Drug Benefit List

NON-INSURED HEALTH BENEFITS
First Nations and Inuit Health Branch
DRUG BENEFIT LIST

2010
The Non-Insured Health Benefits (NIHB) Program provides supplementary health benefits, including prescription and non-prescription drugs, for registered First nations and recognized Inuit throughout Canada. Visit our Web site at: www.healthcanada.gc.ca/nihb
Health Canada Non-Insured Health Benefits
INTRODUCTION Drug Benefit List
Effective 2010
Introduction to NIHB Drug Benefit List
Effective 2010
Table of Contents 1. Background on NIHB Program ................................................................................................iii 2. Purpose of the NIHB Drug Benefit List ....................................................................................iii 3. Drug Review Process ...............................................................................................................iii 4. Benefit Criteria ......................................................................................................................... v A. Drug Benefit Listings .................................................................................................... v B. Deletion Criteria .......................................................................................................... .vi C. Open Benefits...vii D. Limited Use Benefits....................................................................................................vii E. Exception Criteria ........................................................................................................vii F. Exclusions...................................................................................................................viii 5. Policies....................................................................................................................................viii A. Best Price Alternative and Interchangeability .............................................................viii B. No Substitution Claims ............................................................................................viii C. Prescription Quantities ............................................................................................... ix D. Short Term Dispensing ...ix 6. Special Formulary for Chronic Renal Failure Patients .............................................................. x 7. Palliative Care Formulary.......................................................................................................... x 8. Drug Utilization Evaluation........................................................................................................ x 9. General Information ................................................................................................................. xi 10. NIHB Privacy Code ................................................................................................................. xi 11. Pharmacologic-Therapeutic Classification of Drugs................................................................ xi Legend.....................................................................................................................................xii Drug Benefit List 04:00 Antihistamine Drugs ................................................................................................ 1 08:00 Anti-Infective Agents ............................................................................................... 2 10:00 Antineoplastic Agents............................................................................................ 13 12:00 Autonomic Drugs................................................................................................... 16 20:00 Blood Formation and Coagulation......................................................................... 22 24:00 Cardiovascular Drugs............................................................................................ 25 28:00 Central Nervous System Agents ........................................................................... 42 32:00 Contraceptives (Non-Oral) .................................................................................... 70 36:00 Diagnostic Agents ................................................................................................. 71 40:00 Electrolytic, Caloric and Water Balance ................................................................ 73 48:00 Respiratory Tract Agents ...................................................................................... 76 52:00 Eye, Ear, Nose and Throat Preparations .............................................................. 77 56:00 Gastrointestinal Drugs........................................................................................... 83 60:00 Gold Compounds .................................................................................................. 91 64:00 Heavy Metal Antagonists ...................................................................................... 92 68:00 Hormones and Synthetic Substitutes .................................................................... 93 80:00 Serums, Toxoids and Vaccines........................................................................... 101 84:00 Skin and Mucous Membrane Agents .................................................................. 102 86:00 Smooth Muscle Relaxants .................................................................................. 110 88:00 Vitamins .............................................................................................................. 111 92:00 Unclassified Therapeutic Agents......................................................................... 114 94:00 Devices ............................................................................................................... 119 96:00 Pharmaceutical Aids ........................................................................................... 124 Appendix A (Limited Use Benefits and Criteria)........................................................................ A-1 Appendix B (Special Formulary for Chronic Renal Failure Patients) ........................................ B-1 Appendix C (Palliative Care Formulary).................................................................................... C-1 Appendix D (List of Drug Manufacturers).................................................................................. D-1 Appendix E (List of Exclusions) ............................................................................................... E-1 Alphabetical Index of drug products............................................................................................I-1
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1. BACKGROUND ON NIHB PROGRAM The Non-Insured Health Benefits (NIHB) Program of Health Canada provides coverage for approximately 816,000 eligible registered First Nations and recognized Inuit with a limited range of medically necessary health-related goods and services not provided through private or provincial/territorial health insurance plans. These benefits complement provincial and territorial health care programs, such as physician and hospital care, as well as other First Nations and Inuit community-based programs and services. Benefits include drugs, medical transportation, dental care, medical supplies and equipment, crisis intervention counselling and vision care. The authority for the NIHB Program is based on the 1979 Indian Health Policy which describes the responsibility for the health of First Nations as shared amongst various levels of government, the private sector and First Nations communities. As a result of this shared responsibility, when a benefit is covered under another plan, the federal government requires the coordination of benefits to ensure that the other plan meets its obligations. 2. PURPOSE OF THE NIHB DRUG BENEFIT LIST The Drug Benefit List is a listing of the drugs provided as benefits by the Non-Insured Health Benefits (NIHB) Program. The DBL is updated regularly and published annually. The listed drugs are those primarily used in a home or ambulatory setting. A prescription from a licensed practitioner is required for any listed drug to be processed as a benefit. Practitioners are those people authorized to prescribe drugs within the scope of practice in their province or territory. The DBL is a tool for physicians and pharmacists that encourages the selection of optimal, cost-effective drug therapy
3. DRUG REVIEW PROCESS The review process for drug products that are considered for inclusion as a benefit under the NIHB Program varies depending on the type of drug submitted. 3.1 New Chemical Entities / New Combination Drug Products/ Existing Chemical Entities with New Indication Submissions for new chemical entities, new combination drug products and existing chemical entities with new indications, must be sent to the Canadian Agency for Drugs and Technologies in Health (CADTH). Clinical and pharmacoeconomic reviews are coordinated by the Common Drug Review (CDR) Directorate and forwarded to the Canadian Expert Drug Advisory Committee (CEDAC) for recommendations on formulary listing. These recommendations are forwarded to participating drug plans, including the NIHB Program, for consideration. The NIHB Program and other drug plans make listing decisions based on CEDAC recommendations and other specific relevant factors, such as mandate, priorities and resources. Please refer to the Canadian Agency for Drugs and Technologies in Health (CADTH) for a list of requirements for manufacturers submissions and a summary of procedures for the Common Drug Review Process. Inquiries should be directed to: Common Drug Review (CDR) Canadian Agency for Drugs and Technologies in Health 865 Carling Avenue, Suite 600 Ottawa, Ontario K1S 5S8 Telephone: (613) 226-2553 Website: www.cadth.ca Please ensure a copy of the complete CDR submission is also sent to NIHB either electronically to NIHB.Drug.Submisions@hc-sc.gc.ca or on CD ROM to the mailing address indicated in section 3.2.2.4 3.2 Line Extensions, Generics and All Other Submissions Submissions for line extensions, generics and all other submissions are reviewed internally or by the Federal Pharmacy and Therapeutics Committee. Generic drug products are considered for inclusion on the formulary based on provincial interchangeability lists and other relevant factors.
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3.2.1 Federal Pharmacy and Therapeutics Committee The Federal Pharmacy and Therapeutics (FP&T) Committee provides formulary listing recommendations for drug products to participating federal drug plans, including the NIHB Program. The NIHB Program and other federal drug plans make listing decisions based on FP&T Committee recommendations and other specific relevant factors, such as mandate, priorities and resources. The Federal Pharmacy and Therapeutics (FP&T) Committee is an advisory body of health professionals established to provide evidence based pharmacy and medical advice to the drug benefit plans of the six federal departments (Health Canada, Veterans Affairs Canada, Royal Canadian Mounted Police, Correctional Services Canada, Department of National Defense and Citizenship and Immigration Canada). 3.2.2 Submission Requirements All submissions for drug products that are line extensions, generics and all other submissions must be submitted to the NIHB Program. Only drug products with a Health Canada Notice of Compliance will be considered for provision as a benefit. 3.2.2.1 Letter of Authorization The manufacturer will provide a letter authorizing the NIHB Program to gain access to all information with respect to the product in the possession of Health Canada or of the government of any provinces or territory in Canada, Patented Medicine Prices Review Board (PMPRB) or Canadian Agency for Drugs and Technologies in Health (CADTH). 3.2.2.2 Justification for Consideration of Listing The manufacturer will provide a statement indicating the rationale and evidence to justify the provision of the new product. 3.2.2.3 General Information Additional information should include: Evidence of approval by Health Canada, such as a Notice of Compliance (NOC) and Drug Identification Number (DIN).and Two therapeutic Classifications: - American Hospital Formulary Service (AHFS) Pharmacologic Therapeutic Classification and; - The World Health Organizations Anatomical Therapeutic Chemical (ATC) Classification 3.2.2.4 Pricing and Marketing Information The manufacturer must submit current price information for the drug product. Manufacturers are required to notify the NIHB Program of any significant change to listed drug products. Significant changes include changes in DIN, product name, manufacturer or distributor, indication, product monograph, packaging, formulation, manufacturing specifications or discontinuation of a product. Notification of changes should be provided electronically to the NIHB Program.
All submissions for drug products, to be reviewed for inclusion on the NIHB Drug Benefit List (DBL), must be sent to the NIHB Program electronically. Please send all drug submissions to the following email address: NIHB.Drug.Submissions@hc-sc.gc.ca. Submissions will also be accepted on CD ROM when mailed to the following address: c/o Manager of Pharmacy, Benefit Management Non-Insured Health Benefits First Nations and Inuit Health Branch, Health Canada Room 503, Suite 550, Address Locator 4005A 55 Metcalfe Street, Ottawa, Ontario K1A 0K9
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Only ONE copy of the submission is required. Receipt of submission will be acknowledged electronically. 4. BENEFIT CRITERIA The following criteria are the framework for the Non-Insured Health Benefits Program Drug Benefit List (DBL). The criteria provide the basis for decisions about drugs on the formulary relating to: A. Listings B. Deletions C. Open Benefit D. Limited Use E. Exceptions F. Exclusions All drugs that are to be either considered for listing or currently listed as program benefits must, as a minimum: 1. be legally available for sale in Canada with a Notice of Compliance; 2. be sold in Canada (proof may include a copy of the completed notification form issued under the Food and Drug Regulations or listing on a provincial drug benefit formulary); 3. be administered in a home setting or in other ambulatory care settings; 4. not be provided in a provincially/territorially covered setting (hospital/institution) or provided through provincially/territorial covered programs or clinics according to provincial/territorial legislation; and 5. be in accordance with NIHB Program mandate and policies. A. Drug Benefit Listings The Non-Insured Health Benefits (NIHB) Program, with assistance from the Canadian Expert Drug Advisory Committee (CEDAC) and the Federal Pharmacy and Therapeutics (FP&T) Committee, balances a number of factors in making listing decisions about changes to the Drug Benefit List, such as: The needs of First Nations and Inuit recipients; Accumulated scientific and clinical research on currently-listed drugs; Cost-benefit analysis; Availability of alternatives; Current health practices; and Policies and listings in provincial drug formularies.
New formulations and new strengths of listed products may be added or may replace previously approved products. Generic products are added according to provincial interchangeability lists and other relevant factors. Combination products are considered for listing if: 1. each component of the combination makes a contribution to the claimed effect; 2. a pharmacological or pharmaceutical rationale exists for the combination;
Effective 2010
3. the dosage of each component (amount, frequency, duration) is safe and effective for a significant proportion of the patient population requiring such concurrent therapy as defined in the labeling of the drug; and, 4. the cost is reduced, or scientific evidence indicates that the advantages outweigh any additional cost; or 5. an improvement in compliance, resulting in an increase in clinical effectiveness, is demonstrated. Sustained Release Products may be listed when: 1. clinical studies have demonstrated the safety and efficacy of the active ingredient when administered in the sustained released form; and, 2. a therapeutic advantage is demonstrated in the treatment of the disease entity for which the product is indicated (therapeutic advantage is defined as: improved efficacy relative to the conventional dosage with no increase in toxicity; or less toxicity with improved or similar efficacy); or, 3. there is demonstrated improvement in compliance resulting in an increase in clinical effectiveness, or, 4. there is evidence that the sustained release product is at least as cost-effective as the best price alternative in the conventional form that is currently covered; or, 5. there is no suitable conventional dosage form(s) of the drug listed that is readily available. Injectable Drug Products will be considered if they are: 1. self-administered in a home or other ambulatory setting; 2. not part of a physicians standard office supply; 3. not provided in a provincially/territorially covered hospital or institution; or, 4. not provided through provincially/territorial covered programs or clinics according to provincial/territorial legislation. B. Deletion Criteria The following deletion criteria guide the removal or delisting of a drug product from the NIHB drug benefit list. Drugs are deleted: 1. when a product is discontinued from the Canadian market; 2. when new products possessing clearly demonstrated therapeutic and safety advantages or improvements have been listed; 3. when new toxicity data shift the risk/benefit ratio to make the continued listing of the product inappropriate; 4. when new information demonstrates that the product does not have the anticipated therapeutic benefit; 5. when the purchase cost is disproportionate to the benefits provided; or 6. when the drug has a high potential for misuse or abuse.
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NOTE: Drugs may also be removed at the discretion of the Director General, NIHB Program when there are undesirable financial, supply or administrative implications to the continued listing of a product. C. Open Benefits Open benefits are the drugs listed in the NIHB DBL which do not have established criteria or prior approval requirements. D. Limited Use Benefits Limited use drugs are drug products listed on the NIHB DBL that may be inappropriate for general listing, but have value in specific circumstances. These products will have specific criteria for provision as a benefit under the NIHB Program. A product will be designated for limited use when: 1. it has the potential for widespread use outside the indications for which benefit has been demonstrated; 2. it has proven effectiveness, but is associated with predictable severe adverse effects; 3. it is usually a second or third line choice for treatment and is required because of allergies, intolerance, treatment failure or noncompliance with a first line alternative; or 4. it is very costly and a therapeutically effective alternative is available as a benefit. There are three types of limited use benefits: 1. Limited use benefits which do not require prior approval. These include: Multivitamins (which are benefits for children up to 6 years of age); and Prenatal and postnatal vitamins (which are benefits for women of childbearing age (12 to 50 years). 2. Benefits which have a quantity and frequency limit. A maximum quantity of drug is allowed within a specified period of time. No prior approval is required for the recipient to obtain the allowable quantity of drug within the specified period. Drugs with a quantity and frequency limit include smoking cessation products. Recipients are eligible to receive a 3-month supply of smoking cessation products over a one year period which is renewable 12-months from the day the initial prescription was filled. 3. Limited use benefits which require prior approval (using the Limited Use Drugs Request Form). Limited use benefits and the criteria for their coverage are identified in the Drug Benefit List and also in Appendix A. The criteria are also listed on the forms faxed to prescribers for completion.
E. Exceptions Exception drugs are drug products which are not listed in the DBL. These drug products may be approved in special circumstances upon receipt of a completed Exception Drugs Request Form from the attending licensed practitioner. when the prescription is for a recognized clinical indication and dose which is supported by published evidence or authoritative opinion; and when there is significant evidence that the requested drug is superior to drugs already listed as program benefits; or, when a patient has experienced an adverse reaction with a best- price alternative drug, and a higher cost alternative is requested by the prescriber; or when there is supporting evidence that available alternatives are ineffective, toxic, or contraindicated (personal preference alone does not justify an exception).
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F. Exclusions Exclusions are items not listed as benefits on the DBL and are not available through the exception or appeal processes. These include certain drug therapies for particular conditions which fall outside of the NIHB mandate and are not provided as benefits under the NIHB Program. These products are not considered for coverage under the NIHB Program: Anti-obesity drugs; Household products (regular soaps and shampoos); Cosmetics; Alternative therapies, including glucosamine and evening primrose oil; Megavitamins; Drugs with investigational/experimental status; Vaccinations for travel indications; Hair growth stimulants; Fertility agents and impotence drugs; Selected over-the-counter products; Codeine containing cough preparations; Stadol TM NS and generics (butorphanol tartrate nasal spray); and Darvon and 642 (propoxyphene); Fiorinal, Fiorinal C , Fiorinal C and generics (Butalbital containing analgesics with and without codeine); Dalmane, Somnol and generics (flurazepam); Librium, Solium, Medilium and generics (chlordiazepoxide); Tranxene and generics (clorazepate). 5. POLICIES A. Best Price Alternative and Interchangeability The Non-Insured Health Benefits (NIHB) program will reimburse only the best price (lowest cost) alternative product in a group of interchangeable drug products. Pharmacists must follow their provincial/territorial pharmacy legislation/policies to identify interchangeable products and to select the lowest-priced brand. (NIHB may not necessarily reimburse at the cost listed in the provincial drug plan formulary). If a recipient selects a higher cost equivalent, he/she will be responsible for any incremental costs above the cost of the best price equivalent drugs.
B. No Substitution Claims NIHB will consider reimbursement for a higher-cost interchangeable product when a patient has experienced an adverse reaction with a lower-cost alternative. In such circumstances, the prescriber must provide the pharmacist with: 1. a completed and signed Health Canada form: Report of suspected adverse reaction due to drug products marketed in Canada and, the prescription with No Substitution or No Sub handwritten.
2.
Upon receipt, the pharmacist will forward a copy of the form and the prescription to NIHB for review. A copy of the form will be forwarded to the Adverse Drug Reaction Monitoring Program of Health Canada. Forms can be obtained by calling Health Canada at 1-866-234-2345 or by downloading a copy from Health Canada website at http://www.hc-sc.gc.ca/dhp-mps/medeff/report-declaration/ar-ei_form-eng.php or by photocopying a
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copy from the Compendium of Pharmaceuticals and Specialties.
Effective 2010
NOTE: The report of Adverse Reaction form will not need to be resubmitted for renewals or new prescriptions of the same drug for the patient, although No Sub will still have to be written on the prescription.
C. Prescription Quantities The normal quantity dispensed shall be the entire quantity of the drug prescribed. A maximum 100-day supply should be considered for those circumstances where the patient has been stabilized on a medication and the prescriber feels that further adjustment during the prescribed period is unlikely. The physician may continue to prescribe a smaller quantity with repeats at certain intervals when it is in the patients best interest.
D. Short Term Dispensing Policy It is the Programs expectation that certain medications required for long-term maintenance therapy should be prescribed and dispensed in up to 100 days supplies. For refills for medications requiring shortterm dispensing for a shorter time than 28 days due to compliance concerns, the Program will only reimburse a total of one dispensing fee per 28 days, except: a. Refills for intermittent treatment of a chronic disorder (e.g. dosage change) b. Refills for drugs prescribed for as required use (e.g. PRN) c. Refills of methadone d. Others as identified by the NIHB Program
Minimum 28 day supply NIHB will consider compensation for no more than one dispensing fee every 28 days for chronically used oral medication. These medications include (but are not limited to) drugs in the following categories: Alpha-adrenoreceptor Antagonists Anti-dementia Drugs Anti-gout Drugs Anti-Parkinsonian Drugs Anti-platelet aggregation Drugs BPH Drugs Cardiovascular Drugs Enzyme Preparations Drugs for Diabetes Drugs for Treatment of Bone Diseases GI Anti-inflammatory Drugs Thyroid Therapy Proton Pump Inhibitors Urinary Anti-Spasmotics OTCs (including vitamins) H2-Receptor Antagonists Other Drugs for Peptic Ulcer and Gastro-esophageal Reflux Disease (GERD) Note: this list may be amended as required and changes will be communicated through the quarterly drug bulletin and as on-line updates to the Drug Benefit List. Medications on the Short term Dispensing list are identified in the DBL using the symbol ST beside the medication strength and dosage form. Compensation The compensation will be the lesser of the usual and customary fee up to the maximum negotiated NIHB regional dispensing fee for each 28 days supplied. NIHB will continue to audit and recover in instances where quantity reduction occurs. Less than 28 Day Supply For certain high-risk drugs where safety, risk of diversion and compliance are of concern, a less than 28 day supply will be compensated. The drug categories for which less than a 28 day supply will be compensated are: antidepressants anti-psychotics opioids benzodiazepines
Through provider audit, special attention will be given to these drug categories to ensure the appropriateness of short-term dispensing in all cases.
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Implementation - When filling a new prescription for a chronic use drug, the Program will pay a full dispensing fee regardless of the days supply. A new prescription may include a dosage change or an intermittent treatment, based on an assessment by a prescriber. - When refilling a prescription for a chronic use drug that is for less than a 28 day supply or when a need for compliance packaging is identified by the prescriber, the Program will pay no more than one full dispensing fee per 28 day period. - A refill is defined as the second and all subsequent fills for a given strength and dosage of a drug. 6. SPECIAL FORMULARY FOR CHRONIC RENAL FAILURE PATIENTS Recipients with chronic renal failure are eligible to receive a list of supplemental benefits that are not included in the NIHB Drug Benefit List but which are required on a long-term basis. Some supplemental benefits include: darbepoetin alfa products (except in provinces where NIHB recipients are eligible to receive darbepoetin alfa through the provincial programs), calcium products, multivitamins formulated for renal patients and select nutritional supplements formulated for renal patients. New patients requiring drugs on the special formulary will be identified for coverage through the usual prior approval process. Once the patient is confirmed as eligible, coverage will automatically be extended to all drugs in the special formulary for as long as needed.
7. PALLIATIVE CARE FORMULARY Recipients diagnosed with a terminal illness and are near the end of life will be eligible to receive a list of supplemental benefits that are not included in the NIHB Drug Benefit List. The Palliative Care Formulary includes medications used to provide comfort to those near the end of life. Requests for any of the DINs on the Palliative Care Formulary will generate a Palliative Care Application Form, faxed to the prescribing physician. Once completed and submitted, the recipient will be eligible for all medications on the Palliative Care Formulary if the following criteria are met: The recipient: 1. is not receiving care in a provincially covered hospital or provincially covered long-term care facility and 2. has been diagnosed with a terminal illness or disease which is expected to be the primary cause of death within six months or less Once approved, the recipient will be eligible for all medications on the Palliative Care Formulary for six months without the need for further prior approval. If coverage is required beyond the initial six months, an additional six months may be granted upon receipt of another completed Palliative Care Application Form. Please note: During the six month coverage period, a maximum 30 day supply will be reimbursed at any one time. 8. DRUG UTILIZATION EVALUATION A drug utilization evaluation, which is part of the point-of-service or on-line adjudication system, provides an analysis of both previous claims data and current claims data to identify potential drug-related problems. Messages are returned to pharmacists to alert them of the potential problems. These messages are intended to enhance pharmacy practice with additional information. Currently, the system monitors for: potential drug/drug interactions duplicate drugs duplicate therapy
The NIHB Drug Use Evaluation Advisory Committee was established in Fall 2003 to provide advice to the NIHB Drug Use Evaluation (DUE) Program, to promote effective, efficient and optimal drug therapy to First Nations and Inuit recipients.

9. GENERAL INFORMATION Sources of information about the NIHB Program include:
Effective 2010
The NIHB Internet site which provides background information on the program and a copy of the Drug Benefit List. It can be found at: http://www.hc-sc.gc.ca/fniah-spnia/nihb-ssna/provide-fournir/pharmaprod/med-list/index-eng.php The NIHB Drug Bulletin which is available to pharmacists and to medical practitioners through the Health Canadas website. Bulletins can be found at: http://www.hc-sc.gc.ca/fniah-spnia/pubs/nihbssna/index-eng.php#drug-med
Information about the NIHB Program can also be obtained by contacting: Director, Benefit Management Non-Insured Health Benefits First Nations and Inuit Health Branch Room 504, Suite 550 Address Locator 4005A 55 Metcalfe Street Ottawa, Ontario K1A 0K9 10. 10. NIHB PRIVACY CODE The NIHB Program of Health Canada is committed to protecting an individuals privacy and safeguarding the personal information in its possession. When a benefit request is received, the NIHB Program collects, uses, discloses and retains an individuals personal information according to the applicable federal privacy legislation. The information collected is limited to only that information required for the NIHB Program to administer and verify benefits. As a program of the federal government, the NIHB Program must comply with the Privacy Act, the Canadian Charter of Rights and Freedoms, the Access to Information Act, the Treasury Board of Canada Privacy and Data Protection Policies, the Government Security Policy, and Health Canadas Security Policy.
11. PHARMACOLOGIC-THERAPEUTIC CLASSIFICATION OF DRUGS The drugs in the Non-Insured Health Benefits (NIHB) Drug Benefit List are classified according to the AHFS Pharmacologic-Therapeutic classification developed by the American Society of Health-System Pharmacists for the purposes of the AHFS Drug Information. Permission to use this system has been granted by the American Society of Health-System Pharmacists. The Society is not responsible for the accuracy of transpositions from the original context. Drugs are listed alphabetically within each therapeutic classification according to their chemical names. Under each drug, acceptable products are listed.
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LEGEND
1. 2. 3. 4. Pharmacologic-Therapeutic classification Pharmacologic-Therapeutic sub-classification Nonproprietary or generic name of the drug Drug strength and dosage form. indicates the drug is identified as a chronic medication under the Short-Term Dispensing Policy. Drug Identification Number (DIN), assigned by the Therapeutic Products Directorate of Health Canada, to uniquely identify the drug product as to its manufacturer, name and strength of active ingredients, route of administration and pharmaceutical dosage form Brand name of the drug List of all active ingredients in a combination product Strengths of active ingredients in a combination product, listed in the same order as the ingredients List of available brands of drugs. Provincial or territorial drug plan formularies should be consulted to determine interchangeable products and to identify best price (lowest cost) alternatives Three letter identification code assigned to manufacturer An asterisk (*) to the right of the manufacturer code indicates that the product is not available in all regions
ST
5.
6. 7. 8.
9.
10. 11.
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1 2 3 4 5 6 7 8
04:00 ANTIHISTAMINE DRUGS 04.00.00 ANTIHISTAMINE DRUGS CETIRIZINE HCL

ST
10mg Tablet 02231603 APO-CETIRIZINE APX
28:08.08 ACETAMINOPHEN, CAFFEINE, CODEINE PHOSPHATE 300mg & 15mg & 15mg Tablet 00706515 00653241 02163934 PMS-ACET 2 RATIO-LENOLTEC NO.2 TYLENOL WITH CODEINE NO.2 PMS RPH JNO
9 300mg & 15mg & 30mg Tablet 00653276 02163926 10 36:00 DIAGNOSTIC AGENTS 36:26.00 DX DIABETES MELLITUS
GLUCOSE OXIDASE, PEROXIDASE
RATIO-LENOLTEC NO.3 TYLENOL WITH CODEINE NO.3
RPH JNO
Freestyle Strip 00901388 00905500 00950907 09857141 44123028 97799829 99004704 99401062 11 FREESTYLE FREESTYLE FREESTYLE FREESTYLE FREESTYLE FRESSTYLE FREESTYLE FREESTYLE THS * THS THS * THS THS THS THS * THS
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DRUG BENEFIT LIST
Health Canada
Non-Insured Health Benefits
04:00 ANTIHISTAMINE DRUGS

04:00.00 ANTIHISTAMINE DRUGS
BROMPHENIRAMINE MALEATE, PHENYLEPHRINE HCL
Oral Liquid 02243980 DIMETAPP COLD WRI
04:00.00 ANTIHISTAMINE DRUGS

FEXOFENADINE HCL
ST
60mg Tablet 02231462
ALLEGRA
AVT
KETOTIFEN FUMARATE
ST
CETIRIZINE HCL
ST
1mg/mL Syrup 02238337 REACTINE 10mg Tablet 02315955 02231603 02223554 ALLERGY RELIEF ES APO-CETIRIZINE REACTINE PMS-CETIRIZINE REACTINE
JNO
ST
0.2mg/mL Syrup 02221330 APO-KETOTIFEN 02176084 NOVO-KETOTIFEN 02218305 NU-KETOTIFEN 02231679 PMS-KETOTIFEN 1mg Tablet 02230730 02231680 00577308 NOVO-KETOTIFEN PMS-KETOTIFEN ZADITEN
APX NOP NXP PMS NOP PMS NVR
PED APX JNO PMS JNO
ST
20mg Tablet 02315963 01900978
LORATADINE
ST
CHLORPHENIRAMINE MALEATE
ST
1mg/mL Syrup 02019973 CLARITIN 02241523 CLARITIN KIDS 10mg Tablet 00782696 02244692 02280159 CLARITIN LORATADINE LORATADINE
SCH SCH SCH VTH VTH
12mg Sustained Release Tablet 00738964 CHLOR-TRIPOLON 4mg Tablet 00738972 00021288 CHLOR-TRIPOLON NOVOPHENIRAM
ST
SCH SCH NOP
ST
LORATADINE, PSEUDOEPHEDRINE SULFATE

ST
DIPHENHYDRAMINE HCL
25mg Capsule 00757683 PMS-DIPHENHYDRAMINE 50mg Capsule 02019671 BENADRYL 00757691 PMS-DIPHENHYDRAMINE 2.5mg/mL Elixir 00804193 ALLERNIX 02019736 BENADRYL 00833266 DIPHENHYDRAMINE HCL 00792705 PMS-DIPHENHYDRAMINE 50mg/mL Injection 00596612 DIPHENHYDRAMINE 00878200 PMS-DIPHENHYDRAMINE 1.25mg/mL Liquid 02019698 BENADRYL CHILD 12.5MG/5ML Liquid 02298503 JAMP-DIPHENHYDRAMINE 02298503 JAMP-DIPHENHYDRAMINE 25mg Tablet 02176483 ALLER-AIDE 01949454 ALLERGY 02229492 ALLERGY FORMULA 02097583 ALLERNIX 02017849 BENADRYL 02257548 JAMP-DIPHENHYDRAMINE 02239029 NADRYL 50mg Tablet 02097575 ALLERNIX PLUS 02230398 DIPHENHYDRAMINE HCL 02257556 JAMP-DIPHENHYDRAMINE 2010 PMS WLA PMS RPH WLA TAN PMS SDZ PMS WLA JMP JMP RPH TAN SDR RPH WLA JMP RIV RPH TAN JMP
5mg & 120mg Sustained Release Tablet 01970399 CHLOR-TRIPOLON ND 01945157 CLARITIN EXTRA
SCH SCH
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Health Canada
08:00 ANTI-INFECTIVE AGENTS

08:08.00 ANTHELMINTICS
MEBENDAZOLE
100mg Tablet 00556734 VERMOX JNO
08:12.06 CEPHALOSPORINS
CEFPROZIL
25mg/mL Suspension 02293943 APO-CEFPROZIL 02163675 CEFZIL 02303426 SANDOZ CEFPROZIL 50mg/mL Suspension 02293951 APO-CEFPROZIL 02163683 CEFZIL 02293579 RAN-CEFPROZIL 02303434 SANDOZ CEFPROZIL 250mg Tablet 02292998 02163659 02293528 02302179 500mg Tablet 02293005 02163667 02293536 02302187 APO-CEFPROZIL CEFZIL RAN-CEFPROZIL SANDOZ CEFPROZIL APO-CEFPROZIL CEFZIL RAN-CEFPROZIL SANDOZ CEFPROZIL APX BMS SDZ APX BMS RBY SDZ APX BMS RBY SDZ APX BMS RBY SDZ
PYRANTEL PAMOATE
50mg/mL Suspension 01944355 COMBANTRIN 125mg Tablet 01944363 COMBANTRIN PFI PFI
CEFACLOR
250mg Capsule 02230263 APO-CEFACLOR 00465186 CECLOR 02177633 DOM-CEFACLOR 02231432 NU-CEFACLOR 02238200 PDL-CEFACLOR 02237729 SCHEIN-CEFACLOR 500mg Capsule 02230264 APO-CEFACLOR 00465194 CECLOR 02177641 DOM-CEFACLOR 02231433 NU-CEFACLOR 02238201 PDL-CEFACLOR 02237730 SCHEIN-CEFACLOR 25mg/mL Suspension 00465208 CECLOR 02177668 DOM-CEFACLOR 02238202 PDL-CEFACLOR 50mg/mL Suspension 00465216 CECLOR 02177676 DOM-CEFACLOR 02238203 PDL-CEFACLOR 75mg/mL Suspension 02237502 APO-CEFACLOR 00832804 CECLOR BID 02177684 DOM-CEFACLOR 02238204 PDL-CEFACLOR APX PHH DPC NXP PDL SCN APX PHH DPC NXP PDL SCN PHH DPC PDL PHH DPC PDL APX PHH DPC PDL
CEFPROZIL MONOHYDRATE
125MG/5ML Oral Liquid 02329204 RAN-CEFPROZIL 02329204 RAN-CEFPROZIL RBY RBY
CEFUROXIME AXETIL
25mg/mL Suspension 02212307 CEFTIN 250mg Tablet 02244393 APO-CEFUROXIME 02212277 CEFTIN 02242656 RATIO-CEFUROXIME 500mg Tablet 02244394 02212285 02311453 02242657 APO-CEFUROXIME CEFTIN PRO-CEFUROXIME RATIO-CEFUROXIME GSK APX GSK RPH APX GSK PDL RPH
CEPHALEXIN
250mg Capsule 00342084 NOVO-LEXIN 500mg Capsule 00342114 NOVO-LEXIN 25mg/mL Suspension 02177862 DOM-CEPHALEXIN 00342106 NOVO-LEXIN 50mg/mL Suspension 02177870 DOM-CEPHALEXIN 00342092 NOVO-LEXIN NOP NOP DPC NOP DPC NOP
CEFADROXIL
500mg Capsule 02240774 APO-CEFADROXIL 02235134 NOVO-CEFADROXIL 02311062 PRO-CEFADROXIL APX NOP PDL
CEFIXIME
20mg/mL Suspension 00868965 SUPRAX 400mg Tablet 00868981 SUPRAX SAC SAC
2010
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CEPHALEXIN
250mg Tablet 00768723 02177846 00583413 00865877 00828858 02177781 500mg Tablet 00768715 02177854 00583421 00865885 00828866 02177803 APO-CEPHALEX DOM-CEPHALEXIN NOVO-LEXIN NU-CEPHALEX PDL-CEPHALEXIN PMS-CEPHALEXIN APO-CEPHALEX DOM-CEPHALEXIN NOVO-LEXIN NU-CEPHALEX PDL-CEPHALEXIN PMS-CEPHALEXIN APX DPC NOP NXP PDL PMS APX DPC NOP NXP PDL PMS
08:12.12 MACROLIDES
CLARITHROMYCIN
250mg Film Coated Tablet 02274744 APO-CLARITHROMYCIN 01984853 BIAXIN 02248856 GEN-CLARITHROMYCIN 02247573 PMS-CLARITHROMYCIN 02247818 RATIO-CLARITHROMYCIN 02266539 SANDOZ-CLARITHROMYCIN 500mg Film Coated Tablet 02266547 SANDOZ-CLARITHROMYCIN 500mg Film Coated Tablet 02274752 APO-CLARITHROMYCIN 02126710 BIAXIN 02248857 GEN-CLARITHROMYCIN 02247574 PMS-CLARITHROMYCIN 02247819 RATIO-CLARITHROMYCIN 25mg/mL Suspension 02146908 BIAXIN SDZ SDZ NOP PMS PFI NOP PMS PFI APX COB GEN NOP PMI PMS PDL RPH RIV SDZ PFI COB PMS RIV PFI 50mg/mL Suspension 02244641 BIAXIN APX ABB GEN PMS RPH RHO RHO APX ABB GEN PMS RPH ABB ABB
08:12.12 MACROLIDES
AZITHROMYCIN
100MG/5ML Oral Liquid 02332388 SANDOZ-AZITHROMYCIN 200MG/5ML Oral Liquid 02332396 SANDOZ-AZITHROMYCIN 20mg/mL Suspension 02315157 NOVO-AZITHROMYCIN 02274388 PMS-AZITHROMYCIN 02223716 ZITHROMAX 40mg/mL Suspension 02315165 NOVO-AZITHROMYCIN 02274396 PMS-AZITHROMYCIN 02223724 ZITHROMAX 250mg Tablet 02247423 02255340 02278359 02267845 02278588 02261634 02310600 02275287 02275309 02265826 02212021 600mg Tablet 02256088 02261642 02275317 02231143 APO-AZITHROMYCIN CO AZITHROMYCIN GEN-AZITHROMYCIN NOVO-AZITHROMYCIN PHL-AZITHROMYCIN PMS-AZITHROMYCIN PRO-AZITHROMYCIN RATIO-AZITHROMYCIN RIVA-AZITHROMYCIN SANDOZ-AZITHROMYCIN ZITHROMAX CO AZITHROMYCIN PMS-AZITHROMYCIN RIVA-AZITHROMYCIN ZITHROMAX
ERYTHROMYCIN
250mg Enteric Coated Capsule 00726672 APO-ERYTHRO 00607142 ERYC 333mg Enteric Coated Capsule 01925938 APO-ERYTHRO 333mg Enteric Coated Tablet 00873454 ERYC 250mg Tablet 00682020 APO-ERYTHRO BASE APX PFI APX PFI APX
ERYTHROMYCIN ESTOLATE
50mg/mL Suspension 00262595 NOVO-RYTHRO ESTOLATE NOP
ERYTHROMYCIN ETHYLSUCCINATE
40mg/mL Suspension 00605859 NOVO-RYTHRO ETHYLSUCCINATE 80mg/mL Suspension 00652318 NOVO-RYTHRO ETHYLSUCCINATE 600mg Tablet 00637416 APO-ERYTHRO-S 00583782 EES-600 00704377 ERYTHRO-ES NOP
NOP
APX ABB PDL
CLARITHROMYCIN
500mg Extended Release Tablet 02244756 BIAXIN XL ABB
ERYTHROMYCIN STEARATE
250mg Tablet 00545678 APO-ERYTHRO-S 00563854 ERYTHROMYCIN 02051850 NU-ERYTHROMYCIN S 500mg Tablet 00688568 APO-ERYTHRO S 00704393 ERYTHRO APX PDL NXP APX PDL Page 3 of 124
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08:12.16 PENICILLINS
AMOXICILLIN
250mg Capsule 00628115 APO-AMOXI 02238171 GEN-AMOXICILLIN 02239761 MED-AMOXICILLIN 00406724 NOVAMOXIN 00865567 NU-AMOXI 02229584 PENTA-AMOXICILLIN 02230243 PMS-AMOXICILLIN 00644307 PRO-AMOX 02241826 SCHEIN-AMOXICILLIN 500mg Capsule 00628123 APO-AMOXI 02238172 GEN-AMOXICILLIN 02239762 MED-AMOXICILLIN 00406716 NOVAMOXIN 00865575 NU-AMOXI 02233017 PENTA-AMOXICILLIN 02230244 PMS-AMOXICILLIN 00644315 PRO-AMOX 02241827 SCHEIN-AMOXICILLIN 125mg Chewable Tablet 02036347 NOVAMOXIN 250mg Chewable Tablet 02036355 NOVAMOXIN 25mg/mL Suspension 00628131 APO-AMOXI 00452149 NOVAMOXIN 01934171 NOVAMOXIN SUGAR REDUCED 00865540 NU-AMOXI 02229582 PENTA-AMOXICILLIN 02230245 PMS-AMOXICILLIN 00644323 PRO-AMOX 50mg/mL Suspension 00628158 APO-AMOXI 00452130 NOVAMOXIN 01934163 NOVAMOXIN SUGAR REDUCED 00865559 NU-AMOXI 02229583 PENTA-AMOXICILLIN 02230246 PMS-AMOXICILLIN 00644331 PRO-AMOX APX GEN MEC NOP NXP PEN PMS PDL SCN APX GEN MEC NOP NXP PEN PMS PDL SCN NOP NOP APX NOP NOP NXP PEN PMS PDL APX NOP NOP NXP PEN PMS PDL
AMOXICILLIN, CLAVULANIC ACID
250mg & 125mg Tablet 02243350 APO-AMOXI CLAV 500mg & 125mg Tablet 02243351 APO-AMOXI CLAV 01916858 CLAVULIN-F 02243771 RATIO-ACLAVULANATE 875mg & 125mg Tablet 02245623 APO-AMOXI CLAV 02238829 CLAVULIN 02248138 NOVO-CLAVAMOXIN 02247021 RATIO-ACLAVULANATE APX APX GSK RPH APX GSK NOP RPH
AMPICILLIN
250mg Capsule 00020877 NOVO-AMPICILLIN 500mg Capsule 00020885 NOVO-AMPICILLIN 25mg/mL Suspension 00603260 APO-AMPICILLIN 00717495 NU-AMPI 50mg/mL Suspension 00603287 APO-AMPICILLIN 00717649 NU-AMPI 02043203 PENBRITIN NOP NOP APX NXP APX NXP WAY
CLOXACILLIN
250mg Capsule 00618292 APO-CLOXI 02069660 CLOXACILLINE 00337765 NOVO-CLOXIN 00717584 NU-CLOXI 500mg Capsule 00618284 APO-CLOXI 02069679 CLOXACILLINE 00337773 NOVO-CLOXIN 00717592 NU-CLOXI 25mg/mL Suspension 00644633 APO-CLOXI 00337757 NOVO-CLOXIN 00717630 NU-CLOXI APX PRO NOP NXP APX PRO NOP NXP APX NOP NXP
PENICILLIN V BENZATHINE
36mg/mL Suspension 02229618 PEN VEE PED PED
AMOXICILLIN, CLAVULANIC ACID

25mg & 6.25mg/mL Suspension 02243986 APO-AMOXI CLAV 01916882 CLAVULIN-F 125 40mg & 5.7mg/mL Suspension 02288559 APO-AMOXI CLAV 02238831 CLAVULIN 200 50mg & 12.5mg/mL Suspension 02243987 APO-AMOXI CLAV 01916874 CLAVULIN-F 250 80mg & 11.4mg/mL Suspension 02238830 CLAVULIN 400 2010 APX GSK APX GSK APX GSK GSK
60mg/mL Suspension 02229617 PEN VEE
PENICILLIN V POTASSIUM
25mg/mL Suspension 00642223 APO-PEN VK 60mg/mL Suspension 00642231 APO-PEN VK 00391603 NOVO-PEN VK APX APX NOP
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PENICILLIN V POTASSIUM
300mg Tablet 00642215 00021202 00717568 00468029 APO-PEN VK NOVO-PEN VK NU-PEN VK PENICILLINE V APX NOP NXP PDL
08:12.18 QUINOLONES
CIPROFLOXACIN HCL
750mg Tablet 02229523 02155974 02251779 02247341 02251299 02245649 02317443 02161753 02249650 02251337 02248439 02249987 02303744 02267950 02246827 02248758 02251256 APO-CIPROFLOX CIPRO CIPROFLOXACIN CO CIPROFLOXACIN DOM-CIPROFLOXACIN GEN-CIPROFLOXACIN MINT-CIPROFLOXACIN NOVO-CIPROFLOXACIN NU-CIPROFLOXACIN PHL-CIPROFLOXACIN PMS-CIPROFLOXACIN PREM-CIPROFLOXACIN RAN-CIPROFLOX RAN-CIPROFLOXACIN RATIO-CIPROFLOXACIN RHOXAL-CIPROFLOXACIN RIVA-CIPROFLOXACIN APX BAY PDL COB DPC GEN MIN NOP NXP PHH PMS PRE RBY RBY RPH RHO RIV
PIVMECILLINAM HCL
200mg Tablet 00657212 SELEXID LEO
08:12.18 QUINOLONES
CIPROFLOXACIN HCL
250mg Tablet 02229521 02155958 02251752 02247339 02251272 02245647 02317427 02161737 02249634 02251310 02248437 02249960 02317796 02303728 02267934 02246825 02251221 02248756 02266962 500mg Tablet 02229522 02155966 02251760 02247340 02251280 02245648 02317435 02161745 02249642 02251329 02248438 02249979 02317818 02303736 02267942 02246826 02248757 02251248 02266970 APO-CIPROFLOX CIPRO CIPROFLOXCIN CO CIPROFLOXACIN DOM-CIPROFLOXACIN GEN-CIPROFLOXACIN MINT-CIPROFLOXACIN NOVO-CIPROFLOXACIN NU-CIPROFLOXACIN PHL-CIPROFLOXACIN PMS-CIPROFLOXACIN PREM-CIPROFLOXACIN PRO-CIPROFLOXACIN RAN-CIPROFLOX RAN-CIPROFLOXACIN RATIO-CIPROFLOXACIN RIVA-CIPROFLOXACIN SANDOZ-CIPROFLOXACIN TARO-CIPROFLOXACIN APO-CIPROFLOX CIPRO CIPROFLOXACIN CO CIPROFLOXACIN DOM-CIPROFLOXACIN GEN-CIPROFLOXACIN MINT-CIPROFLOXACIN NOVO-CIPROFLOXACIN NU-CIPROFLOXACIN PHL-CIPROFLOXACIN PMS-CIPROFLOXACIN PREM-CIPROFLOXACIN PRO-CIPROFLOXACIN RAN-CIPROFLOX RAN-CIPROFLOXACIN RATIO-CIPROFLOXACIN RHOXAL-CIPROFLOXACIN RIVA-CIPROFLOXACIN TARO-CIPROFLOXACIN APX BAY PDL COB DPC GEN MIN NOP NXP PHH PMS PRE PDL RBY RBY RPH RIV SDZ TAR APX BAY PDL COB DPC GEN MIN NOP NXP PHH PMS PRE PDL RBY RBY RPH RHO RIV TAR
LEVOFLOXACIN
Limited use benefit (prior approval not required). Coverage will be limited to a maximum of 14 days. 250mg Tablet 02284707 02315424 02286920 02313979 02236841 02307200 02248262 02286947 02284677 02298635 500mg Tablet 02284715 02315432 02286939 02313987 02236842 02307219 02248263 02286955 02284685 02298643 APO-LEVOFLOXACIN CO-LEVOFLOXACIN DOM-LEVOFLOXACIN GEN-LEVOFLOXACIN LEVAQUIN LEVOFLOXACIN NOVO-LEVOFLOXACIN PHL-LEVOFLOXACIN PMS-LEVOFLOXACIN SANDOZ LEVOFLOXACIN APO-LEVOFLOXACIN CO-LEVOFLOXACIN DOM-LEVOFLOXACIN GEN-LEVOFLOXACIN LEVAQUIN LEVOFLOXACIN NOVO-LEVOFLOXACIN PHL-LEVOFLOXACIN PMS-LEVOFLOXACIN SANDOZ LEVOFLOXACIN APX CBT DOM GEN JNO SOR NOP PMI PMS SDZ APX CBT DOM GEN JNO SOR NOP PMI PMS SDZ
NORFLOXACIN
400mg Tablet 02229524 02269627 02237682 02239670 02246596 02241483 02301504 APO-NORFLOX CO NORFLOXACIN NOVO-NORFLOXACIN PDL-NORFLOXACINE PMS-NORFLOXACIN RIVA-NORFLOXACIN RIVA-NORFLOXACIN APX COB NOP PDL PMS RIV RIV
2010
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08:12.18 QUINOLONES
OFLOXACIN
200mg Tablet 02231529 APO-OFLOX 300mg Tablet 02231531 APO-OFLOX 02243475 NOVO-OFLOXACIN 400mg Tablet 02231532 APO-OFLOX APX APX NOP APX
08:12.24 TETRACYCLINES
MINOCYCLINE HCL
Limited use benefit (prior approval required). For: a. - patients who cannot tolerate other tetracyclines. b. - patients with severe widespread acne who have failed on tetracycline. 50mg Capsule 02084090 APO-MINOCYCLINE 02239667 DOM-MINOCYCLINE 02237875 MED-MINOCYCLINE 02173514 MINOCIN 02108143 NOVO-MINOCYCLINE 02153394 PDL-MINOCYCLINE 02239238 PMS-MINOCYCLINE 02294419 PMS-MINOCYCLINE 01914138 RATIO-MINOCYCLINE 02242080 RIVA-MINOCYCLINE 02237313 SANDOZ-MINOCYCLINE 100mg Capsule 02084104 APO-MINOCYCLINE 02239668 DOM-MINOCYCLINE 02237876 MED-MINOCYCLINE 02173506 MINOCIN 02239982 MINOCYCLINE 02108151 NOVO-MINOCYCLINE 02154366 PDL-MINOCYCLINE 02294427 PMS-MINOCYCLINE 02239239 PMS-MONOCYCLINE 01914146 RATIO-MINOCYCLINE 02242081 RIVA-MINOCYCLINE 02237314 SANDOZ-MINOCYCLINE APX DPC MEC STI NOP PDL PMS PMS RPH RIV SDZ APX DPC MEC STI IVX NOP PDL PMS PMS RPH RIV SDZ
08:12.20 SULFONAMIDES
SULFAMETHOXAZOLE
500mg Tablet 00421480 APO-SULFAMETHOXAZOLE APX
SULFAMETHOXAZOLE, TRIMETHOPRIM
40mg & 8mg/mL Suspension 00726540 NOVO-TRIMEL 100mg & 20mg Tablet 00445266 APO-SULFATRIM PED 400mg & 80mg Tablet 00445274 APO-SULFATRIM 00510637 NOVO-TRIMEL 00865710 NU-COTRIMOX 00512516 PROTRIN 800mg & 160mg Tablet 00445282 APO-SULFATRIM DS 00510645 NOVO-TRIMEL DS 00865729 NU-COTRIMOX DS 00512524 PROTRIN DF NOP APX APX NOP NXP PDL APX NOP NXP PRO
SULFASALAZINE
500mg Enteric Coated Tablet 00598488 PMS-SULFASALAZINE 02064472 SALAZOPYRIN 500mg Tablet 00598461 PMS-SULFASALAZINE 02064480 SALAZOPYRIN PMS PFI PMS PFI
TETRACYCLINE HCL
250mg Capsule 00580929 APO-TETRA 00156744 TETRACYCLINE 250mg Tablet 00717606 NU-TETRA APX PRO NXP
DOXYCYCLINE
100mg Capsule 00740713 APO-DOXY 00817120 DOXYCIN 00742562 DOXYCYCLINE 00725250 NOVO-DOXYLIN 02044668 NU-DOXYCYCLINE 02289539 PMS-DOXYCYCLINE 02093103 RATIO-DOXYCYCLINE 100mg Tablet 00874256 00860751 00887064 02158574 02044676 02289466 02091232 2010 APO-DOXY DOXYCIN DOXYTAB NOVO-DOXYLIN NU-DOXYCYCLINE PMS-DOXYCYCLINE RATIO-DOXYCYCLINE APX RIV PDL NOP NXP PMS RPH APX RIV PDL NOP NXP PMS RPH
08:12.28 MISCELLANEOUS ANTIBIOTICS

CLINDAMYCIN HCL
150mg Capsule 02245232 APO-CLINDAMYCIN 02248525 CLINDAMYCINE 00030570 DALACIN C 02258331 GEN-CLINDAMYCIN 02241709 NOVO-CLINDAMYCIN 02242409 RIVA-CLINDAMYCIN 300mg Capsule 02245233 APO-CLINDAMYCIN 02248526 CLINDAMYCINE 02182866 DALACIN C 02258358 GEN-CLINDAMYCIN 02241710 NOVO-CLINDAMYCIN 02242410 RIVA-CLINDAMYCIN APX PDL PFI GEN NOP RIV APX PDL PFI GEN NOP RIV
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CLINDAMYCIN PALMITATE HCL
15mg/mL Solution 00225851 DALACIN C PFI
08:14.08 AZOLES
FLUCONAZOLE
50mg Tablet 02237370 00891800 02245292 02236978 02245643 02249294 100mg Tablet 02237371 02281279 02245293 02236979 02245644 02310686 02271516 02249308 APO-FLUCONAZOLE DIFLUCAN GEN-FLUCONAZOLE NOVO-FLUCONAZOLE PMS-FLUCONAZOLE TARO-FLUCONAZOLE APO-FLUCONAZOLE CO FLUCONAZOLE GEN-FLUCONAZOLE NOVO-FLUCONAZOLE PMS-FLUCONAZOLE PRO-FLUCONAZOLE RIVA-FLUCONAZOLE TAR0-FLUCONAZOLE APX PFI GEN NOP PMS TAR APX CBT GEN NOP PMS PDL RIV TAR
FUSIDATE SODIUM
250mg Tablet 01934252 FUCIDIN FC LEO
LINEZOLID
Limited use benefit (prior approval required). Tablets: For treatment of proven vancomycin-resistant enterococci (VRE) infections when other antibiotics are not available, and for the treatment of proven Methicillin-Resistant Staphylococcus aureus (MRSA) infections in patients who cannot tolerate or who had an idiosyncratic reaction with Vancomycin. I.V. solution: When linezolid cannot be administered orally in the above mentioned situations. 2mg/mL Injection 02243685 ZYVOXAM 600mg Tablet 02243684 ZYVOXAM PFI PFI
ITRACONAZOLE
100mg Capsule 02047454 SPORANOX 10mg/mL Solution 02231347 SPORANOX JNO JNO
KETOCONAZOLE
200mg Tablet 02237235 APO-KETOCONAZOLE 02231061 NOVO-KETOCONAZOLE 02122197 NU-KETOCON APX NOP NXP
08:14.04 ALLYLAMINES
TERBINAFINE HCL
250mg Tablet 02239893 02254727 02242503 02031116 02240346 02248845 02240807 02294273 02262924 02262177 APO-TERBINAFINE CO TERBINAFINE GEN-TERBINAFINE LAMISIL NOVO-TERBINAFINE NU-TERBINAFINE PMS-TERBINAFINE PMS-TERBINAFINE RIVA-TERBINAFINE SANDOZ-TERBINAFINE APX COB GEN NVR NOP NXP PMS PMS RIV SDZ
VORICONAZOLE
Limited use benefit (prior approval required). For the treatment of: a. - patients with invasive aspergillosis. b. - culture proven invasive candidiasis with documented resistance to fluconazole. 50mg Tablet 02256460 VFEND PFI PFI
08:14.08 AZOLES
FLUCONAZOLE
150mg Capsule 02241895 APO-FLUCONAZOLE 02311690 CANESORAL 02323419 CO FLUCONAZOLE 02141442 DIFLUCAN 02245697 GEN-FLUCONAZOLE 02243645 NOVO-FLUCONAZOLE 02246620 PMS-FLUCONAZOLE 02282348 PMS-FLUCONAZOLE 02310694 PRO-FLUCONAZOLE 02255510 RIVA-FLUCONAZOLE 10mg/mL Suspension 02024152 DIFLUCAN APX BAY CBT PFI GEN NOP PMS PMS PDL RIV PFI
200mg Tablet 02256479 VFEND
08:14.28 POLYENES
NYSTATIN
100,000U/mL Suspension 02125145 DOM-NYSTATIN 00792667 PMS-NYSTATIN 02194201 RATIO-NYSTATIN 500,000U Tablet 02194198 RATIO-NYSTATIN DPC PMS RPH RPH
08:16.04 ANTITUBERCULOSIS AGENTS

ETHAMBUTOL HCL
100mg Tablet 00247960 ETIBI 400mg Tablet 00247979 ETIBI VAE VAE Page 7 of 124
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08:16.04 ANTITUBERCULOSIS AGENTS

ISONIAZID
10mg/mL Syrup 00265500 ISOTAMINE 00577812 PMS-ISONIAZID 50mg Tablet 00577782 PMS-ISONIAZID VAE PMS PMS VAE PMS
08:18.08 ANTIRETROVIRALS
ATAZANAVIR SULFATE
150mg Capsule 02248610 REYATAZ 200mg Capsule 02248611 REYATAZ 300mg Capsule 02294176 REYATAZ BMS BMS BMS
300mg Tablet 00272655 ISOTAMINE 00577804 PMS-ISONIAZID
DARUNAVIR
Limited use benefit (prior approval required). For the management of HIV in patients who failed or have experienced adverse events to three or more listed protease inhibitors. 300mg Tablet 02284057 PREZISTA 400mg Tablet 02324016 PREZISTA 600mg Tablet 02324024 PREZISTA JNO JNO JNO
PYRAZINAMIDE
500mg Tablet 00618810 PMS-PYRAZINAMIDE 00283991 TEBRAZID PMS VAE
RIFABUTIN
150mg Capsule 02063786 MYCOBUTIN PFI
RIFAMPIN
150mg Capsule 02091887 RIFADIN 00393444 ROFACT 300mg Capsule 02092808 RIFADIN 00210463 RIMACTANE 00343617 ROFACT SAC VAE SAC NVR VAE
DIDANOSINE
125mg Capsule 02244596 VIDEX EC 200mg Capsule 02244597 VIDEX EC 250mg Capsule 02244598 VIDEX EC 400mg Capsule 02244599 VIDEX EC BMS BMS BMS BMS
08:18.04 ADAMANTANES
AMANTADINE HCL
100mg Capsule 02130963 DOM-AMANTADINE 02139200 GEN-AMANTADINE 02199289 MED-AMANTADINE 01990403 PMS-AMANTADINE 10mg/mL Syrup 02130971 DOM-AMANTADINE 02022826 PMS-AMANTADINE 01913999 SYMMETREL DPC GEN MEC PMS DPC PMS BMS
EFAVIRENZ
50mg Capsule 02239886 SUSTIVA 200mg Capsule 02239888 SUSTIVA 600mg Tablet 02246045 SUSTIVA BMS BMS BMS
ABACAVIR
20mg/mL Oral Liquid 02240358 ZIAGEN 300mg Tablet 02240357 ZIAGEN GSK GSK
EFAVIRENZ, EMTRICITABINE, TENOFOVIR DISOPROXIL FUMARATE

Limited use benefit (prior approval required). For the treatment of HIV-1 infection adults where the virus is susceptible to each of tenofovir, emtricitabine and efavirenz, and: a. - Atripla is used to replace existing therapy with its component drugs, or b. - the patient is treatment nave, or c. - the patient has established viral suppression but requires antiretroviral therapy modification due to intolerance or adverse effects. Note: Criteria will be confirmed against medication history.
ABACAVIR, LAMIVUDINE
600mg & 300mg Tablet 02269341 KIVEXA GSK
ABACAVIR, LAMIVUDINE, ZIDOVUDINE

300mg & 150mg & 300mg Tablet 02244757 TRIZIVIR GSK
600mg & 200mg & 300mg Tablet 02300699 ATRIPLA
BMS
2010
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EMTRICITABINE, TENOFOVIR DISOPROXIL FUMARATE
Limited use benefit (prior approval required). For the treatment of patients with HIV infection where the virus is susceptible to both emtricitabine and tenofovir AND where the triple-entity antiretroviral agent (tenofovir/ emtricitabine/efavirenz) is not indicated due to one of the following: a. - efavirenz resistance b. - adverse effects secondary to efavirenz 200mg/300mg Tablet 02274906 TRUVADA GIL
MARAVIROC
Limited use benefit (prior approval required). For the treatment of HIV-1 infection, given in combination with other antiretroviral agents, in patients who have: a. - CR5 tropic viruses; and b. - documented resistance to at least one agent from each of the three major classes of antiretroviral agents (nucleoside reverse transcriptase inhibitors, non-nucleoside reverse transcriptase inhibitors, and protease inhibitors) 150mg Tablet 02299844 CELSENTRI 300mg Tablet 02299852 CELSENTRI VII VII
ETRAVIRINE
Limited use benefit (prior approval required). For use in combination with other antiretroviral agents for treatment-experienced patients with HIV-1 infection who: a.- have failed prior antiretroviral therapy; and b. - have HIV-1 strains resistant to multiple antiretroviral agents, including NNRTIs 100mg Tablet 02306778 INTELENCE JNO
NELFINAVIR MESYLATE
50mg/g Powder for Suspension 02238618 VIRACEPT 250mg Tablet 02238617 VIRACEPT 625mg Tablet 02248761 VIRACEPT PFI PFI PFI
FOSAMPRENAVIR CALCIUM
50mg/mL Oral Suspension 02261553 TELZIR 700mg Tablet 02261545 TELZIR GSK GSK
NEVIRAPINE
200mg Tablet 02238748 VIRAMUNE BOE
RALTEGRAVIR
Limited use benefit (prior approval required). For the treatment of HIV infection in patients who are antiretroviral experienced and have virologic failure due to resistance to at least one agent from each of the three major classes of antiretroviral agents, nucleoside/tide reverse transcriptase inhibitors, non-nucleoside reverse transcriptase inhibitors and protease inhibitors. 400mg Tablet 02301881 ISENTRESS GSK GSK GSK GSK FRS
INDINAVIR SULFATE
200mg Capsule 02229161 CRIXIVAN 400mg Capsule 02229196 CRIXIVAN FRS FRS
LAMIVUDINE
10mg/mL Solution 02192691 3TC 100mg Tablet 02239193 HEPTOVIR 150mg Tablet 02192683 3TC 300mg Tablet 02247825 3TC
RITONAVIR
100mg Capsule 02241480 NORVIR SEC 80mg/mL Liquid 02229145 NORVIR ABB ABB
SAQUINAVIR MESYLATE
200mg Capsule 02216965 INVIRASE 500mg Tablet 02279320 INVIRASE HLR HLR
LAMIVUDINE, ZIDOVUDINE
150mg & 300mg Tablet 02239213 COMBIVIR GSK
LOPINAVIR, RITONAVIR
80mg & 20mg/mL Oral Solution 02243644 KALETRA 100mg & 25mg Tablet 02312301 KALETRA 200mg & 50mg Tablet 02285533 KALETRA ABB ABB ABB
STAVUDINE
15mg Capsule 02216086 ZERIT 20mg Capsule 02216094 ZERIT 30mg Capsule 02216108 ZERIT BMS BMS BMS
2010
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STAVUDINE
40mg Capsule 02216116 ZERIT BMS
08:18.20 INTERFERONS
PEGINTERFERON ALFA-2A, RIBAVIRIN
Limited use benefit (prior approval required). For the treatment of chronic hepatitis C in patients who are treatment nave, upon the written request of a hepatologist or other specialist in this area. a. - For genotypes 1, 4, 5 and 6, an initial 24 week supply will be approved. A further 24 week supply may be approved if patient has a viral reduction of at least 2 logs or HCV is undetectable at 12 weeks (48 weeks total). b. - For genotypes 2 or 3, initial coverage for a maximum of 24 weeks will be approved. Renewals will not be covered 180mcg/0.5mL & 200mg Injection & Tablet 02253429 PEGASYS RBV 180mcg/1mL & 200mg Injection & Tablet 02253410 PEGASYS RBV HLR HLR
TENOFOVIR DISOPROXIL FUMARATE

Limited use benefit (prior approval required). For the management of HIV disease in patients who have failed or have experienced adverse events to an alternative nucleoside reverse transcriptase inhibitor. 245mg Tablet 02247128 VIREAD GIL
TIPRANAVIR
Limited use benefit (prior approval required). For the management of HIV disease in patients a. - who have failed all currently listed protease inhibitors b. - intolerant to all currently listed protease inhibitors 250mg Capsule 02273322 APTIVUS BOE
PEGINTERFERON ALFA-2B
Limited use benefit (prior approval required). For the treatment of chronic hepatitis C in patients who are treatment nave, upon the written request of a hepatologist or other specialist in this area. a. - For genotypes 1, 4, 5 and 6, an initial 24 week supply will be approved. A further 24 week supply may be approved if patient has a viral reduction of at least 2 logs or HCV is undetectable at 12 weeks (48 weeks total). b. - For genotypes 2 or 3, initial coverage for a maximum of 24 weeks will be approved. Renewals will not be covered. 74mcg/Vial Injection 02242966 UNITRON PEG 118.4mcg/Vial Injection 02242967 UNITRON PEG 177.6mcg/Vial Injection 02242968 UNITRON PEG 222mcg/Vial Injection 02242969 UNITRON PEG SCH SCH SCH SCH
ZIDOVUDINE
100mg Capsule 01946323 APO-ZIDOVUDINE 01902660 RETROVIR 10mg/mL Syrup 01902652 RETROVIR APX GSK GSK
PEGINTERFERON ALFA-2A
Limited use benefit (prior approval required). For the treatment of chronic hepatitis C in patients who are treatment nave, upon the written request of a hepatologist or other specialist in this area. a. - For genotypes 1, 4, 5 and 6, an initial 24 week supply will be approved. A further 24 week supply may be approved if patient has a viral reduction of at least 2 logs or HCV is undetectable at 12 weeks (48 weeks total). b. - For genotypes 2 or 3, initial coverage for a maximum of 24 weeks will be approved. Renewals will not be covered 180mcg/0.5mL Injection 02248077 PEGASYS 180mcg/1mL Injection 02248078 PEGASYS HLR HLR
PEGINTERFERON ALFA-2B, RIBAVIRIN

Limited use benefit (prior approval required). For the treatment of chronic hepatitis C in patients who are treatment nave, upon the written request of a hepatologist or other specialist in this area. a. - For genotypes 1, 4, 5 and 6, an initial 24 week supply will be approved. A further 24 week supply may be approved if patient has a viral reduction of at least 2 logs or HCV is undetectable at 12 weeks (48 weeks total). b. - For genotypes 2 or 3, initial coverage for a maximum of 24 weeks will be approved. Renewals will not be covered 50mcg/0.5mL & 200mg Injection & Capsule 02246026 PEGETRON 02254573 PEGETRON REDIPEN 80mcg/0.5mL & 200mg Injection & Capsule 02246027 PEGETRON 02254581 PEGETRON REDIPEN SCH SCH SCH SCH
2010
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Limited use benefit (prior approval required). For the treatment of chronic hepatitis C in patients who are treatment nave, upon the written request of a hepatologist or other specialist in this area. a. - For genotypes 1, 4, 5 and 6, an initial 24 week supply will be approved. A further 24 week supply may be approved if patient has a viral reduction of at least 2 logs or HCV is undetectable at 12 weeks (48 weeks total). b. - For genotypes 2 or 3, initial coverage for a maximum of 24 weeks will be approved. Renewals will not be covered 100mcg/0.5mL & 200mg Injection & Capsule 02246028 PEGETRON 02254603 PEGETRON REDIPEN 120mcg/0.5mL & 200mg Injection & Capsule 02246029 PEGETRON 02254638 PEGETRON REDIPEN 150mcg/0.5mL & 200mg Injection & Capsule 02246030 PEGETRON 02254646 PEGETRON REDIPEN SCH SCH SCH SCH SCH SCH
08:18.32 NUCLEOSIDES AND NUCLEOTIDES

ADEFOVIR DIPIVOXIL
Limited use benefit (prior approval required). For the treatment of chronic hepatitis B infection when used in combination with lamivudine in patients who have developed failure to lamivudine, as defined by an increase in HBV DNA of 1 log10 IU/mL above the nadir, measured on two separate occasions within an interval of at least one month, after the first three months of lamivudine therapy, and when failure to lamivudine is not due to poor adherence to therapy. 10mg Tablet 02247823 HEPSERA GIL
ENTECAVIR
Limited use benefit (prior approval required). For the treatment of chronic hepatitis B infection in patients with cirrhosis documented on radiologic or histologic grounds and a HBV DNA concentration above 2000IU/mL. 0.5mg Tablet 02282224 BARACLUDE BMS
FAMCICLOVIR
125mg Tablet 02292025 02305682 02229110 02278081 02278634 250mg Tablet 02292041 02305690 02229129 02278103 02278642 500mg Tablet 02292068 02305704 02177102 02278111 02278650 APO-FAMCICLOVIR CO FAMCICLOVIR FAMVIR PMS-FAMCICLOVIR SANDOZ-FAMCICLOVIR APO-FAMCICLOVIR CO FAMCICLOVIR FAMVIR PMS-FAMCICLOVIR SANDOZ-FAMCICLOVIR APO-FAMCICLOVIR CO FAMCICLOVIR FAMVIR PMS-FAMCICLOVIR SANDOZ-FAMCICLOVIR APX COB NVR PMS SDZ APX COB NVR PMS SDZ APX COB NVR PMS SDZ

ACYCLOVIR
40mg/mL Suspension 00886157 ZOVIRAX 200mg Tablet 02207621 02242784 02285959 02197405 02237541 02078627 00634506 400mg Tablet 02207648 02242463 02285967 02197413 02237542 02078635 01911627 800mg Tablet 02207656 02242464 02285975 02197421 02237543 02078651 01911635 APO-ACYCLOVIR GEN-ACYCLOVIR NOVO-ACYCLOVIR NU-ACYCLOVIR PDL-ACYCLOVIR RATIO-ACYCLOVIR ZOVIRAX APO-ACYCLOVIR GEN-ACYCLOVIR NOVO-ACYCLOVIR NU-ACYCLOVIR PDL-ACYCLOVIR RATIO-ACYCLOVIR ZOVIRAX APO-ACYCLOVIR GEN-ACYCLOVIR NOVO-ACYCLOVIR NU-ACYCLOVIR PDL-ACYCLOVIR RATIO-ACYCLOVIR ZOVIRAX GSK APX GEN NOP NXP PDL RPH GSK APX GEN NOP NXP PDL RPH GSK APX GEN NOP NXP PDL RPH GSK
GANCICLOVIR SODIUM
500mg Injection 02162695 CYTOVENE HLR
VALACYCLOVIR HCL
500mg Tablet 02295822 02298457 02316447 02219492 APO-VALACYCLOVIR PMS-VALACYCLOVIR RIVA-VALACYCLOVIR VALTREX APX PMS RIV GSK PDL
500mg Tablet 02315173 PRO-VALACYCLOVIR
VALGANCICLOVIR HCL
450mg Tablet 02245777 VALCYTE 2010 HLR Page 11 of 124
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08:30.04 AMEBICIDES
DIIODOHYDROXYQUIN
210mg Tablet 01997769 DIODOQUIN 650mg Tablet 01997750 DIODOQUIN GLE GLE
08:36.00 URINARY ANTI-INFECTIVES

NITROFURANTOIN
100mg Tablet 00312738 APO-NITROFURANTOIN APX
TRIMETHOPRIM
100mg Tablet 02243116 APO-TRIMETHOPRIM 200mg Tablet 02243117 APO-TRIMETHOPRIM APX APX
PAROMOMYCIN SULFATE
250mg Capsule 02078759 HUMATIN ERF
08:30.08 ANTIMALARIALS
CHLOROQUINE PHOSPHATE
250mg Tablet 00021261 NOVO-CHLOROQUINE NOP
HYDROXYCHLOROQUINE SULFATE
200mg Tablet 02246691 02252600 02017709 02311011 APO-HYDROXYQUINE GEN-HYDROXYCHLOROQUINE PLAQUENIL PRO-HYDROXYQUINE APX GEN SAC PDL
PRIMAQUINE PHOSPHATE
26.3mg Tablet 02017776 PRIMAQUINE SAC
PYRIMETHAMINE
25mg Tablet 00004774 DARAPRIM GSK
08:30.92 MISCELLANEOUS ANTIPROTOZOALS

ATOVAQUONE
150mg/mL Suspension 02217422 MEPRON GSK
METRONIDAZOLE
500mg Capsule 02248562 APO-METRONIDAZOLE 250mg Tablet 00545066 APO-METRONIDAZOLE 00420409 METRONIDAZOLE APX APX PDL
PENTAMIDINE ISETHIONATE
300mg/Vial Injection 02183080 PENTAMIDINE MAY
08:36.00 URINARY ANTI-INFECTIVES

NITROFURANTOIN
50mg Capsule 01997637 MACRODANTIN 02231015 NOVO-FURANTOIN 100mg Capsule 02063662 MACROBID 02231016 NOVO-FURANTOIN 50mg Tablet 00319511 2010 APO-NITROFURANTOIN PGP NOP PGP NOP APX Page 12 of 124
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10:00 ANTINEOPLASTIC AGENTS

10:00.00 ANTINEOPLASTIC AGENTS
ALTRETAMINE
50mg Capsule 02126230 HEXALEN LIL

CYPROTERONE ACETATE
50mg Tablet 00704431 02245898 02229723 ANDROCUR APO-CYPROTERONE GEN-CYPROTERONE BEX APX GEN
ANASTROZOLE
1mg Tablet 02224135 ARIMIDEX AZC
ERLOTINIB HYDROCLORIDE
Limited use benefit (prior approval required). Treatment of non-small cell lung cancer (NSCLC) after failure of at least one prior chemotherapy regimen, and whose EGFR expression status is positive or unknown. APX AZC COB GEN NOP PMS PDL RPH SDZ 100mg Tablet 02269015 TARCEVA 150mg Tablet 02269023 TARCEVA HLR HLR
BICALUTAMIDE
50mg Tablet 02296063 APO-BICALUTAMIDE 02184478 CASODEX 02274337 CO BICALUTAMIDE 02302403 GEN-BICALUTAMIDE 02270226 NOVO-BICALUTAMIDE 02275589 PMS-BICALUTAMIDE 02311038 PRO-BICALUTAMIDE 02277700 RATIO-BICALUTAMIDE 02276089 SANDOZ-BICALUTAMIDE
ETOPOSIDE
50mg Capsule 00616192 VEPESID BMS
EXEMESTANE
25mg Tablet 02242705 AROMASIN PFI
BUSERELIN ACETATE
1mg/mL Injection 02225166 SUPREFACT 1mg/mL Nasal Solution 02225158 SUPREFACT 6.3mg/Implant Subcutaneous Injection 02228955 SUPREFACT DEPOT 2 MONTHS 9.45mg/Implant Subcutaneous Injection 02240749 SUPREFACT DEPOT 3 MONTHS SAC SAC SAC
FLUDARABINE PHOSPHATE
10mg Tablet 02246226 FLUDARA BEX
FLUTAMIDE
250mg Tablet 02238560 00637726 02230089 02239388 02230104 APO-FLUTAMIDE EUFLEX NOVO-FLUTAMIDE PDL-FLUTAMIDE PMS-FLUTAMIDE APX SCH NOP PDL PMS
SAC
BUSULFAN
2mg Tablet 00004618 MYLERAN GSK
GOSERELIN ACETATE
3.6mg/Depot Injection 02049325 ZOLADEX AZC AZC
CAPECITABINE
150mg Tablet 02238453 XELODA 500mg Tablet 02238454 XELODA HLR HLR
10.8mg/Depot Injection 02225905 ZOLADEX LA
HYDROXYUREA
500mg Capsule 02247937 APO-HYDROXYUREA 02242920 GEN-HYDROXYUREA 500mg Tablet 00465283 HYDREA APX GEN BMS
CHLORAMBUCIL
2mg Tablet 00004626 LEUKERAN GSK
CYCLOPHOSPHAMIDE
25mg Tablet 02241795 50mg Tablet 00344885 02241796 PROCYTOX CYTOXAN PROCYTOX BAT BMS BAT
2010
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IMATINIB MESYLATE
Limited use benefit (prior approval required). a.- For the treatment of patients with chronic myeloid leukemia in blast crisis, accelerated phase, or in chronic phase after failure of interferon-alpha therapy. b.- For the treatment of patients with gastrointestinal stromal tumour. c.- For newly diagnosed adult patients with Philadelphia chromosome-positive chronic myeloid leukemia (CML). 100mg Tablet 02253275 GLEEVEC 400mg Tablet 02253283 GLEEVEC NVR NOV

LOMUSTINE
40mg Capsule 00360422 CEENU 100mg Capsule 00360414 CEENU BMS BMS
MEGESTROL ACETATE
40mg/mL Suspension 02168979 MEGACE 40mg Tablet 02195917 02223104 02185415 160mg Tablet 02195925 00731323 02223112 02185423 APO-MEGESTROL MEGESTROL NU-MEGESTROL APO-MEGESTROL MEGACE MEGESTROL NU-MEGESTROL BMS APX PDL NXP APX BMS PDL NXP
INTERFERON ALFA-2B
6,000,000IU/mL Injection 02238674 INTRON A 10,000,000IU/mL Injection 02238675 INTRON A 10,000,000IU/Vial Injection 02223406 INTRON A 15,000,000IU/mL Injection 02240693 INTRON A 18,000,000IU/Vial Injection 02231651 INTRON A 25,000,000IU/mL Injection 02240694 INTRON A 50,000,000IU/mL Injection 02240695 INTRON A SCH SCH SCH SCH SCH SCH SCH
MELPHALAN
2mg Tablet 00004715 ALKERAN GSK
MERCAPTOPURINE
50mg Tablet 00004723 PURINETHOL NOP
METHOTREXATE SODIUM
10mg/mL Injection 02182947 METHOTREXATE 25mg/mL Injection 02182777 METHOTREXATE 02182955 METHOTREXATE 02099705 NOVO-METHOTREXATE 2.5mg Tablet 02182963 APO-METHOTREXATE 02170698 METHOTREXATE 02244798 RATIO-METHOTREXATE 10mg Tablet 02182750 METHOTREXATE MAY MAY MAY NOP APX WAY RPH MAY
LETROZOLE
2.5mg Tablet 02231384 02348969 02309114 02344815 FEMARA LETROZOLE PMS-LETROZOLE SANDOZ LETROZOLE NVR CBT PMS SDZ
LEUPROLIDE ACETATE
3.75mg/Vial Injection 00884502 LUPRON DEPOT 7.5mg/Vial Injection 00836273 LUPRON DEPOT 11.25mg/Vial Injection 02239834 LUPRON DEPOT 22.5mg/Vial Injection 02248240 ELIGARD 02230248 LUPRON DEPOT 30mg/Vial Injection 02248999 ELIGARD 02239833 LUPRON DEPOT 45mg/Vial Injection 02268892 ELIGARD ABB ABB ABB SAC ABB SAC ABB SAC
MITOTANE
500mg Tablet 00463221 LYSODREN BMS
NILUTAMIDE
50mg Tablet 02221861 ANANDRON SAC
PROCARBAZINE HCL
50mg Capsule 00012750 NATULAN SIG
LOMUSTINE
10mg Capsule 00360430 CEENU 2010 BMS Page 14 of 124
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RITUXIMAB
Limited use benefit (prior approval required). Prescribed by a rheumatologist for treatment of adult patients with severely active rheumatoid arthritis who have failed to respond to a trial of an anti-TNF agent. Treatment should be combined with methotrexate. Rituximab should not be used in combination with anti-TNF agents. Treatment beyond six months will only be considered for patients who have achieved a response. (Please refer to Appendix A). 10mg/mL Injection 02241927 RITUXAN HLR

TEMOZOLOMIDE
Limited use benefit (prior approval required). For: a. - treatment of adult patients with glioblastoma multiforme or anaplastic astrocytoma, and documented evidence of recurrence or progression after standard therapy (resection, radiotherapy, and chemotherapy). b. - treatment of adult patients with newly diagnosed glioblastoma multiforme concomitantly with radiotherapy and then as maintenance treatment. 5mg Capsule 02241093 TEMODAL 20mg Capsule 02241094 TEMODAL 100mg Capsule 02241095 TEMODAL 250mg Capsule 02241096 TEMODAL SCH SCH SCH SCH
SUNITINIB MALATE
Limited use benefit (Prior approval required) Criteria for initial six month coverage of Sutent: For patients with histologically proven unresectable or recurrent/metastatic GIST who have failed or are unable to tolerate imatinib therapy. Sunitinib will not be funded concomitantly with imatinib. Criteria for assessment at every six months: There is no objective evidence of disease progression. 12.5mg Capsule 02280795 SUTENT 25mg Capsule 02280809 SUTENT 50mg Capsule 02280817 SUTENT PFI PFI PFI
THIOGUANINE
40mg Tablet 00282081 LANVIS GSK
TRETINOIN
10mg Capsule 02145839 VESANOID HLR
TRIPTORELIN PAMOATE
3.75mg/Vial Injection 02240000 TRELSTAR 11.25mg/Vial Injection 02243856 TRELSTAR LA WAT WAT
TAMOXIFEN CITRATE
10mg Tablet 00812404 02088428 00851965 02237459 01926624 02296721 20mg Tablet 00812390 02089858 02048485 00851973 02237460 01926632 02296748 APO-TAMOX GEN-TAMOXIFEN NOVO-TAMOXIFEN PMS-TAMOXIFEN TAMOFEN TAMOXIFEN APO-TAMOX GEN-TAMOXIFEN NOLVADEX D NOVO-TAMOXIFEN PMS-TAMOXIFEN TAMOFEN TAMOXIFEN APX GEN NOP PMS SAC PDL APX GEN AZC NOP PMS SAC PDL
VINCRISTINE SULFATE
1mg/mL Injection 02143305 VINCRISTINE SULFATE 02183013 VINCRISTINE SULFATE NOP MAY
2010
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12:00 AUTONOMIC DRUGS

12:04.00 PARASYMPATHOMIMETIC AGENTS
BETHANECHOL CHLORIDE
10mg Tablet 01947958 01985671 25mg Tablet 01947931 01985558 50mg Tablet 01947923 DUVOID MYOTONACHOL DUVOID MYOTONACHOL DUVOID SHI GLE SHI GLE SHI

GALANTAMINE
Limited use benefit (prior approval required). Initial six month coverage for cholinesterase inhibitors: Diagnosis of mild to moderate Alzheimers disease; AND Mini Mental State Exam (MMSE) score of 10-26, established within the last 60 days; AND Global Deterioration Scale (GDS) score between 4 to 6, established within the last 60 days Continued coverage beyond 6 months will be based on improvement or stabilization of cognition, function or behaviour. Criteria for coverage at every six month interval: Diagnosis is still mild to moderate Alzheimers disease; AND MMSE score > 10; AND GDS score between 4 to 6; AND Improvement or stabilization in at least one of the following domains (please indicate improved, worsened, or no change) 1.Memory, reasoning and perception (e.g., names, tasks, MMSE) 2.Instrumental activities of daily living (IADLs: e.g., telephone, shopping, meal preparation) 3.Basic activities of daily living (e.g., bathing, dressing, hygiene, toileting) 4.Neuropsychiatric symptoms (e.g., agitation, delusions, hallucination, apathy) 8mg Extended Release Capsule 02266717 REMINYL ER 16mg Extended Release Capsule 02266725 REMINYL ER 24mg Extended Release Capsule 02266733 REMINYL ER JNO JNO JNO
DONEPEZIL HCL
Limited use benefit (prior approval required). Initial six month coverage for cholinesterase inhibitors: Diagnosis of mild to moderate Alzheimers disease; AND Mini Mental State Exam (MMSE) score of 10-26, established within the last 60 days; AND Global Deterioration Scale (GDS) score between 4 to 6, established within the last 60 days Continued coverage beyond 6 months will be based on improvement or stabilization of cognition, function or behaviour. Criteria for coverage at every six month interval: Diagnosis is still mild to moderate Alzheimers disease; AND MMSE score > 10; AND GDS score between 4 to 6; AND Improvement or stabilization in at least one of the following domains (please indicate improved, worsened, or no change) 1.Memory, reasoning and perception (e.g., names, tasks, MMSE) 2.Instrumental activities of daily living (IADLs: e.g., telephone, shopping, meal preparation) 3.Basic activities of daily living (e.g., bathing, dressing, hygiene, toileting) 4.Neuropsychiatric symptoms (e.g., agitation, delusions, hallucination, apathy) 5mg Tablet 02232043 10mg Tablet 02232044 ARICEPT ARICEPT PFI PFI
NEOSTIGMINE BROMIDE
15mg Tablet 00869945 PROSTIGMIN VAE
PYRIDOSTIGMINE BROMIDE
180mg Sustained Release Tablet 00869953 MESTINON-SR 60mg Tablet 00869961 MESTINON VAE VAE
2010
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RIVASTIGMINE
Limited use benefit (prior approval required). Initial six month coverage for cholinesterase inhibitors: Diagnosis of mild to moderate Alzheimers disease; AND Mini Mental State Exam (MMSE) score of 10-26, established within the last 60 days; AND Global Deterioration Scale (GDS) score between 4 to 6, established within the last 60 days Continued coverage beyond 6 months will be based on improvement or stabilization of cognition, function or behaviour. Criteria for coverage at every six month interval: Diagnosis is still mild to moderate Alzheimers disease; AND MMSE score > 10; AND GDS score between 4 to 6; AND Improvement or stabilization in at least one of the following domains (please indicate improved, worsened, or no change) 1.Memory, reasoning and perception (e.g., names, tasks, MMSE) 2.Instrumental activities of daily living (IADLs: e.g., telephone, shopping, meal preparation) 3.Basic activities of daily living (e.g., bathing, dressing, hygiene, toileting) 4.Neuropsychiatric symptoms (e.g., agitation, delusions, hallucination, apathy) 1.5mg Capsule 02242115 EXELON 02332809 MYLAN-RIVASTIGMINE 02305984 NOVO-RIVASTIGMINE 02306034 PMS-RIVASTIGMINE 02311283 RATIO-RIVASTIGMINE 02324563 SANDOZ RIVASTIGMINE 3mg Capsule 02242116 02332817 02305992 02306042 02311291 02324571 EXELON MYLAN-RIVASTIGMINE NOVO-RIVASTIGMINE PMS-RIVASTIGMINE RATIO-RIVASTIGMINE SANDOZ RIVASTIGMINE NOV MYL NOP PMS RPH SDZ NOV MYL NOP PMS RPH SDZ NOV MYL NOP PMS RPH SDZ NOV MYL NOP PMS RPH SDZ NOV
12:08.08 ANTIMUSCARINICS / ANTISPASMODICS

IPRATROPIUM BROMIDE
250mcg/mL Inhalation Solution (Multi-Dose) 02126222 APO-IPRAVENT 02239131 GEN-IPRATROPIUM 02210479 NOVO-IPRAMIDE 02231136 PMS-IPRATROPIUM 125mcg/mL Inhalation Solution (Unit Dose) 02231135 PMS-IPRATROPIUM UDV 02097176 RATIO-IPRATROPIUM UDV 250mcg/mL Inhalation Solution (Unit Dose) 02216221 GEN-IPRATROPIUM UDV 02231785 NU-IPRATROPIUM UDV 02231244 PMS-IPRATROPIUM UDV 02231245 PMS-IPRATROPIUM UDV 02097168 RATIO-IPRATROPIUM UDV 99001446 RATIO-IPRATROPIUM UDV 20mcg/Inhalation Inhaler 02247686 ATROVENT HFA 0.03% Nasal Spray 02246083 APO-IPRAVENT 02240508 DOM-IPRATROPIUM 02239627 PMS-IPRATROPIUM 0.06% Nasal Spray 02246084 APO-IPRAVENT APX GEN NOP PMS PMS RPH GEN NXP PMS PMS RPH RPH BOE APX DPC PMS APX
IPRATROPIUM BROMIDE, SALBUTAMOL

0.2mg & 1mg/mL Inhalation Solution (Unit Dose) 02231675 COMBIVENT BOE 02272695 GEN-COMBO GEN 02243789 RATIO-IPRA SAL RPH
SCOPOLAMINE BUTYLBROMIDE
10mg Tablet 00363812 BUSCOPAN BOE
TIOTROPIUM BROMIDE MONOHYDRATE

Limited use benefit (prior approval required). For the treatment of moderate* to severe* chronic obstructive pulmonary disease (COPD), in patients who continue to be symptomatic after an adequate trial (3 months) of ipatropium, at a dose of 8-12 puffs daily. *Canadian Thoracic Society COPD Classification by Symptoms/Disability and Lung Function Moderate: shortness of breath from COPD causing the patient to stop after walking about 100 meters (after a few minutes) on level ground (MRC 3 to 4); 50% FEV1 < 80% predicted, FEV1/FVC <0.7 Severe: shortness of breath from COPD leaving the patient too breathless to leave the house or breathless after undressing (MRC 5), or in the presence of chronic respiratory failure or clinical signs of right heart failure; 30% FEV1 < 50% predicted, FEV1/FVC <0.7 18mcg Powder for Inhalation (Capsule) 02246793 SPIRIVA BOE
4.5mg Capsule 02242117 EXELON 02332825 MYLAN-RIVASTIGMINE 02306018 NOVO-RIVASTIGMINE 02306050 PMS-RIVASTIGMINE 02311305 RATIO-RIVASTIGMINE 02324598 SANDOZ RIVASTIGMINE 6mg Capsule 02242118 02332833 02306026 02306069 02311313 02324601 EXELON MYLAN-RIVASTIGMINE NOVO-RIVASTIGMINE PMS-RIVASTIGMINE RATIO-RIVASTIGMINE SANDOZ RIVASTIGMINE
2mg/mL Oral Liquid 02245240 EXELON
2010
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12:12.04 ALPHA ADRENERGIC AGONISTS

MIDODRINE HCL
2.5mg Tablet 01934392 AMATINE 5mg Tablet 01934406 AMATINE SHI SHI
12:12.08 BETA ADRENERGIC AGONISTS

SALBUTAMOL
1mg/mL Inhalation Solution (Unit Dose) 02216949 DOM-SALBUTAMOL 01926934 GEN-SALBUTAMOL 02084333 MED-SALBUTAMOL 02231783 NU-SALBUTAMOL 02208229 PMS-SALBUTAMOL 01986864 RATIO-SALBUTAMOL 02213419 VENTOLIN PF 2mg/mL Inhalation Solution (Unit Dose) 02173360 GEN-SALBUTAMOL PF 02231784 NU-SALBUTAMOL 02208237 PMS-SALBUTAMOL 02239366 RATIO-SALBUTAMOL 02213427 VENTOLIN PF 100mcg/Inhalation Inhaler 02232570 AIROMIR 02245669 APO-SALVENT CFC FREE 02326450 NOVO-SALBUTAMOL HFA 02244914 RATIO-SALBUTAMOL HFA 02241497 VENTOLIN HFA 0.4mg/mL Oral Liquid 02212390 VENTOLIN 400mcg Powder for Inhalation (Capsule) 00895415 VENTOLIN ROTACAPS 200mcg Powder for Inhalation (Disk) 99000369 VENTODISK & DISKHALER 400mcg Powder for Inhalation (Disk) 99000377 VENTODISK 2mg Tablet 02146843 4mg Tablet 02146851 02165376 APO-SALVENT APO-SALVENT NU-SALBUTAMOL DPC GEN MEC NXP PMS RPH GSK GEN NXP PMS RPH GSK MMH APX NOP RPH GSK GSK GSK GSK GSK APX APX NXP

FORMOTEROL FUMARATE
Limited use benefit (prior approval required). For the treatment of asthma in patients who are using optimal corticosteroid therapy and experiencing breakthrough symptoms requiring regular use of a rapid onset, short duration bronchodilator. Oxeze is not intended for the relief of acute asthma symptoms: patients must have access to an inhaled fast-acting bronchodilator (beta-2 agonist) for symptomatic relief. 12mcg/Capsule Powder for Inhalation 02230898 FORADIL NVR
FORMOTEROL FUMARATE DIHYDRATE

6mcg/Dose Dry Powder Inhaler 02237225 OXEZE TURBUHALER 12mcg/Dose Dry Powder Inhaler 02237224 OXEZE TURBUHALER AZC AZC
FORMOTEROL FUMARATE DIHYDRATE, BUDESONIDE

Limited use benefit (prior approval required). For the treatment of reversible obstructive airway disease in patients who are not adequately controlled on medium doses of inhaled corticosteroids ( e.g. fluticasone 250 - 500 mcg daily, or the equivalent) as the sole agent and require addition of a long- acting beta agonist. Patients using this combination product must also have access to a short-acting bronchodilator for symptomatic relief. 6mcg & 100mcg/Inhalation Inhaler 02245385 SYMBICORT 100 TURBUHALER 6mcg & 200mcg/Inhalation Inhaler 02245386 SYMBICORT 200 TURBUHALER AZC
SALMETEROL XINAFOATE
AZC Limited use benefit (prior approval required). a. - For the treatment of asthma in patients who are using optimal corticosteroid therapy and experiencing breakthrough symptoms requiring regular use of a rapid onset, short duration bronchodilator. Serevent is not intended for the relief of acute asthma symptoms: patients must have access to an inhaled fast-acting bronchodilator (beta-2 agonist) for symptomatic relief. b. - For the treatment of Chronic Obstructive Pulmonary Disease (COPD) in patients not adequately controlled with ipratropium. 50mcg/inhalation Powder Diskus 02231129 SEREVENT DISKUS 50mcg/Inhalation Powder for Inhalation 02214261 SEREVENT DISKHALER GSK GSK
ORCIPRENALINE SULFATE
2mg/mL Syrup 02236783 APO-ORCIPRENALINE 02192675 TANTA-ORCIPRENALINE APX TAN
SALBUTAMOL
5mg/mL Inhalation Solution (Multi-Dose) 02139324 DOM-SALBUTAMOL 02232987 GEN-SALBUTAMOL 02069571 PMS-SALBUTAMOL 00860808 RATIO-SALBUTAMOL 02154412 SANDOZ-SALBUTAMOL 02213486 VENTOLIN 0.5mg/mL Inhalation Solution (Unit Dose) 02208245 PMS-SALBUTAMOL 02239365 RATIO-SALBUTAMOL DPC GEN PMS RPH SDZ GSK PMS RPH
2010
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SALMETEROL XINAFOATE, FLUTICASONE PROPIONATE
Limited use benefit (prior approval required). For treatment of reversible obstructive airway disease in patients who are not adequately controlled on medium doses of inhaled corticosteroids (e.g., fluticasone 250-500mcg daily, or the equivalent) as a sole agent and require addition of a long-acting beta agonist. Patients using this combination product must also have access to a short-acting bronchodilator for symptomatic relief. For the treatment of moderate* to severe* chronic obstructive pulmonary disease (COPD), in patients who continue to be symptomatic after an adequate trial (2-4 months) of ipatropium, at a dose of 12 puffs daily. *Canadian Thoracic Society COPD Classification by Symptoms/Disability Moderate: shortness of breath from COPD causing the patient to stop after walking about 100 meters (after a few minutes) on the level Severe: shortness of breath from COPD leaving the patient too breathless to leave the house or breathless after undressing, or in the presence of chronic respiratory failure or clinical signs of right heart failure. By Symptom/Disability: Moderate: shortness of breath from COPD causing the patient to stop after walking approximately 100 meters (or after a few minutes) on the level. Severe: shortness of breath from COPD resulting in the patient being too breathless to leave the house or breathless after undressing, or the presence of chronic respiratory failure or clinical signs of right heart failure. 25mcg & 125mcg Inhaler 02245126 ADVAIR 25mcg & 250mcg Inhaler 02245127 ADVAIR 50mcg & 100mcg Inhaler 02240835 ADVAIR DISKUS 100 50mcg & 250mcg Inhaler 02240836 ADVAIR DISKUS 250 50mcg & 500mcg Inhaler 02240837 ADVAIR DISKUS 500 GSK GSK GSK GSK GSK
12:12.12 ALPHA AND BETA ADRENERGIC AGONISTS

EPINEPHRINE
1mg/mL Injection 00155357 ADRENALIN 00721891 EPINEPHRINE 00509558 EPIPEN 02247310 TWINJECT 1mg/mL Topical Solution 00155365 ADRENALIN ERF ABB AXL PAL ERF
PSEUDOEPHEDRINE HCL, TRIPROLIDINE HCL

60mg & 2.5mg Tablet 02238302 ACTIFED PFI
12:16.00 SYMPATHOLYTIC AGENTS

DIHYDROERGOTAMINE MESYLATE
1mg/mL Injection 00027243 DIHYDROERGOTAMINE 02241163 DIHYDROERGOTAMINE 4mg/mL Nasal Spray 02228947 MIGRANAL STE SDZ STE
ERGOTAMINE TARTRATE, CAFFEINE

1mg & 100mg Tablet 00176095 CAFERGOT NVR
METHYSERGIDE MALEATE
2mg Tablet 00027499 SANSERT NVR
12:20.04 CENTRALL ACTING SKELETAL MUSCLE RELAXANTS

CYCLOBENZAPRINE HCL
Limited use benefit (prior approval is not required). For relief of muscle spasm associated with acute, painful musculoskeletal conditions. Coverage is limited to 60mg per day for three (3) weeks, renewable every two (2) months. 10mg Tablet 02177145 02220644 02238633 02231353 02080052 02171848 02249359 02212048 02236506 02242079 APO-CYCLOBENZAPRINE CYCLOBENZAPRINE DOM-CYCLOBENZAPRINE GEN-CYCLOPRINE NOVO-CYCLOPRINE NU-CYCLOBENZAPRINE PHL-CYCLOBENZAPRINE PMS-CYCLOBENZAPRINE RATIO-CYCLOBENZAPRINE RIVA-CYCLOBENZAPRINE APX PDL DPC GEN NOP NXP PHH PMS RPH RIV
TERBUTALINE SULFATE
500mcg/Inhalation Powder for Inhalation 00786616 BRICANYL TURBUHALER AZC
12:12.12 ALPHA AND BETA ADRENERGIC AGONISTS

EPINEPHRINE
0.15mg/0.15mL Injection 02268205 TWINJECT 0.5mg/mL Injection 00578657 EPIPEN JR PAL AXL
2010
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TIZANIDINE HCL
Limited use benefit (prior approval required). For treatment of spasticity in patients with multiple sclerosis, who have failed therapy with or are intolerant to baclofen. 4mg Tablet 02259893 02272059 02239170 APO-TIZANIDINE GEN-TIZANIDINE ZANAFLEX APX GEN ELN
12:92.00 MISCELLANEOUS AUTONOMIC DRUGS

NICOTINE (GUM)
Limited use benefit with quantity and frequency limits (prior approval is not required). For smoking cessation: Coverage is limited to 945 pieces during a one-year period. The year starts on the date the first prescription is filled. Once this quantity has been reached, the client is eligible again for coverage for nicotine gum when one year has elapsed from the day the initial prescription was filled. 2mg Gum 02091933 4mg Gum 02091941 NICORETTE NICORETTE PLUS JNO PMJ
12:20.08 DIRECT-ACTING SKELETAL MUSCLE RELAXANTS

DANTROLENE SODIUM
25mg Capsule 01997602 DANTRIUM 100mg Capsule 01997653 DANTRIUM PGP PGP
NICOTINE (PATCH)
Limited use benefit with quantity and frequency limits (prior approval is not required). For smoking cessation: Coverage will be provided for up to the allowable number of patches for one of the following products, during a one-year period. The year starts on the date the first prescription is filled. The number of patches covered in the one-year period is: Habitrol 84 patches or Nicoderm 70 patches or Nicotrol 70 patches Once this quantity has been reached, the client is eligible again for coverage for nicotine patches when one year has elapsed from the day the initial prescription was filled. 7mg Patch (Habitrol) 01943057 HABITROL 14mg Patch (Habitrol) 01943065 HABITROL 21mg Patch (Habitrol) 01943073 HABITROL 36mg Patch (Nicoderm) 02093111 NICODERM 78mg Patch (Nicoderm) 02093138 NICODERM 114mg Patch (Nicoderm) 02093146 NICODERM 8.3mg/10cm2 Patch (Nicotrol) 02065738 NICOTROL TRANSDERMAL 16.6mg/20cm2 Patch (Nicotrol) 02065754 NICOTROL TRANSDERMAL 24.9mg/30cm2 Patch (Nicotrol) 02065762 NICOTROL TRANSDERMAL NVC NVC NVC PMJ PMJ PMJ JNO JNO JNO
12:20.12 GABA-DERIVATIVE SKELETAL MUSCLE RELAXANTS

BACLOFEN
10mg Tablet 02139332 02152584 02138271 02088398 00455881 02084449 02136090 02236963 02063735 02236507 02242150 20mg Tablet 02139391 02152592 02138298 02088401 00636576 02084457 02136104 02236964 02063743 02236508 02242151 APO-BACLOFEN BACLOFEN DOM-BACLOFEN GEN-BACLOFEN LIORESAL MED-BACLOFEN NU-BACLO PHL-BACLOFEN PMS-BACLOFEN RATIO-BACLOFEN RIVA-BACLOFEN APO-BACLOFEN BACLOFEN DOM-BACLOFEN GEN-BACLOFEN LIORESAL DS MED-BACLOFEN NU-BACLO PHL-BACLOFEN PMS-BACLOFEN RATIO-BACLOFEN RIVA-BACLOFEN APX PDL DPC GEN NVR MEC NXP PHH PMS RPH RIV APX PDL DPC GEN NVR MEC NXP PHH PMS RPH RIV
2010
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VARENICLINE
Limited use benefit with quantity and frequency limits (prior approval is not required). Coverage will be limited to 165 tablets during a one-year period. The year starts on the date the first prescription is filled. Once this quantity has been reached, the client is eligible again for coverage for varenicline (Champix) when one year has elapsed from the day the initial prescription was filled. 0.5mg Tablet 02291177 CHAMPIX 0.5mg & 1mg Tablet 02298309 CHAMPIX STARTER PACK 1mg Tablet 02291185 CHAMPIX PFI PFI PFI
2010
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20:00 BLOOD FORMATION COAGULATION AND THROMBOSIS

20:04.04 IRON PREPARATIONS
FERROUS FUMARATE
ST
20:04.04 IRON PREPARATIONS

IRON DEXTRAN
50mg/mL Injection 02205963 DEXIRON 02221780 INFUFER GEN SDZ
20:12.04 ANTICOAGULANTS
EUR NEO GSK EUR GSK VTH PED
300mg Capsule 02237556 EURO-FER 00482064 NEO FER 01923420 PALAFER 300mg/5mL Oral Liquid 02246590 FERRATE O/L 60mg/mL Suspension 01923439 PALAFER 200mg Tablet 02138751 FERROUS FUMARATE 300mg Tablet 00031089 FERROUS FUMARATE
DALTEPARIN SODIUM
7,500IU/0.3mL Injection 99100159 FRAGMIN 10,000IU/0.4mL Injection 09853790 FRAGMIN 99004143 FRAGMIN 10,000IU/mL Injection 02132664 FRAGMIN 12,500IU/0.5mL Injection 99004151 FRAGMIN 15,000IU/0.6mL Injection 09853880 FRAGMIN 99004178 FRAGMIN 18,000IU/0.72mL Injection 09853910 FRAGMIN 99004186 FRAGMIN 25,000IU/mL Injection (Multi-Dose) 02231171 FRAGMIN 2,500IU/0.2mL Injection (Pre-filled Syringe) 02132621 FRAGMIN 5,000IU/0.2mL Injection (Pre-filled Syringe) 02132648 FRAGMIN PFI PMJ PMJ PMJ PMJ PMJ PMJ PMJ PMJ PMJ PMJ PMJ
ST
ST
ST
ST
FERROUS GLUCONATE
ST
300mg Tablet 00545031 00031097 00041157 00021458 80000435
APO-FERROUS GLUCONATE FERROUS GLUCONATE FERROUS GLUCONATE NOVO-FERROGLUC NOVO-FERROGLUC
APX PED PMS NOP NOP VTH
ST
324mg Tablet 00582727 FERROUS GLUCONATE
FERROUS SULFATE
ST
15mg/mL Drop 02237385 FERODAN 02232202 PEDIAFER 02222574 PMS-FERROUS SULFATE 75mg/mL Drop 00762954 FER-IN-SOL 80008309 JAMP SULFATE FERREUX 6mg/mL Syrup 00017884 FER-IN-SOL 02242863 PEDIAFER 30mg/mL Syrup 00758469 FERODAN 80008295 JAMP SULFATE FERREUX 00792675 PMS-FERROUS SULFATE 300mg Tablet 01912518 02246733 02248699 00031100 00179655 00346918 00782114 02125471 00586323 APO-FERROUS SULFATE FC EURO-FERROUS SULFATE FERODAN FERROUS SULFATE FERROUS SULFATE FERROUS SULFATE FERROUS SULFATE FERROUS SULFATE PMS-FERROUS SULFATE
ODN EUR PMS MJO JMP MJO EUR ODN JMP PMS APX EUR ODN PED SDR PMT VTH PDL PMS
ENOXAPARIN SODIUM
30mg/0.3mL Injection 02012472 LOVENOX 40mg/0.4mL Injection 02236883 LOVENOX 60mg/0.6mL Injection 99002965 LOVENOX 80mg/0.8mL Injection 99003058 LOVENOX 100mg/1.0mL Injection 99002981 LOVENOX 120mg/0.8mL Injection 99004941 LEVENOX HP 150mg/1.0mL Injection 02242692 LEVONEX HP 300mg/3mL Injection 02236564 LOVENOX SAC SAC AVT AVT AVT AVT SAC SAC
ST
ST
ST
ST
HEPARIN SODIUM
1,000 U/mL Injection 00740519 HEPALEAN 10,000 U/mL Injection 00740497 HEPALEAN 10U/mL Lock Flush 00725323 HEPARIN LOCK FLUSH ORG ORG ABB Page 22 of 124
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Health Canada
HEPARIN SODIUM
100U/mL Lock Flush 00740578 HEPALEAN LOK 00727520 HEPARIN LEO 00725315 HEPARIN LOCK FLUSH ORG LEO HOS
WARFARIN SODIUM
2.5mg Tablet 02242926 01918346 02244464 02265303 02242682 3mg Tablet 02245618 02240205 02287498 02265311 02242683 4mg Tablet 02242927 02007959 02244465 02265338 02242684 5mg Tablet 02242928 01918354 02244466 02265346 02242685 6mg Tablet 02287501 02242686 APO-WARFARIN COUMADIN GEN-WARFARIN NOVO-WARFARIN TARO-WARFARIN APO-WARFARIN COUMADIN GEN-WARFARIN NOVO-WARFARIN TARO-WARFARIN APO-WARFARIN COUMADIN GEN-WARFARIN NOVO-WARFARIN TARO-WARFARIN APO-WARFARIN COUMADIN GEN-WARFARIN NOVO-WARFARIN TARO-WARFARIN GEN-WARFARIN TARO-WARFARIN APX BMS GEN NOP TAR APX BMS GEN NOP TAR APX BMS GEN NOP TAR APX BMS GEN NOP TAR GEN TAR GEN TAR APX BMS GEN TAR
NADROPARIN CALCIUM
9,500IU/mL Injection 02236913 FRAXIPARINE 19,000IU/mL Injection 02240114 FRAXIPARINE FORTE GSK GSK
NICOUMALONE
1mg Tablet 00010383 4mg Tablet 00010391 SINTROM SINTROM PED PED
RIVAROXABAN
Limited use benefit (prior approval not required). For the prevention of venous thromboembolism following total knee replacement or total hip replacement surgery, for up to two weeks. 10mg Tablet 02316986 XARELTO BAY
TINZAPARIN SODIUM
10,000IU/mL Injection 02167840 INNOHEP 14,000IU/mL Injection 99002612 INNOHEP 20,000IU/mL Injection 02229515 INNOHEP 20,000IU/mL Injection (Graduated Syringe) 02231478 INNOHEP 10,000IU/mL Injection (Pre-filled Syringe) 02229755 INNOHEP 09853898 INNOHEP 20,000IU/mL Injection (Pre-filled Syringe) 09853901 INNOHEP 09853928 INNOHEP 99002620 INNOHEP LEO LEO LEO LEO LEO LEO LEO LEO LEO
7.5mg Tablet 02287528 GEN-WARFARIN 02242697 TARO-WARFARIN 10mg Tablet 02242929 APO-WARFARIN 01918362 COUMADIN 02244467 GEN-WARFARIN 02242687 TARO-WARFARIN
20:12.18 PLATELET AGGREGATION INHIBITORS

ANAGRELIDE HCL
ST
WARFARIN SODIUM
1mg Tablet 02242924 01918311 02244462 02265273 02242680 2mg Tablet 02242925 01918338 02244463 02265281 02242681 2010 APO-WARFARIN COUMADIN GEN-WARFARIN NOVO-WARFARIN TARO-WARFARIN APO-WARFARIN COUMADIN GEN-WARFARIN NOVO-WARFARIN TARO-WARFARIN APX BMS GEN NOP TAR APX BMS GEN NOP TAR
0.5mg Capsule 02236859 AGRYLIN 02253054 GEN-ANAGRELIDE 02274949 PMS-ANAGRELIDE 02260107 RHOXAL-ANAGRELIDE
SHI GEN PMS RHO
CLOPIDOGREL BISULFATE
Limited use benefit (one-year duration, prior approval required). a. - Patients with intra-coronary stent implantation following insertion. b. - Patients with acute coronary syndrome (ACS) (unstable angina or non-ST-segment elevation MI), in combination with ASA.
ST
PLAVIX
SAC Page 23 of 124
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TICLOPIDINE HCL
ST
250mg Tablet 02237701 02239744 02236848 02237560 02238208 02243587
APO-TICLOPIDINE GEN-TICLOPIDINE NOVO-TICLOPIDINE NU-TICLOPIDINE PDL-TICLOPIDINE SANDOZ-TICLOPIDINE
APX GEN NOP NXP PDL SDZ
20:16.00 HEMATOPOIETIC AGENTS

FILGRASTIM
300mcg/mL Injection 01968017 NEUPOGEN 99001454 NEUPOGEN 480mcg/1.6mL Injection 09853464 NEUPOGEN AMG AMG AMG
PEGFILGRASTIM
Limited use benefit (prior approval required). a. - To decrease the incidence of infection, as manifested by febrile neutropenia, in patients with non-myeloid malignancies receiving myelosuppressive antineoplastic drugs with curative intent. and b. - Where access to a health care facility is problematic. 10mg/mL Injection 02249790 NEULASTA AMG
20:24.00 HEMORRHEOLOGIC AGENTS

PENTOXIFYLLINE
ST
400mg Sustained Release Tablet 02230090 APO-PENTOXIFYL 02230401 NU-PENTOXIFYL 01968432 RATIO-PENTOXIFYLLINE 02221977 TRENTAL
APX NXP RPH SAC
20:28.16 HEMOSTATICS
TRANEXAMIC ACID
500mg Tablet 02064405 CYKLOKAPRON PFI
2010
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24:00 CARDIOVASCULAR DRUGS

24:04.04 ANTIARRHYTHMIC AGENTS
AMIODARONE HCL
ST
24:04.04 ANTIARRHYTHMIC AGENTS

PROPAFENONE HYDROCHLORIDE
ST
100mg Tablet 02292173 PMS-AMIODARONE 200mg Tablet 02246194 02036282 02240604 02239835 02242472 02309661 02240071 02245781 02247217 02243836 APO-AMIODARONE CORDARONE GEN-AMIODARONE NOVO-AMIODARONE PMS-AMIODARONE PRO-AMIODARONE RATIO-AMIODARONE RIVA-AMIODARONE RIVA-AMIODARONE SANDOZ-AMIODARONE
PMS APX WAY GEN NOP PMS PDL RPH PHH RIV SDZ
ST
300mg Tablet 02243325 02245373 02243728 02294575 00603716
APO-PROPAFENONE GEN-PROPAFENONE PMS-PROPAFENONE PMS-PROPAFENONE RYTHMOL
APX GEN PMS PMS ABB
24:04.08 CARDIOTONIC AGENTS

DIGOXIN
0.05mg/mL Elixir 02242320 LANOXIN 0.0625mg Tablet 02335700 TOLOXIN 0.125mg Tablet 02335719 TOLOXIN 0.250mg Tablet 02335727 TOLOXIN VIR MTH MTH MTH
DISOPYRAMIDE
ST
100mg Capsule 02224801 RYTHMODAN 150mg Capsule 02224828 RYTHMODAN 250mg Tablet 02224836 RYTHMODAN LA
SAC SAC SAC
ST
24:06.04 BILE ACID SEQUESTRANTS

CHOLESTYRAMINE RESIN
ST
ST
FLECAINIDE ACETATE
ST
4g Powder 00999968 00999967 00890960 02210320
50mg Tablet 02275538 APO-FLECAINIDE 01966197 TAMBOCOR 100mg Tablet 02275546 APO-FLECAINIDE 01966200 TAMBOCOR
APX MMH APX MMH

ST
NOVO-CHOLAMINE NOVO-CHOLAMINE LIGHT PMS-CHOLESTYRAMINE LIGHT PMS-CHOLESTYRAMINE REGULAR
NOP NOP PMS PMS
ST
COLESTIPOL HCL
5g Granules 00642975 02132699 1g Tablet 02132680 COLESTID COLESTID ORANGE COLESTID PFI PFI PFI
MEXILETINE HCL
ST ST
100mg Capsule 02230359 NOVO-MEXILETINE 200mg Capsule 02230360 NOVO-MEXILETINE
NOP NOP
ST
24:06.05 CHOLESTEROL ABSORPTION INHIBITORS

EZETIMIBE
Limited use benefit (prior approval required).
PROCAINAMIDE HCL
ST
250mg Sustained Release Tablet 00638692 PROCAN SR 500mg Sustained Release Tablet 00638676 PROCAN SR 750mg Sustained Release Tablet 00638684 PROCAN SR
PFI PFI PFI
ST
ST
a.- For use in combination with a HMG-CoA reductase inhibitor (statin) in patients with hypercholesterolemia who have not reached target LDL levels despite the use of maximally tolerated statin doses. b.- For use as monotherapy in the management of hypercholesterolemia in patients intolerant to HMG-CoA reductase inhibitors.
ST
PROPAFENONE HYDROCHLORIDE
ST
150mg Tablet 02243324 02245372 02249480 02243727 02294559 02243783 00603708
APO-PROPAFENONE GEN-PROPAFENONE NU-PROPAFENONE PMS-PROPAFENONE PMS-PROPAFENONE PROPAFENONE RYTHMOL
APX GEN NXP PMS PMS PDL ABB
EZETROL
MSP
24:06.06 FIBRIC ACID DERIVATIVES

BEZAFIBRATE
ST
400mg Sustained Release Tablet 02083523 BEZALIP SR
HLR
2010
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BEZAFIBRATE
ST

GEMFIBROZIL
ST
200mg Tablet 02240331 PMS-BEZAFIBRATE
PMS
FENOFIBRATE
ST
67mg Capsule 02243180 APO-FENO-MICRO 02243551 NOVO-FENOFIBRATE 100mg Capsule 02225980 APO-FENOFIBRATE 02223600 NU-FENOFIBRATE 160mg Capsule 02250004 FENOMAX 200mg Capsule 02239864 APO-FENO-MICRO 02240360 FENO-MICRO 02240210 GEN-FENOFIBRATE 02146959 LIPIDIL MICRO 02243552 NOVO-FENOFIBRATE 02249715 NU-FENO-MICRO 02273551 PMS-FENOFIBRATE MICRO 02250039 RATIO-FENOFIBRATE 02247306 RIVA-FENOFIBRATE MICRO 48mg Tablet 02269074 100mg Tablet 02246859 02241601 02289083 02310228 02288044 LIPIDIL EZ APO-FENO-SUPER LIPIDIL SUPRA NOVO-FENOFIBRATE-S PRO-FENO-SUPER SANDOZ FENOFIBRATE S
APX NOP APX NXP CIP APX PDL GEN FOU NOP NXP PMS RPH RIV FOU
ST
ST
ST
600mg Tablet 01979582 02230580 02136058 02230476 00659606 02237292 02142074 02058464 02229604 02230183 02242126
APO-GEMFIBROZIL DOM-GEMFIBROZIL GEMFIBROZIL GEN-GEMFIBROZIL LOPID MED-GEMFIBROZIL NOVO-GEMFIBROZIL NU-GEMFIBROZIL PENTA-GEMFIBROZIL PMS-GEMFIBROZIL RIVA-GEMFIBROZIL
APX DPC PDL GEN PFI MEC NOP NXP PEN PMS RIV
ST
24:06.08 HMG-COA REDUCTASE INHIBITORS

ATORVASTATIN CALCIUM
ST
ST
ST
10mg Tablet 02295261 02310899 02288346 02230711 02302675 02313448 02313707 02350297 20mg Tablet 02295288 02310902 02288354 02230713 02302683 02313456 02313715 02350319 40mg Tablet 02295296 02310910 02288362 02230714 02302691 02313464 02313723 02350327 80mg Tablet 02295318 02310929 02288370 02243097 02302713 02313472 02313758 02350335
APO-ATORVASTATIN CO ATORVASTATIN GD-ATORVASTATIN LIPITOR NOVO-ATORVASTATIN PMS-ATORVASTATIN RAN-ATORVASTATIN RATIO-ATORVASTATIN APO-ATORVASTATIN CO ATORVASTATIN GD-ATORVASTATIN LIPITOR NOVO-ATORVASTATIN PMS-ATORVASTATIN RAN-ATORVASTATIN RATIO-ATORVASTATIN APO-ATORVASTATIN CO ATORVASTATIN GD-ATORVASTATIN LIPITOR NOVO-ATORVASTATIN PMS-ATORVASTATIN RAN-ATORVASTATIN RATIO-ATORVASTATIN APO-ATORVASTATIN CO ATORVASTATIN GD-ATORVASTATIN LIPITOR NOVO-ATORVASTATIN PMS-ATORVASTATIN RAN-ATORVASTATIN RATIO-ATORVASTATIN
APX CBT PFI PFI NOP PMS RBY RPH APX CBT PFI PFI NOP PMS RBY RPH APX CBT PFI PFI NOP PMS RBY RPH APX CBT PFI PFI NOP PMS RBY RPH
APX FOU NOP PDL SDZ FOU APX FOU NOP PDL SDZ
ST
145mg Tablet 02269082 LIPIDIL EZ 160mg Tablet 02246860 02241602 02289091 02310236 02288052 APO-FENO-SUPER LIPIDIL SUPRA NOVO-FENOFIBRATE-S PRO-FENO-SUPER SANDOZ FENOFIBRATE S
ST
ST
GEMFIBROZIL
ST
300mg Capsule 01979574 APO-GEMFIBROZIL 02241608 DOM-GEMFIBROZIL 02136031 GEMFIBROZIL 02185407 GEN-FIBRO 00599026 LOPID 02241704 NOVO-GEMFIBROZIL 02058456 NU-GEMFIBROZIL 02239951 PMS-GEMFIBROZIL
APX DPC PDL GEN PFI NOP NXP PMS
ST
2010
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Health Canada

FLUVASTATIN SODIUM
ST

PRAVASTATIN SODIUM
ST
20mg Capsule 02061562 LESCOL 40mg Capsule 02061570 LESCOL 80mg Extended Release Tablet 02250527 LESCOL XL
NVR NVR NOV
ST
ST
LOVASTATIN
ST
20mg Tablet 02220172 02248572 02243127 00795860 02246542 02231434 02246013 02312670 02267969 02245822 02272288 02247056 40mg Tablet 02220180 02248573 02243129 00795852 02246543 02246014 02312689 02267977 02245823 02272296 02247057
APO-LOVASTATIN CO LOVASTATIN GEN-LOVASTATIN MEVACOR NOVO-LOVASTATIN NU-LOVASTATIN PMS-LOVASTATIN PRO-LOVASTATIN RAN-LOVASTATIN RATIO-LOVASTATIN RIVA-LOVASTATIN SANDOZ-LOVASTATIN APO-LOVASTATIN CO LOVASTATIN GEN-LOVASTATIN MEVACOR NOVO-LOVASTATIN PMS-LOVASTATIN PRO-LOVASTATIN RAN-LOVASTATIN RATIO-LOVASTATIN RIVA-LOVASTATIN SANDOZ-LOVASTATIN
APX COB GEN FRS NOP NXP PMS PDL RBY RPH RIV SDZ APX COB GEN FRS NOP PMS PDL RBY RPH RIV SDZ
20mg Tablet 02243507 02265621 02248183 02249731 02257106 02330962 02317478 02247009 02244351 02249774 02247656 00893757 02243825 02284448 02246931 02247857 02270242 02301806 40mg Tablet 02243508 02265648 02248184 02249758 02257114 02330970 02317486 02247010 02244352 02249782 02247657 02222051 02243826 02284456 02246932 02247858 02270250 02301814
APO-PRAVASTATIN BCI-PRAVASTATIN CO PRAVASTATIN DOM-PRAVASTATIN GEN-PRAVASTATIN JAMP-PRAVASTATIN MINT-PRAVASTATIN NOVO-PRAVASTATIN NU-PRAVASTATIN PHL-PRAVASTATIN PMS-PRAVASTATIN PRAVACHOL PRAVASTATIN-20 RAN-PRAVASTATIN RATIO-PRAVASTATIN RHOXAL-PRAVASTATIN RIVA-PRAVASTATIN ZYM-PRAVASTATIN APO-PRAVASTATIN BCI-PRAVASTATIN CO PRAVASTATIN DOM-PRAVASTATIN GEN-PRAVASTATIN JAMP-PRAVASTATIN MINT-PRAVASTATIN NOVO-PRAVASTATIN NU-PRAVASTATIN PHL-PRAVASTATIN PMS-PRAVASTATIN PRAVACHOL PRAVASTATIN-40 RAN-PRAVASTATIN RATIO-PRAVASTATIN RHOXAL-PRAVASTATIN RIVA-PRAVASTATIN ZYM-PRAVASTATIN
APX BAK COB DPC GEN JMP MIN NOP NXP PHH PMS BMS PDL RBY RPH RHO RIV ZYM APX BAK COB DPC GEN JMP MIN NOP NXP PHH PMS BMS PDL RBY RPH RHO RIV ZYM
ST
ST
PRAVASTATIN SODIUM
ST
10mg Tablet 02243506 02265613 02248182 02249723 02257092 02330954 02317451 02247008 02244350 02249766 02247655 00893749 02243824 02284421 02246930 02247856 02270234 02301792
APO-PRAVASTATIN BCI-PRAVASTATIN CO PRAVASTATIN DOM-PRAVASTATIN GEN-PRAVASTATIN JAMP-PRAVASTATIN MINT-PRAVASTATIN NOVO-PRAVASTATIN NU-PRAVASTATIN PHL-PRAVASTATIN PMS-PRAVASTATIN PRAVACHOL PRAVASTATIN-10 RAN-PRAVASTATIN RATIO-PRAVASTATIN RHOXAL-PRAVASTATIN RIVA-PRAVASTATIN ZYM-PRAVASTATIN
APX BAK COB DPC GEN JMP MIN NOP NXP PHH PMS BMS PDL RBY RPH RHO RIV ZYM
ROSUVASTATIN CALCIUM
ST
5mg Tablet 02265540 10mg Tablet 02247162 20mg Tablet 02247163 40mg Tablet 02247164
CRESTOR CRESTOR CRESTOR CRESTOR
AZC AZC AZC AZC
ST
ST
ST
2010
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Health Canada

SIMVASTATIN
ST

SIMVASTATIN
ST
5mg Tablet 02247011 02265656 02248103 02253747 02281619 02246582 02331020 02250144 02247072 02281546 02252619 02269252 02329131 02247067 02247827 02247297 00884324 02300907 10mg Tablet 02247012 02265664 02248104 02253755 02281627 02246583 02331039 02250152 02247075 02281554 02252635 02269260 02329158 02247068 02247298 02247828 02247221 02265885 00884332 02300915
APO-SIMVASTATIN BCI-SIMVASTATIN CO SIMVASTATIN DOM-SIMVASTATIN DOM-SIMVASTATIN GEN-SIMVASTATIN JAMP-SIMVASTATIN NOVO-SIMVASTATIN NU-SIMVASTATIN PHL-SIMVASTATIN PMS-SIMVASTATIN PMS-SIMVASTATIN RAN-SIMVASTATIN RATIO-SIMVASTATIN RHOXAL-SIMVASTATIN RIVA-SIMVASTATIN ZOCOR ZYM-SIMVASTATIN APO-SIMVASTATIN BCI-SIMVASTATIN CO SIMVASTATIN DOM-SIMVASTATIN DOM-SIMVASTATIN GEN-SIMVASTATIN JAMP-SIMVASTATIN NOVO-SIMVASTATIN NU-SIMVASTATIN PHL-SIMVASTATIN PMS-SIMVASTATIN PMS-SIMVASTATIN RAN-SIMVASTATIN RATIO-SIMVASTATIN RIVA-SIMVASTATIN SANDOZ-SIMVASTATIN SIMVASTATIN-10 TARO-SIMVASTATIN ZOCOR ZYM-SIMVASTATIN
APX BAK COB DPC DPC GEN JMP NOP NXP PMI PMS PMS RBY RPH RHO RIV FRS ZYM APX BAK COB DPC DPC GEN JMP NOP NXP PMI PMS PMS RBY RPH RIV SDZ PDL TAR FRS ZYM
ST
20mg Tablet 02247013 02265672 02248105 02253763 02281635 02246737 02331047 02250160 02247076 02281562 02252643 02269279 02329166 02247069 02247299 02247830 02247222 02265893 00884340 02300923 40mg Tablet 02247014 02265680 02248106 02253771 02281643 02246584 02331055 02250179 02247077 02281570 02252651 02269287 02329174 02247070 02247300 02247831 02247223 02265907 00884359 02300931
APO-SIMVASTATIN BCI-SIMVASTATIN CO SIMVASTATIN DOM-SIMVASTATIN DOM-SIMVASTATIN GEN-SIMVASTATIN JAMP-SIMVASTATIN NOVO-SIMVASTATIN NU-SIMVASTATIN PHL-SIMVASTATIN PMS-SIMVASTATIN PMS-SIMVASTATIN RAN-SIMVASTATIN RATIO-SIMVASTATIN RIVA-SIMVASTATIN SANDOZ-SIMVASTATIN SIMVASTATIN-20 TARO-SIMVASTATIN ZOCOR ZYM-SIMVASTATIN APO-SIMVASTATIN BCI-SIMVASTATIN CO SIMVASTATIN DOM-SIMVASTATIN DOM-SIMVASTATIN GEN-SIMVASTATIN JAMP-SIMVASTATIN NOVO-SIMVASTATIN NU-SIMVASTATIN PHL-SIMVASTATIN PMS-SIMVASTATIN PMS-SIMVASTATIN RAN-SIMVASTATIN RATIO-SIMVASTATIN RIVA-SIMVASTATIN SANDOZ-SIMVASTATIN SIMVASTATIN-40 TARO-SIMVASTATIN ZOCOR ZYM-SIMVASTATIN
APX BAK COB DPC DPC GEN JMP NOP NXP PMI PMS PMS RBY RPH RIV SDZ PDL TAR FRS ZYM APX BAK COB DPC DPC GEN JMP NOP NXP PMI PMS PMS RBY RPH RIV SDZ PDL TAR FRS ZYM
ST
2010
Page 28 of 124
Health Canada

SIMVASTATIN
ST
24:08.16 CENTRAL ALPHA-AGONISTS

METHYLDOPA, HYDROCHLOROTHIAZIDE
ST
80mg Tablet 02247015 02265699 02248107 02253798 02281651 02246585 02331063 02250187 02247078 02281589 02252678 02269295 02329182 02247071 02247301 02247833 02240332 02300974
250mg & 25mg Tablet 00441716 APO-METHAZIDE-25
APX
APO-SIMVASTATIN BCI-SIMVASTATIN CO SIMVASTATIN DOM-SIMVASTATIN DOM-SIMVASTATIN GEN-SIMVASTATIN JAMP-SIMVASTATIN NOVO-SIMVASTATIN NU-SIMVASTATIN PHL-SIMVASTATIN PMS-SIMVASTATIN PMS-SIMVASTATIN RAN-SIMVASTATIN RATIO-SIMVASTATIN RIVA-SIMVASTATIN SANDOZ-SIMVASTATIN ZOCOR ZYM-SIMVASTATIN
APX BAK COB DPC DPC GEN JMP NOP NXP PMI PMS PMS RBY RPH RIV SDZ FRS ZYM
24:08.20 DIRECT VASODILATORS

DIAZOXIDE
ST
100mg Capsule 00503347 PROGLYCEM
SCH
HYDRALAZINE HCL
ST
10mg Tablet 00441619 APO-HYDRALAZINE 01913638 HYDRALAZINE 00759465 NOVO-HYLAZIN 01913204 NU-HYDRAL 25mg Tablet 00441627 APO-HYDRALAZINE 02082071 HYDRALAZINE 00759473 NOVO-HYLAZIN 02004828 NU-HYDRAL 50mg Tablet 00441635 APO-HYDRALAZINE 02082098 HYDRALAZINE 00759481 NOVO-HYLAZIN 02004836 NU-HYDRAL
APX PDL NOP NXP APX PDL NOP NXP APX PDL NOP NXP
ST
ST
24:08.16 CENTRAL ALPHA-AGONISTS

CLONIDINE HCL
ST
0.025mg Tablet 02248732 APO-CLONIDINE 00519251 DIXARIT 02304163 NOVO-CLONIDINE 0.1mg Tablet 00868949 00259527 01910396 02046121 01913786 0.2mg Tablet 00868957 00291889 01908162 02046148 01913220 APO-CLONIDINE CATAPRES CLONIDINE NOVO-CLONIDINE NU-CLONIDINE APO-CLONIDINE CATAPRES CLONIDINE NOVO-CLONIDINE NU-CLONIDINE
APX BOE NOP APX BOE PRO NOP NXP APX BOE PRO NOP NXP
MINOXIDIL
ST
ST
2.5mg Tablet 00514497 LONITEN 10mg Tablet 00514500 LONITEN
PFI PFI
ST
24:12.08 NITRATES AND NITRITES

ISOSORBIDE DINITRATE
ST
ST
5mg Sublingual Tablet 00670944 APO-ISDN 00658812 ISOSORBIDE 10mg Tablet 00441686 APO-ISDN 00584266 ISOSORBIDE 00786667 PMS-ISOSORBIDE 30mg Tablet 00441694 APO-ISDN 00584258 PDL-ISOSORBIDE
APX PDL APX PDL PMS APX PDL
ST
METHYLDOPA
ST
ST
125mg Tablet 00360252 APO-METHYLDOPA 00456365 METHYLDOPA 250mg Tablet 00360260 APO-METHYLDOPA 00453714 METHYLDOPA 500mg Tablet 00426830 APO-METHYLDOPA 00456373 METHYLDOPA
APX PDL APX PDL APX PDL
ST
ISOSORBIDE-5-MONONITRATE
ST
ST
60mg Tablet 02272830 APO-ISMN 02126559 IMDUR 02301288 PMS-ISMN 02311321 PRO-ISMN
APX AZE PMS PDL
METHYLDOPA, HYDROCHLOROTHIAZIDE
ST
NITROGLYCERIN
2% Ointment 01926454 NITROL SQU
250mg & 15mg Tablet 00441708 APO-METHAZIDE-15
APX
2010
Page 29 of 124
Health Canada
24:12.08 NITRATES AND NITRITES

NITROGLYCERIN
ST
24:20.00 ALPHA ADRENERGIC BLOCKING AGENTS

DOXAZOSIN MESYLATE
MMH KEY NVR TRT MMH KEY NVR TRT MMH KEY NVR TRT
ST ST
0.2mg Patch 02162806 01911910 00584223 02230732 0.4mg Patch 02163527 01911902 00852384 02230733 0.6mg Patch 02163535 01911929 02046156 02230734
MINITRAN NITRO-DUR TRANSDERM-NITRO TRINIPATCH MINITRAN NITRO-DUR TRANSDERM-NITRO TRINIPATCH MINITRAN NITRO-DUR TRANSDERM-NITRO TRINIPATCH
ST
1mg Tablet 02240588 01958100 02240978 02240498 02242728 02244527 2mg Tablet 02240589 01958097 02240979 02240499 02242729 02244528 4mg Tablet 02240590 01958119 02240980 02240500 02242730 02244529
APO-DOXAZOSIN CARDURA 1 DOXAZOSIN GEN-DOXAZOSIN NOVO-DOXAZOSIN PMS-DOXAZOSIN APO-DOXAZOSIN CARDURA 2 DOXAZOSIN GEN-DOXAZOSIN NOVO-DOXAZOSIN PMS-DOXAZOSIN APO-DOXAZOSIN CARDURA 4 DOXAZOSIN GEN-DOXAZOSIN NOVO-DOXAZOSIN PMS-DOXAZOSIN
APX PFI PDL GEN NOP PMS APX PFI PDL GEN NOP PMS APX PFI PDL GEN NOP PMS
ST
ST
ST
0.8mg Patch 02011271 NITRO-DUR 0.4mg Spray 02243588 GEN-NITRO 02231441 NITROLINGUAL PUMPSPRAY 02238998 RHO-NITRO PUMPSPRAY 0.3mg Sublingual Tablet 00037613 NITROSTAT 0.6mg Sublingual Tablet 00037621 NITROSTAT
KEY GEN SAC SAC PFI PFI
PRAZOSIN HCL
ST
24:12.92 MISCELLANEOUS VASODILATING AGENTS

DIPYRIDAMOLE
ST
1mg Tablet 00882801 00560952 01934198 01913794 01907158 2mg Tablet 00882828 00560960 01934201 01913808 01910302 5mg Tablet 00882836 00560979 01934228 01913816 01910310
APO-PRAZO MINIPRESS NOVO-PRAZIN NU-PRAZO PRAZOSIN APO-PRAZO MINIPRESS NOVO-PRAZIN NU-PRAZO PRAZOSIN APO-PRAZO MINIPRESS NOVO-PRAZIN NU-PRAZO PRAZOSIN
APX ERF NOP NXP PDL APX ERF NOP NXP PDL APX ERF NOP NXP PDL
25mg Tablet 00895644 02229396 50mg Tablet 00571245 00895652 02229397 00067393 75mg Tablet 00601845 00895660 02229398 00452092
ST
APO-DIPYRIDAMOLE PDL-DIPYRIDAMOLE APO-DIPYRIDAMOLE APO-DIPYRIDAMOLE PDL-DIPYRIDAMOLE PERSANTINE APO-DIPYRIDAMOLE APO-DIPYRIDAMOLE PDL-DIPYRIDAMOLE PERSANTINE
APX PDL APX APX PDL BOE APX APX PDL BOE
ST
ST
ST
TERAZOSIN HCL
ST
DIPYRIDAMOLE, ACETYLSALICYLIC ACID

Limited use benefit (prior approval required). For secondary prevention of stroke or transient ischemic attacks (TIAs) in patients who have failed therapy with ASA alone.
ST
200mg & 25mg Capsule 02242119 AGGRENOX
BOE
NIMODIPINE
ST
1mg Tablet 02234502 02243746 00818658 02230805 02233047 02237476 02243518 02218941
APO-TERAZOSIN DOM-TERAZOSIN HYTRIN NOVO-TERAZOSIN NU-TERAZOSIN PDL-TERAZOSIN PMS-TERAZOSIN RATIO-TERAZOSIN
APX DPC ABB NOP NXP PDL PMS RPH
30mg Capsule 02155923 NIMOTOP
BAY Page 30 of 124
2010
Health Canada
24:20.00 ALPHA ADRENERGIC BLOCKING AGENTS

TERAZOSIN HCL
ST
24:24.00 BETA ADRENERGIC BLOCKING AGENTS

ACEBUTOLOL HCL
ST
2mg Tablet 02234503 02243747 00818682 02230806 02233048 02237477 02243519 02218968 5mg Tablet 02234504 02243748 00818666 02230807 02233049 02237478 02243520 02218976 10mg Tablet 02234505 02243749 00818674 02230808 02233050 02237479 02243521 02218984
APO-TERAZOSIN DOM-TERAZOSIN HYTRIN NOVO-TERAZOSIN NU-TERAZOSIN PDL-TERAZOSIN PMS-TERAZOSIN RATIO-TERAZOSIN APO-TERAZOSIN DOM-TERAZOSIN HYTRIN NOVO-TERAZOSIN NU-TERAZOSIN PDL-TERAZOSIN PMS-TERAZOSIN RATIO-TERAZOSIN APO-TERAZOSIN DOM-TERAZOSIN HYTRIN NOVO-TERAZOSIN NU-TERAZOSIN PDL-TERAZOSIN PMS-TERAZOSIN RATIO-TERAZOSIN
APX DPC ABB NOP NXP PDL PMS RPH APX DPC ABB NOP NXP PDL PMS RPH APX DPC ABB NOP NXP PDL PMS RPH
ST
200mg Tablet 02164418 02147610 02237722 02237886 02239759 02239755 02204525 02165554 02231252 01910159 02257602 01926551 400mg Tablet 02164426 02147629 02237723 02237887 02239760 02239756 02204533 02165562 02231253 01910167 02257610 01926578
ACEBUTOLOL APO-ACEBUTOLOL GEN-ACEBUTOLOL GEN-ACEBUTOLOL (TYPE S) MED-ACEBUTOLOL MED-ACEBUTOLOL (TYPE S) NOVO-ACEBUTOLOL NU-ACEBUTOLOL PENTA-ACEBUTOLOL RHOTRAL SANDOZ-ACEBUTOLOL SECTRAL ACEBUTOLOL APO-ACEBUTOLOL GEN-ACEBUTOLOL GEN-ACEBUTOLOL (TYPE S) MED-ACEBUTOLOL MED-ACEBUTOLOL (TYPE S) NOVO-ACEBUTOLOL NU-ACEBUTOLOL PENTA-ACEBUTOLOL RHOTRAL SANDOZ-ACEBUTOLOL SECTRAL
PDL APX GEN GEN MEC MEC NOP NXP PEN SAC SDZ SAC PDL APX GEN GEN MEC MEC NOP NXP PEN SAC SDZ SAC
ST
ST
ATENOLOL
ST

ACEBUTOLOL HCL
ST
100mg Tablet 02164396 02147602 02237721 02237885 02239758 02239754 02204517 02165546 02231251 01910140 02257599 01926543
ACEBUTOLOL APO-ACEBUTOLOL GEN-ACEBUTOLOL GEN-ACEBUTOLOL (TYPE S) MED-ACEBUTOLOL MED-ACEBUTOLOL (TYPE S) NOVO-ACEBUTOLOL NU-ACEBUTOLOL PENTA-ACEBUTOLOL RHOTRAL SANDOZ-ACEBUTOLOL SECTRAL
PDL APX GEN GEN MEC MEC NOP NXP PEN SAC SDZ SAC
25mg Tablet 02303647 02266660 02247182 02246581 02277379 50mg Tablet 00773689 00828807 02257629 02255545 02229467 02146894 02188961 01912062 00886114 02229585 02238316 02237600 02267985 02171791 02242094 02231731 02039532
GEN-ATENOLOL NOVO-ATENOL PHL-ATENOLOL PMS-ATENOLOL RIVA-ATENOLOL APO-ATENOL ATENOLOL BCI-ATENOLOL CO ATENOLOL DOM-ATENOLOL GEN-ATENOLOL MED-ATENOLOL NOVO-ATENOL NU-ATENOL PENTA-ATENOLOL PHL-ATENOLOL PMS-ATENOLOL RAN-ATENOLOL RATIO-ATENOLOL RIVA-ATENOLOL SANDOZ-ATENOLOL TENORMIN
GEN NOP PMI PMS RIV APX PDL BAK COB DPC GEN MEC NOP NXP PEN PHH PMS RBY RPH RIV SDZ AZC
ST
2010
Page 31 of 124
Health Canada

ATENOLOL
ST

CARVEDILOL
ST
100mg Tablet 00773697 00828793 02257637 02255553 02229468 02147432 02188988 01912054 00886122 02229586 02238318 02237601 02267993 02171805 02242093 02231733 02039540
APO-ATENOL ATENOLOL BCI-ATENOLOL CO ATENOLOL DOM-ATENOLOL GEN-ATENOLOL MED-ATENOLOL NOVO-ATENOL NU-ATENOL PENTA-ATENOLOL PHL-ATENOLOL PMS-ATENOLOL RAN-ATENOLOL RATIO-ATENOLOL RIVA-ATENOLOL SANDOZ-ATENOLOL TENORMIN
APX PDL BAK COB DPC GEN MEC NOP NXP PEN PHH PMS RBY RPH RIV SDZ AZC
3.125mg Tablet 02247933 APO-CARVEDILOL 02248748 DOM-CARVEDILOL 02347512 MYLAN-CARVEDILOL 02248752 PHL-CARVEDILOL 02245914 PMS-CARVEDILOL 02268027 RAN-CARVEDILOL 02252309 RATIO-CARVEDILOL 02338068 ZYM-CARVEDILOL 6.25mg Tablet 02247934 APO-CARVEDILOL 02248749 DOM-CARVEDILOL 02347520 MYLAN-CARVEDILOL 02248753 PHL-CARVEDILOL 02245915 PMS-CARVEDILOL 02268035 RAN-CARVEDILOL 02252317 RATIO-CARVEDILOL 02338092 ZYM-CARVEDILOL 12.5mg Tablet 02247935 APO-CARVEDILOL 02248750 DOM-CARVEDILOL 02347555 MYLAN-CARVEDILOL 02248754 PHL-CARVEDILOL 02245916 PMS-CARVEDILOL 02268043 RAN-CARVEDILOL 02252325 RATIO-CARVEDILOL 02338106 ZYM-CARVEDILOL 25mg Tablet 02247936 02248751 02347571 02248755 02245917 02268051 02252333 02338114 APO-CARVEDILOL DOM-CARVEDILOL MYLAN-CARVEDILOL PHL-CARVEDILOL PMS-CARVEDILOL RAN-CARVEDILOL RATIO-CARVEDILOL ZYM-CARVEDILOL
APX DPC MYL PMI PMS RBY RPH ZYM APX DPC MYL PMI PMS RBY RPH ZYM APX DPC MYL PMI PMS RBY RPH ZYM APX DPC MYL PMI PMS RBY RPH ZYM
ST
ATENOLOL, CHLORTHALIDONE
ST
ST
50mg & 25mg Tablet 02248763 APO-ATENIDONE 02302918 NOVO-ATENOLTHALIDONE 02049961 TENORETIC 100mg & 25mg Tablet 02248764 APO-ATENIDONE 02302926 NOVO-ATENOLTHALIDONE 02049988 TENORETIC
APX NOP AZC APX NOP AZC
ST
ST
BISOPROLOL FUMARATE
ST
5mg Tablet 02256134 02241148 02267470 02302632 02306999 02247439 02321556 10mg Tablet 02256177 02267489 02302640 02307006 02247440 02321572
APO-BISOPROLOL MONOCOR NOVO-BIPOPROLOL PMS-BISOPROLOL PRO-BISOPROLOL SANDOZ-BISOPROLOL ZYM-BISOPROLOL APO-BISOPROLOL NOVO-BIPOPROLOL PMS-BISOPROLOL PRO-BISOPROLOL SANDOZ-BISOPROLOL ZYM-BISOPROLOL
APX BPC NOP PMS PDL SDZ ZYM APX NOP PMS PDL SDZ ZYM
LABETALOL HCL
ST
ST
100mg Tablet 02106272 TRANDATE 200mg Tablet 02106280 TRANDATE
SHI SHI
ST
METOPROLOL TARTRATE
ST
100mg Sustained Release Tablet 02285169 APO-METOPROLOL SR 00658855 LOPRESOR SR 02303396 SANDOZ-METOPROLOL SR 200mg Sustained Release Tablet 02285177 APO-METOPROLOL SR 00534560 LOPRESOR SR 02303418 SANDOZ-METOPROLOL SR
APX NVR SDZ APX NVR SDZ
ST
2010
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Health Canada

METOPROLOL TARTRATE
ST

NADOLOL
ST
25mg Tablet 02246010 02252252 02302055 02296713 02261898 02248855 02315300 02315106 50mg Tablet 00618632 00749354 02172550 02231121 02230448 02174545 00397423 02239771 00648019 00648035 00842648 00865605 02232546 02145413 02230803 02315319 02247875 02315114 100mg Tablet 00618640 00751170 02172569 02231122 02230449 02174553 00397431 02239772 00648027 00648043 00842656 00865613 02232547 02145421 02230804 02315327 02247876 02315122
APO-METOPROLOL DOM-METOPROLOL-L GEN-METOPROLOL (TYPE L) METOPROLOL NOVO-METOPROL CT PMS-METOPROLOL-L RIVA-METOPROLOL L ZYM-METOPROLOL-L APO-METOPROLOL APO-METOPROLOL-L DOM-METOPROLOL-B DOM-METOPROLOL-L GEN-METOPROLOL GEN-METOPROLOL-L LOPRESOR MED-METOPROLOL METOPROLOL NOVO-METOPROL NOVO-METOPROL NU-METOP PENTA-METOPROLOL PMS-METOPROLOL-B PMS-METOPROLOL-L RIVA-METOPROLOL L SANDOZ-METOPROLOL-L ZYM-METOPROLOL-L APO-METOPROLOL APO-METOPROLOL-L DOM-METOPROLOL-B DOM-METOPROLOL-L GEN-METOPROLOL GEN-METOPROLOL-L LOPRESOR MED-METOPROLOL METOPROLOL NOVO-METOPROL NOVO-METOPROL-B NU-METOP PENTA-METOPROLOL PMS-METOPROLOL-B PMS-METOPROLOL-L RIVA-METOPROLOL L SANDOZ-METOPROLOL-L ZYM-METOPROLOL-L
APX DPC GEN PDL NOP PMS RIV ZYM APX APX DPC DPC GEN GEN NVR MEC PDL NOP NOP NXP PEN PMS PMS RIV SDZ ZYM APX APX DPC DPC GEN GEN NVR MEC PDL NOP NOP NXP PEN PMS PMS RIV SDZ ZYM
80mg Tablet 00782467 00818704 02126761
APO-NADOL NADOLOL NOVO-NADOLOL
APX PDL NOP APX
ST
160mg Tablet 00782475 APO-NADOL
OXPRENOLOL HCL
ST
ST
TRASICOR
NVR
PINDOLOL
ST
5mg Tablet 00755877 02231650 02057808 02084376 00869007 00886149 00828416 02231536 02261782 00417270 10mg Tablet 00755885 02238046 02057816 02084384 00869015 00886009 00828424 02231537 02261790 00443174 15mg Tablet 00755893 02238047 02057824 02084392 00869023 00886130 00828432 02231539 02261804 00417289
APO-PINDOL DOM-PINDOLOL GEN-PINDOLOL MED-PINDOLOL NOVO-PINDOL NU-PINDOL PINDOLOL PMS-PINDOLOL SANDOZ-PINDOLOL VISKEN APO-PINDOL DOM-PINDOLOL GEN-PINDOLOL MED-PINDOLOL NOVO-PINDOL NU-PINDOL PINDOLOL PMS-PINDOLOL SANDOZ-PINDOLOL VISKEN APO-PINDOL DOM-PINDOLOL GEN-PINDOLOL MED-PINDOLOL NOVO-PINDOL NU-PINDOL PINDOLOL PMS-PINDOLOL SANDOZ-PINDOLOL VISKEN
APX DPC GEN MEC NOP NXP PDL PMS SDZ NVR APX DPC GEN MEC NOP NXP PDL PMS SDZ NVR APX DPC GEN MEC NOP NXP PDL PMS SDZ NVR
ST
ST
ST
PINDOLOL, HYDROCHLOROTHIAZIDE
ST
NADOLOL
ST
10mg & 25mg Tablet 00568627 VISKAZIDE 10mg & 50mg Tablet 00568635 VISKAZIDE
NVR NVR
40mg Tablet 00782505 00828815 02126753
ST
APO-NADOL NADOLOL NOVO-NADOLOL
APX PDL NOP
PROPRANOLOL HCL
ST
60mg Long Acting Capsule 02042231 INDERAL LA
WAY Page 33 of 124
2010
Health Canada

PROPRANOLOL HCL
ST

SOTALOL HCL
ST
80mg Long Acting Capsule 02042258 INDERAL LA 120mg Long Acting Capsule 02042266 INDERAL LA 160mg Long Acting Capsule 02042274 INDERAL LA 10mg Tablet 00402788 02137313 00496480 00512575 20mg Tablet 00663719 00740675 02044692 00667072 40mg Tablet 00402753 02137321 00496499 02044706 00512532 80mg Tablet 00402761 02137348 00496502 00582271 00512540 APO-PROPRANOLOL DOM-PROPRANOLOL NOVO-PRANOL PROPRANOLOL APO-PROPRANOLOL NOVO-PRANOL NU-PROPRANOLOL PROPRANOLOL APO-PROPRANOLOL DOM-PROPRANOLOL NOVO-PRANOL NU-PROPRANOLOL PROPRANOLOL APO-PROPRANOLOL DOM-PROPRANOLOL NOVO-PRANOL PMS-PROPRANOLOL PROPRANOLOL
WAY WAY WAY APX DPC NOP PDL APX NOP NXP PDL APX DPC NOP NXP PDL APX DPC NOP PMS PDL APX PMS PDL
ST
ST
ST
ST
160mg Tablet 02167794 02270633 02238635 02229779 02237270 02231182 02163772 02238769 02238327 02316536 02084236 02257858 02242157 02234013 02222027
APO-SOTALOL CO SOTALOL DOM-SOTALOL GEN-SOTALOL MED-SOTALOL NOVO-SOTALOL NU-SOTALOL PHL-SOTALOL PMS-SOTALOL PRO-SOTALOL RATIO-SOTALOL RHOXAL-SOTALOL RIVA-SOTALOL SANDOZ-SOTALOL SOTALOL
APX COB DPC GEN MEC NOP NXP PHH PMS PDL RPH RHO RIV SDZ PDL GEN
ST
ST
240mg Tablet 02229780 GEN-SOTALOL
TIMOLOL MALEATE
ST
ST
5mg Tablet 00755842 01947796 02044609 00812455 10mg Tablet 00755850 01947818 02044617 00812447 20mg Tablet 00755869 01947826 00812439
APO-TIMOL NOVO-TIMOL NU-TIMOLOL TIMOLOL APO-TIMOL NOVO-TIMOL NU-TIMOLOL TIMOLOL APO-TIMOL NOVO-TIMOL TIMOLOL
APX NOP NXP PDL APX NOP NXP PDL APX NOP PDL
ST
ST
120mg Tablet 00504335 APO-PROPRANOLOL 00582298 PMS-PROPRANOLOL 00667064 PROPRANOLOL
ST
SOTALOL HCL
ST
80mg Tablet 02210428 02270625 02238634 02229778 02237269 02231181 02200996 02238768 02238326 02316528 02084228 02234008 02242156 02257831 02222019
24:28.08 DIHYDROPYRIDINES
APX COB DPC GEN MEC NOP NXP PHH PMS PDL RPH RHO RIV SDZ PDL
APO-SOTALOL CO SOTALOL DOM-SOTALOL GEN-SOTALOL MED-SOTALOL NOVO-SOTALOL NU-SOTALOL PHL-SOTALOL PMS-SOTALOL PRO-SOTALOL RATIO-SOTALOL RHOXAL-SOTALOL RIVA-SOTALOL SANDOZ-SOTALOL SOTALOL
AMLODIPINE
ST
2.5mg Tablet 02326825 02280124 02326760 02295148 02331489 02330474 02326795
DOM-AMLODIPINE GD-AMLODIPINE PHL-AMLODIPINE PMS-AMLODIPINE RIVA-AMLODIPINE SANDOZ-AMLODIPINE ZYM-AMLODIPINE
DOM PFI PMI PMS RIV SDZ ZYM
2010
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Health Canada
AMLODIPINE
ST
FELODIPINE
ST
5mg Tablet 02273373 02297485 02326833 02280132 02272113 02331071 00878928 02250497 02326779 02284065 02321858 02259605 02331497 02284383 02326809 02342790 10mg Tablet 02273381 02297493 02326841 02280140 02272121 02331098 00878936 02250500 02326787 02284073 02321866 02259613 02331500 02284391 02326817 02342804
APO-AMLODIPINE CO AMLODIPINE DOM-AMLODIPINE GD-AMLODIPINE GEN-AMLODIPINE JAMP-AMLODIPINE NORVASC NOVO-AMLODIPINE PHL-AMLODIPINE PMS-AMLODIPINE RAN-AMLODIPINE RATIO-AMLODIPINE RIVA-AMLODIPINE SANDOZ-AMLODIPINE ZYM-AMLODIPINE ZYM-AMLODIPINE APO-AMLODIPINE CO AMLODIPINE DOM-AMLODIPINE GD-AMLODIPINE GEN-AMLODIPINE JAMP-AMLODIPINE NORVASC NOVO-AMLODIPINE PHL-AMLODIPINE PMS-AMLODIPINE RAN-AMLODIPINE RATIO-AMLODIPINE RIVA-AMLODIPINE SANDOZ-AMLODIPINE ZYM-AMLODIPINE ZYM-AMLODIPINE
APX CBT DOM PFI GEN JMP PFI NOP PMI PMS RBY RPH RIV SDZ ZYM ZYM APX CBT DOM PFI GEN JMP PFI NOP PMI PMS RBY RPH RIV SDZ ZYM ZYM
2.5mg Extended Release Tablet 02057778 PLENDIL 02221985 RENEDIL 5mg Extended Release Tablet 00851779 PLENDIL 02221993 RENEDIL 02280264 SANDOZ-FELODIPINE 09857203 SANDOZ-FELODIPINE 10mg Extended Release Tablet 00851787 PLENDIL 02222000 RENEDIL 02280272 SANDOZ-FELODIPINE 09857204 SANDOZ-FELODIPINE
AZC SAC AZC SAC SDZ SDZ AZC SAC SDZ SDZ
ST
ST
NIFEDIPINE
ST
ST
5mg Capsule 00725110 APO-NIFED 02235897 PMS-NIFEDIPINE 10mg Capsule 00755907 APO-NIFED 02236758 DOM-NIFEDIPINE 00865591 NU-NIFED 02235898 PMS-NIFEDIPINE 20mg Extended Release Tablet 02237618 ADALAT XL 30mg Extended Release Tablet 02155907 ADALAT XL 02349167 MYLAN-NIFEDIPINE ER 60mg Extended Release Tablet 02155990 ADALAT XL 02321149 GEN-NIFEDIPINE XL 10mg Sustained Release Tablet 02197448 APO-NIFED PA 02211092 NIFEDIPINE PA 02212102 NU-NIFEDIPINE PA 20mg Sustained Release Tablet 02181525 APO-NIFED PA 02211106 NIFEDIPINE PA 02200937 NU-NIFEDIPINE PA
APX PMS APX DPC NXP PMS BAY BAY MYL BAY GEN APX PDL NXP APX PDL NXP
ST
ST
ST
ST
ST
AMLODIPINE, ATORVASTATIN
ST
5mg & 10mg Tablet 02273233 CADUET 5mg & 20mg Tablet 02273241 CADUET 5mg & 40mg Tablet 02273268 CADUET 5mg & 80mg Tablet 02273276 CADUET 10mg & 10mg Tablet 02273284 CADUET 10mg & 20mg Tablet 02273292 CADUET 10mg & 40mg Tablet 02273306 CADUET 10mg & 80mg Tablet 02273314 CADUET
ST
PFI PFI PFI PFI PFI PFI PFI PFI
ST
ST
ST
24:28.92 MISCELLANEOUS CALCIUMCHANNEL BLOCKING AGENTS

DILTIAZEM HCL
ST
ST
ST
ST
ST
120mg Controlled Delivery Capsule 02230997 APO-DILTIAZ CD 02097249 CARDIZEM CD 02231472 DILTIAZEM CD 02254808 GEN-DILTIAZEM 02242538 NOVO-DILTAZEM CD 02231052 NU-DILTIAZ CD 02229781 RATIO-DILTIAZEM CD 02243338 SANDOZ-DILTIAZEM CD
APX BPC PDL GEN NOP NXP RPH SDZ
2010
Page 35 of 124
Health Canada

DILTIAZEM HCL
ST

DILTIAZEM HCL
ST
180mg Controlled Delivery Capsule 02230998 APO-DILTIAZ CD 02097257 CARDIZEM CD 02231474 DILTIAZEM CD 02242539 NOVO-DILTAZEM CD 02231053 NU-DILTIAZ CD 02229782 RATIO-DILTIAZEM CD 02243339 SANDOZ-DILTIAZEM CD 240mg Controlled Delivery Capsule 02230999 APO-DILTIAZ CD 02097265 CARDIZEM CD 02231475 DILTIAZEM CD 02242540 NOVO-DILTAZEM CD 02231054 NU-DILTIAZ CD 02229783 RATIO-DILTIAZEM CD 02243340 SANDOZ-DILTIAZEM CD 300mg Controlled Delivery Capsule 02229526 APO-DILTIAZ CD 02097273 CARDIZEM CD 02231057 DILTIAZEM CD 02254832 GEN-DILTIAZEM 02242541 NOVO-DILTAZEM CD 02229784 RATIO-DILTIAZEM CD 02243341 SANDOZ-DILTIAZEM CD 120mg Extended Release Capsule 02291037 APO-DILTIAZ TZ 02231150 TIAZAC 180mg Extended Release Capsule 02291045 APO-DILTIAZ TZ 02231151 TIAZAC 240mg Extended Release Capsule 02291053 APO-DILTIAZ TZ 02231152 TIAZAC 300mg Extended Release Capsule 02291061 APO-DILTIAZ TZ 02231154 TIAZAC 360mg Extended Release Capsule 02291088 APO-DILTIAZ TZ 02231155 TIAZAC 120mg Extended Release Tablet 02256738 TIAZAC XC 180mg Extended Release Tablet 02256746 TIAZAC XC 240mg Extended Release Tablet 02256754 TIAZAC XC 300mg Extended Release Tablet 02256762 TIAZAC XC 360mg Extended Release Tablet 02256770 TIAZAC XC 60mg Sustained Release Capsule 02222957 APO-DILTIAZ SR
APX BPC PDL NOP NXP RPH SDZ APX BPC PDL NOP NXP RPH SDZ APX BPC PDL GEN NOP RPH SDZ APX BPC APX BPC APX BPC APX BPC APX BPC BPC BPC BPC BPC BPC APX
90mg Sustained Release Capsule 02222965 APO-DILTIAZ SR 120mg Sustained Release Capsule 02222973 APO-DILTIAZ SR 02271605 NOVO-DILTIAZEM ER 02245918 SANDOZ-DILTIAZEM T 180mg Sustained Release Capsule 02271613 NOVO-DILTIAZEM ER 02245919 SANDOZ-DILTIAZEM T 240mg Sustained Release Capsule 02271621 NOVO-DILTIAZEM ER 02245920 SANDOZ-DILTIAZEM T 300mg Sustained Release Capsule 02271648 NOVO-DILTIAZEM ER 02245921 SANDOZ-DILTIAZEM T 360mg Sustained Release Capsule 02271656 NOVO-DILTIAZEM ER 02245922 SANDOZ-DILTIAZEM T 30mg Tablet 00771376 00828785 02189038 00862924 00886068 02229593 60mg Tablet 00771384 00828777 02189046 00862932 00886076 02229594 APO-DILTIAZ DILTIAZEM MED-DILTIAZEM NOVO-DILTIAZEM NU-DILTIAZ PENTA-DILTIAZEM APO-DILTIAZ DILTIAZEM MED-DILTIAZEM NOVO-DILTIAZEM NU-DILTIAZ PENTA-DILTIAZEM
APX APX NOP SDZ NOP SDZ NOP SDZ NOP SDZ NOP SDZ APX PDL MEC NOP NXP PEN APX PDL MEC NOP NXP PEN
ST
ST
ST
ST
ST
ST ST
ST
ST
ST
ST
ST
ST
VERAPAMIL HCL
ST
180mg Extended Release Tablet 02231676 COVERA-HS 240mg Extended Release Tablet 02231677 COVERA-HS 120mg Sustained Release Tablet 02246893 APO-VERAP SR 02210347 GEN-VERAPAMIL SR 01907123 ISOPTIN SR 180mg Sustained Release Tablet 02246894 APO-VERAP SR 02210355 GEN-VERAPAMIL SR 01934317 ISOPTIN SR
PFI PFI APX GEN ABB APX GEN ABB
ST
ST
ST
ST
ST
ST
ST
ST
ST
ST
2010
Page 36 of 124
Health Canada

VERAPAMIL HCL
ST
24:32.04 ANGIOTENSIN-CONVERTING ENZYME INHIBITORS

CAPTOPRIL
ST
240mg Sustained Release Tablet 02246895 APO-VERAP SR 02240321 DOM-VERAPAMIL SR 02210363 GEN-VERAPAMIL SR 00742554 ISOPTIN SR 02211920 NOVO-VERAMIL SR 02249812 NU-VERAP SR 02237791 PMS-VERAPAMIL SR 02238276 RIVA-VERAPAMIL 02248082 RIVA-VERAPAMIL SR 80mg Tablet 00782483 02237921 02239769 00812331 00886033 00871028 120mg Tablet 00782491 02237922 02239770 00812358 00886041 00871036 APO-VERAP GEN-VERAPAMIL MED-VERAPAMIL NOVO-VERAMIL NU-VERAP VERAPAMIL APO-VERAP GEN-VERAPAMIL MED-VERAPAMIL NOVO-VERAMIL NU-VERAP VERAPAMIL
APX DPC GEN ABB NOP NXP PMS PHH RIV APX GEN MEC NOP NXP PDL APX GEN MEC NOP NXP PDL
ST
ST
25mg Tablet 00893609 00546283 01910337 02242789 02238552 02163578 02188937 01942972 01913832 02234255 02230204 50mg Tablet 00893617 00546291 01910361 02242790 02238553 02163586 02188945 01942980 01913840 02234256 02230205 100mg Tablet 00893625 02242791 02238554 02163594 02188953 01942999 01913859 02234257 02230206
APO-CAPTO CAPOTEN CAPTOPRIL CAPTOPRIL DOM-CAPTOPRIL GEN-CAPTOPRIL MED-CAPTOPRIL NOVO-CAPTORIL NU-CAPTO PENTA-CAPTOPRIL PMS-CAPTOPRIL APO-CAPTO CAPOTEN CAPTOPRIL CAPTOPRIL DOM-CAPTOPRIL GEN-CAPTOPRIL MED-CAPTOPRIL NOVO-CAPTORIL NU-CAPTO PENTA-CAPTOPRIL PMS-CAPTOPRIL APO-CAPTO CAPTOPRIL DOM-CAPTOPRIL GEN-CAPTOPRIL MED-CAPTOPRIL NOVO-CAPTORIL NU-CAPTO PENTA-CAPTOPRIL PMS-CAPTOPRIL
APX BMS PDL ZYM DPC GEN MEC NOP NXP PEN PMS APX BMS PDL ZYM DPC GEN MEC NOP NXP PEN PMS APX ZYM DPC GEN MEC NOP NXP PEN PMS
ST
ST

BENAZEPRIL HCL
ST
5mg Tablet 02290332 00885835 10mg Tablet 02290340 00885843 20mg Tablet 02273918 00885851
APO-BENAZEPRIL LOTENSIN APO-BENAZEPRIL LOTENSIN APO-BENAZEPRIL LOTENSIN
APX NVR APX NVR APX NVR

ST
ST
ST
CILAZAPRIL
1mg Tablet 02291134 02283778 01911465 02266350 02280442 2.5mg Tablet 02291142 02285215 02283786 01911473 02266369 02280450 APO-CILAZAPRIL GEN-CILAZAPRIL INHIBACE NOVO-CILAZAPRIL PMS-CILAZAPRIL APO-CILAZAPRIL CO CILAZAPRIL GEN-CILAZAPRIL INHIBACE NOVO-CILAZAPRIL PMS-CILAZAPRIL APX GEN HLR NOP PMS APX COB GEN HLR NOP PMS
CAPTOPRIL
ST
6.25mg Tablet 01999559 APO-CAPTO 12.5mg Tablet 00893595 APO-CAPTO 00695661 CAPOTEN 01910329 CAPTOPRIL 02242788 CAPTOPRIL 02238551 DOM-CAPTOPRIL 02163551 GEN-CAPTOPRIL 02188929 MED-CAPTOPRIL 01942964 NOVO-CAPTORIL 01913824 NU-CAPTO 02234254 PENTA-CAPTOPRIL 02230203 PMS-CAPTOPRIL
APX
ST
ST
APX BMS PDL ZYM DPC GEN MEC NOP NXP PEN PMS
2010
Page 37 of 124
Health Canada

CILAZAPRIL
ST

ENALAPRIL MALEATE
ST
5mg Tablet 02291150 02285223 02283794 01911481 02266377 02280469
APO-CILAZAPRIL CO CILAZAPRIL GEN-CILAZAPRIL INHIBACE NOVO-CILAZAPRIL PMS-CILAZAPRIL
APX COB GEN HLR NOP PMS
CILAZAPRIL, HYDROCHLOROTHIAZIDE
ST
5mg & 12.5mg Tablet 02284987 APO-CILAZAPRIL HCTZ 02181479 INHIBACE PLUS 5mg/12.5mg Tablet 02313731 NOVO-CILAZAPRIL/HCTZ
APX HLR
ST
20mg Tablet 02019906 APO ENALAPRIL 02291908 CO ENALAPRIL 02300060 GEN-ENALAPRIL 02233007 NOVO-ENALAPRIL 02300109 PMS-ENALAPRIL 02300028 RATIO-ENALAPRIL 02300834 RIVA-ENALAPRIL 02299976 SANDOZ ENALAPRIL 02323508 SIG-ENALAPRIL 02300141 TARO-ENALAPRIL 00670928 VASOTEC 40mg Tablet 02330601 NOVO-ENALAPRIL
APX COB GEN NOP PMS RPH RIV SDZ SIG TAR FRS NOP
ST
NOP
ENALAPRIL MALEATE
ST
2.5mg Tablet 02020025 02291878 02300036 02300680 02300079 02299984 02300796 02299933 02323478 02300117 00851795 5mg Tablet 02019884 02291886 02300044 02233005 02300087 02299992 02300818 02299941 02323486 02300125 00708879
ENALAPRIL MALEATE, HYDROCHLOROTHIAZIDE

APX COB GEN NOP PMS RPH RIV SDZ SIG TAR FRS APX COB GEN NOP PMS RPH RIV SDZ SIG TAR FRS APX COB GEN NOP PMS RPH RIV SDZ SIG TAR FRS
ST
APO ENALAPRIL CO ENALAPRIL GEN-ENALAPRIL NOVO-ENALAPRIL PMS-ENALAPRIL RATIO-ENALAPRIL RIVA-ENALAPRIL SANDOZ ENALAPRIL SIG-ENALAPRIL TARO-ENALAPRIL VASOTEC APO ENALAPRIL CO ENALAPRIL GEN-ENALAPRIL NOVO-ENALAPRIL PMS-ENALAPRIL RATIO-ENALAPRIL RIVA-ENALAPRIL SANDOZ ENALAPRIL SIG-ENALAPRIL TARO-ENALAPRIL VASOTEC
5mg & 12.5mg Tablet 02300222 NOVO-ENALAPRIL/HCTZ 10mg & 25mg Tablet 02300230 NOVO-ENALAPRIL/HCTZ 00657298 VASERETIC
NOP NOP FRS
ST
FOSINOPRIL SODIUM
ST
ST
10mg Tablet 02266008 02332566 02262401 02331004 01907107 02247802 02303000 02255944 02294524 02275252 02265923 20mg Tablet 02266016 02332574 02262428 02331012 01907115 02247803 02303019 02255952 02294532 02275260 02265931
APO-FOSINOPRIL FOSINOPRIL GEN-FOSINOPRIL JAMP-FOSINOPRIL MONOPRIL NOVO-FOSINOPRIL PDL-FOSINOPRIL PMS-FOSINOPRIL RAN-FOSINOPRIL RATIO-FOSINOPRIL RIVA-FOSINOPRIL APO-FOSINOPRIL FOSINOPRIL GEN-FOSINOPRIL JAMP-FOSINOPRIL MONOPRIL NOVO-FOSINOPRIL PDL-FOSINOPRIL PMS-FOSINOPRIL RAN-FOSINOPRIL RATIO-FOSINOPRIL RIVA-FOSINOPRIL
APX RBY GEN JMP BMS NOP PDL PMS RBY RPH RIV APX RBY GEN JMP BMS NOP PDL PMS RBY RPH RIV
ST
ST
10mg Tablet 02019892 APO ENALAPRIL 02291894 CO ENALAPRIL 02300052 GEN-ENALAPRIL 02233006 NOVO-ENALAPRIL 02300095 PMS-ENALAPRIL 02300001 RATIO-ENALAPRIL 02300826 RIVA-ENALAPRIL 02299968 SANDOZ ENALAPRIL 02323494 SIG-ENALAPRIL 02300133 TARO-ENALAPRIL 00670901 VASOTEC
2010
Page 38 of 124
Health Canada

LISINOPRIL
ST

LISINOPRIL, HYDROCHLOROTHIAZIDE
ST
5mg Tablet 09853685 02217481 02271443 02274833 02285061 02285118 02292203 00839388 02310961 02294230 02256797 02299879 02300958 02289199 02049333 10mg Tablet 09853960 02217503 02271451 02274841 02285088 02285126 02292211 00839396 02310988 02294249 02256800 02299887 02300982 02289202 02049376 20mg Tablet 09854010 02217511 02271478 02274868 02285096 02285134 02292238 00839418 02310996 02294257 02256819 02299895 02300990 02289229 02049384
APO-LISINOPRIL APO-LISINOPRIL (TYPE Z) CO LISINOPRIL GEN-LISINOPRIL NOVO-LISINOPRIL (TYPE P) NOVO-LISINOPRIL (TYPE Z) PMS-LISINOPRIL PRINIVIL PRO-LISINOPRIL RAN-LISINOPRIL RATIO-LISINOPRIL P RATIO-LISINOPRIL Z RIVA-LISINOPRIL SANDOZ LISINOPRIL ZESTRIL APO-LISINOPRIL APO-LISINOPRIL (TYPE Z) CO LISINOPRIL GEN-LISINOPRIL NOVO-LISINOPRIL (TYPE P) NOVO-LISINOPRIL (TYPE Z) PMS-LISINOPRIL PRINIVIL PRO-LISINOPRIL RAN-LISINOPRIL RATIO-LISINOPRIL P RATIO-LISINOPRIL Z RIVA-LISINOPRIL SANDOZ-LISINOPRIL ZESTRIL APO-LISINOPRIL APO-LISINOPRIL (TYPE Z) CO LISINOPRIL GEN-LISINOPRIL NOVO-LISINOPRIL (TYPE P) NOVO-LISINOPRIL (TYPE Z) PMS-LISINOPRIL PRINIVIL PRO-LISINOPRIL RAN-LISINOPRIL RATIO-LISINOPRIL P RATIO-LISINOPRIL Z RIVA-LISINOPRIL SANDOZ LISINOPRIL ZESTRIL
APX APX COB GEN NOP NOP PMS FRS PDL RBY RPH RPH RIV SDZ AZC APX APX COB GEN NOP NOP PMS FRS PDL RBY RPH RPH RIV SDZ AZC APX APX COB GEN NOP NOP PMS FRS PDL RBY RPH RPH RIV SDZ AZC
10mg & 12.5mg Tablet 02261979 APO-LISINOPRIL/HCTZ 02297736 GEN-LISINOPRIL HCTZ 02302136 NOVO-LISINOPRIL/HCTZ (TYPE P) 02301768 NOVO-LISINOPRIL/HCTZ (TYPE Z) 02108194 PRINZIDE 02302365 SANDOZ LISINOPRIL HCT 02103729 ZESTORETIC 20mg & 12.5mg Tablet 02261987 APO-LISINOPRIL/HCTZ 02297744 GEN-LISINOPRIL HCTZ 02302144 NOVO-LISINOPRIL (TYPE P) 02301776 NOVO-LISINOPRIL/HCTZ (TYPE Z) 00884413 PRINZIDE 02302373 SANDOZ LISINOPRIL HCT 02045737 ZESTORETIC 20mg & 25mg Tablet 02261995 APO-LISINOPRIL/HCTZ 02297752 GEN-LISINOPRIL HCTZ 02302152 NOVO-LISINOPRIL/HCTZ (TYPE P) 02301784 NOVO-LISINOPRIL/HCTZ (TYPE Z) 02302381 SANDOZ LISINOPRIL HCT 02045729 ZESTORETIC
APX GEN NOP NOP FRS SDZ AZC APX GEN NOP NOP FRS SDZ AZC APX GEN NOP NOP SDZ AZC
ST
ST
ST
PERINDOPRIL ERBUMINE
ST
2mg Tablet 02123274 4mg Tablet 02123282 8mg Tablet 02246624
COVERSYL COVERSYL COVERSYL
SEV SEV SEV
ST
ST
ST
PERINDOPRIL ERBUMINE, INDAPAMIDE

ST
4mg & 1.25mg Tablet 02246569 COVERSYL PLUS
SEV
PERINDOPRIL ERBUMINE,INDAPAMIDE
ST
8mg/2.5mg Tablet 02321653 COVERSYL PLUS HD
SEV
QUINAPRIL HCL
ST
ACCUPRIL ACCUPRIL ACCUPRIL ACCUPRIL
PFI PFI PFI PFI
ST
ST
ST
2010
Page 39 of 124
Health Canada

QUINAPRIL HCL, HYDROCHLOROTHIAZIDE
ST

RAMIPRIL
ST
10mg & 12.5mg Tablet 02237367 ACCURETIC 20mg & 12.5mg Tablet 02237368 ACCURETIC 20mg & 25mg Tablet 02237369 ACCURETIC
PFI
ST
2.5mg Tablet 02291401 SANDOZ RAMIPRIL 5mg Tablet 02291428 10mg Tablet 02291436 15mg Tablet 02325381 02311194 SANDOZ RAMIPRIL SANDOZ RAMIPRIL APO-RAMIPRIL RATIO-RAMIPRIL
SDZ SDZ SDZ APX RPH
ST
PFI
ST
ST
PFI
ST
RAMIPRIL
ST
1.25mg Capsule 02221829 ALTACE 02251515 APO-RAMIPRIL 02295482 CO RAMIPRIL 02301148 GEN-RAMIPRIL 02331101 JAMP-RAMIPRIL 02295369 PMS-RAMIPRIL 02299372 RAMIPRIL 02310503 RAN RAMIPRIL 02287692 RATIO-RAMIPRIL 2.5mg Capsule 02221837 ALTACE 02251531 APO-RAMIPRIL 02295490 CO RAMIPRIL 02301156 GEN-RAMIPRIL 02331128 JAMP-RAMIPRIL 02247945 NOVO-RAMIPRIL 02247917 PMS-RAMIPRIL 02255316 RAMIPRIL 02310511 RAN RAMIPRIL 02287706 RATIO-RAMIPRIL 5mg Capsule 02221845 02251574 02295504 02301164 02331136 02247946 02247918 02255324 02310538 02287714 ALTACE APO-RAMIPRIL CO RAMIPRIL GEN-RAMIPRIL JAMP-RAMIPRIL NOVO-RAMIPRIL PMS-RAMIPRIL RAMIPRIL RAN RAMIPRIL RATIO-RAMIPRIL
SAC APX COB GEN JMP PMS PMS RBY RPH SAC APX COB GEN JMP NOP PMS PMS RBY RPH SAC APX COB GEN JMP NOP PMS PMS RBY RPH SAC APX COB GEN JMP NOP PMS PMS RBY RPH SDZ
RAMIPRIL, HYDROCHLOROTHIAZIDE
ST
2.5mg/12.5mg Tablet 02283131 ALTACE HCT 5mg/12.5mg Tablet 02283158 ALTACE HCT 5mg/25mg Tablet 02283174 ALTACE HCT 10mg/12.5mg Tablet 02283166 ALTACE HCT 10mg/25mg Tablet 02283182 ALTACE HCT
SAC SAC SAC SAC SAC
ST
ST
ST ST
ST
TRANDOLAPRIL
ST
0.5mg Capsule 02231457 MAVIK 1mg Capsule 02231459 MAVIK 2mg Capsule 02231460 MAVIK 4mg Capsule 02239267 MAVIK
ABB ABB ABB ABB
ST
ST
ST
ST
24:32.08 ANGIOTENSIN II RECEPTOR ANTAGONISTS

CANDESARTAN CILEXETIL
ST
ATACAND ATACAND ATACAND ATACAND
AZE AZC AZC AZC
ST
ST
10mg Capsule 02221853 ALTACE 02251582 APO-RAMIPRIL 02295512 CO RAMIPRIL 02301172 GEN-RAMIPRIL 02331144 JAMP-RAMIPRIL 02247947 NOVO-RAMIPRIL 02247919 PMS-RAMIPRIL 02255332 RAMIPRIL 02310546 RAN RAMIPRIL 02287722 RATIO-RAMIPRIL 1.25mg Tablet 02291398 SANDOZ RAMIPRIL
ST
ST
CANDESARTAN CILEXETIL, HYDROCHLOROTHIAZIDE

ST
16mg/12.5mg Tablet 02244021 ATACAND PLUS 32mg/12.5mg Tablet 02332922 ATACAND PLUS 32mg/25mg Tablet 02332957 ATACAND PLUS
AZC AZE AZE Page 40 of 124
ST
ST
ST
2010
Health Canada

EPOSARTAN MESYLATE
ST

OLMESARTAN MEDOXOMIL, HYDROCHLORTHIAZIDE
SPH SPH
ST
400mg Tablet 02240432 TEVETEN 600mg Tablet 02243942 TEVETEN
ST
20mg/12.5mg Tablet 02319616 OLMETEC PLUS 40mg/12.5mg Tablet 02319624 OLMETEC PLUS 40mg/25mg Tablet 02319632 OLMETEC PLUS
SCH SCH SCH
ST
EPOSARTAN MESYLATE, HYDROCHLOROTHIAZIDE

ST
ST
600mg/12.5mg Tablet 02253631 TEVETEN PLUS
SPH
TELMISARTAN
ST
IRBESARTAN
ST
40mg Tablet 02240769 80mg Tablet 02240770
MICARDIS MICARDIS
BOE BOE
ST
AVAPRO
SAC SAC SAC

ST
ST
150mg Tablet 02237924 AVAPRO 300mg Tablet 02237925 AVAPRO
TELMISARTAN, HYDROCHLOROTHIAZIDE
ST
ST
80mg & 12.5mg Tablet 02244344 MICARDIS PLUS 80mg & 25mg Tablet 02318709 MICARDIS PLUS
BOE BOE
IRBESARTAN, HYDROCHLOROTHIAZIDE
ST
150mg & 12.5mg Tablet 02241818 AVALIDE 300mg & 12.5mg Tablet 02241819 AVALIDE 300mg & 25mg Tablet 02280213 AVALIDE
SAC SAC
VALSARTAN
ST
ST
40mg Tablet 02270528 80mg Tablet 02236808 02244781
DIOVAN DIOVAN DIOVAN
NVR NOV NVR NVR NVR
ST
ST
SAC
ST
LOSARTAN POTASSIUM
ST
COZAAR COZAAR
FRS FRS FRS
160mg Tablet 02244782 DIOVAN 320mg Tablet 02289504 DIOVAN
ST
ST
ST
100mg Tablet 02182882 COZAAR
VALSARTAN, HYDROCHLOROTHIAZIDE
ST
LOSARTAN POTASSIUM, HYDROCHLOROTHIAZIDE

ST
80mg & 12.5mg Tablet 02241900 DIOVAN-HCT 160mg & 12.5mg Tablet 02241901 DIOVAN-HCT 160mg & 25mg Tablet 02246955 DIOVAN-HCT 320mg & 12.5mg Tablet 02308908 DIOVAN-HCT 320mg & 25mg Tablet 02308916 DIOVAN-HCT
NVR NVR NVR NOV NOV
ST
50mg & 12.5mg Tablet 02230047 HYZAAR 100mg & 12.5mg Tablet 02297841 HYZAAR 100mg & 25mg Tablet 02241007 HYZAAR DS
ST
FRS
ST
ST
FRS
ST
ST
FRS
OLMESARTAN MEDOXOMIL
ST
OLMETEC OLMETEC OLMETEC
SCH SCH SCH
ST
24:32.20 MINERALOCORTICOIDE (ALDOSTERONE) RECEPTOR ANTAGONISTS

SPIRONOLACTONE
ST
ST
25mg Tablet 00028606 00613215
ALDACTONE NOVO-SPIROTON
PFI NOP PFI NOP Page 41 of 124
ST
100mg Tablet 00285455 ALDACTONE 00613223 NOVO-SPIROTON
2010
Health Canada
28:00 CENTRAL NERVOUS SYSTEM AGENTS

28:08.04 NONSTEROIDAL ANTIINFLAMMATORY AGENTS
ACETYLSALICYLIC ACID
ST

ACETYLSALICYLIC ACID
ST
80mg Chewable Tablet 02009013 ASAPHEN 02269139 JAMP-ASA 02202352 RIVASA 80mg Delayed Release Tablet 02283905 ACETYLSALICYLIC ACID 02238545 ASAPHEN EC 162mg Delayed Release Tablet 02247550 ASAPHEN EC 325mg Delayed Release Tablet 02284529 PMS-ASA EC 650mg Delayed Release Tablet 02284537 PMS-ASA EC 81mg Enteric Coated Tablet 02243101 ASA 02244993 ASA 02237726 ASPIRIN 02242281 ENTROPHEN EC 02283700 PRAXIS ASA EC 325mg Enteric Coated Tablet 00510696 APO-ASEN ECT 02010526 ASA 02150417 ASPIRIN 02050161 ENTROPHEN 00010332 ENTROPHEN-5 00216666 NOVASEN 02285371 PMS-ASA EC 650mg Enteric Coated Tablet 00472476 ASA 00794244 ASA 02046261 ASA 01905392 ENTROPHEN-10 00229296 NOVASEN 150mg Suppository 00785547 PMS-ASA 650mg Suppository 00582867 ASA
PMS JMP RIV JMP PMS PMS PMS PMS PMS PMS BCD PED PMS APX VTH BCD WAM WAM NOP PMS APX WSB FRS FRS NOP PMS JNO BCD EUR PRO PRO RIV ZYM ZYM
325mg Tablet 00472468 00036145 00230324 00530336 02150328
APO-ASA ASA ASA ASA ASPIRIN
APX PED NOP VTH BCD FRS
ST
ST
650mg Tablet 00010340 ENTROPHEN 10
CELECOXIB
Limited use benefit (prior approval required). For patients with osteoarthritis who have failed therapy with acetaminophen and who: a. - have failed to achieve adequate response with 2 other listed NSAIDs, or b. - have experienced an adverse event attributable to 2 other listed NSAIDs, or c. - have a history of a serious gastrointestinal complication such as bleeding or perforation. For patients with rheumatoid arthritis who: a. - have failed to achieve adequate response with 2 other listed NSAIDs, or b. - have experienced an adverse event attributable to 2 other listed NSAIDs, or c. - have a history of a serious gastrointestinal complication such as bleeding or perforation. 100mg Capsule 02239941 CELEBREX 200mg Capsule 02239942 CELEBREX PFI PFI
ST
ST
ST
ST
ST
DICLOFENAC SODIUM
25mg Delayed Release Tablet 02302616 PMS-DICLOFENAC 25MG DR 50mg Delayed Release Tablet 02302624 PMS-DICLOFENAC 50MG DR 25mg Enteric Coated Tablet 00839175 APO-DICLO 00870951 DICLOFENAC-25 02231662 DOM-DICLOFENAC 00808539 NOVO-DIFENAC 00886017 NU-DICLO 02231502 PMS-DICLOFENAC 02261952 SANDOZ-DICLOFENAC 50mg Enteric Coated Tablet 00839183 APO-DICLO 00870978 DICLOFENAC-50 02231663 DOM-DICLOFENAC 00808547 NOVO-DIFENAC 00886025 NU-DICLO 02231503 PMS-DICLOFENAC 02261960 SANDOZ-DICLOFENAC 00514012 VOLTAREN PMS PMS APX PDL DPC NOP NXP PMS SDZ APX PDL DPC NOP NXP PMS SDZ NVR
ST
ST
80mg Tablet 02150352 02250675 02311496 02311518 02202360 02321750 02321769
ASPIRIN EURO-ASA PRO-ASA 80MG EC TAB PRO-ASA 80MG TAB RIVASA ZYM-ASA ZYM-ASA EC
2010
Page 42 of 124
Health Canada

DICLOFENAC SODIUM
50mg Suppository 02231506 PMS-DICLOFENAC 02241224 SANDOZ DICLOFENAC 02261928 SANDOZ-DICLOFENAC 00632724 VOLTAREN 100mg Suppository 02231508 PMS-DICLOFENAC 02241225 SANDOZ DICLOFENAC 02261936 SANDOZ-DICLOFENAC 00632732 VOLTAREN 75mg Sustained Release Tablet 02224119 DICLOFENAC-SR 02231664 DOM-DICLOFENAC SR 02158582 NOVO-DIFENAC SR 02228203 NU-DICLO SR 02231504 PMS-DICLOFENAC SR 02261901 SANDOZ-DICLOFENAC SR 00782459 VOLTAREN SR 100mg Sustained Release Tablet 02091194 APO-DICLO SR 02224127 DICLOFENAC-SR 02231665 DOM-DICLOFENAC SR 02048698 NOVO-DIFENAC SR 02228211 NU-DICLO SR 02231505 PMS-DICLOFENAC SR 02261944 SANDOZ-DICLOFENAC SR 00590827 VOLTAREN SR PMS SDZ SDZ NVR PMS SDZ SDZ NVR PDL DPC NOP NXP PMS SDZ NVR APX PDL DPC NOP NXP PMS SDZ NVR

FLURBIPROFEN
100mg Tablet 00600792 01912038 01947737 02100517 02020688 ANSAID APO-FLURBIPROFEN FLURBIPROFEN NOVO-FLURPROFEN NU-FLURBIPROFEN PFI APX PRO NOP NXP
IBUPROFEN
200mg Capsule 02241769 ADVIL LIQUI-GEL 02281384 IBUPROFEN 400mg Capsule 02248231 ADVIL LIQUI-GEL 02310880 IBUPROFEN 100mg Chewable Tablet 02246403 ADVIL JUNIOR STRENGTH 40mg/mL Drop 02242522 ADVIL PEDIATRIC 02238626 CHILDREN'S MOTRIN 20mg/mL Oral Liquid 02232297 CHILDREN'S ADVIL 02242365 CHILDREN'S MOTRIN 100mg Tablet 02240527 MOTRIN JUNIOR STRENGTH 200mg Tablet 01933558 00441643 00636517 02238004 02257912 02272849 02186934 ADVIL APO-IBUPROFEN IBUPROFEN IBUPROFEN IBUPROFEN IBUPROFEN MOTRIN WRI APX WAY APX WRI WRI MCL WRI JNO MCL WRI APX PDL VTH PMT VTH MCL APX PDL NXP APX PDL JMP NXP PMS APX PDL NOP NXP
DICLOFENAC SODIUM, MISOPROSTOL

50mg & 200mcg Tablet 01917056 ARTHROTEC 75mg & 200mcg Tablet 02229837 ARTHROTEC PFI PFI
DIFLUNISAL
250mg Tablet 02039486 APO-DIFLUNISAL 02048493 NOVO-DIFLUNISAL 500mg Tablet 02039494 APO-DIFLUNISAL 02058413 NU-DIFLUNISAL APX NOP APX NXP
300mg Tablet 00441651 APO-IBUPROFEN 00636525 IBUPROFEN 02020696 NU-IBUPROFEN 400mg Tablet 00506052 00636533 02317338 02020718 00836133 600mg Tablet 00585114 00658804 00629359 02020726 APO-IBUPROFEN IBUPROFEN JAMP IBUPROFEN NU-IBUPROFEN PMS-IBUPROFEN APO-IBUPROFEN IBUPROFEN NOVO-PROFEN NU-IBUPROFEN
FLURBIPROFEN
50mg Tablet 00647942 01912046 01947729 02100509 02020661 ANSAID APO-FLURBIPROFEN FLURBIPROFEN NOVO-FLURPROFEN NU-FLURBIPROFEN PFI APX PRO NOP NXP
2010
Page 43 of 124
Health Canada

INDOMETHACIN
25mg Capsule 00611158 APO-INDOMETHACIN 00337420 NOVO-METHACIN 00865850 NU-INDO 00646261 PRO-INDO 50mg Capsule 00611166 APO-INDOMETHACIN 00337439 NOVO-METHACIN 00865869 NU-INDO 00646288 PRO-INDO 50mg Suppository 02231799 SANDOZ INDOMETHACIN 100mg Suppository 01934139 RATIO-INDOMETHACIN 02231800 SANDOZ INDOMETHACIN APX NOP NXP PDL APX NOP NXP PDL SDZ RPH SDZ

MELOXICAM
15mg Tablet 02248974 02250020 02248606 02255995 02242786 02258323 02248608 02248268 02248031 APO-MELOXICAM CO MELOXICAM DOM-MELOXICAM GEN-MELOXICAM MOBICOX NOVO-MELOXICAM PHL-MELOXICAM PMS-MELOXICAM RATIO-MELOXICAM APX COB DPC GEN BOE NOP PHH PMS RPH
NAPROXEN
250mg Enteric Coated Tablet 02246699 APO-NAPROXEN EC 02162792 NAPROSYN E 02243312 NOVO-NAPROX 375mg Enteric Coated Tablet 02246700 APO-NAPROXEN EC 02162415 NAPROSYN E 02243313 NOVO-NAPROX 02294702 PMS-NAPROXEN EC 500mg Enteric Coated Tablet 02246701 APO-NAPROXEN EC 02241024 GEN-NAPROXEN EC 02162423 NAPROSYN E 02243314 NOVO-NAPROX 02294710 PMS-NAPROXEN EC 02310953 PRO-NAPROXEN EC 25mg/mL Suspension 02162431 NAPROSYN 750mg Sustained Release Tablet 02162466 NAPROSYN SR 125mg Tablet 00522678 APO-NAPROXEN 00590754 NAPROXEN 00865621 NU-NAPROX 250mg Tablet 00522651 00590762 00565350 00865648 02240786 375mg Tablet 00600806 02243432 00655686 00627097 00865656 02240787 APO-NAPROXEN NAPROXEN NOVO-NAPROX NU-NAPROX RIVA-NAPROXEN APO-NAPROXEN GEN-NAPROXEN NAPROXEN NOVO-NAPROX NU-NAPROX RIVA-NAPROXEN APX HLR NOP APX HLR NOP PMS APX GEN HLR NOP PMS PDL HLR HLR APX PDL NXP APX PDL NOP NXP RIV APX GEN PDL NOP NXP RIV
KETOPROFEN
50mg Capsule 00790427 APO-KETO 02044633 NU-KETOPROFEN 02150808 PMS-KETOPROFEN 50mg Enteric Coated Tablet 00790435 APO KETO-E 02150816 PMS-KETOPROFEN 100mg Enteric Coated Tablet 00842664 APO-KETO-E 02150824 PMS-KETOPROFEN 50mg Suppository 02148773 PMS-KETOPROFEN 100mg Suppository 02015951 PMS-KETOPROFEN 200mg Sustained Release Tablet 02172577 APO-KETO SR 02210487 KETOPROFEN-SR APX NXP PMS APX PMS APX PMS PMS PMS APX PDL
MEFENAMIC ACID
250mg Capsule 02229452 APO-MEFENAMIC 02237826 DOM-MEFENAMIC ACID 02230408 MEFENAMIC 02229569 NU-MEFENAMIC APX DPC PDL NXP
MELOXICAM
7.5mg Tablet 02248973 02250012 02248605 02255987 02242785 02258315 02248607 02248267 02247889 APO-MELOXICAM CO MELOXICAM DOM-MELOXICAM GEN-MELOXICAM MOBICOX NOVO-MELOXICAM PHL-MELOXICAM PMS-MELOXICAM RATIO-MELOXICAM APX COB DPC GEN BOE NOP PHH PMS RPH
2010
Page 44 of 124
Health Canada

NAPROXEN
500mg Tablet 00592277 00618721 00589861 00865664 02240788 APO-NAPROXEN NAPROXEN NOVO-NAPROX NU-NAPROX RIVA-NAPROXEN APX PDL NOP NXP RIV

SULINDAC
200mg Tablet 00778362 00745596 02042584 02239164 00808636 APO-SULIN NOVO-SUNDAC NU-SULINDAC PENTA-SULINDAC SULINDAC APX NOP NXP PEN PDL
NAPROXEN SODIUM
275mg Tablet 02162725 00784354 00887056 00778389 550mg Tablet 02162717 01940309 02153386 02026600 02240828 ANAPROX APO-NAPRO NA NAPROXEN NA NOVO-NAPROX SODIUM ANAPROX DS APO-NAPRO NA DS NAPROXEN-NA DF NOVO-NAPROX SODIUM DS RIVA-NAPROXEN SODIUM HLR APX PDL NOP HLR APX PDL NOP RIV
TIAPROFENIC ACID
200mg Tablet 02179679 NOVO-TIAPROFENIC 02231249 PENTA-TIAPROFENIC 02230827 PMS-TIAPROFENIC 300mg Tablet 02136120 02231060 02179687 02146886 02231250 02145014 APO-TIAPROFENIC DOM-TIAPROFENIC NOVO-TIAPROFENIC NU-TIAPROFENIC PENTA-TIAPROFENIC TIAPROFENIC NOP PEN PMS APX DPC NOP NXP PEN PDL
PIROXICAM
10mg Capsule 00642886 APO-PIROXICAM 02171813 GEN-PIROXICAM 00865761 NU-PIROX 00658839 PIROXICAM 00836249 PMS-PIROXICAM 20mg Capsule 00642894 APO-PIROXICAM 02239536 DOM-PIROXICAM 02171821 GEN-PIROXICAM 00865788 NU-PIROX 00658820 PIROXICAM 00836230 PMS-PIROXICAM 10mg Suppository 02154420 PMS-PIROXICAM 20mg Suppository 02154463 PMS-PIROXICAM 10mg Tablet 00695718 20mg Tablet 00695696 NOVO-PIROCAM NOVO-PIROCAM APX GEN NXP PDL PMS APX DPC GEN NXP PDL PMS PMS PMS NOP NOP
28:08.08 OPIATE AGONISTS

ACETAMINOPHEN, CAFFEINE CITRATE, CODEINE PHOSPHATE
300mg & 15mg & 15mg Tablet 00706515 PMS-ACET 2 00653241 RATIO-LENOLTEC NO.2 02163934 TYLENOL WITH CODEINE NO.2 300mg & 15mg & 30mg Tablet 00653276 RATIO-LENOLTEC NO.3 02163926 TYLENOL WITH CODEINE NO.3 300mg & 30mg & 15mg Tablet 00293504 ATASOL-15 02232388 EXDOL-15 300mg & 30mg & 30mg Tablet 00293512 ATASOL-30 02232389 EXDOL-30 PMS RPH JNO RPH JNO HOR PED HOR PED
ACETAMINOPHEN, CODEINE PHOSPHATE

32mg & 1.6mg/mL Elixir 00816027 PMS-ACETAMINOPHEN WITH CODEINE 02163942 TYLENOL WITH CODEINE 300mg & 30mg Tablet 01999648 ACET CODEINE 30 02232658 PROCET-30 00608882 RATIO-EMTEC-30 00789828 TRIATEC-30 300mg & 60mg Tablet 00621463 LENOLTEC NO.4 02163918 TYLENOL WITH CODEINE NO.4 PMS JNO PMS PDL RPH TRI RPH JNO
SULINDAC
150mg Tablet 00778354 00745588 02042576 00808628 APO-SULIN NOVO-SUNDAC NU-SULINDAC SULINDAC APX NOP NXP PDL
ACETAMINOPHEN, OXYCODONE HCL

325mg & 2.5mg Tablet 01916491 PERCOCET DEMI 2010 BMS Page 45 of 124
Health Canada

ACETAMINOPHEN, OXYCODONE HCL
325mg & 5mg Tablet 02324628 APO-OXYCODONE/ACET 01916548 ENDOCET 02307898 NOVO-OXYCODONE ACET 01916475 PERCOCET 02245758 PMS-OXYCODONE ACETAMINOPHEN 02327171 PRO-OXYCOD ACET 00608165 RATIO-OXYCOCET 02242468 RIVACOCET APX EDM NOP BMS PMS PDL RPH RIV

CODEINE PHOSPHATE
15mg Tablet 00779458 02009889 02243978 00593435 30mg Tablet 02009757 00593451 02243979 CODEINE CODEINE PMS-CODEINE RATIO-CODEINE CODEINE CODEINE PHOSPHATE PMS-CODEINE RPH RIV PMS RPH RIV RPH PMS
ACETYLSALICYLIC ACID, CAFFEINE CITRATE, CODEINE PHOSPHATE

375mg & 30mg & 15mg Tablet 02234510 282 375mg & 30mg & 30mg Tablet 02238645 292 PED PED
FENTANYL
Limited use benefit (prior approval required). For the management of chronic pain in patients who are unresponsive or intolerant to at least one long-acting oral sustained released product, such as morphine, hydromorphone and oxycodone, despite appropriate dose titration and adjunctive therapy including laxatives and antiemetics. 12mcg/h Transdermal Patch 02341379 PMS-FENTANYL MTX 02330105 RAN-FENTANYL MATRIX PATCH 12 02311925 RATIO-FENTANYL 02327112 SANDOZ FENTANYL 25mcg/h Transdermal Patch 02275813 DURAGESIC MAT 02314630 NOVO-FENTANYL 02341387 PMS-FENTANYL MTX 02249391 RAN-FENTANYL 02330113 RAN-FENTANYL MATRIX 02282941 RATIO-FENTANYL 02327120 SANDOZ FENTANYL 50mcg/h Transdermal Patch 02275821 DURAGESIC MAT 02314649 NOVO-FENTANYL 02341395 PMS-FENTANYL MTX 02249413 RAN-FENTANYL 02330121 RAN-FENTANYL MATRIX 02282968 RATIO-FENTANYL 02327147 SANDOZ FENTANYL 75mcg/h Transdermal Patch 02275848 DURAGESIC MAT 02314657 NOVO-FENTANYL 02341409 PMS-FENTANYL MTX 02249421 RAN-FENTANYL 02330148 RAN-FENTANYL MATRIX 02282976 RATIO-FENTANYL 02327155 SANDOZ FENTANYL PMS RBY RPH SDZ JNO NOP PMS RBY RBY RPH SDZ JNO NOP PMS RBY RBY RPH SDZ JNO NOP PMS RBY RBY RPH SDZ
ACETYLSALICYLIC ACID, OXYCODONE HCL

325mg & 5mg Tablet 01916572 PERCODAN 00608157 RATIO-OXYCODAN BMS RPH
CODEINE MONOHYDRATE, CODEINE SULFATE TRIHYDRATE

Limited use benefit (prior approval required). For treatment of: a. - chronic pain and palliative care patients as an alternative to products containing codeine in combination with acetaminophen or ASA with or without caffeine, or b. - chronic pain and palliative care patients as an alternative to regular release codeine tablets when large doses are required. 50mg Long Acting Tablet 02230302 CODEINE CONTIN CR 100mg Long Acting Tablet 02163748 CODEINE CONTIN CR 150mg Long Acting Tablet 02163780 CODEINE CONTIN CR 200mg Long Acting Tablet 02163799 CODEINE CONTIN CR PFR PFR PFR PFR
CODEINE PHOSPHATE
30mg/mL Injection 00544884 CODEINE 00497282 CODEINE PHOSPHATE 60mg/mL Injection 00497290 CODEINE PHOSPHATE 2mg/mL Liquid 00380571 LINCTUS CODEINE 5mg/mL Syrup 00050024 CODEINE PHOSPHATE 00779474 RATIO-CODEINE SDZ ABB ABB ATL ATL RPH
2010
Page 46 of 124
Health Canada

FENTANYL
Limited use benefit (prior approval required). For the management of chronic pain in patients who are unresponsive or intolerant to at least one long-acting oral sustained released product, such as morphine, hydromorphone and oxycodone, despite appropriate dose titration and adjunctive therapy including laxatives and antiemetics. 100mcg/h Transdermal Patch 02275856 DURAGESIC MAT 02314665 NOVO-FENTANYL 02341417 PMS-FENTANYL MTX 02249448 RAN-FENTANYL 02330156 RAN-FENTANYL MATRIX 02282984 RATIO-FENTANYL 02327163 SANDOZ FENTANYL TRANSDERMAL SYSTEM JNO NOP PMS RBY RBY RPH SDZ

HYDROMORPHONE HCL
Limited use benefit. Prior approval required for controlled release capsules only. Regular release dosage forms are full benefits and do not require prior approval. For treatment of moderate to severe chronic pain when other opioids such as morphine have been ineffective in controlling pain or in patients experiencing intolerable side effects. 3mg Suppository 00125105 DILAUDID 01916394 PMS-HYDROMORPHONE 1mg Tablet 00705438 02192101 00885444 2mg Tablet 00125083 02249928 00885436 4mg Tablet 00125121 02249936 00885401 8mg Tablet 00786543 02192144 00885428 DILAUDID PHL-HYDROMORPHONE PMS-HYDROMORPHONE DILAUDID PHL-HYDROMORPHONE PMS-HYDROMORPHONE DILAUDID PHL-HYDROMORPHONE PMS-HYDROMORPHONE DILAUDID PHL-HYDROMORPHONE PMS-HYDROMORPHONE ABB PMS ABB PHH PMS ABB PHH PMS ABB PHH PMS ABB PHH PMS
HYDROMORPHONE HCL
Limited use benefit. Prior approval required for controlled release capsules only. Regular release dosage forms are full benefits and do not require prior approval. For treatment of moderate to severe chronic pain when other opioids such as morphine have been ineffective in controlling pain or in patients experiencing intolerable side effects. 3mg Controlled Release Capsule 02125323 HYDROMORPH CONTIN 6mg Controlled Release Capsule 02125331 HYDROMORPH CONTIN 12mg Controlled Release Capsule 02125366 HYDROMORPH CONTIN 18mg Controlled Release Capsule 02243562 HYDROMORPH CONTIN 24mg Controlled Release Capsule 02125382 HYDROMORPH CONTIN 30mg Controlled Release Capsule 02125390 HYDROMORPH CONTIN 2mg/mL Injection 00627100 DILAUDID 02145901 HYDROMORPHONE 10mg/mL Injection 00622133 DILAUDID HP 02145928 HYDROMORPHONE HP 10 20mg/mL Injection 02146118 DILAUDID HP PLUS 02145936 HYDROMORPHONE HP 20 50mg/mL Injection 02145863 DILAUDID XP 02146126 HYDROMORPHONE HP 50 99003163 HYDROMORPHONE HP 50 1mg/mL Oral Liquid 00786535 DILAUDID 01916386 PMS-HYDROMORPHONE PFR PFR PFR PFR PFR PFR ABB SDZ ABB SDZ ABB SDZ ABB SDZ SDZ ABB PMS
MEPERIDINE HCL
Limited use benefit (prior approval not required). Limited to 2 weeks supply for acute pain. Coverage will be limited to 60 tablets per one month period. 25mg/mL Injection 00497444 PETHIDINE 50mg/mL Injection 02242003 DEMEROL 00725765 MEPERIDINE 00497452 PETHIDINE 75mg/mL Injection 02242004 DEMEROL 00725757 MEPERIDINE 00497460 PETHIDINE 100mg/mL Injection 02242005 DEMEROL 00725749 MEPERIDINE 00497479 PETHIDINE 50mg Tablet 02138018 DEMEROL ABB ABB SDZ ABB ABB SDZ ABB ABB SDZ ABB SAC
MORPHINE HCL
30mg Sustained Release Tablet 00776181 M.O.S. SR 60mg Sustained Release Tablet 00776203 M.O.S. SR VAE VAE
2010
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MORPHINE HCL
1mg/mL Syrup 00614491 DOLORAL 1 00607762 RATIO-MORPHINE 5mg/mL Syrup 00614505 DOLORAL 5 00607770 RATIO-MORPHINE 10mg/mL Syrup 00632503 M.O.S. 10 00690783 RATIO-MORPHINE 20mg/mL Syrup 00690791 RATIO-MORPHINE 50mg/mL Syrup 00690236 M.O.S. 50 10mg Tablet 00690198 20mg Tablet 00690201 40mg Tablet 00690228 60mg Tablet 00690244 M.O.S. 10 M.O.S. 20 M.O.S. 40 M.O.S. 60 ATL RPH ATL RPH VAE RPH RPH VAE VAE VAE VAE VAE

MORPHINE SULFATE
10mg Suppository 00632201 STATEX 20mg Suppository 00596965 STATEX 10mg Sustained Release Capsule 02242163 KADIAN 02019930 M-ESLON 15mg Sustained Release Capsule 02177749 M-ESLON 20mg Sustained Release Capsule 02184435 KADIAN SR 30mg Sustained Release Capsule 02019949 M-ESLON SR 50mg Sustained Release Capsule 02184443 KADIAN SR 60mg Sustained Release Capsule 02019957 M-ESLON SR 100mg Sustained Release Capsule 02184451 KADIAN SR 02019965 M-ESLON SR 200mg Sustained Release Capsule 02177757 M-ESLON SR 15mg Sustained Release Tablet 02015439 MS CONTIN SR 02302764 NOVO-MORPHINE SR 02245284 PMS-MORPHINE SULFATE 02244790 RATIO-MORPHINE SULFATE SR 30mg Sustained Release Tablet 02014297 MS CONTIN SR 02302772 NOVO-MORPHINE SR 02245285 PMS-MORPHINE SULFATE 02244791 RATIO-MORPHINE SULFATE SR 60mg Sustained Release Tablet 02014300 MS CONTIN SR 02302780 NOVO-MORPHINE SR 02245286 PMS-MORPHINE SULFATE 02244792 RATIO-MORPHINE SULFATE SR 100mg Sustained Release Tablet 02014319 MS CONTIN SR 02302799 NOVO-MORPHINE SR 02245287 PMS-MORPHINE SR 200mg Sustained Release Tablet 02014327 MS CONTIN SR 02302802 NOVO-MORPHINE SR 02245288 PMS-MORPHINE SR 1mg/mL Syrup 00591467 STATEX 5mg/mL Syrup 00591475 STATEX PMS PMS MAY SAC SAC MAY SAC MAY SAC MAY SAC SAC PFR NOP PMS RPH
MORPHINE SULFATE
20mg/mL Drop 00621935 STATEX 50mg/mL Drop 00705799 STATEX 0.5mg/mL Injection 02021056 MORPHINE LP 01949047 MORPHINE SULFATE 1mg/mL Injection 02021048 MORPHINE LP 01949055 MORPHINE SULFATE 01980696 MORPHINE SULFATE 2mg/mL Injection 00850314 MORPHINE SULFATE 01964437 MORPHINE SULFATE 02242484 MORPHINE SULFATE 5mg/mL Injection 01964429 MORPHINE SULFATE 10mg/mL Injection 00392588 MORPHINE SULFATE 00850322 MORPHINE SULFATE 15mg/mL Injection 00392561 MORPHINE SULFATE 25mg/mL Injection 00676411 MORPHINE HP 25 50mg/mL Injection 00617288 MORPHINE HP 50 02137267 MORPHINE SULFATE 5mg Suppository 00632228 STATEX 2010 PMS PMS SDZ ABB SDZ ABB SDZ ABB SDZ SDZ SDZ SDZ ABB SDZ SDZ SDZ HOS PMS
PFR NOP PMS RPH
PFR NOP PMS RPH
PFR NOP PMS PFR NOP PMS PMS PMS
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MORPHINE SULFATE
10mg/mL Syrup 00647217 STATEX 5mg Tablet 02009773 02014203 00594652 10mg Tablet 02009765 02014211 00594644 20mg Tablet 02014238 25mg Tablet 02009749 00594636 30mg Tablet 02014254 50mg Tablet 02009706 00675962 M.O.S. SULFATE MS IR STATEX M.O.S. SULFATE MS IR STATEX MS IR M.O.S. SULFATE STATEX MS IR M.O.S. SULFATE STATEX PMS VAE PFR PMS VAE PFR PMS PFR VAE PMS PFR VAE PMS

OXYCODONE HCL
Limited use benefit. Prior approval required for controlled release tablets only. Regular release dosage forms are full benefits and do not require prior approval. For treatment of moderate to severe chronic pain when other opioids such as morphine have been ineffective in controlling pain or in patients experiencing intolerable side effects. 10mg Tablet 02240131 OXY-IR 02319985 PMS-OXYCODONE 00443948 SUPEUDOL 20mg Tablet 02240132 OXY-IR 02319993 PMS-OXYCODONE 02262983 SUPEUDOL PFR PMS SDZ PFR PMS SDZ
28:08.12 OPIATE PARTIAL AGONISTS

PENTAZOCINE HCL
50mg Tablet 02137984 TALWIN SAC
PENTAZOCINE LACTATE
30mg/mL Injection 02241976 TALWIN ABB
OXYCODONE HCL
Limited use benefit. Prior approval required for controlled release tablets only. Regular release dosage forms are full benefits and do not require prior approval. For treatment of moderate to severe chronic pain when other opioids such as morphine have been ineffective in controlling pain or in patients experiencing intolerable side effects. 5mg Controlled Release Tablet 02258129 OXYCONTIN 10mg Controlled Release Tablet 02202441 OXYCONTIN 15mg Controlled Release Tablet 02323192 OXYCONTIN 20mg Controlled Release Tablet 02202468 OXYCONTIN 30mg Controlled Release Tablet 02323206 OXYCONTIN 40mg Controlled Release Tablet 02202476 OXYCONTIN 60mg Controlled Release Tablet 02323214 OXYCONTIN 80mg Controlled Release Tablet 02202484 OXYCONTIN 10mg Suppository 00392480 SUPEUDOL 20mg Suppository 00392472 SUPEUDOL 5mg Tablet 02231934 02319977 00789739 OXY-IR PMS-OXYCODONE SUPEUDOL PFR PFR PFR PFR PFR PFR PFR PFR SDZ SDZ PFR PMS SDZ
ST
28:08.92 MISCELLANEOUS ANALGESICS AND ANTIPYRETICS

ACETAMINOPHEN
ST
80mg Chewable Tablet 02129957 ACETAMIN CHILD 01905856 ACETAMINOPHEN 02017458 ACETAMINOPHEN 02015676 CHILDREN'S ACETAMINOPHEN 02263815 PEDIAPHEN CHEWABLE 160mg Chewable Tablet 02017431 ACETAMINOPHEN 02231011 FEVERHALT 02263823 PEDIAPHEN CHEWABLE 02230934 TANTAPHEN GRAPE 00876038 TEMPRA CHILDREN 80mg/mL Drop 01904140 ACETAMINOPHEN 01905864 ACETAMINOPHEN 00631353 ATASOL 02230787 FEVERHALT 02263793 PEDIAPHEN 02027801 PEDIATRIX 00887587 PMS-ACETAMINOPHEN 00875988 TEMPRA 02046059 TYLENOL GRAPE 16mg/mL Liquid 01905848 ACETAMINOPHEN 02263807 PEDIAPHEN 00792713 PMS-ACETAMINOPHEN 00884553 TEMPRA
WTR TRI RIV TAN EUR RIV PED EUR TAN MJO TAN TRI HOR PED EUR RPH PMS MJO MCL TRI EUR PMS MJO Page 49 of 124
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ACETAMINOPHEN
32mg/mL Liquid 01901389 ACETAMINOPHEN 01958836 ACETAMINOPHEN 02263831 PEDIAPHEN 02027798 PEDIATRIX 00792691 PMS-ACETAMINOPHEN 00875996 TEMPRA DOUBLE STRENGTH 02046040 TYLENOL 120mg Suppository 01919385 ABENOL 02230434 ACET 120 02046660 PMS-ACETAMINOPHEN 160mg Suppository 02230435 ACET 325mg Suppository 01919393 ABENOL 02230436 ACET 325 02046687 PMS-ACETAMINOPHEN 650mg Suppository 01919407 ABENOL 02230437 ACET 650 02046695 PMS-ACETAMINOPHEN
ST

ACETAMINOPHEN
ST
JMP TRI EUR RPH PMS MJO MCL PED PMS PMS PMS PED PMS PMS PED PMS PMS JNO
500mg Tablet 00386626 00549703 00567663 00589233 00605778 00789798 01939122 02022222 02252813 02255251 00545007 02229977 00013668 00482323 00892505 01962353 00863270 00559407 00723908
ACETAMINOPHEN ACETAMINOPHEN ACETAMINOPHEN ACETAMINOPHEN ACETAMINOPHEN ACETAMINOPHEN ACETAMINOPHEN ACETAMINOPHEN ACETAMINOPHEN ACETAMINOPHEN APO-ACETAMINOPHEN APO-ACETAMINOPHEN ATASOL FORTE NOVO-GESIC PMS-ACETAMINOPHEN TANTAPHEN TYLENOL TYLENOL EXTRA STRENGTH TYLENOL EXTRA STRENGTH
PDL PMT PED PMS VTH TRI JMP RIV PMT PMT APX APX HOR NOP PMS TAN MCL MCL MCL
FLOCTAFENINE
200mg Tablet 02244680 APO-FLOCTAFENINE 400mg Tablet 02244681 APO-FLOCTAFENINE APX APX
CHILDREN'S TYLENOL SOFT CHEWS
ST
160mg Tablet 02142805 ACETAMINOPHEN 02021420 CEPHANOL 02241361 TYLENOL JUNIOR STRENGTH 325mg Tablet 00374148 00382752 00589241 00605751 00743542 00789801 01938088 02022214 00544981 02229873 00293482 00389218 00891177 00559393 00723894 ACETAMINOPHEN ACETAMINOPHEN ACETAMINOPHEN ACETAMINOPHEN ACETAMINOPHEN ACETAMINOPHEN ACETAMINOPHEN ACETAMINOPHEN APO-ACETAMINOPHEN APO-ACETAMINOPHEN ATASOL NOVO-GESIC PMS-ACETAMINOPHEN TYLENOL TYLENOL
WTR RIV JNO WAM PRO PMS VTH PMT TRI JMP RIV APX APX HOR NOP PMS MCL MCL
28:12.04 ANTICONVULSANTS BARBITURATES

PHENOBARBITAL
5mg/mL Liquid 00645575 PMS-PHENOBARBITAL 15mg Tablet 00178799 30mg Tablet 00178802 60mg Tablet 00178810 PHENOBARBITAL PHENOBARBITAL PHENOBARBITAL PMS PMS PMS PMS PMS
ST
100mg Tablet 00178829 PHENOBARBITAL
PRIMIDONE
125mg Tablet 00399310 APO-PRIMIDONE 250mg Tablet 00396761 APO-PRIMIDONE APX APX
28:12.08 ANTICONVULSANTS BENZODIAZEPINES

CLONAZEPAM
0.25MG Tablet 02236947 PHL-CLONAZEPAM 0.25MG 02179660 PMS-CLONAZEPAM 2010 PMI PMS
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28:12.08 ANTICONVULSANTS BENZODIAZEPINES

CLONAZEPAM
0.5mg Tablet 02177889 02230366 02220598 02270641 02130998 02224100 02230950 02237277 02239024 02173344 02145227 02236948 02048701 02207818 02311593 02103656 02242077 00382825 02233960 02303310 02345676 1mg Tablet 02230368 02270668 02145235 02048728 02311607 02233982 02303329 2mg Tablet 02177897 02230369 02220601 02270676 02131013 02230951 02237278 02239025 02173352 02145243 02048736 02311615 02103737 02242078 00382841 02233985 02303337 APO-CLONAZEPAM CLONAPAM CLONAZEPAM CO CLONAZEPAM DOM-CLONAZEPAM DOM-CLONAZEPAM-R GEN-CLONAZEPAM MED-CLONAZEPAM NOVO-CLONAZEPAM NU-CLONAZEPAM PHL-CLONAZEPAM PHL-CLONAZEPAM-R 0.5MG PMS-CLONAZEPAM PMS-CLONAZEPAM R PRO-CLONAZEPAM RATIO-CLONAZEPAM RIVA-CLONAZEPAM RIVOTRIL SANDOZ-CLONAZEPAM ZYM-CLONAZEPAM ZYM-CLONAZEPAM CLONAPAM CO CLONAZEPAM PHL-CLONAZEPAM PMS-CLONAZEPAM PRO-CLONAZEPAM SANDOZ-CLONAZEPAM ZYM-CLONAZEPAM APO-CLONAZEPAM CLONAPAM CLONAZEPAM CO CLONAZEPAM DOM-CLONAZEPAM GEN-CLONAZEPAM MED-CLONAZEPAM NOVO-CLONAZEPAM NU-CLONAZEPAM PHL-CLONAZEPAM PMS-CLONAZEPAM PRO-CLONAZEPAM RATIO-CLONAZEPAM RIVA-CLONAZEPAM RIVOTRIL SANDOZ-CLONAZEPAM ZYM-CLONAZEPAM APX VAE PDL COB DPC DPC GEN MEC NOP NXP PHH PMI PMS PMS PDL RPH RIV HLR SDZ ZYM ZYM VAE COB PHH PMS PDL SDZ ZYM APX VAE PDL COB DPC GEN MEC NOP NXP PHH PMS PDL RPH RIV HLR SDZ ZYM
28:12.12 ANTICONVULSANTS HYDANTOINS

PHENYTOIN
100mg Capsule 00022780 DILANTIN 50mg Chewable Tablet 00023698 DILANTIN INFATABS 6mg/mL Suspension 00023442 DILANTIN 30 25mg/mL Suspension 00023450 DILANTIN 125 02250896 TARO-PHENYTOIN PFI PFI PFI PFI TAR
28:12.20 ANTICONVULSANTSSUCCINIMIDES
ETHOSUXIMIDE
250mg Capsule 00022799 ZARONTIN 50mg/mL Syrup 00023485 ZARONTIN ERF ERF
METHSUXIMIDE
300mg Capsule 00022802 CELONTIN ERF
28:12.92 MISCELLANEOUS ANTICONVULSANTS

CARBAMAZEPINE
100mg Chewable Tablet 02231542 PMS-CARBAMAZEPINE 02261855 SANDOZ-CARBAMAZEPINE 02244403 TARO-CARBAMAZEPINE 00369810 TEGRETOL 200mg Chewable Tablet 02231540 PMS-CARBAMAZEPINE 02261863 SANDOZ-CARBAMAZEPINE 02244404 TARO-CARBAMAZEPINE 00665088 TEGRETOL 200mg Extended Release Tablet 02261839 SANDOZ-CARBAMAZEPINE 400mg Extended Release Tablet 02261847 SANDOZ-CARBAMAZEPINE 20mg/mL Suspension 02194333 TEGRETOL 200mg Sustained Release Tablet 02238222 DOM-CARBAMAZEPINE CR 02241882 GEN-CARBAMAZEPINE CR 02231543 PMS-CARBAMAZEPINE SRT 02237907 TARO-CARBAMAZEPINE CR 00773611 TEGRETOL CR PMS SDZ TAR NVR PMS SDZ TAR NVR SDZ SDZ NVR DPC GEN PMS TAR NVR
28:12.12 ANTICONVULSANTS HYDANTOINS

PHENYTOIN
30mg Capsule 00022772 DILANTIN 2010 PFI
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CARBAMAZEPINE
400mg Sustained Release Tablet 02238223 DOM-CARBAMAZEPINE CR 02241883 GEN-CARBAMAZEPINE CR 02231544 PMS-CARBAMAZEPINE SRT 02237908 TARO-CARBAMAZEPINE CR 00755583 TEGRETOL CR 200mg Tablet 00402699 00578460 00782718 02042568 00010405 APO-CARBAMAZEPINE CARBAMAZEPINE NOVO-CARBAMAZ NU-CARBAMAZEPINE TEGRETOL DPC GEN PMS TAR NVR APX PDL NOP NXP NVR

GABAPENTIN
100mg Capsule 02244304 APO-GABAPENTIN 02256142 CO GABAPENTIN 02243743 DOM-GABAPENTIN 02248259 GEN-GABAPENTIN 02084260 NEURONTIN 02244513 NOVO-GABAPENTIN 02246314 PHL-GABAPENTIN 02243446 PMS-GABAPENTIN 02310449 PRO-GABAPENTIN 02319055 RAN-GABAPENTIN 02260883 RATIO-GABAPENTIN 02251167 RIVA-GABAPENTIN 02304775 ZYM-GABAPENTIN 300mg Capsule 02244305 APO-GABAPENTIN 02256150 CO GABAPENTIN 02243744 DOM-GABAPENTIN 02249375 GABAPENTIN 02273853 GABAPENTIN 02248260 GEN-GABAPENTIN 02084279 NEURONTIN 02244514 NOVO-GABAPENTIN 02246315 PHL-GABAPENTIN 02243447 PMS-GABAPENTIN 02310457 PRO-GABAPENTIN 02319063 RAN-GABAPENTIN 02260891 RATIO-GABAPENTIN 02251175 RIVA-GABAPENTIN 02304783 ZYM-GABAPENTIN 400mg Capsule 02244306 APO-GABAPENTIN 02256169 CO GABAPENTIN 02243745 DOM-GABAPENTIN 02249383 GABAPENTIN 02248261 GEN-GABAPENTIN 02084287 NEURONTIN 02244515 NOVO-GABAPENTIN 02246316 PHL-GABAPENTIN 02243448 PMS-GABAPENTIN 02310465 PRO-GABAPENTIN 02319071 RAN-GABAPENTIN 02260905 RATIO-GABAPENTIN 02251183 RIVA-GABAPENTIN 02304791 ZYM-GABAPENTIN 600mg Tablet 02293358 02239717 02248457 02255898 02310473 02260913 02259796 APO-GABAPENTIN NEURONTIN NOVO-GABAPENTIN PMS-GABAPENTIN PRO-GABAPENTIN RATIO-GABAPENTIN RIVA-GABAPENTIN APX COB DPC GEN PFI NOP PMI PMS PDL RBY RPH RIV ZYM APX COB DPC PRE GEN GEN PFI NOP PMI PMS PDL RBY RPH RIV ZYM APX COB DPC PRE GEN PFI NOP PMI PMS PDL RBY RPH RIV ZYM APX PFI NOP PMS PDL RPH RIV
DIVALPROEX SODIUM
125mg Delayed Release Tablet 02265133 GEN-DIVALPROEX 250mg Delayed Release Tablet 02265141 GEN-DIVALPROEX 500mg Delayed Release Tablet 02265168 GEN-DIVALPROEX 125mg Enteric Coated Tablet 02239698 APO-DIVALPROEX 00596418 EPIVAL 02239701 NOVO-DIVALPROEX 02239517 NU-DIVALPROEX 02244138 PMS-DIVALPROEX 250mg Enteric Coated Tablet 02239699 APO-DIVALPROEX 00596426 EPIVAL 02239702 NOVO-DIVALPROEX 02239518 NU-DIVALPROEX 02244139 PMS-DIVALPROEX 500mg Enteric Coated Tablet 02239700 APO-DIVALPROEX 02240343 DIVALPROEX EC 00596434 EPIVAL 02239703 NOVO-DIVALPROEX 02239519 NU-DIVALPROEX 02244140 PMS-DIVALPROEX GEN GEN GEN APX ABB NOP NXP PMS APX ABB NOP NXP PMS APX PDL ABB NOP NXP PMS
2010
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GABAPENTIN
800mg Tablet 02293366 02239718 02247346 02255901 02310481 02260921 02259818 APO-GABAPENTIN NEURONTIN NOVO-GABAPENTIN PMS-GABAPENTIN PRO-GABAPENTIN RATIO-GABAPENTIN RIVA-GABAPENTIN APX PFI NOP PMS PDL RPH RIV

LEVETIRACETAM
Limited use benefit (prior approval required). For the use in combination with other anti-epileptic medication(s) in the treatment of partial seizures in patients who are refractory to adequate trials of three anti-epileptic medications used either as monotherapy or in combination. This product must be prescribed by a Neurologist. 500mg Tablet 02285932 02274191 02247028 02296128 750mg Tablet 02285940 02274205 02247029 02296136 APO-LEVETIRACETAM CO LEVETIRACETAM KEPPRA PMS-LEVETIRACETAM APO-LEVETIRACETAM CO LEVETIRACETAM KEPPRA PMS-LEVETIRACETAM APX COB UCB PMS APX COB UCB PMS
LAMOTRIGINE
2mg Chewable Tablet 02243803 LAMICTAL 5mg Chewable Tablet 02240115 LAMICTAL 25mg Tablet 02245208 02265494 02142082 02302969 02248232 02246897 02243352 100mg Tablet 02245209 02265508 02142104 02302985 02248233 02246898 02243353 150mg Tablet 02245210 02265516 02142112 02302993 02248234 02246899 02246963 APO-LAMOTRIGINE GEN-LAMOTRIGINE LAMICTAL LAMOTRIGINE NOVO-LAMOTRIGINE PMS-LAMOTRIGINE RATIO-LAMOTRIGINE APO-LAMOTRIGINE GEN-LAMOTRIGINE LAMICTAL LAMOTRIGINE NOVO-LAMOTRIGINE PMS-LAMOTRIGINE RATIO-LAMOTRIGINE APO-LAMOTRIGINE GEN-LAMOTRIGINE LAMICTAL LAMOTRIGINE NOVO-LAMOTRIGINE PMS-LAMOTRIGINE RATIO-LAMOTRIGINE GSK GSK APX GEN GSK PDL NOP PMS RPH APX GEN GSK PDL NOP PMS RPH APX GEN GSK PDL NOP PMS RPH
TOPIRAMATE
15mg Sprinkle Capsule 02239907 TOPAMAX SPRINKLE 25mg Sprinkle Capsule 02239908 TOPAMAX SPRINKLE 25mg Tablet 02279614 02287765 02271141 02263351 02315645 02248860 02271184 02262991 02313650 02256827 02260050 02230893 02325136 50mg Tablet 02312085 100mg Tablet 02279630 02287773 02271168 02263378 02315653 02248861 02271192 02263009 02313669 02256835 02260069 02230894 02325144 APO-TOPIRAMATE CO TOPIRAMATE DOM-TOPIRAMATE GEN-TOPIRAMATE MINT-TOPIRAMATE NOVO-TOPIRAMATE PHL-TOPIRAMATE PMS-TOPIRAMATE PRO-TOPIRAMATE RATIO-TOPIRAMATE SANDOZ-TOPIRAMATE TOPAMAX ZYM-TOPIRAMATE PMS-TOPIRAMATE APO-TOPIRAMATE CO TOPIRAMATE DOM-TOPIRAMATE GEN-TOPIRAMATE MINT-TOPIRAMATE NOVO-TOPIRAMATE PHL-TOPIRAMATE PMS-TOPIRAMATE PRO-TOPIRAMATE RATIO-TOPIRAMATE SANDOZ-TOPIRAMATE TOPAMAX ZYM-TOPIRAMATE JNO JNO APX COB DPC GEN MIN NOP PMI PMS PDL RPH SDZ JNO ZYM PMS APX COB DPC GEN MIN NOP PMI PMS PDL RPH SDZ JNO ZYM
LEVETIRACETAM
Limited use benefit (prior approval required). For the use in combination with other anti-epileptic medication(s) in the treatment of partial seizures in patients who are refractory to adequate trials of three anti-epileptic medications used either as monotherapy or in combination. This product must be prescribed by a Neurologist. 250mg Tablet 02285924 02274183 02247027 02296101 APO-LEVETIRACETAM CO LEVETIRACETAM KEPPRA PMS-LEVETIRACETAM APX COB UCB PMS
2010
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TOPIRAMATE
200mg Tablet 02279649 02287781 02271176 02263386 02315661 02248862 02313677 02271206 02263017 02256843 02267837 02230896 02325152 APO-TOPIRAMATE CO TOPIRAMATE DOM-TOPIRAMATE GEN-TOPIRAMATE MINT-TOPIRAMATE NOVO-TOPIRAMATE PDL-TOPIRAMATE PHL-TOPIRAMATE PMS-TOPIRAMATE RATIO-TOPIRAMATE SANDOZ-TOPIRAMATE TOPAMAX ZYM-TOPIRAMATE APX COB DPC GEN MIN NOP PDL PMI PMS RPH SDZ JNO ZYM
28:16.04 ANTIDEPRESSANTS
AMITRIPTYLINE HCL
10mg Tablet 00370991 AMITRIPTYLINE 00335053 APO-AMITRIPTYLINE 02248131 DOM-AMITRIPTYLINE 00037400 NOVO-TRIPTYN 02247302 PMS-AMITRIPTYLINE 25mg Tablet 00371009 AMITRIPTYLINE 00335061 APO-AMITRIPTYLINE 02248132 DOM-AMITRIPTYLINE 00037419 NOVO-TRIPTYN 02247303 PMS-AMITRIPTYLINE 50mg Tablet 00456349 AMITRIPTYLINE 00335088 APO-AMITRIPTYLINE 02248133 DOM-AMITRIPTYLINE 00271152 LEVATE 00037427 NOVO-TRIPTYN 02247304 PMS-AMITRIPTYLINE 75mg Tablet 00754129 APO-AMITRIPTYLINE 00354295 ELAVIL 00405612 LEVATE PRO APX DPC NOP PMS PRO APX DPC NOP PMS PDL APX DPC ICN NOP PMS APX FRS VAE
VALPROATE, SODIUM
50mg/mL Syrup 02238370 APO-VALPROIC 00443832 DEPAKENE 02238817 DOM-VALPROIC ACID 02236807 PMS-VALPROIC ACID 02140063 RATIO-VALPROIC APX ABB DPC PMS RPH
VALPROIC ACID
250mg Capsule 02238048 APO-VALPROIC 00443840 DEPAKENE 02231030 DOM-VALPROIC ACID 02184648 GEN-VALPROIC 02230663 MED-VALPROIC ACID 02100630 NOVO-VALPROIC 02237830 NU-VALPROIC 02238546 PDL-VALPROIC 02231248 PENTA-VALPROIC 02230768 PMS-VALPROIC ACID 02140047 RATIO-VALPROIC ACID 02239714 SANDOZ-VALPROIC 500mg Enteric Coated Capsule 02231031 DOM-VALPROIC ACID 02218321 NOVO-VALPROIC 02260662 PHL-VALPROIC ACID 02229628 PMS-VALPROIC ACID 02140055 RATIO-VALPROIC ACID 02239713 SANDOZ-VALPROIC APX ABB DPC GEN MEC NOP NXP PDL PEN PMS RPH SDZ DPC NOP PHH PMS RPH SDZ
BUPROPION HCL
100mg Sustained Release Tablet 02325373 RATIO-BUPROPION SR PMS
BUPROPION HCL (WELLBUTRIN)

Limited use benefit (prior approval required). For treatment of depression in patients unresponsive to or intolerant of other listed antidepressants. (Note: this product will not be approved for coverage for smoking cessation). 100mg Sustained Release Tablet 02285657 RATIO-BUPROPION 02275074 SANDOZ-BUPROPION SR 150mg Sustained Release Tablet 02313421 PMS-BUPROPION SR 02285665 RATIO-BUPROPION 02275082 SANDOZ-BUPROPION SR 02237825 WELLBUTRIN SR 02275090 WELLBUTRIN XL 300mg Sustained Release Tablet 02275104 WELLBUTRIN XL RPH SDZ PMS RPH SDZ BPC BOV BOV
VIGABATRIN
500mg Powder 02068036 SABRIL 500mg Tablet 02065819 SABRIL OVA OVA
BUPROPION HCL (ZYBAN)

Limited use benefit with quantity and frequency limits (prior approval is not required). For smoking cessation: Coverage is limited to 180 tablets during a one-year period. The year starts on the date the first prescription is filled. Once this quantity has been reached, the client is eligible again for coverage for bupropion HCl when one year has elapsed from the day the initial prescription was filled. 150mg Sustained Release Tablet 02238441 ZYBAN SR BPC Page 54 of 124
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CITALOPRAM
10mg Tablet 02312336 02273543 02270609 02303256 02301822 20mg Tablet 02246056 02239607 02257513 02248050 02248942 02246594 02313405 02304686 02293218 02248996 02248944 02248010 02249227 02285622 02268000 02252112 02249278 02303264 02248170 02301830 30mg Tablet 02296152 40mg Tablet 02246057 02239608 02257521 02248051 02248943 02246595 02313413 02304694 02293226 02248997 02248945 02248011 02249235 02285630 02268019 02252120 02249286 02303272 02248171 02301849 NOVO-CITALOPRAM PHI-CITALOPRAM PMS-CITALOPRAM RIVA-CITALOPRAM ZYM-CITALOPRAM APO-CITALOPRAM CELEXA CITALOPRAM-20 CO CITALOPRAM DOM-CITALOPRAM GEN-CITALOPRAM JAMP-CITALOPRAM MINT-CITALOPRAM NOVO-CITALOPRAM NU-CITALOPRAM PHL-CITALOPRAM PMS-CITALOPRAM PREM-CITALOPRAM RAN-CITALO RAN-CITALOPRAM RATIO-CITALOPRAM RIVA-CITALOPRAM RIVA-CITALOPRAM SANDOZ-CITALOPRAM ZYM-CITALOPRAM CTP APO-CITALOPRAM CELEXA CITALOPRAM CO CITALOPRAM DOM-CITALOPRAM GEN-CITALOPRAM JAMP-CITALOPRAM MINT-CITALOPRAM NOVO-CITALOPRAM NU-CITALOPRAM PHL-CITALOPRAM PMS-CITALOPRAM PREM-CITALOPRAM RAN-CITALO RAN-CITALOPRAM RATIO-CITALOPRAM RIVA-CITALOPRAM RIVA-CITALOPRAM SANDOZ-CITALOPRAM ZYM-CITALOPRAM NOP PMI PMS RIV ZYM APX LUD PDL COB DPC GEN JMP MIN NOP NXP PHH PMS PRE RBY RBY RPH RIV RIV SDZ ZYM ORY APX LUD PDL COB DPC GEN JMP MIN NOP NXP PHH PMS PRE RBY RBY RPH RIV RIV SDZ ZYM
CLOMIPRAMINE HCL
10mg Tablet 00330566 02040786 02130122 02244816 02188996 02230256 25mg Tablet 00324019 02040778 02130130 02244817 02189003 02130165 50mg Tablet 00402591 02040751 02130149 02244818 02189011 02130173 ANAFRANIL APO-CLOMIPRAMINE CLOMIPRAMINE CO CLOMIPRAMINE MED-CLOMIPRAMINE NOVO-CLOPAMINE ANAFRANIL APO-CLOMIPRAMINE CLOMIPRAMINE CO CLOMIPRAMINE MED-CLOMIPRAMINE NOVO-CLOPAMINE ANAFRANIL APO-CLOMIPRAMINE CLOMIPRAMINE CO CLOMIPRAMINE MED-CLOMIPRAMINE NOVO-CLOPAMINE ORY APX PDL COB MEC NOP ORY APX PDL COB MEC NOP ORY APX PDL COB MEC NOP
DESIPRAMINE HCL
10mg Tablet 02216248 02222981 02223341 02211939 25mg Tablet 02216256 02223007 02130092 02223325 02211947 50mg Tablet 02216264 02223015 02130106 02223333 02211955 01946277 75mg Tablet 02216272 02223023 02223368 02211963 01946242 APO-DESIPRAMINE DESIPRAMINE NOVO-DESIPRAMINE NU-DESIPRAMINE APO-DESIPRAMINE DESIPRAMINE DOM-DESIPRAMINE NOVO-DESIPRAMINE NU-DESIPRAMINE APO-DESIPRAMINE DESIPRAMINE DOM-DESIPRAMINE NOVO-DESIPRAMINE NU-DESIPRAMINE PMS-DESIPRAMINE APO-DESIPRAMINE DESIPRAMINE NOVO-DESIPRAMINE NU-DESIPRAMINE PMS-DESIPRAMINE APX PDL NOP NXP APX PDL DPC NOP NXP APX PDL DPC NOP NXP PMS APX PDL NOP NXP PMS APX PDL NXP
100mg Tablet 02216280 APO-DESIPRAMINE 02223031 DESIPRAMINE 02211971 NU-DESIPRAMINE
2010
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DOXEPIN HCL
10mg Capsule 02049996 APO-DOXEPIN 00024325 SINEQUAN 25mg Capsule 02050005 APO-DOXEPIN 01913425 NOVO-DOXEPIN 00024333 SINEQUAN 50mg Capsule 02050013 APO-DOXEPIN 01913433 NOVO-DOXEPIN 00024341 SINEQUAN 75mg Capsule 02050021 APO-DOXEPIN 01913441 NOVO-DOXEPIN 00400750 SINEQUAN 100mg Capsule 02050048 APO-DOXEPIN 01913468 NOVO-DOXEPIN 00326925 SINEQUAN 150mg Capsule 01913476 NOVO-DOXEPIN 10mg Tablet 02150727 25mg Tablet 02150735 50mg Tablet 02150743 75mg Tablet 02150751 DOXEPINE DOXEPINE DOXEPINE DOXEPINE APX ERF APX NOP ERF APX NOP ERF APX NOP ERF APX NOP ERF NOP PDL PDL PDL PDL PDL PDL
FLUOXETINE HCL
10mg Capsule 02216353 APO-FLUOXETINE 02242177 CO-FLUOXETINE 02177617 DOM-FLUOXETINE 02220121 FLUOXETINE 02237813 GEN-FLUOXETINE 02216582 NOVO-FLUOXETINE 02192756 NU-FLUOXETINE 02223481 PHL-FLUOXETINE 02177579 PMS-FLUOXETINE 02314991 PRO-FLUOXETINE 02018985 PROZAC 02241371 RATIO-FLUOXETINE 02242123 RIVA-FLUOXETINE 02243486 SANDOZ-FLUOXETINE 02302659 ZYM-FLUOXETINE 20mg Capsule 02216361 APO-FLUOXETINE 02242178 CO-FLUOXETINE 02177625 DOM-FLUOXETINE 02220148 FLUOXETINE 02237814 GEN-FLUOXETINE 02216590 NOVO-FLUOXETINE 02192764 NU-FLUOXETINE 02223503 PHL-FLUOXETINE 02177587 PMS-FLUOXETINE 02315009 PRO-FLUOXETINE 00636622 PROZAC 02241374 RATIO-FLUOXETINE 02242124 RIVA-FLUOXETINE 02243487 SANDOZ-FLUOXETINE 02302667 ZYM-FLUOXETINE 40mg Capsule 02245283 FXT 4mg/mL Liquid 02231328 APO-FLUOXETINE 02177595 PMS-FLUOXETINE APX SCN DPC PDL GEN NOP NXP PHH PMS PDL LIL RPH RIV SDZ ZYM APX SCN DPC PDL GEN NOP NXP PHH PMS PDL LIL RPH RIV SDZ ZYM ORY APX PMS
100mg Tablet 02150778 DOXEPINE 150mg Tablet 02150786 DOXEPINE
DULOXETINE HCL
Limited use benefit (prior approval required). For the treatment of neuropathic pain in patients with diabetes who have: a.- failed an adequate trial with TWO alternative agents (such as a tricyclic antidepressant or anticonvulsant) due to intolerance or lack of response or b.- a contraindication to alternative agents The dose of duloxetine will be limited to a maximum of 60 mg daily. Note that NIHB has adopted a Common Drug Review CEDAC recommendation that Cymbalta NOT be added to public drug plan formularies for the treatment of major depressive disorder. 30mg Sustained Release Capsule 02301482 CYMBALTA 60mg Sustained Release Capsule 02301490 CYMBALTA LIL LIL
FLUVOXAMINE MALEATE
50mg Tablet 02231329 APO-FLUVOXAMINE 02255529 CO FLUVOXAMINE 02241347 DOM-FLUVOXAMINE 02236753 FLUVOXAMINE 01919342 LUVOX 02239953 NOVO-FLUVOXAMINE 02231192 NU-FLUVOXAMINE 02240682 PMS-FLUVOXAMINE 02218453 RATIO-FLUVOXAMINE 02303345 RIVA-FLUVOX 02247054 SANDOZ-FLUVOXAMINE APX COB DPC PDL SPH NOP NXP PMS RPH RIV SDZ
2010
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FLUVOXAMINE MALEATE
100mg Tablet 02231330 02255537 02241348 02236754 01919369 02239954 02231193 02240683 02218461 02303361 02247055 APO-FLUVOXAMINE CO FLUVOXAMINE DOM-FLUVOXAMINE FLUVOXAMINE LUVOX NOVO-FLUVOXAMINE NU-FLUVOXAMINE PMS-FLUVOXAMINE RATIO-FLUVOXAMINE RIVA-FLUVOX SANDOZ-FLUVOXAMINE APX COB DPC PDL SPH NOP NXP PMS RPH RIV SDZ
MIRTAZAPINE
30mg Tablet 02286629 02274361 02252287 02256118 02259354 02252279 02248762 02312786 02270927 02243910 02265265 02250608 02325179 02325187 APO-MIRTAZAPINE CO MIRTAZAPINE DOM-MIRTAZAPINE GEN-MIRTAZAPINE NOVO-MIRTAZAPINE PHL-MIRTAZAPINE PMS-MIRTAZAPINE PRO-MIRTAZAPINE RATIO-MIRTAZAPINE REMERON RIVA-MIRTAZAPINE SANDOZ-MIRTAZAPINE ZYM-MIRTAZAPINE ZYM-MIRTAZAPINE APX COB DPC GEN NOP PHH PMS PDL RPH ORG RIV SDZ ZYM ZYM APX GEN
IMIPRAMINE HCL
10mg Tablet 00360201 APO-IMIPRAMINE 00371017 IMIPRAMINE 00021504 NOVO-PRAMINE 25mg Tablet 00312797 00371025 APO-IMIPRAMINE IMIPRAMINE APX PRO NOP APX PRO APX PDL NOP APX
45mg Tablet 02286637 APO-MIRTAZAPINE 02256126 GEN-MIRTAZAPINE
MOCLOBEMIDE
100mg Tablet 02232148 02236928 02239746 02237111 150mg Tablet 02232150 00899356 02239747 02237112 02243218 300mg Tablet 02240456 02166747 02239748 02243219 APO-MOCLOBEMIDE MOCLOBEMIDE NOVO-MOCLOBEMIDE NU-MOCLOBEMIDE APO-MOCLOBEMIDE MANERIX NOVO-MOCLOBEMIDE NU-MOCLOBEMIDE PMS-MOCLOBEMIDE APO-MOCLOBEMIDE MANERIX NOVO-MOCLOBEMIDE PMS-MOCLOBEMIDE APX PDL NOP NXP APX HLR NOP NXP PMS APX HLR NOP PMS
50mg Tablet 00326852 APO-IMIPRAMINE 00456357 IMIPRAMINE 00021520 NOVO-PRAMINE 75mg Tablet 00644579 APO-IMIPRAMINE
MAPROTILINE HCL
25mg Tablet 02158612 50mg Tablet 02158620 75mg Tablet 02158639 NOVO-MAPROTILINE NOVO-MAPROTILINE NOVO-MAPROTILINE NOP NOP NOP
MIRTAZAPINE
15mg Orally Disintegrating Tablet 02279894 NOVO-MIRTAZAPINE OD 02248542 REMERON RD 30mg Orally Disintegrating Tablet 02279908 NOVO-MIRTAZAPINE OD 02248543 REMERON RD 45mg Orally Disintegrating Tablet 02279916 NOVO-MIRTAZAPINE OD 02248544 REMERON RD 15mg Tablet 02286610 APO-MIRTAZAPINE 02256096 GEN-MIRTAZAPINE 02281732 MIRTAZAPINE 02273942 PMS-MIRTAZAPINE 02312778 PRO-MIRTAZAPINE 02250594 RHOXAL-MIRTAZAPINE NOP ORG NOP ORG NOP ORG APX GEN MEL PMS PDL RHO
NORTRIPTYLINE HCL
10mg Capsule 02223511 APO-NORTRIPTYLINE 00015229 AVENTYL 02178729 DOM-NORTRIPTYLINE 02231686 GEN-NORTRIPTYLINE 02231781 NOVO-NORTRIPTYLINE 02223139 NU-NORTRIPTYLINE 02177692 PMS-NORTRIPTYLINE 02240789 RATIO-NORTRIPTYLINE 25mg Capsule 02223538 APO-NORTRIPTYLINE 00015237 AVENTYL 02178737 DOM-NORTRIPTYLINE 02231782 NOVO-NORTRIPTYLINE 02223147 NU-NORTRIPTYLINE 02177706 PMS-NORTRIPTYLINE APX PHH DPC GEN NOP NXP PMS RPH APX PHH DPC NOP NXP PMS
2010
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PAROXETINE HCL
10mg Tablet 02240907 02262746 02248447 02248012 02248556 02248719 02248913 02027887 02248450 02247750 02247810 02254743 02248559 02269422 02302012 20mg Tablet 02240908 02262754 02248448 02248013 02248557 02248720 02248914 01940481 02248451 02247751 02247811 02248560 02254751 02269430 02302020 30mg Tablet 02240909 02262762 02248449 02248014 02248558 02248721 02248915 01940473 02248452 02247752 02251361 02247812 02248561 02254778 02269449 02302039 40mg Tablet 02293749 APO-PAROXETINE CO PAROXETINE DOM-PAROXETINE GEN-PAROXETINE NOVO-PAROXETINE NU-PAROXETINE PAROXETINE PAXIL PHL-PAROXETINE PMS-PAROXETINE RATIO-PAROXETINE RHOXAL-PAROXETINE RIVA-PAROXETINE SANDOZ-PAROXETINE ZYM-PAROXETINE APO-PAROXETINE CO PAROXETINE DOM-PAROXETINE GEN-PAROXETINE NOVO-PAROXETINE NU-PAROXETINE PAROXETINE PAXIL PHL-PAROXETINE PMS-PAROXETINE RATIO-PAROXETINE RIVA-PAROXETINE SANDOZ-PAROXETINE SANDOZ-PAROXETINE ZYM-PAROXETINE APO-PAROXETINE CO PAROXETINE DOM-PAROXETINE GEN-PAROXETINE NOVO-PAROXETINE NU-PAROXETINE PAROXETINE PAXIL PHL-PAROXETINE PMS-PAROXETINE PREM-PAROXETINE RATIO-PAROXETINE RIVA-PAROXETINE SANDOZ-PAROXETINE SANDOZ-PAROXETINE ZYM-PAROXETINE PMS-PAROXETINE APX COB DPC GEN NOP NXP PDL GSK PHH PMS RPH RHO RIV SDZ ZYM APX COB DPC GEN NOP NXP PDL GSK PHH PMS RPH RIV SDZ SDZ ZYM APX COB DPC GEN NOP NXP PDL GSK PHH PMS PRE RPH RIV SDZ SDZ ZYM PMS
SERTRALINE
25mg Capsule 02238280 APO-SERTRALINE 02287390 CO SERTRALINE 02245748 DOM-SERTRALINE 02242519 GEN-SERTRALINE 09857435 GEN-SERTRALINE (ONT) 02240485 NOVO-SERTRALINE 02247047 NU-SERTRALINE 02245824 PHL-SERTRALINE 02244838 PMS-SERTRALINE 02245787 RATIO-SERTRALINE 09857460 RHOXAL-SERTRALINE (ONT) 02248496 RIVA-SERTRALINE 02245159 SANDOZ-SERTRALINE 02241302 SERTRALINE-25 02132702 ZOLOFT 02303779 ZYM-SERTRALINE 50mg Capsule 02238281 APO-SERTRALINE 02287404 CO SERTRALINE 02245749 DOM-SERTRALINE 02242520 GEN-SERTRALINE 09857443 GEN-SERTRALINE (ONT) 02240484 NOVO-SERTRALINE 02247048 NU-SERTRALINE 02245825 PHL-SERTRALINE 02244839 PMS-SERTRALINE 02245788 RATIO-SERTRALINE 09857478 RHOXAL-SERTRALINE (ONT) 02248497 RIVA-SERTRALINE 02245160 SANDOZ-SERTRALINE 02241303 SERTRALINE-50 01962817 ZOLOFT 02303809 ZYM-SERTRALINE 100mg Capsule 02238282 APO-SERTRALINE 02287412 CO SERTRALINE 02245750 DOM-SERTRALINE 02242521 GEN-SERTRALINE 09857451 GEN-SERTRALINE (ONT) 02240481 NOVO-SERTRALINE 02247050 NU-SERTRALINE 02245826 PHL-SERTRALINE 02244840 PMS-SERTRALINE 02245789 RATIO-SERTRALINE 09857486 RHOXAL-SERTRALINE (ONT) 02248498 RIVA-SERTRALINE 02245161 SANDOZ-SERTRALINE 02241304 SERTRALINE-100 01962779 ZOLOFT 02303817 ZYM-SERTRALINE APX COB DPC GEN GEN NOP NXP PHH PMS RPH RHO RIV SDZ PDL PFI ZYM APX COB DPC GEN GEN NOP NXP PHH PMS RPH RHO RIV SDZ PDL PFI ZYM APX COB DPC GEN GEN NOP NXP PHH PMS RPH RHO RIV SDZ PDL PFI ZYM
PHENELZINE SULFATE
15mg Tablet 00476552 2010 NARDIL PFI
TRANYLCYPROMINE SULFATE
10mg Tablet 01919598 PARNATE GSK
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TRAZODONE HCL
50mg Tablet 02147637 00579351 02128950 02231683 02144263 02165384 02232543 02236941 01937227 02053187 02277344 02164353 02230284 75mg Tablet 02237339 100mg Tablet 02147645 00579378 02128969 02231684 02144271 02165392 02232544 02236942 01937235 02053195 02277352 02164361 02230285 150mg Tablet 02147653 00702277 02231685 02144298 02165406 02053209 02277360 02164388 APO-TRAZODONE DESYREL DOM-TRAZODONE GEN-TRAZODONE NOVO-TRAZODONE NU-TRAZODONE PENTA-TRAZODONE PHL-TRAZODONE PMS-TRAZODONE RATIO-TRAZODONE RATIO-TRAZODONE TRAZODONE TRAZOREL PMS-TRAZODONE APO-TRAZODONE DESYREL DOM-TRAZODONE GEN-TRAZODONE NOVO-TRAZODONE NU-TRAZODONE PENTA-TRAZODONE PHL-TRAZODONE PMS-TRAZODONE RATIO-TRAZODONE RATIO-TRAZODONE TRAZODONE TRAZOREL APO-TRAZODONE D DESYREL DIVIDOSE GEN-TRAZODONE NOVO-TRAZODONE NU-TRAZODONE D RATIO-TRAZODONE RATIO-TRAZODONE TRAZODONE APX BMS DPC GEN NOP NXP PEN PHH PMS RPH RPH PDL VAE PMS APX BMS DPC GEN NOP NXP PEN PHH PMS RPH RPH PDL VAE APX BMS GEN NOP NXP RPH RPH PDL
TRIMIPRAMINE MALEATE
50mg Tablet 00740810 APO-TRIMIPRAMINE 01940449 NOVO-TRIPRAMINE 02020610 NU-TRIMIPRAMINE 00761729 TRIMIPRAMINE 100mg Tablet 00740829 01940457 02020629 00761737 APO-TRIMIPRAMINE NOVO-TRIPRAMINE NU-TRIMIPRAMINE TRIMIPRAMINE APX NOP NXP PDL APX NOP NXP PDL
VENLAFAXINE HCL
37.5mg Sustained Release Capsule 02331683 APO-VENLAFAXINE XR 02304317 CO VENLAFAXINE XR 02237279 EFFEXOR XR 02310279 GEN-VENLAFAXINE XR 02275023 NOVO-VENLAFAXINE XR 02278545 PMS-VENLAFAXINE XR 02273969 RATIO-VENLAFAXINE XR 02307774 RIVA-VENLAFAXINE XR 02310317 SANDOZ VENLAFAXINE XR 75mg Sustained Release Capsule 02331691 APO-VENLAFAXINE XR 02304325 CO VENLAFAXINE XR 02237280 EFFEXOR XR 02310287 GEN-VENLAFAXINE XR 02275031 NOVO-VENLAFAXINE XR 02278553 PMS-VENLAFAXINE XR 02273977 RATIO-VENLAFAXINE SR 02307782 RIVA-VENLAFAXINE XR 02310325 SANDOZ VENLAFAXINE XR 150mg Sustained Release Capsule 02331705 APO-VENLAFAXINE XR 02304333 CO VENLAFAXINE XR 02237282 EFFEXOR XR 02310295 GEN-VENLAFAXINE XR 02275058 NOVO-VENLAFAXINE XR 02278561 PMS-VENLAFAXINE XR 02273985 RATIO-VENLAFAXINE XR 02307790 RIVA-VENLAFAXINE XR 02310333 SANDOZ VENLAFAXINE XR APX COB WAY GEN NOP PMS RPH RIV SDZ APX COB WAY GEN NOP PMS RPH RIV SDZ APX COB WAY GEN NOP PMS RPH RIV SDZ
TRIMIPRAMINE MALEATE
75mg Capsule 02070987 APO-TRIMIP 02147599 TRIMIPRAMINE 12.5mg Tablet 00740799 APO-TRIMIPRAMINE 02020599 NU-TRIMIPRAMINE 00761702 TRIMIPRAMINE 25mg Tablet 00740802 APO-TRIMIPRAMINE 01940430 NOVO-TRIPRAMINE 02020602 NU-TRIMIPRAMINE 00761710 TRIMIPRAMINE APX PDL APX NXP PRO APX NOP NXP PDL
28:16.08 ANTIPSYCHOTIC AGENTS

CHLORPROMAZINE
25mg/mL Injection 00743518 CHLORPROMAZINE HCL 25mg Tablet 00232823 50mg Tablet 00232807 NOVO-CHLORPROMAZINE NOVO-CHLORPROMAZINE SDZ NOP NOP NOP
100mg Tablet 00232831 NOVO-CHLORPROMAZINE
2010
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CLOZAPINE
25mg Tablet 02248034 00894737 02247243 50mg Tablet 02305003 APO-CLOZAPINE CLOZARIL GEN-CLOZAPINE GEN-CLOZAPINE APX NVR GEN GEN APX NVR GEN GEN

HALOPERIDOL
1mg Tablet 00396818 00587788 00363677 2mg Tablet 00396826 00761745 00363669 5mg Tablet 00396834 00761753 00363650 10mg Tablet 00463698 00761761 00713449 20mg Tablet 00768820 APO-HALOPERIDOL HALOPERIDOL NOVO-PERIDOL APO-HALOPERIDOL HALOPERIDOL NOVO-PERIDOL APO-HALOPERIDOL HALOPERIDOL NOVO-PERIDOL APO-HALOPERIDOL HALOPERIDOL NOVO-PERIDOL NOVO-PERIDOL APX PDL NOP APX PDL NOP APX PDL NOP APX PDL NOP NOP
100mg Tablet 02248035 APO-CLOZAPINE 00894745 CLOZARIL 02247244 GEN-CLOZAPINE 200mg Tablet 02305011 GEN-CLOZAPINE
FLUPENTHIXOL DECANOATE
20mg/mL Injection 02156032 FLUANXOL DEPOT 100mg/mL Injection 02156040 FLUANXOL DEPOT LUD LUD
FLUPENTHIXOL DIHYDROCHLORIDE
0.5mg Tablet 02156008 FLUANXOL 3mg Tablet 02156016 FLUANXOL LUD LUD
HALOPERIDOL DECANOATE
50mg/mL Injection 02130297 HALOPERIDOL LA 02230707 PMS-HALOPERIDOL LA 100mg/mL Injection 02130300 HALOPERIDOL LA 02239640 HALOPERIDOL LA 02230708 PMS-HALOPERIDOL LA SDZ PMS SDZ OMG PMS
FLUPHENAZINE DECANOATE
25mg/mL Injection 02239636 FLUPHENAZINE OMEGA 02091275 PMS-FLUPHENAZINE 100mg/mL Injection 02242570 FLUPHENAZINE OMEGA 00755575 MODECATE 02241928 PMS-FLUPHENAZINE OMG PMS OMG BMS PMS
LOXAPINE HCL
25mg/mL Oral Liquid 02239101 PMS-LOXAPINE PMS
LOXAPINE SUCCINATE
2.5mg Tablet 02242868 PMS-LOXAPINE PMS DPC NXP PDL PHH PMS DPC NXP PDL PHH PMS DPC NXP PHH PDL PMS
FLUPHENAZINE HCL
0.5mg/mL Elixir 00893420 PMS-FLUPHENAZINE 1mg Tablet 00405345 00563846 2mg Tablet 00410632 00563838 5mg Tablet 00405361 APO-FLUPHENAZINE FLUPHENAZINE APO-FLUPHENAZINE FLUPHENAZINE APO-FLUPHENAZINE PMS APX PDL APX PDL APX
5mg Tablet 02239918 02237534 02238196 02236943 02230837 10mg Tablet 02239919 02237535 02238197 02236944 02230838 25mg Tablet 02239920 02237536 02236945 02238198 02230839
DOM-LOXAPINE NU-LOXAPINE PDL-LOXAPINE PHL-LOXAPINE PMS-LOXAPINE DOM-LOXAPINE NU-LOXAPINE PDL-LOXAPINE PHL-LOXAPINE PMS-LOXAPINE DOM-LOXAPINE NU-LOXAPINE PDL-LOXAPINE PDL-LOXAPINE PMS-LOXAPINE
HALOPERIDOL
5mg/mL Injection 00808652 HALOPERIDOL 2mg/mL Solution 00759503 PMS-HALOPERIDOL 0.5mg Tablet 00396796 APO-HALOPERIDOL 00587796 HALOPERIDOL 00363685 NOVO-PERIDOL 2010 SDZ PMS APX PDL NOP
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LOXAPINE SUCCINATE
50mg Tablet 02239921 02237537 02236946 02238199 02230840 DOM-LOXAPINE NU-LOXAPINE PDL-LOXAPINE PDL-LOXAPINE PMS-LOXAPINE DPC NXP PHH PDL PMS

OLANZAPINE
7.5mg Tablet 02281813 02325675 02276739 02303167 02229277 10mg Tablet 02281821 02325683 02276747 02303175 02229285 15mg Tablet 02325691 02276755 02303183 02238850 20mg Tablet 02325713 APO-OLANZAPINE CO OLANZAPINE NOVO-OLANZAPINE PMS-OLANZAPINE ZYPREXA APO-OLANZAPINE CO OLANZAPINE NOVO-OLANZAPINE PMS-OLANZAPINE ZYPREXA CO OLANZAPINE NOVO-OLANZAPINE PMS-OLANZAPINE ZYPREXA CO OLANZAPINE APX CBT NOP PMS LIL APX CBT NOP PMS LIL CBT NOP PMS LIL CBT
METHOTRIMEPRAZINE
2mg Tablet 02238403 02239632 5mg Tablet 02238404 02239633 02232903 25mg Tablet 02238405 02239634 01964925 50mg Tablet 02238406 02239635 APO-METHOPRAZINE METHOTRIMEPRAZINE APO-METHOPRAZINE METHOTRIMEPRAZINE PMS-METHOTRIMEPRAZINE APO-METHOPRAZINE METHOTRIMEPRAZINE NOVO-MEPRAZINE APO-METHOPRAZINE METHOTRIMEPRAZINE APX PDL APX PDL PMS APX PDL NOP APX PDL
PERICYAZINE
5mg Capsule 01926780 NEULEPTIL 10mg Capsule 01926772 NEULEPTIL 20mg Capsule 01926764 NEULEPTIL 10mg/mL Drop 01926756 NEULEPTIL ERF ERF ERF ERF
OLANZAPINE
5mg Orally Disintegrating Tablet 02327562 CO OLANZAPINE ODT 02321343 NOVO-OLANZAPINE ODT 02303191 PMS-OLANZAPINE ODT 02327775 SANDOZ OLANZAPINE ODT 02243086 ZYPREXA ZYDIS 10mg Orally Disintegrating Tablet 02327570 CO OLANZAPINE ODT 02321351 NOVO-OLANZAPINE ODT 02303205 PMS-OLANZAPINE ODT 02327783 SANDOZ OLANZAPINE ODT 02243087 ZYPREXA ZYDIS 15mg Orally Disintegrating Tablet 02281848 APO-OLANZAPINE 02327589 CO OLANZAPINE ODT 02321378 NOVO-OLANZAPINE ODT 02303213 PMS-OLANZAPINE ODT 02327791 SANDOZ OLANZAPINE ODT 02243088 ZYPREXA ZYDIS 2.5mg Tablet 02281791 02325659 02276712 02303116 02229250 5mg Tablet 02281805 02325667 02276720 02303159 02229269 2010 APO-OLANZAPINE CO OLANZAPINE NOVO-OLANZAPINE PMS-OLANZAPINE ZYPREXA APO-OLANZAPINE CO OLANZAPINE NOVO-OLANZAPINE PMS-OLANZAPINE ZYPREXA CBT NOP PMS SDZ LIL CBT NOP PMS SDZ LIL APX CBT NOP PMS SDZ LIL APX CBT NOP PMS LIL APX CBT NOP PMS LIL
PERPHENAZINE
3.2mg/mL Liquid 00751898 PMS-PERPHENAZINE 2mg Tablet 00335134 00563757 4mg Tablet 00335126 00563749 8mg Tablet 00335118 00563730 16mg Tablet 00335096 00563722 APO-PERPHENAZINE PERPHENAZINE APO-PERPHENAZINE PERPHENAZINE APO-PERPHENAZINE PERPHENAZINE APO-PERPHENAZINE PERPHENAZINE PMS APX PDL APX PDL APX PDL APX PDL
PIMOZIDE
2mg Tablet 02245432 00313815 4mg Tablet 02245433 00313823 APO-PIMOZIDE ORAP APO-PIMOZIDE ORAP APX PHH APX PHH
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PIPOTIAZINE PALMITATE
25mg/mL Injection 01926667 PIPORTIL L4 50mg/mL Injection 00894672 PIPORTIL L4 SAC RHO

QUETIAPINE FUMARATE
200mg Tablet 02313936 02316110 02307839 02330458 02284278 02299089 02296594 02317362 02311747 02316722 02314010 02236953 02317923 300mg Tablet 02313944 02316129 02307847 02330466 02284286 02299097 02296608 02317370 02311755 02316730 02314029 02244107 02317931 APO-QUETIAPINE CO QUETIAPINE GEN-QUETIAPINE JAMP-QUETIAPINE NOVO-QUETIAPINE PHL-QUETIAPINE PMS-QUETIAPINE PRO-QUETIAPINE RATIO-QUETIAPINE RIVA-QUETIAPINE SANDOZ-QUETIAPINE SEROQUEL ZYM-QUETIAPINE APO-QUETIAPINE CO QUETIAPINE GEN-QUETIAPINE JAMP-QUETIAPINE NOVO-QUETIAPINE PHL-QUETIAPINE PMS-QUETIAPINE PRO-QUETIAPINE RATIO-QUETIAPINE RIVA-QUETIAPINE SANDOZ-QUETIAPINE SEROQUEL ZYM-QUETIAPINE APX COB GEN JMP NOP PMI PMS PDL RPH RIV SDZ AZC ZYM APX COB GEN JMP NOP PMI PMS PDL RPH RIV SDZ AZC ZYM
PROCHLORPERAZINE
5mg/mL Injection 00789747 PROCHLORPERAZINE 10mg Suppository 00753688 PMS-PROCHLORPERAZINE 00789720 PROCHLORPERAZINE 5mg Tablet 00886440 01964399 00753661 10mg Tablet 00886432 01964402 00753637 APO-PROCHLORAZINE NU-PROCHLOR PMS-PROCHLORPERAZINE APO-PROCHLORAZINE NU-PROCHLOR PMS-PROCHLORPERAZINE SDZ PMS SDZ APX NXP PMS APX NXP PMS
QUETIAPINE FUMARATE
25mg Tablet 02313901 02316080 02307804 02330415 02284235 02299054 02296551 02317346 02311704 02316692 02313995 02236951 02317893 100mg Tablet 02313928 02316099 02307812 02330423 02284243 02299062 02296578 02317354 02311712 02316706 02314002 02236952 02317907 APO-QUETIAPINE CO QUETIAPINE GEN-QUETIAPINE JAMP-QUETIAPINE NOVO-QUETIAPINE PHL-QUETIAPINE PMS-QUETIAPINE PRO-QUETIAPINE RATIO-QUETIAPINE RIVA-QUETIAPINE SANDOZ-QUETIAPINE SEROQUEL ZYM-QUETIAPINE APO-QUETIAPINE CO QUETIAPINE GEN-QUETIAPINE JAMP-QUETIAPINE NOVO-QUETIAPINE PHL-QUETIAPINE PMS-QUETIAPINE PRO-QUETIAPINE RATIO-QUETIAPINE RIVA-QUETIAPINE SANDOZ-QUETIAPINE SEROQUEL ZYM-QUETIAPINE APX COB GEN JMP NOP PMI PMS PDL RPH RIV SDZ AZC ZYM APX COB GEN JMP NOP PMI PMS PDL RPH RIV SDZ AZC ZYM NOP
RISPERIDONE
0.5mg Orally Disintegrating Tablet 02247704 RISPERDAL-M 1mg Orally Disintegrating Tablet 02247705 RISPERDAL-M 2mg Orally Disintegrating Tablet 02247706 RISPERDAL-M 3mg Orally Disintegrating Tablet 02268086 RISPERDAL-M 4mg Orally Disintegrating Tablet 02268094 RISPERDAL-M 1mg/mL Solution 02280396 APO-RISPERIDONE 02279266 PMS-RISPERIDONE 02236950 RISPERDAL JNO JNO JNO JNO JNO APX PMS JNO
150mg Tablet 02284251 NOVO-QUETIAPINE
2010
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RISPERIDONE
0.25mg Tablet 02282119 APO-RISPERIDONE 02282585 CO RISPERIDONE 02282240 GEN-RISPERIDONE 02282690 NOVO-RISPERIDONE 02258439 PHL-RISPERIDONE 02252007 PMS-RISPERIDONE 02312700 PRO-RISPERIDONE 02280906 RAN-RISPERIDONE 02264757 RATIO-RISPERIDONE 02328305 RBX-RISPERIDONE 02240551 RISPERDAL 02283565 RIVA-RISPERIDONE 02303655 SANDOZ RISPERIDONE 02279509 SANDOZ-RISPERIDONE 02303485 ZYM-RISPERIDONE 0.5mg Tablet 02282127 02282593 02282259 02264188 02258447 02252015 02312719 02280914 02264765 02328313 02240552 02283573 02303663 02303493 1mg Tablet 02282135 02282607 02282267 02264196 02258455 02252023 02312727 02280922 02264773 02328321 02025280 02283581 02279800 02303507 APO-RISPERIDONE CO RISPERIDONE GEN-RISPERIDONE NOVO-RISPERIDONE PHL-RISPERIDONE PMS-RISPERIDONE PRO-RISPERIDONE RAN-RISPERIDONE RATIO-RISPERIDONE RBX-RISPERIDONE RISPERDAL RIVA-RISPERIDONE SANDOZ RISPERIDONE ZYM-RISPERIDONE APO-RISPERIDONE CO RISPERIDONE GEN-RISPERIDONE NOVO-RISPERIDONE PHL-RISPERIDONE PMS-RISPERIDONE PRO-RISPERIDONE RAN-RISPERIDONE RATIO-RISPERIDONE RBX-RISPERIDONE RISPERDAL RIVA-RISPERIDONE SANDOZ-RISPERIDONE ZYM-RISPERIDONE APX COB GEN NOP PMI PMS PDL RBY RPH RBY JNO RIV SDZ SDZ ZYM APX COB GEN NOP PMI PMS PDL RBY RPH RBY JNO RIV SDZ ZYM APX COB GEN NOP PMI PMS PDL RBY RPH RBY JNO RIV SDZ ZYM

RISPERIDONE
2mg Tablet 02282143 02282615 02282275 02264218 02258463 02252031 02312735 02280930 02264781 02328348 02025299 02283603 02279819 02303515 3mg Tablet 02282151 02282623 02282283 02264226 02258471 02252058 02312743 02280949 02264803 02328364 02025302 02283611 02279827 02303523 4mg Tablet 02282178 02282631 02282291 02264234 02258498 02252066 02312751 02280957 02264811 02328372 02025310 02283638 02279835 02303531 APO-RISPERIDONE CO RISPERIDONE GEN-RISPERIDONE NOVO-RISPERIDONE PHL-RISPERIDONE PMS-RISPERIDONE PRO-RISPERIDONE RAN-RISPERIDONE RATIO-RISPERIDONE RBX-RISPERIDONE RISPERDAL RIVA-RISPERIDONE SANDOZ-RISPERIDONE ZYM-RISPERIDONE APO-RISPERIDONE CO RISPERIDONE GEN-RISPERIDONE NOVO-RISPERIDONE PHL-RISPERIDONE PMS-RISPERIDONE PRO-RISPERIDONE RAN-RISPERIDONE RATIO-RISPERIDONE RBX-RISPERIDONE RISPERDAL RIVA-RISPERIDONE SANDOZ-RISPERIDONE ZYM-RISPERIDONE APO-RISPERIDONE CO RISPERIDONE GEN-RISPERIDONE NOVO-RISPERIDONE PHL-RISPERIDONE PMS-RISPERIDONE PRO-RISPERIDONE RAN-RISPERIDONE RATIO-RISPERIDONE RBX-RISPERIDONE RISPERDAL RIVA-RISPERIDONE SANDOZ-RISPERIDONE ZYM-RISPERIDONE APX COB GEN NOP PMI PMS PDL RBY RPH RBY JNO RIV SDZ ZYM APX COB GEN NOP PMI PMS PDL RBY RPH RBY JNO RIV SDZ ZYM APX COB GEN NOP PMI PMS PDL RBY RPH RBY JNO RIV SDZ ZYM
THIOPROPERAZINE MESYLATE
10mg Tablet 01927639 MAJEPTIL ERF
THIOTHIXENE
2mg Capsule 00024430 NAVANE 5mg Capsule 00024449 NAVANE ERF ERF
2010
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THIOTHIXENE
10mg Capsule 00024457 NAVANE ERF
28:20.92 MISC ANOREXIGENIC AGENTS & RESPIRATORY & CEREBRAL STIMULANT

METHYLPHENIDATE HCL
20mg Sustained Release Tablet 00632775 RITALIN SR 02320312 SANDOZ-METHYLPHENIDATE SR 5mg Tablet 02273950 02234749 APO-METHYLPHENIDATE PMS-METHYLPHENIDATE NVR SDZ
TRIFLUOPERAZINE HCL
10mg/mL Liquid 00751871 PMS-TRIFLUOPERAZINE 1mg Tablet 00345539 00386529 2mg Tablet 00312754 00386510 5mg Tablet 00312746 00386502 10mg Tablet 00326836 00389943 20mg Tablet 00595942 APO-TRIFLUOPERAZINE TRIFLUOPERAZINE APO-TRIFLUOPERAZINE TRIFLUOPERAZINE APO-TRIFLUOPERAZINE TRIFLUOPERAZINE APO-TRIFLUOPERAZINE TRIFLUOPERAZINE APO-TRIFLUOPERAZINE PMS APX PRO APX PRO APX PRO APX PDL APX
APX PMS APX PMS NVR APX PMS NVR
10mg Tablet 02249324 APO-METHYLPHENIDATE 00584991 PMS-METHYLPHENIDATE 00005606 RITALIN 20mg Tablet 02249332 APO-METHYLPHENIDATE 00585009 PMS-METHYLPHENIDATE 00005614 RITALIN
MODAFINIL
100mg Tablet 02239665 ALERTEC 02285398 APO-MODAFINIL DPY APX
ZIPRASIDONE HCL MONOHYDRATE

Limited use benefit (prior approval required). For the treatment of schizophrenia and schizoaffective disorders in patients who have: a.- intolerance or lack of response to an adequate trial of another antipsychotic agent or b.- a contraindication to another antipsychotic agent 20MG Capsule 02298597 ZELDOX 40MG Capsule 02298600 ZELDOX 60mg Capsule 02298619 ZELDOX 80mg Capsule 02298627 ZELDOX PFI PFI PFI PFI
28:24.08 ANXIOLYTICS, SEDATIVES AND HYPNOTICS - BENZODIAZEPINES

ALPRAZOLAM
0.25mg Tablet 01908189 ALPRAZOLAM 00865397 APO-ALPRAZ 02137534 GEN-ALPRAZOLAM 02237264 MED-ALPRAZOLAM 01913484 NOVO-ALPRAZOL 01913239 NU-ALPRAZ 00548359 XANAX 0.5mg Tablet 01908170 00865400 02137542 02237265 01913492 01913247 00548367 1mg Tablet 02248706 02243611 02229813 00723770 2mg Tablet 02243612 02229814 00813958 ALPRAZOLAM APO-ALPRAZ GEN-ALPRAZOLAM MED-ALPRAZOLAM NOVO-ALPRAZOL NU-ALPRAZ XANAX ALPRAZOLAM APO-ALPRAZ GEN-ALPRAZOLAM XANAX APO-ALPRAZ GEN-ALPRAZOLAM XANAX TS PDL APX GEN MEC NOP NXP PFI PDL APX GEN MEC NOP NXP PFI PDL APX GEN PFI APX GEN PFI
28:20.04 AMPHETAMINES
DEXTROAMPHETAMINE SULFATE
10mg Sustained Release Capsule 01924559 DEXEDRINE SPANSULE 15mg Sustained Release Capsule 01924567 DEXEDRINE SPANSULE 5mg Tablet 01924516 DEXEDRINE GSK GSK GSK
28:20.92 MISC ANOREXIGENIC AGENTS & RESPIRATORY & CEREBRAL STIMULANT

METHYLPHENIDATE HCL
20mg Extended Release Tablet 02266687 APO-METHYLPHENIDATE APX
2010
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BROMAZEPAM
1.5mg Tablet 02177153 02220512 02192705 02230666 02171856 3mg Tablet 02177161 02220520 02192713 00518123 02230667 02230584 02171864 6mg Tablet 02177188 02220539 02192721 00518131 02230668 02230585 02171872 APO-BROMAZEPAM BROMAZEPAM GEN-BROMAZEPAM MED-BROMAZEPAM NU-BROMAZEPAM APO-BROMAZEPAM BROMAZEPAM GEN-BROMAZEPAM LECTOPAM MED-BROMAZEPAM NOVO-BROMAZEPAM NU-BROMAZEPAM APO-BROMAZEPAM BROMAZEPAM GEN-BROMAZEPAM LECTOPAM MED-BROMAZEPAM NOVO-BROMAZEPAM NU-BROMAZEPAM APX PDL GEN MEC NXP APX PDL GEN HLR MEC NOP NXP APX PDL GEN HLR MEC NOP NXP

LORAZEPAM
0.5mg Tablet 00655740 02041413 02041456 02245784 00711101 00865672 00655643 1mg Tablet 00655759 02041421 02041464 02245785 00637742 00865680 00655651 2mg Tablet 00655767 02041448 02041472 02245786 00637750 00865699 00655678 APO-LORAZEPAM ATIVAN ATIVAN SUBLINGUAL DOM-LORAZEPAM NOVO-LORAZEM NU-LORAZ PRO-LORAZEPAM APO-LORAZEPAM ATIVAN ATIVAN SUBLINGUAL DOM-LORAZEPAM NOVO-LORAZEM NU-LORAZ PRO-LORAZEPAM APO-LORAZEPAM ATIVAN ATIVAN SUBLINGUAL DOM-LORAZEPAM NOVO-LORAZEM NU-LORAZ PRO-LORAZEPAM APX WAY WAY DPC NOP NXP PDL APX WAY WAY DPC NOP NXP PDL APX WAY WAY DPC NOP NXP PDL
CLOBAZAM
10mg Tablet 02244638 02248454 02247230 02221799 02238334 02244474 02238797 APO-CLOBAZAM CLOBAZAM DOM-CLOBAZAM FRISIUM NOVO-CLOBAZAM PMS-CLOBAZAM RATIO-CLOBAZAM APX PDL DPC PED NOP PMS RPH
NITRAZEPAM
5mg Tablet 02245230 00511528 02229654 02234003 10mg Tablet 02245231 00511536 02229655 02234007 APO-NITRAZEPAM MOGADON NITRAZADON SANDOZ-NITRAZEPAM APO-NITRAZEPAM MOGADON NITRAZADON SANDOZ-NITRAZEPAM APX ICN VAE SDZ APX ICN VAE SDZ
DIAZEPAM
1mg/mL Oral Solution 00891797 PMS-DIAZEPAM 2mg Tablet 00405329 00434396 02247490 5mg Tablet 00362158 00313580 02247491 00013285 10mg Tablet 00405337 00434388 02247492 00013773 APO-DIAZEPAM DIAZEPAM PMS-DIAZEPAM APO-DIAZEPAM DIAZEPAM PMS-DIAZEPAM VALIUM APO-DIAZEPAM DIAZEPAM PMS-DIAZEPAM VIVOL PMS APX PDL PMS APX PRO PMS HLR APX PDL PMS AXX
OXAZEPAM
10mg Tablet 00402680 00497754 00568392 15mg Tablet 00402745 00497762 00568406 30mg Tablet 00402737 00497770 00568414 APO-OXAZEPAM OXAZEPAM ZAPEX APO-OXAZEPAM OXAZEPAM ZAPEX APO-OXAZEPAM OXAZEPAM ZAPEX APX PDL RIV APX PDL RIV APX PDL RIV
2010
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TEMAZEPAM
15mg Capsule 02225964 APO-TEMAZEPAM 02244814 CO TEMAZEPAM 02229756 DOM-TEMAZEPAM 02231615 GEN-TEMAZEPAM 02237294 MED-TEMAZEPAM 02230095 NOVO-TEMAZEPAM 02223570 NU-TEMAZEPAM 02239071 PENTA-TEMAZEPAM 02229455 PMS-TEMAZEPAM 02243023 RATIO-TEMAZEPAM 00604453 RESTORIL 02229760 TEMAZEPAM 30mg Capsule 02225972 APO-TEMAZEPAM 02244815 CO TEMAZEPAM 02229758 DOM-TEMAZEPAM 02231616 GEN-TEMAZEPAM 02237295 MED-TEMAZEPAM 02230102 NOVO-TEMAZEPAM 02223589 NU-TEMAZEPAM 02239072 PENTA-TEMAZEPAM 02229456 PMS-TEMAZEPAM 02273047 PMS-TEMAZEPAM 02243024 RATIO-TEMAZEPAM 00604461 RESTORIL 02229761 TEMAZEPAM APX COB DPC GEN MEC NOP NXP PEN PMS RPH ORY PDL APX COB DPC GEN MEC NOP NXP PEN PMS PMS RPH ORY PDL
28:24.92 MISCELLANEOUS ANXIOLYTICS, SEDATIVES, AND HYPNOTICS

HYDROXYZINE HCL
2mg/mL Syrup 00024694 ATARAX 00741817 PMS-HYDROXYZINE 10mg Tablet 00646059 25mg Tablet 00646024 50mg Tablet 00646016 APO-HYDROXYZINE APO-HYDROXYZINE APO-HYDROXYZINE ERF PMS APX APX APX
28:28.00 ANTIMANIC AGENTS

LITHIUM CARBONATE
150mg Capsule 02242837 APO-LITHIUM CARB 09857532 APO-LITHIUM CARBONATE 02013231 LITHANE 02216132 PMS-LITHIUM CARBONATE 300mg Capsule 02242838 APO-LITHIUM CARB 09857540 APO-LITHIUM CARBONATE 00236683 CARBOLITH 00406775 LITHANE 02216140 PMS-LITHIUM CARBONATE 600mg Capsule 02011239 CARBOLITH 02216159 PMS-LITHIUM CARBONATE APX APX ERF PMS APX APX VAE ERF PMS VAE PMS
TRIAZOLAM
0.125mg Tablet 00808563 APO-TRIAZO 01995227 GEN-TRIAZOLAM 00886084 NU-TRIAZO 0.25mg Tablet 00808571 APO-TRIAZO 01913506 GEN-TRIAZOLAM 00886092 NU-TRIAZO 00860824 TRIAZOLAM APX GEN NXP APX GEN NXP PDL
LITHIUM CITRATE
60mg/mL Syrup 02074834 PMS-LITHIUM CITRATE PMS
28:32.28 SELECTIVE SEROTONIN AGONISTS

ALMOTRIPTAN MALATE
6.25mg Tablet 02248128 AXERT 12.5mg Tablet 02248129 AXERT MCL MCL
28:24.92 MISCELLANEOUS ANXIOLYTICS, SEDATIVES, AND HYPNOTICS

HYDROXYZINE HCL
10mg Capsule 00739618 HYDROXYZINE 00738824 NOVO-HYDROXYZIN 02241192 RIVA-HYDROXYZIN 25mg Capsule 00739626 HYDROXYZINE 00738832 NOVO-HYDROXYZIN 02241193 RIVA-HYDROXYZIN 50mg Capsule 00739634 HYDROXYZINE 00738840 NOVO-HYDROXYZIN 02241194 RIVA-HYDROXYZIN 2010 PDL NOP RIV PDL NOP RIV PDL NOP RIV
NARATRIPTAN HCL
1mg Tablet 02237820 02314290 AMERGE NOVO-NARATRIPTAN GSK NOP GSK NOP SDZ
2.5mg Tablet 02237821 AMERGE 02314304 NOVO-NARATRIPTAN 02322323 SANDOZ NARATRIPTAN
RIZATRIPTAN
5mg Tablet 02240520 10mg Tablet 02240521 MAXALT MAXALT FRS FRS Page 66 of 124
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28:32.28 SELECTIVE SEROTONIN AGONISTS

RIZATRIPTAN
5mg Wafer 02240518 10mg Wafer 02240519 MAXALT RPD MAXALT RPD FRS FRS
28:32.92 MISCELLANEOUS ANTIMIGRANE AGENTS

PIZOTYLINE HYDROGEN MALATE
1mg Tablet 00511552 SANDOMIGRAN DS PED
28:36.08 ANTIPARKINSONIAN AGENTS ANTICHOLINERGIC AGENTS

BENZTROPINE MESYLATE
1mg/mL Injection 02238903 BENZTROPINE OMEGA 1mg Tablet 00706531 2mg Tablet 00426857 00563862 00587265 PMS-BENZTROPINE APO-BENZTROPINE BENZTROPINE PMS-BENZTROPINE
SUMATRIPTAN HEMISULFATE
5mg Nasal Spray 02230418 IMITREX 20mg Nasal Spray 02230420 IMITREX GSK GSK
OMG PMS APX PDL PMS
SUMATRIPTAN SUCCINATE
12mg/mL Injection 02212188 IMITREX 99000598 IMITREX 25mg Tablet 02257882 02270749 02268906 02286815 02256428 CO SUMATRIPTAN DOM-SUMATRIPTAN GEN-SUMATRIPTAN NOVO-SUMATRIPTAN DF PMS-SUMATRIPTAN GSK GSK COB DPC GEN NOP PMS APX COB DPC GEN GSK NOP PMS RPH SDZ APX COB DPC GEN GSK NOP NOP PMS RPH SDZ
ETHOPROPAZINE HCL
50mg Tablet 01927744 PARSITAN ERF
PROCYCLIDINE HCL
0.5mg/mL Elixir 00587362 PMS-PROCYCLIDINE 2.5mg Tablet 00649392 PMS-PROCYCLIDINE 5mg Tablet 00587354 PMS-PROCYCLIDINE PMS PMS PMS
50mg Tablet 02268388 APO-SUMATRIPTAN 02257890 CO SUMATRIPTAN 02270757 DOM-SUMATRIPTAN 02268914 GEN-SUMATRIPTAN 02212153 IMITREX DF 02286823 NOVO-SUMATRIPTAN DF 02256436 PMS-SUMATRIPTAN 02271583 RATIO-SUMATRIPTAN 02263025 SANDOZ-SUMATRIPTAN 100mg Tablet 02268396 02257904 02270765 02268922 02212161 02239367 02286831 02256444 02271591 02263033 APO-SUMATRIPTAN CO SUMATRIPTAN DOM-SUMATRIPTAN GEN-SUMATRIPTAN IMITREX DF NOVO-SUMATRIPTAN NOVO-SUMATRIPTAN DF PMS-SUMATRIPTAN RATIO-SUMATRIPTAN SANDOZ-SUMATRIPTAN
TRIHEXYPHENIDYL HCL
0.4mg/mL Liquid 00885398 PMS-TRIHEXYPHENIDYL 2mg Tablet 00545058 00572802 5mg Tablet 00545074 00572799 APO-TRIHEX TRIHEXYPHEN APO-TRIHEX TRIHEXYPHEN PMS APX PRO APX PDL
28:36.12 ANTIPARKINSONIAN AGENTS CATECHOL-OMETHYLTRANSFERASE (COMT) INHIBITORS

ENTACAPONE
ST
ZOLMITRIPTAN
2.5mg Tablet 02238660 ZOMIG 02243045 ZOMIG RAPIMELT AZC AZC
200mg Tablet 02243763 COMTAN
NVR
28:32.92 MISCELLANEOUS ANTIMIGRANE AGENTS

PIZOTYLINE HYDROGEN MALATE
0.5mg Tablet 00329320 SANDOMIGRAN
28:36.16 ANTIPARKINSONIAN AGENTS DOPAMINE PRECURSORS

LEVODOPA, BENZERAZIDE
ST
50mg & 12.5mg Capsule 00522597 PROLOPA 100mg & 25mg Capsule 00386464 PROLOPA
HLR HLR
ST
PED
2010
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28:36.16 ANTIPARKINSONIAN AGENTS DOPAMINE PRECURSORS

LEVODOPA, BENZERAZIDE
ST
28:36.20 ANTIPARKINSONIAN AGENTS DOPAMINE RECEPTOR AGONISTS

PRAMIPEXOLE DIHYDROCHLORIDE
ST
200mg & 50mg Capsule 00386472 PROLOPA
HLR
LEVODOPA, CARBIDOPA
ST
100mg & 25mg Controlled Release Tablet 02272873 APO-LEVOCARB CR 02028786 SINEMET CR 200mg & 50mg Controlled Release Tablet 00870935 SINEMET CR 100mg & 10mg Tablet 02195933 APO-LEVOCARB 02244494 NOVO-LEVOCARBIDOPA 02182831 NU-LEVOCARB 00355658 SINEMET 100mg & 25mg Tablet 02195941 APO-LEVOCARB 02244495 NOVO-LEVOCARBIDOPA 02182823 NU-LEVOCARB 02311178 PRO-LEVOCARB 00513997 SINEMET 250mg & 25mg Tablet 02195968 APO-LEVOCARB 02244496 NOVO-LEVOCARBIDOPA 02182858 NU-LEVOCARB 00328219 SINEMET
APX BMS BMS

ST
ST
0.25mg Tablet 02292378 APO-PRAMIPEXOLE 02297302 CO PRAMIPEXOLE 02237145 MIRAPEX 09857268 MIRAPEX (ONT) 02269309 NOVO-PRAMIPEXOLE 02290111 PMS-PRAMIPREXOLE 02315262 SANDOZ-PRAMIPEXOLE 0.5mg Tablet 02292386 02297310 02241594 02269317 02290138 02315270 1mg Tablet 02292394 02297329 02237146 09857269 02269325 02290146 02315289 1.5mg Tablet 02292408 02297337 02237147 09857270 02269333 02290154 02315297 APO-PRAMIPEXOLE CO PRAMIPEXOLE MIRAPEX NOVO-PRAMIPEXOLE PMS-PRAMIPREXOLE SANDOZ-PRAMIPEXOLE APO-PRAMIPEXOLE CO PRAMIPEXOLE MIRAPEX MIRAPEX (ONT) NOVO-PRAMIPEXOLE PMS-PRAMIPREXOLE SANDOZ-PRAMIPEXOLE APO-PRAMIPEXOLE CO PRAMIPEXOLE MIRAPEX MIRAPEX (ONT) NOVO-PRAMIPEXOLE PMS-PRAMIPREXOLE SANDOZ-PRAMIPEXOLE
APX CBT BOE BOE NOP PMS SDZ APX CBT BOE NOP PMS SDZ APX CBT BOE BOE NOP PMS SDZ APX CBT BOE BOE NOP PMS SDZ
ST
APX NOP NXP BMS APX NOP NXP PDL BMS APX NOP NXP BMS
ST
ST
ST
ST
LEVODOPA, CARBIDOPA,ENTACAPONE
ST
50mg & 12.5mg & 200mg Tablet 02305933 STALEVO 75mg & 18.75mg & 200mg Tablet 02337827 STALEVO 100mg & 25mg & 200mg Tablet 02305941 STALEVO 125mg & 31.25mg & 200mg Tablet 02337835 STALEVO 150mg & 37.5mg & 200mg Tablet 02305968 STALEVO
NOV NOV NOV NOV NOV
ST
ST
ST
ROPINIROLE HCL
ST
ST

BROMOCRIPTINE MESYLATE
5mg Capsule 02230454 02230719 02238637 02236949 2.5mg Tablet 02087324 02153378 02238636 02231702 APO-BROMOCRIPTINE BROMOCRIPTINE DOM-BROMOCRIPTINE PMS-BROMOCRIPTINE APO-BROMOCRIPTINE BROMOCRIPTINE DOM-BROMOCRIPTINE PMS-BROMOCRIPTINE APX PRO DPC PMS APX PRO DPC PMS
0.25mg Tablet 02337746 APO-ROPINIROLE 02316846 CO-ROPINIROLE 02326590 PMS-ROPINIROLE 02314037 RAN-ROPINIROLE 02232565 REQUIP 1mg Tablet 02337762 02316854 02326612 02314053 02232567 2mg Tablet 02337770 02316862 02326620 02314061 02232568 APO-ROPINIROLE CO-ROPINIROLE PMS-ROPINIROLE RAN-ROPINIROLE REQUIP APO-ROPINIROLE CO-ROPINIROLE PMS-ROPINIROLE RAN-ROPINIROLE REQUIP
APX CBT PMS RBY GSK APX CBT PMS RBY GSK APX CBT PMS RBY GSK
ST
ST
2010
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ROPINIROLE HCL
ST
5mg Tablet 02337800 02316870 02326639 02314088 02232569
APO-ROPINIROLE CO-ROPINIROLE PMS-ROPINIROLE RAN-ROPINIROLE REQUIP
APX CBT PMS RBY GSK
28:36.32 ANTIPARKINSONIAN AGENTS MONOAMINE OXIDASE B INHIBITORS

SELEGILINE HCL
ST
5mg Tablet 02230641 02238340 02231036 02237289 02068087 02230717 02238102 02231479
APO-SELEGILINE DOM-SELEGILINE GEN-SELEGILINE MED-SELEGILINE NOVO-SELEGILINE NU-SELEGILINE PMS-SELEGILINE SELEGILINE
APX DPC GEN MEC NOP NXP PMS PDL
28:92.00 MISCELLANEOUS CENTRAL NERVOUS SYSTEM AGENTS

ACAMPROSATE CALCIUM
Limited use benefit (prior approval required). For patients who have been abstinent from alcohol for at least four days and where available, are currently enrolled in an alcohol addiction treatment program 333mg Sustained Release Tablet 02293269 CAMPRAL MYL
2010
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32:00 CONTRACEPTIVES (NON-ORAL)

32:00.00 CONTRACEPTIVES (NON-ORAL)
CONDOM, FEMALE
Device 99400484 REALITY FEMALE CONDOM PMS
CONDOM, MALE
Device 99400527 99400485 99400486 99400786 CONDOM, LATEX, LUBRICATED CONDOM, LATEX, LUBRICATED, NONOXYNOL CONDOM, LATEX, NONLUBRICATED CONDOM, NON-LATEX, LUBRICATED
DIAPHRAGM
Device 09991126 OMNIFLEX DIAPHRAGM 75 CSU
INTRAUTERINE DEVICE
Device 98099999 99400482 FLEXI-T IUD NOVA-T IUD PRN BEX
2010
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36:00 DIAGNOSTIC AGENTS (DX)

36:00.00 DIAGNOSTIC AGENTS (DX)
THYROTROPIN ALFA
0.9mg/mL Powder for Solution 02246016 THYROGEN GEE
36:26.00 DX - DIABETES MELLITUS

Ascensia Breeze 2 Strip 00964816 ASCENSIA BREEZE 2 00977119 ASCENSIA BREEZE 2 09991084 ASCENSIA BREEZE 2 44123038 ASCENSIA BREEZE 2 99100388 ASCENSIA BREEZE 2 Ascensia Contour Strip 00950924 ASCENSIA CONTOUR 00964476 ASCENSIA CONTOUR 09857127 ASCENSIA CONTOUR 44123037 ASCENSIA CONTOUR 97799702 ASCENSIA CONTOUR 97799877 ASCENSIA CONTOUR (100) 97799878 ASCENSIA CONTOUR (50) Ascensia Elite Strip 00920363 ASCENSIA ELITE 00950572 ASCENSIA ELITE 00980100 ASCENSIA ELITE 09854088 ASCENSIA ELITE 44123002 ASCENSIA ELITE 97799923 ASCENSIA ELITE BD Test Strip 00900142 00950911 09857132 44123030 99100002 99401067 BD TEST BD TEST BD TEST BD TEST BD TEST BD TEST BAY BAY BAY BAY BAY BAY BAY BAY BAY BAY BAY BAY BAY BAY BAY BAY BAY BAY BTD BTD BTD BTD BTD BTD ROD ROD ROD ROD BAY BAY BAY BAY BAY TRE TRE JAJ JAJ JAJ JAJ JAJ JAJ JAJ JAJ JAJ

Glucose Control Solution 00909556 ADVANTAGE 00977943 ASCENSIA AUTODISC 00977307 ASCENSIA ELITE 00920143 FASTTAKE 99463968 GLUCOFILM 00906867 MEDISENSE 00977845 ONE TOUCH 99480004 ONE TOUCH 99925768 ONE TOUCH Accu-Chek Advantage Strip 00905348 ACCU-CHEK ADVANTAGE 00921076 ACCU-CHEK ADVANTAGE 00950883 ACCU-CHEK ADVANTAGE 09854002 ACCU-CHEK ADVANTAGE 44123021 ACCU-CHEK ADVANTAGE 97799960 ACCU-CHEK ADVANTAGE 99002884 ACCU-CHEK ADVANTAGE Accu-Chek Aviva Strip 97799814 ACCU-CHEK AVIVA (100) 97799815 ACCU-CHEK AVIVA (50) Accu-Chek Compact Strip 00901370 ACCU-CHEK COMPACT 00950900 ACCU-CHEK COMPACT 00965960 ACCU-CHEK COMPACT 00965979 ACCU-CHEK COMPACT 09854282 ACCU-CHEK COMPACT 44123026 ACCU-CHEK COMPACT 97799962 ACCU-CHEK COMPACT 99004364 ACCU-CHEK COMPACT Accutrend Strip 00906697 ACCUTREND 00977031 ACCUTREND 09853162 ACCUTREND 44123006 ACCUTREND Advantage Strip 00908290 ADVANTAGE 00924061 ADVANTAGE 00950661 ADVANTAGE 44123008 ADVANTAGE Ascensia Autodisc Strip 00904945 ASCENSIA AUTODISC 00950878 ASCENSIA AUTODISC 09853693 ASCENSIA AUTODISC 44123019 ASCENSIA AUTODISC 97799926 ASCENSIA AUTODISC 99002604 ASCENSIA AUTODISC ROD BAY BAY JAJ BAY AUC JAJ JAJ JAJ ROD ROD ROD ROD ROD ROD ROD ROD ROD ROD ROD ROD ROD ROD ROD ROD ROD ROD ROD ROD ROD ROD ROD ROD ROD BAY BAY BAY BAY BAY BAY
Chemstrip-BG for Accu-Chek Strip 09853189 CHEMSTRIP BG 00990027 CHEMSTRIP-BG 44123009 CHEMSTRIP-BG 97799958 CHEMSTRIP-BG Encore Strip 00920371 00980200 09853103 44123003 97799922 ENCORE ENCORE ENCORE ENCORE ENCORE
EZ Health Strip 97799564 EZ HEALTH ORACLE (100) 97799565 EZ HEALTH ORACLE (50) FastTake Strip 00903531 FASTTAKE 00950882 FASTTAKE 00967084 FASTTAKE 00967092 FASTTAKE 00967106 FASTTAKE 09854029 FASTTAKE 44123017 FASTTAKE 97799982 FASTTAKE 99002809 FASTTAKE
2010
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Freestyle Strip 00901388 FREESTYLE 00905500 FREESTYLE 00950907 FREESTYLE 09857141 FREESTYLE 44123028 FREESTYLE 97799829 FREESTYLE 99004704 FREESTYLE 99401062 FREESTYLE 97799596 FREESTYLE LITE 97799597 FREESTYLE LITE Itest Strip 97799770 ITEST ABB ABB ABB ABB ABB ABB ABB ABB ABB ABB AUC HOD HOD NCA NCA JAJ JAJ JAJ JAJ JAJ JAJ JAJ JAJ JAJ JAJ JAJ JAJ AUC AUC AUC AUC

Sidekick Strip 00950948 SIDEKICK 44123035 SIDEKICK 97799601 SIDEKICK 99100412 SIDEKICK Surestep Strip 00999482 SURESTEP 09853634 SURESTEP 44123012 SURESTEP 97799979 SURESTEP 99000318 SURESTEP Truetrack Strip 00950957 TRUETRACK 97799602 TRUETRACK 97799603 TRUETRACK 99100413 TRUETRACK HOD AUC HOD HOD JAJ JAJ JAJ JAJ JAJ HOD HOD HOD HOD
Life Brand Strip 97799593 LIFE BRAND 97799594 LIFE BRAND Novamax Strip 97799583 NOVAMAX 97799584 NOVAMAX One Touch Strip 00905399 ONE TOUCH 00950459 ONE TOUCH 09853243 ONE TOUCH 44123011 ONE TOUCH 97799976 ONE TOUCH One Touch Ultra Strip 00907000 ONE TOUCH ULTRA 00950893 ONE TOUCH ULTRA 09854290 ONE TOUCH ULTRA 44123025 ONE TOUCH ULTRA 97799985 ONE TOUCH ULTRA 99004240 ONE TOUCH ULTRA 99401057 ONE TOUCH ULTRA Precision Plus Strip 00906298 PRECISION PLUS ELECTRODES 00977057 PRECISION PLUS ELECTRODES 00977059 PRECISION PLUS ELECTRODES 97799843 PRECISION PLUS ELECTRODES Precision Xtra Strip 00908437 PRECISION XTRA 00909300 PRECISION XTRA 00950894 PRECISION XTRA 00986763 PRECISION XTRA 09854070 PRECISION XTRA 97799840 PRECISION XTRA 99004119 PRECISION XTRA Prestige Smart System Strip 99401066 PRESTIGE SMART SYSTEM
36:88.00 DX - URINE AND FECES CONTENTS

CUPRIC SULFATE
Tablet 00035122 00977314 00980420 99067017 CLINITEST CLINITEST CLINITEST CLINITEST BAY BAY BAY BAY

Strip 00035130 00977160 00980641 99159954 DIASTIX DIASTIX DIASTIX DIASTIX BAY BAY BAY BAY
SODIUM NITROPRUSSIDE
Strip 00035092 00977322 00980595 09853286 99067074 Tablet 00035106 00977292 00980560 09853294 KETOSTIX KETOSTIX KETOSTIX KETOSTIX KETOSTIX ACETEST ACETEST ACETEST ACETEST BAY BAY BAY BAY BAY BAY BAY BAY BAY
AUC AUC AUC AUC AUC AUC AUC THR
2010
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40:00 ELECTROLYTIC, CALORIC, AND WATER BALANCE

40:08.00 ALKALINIZING AGENTS
CITRIC ACID, SODIUM CITRATE
66.8mg & 100mg/mL Solution 00721344 DICITRATE PMS
40:12.00 REPLACEMENT PREPARATIONS

CALCIUM, VITAMIN D
ST
500mg & 400IU Tablet 80015351 PRIVA CAL D FORTE 500mg & 400U Tablet 80003919 BIOCAL-D FORTE
PHA BMI
ST
SODIUM BICARBONATE
300mg Tablet 00481912 SODIUM BICARBONATE XEN
ELECTROLYTE & DEXTROSE

3.56g & 300mg & 470mg & 530mg Powder 01931563 GASTROLYTE REG 25mg & 2.2mg & 2.2mg & 0.9mg/mL Solution 00630365 PEDIALYTE 02219883 PEDIATRIC ELECTROLYTE SAC ABB PMS

CALCIUM CARBONATE
MAGNESIUM
ST
500mg Tablet 00682039 00674346 00621722 02240240 80003773 02246040 02237352 00645923 00618098 00622443 80001122
APO-CAL 500 CAL-500 CALCIUM CALCIUM CALCIUM CALCIUM CARBONATE EURO-CAL NOVO-CALCIUM NU-CAL O-CALCIUM 500 PMS-CALCIUM
APX PDL HAL PMT TRI JMP EUR NOP ODN VTH PMS
25mg Oral Liquid 80009357 JAMP-MAGNESIUM GLUCONATE 28mg Tablet 80009539 JAMP-MAGNESIUM GLUCONATE
JMP
JMP
100mg Tablet 02068400 MAGNESIUM
JAM
MAGNESIUM CITRATE
5.40% Oral Liquid 00262609 CITRO MAG 15GM/300ML TCH
MAGNESIUM GLUCONATE
100mg/mL Oral Liquid 00026697 RATIO-MAGNESIUM RPH
CALCIUM CARBONATE, CHOLECALCIFEROL

ST
500mg & 125IU Tablet 00752673 CAL-500-D 80004966 CALCITE D 500 00688770 CALCITE D-500 02244161 CALCIUM 500 + D 400 00702986 CALCIUM 500MG WITH VIT D 02246041 CALCIUM CARBONATE WITH D 00730599 CALCIUM CARBONATE WITH VIT D 00688975 CALCIUM D-500 02237351 EURO-CAL D 00720798 NEO CAL-D-500 02043025 OS-CAL D 500MG 80004281 PMS-CALCIUM/VITAMIN D 500mg & 400IU Tablet 02244130 CALCITE 500 + D 400 80004963 CALCITE 500 + D 400 80004969 CALCIUM 500 + D 400 80002623 CALCIUM 500MG WITH VIT D 02245511 CARBOCAL D 80002901 CARBOCAL D 80002122 JAMP-CALCIUM+VITAM D
PRO RIV RIV TRI HAL JMP PMT TRI EUR NEO WAY PMS RIV RIV TRI JMP EUR EUR JMP
POTASSIUM CHLORIDE
ST
25MEQ Effervescent Tablet 02085992 K LYTE 8mmol Long Acting Capsule 02242291 EURO-K8 02244068 RIVA-K 8mmol Long Acting Tablet 00602884 APO-K 02246734 EURO-K 600 00613274 PRO-600K 00074225 SLOW K 20mmol Long Acting Tablet 02242261 EURO-K 20 00713376 K-DUR 80004415 ODAN K-20 02243975 RIVA-K 20 1.33MEQ/mL Oral Liquid 01918303 K 10 02238604 PMS-POTASSIUM 25MEQ Powder 02089580 K LYTE
WPC EUR RIV APX EUR PDL NVR EUR KEY ODN RIV GSK PMS WPC
ST
ST
ST
ST
ST
ST
CALCIUM LACTOGLUCONATE
20mg/mL Oral Liquid 80002626 CALCIUM WITHOUT SUGAR 20mg/mL Oral Liquid 80006877 WAMPOLE MINERAL CALCIUM 2010 JMP JMP
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SODIUM CHLORIDE
0.9% Inhalation Diluent 02094657 BACTERIOSTATIC NACL 00801267 SODIUM CHLORIDE 02058235 SODIUM CHLORIDE 0.9% Injection 00060208 SODIUM CHLORIDE 00402249 SODIUM CHLORIDE 02150204 SODIUM CHLORIDE 99002329 SODIUM CHLORIDE BIO BDH BAT ABB OMG
40:28.08 LOOP DIURETICS

FUROSEMIDE
ST
20mg Tablet 00396788 02247371 02248124 00496723 02224690 00337730 02239224 02247493 40mg Tablet 00362166 02247372 02248125 00397792 02224704 00337749 02239225 02247494 80mg Tablet 00707570 00667080 00765953
APO-FUROSEMIDE BIO-FUROSEMIDE DOM-FUROSEMIDE FUROSEMIDE LASIX NOVO-SEMIDE NU-FUROSEMIDE PMS-FUROSEMIDE APO-FUROSEMIDE BIO-FUROSEMIDE DOM-FUROSEMIDE FUROSEMIDE LASIX NOVO-SEMIDE NU-FUROSEMIDE PMS-FUROSEMIDE APO-FUROSEMIDE FUROSEMIDE NOVO-SEMIDE
APX BMI BMI PDL SAC NOP NXP PMS APX BMI BMI PDL SAC NOP NXP PMS APX PDL NOP SAC
40:17.00 CALCIUM-REMOVING RESINS

CALCIUM POLYSTYRENE SULFONATE
1g binds with approx 1.6mmol K Powder 02017741 RESONIUM CALCIUM SAC
ST
40:18.00 ION-REMOVING AGENTS

SODIUM POLYSTYRENE SULFONATE
1g binds with approx 1mmol K Powder 02026961 KAYEXALATE 00765252 K-EXIT 00755338 PMS-SOD POLYSTYRENE SULFONA 250mg/mL Oral Suspension 00769541 PMS-SOD POLYSTYRENE SULF 250mg/mL Retention Enema 00769533 PMS-SOD POLYSTYRENE SULF SAC OMG PMS
ST
ST
PMS
500mg Tablet 02224755 LASIX
40:28.16 POTASSIUM SPARING DIURETICS

PMS
AMILORIDE HCL
ST
40:20.00 CALORIC AGENTS

LEVOCARNITINE
Limited use benefit (prior approval required). For treatment of carnitine deficiency. 100mg/mL Oral Liquid 02144336 CARNITOR 200mg/mL Solution 02144344 CARNITOR IV 330mg Tablet 02144328 CARNITOR SIG SIG SIG
ST
5mg Tablet 02249510 00487805
APO-AMILORIDE MIDAMOR
APX OBP
AMILORIDE HCL, HYDROCHLOROTHIAZIDE

5mg & 50mg Tablet 00870943 AMI-HYDRO 00784400 APO-AMILZIDE 02257378 GEN-AMILAZIDE 00487813 MODURET 01937219 NOVAMILOR 00886106 NU-AMILZIDE 02231254 PENTA-AMILOR HCTZ PDL APX GEN OBP NOP NXP PEN
40:28.08 LOOP DIURETICS

ETHACRYNIC ACID
ST
TRIAMTERENE, HYDROCHLOROTHIAZIDE
ST
EDECRIN
FRS
FUROSEMIDE
ST
10mg/mL Solution 02224720 LASIX
50mg & 25mg Tablet 00441775 APO-TRIAZIDE 00532657 NOVO-TRIAMZIDE 00865532 NU-TRIAZIDE 00519367 PRO-TRIAZIDE 02240846 RIVA-ZIDE
APX NOP NXP PRO RIV
SAC
40:28.20 TIAZIDE DIURETICS

HYDROCHLOROTHIAZIDE
12.5mg Tablet 02327856 APO-HYDRO 02274086 PMS-HYDROCHLOROTHIAZIDE APX BMI
2010
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40:28.20 TIAZIDE DIURETICS

HYDROCHLOROTHIAZIDE
ST
40:28.24 THIAZIDE LIKE DIURETICS

INDAPAMIDE
ST
25mg Tablet 00326844 02247170 02248134 00341975 00021474 02250659 02247386
APO-HYDROCLOROTHIAZIDE BIO-HYDROCHLOROTHIAZIDE DOMHYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE NOVO-HYDRAZIDE NU-HYDRO PMS-HYDROCHLOROTHIAZIDE
APX BMI DPC PDL NOP NXP PMS APX BMI DPC PRO NOP NXP PMS APX PDL
ST
50mg Tablet 00312800 APO-HYDRO 02247171 BIO-HYDROCHLOROTHIAZIDE 02248135 DOMHYDROCHLOROTHIAZIDE 00156604 HYDROCHLOROTHIAZIDE 00021482 NOVO-HYDRAZIDE 02250667 NU-HYDRO 02247387 PMS-HYDROCHLOROTHIAZIDE 100mg Tablet 00644552 APO-HYDRO 00532088 HYDROCHLOROTHIAZIDE
2.5mg Tablet 02223678 02239917 02153483 02049341 00564966 02231184 02223597 02239620 02312549 02242125
APO-INDAPAMIDE DOM-INDAPAMIDE GEN-INDAPAMIDE INDAPAMIDE LOZIDE NOVO-INDAPAMIDE NU-INDAPAMIDE PMS-INDAPAMIDE PRO-INDAPAMIDE RIVA-INDAPAMIDE
APX DPC GEN PRO SEV NOP NXP PMS PDL RIV
METOLAZONE
ST
2.5mg Tablet 00888400 ZAROXOLYN
AVT
40:36.00 IRRIGATING SOLUTIONS

WATER
Injection 00402257 02142546 STERILE WATER FOR INJ STERILE WATER FOR INJ OMG HOS
ST
SPIRONOLACTONE, HYDROCHLOROTHIAZIDE
ST
40:40.00 URICOSURIC AGENTS

PROBENECID
500mg Tablet 00294926 BENURYL
25mg & 25mg Tablet 00180408 ALDACTAZIDE-25 00613231 NOVO-SPIROZINE-25 50mg & 50mg Tablet 00594377 ALDACTAZIDE-50 00657182 NOVO-SPIROZINE-50
PFI NOP PFI NOP
VAE
ST
SULFINPYRAZONE
200mg Tablet 00441767 APO-SULFINPYRAZONE 02045699 NU-SULFINPYRAZONE APX NXP
40:28.24 THIAZIDE LIKE DIURETICS

CHLORTHALIDONE
ST
APO-CHLORTHALIDONE
APX APX
ST
100mg Tablet 00360287 APO-CHLORTHALIDONE
INDAPAMIDE
ST
1.25mg Tablet 02245246 APO-INDAPAMIDE 02239913 DOM-INDAPAMIDE 02240067 GEN-INDAPAMIDE 02227339 INDAPAMIDE 02179709 LOZIDE 02240349 PHL-INDAPAMIDE 02239619 PMS-INDAPAMIDE 02312530 PRO-INDAPAMIDE 02247245 RIVA-INDAPAMIDE
APX DPC GEN PRO SEV PHH PMS PDL RIV
2010
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48:00 RESPIRATORY TRACT AGENTS

48:08.00 ANTITUSSIVES
BROMPHENIRAMINE MALEATE, DEXTROMETHORPHAN HBR, PHENYLEPHRINE HCL
Oral Liquid 02243969 DIMETAPP DM COUGH & COLD WRI
48:10.24 LEUKOTRIENE MODIFIERS

MONTELUKAST
Limited use benefit (prior approval required). For treatment of: a. - asthma when used in patients on concurrent steroid therapy. b. - asthma patients not well controlled with or intolerant to inhaled corticosteroids. 4mg Chewable Tablet 02243602 SINGULAIR 5mg Chewable Tablet 02238216 SINGULAIR FRS FRS FRS FRS
CHLORPHENIRAMINE MALEATE, DEXTROMETHORPHAN HBR, PSEUDOEPHEDRINE HCL

0.2mg & 1.5mg & 3mg/mL Syrup 00896179 TRIAMINIC DM NIGHT TIME NVC
4mg Granules 02247997 SINGULAIR 10mg Tablet 02238217 SINGULAIR
DEXTROMETHORPHAN HBR
15mg/mL Oral Liquid 02241495 DM COUGH SYRUP 1.5mg/mL Sugar Free Liquid 02215268 BENYLIN DM CHILD 3mg/mL Sugar Free Liquid 01928775 BALMINIL DM 01944738 BENYLIN DM 00511013 DM SANS SUCRE 01928791 KOFFEX DM 6mg/mL Sustained Release Sugar Free Liquid 02231404 BENYLIN DM NIGHTTIME 6mg/mL Sustained Release Suspension 02018403 DELSYM 02231313 TRIAMINIC DM 1.5mg/mL Syrup 01953966 ROBITUSSIN PEDIATRIC 2.5mg/mL Syrup 00729655 BUCKLEYS DM 3mg/mL Syrup 00522791 BRONCHOPHAN FORTE DM 00800813 COUGH SYRUP 00833231 COUGH SYRUP DEXTROMETHORPHAN 01928783 KOFFEX DM THC WLA RPH WLA TRI RPH WLA NVC NVC WRI BUY ATL RPH TAN RPH
ZAFIRLUKAST
Limited use benefit (prior approval required). For treatment of: a. - asthma when used in patients on concurrent steroid therapy. b. - asthma patients not well controlled with or intolerant to inhaled corticosteroids. 20mg Tablet 02236606 ACCOLATE AZC
48:10.32 MAST CELL STABILIZERS

SODIUM CROMOGLYCATE
100mg Capsule 00500895 NALCROM 10mg/mL Inhalation Solution (Unit Dose) 02231671 NU-CROMOLYN 02046113 PMS-SOD CROMOGLYCATE 2% Nasal Solution 01950541 CROMOLYN 2% Ophth Solution 02009277 CROMOLYN 02230621 OPTICROM AVT NXP PMS PMS PMS ALL
DEXTROMETHORPHAN HBR, PSEUDOEPHEDRINE HCL

7.5mg & 15mg Oral Liquid 02243062 TRIAMINIC COUGH & CONGESTION 1.5mg & 3mg/mL Sugar Free Liquid 01944746 BENYLIN DM-D CHILD 3mg & 6mg/mL Sugar Free Liquid 01944711 BENYLIN DM-D NVC
WLA WLA
2010
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52:00 EYE, EAR, NOSE AND THROAT (EENT) PREPARATIONS

52:02.00 EENT - ANTIALLERGIC AGENTS
LEVOCABASTINE HCL
0.05% Nasal Spray 02020017 LIVOSTIN 0.05% Ophth Suspension 02131625 LIVOSTIN JNO NVR
52:04.04 EENT - ANTIBACTERIALS

ERYTHROMYCIN
5mg/g Ophth Ointment 02237041 ERYTHROMYCIN 01912755 PMS-ERYTHROMYCIN PHH PMS
FRAMYCETIN SULFATE
0.5% Ophth Ointment 02224895 SOFRAMYCIN STERILE EYE 0.5% Ophth Solution 02224887 SOFRAMYCIN ERF ERF
SODIUM CROMOGLYCATE
2% Nasal Solution 02231390 APO-CROMOLYN APX
GENTAMICIN SULFATE
0.3% Ophth Ointment 02023776 DIOGENT 00028339 GARAMYCIN 02230888 SANDOZ-GENTAMICIN 0.3% Solution 02023822 DIOGENT 00512192 GARAMYCIN 00512184 GARAMYCIN OTIC 02219581 GENTAMICIN 00776521 PMS-GENTAMICIN 02229440 SANDOZ-GENTAMICIN 02229441 SANDOZ-GENTAMICIN OTIC DKT SCH SDZ DKT SCH SCH SPH PMS SDZ SDZ

BACITRACIN ZINC, POLYMYXIN B SULFATE
500IU & 10,000IU/g Ophth Ointment 02160889 OPTIMYXIN 02239157 POLYSPORIN SDZ PFI
CHLORAMPHENICOL
1% Ophth Ointment 02026260 DIOCHLORAM 01980564 PENTAMYCETIN 0.25% Ophth Solution 01980556 PENTAMYCETIN 0.5% Ophth Solution 02023857 DIOCHLORAM 02164051 PENTAMYCETIN DKT SDZ SDZ DKT SDZ
GRAMICIDIN, NEOMYCIN SULFATE, POLYMYXIN B SULFATE

0.025mg & 2.5mg & 10,000U/mL Solution 00807435 OPTIMYXIN PLUS EYE/EAR SDZ
CIPROFLOXACIN HCL
0.3% Ophth Ointment 02200864 CILOXAN 0.3% 0.3% Ophth Solution 02263130 APO-CIPROFLOX 01945270 CILOXAN 02253933 PMS-CIPROFLOXACIN Limited use benefit (prior approval required). a.- for children 16 years old and under (prior approval not required) b.- for acute otitis media with otorrhea through tympanostomy tubes who require treatment c.- for acute otitis externa in the presence of tympanostomy tube or known perforation of the tympanic membrane 0.3%/0.1% Otic Solution 02252716 CIPRODEX Limited use benefit (prior approval required). For treatment of acute diffuse bacterial external otitis. Criteria for coverage include: a. - failure to respond to other listed topical antibiotics, or b. - contraindications to other listed topical antibiotics. 2mg & 10mg/mL Otic Suspension 02240035 CIPRO HC ALC ALC ALC APX ALC PMS
GRAMICIDIN, POLYMYXIN B SULFATE

0.025mg & 10,000U/mL Solution 00701785 OPTIMYXIN EYE/EAR 02239156 POLYSPORIN EYE/EAR SDZ WLA
OFLOXACIN
0.3% Ophth Solution 02248398 APO-OFLOXACIN 02143291 OCUFLOX 02252570 PMS-OFLOXACIN APX ALL PMS
CIPROFLOXACIN HCL, DEXAMETHASONE
POLYMYXIN B SULFATE, TRIMETHOPRIM SULFATE

10,000U & 1mg/mL Ophth Solution 02240363 PMS-POLYTRIMETHOPRIM 02011956 POLYTRIM PMS ALL
SULFACETAMIDE SODIUM
10% Ophth Solution 02023830 DIOSULF DKT
CIPROFLOXACIN HCL, HYDROCORTISONE
TOBRAMYCIN
0.3% Ophth Ointment 00614254 TOBREX 0.3% Ophth Solution 02239577 PMS-TOBRAMYCIN 02241755 SANDOZ-TOBRAMYCIN 00513962 TOBREX ALC PMS SDZ ALC Page 77 of 124
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52:04.20 EENT - ANTIVIRALS

TRIFLURIDINE
1% Ophth Solution 02248529 SANDOZ-TRIFLURIDINE 00687456 VIROPTIC SDZ GSK
52:08.08 EENT - CORTICOSTEROIDS

FLUNISOLIDE
0.025% Nasal Spray 02239288 APO-FLUNISOLIDE 01927167 PMS-FLUNISOLIDE APX PMS

BECLOMETHASONE DIPROPIONATE
50mcg/Dose Nasal Spray 02238796 APO-BECLOMETHASONE 02172712 GEN-BECLO AQ 02237379 MED-BECLOMETHASONE AQ 02238577 NU-BECLOMETHASONE 00872318 RATIO-BECLOMETHASONE AQ 02228300 RIVANASE AQ APX GEN MEC NXP RPH RIV
FLUOROMETHOLONE
0.1% Ophth Solution 02238568 PMS-FLUOROMETHOLONE 0.1% Ophth Suspension 00247855 FML 0.25% Ophth Suspension 00707511 FML FORTE PMS ALL ALL
FLUOROMETHOLONE ACETATE
0.1% Ophth Solution 00756784 FLAREX ALC
BETAMETHASONE SODIUM PHOSPHATE, GENTAMICIN SULFATE

0.1% & 0.3% Ophth Ointment 00586706 GARASONE 0.1% & 0.3% Solution 00682217 GARASONE OPHTH/OTIC 02244999 SANDOZ-PENTASONE OPHTH/OTIC SCH SCH SDZ
FLUTICASONE PROPIONATE
50mcg/Dose Nasal Spray 02294745 APO-FLUTICASONE 02213672 FLONASE 02296071 RATIO-FLUTICASONE APX GSK RPH
BUDESONIDE
64mcg/Dose Nasal Spray 02241003 GEN-BUDESONIDE AQ 02231923 RHINOCORT AQ 100mcg/Dose Nasal Spray 02230648 GEN-BUDESONIDE AQ 100mcg/Dose Powder 02035324 RHINOCORT TURBUHALER GEN AZC GEN AZC
FRAMYCETIN SULFATE, GRAMICIDIN, DEXAMETHASONE

5mg & 0.05mg/mL & 0.5mg Ophth/Otic Solution 02247920 SANDOZ-OPTICORT SDZ 02224623 SOFRACORT EYE/EAR SAC
HYDROCORTISONE, NEOMYCIN SULFATE, POLYMYXIN B SULFATE

10mg & 3.5mg & 10,000U/mL Otic Solution 01912828 CORTISPORIN 02230386 SANDOZ-CORTIMYXIN GSK SDZ
DEXAMETHASONE
0.1% Ophth Ointment 00042579 MAXIDEX 0.1% Ophth Solution 02023865 DIODEX 00785261 PMS-DEXAMETHASONE 00739839 SANDOZ-DEXAMETHASONE 0.1% Ophth Suspension 00042560 MAXIDEX ALC DKT PMS SDZ ALC
MOMETASONE FUROATE
50mcg Nasal Spray 02238465 NASONEX SCH
PREDNISOLONE ACETATE
0.12% Ophth Suspension 00299405 PRED MILD 01916181 SANDOZ PREDNISOLONE 1% Ophth Suspension 02023768 DIOPRED 00301175 PRED FORTE 00700401 RATIO-PREDNISOLONE 01916203 SANDOZ-PREDNISOLONE ALL SDZ DKT ALL RPH SDZ
DEXAMETHASONE, TOBRAMYCIN
0.1% & 0.3% Ophth Ointment 00778915 TOBRADEX 0.1% & 0.3% Ophth Suspension 00778907 TOBRADEX ALC ALC
FLUMETHASONE PIVALATE, CLIOQUINOL

0.02% & 1% Otic Solution 00074454 LOCACORTEN VIOFORM PAL
PREDNISOLONE ACETATE, SULFACETAMIDE SODIUM

0.2% & 10% Ophth Ointment 00307246 BLEPHAMIDE 0.5% & 10% Ophth Solution 02023814 DIOPTIMYD ALL DKT ALL
FLUNISOLIDE
0.025% Nasal Solution 00878790 RATIO-FLUNISOLIDE RPH
0.2% & 10% Ophth Suspension 00807788 BLEPHAMIDE
2010
Page 78 of 124
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PREDNISOLONE SODIUM PHOSPHATE
0.5% Ophth Solution 02148498 PREDNISOLONE CUV
52:28.00 EENT - MOUTHWASHES AND GARGLES

BENZYDAMINE HCL
Limited use benefit (prior approval required). For: a. - treatment of radiation mucositis and oral ulcerative complications of chemotherapy. b. - use in immunocompromised patients who are at risk of mucosal breakdown. 0.15% Rinse 02239044 02239537 02229799 02229777 02230170 APO-BENZYDAMINE DOM-BENZYDAMINE NOVO-BENZYDAMINE PMS-BENZYDAMINE RATIO-BENZYDAMINE APX DPC NOP PMS RPH NOP
TRIAMCINOLONE ACETONIDE
55mcg/Dose Nasal Spray 02213834 NASACORT AQ SAC
52:08.20 EENT - NONSTEROIDAL ANTIINFLAMMATORY AGENTS

DICLOFENAC SODIUM
0.1% Ophth Solution 01940414 VOLTAREN NVR
FLURBIPROFEN SODIUM
0.03% Ophth Solution 00766046 OCUFEN ALL
1.5mg/mL Rinse 02310422 NOVO-BENZYDAMINE
KETOROLAC TROMETHAMINE
0.5% Ophth Solution 01968300 ACULAR 02245821 APO-KETOROLAC 02247461 RATIO-KETOROLAC ALL APX RPH
CHLORHEXIDINE GLUCONATE
0.12% Rinse 02240433 02237452 02207796 PERICHLOR PERIDEX PERIOGARD PMS MMH COP
52:20.00 EENT - MIOTICS

CARBACHOL
1.5% Ophth Solution 00000655 ISOPTO CARBACHOL ALC
52:32.00 EENT - VASOCONSTRICTORS

ANTAZOLINE PHOSPHATE, NAPHAZOLINE HCL
0.5% & 0.05% Ophth Solution 00433519 ALBALON A ALL
52:24.00 EENT - MYDRIATICS

ATROPINE SULFATE
1% Ophth Ointment 00252484 ATROPINE 1% Ophth Solution 02023695 ATROPINE 02148358 ATROPINE SULPHATE MINIMS 00035017 ISOPTO ATROPINE ALC DKT NVR ALC
NAPHAZOLINE HCL
0.1% Ophth Solution 00001147 ALBALON 00390283 NAPHCON FORTE ALL ALC
PHENYLEPHRINE HCL
0.12% Ophth Solution 00395161 PREFRIN LIQUIFILM 2.5% Ophth Solution 02027100 DIONEPHRINE 00465763 MYDFRIN 02148447 PHENYLEPHRINE MINIMS 10% Ophth Solution 02148455 PHENYLEPHRINE ALL DKT ALC NVR NVR
CYCLOPENTOLATE HCL
0.5% Ophth Solution 02148331 CYCLOPENTOLATE 1% Ophth Solution 00252506 CYCLOGYL 02148382 CYCLOPENTOLATE MINIMS 02023644 DIOPENTOLATE NVR ALC NVR DKT
DIPIVEFRIN HCL
0.1% Ophth Solution 02242232 APO-DIPIVEFRIN 02237868 PMS-DIPIVEFRIN APX PMS
52:40.04 EENT - ALPHA-ADRENERGIC AGONISTS

BRIMONIDINE TARTRATE
0.2% Ophth Solution 02236876 ALPHAGAN 02260077 APO-BRIMONIDINE 02246284 PMS-BRIMONIDINE 02243026 RATIO-BRIMONIDINE 02305429 SANDOZ BRIMONIDINE ALL APX PMS RPH SDZ
HOMATROPINE HBR
2% Ophth Solution 00000779 ISOPTO HOMATROPINE 5% Ophth Solution 00000787 ISOPTO HOMATROPINE ALC ALC
2010
Page 79 of 124
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BRIMONIDINE TARTRATE (ALPHAGAN P)
Limited use benefit (prior approval required). For patients who are intolerant to brimonidine tartrate 0.2% or benzalkonium chloride. 0.15% Ophth Solution 02248151 ALPHAGAN P 02301334 APO-BRIMONIDINE P ALL APX
52:40.08 EENT - BETA-ADRENERGIC BLOCKING AGENTS

TIMOLOL MALEATE
0.5% Ophth Solution 00755834 APO-TIMOP 02238771 DOM-TIMOLOL 00893781 GEN-TIMOLOL 02084325 MED-TIMOLOL 02083345 PMS-TIMOLOL 02166720 SANDOZ-TIMOLOL 00451207 TIMOPTIC APX DPC GEN MEC PMS SDZ FRS
BRIMONIDINE TARTRATE, TIMOLOL MALEATE

0.2% & 0.5% Ophth Solution 02248347 COMBIGAN ALL
52:40.12 EENT - CARBONIC ANHYDRASE INHIBITORS

ACETAZOLAMIDE
250mg Tablet 00545015 APO-ACETAZOLAMIDE APX
52:40.08 EENT - BETA-ADRENERGIC BLOCKING AGENTS

BETAXOLOL HCL
0.5% Ophth Solution 02235971 SANDOZ-BETAXOLOL 0.25% Ophth Suspension 01908448 BETOPTIC S SDZ ALC
BRINZOLAMIDE
1% Ophth Suspension 02238873 AZOPT ALC
LEVOBUNOLOL HCL
0.25% Ophth 02241575 00751286 02031159 02241715 Solution APO-LEVOBUNOLOL BETAGAN RATIO-LEVOBUNOLOL SANDOZ-LEVOBUNOLOL APX ALL RPH SDZ ALL PMS RPH SDZ
BRINZOLAMIDE/TIMOLOL MALEATE
1%/0.5% Ophth Solution 02331624 AZARGA ALC
DORZOLAMIDE HCL
2% Ophth Solution 02216205 TRUSOPT FRS
0.5% Ophth Solution 00637661 BETAGAN 02237991 PMS-LEVOBUNOLOL 02031167 RATIO-LEVOBUNOLOL 02241716 SANDOZ-LEVOBUNOLOL
DORZOLAMIDE HCL, TIMOLOL MALEATE

20mg & 5mg/mL Ophth Solution 02240113 COSOPT FRS
METHAZOLAMIDE
50mg Tablet 02245882 APO-METHAZOLAMIDE APX
TIMOLOL MALEATE
0.25% Long Acting Ophth Solution 02171880 TIMOPTIC-XE 0.5% Long Acting Ophth Solution 02171899 TIMOPTIC-XE 0.25% Ophth Gel Solution 02242275 TIMOLOL MALEATE-EX 0.5% Ophth Gel Solution 02290812 APO-TIMOP 02242276 TIMOLOL MALEATE-EX 0.25% Ophth 00755826 02238770 00893773 02084317 02048523 02083353 02166712 Solution APO-TIMOP DOM-TIMOLOL GEN-TIMOLOL MED-TIMOLOL NOVO-TIMOL PMS-TIMOLOL SANDOZ-TIMOLOL FRS FRS PMS APX PMS APX DPC GEN MEC NOP PMS SDZ

CARBACHOL
0.01% Ophth Solution 00042544 MIOSTAT 3% Ophth Solution 00000663 ISOPTO CARBACHOL ALC ALC
PILOCARPINE HCL
4% Ophth Gel 00575240 PILOPINE HS 1% Ophth Solution 00000841 ISOPTO CARPINE 02229556 PILOCARPINE 2% Ophth Solution 00000868 ISOPTO CARPINE 4% Ophth Solution 02023733 DIOCARPINE 00000884 ISOPTO CARPINE ALC ALC SCN ALC DKT ALC
2010
Page 80 of 124
Health Canada

PILOCARPINE NITRATE
2% Ophth Solution 02148463 PILOCARPINE NITRATE MINIMS 4% Ophth Solution 02148471 PILOCARPINE NITRATE MINIMS NVR
52:92.00 MISCELLANEOUS EENT DRUGS

IPRATROPIUM BROMIDE
0.03% Nasal Spray 02163705 ATROVENT 0.06% Nasal Spray 02163713 ATROVENT NVR BOE BOE
LODOXAMIDE TROMETHAMINE
0.1% Ophth Solution 00893560 ALOMIDE ALC
52:40.28 EENT - PROSTAGLANDIN AGENTS

BIMATOPROST
0.01% Ophth Solution 02324997 LUMIGAN 0.03% Ophth Solution 02245860 LUMIGAN ALL ALL
MACROGOL, PROPYLENE GLYCOL

15% & 20% Nasal Gel 02220806 PMS-RHINARIS 00551805 SECARIS 15% & 20% Nasal Spray 00732230 RHINARIS PMS PMS PMS
LATANOPROST
0.005% Ophth Solution 02231493 XALATAN PFI
MINERAL OIL, PETROLATUM

80% & 20% Ophth Ointment 02125706 DUOLUBE BSH
TIMOLOL MALEATE, TRAVOPROST

0.5% & 0.004% Ophth Solution 02278251 DUO TRAV ALC
MINERAL OIL, WHITE PETROLATUM

55.5% & 42.5% Ophth Ointment 00210889 LACRI LUBE ALL
TRAVOPROST
0.004% Ophth Solution 02244896 TRAVATAN 02318008 TRAVATAN Z ALC ALC
PETROLATUM, LANOLIN, MINERAL OIL

94% & 3% & 3% Ophth Ointment 02082519 TEARS NATURALE P.M. ALC

ALUMINUM ACETATE, BENZETHONIUM CHLORIDE
0.5% & 0.03% Otic Solution 00674222 BURO-SOL STI
PETROLATUM, PETROLATUM LIQUID

85% & 15% Ophth Ointment 02133288 HYPOTEARS NVR
POLYVINYL ALCOHOL
1% Ophth Solution 02133253 HYPOTEARS 1.4% Ophth Solution 02229570 ARTIFICIAL TEARS 00045616 LIQUIFILM TEARS 00579408 TEARS PLUS NVR PMS ALL ALL
APRACLONIDINE HCL
0.5% Ophth Solution 02076306 IOPIDINE ALC
DEXTRAN 70, HYDROXYPROPYLMETHYLCELLULOSE

0.1% & 0.3% Ophth Solution 00390291 TEARS NATURALE 01943308 TEARS NATURALE FREE 00743445 TEARS NATURALE II ALC ALC ALC
POLYVINYL ALCOHOL, POVIDONE

1.4% & 0.6% Ophth Solution 02229632 ARTIFICIAL TEARS EXTRA PMS
SODIUM CARBOXYMETHYL CELLULOSE

0.5% Ophth Solution 02049260 REFRESH PLUS ALL ALL ALL ALL
DIPIVEFRIN HCL, LEVOBUNOLOL HCL

0.1% & 0.5% Ophth Solution 02209071 PROBETA ALL
1% Ophth Solution 00870153 CELLUVISC 10mg/mL Ophth Solution 02244650 REFRESH LIQUIGEL
HYDROXYPROPYLMETHYLCELLULOSE
0.5% Ophth Solution 00000809 ISOPTO TEARS 00889806 SANDOZ EYELUBE 1% Ophth Solution 00000817 ISOPTO TEARS 00874965 SANDOZ EYELUBE ALC SDZ ALC SDZ
0.5% Ophth Solution (Multi-Dose) 02231008 REFRESH TEARS
SODIUM CHLORIDE
0.7% Nasal Solution 00857777 OTRIVIN SALINE NVC Page 81 of 124
2010
Health Canada

SODIUM CHLORIDE
0.7% Nasal Spray 00810436 OTRIVIN SALINE 0.9% Nasal Spray 02231476 HYDRA SENSE (ISOTONIC, STERILE SEAWATER) 02030861 NASAL SALINE 00489530 SALINEX 5% Ophth Ointment 00750816 MURO-128 5% Ophth Solution 00750824 MURO-128 02245735 SANDOZ-SODIUM CHLORIDE NVC SCH PDD SDZ BSH BSH SDZ
VERTEPORFIN
Limited use benefit (prior approval required). For treatment of age related macular degeneration for patients with this diagnosis who are being treated by a certified ophthalmologist. 15mg/Vial Injection 02242367 VISUDYNE QLT
2010
Page 82 of 124
Health Canada
56:00 GASTROINTESTINAL DRUGS

56:04.00 ANTACIDS AND ADSORBENTS
BISMUTH SUBSALICYLATE
17.6mg/mL Liquid 02097079 PEPTO BISMOL 262mg Tablet 02177994 PEPTO BISMOL PGI PGI
56:12.00 CATHARTICS AND LAXATIVES

CITRIC ACID, MAGNESIUM OXIDE, SODIUM PICOSULFATE
Oral Liquid 02317966 Powder 02254794 PURG-ODAN PICO-SALAX ODN FEI
MAG OXIDE
420mg Tablet 00299448 MAGNESIUM OXIDE SWS
DIOCTYL CALCIUM SULFOSUCCINATE

ST
56:08.00 ANTIDIARRHEA AGENTS

LOPERAMIDE HCL
ST
0.2mg/mL Liquid 02192667 DIARR-EZE 02016095 PMS-LOPERAMIDE 2mg Tablet 02212005 02229552 02248994 02256452 02239535 02183862 02225182 02132591 02228351 02233998 02238211 02257564 APO-LOPERAMIDE DIARR-EZE DIARRHEA RELIEF DIARRHEA RELIEF DOM-LOPERAMIDE IMODIUM LOPERAMIDE NOVO-LOPERAMIDE PMS-LOPERAMIDE RHOXAL-LOPERAMIDE RIVA-LOPERAMIDE SANDOZ-LOPERAMIDE
PMS PMS APX PMS PMS VTH DPC MCL PDL NOP PMS RHO RIV SDZ
240mg Capsule 02245080 APO-DOCUSATE CALCIUM 00830275 DOCUSATE CALCIUM 02283255 JAMP-DOCUSATE CALCIUM 00842044 NOVO-DOCUSATE CALCIUM 00664553 PMS-DOCUSATE CALCIUM 00809055 RATIO-DOCUSATE CALCIUM
APX TAR JMP NOP PMS RPH
DIOCTYL SODIUM SULFOSUCCINATE

ST
ST

BISACODYL
ST
100mg Capsule 02245079 APO-DOCUSATE SODIUM 02106256 COLACE 00716731 DOCUSATE SODIUM 00794406 DOCUSATE SODIUM 00830267 DOCUSATE SODIUM 02246036 DOCUSATE SODIUM 02239658 DOM-DOCUSATE SODIUM 02247385 EURO-DOCUSATE 02020084 NOVO-DOCUSATE 00703494 PMS-DOCUSATE SODIUM 00870196 RATIO-DOCUSATE SODIUM 00514888 SELAX 01994344 SOFLAX 200mg Capsule 02029529 SOFLAX 250mg Capsule 02006596 SELAX 10mg/mL Drop 02090163 COLACE 00870218 DOCUSATE SODIUM 00880140 PMS-SODIUM DOCUSATE 02006723 SOFLAX 4mg/mL Syrup 02086018 COLACE 00703508 PMS-DOCUSATE SODIUM 00870226 RATIO-DOCUSATE SODIUM 02006758 SOFLAX SYRUP 20mg/mL Syrup 02283239 DOCUSATE SODIUM 50mg/mL Syrup 02283220 DOCUSATE SODIUM 00848417 PMS-DOCUSATE SODIUM
APX WPC TAR SDR TRI RPH DPC EUR NOP PMS RPH ODN PMS PMS ODN WPC RPH PMS PMS WPC PMS RPH PMS JMP JMP PMS
ST
5mg Enteric Coated Tablet 00545023 APO-BISACODYL 00420433 BISACODYL 00714488 BISACOLAX 00254142 DULCOLAX 02246039 JAMP-BISACODYL 00587273 PMS-BISACODYL 5mg Suppository 00003867 DULCOLAX 10mg Suppository 00754595 APO-BISACODYL 00261327 BISACOLAX 00003875 DULCOLAX 00582883 PMS-BISACODYL 00404802 RATIO-BISACODYL 02229743 SOFLAX EX
ST
APX PRO ICN BOE JMP PMS BOE APX ICN BOE PMS RPH PMS
ST
ST
ST
ST
BISACODYL (POLYETHYLENE GLYCOL BASE)

Limited use benefit (prior approval required). For treatment of constipation in patients with spinal cord injury. 10mg Suppository 02241091 MAGIC BULLET DCM
ST
DIOCTYL SODIUM SULFOSUCCINATE, SENNA

50mg & 187mg Tablet 00026123 SENOKOT S PFR
2010
Page 83 of 124
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DIOCTYL SODIUM SULFOSUCCINATE, SENNOSIDES
ST

MINERAL OIL
Liquid 01935348 MINERAL OIL (HEAVY) 100% USP RWP
100mg Capsule 02245946 DOCUSATE SODIUM 50mg & 8.6mg Tablet 02247390 EURO-SENNA S
JMP EUR
ST
PLANTAGO SEED
50% Powder 00599875 MUCILLIUM PMS
DOCUSATE SODIUM
ST
100mg Capsule 02326086 DOCUSATE SODIUM 02303825 EURO-DOCUSATE
POLYETHYLENE GLYCOL
PDL EUR Powder 09991007 POLYETHYLENE GLYCOL WIL
FIBER
ST
POLYETHYLENE GLYCOL 3350

NOP Powder 09991054 POLYETHYLENE GLYCOL 3350 WIL PED
469mg Tablet 00595829 NOVO-FIBRE
GLYCERINE
Adult Suppository 00873462 GLYCERIN 01926039 GLYCERIN 00812250 GLYCERINE 00884022 GLYCERINE Pediatric Suppository 02020815 GLYCERIN INFANT 01926047 GLYCERIN INFANT & CHILD RPH WLA WLA RPH RPH PFI
1g/g Powder 02317680 LAX-A-DAY
POLYETHYLENE GLYCOL, POTASSIUM CHLORIDE, SODIUM BICARBONATE, SODIUM CHLORIDE, SODIUM SULFATE
Oral Liquid 02147793 KLEAN-PREP RVX
PSYLLIUM HYDROPHILIC MUCILLOID

680mg/g Powder 02174812 METAMUCIL ORIGINAL TEXTURE 02174790 METAMUCIL SM TEXT ORANGE 02174782 METAMUCIL SM TEXT ORANGE S/F 02174804 METAMUCIL SM TEXT UNFLAV PGI PGI PGI PGI
LACTULOSE
ST
667mg/mL Oral Liquid 02242814 APO-LACTULOSE 02247383 EURO-LAC 02280078 GPI-LACTULOSE 02295881 LACTULOSE 00703486 PMS-LACTULOSE 02311275 PRO-LACTULOSE 00690686 RATIO-LACTULOSE 00854409 RATIO-LACTULOSE
APX EUR OBP JMP PMS PRO RPH RPH
SENNOSIDES
ST
MACROGOL, POTASSIUM CHLORIDE, SODIUM BICARBONATE, SODIUM CHLORIDE, SODIUM SULFATE

60g & 750mg & 1.68g & 1.46g & 5.68g/L Powder 00677442 COLYTE ZYM 00652512 GOLYTELY BAX 00777838 PEGLYTE PMS
ST
1.7mg/mL Liquid 02144379 SENNALAX 02084651 SENNAPREP 00367729 SENOKOT 00367737 X-PREP 8.6mg Tablet 02247389 80009182 00896411 01949292 02089653 02237105 02068109 00026158 EURO-SENNA JAMP-SENNOSIDES PMS-SENNOSIDES RIVA-SENNA SANDOZ-SENNOSIDES SENNA LAXATIVE SENNATAB SENOKOT
PMS PMS PFR PFR EUR JMP PMS RIV SDZ SDR PMS PFR JMP PMS SDZ
MAGNESIUM HYDROXIDE
80mg/mL Liquid 02150646 MILK OF MAGNESIA PLAIN/SUGARFREE 311mg Tablet 02150638 MILK OF MAGNESIA BCD
ST
BCD
MINERAL OIL
78% Jelly 00608734 02186926 LANSOYL GEL LANSOYL GEL SUGARFREE AXC AXC
12MG Tablet 80009183 JAMP-SENNOSIDES 00896403 PMS-SENNOSIDES 02089645 SANDOZ-SENNOSIDES
SODIUM CITRATE, SODIUM LAURYL SULFOACETATE, SORBITOL

90mg & 9mg & 625mg Enema 02063905 MICROLAX PMS Page 84 of 124
2010
Health Canada

SODIUM PHOSPHATE DIBASIC, SODIUM PHOSPHATE MONOBASIC
180mg & 480mg/mL Oral Liquid 02206218 PHOSPHO SODA FLEET LAXATIVE 02230399 PMS-PHOSPHATES SOLUTION 60mg & 160mg/mL Rectal Liquid 02096900 ENEMOL 00009911 FLEET ENEMA 60mg & 160mg/mL PED Rectal Liquid 00108065 FLEET ENEMA PEDIATRIC JAJ
56:16.00 DIGESTANTS
LIPASE, AMYLASE, PROTEASE
ST
4,000U & 12,000U & 12,000U Capsule (Enteric Coated Particles) 00789445 PANCREASE MT 4 JNO 4,500U & 20,000U & 25,000U Capsule (Enteric Coated Particles) 02203324 ULTRASE MS 4 AXC 8,000U & 30,000U & 30,000U Capsule (Enteric Coated Particles) 00502790 COTAZYM ECS 8 ORG 10,000U & 30,000U & 30,000U Capsule (Enteric Coated Particles) 00789437 PANCREASE MT 10 JNO 10,000U & 33,200U & 37,500U Capsule (Enteric Coated Particles) 02200104 CREON 10 SPH MINIMICROSPHERES 12,000U & 39,000U & 39,000U Capsule (Enteric Coated Particles) 02045834 ULTRASE MT 12 AXC 16,000U & 48,000U & 48,000U Capsule (Enteric Coated Particles) 00789429 PANCREASE MT 16 JNO 20,000U & 55,000U & 55,000U Capsule (Enteric Coated Particles) 00821373 COTAZYM ECS 20 ORG 20,000U & 65,000 & 65,000U Capsule (Enteric Coated Particles) 02045869 ULTRASE MT 20 AXC 25,000U & 74,000U & 62,500U Capsule (Enteric Coated Particles) 01985205 CREON 25 SPH MINIMICROSPHERES 24,000U & 100,000U & 100,000U/g Powder 02230020 VIOKASE 8,000U & 30,000U & 30,000U Tablet 02230019 VIOKASE 16,000U & 60,000U & 60,000U Tablet 02241933 VIOKASE AXC AXC AXC
ST
PMS DPC FRS JAJ

ST
ST
56:14.00 CHOLELITHOLYTIC AGENTS

URSODIOL
ST ST
250mg Tablet 02281317 PHL-URSODIOL C 02273497 PMS-URSODIOL 02238984 URSO 500mg Tablet 02281325 PHL-URSODIOL C 02273500 PMS-URSODIOL 02245894 URSO DS
PHH PMS AXC PHH PMS AXC
ST
ST
ST
56:16.00 DIGESTANTS
LACTASE
3,550U Capsule 02016478 LACTRASE Oral Liquid 00903981 3,000U Tablet 02200384 02239139 02017512 01951637 02230653 LACTAID DAIRY DIGESTIVE DAIRY DIGESTIVE DAIRY FREE DAIRYAID LACTAID RIV MCL PER SDR KIN TAN JNO SDR KIN JNO
ST
ST
ST
ST
ST
4,500U Tablet 02239140 DAIRY DIGESTIVE EXTRA STRENGTH 02224909 DAIRY FREE EXTRA STRENGTH 02230654 LACTAID EXTRA STRENGTH
ST
56:20.00 EMETICS
IPECAC
7% Syrup 00721328 PMS-IPECAC PMS XEN
LIPASE, AMYLASE, PROTEASE

ST
5,000U & 16,600U & 18,750U Capsule 02239007 CREON 5 MINIMICROSPHERES 8,000U & 30,000U & 30,000U Capsule 00263818 COTAZYM 20,000U & 66,400U & 75,000U Capsule 02239008 CREON 20 MINIMICROSPHERES
SPH
ST
14mg/mL Syrup 00378801 IPECAC
ORG SPH
56:22.08 ANTIHISTAMINES
DIMENHYDRINATE
50mg/mL Injection 00392537 DIMENHYDRINATE 00013579 GRAVOL
ST
ST
ST
4,000U & 11,000U & 11,000U Capsule (Enteric Coated Particles) 02181215 COTAZYM ECS4 ORG
SDZ HOR HOR
3mg/mL Liquid 00230197 GRAVOL
2010
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56:22.08 ANTIHISTAMINES
DIMENHYDRINATE
25mg Suppository 00783595 GRAVOL 50mg Suppository 00392553 DIMENHYDRINATE 00013595 GRAVOL
ST
56:22.20 5-HT3 RECEPTOR ANTAGONISTS

ONDANSETRON HCL DIHYDRATE
HOR SDZ HOR HOR APX PRO HOR SDZ NOP PMS ICN VTH JMP 4mg Tablet 02288184 02297868 02313685 02305259 02264056 02278618 02258188 02312247 02278529 02274310 02213567 02239372 8mg Tablet 02288192 02297876 02313693 02305267 02264064 02278626 02258196 02312255 02278537 02274329 02213575 02239373 APO-ONDANSETRON GEN-ONDANSETRON JAMP ONDANSETRON MINT-ONDANSETRON NOVO-ONDANSETRON PHL-ONDANSETRON PMS-ONDANSETRON RAN-ONDANSETRON RATIO-ONDANSETRON SANDOZ-ONDANSETRON ZOFRAN ZOFRAN ODT APO-ONDANSETRON GEN-ONDANSETRON 8MG TAB JAMP ONDANSETRON MINT-ONDANSETRON NOVO-ONDANSETRON PHL-ONDANSETRON PMS-ONDANSETRON RAN-ONDANSETRON RATIO-ONDANSETRON SANDOZ-ONDANSETRON ZOFRAN ZOFRAN ODT APX GEN JMP MIN NOP PHH PMS RBY RPH SDZ GSK GSK APX GEN JMP MIN NOP PHH PMS RBY RPH SDZ GSK GSK
GRAVOL
ST
50mg Tablet 00363766 APO-DIMENHYDRINATE 00156655 DIMENHYDRINATE 00013803 GRAVOL 00399779 NAUSEATOL 00021423 NOVODIMENATE 00586331 PMS-DIMENHYDRINATE 00272671 TRAVAMINE 00605786 TRAVEL AID 02245416 TRAVEL TABLET
DOXYLAMINE SUCCINATE, PYRIDOXINE HCL

10mg & 10mg Tablet 00609129 DICLECTIN DUI
MECLIZINE HCL
ST
25mg Chewable Tablet 00220442 BONAMINE
JNO
56:22.20 5-HT3 RECEPTOR ANTAGONISTS

DOLASETRON MESYLATE
20mg/mL Injection 02231380 ANZEMET 50mg Tablet 02231378 ANZEMET SAC SAC SAC
56:22.92 MISCELLANEOUS ANTIEMETICS

APREPITANT
Limited use benefit (prior approval required). When used in combination with a 5-HT3 antagonist and dexamethasone for the prevention of acute and delayed nausea and vomiting due to highly emetogenic cancer chemotherapy (eg. Cisplatin > 70mg/m2) in patients who have experienced emesis despite treatment with a combination of a 5-HT3 antagonist and dexamethasone in a previous cycle of highly emetogenic chemotherapy. 80mg Capsule 02298791 EMEND 125mg Capsule 02298805 EMEND CBT ZYM CBT ZYM 125mg & 80mg Capsule 02298813 EMEND TRI PACK FRS FRS FRS
100mg Tablet 02231379 ANZEMET
GRANISETRON
1mg Tablet 02308894 02185881 APO-GRANISETRON KYTRIL APX HLR
ONDANSETRON HCL
4mg Tablet 02296349 02344440 8mg Tablet 02296357 02344459 CO-ONDANSETRON ZYM-ONDANSETRON CO-ONDANSETRON ZYM-ONDANSETRON
DOMPERIDONE MALEATE
10mg Tablet 02103613 02238315 02236857 02278669 02157195 02231477 02236466 02268078 01912070 APO-DOMPERIDONE DOM-DOMPERIDONE DOMPERIDONE GEN-DOMPERIDONE NOVO-DOMPERIDONE NU-DOMPERIDONE PMS-DOMPERIDONE RAN-DOMPERIDONE RATIO-DOMPERIDONE APX DPC PDL GEN NOP NXP PMS RBY RPH Page 86 of 124
ONDANSETRON HCL DIHYDRATE

0.8mg/mL Liquid 02291967 APO-ONDANSETRON 02229639 ZOFRAN APX GSK
2010
Health Canada

NABILONE
0.25mg Capsule 02312263 CESAMET 0.5mg Capsule 02256193 CESAMET 1mg Capsule 00548375 CESAMET VAE VAE VAE
56:28.12 HISTAMINE H2-ANTAGONISTS

FAMOTIDINE
ST

CIMETIDINE
ST ST
20mg Tablet 01953842 APO-FAMOTIDINE 02241372 FAMOTIDINE 02196018 GEN-FAMOTIDINE 02022133 NOVO-FAMOTIDINE 02024195 NU-FAMOTIDINE 02238342 PENTA-FAMOTIDINE 00710121 PEPCID 02237148 ULCIDINE 40mg Tablet 01953834 02241373 02196026 02022141 02024209 02238343 00710113 02237149 APO-FAMOTIDINE FAMOTIDINE GEN-FAMOTIDINE NOVO-FAMOTIDINE NU-FAMOTIDINE PENTA-FAMOTIDINE PEPCID ULCIDINE
APX PDL GEN NOP NXP PEN FRS VAE APX PDL GEN NOP NXP PEN FRS VAE
200mg Tablet 00584215 02227436 00582409 00865796 00596469 02229717 300mg Tablet 00487872 00596477 02231287 02227444 00582417 00865818 02229718 400mg Tablet 00600059 00618691 02231288 02227452 00603678 00865826 02229719 600mg Tablet 00600067 00618705 02231290 02227460 00603686 00865834 02229720 800mg Tablet 00749494 02227479 00663727 02229721
APO-CIMETIDINE GEN-CIMETIDINE NOVO-CIMETINE NU-CIMET PDL-CIMETIDINE PMS-CIMETIDINE APO-CIMETIDINE CIMETIDINE DOM-CIMETIDINE GEN-CIMETIDINE NOVO-CIMETINE NU-CIMET PMS-CIMETIDINE APO-CIMETIDINE CIMETIDINE DOM-CIMETIDINE GEN-CIMETIDINE NOVO-CIMETINE NU-CIMET PMS-CIMETIDINE APO-CIMETIDINE CIMETIDINE DOM-CIMETIDINE GEN-CIMETIDINE NOVO-CIMETINE NU-CIMET PMS-CIMETIDINE APO-CIMETIDINE GEN-CIMETIDINE NOVO-CIMETINE PMS-CIMETIDINE
APX GEN NOP NXP PDL PMS APX PDL DPC GEN NOP NXP PMS APX PDL DPC GEN NOP NXP PMS APX PDL DPC GEN NOP NXP PMS APX GEN NOP PMS
ST
NIZATIDINE
ST
ST
150mg Capsule 02220156 APO-NIZATIDINE 00778338 AXID 02185814 DOM-NIZATIDINE 02246046 GEN-NIZATIDINE 02239558 NIZATIDINE 02240457 NOVO-NIZATIDINE 02177714 PMS-NIZATIDINE 300mg Capsule 02220164 APO-NIZATIDINE 00778346 AXID 02246047 GEN-NIZATIDINE 02238195 NIZATIDINE 02239559 NIZATIDINE 02240458 NOVO-NIZATIDINE 02177722 PMS-NIZATIDINE
APX PHH DPC GEN PDL NOP PMS APX PHH GEN PHH PDL NOP PMS
ST
ST
RANITIDINE HCL
ST
ST
15mg/mL Oral Solution 02280833 APO-RANITIDINE 02242940 NOVO-RANITIDINE 02212374 ZANTAC
APX NOP GSK
2010
Page 87 of 124
Health Canada

RANITIDINE HCL
ST
56:28.36 PROTON-PUMP INHIBITORS

AMOXICILLIN, CLARITHROMYCIN, LANSOPRAZOLE
150mg Tablet 00733059 02265591 02248570 02207761 02293471 02219077 00828564 00865737 02242453 00740748 00828823 02245782 02247814 02243229 02212331
APO-RANITIDINE BCI-RANITIDINE CO RANITIDINE GEN-RANITIDINE MAXIMUM STRENGTH ACID REDUCER MED-RANITIDINE NOVO-RANIDINE NU-RANIT PMS-RANITIDINE RANITIDINE RATIO-RANITIDINE RIVA-RANITIDINE RIVA-RANTIDINE SANDOZ-RANITIDINE ZANTAC APO-RANITIDINE BCI-RANITIDINE CO RANITIDINE GEN-RANITIDINE MED-RANITIDINE NOVO-RANIDINE NU-RANIT PMS-RANITIDINE RANITIDINE RATIO-RANITIDINE RIVA-RANITIDINE RIVA-RANITIDINE SANDOZ-RANITIDINE ZANTAC
APX BAK COB GEN PMS MEC NOP NXP PMS PDL RPH PHH RIV SDZ GSK APX BAK COB GEN MEC NOP NXP PMS PDL RPH PHH RIV SDZ GSK
500mg & 500mg & 30mg Kit 02238525 HP-PAC
ABB
LANSOPRAZOLE
(Please refer to Appendix A). Limited use benefit (prior approval not required). Coverage will be limited to 400 tablets/capsules every 180 days.
ST
15mg Sustained Release Capsule 02293811 APO-LANSOPRAZOLE 02280515 NOVO-LANSOPRAZOLE 02165503 PREVACID 30mg Sustained Release Capsule 02293838 APO-LANSOPRAZOLE 02280523 NOVO-LANSOPRAZOLE 02165511 PREVACID
APX NOP ABB APX NOP ABB
ST
ST
300mg Tablet 00733067 02265605 02248571 02207788 02219085 00828556 00865745 02242454 00740756 00828688 02245783 02247815 02243230 02212358
LANSOPRAZOLE ODT
(Please refer to Appendix A). Limited use benefit (prior approval required). Coverage will be limited to 400 tablets/capsules every 180 days. For children 12 years of age or under who are unable to swallow the capsule formulation For patients with dysphagia or a feeding tube when the use of the capsule formulation is not possible.
ST
15MG Orally Disintegrating Tablet 02249464 PREVACID FASTAB 30MG Orally Disintegrating Tablet 02249472 PREVACID FASTAB
TAK TAK
ST
56:28.28 PROSTAGLANDINS
MISOPROSTOL
ST
100mcg Tablet 02244022 APO-MISOPROSTOL 200mcg Tablet 02244023 APO-MISOPROSTOL 02248846 MISOPROSTOL 02244125 PMS-MISOPROSTOL
APX APX PDL PMS
ST
56:28.32 PROTECTANTS
SUCRALFATE
ST
200mg/mL Suspension 02103567 SULCRATE PLUS 1g Tablet 02125250 02045702 02134829 02130939 02100622 APO-SUCRALFATE NOVO-SUCRALATE NU-SUCRALFATE SUCRALFATE-1 SULCRATE
AXC APX NOP NXP PDL AXC
ST
2010
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Health Canada

OMEPRAZOLE MAGNESIUM (PA)
(Please refer to Appendix A). Limited use benefit (prior approval required). Coverage will be limited to 400 tablets/capsules every 180 days. Coverage will be provided for the following medical conditions if the patient has tried at least 30 days each of two of the following open benefit PPIs: Omeprazole (Losec), Rabeprazole (Pariet), Pantoprazole sodium (Pantoloc), Lansoprazole (Prevacid): For treatment of confirmed gastric and duodenal ulcers. OR For mild to moderate gastroesophageal reflux disease (GERD) in patients who have failed on or not tolerated a 4week trial of histamine-2 receptor antagonists. OR For severe gastroesophageal reflux disease (GERD) and complications as first-line therapy for a maximum period of 3 months. Patients should be reassessed endoscopically or with step-down therapy using a histamine-2 receptor antagonist. OR For treatment of nonsteroidal anti-inflammatory drug (NSAID)induced ulcers where the NSAID must be continued. OR For prevention of NSAID-induced ulcers in patients who have history of ulcer complications, are over the age of 65 years, have comorbid disease such as cardiovascular disease or coagulopathies or are on concomitant medications which increase risk of ulcers or bleeding. OR Zollinger-Ellison Syndrome*. OR Barrett's Esophagus*. OR Esophagitis associated with connective tissue disease. (*) Diagnosis must be confirmed by a specialist qualified to diagnose and treat condition
ST

PANTOPRAZOLE MAGNESIUM
(Please refer to Appendix A). Limited use benefit (prior approval required). Coverage will be limited to 400 tablets/capsules every 180 days. Coverage will be provided for the following medical conditions if the patient has tried at least 30 days each of two of the following open benefit PPIs: Omeprazole (Losec), Rabeprazole (Pariet), Pantoprazole sodium (Pantoloc), Lansoprazole (Prevacid): For treatment of confirmed gastric and duodenal ulcers. OR For mild to moderate gastroesophageal reflux disease (GERD) in patients who have failed on or not tolerated a 4week trial of histamine-2 receptor antagonists. OR For severe gastroesophageal reflux disease (GERD) and complications as first-line therapy for a maximum period of 3 months. Patients should be reassessed endoscopically or with step-down therapy using a histamine-2 receptor antagonist. OR For treatment of nonsteroidal anti-inflammatory drug (NSAID)induced ulcers where the NSAID must be continued. OR For prevention of NSAID-induced ulcers in patients who have history of ulcer complications, are over the age of 65 years, have comorbid disease such as cardiovascular disease or coagulopathies or are on concomitant medications which increase risk of ulcers or bleeding. OR Zollinger-Ellison Syndrome*. OR Barrett's Esophagus*. OR Esophagitis associated with connective tissue disease. (*) Diagnosis must be confirmed by a specialist qualified to diagnose and treat condition
ST
10mg Delayed Release Tablet 02230737 LOSEC 02260859 RATIO-OMEPRAZOLE
AZC RPH
40mg Enteric Coated Tablet 02267233 TECTA
NCC
PANTOPRAZOLE SODIUM
ST
OMEPRAZOLE, OMEPRAZOLE MAGNESIUM (NO PA)

ST
10mg Capsule 02119579 LOSEC 02329425 MYLAN-OMEPRAZOLE 02296438 SANDOZ OMEPRAZOLE 20mg Capsule 02245058 APO-OMEPRAZOLE 00846503 LOSEC 02329433 MYLAN-OMEPRAZOLE 02320851 PMS-OMEPRAZOLE 02296446 SANDOZ OMEPRAZOLE 20mg Delayed Release Tablet 02190915 LOSEC 02310260 PMS-OMEPRAZOLE 02260867 RATIO-OMEPRAZOLE
AZC GEN SDZ APX AZC GEN PMS SDZ AZC PMS RPH
ST
ST
40mg Enteric Coated Tablet 02292920 APO-PANTOPRAZOLE 02300486 CO PANTOPRAZOLE 02299585 GEN-PANTOPRAZOLE 02285487 NOVO-PANTOPRAZOLE 02229453 PANTOLOC 02318695 PANTOPRAZOLE 02309866 PHL-PANTOPRAZOLE 02307871 PMS-PANTOPRAZOLE 02305046 RAN-PANTOPRAZOLE 02308703 RATIO-PANTOPRAZOLE 02310201 RIVA-PANTOPRAZOLE 02316463 RIVA-PANTOPRAZOLE 02301083 SANDOZ-PANTOPRAZOLE
APX COB GEN NOP NYC PDL PMI PMS RBY RPH ZYM RIV SDZ
2010
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Health Canada

RABEPRAZOLE SODIUM
ST
56:36.00 ANTI-INFLAMMATORY AGENTS

MESALAZINE
1g/100mL Enema 02153521 PENTASA 4g/100mL Enema 02153556 PENTASA
ST
FEI FEI NOP GSK FEI AXC
10mg Enteric Coated Tablet 02296632 NOVO-RABEPRAZOLE 02243796 PARIET EC 02310805 PMS-RABEPRAZOLE 02315181 PRO-RABEPRAZOLE 02298074 RAN-RABEPRAZOLE 02314177 SANDOZ-RABEPRAZOLE 20mg Enteric Coated Tablet 02296640 NOVO-RABEPRAZOLE 02243797 PARIET EC 02310813 PMS-RABEPRAZOLE 02315203 PRO-RABEPRAZOLE 02298082 RAN-RABEPRAZOLE 02330091 RIVA-RABEPRAZOLE 02314185 SANDOZ-RABEPRAZOLE
NOP JNO PMS PDL RBY SDZ NOP JNO PMS PDL RBY RIV SDZ
400mg Enteric Coated Tablet 02171929 NOVO 5-ASA 500mg Enteric Coated Tablet 01914030 MESASAL 1g Suppository 02153564 PENTASA 1000mg Suppository 02242146 SALOFALK
ST
ST
OLSALAZINE SODIUM
ST
250mg Capsule 02063808 DIPENTUM
LUD
56:32.00 PROKINETIC AGENTS

METOCLOPRAMIDE HCL
1mg/mL Oral Liquid 02230433 PMS-METOCLOPRAMIDE 5mg Tablet 00842826 00871001 02143275 02230431 10mg Tablet 00842834 00870994 02143283 02230432 APO-METOCLOP METOCLOPRAMIDE NU-METOCLOPRAMIDE PMS-METOCLOPRAMIDE APO-METOCLOP METOCLOPRAMIDE NU-METOCLOPRAMIDE PMS-METOCLOPRAMIDE PMS APX PDL NXP PMS APX PDL NXP PMS
56:36.00 ANTI-INFLAMMATORY AGENTS

5-AMINOSALICYLIC ACID
ST
500mg Delayed Release Tablet 02099683 PENTASA 2g/60g Enema 02112795 SALOFALK 4g/60g Enema 02112809 SALOFALK
FEI AXC AXC PGP AXC WAC AXC
ST
400mg Enteric Coated Tablet 01997580 ASACOL 500mg Enteric Coated Tablet 02112787 SALOFALK 800mg Enteric Coated Tablet 02267217 ASACOL 500mg Suppository 02112760 SALOFALK
ST
ST
2010
Page 90 of 124
Health Canada
60:00 GOLD COMPOUNDS

60:00.00 GOLD COMPOUNDS
AURANOFIN
3mg Capsule 01916823 RIDAURA SQU
SODIUM AUROTHIOMALATE
10mg/mL Injection 01927620 MYOCHRYSINE 02245456 SODIUM AUROTHIOMALATE 25mg/mL Injection 01927612 MYOCHRYSINE 02245457 SODIUM AUROTHIOMALATE 50mg/mL Injection 02245458 SODIUM AUROTHIOMALATE SAC SDZ SAC SDZ SDZ
2010
Page 91 of 124
Health Canada
64:00 HEAVY METAL ANTAGONISTS

64:00.00 HEAVY METAL ANTAGONISTS
PENICILLAMINE
250mg Capsule 00016055 CUPRIMINE FRS
2010
Page 92 of 124
Health Canada
68:00 HORMONES AND SYNTHETIC SUBSTITUTES

68:04.00 ADRENALS
50mcg Inhaler 02242029 QVAR 100mcg Inhaler 02242030 QVAR MMH MMH
68:04.00 ADRENALS
DEXAMETHASONE PHOSPHATE
4mg/mL Injection 00664227 DEXAMETHASONE 01977547 DEXAMETHASONE 02204266 DEXAMETHASONE-OMEGA 10mg/mL Injection 00874582 DEXAMETHASONE 00783900 PMS-DEXAMETHASONE SDZ CYX OMG SDZ PMS
BUDESONIDE
0.125mg/mL Inhalation Solution 02229099 PULMICORT NEBUAMP 0.25mg/mL Inhalation Solution 01978918 PULMICORT NEBUAMP 0.5mg/mL Inhalation Solution 01978926 PULMICORT NEBUAMP 100mcg Powder for Inhalation 00852074 PULMICORT TURBUHALER 200mcg Powder for Inhalation 00851752 PULMICORT TURBUHALER 400mcg Powder for Inhalation 00851760 PULMICORT TURBUHALER AZC AZC AZC AZC AZC AZC
FLUDROCORTISONE ACETATE
0.1mg Tablet 02086026 FLORINEF SHI
50mcg/Inhalation Inhaler 02244291 FLOVENT HFA 50 125mcg/Inhalation Inhaler 02244292 FLOVENT HFA 125 250mcg/Inhalation Inhaler 02244293 FLOVENT HFA 250 50mcg/Dose Powder Diskus 02237244 FLOVENT DISKUS 100mcg/Dose Powder Diskus 02237245 FLOVENT DISKUS 250mcg/Dose Powder Diskus 02237246 FLOVENT DISKUS 500mcg/Dose Powder Diskus 02237247 FLOVENT DISKUS GSK GSK GSK GSK GSK GSK GSK
CICLESONIDE
100mg/Inhalation Inhaler 02285606 ALVESCO 200mg/Inhalation Inhaler 02285614 ALVESCO NYC NYC
CORTISONE ACETATE
25mg Tablet 00280437 CORTISONE VAE
HYDROCORTISONE
10mg Tablet 00030910 20mg Tablet 00030929 PMS APX PHH PMS RPH VAE PMS RPH PMS APX VAE PHH PMS PRO RPH CORTEF CORTEF PFI PFI
DEXAMETHASONE
0.1mg/mL Elixir 01946897 PMS-DEXAMETHASONE 0.5mg Tablet 02261081 02237044 01964976 02240684 APO-DEXAMETHASONE PHL-DEXAMETHASONE PMS-DEXAMETHASONE RATIO-DEXAMETHASONE
METHYLPREDNISOLONE
4mg Tablet 00030988 16mg Tablet 00036129 MEDROL MEDROL PFI PFI
0.75mg Tablet 00285471 DEXASONE 01964968 PMS-DEXAMETHASONE 02240685 RATIO-DEXAMETHASONE 2mg Tablet 02279363 4mg Tablet 02250055 00489158 02237046 01964070 02311267 02240687 PMS-DEXAMETHASONE APO-DEXAMETHASONE DEXASONE PHL-DEXAMETHASONE PMS-DEXAMETHASONE PRO-DEXAMETHASONE RATIO-DEXAMETHASONE
METHYLPREDNISOLONE ACETATE
40mg/mL Suspension for Injection 00030759 DEPO-MEDROL 02245400 METHYLPREDNISOLONE ACETATE 02245407 METHYLPREDNISOLONE ACETATE 80mg/mL Suspension for Injection 00030767 DEPO-MEDROL 02245406 METHYLPREDNISOLONE ACETATE 02245408 METHYLPREDNISOLONE ACETATE PMJ SDZ SDZ
PMJ SDZ SDZ
20mg/mL Suspension for Injection (Multi-Dose) 01934325 DEPO-MEDROL PMJ Page 93 of 124
2010
Health Canada
68:04.00 ADRENALS
METHYLPREDNISOLONE ACETATE
40mg/mL Suspension for Injection (Multi-Dose) 01934333 DEPO-MEDROL PMJ 80mg/mL Suspension for Injection (Multi-Dose) 01934341 DEPO-MEDROL PMJ
68:08.00 ANDROGENS
TESTOSTERONE ENANTHATE
200mg/mL Injection 00029246 DELATESTRYL 00739944 PMS-TESTOSTERONE BMS PMS
TESTOSTERONE UNDECANOATE
40mg Capsule 00782327 ANDRIOL 02322498 PMS-TESTOSTERONE ORG PMS
PREDNISOLONE SODIUM PHOSPHATE

1mg/mL Oral Liquid 02230619 PEDIAPRED 02245532 PMS-PREDNISOLONE AVT PMS
68:12.00 CONTRACEPTIVES
ETHINYL ESTRADIOL, DESOGESTREL
25mcg & 150mcg (21) Tablet 02272903 LINESSA (21) 25mcg & 150mcg (28) Tablet 02257238 LINESSA (28) 30mcg & 150mcg (21) Tablet 02317192 APRI 21 02042487 MARVELON (21) 30mcg & 150mcg (28) Tablet 02317206 APRI 28 02042479 MARVELON (28) 02042533 ORTHO CEPT (28)
PREDNISONE
1mg Tablet 00598194 00271373 5mg Tablet 00312770 00156876 APO-PREDNISONE WINPRED APO-PREDNISONE PREDNISONE APX VAE APX PRO APX NOP PRO
ORG ORG BAR ORG BAR ORG JNO
50mg Tablet 00550957 APO-PREDNISONE 00232378 NOVO-PREDNISONE 00607517 PREDNISONE
10mg/mL Suspension for Injection 01999761 KENALOG-10 02229540 TRIAMCINOLONE 40mg/mL Suspension for Injection 01999869 KENALOG-40 02229550 TRIAMCINOLONE 09857128 TRIAMCINOLONE ACETONIDE (5ML) WSB SDZ WSB SDZ SDZ
ETHINYL ESTRADIOL, D-NORGESTREL

50mcg & 250mcg (21) Tablet 02043033 OVRAL (21) WAY
ETHINYL ESTRADIOL, DROSPIRENONE

3mg/0.02mg Tablet 02321157 YAZ 30mcg & 3mg (21) Tablet 02261723 YASMIN (21) BAY BEX BEX
TRIAMCINOLONE DIACETATE
40mg/mL Suspension for Injection 01977555 STERILE TRIAMCINOLONE CYX
30mcg & 3mg (28) Tablet 02261731 YASMIN (28)
TRIAMCINOLONE HEXACETONIDE
20mg/mL Suspension for Injection 02194155 ARISTOSPAN VAO
ETHINYL ESTRADIOL, ETHYNODIOL DIACETATE

30mcg & 2mg (21) Tablet 00469327 DEMULEN 30 (21) 30mcg & 2mg (28) Tablet 00471526 DEMULEN 30 (28) SAC SAC SAC PFI PFI
68:08.00 ANDROGENS
DANAZOL
50mg Capsule 02018144 CYCLOMEN 100mg Capsule 02018152 CYCLOMEN 200mg Capsule 02018160 CYCLOMEN
ETHINYL ESTRADIOL, ETONOGESTREL

Limited use benefit (prior approval required). For patients who are intolerant to or unable to take oral contraceptives. 11.4mg & 2.6mg Device 02253186 NUVARING ORG
TESTOSTERONE CYPIONATE
100mg/mL Injection 00030783 DEPO-TESTOSTERONE 02246063 TESTOSTERONE CYPIONATE PFI SDZ
ETHINYL ESTRADIOL, LEVONORGESTREL

20mcg & 100mcg (21) Tablet 02236974 ALESSE (21) 02298538 AVIANE 21 WAY BAR
2010
Page 94 of 124
Health Canada
ETHINYL ESTRADIOL, LEVONORGESTREL
20mcg & 100mcg (28) Tablet 02236975 ALESSE (28) 02298546 AVIANE 28 WAY BAR
ETHINYL ESTRADIOL, NORGESTIMATE
25mcg & 0.180mg (7), 25mcg & 0.215mg (7), 25mcg & 0.25mg (7) (21) Tablet 02258560 TRI-CYCLEN LO JNO 25mcg & 0.180mg (7), 25mcg & 0.215mg (7), 25mcg & 0.25mg (7), (28) Tablet 02258587 TRI-CYCLEN LO JNO 35mcg & 0.180mg (7), 35mcg & 0.215mg (7), 35mcg & 0.25mg (7) (21) Tablet 02028700 TRI-CYCLEN (21) JNO 35mcg & 0.180mg (7), 35mcg & 0.215mg (7), 35mcg & 0.25mg (7), (28) Tablet 02029421 TRI-CYCLEN (28) JNO 35mcg & 0.25mg (21) Tablet 01968440 CYCLEN (21) 35mcg & 0.25mg (28) Tablet 01992872 CYCLEN (28) JNO JNO
30mcg & 0.05mg (6), 40mcg & 0.075mg (5), 30mcg & 0.125mg (10) (21) Tablet 00707600 TRIQUILAR (21) BEX 30mcg & 0.05mg (6), 40mcg & 0.075mg (5), 30mcg & 0.125mg (10), (28) Tablet 00707503 TRIQUILAR (28) BEX 30mcg & 150mcg (21) Tablet 02042320 MIN OVRAL (21) 02295946 PORTIA 21 30mcg & 150mcg (28) Tablet 02042339 MIN OVRAL (28) 02295954 PORTIA 28 WAY BAR WAY BAR
ETHINYL ESTRADIOL, NORETHINDRONE

35mcg & 0.5mg (21) Tablet 02187086 BREVICON 0.5/35 (21) 00317047 ORTHO 0.5/35 (21) 35mcg & 0.5mg (28) Tablet 02187094 BREVICON 0.5/35 (28) 00340731 ORTHO 0.5/35 (28) PFI JNO PFI JNO
LEVONORGESTREL
52mg Intrauterine Insert 02243005 MIRENA 0.75mg Tablet 02285576 NORLEVO 02241674 PLAN B BAY LAP BAR
35mcg & 0.5mg (7), 35mcg & 1mg (9), 35mcg & 0.5mg (5) (21) Tablet 02187108 SYNPHASIC (21) PFI 35mcg & 0.5mg (7), 35mcg & 1mg (9), 35mcg & 0.5mg (5) (28) Tablet 02187116 SYNPHASIC (28) PFI 35mcg & 1mg (21) Tablet 02189054 BREVICON 1/35 (21) 00372846 ORTHO 1/35 (21) 02197502 SELECT 1/35 (21) 35mcg & 1mg (28) Tablet 02189062 BREVICON 1/35 (28) 00372838 ORTHO 1/35 (28) 02199297 SELECT 1/35 (28) PFI JNO DSP PFI JNO DSP
NORETHINDRONE
0.35mg (28) Tablet 00037605 MICRONOR (28) JNO
68:16.04 ESTROGENS
CONJUGATED ESTROGENS
0.3mg Tablet 02043394 PREMARIN 0.625mg Tablet 00265470 C.E.S. 02043408 PREMARIN 1.25mg Tablet 02043424 PREMARIN 0.625mg/g Vaginal Cream 02043440 PREMARIN WAY VAE WAY WAY WAY
35mcg & 500mcg (7), 35mcg & 750mcg (7), 35mcg & 1mg (7) (21) Tablet 00602957 ORTHO 7/7/7 (21) JNO 35mcg & 500mcg (7), 35mcg & 750mcg (7), 35mcg & 1mg (7), (28) Tablet 00602965 ORTHO 7/7/7 (28) JNO
CONJUGATED ESTROGENS, MEDROXYPROGESTERONE ACETATE

0.625mg & 2.5mg Kit 02242878 PREMPLUS 0.625mg & 5mg Kit 02242879 PREMPLUS WAY WAY
ETHINYL ESTRADIOL, NORETHINDRONE ACETATE

20mcg & 1mg (21) Tablet 00315966 MINESTRIN 1/20 (21) 20mcg & 1mg (28) Tablet 00343838 MINESTRIN 1/20 (28) 30mcg & 1.5mg (21) Tablet 00297143 LOESTRIN 1.5/30 (21) 30mcg & 1.5mg (28) Tablet 00353027 LOESTRIN 1.5/30 (28) 2010 GCL GCL GCL GCL
ESTRADIOL
0.06% Gel 02238704 ESTROGEL SCH NVR NVR
0.39mg Patch 02245676 ESTRADOT 25 0.585mg Patch 02243999 ESTRADOT 37.5
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68:16.04 ESTROGENS
ESTRADIOL
0.78mg Patch 02244000 ESTRADOT 50 1.17mg Patch 02244001 ESTRADOT 75 1.56mg Patch 02244002 ESTRADOT 100 5mg Patch 02243722 10mg Patch 02243724 OESCLIM OESCLIM NVR NVR NVR PAL PAL NVR NVR SDZ SDZ NVR SDZ SHI SHI SHI PMJ NOO
68:16.04 ESTROGENS
ESTROPIPATE
0.625mg Tablet 02089793 OGEN 1.25mg Tablet 02089769 OGEN 2.5mg Tablet 02089777 OGEN PFI PFI PFI
ETHINYL ESTRADIOL, NORETHINDRONE ACETATE

1mg/5mcg Tablet 02242531 FEMHRT WCI
25mcg Patch 00756849 ESTRADERM 50mcg Patch 00756857 ESTRADERM 02246967 SANDOZ-ESTRADIOL DERM 75mcg Patch 02246968 SANDOZ-ESTRADIOL DERM 100mcg Patch 00756792 ESTRADERM 02246969 SANDOZ-ESTRADIOL DERM 0.5mg Tablet 02225190 ESTRACE 1mg Tablet 02148587 2mg Tablet 02148595 ESTRACE ESTRACE
68:16.12 ESTROGEN AGONISTSANTAGONISTS

RALOXIFENE HCL
Limited use benefit (prior approval required). For: a.- secondary prevention of osteoporosis in women who experience failure on bisphosphonates. b. - secondary prevention of osteoporosis in women who have a personal history or a first degree relative with a history of breast cancer. 60mg Tablet 02279215 02239028 02312298 APO-RALOXIFENE EVISTA NOVO-RALOXIFENE APX LIL NOP
68:18.00 GONADOTROPINS
NAFARELIN ACETATE
2mg/mL Nasal Solution 02188783 SYNAREL PFI
2mg Vaginal Ring 02168898 ESTRING 25mcg Vaginal Tablet 02241332 VAGIFEM
ESTRADIOL (ESTRADIOL HEMIHYDRATE)

25mcg Patch 02247499 CLIMARA 25 50mcg Patch 02231509 CLIMARA 50 75mcg Patch 02247500 CLIMARA 75 100mcg Patch 02231510 CLIMARA 100 BEX BEX BEX BEX
68:20.02 ALPHA-GLUCOSIDASE INHIBITORS

ACARBOSE
ST
GLUCOBAY
BAY BAY
ST
100mg Tablet 02190893 GLUCOBAY
ESTRADIOL, NORETHINDRONE ACETATE

0.51mg & 4.8mg Patch 02241837 ESTALIS 250/50 0.62mg & 2.7mg Patch 02241835 ESTALIS 140/50 NVR NVR
ESTRONE
1mg/g Vaginal Cream 00727369 NEO-ESTRONE NEO
2010
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68:20.04 BIGUANIDES
METFORMIN HCL
ST
68:20.08 INSULINS
INSULIN (ISOPHANE) HUMAN BIOSYNTHETIC
APX COB DPC GEN SAC VAE MEC PDL ZYM NOP NXP PMS PDL RBY RPH RHO RIV SDZ APX COB DPC GEN SAC VAE PDL ZYM NOP NXP PMS PDL RBY RPH RIV SDZ 100U/mL Injection 00587737 HUMULIN N 10ML 02024225 NOVOLIN GE NPH 10ML 100U/mL (1.5mL) Injection 01959239 HUMULIN N CARTRIDGE 99000342 NOVOLIN GE NPH PENFILL 100U/mL (3mL) Injection 00908991 HUMULIN N CARTRIDGE 09853804 HUMULIN N CARTRIDGE 99001586 HUMULIN N CARTRIDGE 09853782 NOVOLIN GE NPH PENFILL 99000334 NOVOLIN GE NPH PENFILL 100U/mL Injection (Pre-filled Pen) 02241310 HUMULIN N LIL NOO LIL NOO LIL LIL LIL NOO NOO LIL
500mg Tablet 02167786 02257726 02229994 02148765 02099233 02229516 02230670 02220628 02242794 02045710 02162822 02223562 02314908 02269031 02242974 02233999 02239081 02246820 850mg Tablet 02229785 02257734 02242726 02229656 02162849 02239214 02231058 02242793 02230475 02229517 02242589 02314894 02269058 02242931 02242783 02246821
APO-METFORMIN CO METFORMIN DOM-METFORMIN GEN-METFORMIN GLUCOPHAGE GLYCON MED-METFORMIN METFORMIN METFORMIN NOVO-METFORMIN NU-METFORMIN PMS-METFORMIN PRO-METFORMIN RAN-METFORMIN RATIO-METFORMIN RHOXAL-METFORMIN RIVA-METFORMIN SANDOZ-METFORMIN FC APO-METFORMIN CO METFORMIN DOM-METFORMIN GEN-METFORMIN GLUCOPHAGE GLYCON METFORMIN METFORMIN NOVO-METFORMIN NU-METFORMIN PMS-METFORMIN PRO-METFORMIN RAN-METFORMIN RATIO-METFORMIN RIVA-METFORMIN SANDOZ-METFORMIN
INSULIN (ZINC CRYSTALLINE) HUMAN BIOSYNTHETIC (RDNA ORIGIN)

100U/mL Injection 00586714 HUMULIN R 10ML 100U/mL (1.5mL) Injection 01959220 HUMULIN R CARTRIDGE 100U/mL (3mL) Injection 09853766 HUMULIN R CARTRIDGE 99001594 HUMULIN R CARTRIDGE LIL LIL LIL LIL
ST
INSULIN ASPART
100U/mL Injection 02245397 NOVORAPID 100U/mL (3mL) Injection 02244353 NOVORAPID NOO NOO
INSULIN GLULISINE
100U/mL Injection 02279460 APIDRA 02279479 APIDRA 02294346 APIDRA SOLOSTAR SAC SAC SAC
68:20.08 INSULINS
INSULIN (30% NEUTRAL & 70% ISOPHANE) HUMAN BIOSYNTHETIC
100U/mL Injection 02024217 NOVOLIN GE 30/70 10ML 100U/mL (3mL) Injection 00908134 NOVOLIN GE 30/70 PENFILL 00920681 NOVOLIN GE 30/70 PENFILL 09853812 NOVOLIN GE 30/70 PENFILL NOO NOO NOO NOO
INSULIN HUMAN BIOSYNTHETIC

100U/mL Injection 02024233 NOVOLIN GE TORONTO 100U/mL (3mL) Injection 00908746 NOVOLIN GE TORONTO PENFILL 00921130 NOVOLIN GE TORONTO PENFILL 09853774 NOVOLIN GE TORONTO PENFILL NOO NOO NOO NOO

100U/mL (3mL) Injection 02024314 NOVOLIN GE 40/60 PENFILL NOO
INSULIN HUMAN BIOSYNTHETIC 20% & ISOPHANE 80%

100U/mL (3mL) Injection 09853847 HUMULIN 20/80 CARTRIDGE 99001616 HUMULIN 20/80 CARTRIDGE LIL LIL

100U/mL (3mL) Injection 02024322 NOVOLIN GE 50/50 PENFILL 2010 NOO
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68:20.08 INSULINS
INSULIN HUMAN BIOSYNTHETIC 30% & ISOPHANE 70%
100U/mL Injection 00795879 HUMULIN 30/70 100U/mL (1.5mL) Injection 00909009 HUMULIN 30/70 CARTRIDGE 01959212 HUMULIN 30/70 CARTRIDGE 100U/mL (3mL) Injection 09853855 HUMULIN 30/70 CARTRIDGE 99001632 HUMULIN 30/70 CARTRIDGE LIL LIL LIL LIL LIL
68:20.20 ANTIDIABETIC AGENTS SULFONYLUREAS

GLICLAZIDE
ST
80mg Tablet 02245247 00765996 02229519 02248453 02238103 02294400 02155850
APO-GLICLAZIDE DIAMICRON GEN-GLICLAZIDE GLICLAZIDE NOVO-GLICLAZIDE PMS-GLICAZIDE PROVAL-GLICLAZIDE
APX SEV GEN PDL NOP PMS PRO
INSULIN LISPRO
100IU/mL Injection 02229704 HUMALOG 10ML 100U/mL (1.5mL) Injection 02229705 HUMALOG CARTRIDGE 100U/mL (3mL) Injection 02233562 HUMALOG CARTRIDGE 09853715 HUMALOG CARTRIDGE 99002817 HUMALOG CARTRIDGE 100IU/mL Injection (Pre-filled Pen) 02241283 HUMALOG LIL LIL LIL LIL LIL LIL
GLYBURIDE
ST
INSULIN ZINC SUSPENSION MEDIUM HUMAN BIOSYNTHETIC (RDNA ORIGIN)

100U/mL Injection 00646148 HUMULIN L 10ML LIL
2.5mg Tablet 01913654 02224550 02234513 00720933 00808733 01959352 02084341 01913670 02020734 01900927 02236543 02248008 5mg Tablet 01913662 02224569 02234514 00720941 00808741 01959360 02085887 01913689 02020742 02316544 02236734 01900935 02236548 02248009
APO-GLYBURIDE DIABETA DOM-GLYBURIDE EUGLUCON GEN-GLYBE GLYBURIDE MED-GLYBE NOVO-GLYBURIDE NU-GLYBURIDE RATIO-GLYBURIDE RIVA-GLYBURIDE SANDOZ-GLYBURIDE APO-GLYBURIDE DIABETA DOM-GLYBURIDE EUGLUCON GEN-GLYBE GLYBURIDE MED-GLYBE NOVO-GLYBURIDE NU-GLYBURIDE PDL-GLYBURIDE PMS-GLYBURIDE RATIO-GLYBURIDE RIVA-GLYBURIDE SANDOZ-GLYBURIDE
APX SAC DPC PMS GEN PDL MEC NOP NXP RPH RIV SDZ APX SAC DPC PMS GEN PDL MEC NOP NXP PDL PMS RPH PHH SDZ
ST
68:20.16 MEGLITINIDES
NATEGLINIDE
ST
STARLIX
NVR NVR
ST
120mg Tablet 02245439 STARLIX
REPAGLINIDE
ST
0.5mg Tablet 02239924 GLUCONORM 1mg Tablet 02239925 2mg Tablet 02239926 GLUCONORM GLUCONORM
NOO NOO NOO
ST
ST
TOLBUTAMIDE
ST
68:20.20 ANTIDIABETIC AGENTS SULFONYLUREAS

GLICLAZIDE
ST
500mg Tablet 00312762 APO-TOLBUTAMIDE 00156663 TOLBUTAMIDE
APX PRO
30mg Tablet 02297795 02242987
APO-GLICLAZIDE MR DIAMICRON MR
APX SEV
2010
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68:20.28 THIAZOLIDINEDIONES
PIOGLITAZONE HCL
Limited use benefit (prior approval required). For treatment of type 2 diabetic patients who are not adequately controlled by or are intolerant to metformin and sulfonylureas or for whom these products are contraindicated.
ST
ROSIGLITAZONE MALEATE
ST
15mg Tablet 02303442 02242572 02302942 02302861 02307634 02298279 02326477 02274914 02307669 02303124 02312050 02301423 02297906 02320754 30mg Tablet 02303450 02242573 02302950 02302888 02307642 02298287 02326485 02274922 02307677 02303132 02312069 02301431 02297914 02320762 45mg Tablet 02303469 02242574 02302977 02302896 02307650 02298295 02326493 02274930 02307723 02303140 02312077 02301458 02297922 02320770
ACCEL PIOGLITAZONE ACTOS APO-PIOGLITAZONE CO PIOGLITAZONE DOM-PIOGLITAZONE GEN-PIOGLITAZONE MINT-PIOGLITAZONE NOVO-PIOGLITAZONE PHL-PIOGLITAZONE PMS-PIOGLITAZONE PRO-PIOGLITAZONE RATIO-PIOGLITAZONE SANDOZ PIOGLITAZONE ZYM-PIOGLITAZONE ACCEL PIOGLITAZONE ACTOS APO-PIOGLITAZONE CO PIOGLITAZONE DOM-PIOGLITAZONE GEN-PIOGLITAZONE MINT-PIOGLITAZONE NOVO-PIOGLITAZONE PHL-PIOGLITAZONE PMS-PIOGLITAZONE PRO-PIOGLITAZONE RATIO-PIOGLITAZONE SANDOZ PIOGLITAZONE ZYM-PIOGLITAZONE ACCEL PIOGLITAZONE ACTOS APO-PIOGLITAZONE CO PIOGLITAZONE DOM-PIOGLITAZONE GEN-PIOGLITAZONE MINT-PIOGLITAZONE NOVO-PIOGLITAZONE PHL-PIOGLITAZONE PMS-PIOGLITAZONE PRO-PIOGLITAZONE RATIO-PIOGLITAZONE SANDOZ PIOGLITAZONE ZYM-PIOGLITAZONE
ACP LIL APX COB DOM GEN MIN NOP PMI PMS PDL RPH SDZ ZYM ACP LIL APX COB DOM GEN MIN NOP PMI PMS PDL RPH SDZ ZYM ACP LIL APX COB DOM GEN MIN NOP PMI PMS PDL RPH SDZ ZYM
AVANDIA AVANDIA AVANDIA
GSK GSK GSK
ST
ST
68:22.12 GLYCOGENOLYTIC AGENTS

GLUCAGON RECOMBINANT DNA ORGIN
1mg/mL Injection 02243297 GLUCAGON LIL
68:24.00 PARATHYROID
CALCITONIN SALMON (MIACALCIN)
Limited use benefit (prior approval required). For treatment of patients with postmenopausal osteoporosis who have failed therapy, are intolerant to, or who have contraindications to both bisphosphonates and raloxifene. 200IU/Dose Nasal Spray 02247585 APO-CALCITONIN 02240775 MIACALCIN 02261766 SANDOZ-CALCITONIN APX NVR SDZ
ST
CALCITONIN SALMON (SYNTHETIC)

200IU/mL Injection 01926691 CALCIMAR SAC
68:28.00 PITUITARY
DESMOPRESSIN ACETATE
4mcg/mL Injection 00873993 DDAVP 0.1mg/mL Nasal Solution 00402516 DDAVP 0.1mg/mL Nasal Spray 02242465 APO-DESMOPRESSIN 00836362 DDAVP 0.1mg Tablet 02284030 00824305 02287730 02304368 0.2mg Tablet 02284049 00824143 02287749 02304376 APO-DESMOPRESSIN DDAVP NOVO-DESMOPRESSIN PMS-DESMOPRESSIN APO-DESMOPRESSIN DDAVP NOVO-DESMOPRESSIN PMS-DESMOPRESSIN FEI FEI APX FEI APX FEI NOP PMS APX FEI NOP PMS FEI FEI Page 99 of 124
ST
60mcg Tablet 02284995 DDAVP MELT 120mcg Tablet 02285002 DDAVP MELT 2010
Health Canada
68:28.00 PITUITARY
DESMOPRESSIN ACETATE
240mcg Tablet 02285010 DDAVP MELT FEI
68:36.04 THYROID AGENTS

LEVOTHYROXINE SODIUM
ST
68:32.00 PROGESTINS
MEDROXYPROGESTERONE ACETATE
50mg/mL Injection 00030848 DEPO-PROVERA 150mg/mL Injection 00585092 DEPO-PROVERA 02322250 MEDROXYPROGESTERONE 2.5mg Tablet 02244726 APO-MEDROXY 02247581 DOMMEDROXYPROGESTERONE 02229838 GEN-MEDROXY 02221284 NOVO-MEDRONE 02252740 NU-MEDROXY 02253550 PDL-MEDROXY 00708917 PROVERA 5mg Tablet 02244727 02247582 02229839 02221292 02252759 02253577 00030937 02010739 10mg Tablet 02277298 02247583 02229840 02221306 00729973 02010933 APO-MEDROXY DOMMEDROXYPROGESTERONE GEN-MEDROXY NOVO-MEDRONE NU-MEDROXY PDL-MEDROXY PROVERA PROVERA PAK APO-MEDROXY DOMMEDROXYPROGESTERONE GEN-MEDROXY NOVO-MEDRONE PROVERA PROVERA PFI
ST ST
0.1mg Tablet 02213206 ELTROXIN 02264374 EUTHYROX 02172100 SYNTHROID 0.112mg Tablet 02264390 EUTHYROX 02171228 SYNTHROID 0.125mg Tablet 02264404 EUTHYROX 02172119 SYNTHROID 0.137mg Tablet 02264412 EUTHYROX 02233852 SYNTHROID 0.15mg Tablet 02213214 ELTROXIN 02264420 EUTHYROX 02172127 SYNTHROID 0.175mg Tablet 02264439 EUTHYROX 02172135 SYNTHROID 0.2mg Tablet 02213222 ELTROXIN 02264447 EUTHYROX 02172143 SYNTHROID 0.3mg Tablet 02213230 ELTROXIN 02264455 EUTHYROX 02172151 SYNTHROID
GSK GEN ABB GEN ABB GEN ABB GEN ABB GSK GEN ABB GEN ABB GSK GEN ABB GSK GEN ABB
PFI SDZ
ST
APX DPC
ST
GEN NOP NXP PDL PFI APX DPC GEN NOP NXP PDL PFI PFI APX DPC GEN NOP PFI PFI APX PFI
ST
ST
ST
THYROID
ST
THYROID THYROID
ERF ERF ERF
ST
ST
125mg Tablet 00023965 THYROID
100mg Tablet 02267640 APO-MEDROXY 00030945 PROVERA
68:36.08 ANTITHYROID AGENTS

PROPYLTHIOURACIL
ST
68:36.04 THYROID AGENTS

LEVOTHYROXINE SODIUM
ST
PROPYL THYRACIL
SQU SQU
ST
0.025mg Tablet 02264323 EUTHYROX 02172062 SYNTHROID 0.05mg Tablet 02213192 ELTROXIN 02264331 EUTHYROX 02172070 SYNTHROID 0.075mg Tablet 02264358 EUTHYROX 02172089 SYNTHROID 0.088mg Tablet 02172097 SYNTHROID
GEN ABB GSK GEN ABB GEN ABB ABB
100mg Tablet 00010219 PROPYL THYRACIL
THIAMAZOLE
ST
ST
TAPAZOLE TAPAZOLE
PAL PAL
ST
ST
ST
2010
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80:00 SERUMS, TOXOIDS, AND VACCINES

80:04.00 SERUMS
DOLICHOVESPULA ARENARIA VENOM PROTEIN
120mcg Injection 01948946 YELLOW HORNET VENOM PROTEIN ALK
80:04.00 SERUMS
WHITE FACED HORNET VENOM PROTEIN
120mcg Injection 02226235 VENOMIL WHITE FACED HORNET VENOM PROTEIN HOL
WHITE FACED HORNET VENOM PROTEIN, YELLOW HORNET VENOM PROTEIN, YELLOW JACKET VENOM PROTEIN
120mcg Injection 01948881 MIXED VESPID VENOM PROTEIN 02226294 VENOMIL MIXED VESPID VENOM PROTEIN 550mcg Injection 02221314 MIXED VESPID VENOM PROTEIN ALK HOL
DOLICHOVESPULA MACULATA VENOM PROTEIN EXTRACT

120mcg Injection 01949004 WHITE FACED HORNET VENOM ALK
HONEY BEE VENOM PROTEIN EXTRACT

1.1mg Injection 01948903 HONEY BEE VENOM 120mcg Injection 01948911 HONEY BEE VENOM 02226197 VENOMIL HONEY BEE VENOM 550mcg Injection 02220075 HONEY BEE VENOM ALK ALK HOL HOL
HOL
YELLOW HORNET VENOM PROTEIN

100mcg/mL Injection 02226251 YELLOW JACKET HORNET VENOM PROTEIN 500mcg Injection 02220083 YELLOW HORNET VENOM PROTEIN BAY
HOL
NON POLLEN
Injection 00299979 00514713 ALLERGENIC EXTRACT NON POLLENS ALLERGENIC EXTRACTS ALK MSL
YELLOW JACKET VENOM PROTEIN

120mcg Injection 02226286 VENOMIL YELLOW JACKET VENOM PROTEIN 550mcg Injection 02220113 YELLOW JACKET VENOM PROTEIN HOL
POLISTES SPP VENOM PROTEIN EXTRACT

1.1mg Injection 01948970 WASP VENOM PROTEIN ALK
BAY
POLLEN
Injection 00299987 00464988 ALLERGENIC EXTRACT POLLENS POLLINEX R ALK BEN
POLLEN AND NON POLLEN

Injection 00648922 CENTER-AL ALK
VESPULA SPP VENOM PROTEIN EXTRACT

1.1mg Injection 01948954 YELLOW JACKET VENOM PROTEIN 120mcg Injection 01948962 YELLOW JACKET VENOM PROTEIN ALG
ALK
WASP VENOM PROTEIN

120mcg Injection 02226219 VENOMIL WASP VENOM PROTEIN 550mcg Injection 02220091 WASP VENOM PROTEIN HOL
HOL
2010
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84:00 SKIN AND MUCOUS MEMBRANE AGENTS (SMMA)

84:04.04 SMMA - ANTIBIOTICS
BACITRACIN
500IU Ointment 00584908 BACITIN PMS
84:04.06 SMMA - ANTIVIRALS

ACYCLOVIR
5% Ointment 00569771 ZOVIRAX GSK
IDOXURIDINE
0.1% Topical Solution 00001317 HERPLEX-D LIQUIFILM 02237187 SANDOZ-IDOXURIDINE ALL SDZ
BACITRACIN ZINC, POLYMYXIN B SULFATE

500IU & 10,000IU Ointment 02237227 POLYSPORIN ANTIBIOTIC PFI
84:04.08 SMMA - ANTIFUNGALS

CLOTRIMAZOLE
1% Cream 02150867 00812382 CANESTEN CLOTRIMADERM BCD TAR BCD
CLINDAMYCIN PHOSPHATE
1% Solution 00582301 02266938 DALACIN T TARO-CLINDAMYCIN PFI TAR PMJ
2% Vaginal Cream 02060604 DALACIN
1% & 200mg Cream & Vaginal Suppository 02264099 CANESTEN 3 COMFORT COMBI PAK 1% & 500mg Cream & Vaginal Suppository 02264102 CANESTEN 1 COMFORT COMBI PAK 1% Vaginal Cream 02150891 CANESTEN 00812366 CLOTRIMADERM 2% Vaginal Cream 02150905 CANESTEN 00812374 CLOTRIMADERM
ERYTHROMYCIN, TRETINOIN
4% & 0.01% Gel 02015994 STIEVAMYCIN MILD 4% & 0.025% Gel 01905112 STIEVAMYCIN 4% & 0.05% Gel 01945262 STIEVAMYCIN FORTE STI STI STI
BCD
BCD TAR BCD TAR
FUSIDATE SODIUM
2% Ointment 00586676 FUCIDIN LEO
KETOCONAZOLE
2% Cream 02245662 KETODERM TAR MCL
FUSIDIC ACID
2% Cream 00586668 FUCIDIN LEO
2% Shampoo 02182920 NIZORAL
GRAMICIDIN, POLYMYXIN B SULFATE

0.25mg & 10,000IU Cream 02230844 POLYSPORIN ANTIBIOTIC PFI
MICONAZOLE NITRATE
2% Cream 02085852 02126567 MICATIN MONISTAT-DERM MCL MCL MCL MCL TAR MCL MCL VTH MCL
MUPIROCIN
2% Cream 02239757 BACTROBAN GSK GSK TAR
2% & 100mg Cream & Vaginal Suppository 02126257 MONISTAT 7 DUAL PAK 2% & 400mg Cream & Vaginal Suppository 02126249 MONISTAT 3 DUAL PAK 2% Vaginal Cream 02231106 MICOZOLE 00980625 MONISTAT 02084309 MONISTAT 7 400mg Vaginal Suppository 02171775 MICONAZOLE 02126605 MONISTAT 3
2% Ointment 01916947 BACTROBAN 02279983 TARO-MUPIROCIN 2% OINTMENT
POLYMYXIN B SULFATE, BACITRACIN

10,000IU & 500IU Ointment 00792217 ANTIBIOTIC 00876488 BACIMYXIN 00621366 BIODERM 01942921 POLYTOPIC PDD PMS ODN SDZ
NYSTATIN
100,000IU Cream 00716871 NYADERM 02194236 RATIO-NYSTATIN TAR RPH RPH
84:04.06 SMMA - ANTIVIRALS

ACYCLOVIR
5% Cream 02039524 ZOVIRAX GSK
100,000IU Ointment 02194228 RATIO-NYSTATIN
2010
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84:04.08 SMMA - ANTIFUNGALS

NYSTATIN
Powder 00907472 NYSTATIN WLR TAR RPH RPH
84:04.12 SMMA - SCABICIDES AND PEDICULICIDES

PIPERONYL BUTOXIDE, PYRETHRINS
3% & 0.3% Shampoo 02125447 R&C GSK
25,000IU Vaginal Cream 00716901 NYADERM 100,000IU Vaginal Cream 02194163 RATIO-NYSTATIN 100,000IU Vaginal Tablet 02194171 RATIO-NYSTATIN
84:04.92 SMMA - MISCELLANEOUS LOCAL ANTI-INFECTIVES

BENZOYL PEROXIDE
2.5% Gel (Acetone Base) 00406813 ACETOXYL 5% Gel (Alcohol Base) 02162113 BENZAGEL 00263702 PANOXYL-5 10% Gel (Alcohol Base) 00263699 PANOXYL-10 STI NVC STI STI STI STI STI GAC GAC STI STI GAC WSB GSK NVC VAE STI STI STI GAC NVC STI GAC
TERBINAFINE HCL
1% Cream 02031094 LAMISIL NVR
TERCONAZOLE
0.4% Vaginal Cream 02247651 TARO-TERCONAZOLE 00894729 TERAZOL 7 TAR JNO
20% Gel (Alcohol Base) 00373036 PANOXYL-20 2.5% Gel (Water Base) 02214830 PANOXYL AQUAGEL 4% Gel (Water Base) 01975382 SOLUGEL
0.8% & 80mg Vaginal Cream & Vaginal Suppository 02130874 TERAZOL 3 DUAL PAK JNO
TOLNAFTATE
1% Cream 00576034 1% Powder 01919245 00576042 02029081 1% Spray 00576050 TINACTIN ATHLETES FOOT SPRAY TINACTIN ZEASORB AF TINACTIN AEROSOL SCH SCH SCH STI SCH
5% Gel (Water Base) 00899453 BENZAC AC 01925180 BENZAC W5 02214849 PANOXYL AQUAGEL 8% Gel (Water Base) 02019825 SOLUGEL 10% Gel (Water Base) 01912437 BENZAC AC 01908871 DESQUAM X 2.5% Lotion 02046539 OXY 5 BENZAGEL 5 OXYDERM BENOXYL PANOXYL-5 PANOXYL-10 BENZAC W BENZAGEL PANOXYL BENZAC W
84:04.12 SMMA - SCABICIDES AND PEDICULICIDES

CROTAMITON
10% Cream 00623377 EURAX NVC
ISOPROPYL MYRISTATE
50% Solution 02279592 RESULTZ NYC
5% Lotion 02166607 00374326 10% Lotion 00370568 5% Soap 00483184 10% Soap 00527661 5% Wash 00896276 02162121 02214857 10% Wash 01925199
LINDANE
1% Lotion 00703591 PMS-LINDANE PMS ODN PMS
1% Shampoo 00430617 HEXIT 00703605 PMS-LINDANE
PERMETHRIN
5% Cream 02219905 5% Lotion 02231348 1% Rinse 02231480 00771368 2010 NIX DERMAL KWELLADA-P KWELLADA-P NIX GSK GSK GSK WLA
CHLORHEXIDINE ACETATE
0.5% Dressing 00433497 BACTIGRAS 00905097 BACTIGRAS 5X5CM 00960330 BACTIGRAS 5X5CM SNE SNE SNE Page 103 of 124
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84:04.92 SMMA - MISCELLANEOUS LOCAL ANTI-INFECTIVES

CHLORHEXIDINE GLUCONATE
2% Liquid 01938991 4% Liquid 01938983 STANHEXIDINE STANHEXIDINE OMG OMG
84:06.00 SMMA - ANTI-INFLAMMATORY AGENTS

AMCINONIDE
0.1% Cream 02192284 02247098 02246714 0.1% Lotion 02192276 02247097 CYCLOCORT RATIO-AMCINONIDE TARO-AMCINONIDE CYCLOCORT RATIO-AMCINONIDE STI RPH TAR STI RPH STI RPH
HYDROGEN PEROXIDE
3% Liquid 00167703 00485721 00579297 HYDROGEN PEROXIDE 10V HYDROGEN PEROXIDE 10V PEROXIDE D'HYDROGENE RWP RPH ATL
0.1% Ointment 02192268 CYCLOCORT 02247096 RATIO-AMCINONIDE
METRONIDAZOLE
0.75% Cream 02226839 METROCREAM 1% Cream 02156091 02242919 0.75% Gel 02092832 1% Gel 02297809 NORITATE ROSASOL METROGEL METROGEL GAC SAC STI GAC GAC GAC SAC MMH
0.025% Cream 02089602 PROPADERM SHI
BETAMETHASONE DIPROPIONATE
0.05% Cream 00323071 00804991 02122049 01925350 DIPROSONE RATIO-TOPISONE ROSONE TARO-SONE SCH RPH RIV TAR SCH RPH RIV SCH RPH RIV
0.75% Lotion 02248206 METROLOTION 10% Vaginal Cream 01926861 FLAGYL 0.75% Vaginal Gel 02125226 NIDAGEL
0.05% Lotion 00417246 DIPROSONE 00809187 RATIO-TOPISONE 02122030 ROSONE 0.05% Ointment 00344923 DIPROSONE 00805009 RATIO-TOPISONE 02122057 ROSONE
METRONIDAZOLE, NYSTATIN
100mg & 20,000U/g Vaginal Cream 01926845 FLAGYSTATIN 500mg & 100,000IU Vaginal Suppository 01926829 FLAGYSTATIN AVT AVT
BETAMETHASONE DIPROPIONATE IN PROPYLENE GLYCOL

0.05% Cream 00688622 DIPROLENE 00849650 RATIO-TOPILENE GLYCOL 02122073 ROLENE 0.05% Lotion 00862975 DIPROLENE 01927914 RATIO-TOPILENE GLYCOL 02122065 ROLENE 0.05% Ointment 00629367 DIPROLENE 00849669 RATIO-TOPILENE GLYCOL 02122081 ROLENE SCH RPH RIV SCH RPH RIV SCH RPH RIV
POVIDONE-IODINE
10% Liquid 00158348 BETADINE PFR
SELENIUM SULFIDE
2.5% Lotion 00243000 00594601 SELSUN VERSEL ABB VAO
SILVER SULFADIAZINE
1% Cream 02010917 00323098 09854037 DERMAZIN FLAMAZINE FLAMAZINE 50G PMS SNE SNE
BETAMETHASONE DIPROPIONATE, CLOTRIMAZOLE

0.05% & 1% Cream 00611174 LOTRIDERM SCH
TRICLOSAN
0.5% Liquid 00632317 TERSASEPTIC STI
BETAMETHASONE DIPROPIONATE, SALICYLIC ACID

0.05% & 2% Lotion 00578428 DIPROSALIC 02245688 RATIO-TOPISALIC SCH RPH Page 104 of 124
2010
Health Canada

BETAMETHASONE DIPROPIONATE, SALICYLIC ACID
0.05% & 3% Ointment 00578436 DIPROSALIC SCH

CLOBETASONE BUTYRATE
0.05% Cream 02214415 EUMOVATE GSK
DESONIDE
0.05% Cream 02229315 PMS-DESONIDE 02154862 TRIDESILON 0.05% Lotion 02115514 DESOCORT PMS SCN GAC GAC PMS SCN
BETAMETHASONE DISODIUM PHOSPHATE

0.05mg/mL Enema 02060884 BETNESOL SHI
BETAMETHASONE VALERATE
0.05% Cream 00535427 RATIO-ECTOSONE 0.1% Cream 00716626 00804541 00535435 BETADERM PREVEX B RATIO-ECTOSONE RPH TAR STI RPH RPH RPH RIV TAR TAR TAR SCH
0.05% Ointment 02115522 DESOCORT 02229323 PMS-DESONIDE 02154870 TRIDESILON
DESOXIMETASONE
0.05% Cream 02221918 TOPICORT 0.25% Cream 02221896 TOPICORT 0.05% Gel 02221926 TOPICORT SAC SAC SAC SAC
0.05% Lotion 00653209 RATIO-ECTOSONE 0.1% Lotion 00750050 01940112 RATIO-ECTOSONE RIVASONE
0.05% Ointment 00716642 BETADERM 0.1% Ointment 00716650 BETADERM 0.1% Scalp Lotion 00716634 BETADERM 00027944 VALISONE
0.25% Ointment 02221934 TOPICORT
DIFLUCORTOLONE VALERATE
0.1% Cream 00587826 00587818 NERISONE NERISONE OILY STI STI STI
BUDESONIDE
0.02mg/mL Enema 02052431 ENTOCORT AZC
0.1% Ointment 00587834 NERISONE
CLOBETASOL PROPIONATE
0.05% Cream 02245523 02213265 02024187 02093162 02232191 01910272 CLOBETASOL PROPIONATE DERMOVATE GEN-CLOBETASOL NOVO-CLOBETASOL PMS-CLOBETASOL RATIO-CLOBETASOL TAR TAR GEN NOP PMS RPH TAR TAR GEN NOP PMS RPH TAR GEN PMS RPH TAR
DIFLUCORTOLONE VALERATE, SALICYLIC ACID

0.1% & 3% Cream 02028719 NERISALIC OILY STI
FLUOCINOLONE ACETONIDE
0.025% Ointment 02162512 SYNALAR 0.01% Scalp Lotion 00873292 DERMA-SMOOTHE 0.01% Shampoo 02242738 CAPEX MDC HIL GAC
0.05% Ointment 02245524 CLOBETASOL PROPIONATE 02213273 DERMOVATE 02026767 GEN-CLOBETASOL 02126192 NOVO-CLOBETASOL 02232193 PMS-CLOBETASOL 01910280 RATIO-CLOBETASOL 0.05% Scalp Lotion 02213281 DERMOVATE 02216213 GEN-CLOBETASOL 02232195 PMS-CLOBETASOL 01910299 RATIO-CLOBETASOL 0.05% Solution 02245522 CLOBETASOL PROPIONATE 2010
FLUOCINONIDE
0.05% Cream 02161923 LIDEX 00716863 LYDERM 0.05% Emollient Cream 02163152 LIDEMOL 00598933 TIAMOL 0.05% Gel 02236997 02161974 LYDERM TOPSYN MDC OPT MDC TAR OPT HLR Page 105 of 124
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FLUOCINONIDE
0.05% Ointment 02161966 LIDEX 02236996 LYDERM HLR OPT

HYDROCORTISONE ACETATE
1% Lotion 00681997 DERMAFLEX HC NEO
HYDROCORTISONE ACETATE, ZINC SULFATE

0.5% & 0.5% Ointment 02128446 ANODAN-HC 00505773 ANUSOL HC 02209764 EGOZINC-HC 00607789 RATIO-HEMCORT HC 02179547 RIVASOL HC 02247691 SANDOZ-ANUZINC HC 10mg & 10mg Suppository 02236399 ANODAN-HC 00476285 ANUSOL HC 02210517 EGOZINC HC 00607797 RATIO-HEMCORT HC 02240112 RIVASOL-HC 02242798 SANDOZ ANUZINC HC ODN PFI PMS RPH RIV SDZ ODN PFI PMS RPH RIV SDZ
0.05% Cream 02089912 CUTIVATE GSK
HALCINONIDE
0.1% Cream 02011921 HALOG WSB
HALOBETASOL PROPIONATE
0.05% Cream 01962701 ULTRAVATE 0.05% Ointment 01962728 ULTRAVATE WSB WSB
HYDROCORTISONE
0.5% Cream 00513288 1% Cream 02086034 00192597 00804533 2.5% Cream 00595799 CORTATE BARRIERE HC EMO CORT PREVEX HC EMO CORT SCH SHI STI STI STI AXC VAE SCH STI STI STI STI STI SCH TAR TAR
HYDROCORTISONE ACETATE, ZINC SULFATE, PRAMOXINE HCL

0.5% & 0.5% & 1% Ointment 00505781 ANUGESIC HC 02234466 PROCTODAN HC 02247692 SANDOZ-ANUZINC HC PLUS 10mg & 10mg & 20mg Suppository 00476242 ANUGESIC HC 02240851 PROCTODAN HC 02242797 SANDOZ ANUZINC HC PLUS PFI ODN SDZ PFI ODN SDZ
100mg/60mL Enema 02112736 CORTENEMA 00230316 HYCORT 0.5% Lotion 00513253 1% Lotion 00192600 00578541 2.5% Lotion 00595802 00641154 00856711 CORTATE EMO CORT SARNA HC EMO CORT EMO CORT SCALP SARNA HC
HYDROCORTISONE VALERATE
0.2% Cream 02242984 HYDROVAL TAR TAR WSB
0.2% Ointment 02242985 HYDROVAL 01910132 WESTCORT
HYDROCORTISONE, DIBUCAINE HCL, ESCULIN, FRAMYCETIN SULFATE

5mg & 5mg & 10mg & 10mg Ointment 02247322 PROCTOL 02223252 PROCTOSEDYL 02226383 RATIO-PROCTOSONE 02242527 SANDOZ-PROCTOMYXIN HC 5mg & 5mg & 10mg & 10mg Suppository 02247882 PROCTOL 02223260 PROCTOSEDYL 02226391 RATIO-PROCTOSONE 02242528 SANDOZ PROCTOMYXIN HC ODN AXC RPH SDZ ODN AXC RPH SDZ
0.5% Ointment 00513261 CORTATE 00716685 CORTODERM 1% Ointment 00716693 CORTODERM
HYDROCORTISONE ACETATE
10% Aerosol Foam 00579335 CORTIFOAM 0.5% Cream 00716820 1% Cream 00716839 2% Cream 00749834 2010 HYDERM HYDERM NEO-HC SQU TAR TAR NEO
HYDROCORTISONE, UREA
1% & 10% Cream 00503134 UREMOL HC 1% & 10% Lotion 00560022 UREMOL HC STI STI Page 106 of 124
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MOMETASONE FUROATE
0.1% Cream 00851744 0.1% Lotion 00871095 02266385 ELOCOM ELOCOM TARO-MOMETASONE SCH SCH TAR SCH PMS PMS RPH TAR
84:16.00 SMMA - CELL STIMULANTS AND PROLIFERANTS

TRETINOIN
0.025% Gel 00587966 01926470 0.05% Gel 00641863 01926489 STIEVA-A VITAMIN A ACID STIEVA-A VITAMIN A ACID STI SAC STI SAC STI
0.1% Ointment 00851736 ELOCOM 02244769 PMS-MOMETASONE 02270862 PMS-MOMETASONE 02248130 RATIO-MOMETASONE 02264749 TARO-MOMETASONE
0.025% Solution 00578568 STIEVA-A
84:24.12 BASIC OINTMENTS AND PROTECTANTS

DIMETHICONE
20% Cream 02060841
0.1% Cream 02194058 0.5% Cream 02194066 ARISTOCORT R ARISTOCORT C VAO VAO VAO TAR
BARRIERE
WPC
PETROLATUM
67% Cream 00635189 PREVEX STI
0.1% Ointment 02194031 ARISTOCORT R 0.1% Paste 01964054 ORACORT
ZINC OXIDE
15% Cream 02215799 ZINC OXIDE CREAM 15% HJS RPH GSK
84:08.00 SMMA - ANTIPRURITICS AND LOCAL ANESTHETICS

LIDOCAINE HCL
2% Liquid 01968823 00811874 00001686 LIDODAN VISCOUS PMS-LIDOCAINE VISCOUS XYLOCAINE VISCOUS ODN PMS AZC
25% Ointment 00532576 IHLES PASTE 40% Ointment 02239160 ZINCOFAX EXTRA STRENGTH
84:28.00 KERATOLYTIC AGENTS

ADAPALENE
0.1% Cream 02231592 0.1% Gel 02148749 DIFFERIN DIFFERIN GAC GAC
LIDOCAINE, PRILOCAINE
2.5% & 2.5% Cream 00886858 EMLA 2.5% & 2.5% Patch 02057794 EMLA AZC AZC
CANTHARIDIN
0.7% Liquid 00589497 00619035 CANTHACUR CANTHARONE PMS DOR
84:16.00 SMMA - CELL STIMULANTS AND PROLIFERANTS

TRETINOIN
0.01% Cream 00897329 RETIN A 00657204 STIEVA-A 0.025% Cream 00897310 RETIN A 00578576 STIEVA-A 0.05% Cream 00443794 RETIN A 00518182 STIEVA-A 0.1% Cream 00870021 00662348 0.01% Gel 01926462 2010 RETIN A STIEVA-A FORTE VITAMIN A ACID JAJ STI JAJ STI JAJ STI JAJ STI SAC
CANTHARIDIN, PODOPHYLLIN, SALICYLIC ACID

1% & 2% & 30% Liquid 00772011 CANTHARONE PLUS 1% & 5% & 30% Liquid 00589500 CANTHACUR PS DOR PMS
DITHRANOL
0.1% Cream 00537594 0.2% Cream 00537608 0.4% Lotion 00695351 ANTHRANOL-1 ANTHRANOL-2 ANTHRASCALP MTI MTI MTI
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84:28.00 KERATOLYTIC AGENTS

DITHRANOL
1% Ointment 00566756 ANTHRAFORTE 2% Ointment 00566748 ANTHRAFORTE MTI MTI
84:32.00 KERATOPLASTIC AGENTS

COAL TAR
4.3% Shampoo 00740314 PENTRAX 2.5% Solution 01908855 BALNETAR GEN WSB
FORMALDEHYDE, LACTIC ACID, SALICYLIC ACID

10% & 5% & 25% Ointment 00513091 DUOPLANT STI
COAL TAR, JUNIPER TAR, PINE TAR

1% Shampoo 00249866 POLYTAR STI
LACTIC ACID, SALICYLIC ACID

17% & 17% Liquid 00370576 DUOFILM STI
COAL TAR, JUNIPER TAR, PINE TAR, ZINC PYRITHIONE

0.166% & 0.166% & 0.166% & 1% Shampoo 00628042 MULTI-TAR PLUS MILD 0.33% & 0.33% & 0.33% & 1% Shampoo 02240942 MULTITAR PLUS VAE VAE
PODOFILOX
0.5% Solution 01945149 CONDYLINE CDX
COAL TAR, SALICYLIC ACID

8% & 2% Gel 00560448 P&S PLUS BAK ODN DER
PODOPHYLLIN
25% Liquid 00598208 PODOFILM PMS
SALICYLIC ACID
27% Gel 01939645 20% Liquid 00690333 26% Liquid 00754951 27% Liquid 00837733 15% Plaster 02050285 02050293 40% Plaster 01974335 DUOFORTE 27 SOLUVER OCCLUSAL HP SOLUVER PLUS TRANS PLANTAR TRANS-VER-SAL CLEAR AWAY STI DER GEN DER WSB WSB SCH DER
10% & 3% Liquid 00510335 TARGEL SA 10% & 4% Shampoo 00666114 SEBCUR-T
COAL TAR, SALICYLIC ACID, SULFUR

2% & 2% & 2% Shampoo 00444448 STEREX IDE
84:50.06 PIGMENTING AGENTS

METHOXSALEN
10mg Capsule 00252654 OXSORALEN 01946374 OXSORALEN 00646237 ULTRA MOP 1% Lotion 01907476 00698059 OXSORALEN ULTRA MOP VAE VAE CDX VAE CDX
4% Shampoo 00666106 SEBCUR
SALICYLIC ACID, TRICLOSAN

2% & 0.5% Gel 00754927 PANOXYL ACNE STI
84:92.00 MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS

ACITRETIN
Soriatane should be used with caution in women of childbearing potential due to its teratogenicity. Pregnancy must be excluded. Effective contraception must be used. Manufacturer's literature regarding contraindications and warnings, should be consulted prior to prescribing or dispensing this drug. 10mg Capsule 02070847 SORIATANE 25mg Capsule 02070863 SORIATANE HLR HLR
84:32.00 KERATOPLASTIC AGENTS

COAL TAR
10% Gel 00344508 20% Liquid 00358495 TARGEL ODANS LIQUOR CARBONIS DETERGENT ODN ODN
1% Shampoo 00632295 TERSA-TAR MILD 3% Shampoo 00632309 TERSA-TAR
STI STI
CALCIPOTRIOL
50mcg/g Cream 02150956 DOVONEX LEO
2010
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CALCIPOTRIOL
50mcg/g Ointment 01976133 DOVONEX 50mcg/mL Solution 02194341 DOVONEX LEO LEO

TAZAROTENE
0.05% Cream 02243894 TAZORAC 0.1% Cream 02243895 0.05% Gel 02230784 TAZORAC TAZORAC TAZORAC ALL ALL ALL ALL
CAPSAICIN
0.025% Cream 02157101 CAPSAICIN 02244952 ZODERM 00740306 ZOSTRIX 0.075% Cream 02004240 ZOSTRIX HP 0.075% Ointment 02157128 CAPSAICIN HP VAO EUR GEN GEN VAO
0.1% Gel 02230785
VITAMIN E
30IU Ointment 01910787 VITAMIN E JLF
COLLAGENASE
250U Ointment 02063670 SANTYL HPC
FLUOROURACIL
5% Cream 00330582 EFUDEX VAE
ISOTRETINOIN
Accutane should be used with caution in women of childbearing potential due to its teratogenicity. Pregnancy must be excluded. Effective contraception must be used. Manufacturer's literature regarding contraindications and warnings should be consulted prior to prescribing or dispensing this drug. 10mg Capsule 00582344 ACCUTANE 02257955 CLARUS 40mg Capsule 00582352 ACCUTANE 02257963 CLARUS HLR PRE HLR PRE
PIMECROLIMUS
Limited use benefit (prior approval required). For patients who have failed topical corticosteroid therapy or have experienced side effects from such treatment. Note: Contraindicated in children less than 2 years of age. 1% Cream 02247238 ELIDEL NVC
TACROLIMUS (PROTOPIC)
Limited use benefit (prior approval required). For patients who have failed topical corticosteroid therapy or have experienced side effects from such treatment. Note: Contraindicated in children less than 2 years of age. 0.03% Ointment 02244149 PROTOPIC 0.1% Ointment 02244148 PROTOPIC 2010 AST AST Page 109 of 124
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86:00 SMOOTH MUSCLE RELAXANTS

86:12.00 GENITOURINARY SMOOTH MUSCLE RELAXANTS
DARIFENACIN HYDROBROMIDE
7.5mg Long Acting Tablet 02273217 ENABLEX 15mg Long Acting Tablet 02273225 ENABLEX NOV NOV

TROSPIUM CHLORIDE
Limited use benefit (prior approval required). For the symptomatic relief of patients with an overactive bladder with symptoms of urinary frequency, urgency or urge incontinence or any combination of these in patients who have failed on or are intolerant of therapy with oxybutynin.
ST
FLAVOXATE HCL
ST
TROSEC
ORY
200mg Tablet 02244842 APO-FLAVOXATE 00728179 URISPAS
APX PAL
86:16.00 RESPIRATORY SMOOTH MUSCLE RELAXANTS

AMINOPHYLLINE
225mg Sustained Release Tablet 02014270 PHYLLOCONTIN PFR PFR
OXYBUTYNIN CHLORIDE
ST
1mg/mL Syrup 02231089 APO-OXYBUTYNIN 02223376 PMS-OXYBUTYNIN 2.5mg Tablet 02240549 PMS-OXYBUTYNIN 5mg Tablet 02163543 02241285 02230800 02230394 02158590 02220636 02239073 02240550 02299364 APO-OXYBUTYNIN DOM-OXYBUTYNIN GEN-OXYBUTYNIN NOVO-OXYBUTYNIN NU-OXYBUTYN OXYBUTYNINE PENTA-OXYBUTYNIN PMS-OXYBUTYNIN RIVA-OXYBUTYNIN
APX PMS PMS APX DPC GEN NOP NXP PDL PEN PMS RIV
350mg Sustained Release Tablet 02014289 PHYLLOCONTIN
ST
OXTRIPHYLLINE
20mg/mL Elixir 00476366 CHOLEDYL 00792942 PMS-OXTRIPHYLLINE 100mg Tablet 00441724 APO-OXTRIPHYLLINE 200mg Tablet 00441732 APO-OXTRIPHYLLINE 300mg Tablet 00511692 APO-OXTRIPHYLLINE PFI PMS APX APX APX
ST
SOLIFENACIN SUCCINATE
Limited use benefit (prior approval required). For symptomatic relief in patients with an overactive bladder with symptoms of urinary frequency, urgency or urge incontinence in patients who have failed on or are intolerant of therapy with oxybutynin.
ST
THEOPHYLLINE
5.33mg/mL Elixir 00575151 PMS-THEOPHYLLINE 00466409 PULMOPHYLLIN 00627410 THEOPHYLLINE 5.33mg/mL Solution 01966219 THEOLAIR 100mg Sustained Release Tablet 00692689 APO-THEO 02230085 NOVO-THEOPHYL SR 200mg Sustained Release Tablet 00692697 APO-THEO LA 02230086 NOVO-THEOPHYL SR 300mg Sustained Release Tablet 00692700 APO-THEO LA 02230087 NOVO-THEOPHYL SR 400mg Sustained Release Tablet 02014165 UNIPHYL 600mg Sustained Release Tablet 02014181 UNIPHYL PMS RIV ATL MMH APX NOP APX NOP APX NOP PFR PFR
VESICARE VESICARE
AST AST
ST
TOLTERODINE
ST
2mg Extended Release Capsule 02244612 DETROL LA 4mg Extended Release Capsule 02244613 DETROL LA 1mg Tablet 02239064 2mg Tablet 02239065 DETROL DETROL
PFI PFI PFI PFI
ST
ST
ST
2010
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88:00 VITAMINS
88:04.00 VITAMIN A
VITAMIN A
ST
88:08.00 VITAMIN B COMPLEX

NIACIN
ST
10,000IU Capsule 00557447 VIT A 00253820 VITAMIN A 00297720 VITAMIN A 25,000IU Capsule 00021067 VITAMIN A 50,000IU Capsule 00021075 VITAMIN A
VTH NOP JAM NOP NOP
500mg Tablet 00294950 01939130 02247004 00557412 00309737
NIACIN NIACIN NIACIN NIACIN YEAST FREE VITAMIN B3
VAE ODN PMT VTH JAM
ST
PYRIDOXINE HCL
ST
ST
88:08.00 VITAMIN B COMPLEX

CYANOCOBALAMIN
ST
25mg Tablet 00122645 00232475 01943200 80002890 50mg Tablet 00252689 00305227 00608599 100mg Tablet 00329185 00450677 00464325 00653993 02239348
VITAMIN B6 VITAMIN B6 VITAMIN B6 VITAMIN B6 VITAMIN B6 VITAMIN B6 VITAMIN B6 VITAMIN B6 VITAMIN B6 VITAMIN B6 VITAMIN B6 VITAMIN B6
JAM PMS ODN JMP VAE JAM PMS JAM VTH PED LAL PMT
100mcg/mL Injection 00497533 VITAMIN B12 02241500 VITAMIN B12 1,000mcg/mL Injection 01987003 CYANOCOBALAMIN 02052717 CYANOCOBALAMIN 00521515 VIT B12 00038830 VITAMIN B12
ST
ABB SDZ CYX TAR SDZ ABB JAM JAM VTH PMT
ST ST
25mcg Tablet 00406988 VITAMIN B12 50mcg Tablet 00305243 VITAMIN B12 100mcg Tablet 00450642 VIT B12 02023598 VITAMIN B12 250mcg Tablet 00335940 VITAMIN B12 1000mcg Tablet 80003575 VITAMIN B12
ST
THIAMINE HCL
100mg/mL Injection 02241983 BETAXIN 02243525 THIAMINE 00816078 VITAMIN B1 50mg Tablet 80009633 00268631 JAMP-VITAMIN B1 VITAMIN B1 ABB CYX SDZ JMP VAE PMS JAM
ST
ST
JAM PMT
ST
ST
FOLIC ACID
ST
100mg Tablet 00232467 VITAMIN B1 00407011 VITAMIN B1
1mg Tablet 00318973 00647039 02048841 02236747 5mg Tablet 00426849 02285673 00563781
FOLIC ACID FOLIC ACID FOLIC ACID FOLIC ACID APO-FOLIC ACID EURO-FOLIC FOLIC ACID
JAM VTH PMT PED APX EUR PDL
88:12.00 VITAMIN C
ASCORBIC ACID
ST
ST
250mg Chewable Tablet 00784575 VIT C 00266051 VITAMIN C 00274232 VITAMIN C 00372498 VITAMIN C 500mg Chewable Tablet 00274240 VITAMIN C 00322997 VITAMIN C 00784591 VITAMIN C 02243893 VITAMIN C 02245721 VITAMIN C 1000mg Sustained Release Tablet 00760587 VITAMIN C 100mg Tablet 00466646 APO-C
VTH PMT PED LAL PED LAL VTH PMT PMT PMT APX
ST
NIACIN
ST
NIACIN
PMS VAE
ST
100mg Tablet 00268585 NIACIN
ST
ST
2010
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88:12.00 VITAMIN C
ASCORBIC ACID
ST
88:16.00 VITAMIN D
CHOLECALCIFEROL
ST
250mg Tablet 00466638 00221244 00557811 00162515 500mg Tablet 00266086 00041114 00322326 00036188 00316873 00557838 00721581 01922378 02244469
APO-C VIT C VIT C VITAMIN C ASCORBIC ACID VIT C VIT C VITAMIN C VITAMIN C VITAMIN C VITAMIN C VITAMIN C VITAMIN C
APX ADA VTH PMT PMT ADA LAL PED LAL VTH PVR SWS PMT APX NUL HLR PMT
400IU/mL Drop 00762881 D VI SOL 80003038 JAMP-VITAMIN D 02231624 PEDIAVIT D 1000IU Drop 80001791 DDROPS VITAMIN D 400IU Tablet 00765384 02229879 02238729 02240624 02240858 02244759 VITAMIN D VITAMIN D VITAMIN D VITAMIN D VITAMIN D VITAMIN D
MJO JMP EUR DDP LAL SWS VTH WAM PMT WNP JAM SWS PMT RIV
ST
ST
ST
ST
ST
1000mg Tablet 00466603 APO-C 00854670 C 1000 00897256 REDOXON 00354376 VITAMIN C
1,000IU Tablet 00299383 VITAMIN D 00323179 VITAMIN D 02245842 VITAMIN D 10,000IU Tablet 00821772 D-TABS
ST
88:16.00 VITAMIN D
ALFACALCIDOL
ST
ERGOCALCIFEROL
ST
50,000IU Capsule 02237450 D-FORTE 8,288IU/mL Solution 02017598 DRISDOL
EUR SAC
0.25mcg Capsule 00474517 ONE-ALPHA 1mcg Capsule 00474525 ONE-ALPHA 2mcg/mL Oral Liquid 02240329 ONE-ALPHA
ST
LEO LEO LEO

ST
ST
VITAMIN D
ST
ST
400IU Capsule 80008590 VITAMIN D 800IU Capsule 80003010 EURO D 80008446 VITAMIN D
BMI EUR BMI
CALCITRIOL
ST
0.25mcg Capsule 00481823 ROCALTROL 0.5mcg Capsule 00481815 ROCALTROL 1mcg/mL Solution 00824291 ROCALTROL
HLR HLR HLR
88:20.00 VITAMIN E
ALPHA TOCOPHERYL
ST
ST
ST
400IU Capsule 00122858 VITAMIN E NATUAL SOURCE
JAM
CHOLECALCIFEROL
ST
VITAMIN E
ST
400IU Capsule 02242651 EURO D 80006629 JAMP-VITAMIN D 02243976 RIVA-D 80005560 RIVA-D 400 UNIT CAP 800IU Capsule 80007769 JAMP VIT D3 10,000IU Capsule 02253178 EURO D 50,000IU Capsule 02301911 OSTOFORTE 400IU Drop 80001869 80001792 BABY DDROPS DDROPS VITAMIN D
EUR JMP RIV RIV JMP EUR TRT DDP DDP
50IU/mL Liquid 02162075 AQUASOL E 77IU/mL Liquid 02212889 AQUASOL E
NVC NVC
88:28.00 MULTIVITAMIN PREPARATIONS

MULTIVITAMINS (PEDIATRIC)
Limited use benefit (prior approval is not required). Pediatric multivitamins are benefits for children up to 6 years of age.
ST
ST
ST
ST
ST
Chewable Tablet 00336300 MULTI-VITAMINS CHILD Drop 00558060 00762946 INFANTOL POLY-VI-SOL
NOP HOR MJO Page 112 of 124
ST
2010
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ST
Liquid 00558079 Tablet 80011134 02247975
INFANTOL CENTRUM JUNIOR COMPLETE FLINTSTONES EXTRA C
HOR WYE BCD
ST
MULTIVITAMINS (PRENATAL)
Limited use benefit (prior approval is not required.). Prenatal and postnatal vitamins are benefits only for women of childbearing age (12 to 50 years).
ST
Tablet 80001842 02229535 00815241 80005770 02240840 02241235 02244374
CENTRUM MATERNA MULTI-PRE AND POST NATAL NEO-TINIC PRENATAL & POSTPARTUM PRENATAL AND POSTPARTUM PRENATAL AND POSTPARTUM PRENATAL VITAMINS AND MINERALS
WAY PED NEO PMT VTH SDR PMT
VITAMIN A, CHOLECALCIFEROL, ASCORBIC ACID

ST
2,500IU & 666.67IU & 50mg/mL Drop 02229790 PEDIAVIT 00762903 TR- VI-SOL Oral Liquid 80008471 JAMP-MULTIVITAMIN A/D/C DROPS
EUR MJO JMP
ST
2010
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92:00 UNCLASSIFIED THERAPEUTIC AGENTS

92:00.00 UNCLASSIFIED THERAPEUTIC AGENTS
ABATACEPT
Limited use benefit (prior approval required). For the treatment of: Rheumatoid Arthritis according to established criteria. Juvenile Idiopathic Arthritis (Please refer to Appendix A). 250mg/Vial Injection 02282097 ORENCIA BMS

ALENDRONATE SODIUM
Limited use benefit (prior approval required). For the treatment of: a. - Osteoporosis in patients who are 65 years of age and over or b. - Osteoporosis in patients who have documented hip, vertebral or other fractures or c. - Paget's Disease or d. - Osteoporosis in patients with no evidence of fracture but who have a high (>20%) 10-year fracture risk or e. - Osteoporosis in patients with moderate 10-year fracture risk (10-20%) and use of systemic glucocorticoid therapy > 3 months
ST
ADALIMUMAB
Limited use benefit (prior approval required). For the treatment of: Rheumatoid Arthritis according to established criteria. Psoriatic Arthritis according to established criteria. Ankylosing Spondylitis according to established criteria. Psoriasis according to established criteria. Crohn's disease according to established criteria. (Please refer to Appendix A). 40mg/0.8mL Injection 09857327 HUMIRA PEN 97799757 HUMIRA PEN 09857326 HUMIRA PRE-FILL 97799756 HUMIRA PRE-FILL 40mg/Vial Injection 02258595 HUMIRA ABB ABB ABB ABB ABB
40mg Tablet 02258102 02201038 70mg Tablet 02303078 02248730 02258110 02245329 02286335 02261715 02299712 02273179 02284006 02275279 02270889 02288109 02302004
CO ALENDRONATE FOSAMAX ALENDRONATE-70 APO-ALENDRONATE CO ALENDRONATE FOSAMAX GEN-ALENDRONATE NOVO-ALENDRONATE PHL-ALENDRONATE PMS-ALENDRONATE PMS-ALENDRONATE FC RATIO-ALENDRONATE RIVA-ALENDRONATE SANDOZ ALENDRONATE ZYM-ALENDRONATE
COB FRS PDL APX COB FRS GEN NOP PMI PMS PMS RPH RIV SDZ ZYM
ST
ALENDRONATE SODIUM
ST
ALENDRONATE SODIUM, VITAMIN D3

ST
5mg Tablet 02248727 02233055 02270110 02248251 02288079 10mg Tablet 02248728 02201011 02270129 02247373 02288087
APO-ALENDRONATE FOSAMAX GEN-ALENDRONATE NOVO-ALENDRONATE SANDOZ ALENDRONATE APO-ALENDRONATE FOSAMAX GEN-ALENDRONATE NOVO-ALENDRONATE SANDOZ ALENDRONATE
APX FRS GEN NOP SDZ APX FRS GEN NOP SDZ
70mg/2800U Tablet 02276429 FOSAVANCE 70mg/5600U Tablet 02314940 FOSAVANCE
FRS MSP
ST
ST
ALFUZOSIN HYDROCHLORIDE
ST
10mg Sustained Release Tablet 02315866 APO-ALFUZOSIN ER 02304678 SANDOZ ALFUZOSIN 02245565 XATRAL
APX SDZ SAC
2010
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ALLOPURINOL
ST

CLOSTRIDIUM BOTULINUM NEUROTOXIN
Limited use benefit (prior approval required).
100mg Tablet 00449687 00555681 00402818 00364282 200mg Tablet 00514209 02130157 00479799 00565342 300mg Tablet 00454354 00555703 00402796 00363693 00294322
ALLOPRIN ALLOPURINOL APO-ALLOPURINOL NOVO-PUROL ALLOPRIN ALLOPURINOL APO-ALLOPURINOL NOVO-PUROL ALLOPRIN ALLOPURINOL APO-ALLOPURINOL NOVO-PUROL ZYLOPRIM
VAE PDL APX NOP VAE PDL APX NOP VAE PDL APX NOP GSK
ST
For: a. - the treatment of strabismus and blepharospasm associated with dystonia, including benign essential blepharospasm or VII nerve disorder in patients 12 years of age or older or b. - the treatment of cervical dystonia (spasmodic torticollis) 100U/vial Injection 02324032 XEOMIN MEZ
COLCHICINE
0.6mg Tablet 00572349 COLCHICINE 1mg Tablet 00621374 COLCHICINE ODN ODN
ST
CYCLOSPORINE
Limited use benefit (prior approval required). For transplant therapy.
AZATHIOPRINE
50mg Tablet 02242907 APO-AZATHIOPRINE 00004596 IMURAN 02248843 NU-AZATHIOPRINE APX GSK NXP
10mg Capsule 02237671 NEORAL 25mg Capsule 02150689 NEORAL 02247073 SANDOZ-CYCLOSPORINE 50mg Capsule 02150662 NEORAL 02247074 SANDOZ-CYCLOSPORINE 100mg Capsule 02150670 NEORAL 02242821 SANDOZ-CYCLOSPORINE 100mg/mL Solution 02150697 NEORAL
NVR NVR SDZ NVR SDZ NVR SDZ NVR
BETAHISTINE HCL
16mg Tablet 02280191 02243878 24mg Tablet 02280205 02247998 NOVO-BETAHISTINE SERC NOVO-BETAHISTINE SERC NOP SPH NOP SPH
BOTULINUM TOXIN TYPE A

Limited use benefit (prior approval required). For the treatment of: a. - strabismus and blepharospasm associated with dystonia, including benign essential blepharospasm or VII nerve disorder in patients 12 years of age or older b. - cervical dystonia (spasmodic torticollis) 100IU Injection 01981501 BOTOX ALL
CYPROTERONE ACETATE, ETHINYL ESTRADIOL

2mg & 35mcg Tablet 02290308 CYESTRA-35 02233542 DIANE-35 02309556 NOVOCYPROTERONE/ETHINYL ESTRADIOL PMS BAY NOP
CABERGOLINE
Limited use benefit (prior approval required). For treatment of hyperprolactinemia in patients who have failed therapy with or are intolerant to bromocriptine. 0.5mg Tablet 02301407 CO CABERGOLINE 02242471 DOSTINEX COB PFI
DUTASTERIDE
Limited use benefit (prior approval required). a. - For treatment of Benign Prostatic Hyperplasia (BPH) in patients who do not tolerate or have not responded to an adrenergic blocker. or b. - For use in combination therapy when monotherapy with an alpha-blocker is not sufficient.
ST
0.5mg Capsule 02247813 AVODART
GSK
2010
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ERGOCALCIFEROL
ST

FLUNARIZINE HCL
5mg Capsule 02246082 APO-FLUNARIZINE
8288IU/mL Oral Liquid 80003615 ERDOL
ODN
APX
ETANERCEPT
Limited use benefit (prior approval required). For the treatment of: Rheumatoid Arthritis according to established criteria. Psoriatic Arthritis according to established criteria. Ankylosing Spondylitis according to established criteria. Juvenile Idiopathic Arthritis (Please refer to Appendix A). 25mg/Vial Injection 02242903 ENBREL 50mg/mL Injection 02274728 ENBREL 99100373 ENBREL SURECLICK IMX IMX AMG
GOLIMUMAB
Limited use benefit (prior approval required). For the treatment of: Rheumatoid Arthritis according to established criteria. Psoriatic Arthritis according to established criteria. Ankylosing Spondylitis according to established criteria. (Please refer to Appendix A). 50mg/0.5mL Injection 02324784 SIMPONI AUTO INJECTOR 02324776 SIMPONI PRE-FILLED SYRINGE CER CER
INFLIXIMAB
Limited use benefit (prior approval required). For treatment of: Fistulizing Crohns disease according to established criteria. For adult patients with moderately to severely active Crohns Disease who have had an inadequate response to conventional therapy. (Please refer to Appendix A). or Rheumatoid Arthritis according to established criteria (Please refer to Appendix A).
ETIDRONATE DISODIUM
ST
200mg Tablet 02248686 CO ETIDRONATE 01997629 DIDRONEL 02245330 GEN-ETIDRONATE
COB PGP GEN
ETIDRONATE DISODIUM, CALCIUM CARBONATE

ST
400mg & 500mg Tablet 02263866 CO-ETIDROCAL 02176017 DIDROCAL 02247323 GEN-ETI-CAL CP 02324199 NOVO-ETIDRONATECAL KIT
COB PGP GEN NOP
100mg/Vial Injection 02244016 REMICADE
CEN
LANREOTIDE
60mg/0.3mL Injection 02283395 SOMATULINE AUTOGEL 90mg/0.3mL Injection 02283409 SOMATULINE AUTOGEL 120mg/0.5mL Injection 02283417 SOMATULINE AUTOGEL IPS IPS IPS
EXTEMPORANEOUS MIXTURE
Miscellaneous 00990019 EXTEMPORANEOUS MIXTURE 00999994 EXTEMPORANEOUS MIXTURE 00999997 EXTEMPORANEOUS MIXTURE 00999999 EXTEMPORANEOUS MIXTURE 00915000 STERILE EXTEMPORANEOUS MIXTURE (QC)
LEFLUNOMIDE
Limited use benefit (prior approval required). For treatment of patients with rheumatoid arthritis who: a. - have failed treatment with methotrexate: weekly dose (PO, SC or IM) of 20mg or greater (15mg or greater if patient is 65 years of age or older) for more than 8 weeks. b. - cannot tolerate or have contraindications to methotrexate. 10mg Tablet 02256495 02241888 02319225 02261251 02288265 02283964 APO-LEFLUNOMIDE ARAVA GEN-LEFLUNOMIDE NOVO-LEFLUNOMIDE PMS-LEFLUNOMIDE SANDOZ LEFLUNOMIDE APX SAC GEN NOP PMS SDZ
FINASTERIDE
Limited use benefit (prior approval required). a. - For treatment of Benign Prostatic Hyperplasia (BPH) in patients who do not tolerate or have not responded to an alpha-adrenergic blocker. or b. - For use in combination therapy when monotherapy with an alpha-blocker is not sufficient.
ST
5mg Tablet 02348500 02310112 02010909 02306905 02322579
NOVO-FINASTERIDE PMS-FINASTERIDE PROSCAR RATIO-FINASTERIDE SANDOZ FINASTERIDE
NOP PMS FRS RPH SDZ
2010
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LEFLUNOMIDE
Limited use benefit (prior approval required). For treatment of patients with rheumatoid arthritis who: a. - have failed treatment with methotrexate: weekly dose (PO, SC or IM) of 20mg or greater (15mg or greater if patient is 65 years of age or older) for more than 8 weeks. b. - cannot tolerate or have contraindications to methotrexate. 20mg Tablet 02256509 02241889 02319233 02261278 02288273 02283972 APO-LEFLUNOMIDE ARAVA GEN-LEFLUNOMIDE NOVO-LEFLUNOMIDE PMS-LEFLUNOMIDE SANDOZ LEFLUNOMIDE APX SAC GEN NOP PMS SDZ

OCTREOTIDE
200mcg/mL Injection 02248642 OCTREOTIDE ACETATE OMEGA 02049392 SANDOSTATIN 500mcg/mL Injection 02248641 OCTREOTIDE ACETATE OMEGA 00839213 SANDOSTATIN OMG NOV OMG NVR
PAMIDRONATE DISODIUM
30mg Injection 02059762 AREDIA IV 02244550 PAMIDRONATE DISODIUM 02264951 RHOXAL-PAMIDRONATE 60mg Injection 02244551 PAMIDRONATE DISODIUM 02264978 RHOXAL-PAMIDRONATE 90mg Injection 02059789 AREDIA IV 02244552 PAMIDRONATE DISODIUM 02245999 PMS-PAMIDRONATE 02264986 RHOXAL-PAMIDRONATE NVR MAY RHO HOS SDZ NVR MAY PMS SDZ
LEUCOVORIN CALCIUM
5mg Tablet 02170493 LEUCOVORIN CALCIUM WAY
MYCOPHENOLATE MOFETIL
Limited use benefit (prior approval required). For transplant therapy. 250mg Capsule 02192748 CELLCEPT 500mg Tablet 02237484 CELLCEPT HLR HLR
PENTOSAN POLYSULFATE SODIUM

100mg Capsule 02029448 ELMIRON JNO
MYCOPHENOLATE SODIUM
Limited use benefit (prior approval required). For transplant therapy. 180mg Enteric Coated Tablet 02264560 MYFORTIC 360mg Enteric Coated Tablet 02264579 MYFORTIC NVR NVR
RISEDRONATE SODIUM
ST
NEDOCROMIL SODIUM
2% Ophth Solution 02241407 ALOCRIL ALL
OCTREOTIDE
10mg/Vial Injection 02239323 SANDOSTATIN LAR 20mg/Vial Injection 02239324 SANDOSTATIN LAR 30mg/Vial Injection 02239325 SANDOSTATIN LAR 50mcg/mL Injection 02248639 OCTREOTIDE ACETATE OMEGA 00839191 SANDOSTATIN 100mcg/mL Injection 02248640 OCTREOTIDE ACETATE OMEGA 00839205 SANDOSTATIN NVR NVR NVR
ACTONEL NOVO-RISEDRONATE ACTONEL NOVO-RISEDRONATE ACTONEL NOVO-RISEDRONATE
PGP NOP PGP NOP PGP NOP
ST
ST
OMG NVR OMG NVR
2010
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SIROLIMUS
Limited use benefit (prior approval required). Coverage will be provided as a second line therapy for patients failing mycophenolate mofetil. 1mg/mL Oral Liquid 02243237 RAPAMUNE 1mg Tablet 02247111 RAPAMUNE WAY WAY

ZOLEDRONIC ACID
Limited use benefit (prior approval required). For the treatment of Pagets disease. Coverage will be granted for one dose per 12 month period. 5mg/100mL Injection 02269198 ACLASTA NOV
92:44.00
TACROLIMUS
Limited use benefit (prior approval required). NOP RBY RPH SDZ BOE For transplant therapy. 0.5mg Capsule 02243144 PROGRAF 1mg Capsule 02175991 PROGRAF 5mg Capsule 02175983 PROGRAF 5mg/mL Injection 02176009 PROGRAF 0.5mg Long Acting Capsule 02296462 ADVAGRAF LHL 1mg Long Acting Capsule 02296470 ADVAGRAF 5mg Long Acting Capsule 02296489 ADVAGRAF AST AST AST AST AST AST AST
TAMSULOSIN HCL
ST
0.4mg Long Acting Capsule 02281392 NOVO-TAMSULOSIN 02294885 RAN-TAMSULOSIN 02294265 RATIO-TAMSULOSIN 02295121 SANDOZ TAMSULOSIN 0.4mg Long Acting Tablet 02270102 FLOMAX CR
ST
TAMSULOSIN HYDROCHLORIDE
ST
0.4mg Sustained Release Capsule 02298570 GEN-TAMSULOSIN
MYL
TETRABENAZINE
25mg Tablet 02199270 NITOMAN
USTEKINUMAB
Limited use benefit (prior approval required). For the treatment of moderate to severe psoriasis in patients who meet the following criteria: a. - Body surface area involvement greater than 10% and/or significant involvement of the face, hands, feet or genital region and b. - Intolerance or lack of response to methotrexate and cyclosporine or c. - A contraindication to methotrexate and/or cyclosporine and d. - Intolerance or lack of response to phototherapy or e. - Inability to access phototherapy Coverage beyond 16 weeks will be based on a significant reduction in the Body Surface Area (BSA) involved and improvements in the Psoriasis Area Severity Index (PASI) score and the Dermatology Life Quality Index (DLQI). 45mg/0.5mL Injection 02320673 STELARA JNO
WATER
100% Injection 00038202 STERILE WATER 99002264 STERILE WATER 00905178 WATER FOR INJECTION 00905194 WATER FOR INJECTION 00905224 WATER FOR INJECTION ABB
2010
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94:00 DEVICES
94:00.00 DEVICES
HYDROXYPROPYLCELLULOSE
5mg Ophthalmic Insert 00889970 LACRISERT LAMELLE FRS
94:00.00 DEVICES
SPACER DEVICE
2010
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94:00.00 DEVICES
SPACER DEVICE
Device 99400496 99400497 99400495 99400500 99400499 99400498 00964905 00964891 96899994 96899995 96899996 96899997 99400487 99400488 99400490 99400489 99400507 99400511 99400508 99400501 99400504 99400503 99400502 99400505 99400506 99400787 99400791 99400788 99400790 99400789 99400512 99400516 99400515 99400514 99400513 99400517 2010 ACE ADAPTORS ACE KIT ACE MDI SPACER ACE SPACER WITH LARGE MASK ACE SPACER WITH MEDIUM MASK ACE SPACER WITH SMALL MASK AEROCHAMBER AC BOYZ AEROCHAMBER AC GIRLZ AEROCHAMBER MAX VHC WITH ADULT MASK AEROCHAMBER MAX VHC WITH CHILD MASK AEROCHAMBER MAX VHC WITH INFANT MASK AEROCHAMBER MAX VHC WITH MOUTHPIECE AEROCHAMBER PLUS VHC ADULT AEROCHAMBER PLUS VHC WITH ADULT MASK AEROCHAMBER PLUS VHC WITH INFANT MASK AEROCHAMBER PLUS VHC WITH PEDIATRIC MASK E-Z SPACER E-Z SPACER (MASK ONLY) E-Z SPACER WITH SMALL MASK OPTICHAMBER OPTICHAMBER LARGE MASK OPTICHAMBER MEDIUM MASK OPTICHAMBER SMALL MASK OPTIHALER OPTIVENT IN-LINE MDI SPACER POCKET CHAMBER POCKET CHAMBER WITH ADULT MASK POCKET CHAMBER WITH INFANT MASK POCKET CHAMBER WITH MEDIUM MASK POCKET CHAMBER WITH SMALL MASK RONDO INHALATION CHAMBER RONDO INHALATION CHAMBER-CHILD MASK RONDO INHALATION CHAMBER-INFANT MASK RONDO INHALATION CHAMBER-NEONATAL MASK RONDO INHALATION CHAMBER-UNIVERSAL MASK SPACE CHAMBER AUC AUC AUC AUC AUC AUC TRU TRU TRU TRU TRU TRU TRU TRU TRU TRU WEP WEP WEP AUC AUC AUC AUC AUC AUC MCA MCA MCA MCA MCA KIN KIN KIN KIN KIN AUC
94:00.00 DEVICES
SPACER DEVICE
Device 99400521 99400520 99400518 99400519 99400491 99400493 99400492 99400494 Kit 99400777 99400776 99400775 SPACE CHAMBER ADULT LARGE MASK SPACE CHAMBER ADULT REGULAR MASK SPACE CHAMBER INFANT MASK SPACE CHAMBER PEDIATRIC MASK VENT 170 SPACER VENT 170 SPACER AND MASK VENT 170 SPACER DELUXE VENTAHALER ACE LARGE MASK ACCESSARY KIT ACE MEDIUM MASK ACCESSARY KIT ACE SMALL MASK ACCESSARY KIT AUC AUC AUC AUC NDE NDE NDE GSK AUC AUC AUC
SYRINGE & NEEDLE (NON-INSULIN)

Syringe & Needle 99400534 NON-INSULIN 1CC 99400536 NON-INSULIN 3CC 99400537 NON-INSULIN 5CC 99400538 NON-INSULIN 10CC
SYRINGE (NON-INSULIN)
Syringe 99400530 99400535 99400539 99400548 99400823 99400549 99400531 99400532 99400533 1 Syringe 99400529 LUER LOCK (DISP) 3CC LUER LOCK (DISP) 5CC LUER LOCK (DISP) 10CC LUER LOCK (DISP) 20CC LUER LOCK (DISP) 30CC LUER LOCK (DISP) 60CC NON-INSULIN (DISP) 3CC NON-INSULIN (DISP) 5CC NON-INSULIN (DISP) 10CC NON-INSULIN (DISP) 1CC
BTD
VENTODISK DISKHALER
Device 00905739 VENTODISK DISKHALER GSK
94:01.00 DEVICES (DIABETIC)

GLUCOMETER BATTERIES
Device 99401030 99401031 99401029 99401056 99401032 BATTERIES - 1.5 VOLT BATTERIES - 3 VOLT BATTERIES - AAA BATTERIES - LITHIUM BATTERIES - SIZE J 6V
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INSULIN PUMP SUPPLIES
Device 99401049 99401052 99401053 99401050 99401038 99401047 99401048 09991061 09991062 99401051 ADAPTOR ADHESIVE PAD WITH COTTON ADHESIVE PAD WITHOUT COTTON INFUSION SETS INSULIN PUMP BATTERY INSULIN PUMP CARTRIDGES PISTON ROD RESERVOIR 5XX 1.8ML SYRINGE RESERVOIR 7XX 3.0ML SYRINGE TUBING AUC AUC AUC AUC AUC AUC AUC MDT MDT AUC

LANCET
Lancet 97799817 99401068 97799541 00900834 00995965 00977839 99401063 97799766 97799767 00977853 00901555 00906190 00906239 00977493 00977543 99401055 97799810 97799811 97799807 97799808 00901359 00905917 00977952 99493957 00000165 00902144 00977373 00900141 00977659 00977051 00977896 00984167 ACCU-CHEK MULTICLIX BD LATITUDE EZ HEALTH ORACLE LANCETS FINGERSTIX FINGERSTIX FREESTYLE FREESTYLE ITEST LANCETS 28G (100) ITEST LANCETS 33G (100) LIFESCAN FINE POINT LIFESCAN REGULAR MEDISENSE MICROLET MICROLET MONOLET ORIGINAL MONOLET THIN MPD THIN (100) MPD THIN (200) MPD ULTRA THIN (100) MPD ULTRA THIN (200) ONE TOUCH ULTRA SOFT SOFT TOUCH SOFT TOUCH SOFT TOUCH SOFTCLIX SOFTCLIX SELECT SOFTCLIX SELECT ULTRA-FINE II ULTRA-FINE II UNILET COMFORT TOUCH UNILET COMFORT TOUCH UNILET COMFORT TOUCH ROD BTD TRE BAY BAY ABB ABB AUC AUC JAJ JAJ AUC BAY BAY SHM SHM MPD MPD MPD MPD JAJ ROD ROD ROD BOE BOE BOE BTD BTD BAY BAY BAY
ISOPROPYL ALCOHOL
70% Swab 00480452 02247809 00809357 02240759 99438102 00795232 ALCOHOL PREP SWAB ALCOHOL SWAB ALCOHOL SWABS BD B-D ALCOHOL SWAB MONOJECT ALCOHOL WIPES WEBCOL ALCOHOL PREP PFD TIP BTD BTD SHM JAJ
LANCING DEVICE
Device 99401025 99401020 99401021 99401014 99401017 99401015 99401016 99401022 99401018 99401024 99401023 99401019 B-D LANCET GLUCOLET GLUCOLET 2 MEDISENSE TLC MICROLET MONOJECTOR PENLET PLUS REGULAR ENDCAPS FOR GLUCOLET REGULAR ENDCAPS FOR MICROLET SOFTTOUCH SUPER ENDCAPS FOR GLUCOLET SUPER ENDCAPS FOR MICROLET BTD BAY BAY AUC BAY SHM JAJ BAY BAY ROD BAY BAY
MAGNIFIER
Magnifier 99400550 SYRINGE SCALE MAGNIFIER
2010
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NEEDLE
Needle 00908452 00977756 22g Needle 00977616 00977624 25g Needle 00977071 00977063 27g Needle 00977012 28g Needle 99221028 29g Needle 00977101 97799897 00900513 97799561 00908185 B-D PEN NOVOFINE B-D DISPOSABLE 1 INCH 5155 B-D DISPOSABLE 1 INCH 5156 B-D DISPOSABLE 5/8 INCH 5122 B-D DISPOSABLE 1 INCH 5127 B-D DISPOSABLE INCH 5109 NOVOFINE INSULIN PEN 28G B-D ULTRA-FINE PEN BD ULTRA-FINE PEN NEEDLE 29G OWEN MUMFORD UNIFINE PENTIPS 1/2 INCH SUPER-FINE STANDARD 29G 12.7MM ULTRAFINE PEN ULTRA-FINE 29G BTD NOO BTD BTD

SHARPS CONTAINER
Device 99401026 99401027 99401028 B-D SHARPS CONTAINER 1.4L B-D SHARPS CONTAINER 3.1L B-D SHARPS CONTAINER 3.8L BTD BTD SHM
SYRINGE
0.3cc Syringe 00977961 B-D MICRO-FINE 00977977 B-D ULTRA-FINE / ULTRA-FINE II 00920169 MICRO-FINE 00977951 MONOJECT 99254011 MONOJECT DISP 3/10CC (100) 99253047 MONOJECT DISP 3/10CC (30) 00920053 SYRN MONOJECT 00920193 ULTRA-FINE 0.5cc Syringe 00977985 00920177 00920355 99432799 99432633 00920207 1cc Syringe 99328369 00920045 99433383 99432914 00920215 00909238 B-D ULTRA-FINE II MICRO-FINE MONOJECT MONOJECT (100) MONOJECT (30) ULTRA-FINE B-D ULTRA-FINE MONOJECT MONOJECT (100) MONOJECT (30) ULTRA-FINE ULTRA-FINE II 30G BTD BTD BTD SHM SHM SHM SHM BTD BTD BTD SHM SHM SHM BTD BTD SHM SHM SHM BTD BTD
BTD BTD
BTD NOO BTD BTD AUC PMS BTD
29GX12MM Needle 97799543 ULTI 29GX1/2 WITH SHARP CONTAINER 30g Needle 00921114 00908169 99117796 31g Needle 00977011 00900511 00900512 97799563 97799562 NOVOFINE NOVOFINE 30G NOVOFINE INSULIN PEN 30G B-D ULTRA-FINE PEN III OWEN MUMFORD UNIFINE PENTIPS 1/4 INCH OWEN MUMFORD UNIFINE PENTIPS 5/16 INCH SUPER-FINE MICRO 31G 5MM SUPER-FINE XTRA 31G 8MM
UMI
NOO NOO NOO BTD AUC AUC PMS PMS UMI
31GX6MM Needle 97799545 ULTI 31GX1/4 WITH SHARP CONTAINER 31GX8MM Needle 97799544 ULTI 31GX5/16 WITH SHARP CONTAINER 32g Needle 97799821 NOVOFINE 32G 6MM
UMI
NOO
NEEDLE (NON-INSULIN)
Needle 99400528 NEEDLES (NON-INSULIN) DISPOSABLE
2010
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SYRINGE & NEEDLE
0.3cc Syringe and Needle 99328419 B-D INSULIN 1/3CC 29G UF 1 99639286 B-D MICRO-FINE 1/3CC 00909092 SYRN INS U-II 3/10CC 30G 00905690 SYRN INSULIN MICRO 3/10CC 28G 00906786 SYRN INSULIN ULTRA 3/10CC 29G 97799509 ULTI SYG WITH ULTIGUARD 29G 1/2 97799551 ULTI SYG WITH ULTIGUARD 30G 1/2 97799506 ULTI SYG WITH ULTIGUARD 30G 5/16 97799548 ULTI SYG WITH ULTIGUARD 31G 5/16 00900506 ULTICARE 29G 00964018 ULTICARE 29G 00900503 ULTICARE 30G 00964174 ULTICARE 30G 97799513 ULTICARE 31G SYG 5/16 97799999 ULTICARE INSULIN SYR 29G.3CC 97799996 ULTICARE INSULIN SYR 30G.3CC 97799908 ULTIGUARD INSULIN SYR 29G.3CC 97799905 ULTIGUARD INSULIN SYR 30G.3CC 0.5cc Syringe and Needle 99328377 B-D INSULIN 50U 29G 99221044 B-D MICRO-FINE INSULIN 50U 00983004 INSULIN LO DOSE MICRO 28G 00909084 SYRN INSULIN U-II 30G 00906727 SYRN INSULIN ULTRA 29G 97799508 ULTI SYG WITH ULTIGUARD 29G 1/2 97799550 ULTI SYG WITH ULTIGUARD 30G 1/2 97799505 ULTI SYG WITH ULTIGUARD 30G 5/16 97799547 ULTI SYG WITH ULTIGUARD 31G 5/16 97799518 ULTICARE 28G SYG 1/2 00900505 ULTICARE 29G 00963941 ULTICARE 29G 00900502 ULTICARE 30G 00964115 ULTICARE 30G 97799512 ULTICARE 31G SYG 5/16 97799998 ULTICARE INSULIN SYR 29G.5CC 97799995 ULTICARE INSULIN SYR30G.5CC 97799510 ULTICARE LOW DEAD SPACE SYG 97799907 ULTIGUARD INSULIN SYR 29G.5CC 97799904 ULTIGUARD INSULIN SYR 30G.5CC 2010 BTD BTD BTD BTD BTD UMI UMI UMI UMI UMI UMI UMI UMI UMI UMI UMI UMI UMI

SYRINGE & NEEDLE
1cc Syringe and Needle 99262295 B-D INJECT-EASE WITH MICRO-FINE 99767467 B-D MICRO-FINE INSULIN 100U 00901911 B-D MICRO-FINE INSULIN 28G 00906816 SYRN INSULIN ULTRA 29G 97799507 ULTI SYG WITH ULTIGUARD 29G 1/2 97799549 ULTI SYG WITH ULTIGUARD 30G 1/2 97799504 ULTI SYG WITH ULTIGUARD 30G 5/16 97799546 ULTI SYG WITH ULTIGUARD 31G 5/16 97799517 ULTICARE 28G SYG 1/2 00900504 ULTICARE 29G 00963895 ULTICARE 29G 00900501 ULTICARE 30G 00964069 ULTICARE 30G 97799511 ULTICARE 31G SYG 5/16 97799997 ULTICARE INSULIN SYR 29G.1CC 97799994 ULTICARE INSULIN SYR 30G.1CC 97799906 ULTIGUARD INSULIN SYR 29G.1CC 97799903 ULTIGUARD INSULIN SYR 30G.1CC BTD BTD BTD BTD UMI UMI UMI UMI UMI UMI UMI UMI UMI UMI UMI UMI UMI UMI
SYRINGE CASE
BTD BTD BTD BTD BTD UMI UMI UMI UMI UMI UMI UMI UMI UMI UMI UMI UMI UMI UMI UMI Syringe Case 99400552 MYHEALTH SYRINGE CASE-7 99400551 MYHEALTH SYRINGE CASESINGLE AUC AUC
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96:00 PHARMACEUTICAL AIDS

96:00.00 PHARMACEUTICAL AIDS
LACTOSE
ST
100mg Tablet 00501190 PLACEBO
ODN
METHADONE HCL
Powder 00908835 METHADONE WIL
2010
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APPENDIX A LIMITED USE BENEFITS AND CRITERIA
Appendix A - Limited Use Benefits and Criteria
08:00 ANTI-INFECTIVE AGENTS

08:12.18 QUINOLONES
LEVOFLOXACIN
Limited use benefit (prior approval not required). Coverage will be limited to a maximum of 14 days.
250mg Tablet 02284707 02315424 02286920 02313979 02236841 02307200 02248262 02286947 02284677 02298635 500mg Tablet 02284715 02315432 02286939 02313987 02236842 02307219 02248263 02286955 02284685 02298643
APO-LEVOFLOXACIN CO-LEVOFLOXACIN DOM-LEVOFLOXACIN GEN-LEVOFLOXACIN LEVAQUIN LEVOFLOXACIN NOVO-LEVOFLOXACIN PHL-LEVOFLOXACIN PMS-LEVOFLOXACIN SANDOZ LEVOFLOXACIN APO-LEVOFLOXACIN CO-LEVOFLOXACIN DOM-LEVOFLOXACIN GEN-LEVOFLOXACIN LEVAQUIN LEVOFLOXACIN NOVO-LEVOFLOXACIN PHL-LEVOFLOXACIN PMS-LEVOFLOXACIN SANDOZ LEVOFLOXACIN
APX CBT DOM GEN JNO SOR NOP PMI PMS SDZ APX CBT DOM GEN JNO SOR NOP PMI PMS SDZ
MINOCYCLINE HCL
Limited use benefit (prior approval required). For: a. - patients who cannot tolerate other tetracyclines. b. - patients with severe widespread acne who have failed on tetracycline.
50mg Capsule 02084090 APO-MINOCYCLINE 02239667 DOM-MINOCYCLINE 02237875 MED-MINOCYCLINE 02173514 MINOCIN 02108143 NOVO-MINOCYCLINE 02153394 PDL-MINOCYCLINE 02239238 PMS-MINOCYCLINE 02294419 PMS-MINOCYCLINE 01914138 RATIO-MINOCYCLINE 02242080 RIVA-MINOCYCLINE 02237313 SANDOZ-MINOCYCLINE
APX DPC MEC STI NOP PDL PMS PMS RPH RIV SDZ
2010
Page A-1 de 32
MINOCYCLINE HCL
Limited use benefit (prior approval required). For: a. - patients who cannot tolerate other tetracyclines. b. - patients with severe widespread acne who have failed on tetracycline.
100mg Capsule 02084104 APO-MINOCYCLINE 02239668 DOM-MINOCYCLINE 02237876 MED-MINOCYCLINE 02173506 MINOCIN 02239982 MINOCYCLINE 02108151 NOVO-MINOCYCLINE 02154366 PDL-MINOCYCLINE 02294427 PMS-MINOCYCLINE 02239239 PMS-MONOCYCLINE 01914146 RATIO-MINOCYCLINE 02242081 RIVA-MINOCYCLINE 02237314 SANDOZ-MINOCYCLINE
APX DPC MEC STI IVX NOP PDL PMS PMS RPH RIV SDZ

LINEZOLID
Limited use benefit (prior approval required). Tablets: For treatment of proven vancomycin-resistant enterococci (VRE) infections when other antibiotics are not available, and for the treatment of proven MethicillinResistant Staphylococcus aureus (MRSA) infections in patients who cannot tolerate or who had an idiosyncratic reaction with Vancomycin. I.V. solution: When linezolid cannot be administered orally in the above mentioned situations.
2mg/mL Injection 02243685 ZYVOXAM 600mg Tablet 02243684 ZYVOXAM
PFI PFI
08:14.08 AZOLES
VORICONAZOLE
Limited use benefit (prior approval required). For the treatment of: a. - patients with invasive aspergillosis. b. - culture proven invasive candidiasis with documented resistance to fluconazole.
VFEND
PFI PFI
200mg Tablet 02256479 VFEND
DARUNAVIR
Limited use benefit (prior approval required). For the management of HIV in patients who failed or have experienced adverse events to three or more listed protease inhibitors.
300mg Tablet 02284057 PREZISTA 400mg Tablet 02324016 PREZISTA 600mg Tablet 02324024 PREZISTA
JNO JNO JNO
2010
Page A-2 de 32
EFAVIRENZ, EMTRICITABINE, TENOFOVIR DISOPROXIL FUMARATE
Limited use benefit (prior approval required). For the treatment of HIV-1 infection adults where the virus is susceptible to each of tenofovir, emtricitabine and efavirenz, and: a. - Atripla is used to replace existing therapy with its component drugs, or b. - the patient is treatment nave, or c. - the patient has established viral suppression but requires antiretroviral therapy modification due to intolerance or adverse effects. Note: Criteria will be confirmed against medication history.
600mg & 200mg & 300mg Tablet 02300699 ATRIPLA
BMS
EMTRICITABINE, TENOFOVIR DISOPROXIL FUMARATE

Limited use benefit (prior approval required). For the treatment of patients with HIV infection where the virus is susceptible to both emtricitabine and tenofovir AND where the triple-entity antiretroviral agent (tenofovir/ emtricitabine/efavirenz) is not indicated due to one of the following: a. - efavirenz resistance b. - adverse effects secondary to efavirenz
200mg/300mg Tablet 02274906 TRUVADA
GIL
ETRAVIRINE
Limited use benefit (prior approval required). For use in combination with other antiretroviral agents for treatment-experienced patients with HIV-1 infection who: a.- have failed prior antiretroviral therapy; and b. - have HIV-1 strains resistant to multiple antiretroviral agents, including NNRTIs
100mg Tablet 02306778 INTELENCE
JNO
MARAVIROC
Limited use benefit (prior approval required). For the treatment of HIV-1 infection, given in combination with other antiretroviral agents, in patients who have: a. - CR5 tropic viruses; and b. - documented resistance to at least one agent from each of the three major classes of antiretroviral agents (nucleoside reverse transcriptase inhibitors, nonnucleoside reverse transcriptase inhibitors, and protease inhibitors)
150mg Tablet 02299844 CELSENTRI 300mg Tablet 02299852 CELSENTRI
VII VII
RALTEGRAVIR
Limited use benefit (prior approval required). For the treatment of HIV infection in patients who are antiretroviral experienced and have virologic failure due to resistance to at least one agent from each of the three major classes of antiretroviral agents, nucleoside/tide reverse transcriptase inhibitors, non-nucleoside reverse transcriptase inhibitors and protease inhibitors.
400mg Tablet 02301881 ISENTRESS
FRS
TENOFOVIR DISOPROXIL FUMARATE

Limited use benefit (prior approval required). For the management of HIV disease in patients who have failed or have experienced adverse events to an alternative nucleoside reverse transcriptase inhibitor.
245mg Tablet 02247128 VIREAD
GIL
TIPRANAVIR
Limited use benefit (prior approval required). For the management of HIV disease in patients a. - who have failed all currently listed protease inhibitors b. - intolerant to all currently listed protease inhibitors
250mg Capsule 02273322 APTIVUS
BOE
2010
Page A-3 de 32
PEGINTERFERON ALFA-2A
Limited use benefit (prior approval required). For the treatment of chronic hepatitis C in patients who are treatment nave, upon the written request of a hepatologist or other specialist in this area. a. - For genotypes 1, 4, 5 and 6, an initial 24 week supply will be approved. A further 24 week supply may be approved if patient has a viral reduction of at least 2 logs or HCV is undetectable at 12 weeks (48 weeks total). b. - For genotypes 2 or 3, initial coverage for a maximum of 24 weeks will be approved. Renewals will not be covered
180mcg/0.5mL Injection 02248077 PEGASYS 180mcg/1mL Injection 02248078 PEGASYS
HLR HLR
PEGINTERFERON ALFA-2A, RIBAVIRIN

180mcg/0.5mL & 200mg Injection & Tablet 02253429 PEGASYS RBV 180mcg/1mL & 200mg Injection & Tablet 02253410 PEGASYS RBV
HLR HLR
PEGINTERFERON ALFA-2B
Limited use benefit (prior approval required). For the treatment of chronic hepatitis C in patients who are treatment nave, upon the written request of a hepatologist or other specialist in this area. a. - For genotypes 1, 4, 5 and 6, an initial 24 week supply will be approved. A further 24 week supply may be approved if patient has a viral reduction of at least 2 logs or HCV is undetectable at 12 weeks (48 weeks total). b. - For genotypes 2 or 3, initial coverage for a maximum of 24 weeks will be approved. Renewals will not be covered.
74mcg/Vial Injection 02242966 UNITRON PEG 118.4mcg/Vial Injection 02242967 UNITRON PEG 177.6mcg/Vial Injection 02242968 UNITRON PEG 222mcg/Vial Injection 02242969 UNITRON PEG
SCH SCH SCH SCH

50mcg/0.5mL & 200mg Injection & Capsule 02246026 PEGETRON 02254573 PEGETRON REDIPEN 80mcg/0.5mL & 200mg Injection & Capsule 02246027 PEGETRON 02254581 PEGETRON REDIPEN 100mcg/0.5mL & 200mg Injection & Capsule 02246028 PEGETRON 02254603 PEGETRON REDIPEN 2010
SCH SCH SCH SCH SCH SCH Page A-4 de 32
120mcg/0.5mL & 200mg Injection & Capsule 02246029 PEGETRON 02254638 PEGETRON REDIPEN 150mcg/0.5mL & 200mg Injection & Capsule 02246030 PEGETRON 02254646 PEGETRON REDIPEN
SCH SCH SCH SCH

ADEFOVIR DIPIVOXIL
Limited use benefit (prior approval required). For the treatment of chronic hepatitis B infection when used in combination with lamivudine in patients who have developed failure to lamivudine, as defined by an increase in HBV DNA of 1 log10 IU/mL above the nadir, measured on two separate occasions within an interval of at least one month, after the first three months of lamivudine therapy, and when failure to lamivudine is not due to poor adherence to therapy.
HEPSERA
GIL
ENTECAVIR
Limited use benefit (prior approval required). For the treatment of chronic hepatitis B infection in patients with cirrhosis documented on radiologic or histologic grounds and a HBV DNA concentration above 2000IU/mL.
0.5mg Tablet 02282224 BARACLUDE
BMS
10:00 ANTINEOPLASTIC AGENTS

ERLOTINIB HYDROCLORIDE
Limited use benefit (prior approval required). Treatment of non-small cell lung cancer (NSCLC) after failure of at least one prior chemotherapy regimen, and whose EGFR expression status is positive or unknown.
100mg Tablet 02269015 TARCEVA 150mg Tablet 02269023 TARCEVA
HLR HLR
IMATINIB MESYLATE
Limited use benefit (prior approval required). a.- For the treatment of patients with chronic myeloid leukemia in blast crisis, accelerated phase, or in chronic phase after failure of interferon-alpha therapy. b.- For the treatment of patients with gastrointestinal stromal tumour. c.- For newly diagnosed adult patients with Philadelphia chromosome-positive chronic myeloid leukemia (CML).
100mg Tablet 02253275 GLEEVEC 400mg Tablet 02253283 GLEEVEC
NVR NOV
2010
Page A-5 de 32

RITUXIMAB
Limited use benefit (prior approval required). Prescribed by a rheumatologist for treatment of adult patients with severely active rheumatoid arthritis who have failed to respond to a trial of an anti-TNF agent. Treatment should be combined with methotrexate. Rituximab should not be used in combination with anti-TNF agents. For continued coverage for rituximab beyond twenty-four weeks, patient must meet all the following criteria: a. - Initially prescribed by a rheumatologist b. - Patient has been assessed after the twentieth to twenty-fourth week of rituximab therapy and meets the response criteria of: c. - a >20% reduction in number of tender and swollen joints d. - a >20% improvement in physician global assessment scale. e. - either a >20% improvement in the patient global assessment scale or a >20% reduction in the acute phase as measured by ESR or CRP.
10mg/mL Injection 02241927 RITUXAN
HLR
SUNITINIB MALATE
Limited use benefit (Prior approval required). Criteria for initial six month coverage of Sutent: For patients with histologically proven unresectable or recurrent/metastatic GIST who have failed or are unable to tolerate imatinib therapy. Sunitinib will not be funded concomitantly with imatinib. Criteria for assessment at every six months: There is no objective evidence of disease progression.
12.5mg Capsule 02280795 SUTENT 25mg Capsule 02280809 SUTENT 50mg Capsule 02280817 SUTENT
PFI PFI PFI
TEMOZOLOMIDE
Limited use benefit (prior approval required). For: a. - treatment of adult patients with glioblastoma multiforme or anaplastic astrocytoma, and documented evidence of recurrence or progression after standard therapy (resection, radiotherapy, and chemotherapy). b. - treatment of adult patients with newly diagnosed glioblastoma multiforme concomitantly with radiotherapy and then as maintenance treatment.
5mg Capsule 02241093 TEMODAL 20mg Capsule 02241094 TEMODAL 100mg Capsule 02241095 TEMODAL 250mg Capsule 02241096 TEMODAL
SCH SCH SCH SCH
2010
Page A-6 de 32

DONEPEZIL HCL
Limited use benefit (prior approval required). Initial six month coverage for cholinesterase inhibitors: Diagnosis of mild to moderate Alzheimers disease; AND Mini Mental State Exam (MMSE) score of 10-26, established within the last 60 days; AND Global Deterioration Scale (GDS) score between 4 to 6, established within the last 60 days Continued coverage beyond 6 months will be based on improvement or stabilization of cognition, function or behaviour. Criteria for coverage at every six month interval: Diagnosis is still mild to moderate Alzheimers disease; AND MMSE score > 10; AND GDS score between 4 to 6; AND Improvement or stabilization in at least one of the following domains (please indicate improved, worsened, or no change) 1.Memory, reasoning and perception (e.g., names, tasks, MMSE) 2.Instrumental activities of daily living (IADLs: e.g., telephone, shopping, meal preparation) 3.Basic activities of daily living (e.g., bathing, dressing, hygiene, toileting) 4.Neuropsychiatric symptoms (e.g., agitation, delusions, hallucination, apathy)
ARICEPT ARICEPT
PFI PFI
GALANTAMINE
8mg Extended Release Capsule 02266717 REMINYL ER 16mg Extended Release Capsule 02266725 REMINYL ER 24mg Extended Release Capsule 02266733 REMINYL ER
JNO JNO JNO
2010
Page A-7 de 32

RIVASTIGMINE
1.5mg Capsule 02242115 EXELON 02332809 MYLAN-RIVASTIGMINE 02305984 NOVO-RIVASTIGMINE 02306034 PMS-RIVASTIGMINE 3mg Capsule 02242116 02332817 02305992 02306042 EXELON MYLAN-RIVASTIGMINE NOVO-RIVASTIGMINE PMS-RIVASTIGMINE
NOV MYL NOP PMS NOV MYL NOP PMS NOV MYL NOP PMS NOV MYL NOP PMS NOV
4.5mg Capsule 02242117 EXELON 02332825 MYLAN-RIVASTIGMINE 02306018 NOVO-RIVASTIGMINE 02306050 PMS-RIVASTIGMINE 6mg Capsule 02242118 02332833 02306026 02306069 EXELON MYLAN-RIVASTIGMINE NOVO-RIVASTIGMINE PMS-RIVASTIGMINE
2mg/mL Oral Liquid 02245240 EXELON

TIOTROPIUM BROMIDE MONOHYDRATE
Limited use benefit (prior approval required). For the treatment of moderate* to severe* chronic obstructive pulmonary disease (COPD), in patients who continue to be symptomatic after an adequate trial (3 months) of ipatropium, at a dose of 8-12 puffs daily. *Canadian Thoracic Society COPD Classification by Symptoms/Disability and Lung Function Moderate: shortness of breath from COPD causing the patient to stop after walking about 100 meters (after a few minutes) on level ground (MRC 3 to 4); 50% FEV1 < 80% predicted, FEV1/FVC <0.7 Severe: shortness of breath from COPD leaving the patient too breathless to leave the house or breathless after undressing (MRC 5), or in the presence of chronic respiratory failure or clinical signs of right heart failure; 30% FEV1 < 50% predicted, FEV1/FVC <0.7
18mcg Powder for Inhalation (Capsule) 02246793 SPIRIVA
BOE
2010
Page A-8 de 32

FORMOTEROL FUMARATE
Limited use benefit (prior approval required). For the treatment of asthma in patients who are using optimal corticosteroid therapy and experiencing breakthrough symptoms requiring regular use of a rapid onset, short duration bronchodilator. Oxeze is not intended for the relief of acute asthma symptoms: patients must have access to an inhaled fast-acting bronchodilator (beta-2 agonist) for symptomatic relief.
12mcg/Capsule Powder for Inhalation 02230898 FORADIL
NVR
FORMOTEROL FUMARATE DIHYDRATE

6mcg/Dose Dry Powder Inhaler 02237225 OXEZE TURBUHALER 12mcg/Dose Dry Powder Inhaler 02237224 OXEZE TURBUHALER AZC AZC
FORMOTEROL FUMARATE DIHYDRATE, BUDESONIDE

Limited use benefit (prior approval required). For the treatment of reversible obstructive airway disease in patients who are not adequately controlled on medium doses of inhaled corticosteroids ( e.g. fluticasone 250 - 500 mcg daily, or the equivalent) as the sole agent and require addition of a long- acting beta agonist. Patients using this combination product must also have access to a short-acting bronchodilator for symptomatic relief.
6mcg & 100mcg/Inhalation Inhaler 02245385 SYMBICORT 100 TURBUHALER 6mcg & 200mcg/Inhalation Inhaler 02245386 SYMBICORT 200 TURBUHALER
AZC AZC
SALMETEROL XINAFOATE
Limited use benefit (prior approval required). a. - For the treatment of asthma in patients who are using optimal corticosteroid therapy and experiencing breakthrough symptoms requiring regular use of a rapid onset, short duration bronchodilator. Serevent is not intended for the relief of acute asthma symptoms: patients must have access to an inhaled fast-acting bronchodilator (beta-2 agonist) for symptomatic relief. b. - For the treatment of Chronic Obstructive Pulmonary Disease (COPD) in patients not adequately controlled with ipratropium.
50mcg/inhalation Powder Diskus 02231129 SEREVENT DISKUS 50mcg/Inhalation Powder for Inhalation 02214261 SEREVENT DISKHALER
GSK GSK

Limited use benefit (prior approval required). For treatment of reversible obstructive airway disease in patients who are not adequately controlled on medium doses of inhaled corticosteroids (e.g., fluticasone 250-500mcg daily, or the equivalent) as a sole agent and require addition of a long-acting beta agonist. Patients using this combination product must also have access to a short-acting bronchodilator for symptomatic relief. For the treatment of moderate* to severe* chronic obstructive pulmonary disease (COPD), in patients who continue to be symptomatic after an adequate trial (2-4 months) of ipatropium, at a dose of 12 puffs daily. *Canadian Thoracic Society COPD Classification by Symptoms/Disability Moderate: shortness of breath from COPD causing the patient to stop after walking about 100 meters (after a few minutes) on the level Severe: shortness of breath from COPD leaving the patient too breathless to leave the house or breathless after undressing, or in the presence of chronic respiratory failure or clinical signs of right heart failure. By Symptom/Disability: Moderate: shortness of breath from COPD causing the patient to stop after walking approximately 100 meters (or after a few minutes) on the level. Severe: shortness of breath from COPD resulting in the patient being too breathless to leave the house or breathless after undressing, or the presence of chronic respiratory failure or clinical signs of right heart failure.
25mcg & 125mcg Inhaler 02245126 ADVAIR 25mcg & 250mcg Inhaler 02245127 ADVAIR 50mcg & 100mcg Inhaler 02240835 ADVAIR DISKUS 100 50mcg & 250mcg Inhaler 02240836 ADVAIR DISKUS 250 2010
GSK GSK GSK GSK Page A-9 de 32

Limited use benefit (prior approval required). For treatment of reversible obstructive airway disease in patients who are not adequately controlled on medium doses of inhaled corticosteroids (e.g., fluticasone 250-500mcg daily, or the equivalent) as a sole agent and require addition of a long-acting beta agonist. Patients using this combination product must also have access to a short-acting bronchodilator for symptomatic relief. For the treatment of moderate* to severe* chronic obstructive pulmonary disease (COPD), in patients who continue to be symptomatic after an adequate trial (2-4 months) of ipatropium, at a dose of 12 puffs daily. *Canadian Thoracic Society COPD Classification by Symptoms/Disability Moderate: shortness of breath from COPD causing the patient to stop after walking about 100 meters (after a few minutes) on the level Severe: shortness of breath from COPD leaving the patient too breathless to leave the house or breathless after undressing, or in the presence of chronic respiratory failure or clinical signs of right heart failure. By Symptom/Disability: Moderate: shortness of breath from COPD causing the patient to stop after walking approximately 100 meters (or after a few minutes) on the level. Severe: shortness of breath from COPD resulting in the patient being too breathless to leave the house or breathless after undressing, or the presence of chronic respiratory failure or clinical signs of right heart failure.
50mcg & 500mcg Inhaler 02240837 ADVAIR DISKUS 500
GSK

CYCLOBENZAPRINE HCL
Limited use benefit (prior approval is not required). For relief of muscle spasm associated with acute, painful musculoskeletal conditions. Coverage is limited to 60mg per day for three (3) weeks, renewable every two (2) months.
10mg Tablet 02177145 02220644 02238633 02231353 02080052 02171848 02249359 02212048 02236506 02242079
APO-CYCLOBENZAPRINE CYCLOBENZAPRINE DOM-CYCLOBENZAPRINE GEN-CYCLOPRINE NOVO-CYCLOPRINE NU-CYCLOBENZAPRINE PHL-CYCLOBENZAPRINE PMS-CYCLOBENZAPRINE RATIO-CYCLOBENZAPRINE RIVA-CYCLOBENZAPRINE
APX PDL DPC GEN NOP NXP PHH PMS RPH RIV
TIZANIDINE HCL
Limited use benefit (prior approval required). For treatment of spasticity in patients with multiple sclerosis, who have failed therapy with or are intolerant to baclofen.
4mg Tablet 02259893 02272059 02239170
APO-TIZANIDINE GEN-TIZANIDINE ZANAFLEX
APX GEN ELN

VARENICLINE
Limited use benefit with quantity and frequency limits (prior approval is not required). Coverage will be limited to 165 tablets during a one-year period. The year starts on the date the first prescription is filled. Once this quantity has been reached, the client is eligible again for coverage for varenicline (Champix) when one year has elapsed from the day the initial prescription was filled.
0.5mg Tablet 02291177 CHAMPIX 0.5mg & 1mg Tablet 02298309 CHAMPIX STARTER PACK 1mg Tablet 02291185 CHAMPIX
PFI PFI PFI
2010
Page A-10 de 32

CLOPIDOGREL BISULFATE
Limited use benefit (one-year duration, prior approval required). a. - Patients with intra-coronary stent implantation following insertion. b. - Patients with acute coronary syndrome (ACS) (unstable angina or non-ST-segment elevation MI), in combination with ASA.
PLAVIX
SAC

PEGFILGRASTIM
Limited use benefit (prior approval required). a. - To decrease the incidence of infection, as manifested by febrile neutropenia, in patients with non-myeloid malignancies receiving myelosuppressive antineoplastic drugs with curative intent. and b. - Where access to a health care facility is problematic.
10mg/mL Injection 02249790 NEULASTA
AMG
24:00 CARDIOVASCULAR DRUGS

24:06.05 CHOLESTEROL ABSORPTION INHIBITORS
EZETIMIBE
Limited use benefit (prior approval required). a.- For use in combination with a HMG-CoA reductase inhibitor (statin) in patients with hypercholesterolemia who have not reached target LDL levels despite the use of maximally tolerated statin doses. b.- For use as monotherapy in the management of hypercholesterolemia in patients intolerant to HMG-CoA reductase inhibitors.
EZETROL
MSP
24:12.92 MISCELLANEOUS VASODILATING AGENTS

DIPYRIDAMOLE, ACETYLSALICYLIC ACID
Limited use benefit (prior approval required). For secondary prevention of stroke or transient ischemic attacks (TIAs) in patients who have failed therapy with ASA alone.
200mg & 25mg Capsule 02242119 AGGRENOX
BOE

28:08.04 NONSTEROIDAL ANTI-INFLAMMATORY AGENTS
CELECOXIB
Limited use benefit (prior approval required). For patients with osteoarthritis who have failed therapy with acetaminophen and who: a. - have failed to achieve adequate response with 2 other listed NSAIDs, or b. - have experienced an adverse event attributable to 2 other listed NSAIDs, or c. - have a history of a serious gastrointestinal complication such as bleeding or perforation. For patients with rheumatoid arthritis who: a. - have failed to achieve adequate response with 2 other listed NSAIDs, or b. - have experienced an adverse event attributable to 2 other listed NSAIDs, or c. - have a history of a serious gastrointestinal complication such as bleeding or perforation.
100mg Capsule 02239941 CELEBREX 200mg Capsule 02239942 CELEBREX
PFI PFI
2010
Page A-11 de 32

CODEINE MONOHYDRATE, CODEINE SULFATE TRIHYDRATE
Limited use benefit (prior approval required). For treatment of: a. - chronic pain and palliative care patients as an alternative to products containing codeine in combination with acetaminophen or ASA with or without caffeine, or b. - chronic pain and palliative care patients as an alternative to regular release codeine tablets when large doses are required.
50mg Long Acting Tablet 02230302 CODEINE CONTIN CR 100mg Long Acting Tablet 02163748 CODEINE CONTIN CR 150mg Long Acting Tablet 02163780 CODEINE CONTIN CR 200mg Long Acting Tablet 02163799 CODEINE CONTIN CR
PFR PFR PFR PFR
FENTANYL
Limited use benefit (prior approval required). For the management of chronic pain in patients who are unresponsive or intolerant to at least one long-acting oral sustained released product, such as morphine, hydromorphone and oxycodone, despite appropriate dose titration and adjunctive therapy including laxatives and antiemetics.
12mcg/h Transdermal Patch 02341379 PMS-FENTANYL MTX 02330105 RAN-FENTANYL MATRIX PATCH 12 02311925 RATIO-FENTANYL 02327112 SANDOZ FENTANYL 25mcg/h Transdermal Patch 02275813 DURAGESIC MAT 02314630 NOVO-FENTANYL 02341387 PMS-FENTANYL MTX 02249391 RAN-FENTANYL 02330113 RAN-FENTANYL MATRIX 02282941 RATIO-FENTANYL 02327120 SANDOZ FENTANYL 50mcg/h Transdermal Patch 02275821 DURAGESIC MAT 02314649 NOVO-FENTANYL 02341395 PMS-FENTANYL MTX 02249413 RAN-FENTANYL 02330121 RAN-FENTANYL MATRIX 02282968 RATIO-FENTANYL 02327147 SANDOZ FENTANYL 75mcg/h Transdermal Patch 02275848 DURAGESIC MAT 02314657 NOVO-FENTANYL 02341409 PMS-FENTANYL MTX 02249421 RAN-FENTANYL 02330148 RAN-FENTANYL MATRIX 02282976 RATIO-FENTANYL 02327155 SANDOZ FENTANYL 100mcg/h Transdermal Patch 02275856 DURAGESIC MAT 02314665 NOVO-FENTANYL 02341417 PMS-FENTANYL MTX 02249448 RAN-FENTANYL 02330156 RAN-FENTANYL MATRIX 02282984 RATIO-FENTANYL 02327163 SANDOZ FENTANYL TRANSDERMAL SYSTEM
PMS RBY RPH SDZ JNO NOP PMS RBY RBY RPH SDZ JNO NOP PMS RBY RBY RPH SDZ JNO NOP PMS RBY RBY RPH SDZ JNO NOP PMS RBY RBY RPH SDZ
2010
Page A-12 de 32

HYDROMORPHONE HCL
Limited use benefit. Prior approval required for controlled release capsules only. Regular release dosage forms are full benefits and do not require prior approval. For treatment of moderate to severe chronic pain when other opioids such as morphine have been ineffective in controlling pain or in patients experiencing intolerable side effects.
3mg Controlled Release Capsule 02125323 HYDROMORPH CONTIN 6mg Controlled Release Capsule 02125331 HYDROMORPH CONTIN 12mg Controlled Release Capsule 02125366 HYDROMORPH CONTIN 18mg Controlled Release Capsule 02243562 HYDROMORPH CONTIN 24mg Controlled Release Capsule 02125382 HYDROMORPH CONTIN 30mg Controlled Release Capsule 02125390 HYDROMORPH CONTIN
PFR PFR PFR PFR PFR PFR
MEPERIDINE HCL
Limited use benefit (prior approval not required). Limited to 2 weeks supply for acute pain. Coverage will be limited to 60 tablets per one month period.
DEMEROL
SAC
OXYCODONE HCL
Limited use benefit. Prior approval required for controlled release tablets only. Regular release dosage forms are full benefits and do not require prior approval. For treatment of moderate to severe chronic pain when other opioids such as morphine have been ineffective in controlling pain or in patients experiencing intolerable side effects.
5mg Controlled Release Tablet 02258129 OXYCONTIN 10mg Controlled Release Tablet 02202441 OXYCONTIN 20mg Controlled Release Tablet 02202468 OXYCONTIN 40mg Controlled Release Tablet 02202476 OXYCONTIN 80mg Controlled Release Tablet 02202484 OXYCONTIN
PFR PFR PFR PFR PFR

LEVETIRACETAM
Limited use benefit (prior approval required). For the use in combination with other anti-epileptic medication(s) in the treatment of partial seizures in patients who are refractory to adequate trials of three antiepileptic medications used either as monotherapy or in combination. This product must be prescribed by a Neurologist.
250mg Tablet 02285924 02274183 02247027 02296101 500mg Tablet 02285932 02274191 02247028 02296128
APO-LEVETIRACETAM CO LEVETIRACETAM KEPPRA PMS-LEVETIRACETAM APO-LEVETIRACETAM CO LEVETIRACETAM KEPPRA PMS-LEVETIRACETAM
APX COB UCB PMS APX COB UCB PMS
2010
Page A-13 de 32

LEVETIRACETAM
Limited use benefit (prior approval required). For the use in combination with other anti-epileptic medication(s) in the treatment of partial seizures in patients who are refractory to adequate trials of three antiepileptic medications used either as monotherapy or in combination. This product must be prescribed by a Neurologist.
750mg Tablet 02285940 02274205 02247029 02296136
APO-LEVETIRACETAM CO LEVETIRACETAM KEPPRA PMS-LEVETIRACETAM
APX COB UCB PMS
BUPROPION HCL
100mg Sustained Release Tablet 02325373 RATIO-BUPROPION SR PMS
BUPROPION HCL (WELLBUTRIN)

Limited use benefit (prior approval required). For treatment of depression in patients unresponsive to or intolerant of other listed antidepressants. (Note: this product will not be approved for coverage for smoking cessation).
100mg Sustained Release Tablet 02285657 RATIO-BUPROPION 02275074 SANDOZ-BUPROPION SR 150mg Sustained Release Tablet 02313421 PMS-BUPROPION SR 02285665 RATIO-BUPROPION 02275082 SANDOZ-BUPROPION SR 02237825 WELLBUTRIN SR 02275090 WELLBUTRIN XL 300mg Sustained Release Tablet 02275104 WELLBUTRIN XL
RPH SDZ PMS RPH SDZ BPC BOV BOV
BUPROPION HCL (ZYBAN)

Limited use benefit with quantity and frequency limits (prior approval is not required). For smoking cessation: Coverage is limited to 180 tablets during a one-year period. The year starts on the date the first prescription is filled. Once this quantity has been reached, the client is eligible again for coverage for bupropion HCl when one year has elapsed from the day the initial prescription was filled.
150mg Sustained Release Tablet 02238441 ZYBAN SR
BPC
DULOXETINE HCL
Limited use benefit (prior approval required). For the treatment of neuropathic pain in patients with diabetes who have: a.- failed an adequate trial with TWO alternative agents (such as a tricyclic antidepressant or anticonvulsant) due to intolerance or lack of response or b.- a contraindication to alternative agents The dose of duloxetine will be limited to a maximum of 60 mg daily. Note that NIHB has adopted a Common Drug Review CEDAC recommendation that Cymbalta NOT be added to public drug plan formularies for the treatment of major depressive disorder.
30mg Sustained Release Capsule 02301482 CYMBALTA 60mg Sustained Release Capsule 02301490 CYMBALTA
LIL LIL
2010
Page A-14 de 32

40:20.00 CALORIC AGENTS
LEVOCARNITINE
Limited use benefit (prior approval required). For treatment of carnitine deficiency.
100mg/mL Oral Liquid 02144336 CARNITOR 200mg/mL Solution 02144344 CARNITOR IV 330mg Tablet 02144328 CARNITOR
SIG SIG SIG
48:00 RESPIRATORY TRACT AGENTS

48:10.24 LEUKOTRIENE MODIFIERS
MONTELUKAST
Limited use benefit (prior approval required). For treatment of: a. - asthma when used in patients on concurrent steroid therapy. b. - asthma patients not well controlled with or intolerant to inhaled corticosteroids.
4mg Chewable Tablet 02243602 SINGULAIR 5mg Chewable Tablet 02238216 SINGULAIR 4mg Granules 02247997 SINGULAIR 10mg Tablet 02238217 SINGULAIR
FRS FRS FRS FRS
ZAFIRLUKAST
Limited use benefit (prior approval required). For treatment of: a. - asthma when used in patients on concurrent steroid therapy. b. - asthma patients not well controlled with or intolerant to inhaled corticosteroids.
ACCOLATE
AZC
52:00 EYE, EAR, NOSE AND THROAT (EENT) PREPARATIONS

CIPROFLOXACIN HCL, DEXAMETHASONE
Limited use benefit (prior approval required). a.- for children 16 years old and under (prior approval not required) b.- for acute otitis media with otorrhea through tympanostomy tubes who require treatment c.- for acute otitis externa in the presence of tympanostomy tube or known perforation of the tympanic membrane
0.3%/0.1% Otic Solution 02252716 CIPRODEX
ALC
CIPROFLOXACIN HCL, HYDROCORTISONE

Limited use benefit (prior approval required). For treatment of acute diffuse bacterial external otitis. Criteria for coverage include: a. - failure to respond to other listed topical antibiotics, or b. - contraindications to other listed topical antibiotics.
2mg & 10mg/mL Otic Suspension 02240035 CIPRO HC
ALC
2010
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52:28.00 EENT - MOUTHWASHES AND GARGLES

BENZYDAMINE HCL
Limited use benefit (prior approval required). For: a. - treatment of radiation mucositis and oral ulcerative complications of chemotherapy. b. - use in immunocompromised patients who are at risk of mucosal breakdown.
0.15% Rinse 02239044 02239537 02229799 02229777 02230170
APO-BENZYDAMINE DOM-BENZYDAMINE NOVO-BENZYDAMINE PMS-BENZYDAMINE RATIO-BENZYDAMINE
APX DPC NOP PMS RPH NOP
1.5mg/mL Rinse 02310422 NOVO-BENZYDAMINE

BRIMONIDINE TARTRATE (ALPHAGAN P)
Limited use benefit (prior approval required). For patients who are intolerant to brimonidine tartrate 0.2% or benzalkonium chloride.
0.15% Ophth Solution 02248151 ALPHAGAN P 02301334 APO-BRIMONIDINE P
ALL APX

VERTEPORFIN
Limited use benefit (prior approval required). For treatment of age related macular degeneration for patients with this diagnosis who are being treated by a certified ophthalmologist.
15mg/Vial Injection 02242367 VISUDYNE
QLT

BISACODYL (POLYETHYLENE GLYCOL BASE)
Limited use benefit (prior approval required). For treatment of constipation in patients with spinal cord injury.
10mg Suppository 02241091 MAGIC BULLET
DCM

APREPITANT
Limited use benefit (prior approval required). When used in combination with a 5-HT3 antagonist and dexamethasone for the prevention of acute and delayed nausea and vomiting due to highly emetogenic cancer chemotherapy (eg. Cisplatin > 70mg/m2) in patients who have experienced emesis despite treatment with a combination of a 5-HT3 antagonist and dexamethasone in a previous cycle of highly emetogenic chemotherapy.
80mg Capsule 02298791 EMEND 125mg Capsule 02298805 EMEND 125mg & 80mg Capsule 02298813 EMEND TRI PACK
FRS FRS FRS
2010
Page A-16 de 32

LANSOPRAZOLE
The following PPI status change is primarily based on the Canadian Optimal Medication Prescribing and Utilization Service (COMPUS) report on optimal PPI therapy. The report concluded that; All PPIs are equally efficacious Double dose PPI is not necessary for initial therapy Double dose PPI is effective in H. Pylori eradication; however, treatment is not needed beyond 14 days. PPI use has been associated with increased risk of hip fracture, community-acquired pneumonia and Clostridium difficile associated diarrhea. Although further study is needed to establish clinical significance, it is prudent to use the lowest dose and shortest duration of therapy required to control symptoms. Effective July 5, 2010, all proton pump inhibitors (open benefit and limited use (LU) PPIs) will have a maximum quantity limit of 400 tablets/capsules per 180 day period. This quantity limit will be in effect for the entire class of PPIs. For example, if a patient fills 30 tablets of rabeprazole, then switch to 30 tablets of omeprazole, then switch to 30 capsules of lansoprazole, this will count as 90 PPI tablets/capsules towards the quantity limit. Patients taking two rabeprazole 10mg tablets a day can be switched to one rabeprazole 20mg tablet a day to avoid reaching the quantity limit Patients taking two omeprazole 10mg tablets/capsules a day can be switched to one omeprazole 20mg tablet/capsule a day to avoid reaching the quantity limit Patients with Zollinger Ellison Syndrome, Barretts esophagus, erosive esophagitis and those who remain symptomatic on a single dose PPI will be eligible for additional doses above 400 tablets/capsules per 180 days through the prior approval process. Limited use benefit (prior approval not required). Coverage will be limited to 400 tablets/capsules every 180 days.
15mg Sustained Release Capsule 02293811 APO-LANSOPRAZOLE 02280515 NOVO-LANSOPRAZOLE 02165503 PREVACID 30mg Sustained Release Capsule 02293838 APO-LANSOPRAZOLE 02280523 NOVO-LANSOPRAZOLE 02165511 PREVACID
APX NOP ABB APX NOP ABB
LANSOPRAZOLE ODT
15MG Orally Disintegrating Tablet 02249464 PREVACID FASTAB 30MG Orally Disintegrating Tablet 02249472 PREVACID FASTAB
TAK TAK
2010
Page A-17 de 32

OMEPRAZOLE MAGNESIUM (PA)
10mg Delayed Release Tablet 02230737 LOSEC 02260859 RATIO-OMEPRAZOLE
AZC RPH
OMEPRAZOLE, OMEPRAZOLE MAGNESIUM (NO PA)

10mg Capsule 02119579 LOSEC 02329425 MYLAN-OMEPRAZOLE 02296438 SANDOZ OMEPRAZOLE 20mg Capsule 02245058 APO-OMEPRAZOLE 00846503 LOSEC 02329433 MYLAN-OMEPRAZOLE 02320851 PMS-OMEPRAZOLE 02296446 SANDOZ OMEPRAZOLE 20mg Delayed Release Tablet 02190915 LOSEC 02310260 PMS-OMEPRAZOLE 02260867 RATIO-OMEPRAZOLE
AZC GEN SDZ APX AZC GEN PMS SDZ AZC PMS RPH
2010
Page A-18 de 32

PANTOPRAZOLE MAGNESIUM
40mg Enteric Coated Tablet 02267233 TECTA
NCC
PANTOPRAZOLE SODIUM
40mg Enteric Coated Tablet 02292920 APO-PANTOPRAZOLE 02300486 CO PANTOPRAZOLE 02299585 GEN-PANTOPRAZOLE 02285487 NOVO-PANTOPRAZOLE 02229453 PANTOLOC 02318695 PANTOPRAZOLE 02309866 PHL-PANTOPRAZOLE 02307871 PMS-PANTOPRAZOLE 02305046 RAN-PANTOPRAZOLE 02308703 RATIO-PANTOPRAZOLE 02310201 RIVA-PANTOPRAZOLE 02316463 RIVA-PANTOPRAZOLE 02301083 SANDOZ-PANTOPRAZOLE
APX COB GEN NOP NYC PDL PMI PMS RBY RPH ZYM RIV SDZ
2010
Page A-19 de 32

RABEPRAZOLE SODIUM
10mg Enteric Coated Tablet 02296632 NOVO-RABEPRAZOLE 02243796 PARIET EC 02310805 PMS-RABEPRAZOLE 02315181 PRO-RABEPRAZOLE 02298074 RAN-RABEPRAZOLE 02314177 SANDOZ-RABEPRAZOLE 20mg Enteric Coated Tablet 02296640 NOVO-RABEPRAZOLE 02243797 PARIET EC 02310813 PMS-RABEPRAZOLE 02315203 PRO-RABEPRAZOLE 02298082 RAN-RABEPRAZOLE 02330091 RIVA-RABEPRAZOLE 02314185 SANDOZ-RABEPRAZOLE
NOP JNO PMS PDL RBY SDZ NOP JNO PMS PDL RBY RIV SDZ
68:00 HORMONES AND SYNTHETIC SUBSTITUTES

ETHINYL ESTRADIOL, ETONOGESTREL
Limited use benefit (prior approval required). For patients who are intolerant to or unable to take oral contraceptives.
11.4mg & 2.6mg Device 02253186 NUVARING
ORG
68:16.12 ESTROGEN AGONISTS-ANTAGONISTS

RALOXIFENE HCL
Limited use benefit (prior approval required). For: a.- secondary prevention of osteoporosis in women who experience failure on bisphosphonates. b. - secondary prevention of osteoporosis in women who have a personal history or a first degree relative with a history of breast cancer.
60mg Tablet 02279215 02239028 02312298
APO-RALOXIFENE EVISTA NOVO-RALOXIFENE
APX LIL NOP
2010
Page A-20 de 32
PIOGLITAZONE HCL
15mg Tablet 02303442 02242572 02302942 02302861 02307634 02298279 02326477 02274914 02307669 02303124 02312050 02301423 02297906 02320754 30mg Tablet 02303450 02242573 02302950 02302888 02307642 02298287 02326485 02274922 02307677 02303132 02312069 02301431 02297914 02320762 45mg Tablet 02303469 02242574 02302977 02302896 02307650 02298295 02326493 02274930 02307723 02303140 02312077 02301458 02297922 02320770
ACCEL PIOGLITAZONE ACTOS APO-PIOGLITAZONE CO PIOGLITAZONE DOM-PIOGLITAZONE GEN-PIOGLITAZONE MINT-PIOGLITAZONE NOVO-PIOGLITAZONE PHL-PIOGLITAZONE PMS-PIOGLITAZONE PRO-PIOGLITAZONE RATIO-PIOGLITAZONE SANDOZ PIOGLITAZONE ZYM-PIOGLITAZONE ACCEL PIOGLITAZONE ACTOS APO-PIOGLITAZONE CO PIOGLITAZONE DOM-PIOGLITAZONE GEN-PIOGLITAZONE MINT-PIOGLITAZONE NOVO-PIOGLITAZONE PHL-PIOGLITAZONE PMS-PIOGLITAZONE PRO-PIOGLITAZONE RATIO-PIOGLITAZONE SANDOZ PIOGLITAZONE ZYM-PIOGLITAZONE ACCEL PIOGLITAZONE ACTOS APO-PIOGLITAZONE CO PIOGLITAZONE DOM-PIOGLITAZONE GEN-PIOGLITAZONE MINT-PIOGLITAZONE NOVO-PIOGLITAZONE PHL-PIOGLITAZONE PMS-PIOGLITAZONE PRO-PIOGLITAZONE RATIO-PIOGLITAZONE SANDOZ PIOGLITAZONE ZYM-PIOGLITAZONE
ACP LIL APX COB DOM GEN MIN NOP PMI PMS PDL RPH SDZ ZYM ACP LIL APX COB DOM GEN MIN NOP PMI PMS PDL RPH SDZ ZYM ACP LIL APX COB DOM GEN MIN NOP PMI PMS PDL RPH SDZ ZYM
2mg Tablet 02241112 2010
AVANDIA
GSK
Page A-21 de 32
AVANDIA AVANDIA
GSK GSK
68:24.00 PARATHYROID
CALCITONIN SALMON (MIACALCIN)
Limited use benefit (prior approval required). For treatment of patients with postmenopausal osteoporosis who have failed therapy, are intolerant to, or who have contraindications to both bisphosphonates and raloxifene.
200IU/Dose Nasal Spray 02247585 APO-CALCITONIN 02240775 MIACALCIN 02261766 SANDOZ-CALCITONIN
APX NVR SDZ
84:00 SKIN AND MUCOUS MEMBRANE AGENTS (SMMA)

PIMECROLIMUS
Limited use benefit (prior approval required). For patients who have failed topical corticosteroid therapy or have experienced side effects from such treatment. Note: Contraindicated in children less than 2 years of age.
1% Cream 02247238
ELIDEL
NVC
TACROLIMUS (PROTOPIC)
Limited use benefit (prior approval required). For patients who have failed topical corticosteroid therapy or have experienced side effects from such treatment. Note: Contraindicated in children less than 2 years of age.
0.03% Ointment 02244149 PROTOPIC 0.1% Ointment 02244148 PROTOPIC
AST AST
86:00 SMOOTH MUSCLE RELAXANTS

DARIFENACIN HYDROBROMIDE
7.5mg Long Acting Tablet 02273217 ENABLEX 15mg Long Acting Tablet 02273225 ENABLEX NOV NOV
SOLIFENACIN SUCCINATE
Limited use benefit (prior approval required). For symptomatic relief in patients with an overactive bladder with symptoms of urinary frequency, urgency or urge incontinence in patients who have failed on or are intolerant of therapy with oxybutynin.
5mg Tablet 02277263 10mg Tablet 02277271 2010
VESICARE VESICARE
AST AST Page A-22 de 32

TOLTERODINE
2mg Extended Release Capsule 02244612 DETROL LA 4mg Extended Release Capsule 02244613 DETROL LA 1mg Tablet 02239064 2mg Tablet 02239065 DETROL DETROL
PFI PFI PFI PFI
TROSPIUM CHLORIDE
TROSEC
ORY
88:00 VITAMINS
Chewable Tablet 00336300 MULTI-VITAMINS CHILD Drop 00558060 00762946 Liquid 00558079 Tablet 80011134 02247975 INFANTOL POLY-VI-SOL INFANTOL CENTRUM JUNIOR COMPLETE FLINTSTONES EXTRA C
NOP HOR MJO HOR WYE BCD
MULTIVITAMINS (PRENATAL)
Limited use benefit (prior approval is not required.). Prenatal and postnatal vitamins are benefits only for women of childbearing age (12 to 50 years).
Tablet 80001842 02229535 00815241 80005770 02240840 02241235 02244374
CENTRUM MATERNA MULTI-PRE AND POST NATAL NEO-TINIC PRENATAL & POSTPARTUM PRENATAL AND POSTPARTUM PRENATAL AND POSTPARTUM PRENATAL VITAMINS AND MINERALS
WAY PED NEO PMT VTH SDR PMT
VITAMIN A, CHOLECALCIFEROL, ASCORBIC ACID

Oral Liquid 80008471
JAMP-MULTIVITAMIN A/D/C DROPS
JMP
2010
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92:00 UNCLASSIFIED THERAPEUTIC AGENTS

ABATACEPT
Limited use benefit (prior approval required). For the treatment of severely active RHEUMATOID ARTHRITIS in adult patients who have failed to respond to another biologic agent (infliximab, etanercept, OR adalimumab). Treatment should be combined with DMARDs. Criteria will be confirmed against patients medication history. Note: Initial one-year coverage for rheumatoid arthritis is provided at a dose of 500 mg for patients weighing < 60 kg; 750 mg for patients weighing 60 to 100 kg; and 1000 mg for patients weighing > 100 kg. Doses are given at 0, 2 and 4 weeks, then every 4 weeks. Coverage beyond one year will be based on improvement in number of swollen joints, number of tender joints, ESR or CRP, duration of morning stiffness, Physician Global Assessment scale and Patient Global Assessment scale. For the treatment of JUVENILE IDIOPATHIC ARTHRITIS in children 6 to 17 years with moderate to severe active polyarticular JUVENILE IODIOPATHIC ARTHRITIS who have failed to respond to a trial of etanercept. Criteria will be confirmed against patients medication history. Note: Initial 16-week coverage for juvenile idiopathic arthritis is provided at a dose of 10 mg/kg for children weighing < 75 kg; 750 mg for children weighing 75 to 100 kg; and 1000 mg for patients weighing > 100 kg. Doses are given at 0, 2, and 4 weeks, then every 4 weeks. Coverage beyond 16 weeks will be based on improvement in number of active joints, number of joints with loss of range of motion, ESR, Physician Global Assessment scale, Patient or Parent Global Assessment scale and Child Health Assessment Questionnaire.
250mg/Vial Injection 02282097 ORENCIA
BMS
2010
Page A-24 de 32

ADALIMUMAB
Limited use benefit (prior approval required). Criteria for initial one year coverage for a MAXIMUM dose of 40mg every 2 weeks: 1. Prescribed by a rheumatologist, AND 2. Patient has had a tuberculin skin test performed 3. For the treatment of severely active RHEUMATOID ARTHRITIS: Patient is refractory to methotrexate weekly parenteral (SC or IM) at 20mg or greater (15mg or greater if patient is >65 years of age) for more than 8 weeks PLUS a minimum of two of the following: leflunomide: 20mg daily for 10 weeks OR gold: weekly injections for 20 weeks OR cyclosporine: 2-5 mg/kg/day for 12 weeks OR azathioprine: 2-3 mg/kg/day for 3 months OR sulfasalazine at least 2g daily for 3 months PLUS one of the following combinations: methotrexate with cyclosporine (minimum 4 month trial on both) OR methotrexate with hydroxychloroquine and sulfasalazine (minimum 4 month trial on triple therapy) OR methotrexate with gold (minimum 12 week trial) OR in patients who are intolerant or who have contraindication to methotrexate therapy, or are refractory to a combination of at least 2 DMARDS 4. For the treatment of moderate to severe PSORIATIC ARTHRITIS with at least two of the following: five or more swollen joints if less than five swollen joints, at least one joint proximal to, or including wrist or ankle more than one joint with erosion on imaging study dactylitis of two or more digits tenosynovitis refractory to oral NSAIDs and steroid injections enthesitis refractory to oral NSAIDs and steroid injections (not required for Achilles tendon) inflammatory spinal symptoms refractory to two NSAIDs (minimum four weeks trial each) and has a BASDAI greater than 4 daily use of corticosteroids use of opioids > 12 hours per day for pain resulting from inflammation Patient is refractory to: NSAIDs and methotrexate weekly parenteral (SC or IM) at 20mg or greater (15mg or greater if patient is >65 years of age) for more than 8 weeks PLUS a minimum of one of the following: leflunomide: 20mg daily for 10 weeks OR gold: weekly injections for 20 weeks OR cyclosporine: 2-5 mg/kg/day for 12 weeks OR sulfasalazine at least 2g daily for 3 months 5. For the treatment of ANKYLOSING SPONDYLITIS when the following criteria are met: BASDAI > 4 AND patient is refractory to a three month trial of at least 3 NSAIDs at maximum tolerated dose AND for peripheral joint involvement, patient is refractory to weekly parenteral (SC or IM) at 20mg or greater (15mg or greater if patient is >65 years of age) for more than 8 weeks AND sulfasalazine 2g/day for four months. NOTE: For axial involvement, patient does not need to be tried on methotrexate or sulfasalazine. 6. For the treatment of patients with moderate to severe PSORIASIS who meet all of the following criteria: Body surface area involvement greater than 10% and/or significant involvement of the face, hands, feet or genital region AND Intolerance or lack of response to methotrexate AND cyclosporine OR A contraindication to methotrexate and/or cyclosporine AND Intolerance or lack of response to phototherapy OR Inability to access phototherapy Coverage beyond 16 weeks will be based on a significant reduction in the Body Surface Area (BSA) involved and improvements in the Psoriasis Area Severity Index (PASI) score and the Dermatology Life Quality Index (DLQI). 7. For the treatment of moderately to severely active CROHN'S DISEASE. Initial treatment will allow for an induction dose of adalimumab 160mg followed by 80mg 2 weeks later. Maintenance therapy will only be provided at a dose not exceeding 40mg every two weeks. Criteria for initial four week coverage for the treatment of moderate to severely active Crohn's disease: Patient is an adult with moderate to severely active Crohn's disease refractory to: therapy with 5-ASA products (at least 3g/day for a minimum of 6 weeks); PLUS glucorticoids equivalent to prednisone 40mg/day for a minimum of 2 weeks; OR treatment discontinued due to serious adverse reactions; OR contraindication to glucorticoid therapy;
40mg/0.8mL Injection 09857327 HUMIRA PEN 97799757 HUMIRA PEN 09857326 HUMIRA PRE-FILL 97799756 HUMIRA PRE-FILL 40mg/Vial Injection 02258595 HUMIRA
ABB ABB ABB ABB ABB
2010
Page A-25 de 32

ALENDRONATE SODIUM
5mg Tablet 02248727 02233055 02270110 02248251 02288079 10mg Tablet 02248728 02201011 02270129 02247373 02288087 40mg Tablet 02258102 02201038 70mg Tablet 02303078 02248730 02258110 02245329 02286335 02261715 02299712 02273179 02284006 02275279 02270889 02288109 02302004
APO-ALENDRONATE FOSAMAX GEN-ALENDRONATE NOVO-ALENDRONATE SANDOZ ALENDRONATE APO-ALENDRONATE FOSAMAX GEN-ALENDRONATE NOVO-ALENDRONATE SANDOZ ALENDRONATE CO ALENDRONATE FOSAMAX ALENDRONATE-70 APO-ALENDRONATE CO ALENDRONATE FOSAMAX GEN-ALENDRONATE NOVO-ALENDRONATE PHL-ALENDRONATE PMS-ALENDRONATE PMS-ALENDRONATE FC RATIO-ALENDRONATE RIVA-ALENDRONATE SANDOZ ALENDRONATE ZYM-ALENDRONATE
APX FRS GEN NOP SDZ APX FRS GEN NOP SDZ COB FRS PDL APX COB FRS GEN NOP PMI PMS PMS RPH RIV SDZ ZYM
ALENDRONATE SODIUM, VITAMIN D3

70mg/2800U Tablet 02276429 FOSAVANCE 70mg/5600U Tablet 02314940 FOSAVANCE
FRS MSP
2010
Page A-26 de 32

BOTULINUM TOXIN TYPE A
Limited use benefit (prior approval required). For the treatment of: a. - strabismus and blepharospasm associated with dystonia, including benign essential blepharospasm or VII nerve disorder in patients 12 years of age or older b. - cervical dystonia (spasmodic torticollis)
100IU Injection 01981501 BOTOX
ALL
CABERGOLINE
Limited use benefit (prior approval required). For treatment of hyperprolactinemia in patients who have failed therapy with or are intolerant to bromocriptine.
0.5mg Tablet 02301407 CO CABERGOLINE 02242471 DOSTINEX
COB PFI
CLOSTRIDIUM BOTULINUM NEUROTOXIN

Limited use benefit (prior approval required). For: a. - the treatment of strabismus and blepharospasm associated with dystonia, including benign essential blepharospasm or VII nerve disorder in patients 12 years of age or older or b. - the treatment of cervical dystonia (spasmodic torticollis)
100U/vial Injection 02324032 XEOMIN
MEZ
CYCLOSPORINE
10mg Capsule 02237671 NEORAL 25mg Capsule 02150689 NEORAL 02247073 SANDOZ-CYCLOSPORINE 50mg Capsule 02150662 NEORAL 02247074 SANDOZ-CYCLOSPORINE 100mg Capsule 02150670 NEORAL 02242821 SANDOZ-CYCLOSPORINE 100mg/mL Solution 02150697 NEORAL
NVR NVR SDZ NVR SDZ NVR SDZ NVR
DUTASTERIDE
Limited use benefit (prior approval required). a. - For treatment of Benign Prostatic Hyperplasia (BPH) in patients who do not tolerate or have not responded to an adrenergic blocker. or b. - For use in combination therapy when monotherapy with an alpha-blocker is not sufficient.
0.5mg Capsule 02247813 AVODART
GSK
2010
Page A-27 de 32

ETANERCEPT
Limited use benefit (prior approval required). Criteria for initial one year coverage for a MAXIMUM dose of 50mg weekly: 1. Prescribed by a rheumatologist, AND 2. Patient has had a tuberculin skin test performed 3. For the treatment of severely active RHEUMATOID ARTHRITIS: Patient is refractory to methotrexate weekly parenteral (SC or IM) at 20mg or greater (15mg or greater if patient is >65 years of age) for more than 8 weeks PLUS a minimum of two of the following: leflunomide: 20mg daily for 10 weeks OR gold: weekly injections for 20 weeks OR cyclosporine: 2-5 mg/kg/day for 12 weeks OR azathioprine: 2-3 mg/kg/day for 3 months OR sulfasalazine at least 2g daily for 3 months PLUS one of the following combinations: methotrexate with cyclosporine (minimum 4 month trial on both) OR methotrexate with hydroxychloroquine and sulfasalazine (minimum 4 month trial on triple therapy) OR methotrexate with gold (minimum 12 week trial) OR in patients who are intolerant or who have contraindication to methotrexate therapy, or are refractory to a combination of at least 2 DMARDS 4. For the treatment of moderate to severe PSORIATIC ARTHRITIS with at least two of the following: five or more swollen joints if less than five swollen joints, at least one joint proximal to, or including wrist or ankle more than one joint with erosion on imaging study dactylitis of two or more digits tenosynovitis refractory to oral NSAIDs and steroid injections enthesitis refractory to oral NSAIDs and steroid injections (not required for Achilles tendon) inflammatory spinal symptoms refractory to two NSAIDs (minimum four weeks trial each) and has a BASDAI greater than 4 daily use of corticosteroids use of opioids > 12 hours per day for pain resulting from inflammation Patient is refractory to: NSAIDs and methotrexate weekly parenteral (SC or IM) at 20mg or greater (15mg or greater if patient is >65 years of age) for more than 8 weeks PLUS a minimum of one of the following: leflunomide: 20mg daily for 10 weeks OR gold: weekly injections for 20 weeks OR cyclosporine: 2-5 mg/kg/day for 12 weeks OR sulfasalazine at least 2g daily for 3 months 5. For the treatment of ANKYLOSING SPONDYLITIS when the following criteria are met: BASDAI > 4 AND patient is refractory to a three month trial of at least 3 NSAIDs at maximum tolerated dose AND for peripheral joint involvement, patient is refractory to weekly parenteral (SC or IM) at 20mg or greater (15mg or greater if patient is >65 years of age) for more than 8 weeks AND sulfasalazine 2g/day for four months. NOTE: For axial involvement, patient does not need to be tried on methotrexate or sulfasalazine. 6. For the treatment of severely active polyarticular JUVENILE IDIOPATHIC ARTHRITIS in children 4 to 17 years where the following criteria are met: 5 swollen joints; AND 3 joints with limited range of motion and/or pain/tenderness; AND Condition is refractory to an adequate trial of a therapeutic dose of methotrexate. An adequate trial is defined as at least 3 months of parenteral methotrexate at 10mg/m2 weekly (unless significant toxicity limits the dose tolerated)
25mg/Vial Injection 02242903 ENBREL 50mg/mL Injection 02274728 ENBREL 99100373 ENBREL SURECLICK
IMX IMX AMG
FINASTERIDE
Limited use benefit (prior approval required). a. - For treatment of Benign Prostatic Hyperplasia (BPH) in patients who do not tolerate or have not responded to an alpha-adrenergic blocker. or b. - For use in combination therapy when monotherapy with an alpha-blocker is not sufficient.
5mg Tablet 02348500 02310112 02010909 02306905 02322579
NOVO-FINASTERIDE PMS-FINASTERIDE PROSCAR RATIO-FINASTERIDE SANDOZ FINASTERIDE
NOP PMS FRS RPH SDZ
2010
Page A-28 de 32

GOLIMUMAB
Limited use benefit (prior approval required). Criteria for initial one year coverage for a MAXIMUM dose of 50 mg every month for RHEUMATOID ARTHRITIS, PSORIATIC ARTHRITIS, ANKYLOSING SPONDYLITIS: 1. Prescribed by a rheumatologist, AND 2. Patient has had a tuberculin skin test performed AND 3. For the treatment of severely active RHEUMATOID ARTHRITIS: - Patient is refractory to methotrexate weekly parenteral (SC or IM) at 20 mg or greater (15mg or greater if patient is >65 years of age) for more than 8 weeks PLUS a minimum of two of the following: - leflunomide: 20mg daily for 10 weeks OR - gold: weekly injections for 20 weeks OR - cyclosporine: 2-5 mg/kg/day for 12 weeks OR - azathioprine: 2-3 mg/kg/day for 3 months OR - sulfasalazine at least 2g daily for 3 months PLUS one of the following combinations: - methotrexate with cyclosporine (minimum 4 month trial on both) OR - methotrexate with hydroxychloroquine and sulfasalazine (minimum 4 month trial on triple therapy) OR - methotrexate with gold (minimum 12 week trial) OR - in patients who are intolerant or who have contraindication to methotrexate therapy, or are refractory to a combination of at least 2 DMARDS OR 4. For the treatment of moderate to severe PSORIATIC ARTHRITIS with at least two of the following: - five or more swollen joints - if less than five swollen joints, at least one joint proximal to, or including wrist or ankle - more than one joint with erosion on imaging study - dactylitis of two or more digits - tenosynovitis refractory to oral NSAIDs and steroid injections - enthesitis refractory to oral NSAIDs and steroid injections (not required for Achilles tendon) - inflammatory spinal symptoms refractory to two NSAIDs (minimum four weeks trial each) and has a BASDAI greater than 4 - daily use of corticosteroids - use of opioids > 12 hours per day for pain resulting from inflammation Patient is refractory to: - NSAIDs and - methotrexate weekly parenteral (SC or IM) at 20mg or greater (15mg or greater if patient is >65 years of age) for more than 8 weeks PLUS a minimum of one of the following: - leflunomide: 20mg daily for 10 weeks OR - gold: weekly injections for 20 weeks OR - cyclosporine: 2-5 mg/kg/day for 12 weeks OR - sulfasalazine at least 2g daily for 3 months OR 5. For the treatment of ANKYLOSING SPONDYLITIS when the following criteria are met: - BASDAI > 4 AND - patient is refractory to a three month trial of at least 3 NSAIDs at maximum tolerated dose AND for peripheral joint involvement, patient is refractory to weekly parenteral (SC or IM) at 20mg or greater (15mg or greater if patient is >65 years of age) for more than 8 weeks AND sulfasalazine 2g/day for four months. NOTE: For axial involvement, patient does not need to be tried on methotrexate or sulfasalazine.
50mg/0.5mL Injection 02324784 SIMPONI AUTO INJECTOR 02324776 SIMPONI PRE-FILLED SYRINGE
CER CER
2010
Page A-29 de 32

INFLIXIMAB
CRITERIA FOR INITIAL TWELVE WEEKS OF COVERAGE FOR INFLIXIMAB FOR RHEUMATOID ARTHRITIS Prescribed by a rheumatologist Infliximab for use in combination with methotrexate for the treatment of severely active rheumatoid arthritis Note: Initial coverage is provided for 3 doses of 3mg/kg of infliximab ONLY. Patient is refractory to: Methotrexate: oral therapy at 20mg or greater total weekly dosage (15mg or greater if patient is <65 years of age) for more than 8 weeks. AND Methotrexate: weekly parenteral (SC or IM) at 20mg or greater (15mg or greater if patient is >65 years of age) for more than 8 weeks. PLUS Leflunomide: 20mg daily for 10 weeks PLUS Gold: weekly injections for 20 weeks OR Sulfaslazine: at least 2 gm daily for 3 months OR Azathioprine: 2-3mg/kg/day for 3 months PLUS One of the following combinations: Methotrexate with cyclosporine (minimum 4 month trial on both) OR Methotrexate with hydroxychloroquine and sulfasalazine (minimum 4 month trial on triple therapy) OR Methotrexate with gold (minimum 12 week trial) OR Methotrexate with leflunomide (minimum 8 week trial) OR In patients who are intolerant or who have contraindications to methotrexate therapy, refractory to a combination of a least 2 DMARDs. PLUS Etanercept or Adalimumab: minimum of 12 week trial CRITERIA FOR CONTINUED COVERAGE FOR INFLIXIMAB BEYOND TWELVE WEEKS Patient meets all the following criteria: Initially prescribed by a rheumatologist Previous failure to etanercept or adalimumab Patient has been assessed after the eighth to twelfth week of infliximab therapy and meets the following response criteria >20% reduction in number of tender and swollen joints PLUS >20% improvement in physician global assessment scale PLUS EITHER >20% improvement in the patient global assessment scale, OR >20% reduction in the acute phase as measured by ESR or CRP REQUEST FOR INITIAL COVERAGE OF INFLIXIMAB FOR FISTULIZING CROHNS DISEASE The initial coverage will allow for 3 doses of 5mg/kg/dose, administered at 0, 2 and 6 weeks. For continued coverage, patient must be reassessed after the initial doses. Infliximab is being prescribed by a gastroenterologist Patient is an adult with actively draining perianal or entercutaneous fistula(e) that have recurred or persisted despite: 1.a course of appropriate antibiotic therapy (e.g. ciprofloxacin with or without metronidazole for a minimum of 3 weeks) PLUS 2.immunosuppressive therapy: azathioprine 2 to 2.5mg/kg/day for a minimum of 6 weeks or treatment discontinued at < 6 weeks due to severe adverse reactions. OR 6-mercaptopurine 50-70mg/day for a minimum of 6 weeks or treatment discontinued at <6 weeks due to severe adverse reactions. OR Other. REQUEST FOR INITIAL COVERAGE OF INFLIXIMAB FOR SEVERE ACTIVE CROHNS DISEASE The initial coverage will allow for 3 doses of 5mg/kg/dose, administered at 0, 2 and 6 weeks. For continued coverage, patient must be reassessed after the initial doses. Infliximab is being prescribed by a gastroenterologist Patient is an adult with severe active Crohns disease that has recurred or persisted despite: 1. Therapy with 5-ASA products (at least 3g/day for a minimum of 6 weeks). PLUS 2. Glucocorticoids equivalent to prednisone 40mg/day for a minimum of 2 weeks. OR Treatment discontinued due to serious adverse reactions. OR Contraindication to glucocorticoid therapy. PLUS 3. Azathioprine 2 to 2.5mg/kg/day for a minimum of 3 months. OR 6-mercaptopurine 50 to 70mg/day for a minimum of 3 months. OR Methotrexate 15 to 25mg/week for a minimum of 3 months.
100mg/Vial Injection 02244016 REMICADE
CEN
2010
Page A-30 de 32

LEFLUNOMIDE
Limited use benefit (prior approval required). For treatment of patients with rheumatoid arthritis who: a. - have failed treatment with methotrexate: weekly dose (PO, SC or IM) of 20mg or greater (15mg or greater if patient is 65 years of age or older) for more than 8 weeks. b. - cannot tolerate or have contraindications to methotrexate.
10mg Tablet 02256495 02241888 02319225 02261251 02288265 02283964 20mg Tablet 02256509 02241889 02319233 02261278 02288273 02283972
APO-LEFLUNOMIDE ARAVA GEN-LEFLUNOMIDE NOVO-LEFLUNOMIDE PMS-LEFLUNOMIDE SANDOZ LEFLUNOMIDE APO-LEFLUNOMIDE ARAVA GEN-LEFLUNOMIDE NOVO-LEFLUNOMIDE PMS-LEFLUNOMIDE SANDOZ LEFLUNOMIDE
APX SAC GEN NOP PMS SDZ APX SAC GEN NOP PMS SDZ
MYCOPHENOLATE MOFETIL
250mg Capsule 02192748 CELLCEPT 500mg Tablet 02237484 CELLCEPT
HLR HLR
MYCOPHENOLATE SODIUM
180mg Enteric Coated Tablet 02264560 MYFORTIC 360mg Enteric Coated Tablet 02264579 MYFORTIC
NVR NVR
RISEDRONATE SODIUM
ACTONEL NOVO-RISEDRONATE ACTONEL NOVO-RISEDRONATE ACTONEL NOVO-RISEDRONATE
PGP NOP PGP NOP PGP NOP
2010
Page A-31 de 32

SIROLIMUS
Limited use benefit (prior approval required). Coverage will be provided as a second line therapy for patients failing mycophenolate mofetil.
1mg/mL Oral Liquid 02243237 RAPAMUNE 1mg Tablet 02247111 RAPAMUNE
WAY WAY
ZOLEDRONIC ACID
Limited use benefit (prior approval required). For the treatment of Pagets disease. Coverage will be granted for one dose per 12 month period.
5mg/100mL Injection 02269198 ACLASTA
NOV
92:44.00
TACROLIMUS
0.5mg Capsule 02243144 PROGRAF 1mg Capsule 02175991 PROGRAF 5mg Capsule 02175983 PROGRAF 5mg/mL Injection 02176009 PROGRAF 0.5mg Long Acting Capsule 02296462 ADVAGRAF 1mg Long Acting Capsule 02296470 ADVAGRAF 5mg Long Acting Capsule 02296489 ADVAGRAF
AST AST AST AST AST AST AST
2010
Page A-32 de 32
Appendix A Limited Use Benefits and Criteria

Page
ACCEL PIOGLITAZONE ACCOLATE ACLASTA ACTONEL ACTOS ADVAGRAF ADVAIR ADVAIR DISKUS 100 ADVAIR DISKUS 250 ADVAIR DISKUS 500 AGGRENOX ALENDRONATE-70 ALPHAGAN P APO-ALENDRONATE APO-BENZYDAMINE APO-BRIMONIDINE P APO-CALCITONIN APO-CYCLOBENZAPRINE APO-LANSOPRAZOLE APO-LEFLUNOMIDE APO-LEVETIRACETAM APO-LEVOFLOXACIN APO-MINOCYCLINE APO-OMEPRAZOLE APO-PANTOPRAZOLE APO-PIOGLITAZONE APO-RALOXIFENE APO-TIZANIDINE APTIVUS ARAVA ARICEPT ATRIPLA AVANDIA AVODART BARACLUDE BOTOX CARNITOR CARNITOR IV CELEBREX CELLCEPT CELSENTRI CENTRUM JUNIOR COMPLETE CENTRUM MATERNA CHAMPIX CHAMPIX STARTER PACK CIPRO HC CIPRODEX CO ALENDRONATE CO CABERGOLINE CO LEVETIRACETAM CO PANTOPRAZOLE CO PIOGLITAZONE CODEINE CONTIN CR CO-LEVOFLOXACIN CYCLOBENZAPRINE CYMBALTA DEMEROL DETROL DETROL LA DOM-BENZYDAMINE DOM-CYCLOBENZAPRINE DOM-LEVOFLOXACIN 1 21 15 32 31 21 32 9 9 9 10 11 26 16 26 16 16 22 10 17 31 13 1 1 18 19 21 20 10 3 31 7 3 21 27 5 27 15 15 11 31 3 23 23 10 10 15 15 26 27 13 19 21 12 1 10 14 13 23 23 16 10 1 DOM-MINOCYCLINE DOM-PIOGLITAZONE DOSTINEX DURAGESIC MAT ELIDEL EMEND EMEND TRI PACK ENABLEX ENBREL ENBREL SURECLICK EVISTA EXELON EZETROL FLINTSTONES EXTRA C FORADIL FOSAMAX FOSAVANCE GEN-ALENDRONATE GEN-CYCLOPRINE GEN-LEFLUNOMIDE GEN-LEVOFLOXACIN GEN-PANTOPRAZOLE GEN-PIOGLITAZONE GEN-TIZANIDINE GLEEVEC HEPSERA HUMIRA HUMIRA PEN HUMIRA PRE-FILL HYDROMORPH CONTIN INFANTOL INTELENCE ISENTRESS JAMP-MULTIVITAMIN A/D/C DROPS KEPPRA LEVAQUIN LEVOFLOXACIN LOSEC MAGIC BULLET MED-MINOCYCLINE MIACALCIN MINOCIN MINOCYCLINE MINT-PIOGLITAZONE MULTI-PRE AND POST NATAL MULTI-VITAMINS CHILD MYFORTIC MYLAN-OMEPRAZOLE MYLAN-RIVASTIGMINE NEORAL NEO-TINIC NEULASTA NOVO-ALENDRONATE NOVO-BENZYDAMINE NOVO-CYCLOPRINE NOVO-FENTANYL NOVO-FINASTERIDE NOVO-LANSOPRAZOLE NOVO-LEFLUNOMIDE NOVO-LEVOFLOXACIN NOVO-MINOCYCLINE NOVO-PANTOPRAZOLE

Page
1 21 27 12 22 16 16 22 28 28 20 8 11 23 9 26 26 26 10 31 1 19 21 10 5 5 25 25 25 13 23 3 3 23 13 1 1 18 16 1 22 1 2 21 23 23 31 18 8 27 23 11 26 16 10 12 28 17 31 1 1 19 NOVO-PIOGLITAZONE NOVO-RABEPRAZOLE NOVO-RALOXIFENE NOVO-RISEDRONATE NOVO-RIVASTIGMINE NU-CYCLOBENZAPRINE NUVARING ORENCIA OXEZE TURBUHALER OXYCONTIN PANTOLOC PANTOPRAZOLE PARIET EC PDL-MINOCYCLINE PEGASYS PEGASYS RBV PEGETRON PEGETRON REDIPEN PHL-ALENDRONATE PHL-CYCLOBENZAPRINE PHL-LEVOFLOXACIN PHL-PANTOPRAZOLE PHL-PIOGLITAZONE PLAVIX PMS-ALENDRONATE PMS-ALENDRONATE FC PMS-BENZYDAMINE PMS-BUPROPION SR PMS-CYCLOBENZAPRINE PMS-FENTANYL MTX PMS-FINASTERIDE PMS-LEFLUNOMIDE PMS-LEVETIRACETAM PMS-LEVOFLOXACIN PMS-MINOCYCLINE PMS-MONOCYCLINE PMS-OMEPRAZOLE PMS-PANTOPRAZOLE PMS-PIOGLITAZONE PMS-RABEPRAZOLE PMS-RIVASTIGMINE POLY-VI-SOL PRENATAL & POSTPARTUM PRENATAL AND POSTPARTUM PRENATAL VITAMINS AND MINERALS PREVACID PREVACID FASTAB PREZISTA PROGRAF PRO-PIOGLITAZONE PRO-RABEPRAZOLE PROSCAR PROTOPIC RAN-FENTANYL RAN-FENTANYL MATRIX RAN-FENTANYL MATRIX PATCH 12 RAN-PANTOPRAZOLE RAN-RABEPRAZOLE RAPAMUNE RATIO-ALENDRONATE RATIO-BENZYDAMINE
Page
21 20 20 31 8 10 20 24 9 13 19 19 20 1 4 4 4 4 26 10 1 19 21 11 26 26 16 14 10 12 28 31 13 1 1 2 18 19 21 20 8 23 23 23 23 17 17 2 32 21 20 28 22 12 12 12 19 20 32 26 16
2010
Page A-1 of 2
Appendix A Limited Use Benefits and Criteria

Page
RATIO-BUPROPION RATIO-BUPROPION SR RATIO-CYCLOBENZAPRINE RATIO-FENTANYL RATIO-FINASTERIDE RATIO-MINOCYCLINE RATIO-OMEPRAZOLE RATIO-PANTOPRAZOLE RATIO-PIOGLITAZONE REMICADE REMINYL ER RITUXAN RIVA-ALENDRONATE RIVA-CYCLOBENZAPRINE RIVA-MINOCYCLINE RIVA-PANTOPRAZOLE RIVA-RABEPRAZOLE SANDOZ ALENDRONATE SANDOZ FENTANYL SANDOZ FENTANYL TRANSDERMAL SYSTEM SANDOZ FINASTERIDE SANDOZ LEFLUNOMIDE SANDOZ LEVOFLOXACIN SANDOZ OMEPRAZOLE SANDOZ PIOGLITAZONE SANDOZ-BUPROPION SR SANDOZ-CALCITONIN SANDOZ-CYCLOSPORINE SANDOZ-MINOCYCLINE SANDOZ-PANTOPRAZOLE SANDOZ-RABEPRAZOLE SEREVENT DISKHALER SEREVENT DISKUS SIMPONI AUTO INJECTOR SIMPONI PRE-FILLED SYRINGE SINGULAIR SPIRIVA SUTENT SYMBICORT 100 TURBUHALER SYMBICORT 200 TURBUHALER TARCEVA TECTA TEMODAL TROSEC TRUVADA UNITRON PEG VESICARE VFEND VIREAD VISUDYNE WELLBUTRIN SR WELLBUTRIN XL XEOMIN ZANAFLEX ZYBAN SR ZYM-ALENDRONATE ZYM-PIOGLITAZONE ZYVOXAM 14 14 10 12 28 1 18 19 21 30 7 6 26 10 1 19 20 26 12 12 28 31 1 18 21 14 22 27 1 19 20 9 9 29 29 15 8 6 9 9 5 19 6 23 3 4 22 2 3 16 14 14 27 10 14 26 21 2

Page Page
2010
Page A-2 of 2
APPENDIX B SPECIAL FORMULARY FOR CHRONIC RENAL FAILURE PATIENTS
Appendix B Special Formulary for Chronic Renal Failure Patients
The Special Formulary for Chronic Renal Failure Patients defines selected drugs (for example: darbepoetin alfa, calcium products, water-soluble multivitamin products and selected nutritional products formulated for renal patients) that are covered for identified eligible NIHB clients in chronic renal failure. These drugs are covered in addition to the drugs and products listed in the NIHB Drug Benefit List.

DARBEPOETIN ALFA
25mcg/mL Injection 02246354 ARANESP 40mcg/mL Injection 02246355 ARANESP 100mcg/mL Injection 02246357 ARANESP 200mcg/mL Injection 02246358 ARANESP 500mcg/mL Injection 02246360 ARANESP AMG AMG AMG AMG AMG

40:08.00 ALKALINIZING AGENTS
SODIUM BICARBONATE
500mg Tablet 00392839 SANDOZ SOD BICARBONATE SDZ

CALCIUM (CALCIUM GLUCONOLACTATE, CALCIUM CARBONATE)
300mg & 2940mg Effervescent Tablet 02232482 CALCIUM SANDOZ 1750mg & 2327mg Effervescent Tablet 02232483 GRAMCAL NVC NVC
CALCIUM CARBONATE
500mg Capsule 00648353 CALSAN NVC WAM NVC APX NOP
EPOETIN ALFA
20,000IU/mL Injection 02206072 EPREX 20000IU/0.5mL injection 02243239 EPREX 5,000IU/mL Injection 02243400 EPREX 30000IU/0.75mL Injection 02288680 EPREX 1,000IU/0.5mL Prefilled Syringe 02231583 EPREX 2,000IU/0.5mL Prefilled Syringe 02231584 EPREX 3,000IU/0.3mL Prefilled Syringe 02231585 EPREX 4,000IU/0.4mL Prefilled Syringe 02231586 EPREX 6,000IU/0.6mL Prefilled Syringe 02243401 EPREX 8,000IU/0.8mL Prefilled Syringe 02243403 EPREX 10,000IU/mL Prefilled Syringe 02231587 EPREX 40,000IU/mL Prefilled Syringe 02240722 EPREX JNO JNO JNO JNO JNO JNO JNO JNO JNO JNO JNO JNO
500mg Chewable Tablet 00705373 CALCIUM 00648345 CALSAN 250mg Tablet 00682047 APO-CAL 250 00645958 CALCIUM
CALCIUM CITRATE
300mg Tablet 02231833 CALCIUM CITRATE WNP
PHOSPHORUS
500mg Effervescent Tablet 00225819 PHOSPHATE-NOVARTIS NVR
ZINC GLUCONATE
50mg Tablet 00503169 00505463 ZINC ZINC VTH JAM
2010
Page B-1 of 2
Appendix B Special Formulary for Chronic Renal Failure Patients
The Special Formulary for Chronic Renal Failure Patients defines selected drugs (for example: darbepoetin alfa, calcium products, water-soluble multivitamin products and selected nutritional products formulated for renal patients) that are covered for identified eligible NIHB clients in chronic renal failure. These drugs are covered in addition to the drugs and products listed in the NIHB Drug Benefit List.
40:18.19 PHOSPHATE - REMOVING AGENTS

SEVELAMER HYDROCHLORIDE
Limited Use Benefit ( Prior approval required ). a. - patients with elevated phosphate levels OR elevated phosphate X calcium product despite dietary restriction of phosphate and use of calcium-based phosphate binders (short term elevations should be managed with aluminium based binders) b. - patients with elevated calcium levels despite discontinuation of calcium binder, and Vitamin D analogue and/or modification of dialysate calcium c. - patients with adynamic bone disease and low PTH levels (<100 pg/ml or <0.9 pmol/L) with normal or elevated calcium levels 800mg Tablet 02244310 RENAGEL GEE
88:00 VITAMINS
88:12.00 VITAMIN C
VITAMIN B COMPLEX
Tablet 00123803 B COMPLEX PLUS C JAM
VITAMIN B COMPLEX WITH VITAMIN C

Tablet 02245391 DIAMINE EUR

MULTIVITAMINS
Tablet 02244872 80007498 00558796 REPLAVITE REPLAVITE STRESS PLEX C WNP WNP JAM

56:04.00 ANTACIDS AND ADSORBENTS
ALUMINUM HYDROXIDE
500mg Capsule 02135620 BASALJEL 60mg/mL Liquid 00572527 ALUGEL 64mg/mL Liquid 02125862 AMPHOJEL 600mg Tablet 02124971 AMPHOJEL AXC ATL AXC AXC
96:00 PHARMACEUTICAL AIDS

96:00.00 PHARMACEUTICAL AIDS
NUTRITIONAL SUPPLEMENT
Liquid 09854258 Liquid 09853723 00907995 09853731 NOVASOURCE RENAL NEPRO NOVASOURCE SUPLENA NES ABB NVR ABB ABB ABB NVR
CALCIUM CARBONATE
500mg Tablet 01970240 TUMS 750mg Tablet 01967932 TUMS EXTRA STRENGTH 1000mg Tablet 02151138 TUMS ULTRA STRENGTH GSK GSK GSK
235mL Liquid 99002639 NEPRO 99002647 SUPLENA Powder 09991056 RESOURCE BENEPROTEIN
2010
Page B-2 of 2
APPENDIX C PALLIATIVE CARE FORMULARY
Appendix C Palliative Care Formulary
Effective April 1, 2009, recipients diagnosed with a terminal illness and are near the end of life will be eligible to receive a list of supplemental benefits that are not included in the NIHB Drug Benefit List. The Palliative Care Formulary includes medications used to provide comfort to those near the end of life. Requests for any of the DINs below will generate a Palliative Care Application Form, faxed to the prescribing physician. Once completed and submitted, the recipient will be eligible for all medications on the Palliative Care Formulary if the following criteria are met: The recipient: 1. is not receiving care in a provincially funded hospital or provincially funded long-term care facility and 2. has been diagnosed with a terminal illness or disease which is expected to be the primary cause of death within six months or less Once approved, the recipient will be eligible for all medications on the Palliative Care Formulary for six months without the need for further prior approval. If coverage is required beyond the initial six months, an additional six months may be granted upon receipt of another Palliative Care Application Form completed. Please note: During the six month coverage period, a maximum 30 day supply will be reimbursed at any one time.

ATROPINE SULFATE
0.4mg/mL Injection 00392782 ATROPINE SULFATE 00497231 ATROPINE SULFATE 00960624 ATROPINE SULFATE 0.6mg/mL Injection 00012076 ATROPINE SULFATE 00392693 ATROPINE SULFATE 00497258 ATROPINE SULFATE SDZ ABB SAB GSK SDZ ABB

FENTANYL
12mcg Transdermal Patch 02311925 RATIO-FENTANYL TRANSDERMAL SYSTEM 02327112 SANDOZ FENTANYL 12MCG/HR PATCH 12mcg/h Transdermal Patch 02341379 PMS-FENTANYL MTX 02330105 RAN-FENTANYL MATRIX 25mcg Transdermal Patch 02330113 RAN-FENTANYL MATRIX PATCH 25 02249391 RAN-FENTANYL TRANSDERMAL SYSTEM 02282941 RATIO-FENTANYL TRANSDERMAL SYSTEM 02327120 SANDOZ FENTANYL 25MCG/HR PATCH 25mcg/h Transdermal Patch 02275813 DURAGESIC MAT 25MCG/HR PATCH 02314630 NOVO-FENTANYL 25MCG PATCH 02341387 PMS-FENTANYL MTX 50mcg Transdermal Patch 02330121 RAN-FENTANYL MATRIX PATCH 50 02249413 RAN-FENTANYL TRANSDERMAL SYSTEM 02282968 RATIO-FENTANYL TRANSDERMAL SYSTEM 02327147 SANDOZ FENTANYL 50MCG/HR PATCH RPH SDZ
PMS RBY RBY RBY RPH SDZ
GLYCOPYRROLATE
0.2mg/mL Injection 02039508 GLYCOPYRROLATE SDZ
HYOSCINE BUTYLBROMIDE
20mg/mL Injection 00363839 BUSCOPAN 02229868 HYOSCINE BOE SDZ
SCOPOLAMINE HYDROBROMIDE
0.4mg/mL Injection 00541869 SCOPOLAMINE 0.6mg/mL Injection 00541877 SCOPOLAMINE ABB ABB
JNO NOP PMS RBY RBY RPH SDZ
2010
Page C-1 of 3

FENTANYL
50mcg/h Transdermal Patch 02275821 DURAGESIC MAT 50MCG/HR PATCH 02314649 NOVO-FENTANYL 50MCG PATCH 02341395 PMS-FENTANYL MTX 75mcg Transdermal Patch 02330148 RAN-FENTANYL MATRIX PATCH 75 02249421 RAN-FENTANYL TRANSDERMAL SYSTEM 02282976 RATIO-FENTANYL TRANSDERMAL SYSTEM 02327155 SANDOZ FENTANYL 75MCG/HR PATCH 75mcg/h Transdermal Patch 02275848 DURAGESIC MAT 75MCG/HR PATCH 02314657 NOVO-FENTANYL 75MCG PATCH 02341409 PMS-FENTANYL MTX 100mcg Transdermal Patch 02249448 RAN-FENTANYL TRANSDERMAL SYSTEM 02282984 RATIO-FENTANYL 100MCG/HR PATCH 02327163 SANDOZ FENTANYL 100MCG/HR PATCH 100mcg/h Transdermal Patch 02275856 DURAGESIC MAT 100MCG/HR PATCH 02314665 NOVO-FENTANYL 100MCG PATCH 02341417 PMS-FENTANYL MTX 02330156 RAN-FENTANYL MATRIX PATCH 100 JNO NOP PMS RBY RBY RPH SDZ

FENTANYL CITRATE
50mcg/mL Injection 00888346 FENTANYL CITRATE 02126648 FENTANYL CITRATE 02240434 FENTANYL CITRATE HOS HOS SDZ

METHOTRIMEPRAZINE
25mg/mL Injection 01927698 NOZINAN SAC

DIAZEPAM
5mg/mL Injection 02065614 DIAZEMULS VL 00399728 DIAZEPAM ACG SDZ
JNO NOP PMS RBY RPH SDZ
LORAZEPAM
4mg/mL Injection 02243278 LORAZEPAM SDZ
MIDAZOLAM
1mg/mL Injection 02240285 MIDAZOLAM 02242904 MIDAZOLAM 02243934 MIDAZOLAM 5mg/mL Injection 02240286 MIDAZOLAM 02242905 MIDAZOLAM 02243935 MIDAZOLAM SDZ PPC NOP SDZ PPC NOP
JNO NOP PMS RBY
2010
Page C-2 of 3

56:32.00 PROKINETIC AGENTS
METOCLOPRAMIDE
5mg/mL Injection 02185431 METOCLOPRAMIDE 02243563 METOCLOPRAMIDE OMEGA SDZ OMG
56:92.00 MISCELLANEOUS GI DRUGS

METHYLNALTREXONE BROMIDE
20mg/mL Injection 02308215 RELISTOR WYE
2010
Page C-3 of 3
APPENDIX D LIST OF DRUG MANUFACTURERS
Appendix D List of Drug Manufacturers MFR

ABB ACT ADA AGO ALC ALG ALK ALL AMG APX AST ATL AUC AVT AXC AXL AXX AZC BAK BAR BAT BAX BAY BCD BDH BEN BEX BIH BIO
Manufacturer Name
ABBOTT LABORATORIES LIMITED ACTI-FORM LIMITED ADAMS LABS LIMITED AGOURON PHARMACEUTICALS CANADA INCORPORATED ALCON CANADA INCORPORATED ALLERGOLOGISK LAB A/S ALK ABELLO A/S ALLERGAN INCORPORATED AMGEN CANADA INCORPORATED APOTEX INCORPORATED ASTELLAS PHARMA CANADA INCORPORATED LABORATORIE ATLAS INCORPORATED AUTO CONTROL AVENTIS PHARMA INCORPORATED AXCAN PHARMA INCORPORATED ALLEREX LABORATORY LIMITED AXXESS PHARMA INCORPORATED ASTRAZENECA CANADA INCORPORATED BAKER CUMMINS INCORPORATED. BARR PHARMACEUTICALS INCORPORATED BAXTER CORPORATION BRAINTREE LAB INCORPORATED BAYER INCORPORATED, HEALTHCARE/DIAGNOSTICS BAYER INCORPORATED, CONSUMER CARE DIVISION BDH INCORPORATED BENCARD ALLERGY LABORATORIES BERLEX CANADA INCORPORATED BIOENHANCE MEDICAL INCORPORATED BIONICHE PHARMA (CANADA) LIMITED
MFR
BMI BMS BOE BPC BSH BTD BUY CBS CDX CEN CIP COB COP COS CUV CYX DAW DCL DCM DDP DER DES DKT DOR DPC DPT
Manufacturer Name
BIOMED 2002 INCORPORATED BRISTOL-MYERS SQUIBB CANADA BOEHRINGER INGELHEIM (CANADA) LIMITED BIOVAIL PHARMACEUTICALS CANADA BAUSCH & LOMB CANADA INCORPORATED BECTON DICKINSON W.K. BUCKLEY LIMITED CENTER LABORATORIES INCORPORATED CANDERM PHARMA CENTOCOR INCORPORATED CIPHER PHARMACEUTICALS INCORPORATED COBALT PHARMACEUTICALS INCORPORATED COLGATE ORAL PHRAMACEUTICALS INCORPORATED COSMAIR CANADA INCORPORATED CHAUVIN PHARMACEUTICALS LIMITED CYTEX PHARMACEUTICALS INCORPORATED DAWSON TRADERS LIMITED D.C. LABS LIMITED D & C MOBILITY THE D DROPS COMPANY INCORPORATED DERMIK LABORATORIES CANADA INCORPORATED DESBERGERS LIMITED DIOPTIC LABORATORIES INCORPORATED DORMER LABORATORIES INCORPORATED DOMINION PHARMACAL DERMTEK PHARMACEUTIQUE LIMITED
Page D-1 of 4
2010

DPY DSP DUI EDM ELN ERF EUR FEI FER FOU FRS FTP FUJ GAC GCC GCL GEE GEN GIL GLE GSK HAL HIL HJS HLR HMR HOL HOR HOS HPC ICN
2010
Manufacturer Name
DRAXIS HEALTH INCORPORATED DISPENSA PHARM CANADA LIMITED DUCHESNAY INCORPORATED ENDO CANADA INCORPORATED ELAN PHARMACEUTICALS INCORPORATED ERFA CANADA INCORPORATED EURO-PHARM INTERNATIONAL CANADA INCORPORATED FERRING INCORPORATED FERRARIS MEDICAL FOURNIER PHARMA INCORPORATED MERCK FROSST CANADA LIMITED FTP- PHARMACAL INCORPORATED FUJISAWA CANADA INCORPORATED GALDERMA CANADA INCORPORATED GERMIPHENE CORPORATION GALEN CHEMICALS LIMITED GENZYME CANADA INCORPORATED GENPHARM ULC GILEAD SCIENCES INCORPORATED GLENWOOD LABORATORIES CANADA LIMITED GLAXOSMITHKLINE INCORPORATED HALL LABORATORIES LIMITED HILL DERMACEUTICALS INCORPORATED H.J. SUTTON INDUSTRIES LIMITED HOFFMAN-LAROCHE LIMITED HOECHST MARION ROUSSELL CANADA INCORPORATED HOLLISTER LIMITED CARTER-HORNER CORPORATION HOSPIRA HEALTHCARE CORPORATION HEALTHPOINT CANADA ULC ICN CANADA LIMITED
MFR
IDE IMX IPS IVX JAJ JAM JLF JMP JNO KEY KIN LAL LEO LHL LIF LIL LIN LIO LUD MAY MCA MCL MDC MDT MEC MET MIN MIO
Manufacturer Name
INTERNATIONAL DERMATOLOGICALS INCORPORATED IMMUNEX CORPORATION IPSEN LIMITED IVAX PHARMACEUTICALS INCORPORATED. JOHNSON & JOHNSON C.E. JAMIESON COMPANY LIMITED J.L.FREEMAN JAMP PHARMA CORPORATION JANSSEN-ORTHO INCORPORATED KEY PHARMACEUTICALS INCORPORATED KINSMOR PHARMACEUTICALS INCORPORATED LABORATOIRE LALCO INCORPORATED LEO PHARMA INCORPORATED LIFEHEALTH LIMITED LIFESCAN CANADA LIMITED ELI LILLY CANADA INCORPORATED LINSON PHARMA CORPORATION LIOH INCORPORATED LUNDBECK CANADA INCORPORATED MAYNE PHARMA (CANADA) INCORPORATED MCARTHUR MEDICAL SALES INCORPORATED MCNEIL CONSUMER PRODUCTS COMPANY MEDICIS CANADA CORPORATION MEDTRONIC OF CANADA LIMITED MEDICAN PHARMA INCORPORATED MEDICAL TEXTILES MARKETING INCORPORATED MINT PHARMACEUTICALS INCORPORATED MEDIMMUNE ONCOLOGY INCORPORATED
Page D-2 of 4

MJO MMH MPD MSL MSP MTI NAB NDE NEO NOO NOP NUL NUR NVC NVR NXP NYC OBP ODN OMG OPT ORG ORY OVA PAL PCO PDD PDL PED
2010
Manufacturer Name
MEAD JOHNSON CANADA INCORPORATED 3M PHARMACEUTICALS MEDICAL PLASTIC DEVICES INCORPORATED MEDIC SAVOURE LIMITED MERCK FROSST / SCHERING PHARMA GP MEDICAN TECHNOLOGIES INCORPORATED NABI BIOPHARMACEUTICALS NORDIC DESIGN NEOLAB INCORPORATED NOVO NORDISK CANADA INCORPORATED NOVOPHARM LIMITED NU-LIFE NUTRITIONAL PRODUCTS NUTRICORP INTERNATIONAL NOVARTIS CONSUMER HEALTH CANADA INCORPORATED NOVARTIS PHARMACEUTICALS CANADA INCORPORATED NU-PHARM INCORPORATED NYCOMED CANADA INCORPORATED ORBUS PHARMA INCORPORATED ODAN LABORATORIES LIMITED OMEGA LABORATORIES LIMITED OPTREX LABS LIMITED ORGANON CANADA LIMITED ORYX PHARMACEUTICALS INCORPORATED OVATION PHARMACEUTICALS INCORPORATED PALADIN LABS INCORPORATED PERSON & COVEY INCORPORATED PRODEMDIS ENTREPRISE PRO DOC LIMITED PENDOPHARM INCORPORATED
MFR
PEN PER PFD PFI PFR PGI PGP PHH PHS PMJ PMS PMT PRE PRO PVR QLT RBY RHO RHP RIV ROD RPH RVX RWP SAB SAC SBC SCH SCN SDR
Manufacturer Name
PENTAPHARM PERRIGO INTERNATIONAL PROFESSIONAL DISPOSABLES PFIZER CANADA INCORPORATED PURDUE PHARMA PROCTOR & GAMBLE INCORPORATED PROCTOR & GAMBLE PHARMACEUTICALS INCORPORATED PHARMEL INCORPORATED PANGEO PHARMA (CANADA) INCORPORATED PHARMACIA CANADA INCORPORATED PHARMASCIENCE INCORPORATED PHARMETICS INCORPORATED PREMPHARM INCORPORATED PROVAL PHARMA INCORPORATED PHARMAVITE CORPORATION QLT INCORPORATED RANBAXY PHARMACEUTICALS CANADA INCORPORATED RHOXALPHARMA INCORPORATED RHODIAPHARM INCORPORATED LABORATORIE RIVA INCORPORATED ROCHE DIAGNOSTICS RATIOPHARM INCORPORATED RIVEX PHARMA INCORPORATED RW PACKAGING LIMITED SABEX 2002 INCORPORATED SANOFI-AVENTIS CANADA SMITHKLINE BEECHAM CONSUMER HEALTHCARE INCORPORATED. SCHERING CANADA INCORPORATED SCHEIN PHARMACEUTICAL CANADA INCORPORATED STANLEY PHARMACEUTICALS LIMITED
Page D-3 of 4

SDZ SEA SEV SHI SHM SIG SNE SPH SQU STE STI SWS TAN TAR TCD THC THR TIP TPX TRI TRT TRU UCB VAE VAO VIR VLB VTH WAB
Manufacturer Name
SANDOZ CANADA INCORPORATED SEARLE CANADA SERVIER CANADA INCORPORATED SHIRE CANADA INCORPORATED SHERWOOD INCORPORATED SIGMA-TAU PHARMACEUTICALS INCORPORATED SMITH & NEPHEW INCORPORATED SOLVAY PHARMA INCORPORATED SQUIRE PHARMACEUTICALS INCORPORATED STERIMAX INCORPORATED STIEFEL CANADA INCORPORATED SWISS HERBAL REMEDIES LIMITED TANTA PHARMACEUTICALS INCORPORATED TARO PHARMACEUTICALS INCORPORATED TRANS CANADERM INCORPORATED TRILLIUM HEALTH CARE PRODUCTS INC. THERMOR LIMITED TRIAD PHARMACEUTICALS THERAPEX INCORPORATED TRIANON LABORATORIES INCORPORATED TRITON PHARMA INCORPORATED TRUDELL MEDICAL INTERNATIONAL UBC PHARMA INCORPORATED VALEANT CANADA LIMITED VALEO PHARMA INCORPORATED VIRCO PHARMACEUTICALS CANADA INCORPORATED VITALAB VITA HEALTH PRODUCTS INCORPORATED WAYMAR PHARMACEUTICALS INCORPORATED
MFR
WAM WAT WAY WCC WCI WEP WLA WLR WNP WPC WRI WSB WTR XEN ZIL ZYM
Manufacturer Name
WAMPOLE INCORPORATED WATSON LABORATORIES INCORPORATED WYETH CANADA WOMEN'S CAPITAL CORPORATION WARNER CHILCOTT COMPANY INCORPORATED WE PHARMACEUTICALS WARNER-LAMBERT CONSUMER HEALTHCARE INCORPORATED WIL RICHARDS COMPANY WN PHARMACEUTICALS LIMITED WELLSPRING PHARMACEUTICAL CANADA CORPORATION WHITEHALL-ROBINS INCORPORATED WESTWOOD SQUIBB INCORPORATED WESTCAN PHARMACEUTICALS LIMITED XENEX LABS INCORPORATED ZILA PHARMACEUTICALS ZYMCAN PHARMACEUTICALS
2010
Page D-4 of 4
APPENDIX E LIST OF EXCLUSIONS
Appendix E EXCLUSIONS
Certain drug products are not within the scope of the program. These products will not be reimbursed as benefits under the NIHB Program: Anti-obesity drugs; Household products (regular soaps and shampoos); Cosmetics; Alternative therapies, including glucosamine and evening primrose oil; Megavitamins; Drugs with investigational/experimental status; Vaccinations for travel indications; Hair growth stimulants; Fertility agents and impotence drugs; Selected over-the-counter products; Codeine containing cough preparations; Dalmane, Somnol and generics (flurazepam); Darvon and 642 (propoxyphene); Fiorinal, Fiorinal C , Fiorinal C and generics (Butalbital containing analgesics with and without codeine); Librium, Solium, Medilium and generics (chlordiazepoxide); Stadol TM NS and generics (butorphanol tartrate nasal spray); and Tranxene and generics (clorazepate). The following drugs will be excluded from the NIHB Program as recommended by the Common Drug Review (CDR) and the Federal Pharmacy and Therapeutics Committee (FPT) because published evidence does not support the clinical value or cost of the drug relative to existing therapies, or there is insufficient clinical evidence to support coverage. Of Note: The Appeal Process and the Emergency Supply Policy will not apply for the following drug products.
DIN
02248722 02259052 02247916 02251787 02268507 02268493 02248417 02244521 02244522 02241804 02248503 02248504 02229437 02256290 02256304
MFR
ALL AST BAY BAY BPC BPC FEI AZC AZC SPH GSK GSK NAB PFI PFI
BRAND NAME
ACULAR LS 0.4% OPHTHALMIC SOLUTION AMEVIVE 15MG/0.5ML POWDER FOR SOLUTION CIPRO XL 500MG TABLET CIPRO XL 1000MG TABLET GLUMETZA 1000MG EXTENDED RELEASE TABLET GLUMETZA 500MG EXTENDED RELEASE TABLET GYNAZOLE-1 VAG CREAM 2% NEXIUM 20MG SR TABLET NEXIUM 40MG SR TABLET PANTOLOC 20MG EC TABLET PAXIL CR 12.5MG EXTENDED RELEASE TABLET PAXIL CR 25MG EXTENDED RELEASE TABLET PHOSLO 667MG TABLET RELPAX 20MG TABLET RELPAX 40MG TABLET
2010
Page E-1 of 1
Health Canada
Page
282 292 3TC 5-AMINOSALICYLIC ACID ABACAVIR ABACAVIR, LAMIVUDINE ABACAVIR, LAMIVUDINE, ZIDOVUDINE ABATACEPT ABENOL ACAMPROSATE CALCIUM ACARBOSE ACCEL PIOGLITAZONE ACCOLATE ACCU-CHEK ADVANTAGE ACCU-CHEK AVIVA (100) ACCU-CHEK AVIVA (50) ACCU-CHEK COMPACT ACCU-CHEK MULTICLIX ACCUPRIL ACCURETIC ACCUTANE ACCUTREND ACE ADAPTORS ACE KIT ACE LARGE MASK ACCESSARY KIT ACE MDI SPACER ACE MEDIUM MASK ACCESSARY KIT ACE SMALL MASK ACCESSARY KIT ACE SPACER WITH LARGE MASK ACE SPACER WITH MEDIUM MASK ACE SPACER WITH SMALL MASK ACEBUTOLOL ACEBUTOLOL HCL ACET ACET 120 ACET 325 ACET 650 ACET CODEINE 30 ACETAMIN CHILD ACETAMINOPHEN ACETAMINOPHEN ACETAMINOPHEN, CAFFEINE CITRATE, CODEINE PHOSPHATE ACETAMINOPHEN, CODEINE PHOSPHATE ACETAMINOPHEN, OXYCODONE HCL ACETAZOLAMIDE ACETEST ACETOXYL ACETYLSALICYLIC ACID ACETYLSALICYLIC ACID ACETYLSALICYLIC ACID, CAFFEINE CITRATE, CODEINE PHOSPHATE ACETYLSALICYLIC ACID, OXYCODONE HCL ACITRETIN ACLASTA ACTIFED 73 46 46 9 90 8 8 8 114 50 69 96 99 76 71 71 71 71 121 39 40 109 71 120 120 120 120 120 120 120 120 120 31 31 50 50 50 50 45 49 49 49 45 45 45 80 72 103 42 42 46

Page
ACTONEL ACTOS ACULAR ACYCLOVIR ADALAT XL ADALIMUMAB ADAPALENE ADAPTOR ADEFOVIR DIPIVOXIL ADHESIVE PAD WITH COTTON ADHESIVE PAD WITHOUT COTTON ADRENALIN ADVAGRAF ADVAIR ADVAIR DISKUS 100 ADVAIR DISKUS 250 ADVAIR DISKUS 500 ADVANTAGE ADVIL ADVIL JUNIOR STRENGTH ADVIL LIQUI-GEL ADVIL PEDIATRIC AEROCHAMBER AC BOYZ AEROCHAMBER AC GIRLZ AEROCHAMBER MAX VHC WITH ADULT MASK AEROCHAMBER MAX VHC WITH CHILD MASK AEROCHAMBER MAX VHC WITH INFANT MASK AEROCHAMBER MAX VHC WITH MOUTHPIECE AEROCHAMBER PLUS VHC ADULT AEROCHAMBER PLUS VHC WITH ADULT MASK AEROCHAMBER PLUS VHC WITH INFANT MASK AEROCHAMBER PLUS VHC WITH PEDIATRIC MASK AGGRENOX AGRYLIN AIROMIR ALBALON ALBALON A ALCOHOL PREP SWAB ALCOHOL SWAB ALCOHOL SWABS BD ALDACTAZIDE-25 ALDACTAZIDE-50 ALDACTONE ALENDRONATE SODIUM ALENDRONATE SODIUM, VITAMIN D3 ALENDRONATE-70 ALERTEC ALESSE (21) ALESSE (28) ALFACALCIDOL ALFUZOSIN HYDROCHLORIDE ALKERAN ALLEGRA ALLER-AIDE ALLERGENIC EXTRACT NON POLLENS 117 99 79 11 35 114 107 121 11 121 121 19 118 19 19 19 19 71 43 43 43 43 120 120 120 120 120 120 120 120 120 120 30 23 18 79 79 121 121 121 75 75 41 114 114 114 64 94 95 112 114 14 1 1 101
Page
ALLERGENIC EXTRACT POLLENS ALLERGENIC EXTRACTS ALLERGY ALLERGY FORMULA ALLERGY RELIEF ES ALLERNIX ALLERNIX PLUS ALLOPRIN ALLOPURINOL ALLOPURINOL ALMOTRIPTAN MALATE ALOCRIL ALOMIDE ALPHA TOCOPHERYL ALPHAGAN ALPHAGAN P ALPRAZOLAM ALPRAZOLAM ALTACE ALTACE HCT ALTRETAMINE ALUMINUM ACETATE, BENZETHONIUM CHLORIDE ALVESCO AMANTADINE HCL AMATINE AMCINONIDE AMERGE AMI-HYDRO AMILORIDE HCL AMILORIDE HCL, HYDROCHLOROTHIAZIDE AMINOPHYLLINE AMIODARONE HCL AMITRIPTYLINE AMITRIPTYLINE HCL AMLODIPINE AMLODIPINE, ATORVASTATIN AMOXICILLIN AMOXICILLIN, CLARITHROMYCIN, LANSOPRAZOLE AMOXICILLIN, CLAVULANIC ACID AMPICILLIN ANAFRANIL ANAGRELIDE HCL ANANDRON ANAPROX ANAPROX DS ANASTROZOLE ANDRIOL ANDROCUR ANODAN-HC ANSAID ANTAZOLINE PHOSPHATE, NAPHAZOLINE HCL ANTHRAFORTE ANTHRANOL-1 ANTHRANOL-2 ANTHRASCALP ANTIBIOTIC ANUGESIC HC ANUSOL HC ANZEMET APIDRA 101 101 1 1 1 1 1 115 115 115 66 117 81 112 79 80 64 64 40 40 13 81 93 8 18 104 66 74 74 74 110 25 54 54 34 35 4 88
4 4 55 23 14 45 45 13 94 13 106 43 79 108 107 107 107 102 106 106 86 97
46 108 118 19
2010
Page I-1 of 23
Health Canada
Page
APIDRA SOLOSTAR APO ENALAPRIL APO KETO-E APO-ACEBUTOLOL APO-ACETAMINOPHEN APO-ACETAZOLAMIDE APO-ACYCLOVIR APO-ALENDRONATE APO-ALFUZOSIN ER APO-ALLOPURINOL APO-ALPRAZ APO-AMILORIDE APO-AMILZIDE APO-AMIODARONE APO-AMITRIPTYLINE APO-AMLODIPINE APO-AMOXI APO-AMOXI CLAV APO-AMPICILLIN APO-ASA APO-ASEN ECT APO-ATENIDONE APO-ATENOL APO-ATORVASTATIN APO-AZATHIOPRINE APO-AZITHROMYCIN APO-BACLOFEN APO-BECLOMETHASONE APO-BENAZEPRIL APO-BENZTROPINE APO-BENZYDAMINE APO-BICALUTAMIDE APO-BISACODYL APO-BISOPROLOL APO-BRIMONIDINE APO-BRIMONIDINE P APO-BROMAZEPAM APO-BROMOCRIPTINE APO-C APO-CAL 500 APO-CALCITONIN APO-CAPTO APO-CARBAMAZEPINE APO-CARVEDILOL APO-CEFACLOR APO-CEFADROXIL APO-CEFPROZIL APO-CEFUROXIME APO-CEPHALEX APO-CETIRIZINE APO-CHLORTHALIDONE APO-CILAZAPRIL APO-CILAZAPRIL HCTZ APO-CIMETIDINE APO-CIPROFLOX APO-CITALOPRAM APO-CLARITHROMYCIN APO-CLINDAMYCIN APO-CLOBAZAM APO-CLOMIPRAMINE APO-CLONAZEPAM APO-CLONIDINE APO-CLOXI APO-CLOZAPINE 97 38 44 31 50 80 11 114 114 115 64 74 74 25 54 35 4 4 4 42 42 32 31 26 115 3 20 78 37 67 79 13 83 32 79 80 65 68 111 73 99 37 52 32 2 2 2 2 3 1 75 37 38 87 5 55 3 6 65 55 51 29 4 60 APO-CROMOLYN APO-CYCLOBENZAPRINE APO-CYPROTERONE APO-DESIPRAMINE APO-DESMOPRESSIN APO-DEXAMETHASONE APO-DIAZEPAM APO-DICLO APO-DICLO SR APO-DIFLUNISAL APO-DILTIAZ APO-DILTIAZ CD APO-DILTIAZ SR APO-DILTIAZ TZ APO-DIMENHYDRINATE APO-DIPIVEFRIN APO-DIPYRIDAMOLE APO-DIVALPROEX APO-DOCUSATE CALCIUM APO-DOCUSATE SODIUM APO-DOMPERIDONE APO-DOXAZOSIN APO-DOXEPIN APO-DOXY APO-ERYTHRO APO-ERYTHRO BASE APO-ERYTHRO S APO-ERYTHRO-S APO-FAMCICLOVIR APO-FAMOTIDINE APO-FENOFIBRATE APO-FENO-MICRO APO-FENO-SUPER APO-FERROUS GLUCONATE APO-FERROUS SULFATE FC APO-FLAVOXATE APO-FLECAINIDE APO-FLOCTAFENINE APO-FLUCONAZOLE APO-FLUNARIZINE APO-FLUNISOLIDE APO-FLUOXETINE APO-FLUPHENAZINE APO-FLURBIPROFEN APO-FLUTAMIDE APO-FLUTICASONE APO-FLUVOXAMINE APO-FOLIC ACID APO-FOSINOPRIL APO-FUROSEMIDE APO-GABAPENTIN APO-GEMFIBROZIL APO-GLICLAZIDE APO-GLICLAZIDE MR APO-GLYBURIDE APO-GRANISETRON APO-HALOPERIDOL APO-HYDRALAZINE APO-HYDRO APO-HYDROCLOROTHIAZIDE APO-HYDROXYQUINE APO-HYDROXYUREA APO-HYDROXYZINE APO-IBUPROFEN

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77 19 13 55 99 93 65 42 43 43 36 35 36 36 86 79 30 52 83 83 86 30 56 6 3 3 3 3 11 87 26 26 26 22 22 110 25 50 7 116 78 56 60 43 13 78 56 111 38 74 52 26 98 98 98 86 60 29 74 75 12 13 66 43 APO-IMIPRAMINE APO-INDAPAMIDE APO-INDOMETHACIN APO-IPRAVENT APO-ISDN APO-ISMN APO-K APO-KETO APO-KETO SR APO-KETOCONAZOLE APO-KETO-E APO-KETOROLAC APO-KETOTIFEN APO-LACTULOSE APO-LAMOTRIGINE APO-LANSOPRAZOLE APO-LEFLUNOMIDE APO-LEVETIRACETAM APO-LEVOBUNOLOL APO-LEVOCARB APO-LEVOCARB CR APO-LEVOFLOXACIN APO-LISINOPRIL APO-LISINOPRIL (TYPE Z) APO-LISINOPRIL/HCTZ APO-LITHIUM CARB APO-LITHIUM CARBONATE APO-LOPERAMIDE APO-LORAZEPAM APO-LOVASTATIN APO-MEDROXY APO-MEFENAMIC APO-MEGESTROL APO-MELOXICAM APO-METFORMIN APO-METHAZIDE-15 APO-METHAZIDE-25 APO-METHAZOLAMIDE APO-METHOPRAZINE APO-METHOTREXATE APO-METHYLDOPA APO-METHYLPHENIDATE APO-METOCLOP APO-METOPROLOL APO-METOPROLOL SR APO-METOPROLOL-L APO-METRONIDAZOLE APO-MINOCYCLINE APO-MIRTAZAPINE APO-MISOPROSTOL APO-MOCLOBEMIDE APO-MODAFINIL APO-NADOL APO-NAPRO NA APO-NAPRO NA DS APO-NAPROXEN APO-NAPROXEN EC APO-NIFED APO-NIFED PA APO-NITRAZEPAM APO-NITROFURANTOIN APO-NIZATIDINE APO-NORFLOX APO-NORTRIPTYLINE
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57 75 44 17 29 29 73 44 44 7 44 79 1 84 53 88 116 53 80 68 68 5 39 39 39 66 66 83 65 27 100 44 14 44 97 29 29 80 61 14 29 64 90 33 32 33 12 6 57 88 57 64 33 45 45 44 44 35 35 65 12 87 5 57
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APO-OFLOX APO-OFLOXACIN APO-OLANZAPINE APO-OMEPRAZOLE APO-ONDANSETRON APO-ORCIPRENALINE APO-OXAZEPAM APO-OXTRIPHYLLINE APO-OXYBUTYNIN APO-OXYCODONE/ACET APO-PANTOPRAZOLE APO-PAROXETINE APO-PEN VK APO-PENTOXIFYL APO-PERPHENAZINE APO-PIMOZIDE APO-PINDOL APO-PIOGLITAZONE APO-PIROXICAM APO-PRAMIPEXOLE APO-PRAVASTATIN APO-PRAZO APO-PREDNISONE APO-PRIMIDONE APO-PROCHLORAZINE APO-PROPAFENONE APO-PROPRANOLOL APO-QUETIAPINE APO-RALOXIFENE APO-RAMIPRIL APO-RANITIDINE APO-RISPERIDONE APO-ROPINIROLE APO-SALVENT APO-SALVENT CFC FREE APO-SELEGILINE APO-SERTRALINE APO-SIMVASTATIN APO-SOTALOL APO-SUCRALFATE APO-SULFAMETHOXAZOLE APO-SULFATRIM APO-SULFATRIM DS APO-SULFATRIM PED APO-SULFINPYRAZONE APO-SULIN APO-SUMATRIPTAN APO-TAMOX APO-TEMAZEPAM APO-TERAZOSIN APO-TERBINAFINE APO-TETRA APO-THEO APO-THEO LA APO-TIAPROFENIC APO-TICLOPIDINE APO-TIMOL APO-TIMOP APO-TIZANIDINE APO-TOLBUTAMIDE APO-TOPIRAMATE APO-TRAZODONE APO-TRAZODONE D APO-TRIAZIDE 6 77 61 89 86 18 65 110 110 46 89 58 4 24 61 61 33 99 45 68 27 30 94 50 62 25 34 62 96 40 87 62 68 18 18 69 58 28 34 88 6 6 6 6 75 45 67 15 66 30 7 6 110 110 45 24 34 80 20 98 53 59 59 74 APO-TRIAZO APO-TRIFLUOPERAZINE APO-TRIHEX APO-TRIMETHOPRIM APO-TRIMIP APO-TRIMIPRAMINE APO-VALACYCLOVIR APO-VALPROIC APO-VENLAFAXINE XR APO-VERAP APO-VERAP SR APO-WARFARIN APO-ZIDOVUDINE APRACLONIDINE HCL APREPITANT APRI 21 APRI 28 APTIVUS AQUASOL E ARAVA AREDIA IV ARICEPT ARIMIDEX ARISTOCORT C ARISTOCORT R ARISTOSPAN AROMASIN ARTHROTEC ARTIFICIAL TEARS ARTIFICIAL TEARS EXTRA ASA ASACOL ASAPHEN ASAPHEN EC ASCENSIA AUTODISC ASCENSIA BREEZE 2 ASCENSIA CONTOUR ASCENSIA CONTOUR (100) ASCENSIA CONTOUR (50) ASCENSIA ELITE ASCORBIC ACID ASCORBIC ACID ASPIRIN ATACAND ATACAND PLUS ATARAX ATASOL ATASOL FORTE ATASOL-15 ATASOL-30 ATAZANAVIR SULFATE ATENOLOL ATENOLOL ATENOLOL, CHLORTHALIDONE ATHLETES FOOT SPRAY ATIVAN ATIVAN SUBLINGUAL ATORVASTATIN CALCIUM ATOVAQUONE ATRIPLA ATROPINE ATROPINE SULFATE ATROPINE SULPHATE MINIMS ATROVENT

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66 64 67 12 59 59 11 54 59 37 36 23 10 81 86 94 94 10 112 116 117 16 13 107 107 94 13 43 81 81 42 90 42 42 71 71 71 71 71 71 111 112 42 40 40 66 49 50 45 45 8 31 31 32 103 65 65 26 12 8 79 79 79 81 ATROVENT HFA AURANOFIN AVALIDE AVANDIA AVAPRO AVENTYL AVIANE 21 AVIANE 28 AVODART AXERT AXID AZARGA AZATHIOPRINE AZITHROMYCIN AZOPT BABY DDROPS BACIMYXIN BACITIN BACITRACIN BACITRACIN ZINC, POLYMYXIN B SULFATE BACLOFEN BACLOFEN BACTERIOSTATIC NACL BACTIGRAS BACTIGRAS 5X5CM BACTROBAN BALMINIL DM BALNETAR BARACLUDE BARRIERE BARRIERE HC BATTERIES - 1.5 VOLT BATTERIES - 3 VOLT BATTERIES - AAA BATTERIES - LITHIUM BATTERIES - SIZE J 6V BCI-ATENOLOL BCI-PRAVASTATIN BCI-RANITIDINE BCI-SIMVASTATIN B-D ALCOHOL SWAB B-D DISPOSABLE 5/8 INCH 5122 B-D DISPOSABLE INCH 5109 B-D DISPOSABLE 1 INCH 5155 B-D DISPOSABLE 1 INCH 5127 B-D DISPOSABLE 1 INCH 5156 B-D INJECT-EASE WITH MICROFINE B-D INSULIN 1/3CC 29G UF 1 B-D INSULIN 50U 29G B-D LANCET BD LATITUDE B-D MICRO-FINE B-D MICRO-FINE 1/3CC B-D MICRO-FINE INSULIN 100U B-D MICRO-FINE INSULIN 28G B-D MICRO-FINE INSULIN 50U B-D PEN B-D SHARPS CONTAINER 1.4L B-D SHARPS CONTAINER 3.1L B-D SHARPS CONTAINER 3.8L BD TEST B-D ULTRA-FINE B-D ULTRA-FINE / ULTRA-FINE II
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17 91 41 99 41 57 94 95 115 66 87 80 115 3 80 112 102 102 102 77 20 20 74 103 103 102 76 108 11 107 106 120 120 120 120 120 31 27 88 28 121 122 122 122 122 122 123 123 123 121 121 122 123 123 123 123 122 122 122 122 71 122 122
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B-D ULTRA-FINE II B-D ULTRA-FINE PEN B-D ULTRA-FINE PEN III BD ULTRA-FINE PEN NEEDLE 29G BECLOMETHASONE DIPROPIONATE BENADRYL BENADRYL CHILD BENAZEPRIL HCL BENOXYL BENURYL BENYLIN DM BENYLIN DM CHILD BENYLIN DM NIGHTTIME BENYLIN DM-D BENYLIN DM-D CHILD BENZAC AC BENZAC W BENZAC W5 BENZAGEL BENZAGEL 5 BENZOYL PEROXIDE BENZTROPINE BENZTROPINE MESYLATE BENZTROPINE OMEGA BENZYDAMINE HCL BETADERM BETADINE BETAGAN BETAHISTINE HCL BETAMETHASONE DIPROPIONATE BETAMETHASONE DIPROPIONATE IN PROPYLENE GLYCOL BETAMETHASONE DIPROPIONATE, CLOTRIMAZOLE BETAMETHASONE DIPROPIONATE, SALICYLIC ACID BETAMETHASONE DISODIUM PHOSPHATE BETAMETHASONE SODIUM PHOSPHATE, GENTAMICIN SULFATE BETAMETHASONE VALERATE BETAXIN BETAXOLOL HCL BETHANECHOL CHLORIDE BETNESOL BETOPTIC S BEZAFIBRATE BEZALIP SR BIAXIN BIAXIN XL BICALUTAMIDE BIMATOPROST BIOCAL-D FORTE BIODERM BIO-FUROSEMIDE BIO-HYDROCHLOROTHIAZIDE BISACODYL BISACODYL BISACODYL (POLYETHYLENE GLYCOL BASE) BISACOLAX 122 122 122 122 78 1 1 37 103 75 76 76 76 76 76 103 103 103 103 103 103 67 67 67 79 105 104 80 115 104 104 BISMUTH SUBSALICYLATE BISOPROLOL FUMARATE BLEPHAMIDE BONAMINE BOTOX BOTULINUM TOXIN TYPE A BREVICON 0.5/35 (21) BREVICON 0.5/35 (28) BREVICON 1/35 (21) BREVICON 1/35 (28) BRICANYL TURBUHALER BRIMONIDINE TARTRATE BRIMONIDINE TARTRATE (ALPHAGAN P) BRIMONIDINE TARTRATE, TIMOLOL MALEATE BRINZOLAMIDE BRINZOLAMIDE/TIMOLOL MALEATE BROMAZEPAM BROMAZEPAM BROMOCRIPTINE BROMOCRIPTINE MESYLATE BROMPHENIRAMINE MALEATE, DEXTROMETHORPHAN HBR, PHENYLEPHRINE HCL BROMPHENIRAMINE MALEATE, PHENYLEPHRINE HCL BRONCHOPHAN FORTE DM BUCKLEYS DM BUDESONIDE BUPROPION HCL BUPROPION HCL (WELLBUTRIN) BUPROPION HCL (ZYBAN) BURO-SOL BUSCOPAN BUSERELIN ACETATE BUSULFAN C 1000 C.E.S. CABERGOLINE CADUET CAFERGOT CAL-500 CAL-500-D CALCIMAR CALCIPOTRIOL CALCITE 500 + D 400 CALCITE D 500 CALCITE D-500 CALCITONIN SALMON (MIACALCIN) CALCITONIN SALMON (SYNTHETIC) CALCITRIOL CALCIUM CALCIUM 500 + D 400 CALCIUM 500MG WITH VIT D CALCIUM CARBONATE CALCIUM CARBONATE CALCIUM CARBONATE WITH D CALCIUM CARBONATE WITH VIT D CALCIUM CARBONATE, CHOLECALCIFEROL CALCIUM D-500

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83 32 78 86 115 115 95 95 95 95 19 79 80 80 80 80 65 65 68 68 76 CALCIUM LACTOGLUCONATE CALCIUM POLYSTYRENE SULFONATE CALCIUM WITHOUT SUGAR CALCIUM, VITAMIN D CAMPRAL CANDESARTAN CILEXETIL CANDESARTAN CILEXETIL, HYDROCHLOROTHIAZIDE CANESORAL CANESTEN CANESTEN 1 COMFORT COMBI PAK CANESTEN 3 COMFORT COMBI PAK CANTHACUR CANTHACUR PS CANTHARIDIN CANTHARIDIN, PODOPHYLLIN, SALICYLIC ACID CANTHARONE CANTHARONE PLUS CAPECITABINE CAPEX CAPOTEN CAPSAICIN CAPSAICIN CAPSAICIN HP CAPTOPRIL CAPTOPRIL CARBACHOL CARBAMAZEPINE CARBAMAZEPINE CARBOCAL D CARBOLITH CARDIZEM CD CARDURA 1 CARDURA 2 CARDURA 4 CARNITOR CARNITOR IV CARVEDILOL CASODEX CATAPRES CECLOR CECLOR BID CEENU CEFACLOR CEFADROXIL CEFIXIME CEFPROZIL CEFPROZIL MONOHYDRATE CEFTIN CEFUROXIME AXETIL CEFZIL CELEBREX CELECOXIB CELEXA CELLCEPT CELLUVISC CELONTIN CELSENTRI CENTER-AL CENTRUM JUNIOR COMPLETE CENTRUM MATERNA
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73 74 73 73 69 40 40 7 102 102 102 107 107 107 107 107 107 13 105 37 109 109 109 37 37 79 51 52 73 66 35 30 30 30 74 74 32 13 29 2 2 14 2 2 2 2 2 2 2 2 42 42 55 117 81 51 9 101 113 113
1 76 76 78 54 54 54 81 17 13 13 112 95 115 35 19 73 73 99 108 73 73 73 99 99 112 73 73 73 73 73 73 73 73 73
104 104 105 78
105 111 80 16 105 80 25 25 3 3 13 81 73 102 74 75 83 83 83 83
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CEPHALEXIN CEPHANOL CESAMET CETIRIZINE HCL CHAMPIX CHAMPIX STARTER PACK CHEMSTRIP BG CHEMSTRIP-BG CHILDREN'S ACETAMINOPHEN CHILDREN'S ADVIL CHILDREN'S MOTRIN CHILDREN'S TYLENOL SOFT CHEWS CHLORAMBUCIL CHLORAMPHENICOL CHLORHEXIDINE ACETATE CHLORHEXIDINE GLUCONATE CHLOROQUINE PHOSPHATE CHLORPHENIRAMINE MALEATE CHLORPHENIRAMINE MALEATE, DEXTROMETHORPHAN HBR, PSEUDOEPHEDRINE HCL CHLORPROMAZINE CHLORPROMAZINE HCL CHLORTHALIDONE CHLOR-TRIPOLON CHLOR-TRIPOLON ND CHOLECALCIFEROL CHOLEDYL CHOLESTYRAMINE RESIN CICLESONIDE CILAZAPRIL CILAZAPRIL, HYDROCHLOROTHIAZIDE CILOXAN CILOXAN 0.3% CIMETIDINE CIMETIDINE CIPRO CIPRO HC CIPRODEX CIPROFLOXACIN CIPROFLOXACIN HCL CIPROFLOXACIN HCL, DEXAMETHASONE CIPROFLOXACIN HCL, HYDROCORTISONE CIPROFLOXCIN CITALOPRAM CITALOPRAM CITALOPRAM-20 CITRIC ACID, MAGNESIUM OXIDE, SODIUM PICOSULFATE CITRIC ACID, SODIUM CITRATE CITRO MAG 15GM/300ML CLARITHROMYCIN CLARITIN CLARITIN EXTRA CLARITIN KIDS CLARUS CLAVULIN CLAVULIN 200 CLAVULIN 400 CLAVULIN-F CLAVULIN-F 125 2 50 87 1 21 21 71 71 49 43 43 50 13 77 103 79 12 1 76 CLAVULIN-F 250 CLEAR AWAY CLIMARA 100 CLIMARA 25 CLIMARA 50 CLIMARA 75 CLINDAMYCIN HCL CLINDAMYCIN PALMITATE HCL CLINDAMYCIN PHOSPHATE CLINDAMYCINE CLINITEST CLOBAZAM CLOBAZAM CLOBETASOL PROPIONATE CLOBETASOL PROPIONATE CLOBETASONE BUTYRATE CLOMIPRAMINE CLOMIPRAMINE HCL CLONAPAM CLONAZEPAM CLONAZEPAM CLONIDINE CLONIDINE HCL CLOPIDOGREL BISULFATE CLOSTRIDIUM BOTULINUM NEUROTOXIN CLOTRIMADERM CLOTRIMAZOLE CLOXACILLIN CLOXACILLINE CLOZAPINE CLOZARIL CO ALENDRONATE CO AMLODIPINE CO ATENOLOL CO ATORVASTATIN CO AZITHROMYCIN CO BICALUTAMIDE CO CABERGOLINE CO CILAZAPRIL CO CIPROFLOXACIN CO CITALOPRAM CO CLOMIPRAMINE CO CLONAZEPAM CO ENALAPRIL CO ETIDRONATE CO FAMCICLOVIR CO FLUCONAZOLE CO FLUVOXAMINE CO GABAPENTIN CO LEVETIRACETAM CO LISINOPRIL CO LOVASTATIN CO MELOXICAM CO METFORMIN CO MIRTAZAPINE CO NORFLOXACIN CO OLANZAPINE CO OLANZAPINE ODT CO PANTOPRAZOLE CO PAROXETINE CO PIOGLITAZONE CO PRAMIPEXOLE CO PRAVASTATIN

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4 108 96 96 96 96 6 7 102 6 72 65 65 105 105 105 55 55 51 50 51 29 29 23 115 102 102 4 4 60 60 114 35 31 26 3 13 115 37 5 55 55 51 38 116 11 7 56 52 53 39 27 44 97 57 5 61 61 89 58 99 68 27
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CO QUETIAPINE CO RAMIPRIL CO RANITIDINE CO RISPERIDONE CO SERTRALINE CO SIMVASTATIN CO SOTALOL CO SUMATRIPTAN CO TEMAZEPAM CO TERBINAFINE CO TOPIRAMATE CO VENLAFAXINE XR COAL TAR COAL TAR, JUNIPER TAR, PINE TAR COAL TAR, JUNIPER TAR, PINE TAR, ZINC PYRITHIONE COAL TAR, SALICYLIC ACID COAL TAR, SALICYLIC ACID, SULFUR CODEINE CODEINE CONTIN CR CODEINE MONOHYDRATE, CODEINE SULFATE TRIHYDRATE CODEINE PHOSPHATE CODEINE PHOSPHATE CO-ETIDROCAL CO-FLUOXETINE COLACE COLCHICINE COLCHICINE COLESTID COLESTID ORANGE COLESTIPOL HCL CO-LEVOFLOXACIN COLLAGENASE COLYTE COMBANTRIN COMBIGAN COMBIVENT COMBIVIR COMTAN CONDOM, FEMALE CONDOM, LATEX, LUBRICATED CONDOM, LATEX, LUBRICATED, NONOXYNOL CONDOM, LATEX, NONLUBRICATED CONDOM, MALE CONDOM, NON-LATEX, LUBRICATED CONDYLINE CONJUGATED ESTROGENS CONJUGATED ESTROGENS, MEDROXYPROGESTERONE ACETATE CO-ONDANSETRON CORDARONE CO-ROPINIROLE CORTATE CORTEF CORTENEMA CORTIFOAM CORTISONE CORTISONE ACETATE CORTISPORIN 62 40 88 63 58 28 34 67 66 7 53 59 108 108 108 108 108 46 46 46 46 46 116 56 83 115 115 25 25 25 5 109 84 2 80 17 9 67 70 70 70 70 70 70 108 95 95
59 59 75 1 1 112 110 25 93 37 38 77 77 87 87 5 77 77 5 5 77 77 5 55 55 55 83 73 73 3 1 1 1 109 4 4 4 4 4
86 25 68 106 93 106 106 93 93 78
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CORTODERM COSOPT COTAZYM COTAZYM ECS 8 COTAZYM ECS 20 COTAZYM ECS4 COUGH SYRUP COUGH SYRUP DEXTROMETHORPHAN COUMADIN COVERA-HS COVERSYL COVERSYL PLUS COVERSYL PLUS HD COZAAR CREON 10 MINIMICROSPHERES CREON 20 MINIMICROSPHERES CREON 25 MINIMICROSPHERES CREON 5 MINIMICROSPHERES CRESTOR CRIXIVAN CROMOLYN CROTAMITON CTP CUPRIC SULFATE CUPRIMINE CUTIVATE CYANOCOBALAMIN CYANOCOBALAMIN CYCLEN (21) CYCLEN (28) CYCLOBENZAPRINE CYCLOBENZAPRINE HCL CYCLOCORT CYCLOGYL CYCLOMEN CYCLOPENTOLATE CYCLOPENTOLATE HCL CYCLOPENTOLATE MINIMS CYCLOPHOSPHAMIDE CYCLOSPORINE CYESTRA-35 CYKLOKAPRON CYMBALTA CYPROTERONE ACETATE CYPROTERONE ACETATE, ETHINYL ESTRADIOL CYTOVENE CYTOXAN D VI SOL DAIRY DIGESTIVE DAIRY DIGESTIVE EXTRA STRENGTH DAIRY FREE DAIRY FREE EXTRA STRENGTH DAIRYAID DALACIN DALACIN C DALACIN T DALTEPARIN SODIUM DANAZOL DANTRIUM DANTROLENE SODIUM DARAPRIM DARIFENACIN HYDROBROMIDE 106 80 85 85 85 85 76 76 23 36 39 39 39 41 85 85 85 85 27 9 76 103 55 72 92 106 111 111 95 95 19 19 104 79 94 79 79 79 13 115 115 24 56 13 115 11 13 112 85 85 85 85 85 102 6 102 22 94 20 20 12 110 DARUNAVIR DDAVP DDAVP MELT DDROPS VITAMIN D DELATESTRYL DELSYM DEMEROL DEMULEN 30 (21) DEMULEN 30 (28) DEPAKENE DEPO-MEDROL DEPO-PROVERA DEPO-TESTOSTERONE DERMAFLEX HC DERMA-SMOOTHE DERMAZIN DERMOVATE DESIPRAMINE DESIPRAMINE HCL DESMOPRESSIN ACETATE DESOCORT DESONIDE DESOXIMETASONE DESQUAM X DESYREL DESYREL DIVIDOSE DETROL DETROL LA DEXAMETHASONE DEXAMETHASONE DEXAMETHASONE PHOSPHATE DEXAMETHASONE, TOBRAMYCIN DEXAMETHASONE-OMEGA DEXASONE DEXEDRINE DEXEDRINE SPANSULE DEXIRON DEXTRAN 70, HYDROXYPROPYLMETHYLCELL ULOSE DEXTROAMPHETAMINE SULFATE DEXTROMETHORPHAN HBR DEXTROMETHORPHAN HBR, PSEUDOEPHEDRINE HCL D-FORTE DIABETA DIAMICRON DIAMICRON MR DIANE-35 DIAPHRAGM DIARR-EZE DIARRHEA RELIEF DIASTIX DIAZEPAM DIAZEPAM DIAZOXIDE DICITRATE DICLECTIN DICLOFENAC SODIUM DICLOFENAC SODIUM, MISOPROSTOL DICLOFENAC-25 DICLOFENAC-50

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8 99 99 112 94 76 47 94 94 54 93 100 94 106 105 104 105 55 55 99 105 105 105 103 59 59 110 110 78 93 93 78 93 93 64 64 22 81 DICLOFENAC-SR DIDANOSINE DIDROCAL DIDRONEL DIFFERIN DIFLUCAN DIFLUCORTOLONE VALERATE DIFLUCORTOLONE VALERATE, SALICYLIC ACID DIFLUNISAL DIGOXIN DIHYDROERGOTAMINE DIHYDROERGOTAMINE MESYLATE DIIODOHYDROXYQUIN DILANTIN DILANTIN 30 DILANTIN 125 DILANTIN INFATABS DILAUDID DILAUDID HP DILAUDID HP PLUS DILAUDID XP DILTIAZEM DILTIAZEM CD DILTIAZEM HCL DIMENHYDRINATE DIMENHYDRINATE DIMETAPP COLD DIMETAPP DM COUGH & COLD DIMETHICONE DIOCARPINE DIOCHLORAM DIOCTYL CALCIUM SULFOSUCCINATE DIOCTYL SODIUM SULFOSUCCINATE DIOCTYL SODIUM SULFOSUCCINATE, SENNA DIOCTYL SODIUM SULFOSUCCINATE, SENNOSIDES DIODEX DIODOQUIN DIOGENT DIONEPHRINE DIOPENTOLATE DIOPRED DIOPTIMYD DIOSULF DIOVAN DIOVAN-HCT DIPENTUM DIPHENHYDRAMINE DIPHENHYDRAMINE HCL DIPHENHYDRAMINE HCL DIPIVEFRIN HCL DIPIVEFRIN HCL, LEVOBUNOLOL HCL DIPROLENE DIPROSALIC DIPROSONE DIPYRIDAMOLE DIPYRIDAMOLE, ACETYLSALICYLIC ACID DISOPYRAMIDE
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43 8 116 116 107 7 105 105 43 25 19 19 12 51 51 51 51 47 47 47 47 36 35 35 85 85 1 76 107 80 77 83 83 83 84
64 76 76 112 98 98 98 115 70 83 83 72 65 65 29 73 86 42 43 42 42
78 12 77 79 79 78 78 77 41 41 90 1 1 1 79 81 104 104 104 30 30 25
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DITHRANOL DIVALPROEX EC DIVALPROEX SODIUM DIXARIT DM COUGH SYRUP DM SANS SUCRE DOCUSATE CALCIUM DOCUSATE SODIUM DOCUSATE SODIUM DOLASETRON MESYLATE DOLICHOVESPULA ARENARIA VENOM PROTEIN DOLICHOVESPULA MACULATA VENOM PROTEIN EXTRACT DOLORAL 1 DOLORAL 5 DOM-AMANTADINE DOM-AMITRIPTYLINE DOM-AMLODIPINE DOM-ATENOLOL DOM-BACLOFEN DOM-BENZYDAMINE DOM-BROMOCRIPTINE DOM-CAPTOPRIL DOM-CARBAMAZEPINE CR DOM-CARVEDILOL DOM-CEFACLOR DOM-CEPHALEXIN DOM-CIMETIDINE DOM-CIPROFLOXACIN DOM-CITALOPRAM DOM-CLOBAZAM DOM-CLONAZEPAM DOM-CLONAZEPAM-R DOM-CYCLOBENZAPRINE DOM-DESIPRAMINE DOM-DICLOFENAC DOM-DICLOFENAC SR DOM-DOCUSATE SODIUM DOM-DOMPERIDONE DOM-FLUOXETINE DOM-FLUVOXAMINE DOM-FUROSEMIDE DOM-GABAPENTIN DOM-GEMFIBROZIL DOM-GLYBURIDE DOM-HYDROCHLOROTHIAZIDE DOM-INDAPAMIDE DOM-IPRATROPIUM DOM-LEVOFLOXACIN DOM-LOPERAMIDE DOM-LORAZEPAM DOM-LOXAPINE DOM-MEDROXYPROGESTERONE DOM-MEFENAMIC ACID DOM-MELOXICAM DOM-METFORMIN DOM-METOPROLOL-B DOM-METOPROLOL-L DOM-MINOCYCLINE DOM-MIRTAZAPINE DOM-NIFEDIPINE DOM-NIZATIDINE DOM-NORTRIPTYLINE DOM-NYSTATIN 107 52 52 29 76 76 83 83 84 86 101 101 48 48 8 54 34 31 20 79 68 37 51 32 2 2 87 5 55 65 51 51 19 55 42 43 83 86 56 56 74 52 26 98 75 75 17 5 83 65 60 100 44 44 97 33 33 6 57 35 87 57 7 DOM-OXYBUTYNIN DOM-PAROXETINE DOMPERIDONE DOMPERIDONE MALEATE DOM-PINDOLOL DOM-PIOGLITAZONE DOM-PIROXICAM DOM-PRAVASTATIN DOM-PROPRANOLOL DOM-SALBUTAMOL DOM-SELEGILINE DOM-SERTRALINE DOM-SIMVASTATIN DOM-SOTALOL DOM-SUMATRIPTAN DOM-TEMAZEPAM DOM-TERAZOSIN DOM-TIAPROFENIC DOM-TIMOLOL DOM-TOPIRAMATE DOM-TRAZODONE DOM-VALPROIC ACID DOM-VERAPAMIL SR DONEPEZIL HCL DORZOLAMIDE HCL DORZOLAMIDE HCL, TIMOLOL MALEATE DOSTINEX DOVONEX DOXAZOSIN DOXAZOSIN MESYLATE DOXEPIN HCL DOXEPINE DOXYCIN DOXYCYCLINE DOXYCYCLINE DOXYLAMINE SUCCINATE, PYRIDOXINE HCL DOXYTAB DRISDOL D-TABS DULCOLAX DULOXETINE HCL DUO TRAV DUOFILM DUOFORTE 27 DUOLUBE DUOPLANT DURAGESIC MAT DUTASTERIDE DUVOID EDECRIN EES-600 EFAVIRENZ EFAVIRENZ, EMTRICITABINE, TENOFOVIR DISOPROXIL FUMARATE EFFEXOR XR EFUDEX EGOZINC HC EGOZINC-HC ELAVIL ELECTROLYTE & DEXTROSE ELIDEL ELIGARD

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110 58 86 86 33 99 45 27 34 18 69 58 28 34 67 66 30 45 80 53 59 54 37 16 80 80 115 108 30 30 56 56 6 6 6 86 6 112 112 83 56 81 108 108 81 108 46 115 16 74 3 8 8 ELMIRON ELOCOM ELTROXIN EMEND EMEND TRI PACK EMLA EMO CORT EMO CORT SCALP EMTRICITABINE, TENOFOVIR DISOPROXIL FUMARATE ENABLEX ENALAPRIL MALEATE ENALAPRIL MALEATE, HYDROCHLOROTHIAZIDE ENBREL ENBREL SURECLICK ENCORE ENDOCET ENEMOL ENOXAPARIN SODIUM ENTACAPONE ENTECAVIR ENTOCORT ENTROPHEN ENTROPHEN 10 ENTROPHEN EC ENTROPHEN-10 ENTROPHEN-5 EPINEPHRINE EPINEPHRINE EPIPEN EPIPEN JR EPIVAL EPOSARTAN MESYLATE EPOSARTAN MESYLATE, HYDROCHLOROTHIAZIDE ERDOL ERGOCALCIFEROL ERGOTAMINE TARTRATE, CAFFEINE ERLOTINIB HYDROCLORIDE ERYC ERYTHRO ERYTHRO-ES ERYTHROMYCIN ERYTHROMYCIN ERYTHROMYCIN ESTOLATE ERYTHROMYCIN ETHYLSUCCINATE ERYTHROMYCIN STEARATE ERYTHROMYCIN, TRETINOIN ESTALIS 140/50 ESTALIS 250/50 ESTRACE ESTRADERM ESTRADIOL ESTRADIOL (ESTRADIOL HEMIHYDRATE) ESTRADIOL, NORETHINDRONE ACETATE ESTRADOT 100 ESTRADOT 25 ESTRADOT 37.5 ESTRADOT 50 ESTRADOT 75
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117 107 100 86 86 107 106 106 9 110 38 38 116 116 71 46 85 22 67 11 105 42 42 42 42 42 19 19 19 19 52 41 41 116 112 19 13 3 3 3 3 3 3 3 3 102 96 96 96 96 95 96 96 96 95 95 96 96
59 109 106 106 54 73 109 14
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ESTRING ESTROGEL ESTRONE ESTROPIPATE ETANERCEPT ETHACRYNIC ACID ETHAMBUTOL HCL ETHINYL ESTRADIOL, DESOGESTREL ETHINYL ESTRADIOL, DNORGESTREL ETHINYL ESTRADIOL, DROSPIRENONE ETHINYL ESTRADIOL, ETHYNODIOL DIACETATE ETHINYL ESTRADIOL, ETONOGESTREL ETHINYL ESTRADIOL, LEVONORGESTREL ETHINYL ESTRADIOL, NORETHINDRONE ETHINYL ESTRADIOL, NORETHINDRONE ACETATE ETHINYL ESTRADIOL, NORGESTIMATE ETHOPROPAZINE HCL ETHOSUXIMIDE ETIBI ETIDRONATE DISODIUM ETIDRONATE DISODIUM, CALCIUM CARBONATE ETOPOSIDE ETRAVIRINE EUFLEX EUGLUCON EUMOVATE EURAX EURO D EURO-ASA EURO-CAL EURO-CAL D EURO-DOCUSATE EURO-FER EURO-FERROUS SULFATE EURO-FOLIC EURO-K 20 EURO-K 600 EURO-K8 EURO-LAC EURO-SENNA EURO-SENNA S EUTHYROX EVISTA EXDOL-15 EXDOL-30 EXELON EXEMESTANE EXTEMPORANEOUS MIXTURE EXTEMPORANEOUS MIXTURE EZ HEALTH ORACLE (100) EZ HEALTH ORACLE (50) EZ HEALTH ORACLE LANCETS E-Z SPACER E-Z SPACER (MASK ONLY) E-Z SPACER WITH SMALL MASK EZETIMIBE 96 95 96 96 116 74 7 94 94 94 94 94 94 95 95 95 67 51 7 116 116 13 9 13 98 105 103 112 42 73 73 83 22 22 111 73 73 73 84 84 84 100 96 45 45 17 13 116 116 71 71 121 120 120 120 25 EZETROL FAMCICLOVIR FAMOTIDINE FAMOTIDINE FAMVIR FASTTAKE FELODIPINE FEMARA FEMHRT FENOFIBRATE FENOMAX FENO-MICRO FENTANYL FER-IN-SOL FERODAN FERRATE O/L FERROUS FUMARATE FERROUS FUMARATE FERROUS GLUCONATE FERROUS GLUCONATE FERROUS SULFATE FERROUS SULFATE FEVERHALT FEXOFENADINE HCL FIBER FILGRASTIM FINASTERIDE FINGERSTIX FLAGYL FLAGYSTATIN FLAMAZINE FLAMAZINE 50G FLAREX FLAVOXATE HCL FLECAINIDE ACETATE FLEET ENEMA FLEET ENEMA PEDIATRIC FLEXI-T IUD FLINTSTONES EXTRA C FLOCTAFENINE FLOMAX CR FLONASE FLORINEF FLOVENT DISKUS FLOVENT HFA 125 FLOVENT HFA 250 FLOVENT HFA 50 FLUANXOL FLUANXOL DEPOT FLUCONAZOLE FLUDARA FLUDARABINE PHOSPHATE FLUDROCORTISONE ACETATE FLUMETHASONE PIVALATE, CLIOQUINOL FLUNARIZINE HCL FLUNISOLIDE FLUOCINOLONE ACETONIDE FLUOCINONIDE FLUOROMETHOLONE FLUOROMETHOLONE ACETATE FLUOROURACIL FLUOXETINE FLUOXETINE HCL

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25 11 87 87 11 71 35 14 96 26 26 26 46 22 22 22 22 22 22 22 22 22 49 1 84 24 116 121 104 104 104 104 78 110 25 85 85 70 113 50 118 78 93 93 93 93 93 60 60 7 13 13 93 78 116 78 105 105 78 78 109 56 56 FLUPENTHIXOL DECANOATE FLUPENTHIXOL DIHYDROCHLORIDE FLUPHENAZINE FLUPHENAZINE DECANOATE FLUPHENAZINE HCL FLUPHENAZINE OMEGA FLURBIPROFEN FLURBIPROFEN FLURBIPROFEN SODIUM FLUTAMIDE FLUTICASONE PROPIONATE FLUVASTATIN SODIUM FLUVOXAMINE FLUVOXAMINE MALEATE FML FML FORTE FOLIC ACID FOLIC ACID FORADIL FORMALDEHYDE, LACTIC ACID, SALICYLIC ACID FORMOTEROL FUMARATE FORMOTEROL FUMARATE DIHYDRATE FORMOTEROL FUMARATE DIHYDRATE, BUDESONIDE FOSAMAX FOSAMPRENAVIR CALCIUM FOSAVANCE FOSINOPRIL FOSINOPRIL SODIUM FRAGMIN FRAMYCETIN SULFATE FRAMYCETIN SULFATE, GRAMICIDIN, DEXAMETHASONE FRAXIPARINE FRAXIPARINE FORTE FREESTYLE FREESTYLE LITE FRISIUM FUCIDIN FUCIDIN FC FUROSEMIDE FUROSEMIDE FUSIDATE SODIUM FUSIDIC ACID FXT GABAPENTIN GABAPENTIN GALANTAMINE GANCICLOVIR SODIUM GARAMYCIN GARAMYCIN OTIC GARASONE GARASONE OPHTH/OTIC GASTROLYTE REG GD-AMLODIPINE GD-ATORVASTATIN GEMFIBROZIL GEMFIBROZIL GEN-ACEBUTOLOL GEN-ACEBUTOLOL (TYPE S) GEN-ACYCLOVIR GEN-ALENDRONATE
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60 60 60 60 60 60 43 43 79 13 78 27 56 56 78 78 111 111 18 108 18 18 18 114 9 114 38 38 22 77 78 23 23 72 72 65 102 7 74 74 7 102 56 52 52 16 11 77 77 78 78 73 34 26 26 26 31 31 11 114
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GEN-ALPRAZOLAM GEN-AMANTADINE GEN-AMILAZIDE GEN-AMIODARONE GEN-AMLODIPINE GEN-AMOXICILLIN GEN-ANAGRELIDE GEN-ATENOLOL GEN-AZITHROMYCIN GEN-BACLOFEN GEN-BECLO AQ GEN-BICALUTAMIDE GEN-BROMAZEPAM GEN-BUDESONIDE AQ GEN-CAPTOPRIL GEN-CARBAMAZEPINE CR GEN-CILAZAPRIL GEN-CIMETIDINE GEN-CIPROFLOXACIN GEN-CITALOPRAM GEN-CLARITHROMYCIN GEN-CLINDAMYCIN GEN-CLOBETASOL GEN-CLONAZEPAM GEN-CLOZAPINE GEN-COMBO GEN-CYCLOPRINE GEN-CYPROTERONE GEN-DILTIAZEM GEN-DIVALPROEX GEN-DOMPERIDONE GEN-DOXAZOSIN GEN-ENALAPRIL GEN-ETI-CAL CP GEN-ETIDRONATE GEN-FAMOTIDINE GEN-FENOFIBRATE GEN-FIBRO GEN-FLUCONAZOLE GEN-FLUOXETINE GEN-FOSINOPRIL GEN-GABAPENTIN GEN-GEMFIBROZIL GEN-GLICLAZIDE GEN-GLYBE GEN-HYDROXYCHLOROQUINE GEN-HYDROXYUREA GEN-INDAPAMIDE GEN-IPRATROPIUM GEN-IPRATROPIUM UDV GEN-LAMOTRIGINE GEN-LEFLUNOMIDE GEN-LEVOFLOXACIN GEN-LISINOPRIL GEN-LISINOPRIL HCTZ GEN-LOVASTATIN GEN-MEDROXY GEN-MELOXICAM GEN-METFORMIN GEN-METOPROLOL GEN-METOPROLOL (TYPE L) GEN-METOPROLOL-L GEN-MIRTAZAPINE GEN-NAPROXEN 64 8 74 25 35 4 23 31 3 20 78 13 65 78 37 51 37 87 5 55 3 6 105 51 60 17 19 13 35 52 86 30 38 116 116 87 26 26 7 56 38 52 26 98 98 12 13 75 17 17 53 116 5 39 39 27 100 44 97 33 33 33 57 44

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GEN-NAPROXEN EC GEN-NIFEDIPINE XL GEN-NITRO GEN-NIZATIDINE GEN-NORTRIPTYLINE GEN-ONDANSETRON GEN-ONDANSETRON 8MG TAB GEN-OXYBUTYNIN GEN-PANTOPRAZOLE GEN-PAROXETINE GEN-PINDOLOL GEN-PIOGLITAZONE GEN-PIROXICAM GEN-PRAVASTATIN GEN-PROPAFENONE GEN-QUETIAPINE GEN-RAMIPRIL GEN-RANITIDINE GEN-RISPERIDONE GEN-SALBUTAMOL GEN-SALBUTAMOL PF GEN-SELEGILINE GEN-SERTRALINE GEN-SERTRALINE (ONT) GEN-SIMVASTATIN GEN-SOTALOL GEN-SUMATRIPTAN GENTAMICIN GENTAMICIN SULFATE GEN-TAMOXIFEN GEN-TAMSULOSIN GEN-TEMAZEPAM GEN-TERBINAFINE GEN-TICLOPIDINE GEN-TIMOLOL GEN-TIZANIDINE GEN-TOPIRAMATE GEN-TRAZODONE GEN-TRIAZOLAM GEN-VALPROIC GEN-VENLAFAXINE XR GEN-VERAPAMIL GEN-VERAPAMIL SR GEN-WARFARIN GLEEVEC GLICLAZIDE GLICLAZIDE GLUCAGON GLUCAGON RECOMBINANT DNA ORGIN GLUCOBAY GLUCOFILM GLUCOLET GLUCOLET 2 GLUCOMETER BATTERIES GLUCONORM GLUCOPHAGE GLUCOSE OXIDASE, PEROXIDASE GLYBURIDE GLYBURIDE GLYCERIN GLYCERIN INFANT GLYCERIN INFANT & CHILD GLYCERINE 44 35 30 87 57 86 86 110 89 58 33 99 45 27 25 62 40 88 63 18 18 69 58 58 28 34 67 77 77 15 118 66 7 24 80 20 53 59 66 54 59 37 36 23 14 98 98 99 99 96 71 121 121 120 98 97 71 98 98 84 84 84 84 GLYCERINE GLYCON GOLIMUMAB GOLYTELY GOSERELIN ACETATE GPI-LACTULOSE GRAMICIDIN, NEOMYCIN SULFATE, POLYMYXIN B SULFATE GRAMICIDIN, POLYMYXIN B SULFATE GRANISETRON GRAVOL HABITROL HALCINONIDE HALOBETASOL PROPIONATE HALOG HALOPERIDOL HALOPERIDOL HALOPERIDOL DECANOATE HALOPERIDOL LA HEPALEAN HEPALEAN LOK HEPARIN LEO HEPARIN LOCK FLUSH HEPARIN SODIUM HEPSERA HEPTOVIR HERPLEX-D LIQUIFILM HEXALEN HEXIT HOMATROPINE HBR HONEY BEE VENOM HONEY BEE VENOM PROTEIN EXTRACT HP-PAC HUMALOG HUMALOG 10ML HUMALOG CARTRIDGE HUMATIN HUMIRA HUMIRA PEN HUMIRA PRE-FILL HUMULIN 20/80 CARTRIDGE HUMULIN 30/70 HUMULIN 30/70 CARTRIDGE HUMULIN L 10ML HUMULIN N HUMULIN N 10ML HUMULIN N CARTRIDGE HUMULIN R 10ML HUMULIN R CARTRIDGE HYCORT HYDERM HYDRA SENSE (ISOTONIC, STERILE SEAWATER) HYDRALAZINE HYDRALAZINE HCL HYDREA HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE HYDROCORTISONE HYDROCORTISONE ACETATE HYDROCORTISONE ACETATE, ZINC SULFATE
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84 97 116 84 13 84 77
77 86 85 20 106 106 106 60 60 60 60 22 23 23 22 22 11 9 102 13 103 79 101 101 88 98 98 98 12 114 114 114 97 98 98 98 97 97 97 97 97 106 106 82 29 29 13 74 75 93 106 106
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HYDROCORTISONE ACETATE, ZINC SULFATE, PRAMOXINE HCL HYDROCORTISONE VALERATE HYDROCORTISONE, DIBUCAINE HCL, ESCULIN, FRAMYCETIN SULFATE HYDROCORTISONE, NEOMYCIN SULFATE, POLYMYXIN B SULFATE HYDROCORTISONE, UREA HYDROGEN PEROXIDE HYDROGEN PEROXIDE 10V HYDROMORPH CONTIN HYDROMORPHONE HYDROMORPHONE HCL HYDROMORPHONE HP 10 HYDROMORPHONE HP 20 HYDROMORPHONE HP 50 HYDROVAL HYDROXYCHLOROQUINE SULFATE HYDROXYPROPYLCELLULOSE HYDROXYPROPYLMETHYLCELL ULOSE HYDROXYUREA HYDROXYZINE HYDROXYZINE HCL HYPOTEARS HYTRIN HYZAAR HYZAAR DS IBUPROFEN IBUPROFEN IDOXURIDINE IHLES PASTE IMATINIB MESYLATE IMDUR IMIPRAMINE IMIPRAMINE HCL IMITREX IMITREX DF IMODIUM IMURAN INDAPAMIDE INDAPAMIDE INDERAL LA INDINAVIR SULFATE INDOMETHACIN INFANTOL INFLIXIMAB INFUFER INFUSION SETS INHIBACE INHIBACE PLUS INNOHEP INSULIN (30% NEUTRAL & 70% ISOPHANE) HUMAN BIOSYNTHETIC INSULIN (40% NEUTRAL & 60% ISOPHANE) HUMAN BIOSYNTHETIC INSULIN (50% NEUTRAL & 50% ISOPHANE) HUMAN BIOSYNTHETIC INSULIN (ISOPHANE) HUMAN BIOSYNTHETIC 106 106 106 INSULIN (ZINC CRYSTALLINE) HUMAN BIOSYNTHETIC (RDNA ORIGIN) INSULIN ASPART INSULIN GLULISINE INSULIN HUMAN BIOSYNTHETIC INSULIN HUMAN BIOSYNTHETIC 20% & ISOPHANE 80% INSULIN HUMAN BIOSYNTHETIC 30% & ISOPHANE 70% INSULIN LISPRO INSULIN LO DOSE MICRO 28G INSULIN PUMP BATTERY INSULIN PUMP CARTRIDGES INSULIN PUMP SUPPLIES INSULIN ZINC SUSPENSION MEDIUM HUMAN BIOSYNTHETIC (RDNA ORIGIN) INTELENCE INTERFERON ALFA-2B INTRAUTERINE DEVICE INTRON A INVIRASE IOPIDINE IPECAC IPECAC IPRATROPIUM BROMIDE IPRATROPIUM BROMIDE, SALBUTAMOL IRBESARTAN IRBESARTAN, HYDROCHLOROTHIAZIDE IRON DEXTRAN ISENTRESS ISONIAZID ISOPROPYL ALCOHOL ISOPROPYL MYRISTATE ISOPTIN SR ISOPTO ATROPINE ISOPTO CARBACHOL ISOPTO CARPINE ISOPTO HOMATROPINE ISOPTO TEARS ISOSORBIDE ISOSORBIDE DINITRATE ISOSORBIDE-5-MONONITRATE ISOTAMINE ISOTRETINOIN ITEST ITEST LANCETS 28G (100) ITEST LANCETS 33G (100) ITRACONAZOLE JAMP IBUPROFEN JAMP ONDANSETRON JAMP SULFATE FERREUX JAMP VIT D3 JAMP-AMLODIPINE JAMP-ASA JAMP-BISACODYL JAMP-CALCIUM+VITAM D JAMP-CITALOPRAM JAMP-DIPHENHYDRAMINE JAMP-DOCUSATE CALCIUM JAMP-FOSINOPRIL JAMP-MAGNESIUM GLUCONATE

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97 JAMP-MULTIVITAMIN A/D/C DROPS JAMP-PRAVASTATIN JAMP-QUETIAPINE JAMP-RAMIPRIL JAMP-SENNOSIDES JAMP-SIMVASTATIN JAMP-VITAMIN B1 JAMP-VITAMIN D K 10 K LYTE KADIAN KADIAN SR KALETRA KAYEXALATE K-DUR KENALOG-10 KENALOG-40 KEPPRA KETOCONAZOLE KETODERM KETOPROFEN KETOPROFEN-SR KETOROLAC TROMETHAMINE KETOSTIX KETOTIFEN FUMARATE K-EXIT KIVEXA KLEAN-PREP KOFFEX DM KWELLADA-P KYTRIL LABETALOL HCL LACRI LUBE LACRISERT LAMELLE LACTAID LACTAID EXTRA STRENGTH LACTASE LACTIC ACID, SALICYLIC ACID LACTOSE LACTRASE LACTULOSE LACTULOSE LAMICTAL LAMISIL LAMIVUDINE LAMIVUDINE, ZIDOVUDINE LAMOTRIGINE LAMOTRIGINE LANCET LANCING DEVICE LANOXIN LANREOTIDE LANSOPRAZOLE LANSOPRAZOLE ODT LANSOYL GEL LANSOYL GEL SUGARFREE LANVIS LASIX LATANOPROST LAX-A-DAY LECTOPAM LEFLUNOMIDE LENOLTEC NO.4
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113 27 62 40 84 28 111 112 73 73 48 48 9 74 73 94 94 53 7 102 44 44 79 72 1 74 8 84 76 103 86 32 81 119 85 85 85 108 124 85 84 84 53 7 9 9 53 53 121 121 25 116 88 88 84 84 15 74 81 84 65 116 45
78
97 97 97 97 98 98 123 121 121 121 98
106 104 104 47 47 47 47 47 47 106 12 119 81 13 66 66 81 30 41 41 43 43 102 107 14 29 57 57 67 67 83 115 75 75 33 9 44 112 116 22 121 37 38 23 97
9 14 70 14 9 81 85 85 17 17 41 41 22 9 8 121 103 36 79 79 80 79 81 29 29 29 8 109 72 121 121 7 43 86 22 112 35 42 83 73 55 1 83 38 73
97
97
97
2010
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LESCOL LESCOL XL LETROZOLE LETROZOLE LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM LEUKERAN LEUPROLIDE ACETATE LEVAQUIN LEVATE LEVENOX HP LEVETIRACETAM LEVOBUNOLOL HCL LEVOCABASTINE HCL LEVOCARNITINE LEVODOPA, BENZERAZIDE LEVODOPA, CARBIDOPA LEVODOPA, CARBIDOPA,ENTACAPONE LEVOFLOXACIN LEVOFLOXACIN LEVONEX HP LEVONORGESTREL LEVOTHYROXINE SODIUM LIDEMOL LIDEX LIDOCAINE HCL LIDOCAINE, PRILOCAINE LIDODAN VISCOUS LIFE BRAND LIFESCAN FINE POINT LIFESCAN REGULAR LINCTUS CODEINE LINDANE LINESSA (21) LINESSA (28) LINEZOLID LIORESAL LIORESAL DS LIPASE, AMYLASE, PROTEASE LIPIDIL EZ LIPIDIL MICRO LIPIDIL SUPRA LIPITOR LIQUIFILM TEARS LISINOPRIL LISINOPRIL, HYDROCHLOROTHIAZIDE LITHANE LITHIUM CARBONATE LITHIUM CITRATE LIVOSTIN LOCACORTEN VIOFORM LODOXAMIDE TROMETHAMINE LOESTRIN 1.5/30 (21) LOESTRIN 1.5/30 (28) LOMUSTINE LONITEN LOPERAMIDE LOPERAMIDE HCL LOPID LOPINAVIR, RITONAVIR LOPRESOR LOPRESOR SR 27 27 14 14 117 117 13 14 5 54 22 53 80 77 74 67 68 68 5 5 22 95 100 105 105 107 107 107 72 121 121 46 103 94 94 7 20 20 85 26 26 26 26 81 39 39 66 66 66 77 78 81 95 95 14 29 83 83 26 9 33 32 LORATADINE LORATADINE LORATADINE, PSEUDOEPHEDRINE SULFATE LORAZEPAM LOSARTAN POTASSIUM LOSARTAN POTASSIUM, HYDROCHLOROTHIAZIDE LOSEC LOTENSIN LOTRIDERM LOVASTATIN LOVENOX LOXAPINE HCL LOXAPINE SUCCINATE LOZIDE LUER LOCK (DISP) 3CC LUER LOCK (DISP) 5CC LUER LOCK (DISP) 10CC LUER LOCK (DISP) 20CC LUER LOCK (DISP) 30CC LUER LOCK (DISP) 60CC LUMIGAN LUPRON DEPOT LUVOX LYDERM LYSODREN M.O.S. 10 M.O.S. 20 M.O.S. 40 M.O.S. 50 M.O.S. 60 M.O.S. SR M.O.S. SULFATE MACROBID MACRODANTIN MACROGOL, POTASSIUM CHLORIDE, SODIUM BICARBONATE, SODIUM CHLORIDE, SODIUM SULFATE MACROGOL, PROPYLENE GLYCOL MAG OXIDE MAGIC BULLET MAGNESIUM MAGNESIUM MAGNESIUM CITRATE MAGNESIUM GLUCONATE MAGNESIUM HYDROXIDE MAGNESIUM OXIDE MAGNIFIER MAJEPTIL MANERIX MAPROTILINE HCL MARAVIROC MARVELON (21) MARVELON (28) MATERNA MAVIK MAXALT MAXALT RPD MAXIDEX MAXIMUM STRENGTH ACID REDUCER MEBENDAZOLE

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1 1 1 65 41 41 89 37 104 27 22 60 60 75 120 120 120 120 120 120 81 14 56 105 14 48 48 48 48 48 47 49 12 12 84 MECLIZINE HCL MED-ACEBUTOLOL MED-ACEBUTOLOL (TYPE S) MED-ALPRAZOLAM MED-AMANTADINE MED-AMOXICILLIN MED-ATENOLOL MED-BACLOFEN MED-BECLOMETHASONE AQ MED-BROMAZEPAM MED-CAPTOPRIL MED-CLOMIPRAMINE MED-CLONAZEPAM MED-DILTIAZEM MED-GEMFIBROZIL MED-GLYBE MEDISENSE MEDISENSE TLC MED-METFORMIN MED-METOPROLOL MED-MINOCYCLINE MED-PINDOLOL MED-RANITIDINE MEDROL MEDROXYPROGESTERONE MEDROXYPROGESTERONE ACETATE MED-SALBUTAMOL MED-SELEGILINE MED-SOTALOL MED-TEMAZEPAM MED-TIMOLOL MED-VALPROIC ACID MED-VERAPAMIL MEFENAMIC MEFENAMIC ACID MEGACE MEGESTROL MEGESTROL ACETATE MELOXICAM MELPHALAN MEPERIDINE MEPERIDINE HCL MEPRON MERCAPTOPURINE MESALAZINE MESASAL M-ESLON M-ESLON SR MESTINON MESTINON-SR METAMUCIL ORIGINAL TEXTURE METAMUCIL SM TEXT ORANGE METAMUCIL SM TEXT ORANGE S/F METAMUCIL SM TEXT UNFLAV METFORMIN METFORMIN HCL METHADONE METHADONE HCL METHAZOLAMIDE METHOTREXATE METHOTREXATE SODIUM METHOTRIMEPRAZINE
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86 31 31 64 8 4 31 20 78 65 37 55 51 36 26 98 71 121 97 33 6 33 88 93 100 100 18 69 34 66 80 54 37 44 44 14 14 14 44 14 47 47 12 14 90 90 48 48 16 16 84 84 84 84 97 97 124 124 80 14 14 61
81 83 83 73 73 73 73 84 83 121 63 57 57 9 94 94 102 40 66 67 78 88 2
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METHOTRIMEPRAZINE METHOXSALEN METHSUXIMIDE METHYLDOPA METHYLDOPA METHYLDOPA, HYDROCHLOROTHIAZIDE METHYLPHENIDATE HCL METHYLPREDNISOLONE METHYLPREDNISOLONE ACETATE METHYLPREDNISOLONE ACETATE METHYSERGIDE MALEATE METOCLOPRAMIDE METOCLOPRAMIDE HCL METOLAZONE METOPROLOL METOPROLOL TARTRATE METROCREAM METROGEL METROLOTION METRONIDAZOLE METRONIDAZOLE METRONIDAZOLE, NYSTATIN MEVACOR MEXILETINE HCL MIACALCIN MICARDIS MICARDIS PLUS MICATIN MICONAZOLE MICONAZOLE NITRATE MICOZOLE MICRO-FINE MICROLAX MICROLET MICRONOR (28) MIDAMOR MIDODRINE HCL MIGRANAL MILK OF MAGNESIA MILK OF MAGNESIA PLAIN/SUGARFREE MIN OVRAL (21) MIN OVRAL (28) MINERAL OIL MINERAL OIL (HEAVY) 100% USP MINERAL OIL, PETROLATUM MINERAL OIL, WHITE PETROLATUM MINESTRIN 1/20 (21) MINESTRIN 1/20 (28) MINIPRESS MINITRAN MINOCIN MINOCYCLINE MINOCYCLINE HCL MINOXIDIL MINT-CIPROFLOXACIN MINT-CITALOPRAM MINT-ONDANSETRON MINT-PIOGLITAZONE MINT-PRAVASTATIN MINT-TOPIRAMATE 61 108 51 29 29 29 64 93 93 93 19 90 90 75 33 32 104 104 104 12 12 104 27 25 99 41 41 102 102 102 102 122 84 121 95 74 18 19 84 84 95 95 84 84 81 81 95 95 30 30 6 6 6 29 5 55 86 99 27 53 MIOSTAT MIRAPEX MIRAPEX (ONT) MIRENA MIRTAZAPINE MIRTAZAPINE MISOPROSTOL MISOPROSTOL MITOTANE MIXED VESPID VENOM PROTEIN MOBICOX MOCLOBEMIDE MOCLOBEMIDE MODAFINIL MODECATE MODURET MOGADON MOMETASONE FUROATE MONISTAT MONISTAT 3 MONISTAT 3 DUAL PAK MONISTAT 7 MONISTAT 7 DUAL PAK MONISTAT-DERM MONOCOR MONOJECT MONOJECT (100) MONOJECT (30) MONOJECT ALCOHOL WIPES MONOJECT DISP 3/10CC (100) MONOJECT DISP 3/10CC (30) MONOJECTOR MONOLET ORIGINAL MONOLET THIN MONOPRIL MONTELUKAST MORPHINE HCL MORPHINE HP 25 MORPHINE HP 50 MORPHINE LP MORPHINE SULFATE MORPHINE SULFATE MOTRIN MOTRIN JUNIOR STRENGTH MPD THIN (100) MPD THIN (200) MPD ULTRA THIN (100) MPD ULTRA THIN (200) MS CONTIN SR MS IR MUCILLIUM MULTI-PRE AND POST NATAL MULTITAR PLUS MULTI-TAR PLUS MILD MULTIVITAMINS (PEDIATRIC) MULTIVITAMINS (PRENATAL) MULTI-VITAMINS CHILD MUPIROCIN MURO-128 MYCOBUTIN MYCOPHENOLATE MOFETIL MYCOPHENOLATE SODIUM MYDFRIN MYFORTIC

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80 68 68 95 57 57 88 88 14 101 44 57 57 64 60 74 65 78 102 102 102 102 102 102 32 122 122 122 121 122 122 121 121 121 38 76 47 48 48 48 48 48 43 43 121 121 121 121 48 49 84 113 108 108 112 113 112 102 82 8 117 117 79 117 MYHEALTH SYRINGE CASE-7 MYHEALTH SYRINGE CASESINGLE MYLAN-CARVEDILOL MYLAN-NIFEDIPINE ER MYLAN-OMEPRAZOLE MYLAN-RIVASTIGMINE MYLERAN MYOCHRYSINE MYOTONACHOL NABILONE NADOLOL NADOLOL NADROPARIN CALCIUM NADRYL NAFARELIN ACETATE NALCROM NAPHAZOLINE HCL NAPHCON FORTE NAPROSYN NAPROSYN E NAPROSYN SR NAPROXEN NAPROXEN NAPROXEN NA NAPROXEN SODIUM NAPROXEN-NA DF NARATRIPTAN HCL NARDIL NASACORT AQ NASAL SALINE NASONEX NATEGLINIDE NATULAN NAUSEATOL NAVANE NEDOCROMIL SODIUM NEEDLE NEEDLE (NON-INSULIN) NEEDLES (NON-INSULIN) DISPOSABLE NELFINAVIR MESYLATE NEO CAL-D-500 NEO FER NEO-ESTRONE NEO-HC NEORAL NEOSTIGMINE BROMIDE NEO-TINIC NERISALIC OILY NERISONE NERISONE OILY NEULASTA NEULEPTIL NEUPOGEN NEURONTIN NEVIRAPINE NIACIN NIACIN NIACIN YEAST FREE NICODERM NICORETTE NICORETTE PLUS NICOTINE (GUM)
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123 123 32 35 89 17 13 91 16 87 33 33 23 1 96 76 79 79 44 44 44 44 44 45 45 45 66 58 79 82 78 98 14 86 63 117 122 122 122 9 73 22 96 106 115 16 113 105 105 105 24 61 24 52 9 111 111 111 20 20 20 20
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NICOTINE (PATCH) NICOTROL TRANSDERMAL NICOUMALONE NIDAGEL NIFEDIPINE NIFEDIPINE PA NILUTAMIDE NIMODIPINE NIMOTOP NITOMAN NITRAZADON NITRAZEPAM NITRO-DUR NITROFURANTOIN NITROGLYCERIN NITROL NITROLINGUAL PUMPSPRAY NITROSTAT NIX NIX DERMAL NIZATIDINE NIZATIDINE NIZORAL NOLVADEX D NON POLLEN NON-INSULIN 1CC NON-INSULIN 3CC NON-INSULIN 5CC NON-INSULIN (DISP) 1CC NON-INSULIN (DISP) 3CC NON-INSULIN (DISP) 5CC NON-INSULIN (DISP) 10CC NON-INSULIN 10CC NORETHINDRONE NORFLOXACIN NORITATE NORLEVO NORTRIPTYLINE HCL NORVASC NORVIR NORVIR SEC NOVAMAX NOVAMILOR NOVAMOXIN NOVAMOXIN SUGAR REDUCED NOVASEN NOVA-T IUD NOVO 5-ASA NOVO-ACEBUTOLOL NOVO-ACYCLOVIR NOVO-ALENDRONATE NOVO-ALPRAZOL NOVO-AMIODARONE NOVO-AMLODIPINE NOVO-AMPICILLIN NOVO-ATENOL NOVO-ATENOLTHALIDONE NOVO-ATORVASTATIN NOVO-AZITHROMYCIN NOVO-BENZYDAMINE NOVO-BETAHISTINE NOVO-BICALUTAMIDE NOVO-BIPOPROLOL NOVO-BROMAZEPAM 20 20 23 104 35 35 14 30 30 118 65 65 30 12 29 29 30 30 103 103 87 87 102 15 101 120 120 120 120 120 120 120 120 95 5 104 95 57 35 9 9 72 74 4 4 42 70 90 31 11 114 64 25 35 4 31 32 26 3 79 115 13 32 65 NOVO-CALCIUM NOVO-CAPTORIL NOVO-CARBAMAZ NOVO-CEFADROXIL NOVO-CHLOROQUINE NOVO-CHLORPROMAZINE NOVO-CHOLAMINE NOVO-CHOLAMINE LIGHT NOVO-CILAZAPRIL NOVO-CILAZAPRIL/HCTZ NOVO-CIMETINE NOVO-CIPROFLOXACIN NOVO-CITALOPRAM NOVO-CLAVAMOXIN NOVO-CLINDAMYCIN NOVO-CLOBAZAM NOVO-CLOBETASOL NOVO-CLONAZEPAM NOVO-CLONIDINE NOVO-CLOPAMINE NOVO-CLOXIN NOVO-CYCLOPRINE NOVO-CYPROTERONE/ETHINYL ESTRADIOL NOVO-DESIPRAMINE NOVO-DESMOPRESSIN NOVO-DIFENAC NOVO-DIFENAC SR NOVO-DIFLUNISAL NOVO-DILTAZEM CD NOVO-DILTIAZEM NOVO-DILTIAZEM ER NOVODIMENATE NOVO-DIVALPROEX NOVO-DOCUSATE NOVO-DOCUSATE CALCIUM NOVO-DOMPERIDONE NOVO-DOXAZOSIN NOVO-DOXEPIN NOVO-DOXYLIN NOVO-ENALAPRIL NOVO-ENALAPRIL/HCTZ NOVO-ETIDRONATECAL KIT NOVO-FAMOTIDINE NOVO-FENOFIBRATE NOVO-FENOFIBRATE-S NOVO-FENTANYL NOVO-FERROGLUC NOVO-FIBRE NOVO-FINASTERIDE NOVOFINE NOVOFINE 30G NOVOFINE 32G 6MM NOVOFINE INSULIN PEN 28G NOVOFINE INSULIN PEN 30G NOVO-FLUCONAZOLE NOVO-FLUOXETINE NOVO-FLURPROFEN NOVO-FLUTAMIDE NOVO-FLUVOXAMINE NOVO-FOSINOPRIL NOVO-FURANTOIN NOVO-GABAPENTIN NOVO-GEMFIBROZIL

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NOVO-GESIC 50 NOVO-GLICLAZIDE 98 NOVO-GLYBURIDE 98 NOVO-HYDRAZIDE 75 NOVO-HYDROXYZIN 66 NOVO-HYLAZIN 29 NOVO-INDAPAMIDE 75 NOVO-IPRAMIDE 17 NOVO-KETOCONAZOLE 7 NOVO-KETOTIFEN 1 NOVO-LAMOTRIGINE 53 NOVO-LANSOPRAZOLE 88 NOVO-LEFLUNOMIDE 116 NOVO-LEVOCARBIDOPA 68 NOVO-LEVOFLOXACIN 5 NOVO-LEXIN 2 NOVOLIN GE 30/70 10ML 97 NOVOLIN GE 30/70 PENFILL 97 NOVOLIN GE 40/60 PENFILL 97 NOVOLIN GE 50/50 PENFILL 97 NOVOLIN GE NPH 10ML 97 NOVOLIN GE NPH PENFILL 97 NOVOLIN GE TORONTO 97 NOVOLIN GE TORONTO PENFILL 97 NOVO-LISINOPRIL (TYPE P) 39 NOVO-LISINOPRIL (TYPE Z) 39 NOVO-LISINOPRIL/HCTZ (TYPE P) 39 NOVO-LISINOPRIL/HCTZ (TYPE Z) 39 NOVO-LOPERAMIDE 83 NOVO-LORAZEM 65 NOVO-LOVASTATIN 27 NOVO-MAPROTILINE 57 NOVO-MEDRONE 100 NOVO-MELOXICAM 44 NOVO-MEPRAZINE 61 NOVO-METFORMIN 97 NOVO-METHACIN 44 NOVO-METHOTREXATE 14 NOVO-METOPROL 33 NOVO-METOPROL CT 33 NOVO-METOPROL-B 33 NOVO-MEXILETINE 25 NOVO-MINOCYCLINE 6 NOVO-MIRTAZAPINE 57 NOVO-MIRTAZAPINE OD 57 NOVO-MOCLOBEMIDE 57 NOVO-MORPHINE SR 48 NOVO-NADOLOL 33 NOVO-NAPROX 44 NOVO-NAPROX SODIUM 45 NOVO-NAPROX SODIUM DS 45 NOVO-NARATRIPTAN 66 NOVO-NIZATIDINE 87 NOVO-NORFLOXACIN 5 NOVO-NORTRIPTYLINE 57 NOVO-OFLOXACIN 6 NOVO-OLANZAPINE 61 NOVO-OLANZAPINE ODT 61 NOVO-ONDANSETRON 86 NOVO-OXYBUTYNIN 110 NOVO-OXYCODONE ACET 46 NOVO-PANTOPRAZOLE 89 NOVO-PAROXETINE 58 NOVO-PEN VK 4
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NOVO-PERIDOL NOVOPHENIRAM NOVO-PINDOL NOVO-PIOGLITAZONE NOVO-PIROCAM NOVO-PRAMINE NOVO-PRAMIPEXOLE NOVO-PRANOL NOVO-PRAVASTATIN NOVO-PRAZIN NOVO-PREDNISONE NOVO-PROFEN NOVO-PUROL NOVO-QUETIAPINE NOVO-RABEPRAZOLE NOVO-RALOXIFENE NOVO-RAMIPRIL NOVO-RANIDINE NOVO-RANITIDINE NOVORAPID NOVO-RISEDRONATE NOVO-RISPERIDONE NOVO-RIVASTIGMINE NOVO-RYTHRO ESTOLATE NOVO-RYTHRO ETHYLSUCCINATE NOVO-SALBUTAMOL HFA NOVO-SELEGILINE NOVO-SEMIDE NOVO-SERTRALINE NOVO-SIMVASTATIN NOVO-SOTALOL NOVO-SPIROTON NOVO-SPIROZINE-25 NOVO-SPIROZINE-50 NOVO-SUCRALATE NOVO-SUMATRIPTAN NOVO-SUMATRIPTAN DF NOVO-SUNDAC NOVO-TAMOXIFEN NOVO-TAMSULOSIN NOVO-TEMAZEPAM NOVO-TERAZOSIN NOVO-TERBINAFINE NOVO-THEOPHYL SR NOVO-TIAPROFENIC NOVO-TICLOPIDINE NOVO-TIMOL NOVO-TOPIRAMATE NOVO-TRAZODONE NOVO-TRIAMZIDE NOVO-TRIMEL NOVO-TRIMEL DS NOVO-TRIPRAMINE NOVO-TRIPTYN NOVO-VALPROIC NOVO-VENLAFAXINE XR NOVO-VERAMIL NOVO-VERAMIL SR NOVO-WARFARIN NU-ACEBUTOLOL NU-ACYCLOVIR NU-ALPRAZ NU-AMILZIDE 60 1 33 99 45 57 68 34 27 30 94 43 115 62 90 96 40 88 87 97 117 63 17 3 3 18 69 74 58 28 34 41 75 75 88 67 67 45 15 118 66 30 7 110 45 24 34 53 59 74 6 6 59 54 54 59 37 37 23 31 11 64 74 NU-AMOXI NU-AMPI NU-ATENOL NU-AZATHIOPRINE NU-BACLO NU-BECLOMETHASONE NU-BROMAZEPAM NU-CAL NU-CAPTO NU-CARBAMAZEPINE NU-CEFACLOR NU-CEPHALEX NU-CIMET NU-CIPROFLOXACIN NU-CITALOPRAM NU-CLONAZEPAM NU-CLONIDINE NU-CLOXI NU-COTRIMOX NU-COTRIMOX DS NU-CROMOLYN NU-CYCLOBENZAPRINE NU-DESIPRAMINE NU-DICLO NU-DICLO SR NU-DIFLUNISAL NU-DILTIAZ NU-DILTIAZ CD NU-DIVALPROEX NU-DOMPERIDONE NU-DOXYCYCLINE NU-ERYTHROMYCIN S NU-FAMOTIDINE NU-FENOFIBRATE NU-FENO-MICRO NU-FLUOXETINE NU-FLURBIPROFEN NU-FLUVOXAMINE NU-FUROSEMIDE NU-GEMFIBROZIL NU-GLYBURIDE NU-HYDRAL NU-HYDRO NU-IBUPROFEN NU-INDAPAMIDE NU-INDO NU-IPRATROPIUM UDV NU-KETOCON NU-KETOPROFEN NU-KETOTIFEN NU-LEVOCARB NU-LORAZ NU-LOVASTATIN NU-LOXAPINE NU-MEDROXY NU-MEFENAMIC NU-MEGESTROL NU-METFORMIN NU-METOCLOPRAMIDE NU-METOP NU-MOCLOBEMIDE NU-NAPROX NU-NIFED NU-NIFEDIPINE PA

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NU-NORTRIPTYLINE NU-OXYBUTYN NU-PAROXETINE NU-PEN VK NU-PENTOXIFYL NU-PINDOL NU-PIROX NU-PRAVASTATIN NU-PRAZO NU-PROCHLOR NU-PROPAFENONE NU-PROPRANOLOL NU-RANIT NU-SALBUTAMOL NU-SELEGILINE NU-SERTRALINE NU-SIMVASTATIN NU-SOTALOL NU-SUCRALFATE NU-SULFINPYRAZONE NU-SULINDAC NU-TEMAZEPAM NU-TERAZOSIN NU-TERBINAFINE NU-TETRA NU-TIAPROFENIC NU-TICLOPIDINE NU-TIMOLOL NU-TRAZODONE NU-TRAZODONE D NU-TRIAZIDE NU-TRIAZO NU-TRIMIPRAMINE NU-VALPROIC NUVARING NU-VERAP NU-VERAP SR NYADERM NYSTATIN NYSTATIN O-CALCIUM 500 OCCLUSAL HP OCTREOTIDE OCTREOTIDE ACETATE OMEGA OCUFEN OCUFLOX ODAN K-20 ODANS LIQUOR CARBONIS DETERGENT OESCLIM OFLOXACIN OGEN OLANZAPINE OLMESARTAN MEDOXOMIL OLMESARTAN MEDOXOMIL, HYDROCHLORTHIAZIDE OLMETEC OLMETEC PLUS OLSALAZINE SODIUM OMEPRAZOLE MAGNESIUM (PA) OMEPRAZOLE, OMEPRAZOLE MAGNESIUM (NO PA) OMNIFLEX DIAPHRAGM 75 ONDANSETRON HCL ONDANSETRON HCL DIHYDRATE 57 110 58 5 24 33 45 27 30 62 25 34 88 18 69 58 28 34 88 75 45 66 30 7 6 45 24 34 59 59 74 66 59 54 94 37 37 102 7 103 73 108 117 117 79 77 73 108 96 6 96 61 41 41 41 41 90 89 89 70 86 86
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ONE TOUCH ONE TOUCH ULTRA ONE TOUCH ULTRA SOFT ONE-ALPHA OPTICHAMBER OPTICHAMBER LARGE MASK OPTICHAMBER MEDIUM MASK OPTICHAMBER SMALL MASK OPTICROM OPTIHALER OPTIMYXIN OPTIMYXIN EYE/EAR OPTIMYXIN PLUS EYE/EAR OPTIVENT IN-LINE MDI SPACER ORACORT ORAP ORCIPRENALINE SULFATE ORENCIA ORTHO 0.5/35 (28) ORTHO 0.5/35 (21) ORTHO 7/7/7 (21) ORTHO 7/7/7 (28) ORTHO 1/35 (21) ORTHO 1/35 (28) ORTHO CEPT (28) OS-CAL D 500MG OSTOFORTE OTRIVIN SALINE OVRAL (21) OWEN MUMFORD UNIFINE PENTIPS 1/2 INCH OWEN MUMFORD UNIFINE PENTIPS 1/4 INCH OWEN MUMFORD UNIFINE PENTIPS 5/16 INCH OXAZEPAM OXAZEPAM OXEZE TURBUHALER OXPRENOLOL HCL OXSORALEN OXTRIPHYLLINE OXY 5 OXYBUTYNIN CHLORIDE OXYBUTYNINE OXYCODONE HCL OXYCONTIN OXYDERM OXY-IR P&S PLUS PALAFER PAMIDRONATE DISODIUM PAMIDRONATE DISODIUM PANCREASE MT 10 PANCREASE MT 16 PANCREASE MT 4 PANOXYL PANOXYL ACNE PANOXYL AQUAGEL PANOXYL-10 PANOXYL-20 PANOXYL-5 PANTOLOC PANTOPRAZOLE PANTOPRAZOLE MAGNESIUM PANTOPRAZOLE SODIUM 71 72 121 112 120 120 120 120 76 120 77 77 77 120 107 61 18 114 95 95 95 95 95 95 94 73 112 81 94 122 122 122 65 65 18 33 108 110 103 110 110 49 49 103 49 108 22 117 117 85 85 85 103 108 103 103 103 103 89 89 89 89 PARIET EC PARNATE PAROMOMYCIN SULFATE PAROXETINE PAROXETINE HCL PARSITAN PAXIL PDL-ACYCLOVIR PDL-CEFACLOR PDL-CEPHALEXIN PDL-CIMETIDINE PDL-DIPYRIDAMOLE PDL-FLUTAMIDE PDL-FOSINOPRIL PDL-GLYBURIDE PDL-ISOSORBIDE PDL-LOXAPINE PDL-MEDROXY PDL-MINOCYCLINE PDL-NORFLOXACINE PDL-TERAZOSIN PDL-TICLOPIDINE PDL-TOPIRAMATE PDL-VALPROIC PEDIAFER PEDIALYTE PEDIAPHEN PEDIAPHEN CHEWABLE PEDIAPRED PEDIATRIC ELECTROLYTE PEDIATRIX PEDIAVIT PEDIAVIT D PEGASYS PEGASYS RBV PEGETRON PEGETRON REDIPEN PEGFILGRASTIM PEGINTERFERON ALFA-2A PEGINTERFERON ALFA-2A, RIBAVIRIN PEGINTERFERON ALFA-2B PEGINTERFERON ALFA-2B, RIBAVIRIN PEGLYTE PEN VEE PENBRITIN PENICILLAMINE PENICILLIN V BENZATHINE PENICILLIN V POTASSIUM PENICILLINE V PENLET PLUS PENTA-ACEBUTOLOL PENTA-AMILOR HCTZ PENTA-AMOXICILLIN PENTA-ATENOLOL PENTA-CAPTOPRIL PENTA-DILTIAZEM PENTA-FAMOTIDINE PENTA-GEMFIBROZIL PENTA-METOPROLOL PENTAMIDINE PENTAMIDINE ISETHIONATE PENTAMYCETIN

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90 58 12 58 58 67 58 11 2 3 87 30 13 38 98 29 60 100 6 5 30 24 54 54 22 73 49 49 94 73 49 113 112 10 10 10 10 24 10 10 10 10 84 4 4 92 4 4 5 121 31 74 4 31 37 36 87 26 33 12 12 77 PENTA-OXYBUTYNIN PENTASA PENTA-SULINDAC PENTA-TEMAZEPAM PENTA-TIAPROFENIC PENTA-TRAZODONE PENTA-VALPROIC PENTAZOCINE HCL PENTAZOCINE LACTATE PENTOSAN POLYSULFATE SODIUM PENTOXIFYLLINE PENTRAX PEPCID PEPTO BISMOL PERCOCET PERCOCET DEMI PERCODAN PERICHLOR PERICYAZINE PERIDEX PERINDOPRIL ERBUMINE PERINDOPRIL ERBUMINE, INDAPAMIDE PERINDOPRIL ERBUMINE,INDAPAMIDE PERIOGARD PERMETHRIN PEROXIDE D'HYDROGENE PERPHENAZINE PERPHENAZINE PERSANTINE PETHIDINE PETROLATUM PETROLATUM, LANOLIN, MINERAL OIL PETROLATUM, PETROLATUM LIQUID PHENELZINE SULFATE PHENOBARBITAL PHENOBARBITAL PHENYLEPHRINE PHENYLEPHRINE HCL PHENYLEPHRINE MINIMS PHENYTOIN PHI-CITALOPRAM PHL-ALENDRONATE PHL-AMLODIPINE PHL-ATENOLOL PHL-AZITHROMYCIN PHL-BACLOFEN PHL-CARVEDILOL PHL-CIPROFLOXACIN PHL-CITALOPRAM PHL-CLONAZEPAM PHL-CLONAZEPAM 0.25MG PHL-CLONAZEPAM-R 0.5MG PHL-CYCLOBENZAPRINE PHL-DEXAMETHASONE PHL-FLUOXETINE PHL-GABAPENTIN PHL-HYDROMORPHONE PHL-INDAPAMIDE PHL-LEVOFLOXACIN PHL-LOXAPINE
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110 90 45 66 45 59 54 49 49 117 24 108 87 83 46 45 46 79 61 79 39 39 39 79 103 104 61 61 30 47 107 81 81 58 50 50 79 79 79 51 55 114 34 31 3 20 32 5 55 51 50 51 19 93 56 52 47 75 5 60
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PHL-MELOXICAM PHL-MIRTAZAPINE PHL-ONDANSETRON PHL-PANTOPRAZOLE PHL-PAROXETINE PHL-PIOGLITAZONE PHL-PRAVASTATIN PHL-QUETIAPINE PHL-RISPERIDONE PHL-SERTRALINE PHL-SIMVASTATIN PHL-SOTALOL PHL-TOPIRAMATE PHL-TRAZODONE PHL-URSODIOL C PHL-VALPROIC ACID PHOSPHO SODA FLEET LAXATIVE PHYLLOCONTIN PICO-SALAX PILOCARPINE PILOCARPINE HCL PILOCARPINE NITRATE PILOCARPINE NITRATE MINIMS PILOPINE HS PIMECROLIMUS PIMOZIDE PINDOLOL PINDOLOL PINDOLOL, HYDROCHLOROTHIAZIDE PIOGLITAZONE HCL PIPERONYL BUTOXIDE, PYRETHRINS PIPORTIL L4 PIPOTIAZINE PALMITATE PIROXICAM PIROXICAM PISTON ROD PIVMECILLINAM HCL PIZOTYLINE HYDROGEN MALATE PLACEBO PLAN B PLANTAGO SEED PLAQUENIL PLAVIX PLENDIL PMS-ACET 2 PMS-ACETAMINOPHEN PMS-ACETAMINOPHEN WITH CODEINE PMS-ALENDRONATE PMS-ALENDRONATE FC PMS-AMANTADINE PMS-AMIODARONE PMS-AMITRIPTYLINE PMS-AMLODIPINE PMS-AMOXICILLIN PMS-ANAGRELIDE PMS-ASA PMS-ASA EC PMS-ATENOLOL PMS-ATORVASTATIN PMS-AZITHROMYCIN PMS-BACLOFEN 44 57 86 89 58 99 27 62 63 58 28 34 53 59 85 54 85 110 83 80 80 81 81 80 109 61 33 33 33 99 103 62 62 45 45 121 5 67 124 95 84 12 23 35 45 49 45 114 114 8 25 54 34 4 23 42 42 31 26 3 20 PMS-BENZTROPINE PMS-BENZYDAMINE PMS-BEZAFIBRATE PMS-BICALUTAMIDE PMS-BISACODYL PMS-BISOPROLOL PMS-BRIMONIDINE PMS-BROMOCRIPTINE PMS-BUPROPION SR PMS-CALCIUM PMS-CALCIUM/VITAMIN D PMS-CAPTOPRIL PMS-CARBAMAZEPINE PMS-CARBAMAZEPINE SRT PMS-CARVEDILOL PMS-CEPHALEXIN PMS-CETIRIZINE PMS-CHOLESTYRAMINE LIGHT PMS-CHOLESTYRAMINE REGULAR PMS-CILAZAPRIL PMS-CIMETIDINE PMS-CIPROFLOXACIN PMS-CITALOPRAM PMS-CLARITHROMYCIN PMS-CLOBAZAM PMS-CLOBETASOL PMS-CLONAZEPAM PMS-CLONAZEPAM R PMS-CODEINE PMS-CYCLOBENZAPRINE PMS-DESIPRAMINE PMS-DESMOPRESSIN PMS-DESONIDE PMS-DEXAMETHASONE PMS-DIAZEPAM PMS-DICLOFENAC PMS-DICLOFENAC 25MG DR PMS-DICLOFENAC 50MG DR PMS-DICLOFENAC SR PMS-DIMENHYDRINATE PMS-DIPHENHYDRAMINE PMS-DIPIVEFRIN PMS-DIVALPROEX PMS-DOCUSATE CALCIUM PMS-DOCUSATE SODIUM PMS-DOMPERIDONE PMS-DOXAZOSIN PMS-DOXYCYCLINE PMS-ENALAPRIL PMS-ERYTHROMYCIN PMS-FAMCICLOVIR PMS-FENOFIBRATE MICRO PMS-FENTANYL MTX PMS-FERROUS SULFATE PMS-FINASTERIDE PMS-FLUCONAZOLE PMS-FLUNISOLIDE PMS-FLUOROMETHOLONE PMS-FLUOXETINE PMS-FLUPHENAZINE PMS-FLUTAMIDE PMS-FLUVOXAMINE PMS-FOSINOPRIL

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67 79 26 13 83 32 79 68 54 73 73 37 51 51 32 3 1 25 25 37 87 5 55 3 65 105 50 51 46 19 55 99 105 78 65 42 42 42 43 86 1 79 52 83 83 86 30 6 38 77 11 26 46 22 116 7 78 78 56 60 13 56 38 PMS-FUROSEMIDE PMS-GABAPENTIN PMS-GEMFIBROZIL PMS-GENTAMICIN PMS-GLICAZIDE PMS-GLYBURIDE PMS-HALOPERIDOL PMS-HALOPERIDOL LA PMS-HYDROCHLOROTHIAZIDE PMS-HYDROMORPHONE PMS-HYDROXYZINE PMS-IBUPROFEN PMS-INDAPAMIDE PMS-IPECAC PMS-IPRATROPIUM PMS-IPRATROPIUM UDV PMS-ISMN PMS-ISONIAZID PMS-ISOSORBIDE PMS-KETOPROFEN PMS-KETOTIFEN PMS-LACTULOSE PMS-LAMOTRIGINE PMS-LEFLUNOMIDE PMS-LETROZOLE PMS-LEVETIRACETAM PMS-LEVOBUNOLOL PMS-LEVOFLOXACIN PMS-LIDOCAINE VISCOUS PMS-LINDANE PMS-LISINOPRIL PMS-LITHIUM CARBONATE PMS-LITHIUM CITRATE PMS-LOPERAMIDE PMS-LOVASTATIN PMS-LOXAPINE PMS-MELOXICAM PMS-METFORMIN PMS-METHOTRIMEPRAZINE PMS-METHYLPHENIDATE PMS-METOCLOPRAMIDE PMS-METOPROLOL-B PMS-METOPROLOL-L PMS-MINOCYCLINE PMS-MIRTAZAPINE PMS-MISOPROSTOL PMS-MOCLOBEMIDE PMS-MOMETASONE PMS-MONOCYCLINE PMS-MORPHINE SR PMS-MORPHINE SULFATE PMS-NAPROXEN EC PMS-NIFEDIPINE PMS-NIZATIDINE PMS-NORFLOXACIN PMS-NORTRIPTYLINE PMS-NYSTATIN PMS-OFLOXACIN PMS-OLANZAPINE PMS-OLANZAPINE ODT PMS-OMEPRAZOLE PMS-ONDANSETRON PMS-OXTRIPHYLLINE PMS-OXYBUTYNIN
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PMS-OXYCODONE PMS-OXYCODONE ACETAMINOPHEN PMS-PAMIDRONATE PMS-PANTOPRAZOLE PMS-PAROXETINE PMS-PERPHENAZINE PMS-PHENOBARBITAL PMS-PHOSPHATES SOLUTION PMS-PINDOLOL PMS-PIOGLITAZONE PMS-PIROXICAM PMS-POLYTRIMETHOPRIM PMS-POTASSIUM PMS-PRAMIPREXOLE PMS-PRAVASTATIN PMS-PREDNISOLONE PMS-PROCHLORPERAZINE PMS-PROCYCLIDINE PMS-PROPAFENONE PMS-PROPRANOLOL PMS-PYRAZINAMIDE PMS-QUETIAPINE PMS-RABEPRAZOLE PMS-RAMIPRIL PMS-RANITIDINE PMS-RHINARIS PMS-RISPERIDONE PMS-RIVASTIGMINE PMS-ROPINIROLE PMS-SALBUTAMOL PMS-SELEGILINE PMS-SENNOSIDES PMS-SERTRALINE PMS-SIMVASTATIN PMS-SOD CROMOGLYCATE PMS-SOD POLYSTYRENE SULF PMS-SOD POLYSTYRENE SULFONA PMS-SODIUM DOCUSATE PMS-SOTALOL PMS-SULFASALAZINE PMS-SUMATRIPTAN PMS-TAMOXIFEN PMS-TEMAZEPAM PMS-TERAZOSIN PMS-TERBINAFINE PMS-TESTOSTERONE PMS-THEOPHYLLINE PMS-TIAPROFENIC PMS-TIMOLOL PMS-TOBRAMYCIN PMS-TOPIRAMATE PMS-TRAZODONE PMS-TRIFLUOPERAZINE PMS-TRIHEXYPHENIDYL PMS-URSODIOL PMS-VALACYCLOVIR PMS-VALPROIC ACID PMS-VENLAFAXINE XR PMS-VERAPAMIL SR POCKET CHAMBER POCKET CHAMBER WITH ADULT MASK 49 46 117 89 58 61 50 85 33 99 45 77 73 68 27 94 62 67 25 34 8 62 90 40 88 81 62 17 68 18 69 84 58 28 76 74 74 83 34 6 67 15 66 30 7 94 110 45 80 77 53 59 64 67 85 11 54 59 37 120 120

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POCKET CHAMBER WITH INFANT MASK POCKET CHAMBER WITH MEDIUM MASK POCKET CHAMBER WITH SMALL MASK PODOFILM PODOFILOX PODOPHYLLIN POLISTES SPP VENOM PROTEIN EXTRACT POLLEN POLLEN AND NON POLLEN POLLINEX R POLYETHYLENE GLYCOL POLYETHYLENE GLYCOL POLYETHYLENE GLYCOL 3350 POLYETHYLENE GLYCOL 3350 POLYETHYLENE GLYCOL, POTASSIUM CHLORIDE, SODIUM BICARBONATE, SODIUM CHLORIDE, SODIUM SULFATE POLYMYXIN B SULFATE, BACITRACIN POLYMYXIN B SULFATE, TRIMETHOPRIM SULFATE POLYSPORIN POLYSPORIN ANTIBIOTIC POLYSPORIN EYE/EAR POLYTAR POLYTOPIC POLYTRIM POLYVINYL ALCOHOL POLYVINYL ALCOHOL, POVIDONE POLY-VI-SOL PORTIA 21 PORTIA 28 POTASSIUM CHLORIDE POVIDONE-IODINE PRAMIPEXOLE DIHYDROCHLORIDE PRAVACHOL PRAVASTATIN SODIUM PRAVASTATIN-10 PRAVASTATIN-20 PRAVASTATIN-40 PRAXIS ASA EC PRAZOSIN PRAZOSIN HCL PRECISION PLUS ELECTRODES PRECISION XTRA PRED FORTE PRED MILD PREDNISOLONE PREDNISOLONE ACETATE PREDNISOLONE ACETATE, SULFACETAMIDE SODIUM PREDNISOLONE SODIUM PHOSPHATE PREDNISONE PREDNISONE PREFRIN LIQUIFILM PREMARIN PREM-CIPROFLOXACIN PREM-CITALOPRAM 120 120 120 108 108 108 101 101 101 101 84 84 84 84 84 PREM-PAROXETINE PREMPLUS PRENATAL & POSTPARTUM PRENATAL AND POSTPARTUM PRENATAL VITAMINS AND MINERALS PRESTIGE SMART SYSTEM PREVACID PREVACID FASTAB PREVEX PREVEX B PREVEX HC PREZISTA PRIMAQUINE PRIMAQUINE PHOSPHATE PRIMIDONE PRINIVIL PRINZIDE PRIVA CAL D FORTE PRO-600K PRO-AMIODARONE PRO-AMOX PRO-ASA 80MG EC TAB PRO-ASA 80MG TAB PRO-AZITHROMYCIN PROBENECID PROBETA PRO-BICALUTAMIDE PRO-BISOPROLOL PROCAINAMIDE HCL PROCAN SR PROCARBAZINE HCL PRO-CEFADROXIL PRO-CEFUROXIME PROCET-30 PROCHLORPERAZINE PROCHLORPERAZINE PRO-CIPROFLOXACIN PRO-CLONAZEPAM PROCTODAN HC PROCTOL PROCTOSEDYL PROCYCLIDINE HCL PROCYTOX PRO-DEXAMETHASONE PRO-FENO-SUPER PRO-FLUCONAZOLE PRO-FLUOXETINE PRO-GABAPENTIN PROGLYCEM PROGRAF PRO-HYDROXYQUINE PRO-INDAPAMIDE PRO-INDO PRO-ISMN PRO-LACTULOSE PRO-LEVOCARB PRO-LISINOPRIL PROLOPA PRO-LORAZEPAM PRO-LOVASTATIN PRO-METFORMIN PRO-MIRTAZAPINE PRO-NAPROXEN EC
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58 95 113 113 113 72 88 88 107 105 106 8 12 12 50 39 39 73 73 25 4 42 42 3 75 81 13 32 25 25 14 2 2 45 62 62 5 51 106 106 106 67 13 93 26 7 56 52 29 118 12 75 44 29 84 68 39 67 65 27 97 57 44
102 77 77 102 77 108 102 77 81 81 112 95 95 73 104 68 27 27 27 27 27 42 30 30 72 72 78 78 79 78 78 79 94 94 79 95 5 55
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PRO-OXYCOD ACET PROPADERM PROPAFENONE PROPAFENONE HYDROCHLORIDE PRO-PIOGLITAZONE PROPRANOLOL PROPRANOLOL HCL PROPYL THYRACIL PROPYLTHIOURACIL PRO-QUETIAPINE PRO-RABEPRAZOLE PRO-RISPERIDONE PROSCAR PRO-SOTALOL PROSTIGMIN PROTOPIC PRO-TOPIRAMATE PRO-TRIAZIDE PROTRIN PROTRIN DF PRO-VALACYCLOVIR PROVAL-GLICLAZIDE PROVERA PROVERA PAK PROZAC PSEUDOEPHEDRINE HCL, TRIPROLIDINE HCL PSYLLIUM HYDROPHILIC MUCILLOID PULMICORT NEBUAMP PULMICORT TURBUHALER PULMOPHYLLIN PURG-ODAN PURINETHOL PYRANTEL PAMOATE PYRAZINAMIDE PYRIDOSTIGMINE BROMIDE PYRIDOXINE HCL PYRIMETHAMINE QUETIAPINE FUMARATE QUINAPRIL HCL QUINAPRIL HCL, HYDROCHLOROTHIAZIDE QVAR R&C RABEPRAZOLE SODIUM RALOXIFENE HCL RALTEGRAVIR RAMIPRIL RAMIPRIL RAMIPRIL, HYDROCHLOROTHIAZIDE RAN RAMIPRIL RAN-AMLODIPINE RAN-ATENOLOL RAN-ATORVASTATIN RAN-CARVEDILOL RAN-CEFPROZIL RAN-CIPROFLOX RAN-CIPROFLOXACIN RAN-CITALO RAN-CITALOPRAM RAN-DOMPERIDONE RAN-FENTANYL 46 104 25 25 99 34 33 100 100 62 90 63 116 34 16 109 53 74 6 6 11 98 100 100 56 19 84 93 93 110 83 14 2 8 16 111 12 62 39 40 93 103 90 96 9 40 40 40 40 35 31 26 32 2 5 5 55 55 86 46 RAN-FENTANYL MATRIX RAN-FENTANYL MATRIX PATCH 12 RAN-FOSINOPRIL RAN-GABAPENTIN RANITIDINE RANITIDINE HCL RAN-LISINOPRIL RAN-LOVASTATIN RAN-METFORMIN RAN-ONDANSETRON RAN-PANTOPRAZOLE RAN-PRAVASTATIN RAN-RABEPRAZOLE RAN-RISPERIDONE RAN-ROPINIROLE RAN-SIMVASTATIN RAN-TAMSULOSIN RAPAMUNE RATIO-ACLAVULANATE RATIO-ACYCLOVIR RATIO-ALENDRONATE RATIO-AMCINONIDE RATIO-AMIODARONE RATIO-AMLODIPINE RATIO-ATENOLOL RATIO-ATORVASTATIN RATIO-AZITHROMYCIN RATIO-BACLOFEN RATIO-BECLOMETHASONE AQ RATIO-BENZYDAMINE RATIO-BICALUTAMIDE RATIO-BISACODYL RATIO-BRIMONIDINE RATIO-BUPROPION RATIO-BUPROPION SR RATIO-CARVEDILOL RATIO-CEFUROXIME RATIO-CIPROFLOXACIN RATIO-CITALOPRAM RATIO-CLARITHROMYCIN RATIO-CLOBAZAM RATIO-CLOBETASOL RATIO-CLONAZEPAM RATIO-CODEINE RATIO-CYCLOBENZAPRINE RATIO-DEXAMETHASONE RATIO-DILTIAZEM CD RATIO-DOCUSATE CALCIUM RATIO-DOCUSATE SODIUM RATIO-DOMPERIDONE RATIO-DOXYCYCLINE RATIO-ECTOSONE RATIO-EMTEC-30 RATIO-ENALAPRIL RATIO-FENOFIBRATE RATIO-FENTANYL RATIO-FINASTERIDE RATIO-FLUNISOLIDE RATIO-FLUOXETINE RATIO-FLUTICASONE RATIO-FLUVOXAMINE RATIO-FOSINOPRIL RATIO-GABAPENTIN

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46 46 38 52 88 87 39 27 97 86 89 27 90 63 68 28 118 118 4 11 114 104 25 35 31 26 3 20 78 79 13 83 79 54 54 32 2 5 55 3 65 105 51 46 19 93 35 83 83 86 6 105 45 38 26 46 116 78 56 78 56 38 52 RATIO-GLYBURIDE RATIO-HEMCORT HC RATIO-INDOMETHACIN RATIO-IPRA SAL RATIO-IPRATROPIUM UDV RATIO-KETOROLAC RATIO-LACTULOSE RATIO-LAMOTRIGINE RATIO-LENOLTEC NO.2 RATIO-LENOLTEC NO.3 RATIO-LEVOBUNOLOL RATIO-LISINOPRIL P RATIO-LISINOPRIL Z RATIO-LOVASTATIN RATIO-MAGNESIUM RATIO-MELOXICAM RATIO-METFORMIN RATIO-METHOTREXATE RATIO-MINOCYCLINE RATIO-MIRTAZAPINE RATIO-MOMETASONE RATIO-MORPHINE RATIO-MORPHINE SULFATE SR RATIO-NORTRIPTYLINE RATIO-NYSTATIN RATIO-OMEPRAZOLE RATIO-ONDANSETRON RATIO-OXYCOCET RATIO-OXYCODAN RATIO-PANTOPRAZOLE RATIO-PAROXETINE RATIO-PENTOXIFYLLINE RATIO-PIOGLITAZONE RATIO-PRAVASTATIN RATIO-PREDNISOLONE RATIO-PROCTOSONE RATIO-QUETIAPINE RATIO-RAMIPRIL RATIO-RANITIDINE RATIO-RISPERIDONE RATIO-RIVASTIGMINE RATIO-SALBUTAMOL RATIO-SALBUTAMOL HFA RATIO-SERTRALINE RATIO-SIMVASTATIN RATIO-SOTALOL RATIO-SUMATRIPTAN RATIO-TAMSULOSIN RATIO-TEMAZEPAM RATIO-TERAZOSIN RATIO-TOPILENE GLYCOL RATIO-TOPIRAMATE RATIO-TOPISALIC RATIO-TOPISONE RATIO-TRAZODONE RATIO-VALPROIC RATIO-VALPROIC ACID RATIO-VENLAFAXINE SR RATIO-VENLAFAXINE XR RBX-RISPERIDONE REACTINE REALITY FEMALE CONDOM REDOXON REFRESH LIQUIGEL
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98 106 44 17 17 79 84 53 45 45 80 39 39 27 73 44 97 14 6 57 107 48 48 57 7 89 86 46 46 89 58 24 99 27 78 106 62 40 88 63 17 18 18 58 28 34 67 118 66 30 104 53 104 104 59 54 54 59 59 63 1 70 112 81
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REFRESH PLUS REFRESH TEARS REGULAR ENDCAPS FOR GLUCOLET REGULAR ENDCAPS FOR MICROLET REMERON REMERON RD REMICADE REMINYL ER RENEDIL REPAGLINIDE REQUIP RESERVOIR 5XX 1.8ML SYRINGE RESERVOIR 7XX 3.0ML SYRINGE RESONIUM CALCIUM RESTORIL RESULTZ RETIN A RETROVIR REYATAZ RHINARIS RHINOCORT AQ RHINOCORT TURBUHALER RHO-NITRO PUMPSPRAY RHOTRAL RHOXAL-ANAGRELIDE RHOXAL-CIPROFLOXACIN RHOXAL-LOPERAMIDE RHOXAL-METFORMIN RHOXAL-MIRTAZAPINE RHOXAL-PAMIDRONATE RHOXAL-PAROXETINE RHOXAL-PRAVASTATIN RHOXAL-SERTRALINE (ONT) RHOXAL-SIMVASTATIN RHOXAL-SOTALOL RIDAURA RIFABUTIN RIFADIN RIFAMPIN RIMACTANE RISEDRONATE SODIUM RISPERDAL RISPERDAL-M RISPERIDONE RITALIN RITALIN SR RITONAVIR RITUXAN RITUXIMAB RIVA-ALENDRONATE RIVA-AMIODARONE RIVA-AMLODIPINE RIVA-ATENOLOL RIVA-AZITHROMYCIN RIVA-BACLOFEN RIVA-CIPROFLOXACIN RIVA-CITALOPRAM RIVA-CLINDAMYCIN RIVA-CLONAZEPAM RIVACOCET RIVA-CYCLOBENZAPRINE RIVA-D RIVA-D 400 UNIT CAP 81 81 121 121 57 57 116 16 35 98 68 121 121 74 66 103 107 10 8 81 78 78 30 31 23 5 83 97 57 117 58 27 58 28 34 91 8 8 8 8 117 62 62 62 64 64 9 15 15 114 25 34 31 3 20 5 55 6 51 46 19 112 112 RIVA-ENALAPRIL RIVA-FENOFIBRATE MICRO RIVA-FLUCONAZOLE RIVA-FLUOXETINE RIVA-FLUVOX RIVA-FOSINOPRIL RIVA-GABAPENTIN RIVA-GEMFIBROZIL RIVA-GLYBURIDE RIVA-HYDROXYZIN RIVA-INDAPAMIDE RIVA-K RIVA-K 20 RIVA-LISINOPRIL RIVA-LOPERAMIDE RIVA-LOVASTATIN RIVA-METFORMIN RIVA-METOPROLOL L RIVA-MINOCYCLINE RIVA-MIRTAZAPINE RIVA-NAPROXEN RIVA-NAPROXEN SODIUM RIVANASE AQ RIVA-NORFLOXACIN RIVA-OXYBUTYNIN RIVA-PANTOPRAZOLE RIVA-PAROXETINE RIVA-PRAVASTATIN RIVA-QUETIAPINE RIVA-RABEPRAZOLE RIVA-RANITIDINE RIVA-RANTIDINE RIVA-RISPERIDONE RIVAROXABAN RIVASA RIVA-SENNA RIVA-SERTRALINE RIVA-SIMVASTATIN RIVASOL HC RIVASOL-HC RIVASONE RIVA-SOTALOL RIVASTIGMINE RIVA-TERBINAFINE RIVA-VALACYCLOVIR RIVA-VENLAFAXINE XR RIVA-VERAPAMIL RIVA-VERAPAMIL SR RIVA-ZIDE RIVOTRIL RIZATRIPTAN ROBITUSSIN PEDIATRIC ROCALTROL ROFACT ROLENE RONDO INHALATION CHAMBER RONDO INHALATION CHAMBERCHILD MASK RONDO INHALATION CHAMBERINFANT MASK RONDO INHALATION CHAMBERNEONATAL MASK RONDO INHALATION CHAMBERUNIVERSAL MASK ROPINIROLE HCL

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38 26 7 56 56 38 52 26 98 66 75 73 73 39 83 27 97 33 6 57 44 45 78 5 110 89 58 27 62 90 88 88 63 23 42 84 58 28 106 106 105 34 17 7 11 59 37 37 74 51 66 76 112 8 104 120 120 120 120 120 68 ROSASOL ROSIGLITAZONE MALEATE ROSONE ROSUVASTATIN CALCIUM RYTHMODAN RYTHMODAN LA RYTHMOL SABRIL SALAZOPYRIN SALBUTAMOL SALICYLIC ACID SALICYLIC ACID, TRICLOSAN SALINEX SALMETEROL XINAFOATE SALMETEROL XINAFOATE, FLUTICASONE PROPIONATE SALOFALK SANDOMIGRAN SANDOMIGRAN DS SANDOSTATIN SANDOSTATIN LAR SANDOZ ALENDRONATE SANDOZ ALFUZOSIN SANDOZ ANUZINC HC SANDOZ ANUZINC HC PLUS SANDOZ BRIMONIDINE SANDOZ CEFPROZIL SANDOZ DICLOFENAC SANDOZ ENALAPRIL SANDOZ EYELUBE SANDOZ FENOFIBRATE S SANDOZ FENTANYL SANDOZ FENTANYL TRANSDERMAL SYSTEM SANDOZ FINASTERIDE SANDOZ INDOMETHACIN SANDOZ LEFLUNOMIDE SANDOZ LETROZOLE SANDOZ LEVOFLOXACIN SANDOZ LISINOPRIL SANDOZ LISINOPRIL HCT SANDOZ NARATRIPTAN SANDOZ OLANZAPINE ODT SANDOZ OMEPRAZOLE SANDOZ PIOGLITAZONE SANDOZ PREDNISOLONE SANDOZ PROCTOMYXIN HC SANDOZ RAMIPRIL SANDOZ RISPERIDONE SANDOZ RIVASTIGMINE SANDOZ TAMSULOSIN SANDOZ VENLAFAXINE XR SANDOZ-ACEBUTOLOL SANDOZ-AMIODARONE SANDOZ-AMLODIPINE SANDOZ-ANUZINC HC SANDOZ-ANUZINC HC PLUS SANDOZ-ATENOLOL SANDOZ-AZITHROMYCIN SANDOZ-BETAXOLOL SANDOZ-BICALUTAMIDE SANDOZ-BISOPROLOL SANDOZ-BUPROPION SR SANDOZ-CALCITONIN SANDOZ-CARBAMAZEPINE
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104 99 104 27 25 25 25 54 6 18 108 108 82 18 19 90 67 67 117 117 114 114 106 106 79 2 43 38 81 26 46 47 116 44 116 14 5 39 39 66 61 89 99 78 106 40 63 17 118 59 31 25 34 106 106 31 3 80 13 32 54 99 51
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SANDOZ-CIPROFLOXACIN SANDOZ-CITALOPRAM SANDOZ-CLARITHROMYCIN SANDOZ-CLONAZEPAM SANDOZ-CORTIMYXIN SANDOZ-CYCLOSPORINE SANDOZ-DEXAMETHASONE SANDOZ-DICLOFENAC SANDOZ-DICLOFENAC SR SANDOZ-DILTIAZEM CD SANDOZ-DILTIAZEM T SANDOZ-ESTRADIOL DERM SANDOZ-FAMCICLOVIR SANDOZ-FELODIPINE SANDOZ-FLUOXETINE SANDOZ-FLUVOXAMINE SANDOZ-GENTAMICIN SANDOZ-GENTAMICIN OTIC SANDOZ-GLYBURIDE SANDOZ-IDOXURIDINE SANDOZ-LEVOBUNOLOL SANDOZ-LISINOPRIL SANDOZ-LOPERAMIDE SANDOZ-LOVASTATIN SANDOZ-METFORMIN SANDOZ-METFORMIN FC SANDOZ-METHYLPHENIDATE SR SANDOZ-METOPROLOL SR SANDOZ-METOPROLOL-L SANDOZ-MINOCYCLINE SANDOZ-MIRTAZAPINE SANDOZ-NITRAZEPAM SANDOZ-ONDANSETRON SANDOZ-OPTICORT SANDOZ-PANTOPRAZOLE SANDOZ-PAROXETINE SANDOZ-PENTASONE OPHTH/OTIC SANDOZ-PINDOLOL SANDOZ-PRAMIPEXOLE SANDOZ-PREDNISOLONE SANDOZ-PROCTOMYXIN HC SANDOZ-QUETIAPINE SANDOZ-RABEPRAZOLE SANDOZ-RANITIDINE SANDOZ-RISPERIDONE SANDOZ-SALBUTAMOL SANDOZ-SENNOSIDES SANDOZ-SERTRALINE SANDOZ-SIMVASTATIN SANDOZ-SODIUM CHLORIDE SANDOZ-SOTALOL SANDOZ-SUMATRIPTAN SANDOZ-TERBINAFINE SANDOZ-TICLOPIDINE SANDOZ-TIMOLOL SANDOZ-TOBRAMYCIN SANDOZ-TOPIRAMATE SANDOZ-TRIFLURIDINE SANDOZ-VALPROIC SANSERT SANTYL SAQUINAVIR MESYLATE SARNA HC 5 55 3 51 78 115 78 42 43 35 36 96 11 35 56 56 77 77 98 102 80 39 83 27 97 97 64 32 33 6 57 65 86 78 89 58 78 33 68 78 106 62 90 88 63 18 84 58 28 82 34 67 7 24 80 77 53 78 54 19 109 9 106 SCHEIN-AMOXICILLIN SCHEIN-CEFACLOR SCOPOLAMINE BUTYLBROMIDE SEBCUR SEBCUR-T SECARIS SECTRAL SELAX SELECT 1/35 (21) SELECT 1/35 (28) SELEGILINE SELEGILINE HCL SELENIUM SULFIDE SELEXID SELSUN SENNA LAXATIVE SENNALAX SENNAPREP SENNATAB SENNOSIDES SENOKOT SENOKOT S SERC SEREVENT DISKHALER SEREVENT DISKUS SEROQUEL SERTRALINE SERTRALINE-100 SERTRALINE-25 SERTRALINE-50 SHARPS CONTAINER SIDEKICK SIG-ENALAPRIL SILVER SULFADIAZINE SIMPONI AUTO INJECTOR SIMPONI PRE-FILLED SYRINGE SIMVASTATIN SIMVASTATIN-10 SIMVASTATIN-20 SIMVASTATIN-40 SINEMET SINEMET CR SINEQUAN SINGULAIR SINTROM SIROLIMUS SLOW K SODIUM AUROTHIOMALATE SODIUM AUROTHIOMALATE SODIUM BICARBONATE SODIUM BICARBONATE SODIUM CARBOXYMETHYL CELLULOSE SODIUM CHLORIDE SODIUM CHLORIDE SODIUM CITRATE, SODIUM LAURYL SULFOACETATE, SORBITOL SODIUM CROMOGLYCATE SODIUM NITROPRUSSIDE SODIUM PHOSPHATE DIBASIC, SODIUM PHOSPHATE MONOBASIC SODIUM POLYSTYRENE SULFONATE

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4 2 17 108 108 81 31 83 95 95 69 69 104 5 104 84 84 84 84 84 84 83 115 18 18 62 58 58 58 58 122 72 38 104 116 116 28 28 28 28 68 68 56 76 23 118 73 91 91 73 73 81 74 74 84
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SOFLAX SOFLAX EX SOFLAX SYRUP SOFRACORT EYE/EAR SOFRAMYCIN SOFRAMYCIN STERILE EYE SOFT TOUCH SOFTCLIX SOFTCLIX SELECT SOFTTOUCH SOLIFENACIN SUCCINATE SOLUGEL SOLUVER SOLUVER PLUS SOMATULINE AUTOGEL SORIATANE SOTALOL SOTALOL HCL SPACE CHAMBER SPACE CHAMBER ADULT LARGE MASK SPACE CHAMBER ADULT REGULAR MASK SPACE CHAMBER INFANT MASK SPACE CHAMBER PEDIATRIC MASK SPACER DEVICE SPIRIVA SPIRONOLACTONE SPIRONOLACTONE, HYDROCHLOROTHIAZIDE SPORANOX STALEVO STANHEXIDINE STARLIX STATEX STAVUDINE STELARA STEREX STERILE EXTEMPORANEOUS MIXTURE (QC) STERILE TRIAMCINOLONE STERILE WATER STERILE WATER FOR INJ STIEVA-A STIEVA-A FORTE STIEVAMYCIN STIEVAMYCIN FORTE STIEVAMYCIN MILD SUCRALFATE SUCRALFATE-1 SULCRATE SULCRATE PLUS SULFACETAMIDE SODIUM SULFAMETHOXAZOLE SULFAMETHOXAZOLE, TRIMETHOPRIM SULFASALAZINE SULFINPYRAZONE SULINDAC SULINDAC SUMATRIPTAN HEMISULFATE SUMATRIPTAN SUCCINATE SUNITINIB MALATE 83 83 83 78 77 77 121 121 121 121 110 103 108 108 116 108 34 34 120 120 120 120 120 119 17 41 75 7 68 104 98 48 9 118 108 116 94 118 75 107 107 102 102 102 88 88 88 88 77 6 6 6 75 45 45 67 67 15
76 72 85
74
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SUPER ENDCAPS FOR GLUCOLET SUPER ENDCAPS FOR MICROLET SUPER-FINE MICRO 31G 5MM SUPER-FINE STANDARD 29G 12.7MM SUPER-FINE XTRA 31G 8MM SUPEUDOL SUPRAX SUPREFACT SUPREFACT DEPOT 2 MONTHS SUPREFACT DEPOT 3 MONTHS SURESTEP SUSTIVA SUTENT SYMBICORT 100 TURBUHALER SYMBICORT 200 TURBUHALER SYMMETREL SYNALAR SYNAREL SYNPHASIC (21) SYNPHASIC (28) SYNTHROID SYRINGE SYRINGE & NEEDLE SYRINGE & NEEDLE (NONINSULIN) SYRINGE (NON-INSULIN) SYRINGE CASE SYRINGE SCALE MAGNIFIER SYRN INS U-II 3/10CC 30G SYRN INSULIN MICRO 3/10CC 28G SYRN INSULIN U-II 30G SYRN INSULIN ULTRA 29G SYRN INSULIN ULTRA 3/10CC 29G SYRN MONOJECT TACROLIMUS TACROLIMUS (PROTOPIC) TALWIN TAMBOCOR TAMOFEN TAMOXIFEN TAMOXIFEN CITRATE TAMSULOSIN HCL TAMSULOSIN HYDROCHLORIDE TANTA-ORCIPRENALINE TANTAPHEN TANTAPHEN GRAPE TAPAZOLE TAR0-FLUCONAZOLE TARCEVA TARGEL TARGEL SA TARO-AMCINONIDE TARO-CARBAMAZEPINE TARO-CARBAMAZEPINE CR TARO-CIPROFLOXACIN TARO-CLINDAMYCIN TARO-ENALAPRIL TARO-FLUCONAZOLE TARO-MOMETASONE TARO-MUPIROCIN 2% OINTMENT TARO-PHENYTOIN 121 121 122 122 122 49 2 13 13 13 72 8 15 18 18 8 105 96 95 95 100 122 123 120 120 123 121 123 123 123 123 123 122 118 109 49 25 15 15 15 118 118 18 50 49 100 7 13 108 108 104 51 51 5 102 38 7 107 102 51

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TARO-SIMVASTATIN TARO-SONE TARO-TERCONAZOLE TARO-WARFARIN TAZAROTENE TAZORAC TEARS NATURALE TEARS NATURALE FREE TEARS NATURALE II TEARS NATURALE P.M. TEARS PLUS TEBRAZID TECTA TEGRETOL TEGRETOL CR TELMISARTAN TELMISARTAN, HYDROCHLOROTHIAZIDE TELZIR TEMAZEPAM TEMAZEPAM TEMODAL TEMOZOLOMIDE TEMPRA TEMPRA CHILDREN TEMPRA DOUBLE STRENGTH TENOFOVIR DISOPROXIL FUMARATE TENORETIC TENORMIN TERAZOL 3 DUAL PAK TERAZOL 7 TERAZOSIN HCL TERBINAFINE HCL TERBUTALINE SULFATE TERCONAZOLE TERSASEPTIC TERSA-TAR TERSA-TAR MILD TESTOSTERONE CYPIONATE TESTOSTERONE CYPIONATE TESTOSTERONE ENANTHATE TESTOSTERONE UNDECANOATE TETRABENAZINE TETRACYCLINE TETRACYCLINE HCL TEVETEN TEVETEN PLUS THEOLAIR THEOPHYLLINE THEOPHYLLINE THIAMAZOLE THIAMINE THIAMINE HCL THIOGUANINE THIOPROPERAZINE MESYLATE THIOTHIXENE THYROGEN THYROID THYROID THYROTROPIN ALFA TIAMOL TIAPROFENIC TIAPROFENIC ACID 28 104 103 23 109 109 81 81 81 81 81 8 89 51 51 41 41 9 66 66 15 15 49 49 50 10 32 31 103 103 30 7 19 103 104 108 108 94 94 94 94 118 6 6 41 41 110 110 110 100 111 111 15 63 63 71 100 100 71 105 45 45 TIAZAC TIAZAC XC TICLOPIDINE HCL TIMOLOL TIMOLOL MALEATE TIMOLOL MALEATE, TRAVOPROST TIMOLOL MALEATE-EX TIMOPTIC TIMOPTIC-XE TINACTIN TINACTIN AEROSOL TINZAPARIN SODIUM TIOTROPIUM BROMIDE MONOHYDRATE TIPRANAVIR TIZANIDINE HCL TOBRADEX TOBRAMYCIN TOBREX TOLBUTAMIDE TOLBUTAMIDE TOLNAFTATE TOLOXIN TOLTERODINE TOPAMAX TOPAMAX SPRINKLE TOPICORT TOPIRAMATE TOPSYN TR- VI-SOL TRANDATE TRANDOLAPRIL TRANEXAMIC ACID TRANS PLANTAR TRANSDERM-NITRO TRANS-VER-SAL TRANYLCYPROMINE SULFATE TRASICOR TRAVAMINE TRAVATAN TRAVATAN Z TRAVEL AID TRAVEL TABLET TRAVOPROST TRAZODONE TRAZODONE HCL TRAZOREL TRELSTAR TRELSTAR LA TRENTAL TRETINOIN TRIAMCINOLONE TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE (5ML) TRIAMCINOLONE DIACETATE TRIAMCINOLONE HEXACETONIDE TRIAMINIC COUGH & CONGESTION TRIAMINIC DM TRIAMINIC DM NIGHT TIME TRIAMTERENE, HYDROCHLOROTHIAZIDE
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36 36 24 34 34 81 80 80 80 103 103 23 17 10 20 78 77 77 98 98 103 25 110 53 53 105 53 105 113 32 40 24 108 30 108 58 33 86 81 81 86 86 81 59 59 59 15 15 24 15 94 79 94 94 94 76 76 76 74
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TRIATEC-30 TRIAZOLAM TRIAZOLAM TRICLOSAN TRI-CYCLEN (21) TRI-CYCLEN (28) TRI-CYCLEN LO TRIDESILON TRIFLUOPERAZINE TRIFLUOPERAZINE HCL TRIFLURIDINE TRIHEXYPHEN TRIHEXYPHENIDYL HCL TRIMETHOPRIM TRIMIPRAMINE TRIMIPRAMINE MALEATE TRINIPATCH TRIPTORELIN PAMOATE TRIQUILAR (21) TRIQUILAR (28) TRIZIVIR TROSEC TROSPIUM CHLORIDE TRUETRACK TRUSOPT TRUVADA TUBING TWINJECT TYLENOL TYLENOL EXTRA STRENGTH TYLENOL GRAPE TYLENOL JUNIOR STRENGTH TYLENOL WITH CODEINE TYLENOL WITH CODEINE NO.2 TYLENOL WITH CODEINE NO.3 TYLENOL WITH CODEINE NO.4 ULCIDINE ULTI 29GX1/2 WITH SHARP CONTAINER ULTI 31GX1/4 WITH SHARP CONTAINER ULTI 31GX5/16 WITH SHARP CONTAINER ULTI SYG WITH ULTIGUARD 29G 1/2 ULTI SYG WITH ULTIGUARD 30G 1/2 ULTI SYG WITH ULTIGUARD 30G 5/16 ULTI SYG WITH ULTIGUARD 31G 5/16 ULTICARE 28G SYG 1/2 ULTICARE 29G ULTICARE 30G ULTICARE 31G SYG 5/16 ULTICARE INSULIN SYR 29G.1CC ULTICARE INSULIN SYR 29G.3CC ULTICARE INSULIN SYR 29G.5CC ULTICARE INSULIN SYR 30G.1CC ULTICARE INSULIN SYR 30G.3CC ULTICARE INSULIN SYR30G.5CC ULTICARE LOW DEAD SPACE SYG ULTIGUARD INSULIN SYR 29G.1CC 45 66 66 104 95 95 95 105 64 64 78 67 67 12 59 59 30 15 95 95 8 110 110 72 80 9 121 19 50 50 49 50 45 45 45 45 87 122 122 122 123 123 123 123 123 123 123 123 123 123 123 123 123 123 123 123

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ULTIGUARD INSULIN SYR 29G.3CC ULTIGUARD INSULIN SYR 29G.5CC ULTIGUARD INSULIN SYR 30G.1CC ULTIGUARD INSULIN SYR 30G.3CC ULTIGUARD INSULIN SYR 30G.5CC ULTRA MOP ULTRA-FINE ULTRA-FINE II ULTRA-FINE II 30G ULTRAFINE PEN ULTRA-FINE 29G ULTRASE MS 4 ULTRASE MT 12 ULTRASE MT 20 ULTRAVATE UNILET COMFORT TOUCH UNIPHYL UNITRON PEG UREMOL HC URISPAS URSO URSO DS URSODIOL USTEKINUMAB VAGIFEM VALACYCLOVIR HCL VALCYTE VALGANCICLOVIR HCL VALISONE VALIUM VALPROATE, SODIUM VALPROIC ACID VALSARTAN VALSARTAN, HYDROCHLOROTHIAZIDE VALTREX VARENICLINE VASERETIC VASOTEC VENLAFAXINE HCL VENOMIL HONEY BEE VENOM VENOMIL MIXED VESPID VENOM PROTEIN VENOMIL WASP VENOM PROTEIN VENOMIL WHITE FACED HORNET VENOM PROTEIN VENOMIL YELLOW JACKET VENOM PROTEIN VENT 170 SPACER VENT 170 SPACER AND MASK VENT 170 SPACER DELUXE VENTAHALER VENTODISK VENTODISK & DISKHALER VENTODISK DISKHALER VENTODISK DISKHALER VENTOLIN VENTOLIN HFA VENTOLIN PF VENTOLIN ROTACAPS VEPESID 123 123 123 123 123 108 122 121 122 122 85 85 85 106 121 110 10 106 110 85 85 85 118 96 11 11 11 105 65 54 54 41 41 11 21 38 38 59 101 101 101 101 101 120 120 120 120 18 18 120 120 18 18 18 18 13 VERAPAMIL VERAPAMIL HCL VERMOX VERSEL VERTEPORFIN VESANOID VESICARE VESPULA SPP VENOM PROTEIN EXTRACT VFEND VIDEX EC VIGABATRIN VINCRISTINE SULFATE VINCRISTINE SULFATE VIOKASE VIRACEPT VIRAMUNE VIREAD VIROPTIC VISKAZIDE VISKEN VISUDYNE VIT A VIT B12 VIT C VITAMIN A VITAMIN A VITAMIN A ACID VITAMIN A, CHOLECALCIFEROL, ASCORBIC ACID VITAMIN B1 VITAMIN B12 VITAMIN B3 VITAMIN B6 VITAMIN C VITAMIN D VITAMIN D VITAMIN E VITAMIN E VITAMIN E NATUAL SOURCE VIVOL VOLTAREN VOLTAREN SR VORICONAZOLE WAMPOLE MINERAL CALCIUM WARFARIN SODIUM WASP VENOM PROTEIN WASP VENOM PROTEIN WATER WATER FOR INJECTION WEBCOL ALCOHOL PREP WELLBUTRIN SR WELLBUTRIN XL WESTCORT WHITE FACED HORNET VENOM WHITE FACED HORNET VENOM PROTEIN WHITE FACED HORNET VENOM PROTEIN, YELLOW HORNET VENOM PROTEIN, YELLOW JACKET VENOM PROTEIN WINPRED XALATAN XANAX XANAX TS
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37 36 2 104 82 15 110 101 7 8 54 15 15 85 9 9 10 78 33 33 82 111 111 111 111 111 107 113 111 111 111 111 111 112 112 109 109 112 65 42 43 7 73 23 101 101 75 118 121 54 54 106 101 101 101
94 81 64 64
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Health Canada
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XARELTO XATRAL XELODA XEOMIN X-PREP XYLOCAINE VISCOUS YASMIN (21) YASMIN (28) YAZ YELLOW HORNET VENOM PROTEIN YELLOW HORNET VENOM PROTEIN YELLOW JACKET HORNET VENOM PROTEIN YELLOW JACKET VENOM PROTEIN YELLOW JACKET VENOM PROTEIN ZADITEN ZAFIRLUKAST ZANAFLEX ZANTAC ZAPEX ZARONTIN ZAROXOLYN ZEASORB AF ZELDOX ZERIT ZESTORETIC ZESTRIL ZIAGEN ZIDOVUDINE ZINC OXIDE ZINC OXIDE CREAM 15% ZINCOFAX EXTRA STRENGTH ZIPRASIDONE HCL MONOHYDRATE ZITHROMAX ZOCOR ZODERM ZOFRAN ZOFRAN ODT ZOLADEX ZOLADEX LA ZOLEDRONIC ACID ZOLMITRIPTAN ZOLOFT ZOMIG ZOMIG RAPIMELT ZOSTRIX ZOSTRIX HP ZOVIRAX ZYBAN SR ZYLOPRIM ZYM-ALENDRONATE ZYM-AMLODIPINE ZYM-ASA ZYM-ASA EC ZYM-BISOPROLOL ZYM-CARVEDILOL ZYM-CITALOPRAM ZYM-CLONAZEPAM ZYM-FLUOXETINE ZYM-GABAPENTIN 23 114 13 115 84 107 94 94 94 101 101 101 101 101 1 76 20 87 65 51 75 103 64 9 39 39 8 10 107 107 107 64 3 28 109 86 86 13 13 118 67 58 67 67 109 109 11 54 115 114 34 42 42 32 32 55 51 56 52 ZYM-METOPROLOL-L ZYM-MIRTAZAPINE ZYM-ONDANSETRON ZYM-PAROXETINE ZYM-PIOGLITAZONE ZYM-PRAVASTATIN ZYM-QUETIAPINE ZYM-RISPERIDONE ZYM-SERTRALINE ZYM-SIMVASTATIN ZYM-TOPIRAMATE ZYPREXA ZYPREXA ZYDIS ZYVOXAM

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33 57 86 58 99 27 62 63 58 28 53 61 61 7
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2010
Page I-23 of 23

Drug Benefit List

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NON-INSURED HEALTH BENEFITS

First Nations and Inuit Health Branch

DRUG BENEFIT LIST

Health Canada Non-Insured Health Benefits

INTRODUCTION Drug Benefit List

Introduction to NIHB Drug Benefit List

Introduction to NIHB Drug Benefit List

Introduction to NIHB Drug Benefit List

Introduction to NIHB Drug Benefit List

Introduction to NIHB Drug Benefit List

Introduction to NIHB Drug Benefit List

Introduction to NIHB Drug Benefit List

Introduction to NIHB Drug Benefit List

Introduction to NIHB Drug Benefit List

Introduction to NIHB Drug Benefit List

Introduction to NIHB Drug Benefit List

Introduction to NIHB Drug Benefit List

04:00 ANTIHISTAMINE DRUGS 04.00.00 ANTIHISTAMINE DRUGS CETIRIZINE HCL

10mg Tablet 02231603 APO-CETIRIZINE APX

RATIO-LENOLTEC NO.3 TYLENOL WITH CODEINE NO.3

DRUG BENEFIT LIST

Non-Insured Health Benefits

04:00 ANTIHISTAMINE DRUGS

04:00.00 ANTIHISTAMINE DRUGS

60mg Tablet 02231462

APX NOP NXP PMS NOP PMS NVR

PED APX JNO PMS JNO

20mg Tablet 02315963 01900978

SCH SCH SCH VTH VTH

SCH SCH NOP

LORATADINE, PSEUDOEPHEDRINE SULFATE

Non-Insured Health Benefits

08:00 ANTI-INFECTIVE AGENTS

Non-Insured Health Benefits

APX ABB PDL

Non-Insured Health Benefits

AMOXICILLIN, CLAVULANIC ACID

60mg/mL Suspension 02229617 PEN VEE

Non-Insured Health Benefits

Non-Insured Health Benefits

08:12.28 MISCELLANEOUS ANTIBIOTICS

Non-Insured Health Benefits

08:12.28 MISCELLANEOUS ANTIBIOTICS

200mg Tablet 02256479 VFEND

08:16.04 ANTITUBERCULOSIS AGENTS

Non-Insured Health Benefits

08:16.04 ANTITUBERCULOSIS AGENTS

300mg Tablet 00272655 ISOTAMINE 00577804 PMS-ISONIAZID

EFAVIRENZ, EMTRICITABINE, TENOFOVIR DISOPROXIL FUMARATE

ABACAVIR, LAMIVUDINE, ZIDOVUDINE

600mg & 200mg & 300mg Tablet 02300699 ATRIPLA

Non-Insured Health Benefits

Non-Insured Health Benefits

TENOFOVIR DISOPROXIL FUMARATE

PEGINTERFERON ALFA-2B, RIBAVIRIN

Non-Insured Health Benefits

08:18.32 NUCLEOSIDES AND NUCLEOTIDES

08:18.32 NUCLEOSIDES AND NUCLEOTIDES

500mg Tablet 02315173 PRO-VALACYCLOVIR

Non-Insured Health Benefits

08:36.00 URINARY ANTI-INFECTIVES

08:30.92 MISCELLANEOUS ANTIPROTOZOALS

08:36.00 URINARY ANTI-INFECTIVES