 HARNAL OCAS 0.4mg TAMSULOSIN HYDROCHLORIDE 13.50 THY010 HYTRIN 1mg TERAZOSIN HCL 1mg 5.10 THY012 HYTRIN 2mg TERAZOSIN HCL 2mg 8.30 THY013 HYTRIN 5mg TERAZOSIN HCL 5mg 23.00 TPR110 PROSCAR 5mg FINASTERIDE 5mg 15.00 TPR112 PROSCAR 5mg (GE) FINASTERIDE 5mg 10.00 TPY020 PYRIDIUM 100mg PHENAZOPYRIDINE HCL 100mg 1.20 TPY022 PYRIDIUM 100mg (GE) PHENAZOPYRIDINE HCL 100mg 1.00 TXA016 XATRAL SR 5mg ALFUZOSIN HCL 5mg 6.00 TXA018 XATRAL XL 10mg ALFUZOSIN HCL 10mg 8.00 TVE060 VESICARE 5mg SOLIFENACIN SUCCINATE 5mg 10.50 INSULIN IAC010 ACTRAPID HM 100IU/mL INSULIN 355.00 (10mL) IAC020 ACTRAPID HM PENFILL INSULIN 105.00 100IU/mL (3mL) 100IU/mL IAC030 ACTRAPID-MC INSULIN 310.00 (10mL) SOLOSTAR IAP010 APIDRA INSULIN HUMAN SHORT 140.00 100IU/mL 100U/mL 195.00 IHU006 HUMALOG MIX 25 100U/mL INSULIN KWIPEN LISPRO 25% ,INSULIN LISPRO PROTAMINE 75% x IHU007 10mL INSULIN LISPRO 500.00 IHU008 HUMALOG 100IU/mL INSULIN 180.00 PENFILL 5x3mL IHU010 HUMULIN 70/30 100IU/mL INSULIN (SOLUBLE + ISOPHANE) 260.00 IHU020 (10mL) HUMULIN 70/30 PENFILL INSULIN (SOLUBLE + ISOPHANE) 85.00 100IU/mL (3mL) IHU030 HUMULIN L 100IU/mL LENTE INSULIN 260.00 (10mL) IHU040 HUMULIN N 100IU/mL 360.00 (10mL) IHU042 HUMULIN N PENFILL ISOPHANE INSULIN 85.00 100IU/ML (3mL) IHU050 HUMULIN R 100IU/mL INSULIN 260.00 (10mL) 100IU/mL 3mL ILA020 LANTUS INSULIN 144.00 ILA022 LANTUS 100IU/mL 10mL INSULIN GLARGINE 180.00 ILA021 LANTUS OPTISET INSULIN GLARGINE 144.00 100IU/mLSOLOSTAR 3mL CPA082 LANTUS PRE- INSULIN GLARGINE 160.00 FILLED PEN ILE020 LEVEMIR FLEXPEN INSULIN DETEMIR 198.00 100U/mL HM PENFILL IMI013 MIXTARD INSULIN (SOLUBLE + ISOPHANE) 80.00 10/90 100IU/mL 5x3mL IMI012 MIXTARD HM PENFILL INSULIN (SOLUBLE + ISOPHANE) 80.00 20/80 100IU/mL 5x3mL IMI010 MIXTARD HM PENFILL INSULIN (SOLUBLE + ISOPHANE) 105.00 30/70 100IU/mL 5x3mL IMI014 MIXTARD HM PENFILL INSULIN (SOLUBLE + ISOPHANE) 80.00 50/50 100IU/mL 100IU/mL 5X3mL IMI020 MIXTARD-HM INSULIN (SOLUBLE + ISOPHANE) 355.00 (10mL) IMO010 MONOTARD-HM 100IU/mL INSULIN ZINC SUSPENSION 260.00 (10mL) IMO020 MONOTARD-MC 100IU/mL INSULIN ZN SUSPENSION(PORCINE) 310.00 (10mL) INO010 NOVOMIX 30 FLEXPEN INSULIN ASPART 205.00 INO020 100U/mL NOVORAPID FLEXPEN PENFILL INSULIN ASPART 205.00 NOVORAPID 100u/mL 3mL 205.00 INO021 100U/mL (3mL) INSULIN ASPART 40.00 TNO050 NORMIX 200mg RIFAXIMIN IPR060 PROTAPHANE HM INSULIN ISOPHANE 105.00 PENFILL 100IU/mL (3mL) IPR062 PROTAPHANE-HM INSULIN ISOPHANE 355.00 100IU/mL (10mL) IPR064 PROTAPHANE-MC INSULIN 270.00 100IU/mL (10mL) IUL010 ULTRATARD HM 100IU/mL INSULIN CRYSTALLINE SUSPENSION 260.00 (10mL) APE050 PEN ULTRA 3mL 460.00 ORAL ANTIDIABETIC AGENTS TAC028 ACTOS 30mg 30mg15MG, 33.00 PIOGLITAZONE HCl 18 of 28 19.00 TAC029 ACTOSMET 15mg/850 28'S METFORMIN HClPage 850MG TAC031 ACTOS 15mg PIOGLITAZONE 19.40 TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB VIA AMP VIA AMP AMP VIA AMP VIA AMP VIA VIA AMP VIA AMP VIA AMP PC AMP AMP AMP AMP AMP VIA VIA VIA AMP AMP AMP TAB AMP VIA VIA VIA PC TAB TAB TAB DRUG FORMULARY (MAY 2014) [EFFECTIVE ON MAY 2014] ITEM DRUG DESCRIPTION NO. TAV001 AVANDAMET 1mg/500mg TAV002 AVANDAMET 2mg/500mg TAV003 AVANDAMET 4mg/500mg TAV011 AVANDAMET 4mg/1000mg CPA102 AMARYL 1mg TAM014 AMARYL 2mg TAM016 AMARYL 4mg TAV004 AVANDIA 2mg TAV006 AVANDIA 4mg TAV007 AVANDIA 8mg TDA030 DAONIL 5mg (GE) TDI010 DIABINESE 250mg (GE) TDI018 DIAMICRON MR 30mg TDI019 DIAMICRON (GE)-[GLICLAZIDE] MR 60mg 30'S TDI017 [GLICLAZIDE] TDI020 DIAMICRON 80mg (GE) TGA002 GALVUS MET 50mg/850mg TGA003 GALVUS MET 50mg/500mg TGA004 GALVUS MET 50mg/1000mg TGA005 GALVUS 50mg TGL012 GLUCOBAY 50mg TGL010 GLUCOBAY 100mg TGL020 GLUCOPHAGE 250mg (GE) TGL022 GLUCOPHAGE 500mg TGL023 GLUCOPHAGE XR 500mg TGL025 GLUCOPHAGE XR 750mg TGL024 GLUCOPHAGE 850mg TGL030 GLUCOTROL XL 5mg TGL040 GLUCOVANCE TGL041 500mg/2.5mg GLUCOVANCE 500mg/5mg TJA020 JANUVIA 100mg TJA022 JANUMET 50mg/500mg TJA023 JANUMET 50mg/1000mg TME020 MELBIN 250mg TMI040 MINIDIAB 5mg TN0090 NOVONORM 0.5mg TN0092 NOVONORM 1mg TNO094 NOVONORM 2mg TON040 ONGLYZA 5mg CPA118 ONGLYZA FILM-COATED TAB TRA010 RASTINON 500mg (GE) ANTIDIABETIC AGENTS IBY010 BYETTA 5mcg/20 microlitre IBY012 BYETTA 10mcg/20 microlitre GENERIC NAME UNIT PRICE ($) ROSIGLITAZONE 1mg, METFORMIN 5.00 500mg ROSIGLITAZONE 2mg, METFORMIN 8.60 500mg 4mg, METFORMIN 14.20 ROSIGLITAZONE MELEATE 500mg 4mg,METFORMIN 1000mg 14.20 GLIMEPIRIDE 1mg 2.50 GLIMEPIRIDE 2mg 5.00 GLIMEPIRIDE 4mg 8.00 ROSIGLITAZONE MALEATE 2mg 9.30 ROSIGLITAZONE MALEATE 4mg 17.60 ROSIGLITAZONE MALEATE 8mg 31.00 GLIBENCLAMIDE 5mg 1.50 CHLORPROPAMIDE 250mg 1.50 GLICLAZIDE MR 30mg 4.80 GLICLAZIDE 3.20 GLICLAZIDE 9.60 GLICLAZIDE 80mg 2.70 7.60 VILDAGLIPTIN 50mg, METFORMIN 850mg 500mg 7.60 VILDAGLIPTIN 50mg, METFORMIN 1000mg 7.60 VILDAGLIPTIN 7.10 ACARBOSE 50mg 3.40 ACARBOSE 100mg 3.50 METFORMIN HCL 250mg 0.50 METFORMIN HCL 500mg 1.00 METFORMIN 500mg 2.50 METFORMIN 3.65 METFORMIN HCL 850mg 2.50 GLIPIZIDE 5mg 4.20 METFORMIN, GLIBENCLAMIDE 2.00 METFORMIN HCL; GLIBENCLAMIDE 2.00 SITAGLIPTIN 100mg 17.50 50mg, METFORMIN 8.75 SITAGLIPTIN PHOSPHATE 50mg, 500mg METFORMIN 1000mg 8.75 METFORMIN HCL 250mg 2.40 GLIPIZIDE 5mg 4.00 REPAGLINIDE 0.5mg 3.40 REPAGLINIDE 1mg 4.20 REPAGLINIDE 2 mg 5.50 SAXAGLIPTIN 12.000 SAXAGLIPTIN HCI 13.00 TOLBUTAMIDE 500mg 1.00 EXENATIDE EXENATIDE TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB 2400.00 2400.00 1445.00 15.00 BOX BOX SYR TAB THYROXINE SODIUM 100mcg THYROXINE 50mcg THYROXINE 100mcg 1.00 0.60 1.20 TAB TAB TAB IODINE CARBIMAZOLE 5mg CARBIMAZOLE 5mg PROPYLTHIOURACIL 50mg PROPYLTHIOURACIL 200MG METHIMAZOLE 5mg 0.60 1.00 0.85 1.20 2.20 5.00 ML TAB TAB TAB TAB TAB CLOFIBRATE 500mg BEZAFIBRATE 200mg BEZAFIBRATE 400mg AMLODIPINE 5mg, ATORVASTATIN 10mg 10mg,ATORVASTATIN ATORVASTATIN AMLODIPINE 5mg, 10mg 20mg AMLODIPINE 10mg, ATORVASTATIN 20mg ROSUVASTATIN 5mg ROSUVASTATIN 10mg ROSUVASTATIN 20mg THEOFIBRATE 250mg THEOFIBRATE 500mg EZETIMIBE 10mg FLUVASTATIN SODIUM 20mg FLUVASTATIN SODIUM 40mg FLUVASTATIN SODIUM 80mg FENOFIBRATE 300mg FENOFIBRATE 100mg FENOFIBRATE 200mg FENOFIBRATE 300mg ATORVASTATIN 10mg ATORVASTATIN CALCIUM ATORVASTATIN 20mg ATORVASTATINPage CALCIUM 19 of 28 ATORVASTATIN 40mg 3.00 5.00 11.60 15.80 18.70 24.50 26.20 12.90 16.50 22.40 2.50 4.80 16.50 4.00 7.00 7.60 8.00 3.00 15.30 12.10 11.80 7.20 17.40 11.00 28.90 CAP TAB TAB TAB TAB TAB TAB TAB TAB TAB CAP CAP TAB TAB TAB TAB CAP TAB TAB TAB TAB TAB TAB TAB TAB IVI004 VICTOZA 6mg/mL PRE-FILLED LIRAGLUTIDE PEN TTR004 TRAJENTA 5mg LINAGLIPTIN THYROID PREPARATIONS TEL020 ELTROXIN 100mcg TTH030 THYROXINE 50mcg TTH032 THYROXINE 100mcg ANTITHYROIDS MLU010 LUGOL'S IODINE SOLUTION TNE010 NEO-MERCARZOLE 5mg (GE) TNE012 NEO-MERCAZOL 5mg TPR100 PROPYLTHIOURACIL 50mg TPR102 PROPYLTHIOURACIL 200mg TTA026 TAPAZOLE 5mg ANTIHYPERLIPIDAEMIC AGENTS TAT030 ATROMID-S 500mg TBE070 BEZALIP 200mg TBE072 BEZALIP RETARD 400mg TCA067 CADUET 5mg/10mg TCA068 CADUET 10mg/10mg TCA073 CADUET 5mg/20mg TCA074 CADUET 10mg/20mg TCR028 CRESTOR 5mg TCR030 CRESTOR 10mg TCR032 CRESTOR 20mg TDU014 DUOLIP 250mg TDU016 DUOLIP 500mg TEZ010 EZETROL 10mg TLE010 LESCOL 20mg TLE012 LESCOL 40mg TLE014 LIPANTHYL LESCOL XL 80mg 300mg (GE) TLI027 [FENOFIBRATE] TLI028 LIPANTHYL 100mg TLI029 LIPANTHYL 200mg TLI030 LIPANTHYL 300mg TLI040 LIPITOR 10mg TLI041 LIPITOR 10mg [ATACOR] TLI042 LIPITOR 20mg TLI043 LIPITOR 20mg [ATACOR] TLI044 LIPITOR 40mg PK UNIT DRUG FORMULARY (MAY 2014) [EFFECTIVE ON MAY 2014] ITEM NO. TLI045 TLI046 TLI051 DRUG DESCRIPTION GENERIC NAME LIPITOR 80mg ATORVASTATIN 80mg LIPOBAY 0.2mg CERIVASTATIN SODIUM 0.2mg LIPITOR 10mg [LIPISTAD ATORVASTATIN 10] 30'S TLI052 LIPITOR 20mg [LIPISTAD ATORVASTATIN 20] 30'S TLO020 LOPID 300mg (GE) GEMFIBROZIL 300mg TLO021 LOPID 600mg GEMFIBROZIL 600mg TLO022 LOPID 600mg (GE) GEMFIBROZIL 600mg TLO024 LOPID 900mg GEMFIBROZIL 900mg TME060 MEVACOR 20mg LOVASTATIN 20mg TME061 MEVACOR 20mg (GE) LOVASTATIN 20mg TNI004 NIASPAN 375mg NICOTINIC ACID 375mg TNI005 NIASPAN 500mg NICOTINIC ACID 500mg TNI006 NIASPAN 1000mg NICOTINIC ACID 1000mg TNI010 NICOBID 250mg NIACIN TOL010 OLBETAM 250mg ACIPIMOX 250mg TPR010 PRAVACHOL 10mg PRAVASTATIN SODIUM 10mg TPR012 PRAVACHOL 20mg PRAVASTATIN SODIUM 20mg TPR014 PRAVACHOL 40mg PRAVASTATIN SODIUM 40mg MQU010 QUESTRAN GRANULES 9g CHOLESTYRAMINE RESIN TTR028 TREDAPTIVE 1G/20mg ER NIACIN, LAROPIPRANT CPA068 TREDAPTIVE LAROPIPRANT NICOTINIC ACID TVY021 VYTORIN 10mg/10mg EZETIMIBE / SIMVASTATIN TVY022 VYTORIN 10mg/20mg EZETIMIBE / SIMVASTATIN TVY024 VYTORIN 10mg/40mg EZETIMIBE, SIMVASTATIN TZO010 ZOCOR 10mg SIMVASTATIN 10mg TZO011 ZOCOR 10mg (GE) SIMVASTATIN 10mg TZO012 ZOCOR 20mg SIMVASTATIN 20mg TZO013 ZOCOR 20mg (GE) SIMVASTATIN 20mg TZO014 ZOCOR 40mg SIMVASTATIN 40mg TZO015 ZOCOR 40mg (GE) SIMVASTATIN 40mg TZO016 ZOCOR 80mg SIMVASTATIN 80mg OTHER AGENTS AFFECTING METABOLISM ACTONEL 150mg ONCE-ATAC023 MONTH RISEDRONATE SODIUM 150mg TAC026 ACTONEL 5mg RISEDRONATE SODIUM 5mg TAC027 ACTONEL 35mg RISEDRONATE SODIUM 35mg TEV010 EVISTA 60mg RALOXIFENE HCL 60mg TFO020 FOSAMAX 10mg ALENDRONATE SODIUM 10mg TFO022 FOSAMAX 70mg ALENDRONATE SODIUM 70mg TFO023 FOSAMAX 70mg (GE) ALENDRONATE SODIUM 70mg TFO024 FOSAMAX PLUS ALENDRONATE, COLECALCIFEROL TFO025 FOSAMAX PLUS 5,600IU ALENDRONATE 70mg, COLECALCIFEROL 5600IU HCL IGL010 GLUCAGON INJ 1mg/1mL LYOPHILISED GLUCAGON TON010 ONE-ALPHA 0.25mcg ALFACALCIDOL 0.25mcg TON012 ONE-ALPHA 1mcg ALFACALCIDOL 1mcg TOS030 OSTAC 520mg CLODRONIC ACID TRO030 ROCALTROL 0.25mcg CALCITRIOL 0.25mcg TRO032 ROCALTROL 0.5mcg CALCITRIOL 0.5mcg CSI020 SILKIS OINTMENT 30g CALCITRIOL 3mcg/g ELECTROLYTES AND MINERALS MGE020 GES 45 KCL, NACL, NA2CO3, GLUCOSE MOR005 ORAL REHYDRATION KCL, NACL, NA CITRATE IMA006 SALTS MAGNESIUM SULPHATE MAGNESIUM SULPHATE 49.3% INJ MPO030 POTASSIUM CHLORIDE POTASSIUM CHLORIDE 10% 10% TPO050 500mg POTASSIUM CHLORIDE EYE ANTI-INFECTIVES & ANTISEPTICS DAZ030 AZYTER 15mg/g EYE AZITHROMYCIN DROPS DCE010 CEBEMYXINE EYE NEOMYCIN, POLYMYXIN B OINTMENT 5g CCH010 CHLORAMPHENICOL CHLORAMPHENICOL 2% OINTMENT 2% DCH010 CHLORAMPHENICOL EYE CHLORAMPHENICOL 0.5% DROPS (GE) DCH020 CHLORAMPHENICOL EYE CHLORAMPHENICOL 1% OINTMENT 1% DCH022 CHLORAMPHENICOL CHLORAMPHENICOL 1% OPTICOPSEYE EYEDROPS OINTMENT DCI010 CILOXAN 0.3% CIPROFLOXACIN HCl DCR010 CRAVIT OPHTHALMIC LEVOFLOXACIN SOLUTION EYE DCU010 CUSIVIRAL ACYCLOVIR 3% OINTMENT DFU010 FUCITHALMIC EYE DROPS FUSIDIC ACID 1% DFL010 FLAREX EYE DROPS FLUOROMETHOLONE CGA012 GARAMYCIN CREAM 0.3% GENTAMICIN SULFATE 0.3% 15g (GE) DGA010 GARAMYCIN EYE DROPS GENTAMICIN SULFATE 0.3% (GE) DGA012 GARAMYCIN EYE GENTAMICIN SULFATE 0.3% OINTMENT DMU010 MURO 128 5% EYE SODIUM CHLORIDE HYPERTONICITY OINTMENT EYE DROPS DNE010 NEOSPORIN POLYMYXINB,NEOMYCIN,GRAMICI DIN DNE012 NEOSPORIN EYE DROPS POLYMYXIN B SULPHATE 5000 U (GE) DNE020 NEOSPORIN EYE POLYMYXINB,NEOMYCIN,BACITRA OINTMENTEYE DROPS CIN DNE030 NEVANAC NEPAFENAC DOK010 OKACIN EYE DROPS LOMEFLOXACIN 0.3% DPH020 PHYSIODOSE EYE & SODIUM CHLORIDE NASAL DROP DPO010 POLYFAX EYE5ml OINTMENT POLYMYXIN B, BACITRACIN DSU010 SULPHACETAMIDE EYE SULFACETAMIDE SODIUM 10% DROPS 10% (GE) DSY010 SYSTANE EYE DROPS SDU BORIC ACID, CALCIUM CHLORIDE 15mL BORIC ACID, CALCIUM DSY012 (28's) SYSTANE ULTRA EYE Page 20 of 28 CHLORIDE,HYDROXPROPYL GUAR POLYETHYLENE DSY013 DROPS 10mL GLYCOL,PROPYLENE GLYCOL UNIT PRICE ($) 47.00 12.50 7.20 PK UNIT 11.00 TAB 3.15 8.00 4.40 9.50 11.30 7.00 7.45 9.00 17.10 5.50 9.50 10.00 16.00 18.00 12.00 9.40 20.00 14.30 17.60 26.80 7.80 6.30 8.80 7.10 16.50 11.50 18.00 CAP CAP TAB TAB TAB TAB TAB TAB TAB CAP CAP TAB TAB TAB SACH TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB 300.00 13.50 75.00 16.90 16.00 81.00 60.00 81.00 81.000 620.00 3.20 8.00 75.00 8.00 13.00 6.90 TAB TAB TAB TAB TAB TAB TAB TAB TAB AMP CAP CAP TAB CAP CAP g 3.00 2.80 70.00 SACH SACH AMP 0.50 0.80 ML TAB 60.000 22.00 0.67 12.50 12.00 2.50 63.00 50.00 175.00 78.50 62.00 2.60 44.00 42.00 54.00 32.00 38.00 50.00 82.00 58.00 5.00 54.00 15.00 70.00 115.00 62.00 BOX TUB g BOT TUB CAP BOT BOT TUB TUB BOT g BOT TUB TUB BOT BOT TUB BOT BOT AMP TUB BOT BOT BOX BOT TAB TAB TAB DRUG FORMULARY (MAY 2014) [EFFECTIVE ON MAY 2014] ITEM DRUG DESCRIPTION GENERIC NAME NO. DTA010 TARIVID EYE DROPS OFLOXACIN DTA012 TARIVID EYE DROPS (GE) OFLOXACIN DTA020 TARIVID EYE OINTMENT OFLOXACIN 3mg/g DTE020 TERRAMYCIN EYE OXYTETRACYCLINE, POLYMYXIN B OINTMENT DTO010 TOBREX EYE DROPS (GE) - TOBRAMYCIN 0.3% DTO011 [TOBRAMYCIN] TOBRAMYCIN DTO012 TOBREX EYE OINTMENT TOBRAMYCIN 0.3% DTR004 TRIHERPINE EYE TRIFLUOROTHYMIDINE 1% OINTMENTEYE 2.5g DROPS DVI008 VIGAMOX MOXIFLOXACIN HYDROCHLORIDE 5.4 DZO010 ZOVIRAX EYE OINTMENT ACYCLOVIR 3% ITO010 TOBRAMYCIN 40mg/ml TOBRAMYCIN EYE CORTICOSTEROIDS DEF010 EFEMOLINE EYE DROPS FLUOROMETHOLONE 0.1%... DFM010 FML EYE DROPS 0.02% FLUOROMETHOLONE 0.02% (GE) EYE DROPS 0.1% DFM012 FML FLUOROMETHOLONE 0.1% DHY006 HYDROCORTISONE EYE HYDROCORTISONE 1% OINTMENT DAL019 ALREX EYE1% DROPS 0.2% LOTEPREDNOL DLO010 LOTEMAX EYE DROPS LOTEPREDNOL ETABONATE DMA014 MAXIDEX EYE DROPS DEXAMETHASONE 0.1% DPR010 PRED FORTE EYE DROPS PRENISOLONE ACETATE 1% DPR012 1% PRED-MILD EYE DROPS PRENISOLONE ACETATE 0.12% DSP048 SPERSADEX 0.1% EYE DEXAMETHASONE NA PHOSPHATE DROPS DUL008 ULTRACORTENOL EYE PREDNISOLONE DROPS DUL010 ULTRACORTENOL EYE PREDNISOLONE ACETATE 5mg/mL OINT 1% EYE DROPS DVE010 VEXOL RIMEXOLONE 1% DFM013 FML EYE DROPS 0.1% (GE) FLUOROMETHOLONE 0.1% EYE ANTISEPTICS WITH CORTICOSTEROIDS DBL010 BLEPHAMIDE EYE DROPS SULFACETAMIDE, PREDNISOLONE.. DCO016 CORTIPHENOL-H EYE HYDROCORTISONE 1%/CHLORAMPH 1% DCO020 OINTMET CORTISON-KEMICETINE CHLORAMPHENICOL,HYDROCORTIS EYE OINTMENT ONE DDE020 DEXAMETHASONE 0.1% + DEXAMETHASONE, CHLORAMPHENICOL CHLORAMPHENICOL NEOMYCIN DFM020 FML-NEO EYE DROPS 0.5% FLUOROMETHOLONE, DGA020 GARASONE EYE DROPS GENTAMICIN, BETAMETHASONE DGA030 GARASONE EYE GENTAMICIN, BETAMETHASONE OINTMENT EYE DROPS DMA010 MAXITROL DEXAMETHASONE, NEOMYCIN... DMA012 MAXITROL EYE DEXAMETHASONE, NEOMYCIN... OINTMENT COMP EYE DSP050 SPERSADEX DEXAMETHASONE, DROP CHLORAMPHENICOL DSP010 SPERSADEXOLINE EYE DEXAMETHASONE, CHLORAMPHENICOL DSP012 DROPS SPERSADEXOLINE EYE DEXAMETHASONE, DROPS (GE) EYE DROPS CHLORAMPHENICOL DTO022 TOBRADEX TOBRAMYCIN, DEXAMETHASONE DTO020 TOBRADEX EYE TOBRAMYCIN, DEXAMETHASONE OINTMENT EAR ANTI-INFECTIVES & ANTISEPTICS DOT020 OTOZAMBON EAR DROPS LIGNOCAINE NEOMYCIN POLYMYXIN B MYDRIATIC DRUGS DAT010 ATROPINE EYE DROPS 1% ATROPINE SULFATE 1% DAT012 ATROPINE EYE ATROPINE SULFATE 1% OINTMENT DCY010 CYCLOPENTOLATE EYE CYCLOPENTOLATE HCL 0.5% 0.5% DCY011 DROPS CYCLOPENTOLATE EYE CYCLOPENTOLATE HCL 0.5% DROPS 0.5% MINIM DCY012 HOMATRPINE CYCLOPENTOLATE EYE CYCLOPENTOLATE HCL 1% 2% EYE DHO010 DROPS 1% MINIM HOMATRPINE DMY010 MYDFRIN EYE DROPS PHENYLEPHRINE HCL 2.5% 2.5% DMY020 MYDRIACYL EYE DROPS TROPICAMIDE 1% 1% DMY030 MYDRIN-P EYE DROPS TROPICAMIDE,PHENYLEPHERINE HCL DNY010 NYOLOL EYE DROPS 0.5% TIMOLOL MALEATE 0.5% DPH010 PHENYLEPHERINE PHENYLEPHERINE 10% MINIMS 10% EYE DROPS TROPICAMIDE 0.5% DTR006 TROPICAMIDE 0.5% MIOTIC MINIMS DRUGS IMI004 MIOCHOL-E 20mg INJ ACETYLCHOLINE CI OTHER EYE PREPARATIONS DAC030 ACULAR 0.5% EYE DROPS KETOROLAC TROMETHAMINE DAL018 ALCAINE EYE DROPS PROPARACAINE HCL 0.5% DAL010 ALOMIDE EYE DROPS LODOXAMIDE 0.1% DAL004 ALBALON EYE DROPS NAPHAZOLINE DAL020 ALPHAGAN EYE DROPS BRIMONIDINE TARTRATE DAL022 ALPHAGAN-P 0.15% EYE BRIMONIDINE TARTRATE 0.15% DROPS DAM010 AMETHOCAINE EYE TETRACAINE DROPS 1% MINIMS DAZ010 AZOPT EYE BRINZOLAMIDE 1% DBE020 SUSPENSION BETOPIC-S EYE DROPS BETAXOLOL 0.25% DBE010 BETOPTIC EYE DROPS BETAXOLOL 0.5% DBI010 BION TEARS EYE DROPS DEXTRAN 70%, HYDROXYPROPYL 0.45mL MET DBL006 BLEPHAGEL POLOXAMER 188/PEG-75/SODIUM BO DCA010 CATALIN EYE DROPS PIRENOXINE Na DCO006 COBAMIN EYE SOLN CYANOCOBALAMIN BRIMONIDINE TARTRATE 0.2mg/mL EYE DROPS DCO009 COMBIGAN 2mg,TIMOLOL 5mg50mg, CETRIMIDE DEXPANTHENOL DCO015 CORNEREGEL EYE GEL 0.1mg, WATER FOR INJ. 945.79mg DCO030 COSOPT EYE DROPS DORZOLAMIDE/TIMOLOL MALEATE DCY004 CYCLOGYL 1% EYE CYCLOPENTOLATE 1% DROPS DDU006 DUOTRAV EYE DROPS TRAVOPROST,TIMOLOL DDU010 DURATEARS EYE WHITE PETROLATUM, LIQ LANOLIN OINTMENTEYE DROPS DEM010 EMADINE EMEDASTINE DIFUMARATE 0.05% 0.05% 0.1% EYE DROPS DHI010 HIALID SODIUM HYALURONATE 0.1% 5mL DHY010 HYPOTEARS EYE DROPS POLYVINYL ALCOHOL 1% DHY011 HYPOTEARS EYE GEL VIT A PALMITATE/POLYACRYLIC AC Page 21 of 28 DHY012 HYPOTEARS PLUS EYE POLYVINYL ALCOHOL 1% DROPS UNIT PRICE ($) 50.00 28.00 60.00 38.00 68.00 52.00 83.00 135.00 110.00 355.00 30.00 PK UNIT 60.00 46.00 64.00 22.00 85.00 126.00 60.00 54.00 49.00 54.00 43.00 63.00 133.00 52.00 BOT BOT BOT TUB BOT BOT BOT BOT BOT BOT BOT TUB BOT BOT 39.00 68.50 32.00 7.00 50.00 55.00 42.00 65.00 72.00 52.00 45.00 34.50 73.00 76.00 BOT TUB TUB BOT BOT BOT TUB BOT BOT BOT BOT BOT BOT TUB 45.00 BOT 75.00 60.00 45.00 21.00 20.00 100.00 36.00 134.00 94.00 53.00 24.00 21.00 BOT TUB BOT PC PC BOT BOT BOT BOT BOT PC PC 200.00 AMP 72.00 52.00 105.00 75.00 207.50 230.00 26.50 180.00 94.00 105.00 108.00 131.00 70.00 60.00 235.00 51.50 280.00 50.00 340.00 55.00 75.00 83.00 67.50 60.00 62.00 BOT BOT BOT BOT BOT BOT PC BOT BOT BOT BOX BOX BOT BOT BOT TUB BOT BOT BOT TUB BOT BOT BOT TUB BOT BOT BOT TUB TUB BOT BOT BOT TUB BOT TUB VIA DRUG FORMULARY (MAY 2014) [EFFECTIVE ON MAY 2014] ITEM DRUG DESCRIPTION GENERIC NAME UNIT PRICE NO. ($) DHY014 HYPOTEARS PLUS SDU POLYVINYL ALCOHOL 1% 3.50 EYE DROPS 0.4mLEYE DHY020 HYPROMELLOSE HYPROMELLOSE 0.3% 15.00 DROPS 0.3% DIO010 IOPIDINE EYE DROPS 0.5% APRACLONIDINE HCl 115.00 DIS012 ISOPTO CARPINE EYE PILOCARPINE NITRATE 1% 56.00 DROPS 1% DIS011 ISOPTO CARPINE EYE PILOCARPINE NITRATE 2% 60.00 DROPS 2% DIS010 ISOPTO CARPINE EYE PILOCARPINE NITRATE 4% 88.00 4% EYE DROPS DKA010 DROPS KARY UNI PIRENOXINE 45.00 0.05mg/mL EYE DROPS DLA010 LARMABAK SODIUM CHLORIDE 0.9% 95.00 DLU010 LUMIGAN EYE DROPS BIMATOPROST 390.00 DNA008 NAAXIA EYE DROPS N-ACETYL ASPARTYLGLUTAMIC 35.00 ACID DNA010 NAPHCON-A EYE DROPS NAPHAZOLINE HCL, PHENIRAMINE 54.00 15mL DNA011 NAPHCON-A EYE DROPS NAPHAZOLINE HCL 0.025%, 39.00 15mL(GE)- EYE DROPS NAPHAZOLINE PHENIRAMINE MALEATE 0.3% DNA012 NAPHCON-A HCL, PHENIRAMINE 36.00 3mL DNO010 NOVESIN EYE DROPS OXYBUPROCAINE HCL 0.4% 42.00 DOC010 OCULOSAN EYE DROPS ZINC SULFATE, NAPHAZOLINE 60.00 DOC020 OCUSAN EYE DROPS SODIUM HYALURONATE 0.15% 50.00 0.35ML(20's/BOX) DOP010 OPTICROM EYE DROPS SODIUM CROMOGLYCATE 2% 55.00 (GE) DOP012 OPTICROM 4% EYE DROPS SODIUM CROMOGLYCATE 60.00 (GE) DOP020 OPTIZOLINE EYE DROPS TETRAHYDROZOLINE HCL 0.05% 32.00 DOP021 OPTIZOLINE EYE DROPS TETRAHYDROZOLINE HCL 0.05% 32.00 DPA008 (GE) PATADAY EYE DROPS OLOPATADINE 0.2% HCL 115.00 0.2% DPA010 PATANOL EYE DROPS OLOPATADINE 112.00 0.1% DPR013 PROPINE EYE DROPS DIPIVEFRIN HCL 0.1% 85.00 DPR020 PROTAGENT EYE DROPS POLYVINYL PYRROLIDONE 20mg/mL 38.00 DQU010 QUINAX EYE DROPS AZAPENTACENE POLYSULFONATE 135.00 Na DRE010 REFRESH PLUS EYE CARBOXYMETHCELLULOSE NA 115.00 DROPS (30pcs) (PRESE DRE040 RELESTAT 0.05% EYE EPINASTINE 78.50 DROPS DSI010 SICCAPROTECT EYE DEXPANTHENOL 29.00 DROPS CHLORIDE EYE DNO005 SODIUM SODIUM CHLORIDE 20.00 0.9% EYE GEL DSO020 DROPS SOLCOSERYL HEMODIALYSATE 20% 79.00 DSP040 SPERSACARPINE EYE PILOCARPINE HCL 1% 40.00 DROPS 1% DSP044 SPERSACARPINE EYE PILOCARPINE HCL 4% 40.00 DROPS 4% DSP020 SPERSALLERG EYE DROPS ANTAZOLINE, TETRAHYDROZOLINE 45.00 DSP022 SPERSALLERG SDU EYE ANTAZOLINE, TETRAHYDROZOLINE 70.00 DROPS DSP042 SPERSCARPINE EYE PILOCARPINE HCL 2% 40.00 DROPS 2% EYE DROPS DTI010 TIMOPTOL TIMOLOL MALEATE 0.25% 70.00 0.25% DTI012 TIMOPTOL EYE DROPS TIMOLOL MALEATE 0.5% 85.00 0.5% DTI013 TIMOPTOL EYE DROPS TIMOLOL MALEATE 0.5% 58.00 (GE) DTI014 0.5% TIMOPTOL-XE EYE DROPS TIMOLOL MALEATE 0.5% 85.00 0.5% DTR003 TRAVATAN EYE DROPS TRAVOPROST 365.00 DTR010 TRUSPOT 2% EYE DROPS DORZOLAMIDE HCL 180.00 DVI010 VISCOTEARS EYE GEL POLYACRYLIC ACID 0.02% 80.00 DVI020 VITREOLENT EYE DROPS NA IODIDE 0.3%, K IODIDE 0.3% 60.00 DVD010 VOLTAREN EYE DROPS DICLOFENAC SODIUM 0.1% 85.50 DXA006 XALACOM EYE DROPS LATANOPROST 50mcg,TIMOLOL 5mg 400.00 DXA010 XALATAN EYE DROPS LATANOPROST 0.005% 385.00 DZA012 ZADITEN (SDU) EYE KETOTIFEN 58.00 10's DZA012. DROPS ZADITEN (SDU) EYE KETOTIFEN 0.025% 90.00 DROPS 20's DZA010 ZADITEN EYE DROPS KETOTIFEN 0.025% 100.00 EAR ANTI-INFECTIVES, ANTISEPTICS WITH OR WITHOUT CORTICOSTEROIDS DAP010 APLOSYN EAR DROPS NEOMYCIN, POLYMYXIN, 20.00 FLUOCINOLONE DCH034 CHLORAMPHENICOL EAR CHLORAMPHENICOL 5% 1.00 DROPS 5% DCH032 CHLORAMPHENICOL EAR CHLORAMPHENICOL 10% 1.30 DROP 10% 15mL/BOT DCO018 CORTISON KEMICETINE CHLORAMPHENICOL, 49.50 EAR DROPS & NEOMYCIN DEXAMETHASONE, HYDROCORTISONE NEOMYCIN DDE010 DECADRON 20.00 EYE/EAR DROPS DKE010 KENACOMB EAR DROPS TRIAMCINOLONE, NEOMYCIN... 55.00 DOT010 OTOSPORIN EAR DROPS POLYMYXIN B, HYDROCORTISONE... 105.00 DOT012 OTOSPORIN EAR DROPS POLYMYXIN B, HYDROCORTISONE... 22.00 (GE) DSO010 SOFRADEX EAR/EYE DEXAMETHASONE, FRAMYCETIN... 61.00 DROPS (GE) DTA006 TARIVID EAR DROPS OFLOXACIN 3mg/mL 57.00 DTR008 TROPEX EAR DROPS 10mL PHENAZONE 5%, GLYCEROL 75.00 OTHER EAR PREPARATIONS CAC002 A-CERUMEN EAR DROPS TEA-COCOYL HYDROLYZED 14.00 2ml COLLAGEN, DOL010 OLIVE OIL EAR DROPS OLIVE OIL COCO-BETAINE, 0.60 15mL/BOT EAR DROPS DWA012 WAX-EZE DOCUSATE SODIUM 0.5% 448.00 DWA010 10mL WAXSOL EAR DROPS DOCUSATE SODIUM 0.5% 66.00 MOUTH / THROAT PREPARATION TCE049 CEPACOL CETYLPYRIDINIUM CL 0.07% 1.20 CCO040 CORSODYL CHLORHEXIDINE GLUCONATE 0.2% 0.26 CDA040 DAKTARIN ORAL GEL MICONAZOLE 4.50 TDE050 DEQUADIN LOZENGES DEQUALINIUM CHLORIDE 0.25mg 0.60 TDE051 (GE)-[DEQUALINUM] DEQUALINUM CHLORIDE 0.25mg 0.60 TDI054 DIFFLAM LOZENGES BENZYDAMINE, CETYLPYRIDINIUM 2.80 ADI020 DIFFLAM SOLUTION BENZYDAMINE HCL SOLUTION 0.30 ADI022 120mL DIFFLAM-C SOLUTION BENZYDAMINE HCL, CHLORHEXIDINE 0.60 CEU034 EUROCORT PASTE 5g TRIAMCINOLONE 5.50 ACETONIDE/LIGNOC AGL022 GLYCERINE THYMOL GLYCERIN THYMOL GARGLE 0.22 GARGLE (GE)THYMOL "BLUE" AGL020 GLYCERINE GLYCERIN THYMOL GARGLE 0.13 GARGLE (GE) "RED" CKE030 KENALOG IN ORABASE 5g TRIAMCINOLONE ACETONIDE 0.1% 8.00 CKE032 (GE) ORACORT E 5g (GE) LIGNOCAINE, TRIAMCINOLONE 8.80 COR010 ORAGESIC GEL 5g TRIAMCINOLONE, CHLORHEXIDINE, 6.50 LIGNOCAINE COR020 ORAMEDY PASTE 5g TRIAMCINOLONE ACETONIDE 7.50 CTR034 TRI-GEL 5g TRIAMCINOLONE, LIGNOCAINE 5.00 Page 22 of 28 TTY010 TYROCAINE LOZENGES TYROTHRICIN, BENZOCAINE 0.52 PK UNIT PC BOT BOT BOT BOT BOT BOT BOT BOT BOT BOT BOT BOT BOT BOT BOX BOT BOT BOT BOT BOT BOT BOT BOT BOT BOX BOT BOT BOT TUB BOT BOT BOT BOX BOT BOT BOT BOT BOT BOT BOT TUB BOT BOT BOT BOT BOX BOX BOT BOT ML ML BOT BOT BOT BOT BOT BOT BOT BOT AMP ML BOT BOT TAB ML g TAB TAB TAB ML ML g ML ML g g g g g TAB DRUG FORMULARY (MAY 2014) [EFFECTIVE ON MAY 2014] ITEM DRUG DESCRIPTION GENERIC NAME NO. TOPICAL ANTI-INFECTIVES CAC010 AUREOMYCIN OINTMENT CHLORTETRACYCLINE HCL OINT 3% 3% 15g CBA008 BACTROBAN NASAL MUPIROCIN OINTMENT 3gOINTMENT MUPIROCIN CPA119 BACTROBAN 15g CBA010 BACTROBAN OINTMENT MUPIROCIN 15g CBA012 BACTROBAN OINTMENT MUPIROCIN 2% (GE) CREAM 25g CBU010 15g BURNOL AMINACRIEN HCL, CETRIMIDE CCH008 CHLORAMPHENICOL CHLORAMPHENICOL 2% CREAM CREAM 2% CEL005 ELIDEL 1% 15g PIMECROLIMUS 1% CFL008 FLAMAZINE CREAM 25g SILVER SULFADIAZINE (GE) CFL010 FLAMAZINE CREAM 80g SILVER SULFADIAZINE (GE) CFU030 FUCIDIN CREAM 15g FUSIDIC ACID CFU020 FUCIDIN OINTMENT 5g FUSIDIC ACID CGA011 GARAMYCIN CREAM 0.1% GENTAMICIN SULFATE 0.1% 450g (GE) CGA010 GARAMYCIN SKIN CREAM GENTAMICIN SULFATE 0.1% 15g (GE)SPRAY CNE010 0.1% NEBACETIN NEOMYCIN SULFATE, BACITRACIN 150mL/BOT CREAM 0.5% NEOMYCIN SULFATE 0.5% CNE030 NEOMYCIN (G.E.) CNO010 NORITATE CREAM 1% 30g METRONIDAZOLE 1% CPR028 PROTOPIC OINTMENT TACROLIMUS 0.03% 30g OINTMENT CPR030 PROTOPIC TACROLIMUS 30gGEL 15g CRO010 0.1% ROZEX METRONIDAZOLE 0.75% CSU010 SULPHADIAZINE CREAM SULPHADIAZINE 5% 5% CTE010 TETRACYCLINE TETRACYCLINE TOPICALOINTMENT ANTI-INFECTIVES WITH CORTICOSTEROIDS CBE070 BETNOVATE-C CREAM 15g BETAMETHASONE 0.1%, CLIOQUINOL CBE090 BETNOVATE-N CREAM BETAMETHASONE, NEOMYCIN (GE) CBE080 BETNOVATE-N CREAM BETAMETHASONE, NEOMYCIN 0.5% 15g CPA040 DAKTACORT CREAM 15g MICONAZOLE 2%, HYDROCORTISONE CDA020 DAKTACORT CREAM 15g MICONAZOLE 2%, CDI016 (GE) DIPROGENTA CREAM 15g HYDROCORTISONE BETAMETHASONE DIPROPIONATE .05 CDI018 DIPROGENTA CREAM 450g BETAMETHASONE DIP, GENTAMICIN CDI022 DIPROGENTA OINTMENT BETAMETHASONE DIP, GENTAMICIN 15g CDI024 DIPROGENTA OINTMENT BETAMETHASONE DIP, GENTAMICIN 450g CDI030 DIPROSALIC LOTION BETAMETHASONE DIP, SAL. ACID 10mL/BOT OINTMENT CDI040 DIPROSALIC BETAMETHASONE DIP, SAL. ACID 15g CDI042 DIPROSALIC OINTMENT BETAMETHASONE DIP, SAL. ACID 450g (GE) CDI056 DIPROSONE OINTMENT BETAMETHASONE DIPROPIONATE 0.05% (GE) 0.5 % x 15 g 0.05% CPA115 DERMAID HYDROCORTISONE CFU010 FUCICORT CREAM 15g FUSIDIC ACID 2%, BETAMETHASONE CFU040 FUCIDIN H CREAM 2% FUSIDIC ACID, HYDROCORTISONE CHY032 HYDROCORTISONE 1% + HYDROCORTISONE 1%, MICONAZOLE 2% 1% + HYDROCORTISONE1%, MICONAZOLE 2% CHY042 HYDROCORTISONE NEOMYCIN NEOMYCIN 1% LOTION 1% CHY040 HYDROCORTISONEHYDROCORTISONE1%,NEOMYCIN NEOMYCIN CREAM (GE) HYDROCORTISONE1%, 0.5% CHY050 HYDROCORTISONEVIOFORM CREAM (GE) CLIOQUINOL3% NEOMYCIN... CKE010 KENACOMB CREAM (GE) TRIAMCINOLONE, CKE011 KENACOMB CREAM 5g TRIAMCINOLONE, NEOMYCIN... CNE042 NERISONE C CREAM DIFLUCORTOLONE, CHLORQUINALDOL CPE020 10g/15g PEVISONE CREAM 15g ECONAZOLE1%, TRIAMCINOLONE0.1% CSI006 SICORTEN CREAM 10g HALOMETASONE MONOHYDRATE 0.05% CSY016 SYNALAR-C CREAM 15g FLUOCINOLONE, CLIOQUINOL CSY018 SYNALAR-C OINTMENT FLUOCINOLONE, CLIOQUINOL 15g CSY030 SYNALAR-N CREAM (GE) FLUOCINOLONE 0.025%,NEOMYCIN CTR010 TRAVOCORT CREAM 10g ISOCONAZOLE, DIFLUCORTOLONE CTR032 TRIDERM CREAM 100g BETAMETHASONE, CLOTRIMAZOLE.. CTR033 TRIDERM CREAM 450g BETAMETHASONE, CLOTRIMAZOLE.. (GE) CTR030 TRIDERM CREAM 5g BETAMETHASONE, CLOTRIMAZOLE.. CTT010 TTY CREAM CTcycline/Hydrocortisone/Trav (CTcycline/Hydrocortisone/Tra CPA123 ZARICORT 15 g HYDROCORTISONE 1%, MICONAZLE NITRATE 2% 2% TOPICAL CORTICOSTEROIDS CAD008 ADVANTAN CREAM 0.1% METHYLPREDNISOLONE 10g ACEPONATE 0 CAD010 ADVANTAN OINTMENT METHYLPREDNISOLONE 0.1% 10g ACEPONATE 0 CAD011 ADVANTAN OINTMENT METHYLPREDNISOLONE 0.1% 15g HC LOTION ACEPONATE 0 CAQ005 AQUANIL HYDROCORTISONE CAR010 ARISTOCORT CREAM TRIAMCINOLONE ACETONIDE 0.02% CPA058 BEPROSONE OINTMENT BETAMETHASONE DIPROPINATE CBE042 BETNOVATE CREAM (GE) BETAMETHASONE VALERATE 0.1% CBE040 BETNOVATE CREAM 15g BETAMETHASONE VALERATE 0.1% CBE052 BETNOVATE OINTMENT BETAMETHASONE VALERATE 0.1% (GE) CBE050 BETNOVATE OINTMENT BETAMETHASONE VALERATE 0.1% CBE060 15g BETNOVATE SCALP BETAMETHASONE VALERATE 0.1% LOTION 30mLSCALP CBE064 BETNOVATE BETAMETHASONE SCALP LOTION 450mL0.02% (GE)- & SAL CLOBETASOL/SAL APPLICATION 0.1%ACID CCL010 CLOBETASOL ACID 7.5% OINTMENT CCL016 CLOBEX SHAMPOO 0.05% CLOBETASOL PROPIONATE 0.05% CCU010 CUTIVATE CREAM 15g FLUTICASONE PROPIONATE 0.05% CDE020 DERMOVATE CREAM (GE) CLOBETASOL PROPIONATE 0.05% CDE022 DERMOVATE CREAM 25g CLOBETASOL PROPIONATE 0.05% CDE030 DERMOVATE OINTMENT CLOBETASOL PROPIONATE 0.05% (GE) CDE032 DERMOVATE OINTMENT CLOBETASOL PROPIONATE 0.05% CDE040 25g DERMOVATE SCALP CLOBETASOL PROPIONATE 0.05% APPLICATION 30mL CDI012 DIPROCEL CREAM BETAMETHASONE DIPROPIONATE CDI014 DIPROCEL OINTMENT BETAMETHASONE DIPROPIONATE CDI048 DIPROSONE CREAM BETAMETHASONE DIPROPIONATE 0.0125% 1/4 STRENGTH CDI050 DIPROSONE CREAM BETAMETHASONE DIPROPIONATE Page 23 of 28 1/2 STRENGTH (GE) BETAMETHASONE DIPROPIONATE CDI052 0.025% DIPROSONE CREAM 0.05% (FULL STRENGTH) UNIT PRICE ($) PK UNIT 7.00 68.00 83.00 5.50 4.50 1.00 0.67 21.50 3.47 3.00 4.90 7.60 2.90 2.70 110.00 0.90 4.00 17.30 19.60 6.30 0.80 0.80 g g TUB g g g g g g g g g g g BOT g g g g g g g 3.13 2.90 4.40 5.63 2.50 7.00 6.00 6.70 6.00 75.70 7.60 4.68 1.90 30.00 5.20 5.20 1.20 1.20 1.20 1.20 4.20 6.00 7.10 14.00 6.00 2.67 2.40 1.65 6.50 6.00 4.00 6.00 3.34 37.00 g g g g g g g g g BOT g g g TUBE g g g ML g g g g g g g g g g g g g g g TUB 8.00 7.00 7.50 1.40 2.00 1.00 1.65 3.90 1.65 3.90 4.80 0.80 2.00 3.50 6.10 1.80 3.80 1.80 3.80 4.90 3.80 4.40 1.34 2.00 2.40 g g g g g g g g g g ML ML g ML g g g g g ML g g g g g DRUG FORMULARY (MAY 2014) [EFFECTIVE ON MAY 2014] ITEM DRUG DESCRIPTION GENERIC NAME NO. CDI054 DIPROSONE CREAM 0.05% BETAMETHASONE DIPROPIONATE (GE) 0.05% CDI060 DIPROSONE OINTMENT BETAMETHASONE DIPROPIONATE CEF010 EFCORTELEN LOTION 1% DEXAMETHASONE 1% 30mL/BOTCREAM (GE) 15g CEL038 ELOMET MOMETASONE FUROATE CEL040 ELOMET OINTMENT 15g MOMETASONE FUROATE CEL042 ELOMET SCALP LOTION MOMETASONE FUROATE 0.1% CEU010 0.1% EUMOVATE CREAM 25g CLOBETASONE BUTYRATE CEU030 EURAX-HC CREAM 15g CROTAMITON (GE) CHY020 HYDROCORTISONE HYDROCORTISONE 0.5% CREAM 0.5% (GE) CHY022 HYDROCORTISONE HYDROCORTISONE 1% CREAM 1% (GE) CHY024 HYDROCORTISONE HYDROCORTISONE 1% CREAM 1% 15g (GE) CHY030 HYDROCORTISONE HYDROCORTISONE 1% OINTMENT 1%CREAM (GE) CKE020 KENACORT-A TRIAMCINOLONE ACETONIDE 0.1% 0.1% 15g CLA006 LACTICARE-HC LOTION HYDROCORTISONE,LACTIC ACID/Na 1% CME020 METOSYN CREAM 0.05% FLUOCINONIDE 0.05% CME040 15g NERISONE CREAM 0.1% DIFLUCORTOLONE VALERATE 0.1% 15g CNE046 NERISONE FATTY DIFLUCORTOLONE VALERATE 0.1% OINTMENTOINTMENT 0.1% 10g CNE044 NERISONE DIFLUCORTOLONE VALERATE 0.1% 0.1% 10g CREAM 0.05% CPE010 PERDERM ALCLOMETASONE DIPROPION 0.05% PPR010 PREDENEMA PREDNISOLONE PPR020 PREDFOAM PREDNISOLONE CQU006 QUADRIDERM CREAM 15g BETAMETHASONE/GENTAMICIN/TO LNA CSY008 SYNALAR CREAM 0.005% FLUOCINOLONE ACETONIDE 0.005% (GE) CSY010 SYNALAR CREAM 0.025% FLUOCINOLONE ACETONIDE 0.025% (GE) CSY040 SYNALAR GEL 30g FLUOCINOLONE ACETONIDE 0.025% CSY020 SYNALAR OINTMENT 15g FLUOCINOLONE ACETONIDE 0.025% CSY022 SYNALAR OINTMENT 450g FLUOCINOLONE ACETONIDE 0.025% (GE) ACNE TREATMENT PREPARATIONS CAC012 ACNE AID CREAM 40g SULPHUR 2.5%, RESORCINOL 1.25% CAC013 ACNE AID LIQUID SULFONATED OIL CAC014 ACNEDERM OINTMENT SULFUR 2.5%, ICHTHAMMOL 1% 25g CAK010 AKNE-MYCIN SOLUTION ERYTHROMYCIN SOLUTION 2% 25 mL/BOT (GE) CBR010 BREVOXYL CREAM 4% BENZOYL PEROXIDE 4% 40g CDA075 DALACIN T GEL 1% 15g CLINDAMYCIN PHOSPHATE 1% (GE) CDA070 DALACIN T SOLU.1% ( G. CLINDAMYCIN PHOSPHATE 1% E.) CDA074 DALACIN DALACIN-T CLINDAMYCIN PHOSPHATE 1% T GEL 1% 25g CDA076 [G.E]-[CLINDAMYCIN] CLINDAMYCIN 1% GEL CDA072 DALACIN-T LOTION 1% CLINDAMYCIN PHOSPHATE 1% TDI040 DIANE 21's CYPROTERONE, ETHINYLESTRADIOL CDI009 DIFFERIN CREAM 30g ADAPALENE O.1% CDI011 DIFFERIN GEL 30g ADAPALENE O.1% CDI008 DIFFERIN GEL 15g (GE) ADAPALENE 0.1% CDU003 DUAC GEL CLINDAMYCIN 1%, BENZOYL PEROXIDE 5%BENZOYL PEROXIDE CEP010 EPIDUO GEL 15g ADAPALENE, CER010 ERYLIK GEL 30g ERYTHROMYCIN,TRETINOIN CIS010 ISOTREX 0.05% CREAM ISOTRETINOIN 0.05% CIS011 ISOTREX 0.05% GEL ISOTRETINOIN 0.05% CIS012 ISOTREX 0.1% CREAM ISOTRETINOIN 0.1% CNE020 NEO-MEDROL ACNE METHYLPREDNISOLONE, LOTION(GE) 30mL/BOT NEOMYCINPEROXIDE 5% COX012 OXY-5 BENZOYL COX010 PANOXYL GEL 10% BENZOYL PEROXIDE 10% CPA012 PANOXYL GEL 2.5% 40g BENZOYL PEROXIDE 2.5% CRE020 RETIN-A CREAM 0.025% TRETINOIN 0.025% 25g (GE) CREAM 0.01% 25g TRETINOIN 0.01% CRE010 RETIN-A (GE) CRE022 RETIN-A CREAM 0.05% 25g TRETINOIN 0.05% <Tretinoin> (GE) CRE023 CREAM 0.05% 500g [ACTA] TRETINOIN CRE024 RETIN-A <Tretinoin> CREAM 0.1% 25g TRETINOIN 0.1% (GE) CRE025 CREAM 0.1% 500g [ACTA] TRETINOIN CRE021 RETIN-A 0.025% GEL 15g TRETINOIN 0.025% CRE026 RETIN-A 0.01% GEL 15g TRETINOIN 0.01% TRO010 ROACCUTANE 10mg ISOTRETINOIN 10mg TRO013 ROACCUTANE 10mg (GE) ISOTRETINOIN 10mg TRO012 ROACCUTANE 20mg ISOTRETINOIN 20mg TRO014 ROACCUTANE 20mg (GE) ISOTRETINOIN 20mg CSK010 SKINOREN 20% 30g MCIRONIZED AZELAIC ACID 20% ANTISEPTICS & DISINFECTANTS CAL010 ALCOHOL, BURNING ALCOHOL, BURNING CBE028 BETADINE CREAM 15g POVIDONE-IODINE CBE030 BETADINE SOLUTION POVIDONE-IODINE CCA050 CASTELLANI'S PAINT CASTELLANI'S PAINT CHLORHEXIDINE CCH030 COMPOUND CREAM CHLORHEXIDINE CCI022 CIDEX SOLUTION (28 ACTIVATED GLUTARALDHYDE DAYS) CCI020 CIDEZYME LIQ. CDR010 DRAPOLENE 55g BENZALKONIUM CL, CETRIMIDE CET010 ETHER 450mL ETHER CEU040 EUSOL 3600mL CHLORINATED LIME CHI020 HIBITANE 0.5% IN 70% CHLORHEXIDINE GLUCONATE ALCOHOL 5% CHI018 HIBITANE CHLORHEXIDINE GLUCONATE CONCENTRATE CHI022 HIBITANE SOLUTION IN CHLORHEXIDINE ACETATE 0.05%w/v CHY060 AQ. HYDROGEN PEROXIDE 6% HYDROGEN PEROXIDE 6% (20 volume) CIO010 IODINE TINTURE IODINE TINCTURE CLY010 LYSOL 5000mL CME010 MERCUOCHROME MERCUOCHROME 2.5% Page 24 of 28 SOLUTION CREAM 2.5% CNA010 NASEPTIN 15g CHLORHEXIDINE (GE) UNIT PRICE ($) 1.90 2.40 60.00 5.60 6.00 4.80 4.40 2.20 1.00 1.20 1.20 1.20 3.33 1.20 3.10 4.80 7.10 5.50 3.70 70.00 430.00 7.50 1.65 1.70 2.60 4.50 2.00 PK UNIT 2.20 0.46 2.00 89.00 2.80 6.00 90.00 160.00 4.00 160.00 7.90 4.40 4.40 3.00 14.64 16.50 2.50 5.80 8.10 7.00 140.00 1.30 2.00 2.00 7.70 7.70 7.70 2.20 9.20 1.50 16.70 18.00 31.80 16.00 40.00 32.00 6.50 g ML g BOT g g BOT BOT g BOT TAB g g g g g g g g g BOT g g g g g g g g g g g CAP CAP CAP CAP g 0.30 3.00 0.35 0.40 0.500 0.10 0.23 1.58 0.275 0.14 0.40 0.20 0.15 1.00 0.28 0.13 0.50 1.00 ML g ML ML g ML ML g ML ML ML ML ML ML ML ML ML g g g BOT g g ML g g g g g g g ML g g g g g BOT BOX g g g g g g DRUG FORMULARY (MAY 2014) [EFFECTIVE ON MAY 2014] ITEM DRUG DESCRIPTION NO. AOP010 OPSITE SPRAY CPH010 PHENOL SOL 5% CKM010 POTASSIUM CKM012 PERMANGANATE SOLN CSA024 SAVLON CREAM 30g CPA106 SAVLON CONC SOLUTION CSU008 (GE) SULPHACETAMIDE 20% IN ALCOHOL25mL 50% (HIBITANE) AUN010 UNISEPT CVI020 VIOFORM CREAM (GE) CZI010 ZINC & CASTOR OIL CREAM (GE) FUNGICIDES & ANTIPARASITES A-LICES SCALP HYGIENE GENERIC NAME PHENOL 80% POTASSIUM PERMANGANATE 1% POTASSIUM PERMANGANATE 4% CHLORHEXIDINE, CETRIMIDE CHLORHEXIDINE, CETRIMIDE SULPHACETAMIDE 20% CHLORHEXIDINE CLIOQUINOL 3% ZINE OXIDE, CASTOR OIL CAL040 SHAMPOO MALATHION 1% CAC008 ACETIC ACID 5% ACETIC ACID 2% SOLUTION NAIL CBA020 BATRAFEN CICLOPIROX CBE010 LACQUER BENZYL BENZOATE BENZYL BENZOATE 25% APPLICATION 25% 450mL CCA038 CANESTEN CREAM 1% CLOTRIMAZOLE CCA040 CANESTEN CREAM CLOTRIMAZOLE 15g/20g/500gCREAM (GE) 1% 20g CLOTRIMAZOLE CPA121 CANESTEN CDA030 DAKTARIN CREAM 15g MCIONAZOLE NITRATE 2% (GE) CEX010 EXODERIL CREAM 1% 15g NAFTIFINE HCL CGA004 GAMMA BENZENE GAMMA BENZENE HEXACHLORIDE HEXACHLORIDE 1% CGE010 GENTIAN VIOLET1% (GE) GENTIAN VIOLET CLA010 LAMISIL CREAM TERBINAFINE 1% CLA011 LAMISIL CREAM (GE) TERBINAFINE CLA012 LAMISIL SPRAY 1% 30mL TERBINAFINE 1% CLI010 LINDANE LOTION 1% GAMMA BENZENE HEXACHLORIDE 60mL/BOTSHAMPOO 1% 1% CLI012 LINDANE GAMMA BENZENE HEXACHLORIDE 60mL/BOT 5% NAIL 1% CLO020 LOCERYL AMOROLFINE 5% 2.5mL CREAM CLO022 LACQUER LOCERYL 0.25% AMOROLFINE 0.25% 20g CLO012 LOTREMIN SOLUTION 1% CLOTRIMAZOLE 1% 10mL/BOT CREAM 1% CMY010 MYCOSPOR BIFONAZOLE 1% 15g CMY020 MYCOSTATIN CREAM 15g NYSTATIN 100,000u/g CNI010 NIZORAL CREAM 2% 15g KETOCONAZOLE 2% SHAMPOO CNI020 100mL/BOT KETOCONAZOLE 2% CNI020 NIZORAL SHAMPOO KETOCONAZOLE 2% 60mL/BOT HEADLICE CQU008 QUELLADA PERMETHRIN 10mg/mL TREATMENTSCABIES LIQUID CQU010 QUELLADA PERMETHRIN CSO018 LOTION SODIUM50mg/mL THIOSULPHATE SODIUM THIOSULPHATE 10% 10% CSO020 SODIUM THIOSULPHATE SODIUM THIOSULPHATE 20% SOLUTION CCO030 CORN PAD 20% SALICYLIC ACID 40% CTA020 TARSUM SHAMPOO 120mL COAL TAR, SALICYLIC ACID CTI010 TINEAFAX POWDER (GE) UNDECENOIC ACID 2% 55g/BOT CTR020 TRAVOGEN CREAM 20 g ISOCONAZOLE NITRATE 1% CTR040 TROSYD CREAM 1% 30g TIOCONAZOLE CTR042 TROSYD NAIL SOLUTION TIOCONAZOLE CWH010 WHITFIELD OINTMENT BENZOIC ACID 5%, SAL. ACID 3% CWH020 (GE) WHITFIELD'S SOLUTION BENZOIC ACID 5%, SAL. ACID 3% (GE) CPA120 ZALAIN CREAM 2% 20g SERTACONAZOLE NITRATE CNI022 ZORINAX SHAMPOO KETOCONAZOLE 2% 120mL/BOTSHAMPOO CNI024 ZORINAX KETOCONAZOLE 2% 30mL/BOT PSORIASIS, SEBORRHEA & ICHTHYOSIS CCO004 COAL TAR 10% OINTMENT COAL TAR 10% CCO005 COAL TAR PASTE 5% COAL TAR 5% CCO006 COCOIS OINTMENT COAL TAR SOL.12%, SULPHUR 4% CDA008 DAIVONEX CREAM 30g CALCIOTRIOL CDA010 DAIVONEX OINTMENT 30g CALCIOTRIOL CDA012 DAIVONEX SCALP LOTION CALCIOTRIOL 30mL CDA006 DAIVOBET OINTMENT 15g CALCIPOTRIOL, BETAMETHASONE CDI070 DITHRANOL 1% IN DITHRANOL 1% LASSA'S PASTE CEG010 EGOPSORYL TA SULFUR 0.5%, PHENOL 0.5%, TAR CEL050 ELOSALIC OINTMENT 15g MOMETASONE, SALICYLIC ACID CMI004 MICANOL 1% CREAM 50g DITHRANOL 1% TNE013 NEOTIGASON 10mg ACITRETIN 10mg TNE014 NEOTIGASON 25mg ACITRETIN 25mg CSA033 SAL. ACID OINTMENT 3% SALICYLIC ACID 3% CST016 STIEPROX LIQUID 1.5% CICLOPIROX CSE010 SELSUN SUSPENSION SELENIUM SULFIDE 1% 120mL/BOT CXA010 XAMIOL GEL 15g CALCIPOTRIOL, BETAMETHASONE OTHER DERMOLOGICALS CAC030 ACTOVEGIN 5% CREAM HEMODERIVATIVE 2mg/g 20g CAL020 ALUMINIUM CHLORIDE ALUMINIUM CHLORIDE SOLN 20% SOLUTION 20% CCL020 CLOTRIMAZOLE+SYNALA CLOTRIMAZOLE R+NEOMYCIN CREAM /FLUCINOLONE/NEOM CPA048 DILTIAZEM Cream CTR037 TRILUMA CREAM 15g FLUOCINOLONE,HYDROQUINONE,T RETINOIN CTR038 TRILUMA CREAM 30g FLUOCINOLONE,HYDROQUINONE,T RETINOIN CZI040 ZINDACLIN 1% GEL CLINDAMYCIN, ZINC ACETARE TOPICAL ANTIVIRALS CST020 STOXIL 0.5% 5g IDOXURUDINE CVI012 VIRU-MERZ GEL 10g TROMANTADINE HCL 1% CZO008 ZOVIRAX COLD SORE ACYCLOVIR 5% CREAM 5%COLD 5g (GE) CZO010 ZOVIRAX SORE ACYCLOVIR 5% CREAM 5%CREAM 4g (GE) 5% 10g ACYCLOVIR 5% CZO012 ZOVIRAX KERATOLYTICS Page 25 of 28 CCO020 COLLOMACK SOLUTION SALICYLIC ACID 2G, LACTIC ACID 10mL UNIT PRICE ($) 115.00 0.30 0.30 0.50 0.70 0.16 0.39 7.00 0.70 0.80 PK UNIT 2.40 0.16 310.00 0.30 90.00 2.00 60.00 1.50 2.40 0.60 0.17 5.70 3.40 125.00 80.00 0.80 385.00 4.20 70.00 6.70 3.00 10.00 2.20 180.00 2.50 2.20 0.50 0.80 18.00 0.54 50.00 3.70 4.00 308.00 0.67 2.50 60.00 120.00 30.00 ML ML BOX ML TUB g TUB g g ML ML g g BOT BOT ML BOT g BOT g g g ML BOT ML ML ML ML BOX ML BOT g g BOT g ML TUB BOT BOT 0.90 0.80 3.20 9.00 9.00 7.50 10.60 1.00 1.30 5.70 2.50 19.00 42.00 1.00 1.30 100.00 175.00 g g g g g ML g g g g g CAP CAP g ML BOT BOT 2.00 2.00 1.00 200.00 37.80 34.00 5.00 g ML g TUB g g g 11.00 6.50 8.00 8.00 169.00 g g g g tube 4.00 ML BOT ML ML ML g ML ML PK g g DRUG FORMULARY (MAY 2014) [EFFECTIVE ON MAY 2014] ITEM DRUG DESCRIPTION GENERIC NAME NO. CDU008 DUOFILM GEL SALICYLIC ACID 27% CDU012 DUOFILM SOLUTION 14mL SALICYLIC ACID, LACTIC ACID (GE) CDU010 DUOFILM SOLUTION 15mL SALICYLIC ACID, LACTIC ACID CPO010 PODOPHYLLIN IN SPIRIT TINCT BENZ CO, PODOPHYLLIN 25% 30mL (GE) 5%, SAL. CPO020 PODOPHYLLIN TINCT BENZ CO, PODOPHYLLIN ACID 5% IN COLLODION CPO050 POSALFILIN OINTMENT PODOPHYLLUM, SALICYLIC ACID CSA004 10g SALICYLIC ACID 1% SALICYLIC ACID 1% OINTMENT ACID 2% IN CSA006 SALICYLIC SALICYLIC ACID 2%/SULPHUR 2% SULPHUR 2% CREAM CSA008 SALICYLIC ACID 5% IN AQ SALICYLIC ACID 5% CREAM CSA009 SALICYLIC ACID 10% IN SALICYLIC ACID 10% AQ CREAM ACID IN AQ SALICYLIC ACID 20% CSA010 SALICYCLIC CREAM 20% ACID PAINT SALICYLIC ACID 15% CSA018 SALICYCLIC 15% IN COLLODION CSA020 SALICYCLIC ACID PAINT SALICYLIC ACID 15% 15% (GE) ACID 20% IN CSA023 SALICYLIC SALICYLIC ACID 20% COLLODIO CSA032 SAL. ACID OINTMENT 6% SALICYLIC ACID 6% CSA034 SALICYLIC ACID 4% & SALICYLIC ACID 4%, UREA 20% UREA 20% CREAM CSA035 SALICYLIC ACID 3% IN SALICYLIC ACID 3% ALCOHOL CTR026 TRICHLOROACETIC ACID TRICHLOROACAETIC ACID 10% 10% CTR027 TRICHLOROACETIC ACID TRICHLOROACAETIC ACID 50% 50% CTR028 TRICHLOROACETIC ACID TRICHLOROACAETIC ACID 90% CVE010 90% VERRUMAL SOLUTION FLUOROURACIL 0.5%,SAL. ACID10% 13mL/BOT0.15% CREAM 5g PODOPHYLLOTOXIN 0.15% CWA008 WARTEC CWA010 WARTEC TOPICAL PODOPHYLLOTOXIN 0.5% 0.5% TOPICALSOLUTION ANTIHISTAMINES / ANTIPRURITICS CAN022 ANTHISAN CREAM 2% 15g MEPYRAMINE CCA010 CALAMINE CREAM (GE) CALAMINE 20% CCA020 CALAMINE LOTION (GE) CALAMINE 15% CCA024 CALAMNE-DPH 1% CALAMINE, DIPHENHYDRAMINE CREAM CCA026 CALAMINE + DPH 0.2% CALAMINE, DIPHENHYDRAMINE CCA028 LOTION CALAMINE + 0.25% CALAMINE,MENTHOL 0.25% MENTHOL + 5% CCA029 CALAMINE CALAMINE,SULPHUR 5% SULPHATE LOTION CEU018 EURAX CREAM 15g (GE) CROTAMITON CEU020 EURAX CREAM 450g (GE) CROTAMITON CREAM 10% CHY031 HYDROCORTISONE 1% IN HYDROCORTISONE 1%/CALAMINE CALAMINE LOTION CST010 STEREX SHAMPOO COAL TAR, SAL.ACID, SULPHUR 114mL/BOT CUR010 UREA CREAM 10% UREA 10% TZY024 ZYRTEC-D CETIRIZINE 5mg, PSEUDOEPHEDRINE 120mg CAN020 ANTHISAN CREAM (GE) MEPYRAIMINE MALEATE CREAM TOPICAL ANALGESICS & ANTIINFLAMMATORIES CAN010 ANALGESIC BALM (GE) METHYL SALICYLATE CBE012 BENGAY 28g METHYL SALICYLATE 30%, MENTHOL CBE013 BENGAY 30g (GE) {BAGES METHYL CREAM} 15g SALICYLATE,MENTHOL,CAMPHOR CBO010 BONJELA CHOLINE SALICYLATE 8.7% CDI010 DIFFLAM CREAM 30g BENZYDAMINE CDI019 DIPROGENTA CREAM 450g BETAMETHASONE DIPROPIONATE (GE) 0.05%,GENTAMICIN CPA141 DUROGESIC D-TRANS FENTANYL BASE SULFATE 0.1% CFE010 DERMAL FELDENEPATCH GEL 25g25 mcg/hr PIROXICAM 0.5% CIN010 INDOMET GEL 20g INDOMETHACIN 1% CRU010 RUBESAL CREAM 25g DIETHYLAMINE SALICYLATE/CAMPHO CSO040 SOLCOSERYL JELLY 20g METHYL PARAHYDROXYBENZOATE CSO042 SOLCOSERYL OINTMENT METHYL PARAHYDROXYBENZOATE 20g CPA122 OLFEN GEL 1 % x 20 g DICLOFENAC NA CVO006 VOLTAREN EMULGEL 1% DICLOFENAC CVO010 VOLTAREN EMULGEL 20g DICLOFENAC NA (GE) CPA042 VOLTAREN GEL 1% 20g DICLOFENAC NA ANAESTHETICS - LOCAL & GENERAL DCO014 COCAINE 10% SOLUTION COCAINE DCO010 COCAINE 10% WITH COCAINE ADRENALINE 1:1000 DCO012 COCAINE 5% SOLUTION COCAINE CEL003 ELA-MAX CREAM 4% LIDOCAINE 4% CEM010 EMLA CREAM 5% 5g LIDOCAINE 25mg,PRILOCAINE 25mg CIN018 EMLA INSTILLAGEL CREAM11mL 5% 5g (GE) - LIDOCAINE HYDROCHLOREDE 215.7mg,CHLORHEXIDINE CEM011 [LIDOCAINE + LIDOCAINE 25mg,PRILOCAINE 25mg ILI008 LIGNOCAINE INJ 1% 5mL LIGNOCAINE HCL ILI010 LIGNOCAINE INJ 2% 5mL LIGNOCAINE HCL IMA009 MARCAINE INJ 0.5% 10mL BUPIVACAINE HCL IMA010 MARCAINE INJ 0.5% 20mL BUPIVACAINE HCL IXY004 XYLESTESIN- A 1.8mL LIDOCAINE HCL 20mg/EPINEPHRINE HCL 0.015mg ADRENALINE IXY018 XYLOCAINE 1% + LIDOCAINE, INJ+ 20mL IXY020 ADRENALINE XYLOCAINE 2% LIDOCAINE, ADRENALINE ADRENALINEINJ INJ1% 20mL IXY006 XYLOCAINE 5mL LIDOCAINE HCL IXY007 XYLOCAINE INJ 2% 5mL LIDOCAINE HCL (50'S) IXY008 XYLOCAINE INJ 1% 20mL LIDOCAINE HCL IXY010 XYLOCAINE INJ 2% 20mL LIDOCAINE HCL CXY010 XYLOCAINE JELLY 2% 30g LIDOCAINE HCl 2% CXY020 XYLOCAINE OINTMENT LIDOCAINE HCl 5% 5% 35g CXY040 XYLOCAINE SPRAY 10% LIDOCAINE 10% 80g/BOT & ANTIALLERGICS ANTIHISTAMINES TAC030 ACCOLATE 20mg ZAFIRLUKAST 20mg TAE010 AERIUS 5mg DESLORATADINE 5mg TAT010 ATARAX 10mg HYDROXYZINE 10mg TAT012 ATARAX 25mg HYDROXYZINE 25mg MAT010 ATARAX SYRUP 0.2% HYDROXYZINE Page HCL 26 of 28 200mL MBE010 BENADRYL ELIXIR DIPHENHYDRAMINE HCL 25mg/5mL (GE) UNIT PRICE ($) 7.40 4.10 6.80 4.50 2.18 11.00 0.33 1.20 0.33 0.60 0.60 1.40 0.83 2.00 1.00 1.00 0.19 5.00 6.00 6.00 80.00 109.00 475.00 PK UNIT 45.00 0.90 0.40 0.80 0.17 0.17 0.30 1.50 1.10 0.60 70.00 1.50 7.50 0.84 TUB g ML g ML ML ML g g ML BOT g TAB g 0.60 0.60 0.50 1.90 1.83 1.80 340.00 2.50 1.25 0.62 3.50 2.40 46.00 65.00 2.30 2.20 g g g g g g PATCH g g g g g TUB TUB g g 15.00 17.00 10.00 15.00 30.50 55.00 17.00 30.00 62.00 214.00 260.00 4.00 15.00 15.00 26.00 29.40 10.00 10.00 7.10 3.40 489.00 ML ML ML g g TUB g AMP AMP VIA VIA AMP ML ML AMP AMP ML ML g g BOT 8.20 5.20 1.80 2.80 0.70 0.17 TAB TAB TAB TAB ML ML g ML ML ML ML g g g g g g ML ML ML g g ML ML ML ML BOT g BOT DRUG FORMULARY (MAY 2014) [EFFECTIVE ON MAY 2014] ITEM DRUG DESCRIPTION GENERIC NAME NO. IBE010 BENADRYL INJ DIPHENHYDRAMINE HCL 500mg/10mL TCE042 CELESTAMINE DEXCHLORPHENIRAMINE, BETAMETHA TCE040 CELESTAMINE (GE) DEXCHLORPHENIRAMINE, BETAMETHA MCE030 CELESTAMINE SYRUP DEXCHLORPHENIRAMINE (GE) MALEATE.. 10mg TCL020 CLARITYNE 10mg LORATADINE TCL022 CLARITYNE 10mg (GE) LORATADINE 10mg MCL010 CLARITYNE SYRUP LORATADINE 1mg/mL (GE) SYRUP CPA053 CLARITYNE LORATADINE 1mg/mL ICO010 CORAMINE INJ NIKETHAMINE CDI013 DIPHENHYDRAMINE 2% DIPHENHYDRAMINE 2% CREAM 450g4mg (GE) TDI080 DIMETANE BROMPHENIRAMINE MALEATE 4mg TEM010 EMEND [APREPITANT] APREPITANT TRIPACK THI010 HISMANAL ASTEMIZOLE TIN010 INCIDAL 50 mg MEBHYDROLIN NAPADISYLATE TKE050 KESTINE 10mg EBASTINE 10mg TPE060 PERIACTIN 4mg (GE)CYPROHEPTADINE 4mg [CYPROHEPTADINE] TPH010 PHENERGAN 10mg (GE) PROMETHAZINE HCL 10mg TPH012 PHENERGAN 25mg (GE) PROMETHAZINE HCL 25mg MPH010 PHENERGAN ELIXIR PROMETHAZINE HCL 5MG 5mg/5mL (GE) INJ 25mg/mL PROMETHAZINE HCL IPH010 PHENERGAN TPI010 PIRITON 2mg (GE) CHLORPHENIRAMINE MALEATE 2mg TPI012 PIRITON 4mg (GE) CHLORPHENIRAMINE MALEATE 4mg TPI014 PIRITON SR 12mg (GE) CHLORPHENIRAMINE MALEATE 12mg MPI020 PIRITON SYRUP 2.5mg/5mL CHLORPHENIRAMINE MALEATE (GE) MPI025 PIRITON SYRUP 2mg/5mL CHLORPHENIRAMINE MALEATE (GE) MPI030 PIRITON FORTE SYRUP CHLORPHENIRAMINE MALEATE 4mg/5mL INJ (GE)10mg/mL (GE) CHLORPHENIRAMINE MALEATE IPI010 PIRITON TPL030 PLOKON TAB PIRINHYDRINATE 3mg TPO010 POLARAMINE 2mg (GE) DEXCHLORPHENIRAMINE MALEATE CPA065 POLARAMINE 6mg DEXCHLORPHENIRAMINE TPO012 POLARAMINE SA 6mg (GE) DEXCHLORPHENIRAMINE MALEATE MPO008 POLARAMINE DEXCHLORPHENIRAMINE EXPECTORANTSYRUP GUAIPHENESIN PSEUDOEPHEDRINE MPO010 POLARAMINE DEXCHLORPHENIRAMINE MALEATE 2mg/5mL (GE) TSE020 SEMPREX 8mg ACRIVASTINE 8mg TTE025 TELDANE (GE) TERFENADINE 60mg MTE010 TELDANE SUSPENSION TERFENADINE 30mg/5mL60mg 120mL TTE026 TELFAST FEXOFENADINE HCL 60mg TTE024 TELFAST 120mg FEXOFENADINE HCL 120mg TTE027 TELFAST 180mg FEXOFENADINE HCL 180mg TTE029 TELFAST-D FEXOFENADINE HCL/PSEUDOEPHEDRI MVA010 VALLERGEN FORTE TRIMEPRAZINE TARTRATE 30mg/5mL 100mL MXY010 XYZAL ORAL DROPS LEVOCETIRIZINE 5mg/ml 5mg TXY010 XYZAL LEVOCETIRIZINE 5mg CPA052 XYZAL DROPS 20 ml LEVOCETIRIZINE TZA010 ZADINE 1mg AZATADINE MALEATE 1mg MZA010 ZADINE SYRUP 0.5mg/5mL AZATADINE MALEATE 100mL 10mg TZY020 ZYRTEC CETIRIZINE HCL 10mg TZY022 ZYRTEC 10mg (GE) CETIRIZINE HCL 10mg MZY010 ZYRTEC ORAL CETIRIZINE HCL SOL.1mg/1ml MZY008 ZYRTEC ORAL DROPS 1% CETIRIZINE HCL (10mL) SYRUP 1mg/mL MZY012 ZYRTEC CETIRIZINE HCL 60mL (GE) TBP010 B.P.P. PPA,BROMPHENIRAMINE,PHENYLEP HR TDI090 DIME-TIME BROMPHENIRAMINE,PPA,PHENYLEP HE IMMUNOLOGICALS & IMMUNOSUPPRESSANTS CPA152 BENLYSTA POWDER FOR BELIMUMAB CONCENTRATE FOR FOR INFUSION MYCOPHENOLATE MOFETIL 250mg TCE046 SOLUTION CELLCEPT 250mg TCE048 CELLCEPT CAP 500mg MYCOPHENOLATE MOFETIL 500mg VGA010 GAMMA GLOBULIN 5mL IMMUNE GLOBULIN IV (HUMAN) IHU009 HUMIRA 40mg/0.8mL ADALIMUMAB TIM048 IMURAN 25mg AZATHIOPRINE 25mg TIM050 IMURAN 50mg [APOAZATHIOPRINE 50mg TIM051 AZATHIOPRINE] AZATHIOPRINE TPR091 PROGRAF 1mg TACROLIMUS 1mg TPR092 PROGRAF 5mg TACROLIMUS 5mg IRE040 REBIF 44mcg RECOMBINANT HUMAN INTERFERON DRE050 RESTASIS 0.05% EYE CYCLOSPORINE 0.05% DROPS TSA034 SANDIMMUN NEORAL CYCLOSPORIN A 100mg 100mg TSA036 SANDIMMUN NEORAL CYCLOSPORIN A 25mg 25mg IST004 STELARA INJ 45mg USTEKINUMAB DISEASE-MODIFYING ANIT-RHEUMATIC DRUGS (DMARDs) TAR002 ARAVA 10mg LEFLUNOMIDE INTRAVENOUS & OTHER STERILE SOLUTIONS ISO010 SODIUM BICARBONATE SODIUM BICARBONATE 8.4% 100mL ISO060 SODIUM CHLORIDE 0.9% SODIUM CHLORIDE 0.9% INJ 10mL CHLORIDE 0.9% SODIUM CHLORIDE ISO061 SODIUM INJ 20mL BONE METABOLISM AGENT AFFECTING TBO010 BONVIVA 150mg INJ 3mg/3mL (1 IBANDRONIC ACID 150mg IBO006 SYRING/BOX) IBANDRONIC ACID 150mg IPR052 PROLIA 60mg/Ml DENOSUMAB MPR050 PROTOS 2g STRONTIUM RANELATE CPA128 FORTEO PRE-FILLED PEN TERIPARATIDE 250 mcg/mL, 2.4 mL 1's ANAESTHETICS - LOCAL &xGENERAL Page 27 of 28 CBE025 BETACAINE GEL 30g LIDOCAINE 5% UNIT PRICE ($) 200.00 2.20 1.50 0.19 6.00 3.80 0.50 1.00 50.00 0.70 1.00 1030.00 6.00 2.00 5.00 0.18 1.10 1.10 0.19 25.00 0.40 0.53 1.20 0.17 0.17 0.19 25.00 1.30 0.70 2.50 1.10 50.00 0.17 2.40 2.00 0.80 2.50 5.50 7.50 4.20 1.00 284.00 6.30 105.00 2.50 0.38 4.00 2.40 1.08 8.60 0.60 1.00 2.50 PK UNIT 14000.00 INJ 22.00 41.00 210.00 6052.00 16.50 21.60 18.00 45.00 184.00 870.00 30.00 70.00 18.50 37000.00 CAP CAP VIA SYR TAB TAB TAB TAB CAP AMP PC TAB TAB VIA 20.00 TAB 90.00 2.90 8.00 BOT VIA AMP 320 1650.00 4000.00 15.20 6000.00 TAB SYR SYR SACH PEN 11.00 g VIA TAB TAB ML TAB TAB ML ML AMP g TAB BOX TAB TAB TAB TAB TAB TAB ML AMP TAB TAB CAP ML ML ML ML TAB TAB TAB TAB BOT ML CAP TAB ML TAB TAB TAB TAB ML BOT TAB BOT TAB ML TAB TAB ML ML ML TAB TAB DRUG FORMULARY (MAY 2014) [EFFECTIVE ON MAY 2014] ITEM DRUG DESCRIPTION GENERIC NAME NO. IMI002 MIACALCIC INJ 100 IU/mL SYNTHETIC SALMON CALCITONIN IMI003 MIACALCIC INJ 50 IU/mL SYNTHETIC SALMON CALCITONIN IXY019 XYLOCAINE 2% + LIDOCAINE, ADRENALINE ADRENALINE 1:80,000 INTRAVENOUS & OTHER STERILE SOLUTIONS IAT010 ATROPINE INJ 0.6mg/mL ATROPINE SULFATE (GE) IDE050 DEXTROSE INJ 5% 500mL DEXTROSE IDE060 DEXTROSE INJ 50% 20mL DEXTROSE IGE020 GELOFUSINE 4% 500mL SUCCINYLATED GELATIN NONSTEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDs) CPA092 TORADOL 30MG/ML/AMP KETOROLAC TROMETAMOL MISCELLANEOUS TRE014 RENAGEL 800mg SEVELAMER HCL SODIUM CHLORIDE/POTASSIUM DBS008 BSS SOLUTION 15mL CHLO TS0004 SODIUM BICARBONATE SODIUM BICARBONATE Page 28 of 28 UNIT PRICE ($) 180.00 150.00 4.00 PK UNIT 30.00 77.00 6.50 100.00 AMP BOT AMP BOT 200 AMP 12.50 111.00 1.10 TAB BOT TAB AMP AMP AMP
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