formulary healthformulary.drugplan.health.gov.sk.ca/publns/formularyv56.pdf · 52:00 eye, ear, nose...

Saskatchewan Health
Formulary
Fifty-Sixth Edition July 2006 – June 2007 Updated quarterly

Inquiries should be directed to:

Pharmaceutical Services Division Drug Plan & Extended Benefits Branch

Saskatchewan Health 2nd Floor, 3475 Albert Street

Regina, Saskatchewan S4S 6X6

Website Address: http://formulary.drugplan.health.gov.sk.ca/ Telephone inquiries should be directed as follows: Consumer Inquiries………………..……………Toll Free…….. …………………………………………….……...Regina….…...

1-800-667-7581 (306) 787-3317

Pharmacy Inquiries………………………………Toll Free……. ………………………………………………..……Regina………

1-800-667-7578 (306) 787-3315

Special Support Program Inquiries……………Toll Free…….. …………………………………………….……....Regina….…...

1-800-667-7581 (306) 787-3317

EDS, Palliative Care, "No Substitution" Inquiries…….………. (306) 787-8744 EDS Requests (24-hour message system)…..Toll Free…….. 1-800-667-2549 Profile Release Program………………………………………... (306) 787-1661 Pricing, Contract Inquiries………………………………………. (306) 787-3420 Product Submission Inquiries………………………….……….. (306) 933-5599 Research and Utilization Inquiries……………………………... (306) 787-3307 Hospital Benefit List Inquiries………………………….……….. (306) 787-6823 Facsimile numbers: EDS Unit Fax (EDS requests, Palliative Care forms and "No Substitution" requests only)……………………. General Fax ………………………………………..…..………...

(306) 798-1089 (306) 787-8679

Saskatchewan Drug Information Service: Healthcare Professionals……………….……..Toll Free.…...... ……………………………………………………Saskatoon…… Consumers………………………………………Toll Free……...……………………………………………………Saskatoon…… Website Address: www.usask.ca/druginfo

1-800-667-3425 (306) 966-6340 1-800-665-3784 (306) 966-6378

Copyright - 2006 Her Majesty the Queen in right of the Dominion of Canada, as represented by the Minister of Health of the Province of Saskatchewan

Saskatchewan Health Government of Saskatchewan Minister, The Honourable Len Taylor

ISSN 0701-9823 Printed in Canada

http://formulary.drugplan.health.gov.sk.ca/

56th EDITION

TABLE OF CONTENTSFORMULARY AND DRUG PLAN

PROGRAMS

The Saskatchewan Formulary isPublished Annually

Updates will be provided:Fall 2006

Winter 2007Spring 2007

Please insert sticker updates in the section provided at the back of the Formulary.

TABLE OF CONTENTS

(FORMULARY & DRUG PLAN PROGRAMS)

MEMBERSHIP OF SASKATCHEWAN FORMULARY COMMITTEE.................................... . ivMEMBERSHIP OF SASKATCHEWAN DRUG QUALITY ASSESSMENT COMMITTEE ..... . ivPREFACE.............................................................................................................................. . vNOTES CONCERNING THE FORMULARY......................................................................... . xiiLEGEND................................................................................................................................ . xviii

PHARMACOLOGICAL - THERAPEUTIC CLASSIFICATION OF DRUGS08:00 ANTI-INFECTIVE AGENTS..................................................................................... . 210:00 ANTINEOPLASTIC AGENTS.................................................................................. . 2212:00 AUTONOMIC DRUGS............................................................................................. . 2620:00 BLOOD FORMATION AND COAGULATION.......................................................... . 3624:00 CARDIOVASCULAR DRUGS................................................................................. . 4228:00 CENTRAL NERVOUS SYSTEM AGENTS............................................................. . 7436:00 DIAGNOSTIC AGENTS.......................................................................................... . 11640:00 ELECTROLYTIC, CALORIC AND WATER BALANCE........................................... . 12048:00 ANTITUSSIVES, EXPECTORANTS AND MUCOLYTIC AGENTS......................... . 12652:00 EYE, EAR, NOSE AND THROAT PREPARATIONS.............................................. . 12856:00 GASTROINTESTINAL DRUGS............................................................................... . 13860:00 GOLD COMPOUNDS.............................................................................................. . 14864:00 HEAVY METAL ANTAGONISTS............................................................................. . 15068:00 HORMONES AND SYNTHETIC SUBSTITUTES.................................................... . 15284:00 SKIN AND MUCOUS MEMBRANE AGENTS......................................................... . 17286:00 SMOOTH MUSCLE RELAXANTS.......................................................................... . 19288:00 VITAMINS................................................................................................................ . 19692:00 UNCLASSIFIED THERAPEUTIC AGENTS............................................................ . 20094:00 DIABETIC SUPPLIES...............................................................................………… . 214

APPENDICESAPPENDIX A - EXCEPTION DRUG STATUS PROGRAM................................................ . 218APPENDIX B - ONLINE CRITERIA ADJUDICATION........................................................ . 257APPENDIX C - SPECIAL COVERAGES............................................................................ . 258APPENDIX D - CODES FOR PHARMACY ONLINE CLAIMS PROCESSING..……......... . 264APPENDIX E - MAINTENANCE DRUG SCHEDULE........................................................ . 269APPENDIX F - TRIAL PRESCRIPTION PROGRAM MEDICATION LIST......................... . 270APPENDIX G - SASKATCHEWAN MS DRUGS PROGRAM............................................ . 271APPENDIX H - PHARMACEUTICAL MANUFACTURERS LIST....................................... . 273APPENDIX I - MAXIMUM ALLOWABLE COST (MAC) POLICY..................................... . 275

INDICESINDEX A - THERAPEUTIC CLASSIFICATION LIST......................................................... . 278INDEX B - NUMERICAL LIST OF DRUG IDENTIFICATION NUMBERS.......................... . 280INDEX C - ALPHABETICAL LIST OF PHARMACEUTICAL PRODUCT NAMES.............. . 299

FORMULARY UPDATES...................................................................................................... . 324UPDATE INDEX.......…………………………………............................................................... . 346

NOTE: The Table of Contents for the Supplementary Information regarding non-Drug Plan programs can be found following the Update Index at the back of the book.

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INTRODUCTION

COMMITTEES SASKATCHEWAN FORMULARY COMMITTEE (SFC) Dr. B.R. Schnell Chairperson Dr. M. Caughlin Saskatchewan Medical Association Member currently unnamed Saskatchewan Registered Nurses Association Dr. R. Dobson Member at Large Mr. M. Wolfe - Interim rep Saskatchewan Association of Health Organizations Ms. C. Kanhai Saskatchewan College of Pharmacists Dr. J. de la Rey Nel College of Physicians & Surgeons Mr. G. Peters Saskatchewan Health Dr. D. Quest Chair, DQAC Dr. D. Seibel Member at Large Dr. Y. Shevchuk College of Pharmacy & Nutrition STAFF ASSISTANCE Ms. Gail Bradley Pharmacist, Pharmaceutical Services Drug Plan & Extended Benefits Branch Dr. Lorne Davis Pharmacologist, Pharmaceutical Services Drug Plan & Extended Benefits Branch

SASKATCHEWAN DRUG QUALITY ASSESSMENT COMMITTEE (DQAC) Dr. D. Quest Chairperson Ms. B. Evans College of Pharmacy & Nutrition Dr. A. Paus-Jenssen College of Medicine Dr. B.R. Schnell Chair, SFC Dr. Y. Shevchuk College of Pharmacy & Nutrition Dr. J. Sibley Department of Medicine, College of Medicine Dr. J. Tuchek Department of Pharmacology, College of Medicine Dr. T. W. Wilson Departments of Medicine & Pharmacology, College of Medicine Mr. Kevin Wilson Executive Director, Drug Plan & Extended Benefits Branch Ms. Margaret Baker Director, Pharmaceutical Services Drug Plan & Extended Benefits Branch

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PREFACE

OBJECTIVES The Drug Plan has been established to: • provide coverage to Saskatchewan residents for quality pharmaceutical products of

proven therapeutic effectiveness; • reduce the direct cost of prescription drugs to Saskatchewan residents; • reduce the cost of drug materials; • encourage the rational use of prescription drugs. THE FORMULARY The Saskatchewan Formulary is a listing of the therapeutically effective drugs of proven high quality that have been approved for coverage under the Drug Plan. It is compiled by the Minister of Health with the advice of the Saskatchewan Formulary Committee (SFC). The SFC is advised and assisted by the Drug Quality Assessment Committee (DQAC). Members of both committees are appointed by the Minister of Health. The Saskatchewan Formulary is published annually in July, with quarterly updates. The ongoing work of the SFC includes the evaluation of new drug products as they are introduced, and the periodic re-evaluation of all products. The goal is to list a range and variety of drugs that will enable prescribers to select an effective course of therapy for most patients. THE DRUG REVIEW PROCESS Wtbp TdtD

Saskatchewan is participating in the Common Drug Review (CDR). The CDR provides participating federal, provincial and territorial drug benefit plans with a systematic review of the available clinical evidence, a critique of manufacturer-submitted pharmacoeconomic studies and a formulary listing recommendation made by the Canadian Expert Drug Advisory Committee (CEDAC). For more information about the CDR and CEDAC, visit http://www.Note: The Drug Review process described below is in transition and will be changing to reflect the CDR process.

cadth.ca.

hen a drug is introduced to the Canadian market, the manufacturer submits a request o the Drug Plan so that it can be considered for possible coverage. The request must e supported by scientific reports and manufacturing documents to show that the roduct meets accepted standards of quality, effectiveness and safety.

he DQAC carries out an initial evaluation of the submission, with emphasis on clinical ocuments, such as reports of scientific studies comparing the new product with existing

herapeutic alternatives. In the case of new brands of currently listed products, the QAC ensures that the products meet accepted standards for interchangeability.

v

The DQAC reports its findings to the SFC. Using this information, along with additional details of anticipated cost and impact on patterns of practice, the SFC makes a recommendation to the Minister of Health. These recommendations reflect the "Policy for Inclusion of Products in the Saskatchewan Formulary" (see pages xii - xiv). The membership on the two Committees reflects its unique but complementary mandate. The DQAC is composed of clinical specialists in internal medicine and/or pharmacology, clinical pharmacists and pharmacologists. The SFC is made up of representatives of the associations or institutions related to the regulation, education, delivery and payment of drug therapy in Saskatchewan.

vi

1 Considers pharmacoeconomic impact in addition to the clinical and pharmaceutical aspects reviewedby the DQAC.

2 DQAC advises the Saskatchewan Cancer Agency Pharmacy & Therapeutics Committee regardinginterchangeability and product quality issues.

3 All products listed in the Saskatchewan Formulary are benefits when used in the hospital setting.

Note: All committee recommendations are subject to approval by the Minister of Health.

For more information on the CDR and CEDAC visit http://www.cadth.ca

PRODUCT SUBMISSION PROCESS*

* The Product Submission Process is in transition and will be changing to reflect the Common Drug Review (CDR) and the recommendations of the Canadian Expert Drug Advisory Committee (CEDAC).

MANUFACTURERSUBMISSION

DRUG QUALITY ASSESSMENT COMMITTEE

(DQAC)

SASKATCHEWAN FORMULARY COMMITTEE

(SFC) 1

SASKATCHEWAN FORMULARY

SASKATCHEWAN CANCER AGENCY

PHARMACY & THERAPEUTICSCOMMITTEE 2

AMBULATORY CARE INDICATION

The DQAC reviews the clinical and pharmaceutical aspects of the submission and makes a recommendation to the Formulary Committee or the Advisory Committee on Institutional Pharmacy Practice.

ONCOLOGY INDICATION

ADVISORY COMMITTEE ON INSTITUTIONAL

PHARMACY PRACTICE 3

INSTITUTIONAL INDICATION

SASKATCHEWAN CANCER AGENCY

BENEFIT DRUG LIST

HOSPITAL BENEFIT DRUG LIST

MANUFACTURERSUBMISSION

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REQUEST FOR PRODUCT ASSESSMENT Submission Process Any supplier wishing to have products listed in the Saskatchewan Formulary, the Hospital Benefit Drug List or the Saskatchewan Cancer Agency Benefit List (interchangeable products) may submit requests for product assessment. The route a submission follows is determined by the indication of the products. There is no deadline date for submissions for listing in the Formulary. In general, submissions are reviewed in order of receipt. Clinical Documentation Single-Supplier Product Submissions New Chemical Entities and New Combination Products Saskatchewan is participating in the Common Drug Review (CDR) process. As a consequence, submissions for new chemical entities and new combination products should be made directly to CDR Directorate in accordance to the CDR Submission Guidelines as posted on the Canadian Agency for Drugs and Technologies in Health website http://www.cadth.ca. Single Source Products That Do Not Contain New Chemical Entities Saskatchewan Health will accept submissions of single source products that do not contain new chemical entities or new combinations and that will not fall under the jurisdiction of the CDR process; however, the same submission requirements as per CDR guidelines will apply to this category of products. Line Extension Products The following submission requirements pertain to new strengths and formulations or reformulations of drug products that are currently listed in the Saskatchewan Formulary.

1. Copy of NOC 2. Copy of completed Drug Identification Number (DIN) notification form 3. Copy of approved Product Monograph 4. Justification of the need for the Line Extension 5. Copy of Comprehensive Summary (“Clinical Studies” section only) or other

document accepted by Health Canada and copies of critical studies that address key clinical issues relevant to the new strength, formulation or reformulation or evidence of formulation proportionality or bioequivalence data; and evidence of a similar dissolution profile.

Changes to Benefit Status of Listed Single Source Drug Products to a New Indication The following submission requirements pertain to single source drug products currently listed in the Saskatchewan Formulary that have received a new indication from the Therapeutic Product Directorate (TPD) and where the manufacturer wishes to request expansion of the coverage criteria or a change in benefit status due to the new indication.

1. Copy of NOC 2. Copy of completed Drug Identification Number (DIN) notification form 3. Copy of approved Product Monograph 4. Justification for the Expanded Coverage Criteria or Change in Benefits Status

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5. Copy of Comprehensive Summary (Clinical Studies section only) or other document accepted by Health Canada and copies of critical studies that address key clinical issues relevant to the new indication.

Interchangeable Product Submissions The following submission requirements pertain to multi-source products submitted for listing in an interchangeable grouping in the Saskatchewan Formulary.

A. Drug products in solid oral dosage forms reviewed by the TPD according to the guidelines, “Conduct and Analysis of Bioavailability and Bioequivalence Studies - Part A and B” and have a Canadian Reference Product on the Notice of Compliance. 1. Copy of NOC 2. Copy of completed Drug Identification Number (DIN) notification form 3. Copy of approved Product Monograph Note: Comparative (Bio) studies may be requested on a case-by-case basis.

B. Drug products in solid oral dosage forms reviewed by the TPD according to the

guidelines “Conduct and Analysis of Bioavailability and Bioequivalence Studies - Report C.

1. Copy of NOC 2. Copy of completed Drug Identification Number (DIN) notification form 3. Copy of approved Product Monograph Note: Comparative (Bio) studies may be requested on a case-by-case basis.

C. Drug Products that are cross-referenced

1. Copy of NOC 2. Copy of completed Drug Identification Number (DIN) notification form 3. Copy of approved Product Monograph 4. Letters from both the manufacturer of the submitted product and the

manufacturer of the cross-licensed product, confirming that the two products are identical in all aspects, except for embossing and labelling.

D. Drug products in Aqueous Solutions (e.g. oral, ophthalmics, inhalation,

injections) that have a Canadian Reference Product on the Notice of Compliance.


E. Drug products in semi-solid formulations (e.g. creams, ointments)


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Drug Products Without a Canadian Reference Product The following submission requirements pertain to products submitted for listing in an interchangeable grouping where the active ingredient is designated as an “old drug” by the TPD and the drug product is approved on the basis of DIN application (i.e. an NOC is not issued) or is issued a Notice of Compliance without a Canadian Reference Product.

A. Drug products in solid dosage forms

1. Copy of completed Drug Identification Number (DIN) notification form 2. Copy of approved Product Monograph or Prescribing Information 3. Executive summary of comparative bioavailablity study or

pharmacodynamic study or studies conducted in accordance with the TPD guidelines, “Conduct and Analysis of Bioavailablity and Bioequivalence studies - Part A and B and Report C.

B. Drug Products Not in Solid Oral Dosage Form

1. Copy of completed Drug Identification Number (DIN) notification form 2. Copy of approved Product Monograph or Prescribing Information 3. Executive summary of comparative Bioavailablity study or

pharmacodynamic study or studies conducted in accordance with the TPD guidelines or surrogate comparisons with the reference drug product (i.e. in vivo or vitro test methods or a pharmacodynamic or therapeutic equivalence study).

C. Drug Products That Are Cross-Referenced

1. Copy of completed Drug Identification Number (DIN) notification form 2. Copy of approved Product Monograph or Prescribing Information 3. Letters from both the manufacturer of the submitted product and the

manufacturer of the cross-licensed product, confirming that the two products are identical in all aspects, except for embossing and labelling.

Clinical documentation in support of products to be reviewed may be submitted at any time. The committees meet on a regular basis and will review submission as quickly as possible upon receipt. Details of the criteria for product listings are published in each edition of the Formulary and in the quarterly updates to the Formulary. Notification is required whenever there is a change in formulation or in the clinical information published in the product monograph, for any listed product as well as for any product under review. Manufacturing Documentation A copy of completed and approved Certified Product Information Document (C.P.I.D.) should be submitted with the clinical documentation if possible, but will be accepted at a later date. Economic Evaluation Price information including catalogue or estimated prices should be provided at the time of product submission.

x

Submission of pharmacoeconomic analyses are encouraged. The National Pharmacoeconomic Guidelines serve as a guide. The Formulary Committee will routinely consider direct “medical” costs such as: • impact on laboratory tests for monitoring, evaluation or diagnosis • impact on physician office visits • impact on hospitalization or institutionalization • impact on surgical procedures • increased or decreased incidence and severity of side effects. The availability of quality-of-life analyses is encouraged. Submission of a budget impact analyses for Saskatchewan Health is encouraged. Additional Documentation Required: • A letter authorizing unrestricted communication regarding the drug product between

the Saskatchewan Prescription Drug Plan and: 1. Participating federal/provincial/territorial (F/P/T) drug plans 2. F/P/T governments, including their agencies and departments 3. F/P/T health authorities (including regional authorities and related facilities) 4. Health Canada 5. Patented Medicine Prices Review Board (PMPRB) 6. Canadian Agency for Drugs and Technology in Health (CADTH)

• Expected market share information is requested to allow for an accurate projection of

the impact of a new product. • Product patent expiration date is requested to allow for consideration of the potential

long-term economic impact of the product. • Copies of the initial product launch material, and any subsequent promotional material

sent to physicians and pharmacists. • A letter confirming the ability to supply product. Submission Procedure Requests for product assessment, together with supporting clinical (including notice of compliance and product monograph) and manufacturing documentation should be sent to: Dr. Lorne Davis, Pharmacologist Department of Pharmacology, College of Medicine University of Saskatchewan, 107 Wiggins Road Saskatoon, Saskatchewan S7N 5E5 Copies of the covering letter, the product monograph, notice of compliance, pricing information and economic analysis should be sent to: Ms. Margaret Baker, Director, Pharmaceutical Services Drug Plan and Extended Benefits Branch, Saskatchewan Health 2nd Floor, 3475 Albert Street Regina, Saskatchewan S4S 6X6

xi

NOTES CONCERNING THE FORMULARY Benefits The Saskatchewan Formulary lists the drugs, which are covered by the Drug Plan. A prescription is required for all drugs dispensed under the Drug Plan with the exception of insulin, blood-testing agents, urine-testing agents, syringes, needles, lancets and swabs used by diabetic patients. Certain drugs are covered under the Exception Drug Status Program (EDS) and require that specific medical criteria are met before coverage is granted. See Appendix A for more information regarding EDS. Eligibility With a few exceptions, all Saskatchewan residents with a valid Saskatchewan Health Services card are eligible for coverage under the Drug Plan. The exceptions include those who have prescription costs paid by another agency. For example: Health Canada; First Nations and Inuit Health Branch Workers' Compensation Board Veterans Affairs Canada members of the Royal Canadian Mounted Police members of the Canadian Forces inmates of Federal Penitentiaries

Policy for Inclusion of Products in the Saskatchewan Formulary

1. Only products produced by manufacturers approved by Health Canada will be considered.

2. Only drug products formulated and produced in accordance with sound manufacturing principles and found to comply with official standards will be considered.

3. Only drug products which are valid therapeutic agents, with proven clinical effectiveness, for the diagnosis, prevention or treatment of mental or physical disorders will be listed. The availability of suitable alternative agents, and potential for undesirable effects will be considered.

The medical literature and clinical studies are reviewed and evaluated to determine

if the drug product is therapeutically effective for the treatment of the conditions for which the drug is indicated.

The clinical literature is also reviewed to determine the therapeutic advantages or

disadvantages in relation to alternative agents, which may or may not be listed in the Saskatchewan Formulary.

The rate and severity of potential undesirable effects are reviewed and compared

with those for alternative products. In reviewing products for which suitable alternatives are listed in the Formulary,

consideration will be given to the following additional criteria:

• clinical documentation must clearly demonstrate therapeutic advantages such as:

• more effective for treatment of the condition(s) for which the drug is intended; • increased safety as shown by reduced toxicity and reduced incidence of

adverse reactions and/or side effects; • improved dosing schedule;

xii

• reduced potential for abuse or inappropriate use; O R

• anticipated cost of a product of equivalent therapeutic effectiveness must offer a potential economic advantage over listed alternatives.

4. The cost of therapy relative to the clinical efficacy is reviewed and compared to the

cost of therapy relative to the clinical efficacy of alternative agents.

An increased cost may be justified if the drug product produces better clinical results in a significant portion of the patient population, demonstrates fewer or less severe undesirable effects, or has a dosage regime which improves patient compliance.

The cost of oral combination products relative to the combined costs of the single entities, the cost of the various dosage strengths relative to therapeutic advantages, and the cost of additional dosage forms relative to the therapeutic advantages will be considered when reviewing such products.

5. Some drug products will not be listed as regular benefits, but may be made

available on Exception Drug Status for treatment of selected clinical indications. (See Appendix A)

6. Oral combination products are required to meet the following additional criteria:

• each component must make a contribution to the claimed effect; • the dosage of each component (amount, frequency, duration of therapeutic effect) must be such that the combination is safe and effective for a significant patient population, requiring such concurrent therapy as defined in the labelling; A component may be added to: • enhance safety or effectiveness of the principal active ingredient; • minimize the potential for abuse of the principal active ingredient. • combination fixed ratio must be "right" for: • significant portion of patients; • significant amount of natural history of disease.

7. Sustained, prolonged or delayed release dosage forms are required to meet the

following additional criteria:

• clinical studies have demonstrated the sustained, prolonged or delayed action of the active ingredient;

• the dosage form possesses therapeutic advantages in the treatment of the

disease entity for which the product is indicated;

8. The various strengths of one dosage form will be considered if they possess therapeutic advantages and meet the required standards for quality and cost.

9. The various dosage forms of a drug product will be evaluated individually.

10. Drug products not listed in the Schedules of the Food and Drugs Act, Narcotic

Control Act or the Saskatchewan Pharmacy Act, but usually sold on prescription, will be considered for inclusion.

xiii

11. Products which contain the same amount of the same active ingredient in an equivalent dosage form and are of acceptable equivalent therapeutic effectiveness will be listed as interchangeable.

12. The following will not be listed:

• fertility agents; • drugs used in erectile dysfunction; • certain over-the-counter preparations; • drugs used primarily in hospitals; • antineoplastic agents (these are provided to patients through the

Saskatchewan Cancer Agency); • anti-tuberculosis drugs; • blood derivatives - immune serum globulin for prophylaxis against infectious

hepatitis or measles or for treatment of immune deficiency disease is available from the Health Offices.

• vaccines and sera - most immunological agents are available from the Health Offices.

13. Drug products identified by trade names deemed to be inappropriate, confusing

and/or misleading may not be listed. Some examples include:

• products with similar or identical trade names but containing different active ingredients;

• products with a different strength of ingredient, manufactured by the same supplier, but with a different trade name.

Policy for Formulary Deletion The Minister of Health may delete any product from the Saskatchewan Formulary under the following circumstances: 1. Upon the recommendation of the SFC: • where the standards of quality and/or production have altered and are not

considered to meet accepted standards; • where new information demonstrates that the product does not have adequate

therapeutic benefit; • where undesirable effects of the product make the continued listing of the product

inappropriate; • where new products possessing clearly demonstrated therapeutic advantages

have been listed, thereby making the continued listing of the product unnecessary.

2. Upon the recommendation of the Drug Plan where there are undesirable financial,

supply or administrative implications to continued listing of a product, the Drug Plan will consult with the SFC prior to making a recommendation. The comments of the Committee will be brought to the attention of the Minister.

3. Where the Minister of Health believes a product should be deleted, the Minister will

consult with the SFC before making a final decision. Exception Drug Status Certain drug products may be considered for Exception Drug Status coverage under one or more of the following circumstances:

xiv

• the drug is ordinarily administered only to hospital inpatients and is being administered outside of a hospital because of unusual circumstances;

• the drug is not ordinarily prescribed or administered in Saskatchewan but is being prescribed because it is required in the diagnosis or treatment of a patient having an illness, disability or condition rarely found in this province;

• the drug is infrequently used since therapeutic alternatives listed in the Formulary are usually effective but are contraindicated or found to be ineffective because of the clinical condition of the patient;

• the drug has been deleted from the Formulary, but is required by patients who were previously stabilized on the drug;

• the drug has potential for use in other than approved indications; • the drug has potential for the development of widespread inappropriate use; • the drug is more expensive than listed alternatives and offers an advantage in

only a limited number of indications. The following information is required to process Exception Drug Status requests:

• patient name • patient Health Services Number (9 digits) • name of drug • diagnosis relevant to use of drug • prescriber name • prescriber phone number

Saskatchewan Prescription Drug Plan policy does not allow a fee to be charged to clients for Exception Drug Status applications made to the Drug Plan on the client's behalf. See Appendix A for further details regarding Exception Drug Status. "No Substitution" Prescriptions Drug Plan benefits will be based only on the lowest priced interchangeable brand as listed in the Formulary or sticker updates. Credit towards established deductibles or thresholds (for income based drug coverage under Special Support) will also be based on the lowest priced interchangeable brand. Although the Formulary will continue to list all approved brands, patients will, in addition to their normal share of cost, be responsible for any incremental cost associated with the selection of a higher cost brand. It is important to note that both generic and brand name products are manufactured under the same standards of good manufacturing practice, and that only those brands, which meet the SFC's standards for bioequivalence, are accepted as interchangeable in Saskatchewan. In cases where a patient experiences problems with a specific brand of a medication, a prescriber may make application for exemption from the cost of the "no sub" brand. (See Appendix C for details.) Adverse Drug Reactions Health Canada encourages the reporting of suspected adverse reactions. In Saskatchewan, prescribers, pharmacists, and other health professionals are encouraged to participate in the Sask AR Program; see Supplementary Information at the back of the book.

xv

xvi

Suspected adverse reactions are reported to this program, which in turn, will send the original report to Health Canada. Index Drug products are listed numerically by DIN (drug identification number) as well as alphabetically by generic name and brand name at the back of the Formulary. Pharmacologic-Therapeutic Classification of Drugs The drugs are classified according to the pharmacologic-therapeutic classification developed by the American Society of Hospital Pharmacists for the purpose of the American Hospital Formulary Service. Permission to use this system has been granted by the American Society of Hospital Pharmacists. The Society is not responsible for the accuracy of transpositions or excerpts from the original content. Within each therapeutic classification the drugs are listed alphabetically according to their generic names. Under each drug, acceptable products are listed. Drugs with multiple uses may be listed in one or more classes. Prescription Quantities The Drug Plan places no limitation on the quantities of drugs that may be prescribed. Prescribers shall exercise their professional judgment in determining the course and duration of treatment for their patients. However, in most cases, the Drug Plan will not pay benefits or credit deductibles for more than a 3-month supply of a drug at one time. The quantity dispensed for one dispensing fee shall be determined by the terms of the contract in force when the prescription was dispensed. For drugs listed on the Two Month and 100 Day maintenance drug lists, refer to Appendix E. Because of possible waste and the potential danger of storing large quantities of potent drugs in the home, the Drug Plan does not encourage the dispensing of unreasonably large quantities of prescription drugs. Release of Patient Drug Profiles Saskatchewan prescribers or pharmacists wishing to obtain a drug profile for patients in their care may do so by submitting a written request, stating the patient's name, address, date of birth and Health Services Number to the address below. The drug profile will include all claims for Formulary and Exception Drug Status drugs submitted to the Drug Plan on behalf of the patient in the previous 9-12 months. Please submit written request to: Executive Director Drug Plan & Extended Benefits Branch Saskatchewan Health 2nd Floor, 3475 Albert Street Regina SK S4S 6X6 FAX: (306) 787-8679

LEGEND

LEGEND

1 Pharmacological-Therapeutic classification.

2 Pharmacological-Therapeutic sub-classification.

3 Nonproprietary or generic name of the drug.

4 An asterisk (*) to the left of a drug strength and dosage form indicates that the products listed below are interchangeable.

5 An asterisk (*) to the right of a price indicates that the Drug Plan has negotiated a contract price (Standing Offer Contract - SOC) for that product. Pharmacists will dispense these products except where a prescriber indicates "no substitution" for a product in an interchangeable category (see page xv). In cases where contracts have been negotiated with two suppliers of an interchangeable product, either brand may be used.

6 The price published in the formulary includes a wholesale mark-up, and is the maximum price accepted (at time of publication) expressed as decimal dollars. Pharmacies are required by contract to submit their actual acquisition cost of the drug, which may be less than the published formulary price. For the most up to date information on formulary drug prices refer to the online formulary at http://formulary.drugplan.health.gov.sk.ca.

7 The following symbol: ⌧, to the left of a drug strength and dosage form indicates that the products listed below are NOT interchangeable.

8 Drug strength and dosage form.

9 The Drug Identification Number (DIN), which has been assigned by Health Canada, uniquely identifies the drug product and its manufacturer, name and strength of active ingredients, route of administration, and pharmaceutical dosage form. In some cases, as noted in the formulary, identification numbers are generated by the Drug Plan for billing purposes only.

10 This product requires Exception Drug Status (EDS) approval (see Appendix A for EDS criteria).

All active ingredients of combination products are listed.

12 Strengths of active ingredients are listed in the same order as the ingredients. This example indicates that the tablet contains 100mg of levodopa and 25mg of carbidopa.

13 Brand name of drug.

14 Three letter identification code assigned to each manufacturer. The codes are listed in Appendix H near the back of the Formulary.

15 The size of vials or ampoules of injectables is listed in brackets.

The size of a tube of ophthalmic ointments is listed in brackets.

This product is affected by the Maximum Allowable Cost (MAC) Policy (see Appendix I for MAC policy information)

15

13

12

9

7

8

10

11

6

2

3

4

5

1

14

16

17

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08:00 ANTI-INFECTIVE AGENTS

08:12.16 ANTIBIOTICS (PENICILLINS)

AMOXICILLIN (AMOXYCILLIN)* 250MG CAPSULE

00865567 NU-AMOXI NXP $ 0.0898 *00406724 NOVAMOXIN NOP 0.1120 00628115 APO-AMOXI APX 0.1120 02230243 PMS-AMOXICILLIN PMS 0.112002238171 GEN-AMOXICILLIN GPM 0.1120

CONJUGATED ESTROGENS⌧ 0.625MG TABLET

00265470 C.E.S. VAE 0.1055 02043408 PREMARIN WYA 0.1321

MOXIFLOXACIN HCL 400MG TABLET

02242965 AVALOX (EDS) BAY $ 5.8823

LEVODOPA/CARBIDOPA* 100MG/25MG TABLET

02182823 NU-LEVOCARB NXP 0.3833 02195941 APO-LEVOCARB APX 0.3833 02244495 NOVO-LEVOCARBIDOPA NOP 0.3833 02247606 DOM-LEVO-CARBIDOPA DOM 0.431300513997 SINEMET BMY 0.6839

FLUPENTHIXOL DECANOATE 20MG/ML INJECTION SOLUTION (10ML)

02156032 FLUANXOL DEPOT LUD $ 73.1900

GENTAMICIN SO4* 5MG/G OPHTHALMIC OINTMENT (3.5G)

00028339 GARAMYCIN SCH $ 4.340002230888 SANDOZ GENTAMICIN SDZ 4.3400

PANTOPRAZOLE (MAC)

40MG ENTERIC TABLET02229453 PANTOLOC (EDS) ATA $ 2.0615

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xix

ANTI-INFECTIVE AGENTS8:00

08:00 ANTI-INFECTIVE AGENTS08:04.00 AMEBICIDES

DIIODOHYDROXYQUIN 650MG TABLET

01997750 DIODOQUIN GLW $ 0.7870

08:08.00 ANTHELMINTICS

MEBENDAZOLE 100MG TABLET

00556734 VERMOX JAN $ 3.4503

PRAZIQUANTEL 600MG TABLET

02230897 BILTRICIDE BAY $ 5.8670

PYRANTEL PAMOATE 125MG TABLET

01944363 COMBANTRIN PFC $ 1.0969 50MG/ML ORAL SUSPENSION

01944355 COMBANTRIN PFC $ 0.2926

PYRVINIUM PAMOATE 10MG/ML ORAL SUSPENSION

02019809 VANQUIN PFC $ 0.1899

08:12.00 ANTIBIOTICS

ANTIBIOTIC ASSOCIATED COLITIS OR PSEUDOMEMBRANOUS ENTEROCOLITISIS A SEVERE POTENTIALLY FATAL COLITIS WHICH MAY FOLLOW THEADMINISTRATION OF ANTIBIOTICS, MOST COMMONLY CLINDAMYCIN.THE SYNDROME IS CAUSED BY A BACTERIAL TOXIN.PATIENTS FOR WHOM ANTIBIOTICS ARE PRESCRIBED SHOULD BE ADVISEDTO DISCONTINUE THERAPY AND REPORT TO THE PHYSICIAN IF APERSISTANT DIARRHEA DEVELOPS AND/OR IF BLOOD OR MUCUS APPEARSIN THE STOOL, AND SHOULD BE ADVISED NOT TO USE ANTIDIARRHEALPREPARATIONS WHILE ON THESE DRUGS AS THEY MAY EXACERBATE THECONDITION.

RECOMMENDED TREATMENT INCLUDES STOPPING ANTIBIOTICS AS SOON ASPOSSIBLE, CAREFUL ATTENTION TO FLUIDS AND ELECTROLYTES AND THEUSE OF AN APPROPRIATE ANTIBIOTIC (SUCH AS ORALLY ADMINISTEREDMETRONIDAZOLE OR VANCOMYCIN) DIRECTED AGAINST THE TOXINPRODUCING ORGANISM.

2

08:00 ANTI-INFECTIVE AGENTS08:12.02 ANTIBIOTICS (AMINOGLYCOSIDES)

GENTAMICIN SO4 40MG/ML INJECTION SOLUTION (2ML)

02242652 GENTAMICIN SDZ $ 5.1000

TOBRAMYCIN SEE APPENDIX A FOR EDS CRITERIA 60MG/ML INHALATION SOLUTION (5ML)

02239630 TOBI (EDS) CCL $ 51.1700

08:12.04 ANTIBIOTICS (ANTIFUNGALS)

FLUCONAZOLE SEE APPENDIX A FOR EDS CRITERIA* 150MG CAPSULE

02241895 APO-FLUCONAZOLE APX $ 9.965802243645 NOVO-FLUCONAZOLE NOP 9.971202245697 GEN-FLUCONAZOLE GPM 9.971202141442 DIFLUCAN PFI 15.7944

* 50MG TABLET02236978 NOVO-FLUCONAZOLE (EDS) NOP $ 3.392402237370 APO-FLUCONAZOLE (EDS) APX 3.392402245292 GEN-FLUCONAZOLE (EDS) GPM 3.392402245643 PMS-FLUCONAZOLE (EDS) PMS 3.392402249294 TARO-FLUCONAZOLE (EDS) TAR 3.392402246108 DOM-FLUCONAZOLE (EDS) DOM 3.562100891800 DIFLUCAN (EDS) PFI 5.2603

* 100MG TABLET02236979 NOVO-FLUCONAZOLE (EDS) NOP $ 6.018102237371 APO-FLUCONAZOLE (EDS) APX 6.018102245293 GEN-FLUCONAZOLE (EDS) GPM 6.018102245644 PMS-FLUCONAZOLE (EDS) PMS 6.018102249308 TARO-FLUCONAZOLE (EDS) TAR 6.018102246109 DOM-FLUCONAZOLE (EDS) DOM 6.319100891819 DIFLUCAN (EDS) PFI 9.2008

10MG/ML POWDER FOR ORAL SUSPENSION02024152 DIFLUCAN P.O.S. (EDS) PFI $ 1.0531

ITRACONAZOLE SEE APPENDIX A FOR EDS CRITERIA 100MG CAPSULE

02047454 SPORANOX (EDS) JAN $ 4.0877 10MG/ML ORAL SOLUTION

02231347 SPORANOX (EDS) JAN $ 0.8692

3

08:00 ANTI-INFECTIVE AGENTS08:12.04 ANTIBIOTICS (ANTIFUNGALS)

KETOCONAZOLE SEE APPENDIX A FOR EDS CRITERIA* 200MG TABLET

02122197 NU-KETOCON (EDS) NXP $ 1.284102231061 NOVO-KETOCONAZOLE (EDS) NOP 1.284102237235 APO-KETOCONAZOLE (EDS) APX 1.2841

NYSTATIN 500,000U TABLET

02194198 RATIO-NYSTATIN RPH $ 0.2604* 100,000U/ML ORAL SUSPENSION

02194201 RATIO-NYSTATIN RPH $ 0.056600792667 PMS-NYSTATIN PMS 0.064302125145 DOM-NYSTATIN DOM 0.0674

TERBINAFINE HCL* 250MG TABLET

02248845 NU-TERBINAFINE NXP $ 2.1944 *02254727 CO TERBINAFINE COB 2.738902239893 APO-TERBINAFINE APX 2.739102240807 PMS-TERBINAFINE PMS 2.739102242503 GEN-TERBINAFINE GPM 2.739102240346 NOVO-TERBINAFINE NOP 2.739302031116 LAMISIL NVR 4.3959

VORICONAZOLE SEE APPENDIX A FOR EDS CRITERIA 50MG TABLET

02256460 VFEND (EDS) PFI $ 12.8800 200MG TABLET

02256479 VFEND (EDS) PFI $ 48.5000

08:12.06 ANTIBIOTICS (CEPHALOSPORINS)

CEFIXIME SEE APPENDIX A FOR EDS CRITERIA 400MG TABLET

00868981 SUPRAX (EDS) AVT $ 3.6196 20MG/ML ORAL SUSPENSION

00868965 SUPRAX (EDS) AVT $ 0.3880

4

08:00 ANTI-INFECTIVE AGENTS08:12.06 ANTIBIOTICS (CEPHALOSPORINS)

CEFPROZIL SEE APPENDIX A FOR EDS CRITERIA 250MG TABLET

02163659 CEFZIL (EDS) BMY $ 1.7560 500MG TABLET

02163667 CEFZIL (EDS) BMY $ 3.4432 25MG/ML ORAL SUSPENSION

02163675 CEFZIL (EDS) BMY $ 0.1716 50MG/ML ORAL SUSPENSION

02163683 CEFZIL (EDS) BMY $ 0.3432

CEFUROXIME AXETIL SEE APPENDIX A FOR EDS CRITERIA* 250MG TABLET

02244393 APO-CEFUROXIME (EDS) APX $ 1.099402242656 RATIO-CEFUROXIME (EDS) RPH 1.099402212277 CEFTIN (EDS) GSK 1.6411

* 500MG TABLET02244394 APO-CEFUROXIME (EDS) APX $ 2.177902242657 RATIO-CEFUROXIME (EDS) RPH 2.177902212285 CEFTIN (EDS) GSK 3.2511

25MG/ML ORAL SUSPENSION02212307 CEFTIN (EDS) GSK $ 0.1815

CEPHALEXIN MONOHYDRATE 250MG CAPSULE

00342084 NOVO-LEXIN NOP $ 0.1620 500MG CAPSULE

00342114 NOVO-LEXIN NOP $ 0.3240* 250MG TABLET

00865877 NU-CEPHALEX NXP $ 0.1272 *00583413 NOVO-LEXIN NOP 0.162000768723 APO-CEPHALEX APX 0.162002177781 PMS-CEPHALEXIN PMS 0.162002177846 DOM-CEPHALEXIN DOM 0.1966

* 500MG TABLET00865885 NU-CEPHALEX NXP $ 0.2544 *00583421 NOVO-LEXIN NOP 0.324000768715 APO-CEPHALEX APX 0.3240

25MG/ML ORAL SUSPENSION00342106 NOVO-LEXIN NOP $ 0.0352

50MG/ML ORAL SUSPENSION00342092 NOVO-LEXIN NOP $ 0.0712

5

08:00 ANTI-INFECTIVE AGENTS08:12.12 ANTIBIOTICS (MACROLIDES)

PRESCRIPTIONS FOR SOLID DOSAGE FORMS OF ERYTHROMYCIN SHOULD BEFILLED WITH AN ERYTHROMYCIN BASE PREPARATION OF THE STRENGTHPRESCRIBED; DISPENSE THE STEARATE AND ESTOLATE ONLY WHENSPECIFICALLY PRESCRIBED.

AZITHROMYCIN SEE APPENDIX A FOR EDS CRITERIA* 250MG TABLET

02247423 APO-AZITHROMYCIN (EDS) APX $ 3.372202275287 RATIO-AZITHROMYCIN (EDS) RPH 3.372202255340 CO AZITHROMYCIN (EDS) COB 3.372702265826 SANDOZ AZITHROMYCIN (EDS) SDZ 3.372702261634 PMS-AZITHROMYCIN (EDS) PMS 3.746902267845 NOVO-AZITHROMYCIN (EDS) NOP 3.746902212021 ZITHROMAX (EDS) PFI 5.3441

* 600MG TABLET02261642 PMS-AZITHROMYCIN (EDS) PMS $ 8.273202256088 CO AZITHROMYCIN (EDS) COB 8.273202231143 ZITHROMAX (EDS) PFI 12.8207

20MG/ML ORAL SUSPENSION02223716 ZITHROMAX (EDS) PFI $ 1.1552

40MG/ML ORAL SUSPENSION02223724 ZITHROMAX (EDS) PFI $ 1.6370

CLARITHROMYCIN SEE APPENDIX A FOR EDS CRITERIA 250MG TABLET

01984853 BIAXIN BID (EDS) ABB $ 1.7058 500MG TABLET

02126710 BIAXIN BID (EDS) ABB $ 3.4115 500MG EXTENDED-RELEASE TABLET

02244756 BIAXIN XL (EDS) ABB $ 2.7282 25MG/ML ORAL SUSPENSION

02146908 BIAXIN (EDS) ABB $ 0.2993 50MG/ML ORAL SUSPENSION

02244641 BIAXIN (EDS) ABB $ 0.5987

ERYTHROMYCIN BASE 250MG TABLET

00682020 APO-ERYTHRO-BASE APX $ 0.1938 333MG PARTICLE COATED TABLET

00769991 PCE ABB $ 0.5642 250MG CAPSULE (ENTERIC COATED PELLETS)

00607142 ERYC PFI $ 0.5225 333MG CAPSULE (ENTERIC COATED PELLETS)

00873454 ERYC PFI $ 0.5804

6

08:00 ANTI-INFECTIVE AGENTS08:12.12 ANTIBIOTICS (MACROLIDES)

ERYTHROMYCIN ESTOLATE 25MG/ML ORAL SUSPENSION

00021172 NOVO-RYTHRO ESTOLATE NOP $ 0.0400 50MG/ML ORAL SUSPENSION

00262595 NOVO-RYTHRO ESTOLATE NOP $ 0.0774

ERYTHROMYCIN ETHYLSUCCINATE* 40MG/ML ORAL SUSPENSION

00605859 NOVO-RYTHRO ETHYLSUCCINATE NOP $ 0.073200000299 EES 200 ABB 0.0865

* 80MG/ML ORAL SUSPENSION00652318 NOVO-RYTHRO ETHYLSUCCINATE NOP $ 0.113300453617 EES 400 ABB 0.1310

ERYTHROMYCIN STEARATE 250MG TABLET

00545678 APO-ERYTHRO-S APX $ 0.2245

TELITHROMYCIN SEE APPENDIX A FOR EDS CRITERIA 400MG TABLET

02247520 KETEK (EDS) AVT $ 3.3690

08:12.16 ANTIBIOTICS (PENICILLINS)

AMOXICILLIN (AMOXYCILLIN)* 250MG CAPSULE

00865567 NU-AMOXI NXP $ 0.0898 *00406724 NOVAMOXIN NOP 0.112000628115 APO-AMOXI APX 0.112002230243 PMS-AMOXICILLIN PMS 0.112002238171 GEN-AMOXICILLIN GPM 0.1120

* 500MG CAPSULE00865575 NU-AMOXI NXP $ 0.1748 *00406716 NOVAMOXIN NOP 0.218100628123 APO-AMOXI APX 0.218102230244 PMS-AMOXICILLIN PMS 0.218102238172 GEN-AMOXICILLIN GPM 0.2181

125MG CHEWABLE TABLET02036347 NOVAMOXIN NOP $ 0.2512

7

08:00 ANTI-INFECTIVE AGENTS08:12.16 ANTIBIOTICS (PENICILLINS)

250MG CHEWABLE TABLET02036355 NOVAMOXIN NOP $ 0.3700

* 25MG/ML ORAL SUSPENSION00865540 NU-AMOXI NXP $ 0.0174 *00452149 NOVAMOXIN NOP 0.021700628131 APO-AMOXI APX 0.021702230245 PMS-AMOXICILLIN PMS 0.0217

* 50MG/ML ORAL SUSPENSION00865559 NU-AMOXI NXP $ 0.0261 *00452130 NOVAMOXIN NOP 0.032600628158 APO-AMOXI APX 0.032602230246 PMS-AMOXICILLIN PMS 0.0326

AMOXICILLIN TRIHYDRATE/POTASSIUM CLAVULANATE SEE APPENDIX A FOR EDS CRITERIA* 250MG/125MG TABLET

02243350 APO-AMOXI CLAV (EDS) APX $ 0.663202243770 RATIO-ACLAVULANATE (EDS) RPH 0.663201916866 CLAVULIN-250 (EDS) GSK 1.0242

* 500MG/125MG TABLET02243351 APO-AMOXI CLAV (EDS) APX $ 1.013602243771 RATIO-ACLAVULANATE (EDS) RPH 1.013601916858 CLAVULIN-500 (EDS) GSK 1.5362

* 875MG/125MG TABLET02245623 APO-AMOXI CLAV (EDS) APX $ 1.368202247021 RATIO-ACLAVULANATE (EDS) RPH 1.368202248138 NOVO-CLAVAMOXIN (EDS) NOP 1.368202238829 CLAVULIN-875 (EDS) GSK 2.3043

* 25MG/6.25MG/ML ORAL SUSPENSION02243986 APO-AMOXI CLAV (EDS) APX $ 0.078602244646 RATIO-ACLAVULANATE (EDS) RPH 0.0786

40MG/5.3MG/ML ORAL SUSPENSION02238831 CLAVULIN-200 (EDS) GSK $ 0.1496

* 50MG/12.5MG/ML ORAL SUSPENSION02243987 APO-AMOXI CLAV (EDS) APX $ 0.132202244647 RATIO-ACLAVULANATE (EDS) RPH 0.132201916874 CLAVULIN-250F (EDS) GSK 0.2039

80MG/11.4MG/ML ORAL SUSPENSION02238830 CLAVULIN-400 (EDS) GSK $ 0.2792

AMPICILLIN 250MG CAPSULE

00020877 NOVO-AMPICILLIN NOP $ 0.3332 500MG CAPSULE

00020885 NOVO-AMPICILLIN NOP $ 0.6462

8

08:00 ANTI-INFECTIVE AGENTS08:12.16 ANTIBIOTICS (PENICILLINS)

CLOXACILLIN* 250MG CAPSULE

00337765 NOVO-CLOXIN NOP $ 0.107800618292 APO-CLOXI APX 0.107800717584 NU-CLOXI NXP 0.1078

* 500MG CAPSULE00337773 NOVO-CLOXIN NOP $ 0.211200618284 APO-CLOXI APX 0.211200717592 NU-CLOXI NXP 0.2112

* 25MG/ML ORAL LIQUID00337757 NOVO-CLOXIN NOP $ 0.025900644633 APO-CLOXI APX 0.025900717630 NU-CLOXI NXP 0.0259

PENICILLIN V (POTASSIUM)* 300MG TABLET

00021202 NOVO-PEN-VK NOP $ 0.040700642215 APO-PEN-VK APX 0.040700717568 NU-PEN-VK NXP 0.0407

25MG/ML ORAL SOLUTION00642223 APO-PEN-VK APX $ 0.0484

08:12.24 ANTIBIOTICS (TETRACYCLINES)

THE USE OF TETRACYCLINES DURING TOOTH DEVELOPMENT (LAST HALFOF PREGNANCY, INFANCY AND CHILDHOOD TO THE AGE OF 8 YEARS)MAY CAUSE PERMANENT TOOTH DISCOLORATION (YELLOW-GRAY-BROWN).THIS REACTION IS MORE COMMON DURING LONG-TERM USE OFTETRACYCLINES, BUT HAS BEEN OBSERVED FOLLOWING SHORT-TERMCOURSES. ENAMEL HYPOPLASIA HAS ALSO BEEN REPORTED.TETRACYCLINE DRUGS, THEREFORE, SHOULD NOT BE USED IN THISAGE GROUP UNLESS OTHER DRUGS ARE NOT LIKELY TO BE EFFECTIVEOR ARE CONTRAINDICATED.

DOXYCYCLINE* 100MG CAPSULE

02044668 NU-DOXYCYCLINE NXP $ 0.5094 *00740713 APO-DOXY APX 0.635900817120 DOXYCIN GPM 0.635902093103 RATIO-DOXYCYCLINE RPH 0.635900024368 VIBRAMYCIN PFI 1.8389

* 100MG TABLET02044676 NU-DOXYCYCLINE NXP $ 0.5094 *00860751 DOXYCIN GPM 0.635900874256 APO-DOXY APX 0.635902158574 NOVO-DOXYLIN NOP 0.635900578452 VIBRA-TABS PFI 1.8411

9

08:00 ANTI-INFECTIVE AGENTS08:12.24 ANTIBIOTICS (TETRACYCLINES)

MINOCYCLINE HCL SEE APPENDIX A FOR EDS CRITERIA* 50MG CAPSULE

01914138 RATIO-MINOCYCLINE (EDS) RPH $ 0.580502084090 APO-MINOCYCLINE (EDS) APX 0.580502108143 NOVO-MINOCYCLINE (EDS) NOP 0.580502230735 GEN-MINOCYCLINE (EDS) GPM 0.580502237313 SANDOZ MINOCYCLINE (EDS) SDZ 0.580502239238 PMS-MINOCYCLINE (EDS) PMS 0.580502239667 DOM-MINOCYCLINE (EDS) DOM 0.613102173514 MINOCIN (EDS) STI 0.6456

* 100MG CAPSULE01914146 RATIO-MINOCYCLINE (EDS) RPH $ 1.121102084104 APO-MINOCYCLINE (EDS) APX 1.121102108151 NOVO-MINOCYCLINE (EDS) NOP 1.121102230736 GEN-MINOCYCLINE (EDS) GPM 1.121102237314 SANDOZ MINOCYCLINE (EDS) SDZ 1.121102239239 PMS-MINOCYCLINE (EDS) PMS 1.121102239668 DOM-MINOCYCLINE (EDS) DOM 1.176902173506 MINOCIN (EDS) STI 1.2456

TETRACYCLINE* 250MG CAPSULE

00580929 APO-TETRA APX $ 0.068900717606 NU-TETRA NXP 0.0689

08:12.28 ANTIBIOTICS (MISCELLANEOUS ANTIBIOTICS)

CLINDAMYCIN HCL SEE NOTE REGARDING ANTIBIOTIC ASSOCIATED COLITIS OR PSEUDOMEMBRANOUS ENTERCOLITIS UNDER SECTION 08:12.00 (ANTIBIOTICS)* 150MG CAPSULE

02130033 RATIO-CLINDAMYCIN RPH $ 0.530602241709 NOVO-CLINDAMYCIN NOP 0.530602245232 APO-CLINDAMYCIN APX 0.530602258331 GEN-CLINDAMYCIN GPM 0.530600030570 DALACIN C PFI 0.9252

* 300MG CAPSULE02192659 RATIO-CLINDAMYCIN RPH $ 1.061202241710 NOVO-CLINDAMYCIN NOP 1.061202245233 APO-CLINDAMYCIN APX 1.061202258358 GEN-CLINDAMYCIN GPM 1.061202182866 DALACIN C PFI 1.8504

10

08:00 ANTI-INFECTIVE AGENTS08:12.28 ANTIBIOTICS (MISCELLANEOUS ANTIBIOTICS)

CLINDAMYCIN PALMITATE HCL SEE NOTE REGARDING ANTIBIOTIC ASSOCIATED COLITIS OR PSEUDOMEMBRANOUS ENTERCOLITIS UNDER SECTION 08:12.00 (ANTIBIOTICS) 15MG/ML ORAL SOLUTION

00225851 DALACIN C PFI $ 0.1245

LINEZOLID SEE APPENDIX A FOR EDS CRITERIA 600MG TABLET

02243684 ZYVOXAM (EDS) PFI $ 72.1390

VANCOMYCIN HCL SEE APPENDIX A FOR EDS CRITERIA 125MG CAPSULE

00800430 VANCOCIN (EDS) LIL $ 7.4882 250MG CAPSULE

00788716 VANCOCIN (EDS) LIL $ 14.9752 500MG INJECTION

02241820 PMS-VANCOMYCIN (EDS) PMS $ 24.2000 1GM INJECTION

02241821 PMS-VANCOMYCIN (EDS) PMS $ 48.3700

08:18.00 ANTIVIRALS

ACYCLOVIR* 200MG TABLET

02197405 NU-ACYCLOVIR NXP $ 0.7635 *02078627 RATIO-ACYCLOVIR RPH 0.953002207621 APO-ACYCLOVIR APX 0.953002242784 GEN-ACYCLOVIR GPM 0.953000634506 ZOVIRAX GSK 1.3278

* 400MG TABLET02078635 RATIO-ACYCLOVIR RPH $ 1.875802197413 NU-ACYCLOVIR NXP 1.875802207648 APO-ACYCLOVIR APX 1.875802242463 GEN-ACYCLOVIR GPM 1.875801911627 ZOVIRAX WELLSTAT PAC GSK 2.6136

* 800MG TABLET02197421 NU-ACYCLOVIR NXP $ 3.098502207656 APO-ACYCLOVIR APX 3.098502242464 GEN-ACYCLOVIR GPM 3.098502078651 RATIO-ACYCLOVIR RPH 3.098601911635 ZOVIRAX ZOSTAB PAC GSK 5.1395

11

08:00 ANTI-INFECTIVE AGENTS08:18.00 ANTIVIRALS

AMANTADINE* 100MG CAPSULE

02130963 DOM-AMANTADINE DOM $ 0.3885 *01990403 PMS-AMANTADINE PMS 0.562002034468 ENDANTADINE BMY 0.562002139200 GEN-AMANTADINE GPM 0.562001914006 SYMMETREL BMY 1.1773

* 10MG/ML SYRUP01913999 SYMMETREL BMY $ 0.087902022826 PMS-AMANTADINE PMS 0.087902130971 DOM-AMANTADINE DOM 0.0924

FAMCICLOVIR 125MG TABLET

02229110 FAMVIR NVR $ 2.9122 250MG TABLET

02229129 FAMVIR NVR $ 3.9122 500MG TABLET

02177102 FAMVIR NVR $ 6.9498

VALACYCLOVIR 500MG CAPLET

02219492 VALTREX GSK $ 3.5210

VALGANCICLOVIR HCL SEE APPENDIX A FOR EDS CRITERIA 450MG TABLET

02245777 VALCYTE (EDS) HLR $ 22.9100

08:18.08 ANTIRETROVIRAL AGENTS (HIV FUSION INHIBITORS)

ENFUVIRTIDE SEE APPENDIX A FOR EDS CRITERIA 108MG/VIAL POWDER FOR SOLUTION

02247725 FUZEON (EDS) HLR $ 40.260008:18.08 ANTIRETROVIRAL AGENTS (NONNUCLEOSIDE

REVERSE TRANSCRIPTASE INHIBITORS)

DELAVIRDINE MESYLATE SEE APPENDIX A FOR EDS CRITERIA 100MG TABLET

02238348 RESCRIPTOR (EDS) PFI $ 0.7789

12

08:00 ANTI-INFECTIVE AGENTS08:18.08 ANTIRETROVIRAL AGENTS (NONNUCLEOSIDE

REVERSE TRANSCRIPTASE INHIBITORS)

EFAVIRENZ SEE APPENDIX A FOR EDS CRITERIA 50MG CAPSULE

02239886 SUSTIVA (EDS) BMY $ 1.2713 100MG CAPSULE

02239887 SUSTIVA (EDS) BMY $ 2.5422 200MG CAPSULE

02239888 SUSTIVA (EDS) BMY $ 5.0195 600MG TABLET

02246045 SUSTIVA (EDS) BMY $ 15.0584

NEVIRAPINE SEE APPENDIX A FOR EDS CRITERIA 200MG TABLET

02238748 VIRAMUNE (EDS) BOE $ 5.358208:18.08 ANTIRETROVIRAL AGENTS (NUCLEOSIDE REVERSE

TRANSCRIPTASE INHIBITORS)ABACAVIR SO4 SEE APPENDIX A FOR EDS CRITERIA 300MG TABLET

02240357 ZIAGEN (EDS) GSK $ 6.9189 20MG/ML ORAL SOLUTION

02240358 ZIAGEN (EDS) GSK $ 0.4644

ABACAVIR SO4/LAMIVUDINE SEE APPENDIX A FOR EDS CRITERIA 600MG/300MG TABLET

02269341 KIVEXA (EDS) GSK $ 22.3000

ABACAVIR SO4/LAMIVUDINE/ZIDOVUDINE SEE APPENDIX A FOR EDS CRITERIA 300MG/150MG/300MG TABLET

02244757 TRIZIVIR (EDS) GSK $ 16.6752

13

08:00 ANTI-INFECTIVE AGENTS08:18.08 ANTIRETROVIRAL AGENTS (NUCLEOSIDE REVERSE

TRANSCRIPTASE INHIBITORS)

DIDANOSINE SEE APPENDIX A FOR EDS CRITERIA 125MG CAPSULE (ENTERIC COATED BEADLET)

02244596 VIDEX EC (EDS) BMY $ 3.5582 200MG CAPSULE (ENTERIC COATED BEADLET)



02244599 VIDEX EC (EDS) BMY $ 11.4085

LAMIVUDINE SEE APPENDIX A FOR EDS CRITERIA 100MG TABLET

02239193 HEPTOVIR (EDS) GSK $ 4.7740 150MG TABLET

02192683 3TC (EDS) GSK $ 4.9028 300MG TABLET

02247825 3TC (EDS) GSK $ 9.8056 10MG/ML ORAL SOLUTION

02192691 3TC (EDS) GSK $ 0.3184

LAMIVUDINE/ZIDOVUDINE SEE APPENDIX A FOR EDS CRITERIA 150MG/300MG TABLET

02239213 COMBIVIR (EDS) GSK $ 10.2565

STAVUDINE SEE APPENDIX A FOR EDS CRITERIA 15MG CAPSULE

02216086 ZERIT (EDS) BRI $ 4.3384 20MG CAPSULE



02216116 ZERIT (EDS) BRI $ 4.8779

14

08:00 ANTI-INFECTIVE AGENTS08:18.08 ANTIRETROVIRAL AGENTS (NUCLEOSIDE REVERSE

TRANSCRIPTASE INHIBITORS)

ZIDOVUDINE SEE APPENDIX A FOR EDS CRITERIA* 100MG CAPSULE

01946323 APO-ZIDOVUDINE (EDS) APX $ 1.326001902660 RETROVIR (EDS) GSK 1.8943

10MG/ML SOLUTION01902652 RETROVIR (EDS) GSK $ 0.1962

10MG/ML INJECTION SOLUTION01902644 RETROVIR (EDS) GSK $ 18.0200

08:18.08 ANTIRETROVIRAL AGENTS (PROTEASE INHIBITORS)

AMPRENAVIR SEE APPENDIX A FOR EDS CRITERIA 50MG CAPSULE

02243541 AGENERASE (EDS) GSK $ 0.6944 150MG CAPSULE

02243542 AGENERASE (EDS) GSK $ 2.0450 15MG/ML ORAL SOLUTION

02243543 AGENERASE (EDS) GSK $ 0.2084

ATAZANAVIR SO4 SEE APPENDIX A FOR EDS CRITERIA 150MG CAPSULE

02248610 REYATAZ (EDS) BMY $ 10.6625 200MG CAPSULE

02248611 REYATAZ (EDS) BMY $ 10.6970

FOSAMPRENAVIR CALCIUM SEE APPENDIX A FOR EDS CRITERIA 700MG TABLET

02261545 TELZIR (EDS) GSK $ 8.2647

INDINAVIR SO4 SEE APPENDIX A FOR EDS CRITERIA 200MG CAPSULE

02229161 CRIXIVAN (EDS) MSD $ 1.4300 400MG CAPSULE

02229196 CRIXIVAN (EDS) MSD $ 2.9224

15

08:00 ANTI-INFECTIVE AGENTS08:18.08 ANTIRETROVIRAL AGENTS (PROTEASE INHIBITORS)

LOPINAVIR/RITONAVIR SEE APPENDIX A FOR EDS CRITERIA 133.3MG/33.3MG CAPSULE

02243643 KALETRA (EDS) ABB $ 3.6621 80MG/20MG (ML) ORAL SOLUTION

02243644 KALETRA (EDS) ABB $ 2.2756

NELFINAVIR MESYLATE SEE APPENDIX A FOR EDS CRITERIA 250MG TABLET

02238617 VIRACEPT (EDS) PFI $ 1.9200 625MG TABLET

02248761 VIRACEPT (EDS) PFI $ 4.8000 50MG/G ORAL POWDER

02238618 VIRACEPT (EDS) PFI $ 0.3951

RITONAVIR SEE APPENDIX A FOR EDS CRITERIA 100MG SOFT ELASTIC CAPSULE

02241480 NORVIR SEC (EDS) ABB $ 1.5375 80MG/ML ORAL SOLUTION

02229145 NORVIR (EDS) ABB $ 1.2297

SAQUINAVIR SEE APPENDIX A FOR EDS CRITERIA 200MG CAPSULE

02216965 INVIRASE (EDS) HLR $ 1.9312 200MG SOFT GELATIN CAPSULE

02239083 FORTOVASE (EDS) HLR $ 1.1456

TENOFOVIR DISOPROXIL FUMARATE SEE APPENDIX A FOR EDS CRITERIA 300MG TABLET

02247128 VIREAD (EDS) GSK $ 17.6313

16

08:00 ANTI-INFECTIVE AGENTS08:20.00 ANTIMALARIAL AGENTS

CHLOROQUINE PHOSPHATE 250MG TABLET

00021261 NOVO-CHLOROQUINE NOP $ 0.3481

HYDROXYCHLOROQUINE SO4* 200MG TABLET

02246691 APO-HYDROXYQUINE APX $ 0.358202252600 GEN-HYDROXYCHLOROQUINE GPM 0.358202017709 PLAQUENIL AVT 2.3388

PYRIMETHAMINE 25MG TABLET

00004774 DARAPRIM GSK $ 1.3461

QUININE SO4* 200MG CAPSULE

00021008 NOVO-QUININE NOP $ 0.259400695440 QUININE-ODAN ODN 0.259402254514 APO-QUININE APX 0.2594

* 300MG CAPSULE00021016 NOVO-QUININE NOP $ 0.406900695459 QUININE-ODAN ODN 0.406902254522 APO-QUININE APX 0.4069

300MG TABLET00695432 QUININE-ODAN ODN $ 0.3635

08:22.00 QUINOLONES

CIPROFLOXACIN SEE APPENDIX A FOR EDS CRITERIA* 250MG TABLET

02161737 NOVO-CIPROFLOXACIN (EDS) NOP $ 1.518202229521 APO-CIPROFLOX (EDS) APX 1.518202245647 GEN-CIPROFLOXACIN (EDS) GPM 1.518202246825 RATIO-CIPROFLOXACIN (EDS) RPH 1.518202247339 CO CIPROFLOXACIN (EDS) COB 1.518202248437 PMS-CIPROFLOXACIN (EDS) PMS 1.518202248756 SANDOZ CIPROFLOXACIN (EDS) SDZ 1.518202249634 NU-CIPROFLOXACIN (EDS) NXP 1.518202266962 TARO-CIPROFLOXACIN (EDS) TAR 1.518202267934 RAN-CIPROFLOXACIN (EDS) RAN 1.518202251272 DOM-CIPROFLOXACIN (EDS) DOM 1.771202155958 CIPRO (EDS) BAY 2.6064

17

08:00 ANTI-INFECTIVE AGENTS08:22.00 QUINOLONES

* 500MG TABLET02161745 NOVO-CIPROFLOXACIN (EDS) NOP $ 1.712802229522 APO-CIPROFLOX (EDS) APX 1.712802245648 GEN-CIPROFLOXACIN (EDS) GPM 1.712802246826 RATIO-CIPROFLOXACIN (EDS) RPH 1.712802247340 CO CIPROFLOXACIN (EDS) COB 1.712802248438 PMS-CIPROFLOXACIN (EDS) PMS 1.712802248757 SANDOZ CIPROFLOXACIN (EDS) SDZ 1.712802249642 NU-CIPROFLOXACIN (EDS) NXP 1.712802267942 RAN-CIPROFLOXAXIN (EDS) RAN 1.712802266970 TARO-CIPROFLOXACIN (EDS) TAR 1.712902251280 DOM-CIPROFLOXACIN (EDS) DOM 1.998402155966 CIPRO (EDS) BAY 2.9406

* 750MG TABLET02161753 NOVO-CIPROFLOXACIN (EDS) NOP $ 3.230502229523 APO-CIPROFLOX (EDS) APX 3.230502245649 GEN-CIPROFLOXACIN (EDS) GPM 3.230502246827 RATIO-CIPROFLOXACIN (EDS) RPH 3.230502247341 CO CIPROFLOXACIN (EDS) COB 3.230502248439 PMS-CIPROFLOXACIN (EDS) PMS 3.230502248758 SANDOZ CIPROFLOXACIN (EDS) SDZ 3.230502249650 NU-CIPROFLOXACIN (EDS) NXP 3.230502267950 RAN-CIPROFLOXACIN (EDS) RAN 3.230502251299 DOM-CIPROFLOXACIN (EDS) DOM 3.769002155974 CIPRO (EDS) BAY 5.5463

500MG EXTENDED RELEASE TABLET02247916 CIPRO XL (EDS) BAY $ 3.0621

1000MG EXTENDED RELEASE TABLET02251787 CIPRO XL (EDS) BAY $ 3.0621

100MG/ML ORAL SUSPENSION02237514 CIPRO (EDS) BAY $ 0.5881

LEVOFLOXACIN SEE APPENDIX A FOR EDS CRITERIA* 250MG TABLET

02248262 NOVO-LEVOFLOXACIN (EDS) NOP $ 3.372202236841 LEVAQUIN (EDS) JAN 4.9860

* 500MG TABLET02248263 NOVO-LEVOFLOXACIN (EDS) NOP $ 3.805102236842 LEVAQUIN (EDS) JAN 5.6262

750MG TABLET02246804 LEVAQUIN (EDS) JAN $ 10.0500

18

08:00 ANTI-INFECTIVE AGENTS08:22.00 QUINOLONES

MOXIFLOXACIN HCL SEE APPENDIX A FOR EDS CRITERIA 400MG TABLET

02242965 AVELOX (EDS) BAY $ 5.8823

NORFLOXACIN SEE APPENDIX A FOR EDS CRITERIA* 400MG TABLET

02229524 APO-NORFLOX (EDS) APX $ 1.488202237682 NOVO-NORFLOXACIN (EDS) NOP 1.488202246596 PMS-NORFLOXACIN (EDS) PMS 1.4882

08:26.00 SULFONES

DAPSONE 100MG TABLET

02041510 DAPSONE JAC $ 0.4261

08:36.00 URINARY ANTI-INFECTIVES

METHENAMINE SALTS ARE EFFECTIVE ONLY IN ACIDIC URINE ANDACIDIFICATION OF URINE TO PH 5.5 OR LESS IS RECOMMENDED.

FOSFOMYCIN TROMETHAMINE SEE APPENDIX A FOR EDS CRITERIA 3G ORAL POWDER (SACHET)

02240335 MONUROL (EDS) PFR $ 22.5800

METHENAMINE MANDELATE 500MG ENTERIC TABLET

00499013 MANDELAMINE ERF $ 0.1953

NITROFURANTOIN 50MG CAPSULE (MACROCRYSTALS)

02231015 NOVO-FURANTOIN NOP $ 0.3458 50MG TABLET

00319511 APO-NITROFURANTOIN APX $ 0.1563 100MG TABLET

00312738 APO-NITROFURANTOIN APX $ 0.2084

NITROFURANTOIN MONOHYDRATE 100MG CAPSULE (MACROCRYSTALS)

02063662 MACROBID PGA $ 0.7088

19

08:00 ANTI-INFECTIVE AGENTS08:36.00 URINARY ANTI-INFECTIVES

TRIMETHOPRIM 100MG TABLET

02243116 APO-TRIMETHOPRIM APX $ 0.2052 200MG TABLET

02243117 APO-TRIMETHOPRIM APX $ 0.4216

08:40.00 MISCELLANEOUS ANTI-INFECTIVES

ATOVAQUONE SEE APPENDIX A FOR EDS CRITERIA 150MG/ML SUSPENSION

02217422 MEPRON (EDS) GSK $ 2.5938

ERYTHROMYCIN ETHYLSUCCINATE/SULFISOXAZOLE ACETATE 40MG(BASE)/120MG(BASE) PER ML ORAL SOLUTION

00583405 PEDIAZOLE ABB $ 0.1313

METRONIDAZOLE 250MG TABLET

00545066 APO-METRONIDAZOLE APX $ 0.0749

SULFAMETHOXAZOLE/TRIMETHOPRIM(CO-TRIMOXAZOLE)* 400MG/80MG TABLET

00865710 NU-COTRIMOX NXP $ 0.0420 *00445274 APO-SULFATRIM APX 0.052300510637 NOVO-TRIMEL NOP 0.0523

* 800MG/160MG TABLET00865729 NU-COTRIMOX DS NXP $ 0.1062 *00445282 APO-SULFATRIM DS APX 0.132500510645 NOVO-TRIMEL DS NOP 0.1325

100MG/20MG PEDIATRIC TABLET00445266 APO-SULFATRIM APX $ 0.0955

* 40MG/8MG PER ML ORAL SUSPENSION00726540 NOVO-TRIMEL NOP $ 0.021500846465 APO-SULFATRIM APX 0.021500865753 NU-COTRIMOX NXP 0.0215

20

ANTINEOPLASTIC AGENTS10:00

10:00 ANTINEOPLASTIC AGENTS10:00.00 ANTINEOPLASTIC AGENTS

CYPROTERONE ACETATE SEE APPENDIX A FOR EDS CRITERIA* 50MG TABLET

00704431 ANDROCUR (EDS) PMS $ 1.528302229723 GEN-CYPROTERONE (EDS) GPM 1.528302232872 NOVO-CYPROTERONE (EDS) NOP 1.528302245898 APO-CYPROTERONE (EDS) APX 1.5283

100MG/ML INJECTION00704423 ANDROCUR (EDS) PMS $ 59.3400

INTERFERON ALFA-2A SEE APPENDIX A FOR EDS CRITERIA 9 MILLION IU/1ML INJECTION SOLUTION ALBUMIN (HUMAN) FREE (1ML)

02217058 ROFERON-A (EDS) HLR $ 110.6700

INTERFERON ALFA-2B SEE APPENDIX A FOR EDS CRITERIA 6 MILLION IU/ML INJECTION SOLUTION ALBUMIN (HUMAN) FREE (0.5ML)

02238674 INTRON-A (EDS) SCH $ 73.7600 10 MILLION IU POWDER FOR INJECTION

02223406 INTRON-A (EDS) SCH $ 127.2600 10 MILLION IU/ML INJECTION SOLUTION ALBUMIN (HUMAN) FREE (0.5ML, 1ML)

02238675 INTRON-A (EDS) SCH $ 122.9400 18 MILLION IU/PEN MULTI-DOSE PEN (KIT) ALBUMIN (HUMAN) FREE



02240695 INTRON-A (EDS) SCH $ 709.8000

22

10:00 ANTINEOPLASTIC AGENTS10:00.00 ANTINEOPLASTIC AGENTS

MEGESTROL SEE APPENDIX A FOR EDS CRITERIA* 40MG TABLET

02185415 NU-MEGESTROL (EDS) NXP $ 0.982402195917 APO-MEGESTROL (EDS) APX 0.9824

* 160MG TABLET02195925 APO-MEGESTROL (EDS) APX $ 3.925002185423 NU-MEGESTROL (EDS) NXP 3.935000731323 MEGACE (EDS) BMY 6.1672

40MG/ML ORAL SUSPENSION02168979 MEGACE OS (EDS) BMY $ 1.3437

MERCAPTOPURINE SEE APPENDIX A FOR EDS CRITERIA 50MG TABLET

00004723 PURINETHOL (EDS) NOP $ 3.9798

PEGINTERFERON ALFA-2A SEE APPENDIX A FOR EDS CRITERIA 180UG/0.5ML PRE-FILLED SYRINGE

02248077 PEGASYS (EDS) HLR $ 425.8400 180UG/1ML INJECTION (VIAL)

02248078 PEGASYS (EDS) HLR $ 425.8400

PEGINTERFERON ALFA-2B SEE APPENDIX A FOR EDS CRITERIA 50UG/0.5ML POWDER FOR INJECTION (VIAL)

02242966 UNITRON PEG (EDS) SCH $ 410.8500 80UG/0.5ML POWDER FOR INJECTION (VIAL)



02242969 UNITRON PEG (EDS) SCH $ 410.8500

23

AUTONOMIC DRUGS12:00

12:00 AUTONOMIC DRUGS12:04.00 PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS

BETHANECHOL CHLORIDE 10MG TABLET

01947958 DUVOID RBP $ 0.2688 25MG TABLET

01947931 DUVOID RBP $ 0.4355 50MG TABLET

01947923 DUVOID RBP $ 0.5735

NEOSTIGMINE BROMIDE 15MG TABLET

00869945 PROSTIGMIN VAE $ 0.4742

PYRIDOSTIGMINE BROMIDE 60MG TABLET

00869961 MESTINON VAE $ 0.4660 180MG LONG ACTING TABLET

00869953 MESTINON VAE $ 1.0196

12:08.04 ANTIPARKINSONIAN AGENTS

BENZTROPINE MESYLATE* 2MG TABLET

00426857 APO-BENZTROPINE APX $ 0.058600587265 PMS-BENZTROPINE PMS 0.0586

1MG/ML INJECTION SOLUTION (2ML)02238903 BENZTROPINE OMEGA OMG $ 5.5800

ETHOPROPAZINE 50MG TABLET

01927744 PARSITAN ERF $ 0.2116

PROCYCLIDINE HCL* 5MG TABLET

00587354 PMS-PROCYCLIDINE PMS $ 0.027702125102 DOM-PROCYCLIDINE DOM 0.0291

0.5MG/ML ELIXIR00587362 PMS-PROCYCLIDINE PMS $ 0.0333

TRIHEXYPHENIDYL HCL 2MG TABLET

00545058 APO-TRIHEX APX $ 0.0326 5MG TABLET

00545074 APO-TRIHEX APX $ 0.0586

26

12:00 AUTONOMIC DRUGS12:08.08 ANTIMUSCARINICS/ANTISPASMODICS

DICYCLOMINE HCL 10MG CAPSULE

00361933 FORMULEX VAE $ 0.0992 20MG TABLET

02103095 BENTYLOL AXC $ 0.2157 2MG/ML SYRUP

02102978 BENTYLOL AXC $ 0.0612

HYOSCINE BUTYLBROMIDE 10MG TABLET

00363812 BUSCOPAN BOE $ 0.3398

IPRATROPIUM BROMIDE NOTE: WHEN USING THE INHALATION SOLUTION CARE MUST BE TAKEN TO PREVENT CONTACT WITH EYES. A WELL FITTED NEBULIZER MASK MUST BE USED. 20UG INHALER AEROSOL (PACKAGE)

02247686 ATROVENT HFA BOE $ 19.9000* 0.0125% INHALATION SOLUTION (2ML)

02097176 RATIO-IPRATROPIUM UDV RPH $ 0.820002231135 PMS-IPRATROPIUM PMS 0.820002026759 ATROVENT BOE 1.4686

* 0.025% INHALATION SOLUTION02097141 RATIO-IPRATROPIUM RPH $ 0.600002126222 APO-IPRAVENT APX 0.600002210479 NOVO-IPRAMIDE NOP 0.600002231136 PMS-IPRATROPIUM PMS 0.600002239131 GEN-IPRATROPIUM GPM 0.600000731439 ATROVENT BOE 0.9787

* 0.025% INHALATION SOLUTION (2ML)02097168 RATIO-IPRATROPIUM UDV RPH $ 1.639002216221 GEN-IPRATROPIUM GPM 1.639002231245 PMS-IPRATROPIUM PMS 1.639002231785 NU-IPRATROPIUM NXP 1.639001950681 ATROVENT BOE 2.9380

IPRATROPIUM BROMIDE/SALBUTAMOL SO4 NOTE: SALBUTAMOL STRENGTHS ARE EXPRESSED IN TERMS OF SALBUTAMOL BASE EQUIVALENT. 20UG/100UG INHALER AEROSOL (PACKAGE)

02163721 COMBIVENT BOE $ 23.0500* 0.5MG/2.5MG INHALATION SOLUTION (2.5ML)

02272695 GEN-COMBO STERINEBS GPM $ 1.003702243789 RATIO-IPRA SAL UDV RPH 1.003702231675 COMBIVENT BOE 1.6360

27

12:00 AUTONOMIC DRUGS12:08.08 ANTIMUSCARINICS/ANTISPASMODICS

TIOTROPIUM BROMIDE MONOHYDRATE SEE APPENDIX A FOR EDS CRITERIA 18UG/DOSE INHALATION POWDER CAPSULE

02246793 SPIRIVA (EDS) BOE $ 2.2785

12:12.00 SYMPATHOMIMETIC (ADRENERGIC) AGENTS

EPINEPHRINE⌧ 0.15MG/DOSE INJECTION SOLUTION (PACKAGE)

02247310 TWINJECT PAL $ 85.720000578657 EPIPEN JR. ALX 87.8900

⌧ 0.3MG/DOSE INJECTION SOLUTION (PACKAGE)02268205 TWINJECT PAL $ 85.720000509558 EPIPEN ALX 87.8900

EPINEPHRINE HCL 1MG/ML INJECTION SOLUTION (1ML)

00721891 EPINEPHRINE HOS $ 2.8319

FENOTEROL HYDROBROMIDE 100UG INHALER AEROSOL (PACKAGE)

02006383 BEROTEC BOE $ 11.6400 0.1% INHALATION SOLUTION

00541389 BEROTEC BOE $ 0.8317

FORMOTEROL FUMARATE SEE APPENDIX A FOR EDS CRITERIA 12UG/INHALATION POWDER CAPSULE

02230898 FORADIL (EDS) NVR $ 0.8078 6UG/DOSE POWDER FOR INHALATION (PACKAGE)

02237225 OXEZE TURBUHALER (EDS) AST $ 35.4800 12UG/DOSE POWDER FOR INHALATION (PACKAGE)

02237224 OXEZE TURBUHALER (EDS) AST $ 47.2600

FORMOTEROL FUMARATE DIHYDRATE/BUDESONIDE SEE APPENDIX A FOR EDS CRITERIA 6UG/100UG POWDER FOR INHALATION (PACKAGE)

02245385 SYMBICORT TURBUHALER(EDS) AST $ 65.1000 6UG/200UG POWDER FOR INHALATION (PACKAGE)

02245386 SYMBICORT TURBUHALER(EDS) AST $ 84.6300

MIDODRINE HCL SEE APPENDIX A FOR EDS CRITERIA 2.5MG TABLET

01934392 AMATINE (EDS) RBP $ 0.5290 5MG TABLET

01934406 AMATINE (EDS) RBP $ 0.8935

28

12:00 AUTONOMIC DRUGS12:12.00 SYMPATHOMIMETIC (ADRENERGIC) AGENTS

ORCIPRENALINE SO4 2MG/ML SYRUP

02236783 APO-ORCIPRENALINE APX $ 0.0415

SALBUTAMOL SO4 NOTE: PRODUCT STRENGTHS ARE EXPRESSED IN TERMS OF SALBUTAMOL BASE EQUIVALENT. 2MG TABLET

02146843 APO-SALVENT APX $ 0.1075 4MG TABLET

02146851 APO-SALVENT APX $ 0.1796 200UG/DOSE AEROSOL POWDER DISK (8)

02214997 VENTODISK GSK $ 1.5206 400UG/DOSE AEROSOL POWDER DISK (8)

02215004 VENTODISK GSK $ 2.1130* 0.4MG/ML ORAL LIQUID

02091186 PMS-SALBUTAMOL PMS $ 0.051702212390 VENTOLIN GSK 0.0738

* 100UG/DOSE INHALER AEROSOL (PACKAGE) (CFC-FREE)

02244914 RATIO-SALBUTAMOL HFA RPH $ 8.390002245669 APO-SALVENT CFC FREE APX 8.390002232570 AIROMIR MDA 8.4000

* 0.5MG/ML INHALATION SOLUTION PRESERVATIVE FREE (2.5ML)

02208245 PMS-SALBUTAMOL PMS $ 0.404702239365 RATIO-SALBUTAMOL P.F. RPH 0.404702243828 APO-SALVENT APX 0.4047

* 1MG/ML INHALATION SOLUTION PRESERVATIVE FREE (2.5ML)

01926934 GEN-SALBUTAMOL STERINEB GPM $ 0.661001986864 RATIO-SALBUTAMOL RPH 0.661002208229 PMS-SALBUTAMOL PMS 0.661002231488 APO-SALVENT APX 0.661002231783 NU-SALBUTAMOL NXP 0.661002216949 DOM-SALBUTAMOL DOM 0.741002213419 VENTOLIN NEBULES P.F. GSK 1.0480

* 2MG/ML INHALATION SOLUTION PRESERVATIVE FREE (2.5ML)

02173360 GEN-SALBUTAMOL STERINEB GPM $ 1.253802208237 PMS-SALBUTAMOL PMS 1.253802231678 APO-SALVENT APX 1.253802231784 NU-SALBUTAMOL NXP 1.253802239366 RATIO-SALBUTAMOL P.F. RPH 1.253801945203 VENTOLIN NEBULES P.F. GSK 1.9905

29

12:00 AUTONOMIC DRUGS12:12.00 SYMPATHOMIMETIC (ADRENERGIC) AGENTS

* 5MG/ML INHALATION SOLUTION00860808 RATIO-SALBUTAMOL RPH $ 0.640202069571 PMS-SALBUTAMOL RESP. SOL. PMS 0.640202154412 SANDOZ SALBUTAMOL RES.SOL SDZ 0.640202232987 GEN-SALBUTAMOL RESPIR.SOL GPM 0.640202139324 DOM-SALBUTAMOL RESPIR.SOL DOM 0.720502213486 VENTOLIN RESPIRATOR SOLN. GSK 1.0167

SALMETEROL XINAFOATE SEE APPENDIX A FOR EDS CRITERIA 50UG/DOSE AEROSOL POWDER DISK (4)

02214261 SEREVENT (EDS) GSK $ 3.7918 50UG/DOSE POWDER FOR INHALATION (PACKAGE)

02231129 SEREVENT DISKUS (EDS) GSK $ 56.8800

SALMETEROL XINAFOATE/FLUTICASONE PROPIONATE SEE APPENDIX A FOR EDS CRITERIA 25UG/125UG INHALER AEROSOL (PACKAGE)

02245126 ADVAIR (EDS) GSK $ 97.3300 25UG/250UG INHALER AEROSOL (PACKAGE)

02245127 ADVAIR (EDS) GSK $ 138.1600 50UG/100UG POWDER FOR INHALATION (PACKAGE)

02240835 ADVAIR DISKUS (EDS) GSK $ 81.3000 50UG/250UG POWDER FOR INHALATION (PACKAGE)

02240836 ADVAIR DISKUS (EDS) GSK $ 97.3300 50UG/500UG POWDER FOR INHALATION (PACKAGE)

02240837 ADVAIR DISKUS (EDS) GSK $ 138.1600

TERBUTALINE SO4 0.5MG/DOSE POWDER FOR INHALATION (PACKAGE)

00786616 BRICANYL TURBUHALER AST $ 15.9500

12:16.00 SYMPATHOLYTIC AGENTS (ANTIMIGRAINE DRUGS)

ALMOTRIPTAN MALATE THE MAXIMUM QUANTITY THAT CAN BE CLAIMED THROUGH THE DRUG PLAN IS LIMITED TO 6 DOSES PER 30 DAYS WITHIN A 60 DAY PERIOD. SEE APPENDIX A FOR EDS CRITERIA. 6.25MG TABLET

02248128 AXERT (EDS) JAN $ 14.0508 12.5MG TABLET

02248129 AXERT (EDS) JAN $ 14.0508

30

12:00 AUTONOMIC DRUGS12:16.00 SYMPATHOLYTIC AGENTS (ANTIMIGRAINE DRUGS)

DIHYDROERGOTAMINE MESYLATE* 1MG/ML INJECTION SOLUTION (1ML)

02241163 DIHYDROERGOTAMINE MESYL. SDZ $ 4.040000027243 DIHYDROERGOTAMINE STE 4.7700

4MG/ML NASAL SPRAY02228947 MIGRANAL STE $ 11.2000

FLUNARIZINE HCL SEE APPENDIX A FOR EDS CRITERIA* 5MG CAPSULE

02246082 APO-FLUNARIZINE (EDS) APX $ 0.576100846341 SIBELIUM (EDS) PMS 0.5761

METHYSERGIDE MALEATE SEE APPENDIX A FOR EDS CRITERIA 2MG TABLET

00027499 SANSERT (EDS) NVR $ 0.9033

NARATRIPTAN HCL THE MAXIMUM QUANTITY THAT CAN BE CLAIMED THROUGH THE DRUG PLAN IS LIMITED TO 6 DOSES PER 30 DAYS WITHIN A 60 DAY PERIOD. SEE APPENDIX A FOR EDS CRITERIA 1MG TABLET

02237820 AMERGE (EDS) GSK $ 14.0740 2.5MG TABLET

02237821 AMERGE (EDS) GSK $ 14.8300

PIZOTYLINE HYDROGEN MALATE 0.5MG TABLET

00329320 SANDOMIGRAN PED $ 0.3771 1MG TABLET

00511552 SANDOMIGRAN DS PED $ 0.6261

PROPRANOLOL SEE SECTION 24:04.00 (CARDIAC DRUGS)

31


RIZATRIPTAN BENZOATE THE MAXIMUM QUANTITY THAT CAN BE CLAIMED THROUGH THE DRUG PLAN IS LIMITED TO 6 DOSES PER 30 DAYS WITHIN A 60 DAY PERIOD. SEE APPENDIX A FOR EDS CRITERIA 5MG TABLET

02240520 MAXALT (EDS) MSD $ 15.0508 10MG TABLET

02240521 MAXALT (EDS) MSD $ 15.0508 5MG WAFER

02240518 MAXALT RPD (EDS) MSD $ 15.0508 10MG WAFER

02240519 MAXALT RPD (EDS) MSD $ 15.0508

SUMATRIPTAN THE MAXIMUM QUANTITY THAT CAN BE CLAIMED THROUGH THE DRUG PLAN IS LIMITED TO 6 DOSES PER 30 DAYS WITHIN A 60 DAY PERIOD. SEE APPENDIX A FOR EDS CRITERIA* 25MG TABLET

02256428 PMS-SUMATRIPTAN (EDS) PMS $ 9.754202257882 CO SUMATRIPTAN (EDS) COB 9.754202268906 GEN-SUMATRIPTAN (EDS) GPM 9.754202270749 DOM-SUMATRIPTAN (EDS) DOM 10.241902239738 IMITREX DF (EDS) GSK 14.2832

* 50MG TABLET02256436 PMS-SUMATRIPTAN (EDS) PMS $ 9.835602257890 CO SUMATRIPTAN (EDS) COB 9.835602263025 SANDOZ SUMATRIPTAN (EDS) SDZ 9.835602268388 APO-SUMATRIPTAN (EDS) APX 9.835602268914 GEN-SUMATRIPTAN (EDS) GPM 9.835602271583 RATIO-SUMATRIPTAN (EDS) RPH 9.835602270757 DOM-SUMATRIPTAN (EDS) DOM 10.327402212153 IMITREX DF (EDS) GSK 15.0504

* 100MG TABLET02239367 NOVO-SUMATRIPTAN (EDS) NOP $ 10.835602256444 PMS-SUMATRIPTAN (EDS) PMS 10.835602257904 CO SUMATRIPTAN (EDS) COB 10.835602263033 SANDOZ SUMATRIPTAN (EDS) SDZ 10.835602268396 APO-SUMATRIPTAN (EDS) APX 10.835602268922 GEN-SUMATRIPTAN (EDS) GPM 10.835602271591 RATIO-SUMATRIPTAN (EDS) RPH 10.835602270765 DOM-SUMATRIPTAN (EDS) DOM 11.377402212161 IMITREX DF (EDS) GSK 16.5794

32


6MG/0.5ML INJECTION SOLUTION02212188 IMITREX (EDS) GSK $ 44.7100

5MG NASAL SPRAY02230418 IMITREX (EDS) GSK $ 14.2900

20MG NASAL SPRAY02230420 IMITREX (EDS) GSK $ 15.0600

ZOLMITRIPTAN THE MAXIMUM QUANTITY THAT CAN BE CLAIMED THROUGH THE DRUG PLAN IS LIMITED TO 6 DOSES PER 30 DAYS WITHIN A 60 DAY PERIOD. SEE APPENDIX A FOR EDS CRITERIA 2.5MG TABLET

02238660 ZOMIG (EDS) AST $ 14.4740 2.5MG ORALLY DISPERSIBLE TABLET

02243045 ZOMIG RAPIMELT (EDS) AST $ 14.4740 5MG NASAL SPRAY

02248993 ZOMIG (EDS) AST $ 28.9478

12:20.00 SKELETAL MUSCLE RELAXANTS

BACLOFEN* 10MG TABLET

02138271 DOM-BACLOFEN DOM $ 0.2078 *02063735 PMS-BACLOFEN PMS 0.315902088398 GEN-BACLOFEN GPM 0.315902136090 NU-BACLO NXP 0.315902139332 APO-BACLOFEN APX 0.315902236507 RATIO-BACLOFEN RPH 0.315900455881 LIORESAL NVR 0.5979

* 20MG TABLET02138298 DOM-BACLOFEN DOM $ 0.4238 *02063743 PMS-BACLOFEN PMS 0.614902088401 GEN-BACLOFEN GPM 0.614902136104 NU-BACLO NXP 0.614902139391 APO-BACLOFEN APX 0.614902236508 RATIO-BACLOFEN RPH 0.614900636576 LIORESAL-DS NVR 1.1637

0.05MG/ML INJECTION (1ML)02131048 LIORESAL INTRATHECAL(EDS) NVR $ 11.7800

0.5MG/ML INJECTION (20ML)02131056 LIORESAL INTRATHECAL(EDS) NVR $ 176.4000

2MG/ML INJECTION (5ML)02131064 LIORESAL INTRATHECAL(EDS) NVR $ 176.4000

33

12:00 AUTONOMIC DRUGS12:20.00 SKELETAL MUSCLE RELAXANTS

CYCLOBENZAPRINE HCL SEE APPENDIX A FOR EDS CRITERIA* 10MG TABLET

02080052 NOVO-CYCLOPRINE (EDS) NOP $ 0.408502171848 NU-CYCLOBENZAPRINE (EDS) NXP 0.408502177145 APO-CYCLOBENZAPRINE (EDS) APX 0.408502212048 PMS-CYCLOBENZAPRINE (EDS) PMS 0.408502231353 GEN-CYCLOBENZAPRINE (EDS) GPM 0.408502236506 RATIO-CYCLOBENZAPRINE (EDS) RPH 0.408502238633 DOM-CYCLOBENZAPRINE (EDS) DOM 0.4289

DANTROLENE SODIUM 25MG CAPSULE

01997602 DANTRIUM PGA $ 0.3985 100MG CAPSULE

01997653 DANTRIUM PGA $ 0.8095

TIZANIDINE HCL SEE APPENDIX A FOR EDS CRITERIA* 4MG TABLET

02259893 APO-TIZANIDINE (EDS) APX $ 0.554002239170 ZANAFLEX (EDS) RBP 0.7387

34

BLOOD FORMATION AND COAGULATION20:00

20:00 BLOOD FORMATION AND COAGULATION20:04.04 IRON PREPARATIONS

IRON DEXTRAN SEE APPENDIX A FOR EDS CRITERIA* 50MG/ML INJECTION SOLUTION (2ML)

02205963 DEXIRON (EDS) GPM $ 29.840002221780 INFUFER (EDS) SDZ 29.8400

IRON SODIUM FERRIC GLUCONATE SEE APPENDIX A FOR EDS CRITERIA 12.5MG/ML INJECTION SOLUTION

02243333 FERRLECIT (EDS) JAN $ 25.4400

IRON SUCROSE SEE APPENDIX A FOR EDS CRITERIA 20MG/ML INJECTION (5ML)

02243716 VENOFER (EDS) GPM $ 53.0000

20:12.04 ANTICOAGULANTS

ACENOCOUMAROL 1MG TABLET

00010383 SINTROM PED $ 0.5101 4MG TABLET

00010391 SINTROM PED $ 1.6039

DALTEPARIN SODIUM SEE APPENDIX A FOR EDS CRITERIA 2,500IU SYRINGE (0.2ML)

02132621 FRAGMIN (EDS) PFI $ 5.3600 10,000IU/ML INJECTION SOLUTION (1ML)

02132664 FRAGMIN (EDS) PFI $ 16.9300 25,000IU/ML SYRINGE (0.2ML, 0.3ML, 0.4ML, 0.5ML, 0.6ML, 0.72ML)

02132648 FRAGMIN (EDS) PFI $ 38.6000 25,000IU/ML INJECTION SOLUTION (3.8ML)

02231171 FRAGMIN (EDS) PFI $ 160.8000

36

20:00 BLOOD FORMATION AND COAGULATION20:12.04 ANTICOAGULANTS

ENOXAPARIN 30MG/0.3ML SYRINGE (0.3ML)

02012472 LOVENOX (EDS) AVT $ 6.5600 40MG/0.4ML SYRINGE (0.4ML)




99002981 LOVENOX (EDS) AVT $ 21.7000 100MG/ML INJECTION SOLUTION (3ML)


99004941 LOVENOX HP (EDS) AVT $ 26.0400 150MG/1.0ML SYRINGE (1ML)

02242692 LOVENOX HP (EDS) AVT $ 32.5500

HEPARIN 10,000 USP U/ML INJECTION SOLUTION (5ML)

00740497 HEPALEAN ORG $ 6.4000

NADROPARIN CALCIUM SEE APPENDIX A FOR EDS CRITERIA 9,500IU/ML SYRINGE (0.3ML, 0.4ML, 0.6ML, 0.8ML, 1ML)

02236913 FRAXIPARINE (EDS) AVT $ 9.7200 19,000IU/ML SYRINGE (0.6ML, 0.8ML, 1ML)

02240114 FRAXIPARINE FORTE (EDS) AVT $ 19.4300

TINZAPARIN SODIUM SEE APPENDIX A FOR EDS CRITERIA 10,000IU/ML INJECTION SOLUTION (2ML)

02167840 INNOHEP (EDS) LEO $ 34.7200 10,000IU/ML SYRINGE (0.35ML, 0.45ML)

02229755 INNOHEP (EDS) LEO $ 7.8800 20,000IU/ML INJECTION SOLUTION (2ML)

02229515 INNOHEP (EDS) LEO $ 69.4400 20,000IU/ML SYRINGE (0.5ML, 0.7ML, 0.9ML)

02231478 INNOHEP (EDS) LEO $ 31.2500

37

20:00 BLOOD FORMATION AND COAGULATION20:12.04 ANTICOAGULANTS

WARFARIN* 1MG TABLET

02242680 TARO-WARFARIN TAR $ 0.193402242924 APO-WARFARIN APX 0.193402244462 GEN-WARFARIN GPM 0.193402265273 NOVO-WARFARIN NOP 0.193401918311 COUMADIN BMY 0.3162

* 2MG TABLET02242681 TARO-WARFARIN TAR $ 0.204602242925 APO-WARFARIN APX 0.204602244463 GEN-WARFARIN GPM 0.204602265281 NOVO-WARFARIN NOP 0.204601918338 COUMADIN BMY 0.3344

* 2.5MG TABLET02242682 TARO-WARFARIN TAR $ 0.163802242926 APO-WARFARIN APX 0.163802244464 GEN-WARFARIN GPM 0.163802265303 NOVO-WARFARIN NOP 0.163801918346 COUMADIN BMY 0.2677

* 3MG TABLET02242683 TARO-WARFARIN TAR $ 0.253602245618 APO-WARFARIN APX 0.253602265311 NOVO-WARFARIN NOP 0.253602240205 COUMADIN BMY 0.4145



* 10MG TABLET02242687 TARO-WARFARIN TAR $ 0.294402242929 APO-WARFARIN APX 0.294402244467 GEN-WARFARIN GPM 0.294401918362 COUMADIN BMY 0.4812

38

20:00 BLOOD FORMATION AND COAGULATION20:12.20 ANTIPLATELET DRUGS

SULFINPYRAZONE SEE SECTION 40:40:00 (URICOSURIC DRUGS)

20:16.00 HEMATOPOIETIC AGENTS

DARBEPOETIN ALFA SEE APPENDIX A FOR EDS CRITERIA 25UG/ML PRE-FILLED SYRINGE (0.4ML)

02246354 ARANESP (EDS) AMG $ 31.4500 40UG/ML PRE-FILLED SYRINGE (0.5ML)

02246355 ARANESP (EDS) AMG $ 62.8900 100UG/ML PRE-FILLED SYRINGE (0.3ML, 0.4ML, 0.5ML)

02246357 ARANESP (EDS) AMG $ 152.4000 200UG/ML PRE-FILLED SYRINGE (0.3ML, 0.4ML, 0.5ML)

02246358 ARANESP (EDS) AMG $ 297.3000 500UG/ML PRE-FILLED SYRINGE (0.3ML)

02246360 ARANESP (EDS) AMG $ 442.2000

EPOETIN ALFA SEE APPENDIX A FOR EDS CRITERIA 1000IU/0.5ML PRE-FILLED SYRINGE

02231583 EPREX (EDS) JAN $ 15.4700 2000IU/0.5ML PRE-FILLED SYRINGE






02243403 EPREX (EDS) JAN $ 119.0000 10000IU/ML PRE-FILLED SYRINGE

02231587 EPREX (EDS) JAN $ 147.5000 20000IU STERILE SOLUTION FOR INJECTION

02206072 EPREX (EDS) JAN $ 290.6800

39

20:00 BLOOD FORMATION AND COAGULATION20:16.00 HEMATOPOIETIC AGENTS

FILGRASTIM SEE APPENDIX A FOR EDS CRITERIA 300UG/ML INJECTION SOLUTION

01968017 NEUPOGEN (EDS) AMG $ 285.0300

20:24.00 HEMORRHEOLOGIC AGENTS

CLOPIDOGREL BISULFATE SEE APPENDIX A FOR EDS CRITERIA 75MG TABLET

02238682 PLAVIX (EDS) BMY $ 2.6057

PENTOXIFYLLINE* 400MG SUSTAINED RELEASE TABLET

01968432 RATIO-PENTOXIFYLLINE RPH $ 0.416402230090 APO-PENTOXIFYLLINE SR APX 0.416402230401 NU-PENTOXIFYLLINE-SR NXP 0.416402221977 TRENTAL AVT 0.7307

TICLOPIDINE HCL SEE APPENDIX A FOR EDS CRITERIA* 250MG TABLET

02237560 NU-TICLOPIDINE (EDS) NXP $ 0.5985 *02237701 APO-TICLOPIDINE (EDS) APX 0.747102243587 SANDOZ TICLOPIDINE (EDS) SDZ 0.747102236848 NOVO-TICLOPIDINE (EDS) NOP 0.747202239744 GEN-TICLOPIDINE (EDS) GPM 0.747202243327 PMS-TICLOPIDINE (EDS) PMS 0.747202243808 DOM-TICLOPIDINE (EDS) DOM 0.7844

40

CARDIOVASCULAR DRUGS24:00

24:00 CARDIOVASCULAR DRUGS24:04.00 CARDIAC DRUGS

ACEBUTOLOL HCL* 100MG TABLET

02165546 NU-ACEBUTOLOL NXP $ 0.1418 *01910140 RHOTRAL ROP 0.176902147602 APO-ACEBUTOLOL APX 0.176902204517 NOVO-ACEBUTOLOL NOP 0.176902237721 GEN-ACEBUTOLOL GPM 0.176902237885 GEN-ACEBUTOLOL (TYPE S) GPM 0.176902257599 SANDOZ ACEBUTOLOL SDZ 0.176901926543 SECTRAL AVT 0.3097

* 200MG TABLET02165554 NU-ACEBUTOLOL NXP $ 0.2121 *01910159 RHOTRAL ROP 0.264802036436 MONITAN WYA 0.264802147610 APO-ACEBUTOLOL APX 0.264802204525 NOVO-ACEBUTOLOL NOP 0.264802237722 GEN-ACEBUTOLOL GPM 0.264802237886 GEN-ACEBUTOLOL (TYPE S) GPM 0.264802257602 SANDOZ ACEBUTOLOL SDZ 0.264801926551 SECTRAL AVT 0.4645

* 400MG TABLET02165562 NU-ACEBUTOLOL NXP $ 0.4214 *01910167 RHOTRAL ROP 0.526002036444 MONITAN WYA 0.526002147629 APO-ACEBUTOLOL APX 0.526002204533 NOVO-ACEBUTOLOL NOP 0.526002237723 GEN-ACEBUTOLOL GPM 0.526002237887 GEN-ACEBUTOLOL (TYPE S) GPM 0.526002257610 SANDOZ ACEBUTOLOL SDZ 0.5260

AMIODARONE AMIODARONE IS INDICATED IN TREATMENT OF SEVERE CARDIAC ARRHYTHMIAS. THIS DRUG SHOULD ONLY BE USED UNDER THE SUPERVISION OF A CARDIOLOGIST OR AN INTERNIST WITH EQUIVALENT EXPERIENCE IN CARDIOLOGY.* 200MG TABLET

02239835 NOVO-AMIODARONE NOP $ 1.407402240071 RATIO-AMIODARONE RPH 1.407402240604 GEN-AMIODARONE GPM 1.407402242472 PMS-AMIODARONE PMS 1.407402243836 SANDOZ AMIODARONE SDZ 1.407402246194 APO-AMIODARONE APX 1.407402036282 CORDARONE WYA 2.2339

42


AMLODIPINE BESYLATE 5MG TABLET

00878928 NORVASC PFI $ 1.3866 10MG TABLET

00878936 NORVASC PFI $ 2.0582

ATENOLOL* 25MG TABLET

02246581 PMS-ATENOLOL PMS $ 0.190802266660 NOVO-ATENOL NOP 0.1908

* 50MG TABLET02257629 BCI ATENOLOL BAK $ 0.1880 *00886114 NU-ATENOL NXP 0.381401912062 NOVO-ATENOL NOP 0.381402237600 PMS-ATENOLOL PMS 0.381402231731 SANDOZ ATENOLOL SDZ 0.381402255545 CO ATENOLOL COB 0.381400773689 APO-ATENOL APX 0.381402146894 GEN-ATENOLOL GPM 0.381402171791 RATIO-ATENOLOL RPH 0.381402267985 RAN-ATENOLOL RAN 0.381402229467 DOM-ATENOLOL DOM 0.400502039532 TENORMIN AST 0.6236

* 100MG TABLET02257637 BCI ATENOLOL BAK $ 0.3205 *00773697 APO-ATENOL APX 0.626800886122 NU-ATENOL NXP 0.626801912054 NOVO-ATENOL NOP 0.626802147432 GEN-ATENOLOL GPM 0.626802171805 RATIO-ATENOLOL RPH 0.626802237601 PMS-ATENOLOL PMS 0.626802255553 CO ATENOLOL COB 0.626802267993 RAN-ATENOLOL RAN 0.626802231733 SANDOZ ATENOLOL SDZ 0.626802229468 DOM-ATENOLOL DOM 0.658202039540 TENORMIN AST 1.0250

43


BISOPROLOL FUMARATE SEE APPENDIX A FOR EDS CRITERIA* 5MG TABLET

02247439 SANDOZ BISOPROLOL (EDS) SDZ $ 0.239302256134 APO-BISOPROLOL (EDS) APX 0.239302267470 NOVO-BISOPROLOL (EDS) NOP 0.239302241148 MONOCOR (EDS) BVL 0.3912

* 10MG TABLET02247440 SANDOZ BISOPROLOL (EDS) SDZ $ 0.396502256177 APO-BISOPROLOL (EDS) APX 0.396502267489 NOVO-BISOPROLOL (EDS) NOP 0.396502241149 MONOCOR (EDS) BVL 0.6293

CAPTOPRIL SEE SECTION 24:08.00 (HYPOTENSIVE DRUGS)

CARVEDILOL SEE APPENDIX A FOR EDS CRITERIA* 3.125MG TABLET

02248748 DOM-CARVEDILOL (EDS) DOM $ 0.7033 *02245914 PMS-CARVEDILOL (EDS) PMS 0.868102246529 NOVO-CARVEDILOL (EDS) NOP 0.868102247933 APO-CARVEDILOL (EDS) APX 0.868102248715 NU-CARVEDILOL (EDS) NXP 0.868102252309 RATIO-CARVEDILOL (EDS) RPH 0.868102268027 RAN-CARVEDILOL (EDS) RAN 0.868102229650 COREG (EDS) GSK 1.4657

* 6.25MG TABLET02248749 DOM-CARVEDILOL (EDS) DOM $ 0.7033 *02245915 PMS-CARVEDILOL (EDS) PMS 0.868102246530 NOVO-CARVEDILOL (EDS) NOP 0.868102247934 APO-CARVEDILOL (EDS) APX 0.868102248716 NU-CARVEDILOL (EDS) NXP 0.868102252317 RATIO-CARVEDILOL (EDS) RPH 0.868102268035 RAN-CARVEDILOL (EDS) RAN 0.868102229651 COREG (EDS) GSK 1.4657

* 12.5MG TABLET02248750 DOM-CARVEDILOL (EDS) DOM $ 0.7033 *02245916 PMS-CARVEDILOL (EDS) PMS 0.868102246531 NOVO-CARVEDILOL (EDS) NOP 0.868102247935 APO-CARVEDILOL (EDS) APX 0.868102248717 NU-CARVEDILOL (EDS) NXP 0.868102252325 RATIO-CARVEDILOL (EDS) RPH 0.868102268043 RAN-CARVEDILOL (EDS) RAN 0.868102229652 COREG (EDS) GSK 1.4657

44


* 25MG TABLET02248751 DOM-CARVEDILOL (EDS) DOM $ 0.7033 *02245917 PMS-CARVEDILOL (EDS) PMS 0.868102246532 NOVO-CARVEDILOL (EDS) NOP 0.868102247936 APO-CARVEDILOL (EDS) APX 0.868102248718 NU-CARVEDILOL (EDS) NXP 0.868102252333 RATIO-CARVEDILOL (EDS) RPH 0.868102268051 RAN-CARVEDILOL (EDS) RAN 0.868102229653 COREG (EDS) GSK 1.4657

DIGOXIN 0.0625MG TABLET

02242321 LANOXIN VIR $ 0.2364 0.125MG TABLET

02242322 LANOXIN VIR $ 0.2364 0.25MG TABLET

02242323 LANOXIN VIR $ 0.2364 0.05MG/ML ELIXIR

02242320 LANOXIN VIR $ 0.3864

DILTIAZEM HCL* 30MG TABLET

00886068 NU-DILTIAZ NXP $ 0.1760 *00771376 APO-DILTIAZ APX 0.225200862924 NOVO-DILTAZEM NOP 0.225202146916 GEN-DILTIAZEM GPM 0.225202097370 CARDIZEM BVL 0.4031

* 60MG TABLET00886076 NU-DILTIAZ NXP $ 0.3085 *00771384 APO-DILTIAZ APX 0.394700862932 NOVO-DILTAZEM NOP 0.394702146924 GEN-DILTIAZEM GPM 0.394702097389 CARDIZEM BVL 0.7070

60MG SUSTAINED-RELEASE CAPSULE02222957 APO-DILTIAZ SR APX $ 0.3944



* 120MG CONTROLLED DELIVERY CAPSULE02243338 SANDOZ DILTIAZEM CD SDZ $ 0.870302230997 APO-DILTIAZ CD APX 0.870302231052 NU-DILTIAZ-CD NXP 0.870302242538 NOVO-DILTAZEM CD NOP 0.870302254808 GEN-DILTIAZEM CD GPM 0.870302229781 RATIO-DILTIAZEM CD RPH 0.870402097249 CARDIZEM CD BVL 1.3486

45


* 120MG EXTENDED RELEASE CAPSULE02245918 SANDOZ DILTIAZEM T SDZ $ 0.552702271605 NOVO-DILTIAZEM HCL NOP 0.552702231150 TIAZAC BVL 0.8773

120MG EXTENDED RELEASE TABLET02256738 TIAZAC XC BVL $ 0.8334

* 180MG CONTROLLED DELIVERY CAPSULE02229782 RATIO-DILTIAZEM CD RPH $ 1.155102230998 APO-DILTIAZ CD APX 1.155102231053 NU-DILTIAZ-CD NXP 1.155102242539 NOVO-DILTAZEM CD NOP 1.155102243339 SANDOZ DILTIAZEM CD SDZ 1.155102254816 GEN-DILTIAZEM CD GPM 1.155102097257 CARDIZEM CD BVL 1.7902



* 240MG CONTROLLED DELIVERY CAPSULE02230999 APO-DILTIAZ CD APX $ 1.532202231054 NU-DILTIAZ-CD NXP 1.532202242540 NOVO-DILTAZEM CD NOP 1.532202243340 SANDOZ DILTIAZEM CD SDZ 1.532202254824 GEN-DILTIAZEM CD GPM 1.532202229783 RATIO-DILTIAZEM CD RPH 1.532302097265 CARDIZEM CD BVL 2.3745



* 300MG CONTROLLED DELIVERY CAPSULE02229526 APO-DILTIAZ CD APX $ 1.915302229784 RATIO-DILTIAZEM CD RPH 1.915302242541 NOVO-DILTAZEM CD NOP 1.915302243341 SANDOZ DILTIAZEM CD SDZ 1.915302254832 GEN-DILTIAZEM CD GPM 1.915302097273 CARDIZEM CD BVL 2.9681


46





DISOPYRAMIDE 100MG CAPSULE

02224801 RYTHMODAN AVT $ 0.2506 150MG CAPSULE

02224828 RYTHMODAN AVT $ 0.3541 250MG SUSTAINED RELEASE TABLET

02224836 RYTHMODAN-LA AVT $ 0.8398

FLECAINIDE ACETATE 50MG TABLET

01966197 TAMBOCOR MDA $ 0.5611 100MG TABLET

01966200 TAMBOCOR MDA $ 1.1223

METOPROLOL TARTRATE* 25MG TABLET

02246010 APO-METOPROLOL APX $ 0.069802248855 PMS-METOPROLOL-L PMS 0.069802261898 NOVO-METOPROL CT NOP 0.069802252252 DOM-METOPROLOL-L DOM 0.0733

* 50MG TABLET02231121 DOM-METOPROLOL-L DOM $ 0.0859 *00618632 APO-METOPROLOL APX 0.133000648035 NOVO-METOPROL NOP 0.133000749354 APO-METOPROLOL-TYPE L APX 0.133000842648 NOVO-METOPROL (UNCOATED) NOP 0.133000865605 NU-METOP NXP 0.133002145413 PMS-METOPROLOL-B PMS 0.133002174545 GEN-METOPROLOL (TYPE L) GPM 0.133002230803 PMS-METOPROLOL-L PMS 0.133002247875 SANDOZ METOPROLOL L SDZ 0.133002172550 DOM-METOPROLOL DOM 0.139600397423 LOPRESOR NVR 0.248700402605 BETALOC AST 0.2512

47


* 100MG TABLET02231122 DOM-METOPROLOL-L DOM $ 0.1577 *00618640 APO-METOPROLOL APX 0.241200648043 NOVO-METOPROL NOP 0.241200751170 APO-METOPROLOL-TYPE L APX 0.241200842656 NOVO-METOPROL (UNCOATED) NOP 0.241200865613 NU-METOP NXP 0.241202145421 PMS-METOPROLOL-B PMS 0.241202174553 GEN-METOPROLOL (TYPE L) GPM 0.241202230804 PMS-METOPROLOL-L PMS 0.241202247876 SANDOZ METOPROLOL L SDZ 0.241202172569 DOM-METOPROLOL DOM 0.253300402540 BETALOC AST 0.430200397431 LOPRESOR NVR 0.5101

100MG SUSTAINED RELEASE TABLET00658855 LOPRESOR-SR NVR $ 0.2659

⌧ 200MG SUSTAINED RELEASE TABLET00534560 LOPRESOR-SR NVR $ 0.482400497827 BETALOC DURULES AST 0.4964

MEXILETINE HCL 100MG CAPSULE

02230359 NOVO-MEXILETINE NOP $ 0.8856 200MG CAPSULE

02230360 NOVO-MEXILETINE NOP $ 1.1859

NADOLOL* 40MG TABLET

00782505 APO-NADOL APX $ 0.267502126753 NOVO-NADOLOL NOP 0.2675

* 80MG TABLET00782467 APO-NADOL APX $ 0.381402126761 NOVO-NADOLOL NOP 0.3814

* 160MG TABLET00523372 CORGARD PPZ $ 0.715600782475 APO-NADOL APX 0.7156

48


NIFEDIPINE 5MG CAPSULE

00725110 APO-NIFED APX $ 0.2648* 10MG CAPSULE

00755907 APO-NIFED APX $ 0.201600865591 NU-NIFED NXP 0.2016

* 10MG SUSTAINED RELEASE TABLET02197448 APO-NIFED PA APX $ 0.243602212102 NU-NIFEDIPINE-PA NXP 0.2436

* 20MG SUSTAINED RELEASE TABLET02181525 APO-NIFED PA APX $ 0.423202200937 NU-NIFEDIPINE-PA NXP 0.4232

20MG EXTENDED-RELEASE TABLET02237618 ADALAT XL BAY $ 0.9096



PINDOLOL* 5MG TABLET

00886149 NU-PINDOL NXP $ 0.1840 *00755877 APO-PINDOL APX 0.247700869007 NOVO-PINDOL NOP 0.247702057808 GEN-PINDOLOL GPM 0.247702231536 PMS-PINDOLOL PMS 0.247702231650 DOM-PINDOLOL DOM 0.260100417270 VISKEN NVR 0.5101

* 10MG TABLET00886009 NU-PINDOL NXP $ 0.3278 *00755885 APO-PINDOL APX 0.430200869015 NOVO-PINDOL NOP 0.430202057816 GEN-PINDOLOL GPM 0.430202231537 PMS-PINDOLOL PMS 0.430202238046 DOM-PINDOLOL DOM 0.451700443174 VISKEN NVR 0.8711

* 15MG TABLET00755893 APO-PINDOL APX $ 0.632100869023 NOVO-PINDOL NOP 0.632100886130 NU-PINDOL NXP 0.632102057824 GEN-PINDOLOL GPM 0.632102231539 PMS-PINDOLOL PMS 0.632102238047 DOM-PINDOLOL DOM 0.663600417289 VISKEN NVR 1.2636

49


PROCAINAMIDE HCL 375MG CAPSULE

00713333 APO-PROCAINAMIDE APX $ 0.2497 500MG CAPSULE

00713341 APO-PROCAINAMIDE APX $ 0.3321 250MG SUSTAINED RELEASE TABLET

00638692 PROCAN-SR ERF $ 0.3581 500MG SUSTAINED RELEASE TABLET

00638676 PROCAN-SR ERF $ 0.3386 750MG SUSTAINED RELEASE TABLET

00638684 PROCAN-SR ERF $ 0.5078

PROPAFENONE HCL* 150MG TABLET

02243324 APO-PROPAFENONE APX $ 0.463902243727 PMS-PROPAFENONE PMS 0.463902245372 GEN-PROPAFENONE GPM 0.463902249480 NU-PROPAFENONE NXP 0.463900603708 RYTHMOL ABB 1.1225

* 300MG TABLET02243325 APO-PROPAFENONE APX $ 0.817802243728 PMS-PROPAFENONE PMS 0.817802245373 GEN-PROPAFENONE GPM 0.817800603716 RYTHMOL ABB 1.9785

PROPRANOLOL* 10MG TABLET

00402788 APO-PROPRANOLOL APX $ 0.020900582255 PMS-PROPRANOLOL PMS 0.020902137313 DOM-PROPRANOLOL DOM 0.021800496480 NOVO-PRANOL NOP 0.0261

* 20MG TABLET00663719 APO-PROPRANOLOL APX $ 0.037600740675 NOVO-PRANOL NOP 0.037602044692 NU-PROPRANOLOL NXP 0.0376

* 40MG TABLET00402753 APO-PROPRANOLOL APX $ 0.037800496499 NOVO-PRANOL NOP 0.037800582263 PMS-PROPRANOLOL PMS 0.037802044706 NU-PROPRANOLOL NXP 0.037802137321 DOM-PROPRANOLOL DOM 0.0396

50


* 80MG TABLET00402761 APO-PROPRANOLOL APX $ 0.063500496502 NOVO-PRANOL NOP 0.063500582271 PMS-PROPRANOLOL PMS 0.063502137348 DOM-PROPRANOLOL DOM 0.0667

120MG TABLET00504335 APO-PROPRANOLOL APX $ 0.1149

60MG LONG ACTING CAPSULE02042231 INDERAL-LA WYA $ 0.5096




QUINIDINE BISULFATE 250MG SUSTAINED RELEASE TABLET

00249580 BIQUIN DURULES AST $ 0.4579

SOTALOL HCL* 80MG TABLET

02238634 DOM-SOTALOL DOM $ 0.4684 *02084228 RATIO-SOTALOL RPH 0.643702200996 NU-SOTALOL NXP 0.643702210428 APO-SOTALOL APX 0.643702229778 GEN-SOTALOL GPM 0.643702231181 NOVO-SOTALOL NOP 0.643702238326 PMS-SOTALOL PMS 0.643702257831 SANDOZ SOTALOL SDZ 0.6437

* 160MG TABLET02238635 DOM-SOTALOL DOM $ 0.5091 *02084236 RATIO-SOTALOL RPH 0.704402163772 NU-SOTALOL NXP 0.704402167794 APO-SOTALOL APX 0.704402229779 GEN-SOTALOL GPM 0.704402231182 NOVO-SOTALOL NOP 0.704402234013 SANDOZ SOTALOL SDZ 0.704402238327 PMS-SOTALOL PMS 0.7044

51


TIMOLOL MALEATE* 5MG TABLET

00755842 APO-TIMOL APX $ 0.197201947796 NOVO-TIMOL NOP 0.1972

* 10MG TABLET00755850 APO-TIMOL APX $ 0.307601947818 NOVO-TIMOL NOP 0.3076

* 20MG TABLET00755869 APO-TIMOL APX $ 0.615201947826 NOVO-TIMOL NOP 0.6152

VERAPAMIL HCL SEE SECTION 24:08.00 (HYPOTENSIVE DRUGS)

24:06.00 ANTILIPEMIC DRUGS

ATORVASTATIN CALCIUM 10MG TABLET

02230711 LIPITOR PFI $ 1.8055 20MG TABLET



02243097 LIPITOR PFI $ 2.4261

BEZAFIBRATE SEE APPENDIX A FOR EDS CRITERIA 200MG TABLET

02240331 PMS-BEZAFIBRATE (EDS) PMS $ 0.9585 400MG SUSTAINED RELEASE TABLET

02083523 BEZALIP SR (EDS) HLR $ 1.7360

CHOLESTYRAMINE RESIN 444MG/G ORAL POWDER (9G)

02210320 PMS-CHOLESTYRAMINE PMS $ 0.6952 800MG/G ORAL POWDER (5G)

00890960 PMS-CHOLESTYRAMINE LIGHT PMS $ 0.6952

52

24:00 CARDIOVASCULAR DRUGS24:06.00 ANTILIPEMIC DRUGS

COLESTIPOL HCL RESIN 5G GRANULES

00642975 COLESTID PFI $ 0.9234 7.5G GRANULES

02132699 COLESTID PFI $ 0.9234 1G TABLET

02132680 COLESTID PFI $ 0.2634

EZETIMIBE 10MG TABLET

02247521 EZETROL MSD $ 1.7658

FENOFIBRATE* 200MG CAPSULE

02146959 LIPIDIL-MICRO FFR $ 1.181602239864 APO-FENO-MICRO APX 1.181602240210 GEN-FENOFIBR. MICRO GPM 1.181602243552 NOVO-FENOFIB. MICRO NOP 1.181602249715 NU-FENO-MICRO NXP 1.181602250039 RATIO-FENOFIBRATE MC RPH 1.181602273551 PMS-FENOFIBRATE PMS 1.181602240337 DOM-FENOFIBR. MICRO DOM 1.3785

FLUVASTATIN SODIUM 20MG CAPSULE

02061562 LESCOL NVR $ 0.8677 40MG CAPSULE

02061570 LESCOL NVR $ 1.2148

GEMFIBROZIL* 300MG CAPSULE

01979574 APO-GEMFIBROZIL APX $ 0.321602058456 NU-GEMFIBROZIL NXP 0.321602185407 GEN-GEMFIBROZIL GPM 0.321602239951 PMS-GEMFIBROZIL PMS 0.321602241704 NOVO-GEMFIBROZIL NOP 0.321602241608 DOM-GEMFIBROZIL DOM 0.337700599026 LOPID PFI 0.5590

* 600MG TABLET01979582 APO-GEMFIBROZIL APX $ 0.816002058464 NU-GEMFIBROZIL NXP 0.816002142074 NOVO-GEMFIBROZIL NOP 0.816002230183 PMS-GEMFIBROZIL PMS 0.816002230476 GEN-GEMFIBROZIL GPM 0.816002230580 DOM-GEMFIBROZIL DOM 0.856800659606 LOPID PFI 1.1190

53


LOVASTATIN* 20MG TABLET

02231434 NU-LOVASTATIN NXP $ 0.8104 *02220172 APO-LOVASTATIN APX 1.183402243127 GEN-LOVASTATIN GPM 1.183402245822 RATIO-LOVASTATIN RPH 1.183402246013 PMS-LOVASTATIN PMS 1.183402246542 NOVO-LOVASTATIN NOP 1.183402247056 SANDOZ LOVASTATIN SDZ 1.183402248572 CO LOVASTATIN COB 1.183402267969 RAN-LOVASTATIN RAN 1.183402247231 DOM-LOVASTATIN DOM 1.242600795860 MEVACOR MSD 2.0124

* 40MG TABLET02220180 APO-LOVASTATIN APX $ 2.182702231435 NU-LOVASTATIN NXP 2.182702245823 RATIO-LOVASTATIN RPH 2.182702246543 NOVO-LOVASTATIN NOP 2.182702248573 CO LOVASTATIN COB 2.182702267977 RAN-LOVASTATIN RAN 2.182702243129 GEN-LOVASTATIN GPM 2.182802246014 PMS-LOVASTATIN PMS 2.182802247057 SANDOZ LOVASTATIN SDZ 2.182802247232 DOM-LOVASTATIN DOM 2.292000795852 MEVACOR MSD 3.7115

PRAVASTATIN* 10MG TABLET

02244350 NU-PRAVASTATIN NXP $ 0.7476 *02243506 APO-PRAVASTATIN APX 1.034002246930 RATIO-PRAVASTATIN RPH 1.034002247008 NOVO-PRAVASTATIN NOP 1.034002247655 PMS-PRAVASTATIN PMS 1.034002247856 SANDOZ PRAVASTATIN SDZ 1.034002257092 GEN-PRAVASTATIN GPM 1.034002249723 DOM-PRAVASTATIN DOM 1.085800893749 PRAVACHOL SQU 1.6912

54


* 20MG TABLET02244351 NU-PRAVASTATIN NXP $ 0.8820 *02246931 RATIO-PRAVASTATIN RPH 1.219902247656 PMS-PRAVASTATIN PMS 1.219902247857 SANDOZ PRAVASTATIN SDZ 1.219902257106 GEN-PRAVASTATIN GPM 1.219902243507 APO-PRAVASTATIN APX 1.220002247009 NOVO-PRAVASTATIN NOP 1.220002249731 DOM-PRAVASTATIN DOM 1.281000893757 PRAVACHOL SQU 1.9950

* 40MG TABLET02244352 NU-PRAVASTATIN NXP $ 1.0624 *02246932 RATIO-PRAVASTATIN RPH 1.469502247010 NOVO-PRAVASTATIN NOP 1.469502247657 PMS-PRAVASTATIN PMS 1.469502247858 SANDOZ PRAVASTATIN SDZ 1.469502257114 GEN-PRAVASTATIN GPM 1.469502243508 APO-PRAVASTATIN APX 1.469502249758 DOM-PRAVASTATIN DOM 1.543102222051 PRAVACHOL SQU 2.4030

ROSUVASTATIN CALCIUM 5MG TABLET

02265540 CRESTOR AST $ 1.3997 10MG TABLET



02247164 CRESTOR AST $ 2.1592

SIMVASTATIN* 5MG TABLET

02247072 NU-SIMVASTATIN NXP $ 0.4214 *02246582 GEN-SIMVASTATIN GPM 0.615202247011 APO-SIMVASTATIN APX 0.615202250144 NOVO-SIMVASTATIN NOP 0.615202269252 PMS-SIMVASTATIN PMS 0.615202253747 DOM-SIMVASTATIN DOM 0.646000884324 ZOCOR MSD 1.0460

55


* 10MG TABLET02247075 NU-SIMVASTATIN NXP $ 0.8333 *02246583 GEN-SIMVASTATIN GPM 1.216802247012 APO-SIMVASTATIN APX 1.216802247068 RATIO-SIMVASTATIN RPH 1.216802247828 SANDOZ SIMVASTATIN SDZ 1.216802248104 CO SIMVASTATIN COB 1.216802250152 NOVO-SIMVASTATIN NOP 1.216802252635 PMS-SIMVASTATIN PMS 1.216802265885 TARO-SIMVASTATIN TAR 1.216802269260 PMS-SIMVASTATIN PMS 1.216802253755 DOM-SIMVASTATIN DOM 1.277600884332 ZOCOR MSD 2.0691



56


* 80MG TABLET02247078 NU-SIMVASTATIN NXP $ 1.0299 *02246585 GEN-SIMVASTATIN GPM 1.503902247015 APO-SIMVASTATIN APX 1.503902247071 RATIO-SIMVASTATIN RPH 1.503902247833 SANDOZ SIMVASTATIN SDZ 1.503902248107 CO SIMVASTATIN COB 1.503902250187 NOVO-SIMVASTATIN NOP 1.503902252678 PMS-SIMVASTATIN PMS 1.503902269295 PMS-SIMVASTATIN PMS 1.503902253798 DOM-SIMVASTATIN DOM 1.579002240332 ZOCOR MSD 2.5571

24:08.00 HYPOTENSIVE DRUGS

ANTIHYPERTENSIVE COMBINATION PRODUCTS:FIXED COMBINATION DRUGS ARE NOT INDICATED FOR INITIAL THERAPYOF HYPERTENSION. HYPERTENSION REQUIRES THERAPY TO BE TITRATEDTO THE INDIVIDUAL PATIENT. IF THE FIXED COMBINATIONREPRESENTS THE DOSAGE SO DETERMINED, ITS USE MAY BE MORECONVENIENT IN PATIENT MANAGEMENT. THE TREATMENT OFHYPERTENSION IS NOT STATIC, BUT MUST BE RE-EVALUATED ASCONDITIONS IN EACH PATIENT WARRANT.

ACEBUTOLOL HCL SEE SECTION 24:04.00 (CARDIAC DRUGS)

AMILORIDE HCL/HYDROCHLOROTHIAZIDE SEE NOTE REGARDING COMBINATION PRODUCTS UNDER SECTION 24:08.00 (HYPOTENSIVE DRUGS)* 5MG/50MG TABLET

00886106 NU-AMILZIDE NXP $ 0.1667 *00784400 APO-AMILZIDE APX 0.208001937219 NOVAMILOR NOP 0.208002257378 GEN-AMILAZIDE GPM 0.208000487813 MODURET PRM 0.3816

ATENOLOL SEE SECTION 24:04.00 (CARDIAC DRUGS)

ATENOLOL/CHLORTHALIDONE SEE NOTE REGARDING COMBINATION PRODUCTS UNDER SECTION 24:08.00 (HYPOTENSIVE DRUGS)* 50MG/25MG TABLET

02248763 APO-ATENIDONE APX $ 0.471302049961 TENORETIC AST 0.6934

* 100MG/25MG TABLET02248764 APO-ATENIDONE APX $ 0.772302049988 TENORETIC AST 1.1363

57

24:00 CARDIOVASCULAR DRUGS24:08.00 HYPOTENSIVE DRUGS

BENAZEPRIL HCL 5MG TABLET

00885835 LOTENSIN NVR $ 0.6972 10MG TABLET

00885843 LOTENSIN NVR $ 0.8243 20MG TABLET

00885851 LOTENSIN NVR $ 0.9456

CANDESARTAN CILEXETIL 4MG TABLET

02239090 ATACAND AST $ 0.7378 8MG TABLET

02239091 ATACAND AST $ 1.2070 16MG TABLET

02239092 ATACAND AST $ 1.2070

CANDESARTAN CILEXETIL/HYDROCHLOROTHIAZIDE SEE NOTE REGARDING COMBINATION PRODUCTS UNDER SECTION 24:08.00 (HYPOTENSIVE DRUGS) 16MG/12.5MG TABLET

02244021 ATACAND PLUS AST $ 1.2062

CAPTOPRIL 6.25MG TABLET

01999559 APO-CAPTO APX $ 0.1297* 12.5MG TABLET

00695661 CAPOTEN SQU $ 0.230100893595 APO-CAPTO APX 0.230101913824 NU-CAPTO NXP 0.230101942964 NOVO-CAPTORIL NOP 0.230102163551 GEN-CAPTOPRIL GPM 0.230102230203 PMS-CAPTOPRIL PMS 0.230102242788 CAPTOPRIL ZYP 0.230102238551 DOM-CAPTOPRIL DOM 0.2416

* 25MG TABLET00546283 CAPOTEN SQU $ 0.325500893609 APO-CAPTO APX 0.325501913832 NU-CAPTO NXP 0.325501942972 NOVO-CAPTORIL NOP 0.325502163578 GEN-CAPTOPRIL GPM 0.325502230204 PMS-CAPTOPRIL PMS 0.325502242789 CAPTOPRIL ZYP 0.325502238552 DOM-CAPTOPRIL DOM 0.3418

58

24:00 CARDIOVASCULAR DRUGS24:08.00 HYPOTENSIVE DRUGS* 50MG TABLET

00546291 CAPOTEN SQU $ 0.606600893617 APO-CAPTO APX 0.606601913840 NU-CAPTO NXP 0.606601942980 NOVO-CAPTORIL NOP 0.606602163586 GEN-CAPTOPRIL GPM 0.606602230205 PMS-CAPTOPRIL PMS 0.606602242790 CAPTOPRIL ZYP 0.606602238553 DOM-CAPTOPRIL DOM 0.6369

* 100MG TABLET00546305 CAPOTEN SQU $ 1.127900893625 APO-CAPTO APX 1.127901913859 NU-CAPTO NXP 1.127901942999 NOVO-CAPTORIL NOP 1.127902163594 GEN-CAPTOPRIL GPM 1.127902230206 PMS-CAPTOPRIL PMS 1.127902242791 CAPTOPRIL ZYP 1.127902238554 DOM-CAPTOPRIL DOM 1.1843

CILAZAPRIL* 1MG TABLET

02266350 NOVO-CILAZAPRIL NOP $ 0.448101911465 INHIBACE HLR 0.6626

* 2.5MG TABLET02266369 NOVO-CILAZAPRIL NOP $ 0.516501911473 INHIBACE HLR 0.7637

* 5MG TABLET02266377 NOVO-CILAZAPRIL NOP $ 0.600001911481 INHIBACE HLR 0.8872

CILAZAPRIL/HYDROCHLOROTHIAZIDE SEE NOTE REGARDING COMBINATION PRODUCTS UNDER SECTION 24:08.00 (HYPOTENSIVE DRUGS) 5MG/12.5MG TABLET

02181479 INHIBACE PLUS HLR $ 0.8870

59


CLONIDINE HCL SEE APPENDIX A FOR EDS CRITERIA* 0.025MG TABLET

02248732 APO-CLONIDINE (EDS) APX $ 0.197200519251 DIXARIT (EDS) BOE 0.2952

* 0.1MG TABLET00868949 APO-CLONIDINE APX $ 0.191501913786 NU-CLONIDINE NXP 0.191502046121 NOVO-CLONIDINE NOP 0.191500259527 CATAPRES BOE 0.201102247607 DOM-CLONIDINE DOM 0.2011

* 0.2MG TABLET00868957 APO-CLONIDINE APX $ 0.341701913220 NU-CLONIDINE NXP 0.341702046148 NOVO-CLONIDINE NOP 0.341700291889 CATAPRES BOE 0.358702247608 DOM-CLONIDINE DOM 0.3587

DILTIAZEM HCL NOTE: THE SUSTAINED RELEASE DOSAGE FORMS ARE APPROVED AS ANTIHYPERTENSIVE AGENTS (SEE SECTION 24:04.00)

DOXAZOSIN MESYLATE* 1MG TABLET

02240498 GEN-DOXAZOSIN GPM $ 0.376002240588 APO-DOXAZOSIN APX 0.376002242728 NOVO-DOXAZOSIN NOP 0.376002244527 PMS-DOXAZOSIN PMS 0.376001958100 CARDURA-1 AST 0.6147

* 2MG TABLET02240499 GEN-DOXAZOSIN GPM $ 0.451202240589 APO-DOXAZOSIN APX 0.451202242729 NOVO-DOXAZOSIN NOP 0.451202244528 PMS-DOXAZOSIN PMS 0.451201958097 CARDURA-2 AST 0.7373

* 4MG TABLET02240500 GEN-DOXAZOSIN GPM $ 0.586502240590 APO-DOXAZOSIN APX 0.586502242730 NOVO-DOXAZOSIN NOP 0.586502244529 PMS-DOXAZOSIN PMS 0.586501958119 CARDURA-4 AST 0.9586

60


ENALAPRIL MALEATE 2.5MG TABLET

00851795 VASOTEC MSD $ 0.7849 5MG TABLET



00670928 VASOTEC MSD $ 1.3462

ENALAPRIL MALEATE/HYDROCHLOROTHIAZIDE SEE NOTE REGARDING COMBINATION PRODUCTS UNDER SECTION 24:08.00 (HYPOTENSIVE DRUGS) 5MG/12.5MG TABLET

02242826 VASERETIC MSD $ 0.9285 10MG/25MG TABLET

00657298 VASERETIC MSD $ 1.1159

EPROSARTAN MESYLATE 400MG TABLET

02240432 TEVETEN SLV $ 0.7378 600MG TABLET

02243942 TEVETEN SLV $ 1.1067

EPROSARTAN MESYLATE/HYDROCHOLORTHIAZIDE SEE NOTE REGARDING COMBINATION PRODUCTS UNDER SECTION 24:08.00 (HYPOTENSIVE DRUGS) 600MG/12.5MG TABLET

02253631 TEVETEN PLUS SLV $ 1.1067

FELODIPINE* 2.5MG SUSTAINED RELEASE TABLET

02221985 RENEDIL AVT $ 0.550102057778 PLENDIL AST 0.5520

* 5MG SUSTAINED RELEASE TABLET02221993 RENEDIL AVT $ 0.735300851779 PLENDIL AST 0.7375

* 10MG SUSTAINED RELEASE TABLET02222000 RENEDIL AVT $ 1.102400851787 PLENDIL AST 1.1064

61


FOSINOPRIL* 10MG TABLET

02242733 LIN-FOSINOPRIL PMS $ 0.540002247802 NOVO-FOSINOPRIL NOP 0.540002255944 PMS-FOSINOPRIL PMS 0.540002262401 GEN-FOSINOPRIL GPM 0.540002266008 APO-FOSINOPRIL APX 0.540002275252 RATIO-FOSINOPRIL RPH 0.540001907107 MONOPRIL BMY 0.8829

* 20MG TABLET02242734 LIN-FOSINOPRIL PMS $ 0.649402247803 NOVO-FOSINOPRIL NOP 0.649402255952 PMS-FOSINOPRIL PMS 0.649402262428 GEN-FOSINOPRIL GPM 0.649402266016 APO-FOSINOPRIL APX 0.649402275260 RATIO-FOSINOPRIL RPH 0.649401907115 MONOPRIL BMY 1.0617

HYDRALAZINE HCL* 10MG TABLET

00441619 APO-HYDRALAZINE APX $ 0.111400759465 NOVO-HYLAZIN NOP 0.1114

* 25MG TABLET00441627 APO-HYDRALAZINE APX $ 0.191400759473 NOVO-HYLAZIN NOP 0.1914

* 50MG TABLET00441635 APO-HYDRALAZINE APX $ 0.300600759481 NOVO-HYLAZIN NOP 0.3006

IRBESARTAN 75MG TABLET

02237923 AVAPRO BMY $ 1.2397 150MG TABLET

02237924 AVAPRO BMY $ 1.2397 300MG TABLET

02237925 AVAPRO BMY $ 1.2397

62


IRBESARTAN/HYDROCHLOROTHIAZIDE SEE NOTE REGARDING COMBINATION PRODUCTS UNDER SECTION 24:08.00 (HYPOTENSIVE DRUGS) 150MG/12.5MG TABLET

02241818 AVALIDE BMY $ 1.2397 300MG/12.5MG TABLET

02241819 AVALIDE BMY $ 1.2397

LABETALOL HCL* 100MG TABLET

02243538 APO-LABETALOL APX $ 0.214502106272 TRANDATE RBP 0.2553

* 200MG TABLET02243539 APO-LABETALOL APX $ 0.364402106280 TRANDATE RBP 0.4515

LISINOPRIL* 5MG TABLET

02217481 APO-LISINOPRIL APX $ 0.584600839388 PRINIVIL MSD 0.602202049333 ZESTRIL AST 0.7530

* 10MG TABLET02217503 APO-LISINOPRIL APX $ 0.702500839396 PRINIVIL MSD 0.723402049376 ZESTRIL AST 0.9046

* 20MG TABLET02217511 APO-LISINOPRIL APX $ 0.844100839418 PRINIVIL MSD 0.869602049384 ZESTRIL AST 1.0869

LISINOPRIL/HYDROCHLOROTHIAZIDE SEE NOTE REGARDING COMBINATION PRODUCTS UNDER SECTION 24:08.00 (HYPOTENSIVE DRUGS)* 10MG/12.5MG TABLET

02108194 PRINZIDE MSD $ 0.723502103729 ZESTORETIC AST 0.9046

* 20MG/12.5MG TABLET00884413 PRINZIDE MSD $ 0.869302045737 ZESTORETIC AST 1.0869

* 20MG/25MG TABLET00884421 PRINZIDE MSD $ 0.869302045729 ZESTORETIC AST 1.0869

63


LOSARTAN POTASSIUM 25MG TABLET

02182815 COZAAR MSD $ 1.2790 50MG TABLET

02182874 COZAAR MSD $ 1.2790 100MG TABLET

02182882 COZAAR MSD $ 1.2790

LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE SEE NOTE REGARDING COMBINATION PRODUCTS UNDER SECTION 24:08.00 (HYPOTENSIVE DRUGS) 50MG/12.5MG TABLET

02230047 HYZAAR MSD $ 1.2790 100MG/25MG TABLET

02241007 HYZAAR DS MSD $ 1.2790

METHYLDOPA 125MG TABLET

00360252 APO-METHYLDOPA APX $ 0.1049 250MG TABLET

00360260 APO-METHYLDOPA APX $ 0.1519 500MG TABLET

00426830 APO-METHYLDOPA APX $ 0.2690

METHYLDOPA/HYDROCHLOROTHIAZIDE SEE NOTE REGARDING COMBINATION PRODUCTS UNDER SECTION 24:08.00 (HYPOTENSIVE DRUGS) 250MG/15MG TABLET

00441708 APO-METHAZIDE-15 APX $ 0.1823 250MG/25MG TABLET

00441716 APO-METHAZIDE-25 APX $ 0.1991

METOPROLOL TARTRATE SEE SECTION 24:04.00 (CARDIAC DRUGS)

MINOXIDIL SEE APPENDIX A FOR EDS CRITERIA 2.5MG TABLET

00514497 LONITEN (EDS) PFI $ 0.3568 10MG TABLET

00514500 LONITEN (EDS) PFI $ 0.7867

64


NADOLOL SEE SECTION 24:04.00 (CARDIAC DRUGS)

NIFEDIPINE SEE SECTION 24:04.00 (CARDIAC DRUGS)

OXPRENOLOL HCL 40MG TABLET

00402575 TRASICOR NVR $ 0.2975 80MG TABLET

00402583 TRASICOR NVR $ 0.4507

PERINDOPRIL ERBUMINE 2MG TABLET

02123274 COVERSYL SEV $ 0.6510 4MG TABLET

02123282 COVERSYL SEV $ 0.8138 8MG TABLET

02246624 COVERSYL SEV $ 1.1393

PERINDOPRIL ERBUMINE/INDAPAMIDE SEE NOTE REGARDING COMBINATION PRODUCTS UNDER SECTION 24:08.00 (HYPOTENSIVE DRUGS) 4MG/1.25MG TABLET

02246569 COVERSYL PLUS SEV $ 1.0200

PINDOLOL SEE SECTION 24:04.00 (CARDIAC DRUGS)

PINDOLOL/HYDROCHLOROTHIAZIDE SEE NOTE REGARDING COMBINATION PRODUCTS UNDER SECTION 24:08.00 (HYPOTENSIVE DRUGS) 10MG/25MG TABLET

00568627 VISKAZIDE NVR $ 0.7971 10MG/50MG TABLET

00568635 VISKAZIDE NVR $ 0.7971

PRAZOSIN* 1MG TABLET

00882801 APO-PRAZO APX $ 0.223001934198 NOVO-PRAZIN NOP 0.2230

* 2MG TABLET00882828 APO-PRAZO APX $ 0.302901934201 NOVO-PRAZIN NOP 0.3029

* 5MG TABLET00882836 APO-PRAZO APX $ 0.413001934228 NOVO-PRAZIN NOP 0.4130

65


PROPRANOLOL SEE SECTION 24:04.00 (CARDIAC DRUGS)

QUINAPRIL HCL 5MG TABLET

01947664 ACCUPRIL PFI $ 0.9271 10MG TABLET



01947699 ACCUPRIL PFI $ 0.9271

QUINAPRIL HCL/HYDROCHLOROTHIAZIDE SEE NOTE REGARDING COMBINATION PRODUCTS UNDER SECTION 24:08.00 (HYPOTENSIVE DRUGS) 10MG/12.5MG TABLET

02237367 ACCURETIC PFI $ 0.9270 20MG/12.5MG TABLET

02237368 ACCURETIC PFI $ 0.9270 20MG/25MG TABLET

02237369 ACCURETIC PFI $ 0.8914

RAMIPRIL 1.25MG CAPSULE

02221829 ALTACE AVT $ 0.7060 2.5MG CAPSULE

02221837 ALTACE AVT $ 0.8140 5MG CAPSULE

02221845 ALTACE AVT $ 0.8140 10MG CAPSULE

02221853 ALTACE AVT $ 1.0310

SPIRONOLACTONE/HYDROCHLOROTHIAZIDE SEE NOTE REGARDING COMBINATION PRODUCTS UNDER SECTION 24:08.00 (HYPOTENSIVE DRUGS)* 25MG/25MG TABLET

00613231 NOVO-SPIROZINE NOP $ 0.093200180408 ALDACTAZIDE-25 PFI 0.0969

* 50MG/50MG TABLET00657182 NOVO-SPIROZINE NOP $ 0.242600594377 ALDACTAZIDE-50 PFI 0.2523

66


TELMISARTAN 40MG TABLET

02240769 MICARDIS BOE $ 1.2258 80MG TABLET

02240770 MICARDIS BOE $ 1.2258

TELMISARTAN/HYDROCHLOROTHIAZIDE SEE NOTE REGARDING COMBINATION PRODUCTS UNDER SECTION 24:08.00 (HYPOTENSIVE DRUGS) 80MG/12.5MG TABLET

02244344 MICARDIS PLUS BOE $ 1.2258

TERAZOSIN HCL* 1MG TABLET

02243746 DOM-TERAZOSIN DOM $ 0.2957 *02218941 RATIO-TERAZOSIN RPH 0.378702230805 NOVO-TERAZOSIN NOP 0.378702233047 NU-TERAZOSIN NXP 0.378702234502 APO-TERAZOSIN APX 0.378702243518 PMS-TERAZOSIN PMS 0.378700818658 HYTRIN ABB 0.6947

* 2MG TABLET02243747 DOM-TERAZOSIN DOM $ 0.3759 *02218968 RATIO-TERAZOSIN RPH 0.481302230806 NOVO-TERAZOSIN NOP 0.481302233048 NU-TERAZOSIN NXP 0.481302234503 APO-TERAZOSIN APX 0.481302243519 PMS-TERAZOSIN PMS 0.481300818682 HYTRIN ABB 0.8830

* 5MG TABLET02243748 DOM-TERAZOSIN DOM $ 0.5105 *02218976 RATIO-TERAZOSIN RPH 0.653802230807 NOVO-TERAZOSIN NOP 0.653802233049 NU-TERAZOSIN NXP 0.653802234504 APO-TERAZOSIN APX 0.653802243520 PMS-TERAZOSIN PMS 0.653800818666 HYTRIN ABB 1.1992

67


* 10MG TABLET02218984 RATIO-TERAZOSIN RPH $ 0.957002230808 NOVO-TERAZOSIN NOP 0.957002233050 NU-TERAZOSIN NXP 0.957002234505 APO-TERAZOSIN APX 0.957002243521 PMS-TERAZOSIN PMS 0.957002243749 DOM-TERAZOSIN DOM 1.004900818674 HYTRIN ABB 1.7554

1MG TABLET (7) 2MG TABLET (7) 5MG TABLET (14) (PACKAGE)

02187876 HYTRIN STARTER PACK ABB $ 24.0900

TIMOLOL MALEATE SEE SECTION 24:04.00 (CARDIAC DRUGS)

TRANDOLAPRIL 0.5MG CAPSULE

02231457 MAVIK ABB $ 0.6727 1MG CAPSULE



02239267 MAVIK ABB $ 1.0308

TRIAMTERENE/HYDROCHLOROTHIAZIDE SEE NOTE REGARDING COMBINATION PRODUCTS UNDER SECTION 24:08.00 (HYPOTENSIVE DRUGS)* 50MG/25MG TABLET

00865532 NU-TRIAZIDE NXP $ 0.0416 *00441775 APO-TRIAZIDE APX 0.066000532657 NOVO-TRIAMZIDE NOP 0.0660

VALSARTAN 40MG TABLET

02270528 DIOVAN NVR $ 1.1971 80MG TABLET

02244781 DIOVAN NVR $ 1.2068 160MG TABLET

02244782 DIOVAN NVR $ 1.2068

68


VALSARTAN/HYDROCHLOROTHIAZIDE SEE NOTE REGARDING COMBINATION PRODUCTS UNDER SECTION 24:08.00 (HYPOTENSIVE DRUGS) 80MG/12.5MG TABLET

02241900 DIOVAN-HCT NVR $ 1.2068 160MG/12.5MG TABLET

02241901 DIOVAN-HCT NVR $ 1.2068 160MG/25MG TABLET

02246955 DIOVAN-HCT NVR $ 1.2068

VERAPAMIL HCL* 80MG TABLET

00886033 NU-VERAP NXP $ 0.2378 *00782483 APO-VERAP APX 0.296802237921 GEN-VERAPAMIL GPM 0.2968

* 120MG TABLET00782491 APO-VERAP APX $ 0.461200886041 NU-VERAP NXP 0.461202237922 GEN-VERAPAMIL GPM 0.461200554324 ISOPTIN ABB 0.4728

* 120MG SUSTAINED RELEASE TABLET02210347 GEN-VERAPAMIL SR GPM $ 0.748702246893 APO-VERAP SR APX 0.748701907123 ISOPTIN SR ABB 1.2756

180MG CONTROLLED-ONSET EXTENDED-RELEASE TABLET

02231676 COVERA-HS PFI $ 0.8802* 180MG SUSTAINED RELEASE TABLET

02210355 GEN-VERAPAMIL SR GPM $ 0.711602246894 APO-VERAP SR APX 0.711601934317 ISOPTIN SR ABB 1.4405

240MG CONTROLLED-ONSET EXTENDED-RELEASE TABLET

02231677 COVERA-HS PFI $ 0.9840* 240MG SUSTAINED RELEASE TABLET

02249812 NU-VERAP SR NXP $ 0.6841 *02210363 GEN-VERAPAMIL SR GPM 0.946202211920 NOVO-VERAMIL SR NOP 0.946202237791 PMS-VERAPAMIL SR PMS 0.946202246895 APO-VERAP SR APX 0.946202240321 DOM-VERAPAMIL SR DOM 0.993500742554 ISOPTIN SR ABB 1.9209

69

24:00 CARDIOVASCULAR DRUGS24:12.00 VASODILATING DRUGS

BETAHISTINE DIHYDROCHLORIDE 16MG TABLET

02243878 SERC SLV $ 0.4557 24MG TABLET

02247998 SERC SLV $ 0.6836

DIPYRIDAMOLE SEE APPENDIX A FOR EDS CRITERIA 50MG TABLET

00067393 PERSANTINE (EDS) BOE $ 0.4209 75MG TABLET

00452092 PERSANTINE (EDS) BOE $ 0.5668

DIPYRIDAMOLE/ACETYLSALICYLIC ACID SEE APPENDIX A FOR EDS CRITERIA 200MG/25MG CAPSULE

02242119 AGGRENOX (EDS) BOE $ 0.8930

ISOSORBIDE DINITRATE 10MG TABLET

00441686 APO-ISDN APX $ 0.0388 30MG TABLET

00441694 APO-ISDN APX $ 0.0909 5MG SUBLINGUAL TABLET

00670944 APO-ISDN APX $ 0.0651

ISOSORBIDE-5 MONONITRATE* 60MG EXTENDED-RELEASE TABLET

02272830 APO-ISMN APX $ 0.537102126559 IMDUR AST 0.7154

NIMODIPINE SEE APPENDIX A FOR EDS CRITERIA 30MG CAPSULE

02155923 NIMOTOP (EDS) BAY $ 6.2209

70

24:00 CARDIOVASCULAR DRUGS24:12.00 VASODILATING DRUGS

NITROGLYCERIN NOTE: TO PREVENT DEVELOPMENT OF TOLERANCE, PATCHES SHOULD BE REMOVED AFTER 12-14 HOURS TO PROVIDE DAILY NITRATE-FREE PERIODS OF 10-12 HOURS. THE NITRATE-FREE PERIOD SHOULD BE TIMED TO COINCIDE WITH THE PERIOD IN WHICH ANGINA IS LEAST LIKELY TO OCCUR (USUALLY AT NIGHT).⌧ 0.2MG/HR. TRANSDERMAL THERAPEUTIC SYSTEM

01911910 NITRO-DUR 0.2 KEY $ 0.615002230732 TRINIPATCH 0.2 NVR 0.615000584223 TRANSDERM-NITRO 0.2 NVR 0.634002162806 MINITRAN 0.2 MDA 0.6340

⌧ 0.4MG/HR. TRANSDERMAL THERAPEUTIC SYSTEM01911902 NITRO-DUR 0.4 KEY $ 0.694402230733 TRINIPATCH 0.4 NVR 0.694400852384 TRANSDERM-NITRO 0.4 NVR 0.715502163527 MINITRAN 0.4 MDA 0.7155

⌧ 0.6MG/HR. TRANSDERMAL THERAPEUTIC SYSTEM01911929 NITRO-DUR 0.6 KEY $ 0.694402230734 TRINIPATCH 0.6 NVR 0.694402046156 TRANSDERM-NITRO 0.6 NVR 0.715502163535 MINITRAN 0.6 MDA 0.7158

0.8MG/HR. TRANSDERMAL THERAPEUTIC SYSTEM02011271 NITRO-DUR 0.8 KEY $ 1.2044

0.3MG SUBLINGUAL TABLET00037613 NITROSTAT PFI $ 0.0302

0.6MG SUBLINGUAL TABLET00037621 NITROSTAT PFI $ 0.0314

2% OINTMENT01926454 NITROL PAL $ 0.6407

* 0.4MG/DOSE LINGUAL SPRAY (PACKAGE)02238998 RHO-NITRO PUMPSPRAY ROP $ 9.180002243588 GEN-NITRO SL SPRAY GPM 9.180002231441 NITROLINGUAL PUMPSPRAY AVT 13.1200

71

CENTRAL NERVOUS SYSTEM AGENTS28:00

28:00 CENTRAL NERVOUS SYSTEM AGENTS28:08.04 NON-STEROIDAL ANTI-INFLAMMATORY AGENTS

ACETYLSALICYLIC ACID* 325MG ENTERIC TABLET

00216666 NOVASEN NOP $ 0.023900010332 ENTROPHEN PED 0.0607

* 650MG ENTERIC TABLET00229296 NOVASEN NOP $ 0.038200010340 ENTROPHEN PED 0.1040

CELECOXIB SEE APPENDIX A FOR EDS CRITERIA 100MG CAPSULE

02239941 CELEBREX (EDS) PFI $ 0.7053 200MG CAPSULE

02239942 CELEBREX (EDS) PFI $ 1.4105

DICLOFENAC SODIUM* 25MG ENTERIC TABLET

00808539 NOVO-DIFENAC NOP $ 0.206400839175 APO-DICLO APX 0.206400886017 NU-DICLO NXP 0.206402231502 PMS-DICLOFENAC PMS 0.206402231662 DOM-DICLOFENAC DOM 0.2167

* 50MG ENTERIC TABLET00886025 NU-DICLO NXP $ 0.3339 *00808547 NOVO-DIFENAC NOP 0.427200839183 APO-DICLO APX 0.427202231503 PMS-DICLOFENAC PMS 0.427202231663 DOM-DICLOFENAC DOM 0.448600514012 VOLTAREN NVR 0.7739

* 75MG SUSTAINED RELEASE TABLET02228203 NU-DICLO-SR NXP $ 0.4839 *02158582 NOVO-DIFENAC SR NOP 0.619102162814 APO-DICLO SR APX 0.619102231504 PMS-DICLOFENAC-SR PMS 0.619102231664 DOM-DICLOFENAC SR DOM 0.650100782459 VOLTAREN-SR NVR 1.0874

* 100MG SUSTAINED RELEASE TABLET02228211 NU-DICLO-SR NXP $ 0.6677 *02048698 NOVO-DIFENAC SR NOP 0.854402091194 APO-DICLO SR APX 0.854402231505 PMS-DICLOFENAC-SR PMS 0.854402231665 DOM-DICLOFENAC SR DOM 0.897100590827 VOLTAREN-SR NVR 1.5500

74


* 50MG SUPPOSITORY02231506 PMS-DICLOFENAC PMS $ 0.676802241224 SAB-DICLOFENAC SDZ 0.676800632724 VOLTAREN NVR 1.1617

* 100MG SUPPOSITORY02231508 PMS-DICLOFENAC PMS $ 0.911102241225 SAB-DICLOFENAC SDZ 0.911100632732 VOLTAREN NVR 1.5643

DICLOFENAC SODIUM/MISOPROSTOL 50MG/200UG ENTERIC TABLET

01917056 ARTHROTEC PFI $ 0.6252 75MG/200UG ENTERIC TABLET

02229837 ARTHROTEC 75 PFI $ 0.8509

DIFLUNISAL* 250MG TABLET

02039486 APO-DIFLUNISAL APX $ 0.612702048493 NOVO-DIFLUNISAL NOP 0.6127

* 500MG TABLET02039494 APO-DIFLUNISAL APX $ 0.749402048507 NOVO-DIFLUNISAL NOP 0.7494

ETODOLAC SEE APPENDIX A FOR EDS CRITERIA 200MG CAPSULE

02232317 APO-ETODOLAC (EDS) APX $ 0.6510 300MG CAPSULE

02232318 APO-ETODOLAC (EDS) APX $ 0.6510

FLURBIPROFEN* 50MG TABLET

01912046 APO-FLURBIPROFEN APX $ 0.278202020661 NU-FLURBIPROFEN NXP 0.278202100509 NOVO-FLURPROFEN NOP 0.278200647942 ANSAID PFI 0.5560

* 100MG TABLET00675199 RATIO-FLURBIPROFEN RPH $ 0.380701912038 APO-FLURBIPROFEN APX 0.380702020688 NU-FLURBIPROFEN NXP 0.380702100517 NOVO-FLURPROFEN NOP 0.380700600792 ANSAID PFI 0.7279

75


IBUPROFEN* 300MG TABLET

00441651 APO-IBUPROFEN APX $ 0.074900327794 MOTRIN MCL 0.1326

* 400MG TABLET00506052 APO-IBUPROFEN APX $ 0.109600364142 MOTRIN MCL 0.1723

* 600MG TABLET00585114 APO-IBUPROFEN APX $ 0.050500629359 NOVO-PROFEN NOP 0.050502020726 NU-IBUPROFEN NXP 0.0505

INDOMETHACIN* 25MG CAPSULE

00337420 NOVO-METHACIN NOP $ 0.094500611158 APO-INDOMETHACIN APX 0.094500865850 NU-INDO NXP 0.0945

* 50MG CAPSULE00337439 NOVO-METHACIN NOP $ 0.164000611166 APO-INDOMETHACIN APX 0.164000865869 NU-INDO NXP 0.1640

* 50MG SUPPOSITORY02146932 RHODACINE RHO $ 0.870202231799 SAB-INDOMETHACIN SDZ 0.8702

* 100MG SUPPOSITORY02146940 RHODACINE RHO $ 0.966802231800 SAB-INDOMETHACIN SDZ 0.9668

KETOPROFEN* 50MG CAPSULE

00790427 APO-KETO APX $ 0.180402150808 PMS-KETOPROFEN PMS 0.1804

50MG ENTERIC COATED TABLET00790435 APO-KETO-E APX $ 0.1804

⌧ 100MG ENTERIC COATED TABLET00842664 APO-KETO-E APX $ 0.334002150824 PMS-KETOPROFEN-EC PMS 0.3340

200MG SUSTAINED RELEASE TABLET02172577 APO-KETOPROFEN SR APX $ 0.6680

50MG SUPPOSITORY02148773 PMS-KETOPROFEN PMS $ 0.8536

100MG SUPPOSITORY02015951 PMS-KETOPROFEN PMS $ 1.0774

76


MEFENAMIC ACID* 250MG CAPSULE

02229452 APO-MEFENAMIC APX $ 0.359002229569 NU-MEFENAMIC NXP 0.359002231208 PMS-MEFENAMIC ACID PMS 0.359002237826 DOM-MEFENAMIC ACID DOM 0.3769

MELOXICAM SEE APPENDIX A FOR EDS CRITERIA* 7.5MG TABLET

02247889 RATIO-MELOXICAM (EDS) RPH $ 0.533202248267 PMS-MELOXICAM (EDS) PMS 0.533202248973 APO-MELOXICAM (EDS) APX 0.533202250012 CO MELOXICAM (EDS) COB 0.533202255987 GEN-MELOXICAM (EDS) GPM 0.533202258315 NOVO-MELOXICAM (EDS) NOP 0.533202248605 DOM-MELOXICAM (EDS) DOM 0.559902242785 MOBICOX (EDS) BOE 0.8692

* 15MG TABLET02248031 RATIO-MELOXICAM (EDS) RPH $ 0.615202248268 PMS-MELOXICAM (EDS) PMS 0.615202248974 APO-MELOXICAM (EDS) APX 0.615202250020 CO MELOXICAM (EDS) COB 0.615202255995 GEN-MELOXICAM (EDS) GPM 0.615202258323 NOVO-MELOXICAM (EDS) NOP 0.615202248606 DOM-MELOXICAM (EDS) DOM 0.646002242786 MOBICOX (EDS) BOE 1.0029

NABUMETONE SEE APPENDIX A FOR EDS CRITERIA* 500MG TABLET

02238639 APO-NABUMETONE (EDS) APX $ 0.545302240867 NOVO-NABUMETONE (EDS) NOP 0.545302242912 SANDOZ NABUMETONE (EDS) SDZ 0.545302244563 GEN-NABUMETONE (EDS) GPM 0.5453

750MG TABLET02240868 NOVO-NABUMETONE (EDS) NOP $ 0.7406

77


NAPROXEN 125MG TABLET

00522678 APO-NAPROXEN APX $ 0.0828* 250MG TABLET

00865648 NU-NAPROX NXP $ 0.0929 *00522651 APO-NAPROXEN APX 0.115900565350 NOVO-NAPROX NOP 0.1159

* 375MG TABLET00865656 NU-NAPROX NXP $ 0.1268 *00600806 APO-NAPROXEN APX 0.158200627097 NOVO-NAPROX NOP 0.1582

* 500MG TABLET00865664 NU-NAPROX NXP $ 0.1834 *00589861 NOVO-NAPROX NOP 0.229000592277 APO-NAPROXEN APX 0.2290

* 750MG SUSTAINED RELEASE TABLET02177072 APO-NAPROXEN SR APX $ 0.825102231327 NOVO-NAPROX SR NOP 0.825102162466 NAPROSYN-S.R. HLR 1.3778

* 500MG SUPPOSITORY02017237 PMS-NAPROXEN PMS $ 0.860102230477 SAB-NAPROXEN SDZ 0.8601

25MG/ML SUSPENSION02162431 NAPROSYN HLR $ 0.0654

PHENYLBUTAZONE 100MG TABLET

00312789 APO-PHENYLBUTAZONE APX $ 0.0814

PIROXICAM* 10MG CAPSULE

00642886 APO-PIROXICAM APX $ 0.450000695718 NOVO-PIROCAM NOP 0.450000836249 PMS-PIROXICAM PMS 0.450000865761 NU-PIROX NXP 0.450002171813 GEN-PIROXICAM GPM 0.4500

78


* 20MG CAPSULE00642894 APO-PIROXICAM APX $ 0.776700695696 NOVO-PIROCAM NOP 0.776700836230 PMS-PIROXICAM PMS 0.776700865788 NU-PIROX NXP 0.776702171821 GEN-PIROXICAM GPM 0.7767

10MG SUPPOSITORY02154420 PMS-PIROXICAM PMS $ 0.8040

20MG SUPPOSITORY02154463 PMS-PIROXICAM PMS $ 1.7860

SULINDAC* 150MG TABLET

00745588 NOVO-SUNDAC NOP $ 0.414900778354 APO-SULIN APX 0.414902042576 NU-SULINDAC NXP 0.4149

* 200MG TABLET00745596 NOVO-SUNDAC NOP $ 0.525200778362 APO-SULIN APX 0.5252

TIAPROFENIC ACID* 200MG TABLET

02136112 APO-TIAPROFENIC APX $ 0.373002179679 NOVO-TIAPROFENIC NOP 0.373002230827 PMS-TIAPROFENIC PMS 0.3730

* 300MG TABLET02136120 APO-TIAPROFENIC APX $ 0.445302146886 NU-TIAPROFENIC NXP 0.445302179687 NOVO-TIAPROFENIC NOP 0.445302230828 PMS-TIAPROFENIC PMS 0.445302231060 DOM-TIAPROFENIC DOM 0.500802221950 SURGAM AVT 0.7794

79

28:00 CENTRAL NERVOUS SYSTEM AGENTS28:08.08 OPIATE AGONISTS (NARCOTIC ANALGESICS)

ACETAMINOPHEN/CAFFEINE/CODEINE* 300MG ACETAMINOPHEN & 15MG CODEINE/TABLET

00653241 RATIO-LENOLTEC NO.2 RPH $ 0.064602163934 TYLENOL WITH CODEINE NO.2 JAN 0.0762

325MG ACETAMINOPHEN & 15MG CODEINE/TABLET00293504 ATASOL-15 HOR $ 0.0646

* 300MG ACETAMINOPHEN & 30MG CODEINE/TABLET00653276 RATIO-LENOLTEC NO.3 RPH $ 0.071102163926 TYLENOL WITH CODEINE NO.3 JAN 0.0839

325MG ACETAMINOPHEN & 30MG CODEINE/TABLET00293512 ATASOL-30 HOR $ 0.0700

ACETAMINOPHEN/CODEINE 300MG/30MG TABLET

00608882 RATIO-EMTEC RPH $ 0.1411* 300MG/60MG TABLET

00621463 RATIO-LENOLTEC NO.4 RPH $ 0.150202163918 TYLENOL WITH CODEINE NO.4 JAN 0.1771

32MG/1.6MG/ML ELIXIR02163942 TYLENOL WITH CODEINE ELX JAN $ 0.0984

ACETYLSALICYLIC ACID/CAFFEINE/CODEINE 375MG/30MG/30MG TABLET

02238645 292 PED $ 0.1834

CODEINE SEE APPENDIX A FOR EDS CRITERIA 50MG CONTROLLED RELEASE TABLET

02230302 CODEINE CONTIN (EDS) PFR $ 0.3182 100MG CONTROLLED RELEASE TABLET



02163799 CODEINE CONTIN (EDS) PFR $ 1.2725

CODEINE PHOSPHATE⌧ 15MG TABLET

02243978 PMS-CODEINE PMS $ 0.069600593435 RATIO-CODEINE RPH 0.0832

⌧ 30MG TABLET02243979 PMS-CODEINE PMS $ 0.083900593451 RATIO-CODEINE RPH 0.1080

5MG/ML SYRUP00779474 RATIO-CODEINE RPH $ 0.0266

80


FENTANYL SEE APPENDIX A FOR EDS CRITERIA 25UG/HR TRANSDERMAL SYSTEM

01937383 DURAGESIC (EDS) JAN $ 10.2900 50UG/HR TRANSDERMAL SYSTEM



01937413 DURAGESIC (EDS) JAN $ 33.8846

HYDROMORPHONE HCL* 1MG TABLET

00705438 DILAUDID ABB $ 0.104100885444 PMS-HYDROMORPHONE PMS 0.1041

* 2MG TABLET00125083 DILAUDID ABB $ 0.153800885436 PMS-HYDROMORPHONE PMS 0.1538



3MG CONTROLLED-RELEASE CAPSULE02125323 HYDROMORPH CONTIN PFR $ 0.6786

6MG CONTROLLED RELEASE CAPSULE02125331 HYDROMORPH CONTIN PFR $ 1.0180





* 1MG/ML ORAL LIQUID01916386 PMS-HYDROMORPHONE PMS $ 0.070800786535 DILAUDID ABB 0.0859

81


* 2MG/ML INJECTION SOLUTION (1ML)00627100 DILAUDID ABB $ 1.240002145901 HYDROMORPHONE HCL SDZ 1.2400

* 10MG/ML INJECTION SOLUTION (1ML)00622133 DILAUDID-HP ABB $ 3.030002145928 HYDROMORPHONE HP 10 SDZ 3.0300

* 20MG/ML INJECTION SOLUTION (1ML)02146118 DILAUDID HP-PLUS ABB $ 4.820002145936 HYDROMORPHONE HP 20 SDZ 4.8300

* 50MG/ML INJECTION SOLUTION (1ML)02145863 DILAUDID-XP ABB $ 10.800002146126 HYDROMORPHONE HP 50 SDZ 10.8000

250MG STERILE POWDER02085895 DILAUDID ABB $ 76.1100

3MG SUPPOSITORY00125105 DILAUDID ABB $ 2.3979

MEPERIDINE HCL 50MG TABLET

02138018 DEMEROL AVT $ 0.1349 50MG/ML INJECTION SOLUTION (1ML)

00725765 MEPERIDINE HYDROCHLORIDE SDZ $ 0.9300 100MG/ML INJECTION SOLUTION (1ML)

00725749 MEPERIDINE HYDROCHLORIDE SDZ $ 1.0400

METHADONE HCL COVERAGE RESTRICTED TO DRUG PLAN REGISTERED PALLIATIVE CARE PATIENTS ONLY. EDS IS NOT REQUIRED FOR THESE PATIENTS. 1MG TABLET

02247698 METADOL (PALL CARE) PMS $ 0.1628 5MG TABLET



02247701 METADOL (PALL CARE) PMS $ 1.6275 1MG/ML ORAL SUSPENSION

02247694 METADOL (PALL CARE) PMS $ 0.0912

82


MORPHINE ORAL FORMS CONTAIN MORPHINE HYDROCHLORIDE OR SULFATE, INJECTABLE FORMS CONTAIN MORPHINE SULFATE.* 5MG TABLET

00594652 STATEX PAL $ 0.119402009773 MOS-SULFATE VAE 0.119402014203 MSIR PFR 0.1276

* 10MG TABLET00594644 STATEX PAL $ 0.184500690198 M.O.S. VAE 0.184502009765 MOS-SULFATE VAE 0.184502014211 MSIR PFR 0.1984

* 20MG TABLET02014238 MSIR PFR $ 0.350100690201 M.O.S. VAE 0.3519

* 25MG TABLET00594636 STATEX PAL $ 0.244202009749 MOS-SULFATE VAE 0.2442

30MG TABLET02014254 MSIR PFR $ 0.4494

40MG TABLET00690228 M.O.S. VAE $ 0.4573

* 50MG TABLET00675962 STATEX PAL $ 0.374402009706 MOS-SULFATE VAE 0.3744

60MG TABLET00690244 M.O.S. VAE $ 0.6349

10MG EXTENDED-RELEASE CAPSULE02019930 M-ESLON AVT $ 0.3147


* 15MG SUSTAINED RELEASE TABLET02244790 RATIO-MORPHINE SR RPH $ 0.407102245284 PMS-MORPHINE SULFATE SR PMS 0.407102015439 MS CONTIN PFR 0.6903

20MG SUSTAINED-RELEASE CAPSULE02184435 KADIAN ABB $ 0.8173



83


30MG SUSTAINED-RELEASE TABLET00776181 M.O.S.-S.R. VAE $ 0.5953




60MG SUSTAINED-RELEASE TABLET00776203 M.O.S.-S.R. VAE $ 1.0447



100MG SUSTAINED RELEASE TABLET02014319 MS CONTIN PFR $ 2.8013


200MG SUSTAINED RELEASE TABLET02014327 MS CONTIN PFR $ 5.2076

* 1MG/ML ORAL SOLUTION00486582 M.O.S. VAE $ 0.021700591467 STATEX PAL 0.021700607762 RATIO-MORPHINE RPH 0.0217

* 5MG/ML ORAL SOLUTION00591475 STATEX PAL $ 0.087300607770 RATIO-MORPHINE RPH 0.087300514217 M.O.S. VAE 0.0914

* 10MG/ML ORAL SOLUTION00632503 M.O.S. VAE $ 0.199500690783 RATIO-MORPHINE RPH 0.1995

* 20MG/ML ORAL SOLUTION00621935 STATEX PAL $ 0.540400690791 RATIO-MORPHINE RPH 0.540400632481 M.O.S. VAE 0.5686

10MG/ML INJECTION SOLUTION (1ML)00392588 MORPHINE SO4 SDZ $ 0.9600

15MG/ML INJECTION SOLUTION (1ML)00392561 MORPHINE SO4 SDZ $ 0.9800

50MG/ML INJECTION SOLUTION (1ML)00617288 MORPHINE HP50 SDZ $ 3.8000

84


5MG SUPPOSITORY00632228 STATEX PAL $ 1.8109




OXYCODONE HCL 5MG IMMEDIATE RELEASE TABLET

02231934 OXY-IR PFR $ 0.2739 10MG IMMEDIATE RELEASE TABLET

02240131 OXY-IR PFR $ 0.4034 20MG IMMEDIATE RELEASE TABLET

02240132 OXY-IR PFR $ 0.7005 5MG CONTROLLED RELEASE TABLET

02258129 OXYCONTIN PFR $ 0.6510 10MG CONTROLLED RELEASE TABLET




02202484 OXYCONTIN PFR $ 4.3431

PROPOXYPHENE SEVERE TOXIC INTERACTION BETWEEN PROPOXYPHENE AND CENTRAL NERVOUS SYSTEM DEPRESSANTS, PARTICULARLY ALCOHOL AND DIAZEPAM, HAS BEEN NOTED. IT IS RECOMMENDED THAT ALL PRODUCTS WHICH CONTAIN PROPOXYPHENE SHOULD BE USED ONLY WITH EXTREME CAUTION AND WITH FULL PATIENT AWARENESS OF THE SERIOUS POTENTIAL FOR INTERACTION.

65MG TABLET00010081 642 PED $ 0.1154

28:08.12 OPIATE PARTIAL AGONISTS

PENTAZOCINE 50MG TABLET

02137984 TALWIN AVT $ 0.3893

85

28:00 CENTRAL NERVOUS SYSTEM AGENTS28:08.92 MISCELLANEOUS ANALGESICS AND ANTIPYRETICS

FLOCTAFENINE 200MG TABLET

02244680 APO-FLOCTAFENINE APX $ 0.4375 400MG TABLET

02244681 APO-FLOCTAFENINE APX $ 0.8512

28:12.04 ANTICONVULSANTS (BARBITURATES)

PHENOBARBITAL 15MG TABLET

00178799 PMS-PHENOBARBITAL PMS $ 0.0651 30MG TABLET



00178829 PMS-PHENOBARBITAL PMS $ 0.1437 5MG/ML ELIXIR

00645575 PMS-PHENOBARBITAL PMS $ 0.0868

PRIMIDONE 125MG TABLET

00399310 APO-PRIMIDONE APX $ 0.0516 250MG TABLET

00396761 APO-PRIMIDONE APX $ 0.0814

28:12.08 ANTICONVULSANTS (BENZODIAZEPINES)

CLONAZEPAM* 0.5MG TABLET

02130998 DOM-CLONAZEPAM DOM $ 0.0905 *02224100 DOM-CLONAZEPAM-R DOM 0.0905 *02103656 RATIO-CLONAZEPAM RPH 0.126602173344 NU-CLONAZEPAM NXP 0.126602177889 APO-CLONAZEPAM APX 0.126602207818 PMS-CLONAZEPAM-R PMS 0.126602230950 GEN-CLONAZEPAM GPM 0.126602233960 SANDOZ CLONAZEPAM SDZ 0.126602239024 NOVO-CLONAZEPAM NOP 0.126602270641 CO CLONAZEPAM COB 0.126600382825 RIVOTRIL HLR 0.2109

86

28:00 CENTRAL NERVOUS SYSTEM AGENTS28:12.08 ANTICONVULSANTS (BENZODIAZEPINES)

* 1MG TABLET02048728 PMS-CLONAZEPAM PMS $ 0.201902233982 SANDOZ CLONAZEPAM SDZ 0.201902270668 CO CLONAZEPAM COB 0.2019

* 2MG TABLET02131013 DOM-CLONAZEPAM DOM $ 0.1426 *02048736 PMS-CLONAZEPAM PMS 0.218102103737 RATIO-CLONAZEPAM RPH 0.218102173352 NU-CLONAZEPAM NXP 0.218102177897 APO-CLONAZEPAM APX 0.218102230951 GEN-CLONAZEPAM GPM 0.218102233985 SANDOZ CLONAZEPAM SDZ 0.218102239025 NOVO-CLONAZEPAM NOP 0.218102270676 CO CLONAZEPAM COB 0.218100382841 RIVOTRIL HLR 0.3635

NITRAZEPAM* 5MG TABLET

02229654 NITRAZADON VAE $ 0.093002234003 SANDOZ NITRAZEPAM SDZ 0.093002245230 APO-NITRAZEPAM APX 0.093000511528 MOGADON VAE 0.1550

* 10MG TABLET02229655 NITRAZADON VAE $ 0.139102234007 SANDOZ NITRAZEPAM SDZ 0.139102245231 APO-NITRAZEPAM APX 0.139100511536 MOGADON VAE 0.2319

28:12.12 ANTICONVULSANTS (HYDANTOINS)

PHENYTOIN 30MG CAPSULE

00022772 DILANTIN PFI $ 0.0561 100MG CAPSULE

00022780 DILANTIN PFI $ 0.0701 50MG TABLET

00023698 DILANTIN PFI $ 0.0770 6MG/ML ORAL SUSPENSION

00023442 DILANTIN PFI $ 0.0425* 25MG/ML ORAL SUSPENSION

02250896 TARO-PHENYTOIN TAR $ 0.033800023450 DILANTIN PFI 0.0502

87

28:00 CENTRAL NERVOUS SYSTEM AGENTS28:12.20 ANTICONVULSANTS (SUCCINIMIDES)

ETHOSUXIMIDE 250MG CAPSULE

00022799 ZARONTIN ERF $ 0.3173 50MG/ML ORAL SYRUP

00023485 ZARONTIN ERF $ 0.0635

METHSUXIMIDE 300MG CAPSULE

00022802 CELONTIN ERF $ 0.3509

28:12.92 MISCELLANEOUS ANTICONVULSANTS

CARBAMAZEPINE SEE APPENDIX A FOR EDS CRITERIA* 100MG CHEWABLE TABLET

02231542 PMS-CARBAMAZEPINE CHEWTAB PMS $ 0.092902244403 TARO-CARBAMAZEPINE TAR 0.092900369810 TEGRETOL NVR 0.1451

* 200MG TABLET00402699 APO-CARBAMAZEPINE APX $ 0.086300782718 NOVO-CARBAMAZ NOP 0.086302042568 NU-CARBAMAZEPINE NXP 0.086300010405 TEGRETOL NVR 0.3457

* 200MG CONTROLLED RELEASE TABLET02231543 PMS-CARBAMAZEPINE CR (EDS) PMS $ 0.204802237907 TARO-CARBAMAZEPINE CR (EDS) TAR 0.204802241882 GEN-CARBAMAZEPINE CR (EDS) GPM 0.204802238222 DOM-CARBAMAZEPINE CR (EDS) DOM 0.256000773611 TEGRETOL CR (EDS) NVR 0.3553

* 400MG CONTROLLED RELEASE TABLET02231544 PMS-CARBAMAZEPINE CR (EDS) PMS $ 0.409502241883 GEN-CARBAMAZEPINE CR (EDS) GPM 0.409502237908 TARO-CARBAMAZEPINE CR (EDS) TAR 0.409602238223 DOM-CARBAMAZEPINE CR (EDS) DOM 0.512100755583 TEGRETOL CR (EDS) NVR 0.7104

20MG/ML ORAL SUSPENSION02194333 TEGRETOL NVR $ 0.0686

88

28:00 CENTRAL NERVOUS SYSTEM AGENTS28:12.92 MISCELLANEOUS ANTICONVULSANTS

CLOBAZAM* 10MG TABLET

02238334 NOVO-CLOBAZAM NOP $ 0.233702238797 RATIO-CLOBAZAM RPH 0.233702244474 PMS-CLOBAZAM PMS 0.233702244638 APO-CLOBAZAM APX 0.233702247230 DOM-CLOBAZAM DOM 0.245302221799 FRISIUM PAL 0.4768

DIVALPROEX SODIUM* 125MG ENTERIC COATED TABLET

02239517 NU-DIVALPROEX NXP $ 0.1139 *02239698 APO-DIVALPROEX APX 0.149402239701 NOVO-DIVALPROEX NOP 0.149402244138 PMS-DIVALPROEX PMS 0.149402265133 GEN-DIVALPROEX GPM 0.149402245751 DOM-DIVALPROEX DOM 0.174400596418 EPIVAL ABB 0.2741

* 250MG ENTERIC COATED TABLET02239518 NU-DIVALPROEX NXP $ 0.2047 *02239699 APO-DIVALPROEX APX 0.268602239702 NOVO-DIVALPROEX NOP 0.268602244139 PMS-DIVALPROEX PMS 0.268602265141 GEN-DIVALPROEX GPM 0.268602245752 DOM-DIVALPROEX DOM 0.313400596426 EPIVAL ABB 0.4925

* 500MG ENTERIC COATED TABLET02239519 NU-DIVALPROEX NXP $ 0.4095 *02239700 APO-DIVALPROEX APX 0.537302239703 NOVO-DIVALPROEX NOP 0.537302244140 PMS-DIVALPROEX PMS 0.537302265168 GEN-DIVALPROEX GPM 0.537302245753 DOM-DIVALPROEX DOM 0.627000596434 EPIVAL ABB 0.9857

GABAPENTIN* 100MG CAPSULE

02243743 DOM-GABAPENTIN DOM $ 0.2069 *02243446 PMS-GABAPENTIN PMS 0.273502244304 APO-GABAPENTIN APX 0.273502244513 NOVO-GABAPENTIN NOP 0.273502246742 NU-GABAPENTIN NXP 0.273502248259 GEN-GABAPENTIN GPM 0.273502256142 CO GABAPENTIN COB 0.273502260883 RATIO-GABAPENTIN RPH 0.273502084260 NEURONTIN PFI 0.4514

89


* 300MG CAPSULE02243744 DOM-GABAPENTIN DOM $ 0.4904 *02243447 PMS-GABAPENTIN PMS 0.665102244305 APO-GABAPENTIN APX 0.665102244514 NOVO-GABAPENTIN NOP 0.665102246743 NU-GABAPENTIN NXP 0.665102248260 GEN-GABAPENTIN GPM 0.665102256150 CO GABAPENTIN COB 0.665102260891 RATIO-GABAPENTIN RPH 0.665102273853 GABAPENTIN GPM 0.719402084279 NEURONTIN PFI 1.0980

* 400MG CAPSULE02243745 DOM-GABAPENTIN DOM $ 0.5996 *02243448 PMS-GABAPENTIN PMS 0.792602244306 APO-GABAPENTIN APX 0.792602244515 NOVO-GABAPENTIN NOP 0.792602246744 NU-GABAPENTIN NXP 0.792602248261 GEN-GABAPENTIN GPM 0.792602256169 CO GABAPENTIN COB 0.792602260905 RATIO-GABAPENTIN RPH 0.792602084287 NEURONTIN PFI 1.3084

LAMOTRIGINE 5MG CHEWABLE TABLET

02240115 LAMICTAL GSK $ 0.1620* 25MG TABLET

02243352 RATIO-LAMOTRIGINE RPH $ 0.226602245208 APO-LAMOTRIGINE APX 0.226602246897 PMS-LAMOTRIGINE PMS 0.226602248232 NOVO-LAMOTRIGINE NOP 0.226602265494 GEN-LAMOTRIGINE GPM 0.226602142082 LAMICTAL GSK 0.3795

* 100MG TABLET02243353 RATIO-LAMOTRIGINE RPH $ 0.906402245209 APO-LAMOTRIGINE APX 0.906402246898 PMS-LAMOTRIGINE PMS 0.906402248233 NOVO-LAMOTRIGINE NOP 0.906402265508 GEN-LAMOTRIGINE GPM 0.906402142104 LAMICTAL GSK 1.5147

* 150MG TABLET02245210 APO-LAMOTRIGINE APX $ 1.359702246899 PMS-LAMOTRIGINE PMS 1.359702265516 GEN-LAMOTRIGINE GPM 1.359702246963 RATIO-LAMOTRIGINE RPH 1.359702248234 NOVO-LAMOTRIGINE NOP 1.359702142112 LAMICTAL GSK 2.2851

90


LEVETIRACETAM* 250MG TABLET

02274183 CO LEVETIRACETAM COB $ 1.212502247027 KEPPRA LUD 1.6167

* 500MG TABLET02274191 CO LEVETIRACETAM COB $ 1.481102247028 KEPPRA LUD 1.9747

* 750MG TABLET02274205 CO LEVETIRACETAM COB $ 2.107702247029 KEPPRA LUD 2.8102

OXCARBAZEPINE SEE APPENDIX A FOR EDS CRITERIA 150MG TABLET

02242067 TRILEPTAL (EDS) NVR $ 0.8982 300MG TABLET

02242068 TRILEPTAL (EDS) NVR $ 1.7957 600MG TABLET

02242069 TRILEPTAL (EDS) NVR $ 3.5914 60MG/ML ORAL SUSPENSION

02244673 TRILEPTAL (EDS) NVR $ 0.3592

TOPIRAMATE* 25MG TABLET

02248860 NOVO-TOPIRAMATE NOP $ 0.797502256827 RATIO-TOPIRAMATE RPH 0.797502260050 SANDOZ TOPIRAMATE SDZ 0.797502262991 PMS-TOPIRAMATE PMS 0.797502263351 GEN-TOPIRAMATE GPM 0.797502271141 DOM-TOPIRAMATE DOM 0.837402230893 TOPAMAX JAN 1.2999

* 100MG TABLET02248861 NOVO-TOPIRAMATE NOP $ 1.511402256835 RATIO-TOPIRAMATE RPH 1.511402260069 SANDOZ TOPIRAMATE SDZ 1.511402263009 PMS-TOPIRAMATE PMS 1.511402263378 GEN-TOPIRAMATE GPM 1.511402271168 DOM-TOPIRAMATE DOM 1.587102230894 TOPAMAX JAN 2.4637

91


* 200MG TABLET02248862 NOVO-TOPIRAMATE NOP $ 2.392502256843 RATIO-TOPIRAMATE RPH 2.392502263017 PMS-TOPIRAMATE PMS 2.392502263386 GEN-TOPIRAMATE GPM 2.392502267837 SANDOZ TOPIRAMATE SDZ 2.392502271176 DOM-TOPIRAMATE DOM 2.512102230896 TOPAMAX JAN 3.6789

15MG SPRINKLE CAPSULE02239907 TOPAMAX JAN $ 1.1679

25MG SPRINKLE CAPSULE02239908 TOPAMAX JAN $ 1.2263

VALPROATE SODIUM* 50MG/ML ORAL SYRUP

02140063 RATIO-VALPROIC RPH $ 0.062602236807 PMS-VALPROIC ACID PMS 0.062602238370 APO-VALPROIC APX 0.062602238817 DOM-VALPROIC ACID DOM 0.065800443832 DEPAKENE ABB 0.1078

VALPROIC ACID* 250MG CAPSULE

02100630 NOVO-VALPROIC NOP $ 0.280402140047 RATIO-VALPROIC RPH 0.280402184648 GEN-VALPROIC GPM 0.280402230768 PMS-VALPROIC PMS 0.280402237830 NU-VALPROIC NXP 0.280402238048 APO-VALPROIC APX 0.280402239714 SANDOZ VALPROIC SDZ 0.280402231030 DOM-VALPROIC ACID DOM 0.294400443840 DEPAKENE ABB 0.5172

* 500MG ENTERIC COATED CAPSULE02140055 RATIO-VALPROIC RPH $ 0.563902218321 NOVO-VALPROIC NOP 0.563902229628 PMS-VALPROIC ACID E.C. PMS 0.563902239713 SANDOZ VALPROIC SDZ 0.563900507989 DEPAKENE ABB 1.0343

VIGABATRIN 500MG TABLET

02065819 SABRIL PAL $ 0.9885 500MG SACHET

02068036 SABRIL PAL $ 0.9885

92

28:00 CENTRAL NERVOUS SYSTEM AGENTS28:16.04 PSYCHOTHERAPEUTIC AGENTS (ANTIDEPRESSANTS)

PHENELZINE AND TRANYLCYPROMINE:MONOAMINE OXIDASE INHIBITORS INTERACT WITH SYMPATHOMIMETICDRUGS, FOODS AND ALCOHOLIC BEVERAGES CONTAINING TYRAMINE OROTHER PRESSOR AMINES (EG. CHEESE, HERRING, CHICKEN LIVERS,BROAD BEANS, CHIANTI WINE, ETC.) AND MAY EVOKE HYPERTENSION.THESE DRUGS ARE CONTRAINDICATED IN PATIENTS WITHCEREBROVASCULAR AND CARDIOVASCULAR DISEASE. THE MANUFACTURERS'LITERATURE REGARDING PRECAUTIONS AND CONTRAINDICATIONSSHOULD BE CONSULTED PRIOR TO PRESCRIBING THESE DRUGS.

AMITRIPTYLINE* 10MG TABLET

00037400 NOVO-TRIPTYN NOP $ 0.056500335053 APO-AMITRIPTYLINE APX 0.056502247302 PMS-AMITRIPTYLINE PMS 0.056602248131 DOM-AMITRIPTYLINE DOM 0.0595

* 25MG TABLET00037419 NOVO-TRIPTYN NOP $ 0.108000335061 APO-AMITRIPTYLINE APX 0.108002247303 PMS-AMITRIPTYLINE PMS 0.108002248132 DOM-AMITRIPTYLINE DOM 0.1135

* 50MG TABLET00037427 NOVO-TRIPTYN NOP 0.200800335088 APO-AMITRIPTYLINE APX 0.200802247304 PMS-AMITRIPTYLINE PMS 0.200902248133 DOM-AMITRIPTYLINE DOM $ 0.2110

BUPROPION HCL SEE APPENDIX A FOR EDS CRITERIA 100MG TABLET

02237824 WELLBUTRIN SR (EDS) BVL $ 0.6169 150MG TABLET

02237825 WELLBUTRIN SR (EDS) BVL $ 0.9254 150MG EXTENDED-RELEASE TABLET

02275090 WELLBUTRIN XL (EDS) BVL $ 0.5632 300MG EXTENDED-RELEASE TABLET

02275104 WELLBUTRIN XL (EDS) BVL $ 1.1263

93


CITALOPRAM HYDROBROMIDE* 20MG TABLET

02248942 DOM-CITALOPRAM DOM $ 0.6195 *02246056 APO-CITALOPRAM APX 0.949402246594 GEN-CITALOPRAM GPM 0.949402248010 PMS-CITALOPRAM PMS 0.949402248050 CO CITALOPRAM COB 0.949402248170 SANDOZ CITALOPRAM SDZ 0.949402248996 NU-CITALOPRAM NXP 0.949402251558 NOVO-CITALOPRAM NOP 0.949402252112 RATIO-CITALOPRAM RPH 0.949402268000 RAN-CITALOPRAM RAN 0.949402239607 CELEXA LUD 1.3563

* 40MG TABLET02248943 DOM-CITALOPRAM DOM $ 0.6195 *02246057 APO-CITALOPRAM APX 0.949402246595 GEN-CITALOPRAM GPM 0.949402248011 PMS-CITALOPRAM PMS 0.949402248051 CO CITALOPRAM COB 0.949402248171 SANDOZ CITALOPRAM SDZ 0.949402248997 NU-CITALOPRAM NXP 0.949402251566 NOVO-CITALOPRAM NOP 0.949402252120 RATIO-CITALOPRAM RPH 0.949402268019 RAN-CITALOPRAM RAN 0.949402239608 CELEXA LUD 1.3563

CLOMIPRAMINE HCL* 10MG TABLET

02040786 APO-CLOMIPRAMINE APX $ 0.176502139340 GEN-CLOMIPRAMINE GPM 0.176502244816 CO CLOMIPRAMINE COB 0.176500330566 ANAFRANIL ORX 0.2801

* 25MG TABLET02040778 APO-CLOMIPRAMINE APX $ 0.240402139359 GEN-CLOMIPRAMINE GPM 0.240402244817 CO CLOMIPRAMINE COB 0.240400324019 ANAFRANIL ORX 0.3815

* 50MG TABLET02040751 APO-CLOMIPRAMINE APX $ 0.442502139367 GEN-CLOMIPRAMINE GPM 0.442502244818 CO CLOMIPRAMINE COB 0.442500402591 ANAFRANIL ORX 0.7025

94


DESIPRAMINE HCL* 10MG TABLET

01946250 PMS-DESIPRAMINE PMS $ 0.206702211939 NU-DESIPRAMINE NXP 0.206702216248 APO-DESIPRAMINE APX 0.206702130084 DOM-DESIPRAMINE DOM 0.2170

* 25MG TABLET01946269 PMS-DESIPRAMINE PMS $ 0.276101948784 RATIO-DESIPRAMINE RPH 0.276102211947 NU-DESIPRAMINE NXP 0.276102216256 APO-DESIPRAMINE APX 0.276102130092 DOM-DESIPRAMINE DOM 0.289802099128 NORPRAMIN AVT 0.4138

* 50MG TABLET01946277 PMS-DESIPRAMINE PMS $ 0.446001948792 RATIO-DESIPRAMINE RPH 0.446002211955 NU-DESIPRAMINE NXP 0.446002216264 APO-DESIPRAMINE APX 0.446002130106 DOM-DESIPRAMINE DOM 0.468302099136 NORPRAMIN AVT 0.7293

* 75MG TABLET01946242 PMS-DESIPRAMINE PMS $ 0.687302211963 NU-DESIPRAMINE NXP 0.687302216272 APO-DESIPRAMINE APX 0.6873

* 100MG TABLET02211971 NU-DESIPRAMINE NXP $ 0.934202216280 APO-DESIPRAMINE APX 0.9342

DOXEPIN HCL* 10MG CAPSULE

02049996 APO-DOXEPIN APX $ 0.189400024325 SINEQUAN ERF 0.2705

* 25MG CAPSULE01913425 NOVO-DOXEPIN NOP $ 0.232202050005 APO-DOXEPIN APX 0.232200024333 SINEQUAN ERF 0.3318

95


* 50MG CAPSULE01913433 NOVO-DOXEPIN NOP 0.430902050013 APO-DOXEPIN APX 0.430900024341 SINEQUAN ERF 0.6156



150MG CAPSULE01913476 NOVO-DOXEPIN NOP $ 1.2228

FLUOXETINE* 10MG CAPSULE

02177617 DOM-FLUOXETINE DOM $ 1.0234 *02177579 PMS-FLUOXETINE PMS 1.277402192756 NU-FLUOXETINE NXP 1.277402216353 APO-FLUOXETINE APX 1.277402216582 NOVO-FLUOXETINE NOP 1.277402237813 GEN-FLUOXETINE GPM 1.277402241371 RATIO-FLUOXETINE RPH 1.277402242177 CO FLUOXETINE COB 1.277402243486 SANDOZ FLUOXETINE SDZ 1.277402018985 PROZAC LIL 1.8349

* 20MG CAPSULE02177625 DOM-FLUOXETINE DOM $ 0.6929 *02177587 PMS-FLUOXETINE PMS 1.097202192764 NU-FLUOXETINE NXP 1.097202216361 APO-FLUOXETINE APX 1.097202216590 NOVO-FLUOXETINE NOP 1.097202237814 GEN-FLUOXETINE GPM 1.097202241374 RATIO-FLUOXETINE RPH 1.097202242178 CO FLUOXETINE COB 1.097202243487 SANDOZ FLUOXETINE SDZ 1.097200636622 PROZAC LIL 1.8758

* 4MG/ML ORAL SOLUTION02177595 PMS-FLUOXETINE PMS $ 0.501902231328 APO-FLUOXETINE APX 0.5019

96


FLUVOXAMINE MALEATE* 50MG TABLET

02218453 RATIO-FLUVOXAMINE RPH $ 0.537302231192 NU-FLUVOXAMINE NXP 0.537302231329 APO-FLUVOXAMINE APX 0.537302239953 NOVO-FLUVOXAMINE NOP 0.537302240682 PMS-FLUVOXAMINE PMS 0.537302247054 SANDOZ FLUVOXAMINE SDZ 0.537302255529 CO FLOVOXAMINE COB 0.537301919342 LUVOX SLV 0.895502241347 DOM-FLUVOXAMINE DOM 1.7919

* 100MG TABLET02218461 RATIO-FLUVOXAMINE RPH $ 0.965902231193 NU-FLUVOXAMINE NXP 0.965902231330 APO-FLUVOXAMINE APX 0.965902239954 NOVO-FLUVOXAMINE NOP 0.965902240683 PMS-FLUVOXAMINE PMS 0.965902247055 SANDOZ FLUVOXAMINE SDZ 0.965902255537 CO FLUVOXAMINE COB 0.965901919369 LUVOX SLV 1.609902241348 DOM-FLUVOXAMINE DOM 3.1596

IMIPRAMINE* 10MG TABLET

00021504 NOVO-PRAMINE NOP $ 0.112600360201 APO-IMIPRAMINE APX 0.1126

* 25MG TABLET00021512 NOVO-PRAMINE NOP $ 0.179100312797 APO-IMIPRAMINE APX 0.179100010472 TOFRANIL NVR 0.2688

* 50MG TABLET00021520 NOVO-PRAMINE NOP $ 0.332600326852 APO-IMIPRAMINE APX 0.332600010480 TOFRANIL NVR 0.4996

MAPROTILINE 25MG TABLET

02158612 NOVO-MAPROTILINE NOP $ 0.5960 50MG TABLET

02158620 NOVO-MAPROTILINE NOP $ 1.1285 75MG TABLET

02158639 NOVO-MAPROTILINE NOP $ 1.5412

97


MIRTAZAPINE* 15MG TABLET

02256096 GEN-MIRTAZAPINE GPM $ 0.406902273942 PMS-MIRTAZAPINE PMS 0.406902250594 SANDOZ MIRTAZAPINE SDZ 0.4232

15MG ORALLY DISINTEGRATING TABLET02248542 REMERON RD ORG $ 0.4232

* 30MG TABLET02248762 PMS-MIRTAZAPINE PMS $ 0.846302250608 SANDOZ MIRTAZAPINE SDZ 0.846302256118 GEN-MIRTAZAPINE GPM 0.846302259354 NOVO-MIRTAZAPINE NOP 0.846302267292 SANDOZ MIRTAZAPINE FC SDZ 0.846302270927 RATIO-MIRTAZAPINE RPH 0.846302252287 DOM-MIRTAZAPINE DOM 0.888702243910 REMERON ORG 1.3454


45MG TABLET02256126 GEN-MIRTAZAPINE GPM $ 1.2207


MOCLOBEMIDE* 100MG TABLET

02232148 APO-MOCLOBEMIDE APX $ 0.273502237111 NU-MOCLOBEMIDE NXP 0.273502239746 NOVO-MOCLOBEMIDE NOP 0.2735

* 150MG TABLET02237112 NU-MOCLOBEMIDE NXP $ 0.2916 *02232150 APO-MOCLOBEMIDE APX 0.396502239747 NOVO-MOCLOBEMIDE NOP 0.396502243218 PMS-MOCLOBEMIDE PMS 0.396502243348 DOM-MOCLOBEMIDE DOM 0.416400899356 MANERIX HLR 0.6444

* 300MG TABLET02239748 NOVO-MOCLOBEMIDE NOP $ 0.778602240456 APO-MOCLOBEMIDE APX 0.778602243219 PMS-MOCLOBEMIDE PMS 0.778602243349 DOM-MOCLOBEMIDE DOM 0.908402166747 MANERIX HLR 1.2655

98


NORTRIPTYLINE* 10MG CAPSULE

02177692 PMS-NORTRIPTYLINE PMS $ 0.136802223139 NU-NORTRIPTYLINE NXP 0.136802223511 APO-NORTRIPTYLINE APX 0.136802231686 GEN-NORTRIPTYLINE GPM 0.136802231781 NOVO-NORTRIPTYLINE NOP 0.136802240789 RATIO-NORTRIPTYLINE RPH 0.136802178729 DOM-NORTRIPTYLINE DOM 0.143600015229 AVENTYL PML 0.2170

* 25MG CAPSULE02231782 NOVO-NORTRIPTYLINE NOP $ 0.276402240790 RATIO-NORTRIPTYLINE RPH 0.276402177706 PMS-NORTRIPTYLINE PMS 0.276402223147 NU-NORTRIPTYLINE NXP 0.276402223538 APO-NORTRIPTYLINE APX 0.276402231687 GEN-NORTRIPTYLINE GPM 0.276402178737 DOM-NORTRIPTYLINE DOM 0.290200015237 AVENTYL PML 0.4387

PAROXETINE HCL* 10MG TABLET

02247750 PMS-PAROXETINE PMS $ 1.131702248719 NU-PAROXETINE NXP 1.131702262746 CO PAROXETINE COB 1.1317

* 20MG TABLET02248448 DOM-PAROXETINE DOM $ 0.7530 *02240908 APO-PAROXETINE APX 1.086902247751 PMS-PAROXETINE PMS 1.086902247811 RATIO-PAROXETINE RPH 1.086902248013 GEN-PAROXETINE GPM 1.086902248557 NOVO-PAROXETINE NOP 1.086902248720 NU-PAROXETINE NXP 1.086902254751 SANDOZ PAROXETINE SDZ 1.086902262754 CO PAROXETINE COB 1.086901940481 PAXIL GSK 1.8308

99


* 30MG TABLET02248449 DOM-PAROXETINE DOM $ 0.7976 *02240909 APO-PAROXETINE APX 1.155202247752 PMS-PAROXETINE PMS 1.155202247812 RATIO-PAROXETINE RPH 1.155202248014 GEN-PAROXETINE GPM 1.155202248558 NOVO-PAROXETINE NOP 1.155202248721 NU-PAROXETINE NXP 1.155202254778 SANDOZ PAROXETINE SDZ 1.155202262762 CO PAROXETINE COB 1.155201940473 PAXIL GSK 1.9451

PHENELZINE SO4 SEE NOTE REGARDING MONOAMINE OXIDASE INHIBITORS UNDER SECTION 28:16.04 15MG TABLET

00476552 NARDIL ERF $ 0.3778

SERTRALINE HYDROCHLORIDE* 25MG CAPSULE

02247047 NU-SERTRALINE NXP $ 0.3745 *02238280 APO-SERTRALINE APX 0.546902240485 NOVO-SERTRALINE NOP 0.546902242519 GEN-SERTRALINE GPM 0.546902244838 PMS-SERTRALINE PMS 0.546902245159 SANDOZ SERTRALINE SDZ 0.546902245787 RATIO-SERTRALINE RPH 0.546902245748 DOM-SERTRALINE DOM 0.574202132702 ZOLOFT PFI 0.8698

* 50MG CAPSULE02247048 NU-SERTRALINE NXP $ 0.7490 *02238281 APO-SERTRALINE APX 1.093702240484 NOVO-SERTRALINE NOP 1.093702242520 GEN-SERTRALINE GPM 1.093702244839 PMS-SERTRALINE PMS 1.093702245160 SANDOZ SERTRALINE SDZ 1.093702245788 RATIO-SERTRALINE RPH 1.093702245749 DOM-SERTRALINE DOM 1.148401962817 ZOLOFT PFI 1.7395

100


* 100MG CAPSULE02247050 NU-SERTRALINE NXP $ 0.8193 *02238282 APO-SERTRALINE APX 1.196302240481 NOVO-SERTRALINE NOP 1.196302242521 GEN-SERTRALINE GPM 1.196302244840 PMS-SERTRALINE PMS 1.196302245161 SANDOZ SERTRALINE SDZ 1.196302245789 RATIO-SERTRALINE RPH 1.196302245750 DOM-SERTRALINE DOM 1.256001962779 ZOLOFT PFI 1.8228

TRANYLCYPROMINE SO4 SEE NOTE REGARDING MONOAMINE OXIDASE INHIBITORS UNDER SECTION 28:16.04 10MG TABLET

01919598 PARNATE GSK $ 0.3734

TRAZODONE* 50MG TABLET

02230284 TRAZOREL VAE $ 0.1708 *00579351 DESYREL BRI 0.240301937227 PMS-TRAZODONE PMS 0.240302053187 RATIO-TRAZODONE RPH 0.240302144263 NOVO-TRAZODONE NOP 0.240302147637 APO-TRAZODONE APX 0.240302165384 NU-TRAZODONE NXP 0.240302231683 GEN-TRAZODONE GPM 0.240302128950 DOM-TRAZODONE DOM 0.2575

* 100MG TABLET02230285 TRAZOREL VAE $ 0.3052 *00579378 DESYREL BRI 0.429301937235 PMS-TRAZODONE PMS 0.429302053195 RATIO-TRAZODONE RPH 0.429302144271 NOVO-TRAZODONE NOP 0.429302147645 APO-TRAZODONE APX 0.429302165392 NU-TRAZODONE NXP 0.429302231684 GEN-TRAZODONE GPM 0.429302128969 DOM-TRAZODONE DOM 0.5093

101


TRIMIPRAMINE 75MG CAPSULE

02070987 APO-TRIMIP APX $ 0.5639* 12.5MG TABLET

00740799 APO-TRIMIP APX $ 0.089002020599 NU-TRIMIPRAMINE NXP 0.0890

* 25MG TABLET00740802 APO-TRIMIP APX $ 0.112902020602 NU-TRIMIPRAMINE NXP 0.1129



VENLAFAXINE HCL 37.5MG EXTENDED-RELEASE CAPSULE

02237279 EFFEXOR XR WYA $ 0.9113 75MG EXTENDED-RELEASE CAPSULE

02237280 EFFEXOR XR WYA $ 1.8225 150MG EXTENDED-RELEASE CAPSULE

02237282 EFFEXOR XR WYA $ 1.924328:16.08 PSYCHOTHERAPEUTIC AGENTS (ANTIPSYCHOTIC AGENTS)

CHLORPROMAZINE 25MG TABLET

00232823 NOVO-CHLORPROMAZINE NOP $ 0.1818 50MG TABLET

00232807 NOVO-CHLORPROMAZINE NOP $ 0.2078 100MG TABLET

00232831 NOVO-CHLORPROMAZINE NOP $ 0.3472 25MG/ML INJECTION SOLUTION (2ML)

00743518 CHLORPROMAZINE SDZ $ 1.4200

102

28:00 CENTRAL NERVOUS SYSTEM AGENTS28:16.08 PSYCHOTHERAPEUTIC AGENTS (ANTIPSYCHOTIC AGENTS)

CLOZAPINE SEE APPENDIX A FOR EDS CRITERIA* 25MG TABLET

02247243 GEN-CLOZAPINE (EDS) GPM $ 0.715500894737 CLOZARIL (EDS) NVR 1.0221

* 100MG TABLET02247244 GEN-CLOZAPINE (EDS) GPM $ 2.869400894745 CLOZARIL (EDS) NVR 4.0780

FLUPENTHIXOL DECANOATE 20MG/ML INJECTION SOLUTION (10ML)

02156032 FLUANXOL DEPOT LUD $ 73.1900 100MG/ML INJECTION SOLUTION (2ML)

02156040 FLUANXOL DEPOT LUD $ 73.1900

FLUPENTHIXOL DIHYDROCHLORIDE 0.5MG TABLET

02156008 FLUANXOL LUD $ 0.2528 3MG TABLET

02156016 FLUANXOL LUD $ 0.5461

FLUPHENAZINE DECANOATE 25MG/ML INJECTION SOLUTION (5ML)

02091275 PMS-FLUPHENAZINE DECAN. PMS $ 25.1300* 100MG/ML INJECTION SOLUTION (1ML)

00755575 MODECATE CONCENTRATE SQU $ 32.320002241928 PMS-FLUPHENAZINE DECAN. PMS 32.3200

FLUPHENAZINE HCL 1MG TABLET

00405345 APO-FLUPHENAZINE APX $ 0.1823 2MG TABLET

00410632 APO-FLUPHENAZINE APX $ 0.2214 5MG TABLET

00405361 APO-FLUPHENAZINE APX $ 0.1867

103


HALOPERIDOL* 0.5MG TABLET

00363685 NOVO-PERIDOL NOP $ 0.039100396796 APO-HALOPERIDOL APX 0.0391

* 1MG TABLET00363677 NOVO-PERIDOL NOP $ 0.066700396818 APO-HALOPERIDOL APX 0.0667



* 10MG TABLET00463698 APO-HALOPERIDOL APX $ 0.144300713449 NOVO-PERIDOL NOP 0.1443

* 2MG/ML ORAL SOLUTION00759503 PMS-HALOPERIDOL PMS $ 0.116500587702 APO-HALOPERIDOL APX 0.1274

5MG/ML INJECTION SOLUTION (1ML)00808652 HALOPERIDOL SDZ $ 4.2000

HALOPERIDOL DECANOATE* 50MG/ML INJECTION SOLUTION (5ML)

02130297 HALOPERIDOL LA SDZ $ 30.420002242361 APO-HALOPERIDOL LA APX 30.4200

* 100MG/ML INJECTION SOLUTION (5ML)02130300 HALOPERIDOL LA SDZ $ 60.110002242362 APO-HALOPERIDOL LA APX 60.1100

LOXAPINE SUCCINATE* 5MG TABLET

02230837 PMS-LOXAPINE PMS $ 0.162802237534 NU-LOXAPINE NXP 0.162802237651 APO-LOXAPINE APX 0.162802239918 DOM-LOXAPINE DOM 0.1709

104


* 10MG TABLET02230838 PMS-LOXAPINE PMS $ 0.271102237535 NU-LOXAPINE NXP 0.271102237652 APO-LOXAPINE APX 0.271102239919 DOM-LOXAPINE DOM 0.2846



OLANZAPINE SEE APPENDIX A FOR EDS CRITERIA 2.5MG TABLET

02229250 ZYPREXA (EDS) LIL $ 1.8310 5MG TABLET

02229269 ZYPREXA (EDS) LIL $ 3.6619 7.5MG TABLET



02238850 ZYPREXA (EDS) LIL $ 10.4250 5MG ORALLY DISINTEGRATING TABLET

02243086 ZYPREXA ZYDIS (EDS) LIL $ 3.6619 10MG ORALLY DISINTEGRATING TABLET

02243087 ZYPREXA ZYDIS (EDS) LIL $ 7.3238 15MG ORALLY DISINTEGRATING TABLET

02243088 ZYPREXA ZYDIS (EDS) LIL $ 10.9857

PERICYAZINE 5MG CAPSULE

01926780 NEULEPTIL ERF $ 0.1903 10MG CAPSULE

01926772 NEULEPTIL ERF $ 0.3071 20MG CAPSULE

01926764 NEULEPTIL ERF $ 0.4850 10MG/ML ORAL DROPS

01926756 NEULEPTIL ERF $ 0.3245

105


PERPHENAZINE 2MG TABLET

00335134 APO-PERPHENAZINE APX $ 0.0664 4MG TABLET



00335096 APO-PERPHENAZINE APX $ 0.1351

PIMOZIDE* 2MG TABLET

00313815 ORAP PML $ 0.247302245432 APO-PIMOZIDE APX 0.2473

* 4MG TABLET00313823 ORAP PML $ 0.448802245433 APO-PIMOZIDE APX 0.4488

PIPOTIAZINE PALMITATE 25MG/ML INJECTION SOLUTION (1ML)

01926667 PIPORTIL L4 AVT $ 14.5300 50MG/ML INJECTION SOLUTION (2ML)

01926675 PIPORTIL L4 AVT $ 46.7800

PROCHLORPERAZINE 5MG TABLET

00886440 APO-PROCHLORAZINE APX $ 0.1145 10MG TABLET

00886432 APO-PROCHLORAZINE APX $ 0.1400 5MG/ML INJECTION SOLUTION (2ML)

00789747 PROCHLORPERAZINE MESYLATE SDZ $ 1.4600 10MG SUPPOSITORY

00789720 SAB-PROCHLOPERAZINE SDZ $ 0.9006

QUETIAPINE 25MG TABLET

02236951 SEROQUEL AST $ 0.5362 100MG TABLET



02244107 SEROQUEL AST $ 4.1625

106


RISPERIDONE 0.25MG TABLET

02240551 RISPERDAL JAN $ 0.5175 0.5MG TABLET

02240552 RISPERDAL JAN $ 0.8655 0.5MG ORALLY DISINTEGRATING TABLET

02247704 RISPERDAL M-TAB JAN $ 0.7541 1MG TABLET

02025280 RISPERDAL JAN $ 1.1972 1MG ORALLY DISINTEGRATING TABLET







02268094 RISPERDAL M-TAB JAN $ 4.1592 1MG/ML ORAL SOLUTION

02236950 RISPERDAL JAN $ 1.3766 25MG/VIAL POWDER FOR INJECTION (VIAL)

02255707 RISPERDAL CONSTA (EDS) JAN $ 200.1700 37.5MG/VIAL POWDER FOR INJECTION (VIAL)

02255723 RISPERDAL CONSTA (EDS) JAN $ 283.0900 50MG/VIAL POWDER FOR INJECTION (VIAL)

02255758 RISPERDAL CONSTA (EDS) JAN $ 358.5500

THIOTHIXENE 2MG CAPSULE

00024430 NAVANE ERF $ 0.3255 5MG CAPSULE

00024449 NAVANE ERF $ 0.3604 10MG CAPSULE

00024457 NAVANE ERF $ 0.4639

107


TRIFLUOPERAZINE 1MG TABLET

00345539 APO-TRIFLUOPERAZINE APX $ 0.1102 2MG TABLET



00326836 APO-TRIFLUOPERAZINE APX $ 0.2295

ZUCLOPENTHIXOL ACETATE SEE APPENDIX A FOR EDS CRITERIA 50MG/ML INJECTION (1ML)

02230405 CLOPIXOL ACUPHASE (EDS) LUD $ 15.1900

ZUCLOPENTHIXOL DECANOATE SEE APPENDIX A FOR EDS CRITERIA 200MG/ML INJECTION (10ML)

02230406 CLOPIXOL DEPOT (EDS) LUD $ 151.9000

ZUCLOPENTHIXOL DIHYDROCHLORIDE SEE APPENDIX A FOR EDS CRITERIA 10MG TABLET

02230402 CLOPIXOL (EDS) LUD $ 0.3906 25MG TABLET

02230403 CLOPIXOL (EDS) LUD $ 0.9765

28:20.00 RESPIRATORY AND CEREBRAL STIMULANTS

DEXTROAMPHETAMINE SO4 5MG TABLET

01924516 DEXEDRINE GSK $ 0.5547 10MG SPANSULE CAPSULE

01924559 DEXEDRINE GSK $ 0.7957 15MG SPANSULE CAPSULE

01924567 DEXEDRINE GSK $ 0.9729

108

28:00 CENTRAL NERVOUS SYSTEM AGENTS28:20.00 RESPIRATORY AND CEREBRAL STIMULANTS

METHYLPHENIDATE HCL 5MG TABLET

02234749 PMS-METHYLPHENIDATE PMS $ 0.1028* 10MG TABLET

00584991 PMS-METHYLPHENIDATE PMS $ 0.172602249324 APO-METHYLPHENIDATE APX 0.172600005606 RITALIN NVR 0.3163

* 20MG TABLET00585009 PMS-METHYLPHENIDATE PMS $ 0.383702249332 APO-METHYLPHENIDATE APX 0.383700005614 RITALIN NVR 0.5527

20MG SUSTAINED RELEASE TABLET00632775 RITALIN SR NVR $ 0.5549

MODAFINIL SEE APPENDIX A FOR EDS CRITERIA 100MG TABLET

02239665 ALERTEC (EDS) RBP $ 1.302028:24.04 ANXIOLYTICS, SEDATIVES AND HYPNOTICS

(BARBITURATES)

PHENOBARBITAL SEE SECTION 28:12.04 (ANTICONVULSANTS)

28:24.08 ANXIOLYTICS, SEDATIVES AND HYPNOTICS (BENZODIAZEPINES)

ALPRAZOLAM* 0.25MG TABLET

00865397 APO-ALPRAZ APX $ 0.082501913239 NU-ALPRAZ NXP 0.082501913484 NOVO-ALPRAZOL NOP 0.082502137534 GEN-ALPRAZOLAM GPM 0.082500548359 XANAX PFI 0.2642

* 0.5MG TABLET00865400 APO-ALPRAZ APX $ 0.099901913247 NU-ALPRAZ NXP 0.099901913492 NOVO-ALPRAZOL NOP 0.099902137542 GEN-ALPRAZOLAM GPM 0.099900548367 XANAX PFI 0.3159

109

28:00 CENTRAL NERVOUS SYSTEM AGENTS28:24.08 ANXIOLYTICS, SEDATIVES AND HYPNOTICS

(BENZODIAZEPINES)

BROMAZEPAM* 1.5MG TABLET

02171856 NU-BROMAZEPAM NXP $ 0.075202177153 APO-BROMAZEPAM APX 0.075202192705 GEN-BROMAZEPAM GPM 0.0752

* 3MG TABLET02171864 NU-BROMAZEPAM NXP $ 0.095702177161 APO-BROMAZEPAM APX 0.095702192713 GEN-BROMAZEPAM GPM 0.095702230584 NOVO-BROMAZEPAM NOP 0.095700518123 LECTOPAM HLR 0.1595

* 6MG TABLET02171872 NU-BROMAZEPAM NXP $ 0.139802177188 APO-BROMAZEPAM APX 0.139802192721 GEN-BROMAZEPAM GPM 0.139802230585 NOVO-BROMAZEPAM NOP 0.139800518131 LECTOPAM HLR 0.2330

CHLORDIAZEPOXIDE 5MG CAPSULE

00522724 APO-CHLORDIAZEPOXIDE APX $ 0.0720 10MG CAPSULE

00522988 APO-CHLORDIAZEPOXIDE APX $ 0.1134 25MG CAPSULE

00522996 APO-CHLORDIAZEPOXIDE APX $ 0.1758

CLORAZEPATE DIPOTASSIUM* 3.75MG CAPSULE

00628190 NOVO-CLOPATE NOP $ 0.115800860689 APO-CLORAZEPATE APX 0.1158

* 7.5MG CAPSULE00628204 NOVO-CLOPATE NOP $ 0.209000860700 APO-CLORAZEPATE APX 0.2090

* 15MG CAPSULE00628212 NOVO-CLOPATE NOP $ 0.418400860697 APO-CLORAZEPATE APX 0.4184

110


(BENZODIAZEPINES)

DIAZEPAM* 2MG TABLET

00272434 NOVO-DIPAM NOP $ 0.055200405329 APO-DIAZEPAM APX 0.055202247490 PMS-DIAZEPAM PMS 0.055202247173 BIO-DIAZEPAM BMD 0.0662

* 5MG TABLET00272442 NOVO-DIPAM NOP $ 0.070600362158 APO-DIAZEPAM APX 0.070602247491 PMS-DIAZEPAM PMS 0.070600013765 VIVOL AXX 0.088602247174 BIO-DIAZEPAM BMD 0.097700013285 VALIUM HLR 0.1630

* 10MG TABLET00272450 NOVO-DIPAM NOP $ 0.094100405337 APO-DIAZEPAM APX 0.094102247492 PMS-DIAZEPAM PMS 0.094102247176 BIO-DIAZEPAM BMD 0.113000013773 VIVOL AXX 0.1460

5MG/ML RECTAL GEL (DELIVERY SYSTEM)02238162 DIASTAT RBP $ 72.9700

FLURAZEPAM HCL 15MG CAPSULE

00521698 APO-FLURAZEPAM APX $ 0.0879 30MG CAPSULE

00521701 APO-FLURAZEPAM APX $ 0.1009

LORAZEPAM* 0.5MG TABLET

00655740 APO-LORAZEPAM APX $ 0.039000711101 NOVO-LORAZEM NOP 0.039000728187 PMS-LORAZEPAM PMS 0.039000865672 NU-LORAZ NXP 0.039002245784 DOM-LORAZEPAM DOM 0.040902041413 ATIVAN WYA 0.0814

* 1MG TABLET00637742 NOVO-LORAZEM NOP $ 0.048500655759 APO-LORAZEPAM APX 0.048500728195 PMS-LORAZEPAM PMS 0.048500865680 NU-LORAZ NXP 0.048502245785 DOM-LORAZEPAM DOM 0.050902041421 ATIVAN WYA 0.1009

111


(BENZODIAZEPINES)

* 2MG TABLET00637750 NOVO-LORAZEM NOP $ 0.075900655767 APO-LORAZEPAM APX 0.075900728209 PMS-LORAZEPAM PMS 0.075900865699 NU-LORAZ NXP 0.075902245786 DOM-LORAZEPAM DOM 0.079702041448 ATIVAN WYA 0.1585

OXAZEPAM 10MG TABLET

00402680 APO-OXAZEPAM APX $ 0.0456 15MG TABLET

00402745 APO-OXAZEPAM APX $ 0.0717 30MG TABLET

00402737 APO-OXAZEPAM APX $ 0.0977

TEMAZEPAM* 15MG CAPSULE

02223570 NU-TEMAZEPAM NXP $ 0.119602225964 APO-TEMAZEPAM APX 0.119602229455 PMS-TEMAZEPAM PMS 0.119602230095 NOVO-TEMAZEPAM NOP 0.119602231615 GEN-TEMAZEPAM GPM 0.119602243023 RATIO-TEMAZEPAM RPH 0.119602244814 CO-TEMAZEPAM COB 0.119602229756 DOM-TEMAZEPAM DOM 0.149300604453 RESTORIL ORX 0.1899

* 30MG CAPSULE02223589 NU-TEMAZEPAM NXP $ 0.143902225972 APO-TEMAZEPAM APX 0.143902229456 PMS-TEMAZEPAM PMS 0.143902230102 NOVO-TEMAZEPAM NOP 0.143902231616 GEN-TEMAZEPAM GPM 0.143902243024 RATIO-TEMAZEPAM RPH 0.143902244815 CO-TEMAZEPAM COB 0.143902229758 DOM-TEMAZEPAM DOM 0.179500604461 RESTORIL ORX 0.2284

TRIAZOLAM* 0.125MG TABLET

00808563 APO-TRIAZO APX $ 0.060401995227 GEN-TRIAZOLAM GPM 0.0604

* 0.25MG TABLET00808571 APO-TRIAZO APX $ 0.076001913506 GEN-TRIAZOLAM GPM 0.076000443158 HALCION PFI 0.2288

112

28:00 CENTRAL NERVOUS SYSTEM AGENTS28:24.92 MISCELLANEOUS ANXIOLYTICS, SEDATIVES

AND HYPNOTICS

BUSPIRONE 5MG TABLET

02230941 PMS-BUSPIRONE PMS $ 0.4323* 10MG TABLET

02232564 DOM-BUSPIRONE DOM $ 0.4814 *02207672 NU-BUSPIRONE NXP 0.707602211076 APO-BUSPIRONE APX 0.707602230874 GEN-BUSPIRONE GPM 0.707602230942 PMS-BUSPIRONE PMS 0.707602231492 NOVO-BUSPIRONE NOP 0.707602237858 RATIO-BUSPIRONE RPH 0.707602262916 CO BUSPIRONE COB 0.707600603821 BUSPAR BRI 1.0781

CHLORAL HYDRATE* 100MG/ML SYRUP

00792659 PMS-CHLORAL HYDRATE SYRUP PMS $ 0.047102247621 CHLORAL HYDRATE SYRUP ODN 0.0471

HYDROXYZINE* 10MG CAPSULE

00646059 APO-HYDROXYZINE APX $ 0.121100738824 NOVO-HYDROXYZIN NOP 0.1211

* 25MG CAPSULE00646024 APO-HYDROXYZINE APX $ 0.154700738832 NOVO-HYDROXYZIN NOP 0.1547

* 50MG CAPSULE00646016 APO-HYDROXYZINE APX $ 0.224400738840 NOVO-HYDROXYZIN NOP 0.2244

* 2MG/ML ORAL SYRUP00741817 PMS-HYDROXYZINE PMS $ 0.042200024694 ATARAX ERF 0.0539

113

28:00 CENTRAL NERVOUS SYSTEM AGENTS28:24.92 MISCELLANEOUS ANXIOLYTICS, SEDATIVES

AND HYPNOTICS

METHOTRIMEPRAZINE 2MG TABLET

02238403 APO-METHOPRAZINE APX $ 0.0548* 5MG TABLET

01927655 NOZINAN AVT $ 0.057302232903 PMS-METHOTRIMEPRAZINE PMS 0.057302238404 APO-METHOPRAZINE APX 0.0573

* 25MG TABLET01927663 NOZINAN AVT $ 0.122802232904 PMS-METHOTRIMEPRAZINE PMS 0.122802238405 APO-METHOPRAZINE APX 0.1228

* 50MG TABLET01927671 NOZINAN AVT $ 0.167202232905 PMS-METHOTRIMEPRAZINE PMS 0.167202238406 APO-METHOPRAZINE APX 0.1672

28:28.00 ANTIMANIC AGENTS

LITHIUM CARBONATE* 150MG CAPSULE

02216132 PMS-LITHIUM CARBONATE PMS $ 0.057802242837 APO-LITHIUM CARBONATE APX 0.057800461733 CARBOLITH VAE 0.1238

* 300MG CAPSULE02216140 PMS-LITHIUM CARBONATE PMS $ 0.060602242838 APO-LITHIUM CARBONATE APX 0.060600236683 CARBOLITH VAE 0.1017

* 600MG CAPSULE02216159 PMS-LITHIUM CARBONATE PMS $ 0.147602011239 CARBOLITH VAE 0.1845

300MG SUSTAINED RELEASE TABLET00590665 DURALITH JAN $ 0.2258

114

DIAGNOSTIC AGENTS36:00

36:00 DIAGNOSTIC AGENTS36:04.00 ADRENAL INSUFFICIENCY

COSYNTROPIN ZINC HYDROXIDE SEE SECTION 68:28.00 (PITUITARY AGENTS)

36:26.00 DIABETES MELLITUS

NOTE: THE IDENTIFICATION NUMBERS LISTED IN THIS SECTIONHAVE BEEN GENERATED BY THE PRESCRIPTION DRUG PLAN FORBILLING PURPOSES ONLY.

BLOOD GLUCOSE TEST STRIP⌧ STRIP

00950432 ACCUTREND BOM $ 0.732400950459 ONE TOUCH LSN 0.759500950734 SURESTEP LSN 0.759500950911 BD TEST STRIPS BDC 0.791000950907 FREESTYLE MDS 0.802900950882 FASTTAKE LSN 0.845300950300 PRECISION PLUS MDS 0.862600950893 ONE TOUCH ULTRA LSN 0.862600950894 PRECISION XTRA MDS 0.862600950902 SOF-TACT MDS 0.862600950912 PRECISION EASY ABB 0.862600950878 ASCENSIA DEX BAY 0.868000950900 ACCU-CHEK COMPACT BOM 0.868000950924 ASCENSIA MICROFILL BAY 0.868000950926 ACCU-CHEK ADVANTAGE BOM 0.868000950949 ACCU-CHEK AVIVA BOM 0.868000950572 ELITE BAY 0.9388

HYDROXYBUTYRATE DEHYDROGENASE BLOOD KETONE TEST STRIP

00950896 PRECISION XTRA KETONE MDS $ 1.6344

116

36:00 DIAGNOSTIC AGENTS36:88.00 URINE CONTENTS

NOTE: THE IDENTIFICATION NUMBERS LISTED IN THIS SECTIONHAVE BEEN GENERATED BY THE PRESCRIPTION DRUG PLAN FORBILLING PURPOSES ONLY.

CUPRIC SO4 REAGENT TABLET

00035122 CLINITEST BAY $ 0.1028

GLUCOSE OXIDASE/PEROXIDASE REAGENT STICK

00035130 DIASTIX BAY $ 0.1164

GLUCOSE OXIDASE/PEROXIDASE/SODIUMNITROFERRICYANIDE/GLYCINE REAGENT STICK

00950238 CHEMSTRIP UG 5000K BOM $ 0.1389

GLUCOSE OXIDASE/PEROXIDASE/SODIUMNITROPRUSSIDE REAGENT STICK

00035149 KETO DIASTIX BAY $ 0.1395

SODIUM NITROPRUSSIDE REAGENT STICK

00035092 KETOSTIX BAY $ 0.1296 TABLET

00035106 ACETEST BAY $ 0.1780

117

ELECTROLYTIC, CALORIC AND WATER BALANCE

40:00

40:00 ELECTROLYTIC, CALORIC AND WATER BALANCE40:12.00 REPLACEMENT AGENTS

POTASSIUM CHLORIDE 8MMOL LONG ACTING CAPSULE

02042304 MICRO-K EXTENCAPS WYA $ 0.1009⌧ 8MMOL LONG ACTING TABLET

00602884 APO-K APX $ 0.097600074225 SLOW-K NVR 0.1318

20MMOL LONG ACTING TABLET00713376 K-DUR SCH $ 0.2165

* 1.33MMOL/ML ORAL SOLUTION02238604 PMS-POTASSIUM CHLORIDE PMS $ 0.013901918303 K-10 GSK 0.0157

20MMOL/PACKAGE POWDER (3G)00481211 K-LOR ABB $ 0.3165

25MMOL/PACKAGE POWDER (7.8G)02089580 K-LYTE/CL WEL $ 0.5422

40:18.00 POTASSIUM-REMOVING RESINS

CALCIUM POLYSTYRENE SULFONATE POWDER (1G BINDS WITH APPROX. 1.6MMOL. K)

02017741 RESONIUM CALCIUM AVT $ 0.3031

SODIUM POLYSTYRENE SULFONATE 250MG/ML ORAL SUSPENSION

00769541 PMS-SOD POLYSTYRENE SULF PMS $ 0.1027* POWDER (1G BINDS WITH APPROX.1MMOL K IN VIVO)

00755338 PMS-SOD POLYSTYRENE SULF PMS $ 0.155402026961 KAYEXALATE AVT 0.1647

250MG/ML RETENTION ENEMA00769533 PMS-SOD POLY SULF (120ML) PMS $ 14.8000

120

40:00 ELECTROLYTIC, CALORIC AND WATER BALANCE40:28.00 DIURETICS

ACETAZOLAMIDE SEE SECTION 52:10.00 (CARBONIC ANHYDRASE INHIBITORS)

BUMETANIDE SEE APPENDIX A FOR EDS CRITERIA 1MG TABLET

00728284 BURINEX (EDS) LEO $ 0.7324 5MG TABLET

00728276 BURINEX (EDS) LEO $ 2.7939

CHLORTHALIDONE 50MG TABLET

00360279 APO-CHLORTHALIDONE APX $ 0.0852

ETHACRYNIC ACID SEE APPENDIX A FOR EDS CRITERIA 25MG TABLET

02258528 EDECRIN (EDS) MSD $ 0.3391

FUROSEMIDE* 20MG TABLET

02239224 NU-FUROSEMIDE NXP $ 0.0336 *02247493 PMS-FUROSEMIDE PMS 0.040500337730 NOVO-SEMIDE NOP 0.048300396788 APO-FUROSEMIDE APX 0.048302247371 BIO-FUROSEMIDE BMD 0.048402248124 DOM-FUROSEMIDE DOM 0.050702224690 LASIX AVT 0.0786

* 40MG TABLET02239225 NU-FUROSEMIDE NXP $ 0.0503 *02247494 PMS-FUROSEMIDE PMS 0.060600337749 NOVO-SEMIDE NOP 0.072700362166 APO-FUROSEMIDE APX 0.072702247372 BIO-FUROSEMIDE BMD 0.072702248125 DOM-FUROSEMIDE DOM 0.076402224704 LASIX AVT 0.1205

10MG/ML ORAL SOLUTION02224720 LASIX AVT $ 0.2474

121

40:00 ELECTROLYTIC, CALORIC AND WATER BALANCE40:28.00 DIURETICS

HYDROCHLOROTHIAZIDE 12.5 TABLET

02274086 PMS-HYDROCHLOROTHIAZIDE PMS $ 0.0343* 25MG TABLET

02250659 NU-HYDRO NXP $ 0.0357 *00021474 NOVO-HYDRAZIDE NOP 0.051600326844 APO-HYDRO APX 0.051602247170 BIO-HYDROCHLOROTHIAZIDE BMD 0.051602247386 PMS-HYDROCHLOROTHIAZIDE PMS 0.051602248134 DOM-HYDROCHLOROTHIAZIDE DOM 0.0543

* 50MG TABLET02250667 NU-HYDRO NXP $ 0.0517 *02247387 PMS-HYDROCHLOROTHIAZIDE PMS 0.070600021482 NOVO-HYDRAZIDE NOP 0.070600312800 APO-HYDRO APX 0.070602247171 BIO-HYDROCHLOROTHIAZIDE BMD 0.070602248135 DOM-HYDROCHLOROTHIAZIDE DOM 0.0743

INDAPAMIDE HEMIHYDRATE* 1.25MG TABLET

02239913 DOM-INDAPAMIDE DOM $ 0.1752 *02227339 INDAPAMIDE PRO 0.203702239619 PMS-INDAPAMIDE PMS 0.203702240067 GEN-INDAPAMIDE GPM 0.203702245246 APO-INDAPAMIDE APX 0.203702179709 LOZIDE SEV 0.3234

* 2.5MG TABLET02239917 DOM-INDAPAMIDE DOM $ 0.2500 *02049341 INDAPAMIDE PRO 0.323002153483 GEN-INDAPAMIDE GPM 0.323002223597 NU-INDAPAMIDE NXP 0.323002223678 APO-INDAPAMIDE APX 0.323002231184 NOVO-INDAPAMIDE NOP 0.323002239620 PMS-INDAPAMIDE PMS 0.323000564966 LOZIDE SEV 0.5289

METOLAZONE 2.5MG TABLET

00888400 ZAROXOLYN AVT $ 0.1747

122

40:00 ELECTROLYTIC, CALORIC AND WATER BALANCE40:28.10 POTASSIUM SPARING DIURETICS

AMILORIDE HCL 5MG TABLET

02249510 APO-AMILORIDE APX $ 0.2173

SPIRONOLACTONE* 25MG TABLET

00613215 NOVO-SPIROTON NOP $ 0.075100028606 ALDACTONE PFI 0.0782

* 100MG TABLET00613223 NOVO-SPIROTON NOP $ 0.230100285455 ALDACTONE PFI 0.2393

40:40.00 URICOSURIC DRUGS

PROBENECID 500MG TABLET

00294926 BENURYL VAE $ 0.2045

SULFINPYRAZONE* 100MG TABLET

00441759 APO-SULFINPYRAZONE APX $ 0.151902045680 NU-SULFINPYRAZONE NXP 0.1519

* 200MG TABLET00441767 APO-SULFINPYRAZONE APX $ 0.214902045699 NU-SULFINPYRAZONE NXP 0.2149

123

ANTITUSSIVES, EXPECTORANTS AND MUCOLYTIC AGENTS

48:00

48:00 ANTITUSSIVES, EXPECTORANTS AND MUCOLYTIC AGENTS

48:24.00 MUCOLYTIC AGENTS

ACETYLCYSTEINE* 20% SOLUTION (30ML)

02243098 ACETYLCYSTEINE SOLUTION SDZ $ 17.930002091526 MUCOMYST WEL 19.1600

DORNASE ALFA SEE APPENDIX A FOR EDS CRITERIA 1MG/ML INHALATION SOLUTION (2.5ML)

02046733 PULMOZYME (EDS) HLR $ 37.2300

126

EYE, EAR, NOSE AND THROAT PREPARATIONS

52:00

52:00 EYE, EAR, NOSE AND THROAT PREPARATIONS52:04.04 ANTI-INFECTIVES (ANTIBIOTICS)

FUSIDIC ACID SEE APPENDIX A FOR EDS CRITERIA 1% OPHTHALMIC DROPS (PRESERVATIVE FREE)

02243861 FUCITHALMIC (EDS) LEO $ 0.8190 1% OPHTHALMIC DROPS (G)

02243862 FUCITHALMIC (EDS) LEO $ 1.7630

GENTAMICIN SO4 TOPICAL GENTAMICIN SHOULD BE RESERVED FOR THERAPY OF SERIOUS INFECTIONS INSUSCEPTIBLE TO OTHER AGENTS SINCE RESISTANT ORGANISMS CAN DEVELOP. GENTAMICIN SO4 5MG/ML IS EQUIVALENT TO 3MG/ML GENTAMICIN BASE.* 5MG/ML OPHTHALMIC SOLUTION

00512192 GARAMYCIN SCH $ 0.440600776521 PMS-GENTAMYCIN PMS 0.440602229440 SANDOZ GENTAMICIN SDZ 0.440600436771 ALCOMICIN ALC 0.5187

* 5MG/ML OTIC SOLUTION02229441 SANDOZ GENTAMICIN SDZ $ 1.119802230889 PMS-GENTAMICIN PMS 1.119800512184 GARAMYCIN SCH 1.1998

* 5MG/G OPHTHALMIC OINTMENT (3.5G)00028339 GARAMYCIN SCH $ 4.340002230888 SANDOZ GENTAMICIN SDZ 4.3400

POLYMYXIN B SO4/NEOMYCIN SO4/GRAMICIDIN* 10,000U/2.5MG/0.025MG PER ML EYE/EAR SOLUTION

00807435 OPTIMYXIN PLUS SDZ $ 0.678200694371 NEOSPORIN GSK 0.8333

POLYMYXIN B SO4/TRIMETHOPRIM SO4* 10,000U/1MG PER ML OPHTHALMIC SOLUTION

02240363 PMS-POLYTRIMETHOPRIM PMS $ 0.719402011956 POLYTRIM ALL 2.7516

TOBRAMYCIN SEE APPENDIX A FOR EDS CRITERIA* 0.3% OPHTHALMIC SOLUTION

02239577 PMS-TOBRAMYCIN (EDS) PMS $ 1.137102241755 SANDOZ TOBRAMYCIN (EDS) SDZ 1.137102245698 APO-TOBRAMYCIN (EDS) APX 1.137100513962 TOBREX (EDS) ALC 1.8077

0.3% OPHTHALMIC OINTMENT (3.5G)00614254 TOBREX (EDS) ALC $ 8.9800

128

52:00 EYE, EAR, NOSE AND THROAT PREPARATIONS52:04.06 ANTI-INFECTIVES (ANTIVIRALS)

TRIFLURIDINE* 1% OPHTHALMIC SOLUTION (7.5ML)

02248529 SANDOZ TRIFLURIDINE SDZ $ 24.500000687456 VIROPTIC THM 24.7300

52:04.08 ANTI-INFECTIVES (SULFONAMIDES)

SULFACETAMIDE (SODIUM) 10% OPHTHALMIC OINTMENT (3.5G)

00252522 CETAMIDE ALC $ 3.1000

52:04.12 ANTI-INFECTIVES (MISCELLANEOUS)

ALUMINUM ACETATE/BENZETHONIUM CHLORIDE 0.5%/0.03% OTIC SOLUTION

00674222 BURO-SOL-OTIC STI $ 0.2821

CIPROFLOXACIN SEE APPENDIX A FOR EDS CRITERIA* 0.3% OPHTHALMIC SOLUTION

02253933 PMS-CIPROFLOXACIN (EDS) PMS $ 1.223902263130 APO-CIPROFLOX (EDS) APX 1.223901945270 CILOXAN (EDS) ALC 2.1049

0.3% OPHTHALMIC OINTMENT (3.5G)02200864 CILOXAN (EDS) ALC $ 10.5300

MOXIFLOXACIN HCL SEE APPENDIX A FOR EDS CRITERIA 0.5% OPHTHALMIC SOLUTION

02252260 VIGAMOX (EDS) ALC $ 4.3400

OFLOXACIN SEE APPENDIX A FOR EDS CRITERIA* 0.3% OPHTHALMIC SOLUTION

02248398 APO-OFLOXACIN (EDS) APX $ 1.076402252570 PMS-OFLOXACIN (EDS) PMS 1.076402143291 OCUFLOX (EDS) ALL 2.2113

129

52:00 EYE, EAR, NOSE AND THROAT PREPARATIONS52:08.00 ANTI-INFLAMMATORY AGENTS

BECLOMETHASONE DIPROPIONATE* 50UG/DOSE AQUEOUS NASAL SPRAY (PACKAGE)

00872318 RATIO-BECLOMETHASONE AQ. RPH $ 13.310002172712 GEN-BECLO AQ. GPM 13.310002238577 NU-BECLOMETHASONE NXP 13.310002238796 APO-BECLOMETHASONE APX 13.3100

BUDESONIDE* 64UG/DOSE NASAL SPRAY (PACKAGE)

02241003 GEN-BUDESONIDE AQ GPM $ 9.150002231923 RHINOCORT AQUA AST 11.0700

100UG/DOSE NASAL SPRAY (PACKAGE)02230648 GEN-BUDESONIDE AQ GPM $ 13.8300

100UG POWDER FOR INHALATION (PACKAGE)02035324 RHINOCORT TURBUHALER AST $ 24.6300

DEXAMETHASONE 0.1% OPHTHALMIC SUSPENSION

00042560 MAXIDEX ALC $ 1.6710 0.1% OPHTHALMIC/OTIC SOLUTION

00785261 PMS-DEXAMETHASONE SOD PHO PMS $ 0.733500739839 SANDOZ DEXAMETHASONE SDZ 1.0850

0.1% OPHTHALMIC OINTMENT (3.5G)00042579 MAXIDEX ALC $ 9.0600

FLUNISOLIDE* 0.025% NASAL SOLUTION (PACKAGE)

00878790 RATIO-FLUNISOLIDE RPH $ 13.530002239288 APO-FLUNISOLIDE APX 13.530001927167 RHINARIS-F PMS 15.040002162687 RHINALAR HLR 21.4900

FLUOROMETHOLONE* 0.1% OPHTHALMIC SUSPENSION

02238568 PMS-FLUOROMETHOLONE PMS $ 1.755600247855 FML ALL 2.3740

FLUOROMETHOLONE ACETATE 0.1% OPHTHALMIC SUSPENSION

00756784 FLAREX ALC $ 1.8879

FLUTICASONE PROPIONATE 50UG/DOSE AQUEOUS NASAL SPRAY (PACKAGE)

02213672 FLONASE GSK $ 28.9000

130

52:00 EYE, EAR, NOSE AND THROAT PREPARATIONS52:08.00 ANTI-INFLAMMATORY AGENTS

KETOROLAC TROMETHAMINE SEE APPENDIX A FOR EDS CRITERIA* 0.5% OPHTHALMIC SOLUTION

02245821 APO-KETOROLAC (EDS) APX $ 2.187402247461 RATIO-KETOROLAC (EDS) RPH 2.187401968300 ACULAR (EDS) ALL 3.6456

MOMETASONE FUROATE MONOHYDRATE 0.05% AQUEOUS NASAL SPRAY

02238465 NASONEX SCH $ 28.0000

PREDNISOLONE ACETATE* 0.12% OPHTHALMIC SUSPENSION

01916181 SANDOZ PREDNISOLONE SDZ $ 1.247800299405 PRED MILD ALL 1.6243

1.0% OPHTHALMIC SUSPENSION01916203 SANDOZ PREDNISOLONE SDZ $ 1.844500700401 RATIO-PREDNISOLONE RPH 2.647400301175 PRED FORTE ALL 3.9842

TRIAMCINOLONE ACETONIDE AQUEOUS NASAL SPRAY (PACKAGE)

02213834 NASACORT AQ AVT $ 24.020052:08.00 COMBINATION ANTI-INFECTIVE/

ANTI-INFLAMMATORY AGENTS

CIPROFLOXACIN/HYDROCORTISONE SEE APPENDIX A FOR EDS CRITERIA 0.2%/1% OTIC SUSPENSION

02240035 CIPRO HC (EDS) ALC $ 2.3400

FRAMYCETIN SO4/GRAMICIDIN/DEXAMETHASONE BASE* 5MG/50UG/0.5MG PER ML EYE/EAR SOLUTION

02247920 SANDOZ OPTICORT SDZ $ 1.291202224623 SOFRACORT AVT 1.6751

GENTAMICIN SO4/BETAMETHASONE SODIUM PHOSPHATE* 0.3%/0.1% OTIC/OPHTHALMIC SOLUTION

00682217 GARASONE SCH $ 1.489602244999 SANDOZ PENTASONE SDZ 1.4896

IODOCHLORHYDROXYQUIN/FLUMETHASONE PIVALATE 1%/0.02% OTIC SOLUTION

00074454 LOCACORTEN-VIOFORM PAL $ 1.4398

131

52:00 EYE, EAR, NOSE AND THROAT PREPARATIONS52:08.00 COMBINATION ANTI-INFECTIVE/

ANTI-INFLAMMATORY AGENTS

POLYMYXIN B SO4/BACITRACIN (ZINC)/NEOMYCIN SO4/HYDROCORTISONE 10000U/400U/5MG/10MG PER G OPHTHALMIC OINTMENT (3.5G)

02242485 SANDOZ CORTIMYXIN SDZ $ 9.7300

POLYMYXIN B SO4/NEOMYCIN SO4/DEXAMETHASONE 6,000U/5MG/1MG PER ML OPHTHALMIC SOLUTION

00042676 MAXITROL ALC $ 2.0659 6,000U/5MG/1MG PER G OPHTHALMIC OINTMENT (3.5G)

00358177 MAXITROL ALC $ 10.0800

POLYMYXIN B SO4/NEOMYCIN SO4/HYDROCORTISONE 10,000U/5MG/10MG PER ML EYE/EAR SUSPENSION

02025736 CORTISPORIN GSK $ 1.2988* 10,000U/5MG/10MG PER ML OTIC SOLUTION

02230386 SANDOZ CORTIMYXIN SDZ $ 1.000401912828 CORTISPORIN GSK 1.2988

SULFACETAMIDE SODIUM/PREDNISOLONE ACETATE 100MG/2MG PER G OPHTHALMIC OINTMENT (3.5G)

00307246 BLEPHAMIDE S.O.P. ALL $ 12.9400

TOBRAMYCIN/DEXAMETHASONE SEE APPENDIX A FOR EDS CRITERIA 0.3%/0.1% OPHTHALMIC SUSPENSION

00778907 TOBRADEX (EDS) ALC $ 2.1353 0.3%/0.1% OPHTHALMIC OINTMENT (3.5G)

00778915 TOBRADEX (EDS) ALC $ 11.0700

52:10.00 CARBONIC ANHYDRASE INHIBITORS

ACETAZOLAMIDE 250MG TABLET

00545015 APO-ACETAZOLAMIDE APX $ 0.1015

BRINZOLAMIDE 1% OPHTHALMIC SUSPENSION

02238873 AZOPT ALC $ 3.4937

DORZOLAMIDE HCL 2% OPHTHALMIC SOLUTION

02216205 TRUSOPT MSD $ 3.8344

132

52:00 EYE, EAR, NOSE AND THROAT PREPARATIONS52:10.00 CARBONIC ANHYDRASE INHIBITORS

METHAZOLAMIDE 50MG TABLET

02245882 APO-METHAZOLAMIDE APX $ 0.5106

52:20.00 MIOTICS

CARBACHOL 1.5% OPHTHALMIC SOLUTION

00000655 ISOPTO CARBACHOL ALC $ 0.7307 3% OPHTHALMIC SOLUTION

00000663 ISOPTO CARBACHOL ALC $ 0.8800

PILOCARPINE HCL 1% OPHTHALMIC SOLUTION

00000841 ISOPTO CARPINE ALC $ 0.2221 2% OPHTHALMIC SOLUTION

00000868 ISOPTO CARPINE ALC $ 0.2561 4% OPHTHALMIC SOLUTION

00000884 ISOPTO CARPINE ALC $ 0.2894 4% OPHTHALMIC GEL (5G)

00575240 PILOPINE-HS ALC $ 13.5600

52:24.00 MYDRIATICS

ATROPINE SO4 1% OPHTHALMIC SOLUTION

00035017 ISOPTO ATROPINE ALC $ 0.6510

DIPIVEFRIN HCL* 0.1% OPHTHALMIC SOLUTION

02032376 RATIO-DIPIVEFRIN RPH $ 1.080702237868 PMS-DIPIVEFRIN PMS 1.0807

HOMATROPINE HYDROBROMIDE 2% OPHTHALMIC SOLUTION

00000779 ISOPTO HOMATROPINE ALC $ 0.6619 5% OPHTHALMIC SOLUTION

00000787 ISOPTO HOMATROPINE ALC $ 0.7885

133

52:00 EYE, EAR, NOSE AND THROAT PREPARATIONS52:36.00 MISCELLANEOUS E.E.N.T. DRUGS

APRACLONIDINE HCL 0.5% OPHTHALMIC SOLUTION (5ML)

02076306 IOPIDINE ALC $ 23.0800 1% OPHTHALMIC SOLUTION (1 TREATMENT)

00888354 IOPIDINE ALC $ 11.9200

BETAXOLOL HCL 0.25% OPHTHALMIC SUSPENSION

01908448 BETOPTIC S ALC $ 2.4456

BIMATOPROST 0.03% OPHTHALMIC SOLUTION

02245860 LUMIGAN ALL $ 11.7400

BRIMONIDINE TARTRATE 0.15% OPHTHALMIC SOLUTION

02248151 ALPHAGAN P ALL $ 2.5064* 0.2% OPHTHALMIC SOLUTION

02243026 RATIO-BRIMONIDINE RPH $ 2.256802246284 PMS-BRIMONIDINE PMS 2.256802260077 APO-BRIMONIDINE APX 2.256802236876 ALPHAGAN ALL 3.5810

BRIMONIDINE TARTRATE/TIMOLOL MALEATE SEE APPENDIX A FOR EDS CRITERIA 0.2%/0.5% OPHTHALMIC SOLUTION

02248347 COMBIGAN ALL $ 4.2800

DICLOFENAC SODIUM SEE APPENDIX A FOR EDS CRITERIA 0.1% OPHTHALMIC SOLUTION (ML)

01940414 VOLTAREN OPHTHA (EDS) NVO $ 2.5715

DORZOLAMIDE HCL/TIMOLOL MALEATE 2%/0.5% OPHTHALMIC SOLUTION

02240113 COSOPT MSD $ 5.8120

GATIFLOXACIN SEE APPENDIX A FOR EDS CRITERIA 0.3% OPHTHALMIC SOLUTION

02257270 ZYMAR (EDS) ALL $ 2.7342

134


IPRATROPIUM BROMIDE* 21UG/DOSE NASAL SPRAY (PACKAGE)

02239627 PMS-IPRATROPIUM PMS $ 19.040002246083 APO-IPRAVENT APX 19.040002240508 DOM-IPRATROPIUM DOM 22.200002163705 ATROVENT NASAL SPRAY BOE 32.3300

LATANOPROST 50UG/ML OPHTHALMIC SOLUTION (2.5ML)

02231493 XALATAN PFI $ 29.3400

LATANOPROST/TIMOLOL MALEATE 50UG/5MG PER ML OPHTHALMIC SOLUTION (2.5ML)

02246619 XALACOM PFI $ 33.2100

LEVOBUNOLOL HCL* 0.25% OPHTHALMIC SOLUTION

02031159 RATIO-LEVOBUNOLOL RPH $ 1.276002197456 NOVO-LEVOBUNOLOL NOP 1.276002241575 APO-LEVOBUNOLOL APX 1.276002241715 SANDOZ LEVOBUNOLOL SDZ 1.2760

* 0.5% OPHTHALMIC SOLUTION02241574 APO-LEVOBUNOLOL APX $ 1.686102241716 SANDOZ LEVOBUNOLOL SDZ 1.686102237991 PMS-LEVOBUNOLOL PMS 1.687202031167 RATIO-LEVOBUNOLOL RPH 1.688302197464 NOVO-LEVOBUNOLOL NOP 1.688300637661 BETAGAN ALL 2.9751

LEVOCABASTINE HYDROCHLORIDE 0.5MG PER ML OPHTHALMIC SUSPENSION (5ML)

02131625 LIVOSTIN NVO $ 25.8900

LODOXAMIDE TROMETHAMINE 0.1% OPHTHALMIC SOLUTION

00893560 ALOMIDE ALC $ 1.1122

SODIUM CROMOGLYCATE 2% NASAL METERED DOSE MIST (PACKAGE)

01950541 CROMOLYN PMS $ 14.9300

135


TIMOLOL MALEATE* 0.25% OPHTHALMIC SOLUTION

00755826 APO-TIMOP APX $ 1.681800893773 GEN-TIMOLOL GPM 1.681802083353 PMS-TIMOLOL PMS 1.681802166712 SANDOZ TIMOLOL SDZ 1.681802238770 DOM-TIMOLOL DOM 1.7664

* 0.5% OPHTHALMIC SOLUTION00755834 APO-TIMOP APX $ 2.018100893781 GEN-TIMOLOL GPM 2.018102083345 PMS-TIMOLOL PMS 2.018102166720 SANDOZ TIMOLOL SDZ 2.018102238771 DOM-TIMOLOL DOM 2.119000451207 TIMOPTIC MSD 3.5491

* 0.25% OPHTHALMIC GEL FORMING SOLUTION02242275 PMS-TIMOLOL MALEATE PMS $ 2.829702171880 TIMOPTIC-XE MSD 3.7889

* 0.5% OPHTHALMIC GEL FORMING SOLUTION02242276 PMS-TIMOLOL MALEATE PMS $ 3.385202171899 TIMOPTIC-XE MSD 4.5332

TRAVOPROST 0.004% OPHTHALMIC SOLUTION (2.5ML)

02244896 TRAVATAN ALC $ 29.3400

136

GASTROINTESTINAL DRUGS56:00

56:00 GASTROINTESTINAL DRUGS56:08.00 ANTIDIARRHEA AGENTS

DIPHENOXYLATE HCL 2.5MG TABLET

00036323 LOMOTIL PFI $ 0.4729

LOPERAMIDE HCL* 2MG CAPLET

02132591 NOVO-LOPERAMIDE NOP $ 0.267602212005 APO-LOPERAMIDE APX 0.267602228351 PMS-LOPERAMIDE PMS 0.267602239535 DOM-LOPERAMIDE DOM 0.280902229552 DIARR-EZE PMS 0.354502183862 IMODIUM MCL 0.8229

2MG TABLET02257564 SANDOZ LOPERAMIDE SDZ $ 0.2676

* 0.2MG/ML ORAL SOLUTION02016095 PMS-LOPERAMIDE HCL PMS $ 0.091202192667 DIARR-EZE PMS 0.1058

56:12.00 CATHARTICS AND LAXATIVES

LACTULOSE SEE APPENDIX A FOR EDS CRITERIA 667MG/ML SYRUP

00703486 PMS-LACTULOSE (EDS) PMS $ 0.0158* 667MG/ML SOLUTION

00854409 RATIO-LACTULOSE (EDS) RPH $ 0.015802242814 APO-LACTULOSE (EDS) APX 0.0158

56:16.00 DIGESTANTS

PANCRELIPASE (LIPASE/AMYLASE/PROTEASE) 4000U/12000U/12000U CAPSULE CONTAINING

02181215 COTAZYME ECS 4 ORG $ 0.1948 4000U/12000U/12000U CAPSULE CONTAINING ENTERIC COATED PARTICLES

00789445 PANCREASE MT 4 JAN $ 0.4077 4000U/20000U/25000U CAPSULE CONTAINING ENTERIC COATED PARTICLES

02242374 PANCREASE JAN $ 0.4070 4500U/20000U/25000U CAPSULE CONTAINING ENTERIC COATED PARTICLES

02203324 ULTRASE MS4 AXC $ 0.2214

138

56:00 GASTROINTESTINAL DRUGS56:16.00 DIGESTANTS

5000U/16600U/18750U CAPSULE CONTAINING ENTERIC COATED PARTICLES

02239007 CREON 5 SLV $ 0.1812 8000U/30000U/30000U CAPSULE

00263818 COTAZYM ORG $ 0.2745 8000U/30000U/30000U CAPSULE CONTAINING ENTERIC COATED PARTICLES

00502790 COTAZYM ECS 8 ORG $ 0.3771 10000U/30000U/30000U CAPSULE CONTAINING ENTERIC COATED PARTICLES


02200104 CREON 10 SLV $ 0.2897 12000U/39000U/39000U CAPSULE CONTAINING ENTERIC COATED PARTICLES

02045834 ULTRASE MT12 AXC $ 0.4330 16000U/48000U/48000U CAPSULE CONTAINING ENTERIC COATED PARTICLES


00821373 COTAZYM ECS 20 ORG $ 0.9738 20000U/65000U/65000U CAPSULE CONTAINING ENTERIC COATED PARTICLES

02045869 ULTRASE MT20 AXC $ 0.7503 20000U/66400U/75000U CAPSULE CONTAINING ENTERIC COATED PARTICLES

02239008 CREON 20 SLV $ 0.8597 25000U/74000U/62500U CAPSULE CONTAINING ENTERIC COATED PARTICLES

01985205 CREON 25 SLV $ 0.9049 8000U/30000U/30000U TABLET

02230019 VIOKASE AXC $ 0.2303 16000U/60000U/60000U TABLET

02241933 VIOKASE AXC $ 0.3470 24000U/100000U/100000U POWDER

02230020 VIOKASE AXC $ 0.4951

139

56:00 GASTROINTESTINAL DRUGS56:22.00 ANTI-EMETICS

DIMENHYDRINATE* 50MG TABLET

00013803 GRAVOL HOR $ 0.019000363766 APO-DIMENHYDRINATE APX 0.024500021423 NOVO-DIMENATE NOP 0.0408

3MG/ML ORAL LIQUID00230197 GRAVOL HOR $ 0.0730

* 50MG/ML INJECTION SOLUTION (5ML)00013579 GRAVOL HOR $ 3.040000392537 DIMENHYDRINATE IM SDZ 3.6900

50MG SUPPOSITORY00013595 GRAVOL HOR $ 0.5046

100MG SUPPOSITORY00013609 GRAVOL HOR $ 0.5263

DOXYLAMINE SUCCINATE/PYRIDOXINE HCL 10MG/10MG DELAYED RELEASE TABLET

00609129 DICLECTIN DUI $ 1.3020

MECLIZINE HCL 25MG TABLET

00220442 BONAMINE PFC $ 0.4796

SCOPOLAMINE 1.5MG TRANSDERMAL THERAPEUTIC SYSTEM

00550094 TRANSDERM-V PMS $ 4.1800

56:40.00 MISCELLANEOUS GASTROINTESTINAL DRUGS

BUDESONIDE SEE APPENDIX A FOR EDS CRITERIA 3MG CONTROLLED ILEAL RELEASE CAPSULE

02229293 ENTOCORT (EDS) AST $ 1.6536

CIMETIDINE* 300MG TABLET

00865818 NU-CIMET NXP $ 0.0722 *00487872 APO-CIMETIDINE APX 0.093400582417 NOVO-CIMETINE NOP 0.093402227444 GEN-CIMETIDINE GPM 0.093402229718 PMS-CIMETIDINE PMS 0.093402231287 DOM-CIMETIDINE DOM 0.0980

140

56:00 GASTROINTESTINAL DRUGS56:40.00 MISCELLANEOUS GASTROINTESTINAL DRUGS

* 400MG TABLET00865826 NU-CIMET NXP $ 0.1134 *00600059 APO-CIMETIDINE APX 0.146500603678 NOVO-CIMETINE NOP 0.146502227452 GEN-CIMETIDINE GPM 0.146502229719 PMS-CIMETIDINE PMS 0.146502231288 DOM-CIMETIDINE DOM 0.1539

* 600MG TABLET00865834 NU-CIMET NXP $ 0.1444 *00600067 APO-CIMETIDINE APX 0.186700603686 NOVO-CIMETINE NOP 0.186702227460 GEN-CIMETIDINE GPM 0.186702229720 PMS-CIMETIDINE PMS 0.186702231290 DOM-CIMETIDINE DOM 0.1960

DOMPERIDONE MALEATE* 10MG TABLET

02238315 DOM-DOMPERIDONE DOM $ 0.1155 *01912070 RATIO-DOMPERIDONE RPH 0.162402103613 APO-DOMPERIDONE APX 0.162402157195 NOVO-DOMPERIDONE NOP 0.162402231477 NU-DOMPERIDONE NXP 0.162402236466 PMS-DOMPERIDONE PMS 0.162402268078 RAN-DOMPERIDONE RAN 0.1624

ESOMEPRAZOLE MAGNESIUM TRIHYDRATE (MAC)

SEE APPENDIX A FOR EDS CRITERIA SEE APPENDIX I FOR MAC POLICY 20MG DELAYED RELEASE TABLET

02244521 NEXIUM (EDS) AST 2.2785 40MG DELAYED RELEASE TABLET

02244522 NEXIUM (EDS) AST 2.2785

141


FAMOTIDINE* 20MG TABLET

02024195 NU-FAMOTIDINE NXP $ 0.4625 *01953842 APO-FAMOTIDINE APX 0.639802022133 NOVO-FAMOTIDINE NOP 0.639802196018 GEN-FAMOTIDINE GPM 0.639800710121 PEPCID MSD 1.0876

* 40MG TABLET02024209 NU-FAMOTIDINE NXP $ 0.8324 *01953834 APO-FAMOTIDINE APX 1.151402022141 NOVO-FAMOTIDINE NOP 1.151402196026 GEN-FAMOTIDINE GPM 1.151400710113 PEPCID MSD 1.9773

LANSOPRAZOLE (MAC)

SEE APPENDIX A FOR EDS CRITERIA SEE APPENDIX I FOR MAC POLICY 15MG DELAYED RELEASE CAPSULE

02165503 PREVACID (EDS) ABB 2.1700 30MG DELAYED RELEASE CAPSULE

02165511 PREVACID (EDS) ABB 2.1700 30MG ORALLY DISINTEGRATING TABLET

02249472 PREVACID FASTAB (EDS) ABB 2.1700

LANSOPRAZOLE/CLARITHROMYCIN/AMOXICILLIN SEE APPENDIX A FOR EDS CRITERIA 30MG/500MG/500MG 7-DAY PACKAGE

02238525 HP-PAC (EDS) ABB $ 84.9000

METOCLOPRAMIDE HCL 5MG TABLET

02230431 PMS-METOCLOPRAMIDE PMS $ 0.0604* 10MG TABLET

00842834 APO-METOCLOP APX $ 0.063302143283 NU-METOCLOPRAMIDE NXP 0.063302230432 PMS-METOCLOPRAMIDE PMS 0.0633

1MG/ML ORAL SOLUTION02230433 PMS-METOCLOPRAMIDE PMS $ 0.0398

142


MISOPROSTOL* 100UG TABLET

02240754 NOVO-MISOPROSTOL NOP $ 0.186002244022 APO-MISOPROSTOL APX 0.1860

* 200UG TABLET02244023 APO-MISOPROSTOL APX $ 0.309702244125 PMS-MISOPROSTOL PMS 0.3097

NIZATIDINE* 150MG CAPSULE

02177714 PMS-NIZATIDINE PMS $ 0.573702220156 APO-NIZATIDINE APX 0.573702240457 NOVO-NIZATIDINE NOP 0.573702246046 GEN-NIZATIDINE GPM 0.573702247051 NU-NIZATIDINE NXP 0.573702185814 DOM-NIZATIDINE DOM 0.602300778338 AXID PML 0.9106

* 300MG CAPSULE02177722 PMS-NIZATIDINE PMS $ 1.039502220164 APO-NIZATIDINE APX 1.039502240458 NOVO-NIZATIDINE NOP 1.039502246047 GEN-NIZATIDINE GPM 1.039502247052 NU-NIZATIDINE NXP 1.039500778346 AXID PML 1.6499

OLSALAZINE SODIUM 250MG CAPSULE

02063808 DIPENTUM PFI $ 0.5383

OMEPRAZOLE (MAC)

SEE APPENDIX A FOR EDS CRITERIA SEE APPENDIX I FOR MAC POLICY 20MG CAPSULE

02245058 APO-OMEPRAZOLE (EDS) APX $ 1.3563

OMEPRAZOLE MAGNESIUM (MAC)

SEE APPENDIX A FOR EDS CRITERIA SEE APPENDIX I FOR MAC POLICY 10MG DELAYED RELEASE TABLET

02230737 LOSEC (EDS) AST 1.8988 20MG DELAYED RELEASE TABLET

02190915 LOSEC (EDS) AST 2.3870

143


PANTOPRAZOLE (MAC)

SEE APPENDIX A FOR EDS CRITERIA SEE APPENDIX I FOR MAC POLICY 40MG ENTERIC TABLET

02229453 PANTOLOC (EDS) ATA 2.0615

RABEPRAZOLE SODIUM (MAC)

SEE APPENDIX A FOR EDS CRITERIA SEE APPENDIX I FOR MAC POLICY 10MG TABLET

02243796 PARIET (EDS) JAN $ 0.7053

RANITIDINE* 150MG TABLET

00865737 NU-RANIT NXP $ 0.3003 *00733059 APO-RANITIDINE APX 0.438600828564 NOVO-RANIDINE NOP 0.438600828823 RATIO-RANITIDINE RPH 0.438602207761 GEN-RANITIDINE GPM 0.438602242453 PMS-RANITIDINE PMS 0.438602243229 SANDOZ RANITIDINE SDZ 0.438602248570 CO RANITIDINE COB 0.438602243038 DOM-RANITIDINE DOM 0.460502212331 ZANTAC GSK 1.2420

* 300MG TABLET00865745 NU-RANIT NXP $ 0.5787 *00733067 APO-RANITIDINE APX 0.844900828556 NOVO-RANIDINE NOP 0.844900828688 RATIO-RANITIDINE RPH 0.844902207788 GEN-RANITIDINE GPM 0.844902242454 PMS-RANITIDINE PMS 0.844902243230 SANDOZ RANITIDINE SDZ 0.844902248571 CO RANITIDINE COB 0.844902243039 DOM-RANITIDINE DOM 0.887100641790 ZANTAC GSK 2.3379

* 15MG/ML ORAL SOLUTION02242940 NOVO-RANIDINE NOP $ 0.141602212374 ZANTAC GSK 0.2114

144


SUCRALFATE* 1G TABLET

02134829 NU-SUCRALFATE NXP $ 0.2557 *02045702 NOVO-SUCRALATE NOP 0.319202125250 APO-SUCRALFATE APX 0.319202238209 PMS-SUCRALFATE PMS 0.319202239912 DOM-SUCRALFATE DOM 0.335202100622 SULCRATE AXC 0.5578

200MG/ML ORAL SUSPENSION02103567 SULCRATE SUSPENSION PLUS AXC $ 0.1014

SULFASALAZINE (SALICYLAZOSULFAPYRIDINE)* 500MG TABLET

00598461 PMS-SULFASALAZINE PMS $ 0.228002064480 SALAZOPYRIN PFI 0.2548

* 500MG ENTERIC TABLET00598488 PMS-SULFASALAZINE PMS $ 0.347202064472 SALAZOPYRIN PFI 0.3985

5-AMINOSALICYLIC ACID (MESALAZINE)⌧ 400MG ENTERIC COATED TABLET

02171929 NOVO-5-ASA NOP $ 0.429701997580 ASACOL PGA 0.5371

500MG DELAYED RELEASE TABLET02099683 PENTASA FEI $ 0.6043

⌧ 500MG ENTERIC COATED TABLET02112787 SALOFALK AXC $ 0.525201914030 MESASAL GSK 0.6230

800MG DELAYED RELEASE TABLET02267217 ASACOL 800 PGA $ 1.0742

1.0G/100ML RETENTION ENEMA02153521 PENTASA FEI $ 4.0300

2.0G/60G RETENTION ENEMA02112795 SALOFALK RETENTION ENEMA AXC $ 3.8100

4.0G/60G RETENTION ENEMA02112809 SALOFALK RETENTION ENEMA AXC $ 6.4700

4.0G/100ML RETENTION ENEMA02153556 PENTASA FEI $ 4.8400

500MG SUPPOSITORY02112760 SALOFALK AXC $ 1.1820

⌧ 1.0G SUPPOSITORY02242146 SALOFALK AXC $ 1.736002153564 PENTASA FEI 1.7686

145

GOLD COMPOUNDS60:00

60:00 GOLD COMPOUNDS60:00.00 GOLD COMPOUNDS

AURANOFIN AURANOFIN SHOULD BE CONSIDERED ONLY WHEN SALICYLATES OR OTHER NON-STEROIDAL ANTI-INFLAMMATORY DRUGS, AND, WHEN APPROPRIATE, STEROIDS, HAVE PROVEN TO BE INADEQUATE FOR CONTROLLING THE SYMPTOMS OF RHEUMATOID ARTHRITIS. PHYSICIANS PLANNING TO USE AURANOFIN SHOULD BE EXPERIENCED WITH CHRYSOTHERAPY AND SHOULD THOROUGHLY FAMILIARIZE THEMSELVES WITH THE TOXICITY AND BENEFITS OF AURANOFIN. ADVERSE REACTIONS WERE REPORTED IN 62% OF 4,784 PATIENTS TREATED WITH AURANOFIN. MOST COMMON WERE DIARRHEA (47%), RASH (24%), PRURITIS (17%), ABDOMINAL PAIN (14%), AND STOMATITIS (13%). POTENTIALLY SERIOUS ADVERSE REACTIONS WERE ANEMIA (1.6%), LEUKOPENIA (1.9%), THROMBOCYTOPENIA (0.9%) AND PROTEINUREA (5.0%). 3MG CAPSULE

01916823 RIDAURA PAL $ 2.1119

SODIUM AUROTHIOMALATE* 10MG/ML INJECTION SOLUTION (1ML)

02245456 SODIUM AUROTHIOMALATE SDZ $ 8.820001927620 MYOCHRYSINE AVT 10.7900

* 25MG/ML INJECTION SOLUTION (1ML)02245457 SODIUM AUROTHIOMALATE SDZ $ 10.690001927612 MYOCHRYSINE AVT 13.0900

* 50MG/ML INJECTION SOLUTION (1ML)02245458 SODIUM AUROTHIOMALATE SDZ $ 16.590001927604 MYOCHRYSINE AVT 20.3300

148

HEAVY METAL ANTAGONISTS64:00

64:00 HEAVY METAL ANTAGONISTS64:00.00 HEAVY METAL ANTAGONISTS

DEFEROXAMINE MESYLATE SEE APPENDIX A FOR EDS CRITERIA* 500MG/VIAL POWDER FOR SOLUTION

02241600 DESFERRIOXAMINE MESILATE (EDS) DBU $ 8.880002242055 PMS-DEFEROXAMINE (EDS) PMS 8.880001981242 DESFERAL (EDS) NVR 14.1900

* 2G/VIAL POWDER FOR SOLUTION02247022 DESFERRIOXAMINE MESILATE (EDS) DBU $ 38.140002243450 PMS-DEFEROXAMINE (EDS) PMS 45.570001981250 DESFERAL (EDS) NVR 56.9700

PENICILLAMINE 125MG CAPSULE

00497894 CUPRIMINE MSD $ 0.5581 250MG CAPSULE

00016055 CUPRIMINE MSD $ 0.8616

150

HORMONES AND SYNTHETIC SUBSTITUTES

68:00

68:00 HORMONES AND SYNTHETIC SUBSTITUTES68:04.00 ADRENAL CORTICOSTEROIDS

COMPARABLE ANTI-INFLAMMATORY ACTIVITY OF ORALCORTICOSTEROIDS(MINERALCORTICOID ACTIVITY NOT COMPARABLE)

COMPARABLEDURATION OF ANTI-INFLAMMATORYACTION PRODUCT DOSE

SHORT ACTING - CORTISONE 25 mg - HYDROCORTISONE 20 mg - PREDNISONE 5 mg - METHYLPREDNISOLONE 4 mg

INTERMEDIATE ACTING - TRIAMCINOLONE 4 mg

LONG ACTING - DEXAMETHASONE 0.75 mg - BETAMETHASONE 0.60 mg

THESE CLASSIFICATIONS ARE IMPORTANT CONSIDERATIONS IN ALTERNATEDAY STEROID THERAPY.

COMPARABLE ANTI-INFLAMMATORY ACTIVITY OF SOLUBLEINJECTABLE CORTICOSTEROIDS

COMPARABLEANTI-INFLAMMATORY

PRODUCT % ACTIVE BASE DOSE

HYDROCORTISONESODIUM SUCCINATE 74.8 100 mg

DEXAMETHASONE21 PHOSPHATE 76.1 4 mg

152


BECLOMETHASONE DIPROPIONATE 50UG/INHALATION AEROSOL (PACKAGE) (CFC-FREE)

02242029 QVAR MDA $ 31.6900 100UG/INHALATION AEROSOL (PACKAGE) (CFC-FREE)

02242030 QVAR MDA $ 63.3700

BETAMETHASONE ACETATE/BETAMETHASONE SODIUM PHOSPHATE* 3MG/3MG PER ML INJECTION SUSPENSION (1ML)

00028096 CELESTONE SOLUSPAN SCH $ 4.290002237835 BETAJECT SDZ 4.2900

BUDESONIDE 0.125MG/ML INHALATION SOLUTION (2ML)

02229099 PULMICORT NEBUAMP AST $ 0.4480 0.25MG/ML INHALATION SOLUTION (2ML)

01978918 PULMICORT NEBUAMP AST $ 0.8960 0.5MG/ML INHALATION SOLUTION (2ML)

01978926 PULMICORT NEBUAMP AST $ 1.7910 100UG POWDER FOR INHALATION (PACKAGE)

00852074 PULMICORT TURBUHALER AST $ 32.9900 200UG POWDER FOR INHALATION (PACKAGE)

00851752 PULMICORT TURBUHALER AST $ 66.0300 400UG POWDER FOR INHALATION (PACKAGE)

00851760 PULMICORT TURBUHALER AST $ 118.8100

CORTISONE ACETATE 25MG TABLET

00280437 CORTISONE VAE $ 0.3327

153


DEXAMETHASONE* 0.5MG TABLET

00295094 DEXASONE VAE $ 0.213801964976 PMS-DEXAMETHASONE PMS 0.213802240684 RATIO-DEXAMETHASONE RPH 0.213802261081 APO-DEXAMETHASONE APX 0.2138

* 0.75MG TABLET01964968 PMS-DEXAMETHASONE PMS $ 0.488302240685 RATIO-DEXAMETHASONE RPH 0.4883

* 4MG TABLET00489158 DEXASONE VAE $ 0.832601964070 PMS-DEXAMETHASONE PMS 0.832602240687 RATIO-DEXAMETHASONE RPH 0.832602250055 APO-DEXAMETHASONE APX 0.8326

DEXAMETHASONE 21-PHOSPHATE* 4MG/ML INJECTION SOLUTION (5ML)

00664227 DEXAMETHASONE SOD PHO INJ SDZ $ 9.170001977547 DEXAMETHASONE SOD PHO INJ CYT 9.1700

FLUDROCORTISONE ACETATE 0.1MG TABLET

02086026 FLORINEF RBP $ 0.2355

FLUTICASONE PROPIONATE 50UG/INHALATION AEROSOL (PACKAGE)

02244291 FLOVENT HFA GSK $ 25.4600 125UG/INHALATION AEROSOL (PACKAGE)

02244292 FLOVENT HFA GSK $ 41.0300 250UG/INHALATION AEROSOL (PACKAGE)

02244293 FLOVENT HFA GSK $ 83.6900 50UG/DOSE POWDER FOR INHALATION (PACKAGE)

02237244 FLOVENT DISKUS GSK $ 15.3500 100UG/DOSE POWDER FOR INHALATION (PACKAGE)



02237247 FLOVENT DISKUS GSK $ 83.6900

154


HYDROCORTISONE 10MG TABLET

00030910 CORTEF PFI $ 0.1527 20MG TABLET

00030929 CORTEF PFI $ 0.2760

HYDROCORTISONE SODIUM SUCCINATE 100MG INJECTION POWDER

00030600 SOLU-CORTEF PFI $ 3.4800 250MG INJECTION POWDER

00030619 SOLU-CORTEF PFI $ 6.0500

METHYLPREDNISOLONE 4MG TABLET

00030988 MEDROL PFI $ 0.3529 16MG TABLET

00036129 MEDROL PFI $ 1.0182

METHYLPREDNISOLONE ACETATE* 40MG/ML INJECTION SUSPENSION (1ML)

02245400 METHYLPREDNISOLONE ACETATE SDZ $ 4.210000030759 DEPO-MEDROL PFI 5.1000

* 80MG/ML INJECTION SUSPENSION (1ML)02245406 METHYLPREDNISOLONE SDZ $ 8.070000030767 DEPO-MEDROL PFI 9.7700

PREDNISOLONE SODIUM PHOSPHATE* 1MG/ML ORAL LIQUID

02245532 PMS-PREDNISOLONE PMS $ 0.072802230619 PEDIAPRED AVT 0.1147

PREDNISONE* 1MG TABLET

00271373 WINPRED VAE $ 0.112300598194 APO-PREDNISONE APX 0.1123

* 5MG TABLET00021695 NOVO-PREDNISONE NOP $ 0.028300312770 APO-PREDNISONE APX 0.0283

* 50MG TABLET00232378 NOVO-PREDNISONE NOP $ 0.118800550957 APO-PREDNISONE APX 0.1188

155


TRIAMCINOLONE ACETONIDE* 10MG/ML INJECTION SUSPENSION (5ML)

01999761 KENALOG 10 WSD $ 15.940002229540 TRIAMCINOLONE ACETONIDE SDZ 22.0200

* 40MG/ML INJECTION SUSPENSION (1ML)01977563 TRIAMCINOLONE ACETONIDE CYT $ 5.180002229550 TRIAMCINOLONE SDZ 5.970001999869 KENALOG 40 WSD 7.4000

TRIAMCINOLONE HEXACETONIDE SEE APPENDIX A FOR EDS CRITERIA 20MG/ML INJECTION SUSPENSION

02194155 ARISTOSPAN (EDS) VAL $ 13.5700

68:08.00 ANDROGENS

DANAZOL 50MG CAPSULE

02018144 CYCLOMEN AVT $ 0.8119 100MG CAPSULE

02018152 CYCLOMEN AVT $ 1.2048 200MG CAPSULE

02018160 CYCLOMEN AVT $ 1.9253

TESTOSTERONE CYPIONATE* 100MG/ML OILY INJECTION SOLUTION (10ML)

01977601 TESTOSTERONE CYPIONATE CYT $ 7.550002246063 TESTOSTERONE CYPIONATE SDZ 19.480000030783 DEPO-TESTOSTERONE PFI 26.2000

TESTOSTERONE ENANTHATE 200MG/ML OILY INJECTION SOLUTION (ML)

00029246 DELATESTRYL THM $ 5.3000

TESTOSTERONE UNDECANOATE 40MG CAPSULE

00782327 ANDRIOL ORG $ 1.0199

156

68:00 HORMONES AND SYNTHETIC SUBSTITUTES68:12.00 CONTRACEPTIVES

DROSPIRENONE/ETHINYL ESTRADIOL 3.0MG/0.030MG (21 TABLET)

02261723 YASMIN 21 BEX $ 12.5900 3.0MG/0.030MG (28 TABLET)

02261731 YASMIN 28 BEX $ 12.5900

ETHINYL ESTRADIOL/D-NORGESTREL 0.05MG/0.25MG (21 TABLET)

02043033 OVRAL WYA $ 14.0900 0.05MG/0.25MG (28 TABLET)

02043041 OVRAL WYA $ 14.0900

ETHINYL ESTRADIOL/DESOGESTREL⌧ 0.03MG/0.15MG (21 TABLET)

02042487 MARVELON ORG $ 13.300002042541 ORTHO-CEPT JAN 14.3200

⌧ 0.03MG/0.15MG (28 TABLET)02042479 MARVELON ORG $ 13.300002042533 ORTHO-CEPT JAN 14.3200

ETHINYL ESTRADIOL/ETHYNODIOL DIACETATE 0.03MG/2MG (21 TABLET)

00469327 DEMULEN 30 PFI $ 13.1700 0.03MG/2MG (28 TABLET)

00471526 DEMULEN 30 PFI $ 14.0900

ETHINYL ESTRADIOL/L-NORGESTREL 0.02MG/0.1MG (21 TABLET)

02236974 ALESSE WYA $ 14.0900 0.02MG/0.1MG (28 TABLET)

02236975 ALESSE WYA $ 14.0900⌧ 0.03MG/0.05MG(6)0.04MG/0.075MG(5) 0.03MG/0.125MG(10) (21 TABLET)

00707600 TRIQUILAR BEX $ 12.270002043726 TRIPHASIL WYA 14.0900

⌧ 0.03MG/0.05MG(6)0.04MG/0.075MG(5) 0.03MG/0.125MG(10) INERT TABLETS (7) (28 TABLET)

00707503 TRIQUILAR BEX $ 12.270002043734 TRIPHASIL WYA 14.0900

0.03MG/0.15MG (21 TABLET)02042320 MIN-OVRAL WYA $ 14.0900

0.03MG/0.15MG (28 TABLET)02042339 MIN-OVRAL WYA $ 14.0900

157


ETHINYL ESTRADIOL/NORETHINDRONE⌧ 0.035MG/0.5MG (21 TABLET)

02187086 BREVICON PFI $ 12.070000317047 ORTHO 0.5/35 JAN 14.3200

⌧ 0.035MG/0.5MG (28 TABLET)02187094 BREVICON PFI $ 12.070000340731 ORTHO 0.5/35 JAN 14.3200

0.035MG/0.5MG (7) 0.035MG/0.75MG (7) 0.035/1.0MG (7) (21 TABLET)

00602957 ORTHO 7/7/7 JAN $ 14.3200 0.035MG/0.5MG (7) 0.035MG/0.75MG (7) 0.035MG/1.0MG (7) INERT TABLETS (7) (28 TABLET)

00602965 ORTHO 7/7/7 JAN $ 14.3200 0.035MG/0.5MG(7)0.035MG/1.0MG(9) 0.035MG/0.5MG(5) (21 TABLET)

02187108 SYNPHASIC PFI $ 11.0900 0.035MG/0.5MG(7)0.035MG/1.0MG(9) 0.035MG/0.5MG(5) INERT TABLETS (7) (28 TABLET)

02187116 SYNPHASIC PFI $ 11.0900⌧ 0.035MG/1MG (21 TABLET)

02197502 SELECT 1/35 PFI $ 8.150002189054 BREVICON 1/35 PFI 12.070000372846 ORTHO 1/35 JAN 14.3200

⌧ 0.035MG/1MG (28 TABLET)02199297 SELECT 1/35 PFI $ 8.150002189062 BREVICON 1/35 PFI 12.070000372838 ORTHO 1/35 JAN 14.3200

ETHINYL ESTRADIOL/NORETHINDRONE ACETATE 0.02MG/1MG (21 TABLET)

00315966 MINESTRIN 1/20 SQR $ 12.6800 0.02MG/1MG (28 TABLET)

00343838 MINESTRIN 1/20 SQR $ 12.6800 0.03MG/1.5MG (21 TABLET)

00297143 LOESTRIN 1.5/30 SQR $ 12.6800 0.03MG/1.5MG (28 TABLET)

00353027 LOESTRIN 1.5/30 SQR $ 12.6800

158


ETHINYL ESTRADIOL/NORGESTIMATE 0.035MG/0.18MG (7) 0.035MG/0.215MG (7) 0.035MG/0.25MG (7) (21 TABLET)

02028700 TRI-CYCLEN JAN $ 14.3200 0.035MG/0.18MG (7) 0.035MG/0.215MG (7) 0.035MG/0.25MG (7) INERT TABLETS (7) (28 TABLET)

02029421 TRI-CYCLEN JAN $ 14.3200 0.035MG/0.25MG (21 TABLET)

01968440 CYCLEN JAN $ 14.3200 0.035MG/0.25MG (28 TABLET)

01992872 CYCLEN JAN $ 14.3200

LEVONORGESTREL 0.75MG TABLET

02241674 PLAN B PAL $ 8.6600 52MG EXTENDED RELEASE INTRAUTERINE INSERT

02243005 MIRENA BEX $ 329.6300

NORETHINDRONE 0.35MG (28 TABLET)

00037605 MICRONOR JAN $ 14.3200

NORGESTIMATE/ETHINYL ESTRADIOL 0.180MG/0.25MG(7) 0.215MG/0.25MG(7) 0.250MG/0.25MG(7) (21 TABLET)

02258560 TRI-CYCLEN LO JAN $ 12.4800 0.180MG/0.25MG(7) 0.215MG/0.25MG(7) 0.250MG/0.25MG (7) INERT TABLETS (7) (28 TABLET)

02258587 TRI-CYCLEN LO JAN $ 12.4800

159

68:00 HORMONES AND SYNTHETIC SUBSTITUTES68:16.00 ESTROGENS

CONJUGATED ESTROGENS 0.3MG TABLET

02043394 PREMARIN WYA $ 0.1321⌧ 0.625MG TABLET

00265470 C.E.S. VAE $ 0.105502043408 PREMARIN WYA 0.1321

0.9MG TABLET02043416 PREMARIN WYA $ 0.2750

⌧ 1.25MG TABLET00265489 C.E.S. VAE $ 0.187702043424 PREMARIN WYA 0.2347

0.625MG/G VAGINAL CREAM02043440 PREMARIN WYA $ 0.6300

CONJUGATED ESTROGENS/MEDROXYPROGESTERONEACETATE 0.625MG/2.5MG TABLET (PACKAGE)

02242878 PREMPLUS WYA $ 7.6000 0.625MG/5MG TABLET (PACKAGE)

02242879 PREMPLUS WYA $ 7.6000

ESTRADIOL SEE APPENDIX A FOR EDS CRITERIA 0.5MG TABLET

02225190 ESTRACE RBP $ 0.1224 1MG TABLET

02148587 ESTRACE RBP $ 0.2364 2MG TABLET

02148595 ESTRACE RBP $ 0.4172 0.06% TRANSDERMAL GEL SPRAY (PACKAGE)

02238704 ESTROGEL (EDS) SCH $ 21.1600 2MG VAGINAL RING (7.5UG/24 HOURS)

02168898 ESTRING PAL $ 65.1000 25UG VAGINAL TABLET

02241332 VAGIFEM NOO $ 2.7600⌧ 25UG TRANSDERMAL THERAPEUTIC SYSTEM (PKG)

02247499 CLIMARA 25 (EDS) BEX $ 20.730002245676 ESTRADOT (EDS) NVR 20.800002243722 OESCLIM (EDS) PAL 21.160000756849 ESTRADERM (EDS) NVR 25.4000

37.5UG TRANSDERMAL THERAPEUTIC SYSTEM (PKG)02243999 ESTRADOT (EDS) NVR $ 20.8000

* 50UG TRANSDERMAL PATCH (PKG)02246967 SANDOZ ESTRADIOL DERM (EDS) SDZ $ 14.800002244000 ESTRADOT (EDS) NVR 22.2317

160

68:00 HORMONES AND SYNTHETIC SUBSTITUTES68:16.00 ESTROGENS

⌧ 50UG TRANSDERMAL THERAPEUTIC SYSTEM (PKG)02243724 OESCLIM (EDS) PAL $ 21.160002231509 CLIMARA 50 (EDS) BEX 22.140000756857 ESTRADERM (EDS) NVR 27.1600


75UG TRANSDERMAL THERAPEUTIC SYSTEM (PKG)02247500 CLIMARA 75 (EDS) BEX $ 23.6000


⌧ 100UG TRANSDERMAL THERAPEUTIC SYSTEM (PKG)02231510 CLIMARA 100 (EDS) BEX $ 24.960000756792 ESTRADERM (EDS) NVR 30.6600

ESTRADIOL & NORETHINDRONE ACETATE/ESTRADIOL SEE APPENDIX A FOR EDS CRITERIA 50UG & 140UG/50UG TRANSDERMAL THERAPEUTIC SYSTEM (8)

02243529 ESTALIS-SEQUI (EDS) NVR $ 23.0800⌧ 50UG & 250UG/50UG TRANSDERMAL THERAPEUTIC SYSTEM (8)

02243530 ESTALIS-SEQUI (EDS) NVR $ 23.200002108186 ESTRACOMB (EDS) NVR 23.8400

ESTRADIOL VALERATE 10MG/ML OILY INJECTION SUSPENSION (5ML)

00029238 DELESTROGEN THM $ 17.8600

ESTRADIOL/NORETHINDRONE ACETATE SEE APPENDIX A FOR EDS CRITERIA 50UG/140UG TRANSDERMAL THERAPEUTIC SYSTEM (8 )

02241835 ESTALIS (EDS) NVR $ 24.8500 50UG/250UG TRANSDERMAL THERAPEUTIC SYSTEM (8 )

02241837 ESTALIS (EDS) NVR $ 24.8500

ESTROPIPATE (CALCULATED AS SODIUMESTRONE SULFATE) 0.625MG TABLET

02089793 OGEN PFI $ 0.1704 1.25MG TABLET

02089769 OGEN PFI $ 0.3043 2.5MG TABLET

02089777 OGEN PFI $ 0.4811

161

68:00 HORMONES AND SYNTHETIC SUBSTITUTES68:16.12 ESTROGEN AGONIST-ANTAGONISTS

RALOXIFENE HCL SEE APPENDIX A FOR EDS CRITERIA 60MG TABLET

02239028 EVISTA (EDS) LIL $ 1.8368

68:18.00 GONADOTROPINS

CHORIONIC GONADOTROPIN SEE APPENDIX A FOR EDS CRITERIA 10000IU/VIAL INJECTION

01925679 PROFASI HP (EDS) SRO $ 55.990068:20.08 ANTI-DIABETIC DRUGS

(INSULINS-HUMAN BIOSYNTHETIC)

INSULIN (ISOPHANE) HUMAN BIOSYNTHETIC⌧ 100U/ML INJECTION SUSPENSION (10ML)

00587737 HUMULIN-N LIL $ 17.560002024225 NOVOLIN GE NPH NOO 20.1800

⌧ 100U/ML INJECTION SUSPENSION (5X3ML)01959239 HUMULIN-N CARTRIDGE LIL $ 36.410002024268 NOVOLIN GE NPH PENFILL NOO 40.3400

INSULIN (REGULAR) ASPART SEE APPENDIX A FOR EDS CRITERIA 100U/ML INJECTION SOLUTION (10ML)

02245397 NOVORAPID (EDS) NOO $ 28.4200 100U/ML INJECTION SOLUTION (5X3ML)

02244353 NOVORAPID (EDS) NOO $ 56.8600

INSULIN (REGULAR) HUMAN BIOSYNTHETIC⌧ 100U/ML INJECTION SOLUTION (10ML)

00586714 HUMULIN-R LIL $ 17.560002024233 NOVOLIN GE TORONTO NOO 20.1800

⌧ 100U/ML INJECTION SOLUTION (5X3ML)01959220 HUMULIN-R CARTRIDGE LIL $ 36.410002024284 NOVOLIN GE TORONTO PENFIL NOO 40.3400

INSULIN (REGULAR) LISPRO SEE APPENDIX A FOR EDS CRITERIA 100U/ML INJECTION SOLUTION (10ML)

02229704 HUMALOG (EDS) LIL $ 26.4000 100U/ML INJECTION SOLUTION (5X3ML)

02229705 HUMALOG CARTRIDGE (EDS) LIL $ 52.8000

162

68:00 HORMONES AND SYNTHETIC SUBSTITUTES68:20.08 ANTI-DIABETIC DRUGS

(INSULINS-HUMAN BIOSYNTHETIC)

INSULIN (REGULAR/ISOPHANE) HUMAN BIOSYNTHETIC 100U/ML INJECTION SUSPENSION 10%/90% (5X3ML)

02024292 NOVOLIN GE 10/90 PENFILL NOO $ 40.3400 100U/ML INJECTION SUSPENSION 20%/80% (5X3ML)

02024306 NOVOLIN GE 20/80 PENFILL NOO $ 40.3400⌧ 100U/ML INJECTION SUSPENSION 30%/70% (10ML)

00795879 HUMULIN 30/70 LIL $ 17.560002024217 NOVOLIN GE 30/70 NOO 20.1800

⌧ 100U/ML INJECTION SUSPENSION 30%/70% (5X3ML)

01959212 HUMULIN 30/70 CARTRIDGE LIL $ 36.410002025248 NOVOLIN GE 30/70 PENFILL NOO 40.3400

100U/ML INJECTION SUSPENSION 40%/60% (5X3ML)

02024314 NOVOLIN GE 40/60 PENFILL NOO $ 40.3400 100U/ML INJECTION SUSPENSION 50%/50% (5X3ML)

02024322 NOVOLIN GE 50/50 PENFILL NOO $ 40.3400

INSULIN (REGULAR/PROTAMINE) LISPRO SEE APPENDIX A FOR EDS CRITERIA 100U/ML INJECTION SUSPENSION 25%/75% (5X3ML)

02240294 HUMALOG MIX25 (EDS) LIL $ 52.8000

68:20.20 ANTI-DIABETIC DRUGS (ORAL HYPOGLYCEMICS)

ACARBOSE 50MG TABLET

02190885 PRANDASE BAY $ 0.2653 100MG TABLET

02190893 PRANDASE BAY $ 0.3673

CHLORPROPAMIDE 100MG TABLET

00399302 APO-CHLORPROPAMIDE APX $ 0.0782* 250MG TABLET

00021350 NOVO-PROPAMIDE NOP $ 0.045400312711 APO-CHLORPROPAMIDE APX 0.0454

163

68:00 HORMONES AND SYNTHETIC SUBSTITUTES68:20.20 ANTI-DIABETIC DRUGS (ORAL HYPOGLYCEMICS)

GLYBURIDE* 2.5MG TABLET

02020734 NU-GLYBURIDE NXP $ 0.0309 *00720933 EUGLUCON PMS 0.042700808733 GEN-GLYBE GPM 0.042701900927 RATIO-GLYBURIDE RPH 0.042701913654 APO-GLYBURIDE APX 0.042701913670 NOVO-GLYBURIDE NOP 0.042702236733 PMS-GLYBURIDE PMS 0.042702234513 DOM-GLYBURIDE DOM 0.044902224550 DIABETA AVT 0.1201

* 5MG TABLET02020742 NU-GLYBURIDE NXP $ 0.0536 *00720941 EUGLUCON PMS 0.074100808741 GEN-GLYBE GPM 0.074101913662 APO-GLYBURIDE APX 0.074101913689 NOVO-GLYBURIDE NOP 0.074102236734 PMS-GLYBURIDE PMS 0.074102248009 SANDOZ GLYBURIDE SDZ 0.074101900935 RATIO-GLYBURIDE RPH 0.074302234514 DOM-GLYBURIDE DOM 0.077802224569 DIABETA AVT 0.2153

METFORMIN* 500MG TABLET

02229516 GLYCON VAE $ 0.0604 *02045710 NOVO-METFORMIN NOP 0.132002148765 GEN-METFORMIN GPM 0.132002162822 NU-METFORMIN NXP 0.132002167786 APO-METFORMIN APX 0.132002223562 PMS-METFORMIN PMS 0.132002242794 METFORMIN ZYP 0.132002242974 RATIO-METFORMIN RPH 0.132002246820 SANDOZ METFORMIN FC SDZ 0.132002257726 CO METFORMIN COB 0.132002269031 RAN-METFORMIN RAN 0.132002229994 DOM-METFORMIN DOM 0.150402099233 GLUCOPHAGE AVT 0.2507

164


* 850MG TABLET02239214 GLYCON VAE $ 0.1553 *02229517 NU-METFORMIN NXP 0.226802229656 GEN-METFORMIN GPM 0.226802229785 APO-METFORMIN APX 0.226802230475 NOVO-METFORMIN NOP 0.226802242589 PMS-METFORMIN PMS 0.226802242793 METFORMIN ZYP 0.226802242931 RATIO-METFORMIN RPH 0.226802246821 SANDOZ METFORMIN FC SDZ 0.226802257734 CO METFORMIN COB 0.226802269058 RAN-METFORMIN RAN 0.226802242726 DOM-METFORMIN DOM 0.238202162849 GLUCOPHAGE AVT 0.3176

NATEGLINIDE SEE APPENDIX A FOR EDS CRITERIA 60MG TABLET

02245438 STARLIX (EDS) NVR $ 0.5472 120MG TABLET

02245439 STARLIX (EDS) NVR $ 0.5472 180MG TABLET

02245440 STARLIX (EDS) NVR $ 0.5859

PIOGLITAZONE HCL SEE APPENDIX B FOR ONLINE ADJUDICATION 15MG TABLET

02242572 ACTOS (ONLINE ADJUDICATION) LIL $ 2.2832 30MG TABLET

02242573 ACTOS (ONLINE ADJUDICATION) LIL $ 3.1986 45MG TABLET

02242574 ACTOS (ONLINE ADJUDICATION) LIL $ 4.7660

REPAGLINIDE SEE APPENDIX A FOR EDS CRITERIA 0.5MG TABLET

02239924 GLUCONORM (EDS) NOO $ 0.3134 1MG TABLET

02239925 GLUCONORM (EDS) NOO $ 0.3259 2MG TABLET

02239926 GLUCONORM (EDS) NOO $ 0.3385

165


ROSIGLITAZONE MALEATE SEE APPENDIX B FOR ONLINE ADJUDICATION 2MG TABLET

02241112 AVANDIA (ONLINE ADJUDICATION) GSK $ 1.3947 4MG TABLET

02241113 AVANDIA (ONLINE ADJUDICATION) GSK $ 2.1884 8MG TABLET

02241114 AVANDIA (ONLINE ADJUDICATION) GSK $ 3.1294

ROSIGLITAZONE MALEATE/METFORMIN HCL SEE APPENDIX A FOR EDS CRITERIA 1MG/500MG TABLET

02247085 AVANDAMET (EDS) GSK $ 0.6510 2MG/500MG TABLET




02248441 AVANDAMET (EDS) GSK $ 2.2243

TOLBUTAMIDE 500MG TABLET

00312762 APO-TOLBUTAMIDE APX $ 0.0896

68:24.00 PARATHYROID

CALCITONIN SALMON SEE APPENDIX A FOR EDS CRITERIA 100IU/ML INJECTION (1ML)

02007134 CALTINE 100 (EDS) FEI $ 8.4900 200IU/ML INJECTION (2ML)

01926691 CALCIMAR (EDS) AVT $ 49.8500* 200IU/DOSE NASAL SPRAY (BOTTLE)

02247585 APO-CALCITONIN (EDS) APX $ 26.220002240775 MIACALCIN (EDS) NVR 27.9300

166

68:00 HORMONES AND SYNTHETIC SUBSTITUTES68:28.00 PITUITARY AGENTS

COSYNTROPIN ZINC HYDROXIDE 1MG/ML INJECTION SUSPENSION (1ML)

00253952 SYNACTHEN DEPOT NVR $ 28.8600

DESMOPRESSIN SEE APPENDIX A FOR EDS CRITERIA 0.1MG TABLET

00824305 D.D.A.V.P. (EDS) FEI $ 1.4341 0.2MG TABLET

00824143 D.D.A.V.P. (EDS) FEI $ 2.8681 4UG/ML INJECTION (1ML)

00873993 D.D.A.V.P. (EDS) FEI $ 11.5100 10UG/DOSE INTRANASAL SOLUTION

00402516 D.D.A.V.P. (EDS) FEI $ 51.2200* 10UG/DOSE INTRANASAL SOLUTION (SPRAY PUMP)

02242465 APO-DESMOPRESSIN (EDS) APX $ 71.700000836362 D.D.A.V.P. (EDS) FEI 102.4300

150UG/DOSE INTRANASAL SOLUTION (SPRAY PUMP)02237860 OCTOSTIM (EDS) FEI $ 416.0000

SOMATROPIN SEE APPENDIX A FOR EDS CRITERIA 3.33MG INJECTION (VIAL)

02215136 SAIZEN (EDS) SRO $ 157.2200⌧ 5MG INJECTION (VIAL)

02216183 NUTROPIN (EDS) HLR $ 195.900002237971 SAIZEN (EDS) SRO 236.010000745626 HUMATROPE (EDS) LIL 238.3500

6MG INJECTION (CARTRIDGE)02243077 HUMATROPE CARTRIDGE (EDS) LIL $ 303.8300

8.8MG INJECTION (VIAL)02272083 SAIZEN (EDS) SRO $ 377.5800

⌧ 10MG INJECTION (VIAL)02229722 NUTROPIN AQ (EDS) HLR $ 386.800002216191 NUTROPIN (EDS) HLR 411.8000

10MG INJECTION (CARTRIDGE)02249002 NUTROPIN AQ PEN (EDS) HLR $ 411.8000

12MG INJECTION (CARTRIDGE)02243078 HUMATROPE CARTRIDGE (EDS) LIL $ 590.0400

167

68:00 HORMONES AND SYNTHETIC SUBSTITUTES68:32.00 PROGESTINS

CONJUGATED ESTROGENS/MEDROXYPROGESTERONEACETATE SEE SECTION 68:16.00 (ESTROGENS)

ESTRADIOL & NORETHINDRONE ACETATE/ESTRADIOL SEE SECTION 68:16.00 (ESTROGENS)

ESTRADIOL/NORETHINDRONE ACETATE SEE SECTION 68:16.00 (ESTROGENS)

MEDROXYPROGESTERONE ACETATE* 2.5MG TABLET

02148552 RATIO-MPA RPH $ 0.086202221284 NOVO-MEDRONE NOP 0.086202229838 GEN-MEDROXY GPM 0.086202244726 APO-MEDROXY APX 0.086202246627 PMS-MEDROXYPROGESTERONE PMS 0.086202252740 NU-MEDROXY NXP 0.086202247581 DOM-MEDROXYPROGESTERONE DOM 0.090500708917 PROVERA PFI 0.1737

* 5MG TABLET02148560 RATIO-MPA RPH $ 0.170302221292 NOVO-MEDRONE NOP 0.170302229839 GEN-MEDROXY GPM 0.170302244727 APO-MEDROXY APX 0.170302246628 PMS-MEDROXYPROGESTERONE PMS 0.170302252759 NU-MEDROXY NXP 0.170302247582 DOM-MEDROXYPROGESTERONE DOM 0.178800030937 PROVERA PFI 0.3436

* 10MG TABLET02148579 RATIO-MPA RPH $ 0.343902221306 NOVO-MEDRONE NOP 0.343902229840 GEN-MEDROXY GPM 0.343902246629 PMS-MEDROXYPROGESTERONE PMS 0.343902247583 DOM-MEDROXYPROGESTERONE DOM 0.361100729973 PROVERA PFI 0.6970

50MG/ML INJECTION SUSPENSION (5ML)00030848 DEPO-PROVERA PFI $ 26.2500

150MG/ML INJECTION SUSPENSION (1ML)00585092 DEPO-PROVERA PFI $ 28.1600

PROGESTERONE (MICRONIZED) SEE APPENDIX A FOR EDS CRITERIA 100MG CAPSULE

02166704 PROMETRIUM (EDS) SCH $ 0.9204

168

68:00 HORMONES AND SYNTHETIC SUBSTITUTES68:36.04 THYROID AGENTS

LEVOTHYROXINE (SODIUM) 0.025MG TABLET

02172062 SYNTHROID ABB $ 0.0852* 0.05MG TABLET

02213192 ELTROXIN GSK $ 0.028502172070 SYNTHROID ABB 0.0585

0.075MG TABLET02172089 SYNTHROID ABB $ 0.0920


* 0.1MG TABLET02213206 ELTROXIN GSK $ 0.035002172100 SYNTHROID ABB 0.0721







THYROID 30MG TABLET

00023949 THYROID ERF $ 0.0401 60MG TABLET

00023957 THYROID ERF $ 0.0497 125MG TABLET

00023965 THYROID ERF $ 0.0868

169

68:00 HORMONES AND SYNTHETIC SUBSTITUTES68:36.08 ANTITHYROID AGENTS

METHIMAZOLE 5MG TABLET

00015741 TAPAZOLE PAL $ 0.2510

PROPYLTHIOURACIL 50MG TABLET

00010200 PROPYL-THYRACIL PAL $ 0.2231 100MG TABLET

00010219 PROPYL-THYRACIL PAL $ 0.3491

170

SKIN AND MUCOUS MEMBRANE AGENTS

84:00

84:00 SKIN AND MUCOUS MEMBRANE AGENTS84:04.04 ANTI-INFECTIVES (ANTIBIOTICS)

CLINDAMYCIN PHOSPHATE* 1% TOPICAL SOLUTION

02266938 TARO-CLINDAMYCIN TAR $ 0.245300582301 DALACIN T PFI 0.3190

ERYTHROMYCIN/ETHYL ALCOHOL 2%/71.2% TOPICAL LOTION/PRE-MOISTENED PADS

02047799 T-STAT WSD $ 0.1923

FRAMYCETIN SO4 1% GAUZE (10CM X 10CM)

01988840 SOFRA-TULLE ERF $ 1.1773 1% GAUZE (30CM X 10CM)

01987682 SOFRA-TULLE ERF $ 3.3961

FUSIDIC ACID 2% TOPICAL CREAM

00586668 FUCIDIN LEO $ 0.6260

MUPIROCIN 2% CREAM

02239757 BACTROBAN GCH $ 0.5512 2% OINTMENT

01916947 BACTROBAN GCH $ 0.5512

POLYMYXIN B SO4/NEOMYCIN SO4/BACITRACIN(ZINC) 5,000U/5MG/400U PER G TOPICAL OINTMENT

00666122 NEOSPORIN GSK $ 0.4652

POLYMYXIN B SO4/NEOMYCIN SO4/GRAMICIDIN 10,000U/5MG/0.25MG PER G TOPICAL CREAM

00666203 NEOSPORIN GSK $ 0.4652

SODIUM FUSIDATE 2% TOPICAL OINTMENT

00586676 FUCIDIN LEO $ 0.6260

84:04.08 ANTI-INFECTIVES (ANTI-FUNGALS)

CICLOPIROX OLAMINE 1% TOPICAL CREAM

02221802 LOPROX AVT $ 0.5968

172

84:00 SKIN AND MUCOUS MEMBRANE AGENTS84:04.08 ANTI-INFECTIVES (ANTI-FUNGALS)

CLOTRIMAZOLE 200MG VAGINAL TABLET

02150921 CANESTEN-3-COMBI-PAK BCD $ 13.1100* 1% TOPICAL CREAM

00812382 CLOTRIMADERM TAR $ 0.230802150867 CANESTEN BCD 0.3705

* 1% VAGINAL CREAM00812366 CLOTRIMADERM TAR $ 0.189902150891 CANESTEN-6 BCD 0.2400

* 2% VAGINAL CREAM00812374 CLOTRIMADERM TAR $ 0.379802150905 CANESTEN-3 BCD 0.4800

500MG VAGINAL SUPPOSITORY/1% TOPICAL CREAM (COMBINATION PACKAGE)

02150948 CANESTEN-1-COMBI-PAK BCD $ 13.1100

ECONAZOLE NITRATE 150MG VAGINAL SUPPOSITORY

02010267 ECOSTATIN WSD $ 6.4197 1% TOPICAL CREAM

02011948 ECOSTATIN WSD $ 0.4898

KETOCONAZOLE* 2% TOPICAL CREAM

02245662 KETODERM OPT $ 0.343700703974 NIZORAL MCL 0.5162

MICONAZOLE NITRATE 100MG VAGINAL SUPPOSITORY

02084295 MONISTAT-7 MCL $ 1.7222 100MG VAGINAL SUPPOSITORY/2% TOPICAL CREAM (COMBINATION PACKAGE)

02126257 MONISTAT 7 COMBINATION MCL $ 13.8000 400MG VAGINAL OVULES

02126605 MONISTAT-3 MCL $ 4.0182 400MG VAGINAL OVULES/2% TOPICAL CREAM (COMBINATION PACKAGE)

02126249 MONISTAT 3 COMBINATION MCL $ 13.8000* 2% VAGINAL CREAM

02231106 MICOZOLE TAR $ 0.164102084309 MONISTAT-7 MCL 0.3445

2% TOPICAL CREAM02085852 MICATIN MCL $ 0.3849

173

84:00 SKIN AND MUCOUS MEMBRANE AGENTS84:04.08 ANTI-INFECTIVES (ANTI-FUNGALS)

NYSTATIN 100,000U VAGINAL TABLET

02194171 RATIO-NYSTATIN RPH $ 0.1519* 100,000U/G TOPICAL CREAM

00716871 NYADERM TAR $ 0.076002194236 RATIO-NYSTATIN RPH 0.076000029092 MYCOSTATIN PPZ 0.3122

100,000U/G TOPICAL OINTMENT02194228 RATIO-NYSTATIN RPH $ 0.1556

* 25,000U/G VAGINAL CREAM00716901 NYADERM TAR $ 0.053400295973 MYCOSTATIN PPZ 0.0980

100,000U/G VAGINAL CREAM02194163 RATIO-NYSTATIN RPH $ 0.2771

100,000U/G TOPICAL POWDER02195704 CANDISTATIN WSD $ 0.4218

TERBINAFINE HCL 1% TOPICAL CREAM

02031094 LAMISIL NVR $ 0.5213 1% TOPICAL SPRAY SOLUTION

02238703 LAMISIL NVR $ 0.5238

TERCONAZOLE 80MG VAGINAL OVULES

00894710 TERAZOL-3 JAN $ 6.9188 80MG VAGINAL OVULES/0.8% CREAM (DUAL-PAK)

02130874 TERAZOL-3 DUAL-PAK JAN $ 20.7600* 0.4% VAGINAL CREAM (PKG)

02247651 TARO-TERCONAZOLE TAR $ 13.313000894729 TERAZOL-7 JAN 20.7600

0.8% VAGINAL CREAM (PKG)01934155 TERAZOL-3 JAN $ 20.7600

84:04.12 ANTI-INFECTIVES (SCABICIDES AND PEDICULICIDES)

CROTAMITON 10% TOPICAL CREAM

00623377 EURAX CLC $ 0.3744

174

84:00 SKIN AND MUCOUS MEMBRANE AGENTS84:04.12 ANTI-INFECTIVES (SCABICIDES AND PEDICULICIDES)

GAMMA-BENZENE HEXACHLORIDE 1% TOPICAL LOTION

00703591 PMS-LINDANE PMS $ 0.1270* 1% SHAMPOO

00430617 HEXIT SHAMPOO ODN $ 0.121600703605 PMS-LINDANE PMS 0.1270

PERMETHRIN* 1% CREME RINSE

02231480 KWELLADA-P CREME RINSE GCH $ 0.112900771368 NIX CREME RINSE IPC 0.1299

5% TOPICAL CREAM02219905 NIX DERMAL CREAM GCH $ 0.4991

5% TOPICAL LOTION02231348 KWELLADA-P LOTION GCH $ 0.2697

PYRETHINS/PIPERONYL BUTOXIDE/PETROLEUM DISTILLATE 0.33%/3.0%/1.2% SHAMPOO/CONDITIONER

02125447 R&C SHAMPOO/CONDITIONER GCH $ 0.1090

84:04.16 MISCELLANEOUS ANTI-INFECTIVES

HEXACHLOROPHENE 3% TOPICAL EMULSION

02017733 PHISOHEX AVT $ 0.0620

METRONIDAZOLE 0.75% TOPICAL GEL

02092832 METROGEL GAC $ 0.6510 0.75% TOPICAL CREAM

02226839 METROCREAM GAC $ 0.5354 0.75% TOPICAL LOTION

02248206 METROLOTION GAC $ 0.5354 1% TOPICAL CREAM

02156091 NORITATE DER $ 0.5354 1% TOPICAL CREAM (WITH SUNSCREEN)

02242919 ROSASOL STI $ 0.5357 0.75% VAGINAL GEL

02125226 NIDAGEL MDA $ 0.2834 10% VAGINAL CREAM

01926861 FLAGYL AVT $ 0.2189

175

84:00 SKIN AND MUCOUS MEMBRANE AGENTS84:04.16 MISCELLANEOUS ANTI-INFECTIVES

POVIDONE-IODINE 200MG VAGINAL SUPPOSITORY

00026050 BETADINE PFR $ 0.7945 10% VAGINAL SOLUTION

00026093 BETADINE PFR $ 0.0468

SULFACETAMIDE (SODIUM)/COLLOIDAL SULPHUR 10%/5% TOPICAL LOTION

02220407 SULFACET-R DER $ 0.8637

84:06.00 ANTI-INFLAMMATORY AGENTS

SEE INSERT THIS SECTION FOR TABLES SHOWING APPROXIMATERELATIVE POTENCIES OF TOPICAL STEROID PREPARATIONS, RELATIVERATES OF PENETRATION IN DIFFERENT ANATOMICAL SITES AND SUGGESTED GUIDELINES FOR TOPICAL STEROID THERAPY

AMCINONIDE* 0.1% TOPICAL CREAM

02246714 TARO-AMCINONIDE TAR $ 0.297302247098 RATIO-AMCINONIDE RPH 0.297302192284 CYCLOCORT STI 0.5585

* 0.1% TOPICAL OINTMENT02247096 RATIO-AMCINONIDE RPH $ 0.297302192268 CYCLOCORT STI 0.5585

* 0.1% TOPICAL LOTION02247097 RATIO-AMCINONIDE RPH $ 0.246602192276 CYCLOCORT STI 0.4693

BECLOMETHASONE DIPROPIONATE 0.025% TOPICAL CREAM

02089602 PROPADERM RBP $ 0.6431 0.025% TOPICAL LOTION

02089610 PROPADERM RBP $ 0.3961

176

GUIDELINES FOR TOPICAL STEROID THERAPY 1. Apply an appropriately potent compound to bring

the condition under control. 2.

Continue treatment, with a less potent preparation after control is achieved.

3.

Reduce the frequency of application.

4.

If required, continue application with the weakest preparation that will control the condition.

5.

Once healed, "tail off" treatment.

6.

Use special care in treating children, the elderly, and in certain anatomical sites (e.g. face and flexures).

7.

Use combination products (those containing anti-infective agents) only for short periods of time.

177

APPROXIMATERELATIVE POTENCIES

ofTOPICAL STEROID

PREPARATIONS

The classification of products in this table is based on The Rx Files - Topical Corticosteroids: Comparison Chart September 2004. Available from:http://www.rxfiles.ca/acrobat/CHT-SteroidClassPotencyCOLOR.pdf (Access verified May 18, 2006)

In general, ointments, as a result of their more occlusive property, tend to exhibit higher potency than creams of the same strength. Cream formulations, in turn, appear to be more potent than lotions containing the same concentration of the same anti-inflammatory agent.

178

ULTRA HIGH

POTENCY

GROUP I

Betamethasone dipropionate 0.05% glycol cream, ointment, lotion Betamethasone dipropionate 0.05%/salicylic acid 3% ointment Clobetasol propionate 0.05% cream, ointment, scalp lotion Halobetasol propionate 0.05% ointment

GROUP II

Amcinonide 0.1% ointment Betamethasone dipropionate 0.05% ointment Desoximetasone 0.25% cream, ointment Desoximetasone 0.5% gel Fluocinonide 0.05% cream, ointment, gel, emollient base Halcinonide 0.1% cream, ointment, solution Halobetasol propionate 0.05% cream

HIGH POTENCY

GROUP III

Betamethasone dipropionate 0.05% cream Betamethasone valerate 0.1% ointment Triamcinolone acetonide 0.1% ointment Mometasone furoate 0.1%, ointment

GROUP IV

Amcinonide 0.1% cream, lotion Beclomethasone dipropionate 0.025% cream, lotion Clobetasone butyrate, 0.05% cream, ointment Desoximetasone 0.05% cream Diflucortolone valerate,0.1%, cream, ointment Fluocinolone acetonide 0.025% ointment Hydrocortisone valerate 0.2% ointment Mometasone furoate 0.1% cream,, lotion Triamcinolone acetonide 0.1% cream

MID POTENCY

GROUP V

Betamethasone valerate 0.1% cream, lotion Betamethasone valerate 0.05% cream, ointment, lotion Fluocinolone acetonide 0.01% cream, solution, shampoo Fluocinolone acetonide 0.025% cream Hydrocortisone valerate 0.2% cream Triamcinolone acetonide 0.025% cream

GROUP

VI

Desonide 0.05% cream, ointment, lotion Hydrocortisone/Urea 1%/10%, cream, lotion

LOW POTENCY

GROUP

VII

Hydrocortisone 2.5% cream, lotion, scalp solution 1% cream, ointment, lotion 0.5% lotion

179

RELATIVE RATES OF PERCUTANEOUS PENETRATION IN DIFFERENT ANATOMICAL SITES (Based on hydrocortisone/forearm = 1) SITE

RELATIVE PENETRATION

Foot (plantar) 0.14 Palm 0.83 Forearm 1.0 Back 1.7 Scalp 3.5 Forehead 6.0 Jaw angle/cheeks 13.0 Scrotum 42.0

Arndt, K.A., Manual of Dermatological Therapeutics, 2nd Edition, p. 293

GUIDE TO TOPICAL QUANTITIES IN DERMATOLOGY Amount used three times daily for one week, average adult.

SITE

% BODY

SURFACE

VANISHING

CREAM

GREASE

BASE

SHAKE LOTION

THIN (NON SHAKE

LOTION)

PROPYLENE

GLYCOL

ONE WHOLE HAND or FOOT

2%

7.5g 10g 20mL 5mL 15mL

ONE WHOLE ARM

9% 30g 45g 90mL 24mL 60mL

TRUNK 36% 120g 180g 360mL 90mL

240mL

GENITAL AREA

1% 7.5g 5g not used here 5mL 7.5mL

ONE TOTAL LEG

18% 60g 90g 180mL 45mL 120mL

TOTAL FACE

4.5% 15g 20g 40mL 10mL 30mL

BODY

100% 375g 500g 1000mL 240mL 750mL

180

84:00 SKIN AND MUCOUS MEMBRANE AGENTS84:06.00 ANTI-INFLAMMATORY AGENTS

BETAMETHASONE DIPROPIONATE PENETRATION OF ACTIVE DRUG THROUGH THE EPIDERMIS IS ENHANCED BY THE PROPYLENE GLYCOL BASE, RESULTING IN INCREASED POTENCY, BECAUSE OF THE DIFFERENCE IN POTENCY YET SIMILARITY OF THE NAMES (DIPROSONE-DIPROLENE) EXTRA CAUTION IS ADVISED.* 0.05% TOPICAL CREAM

00323071 DIPROSONE SCH $ 0.222201925350 TARO-SONE TAR 0.2222

* 0.05% TOPICAL OINTMENT00344923 DIPROSONE SCH $ 0.233700805009 RATIO-TOPISONE RPH 0.2337

* 0.05% TOPICAL LOTION00417246 DIPROSONE SCH $ 0.214900809187 RATIO-TOPISONE RPH 0.2149

* 0.05% TOPICAL GLYCOL CREAM00688622 DIPROLENE SCH $ 0.562800849650 RATIO-TOPILENE RPH 0.5628

* 0.05% TOPICAL GLYCOL OINTMENT00629367 DIPROLENE SCH $ 0.562800849669 RATIO-TOPILENE RPH 0.5628

* 0.05% TOPICAL GLYCOL LOTION00862975 DIPROLENE SCH $ 0.508301927914 RATIO-TOPILENE RPH 0.5083

BETAMETHASONE DIPROPIONATE/SALICYLIC ACID 0.05%/3% TOPICAL OINTMENT

00578436 DIPROSALIC SCH $ 0.7697* 0.05%/2% TOPICAL LOTION

00578428 DIPROSALIC SCH $ 0.382402245688 RATIO-TOPISALIC RPH 0.3824

BETAMETHASONE DISODIUM PHOSPHATE 5MG/100ML ENEMA (100ML)

02060884 BETNESOL ENEMA RBP $ 9.2600

181


BETAMETHASONE VALERATE* 0.05% TOPICAL CREAM

00716618 BETADERM TAR $ 0.065800535427 RATIO-ECTOSONE RPH 0.0664

* 0.1% TOPICAL CREAM00716626 BETADERM TAR $ 0.098000535435 RATIO-ECTOSONE RPH 0.0990

0.05% TOPICAL OINTMENT00716642 BETADERM TAR $ 0.0658

0.1% TOPICAL OINTMENT00716650 BETADERM TAR $ 0.0981

0.05% TOPICAL LOTION00653209 RATIO-ECTOSONE MILD RPH $ 0.2062

0.1% TOPICAL LOTION00750050 RATIO-ECTOSONE RPH $ 0.2713

* 0.1% SCALP LOTION00716634 BETADERM TAR $ 0.092700027944 VALISONE SCH 0.092700653217 RATIO-ECTOSONE RPH 0.0927

BUDESONIDE 0.02MG/ML ENEMA (100ML)

02052431 ENTOCORT AST $ 8.6100

CLOBETASOL PROPIONATE* 0.05% TOPICAL CREAM

01910272 RATIO-CLOBETASOL RPH $ 0.441402024187 GEN-CLOBETASOL GPM 0.441402093162 NOVO-CLOBETASOL NOP 0.441402232191 PMS-CLOBETASOL PMS 0.441402245523 TARO-CLOBETASOL CREAM TAR 0.441402213265 DERMOVATE OPT 0.8131

* 0.05% TOPICAL OINTMENT02026767 GEN-CLOBETASOL GPM $ 0.441402126192 NOVO-CLOBETASOL NOP 0.441402232193 PMS-CLOBETASOL PMS 0.441402245524 TARO-CLOBETASOL OINTMENT TAR 0.441402213273 DERMOVATE OPT 0.8131

* 0.05% SCALP APPLICATION02216213 GEN-CLOBETASOL GPM $ 0.386802232195 PMS-CLOBETASOL PMS 0.386802245522 TARO-CLOBETASOL SOLUTION TAR 0.386801910299 RATIO-CLOBETASOL RPH 0.386802213281 DERMOVATE OPT 0.6169

182


CLOBETASONE BUTYRATE 0.05% TOPICAL CREAM

02214415 EUMOVATE GCH $ 0.4774 0.05% TOPICAL OINTMENT

02214423 EUMOVATE GCH $ 0.4142

DESONIDE* 0.05% TOPICAL CREAM

02229315 PMS-DESONIDE PMS $ 0.283702048639 DESOCORT GAC 0.3147

* 0.05% TOPICAL OINTMENT02229323 PMS-DESONIDE PMS $ 0.283702115522 DESOCORT GAC 0.3147

0.05% TOPICAL LOTION02115514 DESOCORT GAC $ 0.1574

DESOXIMETASONE 0.05% TOPICAL CREAM

02221918 TOPICORT MILD AVT $ 0.4530 0.25% TOPICAL CREAM

02221896 TOPICORT AVT $ 0.6538 0.05% TOPICAL GEL

02221926 TOPICORT AVT $ 0.4467 0.25% TOPICAL OINTMENT

02221934 TOPICORT AVT $ 0.5761

DIFLUCORTOLONE VALERATE 0.1% TOPICAL CREAM

00587826 NERISONE STI $ 0.3943 0.1% TOPICAL OILY CREAM

00587818 NERISONE STI $ 0.3943 0.1% TOPICAL OINTMENT

00587834 NERISONE STI $ 0.3943

FLUOCINOLONE ACETONIDE 0.025% TOPICAL OINTMENT

02162512 SYNALAR REGULAR MDC $ 0.4676 0.01% TOPICAL SOLUTION

02162504 SYNALAR MDC $ 0.4440 0.01% TOPICAL OIL

00873292 DERMA-SMOOTHE/FS HDI $ 0.2681 0.01% SHAMPOO

02242738 CAPEX SHAMPOO GAC $ 0.2842

183


FLUOCINONIDE* 0.05% TOPICAL CREAM

00716863 LYDERM OPT $ 0.500702161923 LIDEX MDC 0.5010

* 0.05% TOPICAL GEL02236997 LYDERM OPT $ 0.371102161974 TOPSYN MDC 0.5561

* 0.05% TOPICAL OINTMENT02236996 LYDERM OPT $ 0.365702161966 LIDEX MDC 0.5525

0.05% IN EMOLLIENT BASE02163152 LIDEMOL MDC $ 0.6041

HALCINONIDE 0.1% TOPICAL CREAM

02011921 HALOG WSD $ 0.5480 0.1% TOPICAL OINTMENT

02010283 HALOG WSD $ 0.5480 0.1% TOPICAL SOLUTION

02010291 HALOG WSD $ 0.5480

HALOBETASOL PROPIONATE SEE APPENDIX A FOR EDS CRITERIA 0.05% CREAM

01962701 ULTRAVATE (EDS) WSD $ 0.8449 0.05% OINTMENT

01962728 ULTRAVATE (EDS) WSD $ 0.8449

HYDROCORTISONE* 0.5% TOPICAL CREAM

00513288 CORTATE SCP $ 0.144800716820 HYDERM TAR 0.1809

* 1% TOPICAL CREAM00716839 HYDERM TAR $ 0.039500192597 EMO-CORT STI 0.1718

2.5% TOPICAL CREAM00595799 EMO-CORT STI $ 0.2344

* 0.5% TOPICAL OINTMENT00513261 CORTATE SCP $ 0.144800716685 CORTODERM TAR 0.1519

1% TOPICAL OINTMENT00716693 CORTODERM TAR $ 0.0424

0.5% TOPICAL LOTION00513253 CORTATE SCP $ 0.1177

184


⌧ 1% TOPICAL LOTION00578541 SARNA HC STI $ 0.093800192600 EMO-CORT STI 0.1587

⌧ 2.5% TOPICAL LOTION00856711 SARNA HC STI $ 0.181200595802 EMO-CORT STI 0.2099

2.5% SCALP SOLUTION00641154 EMO-CORT STI $ 0.1985

* 100MG/60ML ENEMA (60ML)00230316 HYCORT VAE $ 5.580002112736 CORTENEMA AXC 6.5700

HYDROCORTISONE ACETATE 10% RECTAL AEROSOL FOAM (15G)

00579335 CORTIFOAM PAL $ 92.3000

HYDROCORTISONE VALERATE* 0.2% TOPICAL CREAM

01910124 WESTCORT WSD $ 0.180902242984 HYDROVAL OPT 0.1809

* 0.2% TOPICAL OINTMENT01910132 WESTCORT WSD $ 0.180902242985 HYDROVAL OPT 0.1809

HYDROCORTISONE/UREA 1%/10% TOPICAL CREAM

00503134 UREMOL-HC STI $ 0.1747 1%/10% TOPICAL LOTION

00560022 UREMOL-HC STI $ 0.0970

MOMETASONE FUROATE 0.1% TOPICAL CREAM

00851744 ELOCOM SCH $ 0.6940* 0.1% TOPICAL OINTMENT

02244769 PMS-MOMETASONE PMS $ 0.379102248130 RATIO-MOMETASONE RPH 0.379102264749 TARO-MOMETASONE OINTMENT TAR 0.379102270862 PMS-MOMETASONE PMS 0.379100851736 ELOCOM SCH 0.6940

0.1% TOPICAL LOTION00871095 ELOCOM SCH $ 0.5397

185


TRIAMCINOLONE ACETONIDE* 0.1% TOPICAL CREAM

00716960 TRIADERM TAR $ 0.070602194058 ARISTOCORT R VAL 0.1411

0.1% TOPICAL OINTMENT02194031 ARISTOCORT R VAL $ 0.1411

* 0.1% ORAL TOPICAL OINTMENT01964054 ORACORT DENTAL PASTE TAR $ 1.171801999788 KENALOG-ORABASE WSD 1.4431

84:06.00 COMBINATION ANTI-INFECTIVE/ ANTI-INFLAMMATORY AGENTS

BETAMETHASONE DIPROPIONATE/CLOTRIMAZOLE 0.05%/1% TOPICAL CREAM

00611174 LOTRIDERM SCH $ 0.6706

FUSIDIC ACID/HYDROCORTISONE ACETATE 2%/1% TOPICAL CREAM

02238578 FUCIDIN H LEO $ 1.0446

NEOMYCIN/GRAMICIDIN/NYSTATIN/TRIAMCINOLONE ACETONIDE 2.5MG/0.25MG/100,000U/1MG PER G TOPICAL CREAM

00717002 VIADERM-KC TAR $ 0.4594 2.5MG/0.25MG/100,000U/1MG PER G TOPICAL OINTMENT

00717029 VIADERM-KC TAR $ 0.4594

POLYMYXIN B SO4/BACITRACIN (ZINC)/NEOMYCIN SO4/HYDROCORTISONE 5000U/400U/5MG/10MG PER G TOPICAL OINTMENT

00666246 CORTISPORIN GSK $ 0.7828

84:08.00 ANTIPRURITICS AND LOCAL ANAESTHETICS

PHENAZOPYRIDINE 100MG TABLET

00271489 PHENAZO VAE $ 0.1281 200MG TABLET

00454583 PHENAZO VAE $ 0.1598

186

84:00 SKIN AND MUCOUS MEMBRANE AGENTS84:12.00 ASTRINGENTS

ALUMINUM ACETATE/BENZETHONIUM CHLORIDE 0.35%/0.023% POWDER (2.36G PACKAGE)

00579947 BURO-SOL STI $ 0.7487

84:16.00 CELL STIMULANTS AND PROLIFERANTS

CONDITIONS OTHER THAN ACNE VULGARIS ARE NOT APPROVED INDICATIONS FOR THE USE OF TOPICAL RETINOIDS.

ADAPALENE 0.1% TOPICAL CREAM

02231592 DIFFERIN GAC $ 0.6752 0.1% TOPICAL GEL

02148749 DIFFERIN GAC $ 0.6752

TRETINOIN SEE APPENDIX A FOR EDS CRITERIA* 0.01% TOPICAL CREAM

00657204 STIEVA-A STI $ 0.308201926497 VITAMIN A ACID DER 0.308200897329 RETIN A JAN 0.3863

* 0.01% TOPICAL GEL00587958 STIEVA-A STI $ 0.308201926462 VITAMIN A ACID DER 0.308200870013 RETIN A JAN 0.3748

* 0.025% TOPICAL CREAM00578576 STIEVA-A STI $ 0.308201926500 VITAMIN A ACID DER 0.308200897310 RETIN A JAN 0.3863

* 0.025% TOPICAL GEL00587966 STIEVA-A STI $ 0.308201926470 VITAMIN A ACID DER 0.308200443816 RETIN A JAN 0.3748

0.025% TOPICAL SOLUTION00578568 STIEVA-A STI $ 0.1932

* 0.05% TOPICAL CREAM00518182 STIEVA-A STI $ 0.309001926519 VITAMIN A ACID DER 0.309000443794 RETIN A JAN 0.3748

* 0.05% TOPICAL GEL00641863 STIEVA-A STI $ 0.308201926489 VITAMIN A ACID DER 0.3082

* 0.1% TOPICAL CREAM00662348 STIEVA-A FORTE (EDS) STI $ 0.308201926527 VITAMIN A ACID (EDS) DER 0.308200870021 RETIN A (EDS) JAN 0.3863

187

84:00 SKIN AND MUCOUS MEMBRANE AGENTS84:28.00 KERATOLYTIC AGENTS

BENZOYL PEROXIDE 10% BAR

00527661 PANOXYL STI $ 9.1400* 10% TOPICAL LOTION

00432938 OXYDERM VAE $ 0.167700370568 BENOXYL STI 0.1910

* 20% TOPICAL LOTION00187585 BENOXYL STI $ 0.212200374318 OXYDERM VAE 0.2176

10% WASH01925199 BENZAC W GAC $ 0.0633

10% TOPICAL GEL (ALCOHOL BASE)00263699 PANOXYL-10 STI $ 0.1492

⌧ 10% TOPICAL GEL (AQUEOUS BASE)01908871 DESQUAM-X WSD $ 0.109601912437 BENZAC AC GAC 0.1682



CLINDAMYCIN PHOSPHATE/BENZOYL PEROXIDE* 1%/5% TOPICAL GEL

02248472 BENZACLIN DER $ 0.926602243158 CLINDOXYL GEL STI 0.9353

DITHRANOL 0.1% TOPICAL CREAM

00537594 ANTHRANOL MTI $ 0.6094 0.2% TOPICAL CREAM

00537608 ANTHRANOL MTI $ 0.6424 0.4% TOPICAL LOTION

00695351 ANTHRASCALP MTI $ 0.7595 1% TOPICAL OINTMENT

00566756 ANTHRAFORTE-1 MTI $ 0.8296 2% TOPICAL OINTMENT

00566748 ANTHRAFORTE-2 MTI $ 0.8752

ERYTHROMYCIN/BENZOYL PEROXIDE 3%/5% TOPICAL GEL

02225271 BENZAMYCIN DER $ 0.9389

PODOFILOX⌧ 0.5% TOPICAL SOLUTION (PACKAGE)

01945149 CONDYLINE CDX $ 40.150002074788 WARTEC PAL 41.6300

188

84:00 SKIN AND MUCOUS MEMBRANE AGENTS84:36.00 MISCELLANEOUS SKIN & MUCOUS

MEMBRANE AGENTS

ACITRETIN SEE APPENDIX A FOR EDS CRITERIA 10MG CAPSULE

02070847 SORIATANE (EDS) HLR $ 1.7621 25MG CAPSULE

02070863 SORIATANE (EDS) HLR $ 3.0952

CALCIPOTRIOL 50UG/G TOPICAL CREAM

02150956 DOVONEX LEO $ 0.7568 50UG/G TOPICAL OINTMENT

01976133 DOVONEX LEO $ 0.7568 50UG/ML SCALP SOLUTION

02194341 DOVONEX LEO $ 0.7568

CYCLOSPORINE NOTE: THE IDENTIFICATION NUMBERS LISTED FOR THIS PRODUCT HAVE BEEN GENERATED BY THE PRESCRIPTION DRUG PLAN FOR BILLING PURPOSES ONLY. SEE APPENDIX A FOR EDS CRITERIA 10MG CAPSULE

00950792 NEORAL (EDS) NVR $ 0.6770 25MG CAPSULE



00950815 NEORAL (EDS) NVR $ 6.1368 100MG/ML LIQUID

00950823 NEORAL (EDS) NVR $ 5.4550

IMIQUIMOD SEE APPENDIX A FOR EDS CRITERIA 5% TOPICAL CREAM (5G SACHET)

02239505 ALDARA (EDS) MDA $ 12.7588

ISOTRETINOIN* 10MG CAPSULE

00582344 ACCUTANE HLR $ 1.482202257963 CLARUS PRM 1.4822

* 40MG CAPSULE00582352 ACCUTANE HLR $ 3.024702257955 CLARUS PRM 3.0247

189

84:00 SKIN AND MUCOUS MEMBRANE AGENTS84:36.00 MISCELLANEOUS SKIN & MUCOUS

MEMBRANE AGENTS

METHOTREXATE* 2.5MG TABLET

02170698 METHOTREXATE WYA $ 0.686302182963 APO-METHOTREXATE DBU 0.686302244798 RATIO-METHOTREXATE RPH 0.6863

10MG TABLET02182750 METHOTREXATE DBU $ 2.6627

PIMECROLIMUS SEE APPENDIX A FOR EDS CRITERIA 1% TOPICAL CREAM

02247238 ELIDEL (EDS) NVR $ 2.2457

TACROLIMUS SEE APPENDIX A FOR EDS CRITERIA 0.03% TOPICAL OINTMENT

02244149 PROTOPIC (EDS) FUJ $ 2.3330 0.1% TOPICAL OINTMENT

02244148 PROTOPIC (EDS) FUJ $ 2.4960

TAZAROTENE 0.05% TOPICAL CREAM

02243894 TAZORAC ALL $ 1.4338 0.05% TOPICAL GEL

02230784 TAZORAC ALL $ 1.4338 0.1% TOPICAL CREAM

02243895 TAZORAC ALL $ 1.4338 0.1% TOPICAL GEL

02230785 TAZORAC ALL $ 1.433884:50.06 DEPIGMENTING & PIGMENTING AGENTS

(PIGMENTING AGENTS)

METHOXSALEN SEE APPENDIX A FOR EDS CRITERIA⌧ 10MG CAPSULE

00252654 OXSORALEN ULTRA (EDS) VAE $ 0.466600646237 ULTRAMOP (EDS) CDX 0.516001946374 OXSORALEN (EDS) VAE 0.6264

⌧ 1% LOTION00698059 ULTRAMOP (EDS) CDX $ 1.119801907476 OXSORALEN (EDS) VAE 1.5939

190

SMOOTH MUSCLE RELAXANTS86:00

86:00 SMOOTH MUSCLE RELAXANTS86:12.00 GENITOURINARY SMOOTH MUSCLE RELAXANTS

FLAVOXATE HCL SEE APPENDIX A FOR EDS CRITERIA* 200MG TABLET

02244842 APO-FLAVOXATE (EDS) APX $ 0.337702245480 PMS-FLAVOXATE (EDS) PMS 0.337700728179 URISPAS (EDS) PAL 0.5360

OXYBUTYNIN CHLORIDE* 5MG TABLET

02241285 DOM-OXYBUTYNIN DOM $ 0.1728 *02158590 NU-OXYBUTYN NXP 0.269702163543 APO-OXYBUTYNIN APX 0.269702220059 OXYBUTYN VAE 0.269702230394 NOVO-OXYBUTYNIN NOP 0.269702230800 GEN-OXYBUTYNIN GPM 0.269702240550 PMS-OXYBUTYNIN PMS 0.2697

* 1MG/ML SYRUP02223376 PMS-OXYBUTYNIN PMS $ 0.067501924753 DITROPAN JAN 0.1053

TOLTERODINE L-TARTRATE SEE APPENDIX A FOR EDS CRITERIA 2MG EXTENDED-RELEASE CAPSULE

02244612 DETROL LA (EDS) PFI $ 1.9747 4MG EXTENDED-RELEASE CAPSULE

02244613 DETROL LA (EDS) PFI $ 1.9747

192

86:00 SMOOTH MUSCLE RELAXANTS86:16.00 RESPIRATORY SMOOTH MUSCLE RELAXANTS

AMINOPHYLLINE 225MG SUSTAINED RELEASE TABLET

02014270 PHYLLOCONTIN PFR $ 0.2306 350MG SUSTAINED RELEASE TABLET

02014289 PHYLLOCONTIN-350 PFR $ 0.2939

OXTRIPHYLLINE 100MG TABLET

00441724 APO-OXTRIPHYLLINE APX $ 0.0516 200MG TABLET

00441732 APO-OXTRIPHYLLINE APX $ 0.0733 300MG TABLET

00511692 APO-OXTRIPHYLLINE APX $ 0.1031* 20MG/ML ELIXIR

00792942 PMS-OXTRIPHYLLINE PMS $ 0.024900476366 CHOLEDYL ERF 0.0378

THEOPHYLLINE (ANHYDROUS)⌧ 100MG SUSTAINED RELEASE TABLET

00692689 APO-THEO-LA APX $ 0.141102230085 NOVO-THEOPHYL SR NOP 0.1411

⌧ 200MG SUSTAINED RELEASE TABLET00692697 APO-THEO-LA APX $ 0.146502230086 NOVO-THEOPHYL SR NOP 0.1465

⌧ 300MG SUSTAINED RELEASE TABLET00692700 APO-THEO-LA APX $ 0.151902230087 NOVO-THEOPHYL SR NOP 0.1519

400MG SUSTAINED RELEASE TABLET02014165 UNIPHYL PFR $ 0.5297

600MG SUSTAINED RELEASE TABLET02014181 UNIPHYL PFR $ 0.6417

5.33MG/ML SOLUTION01966219 THEOLAIR LIQUID MDA $ 0.0208

193

VITAMINS88:00

88:00 VITAMINS88:08.00 VITAMIN B

CYANOCOBALAMIN* 1MG/ML INJECTION SOLUTION (10ML)

00521515 VITAMIN B12 SDZ $ 4.890001987003 CYANOCOBALAMIN CYT 4.8900

FOLIC ACID 5MG TABLET

00426849 APO-FOLIC APX $ 0.0439

LEUCOVORIN CALCIUM (FOLINIC ACID) SEE APPENDIX A FOR EDS CRITERIA 5MG TABLET

02170493 LEUCOVORIN (EDS) WYA $ 6.1688

NIACIN 50MG TABLET

00268593 NIACIN VAE $ 0.0154 100MG TABLET

00268585 NIACIN VAE $ 0.0317* 500MG TABLET

00294950 NIACIN VAE $ 0.049501939130 NIACIN ODN 0.0760

PYRIDOXINE HCL* 25MG TABLET

00268607 VITAMIN B6 VAE $ 0.028001943200 VITAMIN B6 ODN 0.0320

THIAMINE HCL 50MG TABLET

00268631 VITAMIN B1 VAE $ 0.0620* 100MG/ML INJECTION SOLUTION (10ML)

00816078 VITAMIN B1 SAB $ 12.890002193221 THIAMIJECT OMG 12.8900

196

88:00 VITAMINS88:16.00 VITAMIN D

VITAMIN D IS TOXIC IN EXCESSIVE DOSES.

ALFACALCIDOL SEE APPENDIX A FOR EDS CRITERIA 0.25UG CAPSULE

00474517 ONE-ALPHA (EDS) LEO $ 0.4438 1.0UG CAPSULE

00474525 ONE-ALPHA (EDS) LEO $ 1.3284 2UG/ML ORAL DROPS (ML)

02240329 ONE-ALPHA (EDS) LEO $ 5.0746

CALCIFEROL 8,288IU/ML ORAL SOLUTION

02017598 DRISDOL AVT $ 0.4411

CALCITRIOL SEE APPENDIX A FOR EDS CRITERIA 0.25UG CAPSULE

00481823 ROCALTROL (EDS) HLR $ 0.9872 0.5UG CAPSULE

00481815 ROCALTROL (EDS) HLR $ 1.5699 1UG/ML ORAL SOLUTION

00824291 ROCALTROL (EDS) HLR $ 3.1444

DOXERCALCIFEROL SEE APPENDIX A FOR EDS CRITERIA 2.5UG CAPSULE

02243790 HECTOROL (EDS) RBP $ 1.8445

VITAMIN D 50,000IU CAPSULE

00009830 OSTOFORTE MSD $ 0.2354

197

UNCLASSIFIED THERAPEUTIC AGENTS92:00

92:00 UNCLASSIFIED THERAPEUTIC AGENTS92:00.00 UNCLASSIFIED THERAPEUTIC AGENTS

ADALIMUMAB SEE APPENDIX A FOR EDS CRITERIA 40MG/0.8ML PRE-FILLED SYRINGE

02258595 HUMIRA (EDS) ABB $ 694.9000

ALENDRONATE SODIUM SEE APPENDIX A FOR EDS CRITERIA* 10MG TABLET

02247373 NOVO-ALENDRONATE (EDS) NOP $ 1.199702248728 APO-ALENDRONATE (EDS) APX 1.199702270129 GEN-ALENDRONATE (EDS) GPM 1.199702201011 FOSAMAX (EDS) MSD 2.0398

* 40MG TABLET02258102 CO ALENDRONATE (EDS) COB $ 2.831602201038 FOSAMAX (EDS) MSD 4.1669

* 70MG TABLET02248730 APO-ALENDRONATE (EDS) APX $ 6.048902258110 CO ALENDRONATE (EDS) COB 6.048902261715 NOVO-ALENDRONATE (EDS) NOP 6.048902273179 PMS-ALENDRONATE (EDS) PMS 6.048902275279 RATIO-ALENDRONATE (EDS) RPH 6.048902245329 FOSAMAX (EDS) MSD 10.2860

ALFUZOSIN 10MG PROLONGED-RELEASE TABLET

02245565 XATRAL AVT $ 1.0308

ALLOPURINOL* 100MG TABLET

00364282 NOVO-PUROL NOP $ 0.084700402818 APO-ALLOPURINOL APX 0.084700004588 ZYLOPRIM GSK 0.1152

* 200MG TABLET00479799 APO-ALLOPURINOL APX $ 0.141100565342 NOVO-PUROL NOP 0.141100506370 ZYLOPRIM GSK 0.1911

* 300MG TABLET00363693 NOVO-PUROL NOP $ 0.230600402796 APO-ALLOPURINOL APX 0.230600294322 ZYLOPRIM GSK 0.3123

200


ANAGRELIDE HCL* 0.5MG CAPSULE

02253054 GEN-ANAGRELIDE GPM $ 3.633802260107 SANDOZ ANAGRELIDE SDZ 3.633802274949 PMS-ANAGRELIDE PMS 3.633802236859 AGRYLIN RBP 5.0845

ANAKINRA SEE APPENDIX A FOR EDS CRITERIA 100MG/0.67ML PRE-FILLED SYRINGE

02245913 KINERET (EDS) AMG $ 49.3500

AZATHIOPRINE* 50MG TABLET

02231491 GEN-AZATHIOPRINE GPM $ 0.587902236819 NOVO-AZATHIOPRINE NOP 0.587902242907 APO-AZATHIOPRINE APX 0.587902248843 NU-AZATHIOPRINE NXP 0.587900004596 IMURAN GSK 0.9751

BETAINE ANHYDROUS 1G/SCOOP POWDER FOR ORAL SOLUTION

02238526 CYSTADANE ORP $ 1.4748

BOSENTAN SEE APPENDIX A FOR EDS CRITERIA 62.5MG TABLET

02244981 TRACLEER (EDS) ACT $ 64.7143 125MG TABLET

02244982 TRACLEER (EDS) ACT $ 64.7143

BOTULINUM TOXIN TYPE A SEE APPENDIX A FOR EDS CRITERIA 100IU STERILE LYOPHILIZED POWDER (IU)

01981501 BOTOX (EDS) ALL $ 3.8700

BROMOCRIPTINE MESYLATE* 5MG CAPSULE

02230454 APO-BROMOCRIPTINE APX $ 1.053702236949 PMS-BROMOCRIPTINE PMS 1.0537

* 2.5MG TABLET02087324 APO-BROMOCRIPTINE APX $ 0.591702231702 PMS-BROMOCRIPTINE PMS 0.591702238636 DOM-BROMOCRIPTINE DOM 0.621300371033 PARLODEL NVR 1.1173

201


BUSERELIN ACETATE SEE APPENDIX A FOR EDS CRITERIA 1.05MG/ML INJECTION (2)

02225166 SUPREFACT (EDS) AVT $ 112.1500 1.05MG/ML INTRANASAL SOLUTION

02225158 SUPREFACT (EDS) AVT $ 71.5500

CABERGOLINE SEE APPENDIX A FOR EDS CRITERIA 0.5MG TABLET

02242471 DOSTINEX (EDS) PAL $ 13.7253

COLCHICINE 0.6MG TABLET

00572349 COLCHICINE-ODAN ODN $ 0.2501 1MG TABLET

00621374 COLCHICINE-ODAN ODN $ 0.5149

CYCLOSPORINE (TRANSPLANT) SEE APPENDIX A FOR EDS CRITERIA 10MG CAPSULE




02150670 NEORAL (EDS) NVR $ 6.1368 100MG/ML LIQUID

02150697 NEORAL (EDS) NVR $ 5.4550

DONEPEZIL HCL SEE APPENDIX A FOR EDS CRITERIA 5MG TABLET

02232043 ARICEPT (EDS) PFI $ 4.9770 10MG TABLET

02232044 ARICEPT (EDS) PFI $ 4.9770

DUTASTERIDE 0.5MG CAPSULE

02247813 AVODART GSK $ 1.6801

ENTACAPONE 200MG TABLET

02243763 COMTAN NVR $ 1.6223

202


ETANERCEPT SEE APPENDIX A FOR EDS CRITERIA 25MG/VIAL POWDER FOR INJECTION (VIAL)

02242903 ENBREL (EDS) AMG $ 193.1500 50MG/ML PRE-FILLED SYRINGE

02274728 ENBREL (EDS) AMG $ 378.7900

ETIDRONATE DISODIUM* 200MG TABLET

02245330 GEN-ETIDRONATE GPM $ 0.895902248686 CO ETIDRONATE COB 0.895901997629 DIDRONEL PGA 1.5039

ETIDRONATE DISODIUM/CALCIUM CARBONATE 400MG/1250MG TABLET (PACKAGE)

02176017 DIDROCAL PGA $ 42.1200

FINASTERIDE 5MG TABLET

02010909 PROSCAR MSD $ 1.8949

GALANTAMINE HYDROBROMIDE SEE APPENDIX A FOR EDS CRITERIA 4MG TABLET

02244298 REMINYL (EDS) JAN $ 2.6804 8MG TABLET

02244299 REMINYL (EDS) JAN $ 2.6804 12MG TABLET

02244300 REMINYL (EDS) JAN $ 2.6804 8MG EXTENDED-RELEASE CAPSULE

02266717 REMINYL ER (EDS) JAN $ 4.9802 16MG EXTENDED-RELEASE CAPSULE

02266725 REMINYL ER (EDS) JAN $ 4.9802 24MG EXTENDED-RELEASE CAPSULE

02266733 REMINYL ER (EDS) JAN $ 4.9802

GLATIRAMER ACETATE SEE APPENDIX G FOR EDS CRITERIA 20MG INJECTION (PRE-FILLED SYRINGE)

02245619 COPAXONE (EDS) TVM $ 44.2000

GLUCAGON 1MG INJECTION POWDER (RDNA ORIGIN)

02243297 GLUCAGON LIL $ 89.1800

203


GOSERELIN ACETATE SEE APPENDIX A FOR EDS CRITERIA 3.6MG/SYRINGE

02049325 ZOLADEX (EDS) AST $ 411.7500

INFLIXIMAB WHEN BILLING, SUBMIT QUANTITY IN TERMS OF MILLIGRAMS. NOTE: THE IDENTIFICATION NUMBER LISTED FOR THIS PRODUCT FOR CROHN'S DISEASE HAS BEEN GENERATED BY THE PRESCRIPTION DRUG PLAN FOR BILLING PURPOSES ONLY. SEE APPENDIX A FOR EDS CRITERIA. 100MG/VIAL INJECTION (MG) (CROHN'S DISEASE)

00950899 REMICADE (EDS) SCH $ 9.7000 100MG/VIAL INJECTION (MG) (RHEUMATOID ARTHRITIS)

02244016 REMICADE (EDS) SCH $ 9.7000

INTERFERON BETA-1A SEE APPENDIX G FOR EDS CRITERIA 22UG (6 MILLION IU) PRE-FILLED SYRINGE

02237319 REBIF (EDS) SRO $ 124.7800 44UG (12 MILLION IU) PRE-FILLED SYRINGE

02237320 REBIF (EDS) SRO $ 150.0000 30UG POWDER FOR IM INJECTION (VIAL)

02237770 AVONEX (EDS) BGN $ 347.3000 30UG (30 MILLION IU) PRE-FILLED SYRINGE

02269201 AVONEX (EDS) BGN $ 368.6830

INTERFERON BETA-1B SEE APPENDIX G FOR EDS CRITERIA 0.3MG POWDER FOR INJECTION (3ML)

02169649 BETASERON (EDS) BEX $ 100.4700

KETOTIFEN FUMARATE SEE APPENDIX A FOR EDS CRITERIA* 1MG TABLET

02230730 NOVO-KETOTIFEN (EDS) NOP $ 0.687402231680 PMS-KETOTIFEN (EDS) PMS 0.687400577308 ZADITEN (EDS) PAL 0.8594

* 0.2MG/ML SYRUP02176084 NOVO-KETOTIFEN (EDS) NOP $ 0.144302221330 APO-KETOTIFEN (EDS) APX 0.144302231679 PMS-KETOTIFEN (EDS) PMS 0.144300600784 ZADITEN (EDS) PAL 0.1925

204


LEFLUNOMIDE SEE APPENDIX A FOR EDS CRITERIA* 10MG TABLET

02256495 APO-LEFLUNOMIDE (EDS) APX $ 6.555302261251 NOVO-LEFLUNOMIDE (EDS) NOP 6.555302241888 ARAVA (EDS) AVT 10.9260

* 20MG TABLET02256509 APO-LEFLUNOMIDE (EDS) APX $ 6.555302261278 NOVO-LEFLUNOMIDE (EDS) NOP 6.555302241889 ARAVA (EDS) AVT 10.9260

LEUPROLIDE ACETATE SEE APPENDIX A FOR EDS CRITERIA 3.75MG/ML INJECTION

00884502 LUPRON DEPOT (EDS) ABB $ 350.4600 7.5MG/ML INJECTION

00836273 LUPRON DEPOT (EDS) ABB $ 417.9700 11.25MG (3-MONTH SR) DEPOT INJECTION

02239834 LUPRON DEPOT (EDS) ABB $ 999.0200

LEVODOPA/BENZERAZIDE 50MG/12.5MG CAPSULE

00522597 PROLOPA HLR $ 0.2906 100MG/25MG CAPSULE

00386464 PROLOPA HLR $ 0.4785 200MG/50MG CAPSULE

00386472 PROLOPA HLR $ 0.8033

LEVODOPA/CARBIDOPA* 100MG/10MG TABLET

02182831 NU-LEVOCARB NXP $ 0.256602195933 APO-LEVOCARB APX 0.256602244494 NOVO-LEVOCARBIDOPA NOP 0.256600355658 SINEMET BMY 0.4580

* 100MG/25MG TABLET02182823 NU-LEVOCARB NXP $ 0.383302195941 APO-LEVOCARB APX 0.383302244495 NOVO-LEVOCARBIDOPA NOP 0.383302247606 DOM-LEVO-CARBIDOPA DOM 0.431300513997 SINEMET BMY 0.6839

205


* 250MG/25MG TABLET02182858 NU-LEVOCARB NXP $ 0.427902195968 APO-LEVOCARB APX 0.427902244496 NOVO-LEVOCARBIDOPA NOP 0.427900328219 SINEMET BMY 0.7634

100MG/25MG CONTROLLED RELEASE TABLET02028786 SINEMET CR BMY $ 0.7135

* 200MG/50MG CONTROLLED RELEASE TABLET02245211 APO-LEVOCARB CR APX $ 0.801300870935 SINEMET CR BMY 1.3163

MONTELUKAST SODIUM SEE APPENDIX A FOR EDS CRITERIA 4MG CHEWABLE TABLET

02243602 SINGULAIR (EDS) MSD $ 1.4739 5MG CHEWABLE TABLET

02238216 SINGULAIR (EDS) MSD $ 1.6275 10MG TABLET

02238217 SINGULAIR (EDS) MSD $ 2.3943 4MG ORAL GRANULE

02247997 SINGULAIR (EDS) MSD $ 1.4739

MYCOPHENOLATE MOFETIL SEE APPENDIX A FOR EDS CRITERIA 250MG CAPSULE

02192748 CELLCEPT (EDS) HLR $ 2.2373 500MG TABLET

02237484 CELLCEPT (EDS) HLR $ 4.4746 200MG/ML SUSPENSION

02242145 CELLCEPT (EDS) HLR $ 1.7899

MYCOPHENOLATE SODIUM SEE APPENDIX A FOR EDS CRITERIA 180MG ENTERIC COATED TABLET

02264560 MYFORTIC (EDS) NVR $ 2.1250 360MG ENTERIC COATED TABLET

02264579 MYFORTIC (EDS) NVR $ 4.1670

NABILONE SEE APPENDIX A FOR EDS CRITERIA 1MG CAPSULE

00548375 CESAMET (EDS) VAE $ 6.7325

206


NAFARELIN ACETATE SEE APPENDIX A FOR EDS CRITERIA 2MG/ML NASAL SOLUTION

02188783 SYNAREL (EDS) FEI $ 303.8000

OCTREOTIDE WHEN BILLING LAR FORM, SUBMIT QUANTITY IN TERMS OF MILLIGRAMS. SEE APPENDIX A FOR EDS CRITERIA* 50UG INJECTION (1ML)

02248639 OCTREOTIDE ACETATE (EDS) OMG $ 4.330000839191 SANDOSTATIN (EDS) NVR 5.4200

* 100UG INJECTION (1ML)02248640 OCTREOTIDE ACETATE (EDS) OMG $ 8.190000839205 SANDOSTATIN (EDS) NVR 10.2300

* 200UG/ML INJECTION (5ML)02248642 OCTREOTIDE ACETATE (EDS) OMG $ 78.650002049392 SANDOSTATIN (EDS) NVR 98.3100

* 500UG INJECTION (1ML)02248641 OCTREOTIDE ACETATE (EDS) OMG $ 38.440000839213 SANDOSTATIN (EDS) NVR 48.0400

10MG/VIAL POWDER FOR INJECTION (MG)02239323 SANDOSTATIN LAR (EDS) NVR $ 121.1400



PAMIDRONATE DISODIUM SEE APPENDIX A FOR EDS CRITERIA* 30MG INJECTION

02244550 PAMIDRONATE DISODIUM (EDS) DBU $ 95.860002264951 PAMIDRONATE DISODIUM (EDS) SDZ 95.860002245998 PMS-PAMIDRONATE (EDS) PMS 100.910002059762 AREDIA (EDS) NVR 176.0200

* 60MG INJECTION02244551 PAMIDRONATE DISODIUM (EDS) DBU $ 191.720002264978 PAMIDRONATE DISODIUM (EDS) SDZ 191.7200

* 90MG INJECTION02244552 PAMIDRONATE DISODIUM (EDS) DBU $ 287.580002264986 PAMIDRONATE DISODIUM (EDS) SDZ 287.580002245999 PMS-PAMIDRONATE (EDS) PMS 302.720002249685 PAM. DISODIUM OMEGA (EDS) OMG 480.000002059789 AREDIA (EDS) NVR 516.6800

207


PEGINTERFERON ALFA-2A/RIBAVIRIN SEE APPENDIX A FOR EDS CRITERIA 180UG/0.5ML PRE-FILLED SYRINGE/200MG TABLET

02253429 PEGASYS RBV (EDS) HLR $ 425.8400 180UG/0.5ML VIAL/200MG TABLET

02253410 PEGASYS RBV (EDS) HLR $ 425.8400

PEGINTERFERON ALFA-2B/RIBAVIRIN SEE APPENDIX A FOR EDS CRITERIA 50UG/0.5ML POWDER FOR SOLUTION/200MG CAPSULE

02246026 PEGETRON (EDS) SCH $ 782.2000 50UG/0.5ML SINGLE DOSE REDIPEN/200MG CAPSULE

02254573 PEGETRON REDIPEN (EDS) SCH $ 782.2000 80UG/0.5ML POWDER FOR SOLUTION/200MG CAPSULE








02254646 PEGETRON REDIPEN (EDS) SCH $ 861.1800

PENTOSAN POLYSULFATE SO4 SEE APPENDIX A FOR EDS CRITERIA 100MG CAPSULE

02029448 ELMIRON (EDS) JAN $ 1.4805

PERGOLIDE MESYLATE 0.05MG TABLET

02123320 PERMAX RBP 0.2696 0.25MG TABLET

02123339 PERMAX RBP 0.9883 1MG TABLET

02123347 PERMAX RBP 3.3690

208


PRAMIPEXOLE DIHYDROCHLORIDE 0.25MG TABLET

02237145 MIRAPEX BOE $ 1.1408 0.5MG TABLET

02241594 MIRAPEX BOE $ 2.2816 1MG TABLET

02237146 MIRAPEX BOE $ 2.2816 1.5MG TABLET

02237147 MIRAPEX BOE $ 2.2816

RIFABUTIN SEE APPENDIX A FOR EDS CRITERIA 150MG CAPSULE

02063786 MYCOBUTIN (EDS) PFI $ 4.2000

RISEDRONATE SODIUM SEE APPENDIX A FOR EDS CRITERIA 5MG TABLET

02242518 ACTONEL (EDS) PGA $ 1.9042 30MG TABLET

02239146 ACTONEL (EDS) PGA $ 12.3365 35MG TABLET

02246896 ACTONEL (EDS) PGA $ 10.1556

RIVASTIGMINE SEE APPENDIX A FOR EDS CRITERIA 1.5MG CAPSULE

02242115 EXELON (EDS) NVR $ 2.6523 3MG CAPSULE

02242116 EXELON (EDS) NVR $ 2.6523 4.5MG CAPSULE

02242117 EXELON (EDS) NVR $ 2.6523 6MG CAPSULE

02242118 EXELON (EDS) NVR $ 2.6523 2MG/ML ORAL SOLUTION

02245240 EXELON (EDS) NVR $ 1.4157

209


ROPINIROLE HCL 0.25MG TABLET

02232565 REQUIP GSK $ 0.2878 1MG TABLET



02232569 REQUIP GSK $ 3.5684

SELEGILINE HCL SEE APPENDIX A FOR EDS CRITERIA* 5MG TABLET

02068087 NOVO-SELEGILINE (EDS) NOP $ 1.372602230641 APO-SELEGILINE (EDS) APX 1.372602230717 NU-SELEGILINE (EDS) NXP 1.372602231036 GEN-SELEGILINE (EDS) GPM 1.372602238102 PMS-SELEGILINE (EDS) PMS 1.372602238340 DOM-SELEGILINE (EDS) DOM 1.4414

SEVELAMER HCL SEE APPENDIX A FOR EDS CRITERIA 800MG TABLET

02244310 RENAGEL (EDS) GZY $ 1.5407

SIROLIMUS SEE APPENDIX A FOR EDS CRITERIA 1MG/ML ORAL SOLUTION

02243237 RAPAMUNE (EDS) WYA $ 7.5200 1MG TABLET

02247111 RAPAMUNE (EDS) WYA $ 7.3200

SODIUM CROMOGLYCATE SEE APPENDIX A FOR EDS CRITERIA 100MG CAPSULE

00500895 NALCROM (EDS) AVT $ 1.2812* 10MG/ML INHALATION SOLUTION (2ML)

02046113 PMS-SODIUM CROMOGLYCATE PMS $ 0.525802231431 APO-CROMOLYN APX 0.525802231671 NU-CROMOLYN NXP 0.525802145448 DOM-SODIUM CROMOGLYCATE DOM 0.6562

SODIUM FLUORIDE 20MG TABLET

02099225 FLUOTIC AVT $ 0.3881

210


TACROLIMUS SEE APPENDIX A FOR EDS CRITERIA 0.5MG CAPSULE

02243144 PROGRAF (EDS) FUJ $ 2.1375 1MG CAPSULE

02175991 PROGRAF (EDS) FUJ $ 2.7342 5MG CAPSULE

02175983 PROGRAF (EDS) FUJ $ 12.9200 5MG/ML AMPOULE

02176009 PROGRAF (EDS) FUJ $ 131.2000

TAMSULOSIN HCL 0.4MG CONTROLLED RELEASE TABLET

02270102 FLOMAX CR BOE $ 0.6510 0.4MG SUSTAINED RELEASE CAPSULE

02238123 FLOMAX BOE $ 1.0587

TETRABENAZINE 25MG TABLET

02199270 NITOMAN RBP $ 6.5100

TRIMEPRAZINE TARTRATE 2.5MG TABLET

01926306 PANECTYL ERF $ 0.2480 5MG TABLET

01926292 PANECTYL ERF $ 0.3084

URSODIOL SEE APPENDIX A FOR EDS CRITERIA 250MG TABLET

02238984 URSO (EDS) AXC $ 1.3385 500MG TABLET

02245894 URSO DS (EDS) AXC $ 2.5389

ZAFIRLUKAST SEE APPENDIX A FOR EDS CRITERIA 20MG TABLET

02236606 ACCOLATE (EDS) AST $ 0.7822

ZOLEDRONIC ACID SEE APPENDIX A FOR EDS CRITERIA 5MG/100ML INJECTION SOLUTION (VIAL)

02269198 ACLASTA (EDS) NVR $ 675.0000

211

DIABETIC SUPPLIES94:00

94:00 DIABETIC SUPPLIES94:00.00 DIABETIC SUPPLIES

NOTE: SOME OF THE IDENTIFICATION NUMBERS LISTED IN THISSECTION HAVE BEEN GENERATED BY THE PRESCRIPTION DRUG PLANFOR BILLING PURPOSES ONLY.

ISOPROPYL ALCOHOL⌧ 70% SWAB

00795232 WEBCOL ALCOHOL PREP TYC $ 0.012202247809 LIFEBRAND ALCOHOL SWAB LIF 0.013300480452 ALCOHOL PREP PFD 0.015999438102 MONOJECT ALCOHOL SWAB TYC 0.017302240759 BD ALCOHOL SWAB BDC 0.0175

LANCET⌧ LANCET

99401055 MONOLET THIN TYC $ 0.048600977659 BD ULTRA FINE II LANCET BDC 0.050700930610 AMES BAY 0.052800977543 MONOLET ORIGINAL TYC 0.058000950913 EQUATE THIN MPD 0.059300906190 PRECISION THIN MDS 0.060899401063 FREESTYLE MDS 0.060800950914 EQUATE ULTRATHIN MPD 0.064900906239 MICROLET BAY 0.069000901359 ONE TOUCH ULTRA SOFT LSN 0.070600977853 LIFESCAN FINE POINT LSN 0.070600950953 ASCENSIA BAY 0.072500950958 MPD LANCET MPD 0.082400950927 BD ULTRAFINE 33 BDC 0.083400000165 SOFTCLIX BOM 0.083600950944 ACCU-CHEK MULTICLIX BOM 0.101200995965 GLUCOLET FINGERSTIX BAY 0.137700950915 SOFTCLIX PRO BOM 0.141100905916 SAFE-T-PRO BOM 0.1953

214

94:00 DIABETIC SUPPLIES94:00.00 DIABETIC SUPPLIES

NEEDLE 28G NEEDLE

99221028 NOVOFINE 12MM NOO $ 0.3038⌧ 29G NEEDLE

00964344 UNIFINE ACM $ 0.173200977101 BD ULTRA FINE 12.7MM BDC 0.2474

⌧ 30G NEEDLE00908169 NOVOFINE 8MM NOO $ 0.303899117796 NOVOFINE 6MM NOO 0.3038

⌧ 31G NEEDLE00964220 UNIFINE ACM $ 0.195300964271 UNIFINE ACM 0.195300977011 BD ULTRAFINE 5MM, 8MM BDC 0.2474

32G NEEDLE00950941 NOVOFINE 6MM NOO $ 0.3342

SYRINGE⌧ 0.3CC SYRINGE

00964018 ULTICARE 29G ACM $ 0.204100964174 ULTICARE 30G ACM 0.214400977951 MONOJECT PLUS 29G TYC 0.238699254011 MONOJECT ULTRA COMFORT TYC 0.238600920193 BD ULTRA FINE BDC 0.281300977977 BD ULTRAFINE II SHORT BDC 0.281300950942 BD ULTRAFINE II 1/2 UNIT BDC 0.2892

⌧ 0.5CC SYRINGE00963941 ULTICARE 29G ACM $ 0.204100964115 ULTICARE 30G ACM 0.214400920355 MONOJECT ULTRA COMFORT TYC 0.238699432799 MONOJECT PLUS 29G TYC 0.238600920207 BD ULTRA FINE BDC 0.281300977985 BD ULTRA FINE II SHORT BDC 0.2813

⌧ 1CC SYRINGE00963895 ULTICARE 29G ACM $ 0.204100964069 ULTICARE 30G ACM 0.214400920045 MONOJECT ULTRA COMFORT TYC 0.238699433383 MONOJECT PLUS 29G TYC 0.238600909238 BD ULTRA FINE II SHORT BDC 0.281300920215 BD ULTRA FINE BDC 0.2813

215

APPENDICES

APPENDIX A - EXCEPTION DRUG STATUS PROGRAM

APPENDIX B - ONLINE ADJUDICATION

APPENDIX C - SPECIAL COVERAGES

APPENDIX D - CODES FOR PHARMACY ONLINE CLAIMS PROCESSING

APPENDIX E - MAINTENANCE DRUG SCHEDULE

APPENDIX F - TRIAL PRESCRIPTION PROGRAM MEDICATION LIST

APPENDIX G - SASKATCHEWAN MS DRUGS PROGRAM

APPENDIX H - PHARMACEUTICAL MANUFACTURERS LIST

APPENDIX I - MAXIMUM ALLOWABLE COST (MAC) POLICY

APPENDIX A

EXCEPTION DRUG STATUS PROGRAM NOTES REGARDING THE EXCEPTION DRUG STATUS (EDS) PROGRAM • Physicians, dentists, duly qualified optometrists (or authorized office staff), nurse

practitioners and pharmacists may apply for EDS. • Requests can be submitted by telephone, by mail or by fax. A toll-free line with an

electronic message system is available exclusively for requests on a 24-hour basis. The telephone number to access this line is 1-800-667-2549; the Drug Plan EDS Unit fax number is (306) 798-1089.

• Patients are notified by letter if coverage has been approved and the time period for which coverage has been approved.

• If a request has been denied, letters are sent to the patient and prescriber notifying them of the reason for the denial. In most cases, the Drug Plan requires more information to determine the patient's eligibility for coverage, and will reconsider coverage at such time as further information is received.

• If the drug requested is not a benefit under the Drug Plan, the patient and prescriber are notified. Payment for the medication is the responsibility of the patient in these cases. It is important to note that not all medications currently available on the market in Canada are benefits under the Saskatchewan Drug Plan or under the Exception Drug Status Program of the Drug Plan.

• The majority of EDS requests are routinely backdated 30 days from the time the Drug Plan receives the request. Provision can be made for further backdating of EDS coverage on a case-by-case basis by staff in Pharmaceutical Services Division. However, there is no provision or backdating further than one year from the current date. Requests for backdating can be made by a health professional or the patient. Patients are expected to meet EDS criteria within the dates requested.

• Saskatchewan Prescription Drug Plan policy does not allow a fee to be charged to clients for Exception Drug Status applications made to the Drug Plan on the client's behalf.

• See NOTES CONCERNING THE FORMULARY, pages xii-xvi for additional general information regarding Exception Drug Status coverage.

Coverage may be provided for other products in certain instances. REQUIREMENTS FOR REVIEW OF DRUGS FOR NON-APPROVED INDICATIONS Occasionally drugs are required for non-approved indications on a case by case basis. In order to conduct a timely review of these requests the drug review committees request the following information be provided by the prescriber: ● the disease or problem being treated ● list of previous therapies tried and the response achieved ● other non-exception options available and why not appropriate ● name of the drug being requested ● clinical evidence available to support use of the drug with provision of such evidence ● outcome measures that will be followed to assess the effect of the drug ● dose of the drug and length of time to be used CRITERIA FOR COVERAGE UNDER EXCEPTION DRUG STATUS Following are the criteria for coverage of certain drugs under Exception Drug Status. Professional staff at the Drug Plan can provide further information.

218

The following information is required to process all Exception Drug Status requests: • Patient name; patient Health Services Number (9 digits); name of drug;

diagnosis* relevant to use of drug; prescriber name and phone number. *For pharmacist-initiated EDS requests: The diagnosis, which must be obtained from the physician or physician's agent, is to be consistently documented within the pharmacy, whether the documentation is on the original prescription, computer file, or EDS fax form. abacavir SO4, oral solution, 20mg/mL; tablet, 300mg (Ziagen-GSK)

For management of HIV disease. This drug, as with other antivirals in the treatment of HIV, should be used under the direction of an infectious disease specialist.

abacavir SO4/lamivudine, tablet, 600mg/300mg (Kivexa-GSK) For management of HIV disease. This drug, as with other antivirals in the treatment of HIV, should be used under the direction of an infectious disease specialist.

abacavir SO4/lamivudine/zidovudine, tablet, 300mg/150mg/300mg (Trizivir-GSK)


Accolate - see zafirlukast acitretin, capsule, 10mg, 25mg (Soriatane-HLR)

For treatment of severe: (a) Intractable psoriasis (b) Darier’s disease (c) Ichthyosiform dermatoses (d) Palmoplantar pustulosis

and other disorders of keratization. For detailed patient information see page 256. Aclasta - see zoledronic acid Actonel - see risedronate sodium Actos - see pioglitazone HCl Acular - see ketorolac tromethamine adalimumab, solution for injection, 40mg/0.8mL (Humira-ABB)

For treatment of active rheumatoid arthritis in patients: (a) Who have failed methotrexate and leflunomide. (b) Intolerant to methotrexate and leflunomide. Note: Treatment should be combined with an immunosuppressant. This product should be used in consultation with a specialist in this area. Exceptions can be considered in cases where methotrexate or leflunomide are contraindicated.

Advair - see salmeterol xinafoate/fluticasone propionate Advair Diskus - see salmeterol xinafoate/fluticasone propionate Agenerase - see amprenavir Aggrenox - see dipyridamole/acetylsalicylic acid Aldara - see imiquimod *alendronate sodium, tablet, 10mg (Fosamax-MSD) (Apo-Alendronate-APX) (Novo-Alendronate-NOP) (Gen-Alendronate-GPM); tablet, 70mg (Fosamax-MSD) (CO Alendronate-COB) (pms-Alendronate-PMS) (Apo-Alendronate-APX) (Novo-Alendronate-NOP) (ratio-Alendronate-RPH)

For treatment of osteoporosis in patients: (a) Unresponsive to etidronate disodium/calcium (Didrocal) after receiving it for one

year. (b) Intolerant to etidronate disodium/calcium (Didrocal). (c) With pre-existing and/or recent fractures, and: (d) Glucocorticoid-induced osteoporosis in patients who have received systemic

glucocorticoid treatment for at least 3 months.

219

*alendronate sodium, tablet, 40mg (Fosamax-MSD) (CO Alendronate-COB) For treatment of symptomatic Paget’s disease of the bone. Alertec - see modafinil alfacalcidol, capsule, 0.25ug, 1ug; oral drops, 2ug/mL (One-Alpha-LEO)

For management of: (a) Hypocalcemia in chronic renal disease patients prior to initiation of dialysis. (b) Osteodystrophy in chronic renal disease patients prior to initiation of dialysis.

Note: Coverage for dialysis patients is provided under the Saskatchewan Aids to Independent Living (S.A.I.L.) Program. Exception Drug Status coverage is not required for S.A.I.L. patients.

almotriptan malate, tablet, 6.25mg, 12.5mg (Axert-JAN)

For treatment of migraine headaches. Eligibility will be restricted to beneficiaries over 18 and under 65 years of age.

The maximum quantity that can be claimed through the Drug plan is limited to 6 doses per 30 days within a 60-day period. Patients requiring more than 12 doses in a consecutive 60-day period should be considered for migraine prophylaxis therapy if they are not already receiving such therapy.

Amatine - see midodrine HCl Amerge - see naratriptan HCl amoxicillin trihydrate/potassium clavulanate, oral suspension, 40mg/5.3mg/mL, 80mg/11.4mg/mL (Clavulin-GSK); *oral suspension, 25mg/6.25mg (Apo-Amoxi Clav-APX) (ratio-Aclavulanate-RPH) 50mg/12.5mg/mL (Clavulin-GSK) (Apo-Amoxi Clav-APX) (ratio-Aclavulanate-RPH); *tablet, 250mg/125mg, 500mg/125mg (Clavulin-GSK) (Apo-Amoxi Clav-APX) (ratio-Aclavulanate-RPH); *tablet, 875mg/125mg (Clavulin-GSK) (Apo-Amoxi Clav-APX) (Novo-Clavamoxin-NOP) (ratio-Aclavulante-RPH)

For treatment of: (a) Upper and lower respiratory tract infections in patients unresponsive to first-line

antibiotics. (b) Infections caused by organisms known to be resistant or unresponsive to

alternative antibiotics. (c) Respiratory tract infections in nursing home patients. (d) Pneumonia in patients in the community with comorbidity e.g. chronic underlying

lung disease (excluding asthma), diabetes mellitus, renal insufficiency, heart failure, stroke.

(e) Infection in patients with neutropenia. (f) Pneumonia caused by aspiration. (g) For human, cat and dog bites. (h) Diabetic foot infections, and: (i) For completion of treatment initiated in hospital.

amprenavir, capsule, 50mg, 150mg; oral solution, 15mg/mL (Agenerase-GSK)

For management of HIV disease in patients who have failed other protease inhibitor combinations. This drug, as with other antivirals in the treatment of HIV, should be used under the direction of an infectious disease specialist.

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anakinra, subcutaneous injection (pre-filled syringe), 100mg/0.67mL (Kineret-AMG) For treatment of active rheumatoid arthritis in patients: (a) Who have failed methotrexate and leflunomide. (b) Intolerant to methotrexate and leflunomide. (Note - exceptions can be considered in cases where methotrexate or leflunomide are contraindicated). This product should be used in consultation with a specialist in this area. Note: Coverage will not be provided when used in combination with TNF blocking agents (i.e. infliximab and etanercept) due to the significantly higher risk of adverse events. Treatment should be combined with an immunosuppressant.

Androcur - see cyproterone acetate Apo-Alendronate - see alendronate sodium Apo-Amoxi Clav - see amoxicillin trihydrate/potassium clavulanate Apo-Bisoprolol - see bisoprolol fumarate Apo-Calcitonin - see calcitonin salmon Apo-Carvedilol - see carvedilol Apo-Cefuroxime - see cefuroxime axetil Apo-Ciproflox - see ciprofloxacin Apo-Clonidine - see clonidine HCl Apo-Cyclobenzaprine - see cyclobenzaprine HCl Apo-Cyproterone - see cyproterone Apo-Desmopressin - see desmopressin Apo-Etodolac - see etodolac Apo-Flavoxate - see flavoxate Apo-Fluconazole - see fluconazole Apo-Flunarizine - see flunarizine Apo-Ketoconazole - see ketoconazole Apo-Ketorolac - see ketorolac tromethamine Apo-Ketotifen - see ketotifen fumarate Apo-Lactulose - see lactulose Apo-Leflunomide - see leflunomide Apo-Megestrol - see megestrol acetate tablet Apo-Meloxicam - see meloxicam Apo-Minocycline - see minocycline HCl Apo-Nabumetone - see nabumetone Apo-Norflox - see norfloxacin Apo-Ofloxacin - see ofloxacin Apo-Omeprazole - see omeprazole Apo-Selegiline - see selegiline HCl Apo-Sumatriptan - see sumatriptan Apo-Ticlopidine - see ticlopidine HCl Apo-Tizanidine - see tizanidine HCl Apo-Tobramycin - see tobramycin Apo-Zidovudine - zidovudine Aranesp - see darbepoetin alfa Arava - see leflunomide Aredia - see pamidronate Aricept - see donepezil HCl Aristospan - see triamcinolone/hexacetonide atazanavir SO4, capsule, 150mg, 200mg (Reyataz-BMY)


atovaquone, suspension, 150mg/mL (Mepron-GSK) For treatment of Pneumocystis carinii pneumonia (PCP) in patients intolerant to

trimethoprim/sulfamethoxazole. Avandamet - see rosiglitazone maleate/metformin HCl

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Avandia - see rosiglitazone maleate Avelox - see moxifloxacin HCl Avonex - see Appendix G Avonex PS - see Appendix G Axert - see almotriptan malate *azithromycin, tablet, 250mg (Zithromax-PFI) (Apo-Azithromycin-APX) (Novo-Azithromycin-NOP) (CO Azithromycin-COB) (pms-Azithromycin-PMS) (Sandoz Azithromycin-SDZ) (ratio-Azithromycin-RPH); oral suspension, 20mg/mL, 40mg/mL (Zithromax-PFI) For treatment of:

(a) Pneumonia. (b) Upper and lower respiratory tract bacterial infections known to be resistant or

unresponsive to alternative antibiotics. (c) Infections in patients allergic to alternative antibiotics. (d) Infection (and prophylaxis) in patients with non-tuberculous Mycobacterium. (e) Chlamydia trachomatis infections, and: (f) For completion of treatment initiated in hospital with macrolides or quinolones. (g) For patients intolerant to erythromycin and/or other antibiotics.

azithromycin, tablet, 600mg (Zithromax-PFI) (CO Azithromycin-COB) (pms-Azithromycin-PMS)

For treatment (and prophylaxis) in patients with non-tuberculous Mycobacterium. baclofen, injection, 0.05mg/mL, 0.5mg/mL, 2mg/mL (Lioresal Intrathecal-NVR)

For treatment of severe spastic conditions in patients: (a) Unresponsive to oral baclofen. (b) Intolerant to oral baclofen.

Betaseron - see Appendix G bezafibrate, tablet, 200mg (pms-Bezafibrate-PMS); sustained release tablet, 400mg (Bezalip SR-HLR)

For treatment of hyperlipidemia in patients: (a) Unresponsive to gemfibrozil or fenofibrate. (b) Who have experienced side effects with gemfibrozil or fenofibrate.

Bezalip SR - see bezafibrate Biaxin - see clarithromycin Biaxin XL - see clarithromycin *bisoprolol fumarate, tablet, 5mg, 10mg (Monocor-BVL) (Sandoz Bisoprolol-SDZ) (Apo-Bisoprolol-APX) (Novo-Bisoprolol-NOP)

For treatment of stable symptomatic congestive heart failure in patients: (a) Who are taking an ACE inhibitor. (b) Intolerant to an ACE inhibitor.

bosentan, tablet, 62.5mg, 125mg (Tracleer-ACT)

For treatment of pulmonary arterial hypertension on the recommendation of a specialist.

Botox - see botulinum toxin type A botulinum toxin type A, sterile lyophilized powder, 100IU (Botox-ALL)

For treatment of: (a) Eye dystonias, that is, blepharospasm and strabismus. (b) Cervical dystonia, that is, torticollis.

(c) Other forms of severe spasticity. (d) Hyperhidrosis of the axilla.

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budesonide, controlled ileal release capsule, 3mg (Entocort-AST) (a) For treatment of mild to moderate Crohn's Disease affecting the ileum and/or

ascending colon. Coverage will be provided for up to 8 weeks. (b) Maintenance treatment will be approved for patients unresponsive or intolerant to

other agents. bumetanide, tablet, 1mg, 2mg, 5mg (Burinex-LEO) For treatment of patients intolerant to furosemide. bupropion HCl, tablet, 100mg, 150mg (Wellbutrin SR-BVL); tablet; extended-release tablet, 150mg, 300mg (Wellbutrin XL-BVL) For treatment of depression. Burinex - see bumetanide buserelin acetate, intranasal solution, 1.05mg/mL; injection, 1.05mg/mL (Suprefact-HRU)

For treatment of: (a) Endometriosis. (Coverage may be repeated after a six month lapse, for another 6

month course). (b) Menorrhagia in preparation for endometrial ablation, and: (c) For pre-treatment of uterine fibroids prior to surgical removal.

cabergoline, tablet, 0.5mg (Dostinex-PFI) For treatment of hyperprolactinemic disorders in patients: (a) Unresponsive to bromocriptine. (b) Intolerant to bromocriptine.

Calcimar - see calcitonin salmon calcitonin salmon, injection, 100IU/mL (Caltine-FEI); *injection, 200IU/mL (Calcimar-AVT) (Apo-Calcitonin-APX)

For treatment of: (a) Crush fracture with bone pain. Coverage will be provided for a maximum of 3

months. (b) Osteogenesis imperfecta, and: (c) For symptomatic treatment of Paget's disease of the bone. *calcitonin salmon, nasal spray, 200IU/dose (Miacalcin-NVR) (Apo-Calcitonin-APX)

For treatment of osteoporosis in patients: (a) Intolerant to listed bisphosphonates. (b) Unresponsive to listed bisphosphonates after treatment for one year, and: (c) For crush fracture with bone pain. Coverage will be provided for a maximum of 3

months as an alternative to the subcutaneous dosage form. calcitriol, capsule, 0.25ug, 0.5ug; oral solution, 1ug/mL (Rocaltrol-HLR)

(a) For management of hypocalcemia and osteodystrophy in patients with chronic renal failure undergoing renal dialysis. Note: Coverage for dialysis patients is provided under the Saskatchewan Aids to Independent Living (SAIL) Program. Exception Drug Status coverage is NOT required for SAIL patients.

(b) For management of hypocalcemia and clinical manifestations associated with post-surgical hypoparathyroidism, idiopathic hypoparathyroidism, pseudohypoparathyroidism, or vitamin D resistant rickets.

Caltine - see calcitonin salmon

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*carbamazepine, controlled release tablet, 200mg, 400mg (Tegretol CR-NVR) (pms-Carbamazepine-CR-PMS) (Dom-Carbamazepine CR-DOM) (Taro-Carbamazepine CR-TAR) (Gen-Carbamazepine CR-GPM)

For treatment in patients: (a) Uncontrolled using the regular tablet dosage form. (b) Experiencing unacceptable adverse reactions using the regular tablet dosage

form. *carvedilol, tablet, 3.125mg, 6.25mg, 12.5mg, 25mg (Coreg-GSK) (Apo-Carvedilol-APX) (pms-Carvedilol-PMS) (Novo-Carvedilol-NOP) (Nu-Carvedilol-NXP) (Dom-Carvedilol-DOM) (ratio-Carvedilol-RPH) (Ran-Carvedilol-RAN)

For treatment of stable symptomatic congestive heart failure in patients: (a) Taking an ACE inhibitor. (b) Intolerant to an ACE inhibitor.

cefixime, tablet, 400mg; suspension, 20mg/mL (Suprax-AVT) For treatment of:

(a) Infections in patients allergic to alternative antibiotics. (Note: patients who have had an anaphylactic reaction to penicillin should not receive cephalosporins.)

(b) Infections caused by organisms known to be: • Resistant to alternative antibiotics. • Unresponsive to alternative antibiotics.

(c) Uncomplicated gonorrhea. cefprozil, tablet, 250mg, 500mg; suspension, 25mg/mL, 50mg/mL (Cefzil-BMY) For treatment of:

(a) Upper and lower respiratory tract infections in patients unresponsive to first-line antibiotics.

(b) Infections caused by organisms known to be resistant or unresponsive to alternative antibiotics.

(c) Infections in patients allergic to alternative antibiotics. (Note: patients who have had an anaphylactic reaction to penicillin should not receive cephalosporins.)

(d) Respiratory tract infections in nursing home patients. (e) Pneumonia in patients in the community with comorbidity e.g. chronic underlying

lung disease (excluding asthma), diabetes mellitus, renal insufficiency, heart failure, stroke, and:

(f) For completion of antibiotic treatment initiated in hospital. Ceftin - see cefuroxime axetil cefuroxime axetil, suspension, 25mg/mL (Ceftin-GSK) *tablet, 250mg, 500mg (Ceftin-GSK) (ratio-Cefuroxime-RPH) (Apo-Cefuroxime-APX) For treatment of:

(a) Upper and lower respiratory tract infections in patients unresponsive to first-line antibiotics.

(b) Infections caused by organisms known to be resistant or unresponsive to alternative antibiotics.

(c) Infections in patients allergic to alternative antibiotics. (Note: patients who have had an anaphylactic reaction to penicillin should not receive cephalosporins.)

(d) Respiratory tract infections in nursing home patients. (e) Pneumonia in patients in the community with comorbidity i.e. chronic underlying

lung disease (excluding asthma), diabetes mellitus, renal insufficiency, heart failure, stroke, and:

(f) For completion of antibiotic treatment initiated in hospital.

Cefzil - see cefprozil

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Celebrex - see celecoxib celecoxib, capsule, 100mg, 200mg (Celebrex-PFI)

For treatment of: (a) Patients age 65 and over (approved automatically through the online computer

system). (b) Rheumatoid arthritis and osteoarthritis in patients who have one of the following

factors: • past history of ulcers; • concurrent prednisone therapy; • concurrent warfarin therapy.

(c) Patients intolerant to other NSAIDs listed in the Formulary. CellCept - see mycophenolate mofetil Cesamet - see nabilone chorionic gonadotropin, injection, 10,000IU/vial (Profasi HP-SRO)

For treatment of: (a) Habitual abortion. (b) Delayed puberty. Ciloxan - see ciprofloxacin Cipro - see ciprofloxacin tablet Cipro HC - see ciprofloxacin/hydrocortisone Cipro XL - see ciprofloxacin *ciprofloxacin, ophthalmic solution, 0.3% (Ciloxan-ALC) (pms-Ciprofloxacin-PMS) (Apo-Ciprolox-APX); ophthalmic ointment, 0.3% (Ciloxan-ALC)

For treatment of ophthalmic infections: (a) Caused by gram-negative organisms. (b) Unresponsive to alternative agents.

*ciprofloxacin, tablet, 250mg, 500mg, (Apo-Ciproflox-APX) (CO Ciprofloxacin-COB) (Gen-Ciprofloxacin-GPM) (Novo-Ciprofloxacin-NOP) (pms-Ciprofloxacin-PMS) (ratio-Ciprofloxacin-RPH) (Sandoz Ciprofloxacin-SDZ) (Dom-Ciprofloxacin-DOM) (Nu-Ciprofloxacin-NXP) (Ran-Ciprofloxacin-RAN) (Taro-Ciprofloxacin-TAR); tablet, 750mg (Apo-Ciproflox-APX) (CO Ciprofloxacin-COB) (Gen-Ciprofloxacin-GPM) (Novo-Ciprofloxacin-NOP) (pms-Ciprofloxacin-PMS) (ratio-Ciprofloxacin-RPH) (Sandoz Ciprofloxacin-SDZ) (Dom-Ciprofloxacin-DOM) (Nu-Ciprofloxacin-NXP) (Ran-Ciprofloxacin-RAN); oral suspension100mg/mL (Cipro-BAY) For treatment of:

(a) Infections caused by Pseudomonas aeruginosa. (b) Infections in patients allergic to two or more alternative antibiotics. (c) Infections known to be resistant to alternative antibiotics. Resistance must be

determined by culture and sensitivity testing (C&S). (d) Patients with severe diabetic foot infections in combination with other antibiotics. (e) Infection (and prophylaxis) in patients with prolonged neutropenia. (f) Genitourinary tract infections in patients allergic or unresponsive to alternative

antibiotics. (g) Patients with bronchiectasis or cystic fibrosis. (h) Gonorrhea, and: (i) For completion of antibiotic treatment initiated in hospital when alternatives are

not appropriate.

ciprofloxacin, extended release tablet, 500mg (Cipro XL-BAY) For treatment of uncomplicated urinary tract infections in patients: (a) Unresponsive to first-line agents. (b) Allergic to first-line agents.

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ciprofloxacin, extended release tablet, 1000mg (Cipro XL-BAY)

For treatment of complicated urinary tract infections in patients: (a) Unresponsive to first-line agents. (b) Allergic to first-line agents.

ciprofloxacin/hydrocortisone, otic suspension, 0.2%/1% (Cipro HC-ALC)

For treatment of: (a) Otitis externa in patients who have failed previous treatment with listed

combination anti-infective/anti-inflammatory agents. (b) Patients with perforation of the tympanic membrane.

clarithromycin, tablet, 250mg, 500mg; oral suspension, 25mg/mL, 50mg/mL (Biaxin-ABB); extended-release tablet, 500mg (Biaxin XL-ABB)

For treatment of: (a) Pneumonia. (b) Upper and lower respiratory tract bacterial infections known to be resistant to

alternative antibiotics. (c) Upper and lower respiratory tract bacterial infections known to be unresponsive

to alternative antibiotics. (d) Infections in patients allergic to alternative antibiotics. (e) For treatment (and prophylaxis) in patients with non-tuberculous Mycobacterium,

and: (f) For one week for eradication of H. pylori-related infections when used in

combination treatment regimens for the treatment of peptic ulcer disease. (g) For completion of treatment initiated in hospital with macrolides or quinolones. (h) For patients intolerant to erythromycin and/or other antibiotics.

Clavulin - see amoxicillin trihydrate/potassium clavulanate Climara - see estradiol *clonidine HCl, tablet, 0.025mg (Dixarit-BOE) (Apo-Clonidine-APX)

For treatment of: (a) Menopausal flushing.

(b) Attention Deficit Hyperactivity Disorder.

clopidogrel bisulfate, tablet, 75mg (Plavix-AVT) (a) For treatment of patients who have experienced a transient ischemic attack,

stroke, or a myocardial infarction while on acetylsalicylic acid. (b) For treatment of patients who have experienced a transient ischemic attack,

stroke, or who have had a myocardial infarction and have a clearly demonstrated allergy to acetylsalicylic acid (manifested by asthma or nasal polyps).

(c) For treatment of patients who have experienced a transient ischemic attack, stroke, or a myocardial infarction and are intolerant of acetylsalicylic acid (manifested by gastrointestinal hemorrhage).

(d) When prescribed following intracoronary stent placement. Coverage will be provided for a period of 1 year. In patients intolerant or allergic to ASA coverage may be renewed.

(e) For reduction of atherothrombotic events in patients with acute coronary syndrome (i.e. unstable angina or non-Q-wave myocardial infarction without ST segment elevation) concurrently with acetylsalicylic acid. Coverage will also be considered for patients intolerant or allergic to acetylsalicylic acid. Coverage will be provided for a period of 1 year. In patients intolerant or allergic to ASA coverage may be renewed.

Clopixol - see zuclopenthixol *clozapine, tablet, 25mg, 100mg (Clozaril-NVR) (Gen-Clozapine-GPM) For treatment of schizophrenia in patients who are either treatment resistant or

treatment intolerant and have no other medical contraindications.

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Clozaril - see clozapine CO Azithromycin - see azithromycin CO Ciprofloxacin - see ciprofloxacin CO Sumatriptan - see sumatriptan CO Meloxicam - see meloxicam codeine, controlled release tablet, 50mg, 100mg, 150mg, 200mg (Codeine Contin-PFR)

For treatment of palliative and chronic pain patients as an alternative to: (a) ASA/codeine combination products or acetaminophen/codeine combination

products. (b) Regular release tablet when large doses are required. In non-palliative patients, coverage will only be approved for a 6 month course of

therapy, subject to review. Codeine Contin - see codeine Combivir - see lamivudine/zidovudine Copaxone - see Appendix G Coreg - see carvedilol Crixivan - see indinavir SO4

*cyclobenzaprine HCl, tablet, 10mg (Apo-Cyclobenzaprine-APX) (Novo-Cycloprine-NOP) (Nu-Cyclobenzaprine-NXP) (pms-Cyclobenzaprine-PMS) (Gen-Cyclobenzaprine-GPM) (Med-Cyclobenzaprine-MED) (Flexitec-TCH) (Dom-Cyclobenzaprine-DOM) As an adjunct to rest and physical therapy for relief of muscle spasm associated with

acute, painful musculoskeletal conditions: (a) Not responding to alternative therapy. (b) Experiencing severe adverse reactions to alternative therapy.

Coverage will be provided for up to a 3 week period. Coverage can be renewed for a 3 week period every 3 months.

cyclosporine, capsule, 10mg, 25mg, 50mg, 100mg; liquid, 100mg/mL (Neoral-NVR)

For treatment of: (a) Nephrotic syndrome. (b) Severe active rheumatoid arthritis in patients for whom classical slow-acting anti-

rheumatic agents are inappropriate or ineffective, and: (c) For induction and maintenance of remission of severe psoriasis in patients for

whom conventional therapy is ineffective or inappropriate. For the above indications prescriptions are subject to deductible (where applicable)

and co-payment as for other drugs covered under the Drug Plan. Pharmacies note: claims on behalf of these patients must use the following identifying numbers (not the DIN):

10mg – 00950792 100mg – 00950815 25mg – 00950793 100mg/mL – 00950823 50mg – 00950807 cyclosporine, capsule, 10mg, 25mg, 50mg, 100mg; liquid, 100mg/mL (Neoral-NVR) For prophylaxis of:

(a) Graft rejection following solid organ transplant. (b) Bone marrow transplant procedures. In such cases, the cost is covered at 100% and the deductible (where applicable) does not apply.

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cyproterone acetate, injection, 100mg/mL (Androcur Depot-PMS); *tablet, 50mg (Androcur-PMS) (Gen-Cyproterone-GPM) (Novo-Cyproterone-NOP) (Apo-Cyproterone-APX) For treatment of hirsuitism. dalteparin sodium, syringe, 2,500IU/mL (0.2mL), 25,000IU/mL (0.2mL, 0.3mL, 0.4mL, 0.5mL, 0.6mL, 0.72mL); injection solution, 10,000IU/mL (1mL), 25,000IU/mL (3.8mL) (Fragmin-PFI)

(a) For treatment of venous thromboembolism for up to 10 days. (b) For prophylaxis following total knee arthroplasty and for major orthopedic trauma

for up to 10 days (treatment duration may be reassessed). (c) For long-term outpatient prophylaxis in patients who are pregnant. (d) For long-term outpatient prophylaxis in patients who are intolerant to, or have

failed, warfarin therapy. (e) For long-term outpatient prophylaxis in patients who have lupus anticoagulant

syndrome. (f) Prophylaxis in patients undergoing total hip replacement or following hip fracture

surgery for up to 35 days following the procedure. darbepoetin alfa, pre-filled syringe, 25ug/mL (0.4mL), 40ug/mL (0.5mL), 100ug/mL (0.3mL, 0.4mL, 0.5mL), 200ug/mL (0.3mL, 0.4mL, 0.5mL), 500ug/mL (0.3mL) (Aranesp-AMG)

For treatment of anemia in chronic renal disease patients prior to initiation of dialysis. Note: Coverage for dialysis patients is provided under the Saskatchewan Aids to Independent Living (S.A.I.L.) Program. Exception Drug Status coverage is not required for S.A.I.L. patients.

DDAVP - see desmopressin acetate *deferoxamine mesylate, powder for solution, 500mg/vial, 2g/vial (pms-Deferoxamine-PMS) (Desferal-NVR) (Desferrioxamine Mesilate-DBU) For treatment of iron overload in patients with transfusion-dependent anemias. delavirdine mesylate, tablet, 100mg (Rescriptor-PFI) For management of HIV disease. This drug, as with other antivirals in the treatment of

HIV, should be used under the direction of an infectious disease specialist. Desferal - see deferoxamine mesylate Desferrioxamine Mesilate - see deferoxamine mesylate desmopressin, tablet, 0.1mg, 0.2mg (DDAVP-FEI) *intranasal solution, 10ug/dose (DDAVP-FEI) (Apo-Desmopressin-APX)

For treatment of: (a) Diabetes insipidus. (b) Enuresis in children over 5 years of age refractory to bed-wetting alarms or

alternative agents listed in the Formulary. (c) Nocturia in patients with a recognized neurologic disorder which causes detrusor

over-activity confirmed by cystogram in the absence of obstruction, who have not responded or are intolerant to at least two anticholinergic drugs.

desmopressin, injection, 4ug/mL (DDAVP-FEI); intranasal solution, 150ug/dose (Octostim-FEI) For prophylaxis of mild hemophilia A and mild von Willebrand's disease. Detrol LA - see tolterodine L-tartrate DexIron - see iron dextran

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diclofenac sodium, ophthalmic solution, 0.1% (Voltaren Ophtha-NVO) For treatment of:

(a) Post-operative ocular inflammation in patients undergoing cataract surgery. (b) Long-term inflammatory conditions unresponsive to short-term topical steroids,

and: (c) For prophylaxis of aphakic macular edema following cataract surgery.

didanosine, powder for oral solution (package), 4g (Videx-BMY); capsule (enteric coated beadlet), 125mg, 200mg, 250mg, 400mg (Videx EC-BMY) For management of HIV disease. This drug, as with other antivirals in the treatment

of HIV, should be used under the direction of an infectious disease specialist.

Diflucan - see fluconazole dipyridamole, tablet, 50mg, 75mg (Persantine-BOE)

For treatment following: (a) Transluminal angioplasty, for a maximum of 6 months. (b) Bypass surgery, for a maximum of 12 months. (c) Prosthetic heart valve replacement, for 12 months. This is renewable on a yearly

basis. dipyridamole/acetylsalicylic acid, capsule, 200mg/25mg (Aggrenox-BOE)

For treatment of patients who have had a: (a) Stroke while on acetylsalicylic acid. (b) Transient ischemic attack while on acetylsalicylic acid.

Dixarit - see clonidine HCl Dom-Carbamazepine CR - see carbamazepine Dom-Carvedilol - see carvedilol Dom-Ciprofloxacin - see ciprofloxacin Dom-Cyclobenzaprine - see cyclobenzaprine HCl Dom-Fluconazole - see fluconazole Dom-Meloxicam - see meloxicam Dom-Minocycline - see minocycline HCl Dom-Selegiline - see selegiline HCl Dom-Sumatriptan - see sumatriptan Dom-Ticlopidine - see ticlopidine HCl donepezil HCl, tablet, 5mg, 10mg (Aricept-PFI)

(a) A diagnosis of probable Alzheimer's disease as per DSM-IV criteria. (b) A mild to moderate stage of the disease with a MMSE score of 10-26 established

within 60-days prior to application for coverage by a clinician or nurse practitioner.

(c) A Functional Activities Questionnaire (FAQ) must be completed within 60-days prior to initial application for coverage by a clinician or nurse practitioner.

(d) Patients must discontinue all drugs with anticholinergic activity at least 14 days before the MMSE and FAQ are administered. Drugs with anticholinergic activity are not to be used concurrently with donepezil therapy. List all current medications patient was taking at the time of assessment.

(e) Patients intolerant to one drug may be switched to another drug in this class. Intolerance should be observed within the first month of treatment.

• Eligible patients currently taking donepezil would require assessment at 6

month intervals. To continue receiving donepezil, patients must not have both a greater than 2 point reduction in MMSE and a 1 point increase in FAQ in a 6 month evaluation period. Scores are compared to the most recent test results.

• Eligible new patients will enter a 3 month treatment period with donepezil. During the 3 month trial, patients must exhibit an improvement from the initial MMSE or FAQ to continue treatment with donepezil. The improvement must be at least 2 MMSE points or -1 FAQ. Patients who meet these requirements will be re-evaluated at 6 month intervals. To continue receiving donepezil, patients must

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not have both a greater than 2 point reduction in MMSE and a 1 point increase in FAQ in a 6 month evaluation period. Scores are compared to the most recent test results.

• The MMSE score must remain at 10 or greater at all times to be eligible for coverage.

• Patients who do not meet criteria to continue donepezil can be re-evaluated

within 3 months to confirm deterioration before coverage is discontinued.

• Donepezil does not need to be discontinued prior to MMSE or FAQ testing.

• A patient intolerant of one drug and switching to a second will be considered a "new" patient and will be assessed as such.

• Coverage will not be considered for patients who have failed on other drugs in

this class.

Initial EDS applications for donepezil (Aricept) will only be accepted from physicians on the Aricept/Exelon/Reminyl EDS application form. This form is available online at http://formulary.drugplan.health.gov.sk.ca or by calling the Drug Plan. EDS renewals can be submitted either by telephone, mail or fax.

dornase alfa, inhalation solution, 1mg/mL (Pulmozyme-HLR) For treatment of cystic fibrosis patients who meet the following criteria:

(a) At least 5 years of age. (b) Lung function greater than 40% (as measured by FVC). (c) Physicians will be requested to provide evidence of the beneficial effect of this

drug in their patients after 6 months of therapy before additional coverage is granted.

Renewal of coverage will be provided for a 6 month period if any of the following criteria are met: (a) FEV1 has improved by 10% from pre-treatment value. (b) Decreased antibiotic utilization. (c) Decreased hospitalizations. (d) Decreased absenteeism from school or work. (e) If the individual deteriorates upon discontinuation of Pulmozyme therapy.

Physicians must provide appropriate documentation to establish benefit. Dostinex - see cabergoline doxercalciferol, capsule, 2.5ug (Hectorol-DPY)

For management of: (a) Hypocalcemia (b) Osteodystrophy (c) Secondary hyperparathyroidism in chronic renal disease patients prior to initiation of dialysis.

Note: Coverage for dialysis patients is provided under the Saskatchewan Aids to Independent Living (SAIL) Program. Exception Drug Status coverage is NOT required for SAIL patients.

Duragesic - see fentanyl Edecrin - see ethacrynic acid efavirenz, capsule, 50mg, 100mg, 200mg; tablet, 600mg (Sustiva-BMY)

For management of HIV disease. This drug, as with other antivirals in treatment of HIV, should be used under the direction of an infectious disease specialist.

Eldepryl - see selegiline HCl Elidel - see pimecrolimus Elmiron - see pentosan polysulfate sodium Enbrel - see etanercept

230

http://formulary.drugplan.gov.sk.ca/

enfuvirtide, powder for solution, 108mg/vial (vial) (Fuzeon-HLR) For management of HIV disease on a case-by-case basis, following committee review of each case. (It was noted that enfuvirtide is not first-line therapy. The most appropriate use of this product is for “salvage therapy”). This drug, as with other antivirals in the treatment of HIV, should be used under the direction of an infectious disease specialist.

enoxaparin, syringe, 30mg/mL, 40mg/mL, 60mg/mL, 80mg/mL, 100mg/mL (Lovenox-AVT); injection solution, 100mg/mL (3mL); 150mg/mL (Lovenox HP-AVT)




syndrome. (f) For treatment of pediatric patients where anticoagulant therapy is required and

warfarin cannot be administered. (g) Prophylaxis in patients undergoing total hip replacement or following hip fracture

surgery for up to 35 days following the procedure. Entocort - see budesonide epoetin alfa, pre-filled syringe, 1,000 IU/0.5mL, 2,000IU/0.5mL, 3,000IU/0.3mL, 4,000IU/0.4mL, 5,000IU/0.5mL, 6,000IU/0.6mL, 8,000IU/0.8mL, 10,000IU/mL; sterile solution for injection, 20,000IU (Eprex-JAN)

For treatment of anemia in: (a) Chronic renal disease patients prior to initiation of dialysis. Note: Coverage for

dialysis patients is provided under the Saskatchewan Aids to Independent Living (S.A.I.L.) Program. Exception Drug Status coverage is not required for S.A.I.L. patients.

(b) AIDS patients. (c) Transplant patients.

Eprex - see epoetin alfa esomeprazole magnesium trihydrate, delayed release tablet, 20mg, 40mg (Nexium-AST)

(a) For a maximum of 8 weeks in treatment of peptic ulcer disease, which includes gastric and duodenal ulcers, in patients not responding or experiencing unusual or severe adverse reactions to a reasonable trial with H2 blockers, sucralfate or misoprostol. Coverage for a repeat treatment will be approved only after a 3-6 month period of no treatment or prophylaxis with an H2 blocker, sucralfate or misoprostol.

(b) For treatment of symptoms of gastroesophageal reflux disease (GERD). It was noted that patients with non-erosive GERD could potentially be reduced to stop-down therapy with an H2 antagonist depending on symptom resolution.

(c) For treatment of severe erosive esophagitis and Zollinger-Ellison Syndrome. (d) For one week for eradication of H. pylori-related infections in individuals with

peptic ulcer disease. Provision will be made for additional coverage in treatment failures.

(e) For first-line prevention of gastroduodenal hemorrhage in high risk patients with prior history of gastroduodenal bleeds for whom anticoagulant, glucocorticosteroid or NSAID therapy cannot be avoided. Coverage is renewable on a yearly basis for patients if discontinuation of offending agents or replacement with less damaging alternatives is not feasible.

(f) For a maximum of 8 weeks in patients discharged from hospital, on a proton pump inhibitor, following a gastroduodenal bleed.

231

Estalis - see estradiol/norethindrone acetate Estalis-Sequi - see estradiol & norethindrone acetate/estradiol Estracomb - see estradiol & norethindrone acetate/estradiol Estraderm - see estradiol estradiol, transdermal gel (metered dose pump), 0.06% (Estrogel-SCH); +transdermal therapeutic system, 25ug, 50ug, 100ug (Estraderm-NVR), 25ug, 50ug, 75ug, 100ug (Climara-BEX), 25ug, 50ug (Oesclim-PAL) *transdermal therapeutic system, 25ug, 37.5ug, 50ug, 75ug, 100ug (Estradot-NVR) (Sandoz Estradiol Derm-SDZ)

For treatment of patients: (a) Intolerant to oral estrogen. (b) With a fasting plasma triglyceride level of 4.5 mmol/L or more.

estradiol/norethindrone acetate, transdermal therapeutic system (8), 50ug/140ug, 50ug/250ug (Estalis-NVR)

For treatment of patients: (a) Intolerant to oral hormone replacement therapy (either estrogen or progesterone). (b) With a fasting plasma triglyceride level of 4.5 mmol/L or more.

estradiol & norethindrone acetate/estradiol, transdermal therapeutic system (8), 50ug & 140ug/50ug (Estalis-Sequi-NVR) +50ug & 250ug/50ug (Estracomb-NVR) (Estalis-Sequi-NVR)

For treatment of patients: (a) Intolerant to oral hormone replacement therapy (either estrogen or progesterone). (b) With a fasting plasma triglyceride level of 4.5 mmol/L or more.

Estradot - see estradiol Estrogel - see estradiol etanercept, powder for injection (vial), 25mg/vial; pre-filled syringe, 50mg/mL (Enbrel-AMG)

For treatment of: (a) Active rheumatoid arthritis in patients who have failed or are intolerant to

methotrexate and leflunomide. (b) Active juvenile rheumatoid arthritis in pediatric patients who have failed one

DMARD. (c) Psoriatic arthritis in patients who have failed or are intolerant to methotrexate and

leflunomide. This product should be used in consultation with a specialist in this area. Note: Exceptions can be considered in cases where methotrexate or leflunomide are contraindicated. Treatment should be combined with an immunosuppressant.

ethacrynic acid, tablet, 25mg (Edecrin-MSD) For treatment of patients intolerant to furosemide. etodolac, capsule, 200mg, 300mg (Apo-Etodolac-APX) For treatment of patients intolerant to other NSAIDs listed in the Formulary. Evista - see raloxifene HCl Exelon - see rivastigmine fentanyl, transdermal system, 25ug/hr, 50ug/hr, 75ug/hr, 100ug/hr (Duragesic-JAN)

For treatment of patients: (a) Intolerant to, or unable to take, oral sustained-release strong opioids. (b) As an alternative to subcutaneous narcotic infusion therapy.

232

Ferrlecit - see iron ferric sodium gluconate complex filgrastim, injection solution, 300ug/mL (Neupogen-AMG)

For treatment of: (a) Congenital, cyclic or idiopathic neutropenia in patients with absolute neutrophil

counts of less than or equal to 500. (b) Non-cancer patients who have undergone bone marrow transplantation. (c) AIDS patients with absolute neutrophil counts of less than 500.

*flavoxate HCl, tablet, 200mg (Urispas-PMS) (Apo-Flavoxate-APX) (pms-Flavoxate-PMS)

For treatment of urinary tract spasms in patients: (a) Unresponsive to listed alternatives. (b) Intolerant to listed alternatives.

Flexitec - see cyclobenzaprine HCl fluconazole, powder for oral suspension, 10mg/mL (Diflucan-PFI); *tablet, 50mg, 100mg (Diflucan-PFI) (Apo-Fluconazole-APX) (Gen-Fluconazole-GPM) (pms-Fluconazole-PMS) (Novo-Fluconazole-NOP) (Dom-Fluconazole-DOM) (Taro-Fluconazole-TAR)

For treatment of: (a) Fungal meningitis in immunocompromised patients. (b) Severe or life-threatening fungal infections. (c) Severe dermatophytoses unresponsive to other forms of therapy including

ketoconazole. Note: the 150mg capsule form of fluconazole is listed as a regular benefit in the

Saskatchewan Formulary. *flunarizine HCl, capsule, 5mg (Sibelium-JAN) (Apo-Flunarizine-APX) For prophylaxis of migraines in cases where alternative prophylactic agents have not

been effective. Foradil - see formoterol fumarate +formoterol fumarate, powder for inhalation (capsule), 12ug (Foradil-NVR); powder for inhalation (package), 6ug/dose, 12ug/dose (Oxeze Turbuhaler-AST)

For treatment of: (a) Asthma uncontrolled on concurrent inhaled steroid therapy. It is important that

these patients also have access to a short-acting beta-2 agonist for symptomatic relief.

(b) COPD unresponsive to short-acting beta agonists or short-acting anticholinergic bronchodilators.

formoterol fumarate dihydrate/budesonide, powder for inhalation (package), 6ug/100ug, 6ug/200ug (Symbicort Turbuhaler-AST)

For treatment of: (a) Asthma in patients uncontrolled on inhaled steroid therapy. It is important that


(b) COPD in patients who are uncontrolled on a long-acting beta-2 agonist alone. Fortovase - see saquinavir Fosamax - see alendronate sodium

233

fosamprenavir calcium, tablet, 700mg (Telzir-GSK) For the management of HIV disease in patients who have failed other protease inhibitor combinations. This drug, as with other antivirals in the treatment of HIV, should be used under the direction of an infectious disease specialist.

fosfomycin tromethamine, oral powder (sachet), 3g (Monurol-PFR) For treatment of urinary tract Infections:

(a) With organisms resistant to first line therapy. (b) In patients allergic to first line agents. (c) In pregnancy when first line agents are inappropriate.

Fragmin - see dalteparin sodium Fraxiparine - see nadroparin calcium Fraxiparine Forte - see nadroparin calcium Fucithalmic - see fusidic acid fusidic acid, ophthalmic drops (preservative free), 1%; ophthalmic drops 1% (Fucithalmic-LEO)

For treatment of patients unresponsive to listed alternatives. Fuzeon - see enfuvirtide galantamine hydrobromide, tablet, 4mg, 8mg, 12mg (Reminyl-JAN); extended release capsule, 8mg, 16mg, 24mg (Reminyl ER-JAN) A diagnosis of probable Alzheimer's disease as per DSM-IV criteria.

(a) A mild to moderate stage of the disease with a MMSE score of 10-26 established within 60-days prior to application for coverage by a clinician.

(b) A Functional Activities Questionnaire (FAQ) must be completed within 60-days prior to initial application for coverage by a clinician.

(c) Patients must discontinue all drugs with anticholinergic activity at least 14 days before the MMSE and FAQ are administered. Drugs with anticholinergic activity are not to be used concurrently with galantamine hydrobromide therapy. List all current medications patient was taking at the time of assessment.

(d) Patients intolerant to one drug may be switched to another drug in this class. Intolerance should be observed within the first month of treatment.

• Eligible patients currently taking galantamine hydrobromide would require

assessment at 6 month intervals. To continue receiving galantamine hydrobromide, patients must not have both a greater than 2 point reduction in MMSE and a 1 point increase in FAQ in a 6 month evaluation period. Scores are compared to the most recent test results.

• Eligible new patients will enter a 3 month treatment period with galantamine

hydrobromide. During the 3 month trial, patients must exhibit an improvement from the initial MMSE or FAQ to continue treatment with galantamine hydrobromide. The improvement must be at least 2 MMSE points or -1 FAQ. Patients who meet these requirements will be re-evaluated at 6 month intervals. To continue receiving galantamine hydrobromide, patients must not have both a greater than 2 point reduction in MMSE and a 1 point increase in FAQ in a 6 month evaluation period. Scores are compared to the most recent test results.

• The MMSE score must remain at 10 or greater at all times to be eligible for

coverage.

• Patients who do not meet criteria to continue galantamine hydrobromide can be re-evaluated within 3 months to confirm deterioration before coverage is discontinued.

• Galantamine hydrobromide does not need to be discontinued prior to MMSE or

FAQ testing.

234

• A patient intolerant of one drug and switching to a second will be considered a

"new" patient and will be assessed as such.

• Coverage will not be considered for patients who have failed on other drugs in this class.

Initial EDS applications for galantamine (Reminyl) will only be accepted from physicians on the Aricept/Exelon/Reminyl EDS application form. This form is available online at http://formulary.drugplan.health.gov.sk.ca by calling the Drug Plan. EDS renewals can be submitted either by telephone, mail or fax.

gatifloxacin, ophthalmic solution, 0.3% (Zymar-ALL) For treatment of ophthalmic infections: (a) Caused by gram-negative organisms. (b) Unresponsive to alternative agents.

Gen-Carbamazepine CR - see carbamazepine Gen-Ciprofloxacin - see ciprofloxacin Gen-Clozapine - see clozapine Gen-Cycloprine - see cyclobenzaprine HCl Gen-Cyproterone - see cyproterone acetate Gen-Fluconazole - see fluconazole Gen-Meloxicam - see meloxicam Gen-Minocycline - see minocycline HCl Gen-Nabumetone - see nabumetone Gen-Selegiline - see selegiline HCl Gen-Sumatriptan - see sumatriptan Gen-Ticlopidine - see ticlopidine HCl glatiramer acetate, injection, 20mg (pre-filled syringe) (Copaxone-TVM) See Appendix G GlucoNorm - see repaglinide goserelin acetate, 3.6mg/syringe (Zoladex-AST)

For treatment of: (a) Endometriosis. (Coverage may be repeated after a six month lapse, for another

6 month course). (b) Menorrhagia in preparation for endometrial ablation, and: (c) For pre-treatment of uterine fibroids prior to surgical removal. Coverage will be provided for a maximum of 6 months.

halobetasol propionate, cream, 0.05%; ointment, 0.05% (Ultravate-WSD) For treatment of patients refractory to or intolerant of other listed products. Hectorol - see doxercalciferol Heptovir - see lamivudine Hp-PAC - see lansoprazole/clarithromycin/amoxicillin Humalog - see insulin lispro Humalog Mix25 - see insulin (regular/protamine) lispro Humatrope - see somatropin Humira - see adalimumab imiquimod, topical cream (single-use packet), 5% (Aldara-MDA)

For treatment of genital warts in patients: (a) Unresponsive to podofilox. (b) With a large wart area.

235


Imitrex - see sumatriptan indinavir SO4, capsule, 200mg, 400mg (Crixivan-MSD)


infliximab, injection (mg),100mg/vial (Remicade-SCH) Crohn's Disease: (a) Moderate to severe Crohn's Disease:

• For treatment of patients who demonstrate continuing symptoms despite the use of optimal conventional therapies such as 5-ASA agents, glucocorticoids and immunosuppressive therapy.

• For treatment of patients who are intolerant to conventional therapy including 5-ASA agents, glucocorticoids and immunosuppressive therapy.

(b) Fistulizing Crohn's Disease: • For treatment of patients with symptomatic enterocutaneous or perineal

fistulae, enterovaginal fistulae or enterovesical fistulae (i.e. any type of fistulizing Crohn’s Disease).

Note: This product should be used in consultation with a specialist in this area.

Pharmacies note: claims on behalf of Crohn's Disease patients must use the following identifying number (not the DIN):

00950899

Rheumatoid Arthritis: For treatment of active rheumatoid arthritis in patients: (a) Who have failed treatment with methotrexate. (b) Intolerant to methotrexate and leflunomide.

Treatment should be combined with an immunosuppressant. This product should be used in consultation with a specialist in this area. (Note: Exceptions can be considered in cases where methotrexate or leflunomide are contraindicated.

Infufer - see iron dextran Innohep - see tinzaparin sodium insulin aspart, injection solution, 100U/ml (5x3ml) (10ml) (NovoRapid-NOO) For treatment of difficult to control diabetes. insulin lispro, injection solution, 100U/mL (5 x 1.5mL, 5 x 3mL) (Humalog-LIL)

For treatment of: (a) Patients using insulin pumps. (b) Difficult to control diabetes.

insulin (regular/protamine) lispro, injection suspension, 100U/mL, 25%/75% (5x3mL) (Humalog Mix25-LIL) For treatment of difficult to control diabetes. interferon alfa-2a, injection solution albumin (human) free, 9 million IU/1mL (Roferon-A-HLR)

For treatment of: (a) Chronic active hepatitis B for a period of up to 6 months. (b) Chronic active hepatitis C. Coverage will be provided for a duration of up to 48

weeks. Genotypes 2 and 3 may respond to 24 weeks of therapy. Note: Interferons are not interchangeable. Pharmacists should dispense the product

specified by the physician.

236

interferon alfa-2b, powder for injection, 10 million IU; injection solution albumin (human) free, 6 million IU/mL (0.5mL), 10 million IU/mL (0.5mL, 1mL); multi-dose pen (kit) albumin (human) free, 18 million IU/pen, 30 million IU/pen, 60 million IU/pen (Intron-A-SCH)

For treatment of: (a) Chronic active hepatitis B for a period of up to 6 months. (b) Chronic active hepatitis C. Coverage will be provided for a duration of up to 48

weeks therapy. Genotypes 2 and 3 may respond to 24 weeks therapy. Note: Interferons are not interchangeable. Pharmacists should dispense the product

specified by the physician. Intron A - see interferon alfa-2b interferon beta-1a, powder for IM injection, 30ug (Avonex-BGN); pre-filled syringe, 30ug (Avonex PS-BGN) See Appendix G interferon beta-1a, pre-filled syringe, 22ug (6 million IU), 44ug (12 million IU) (Rebif-SRO) See Appendix G interferon beta-1b, powder for injection, 0.3mg (3mL) (Betaseron-BEX) See Appendix G Intron A - see interferon alfa-2b Invirase - see saquinavir *iron dextran, injection, 50mg/mL (Infufer-SAB) (DexIron-GPM) For treatment of iron deficiency when patients are intolerant to oral iron replacement

products. Note: Coverage for dialysis patients is provided under the Saskatchewan Aids to Independent Living (S.A.I.L.) Program. Exception Drug Status coverage is not required for S.A.I.L. patients.

iron ferric sodium gluconate complex, injection solution, 12.5mg/mL (Ferrlecit-JAN)

For treatment of iron deficiency anemia in patients: (a) Undergoing chronic hemodialysis who are receiving supplemental erythropoetin. (b) Intolerant to oral iron replacement products.

iron sucrose, injection, 20mg/mL (Venofer-GPM) For treatment of iron deficiency when patients are intolerant to oral iron replacement products and intravenous iron dextran.

itraconazole, capsule, 100mg; oral solution, 10mg/mL (Sporanox-JAN) For treatment of: (a) Severe or life-threatening fungal infections. (b) Severe dermatophytoses unresponsive to other forms of therapy. (c) Onychomycosis.

Kaletra - see lopinavir/ritonavir Ketek - see telithromycin *ketoconazole, tablet, 200mg (Apo-Ketoconazole-APX) (Nu-Ketocon-NXP) (Novo-Ketoconazole-NOP)

For treatment of: (a) Severe or life-threatening fungal infections. (b) Severe dermatophytoses. (c) Dermatophytoses unresponsive to other forms of therapy.

237

*ketorolac tromethamine, ophthalmic solution, 0.5% (Acular-ALL) (Apo-Ketoralac-APX) (ratio-Ketorolac-RPH)

For treatment of: (a) Post-operative ocular inflammation in patients undergoing cataract surgery. (b) Long-term inflammatory conditions unresponsive to short-acting topical steroids,

and: (c) For prophylaxis of aphakic macular edema following cataract surgery.

+ketotifen fumarate, tablet, 1mg (Zaditen-NVR) (Novo-Ketotifen-NOP) (pms-Ketotifen-PMS); syrup, 0.2mg/mL (Zaditen-NVR) (Novo-Ketotifen-NOP) (Apo-Ketotifen-APX) (pms-Ketotifen-PMS)

For treatment of pediatric patients with asthma who are: (a) Unresponsive to (b) Unable to administer alternative prophylactic agents listed in the Formulary.

Kineret - see anakinra Kivexa - see abacavir SO4/lamivudine lactulose, syrup, 667mg/mL (pms-Lactulose-PMS); *solution, 667mg/mL (ratio-Lactulose-RPH) (Apo-Lactulose-APX) For treatment of portal systemic encephalopathy. lamivudine, tablet, 100mg (Heptovir-GSK) For management of hepatitis B. lamivudine, tablet, 150mg, 300mg; oral solution, 10mg/mL (3TC-GSK)


lamivudine/zidovudine, tablet, 150mg/300mg (Combivir-GSK) For management of HIV disease. This drug, as with other antivirals in the treatment of HIV, should be used under the direction of an infectious disease specialist.

lansoprazole, delayed release capsule, 15mg, 30mg (Prevacid-ABB); delayed release tablet, 30mg (Prevacid FasTab-ABB)


(b) For treatment of symptoms of gastroesophageal reflux disease (GERD). It was noted that patients with non-erosive GERD could potentially be reduced to step-down therapy with an H2 antagonist depending on symptom resolution.





lansoprazole/clarithromycin/amoxicillin, 7 day package, 30mg/500mg/500mg (Hp-PAC-ABB)

For one week for eradication of H. pylori-related infections in individuals with peptic ulcer disease. Provision will be made for additional coverage in treatment failures.

238

*leflunomide, tablet, 10mg, 20mg (Arava-AVT) (Apo-Leflunomide-APX) (Novo-Leflunomide-NOP)

For treatment of active rheumatoid arthritis in patients: (a) That have failed methotrexate and at least one other DMARD (e.g. sulfasalazine,

azathioprine or hydroxychloroquine). (b) Intolerant to methotrexate and at least one other DMARD (e.g. sulfasalazine,

azathioprine or hydroxychloroquine). Note: Leflunomide is contraindicated in patients with pre-existing impairment of liver function.

Leucovorin - see leucovorin calcium leucovorin calcium, tablet, 5mg (Leucovorin-WYA) For treatment of folic acid deficiency in patients who have been on long-term therapy

with trimethoprim/sulfamethoxazole. leuprolide acetate, injection, 3.75mg/mL, 7.5mg/mL; depot injection, 11.25mg (3-month SR) (Lupron Depot-ABB)


6 month course). (b) Menorrhagia in preparation for endometrial ablation, and: (c) For pre-treatment of uterine fibroids prior to surgical removal. Coverage will be provided for a maximum of 6 months.

Levaquin - see levofloxacin *levofloxacin, tablet, 250mg, 500mg (Levaquin-JAN) (Novo-Levofloxacin-NOP) For treatment of:

(a) Pneumonia in patients with underlying lung disease (excluding asthma). (b) Pneumonia in nursing home patients. (c) Infections in patients allergic to two or more alternative antibiotics. (d) Infections known to be resistant to alternative antibiotics. Resistance must be

determined by C & S. Where C & S cannot be obtained coverage will be approved when a patient has failed at least 2 other classes of antibiotics, and:

(e) For completion of antibiotic treatment initiated in hospital when alternatives are not appropriate.

levofloxacin, tablet, 750mg (Levaquin-JAN) EDS will only be approved for five days. For treatment of pneumonia in patients:

(a) With underlying lung disease (excluding asthma) (b) In a nursing home. (c) Allergic to two or more alternative antibiotics. (d) Known to be resistant to alternative antibiotics. Resistance must be determined

by C & S. Where C & S cannot be obtained coverage will be approved when a patient has failed at least 2 other classes of antibiotics, and:

(e) For completion of antibiotic treatment of pneumonia initiated in hospital when alternatives are not appropriate.

linezolid, tablet, 600mg (Zyvoxam-PFI)

Following consultation with an infectious disease specialist For treatment of gram-positive infections in patients: (a) Resistant to vancomycin. (b) Intolerant to or experiencing severe adverse effects from vancomycin, and: (c) For completion of therapy initiated in hospital with intravenous vancomycin,

quinupristin/dalfopristin or linezolid for patients who can be discharged on oral therapy.

Lioresal Intrathecal - see baclofen

239

Loniten - see minoxidil lopinavir/ritonavir, capsule, 133.3mg/33.3mg; oral solution, 80mg/20mg(mL) (Kaletra-ABB)


Losec - see omeprazole magnesium Lovenox - see enoxaparin Lovenox HP - see enoxaparin Lupron Depot - see leuprolide acetate Maxalt - see rizatriptan benzoate Maxalt RPD - see rizatriptan benzoate Med-Cyclobenzaprine - see cyclobenzaprine HCl Med-Minocycline - see minocycline HCl Med-Selegiline - see selegiline HCl Megace - see megestrol acetate tablet Megace OS - see megestrol acetate oral suspension *megestrol acetate, tablet, 40mg, 160mg (Apo-Megestrol-APX) (Nu-Megestrol-NXP) (Megace-BMY)

For treatment of: (a) Anorexia (b) Cachexia (c) Unexplained weight loss in patients with a diagnosis of acquired immunodeficiency (AIDS).

megestrol acetate, oral suspension, 40mg/mL (Megace OS-BMY)

For treatment of: (a) Anorexia (b) Cachexia (c) Unexplained weight loss in patients with a diagnosis of acquired immunodeficiency syndrome (AIDS) who are intolerant to tablets.

*meloxicam, tablet, 7.5mg, 15mg (Mobicox-BOE) (pms-Meloxicam-PMS) (ratio-Meloxicam-RPH) (Apo-Meloxicam-APX) (Dom-Meloxicam-DOM) (CO Meloxicam-COB) (Gen-Meloxicam-GPM) (Novo-Meloxicam-NOP) For treatment of patients intolerant to other NSAIDs listed in the formulary. Mepron - see atovaquone mercaptopurine, tablet, 50mg (Purinethol-GSK)

For treatment of: (a) Crohn's disease.

(c) Rheumatoid arthritis. +methoxsalen, capsule, 10mg (Oxsoralen-ICN) (Oxsoralen Ultra-ICN) (Ultramop-CDX); lotion, 1% (Oxsoralen-ICN) (Ultramop-CDX) For treatment of psoriasis, for use prior to PUVA therapy. methysergide maleate, tablet, 2mg (Sansert-NVR) For prophylaxis of recurrent vascular headaches. Coverage will be provided for up to

6 months at a time with a 3-4 week medication free interval between courses of therapy.

Miacalcin - see calcitonin salmon nasal spray

240

midodrine HCl, tablet, 2.5mg, 5mg (Amatine-RBP) For treatment of orthostatic hypotension. Minocin - see minocycline HCl * minocycline HCl, capsule, 50mg, 100mg (Minocin-WYA) (Apo-Minocycline-APX) (Novo-Minocycline-NOP) (ratio-Minocycline-RPH) (Gen-Minocycline-GPM) (Med-Minocycline-MED) (Dom-Minocycline-DOM) (Sandoz Minocycline-SDZ) (pms-Minocycline-PMS) For treatment of acne unresponsive to tetracycline. minoxidil, tablet, 2.5mg, 10mg (Loniten-PFI) For control of hypertension unresponsive to all other listed therapeutic agents. Mobicox - see meloxicam modafinil, tablet, 100mg (Alertec-DPY)

For treatment of: (a) Patients with sleep laboratory-confirmed diagnosis of narcolepsy. (b) Patients with sleep laboratory-confirmed diagnosis of idiopathic CNS

hypersomnia.

Monocor - see bisoprolol fumarate montelukast sodium, chewable tablet, 4mg, 5mg; tablet, 10mg; oral granules, 4mg (Singulair-MSD)

For adjunctive treatment of asthma in patients uncontrolled on inhaled corticosteroids. Monurol - see fosfomycin tromethamine moxifloxacin HCl, tablet, 400mg (Avelox-BAY) For treatment of:

(a) Pneumonia in patients with underlying lung disease (excluding asthma) and pneumonia in nursing home patients.

(b) Infections in patients allergic to two or more alternative antibiotics. (c) Infections known to be resistant to alternative antibiotics. Resistance must be

determined by C & S. Where a C & S cannot be obtained coverage will be approved when a patient has failed at least 2 other classes of antibiotics, and:

(d) For completion of antibiotic treatment initiated in hospital when alternatives are not appropriate.

moxifloxacin HCl, ophthalmic solution, 0.5% (Vigamox-ALC) For treatment of ophthalmic infections unresponsive to alternative agents. Mycobutin - see rifabutin mycophenolate mofetil, capsule, 250mg; tablet, 500mg; powder for oral suspension, 200mg/mL (CellCept-HLR)

(a) For prevention of acute rejection in transplant patients. (b) For treatment of proliferative lupus nephritis in patients refractory or intolerant to

standard therapy such as cyclophosphamide and cyclosporine. mycophenolate sodium, enteric coated tablet, 180mg, 360mg (Myfortic-NVR) For prevention of acute rejection in renal transplant patients. Myfortic - see mycophenolate sodium

241

nabilone, capsule, 1mg (Cesamet-LIL) For treatment of nausea and anorexia in AIDS patients. *nabumetone, tablet, 500mg (Apo-Nabumetone-APX) (Gen-Nabumetone-GPM) (Novo-Nabumetone-NOP) (Sandoz Nabumetone-SDZ); 750mg (Novo-Nabumetone-NOP) For treatment of patients intolerant to other NSAIDs listed in the Formulary. nadroparin calcium, syringe, 9,500IU/mL (0.3mL, 0.4mL, 0.6mL, 0.8mL, 1.0mL) (Fraxiparine-AVT); syringe, 19,000IU/mL (0.6mL, 0.8mL, 1mL) (Fraxiparine Forte-AVT)





surgery for up to 35 days following the procedure. nafarelin acetate, intranasal solution, 2mg/mL (Synarel-HLR)


6 month course). (b) Menorrhagia in preparation for endometrial ablation, and: (c) For pre-treatment of uterine fibroids prior to surgical removal. Coverage will be provided for a maximum of 6 months

Nalcrom - see sodium cromoglycate naratriptan HCl, tablet, 1mg, 2.5mg (Amerge-GSK) For treatment of migraine headaches. Eligibility will be restricted to beneficiaries over

18 and under 65 years of age. The maximum quantity that can be claimed through the Drug Plan is limited to 6

doses per 30 days within a 60-day period. Patients requiring more than 12 doses in a consecutive 60-day period should be considered for migraine prophylaxis therapy if

they are not already receiving such therapy. nateglinide, tablet, 60mg, 120mg, 180mg (Starlix-NVR)

For treatment of diabetes in patients: (a) Uncontrolled on sulfonylureas. (b) Intolerant to sulfonylureas.

nelfinavir mesylate, tablet, 250mg, 625mg; oral powder, 50mg/g (Viracept-PFI)


Neoral - see cyclosporine Neupogen - see filgrastim nevirapine, tablet, 200mg (Viramune-BOE)


Nexium - see esomeprazole magnesium trihydrate

242

nimodipine, capsule, 30mg (Nimotop-BAY) For treatment of subarachnoid hemorrhage to complete a 3 week course of treatment

in cases where a patient is discharged from hospital before completion of the treatment period.

Nimotop - see nimodipine Nizoral - see ketoconazole *norfloxacin, tablet, 400mg (Apo-Norflox-APX) (Novo-Norfloxacin-NOP) (pms-Norfloxacin-PMS) For treatment of genitourinary tract infections:

(a) Caused by Pseudomonas aeruginosa. (b) In patients allergic to alternative agents. (c) With organisms known to be resistant to alternative antibiotics, and: (d) For adults with gonoccoccal urethritis or cervicitis.

Norvir - see ritonavir Norvir SEC - see ritonavir Novo-Alendronate - see alendronate sodium Novo-Bisoprolol - see bisoprolol fumarate Novo-Carvedilol - see carvedilol Novo-Ciprofloxacin - see ciprofloxacin Novo-Clavamoxin - see amoxicillin trihydrate/potassium clavulanate Novo-Cycloprine - see cyclobenzaprine HCl Novo-Cyproterone - see cyproterone acetate Novo-Fluconazole - see fluconazole Novo-Ketoconazole - see ketoconazole Novo-Ketotifen - see ketotifen fumarate Novo-Leflunomide - see leflunomide Novo-Levofloxacin - see levofloxacin Novo-Meloxicam - see meloxicam Novo-Minocycline - see minocycline HCl Novo-Nabumetone - see nabumetone Novo-Norfloxacin - see norfloxacin NovoRapid - see insulin aspart Novo-Selegiline - see selegiline HCl Novo-Sumatriptan - see sumatriptan Novo-Ticlopidine - see ticlopidine Nu-Carvedilol - see carvedilol Nu-Ciprofloxacin - see ciprofloxacin Nu-Cyclobenzaprine - see cyclobenzaprine HCl Nu-Ketocon - see ketoconazole Nu-Megestrol - see megestrol acetate tablet Nu-Selegiline - see selegiline HCl Nu-Ticlopidine - see ticlopidine HCl Nutropin - see somatropin Nutropin AQ - see somatropin Nutropin AQ Pen - see somatropin Octostim - see desmopressin *octreotide, injection, 50ug/mL (1mL), 100ug/mL (1mL), 200ug/mL (5mL), 500ug/mL (1mL) (Sandostatin-NVR) (Octreotide Acetate-OMG); powder for injection, 10mg/vial, 20mg/vial, 30mg/vial (Sandostatin LAR-NVR) (a) For management of terminal malignant bowel obstruction in palliative patients. (b) For treatment of acromegaly. Note: Coverage for federally approved cancer indications is provided under the

Saskatchewan Cancer Foundation according to their guidelines.

243

Octreotide Acetate - see octreotide Ocuflox - see ofloxacin ophthalmic solution Oesclim - see estradiol *ofloxacin, ophthalmic solution, 0.3% (Ocuflox-ALL) (Apo-Ofloxacin-APX) (pms-Ofloxacin-PMS)

For the treatment of ophthalmic infections: (a) Caused by gram-negative organisms. (b) Unresponsive to alternative agents, and: (c) Infiltrative corneal infections.

olanzapine, tablet, 2.5mg, 5mg, 7.5mg, 10mg, 15mg (Zyprexa-LIL); orally disintegrating tablet, 5mg, 10mg, 15mg (Zyprexa Zydis-LIL)

For treatment of: (a) Schizophrenia. (b) Other psychotic conditions where there has been:

1. Treatment failure to other atypical anti-psychotic agents. 2. Intolerance to other atypical anti-psychotic agents.

(c) Patients with acute mania of bi-polar affective disorder for an additional 4 weeks following hospital discharge, and:

(d) For maintenance treatment of bipolar disorder in patients unresponsive to lithium, valproate and one of the third-line agents (lamotrigine, topiramate or gabapentin).

omeprazole, capsule, 20mg (Apo-Omeprazole-APX)







omeprazole magnesium, delayed release tablet, 10mg (Losec-AST)

For treatment of: (a) Symptoms of gastroesophageal reflux disease (GERD). It was noted that

patients with non-erosive GERD could potentially be reduced to step-down therapy with an H2 antagonist depending on symptom resolution.

(b) Severe erosive esophagitis and Zollinger-Ellison syndrome. This is renewable on a yearly basis, and:

(c) For maintenance therapy of healed reflux esophagitis. This is renewable on a yearly basis.

244

omeprazole magnesium, delayed release tablet, 20mg (Losec-AST) (a) For a maximum of 8 weeks in treatment of peptic ulcer disease, which includes

gastric and duodenal ulcers, in patients not responding or experiencing unusual or severe adverse reactions to a reasonable trial with H2 blockers, sucralfate or misoprostol. Coverage for a repeat treatment will be approved only after a 3-6 month period of no treatment or prophylaxis with an H2 blocker, sucralfate or misoprostol.






One-Alpha - see alfacalcidol oxcarbazepine, tablet, 150mg, 300mg, 600mg; oral suspension, 60mg/mL (Trileptil-NVR) For treatment of partial seizures in patients intolerant to carbamazepine. Oxeze Turbuhaler - see formoterol fumarate Oxsoralen - see methoxsalen *pamidronate disodium injection, 30mg, (Aredia-NVR) (Pamidronate Disodium Injection-DBU) (pms-Pamidronate-PMS) (Sandoz Pamidronate-SDZ); *injection, 90mg (Aredia-NVR) (Pamidronate Disodium Injection-DBU) (pms-Pamidronate-PMS) (Sandoz Pamidronate-SDZ) (Pamidronate Disodium Omega-OMG); *injection, 60mg (Pamidronate Disodium Injection-DBU) (Sandoz Pamidronate-SDZ)

For treatment of osteoporosis in patients intolerant to oral bisphosphonates.

pantoprazole, enteric-coated tablet, 40mg (Pantoloc-ATA) (a) For a maximum of 8 weeks in treatment of peptic ulcer disease, which includes

gastric and duodenal ulcers, in patients not responding or experiencing unusual or severe adverse reactions to a reasonable trial with H2 blockers, sucralfate or misoprostol. Coverage for a repeat treatment will be approved only after a 3-6 month period of no treatment or prophylaxis with an H2 blocker, sucralfate or misoprostol.




245



Pantoloc - see pantoprazole Pariet - see rabeprazole sodium Pegetron - see peginterferon alfa-2b/ribavirin peginterferon alfa-2a, injection (pre-filled syringe), 180ug/0.5mL, injection (vial) 180ug/1mL (Pegasys-HLR)

(a) For treatment of chronic active hepatitis C. Coverage will be provided for a duration of up to 48 weeks. Genotypes 2 and 3 may respond to 24 weeks of therapy.

(b) For the management of hepatitis B for up to 48 weeks.

peginterferon alfa-2a/ribavirin, injection (pre-filled syringe)/tablet, 180ug/0.5mL/200mg; injection (vial)/tablet, 180ug/1mL/200mg (Pegasys RBV-HLR)

For treatment of chronic active hepatitis C. Coverage will be provided for a duration of up to 48 weeks. Genotypes 2 and 3 may respond to 24 weeks of therapy.

peginterferon alfa-2b/ribavirin, powder for solution/capsule, 50ug/0.5mL/200mg, 80ug/0.5mL/200mg, 100ug/0.5mL/200mg, 120ug/0.5mL/200mg, 150ug/0.5mL/200mg (Pegetron Redipen-SCH)


peginterferon alfa-2b, powder for injection (vial), 50ug/0.5mL, 80ug/0.5mL, 120ug/0.5mL, 150ug/0.5mL (Unitron PEG-SCH)


peginterferon alfa-2b/ribavirin, powder for solution/capsule, 50ug/200mg, 80ug/200mg, 100ug/200mg, 120ug/200mg, 150ug/200mg (Pegetron-SCH)


pentosan polysulfate sodium, capsule, 100mg (Elmiron-JAN) For treatment of interstitial cystitis where other treatments have failed. Persantine - see dipyridamole pimecrolimus, topical cream, 1% (Elidel-NVR)

For treatment of atopic dermatitis in patients: (a) Unresponsive to topical steroids tried within the last 3 months. (b) Intolerant to topical steroids tried within the last 3 months.

pioglitazone HCl, tablet, 15mg, 30mg, 45mg (Actos-LIL) See Appendix B for online adjudication criteria.

Plavix - see clopidogrel bisulfate pms-Alendronate - see alendronate sodium pms-Azithromycin - see azithromycin pms-Bezafibrate - see bezafibrate pms-Carbamazepine-CR - see carbamazepine

246

pms-Carvedilol - see carvedilol pms-Ciprofloxacin - see ciprofloxacin pms-Cyclobenzaprine - see cyclobenzaprine HCl pms-Deferoxamine - see deferoxamine mesylate pms-Flavoxate - see flavoxate HCl pms-Fluconazole - see fluconazole pms-Ketotifen - see ketotifen pms-Lactulose - see lactulose pms-Meloxicam - see meloxicam pms-Minocycline - see minocycline HCl pms-Norfloxacin - see norfloxacin pms-Ofloxacin - see ofloxacin pms-Sumatriptan - see sumatriptan pms-Ticlopidine - see ticlopidine HCl pms-Tobramycin - see tobramycin pms-Vancomycin - see vancomycin HCl Prevacid - see lansoprazole Prevacid FasTab - see lansoprazole Profasi HP - see chorionic gonadotropin progesterone (micronized), capsule, 100mg (Prometrium-SCH)

For treatment of patients: (a) Intolerant to medroxyprogesterone acetate (Provera). (b) Having low high-density lipoproteins. Prograf - see tacrolimus Prometrium - see progesterone (micronized) Protopic - see tacrolimus Pulmozyme - see dornase alfa Purinethol - see mercaptopurine rabeprazole sodium, tablet, 10mg (Pariet-JAN)





(e) First-line prevention of gastroduodenal hemorrhage in high-risk patients with prior history of gastroduodenal bleeds for whom anticoagulant, glucocorticosteroid or NSAID therapy cannot be avoided. Coverage is renewable on a yearly basis for patients if discontinuation of offending agents or replacement with less damaging alternatives is not feasible.


raloxifene HCl, tablet, 60mg (Evista-LIL)

For treatment of osteoporosis in patients: (a) Unresponsive to etidronate disodium/calcium (Didrocal) after receiving it for 1

year. (b) Intolerant to etidronate disodium/calcium (Didrocal).

247

Ran-Carvedilol - see carvedilol Rapamune - see sirolimus ratio-Aclavulanate - see amoxicillin trihydrate/potassium clavulanate ratio-Alendronate - see alendronate sodium ratio-Azithromycin - see azithromycin ratio-Carvedilol - see carvedilol ratio-Cefuroxime - see cefuroxime axetil ratio-Ciprofloxacin - see ciprofloxacin ratio-Ketorolac - see ketorolac tromethamine ratio-Lactulose - see lactulose ratio-Meloxicam - see meloxicam ratio-Minocycline - see minocycline HCl Rebif - see Appendix G Remicade - see infliximab Reminyl - see galantamine hydrobromide Reminyl ER - see galantamine hydrobromide Renagel - see sevelamer HCl repaglinide, tablet, 0.5mg, 1mg, 2mg (GlucoNorm-NOO)

For treatment of diabetes in patients: (a) Uncontrolled on sulfonylureas. (b) Intolerant to sulfonylureas.

Rescriptor - see delavirdine mesylate Retin A - see tretinoin Retrovir - see zidovudine Reyataz - see atazanavir SO4 rifabutin, capsule, 150mg (Mycobutin-PFI) For treatment (and prophylaxis) of Mycobacterium avium complex (MAC) infection. risedronate sodium, tablet, 5mg, 35mg (Actonel-PGA)

For treatment of osteoporosis in patients: (a) Unresponsive to etidronate disodium/calcium (Didrocal) after receiving it for one

year. (b) Intolerant to etidronate disodium/calcium (Didrocal). (c) Who have pre-existing and/or recent fractures, and: (d) Glucocorticoid-induced osteoporosis in patients who have received systemic

glucocorticoid treatment for at least 3 months.

risedronate sodium, tablet, 30mg (Actonel-PGA) For treatment of symptomatic Paget's disease of the bone. Risperdal Consta - see risperidone risperidone, powder for suspension sustained-release, 25mg/vial, 37.5mg/vial, 50mg/vial (Risperdal Consta-JAN)

For treatment of patients exhibiting a compliance problem with an oral antipsychotic and in whom the administration of a conventional injectable extended action antipsychotic is ineffective or poorly tolerated.

ritonavir, oral solution, 80mg/mL (Norvir-ABB); soft elastic capsule, 100mg (Norvir SEC-ABB)


248

rivastigmine, capsule, 1.5mg, 3mg, 4.5mg, 6mg; oral solution, 2mg/mL (Exelon-NVR)

(a) A diagnosis of probable Alzheimer's disease as per DSM-IV criteria. (b) A mild to moderate stage of the disease with a MMSE score of 10-26 established

within 60-days prior to application for coverage by a clinician. (c) A Functional Activities Questionnaire (FAQ) must be completed. (d) Patients must discontinue all drugs with anticholinergic activity at least 14 days

before the MMSE and FAQ are administered. Drugs with anticholinergic activity are not to be used concurrently with rivastigmine therapy. List all current medications patient was taking at the time of assessment.

(e) Patients intolerant to one drug may be switched to another drug in this class. Intolerance should be observed within the first month of treatment.

• Eligible patients currently taking rivastigmine would require assessment at 6

month intervals. To continue receiving rivastigmine, patients must not have both a greater than 2 point reduction in MMSE and a 1 point increase in FAQ in a 6 month evaluation period. Scores are compared to the most recent test results.

• Eligible new patients will enter a 3 month treatment period with rivastigmine.

During the 3 month trial, patients must exhibit an improvement from the initial MMSE or FAQ to continue treatment with rivastigmine. The improvement must be at least 2 MMSE points or -1 FAQ. Patients who meet these requirements will be re-evaluated at 6 month intervals. To continue receiving rivastigmine, patients must not have both a greater than 2 point reduction in MMSE and a 1 point increase in FAQ in a 6 month evaluation period. Scores are compared to the most recent test results.

The MMSE score must remain at 10 or greater at all times to be eligible for coverage. • Patients who do not meet criteria to continue rivastigmine can be re-evaluated

within 3 months to confirm deterioration before coverage is discontinued.

• Rivastigmine does not need to be discontinued prior to MMSE or FAQ testing. • A patient intolerant of one drug and switching to a second will be considered a

"new" patient and will be assessed as such.

• Coverage will not be considered for patients who have failed on other drugs in this class.

Initial EDS application for rivastigmine (Exelon) will only be accepted from physicians on the Aricept/Exelon/Reminyl EDS application form. This form is available online at http://formulary.drugplan.health.gov.sk.ca or by calling the Drug Plan. EDS renewals can be submitted either by telephone, mail or fax.

rizatriptan benzoate, tablet, 5mg, 10mg (Maxalt-MSD); wafer, 5mg, 10mg (Maxalt RPD-MSD) For treatment of migraine headaches. Eligibility will be restricted to beneficiaries over


doses per 30 days within a 60-day period. Patients requiring more than 12 doses in a consecutive 60-day period should be considered for migraine prophylaxis therapy if they are not already receiving such therapy.

Rocaltrol - see calcitriol Roferon-A - see interferon alfa-2a rosiglitazone maleate, tablet, 2mg, 4mg, 8mg (Avandia-GSK)

See Appendix B for online adjudication criteria.

249

http://formulary.drugplan.gov.sk.ca/

rosiglitazone maleate/metformin HCl, tablet, 1mg/500mg, 2mg/500mg, 4mg/500mg, 2mg/1000mg, 4mg/1000mg (Avandamet-GSK)

For the convenience of patients who have been stabilized on metformin and rosiglitazone.

SAB-Tobramycin - see tobramycin ophthalmic solution Saizen - see somatropin salmeterol xinafoate, metered dose inhaler, 25ug/actuation; powder disk, 50ug/blister (Serevent-GSK); powder for inhalation (package), 50ug/dose (Serevent Diskus-GSK)

For treatment of: (a) Asthma uncontrolled on concurrent inhaled steroid therapy.

It is important that these patients also have access to a short-acting beta-2 agonist for symptomatic relief.

(b) COPD unresponsive to short-acting beta agonists or short-acting anticholinergic bronchodilators.

salmeterol xinafoate/fluticasone propionate, metered dose inhaler (package), 25ug/125ug, 25ug/250ug (Advair-GSK); powder for inhalation (package), 50ug/100ug, 50ug/250ug, 50ug/500ug (Advair Diskus-GSK)

For treatment of: (a) Asthma in patients uncontrolled on inhaled steroid therapy. It is important that


(b) COPD in patients who are uncontrolled on long-acting beta-2 agonists alone. Sandostatin - see octreotide Sandostatin LAR - see octreotide Sandoz Azithromycin - see azithromycin Sandoz Bisoprolol - see bisoprolol fumarate Sandoz Ciprofloxacin - see ciprofloxacin Sandoz Estradiol Derm - see estradiol Sandoz Minocycline - see minocycline HCl Sandoz Nabumetone - see nabumetone Sandoz Pamidronate - see pamidronate Sandoz Sumatriptan - see sumatriptan Sandoz Ticlopidine - see ticlopidine HCl Sansert - see methysergide maleate saquinavir, capsule, 200mg (Invirase-HLR); soft gelatin capsule, 200mg (Fortovase-HLR)


*selegiline HCl, tablet, 5mg (Novo-Selegiline-NOP) (Apo-Selegiline-APX) (Gen-Selegiline-GPM) (Nu-Selegiline-NXP) (Dom-Selegiline-DOM) (pms-Selegiline-PMS) (a) For use as an adjunct in cases of Parkinson's disease being treated with

levodopa, levodopa/benzerazide, levodopa/carbidopa, or bromocriptine. (b) For prophylaxis in early Parkinsonism. Serevent - see salmeterol xinafoate Serevent Diskus - see salmeterol xinafoate

250

sevelamer HCl, tablet, 800mg (Renagel-GZY) For treatment of end-stage renal disease in patients: (a) Intolerant to aluminum or calcium containing phosphate binding agents. (b) Where aluminum or calcium containing phosphate binding agents are

inappropriate. Sibelium - see flunarizine HCl Singulair - see montelukast sodium sirolimus, tablet, 1mg; oral solution, 1mg/mL (Rapamune-WYA)

For prophylaxis of graft rejection in transplant patients. sodium cromoglycate, capsule, 100mg (Nalcrom-AVT)

For treatment of: (a) Patients who experience severe reactions to foods which cannot be avoided. (b) Crohn's Disease unresponsive to traditional therapy.

(c) Ulcerative colitis in patients unresponsive to traditional therapy. somatropin, injection, 5mg (Humatrope-LIL), 6mg, 12mg (Humatrope Cartridge-LIL)

For treatment of children who have growth failure due to inadequate secretion of normal endogenous growth hormone.

+somatropin, injection, 3.33mg, 8.8mg (Saizen-SRO), 5mg (Nutropin-HLR) (Saizen-SRO), 10mg (Nutropin AQ-HLR) (Nutropin-HLR); cartridge, 10 mg (Nutropin AQ Pen-HLR)

For treatment of children who have growth failure: (a) Due to inadequate secretion of normal endogenous growth hormone. (b) Associated with chronic renal insufficiency. Note: Exception Drug Status

coverage is not required for S.A.I.L. patients. Coverage is provided under Saskatchewan Aids to Independent Living (S.A.I.L.) Program.

Soriatane - see acitretin Spiriva - see tiotropium bromide monohydrate Sporanox - see itraconazole Starlix - see nateglinide stavudine, capsule, 15mg, 20mg, 30mg, 40mg (Zerit-BRI)


Stieva-A Forte - see tretinoin *sumatriptan, tablet, 25mg (Imitrex DF-GSK) (CO Sumatriptan-COB) (Gen-Sumatriptan-GPM) (pms-Sumatriptan-PMS) (Dom-Sumatriptan-DOM): 50mg (Imitrex DF-GSK) (Apo-Sumatriptan-APX) (CO Sumatriptan-COB) (Gen-Sumatriptan-GPM) (pms-Sumatriptan-PMS) (Sandoz Sumatriptan-SDZ) (ratio-Sumatriptan-RPH) (Dom-Sumatriptan-DOM); 100mg (Imitrex DF-GSK) (Apo-Sumatriptan-APX) (CO Sumatriptan-COB) (Gen-Sumatriptan-GPM) (Novo-Sumatriptan-NOP) (pms-Sumatriptan-PMS) (Sandoz Sumatriptan-SDZ) (ratio-Sumatriptan-RPH) (Dom-Sumatriptan-DOM); injection solution, 6mg/0.5mL; nasal spray, 5mg, 20mg (Imitrex-GSK) For treatment of migraine headaches. Eligibility will be restricted to beneficiaries over



251

Suprax - see cefixime Suprefact - see buserelin acetate Sustiva - see efavirenz Symbicort Turbuhaler - see formoterol fumarate dihydrate/budesonide Synarel - see nafarelin acetate 3TC - see lamivudine tacrolimus, capsule, 0.5mg, 1mg, 5mg; ampoule, 5mg/mL (Prograf-FUJ)

For prophylaxis of : a) Graft rejection. b) Rejection in post bone marrow/stem cell transplant patients.

tacrolimus, topical ointment, 0.03%, 0.1% (Protopic-FUJ)

For treatment atopic dermatitis in patients: (a) Unresponsive to topical steroids tried within the last 3 months. (b) Intolerant to topical steroids tried within the last 3 months.

Taro-Carbamazepine CR - see carbamazepine Taro-Ciprofloxacin - see ciprofloxacin Taro-Fluconazole - see fluconazole Tegretol CR - see carbamazepine telithromycin, tablet, 400mg (Ketek-AVT)

For treatment of: (a) Pneumonia. (b) Upper and lower respiratory tract bacterial infections known to be resistant or

unresponsive to alternative antibiotics. (c) Infections in patients allergic to alternative antibiotics. (d) Infection (and prophylaxis) in patients with non-tuberculous Mycobacterium, and: (e) For completion of treatment initiated in hospital with macrolides or quinolones. (f) For patients intolerant to erythromycin and/or other antibiotics.

Telzir - see fosamprenavir calcium tenofovir disoproxil fumarate, tablet, 300mg (Viread-GSI)

For treatment of HIV in patients: (a) Who failed an alternative nucleoside reverse transcriptase inhibitor. (b) Intolerant to an alternative nucleoside reverse transcriptase inhibitor. This drug, as with other antivirals in the treatment of HIV, should be used under the direction of an infectious disease specialist.

*ticlopidine HCl, tablet, 250mg (Apo-Ticlopidine-APX) (Nu-Ticlopidine-NXP) (Gen-Ticlopidine-GPM) (pms-Ticlopidine-PMS) (Dom-Ticlopidine-DOM) (Sandoz Ticlopidine-SDZ) (Novo-Ticlopidine-NOP)

For treatment of patients who have experienced a: (a) Transient ischemic attack, stroke, or myocardial infarction while on

acetylsalicylic acid. (b) Transient ischemic attack, stroke or myocardial infarction and have clearly

demonstrated allergy to acetylsalicylic acid (manifested by asthma or nasal polyps).

(c) Transient ischemic attack, stroke or a myocardial infarction and are intolerant of acetylsalicylic acid (manifested by gastrointestinal hemorrhage).

252

tinzaparin sodium, syringe, 10,000IU/mL (0.35mL, 0.45mL), 20,000IU/mL (0.5mL, 0.7mL, 0.9mL); injection solution, 10,000IU/mL (2mL), 20,000IU/mL (2mL) (Innohep-LEO)





surgery for up to 35 days following the procedure.

tiotropium bromide monohydrate, powder capsule, 18ug/dose (Spiriva-BOE) For treatment of COPD in patients unresponsive to short-acting beta agonists or short-acting anticholinergic bronchodilators.

*tizanidine HCl, tablet, 4mg (Zanaflex-DPY) (Apo-Tizanidine-APX)

For treatment of severe spasticity in patients: (a) Unresponsive to baclofen or benzodiazepines. (b) Intolerant to baclofen or benzodiazepines.

TOBI - see tobramycin inhalation solution Tobradex - see tobramycin/dexamethasone Tobramycin - see tobramycin ophthalmic solution tobramycin, inhalation solution, 60mg/mL (TOBI-CCL)

For treatment of cystic fibrosis patients intolerant to injectable tobramycin when used for inhalation.

tobramycin, ophthalmic ointment, 0.3% (Tobrex-ALC); *ophthalmic solution, 0.3% (Tobrex-ALC) (pms-Tobramycin-PMS) (SAB-Tobramycin-SAB) (Apo-Tobramycin-APX) For treatment of ophthalmic infections in cases unresponsive to gentamicin

ophthalmic. tobramycin/dexamethasone, ophthalmic suspension, 0.3%/0.1%; ophthalmic ointment, 0.3%/0.1% (Tobradex-ALC)

(a) For treatment of ophthalmic infections in cases unresponsive to therapeutic alternatives.

(b) For post-operative long-term (>7days) use. Tobrex - see tobramycin tolterodine l-tartrate, extended-release capsule, 2mg, 4mg (Detrol LA-PFI) For treatment of patients intolerant to oxybutynin chloride. Tracleer - see bosentan *tretinoin, cream, 0.1% (Stieva-A Forte-STI) (Retin A-JAN) (Vitamin A Acid-DER) For treatment of acne unresponsive to alternative topical therapy. triamcinolone hexacetonide, injection suspension, 20mg/mL (Aristospan-STI) For intra-articular injection in the management of pediatric chronic inflammatory

arthropathies.

253

Trileptal - see oxcarbazepine Trizivir - see abacavir SO4/lamivudine/zidovudine Ultramop - see methoxsalen Ultravate - see halobetasol propionate Unitron PEG - see peginterferon alfa-2b Urispas - see flavoxate HCl Urso - see ursodiol ursodiol, tablet, 250mg (Urso-AXC), 500mg (Urso DS-AXC) For management of cholestatic liver diseases such as primary biliary cirrhosis. Valcyte - see valganciclovir HCl valganciclovir HCl, tablet, 450mg (Valcyte-HLR)

(a) For treatment of retinitis arising from CMV infection in patients with HIV infection. (b) For treatment ( and prophylaxis) of CMV infection in solid organ transplant

patients. Coverage will be approved for a six month period.

Vancocin - see vancomycin HCl vancomycin HCl, capsule, 125mg, 250mg (Vancocin-LIL); injection, 500mg, 1g (pms-Vancomycin-PMS)

For treatment of Clostridium difficile infections for up to two consecutive two week periods after no response, allergies or intolerance to a course of metronidazole. Repeat approvals will only be granted with laboratory evidence of C. difficile toxin.

Venofer - see iron sucrose Vfend - see voriconazole Videx - see didanosine Videx EC - see didanosine Vigamox - see moxifloxacin HCl Viracept - see nelfinavir mesylate Viramune - see nevirapine Viread - see tenofovir disoproxil fumarate Vitamin A Acid - see tretinoin Voltaren Ophtha - see diclofenac sodium voriconazole, tablet, 50mg, 200mg; powder for injection (vial), 200mg/vial (Vfend-PFI)

For step-down treatment of patients treated in hospital for invasive aspergillosis and other serious fungal infections in consultation with an infectious disease specialist.

Wellbutrin SR - see bupropion HCl Wellbutrin XL - see bupropion HCl Zaditen - see ketotifen fumarate zafirlukast, tablet, 20mg (Accolate-AST)

For treament of asthma: (a) When used in patients on concurrent steroid therapy. (b) In patients uncontrolled on inhaled corticosteroids.

Zanaflex - see tizanidine HCl Zerit - see stavudine Ziagen - see abacavir SO4

254

zidovudine, syrup, 10mg/mL; injection, 10mg/mL (Retrovir-GSK) *capsule, 100mg (Retrovir-GSK) (Apo-Zidovudine-APX)


Zithromax - see azithromycin Zoladex - see goserelin acetate zoledronic acid, solution, 5mg/100mL (Aclasta-NVR)

For symptomatic treatment of Paget’s disease of the bone. Note: only one treatment per year is required.

zolmitriptan, tablet, 2.5mg (Zomig-AST); orally dispersible tablet, 2.5mg (Zomig Rapimelt-AST); nasal spray, 5mg (Zomig Nasal Spray-AST) For treatment of migraine headaches. Eligibility will be restricted to beneficiaries over



Zomig - see zolmitriptan Zomig Nasal Spray - see zolmitriptan Zomig Rapimelt - see zolmitriptan zuclopenthixol, acetate injection, 50mg/mL (Clopixol-Acuphase-AVT); decanoate injection, 200mg/mL (Clopixol-Depot-AVT); dihydrochloride tablet, 10mg, 25mg, (Clopixol-AVT) For treatment of schizophrenia in patients unresponsive to other neuroleptic

medications. Zymar - see gatifloxacin Zyprexa - see olanzapine Zyprexa Zydis - see olanzapine Zyvoxam - see linezolid LEGEND: *These brands of products have been approved as interchangeable. +These brands of products have NOT been approved as interchangeable.

255

SORIATANE Important Information for Female Patients: Soriatane can cause deformed babies if a female takes it before or during pregnancy. • Do not take Soriatane if you are or may become pregnant during treatment or for an

undetermined period of time* after treatment has stopped. • You must avoid becoming pregnant while you are taking Soriatane and for an

undetermined period of time* after you stop taking Soriatane. • You must discuss effective birth control with your doctor before beginning treatment

and you must use effective birth control: for at least 1 month before you start Soriatane; while you are taking Soriatane; and for an undetermined period of time* after you stop taking Soriatane, bearing in mind that any method of birth control can fail.

• It is recommended that you either abstain from sexual intercourse or use 2 reliable

methods of birth control at the same time. • Do not take Soriatane until you are sure that you are not pregnant: you must have a

serum pregnancy test within 2 weeks before you start Soriatane; you must wait until the second or third day of your next menstrual period before you start Soriatane.

• Contact your doctor immediately if you do become pregnant while taking Soriatane or

after treatment has stopped. You should discuss with your doctor the serious risk of your baby having severe birth deformities because you are taking or have taken Soriatane. You should also discuss the desirability of continuing your pregnancy.

• Do not breast feed while taking Soriatane or for an extended period of time after

treatment has stopped. * Soriatane remains in your body for prolonged periods of time after you have

stopped treatment. It is not known exactly how long you must avoid pregnancy after Soriatane is stopped. The drug has been found in the blood of some patients for at least 2 years following treatment. Discuss this with your doctor. Talk with your doctor before you stop birth control.

Important Information for All Patients: Soriatane can cause deformed babies if taken by a female before or during pregnancy. • Do not give Soriatane to anyone else who has similar symptoms. • Do not donate blood, while you are taking Soriatane or for an extended period of time

after treatment has stopped. This is because your blood should not be given to a pregnant female.

• Do not consume alcohol while taking Soriatane.

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APPENDIX B

ONLINE CRITERIA ADJUDICATION

Online Adjudication Online adjudication is available for approval of certain criteria based medications. Claims for these medications can be submitted and adjudicated automatically through the online computer system. For these specific medications, the Drug Plan computer system checks the patient’s online drug profile and if the necessary alternate drugs appear on the Drug Plan profile the coverage and approval letter is automatically generated for the patient. This means the prescriber or pharmacist will no longer be required to apply for coverage for these specific medications via phone, fax or mail. Please Note: Requests for these medications are still accepted by telephone, mail or fax. This may be required if for some reason the patient’s computer profile is incomplete or if there are unusual circumstances surrounding the application. Online Adjudication Medications pioglitazone HCl, tablet, 15mg, 30mg, 45mg (Actos-LIL) For treatment of patients who have had previous prescriptions for metformin or sulfonylureas (as indicated by prescription claims on their online Drug Plan profile). rosiglitazone maleate, tablet, 2mg, 4mg, 8mg (Avandia-GSK) For treatment of patients who have had previous prescriptions for metformin or sulfonylureas (as indicated by prescription claims on their online Drug Plan profile). Please Note: These products should be used in patients with diabetes who are not adequately controlled on or are intolerant to metformin or sulfonylureas.

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APPENDIX C

SPECIAL COVERAGES

INCOME BASED DRUG BENEFITS - SPECIAL SUPPORT PROGRAM An income based program was implemented on July 1, 2002. Families pay the full cost of their prescriptions unless they apply to the income based program, the Special Support Program. What is Special Support? The Special Support Program is designed to help those whose benefit drug costs are high in relation to their income. Based on the income information provided on the application form (with photocopies of income tax) along with Drug Plan records, the Drug Plan will calculate a family threshold deductible and may establish a consumer co-payment to reduce the consumer's share of drug costs. Benefits are determined by family income (adjusted for number of dependents) and actual benefit drug costs. How does a person apply? Residents can call the Drug Plan at 787-3317 (in Regina) or toll-free at 1-800-667-7581 and request an application form be sent to them or they may pick up a form at their community pharmacy. The benefit period is January 1 to December 31. There are two application forms available on the health website: www.health.gov.sk.ca/health_forms.html. The differences include: 1) CRA Application/Consent form:

- one time completion of application form - must sign “CONSENT to Canada Revenue Agency” section - must forward documentation of income initially; subsequent years the

coverage will automatically be renewed as long as the applicant and spouse both file individual income tax to CRA

2) Annual Application: - must re-apply annually by October 1 - must sign “CONSENT and DECLARATION” section - must forward document of income each year, such as the Notice of

Assessment or pages 1 and 2 of their income tax forms. If the family income or medication costs change during the coverage period, the consumer may wish to contact the Drug Plan for a reassessment of coverage: 1. changes in income must be made in writing with supporting documentation; 2. a request to review the assessment should be made in writing; or 3. the pharmacist may telephone requesting the coverage be reviewed because of new

drugs. Income Supplement Recipients Adults in families receiving Family Health Benefits, and seniors receiving the Saskatchewan Income Plan supplement (S.I.P.) or receiving the federal Guaranteed Income Supplement (G.I.S.) and residing in a special care home will pay a $100 semi-annual deductible. Other seniors receiving G.I.S. (ie. living in the community) have a $200 semi-annual deductible. (If these patients have high drug costs they may also apply for Special Support.) Other seniors will have coverage based on their income and drug cost it they apply for special support.

*MAC & LCA policies apply.

258

http://www.health.gov.sk.ca/health_forms.html

Children under 18 years of age of families receiving Family Health Benefits are eligible for the same benefits as Supplementary Health beneficiaries with Plan Two coverage. This means all covered drugs will be provided at no charge*. Also certain dental services, medical supplies and appliances, optical services, chiropractic services, and emergency medical transportation costs will be covered. Adults receiving Family Health Benefits are also eligible for chiropractic services and an eye examination every two years. Inquiries regarding benefits, contact the Supplementary Health Program: Regina: 787-3124 Toll-free: 1-800-266-0695 Inquiries regarding prescription drugs should be directed to the Drug Plan: Regina: 787-3317 Toll-free: 1-800-667-7581

SUMMARY OF FAMILY HEALTH BENEFITS

HEALTH BENEFITS

CHILDREN

PARENTS OR GUARDIANS

Dental Coverage

Covers the majority of the cost of most services

Coverage not provided

Optometric Services

Eye examinations once a year Basic Eyeglasses

Eye examinations covered once every two years

Emergency Ambulance

Covered


Medical Supplies

Basic coverage, some items require prior approval


Chiropractic Services

Covered

Covered

Drug Coverage

No charge for Formulary drugs*

$100 semi-annual family deductible; 35% consumer co-payment there after Drug Plan Special Support Program available if provides better coverage (Consumer must apply)


259

SUPPLEMENTARY HEALTH (SOCIAL ASSISTANCE) BENEFICIARIES Plan One Drug Coverage Holders of Supplementary Health cards designated as "Plan One" may obtain prescriptions for Formulary drugs at a nominal consumer charge, currently no more than $2.00* per prescription. In addition, they may obtain the following prescribed drugs without charge: insulin, oral hypoglycemics, injectable Vitamin B12, oral contraceptives, allergenic

extracts, and products used in megavitamin therapy. Beneficiaries under the age of 18 may obtain Formulary drugs or approved Exception Drug Status drugs without charge*. Cost of allergenic extracts and products used in megavitamin therapy are covered by the Supplementary Health Program of Saskatchewan Health. All of the other products listed above are covered and processed through the Drug Plan. Plan Two Drug Coverage Beneficiaries requiring five or more Formulary drugs on a regular basis can be considered for "Plan Two" drug coverage. Plan Two coverage may be initiated by contacting the Drug Plan at 787-8744 or (toll-free) 1-800-667-7581. The request can be made by the patient or a health professional (ie. physician, social worker). Holders of Supplementary Health cards designated as "Plan Two" may obtain the products available under "Plan One" together with any Formulary drugs or approved Exception Drug Status drugs, without charge*. Plan Three Drug Coverage Holders of Supplementary Health cards designated as "Plan Three" may obtain, in addition to drugs available under the Drug Plan, certain other prescribed select over-the-counter (OTC) products and drugs at no charge*. The cost of such drugs is covered by the Supplementary Health Program of Saskatchewan Health. All pharmacy claims are processed by the Drug Plan. Pharmacies may contact the Drug Plan at 787-3315 (Regina) or (toll-free) 1-800-667-7578 with inquires regarding Plan Three drug coverage. EMERGENCY ASSISTANCE Eligibility Residents who require immediate treatment with covered prescription drugs and are unable to cover their share of the cost, may access Emergency Assistance. An eligible beneficiary may obtain a limited supply of covered prescription drug(s) at a reduced cost. Generally, this is a one-time assistance for no more than a month’s supply. The level of assistance provided will be in accordance with the consumer's ability to pay. A Special Support Application must be completed for future assistance.


260

Request Process During regular office hours, the patient's pharmacy may call the Drug Plan at 787-3315 (Regina) or toll-free at 1-800-667-7578 to provide the information needed to support the request, as follows: • patient identification (health services number); • pharmacy identification (name, number); • name and cost of the drug(s) required immediately; • reason for the request, including evidence that other sources of credit or assistance

have been explored and are not available. Following approval by the Drug Plan, the claims may be submitted via the online system. The patient may obtain up to a one-month supply of covered drug product(s) included in the request. For future assistance, complete and submit a "Special Support" form. Outside regular office hours, the pharmacy may provide up to a four-day supply of benefit drug products in an emergency situation. The paper claim will be honoured by the Drug Plan at the rate of payment specified by the pharmacist. A completed "Request for Special Support" form must be submitted for future assistance. EXCEPTION DRUG STATUS PROGRAM Please refer to Appendix A for detailed information and criteria for coverage of medications under the Exception Drug Status Program. For general information regarding Exception Drug Status, see "Notes Concerning the Formulary". PALLIATIVE CARE COVERAGE Definition of Palliative Care Patients who are in the late stages of a terminal illness, where life expectancy is measured in months, and for whom treatment aimed at cure or prolongation of life is no longer deemed appropriate, but for whom care is aimed at improving or maintaining the quality of remaining life (eg. management of symptoms such as pain, nausea and stress), will be eligible for Drug Plan Palliative Care drug benefits. The patient's physician must submit a completed Drug Plan "Request for Palliative Care Coverage" form to the Drug Plan in order to register a patient for this program. Drug Benefits under Palliative Care A palliative care patient who is registered with the Drug Plan is entitled to receive prescription drugs listed in the Saskatchewan Formulary at no charge* to them. The patient's pharmacy will bill the Drug Plan for 100% of the cost of benefit medications. Coverage is also provided for some commonly used laxatives, on prescription request, to patients registered under this program. Exception Drug Status Drugs for Palliative Care Patients Drugs listed under the Exception Drug Status program still require a separate physician request on behalf of the patient. To be eligible for approval of Exception Drug Status drugs, palliative care patients must meet the criteria as outlined in Appendix A of the current Saskatchewan Formulary. The Drug Plan must be provided with all relevant information to determine if the patient meets the criteria for the Exception Drug Status drug being requested on the patient's behalf.


261

Provisional Approval of Palliative Care Coverage Provisional approval may be granted in response to a telephoned request from the pharmacist, the physician or social worker involved in the patient's care. At the time of the request, the pharmacist or social worker must be in possession of a signed Palliative Care form. After provisional coverage has been granted, the pharmacist or social worker must forward the signed form to the Drug Plan. Provisional approval may be withheld by the Drug Plan if the pharmacist or social worker is not in receipt of a signed form. All physicians requesting provisional approval must provide the Drug Plan with a signed form on the patient's behalf in a timely manner. For provisional approval of Palliative Care, please contact the Drug Plan at 787-8744 to arrange coverage. Notification of Physician and Patient Upon receipt of a signed Palliative Care form, notification letters are generated by the Drug Plan, to the patient and the requesting physician. Backdating of Palliative Care Coverage Palliative Care coverage is routinely backdated 30 days from the date the form is received by the Drug Plan. In certain cases where a patient is eligible for coverage but application is inadvertently not made, the Drug Plan will consider backdating at the physician's request, beyond this period. Palliative Care Benefits under Health Regions Patients, pharmacists or physicians should contact the home care office in their health region to inquire about coverage provided by the region for dietary supplements and other basic supplies. "NO SUB" PRESCRIPTION DRUG COVERAGE It is recognized that extremely rare cases may exist in which a person is not able to use a particular brand of product. In such cases, the prescriber may request exemption from full payment of incremental cost when a specific brand of drug in an interchangeable or maximum allowable cost category is found to be essential for a particular patient. There is no provision for "blanket" exemptions. Each request must be patient and product specific. The request may be submitted in writing or by telephone (787-8744 or toll-free 1-800-667-2549) and must provide sufficient details to permit thorough, objective assessment. S.A.I.L. COVERAGE (SASKATCHEWAN AIDS TO INDEPENDENT LIVING) Saskatchewan Aids to Independent Living S.A.I.L., provides coverage for Formulary and non-Formulary disease-related drugs for persons registered on the Cystic Fibrosis, End Stage Renal and Paraplegic Programs. SAIL also provides assistance for other items such as nutritional products. For general inquiries regarding this program, telephone (306) 787-7121. For drug inquiries, telephone (306) 787-3315 or 1-800-667-7578 (press #1).


262


263

SASKATCHEWAN CANCER AGENCY Prescriptions for drugs covered by the Saskatchewan Cancer Agency are provided free of charge to registered cancer patients by either the Allan Blair Cancer Centre Pharmacy in Regina (telephone: (306) 766-2816) or the Saskatoon Cancer Centre Pharmacy (telephone: (306) 655-2680). These drugs would be provided when requested by a clinic oncologist or a physician working in association with the Cancer Agency. These drugs are not covered by the Drug Plan. Special Drug Authorization In addition to Formulary and Exception Drug Status benefits, beneficiaries with Plan One and Plan Two coverage may be eligible for a selected panel of products under the Supplementary Health Program through the Special Drug Authorization process. Selected OTC products which are currently benefits for Plan Three beneficiaries could be considered for coverage when prescribed for Plan One and Plan Two beneficiaries on a case-by-case basis. The prescriber must submit a request on the patient's behalf. Requests may be submitted in writing or by telephone at (306) 787-8744 or (toll-free) 1-800-667-2549.

APPENDIX D

CODES FOR PHARMACY ONLINE CLAIMS PROCESSING The following is a list of error and warning codes that may appear when processing claims on the online system. The error codes are highlighted. CODE DESCRIPTION AA HSN not on file

AB Registry Number (DIAND) not on file

AI Registered Indian/Inuit beneficiary not covered by the Drug Plan

AR HSN does not have current valid coverage

CA Prescription number required

CB Prescriber ineligible on dispensing date

CC Prescriber number required

CD Prescriber inactive (dispensing date within 365 days of expiry date)

CE Prescriber not on file

CF Prescriber inactive (dispensing date greater than 365 days from expiry date)

CG Prescriber suspended or revoked on dispensing date

CH Invalid Pharmacist Organization ID

CI Pharmacist not on file

CJ Pharmacist ineligible on dispensing date

CK Invalid Health Provider Organization ID

CM Prescriber not eligible for methadone DIN claimed

CO Pharmacy not on file

CP Pharmacy inactive (no contract for dispensing date)

CR Dispensing date is more than 62 days in the past

CS Dispensing date invalid

CT Invalid prescription number

EC ECP fee not allowed as EC prescription not found

ED Duplicate submission of ECP fee

EF Maximum ECP fee exceeded

FC Limited time for formulary clearance

GA Benefit Rxs - possible duplicate (same pharmacy/same prescriber)

GB Benefit Rxs - possible duplicate (same pharmacy/different prescriber)

264

CODE DESCRIPTION GC Non-formulary drug - maximum allowable unit drug cost exceeded &

recommended quantity exceeded GE Formulary/EDS drug - maximum allowable unit drug cost exceeded

GG Non-formulary drug - maximum allowable unit drug cost exceeded - check unit drug cost

GH Non-formulary drug - maximum allowable unit drug cost exceeded

GI Dispense SOC for payment

GJ Non-formulary drug - maximum allowable unit drug cost exceeded & recommended quantity exceeded & possible duplicate

GK Total prescription cost exceeded (communications unavailable)

GL Patient paid exceeded (communications unavailable)

GM Recommended quantity exceeded & possible duplicate

GN Non-formulary drug - maximum allowable unit drug cost exceeded & possible duplicate

GO Dispensing fee exceeds maximum allowable

GP Benefit Rxs - possible duplicate (different pharmacy/same prescriber)

GQ Benefit Rxs - possible duplicate (different pharmacy/different prescriber)

GR Age inconsistent with drug

GT Total prescription cost invalid (communications unavailable)

GU Patient paid invalid (communications unavailable)

GW Compound unit drug cost & compounding fee exceeds established amounts

GX Compound quantity must be one (1)

GY Compound unit drug cost exceeds established amount

GZ Compounding fee exceeds established amount

HA Non-benefit DIN

HB DIN not on file

HC Benefit Rxs - 3 submissions exceeded (same drug/same pharmacy)

HD Benefit Rxs - 3 submissions exceeded (same drug/different pharmacy(s))

HE Possible benefit under Exception Drug Status

HF Palliative Care - 3 submissions exceeded (same drug/same pharmacy)

HG Palliative Care - 3 submissions exceeded (same drug/different pharmacy(s))

HH Palliative Care - 3 submissions exceeded (same drug & same/different pharmacy(s)) & recommended quantity exceeded

265

CODE DESCRIPTION HI Palliative Care - 3 submissions exceeded (same drug & same/different

pharmacy(s)) & non-formulary maximum allowable unit drug cost exceeded HJ Palliative Care - 3 submissions exceeded (same drug & same/different

pharmacy(s)) & recommended quantity exceeded & non-formulary maximum allowable unit drug cost exceeded

IP Alternative Reimbursement not allowed

IS Alternative Reimbursement Fee exceeds maximum allowable

IT Alternative Reimbursement Type (Quantity) invalid

KA Benefit & non-benefit Rxs - possible duplicate (same pharmacy/same prescriber)

KB Benefit & non-benefit Rxs - possible duplicate (same pharmacy/different

prescriber) KJ Benefit & non-benefit Rxs - possible duplicate & recommended quantity

exceeded & non-formulary maximum allowable unit drug cost exceeded KM Benefit & non-benefit Rxs - possible duplicate & recommended quantity

exceeded KN Benefit & non-benefit Rxs - possible duplicate & non-formulary maximum

allowable unit drug cost exceeded KP Benefit & non-benefit Rxs - possible duplicate (different pharmacy/same

prescriber) KQ Benefit & non-benefit Rxs - possible duplicate (different pharmacy/different

prescriber) LA Non-benefit Rxs - possible duplicate (same pharmacy/same prescriber)

LB Non-benefit Rxs - possible duplicate (same pharmacy/different prescriber)

LC Non-benefit Rxs - possible duplicate for Registered Indian/Inuit beneficiary not covered by the Drug Plan

LD Non-benefit Rxs - possible duplicate for HSN without current valid coverage

LE Non-benefit Rxs - possible duplicate for non-benefit DIN

LF Non-benefit Rxs - possible duplicate & 3 submissions exceeded (same drug/same pharmacy)

LG Non-benefit Rxs - possible duplicate & 3 submissions exceeded (same

drug/different pharmacy(s)) LH Non-benefit Rxs - possible duplicate & possible benefit under Exception Drug

Status

266

CODE DESCRIPTION LI Non-benefit Rxs - possible duplicate & maximum allowable quantity exceeded

LJ Non-benefit Rxs - possible duplicate & authorized quantity limit exceeded

LP Non-benefit Rxs - possible duplicate (different pharmacy/same prescriber)

LQ Non-benefit Rxs - possible duplicate (different pharmacy/different prescriber)

MA Drug markup percentage exceeds maximum allowable

MB Discount percentage exceeds 100%

NA Transmission error - resend

PA Online EDS adjudication (OEA) successful

PB Online EDS adjudication (OEA) not successful

RC Void - original claim not found

RD Void - original claim previously voided

RE Void not allowed - claim paid to family

RN Void not allowed - original claim has been adjusted

SA Not authorized for automated interface to pharmacy PC - contact Drug Plan Help Desk

SF File error - contact Drug Plan Help Desk

TB Drug not eligible for Trial Prescription Program

TC Trial not allowed - not a new medication (previous Rx submitted from same pharmacy)

TD Trial not allowed - not a new medication (previous Rx submitted from different

pharmacy) TE Duplicate trial prescription (same pharmacy)

TF Duplicate trial prescription (different pharmacy)

TG Remainder not allowed - no trial within last 14 days

TH Remainder-duplicate prescription (same pharmacy)

TJ Remainder not allowed - dispensed too soon after trial prescription

TK Remainder not allowed - regular Rx submitted within last 14 days (same pharmacy)

TL Remainder not allowed - regular Rx submitted within last 14 days (different

pharmacy) TM Remainder - dispensing fee not allowed - the 2nd fee should be billed as an

Alternative Reimbursement TN Regular Rx not allowed - trial submitted within last 14 days (same pharmacy)

TP Alternative Reimbursement not allowed - no trial within last 30 days

267

268

CODE DESCRIPTION TQ Alternative Reimbursement - duplicate submitted within last 30 days (same

pharmacy) YI Maximum allowable quantity exceeded

YK Recommended quantity exceeded

YL Authorized quantity limit exceeded

YM Quantity submitted is lower than the minimum billing quantity for this drug (check 100 day & Two Month Drug Lists)

APPENDIX E

MAINTENANCE DRUG SCHEDULE The following lists of drugs are appended to the contract between Saskatchewan Health and each Saskatchewan pharmacy. Prescribing and dispensing should be in these quantities once the medical therapy of a patient is in the maintenance stage, unless there are unusual circumstances that require these quantities not be dispensed.

100 DAY LIST (by product categories)

ANTICONVULSANTS carbamazepine clobazam clonazepam divalproex sodium ethosuximide gabapentin lamotrigine levetiracetam methsuximide nitrazepam oxcarbazepine phenytoin primidone topiramate valproate sodium valproic acid vigabatrin ANTI-THYROIDS methimazole propylthiouracil DIGITALIS PREPARATIONS digoxin

DIURETICS amiloride HCl amiloride HCl/hydrochlorothiazide chlorthalidone furosemide hydrochlorothiazide indapamide hemihydrate metolazone spironolactone spironolactone/hydrochlorothiazide triamterene/hydrochlorothiazide ORAL HYPOGLYCEMICS acarbose chlorpropamide glyburide metformin nateglinide pioglitazone HCl repaglinide rosiglitazone maleate tolbutamide PHENOBARBITAL phenobarbital THYROID PREPARATIONS thyroid levothyroxine (sodium)

TWO MONTH DRUG LIST (by product categories)

ESTROGENS conjugated estrogens estradiol estropipate ethinyl estradiol piperazine estrone sulfate stilboestrol stilboestrol sodium diphosphate

ORAL CONTRACEPTIVES

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APPENDIX F

TRIAL PRESCRIPTION PROGRAM MEDICATION LIST A trial prescription provides a patient with a 7 or 10 day supply of new medication to determine if it will be tolerated. The following list of drugs is appended to the contract between Saskatchewan Health and each Saskatchewan pharmacy. These medications are eligible for reimbursement under the Trial Prescription Program. ALPHA ADRENERGIC BLOCKERS doxazosin prazosin terazosin ANTIDEPRESSANT AGENTS fluoxetine fluvoxamine moclobemide paroxetine sertraline ANTILIPEMIC AGENTS cholestyramine colestipol gemfibrozil CALCIUM CHANNEL BLOCKERS amlodipine diltiazem felodipine nifedipine verapamil GASTROINTESTINAL AGENTS misoprostol HEMORRHELOGIC AGENTS pentoxifylline NONSTEROIDAL ANTI-INFLAMMATORY AGENTS diclofenac diclofenac/misoprostol flurbiprofen indomethacin ketoprofen piroxicam sulindac tiaprofenic acid tolmetin

270

APPENDIX G

SASKATCHEWAN MS DRUGS PROGRAM CRITERIA FOR COVERAGE OF MS DRUGS Approval for coverage will be given to patients who are assessed and meet the following criteria: • have clinical definite relapsing and remitting multiple sclerosis; • have had at least two attacks of MS during the previous two years (an attack is

defined as the appearance of new symptoms or worsening of old symptoms, lasting at least 24 hours in the absence of fever, preceded by stability for at least one month);

• are fully ambulatory 100 meters without aids (canes, walkers or wheelchairs)-Extended Disability Status Scale (EDSS) 5.5 or less;

• are age 18 or older. Contraindications to Treatment • concurrent illness likely to alter compliance or substantially reduce life expectancy; • pregnancy is planned or occurs; • nursing women; • active, severe depression. Physicians should also forward the following information: • documentation of attacks, date of onset, date of diagnosis; • neurological findings, Extended Disability Status Scale (EDSS)-if known; • MRI reports or other significant information; • list of current medications. PROCEDURE FOR OBTAINING COVERAGE OF MS DRUGS UNDER DRUG PLAN • Requests are initiated by a physician. The patient and physician complete the

application form and the physician forwards any relevant information to the Saskatchewan MS Drugs Program. For a copy of the application form please refer to the website at: http://formulary.drugplan.health.gov.sk.ca/

• The MS Drug Advisory Panel reviews the application form and relevant

documentation and renders a decision. Note: A patient's eligibility for coverage is determined by the MS Drug Advisory Panel. The Drug Plan is notified of the decision and communicates the results to the patient and the physician.

• Questions regarding eligibility should be directed to: Saskatchewan MS Drugs Program Suite 7703-7th Floor Saskatoon City Hospital Saskatoon, S7K 0M7 Telephone: (306) 655-8400 FAX: (306) 655-8404 • Upon approval of coverage, patients are encouraged to apply for assistance with

the cost of these medications under the Drug Plan Special Support Program. For more detailed information regarding this program, see Appendix C.

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MS DRUG APPROVAL PROCESS

Fax #: (306) 655-8404

(Patient consent)

(Special Support Approval)

Physician

EDSApplication

MS Drug Advisory

Panel

ApprovedNot

Approved

Patient Education Schedule

Response to Physician

&Patient

Drug Plan Online Update

PhysicianLetter

PatientLetter

Follow-upOn-going

Assessment

MS Drug Advisory

Panel

272

PHARMACEUTICAL MANUFACTURERS LISTABB Abbott Laboratories Ltd.ACM AutoControl Medical ACT Actelion Pharmaceutiques CanadaALC Alcon Canada Inc.ALL Allergan Inc.ALX Allerex Laboratory Ltd. AMG Amgen Canada Inc.APX Apotex Inc.AST AstraZenecaATA Altana Pharma Inc.AVT Aventis Pharma Inc.AXC Axcan PharmaAXX Axxess PharmaBAK Baker Cummins Inc.BAY Bayer Inc.-Healthcare DivisionBCD Bayer Inc.-Consumer Care DivisionBDC Becton-Dickinson Canada Inc.BEX Berlex Canada Inc.BGN Biogen Canada Inc.BMD BioMed 2002 Inc.BMY Bristol-Myers Squibb Canada Co.BOE Boehringer Ingelheim (Canada) Ltd.BOM Roche Diagnostics, Division of Hoffmann-LaRoche LimitedBRI Bristol Pharmaceutical Products - Bristol-Myers SquibbBVL Biovail PharmaceuticalsCCL Chiron Canada ULC.CDX Canderm Pharma Inc.CLC Columbia Laboratories Canada Inc.COB Cobalt Pharmaceuticals Inc.CYT Cytex Pharmaceuticals Inc.DBU Mayne Pharma (Canada) Inc.DER Dermik Laboratories Canada Inc.DOM Dominion PharmacalDUI Duchesnay Inc.ERF Erfa Canada Inc.FEI Ferring Inc.FFR Fournier Pharma Inc.FUJ Fujisawa Canada Inc.GAC Galderma Canada Inc.GCH GlaxoSmithKline Consumer Healthcare Inc.GLW Glenwood Laboratories Canada Ltd.GPM Genpharm Inc.GSK GlaxoSmithKlineGZY Genzyme Canada Inc.HDI Hill Dermaceuticals, Inc.HLR Hoffmann-LaRoche Ltd.HOR Carter-Horner Corp.HOS Hospira Healthcare Corp.IPC Insight Pharmaceuticals Corp.JAC Jacobus Pharma Inc.JAN Janssen-Ortho Inc.KEY Key, Division of Schering Canada Inc.LEO Leo Pharma Inc.LIL Eli Lilly Canada Inc.LSN Lifescan Canada Ltd.LUD Lundbeck Canada Inc

APPENDIX H

273

MCL McNeil Consumer HealthcareMDA 3M Pharmaceuticals, 3M Canada CompanyMDC Medicis Canada Ltd.MDS Medisense Canada Inc.MPD Medical Plastic Devices Inc.MSD Merck Frosst Canada Ltd.MTI Medican Technologies Inc.NOO Novo Nordisk Canada Inc.NOP Novopharm Ltd.NVO Novartis Ophthalmics, Novartis Pharmaceuticals Canada Inc.NVR Novartis Pharmaceuticals Canada Inc.NXP Nu-Pharm Inc.ODN Odan Laboratories LimitedOMG Omega Laboratories Ltd.OPT TaroPharma, Division of Taro Pharmaceuticals Inc.ORG Organon Canada Ltd.ORP Orphan Medical Inc.ORX Oryx Pharmaceuticals Inc.PAL Paladin Labs Inc.PED PendoPharm Inc.PFC Pfizer Canada Inc.-Consumer Health Care DivisionPFD Professional Disposables Inc.PFI Pfizer Canada Inc.PFR Purdue PharmaPGA Procter & Gamble Pharm. Canada, Inc.PML PharmMel Inc.PMS Pharmascience Inc.PPZ Princeton Pharmaceutical Products - Bristol-Myers SquibbPRM PremPharm Inc.PRO Proval Pharma Inc.RAN Ranbaxy Pharmaceuticals Canada Inc.RBP Shire BioChem Inc.ROP RhodiapharmRPH Ratiopharm Inc.SAB Sabex Inc.SCH Schering Canada Inc.SCP Schering-Plough Healthcare ProductsSDZ Sandoz Canada Inc.SEV Servier Canada Inc.SLV Solvay Pharma Inc.SQU Squibb Pharmaceutical Products - Bristol-Myers SquibbSRO Serono Canada Inc.STE SteriMax Inc.STI Stiefel Canada Inc.TAR Taro Pharmaceuticals Inc.THM Theramed CorporationTVM Teva Marion Partners CanadaTYC Tyco HealthcareVAE Valeant Canada Inc.VAL Valeo Pharma Inc.VIR Virco Pharmaceuticals (Canada), Inc.WEL Wellspring Pharmaceutical Canada Corp.WSD Westwood Squibb CanadaWYA Wyeth PharmaceuticalsZYP Zymcan Pharmaceuticals Inc.

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APPENDIX I

MAXIMUM ALLOWABLE COST (MAC) POLICY

For many common medical conditions, drug manufacturers market a wide variety of prescription drugs that often vary in price but achieve the same medical effect. Under the MAC policy, the Drug Plan obtains expert advice on which prescription drug products within a group of similar medications are safe and beneficial, and the most cost-effective. The price of the most cost-effective drugs are used as a guide to set the maximum allowable cost the Drug Plan will cover for other similar drugs used to treat the same condition. The price is not necessarily set at the lowest cost drug. Patients have two options if they are prescribed a drug whose price is above the MAC for the group; (1) they can either continue to take the higher priced drug and pay the difference in cost over the MAC or, (2) they can talk to their physician about switching to a drug that is within the MAC. If the patient wishes to switch medications they will need a new prescription from their physician. If the patient chooses to remain on a higher priced drug, then only the maximum allowable cost will go towards their deductible and/or calculation of their co-payment. The expert drug review committees assess the need for exemptions (and any exemption criteria) as they review each possible MAC group. Exemption criteria (where applicable) are noted in the chart below for each group. Exemption requests are considered on a case-by-case basis. Prescribers or pharmacists may make exemption requests, with supporting detailed information, to the Drug Plan via the Exception Drug Status process. The MAC policy applies equally to all Saskatchewan residents eligible for benefits under the Drug Plan and Extended Benefits Branch.

MAXIMUM ALLOWABLE COST GROUP(S) Proton Pump Inhibitors (PPIs)

Group includes esomeprazole, lansoprazole, omeprazole*, omeprazole magnesium, pantoprazole, rabeprazole*

Maximum Allowable Cost $1.51 per tablet or capsule (subject to the patient’s usual co-payment and deductible).

Exemption Criteria - Patients who are intolerant or refractory to at least two drugs priced within the MAC policy.

- Patients requiring administration of a PPI by nasogastric tube.

Notes - These drugs are available under the Exception Drug Status (EDS) program. Patients must meet EDS criteria to qualify for coverage. See Appendix A for information on EDS criteria for specific PPIs.

- HP-PAC prescriptions are not affected by this policy. *At time of print, omeprazole 20mg capsule (Apo-Omeprazole) and rabeprazole 10mg tablet (Pariet) are within the MAC.

275

INDICES

INDEX A - THERAPEUTIC CLASSIFICATION LIST

INDEX B - NUMERICAL LIST OF DRUG IDENTIFICATION NUMBERS

INDEX C - ALPHABETICAL LIST OF PHARMACEUTICAL PRODUCT NAMES

INDEX A

THERAPEUTIC CLASSIFICATION LIST08:00 ANTI-INFECTIVE AGENTS................................................................................................... . 2

08:04.00 AMEBICIDES................................................................................................................ . 208:08.00 ANTHELMINTICS......................................................................................................... . 208:12.00 ANTIBIOTICS................................................................................................................ . 208:12.02 ANTIBIOTICS (AMINOGLYCOSIDES)......................................................................... . 308:12.04 ANTIBIOTICS (ANTIFUNGALS)................................................................................... . 308:12.06 ANTIBIOTICS (CEPHALOSPORINS)........................................................................... . 408:12.12 ANTIBIOTICS (MACROLIDES)..................................................................................... . 608:12.16 ANTIBIOTICS (PENICILLINS)...................................................................................... . 708:12.24 ANTIBIOTICS (TETRACYCLINES)............................................................................... . 908:12.28 ANTIBIOTICS (MISCELLANEOUS ANTIBIOTICS)...................................................... . 1008:18.00 ANTIVIRALS................................................................................................................. . 1108:18.08 ANTIRETROVIRAL AGENTS (HIV FUSION INHIBITORS).......................................... . 1208:18.08 ANTIRETROVIRAL AGENTS (NONNUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS)....................................................................... . 1208:18.08 ANTIRETROVIRAL AGENTS (NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS)....................................................................... . 1308:18.08 ANTIRETROVIRAL AGENTS (PROTEASE INHIBITORS)........................................... . 1508:20.00 ANTIMALARIAL AGENTS............................................................................................. . 1708:22.00 QUINOLONES.............................................................................................................. . 1708:26.00 SULFONES................................................................................................................... . 1908:36.00 URINARY ANTI-INFECTIVES....................................................................................... . 1908:40.00 MISCELLANEOUS ANTI-INFECTIVES........................................................................ . 20

10:00 ANTINEOPLASTIC AGENTS................................................................................................ . 2210:00.00 ANTINEOPLASTIC AGENTS........................................................................................ . 22

12:00 AUTONOMIC DRUGS........................................................................................................... . 2612:04.00 PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS............................................. . 2612:08.04 ANTIPARKINSONIAN AGENTS................................................................................... . 2612:08.08 ANTIMUSCARINICS/ANTISPASMODICS.................................................................... . 2712:12.00 SYMPATHOMIMETIC (ADRENERGIC) AGENTS........................................................ . 2812:16.00 SYMPATHOLYTIC AGENTS (ANTIMIGRAINE DRUGS)............................................. . 3012:20.00 SKELETAL MUSCLE RELAXANTS.............................................................................. . 33

20:00 BLOOD FORMATION AND COAGULATION....................................................................... . 3620:04.04 IRON PREPARATIONS................................................................................................ . 3620:12.04 ANTICOAGULANTS..................................................................................................... . 3620:12.20 ANTIPLATELET DRUGS.............................................................................................. . 3920:16.00 HEMATOPOIETIC AGENTS......................................................................................... . 3920:24.00 HEMORRHEOLOGIC AGENTS.................................................................................... . 40

24:00 CARDIOVASCULAR DRUGS............................................................................................... . 4224:04.00 CARDIAC DRUGS........................................................................................................ . 4224:06.00 ANTILIPEMIC DRUGS.................................................................................................. . 5224:08.00 HYPOTENSIVE DRUGS............................................................................................... . 5724:12.00 VASODILATING DRUGS.............................................................................................. . 70

28:00 CENTRAL NERVOUS SYSTEM AGENTS........................................................................... . 7428:08.04 NON-STEROIDAL ANTI-INFLAMMATORY AGENTS.................................................. . 7428:08.08 OPIATE AGONISTS (NARCOTIC ANALGESICS)....................................................... . 8028:08.12 OPIATE PARTIAL AGONISTS...................................................................................... . 8528:08.92 MISCELLANEOUS ANALGESICS AND ANTIPYRETICS............................................ . 8628:12.04 ANTICONVULSANTS (BARBITURATES).................................................................... . 8628:12.08 ANTICONVULSANTS (BENZODIAZEPINES).............................................................. . 8628:12.12 ANTICONVULSANTS (HYDANTOINS)........................................................................ . 8728:12.20 ANTICONVULSANTS (SUCCINIMIDES)...................................................................... . 8828:12.92 MISCELLANEOUS ANTICONVULSANTS.................................................................... . 8828:16.04 PSYCHOTHERAPEUTIC AGENTS (ANTIDEPRESSANTS)........................................ . 9328:16.08 PSYCHOTHERAPEUTIC AGENTS (ANTIPSYCHOTIC AGENTS).............................. . 10228:20.00 RESPIRATORY AND CEREBRAL STIMULANTS........................................................ . 10828:24.04 ANXIOLYTICS, SEDATIVES AND HYPNOTICS (BARBITURATES)........................... . 10928:24.08 ANXIOLYTICS, SEDATIVES AND HYPNOTICS (BENZODIAZEPINES)..................... . 10928:24.92 MISCELLANEOUS ANXIOLYTICS, SEDATIVES AND HYPNOTICS.......................... . 11328:28.00 ANTIMANIC AGENTS................................................................................................... . 114

36:00 DIAGNOSTIC AGENTS......................................................................................................... . 11636:04.00 ADRENAL INSUFFICIENCY......................................................................................... . 11636:26.00 DIABETES MELLITUS.................................................................................................. . 11636:88.00 URINE CONTENTS...................................................................................................... . 117

278

40:00 ELECTROLYTIC, CALORIC AND WATER BALANCE........................................................ . 12040:12.00 REPLACEMENT AGENTS............................................................................................ . 12040:18.00 POTASSIUM-REMOVING RESINS.............................................................................. . 12040:28.00 DIURETICS................................................................................................................... . 12140:28.10 POTASSIUM SPARING DIURETICS............................................................................ . 12340:40.00 URICOSURIC DRUGS.................................................................................................. . 123

48:00 ANTITUSSIVES, EXPECTORANTS AND MUCOLYTIC AGENTS...................................... . 12648:24.00 MUCOLYTIC AGENTS................................................................................................. . 126

52:00 EYE, EAR, NOSE AND THROAT PREPARATIONS............................................................ . 12852:04.04 ANTI-INFECTIVES (ANTIBIOTICS).............................................................................. . 12852:04.06 ANTI-INFECTIVES (ANTIVIRALS)............................................................................... . 12952:04.08 ANTI-INFECTIVES (SULFONAMIDES)........................................................................ . 12952:04.12 ANTI-INFECTIVES (MISCELLANEOUS)...................................................................... . 12952:08.00 ANTI-INFLAMMATORY AGENTS................................................................................. . 13052:08.00 COMBINATION ANTI-INFECTIVE/ ANTI-INFLAMMATORY AGENTS........................ . 13152:10.00 CARBONIC ANHYDRASE INHIBITORS...................................................................... . 13252:20.00 MIOTICS....................................................................................................................... . 13352:24.00 MYDRIATICS................................................................................................................ . 13352:36.00 MISCELLANEOUS E.E.N.T. DRUGS........................................................................... . 134

56:00 GASTROINTESTINAL DRUGS............................................................................................. . 13856:08.00 ANTIDIARRHEA AGENTS............................................................................................ . 13856:12.00 CATHARTICS AND LAXATIVES.................................................................................. . 13856:16.00 DIGESTANTS............................................................................................................... . 13856:22.00 ANTI-EMETICS............................................................................................................. . 14056:40.00 MISCELLANEOUS GASTROINTESTINAL DRUGS..................................................... . 140

60:00 GOLD COMPOUNDS............................................................................................................ . 14860:00.00 GOLD COMPOUNDS................................................................................................... . 148

64:00 HEAVY METAL ANTAGONISTS.......................................................................................... . 15064:00.00 HEAVEY METAL ANTAGONISTS................................................................................ . 150

68:00 HORMONES AND SYNTHETIC SUBSTITUTES.................................................................. . 15268:04.00 ADRENAL CORTICOSTEROIDS................................................................................. . 15268:08.00 ANDROGENS............................................................................................................... . 15668:12.00 CONTRACEPTIVES..................................................................................................... . 15768:16.00 ESTROGENS................................................................................................................ . 16068:16.12 ESTROGEN AGONIST-ANTAGONISTS...................................................................... . 16268:18.00 GONADOTROPINS...................................................................................................... . 16268:20.08 ANTI-DIABETIC DRUGS (INSULINS-HUMAN BIOSYNTHETIC)................................ . 16268:20.20 ANTI-DIABETIC DRUGS (ORAL HYPOGLYCEMICS)................................................. . 16368:24.00 PARATHYROID............................................................................................................ . 16668:28.00 PITUITARY AGENTS.................................................................................................... . 16768:32.00 PROGESTINS............................................................................................................... . 16868:36.04 THYROID AGENTS...................................................................................................... . 16968:36.08 ANTITHYROID AGENTS.............................................................................................. . 170

84:00 SKIN AND MUCOUS MEMBRANE AGENTS....................................................................... . 17284:04.04 ANTI-INFECTIVES (ANTIBIOTICS).............................................................................. . 17284:04.08 ANTI-INFECTIVES (ANTI-FUNGALS).......................................................................... . 17284:04.12 ANTI-INFECTIVES (SCABICIDES AND PEDICULICIDES)......................................... . 17484:04.16 MISCELLANEOUS ANTI-INFECTIVES........................................................................ . 17584:06.00 ANTI-INFLAMMATORY AGENTS................................................................................. . 17684:06.00 COMBINATION ANTI-INFECTIVE/ ANTI-INFLAMMATORY AGENTS........................ . 18684:08.00 ANTIPRURITICS AND LOCAL ANAESTHETICS......................................................... . 18684:12.00 ASTRINGENTS............................................................................................................. . 18784:16.00 CELL STIMULANTS AND PROLIFERANTS................................................................ . 18784:28.00 KERATOLYTIC AGENTS.............................................................................................. . 18884:36.00 MISCELLANEOUS SKIN & MUCOUS MEMBRANE AGENTS.................................... . 18984:50.06 DEPIGMENTING & PIGMENTING AGENTS (PIGMENTING AGENTS)...................... . 190

86:00 SMOOTH MUSCLE RELAXANTS........................................................................................ . 19286:12.00 GENITOURINARY SMOOTH MUSCLE RELAXANTS................................................. . 19286:16.00 RESPIRATORY SMOOTH MUSCLE RELAXANTS..................................................... . 193

88:00 VITAMINS.............................................................................................................................. . 19688:08.00 VITAMIN B.................................................................................................................... . 19688:16.00 VITAMIN D.................................................................................................................... . 197

92:00 UNCLASSIFIED THERAPEUTIC AGENTS.......................................................................... . 20092:00.00 UNCLASSIFIED THERAPEUTIC AGENTS.................................................................. . 200

94:00 DIABETIC SUPPLIES........................................................................................................... . 21494:00.00 DIABETIC SUPPLIES................................................................................................... . 214

279

INDEX B

NUMERICAL LIST OF DRUG IDENTIFICATION NUMBERS

DIN PAGE DIN PAGE DIN PAGE00000165 214 00024325 95 00225851 1100000299 7 00024333 95 00229296 7400000655 133 00024341 96 00230197 14000000663 133 00024368 9 00230316 18500000779 133 00024430 107 00232378 15500000787 133 00024449 107 00232807 10200000841 133 00024457 107 00232823 10200000868 133 00024694 113 00232831 10200000884 133 00026050 176 00236683 11400004588 200 00026093 176 00247855 13000004596 201 00027243 31 00249580 5100004723 23 00027499 31 00252522 12900004774 17 00027944 182 00252654 19000005606 109 00028096 153 00253952 16700005614 109 00028339 128 00259527 6000009830 197 00028606 123 00262595 700010081 85 00029092 174 00263699 18800010200 170 00029238 161 00263818 13900010219 170 00029246 156 00265470 16000010332 74 00030570 10 00265489 16000010340 74 00030600 155 00268585 19600010383 36 00030619 155 00268593 19600010391 36 00030759 155 00268607 19600010405 88 00030767 155 00268631 19600010472 97 00030783 156 00271373 15500010480 97 00030848 168 00271489 18600013285 111 00030910 155 00272434 11100013579 140 00030929 155 00272442 11100013595 140 00030937 168 00272450 11100013609 140 00030988 155 00280437 15300013765 111 00035017 133 00285455 12300013773 111 00035092 117 00291889 6000013803 140 00035106 117 00293504 8000015229 99 00035122 117 00293512 8000015237 99 00035130 117 00294322 20000015741 170 00035149 117 00294926 12300016055 150 00036129 155 00294950 19600020877 8 00036323 138 00295094 15400020885 8 00037400 93 00295973 17400021008 17 00037419 93 00297143 15800021016 17 00037427 93 00299405 13100021172 7 00037605 159 00301175 13100021202 9 00037613 71 00307246 13200021261 17 00037621 71 00312711 16300021350 163 00042560 130 00312738 1900021423 140 00042579 130 00312746 10800021474 122 00042676 132 00312754 10800021482 122 00067393 70 00312762 16600021504 97 00074225 120 00312770 15500021512 97 00074454 131 00312789 7800021520 97 00125083 81 00312797 9700021695 155 00125105 82 00312800 12200022772 87 00125121 81 00313815 10600022780 87 00178799 86 00313823 10600022799 88 00178802 86 00315966 15800022802 88 00178810 86 00317047 15800023442 87 00178829 86 00319511 1900023450 87 00180408 66 00323071 18100023485 88 00187585 188 00324019 9400023698 87 00192597 184 00326836 10800023949 169 00192600 185 00326844 12200023957 169 00216666 74 00326852 9700023965 169 00220442 140 00326925 96

280

DIN PAGE DIN PAGE DIN PAGE00327794 76 00399310 86 00474525 19700328219 206 00400750 96 00476366 19300329320 31 00402516 167 00476552 10000330566 94 00402540 48 00479799 20000335053 93 00402575 65 00480452 21400335061 93 00402583 65 00481211 12000335088 93 00402591 94 00481815 19700335096 106 00402605 47 00481823 19700335118 106 00402680 112 00486582 8400335126 106 00402699 88 00487813 5700335134 106 00402737 112 00487872 14000337420 76 00402745 112 00489158 15400337439 76 00402753 50 00496480 5000337730 121 00402761 51 00496499 5000337749 121 00402788 50 00496502 5100337757 9 00402796 200 00497827 4800337765 9 00402818 200 00497894 15000337773 9 00403571 188 00499013 1900340731 158 00405329 111 00500895 21000342084 5 00405337 111 00502790 13900342092 5 00405345 103 00503134 18500342106 5 00405361 103 00504335 5100342114 5 00406716 7 00506052 7600343838 158 00406724 7 00506370 20000344923 181 00410632 103 00507989 9200345539 108 00417246 181 00509558 2800353027 158 00417270 49 00510637 2000355658 205 00417289 49 00510645 2000358177 132 00426830 64 00511528 8700360201 97 00426849 196 00511536 8700360252 64 00426857 26 00511552 3100360260 64 00430617 175 00511692 19300360279 121 00432938 188 00512184 12800361933 27 00436771 128 00512192 12800362158 111 00441619 62 00513253 18400362166 121 00441627 62 00513261 18400363650 104 00441635 62 00513288 18400363669 104 00441651 76 00513962 12800363677 104 00441686 70 00513997 20500363685 104 00441694 70 00514012 7400363693 200 00441708 64 00514217 8400363766 140 00441716 64 00514497 6400363812 27 00441724 193 00514500 6400364142 76 00441732 193 00518123 11000364282 200 00441759 123 00518131 11000369810 88 00441767 123 00518182 18700370568 188 00441775 68 00519251 6000371033 201 00443158 112 00521515 19600372838 158 00443174 49 00521698 11100372846 158 00443794 187 00521701 11100373036 188 00443816 187 00522597 20500374318 188 00443832 92 00522651 7800382825 86 00443840 92 00522678 7800382841 87 00445266 20 00522724 11000386464 205 00445274 20 00522988 11000386472 205 00445282 20 00522996 11000392537 140 00451207 136 00523372 4800392561 84 00452092 70 00527661 18800392588 84 00452130 8 00532657 6800396761 86 00452149 8 00534560 4800396788 121 00453617 7 00535427 18200396796 104 00454583 186 00535435 18200396818 104 00455881 33 00537594 18800396826 104 00461733 114 00537608 18800396834 104 00463698 104 00541389 2800397423 47 00469327 157 00545015 13200397431 48 00471526 157 00545058 2600399302 163 00474517 197 00545066 20

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288


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290


291


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294


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296

DIN PAGE DIN PAGE DIN PAGE02257882 32 02265540 55 02271176 9202257890 32 02265826 6 02271583 3202257904 32 02265885 56 02271591 3202257955 189 02265893 56 02271605 4602257963 189 02265907 56 02271613 4602258102 200 02266008 62 02271621 4602258110 200 02266016 62 02271648 4602258129 85 02266350 59 02271656 4702258315 77 02266369 59 02272083 16702258323 77 02266377 59 02272695 2702258331 10 02266660 43 02272830 7002258358 10 02266717 203 02273179 20002258528 121 02266725 203 02273551 5302258560 159 02266733 203 02273853 9002258587 159 02266938 172 02273942 9802258595 200 02266962 17 02274086 12202259354 98 02266970 18 02274183 9102259893 34 02267217 145 02274191 9102260050 91 02267292 98 02274205 9102260069 91 02267470 44 02274728 20302260077 134 02267489 44 02274949 20102260107 201 02267837 92 02275090 9302260883 89 02267845 6 02275104 9302260891 90 02267934 17 02275252 6202260905 90 02267942 18 02275260 6202261081 154 02267950 18 02275279 20002261251 205 02267969 54 02275287 602261278 205 02267977 54 99002965 3702261545 15 02267985 43 99002981 3702261634 6 02267993 43 99003058 3702261642 6 02268000 94 99004941 3702261715 200 02268019 94 99117796 21502261723 157 02268027 44 99221028 21502261731 157 02268035 44 99254011 21502261898 47 02268043 44 99401055 21402262401 62 02268051 45 99401063 21402262428 62 02268078 141 99432799 21502262746 99 02268086 107 99433383 21502262754 99 02268094 107 99438102 21402262762 100 02268205 2802262916 113 02268388 3202262991 91 02268396 3202263009 91 02268906 3202263017 92 02268914 3202263025 32 02268922 3202263033 32 02269031 16402263130 129 02269058 16502263351 91 02269198 21102263378 91 02269201 20402263386 92 02269252 5502264560 206 02269260 5602264579 206 02269279 5602264749 185 02269287 5602264951 207 02269295 5702264978 207 02269341 1302264986 207 02270102 21102265133 89 02270129 20002265141 89 02270528 6802265168 89 02270641 8602265273 38 02270668 8702265281 38 02270676 8702265303 38 02270749 3202265311 38 02270757 3202265338 38 02270765 3202265346 38 02270862 18502265494 90 02270927 9802265508 90 02271141 9102265516 90 02271168 91

297

INDEX C

ALPHABETICAL LIST OF PHARMACEUTICAL PRODUCT NAMES

PRODUCT NAME Page PRODUCT NAME Page292 80 ALFACALCIDOL 1973TC (EDS) 14 ALFUZOSIN 2005-AMINOSALICYLIC ACID ALLOPURINOL 200 (MESALAZINE) 145 ALMOTRIPTAN MALATE 30642 85 ALOMIDE 135ABACAVIR SO4 13 ALPHAGAN 134ABACAVIR SO4/LAMIVUDINE 13 ALPHAGAN P 134ABACAVIR SO4/ ALPRAZOLAM 109 LAMIVUDINE/ZIDOVUDINE 13 ALTACE 66ACARBOSE 163 ALUMINUM ACETATE/ ACCOLATE (EDS) 211 BENZETHONIUM CHLORIDE 129ACCU-CHEK ADVANTAGE 116 " 187ACCU-CHEK AVIVA 116 AMANTADINE 12ACCU-CHEK COMPACT 116 AMATINE (EDS) 28ACCU-CHEK MULTICLIX 214 AMCINONIDE 176ACCUPRIL 66 AMERGE (EDS) 31ACCURETIC 66 AMES 214ACCUTANE 189 AMILORIDE HCL 123ACCUTREND 116 AMILORIDE HCL/ACEBUTOLOL HCL 42 HYDROCHLOROTHIAZIDE 57 " 57 AMINOPHYLLINE 193ACENOCOUMAROL 36 AMIODARONE 42ACETAMINOPHEN/CAFFEINE/CODEINE 80 AMITRIPTYLINE 93ACETAMINOPHEN/CODEINE 80 AMLODIPINE BESYLATE 43ACETAZOLAMIDE 121 AMOXICILLIN (AMOXYCILLIN) 7 " 132 AMOXICILLIN TRIHYDRATE/ ACETEST 117 POTASSIUM CLAVULANATE 8ACETYLCYSTEINE 126 AMPICILLIN 8ACETYLCYSTEINE SOLUTION 126 AMPRENAVIR 15ACETYLSALICYLIC ACID 74 ANAFRANIL 94ACETYLSALICYLIC ACID/ ANAGRELIDE HCL 201 CAFFEINE/CODEINE 80 ANAKINRA 201ACITRETIN 189 ANDRIOL 156ACLASTA (EDS) 211 ANDROCUR (EDS) 22ACTONEL (EDS) 209 ANSAID 75ACTOS (ONLINE ADJUDICATION) 165 ANTHRAFORTE-1 188ACULAR (EDS) 131 ANTHRAFORTE-2 188ACYCLOVIR 11 ANTHRANOL 188ADALAT XL 49 ANTHRASCALP 188ADALIMUMAB 200 APO-ACEBUTOLOL 42ADAPALENE 187 APO-ACETAZOLAMIDE 132ADVAIR (EDS) 30 APO-ACYCLOVIR 11ADVAIR DISKUS (EDS) 30 APO-ALENDRONATE (EDS) 200AGENERASE (EDS) 15 APO-ALLOPURINOL 200AGGRENOX (EDS) 70 APO-ALPRAZ 109AGRYLIN 201 APO-AMILORIDE 123AIROMIR 29 APO-AMILZIDE 57ALCOHOL PREP 214 APO-AMIODARONE 42ALCOMICIN 128 APO-AMITRIPTYLINE 93ALDACTAZIDE-25 66 APO-AMOXI 7ALDACTAZIDE-50 66 " 8ALDACTONE 123 APO-AMOXI CLAV (EDS) 8ALDARA (EDS) 189 APO-ATENIDONE 57ALENDRONATE SODIUM 200 APO-ATENOL 43ALERTEC (EDS) 109 APO-AZATHIOPRINE 201ALESSE 157 APO-AZITHROMYCIN (EDS) 6

299

PRODUCT NAME Page PRODUCT NAME PageAPO-BACLOFEN 33 APO-FLOCTAFENINE 86APO-BECLOMETHASONE 130 APO-FLUCONAZOLE 3APO-BENZTROPINE 26 APO-FLUCONAZOLE (EDS) 3APO-BISOPROLOL (EDS) 44 APO-FLUNARIZINE (EDS) 31APO-BRIMONIDINE 134 APO-FLUNISOLIDE 130APO-BROMAZEPAM 110 APO-FLUOXETINE 96APO-BROMOCRIPTINE 201 APO-FLUPHENAZINE 103APO-BUSPIRONE 113 APO-FLURAZEPAM 111APO-CALCITONIN (EDS) 166 APO-FLURBIPROFEN 75APO-CAPTO 58 APO-FLUVOXAMINE 97 " 59 APO-FOLIC 196APO-CARBAMAZEPINE 88 APO-FOSINOPRIL 62APO-CARVEDILOL (EDS) 44 APO-FUROSEMIDE 121 " 45 APO-GABAPENTIN 89APO-CEFUROXIME (EDS) 5 " 90APO-CEPHALEX 5 APO-GEMFIBROZIL 53APO-CHLORDIAZEPOXIDE 110 APO-GLYBURIDE 164APO-CHLORPROPAMIDE 163 APO-HALOPERIDOL 104APO-CHLORTHALIDONE 121 APO-HALOPERIDOL LA 104APO-CIMETIDINE 140 APO-HYDRALAZINE 62 " 141 APO-HYDRO 122APO-CIPROFLOX (EDS) 17 APO-HYDROXYQUINE 17 " 18 APO-HYDROXYZINE 113 " 129 APO-IBUPROFEN 76APO-CITALOPRAM 94 APO-IMIPRAMINE 97APO-CLINDAMYCIN 10 APO-INDAPAMIDE 122APO-CLOBAZAM 89 APO-INDOMETHACIN 76APO-CLOMIPRAMINE 94 APO-IPRAVENT 27APO-CLONAZEPAM 86 " 135 " 87 APO-ISDN 70APO-CLONIDINE 60 APO-ISMN 70APO-CLONIDINE (EDS) 60 APO-K 120APO-CLORAZEPATE 110 APO-KETO 76APO-CLOXI 9 APO-KETOCONAZOLE (EDS) 4APO-CROMOLYN 210 APO-KETO-E 76APO-CYCLOBENZAPRINE (EDS) 34 APO-KETOPROFEN SR 76APO-CYPROTERONE (EDS) 22 APO-KETOROLAC (EDS) 131APO-DESIPRAMINE 95 APO-KETOTIFEN (EDS) 204APO-DESMOPRESSIN (EDS) 167 APO-LABETALOL 63APO-DEXAMETHASONE 154 APO-LACTULOSE (EDS) 138APO-DIAZEPAM 111 APO-LAMOTRIGINE 90APO-DICLO 74 APO-LEFLUNOMIDE (EDS) 205APO-DICLO SR 74 APO-LEVOBUNOLOL 135APO-DIFLUNISAL 75 APO-LEVOCARB 205APO-DILTIAZ 45 " 206APO-DILTIAZ CD 45 APO-LEVOCARB CR 206 " 46 APO-LISINOPRIL 63APO-DILTIAZ SR 45 APO-LITHIUM CARBONATE 114APO-DIMENHYDRINATE 140 APO-LOPERAMIDE 138APO-DIVALPROEX 89 APO-LORAZEPAM 111APO-DOMPERIDONE 141 " 112APO-DOXAZOSIN 60 APO-LOVASTATIN 54APO-DOXEPIN 95 APO-LOXAPINE 104 " 96 " 105APO-DOXY 9 APO-MEDROXY 168APO-ERYTHRO-BASE 6 APO-MEFENAMIC 77APO-ERYTHRO-S 7 APO-MEGESTROL (EDS) 23APO-ETODOLAC (EDS) 75 APO-MELOXICAM (EDS) 77APO-FAMOTIDINE 142 APO-METFORMIN 164APO-FENO-MICRO 53 " 165APO-FLAVOXATE (EDS) 192 APO-METHAZIDE-15 64

300

PRODUCT NAME Page PRODUCT NAME PageAPO-METHAZIDE-25 64 APO-SIMVASTATIN 56APO-METHAZOLAMIDE 133 " 57APO-METHOPRAZINE 114 APO-SOTALOL 51APO-METHOTREXATE 190 APO-SUCRALFATE 145APO-METHYLDOPA 64 APO-SULFATRIM 20APO-METHYLPHENIDATE 109 APO-SULFATRIM DS 20APO-METOCLOP 142 APO-SULFINPYRAZONE 123APO-METOPROLOL 47 APO-SULIN 79 " 48 APO-SUMATRIPTAN (EDS) 32APO-METOPROLOL-TYPE L 47 APO-TEMAZEPAM 112 " 48 APO-TERAZOSIN 67APO-METRONIDAZOLE 20 " 68APO-MINOCYCLINE (EDS) 10 APO-TERBINAFINE 4APO-MISOPROSTOL 143 APO-TETRA 10APO-MOCLOBEMIDE 98 APO-THEO-LA 193APO-NABUMETONE (EDS) 77 APO-TIAPROFENIC 79APO-NADOL 48 APO-TICLOPIDINE (EDS) 40APO-NAPROXEN 78 APO-TIMOL 52APO-NAPROXEN SR 78 APO-TIMOP 136APO-NIFED 49 APO-TIZANIDINE (EDS) 34APO-NIFED PA 49 APO-TOBRAMYCIN (EDS) 128APO-NITRAZEPAM 87 APO-TOLBUTAMIDE 166APO-NITROFURANTOIN 19 APO-TRAZODONE 101APO-NIZATIDINE 143 APO-TRIAZIDE 68APO-NORFLOX (EDS) 19 APO-TRIAZO 112APO-NORTRIPTYLINE 99 APO-TRIFLUOPERAZINE 108APO-OFLOXACIN (EDS) 129 APO-TRIHEX 26APO-OMEPRAZOLE (EDS) 143 APO-TRIMETHOPRIM 20APO-ORCIPRENALINE 29 APO-TRIMIP 102APO-OXAZEPAM 112 APO-VALPROIC 92APO-OXTRIPHYLLINE 193 APO-VERAP 69APO-OXYBUTYNIN 192 APO-VERAP SR 69APO-PAROXETINE 99 APO-WARFARIN 38 " 100 APO-ZIDOVUDINE (EDS) 15APO-PENTOXIFYLLINE SR 40 APRACLONIDINE HCL 134APO-PEN-VK 9 ARANESP (EDS) 39APO-PERPHENAZINE 106 ARAVA (EDS) 205APO-PHENYLBUTAZONE 78 AREDIA (EDS) 207APO-PIMOZIDE 106 ARICEPT (EDS) 202APO-PINDOL 49 ARISTOCORT R 186APO-PIROXICAM 78 ARISTOSPAN (EDS) 156 " 79 ARTHROTEC 75APO-PRAVASTATIN 54 ARTHROTEC 75 75 " 55 ASACOL 145APO-PRAZO 65 ASACOL 800 145APO-PREDNISONE 155 ASCENSIA 214APO-PRIMIDONE 86 ASCENSIA DEX 116APO-PROCAINAMIDE 50 ASCENSIA MICROFILL 116APO-PROCHLORAZINE 106 ATACAND 58APO-PROPAFENONE 50 ATACAND PLUS 58APO-PROPRANOLOL 50 ATARAX 113 " 51 ATASOL-15 80APO-QUININE 17 ATASOL-30 80APO-RANITIDINE 144 ATAZANAVIR SO4 15APO-SALVENT 29 ATENOLOL 43APO-SALVENT CFC FREE 29 " 57APO-SELEGILINE (EDS) 210 ATENOLOL/CHLORTHALIDONE 57APO-SERTRALINE 100 ATIVAN 111 " 101 " 112APO-SIMVASTATIN 55 ATORVASTATIN CALCIUM 52

ATOVAQUONE 20

301

PRODUCT NAME Page PRODUCT NAME PageATROPINE SO4 133 BETAMETHASONE DIPROPIONATE/ ATROVENT 27 SALICYLIC ACID 181ATROVENT HFA 27 BETAMETHASONE DISODIUM ATROVENT NASAL SPRAY 135 PHOSPHATE 181AURANOFIN 148 BETAMETHASONE VALERATE 182AVALIDE 63 BETASERON (EDS) 204AVANDAMET (EDS) 166 BETAXOLOL HCL 134AVANDIA (ONLINE ADJUDICATION) 166 BETHANECHOL CHLORIDE 26AVAPRO 62 BETNESOL ENEMA 181AVELOX (EDS) 19 BETOPTIC S 134AVENTYL 99 BEZAFIBRATE 52AVODART 202 BEZALIP SR (EDS) 52AVONEX (EDS) 204 BIAXIN (EDS) 6AXERT (EDS) 30 BIAXIN BID (EDS) 6AXID 143 BIAXIN XL (EDS) 6AZATHIOPRINE 201 BILTRICIDE 2AZITHROMYCIN 6 BIMATOPROST 134AZOPT 132 BIO-DIAZEPAM 111BACLOFEN 33 BIO-FUROSEMIDE 121BACTROBAN 172 BIO-HYDROCHLOROTHIAZIDE 122BCI ATENOLOL 43 BIQUIN DURULES 51BD ALCOHOL SWAB 214 BISOPROLOL FUMARATE 44BD TEST STRIPS 116 BLEPHAMIDE S.O.P. 132BD ULTRA FINE 215 BLOOD GLUCOSE TEST STRIP 116BD ULTRA FINE 12.7MM 215 BONAMINE 140BD ULTRA FINE II LANCET 214 BOSENTAN 201BD ULTRA FINE II SHORT 215 BOTOX (EDS) 201BD ULTRAFINE 33 214 BOTULINUM TOXIN TYPE A 201BD ULTRAFINE 5MM, 8MM 215 BREVICON 158BD ULTRAFINE II 1/2 UNIT 215 BREVICON 1/35 158BD ULTRAFINE II SHORT 215 BRICANYL TURBUHALER 30BECLOMETHASONE DIPROPIONATE 130 BRIMONIDINE TARTRATE 134 " 153 BRIMONIDINE TARTRATE/ " 176 TIMOLOL MALEATE 134BENAZEPRIL HCL 58 BRINZOLAMIDE 132BENOXYL 188 BROMAZEPAM 110BENTYLOL 27 BROMOCRIPTINE MESYLATE 201BENURYL 123 BUDESONIDE 130BENZAC AC 188 " 140BENZAC W 188 " 153BENZACLIN 188 " 182BENZAMYCIN 188 BUMETANIDE 121BENZOYL PEROXIDE 188 BUPROPION HCL 93BENZTROPINE MESYLATE 26 BURINEX (EDS) 121BENZTROPINE OMEGA 26 BURO-SOL 187BEROTEC 28 BURO-SOL-OTIC 129BETADERM 182 BUSCOPAN 27BETADINE 176 BUSERELIN ACETATE 202BETAGAN 135 BUSPAR 113BETAHISTINE DIHYDROCHLORIDE 70 BUSPIRONE 113BETAINE ANHYDROUS 201 C.E.S. 160BETAJECT 153 CABERGOLINE 202BETALOC 47 CALCIFEROL 197 " 48 CALCIMAR (EDS) 166BETALOC DURULES 48 CALCIPOTRIOL 189BETAMETHASONE ACETATE/ CALCITONIN SALMON 166 BETAMETHASONE SODIUM CALCITRIOL 197 PHOSPHATE 153 CALCIUM POLYSTYRENE SULFONATE 120BETAMETHASONE DIPROPIONATE 181 CALTINE 100 (EDS) 166BETAMETHASONE DIPROPIONATE/ CANDESARTAN CILEXETIL 58 CLOTRIMAZOLE 186

302

PRODUCT NAME Page PRODUCT NAME PageCANDESARTAN CILEXETIL/ CIPROFLOXACIN 17 HYDROCHLOROTHIAZIDE 58 " 129CANDISTATIN 174 CIPROFLOXACIN/HYDROCORTISONE 131CANESTEN 173 CITALOPRAM HYDROBROMIDE 94CANESTEN-1-COMBI-PAK 173 CLARITHROMYCIN 6CANESTEN-3 173 CLARUS 189CANESTEN-3-COMBI-PAK 173 CLAVULIN-200 (EDS) 8CANESTEN-6 173 CLAVULIN-250 (EDS) 8CAPEX SHAMPOO 183 CLAVULIN-250F (EDS) 8CAPOTEN 58 CLAVULIN-400 (EDS) 8 " 59 CLAVULIN-500 (EDS) 8CAPTOPRIL 44 CLAVULIN-875 (EDS) 8 " 58 CLIMARA 100 (EDS) 161CAPTOPRIL 58 CLIMARA 25 (EDS) 160 " 59 CLIMARA 50 (EDS) 161CARBACHOL 133 CLIMARA 75 (EDS) 161CARBAMAZEPINE 88 CLINDAMYCIN HCL 10CARBOLITH 114 CLINDAMYCIN PALMITATE HCL 11CARDIZEM 45 CLINDAMYCIN PHOSPHATE 172CARDIZEM CD 45 CLINDAMYCIN PHOSPHATE/ " 46 BENZOYL PEROXIDE 188CARDURA-1 60 CLINDOXYL GEL 188CARDURA-2 60 CLINITEST 117CARDURA-4 60 CLOBAZAM 89CARVEDILOL 44 CLOBETASOL PROPIONATE 182CATAPRES 60 CLOBETASONE BUTYRATE 183CEFIXIME 4 CLOMIPRAMINE HCL 94CEFPROZIL 5 CLONAZEPAM 86CEFTIN (EDS) 5 CLONIDINE HCL 60CEFUROXIME AXETIL 5 CLOPIDOGREL BISULFATE 40CEFZIL (EDS) 5 CLOPIXOL (EDS) 108CELEBREX (EDS) 74 CLOPIXOL ACUPHASE (EDS) 108CELECOXIB 74 CLOPIXOL DEPOT (EDS) 108CELESTONE SOLUSPAN 153 CLORAZEPATE DIPOTASSIUM 110CELEXA 94 CLOTRIMADERM 173CELLCEPT (EDS) 206 CLOTRIMAZOLE 173CELONTIN 88 CLOXACILLIN 9CEPHALEXIN MONOHYDRATE 5 CLOZAPINE 103CESAMET (EDS) 206 CLOZARIL (EDS) 103CETAMIDE 129 CO ALENDRONATE (EDS) 200CHEMSTRIP UG 5000K 117 CO ATENOLOL 43CHLORAL HYDRATE 113 CO AZITHROMYCIN (EDS) 6CHLORAL HYDRATE SYRUP 113 CO BUSPIRONE 113CHLORDIAZEPOXIDE 110 CO CIPROFLOXACIN (EDS) 17CHLOROQUINE PHOSPHATE 17 " 18CHLORPROMAZINE 102 CO CITALOPRAM 94CHLORPROMAZINE 102 CO CLOMIPRAMINE 94CHLORPROPAMIDE 163 CO CLONAZEPAM 86CHLORTHALIDONE 121 " 87CHOLEDYL 193 CO ETIDRONATE 203CHOLESTYRAMINE RESIN 52 CO FLOVOXAMINE 97CHORIONIC GONADOTROPIN 162 CO FLUOXETINE 96CICLOPIROX OLAMINE 172 CO FLUVOXAMINE 97CILAZAPRIL 59 CO GABAPENTIN 89CILAZAPRIL/HYDROCHLOROTHIAZIDE 59 " 90CILOXAN (EDS) 129 CO LEVETIRACETAM 91CIMETIDINE 140 CO LOVASTATIN 54CIPRO (EDS) 17 CO MELOXICAM (EDS) 77 " 18 CO METFORMIN 164CIPRO HC (EDS) 131 " 165CIPRO XL (EDS) 18 CO PAROXETINE 99

303

PRODUCT NAME Page PRODUCT NAME PageCO PAROXETINE 100 CYANOCOBALAMIN 196CO RANITIDINE 144 CYCLEN 159CO SIMVASTATIN 56 CYCLOBENZAPRINE HCL 34 " 57 CYCLOCORT 176CO SUMATRIPTAN (EDS) 32 CYCLOMEN 156CO TERBINAFINE 4 CYCLOSPORINE 189CODEINE 80 CYCLOSPORINE (TRANSPLANT) 202CODEINE CONTIN (EDS) 80 CYPROTERONE ACETATE 22CODEINE PHOSPHATE 80 CYSTADANE 201COLCHICINE 202 D.D.A.V.P. (EDS) 167COLCHICINE-ODAN 202 DALACIN C 10COLESTID 53 " 11COLESTIPOL HCL RESIN 53 DALACIN T 172COMBANTRIN 2 DALTEPARIN SODIUM 36COMBIGAN 134 DANAZOL 156COMBIVENT 27 DANTRIUM 34COMBIVIR (EDS) 14 DANTROLENE SODIUM 34COMTAN 202 DAPSONE 19CONDYLINE 188 DAPSONE 19CONJUGATED ESTROGENS 160 DARAPRIM 17CONJUGATED ESTROGENS/ DARBEPOETIN ALFA 39 MEDROXYPROGESTERONE ACETATE 160 DEFEROXAMINE MESYLATE 150 " 168 DELATESTRYL 156COPAXONE (EDS) 203 DELAVIRDINE MESYLATE 12CORDARONE 42 DELESTROGEN 161COREG (EDS) 44 DEMEROL 82 " 45 DEMULEN 30 157CORGARD 48 DEPAKENE 92CORTATE 184 DEPO-MEDROL 155CORTEF 155 DEPO-PROVERA 168CORTENEMA 185 DEPO-TESTOSTERONE 156CORTIFOAM 185 DERMA-SMOOTHE/FS 183CORTISONE 153 DERMOVATE 182CORTISONE ACETATE 153 DESFERAL (EDS) 150CORTISPORIN 132 DESFERRIOXAMINE MESILATE (EDS) 150 " 186 DESIPRAMINE HCL 95CORTODERM 184 DESMOPRESSIN 167COSOPT 134 DESOCORT 183COSYNTROPIN ZINC HYDROXIDE 116 DESONIDE 183 " 167 DESOXIMETASONE 183COTAZYM 139 DESQUAM-X 188COTAZYM ECS 20 139 DESYREL 101COTAZYM ECS 8 139 DETROL LA (EDS) 192COTAZYME ECS 4 138 DEXAMETHASONE 130CO-TEMAZEPAM 112 " 154COUMADIN 38 DEXAMETHASONE 21-PHOSPHATE 154COVERA-HS 69 DEXAMETHASONE SOD PHO INJ 154COVERSYL 65 DEXASONE 154COVERSYL PLUS 65 DEXEDRINE 108COZAAR 64 DEXIRON (EDS) 36CREON 10 139 DEXTROAMPHETAMINE SO4 108CREON 20 139 DIABETA 164CREON 25 139 DIARR-EZE 138CREON 5 139 DIASTAT 111CRESTOR 55 DIASTIX 117CRIXIVAN (EDS) 15 DIAZEPAM 111CROMOLYN 135 DICLECTIN 140CROTAMITON 174 DICLOFENAC SODIUM 74CUPRIC SO4 REAGENT 117 " 134CUPRIMINE 150 DICLOFENAC SODIUM/MISOPROSTOL 75CYANOCOBALAMIN 196 DICYCLOMINE HCL 27

304

PRODUCT NAME Page PRODUCT NAME PageDIDANOSINE 14 DOM-CLONAZEPAM-R 86DIDROCAL 203 DOM-CLONIDINE 60DIDRONEL 203 DOM-CYCLOBENZAPRINE (EDS) 34DIFFERIN 187 DOM-DESIPRAMINE 95DIFLUCAN 3 DOM-DICLOFENAC 74DIFLUCAN (EDS) 3 DOM-DICLOFENAC SR 74DIFLUCAN P.O.S. (EDS) 3 DOM-DIVALPROEX 89DIFLUCORTOLONE VALERATE 183 DOM-DOMPERIDONE 141DIFLUNISAL 75 DOM-FENOFIBR. MICRO 53DIGOXIN 45 DOM-FLUCONAZOLE (EDS) 3DIHYDROERGOTAMINE 31 DOM-FLUOXETINE 96DIHYDROERGOTAMINE MESYLATE 31 DOM-FLUVOXAMINE 97DIHYDROERGOTAMINE MESYLATE 31 DOM-FUROSEMIDE 121DIIODOHYDROXYQUIN 2 DOM-GABAPENTIN 89DILANTIN 87 " 90DILAUDID 81 DOM-GEMFIBROZIL 53 " 82 DOM-GLYBURIDE 164DILAUDID HP-PLUS 82 DOM-HYDROCHLOROTHIAZIDE 122DILAUDID-HP 82 DOM-INDAPAMIDE 122DILAUDID-XP 82 DOM-IPRATROPIUM 135DILTIAZEM HCL 45 DOM-LEVO-CARBIDOPA 205 " 60 DOM-LOPERAMIDE 138DIMENHYDRINATE 140 DOM-LORAZEPAM 111DIMENHYDRINATE IM 140 " 112DIODOQUIN 2 DOM-LOVASTATIN 54DIOVAN 68 DOM-LOXAPINE 104DIOVAN-HCT 69 " 105DIPENTUM 143 DOM-MEDROXYPROGESTERONE 168DIPHENOXYLATE HCL 138 DOM-MEFENAMIC ACID 77DIPIVEFRIN HCL 133 DOM-MELOXICAM (EDS) 77DIPROLENE 181 DOM-METFORMIN 164DIPROSALIC 181 " 165DIPROSONE 181 DOM-METOPROLOL 47DIPYRIDAMOLE 70 " 48DIPYRIDAMOLE/ DOM-METOPROLOL-L 47 ACETYLSALICYLIC ACID 70 " 48DISOPYRAMIDE 47 DOM-MINOCYCLINE (EDS) 10DITHRANOL 188 DOM-MIRTAZAPINE 98DITROPAN 192 DOM-MOCLOBEMIDE 98DIVALPROEX SODIUM 89 DOM-NIZATIDINE 143DIXARIT (EDS) 60 DOM-NORTRIPTYLINE 99DOM-AMANTADINE 12 DOM-NYSTATIN 4DOM-AMITRIPTYLINE 93 DOM-OXYBUTYNIN 192DOM-ATENOLOL 43 DOM-PAROXETINE 99DOM-BACLOFEN 33 " 100DOM-BROMOCRIPTINE 201 DOMPERIDONE MALEATE 141DOM-BUSPIRONE 113 DOM-PINDOLOL 49DOM-CAPTOPRIL 58 DOM-PRAVASTATIN 54 " 59 " 55DOM-CARBAMAZEPINE CR (EDS) 88 DOM-PROCYCLIDINE 26DOM-CARVEDILOL (EDS) 44 DOM-PROPRANOLOL 50 " 45 " 51DOM-CEPHALEXIN 5 DOM-RANITIDINE 144DOM-CIMETIDINE 140 DOM-SALBUTAMOL 29 " 141 DOM-SALBUTAMOL RESPIR. SOL 30DOM-CIPROFLOXACIN (EDS) 17 DOM-SELEGILINE (EDS) 210 " 18 DOM-SERTRALINE 100DOM-CITALOPRAM 94 " 101DOM-CLOBAZAM 89 DOM-SIMVASTATIN 55DOM-CLONAZEPAM 86 " 56 " 87 " 57

305

PRODUCT NAME Page PRODUCT NAME PageDOM-SODIUM CROMOGLYCATE 210 EPINEPHRINE 28DOM-SOTALOL 51 EPINEPHRINE HCL 28DOM-SUCRALFATE 145 EPIPEN 28DOM-SUMATRIPTAN (EDS) 32 EPIPEN JR. 28DOM-TEMAZEPAM 112 EPIVAL 89DOM-TERAZOSIN 67 EPOETIN ALFA 39 " 68 EPREX (EDS) 39DOM-TIAPROFENIC 79 EPROSARTAN MESYLATE 61DOM-TICLOPIDINE (EDS) 40 EPROSARTAN MESYLATE/ DOM-TIMOLOL 136 HYDROCHOLORTHIAZIDE 61DOM-TOPIRAMATE 91 EQUATE THIN 214 " 92 EQUATE ULTRATHIN 214DOM-TRAZODONE 101 ERYC 6DOM-VALPROIC ACID 92 ERYTHROMYCIN BASE 6DOM-VERAPAMIL SR 69 ERYTHROMYCIN ESTOLATE 7DONEPEZIL HCL 202 ERYTHROMYCIN ETHYLSUCCINATE 7DORNASE ALFA 126 ERYTHROMYCIN ETHYLSUCCINATE/ DORZOLAMIDE HCL 132 SULFISOXAZOLE ACETATE 20DORZOLAMIDE HCL/ ERYTHROMYCIN STEARATE 7 TIMOLOL MALEATE 134 ERYTHROMYCIN/BENZOYL PEROXIDE 188DOSTINEX (EDS) 202 ERYTHROMYCIN/ETHYL ALCOHOL 172DOVONEX 189 ESOMEPRAZOLE MAGNESIUM DOXAZOSIN MESYLATE 60 TRIHYDRATE (MAC) 141DOXEPIN HCL 95 ESTALIS (EDS) 161DOXERCALCIFEROL 197 ESTALIS-SEQUI (EDS) 161DOXYCIN 9 ESTRACE 160DOXYCYCLINE 9 ESTRACOMB (EDS) 161DOXYLAMINE SUCCINATE/ ESTRADERM (EDS) 160 PYRIDOXINE HCL 140 " 161DRISDOL 197 ESTRADIOL 160DROSPIRENONE/ETHINYL ESTRADIOL 157 ESTRADIOL & NORETHINDRONE DURAGESIC (EDS) 81 ACETATE/ESTRADIOL 161DURALITH 114 " 168DUTASTERIDE 202 ESTRADIOL VALERATE 161DUVOID 26 ESTRADIOL/NORETHINDRONE ACETATE 161ECONAZOLE NITRATE 173 " 168ECOSTATIN 173 ESTRADOT (EDS) 160EDECRIN (EDS) 121 " 161EES 200 7 ESTRING 160EES 400 7 ESTROGEL (EDS) 160EFAVIRENZ 13 ESTROPIPATE (CALCULATED AS EFFEXOR XR 102 SODIUM ESTRONE SULFATE) 161ELIDEL (EDS) 190 ETANERCEPT 203ELITE 116 ETHACRYNIC ACID 121ELMIRON (EDS) 208 ETHINYL ESTRADIOL/DESOGESTREL 157ELOCOM 185 ETHINYL ESTRADIOL/D-NORGESTREL 157ELTROXIN 169 ETHINYL ESTRADIOL/ EMO-CORT 184 ETHYNODIOL DIACETATE 157 " 185 ETHINYL ESTRADIOL/L-NORGESTREL 157ENALAPRIL MALEATE 61 ETHINYL ESTRADIOL/NORETHINDRONE 158ENALAPRIL MALEATE/ ETHINYL ESTRADIOL/ HYDROCHLOROTHIAZIDE 61 NORETHINDRONE ACETATE 158ENBREL (EDS) 203 ETHINYL ESTRADIOL/NORGESTIMATE 159ENDANTADINE 12 ETHOPROPAZINE 26ENFUVIRTIDE 12 ETHOSUXIMIDE 88ENOXAPARIN 37 ETIDRONATE DISODIUM 203ENTACAPONE 202 ETIDRONATE DISODIUM/ ENTOCORT 182 CALCIUM CARBONATE 203ENTOCORT (EDS) 140 ETODOLAC 75ENTROPHEN 74 EUGLUCON 164EPINEPHRINE 28 EUMOVATE 183

306

PRODUCT NAME Page PRODUCT NAME PageEURAX 174 FRAGMIN (EDS) 36EVISTA (EDS) 162 FRAMYCETIN SO4 172EXELON (EDS) 209 FRAMYCETIN SO4/ EZETIMIBE 53 GRAMICIDIN/DEXAMETHASONE BASE 131EZETROL 53 FRAXIPARINE (EDS) 37FAMCICLOVIR 12 FRAXIPARINE FORTE (EDS) 37FAMOTIDINE 142 FREESTYLE 116FAMVIR 12 " 214FASTTAKE 116 FRISIUM 89FELODIPINE 61 FUCIDIN 172FENOFIBRATE 53 FUCIDIN H 186FENOTEROL HYDROBROMIDE 28 FUCITHALMIC (EDS) 128FENTANYL 81 FUROSEMIDE 121FERRLECIT (EDS) 36 FUSIDIC ACID 128FILGRASTIM 40 " 172FINASTERIDE 203 FUSIDIC ACID/FLAGYL 175 HYDROCORTISONE ACETATE 186FLAREX 130 FUZEON (EDS) 12FLAVOXATE HCL 192 GABAPENTIN 89FLECAINIDE ACETATE 47 GABAPENTIN 90FLOCTAFENINE 86 GALANTAMINE HYDROBROMIDE 203FLOMAX 211 GAMMA-BENZENE HEXACHLORIDE 175FLOMAX CR 211 GARAMYCIN 128FLONASE 130 GARASONE 131FLORINEF 154 GATIFLOXACIN 134FLOVENT DISKUS 154 GEMFIBROZIL 53FLOVENT HFA 154 GEN-ACEBUTOLOL 42FLUANXOL 103 GEN-ACEBUTOLOL (TYPE S) 42FLUANXOL DEPOT 103 GEN-ACYCLOVIR 11FLUCONAZOLE 3 GEN-ALENDRONATE (EDS) 200FLUDROCORTISONE ACETATE 154 GEN-ALPRAZOLAM 109FLUNARIZINE HCL 31 GEN-AMANTADINE 12FLUNISOLIDE 130 GEN-AMILAZIDE 57FLUOCINOLONE ACETONIDE 183 GEN-AMIODARONE 42FLUOCINONIDE 184 GEN-AMOXICILLIN 7FLUOROMETHOLONE 130 GEN-ANAGRELIDE 201FLUOROMETHOLONE ACETATE 130 GEN-ATENOLOL 43FLUOTIC 210 GEN-AZATHIOPRINE 201FLUOXETINE 96 GEN-BACLOFEN 33FLUPENTHIXOL DECANOATE 103 GEN-BECLO AQ. 130FLUPENTHIXOL DIHYDROCHLORIDE 103 GEN-BROMAZEPAM 110FLUPHENAZINE DECANOATE 103 GEN-BUDESONIDE AQ 130FLUPHENAZINE HCL 103 GEN-BUSPIRONE 113FLURAZEPAM HCL 111 GEN-CAPTOPRIL 58FLURBIPROFEN 75 " 59FLUTICASONE PROPIONATE 130 GEN-CARBAMAZEPINE CR (EDS) 88 " 154 GEN-CIMETIDINE 140FLUVASTATIN SODIUM 53 " 141FLUVOXAMINE MALEATE 97 GEN-CIPROFLOXACIN (EDS) 17FML 130 " 18FOLIC ACID 196 GEN-CITALOPRAM 94FORADIL (EDS) 28 GEN-CLINDAMYCIN 10FORMOTEROL FUMARATE 28 GEN-CLOBETASOL 182FORMOTEROL FUMARATE DIHYDRATE/ GEN-CLOMIPRAMINE 94 BUDESONIDE 28 GEN-CLONAZEPAM 86FORMULEX 27 " 87FORTOVASE (EDS) 16 GEN-CLOZAPINE (EDS) 103FOSAMAX (EDS) 200 GEN-COMBO STERINEBS 27FOSAMPRENAVIR CALCIUM 15 GEN-CYCLOBENZAPRINE (EDS) 34FOSFOMYCIN TROMETHAMINE 19 GEN-CYPROTERONE (EDS) 22FOSINOPRIL 62 GEN-DILTIAZEM 45

307

PRODUCT NAME Page PRODUCT NAME PageGEN-DILTIAZEM CD 45 GEN-TOPIRAMATE 91 " 46 " 92GEN-DIVALPROEX 89 GEN-TRAZODONE 101GEN-DOXAZOSIN 60 GEN-TRIAZOLAM 112GEN-ETIDRONATE 203 GEN-VALPROIC 92GEN-FAMOTIDINE 142 GEN-VERAPAMIL 69GEN-FENOFIBR. MICRO 53 GEN-VERAPAMIL SR 69GEN-FLUCONAZOLE 3 GEN-WARFARIN 38GEN-FLUCONAZOLE (EDS) 3 GLATIRAMER ACETATE 203GEN-FLUOXETINE 96 GLUCAGON 203GEN-FOSINOPRIL 62 GLUCAGON 203GEN-GABAPENTIN 89 GLUCOLET FINGERSTIX 214 " 90 GLUCONORM (EDS) 165GEN-GEMFIBROZIL 53 GLUCOPHAGE 164GEN-GLYBE 164 " 165GEN-HYDROXYCHLOROQUINE 17 GLUCOSE OXIDASE/GEN-INDAPAMIDE 122 PEROXIDASE REAGENT 117GEN-IPRATROPIUM 27 GLUCOSE OXIDASE/PEROXIDASE/SODIUMGEN-LAMOTRIGINE 90 NITROFERRICYANIDE/GEN-LOVASTATIN 54 GLYCINE REAGENT 117GEN-MEDROXY 168 GLUCOSE OXIDASE/PEROXIDASE/SODIUMGEN-MELOXICAM (EDS) 77 NITROPRUSSIDE REAGENT 117GEN-METFORMIN 164 GLYBURIDE 164 " 165 GLYCON 164GEN-METOPROLOL (TYPE L) 47 " 165 " 48 GOSERELIN ACETATE 204GEN-MINOCYCLINE (EDS) 10 GRAVOL 140GEN-MIRTAZAPINE 98 HALCINONIDE 184GEN-NABUMETONE (EDS) 77 HALCION 112GEN-NITRO SL SPRAY 71 HALOBETASOL PROPIONATE 184GEN-NIZATIDINE 143 HALOG 184GEN-NORTRIPTYLINE 99 HALOPERIDOL 104GEN-OXYBUTYNIN 192 HALOPERIDOL 104GEN-PAROXETINE 99 HALOPERIDOL DECANOATE 104 " 100 HALOPERIDOL LA 104GEN-PINDOLOL 49 HECTOROL (EDS) 197GEN-PIROXICAM 78 HEPALEAN 37 " 79 HEPARIN 37GEN-PRAVASTATIN 54 HEPTOVIR (EDS) 14 " 55 HEXACHLOROPHENE 175GEN-PROPAFENONE 50 HEXIT SHAMPOO 175GEN-RANITIDINE 144 HOMATROPINE HYDROBROMIDE 133GEN-SALBUTAMOL RESPIR. SOL 30 HP-PAC (EDS) 142GEN-SALBUTAMOL STERINEB 29 HUMALOG (EDS) 162GEN-SELEGILINE (EDS) 210 HUMALOG CARTRIDGE (EDS) 162GEN-SERTRALINE 100 HUMALOG MIX25 (EDS) 163 " 101 HUMATROPE (EDS) 167GEN-SIMVASTATIN 55 HUMATROPE CARTRIDGE (EDS) 167 " 56 HUMIRA (EDS) 200 " 57 HUMULIN 30/70 163GEN-SOTALOL 51 HUMULIN 30/70 CARTRIDGE 163GEN-SUMATRIPTAN (EDS) 32 HUMULIN-N 162GENTAMICIN 3 HUMULIN-N CARTRIDGE 162GENTAMICIN SO4 3 HUMULIN-R 162 " 128 HUMULIN-R CARTRIDGE 162GENTAMICIN SO4/BETAMETHASONE HYCORT 185 SODIUM PHOSPHATE 131 HYDERM 184GEN-TEMAZEPAM 112 HYDRALAZINE HCL 62GEN-TERBINAFINE 4 HYDROCHLOROTHIAZIDE 122GEN-TICLOPIDINE (EDS) 40 HYDROCORTISONE 155GEN-TIMOLOL 136 " 184

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PRODUCT NAME Page PRODUCT NAME PageHYDROCORTISONE ACETATE 185 IRBESARTAN 62HYDROCORTISONE SODIUM SUCCINATE 155 IRBESARTAN/HYDROCHLOROTHIAZIDE 63HYDROCORTISONE VALERATE 185 IRON DEXTRAN 36HYDROCORTISONE/UREA 185 IRON SODIUM FERRIC GLUCONATE 36HYDROMORPH CONTIN 81 IRON SUCROSE 36HYDROMORPHONE HCL 81 ISOPROPYL ALCOHOL 214HYDROMORPHONE HCL 82 ISOPTIN 69HYDROMORPHONE HP 10 82 ISOPTIN SR 69HYDROMORPHONE HP 20 82 ISOPTO ATROPINE 133HYDROMORPHONE HP 50 82 ISOPTO CARBACHOL 133HYDROVAL 185 ISOPTO CARPINE 133HYDROXYBUTYRATE DEHYDROGENASE 116 ISOPTO HOMATROPINE 133HYDROXYCHLOROQUINE SO4 17 ISOSORBIDE DINITRATE 70HYDROXYZINE 113 ISOSORBIDE-5 MONONITRATE 70HYOSCINE BUTYLBROMIDE 27 ISOTRETINOIN 189HYTRIN 67 ITRACONAZOLE 3 " 68 K-10 120HYTRIN STARTER PACK 68 KADIAN 83HYZAAR 64 " 84HYZAAR DS 64 KALETRA (EDS) 16IBUPROFEN 76 KAYEXALATE 120IMDUR 70 K-DUR 120IMIPRAMINE 97 KENALOG 10 156IMIQUIMOD 189 KENALOG 40 156IMITREX (EDS) 33 KENALOG-ORABASE 186IMITREX DF (EDS) 32 KEPPRA 91IMODIUM 138 KETEK (EDS) 7IMURAN 201 KETO DIASTIX 117INDAPAMIDE 122 KETOCONAZOLE 4INDAPAMIDE HEMIHYDRATE 122 " 173INDERAL-LA 51 KETODERM 173INDINAVIR SO4 15 KETOPROFEN 76INDOMETHACIN 76 KETOROLAC TROMETHAMINE 131INFLIXIMAB 204 KETOSTIX 117INFUFER (EDS) 36 KETOTIFEN FUMARATE 204INHIBACE 59 KINERET (EDS) 201INHIBACE PLUS 59 KIVEXA (EDS) 13INNOHEP (EDS) 37 K-LOR 120INSULIN (ISOPHANE) HUMAN K-LYTE/CL 120 BIOSYNTHETIC 162 KWELLADA-P CREME RINSE 175INSULIN (REGULAR) ASPART 162 KWELLADA-P LOTION 175INSULIN (REGULAR) HUMAN LABETALOL HCL 63 BIOSYNTHETIC 162 LACTULOSE 138INSULIN (REGULAR) LISPRO 162 LAMICTAL 90INSULIN (REGULAR/ISOPHANE) LAMISIL 4 HUMAN BIOSYNTHETIC 163 " 174INSULIN (REGULAR/PROTAMINE) LAMIVUDINE 14 LISPRO 163 LAMIVUDINE/ZIDOVUDINE 14INTERFERON ALFA-2A 22 LAMOTRIGINE 90INTERFERON ALFA-2B 22 LANCET 214INTERFERON BETA-1A 204 LANOXIN 45INTERFERON BETA-1B 204 LANSOPRAZOLE (MAC) 142INTRON-A (EDS) 22 LANSOPRAZOLE/CLARITHROMYCIN/ INVIRASE (EDS) 16 AMOXICILLIN 142IODOCHLORHYDROXYQUIN/ LASIX 121 FLUMETHASONE PIVALATE 131 LATANOPROST 135IOPIDINE 134 LATANOPROST/TIMOLOL MALEATE 135IPRATROPIUM BROMIDE 27 LECTOPAM 110 " 135 LEFLUNOMIDE 205IPRATROPIUM BROMIDE/ LESCOL 53 SALBUTAMOL SO4 27 LEUCOVORIN (EDS) 196

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PRODUCT NAME Page PRODUCT NAME PageLEUCOVORIN CALCIUM (FOLINIC ACID) 196 MARVELON 157LEUPROLIDE ACETATE 205 MAVIK 68LEVAQUIN (EDS) 18 MAXALT (EDS) 32LEVETIRACETAM 91 MAXALT RPD (EDS) 32LEVOBUNOLOL HCL 135 MAXIDEX 130LEVOCABASTINE HYDROCHLORIDE 135 MAXITROL 132LEVODOPA/BENZERAZIDE 205 MEBENDAZOLE 2LEVODOPA/CARBIDOPA 205 MECLIZINE HCL 140LEVOFLOXACIN 18 MEDROL 155LEVONORGESTREL 159 MEDROXYPROGESTERONE ACETATE 168LEVOTHYROXINE (SODIUM) 169 MEFENAMIC ACID 77LIDEMOL 184 MEGACE (EDS) 23LIDEX 184 MEGACE OS (EDS) 23LIFEBRAND ALCOHOL SWAB 214 MEGESTROL 23LIFESCAN FINE POINT 214 MELOXICAM 77LINEZOLID 11 MEPERIDINE HCL 82LIN-FOSINOPRIL 62 MEPERIDINE HYDROCHLORIDE 82LIORESAL 33 MEPRON (EDS) 20LIORESAL INTRATHECAL(EDS) 33 MERCAPTOPURINE 23LIORESAL-DS 33 MESASAL 145LIPIDIL-MICRO 53 M-ESLON 83LIPITOR 52 " 84LISINOPRIL 63 MESTINON 26LISINOPRIL/HYDROCHLOROTHIAZIDE 63 METADOL (PALL CARE) 82LITHIUM CARBONATE 114 METFORMIN 164LIVOSTIN 135 METFORMIN 164LOCACORTEN-VIOFORM 131 " 165LODOXAMIDE TROMETHAMINE 135 METHADONE HCL 82LOESTRIN 1.5/30 158 METHAZOLAMIDE 133LOMOTIL 138 METHENAMINE MANDELATE 19LONITEN (EDS) 64 METHIMAZOLE 170LOPERAMIDE HCL 138 METHOTREXATE 190LOPID 53 METHOTREXATE 190LOPINAVIR/RITONAVIR 16 METHOTRIMEPRAZINE 114LOPRESOR 47 METHOXSALEN 190 " 48 METHSUXIMIDE 88LOPRESOR-SR 48 METHYLDOPA 64LOPROX 172 METHYLDOPA/HYDROCHLOROTHIAZIDE 64LORAZEPAM 111 METHYLPHENIDATE HCL 109LOSARTAN POTASSIUM 64 METHYLPREDNISOLONE 155LOSARTAN POTASSIUM/ METHYLPREDNISOLONE 155 HYDROCHLOROTHIAZIDE 64 METHYLPREDNISOLONE ACETATE 155LOSEC (EDS) 143 METHYLPREDNISOLONE ACETATE 155LOTENSIN 58 METHYSERGIDE MALEATE 31LOTRIDERM 186 METOCLOPRAMIDE HCL 142LOVASTATIN 54 METOLAZONE 122LOVENOX (EDS) 37 METOPROLOL TARTRATE 47LOVENOX HP (EDS) 37 " 64LOXAPINE SUCCINATE 104 METROCREAM 175LOZIDE 122 METROGEL 175LUMIGAN 134 METROLOTION 175LUPRON DEPOT (EDS) 205 METRONIDAZOLE 20LUVOX 97 " 175LYDERM 184 MEVACOR 54M.O.S. 83 MEXILETINE HCL 48 " 84 MIACALCIN (EDS) 166M.O.S.-S.R. 84 MICARDIS 67MACROBID 19 MICARDIS PLUS 67MANDELAMINE 19 MICATIN 173MANERIX 98 MICONAZOLE NITRATE 173MAPROTILINE 97 MICOZOLE 173

310

PRODUCT NAME Page PRODUCT NAME PageMICRO-K EXTENCAPS 120 NADOLOL 48MICROLET 214 " 65MICRONOR 159 NADROPARIN CALCIUM 37MIDODRINE HCL 28 NAFARELIN ACETATE 207MIGRANAL 31 NALCROM (EDS) 210MINESTRIN 1/20 158 NAPROSYN 78MINITRAN 0.2 71 NAPROSYN-S.R. 78MINITRAN 0.4 71 NAPROXEN 78MINITRAN 0.6 71 NARATRIPTAN HCL 31MINOCIN (EDS) 10 NARDIL 100MINOCYCLINE HCL 10 NASACORT AQ 131MIN-OVRAL 157 NASONEX 131MINOXIDIL 64 NATEGLINIDE 165MIRAPEX 209 NAVANE 107MIRENA 159 NEEDLE 215MIRTAZAPINE 98 NELFINAVIR MESYLATE 16MISOPROSTOL 143 NEOMYCIN/GRAMICIDIN/NYSTATIN/ MOBICOX (EDS) 77 TRIAMCINOLONE ACETONIDE 186MOCLOBEMIDE 98 NEORAL (EDS) 189MODAFINIL 109 " 202MODECATE CONCENTRATE 103 NEOSPORIN 128MODURET 57 " 172MOGADON 87 NEOSTIGMINE BROMIDE 26MOMETASONE FUROATE 185 NERISONE 183MOMETASONE FUROATE NEULEPTIL 105 MONOHYDRATE 131 NEUPOGEN (EDS) 40MONISTAT 3 COMBINATION 173 NEURONTIN 89MONISTAT 7 COMBINATION 173 " 90MONISTAT-3 173 NEVIRAPINE 13MONISTAT-7 173 NEXIUM (EDS) 141MONITAN 42 NIACIN 196MONOCOR (EDS) 44 NIACIN 196MONOJECT ALCOHOL SWAB 214 NIDAGEL 175MONOJECT PLUS 29G 215 NIFEDIPINE 49MONOJECT ULTRA COMFORT 215 " 65MONOLET ORIGINAL 214 NIMODIPINE 70MONOLET THIN 214 NIMOTOP (EDS) 70MONOPRIL 62 NITOMAN 211MONTELUKAST SODIUM 206 NITRAZADON 87MONUROL (EDS) 19 NITRAZEPAM 87MORPHINE 83 NITRO-DUR 0.2 71MORPHINE HP50 84 NITRO-DUR 0.4 71MORPHINE SO4 84 NITRO-DUR 0.6 71MOS-SULFATE 83 NITRO-DUR 0.8 71MOTRIN 76 NITROFURANTOIN 19MOXIFLOXACIN HCL 19 NITROFURANTOIN MONOHYDRATE 19 " 129 NITROGLYCERIN 71MPD LANCET 214 NITROL 71MS CONTIN 83 NITROLINGUAL PUMPSPRAY 71 " 84 NITROSTAT 71MSIR 83 NIX CREME RINSE 175MUCOMYST 126 NIX DERMAL CREAM 175MUPIROCIN 172 NIZATIDINE 143MYCOBUTIN (EDS) 209 NIZORAL 173MYCOPHENOLATE MOFETIL 206 NORETHINDRONE 159MYCOPHENOLATE SODIUM 206 NORFLOXACIN 19MYCOSTATIN 174 NORGESTIMATE/ETHINYL ESTRADIOL 159MYFORTIC (EDS) 206 NORITATE 175MYOCHRYSINE 148 NORPRAMIN 95NABILONE 206 NORTRIPTYLINE 99NABUMETONE 77 NORVASC 43

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PRODUCT NAME Page PRODUCT NAME PageNORVIR (EDS) 16 NOVOFINE 6MM 215NORVIR SEC (EDS) 16 NOVOFINE 8MM 215NOVAMILOR 57 NOVO-FLUCONAZOLE 3NOVAMOXIN 7 NOVO-FLUCONAZOLE (EDS) 3 " 8 NOVO-FLUOXETINE 96NOVASEN 74 NOVO-FLURPROFEN 75NOVO-5-ASA 145 NOVO-FLUVOXAMINE 97NOVO-ACEBUTOLOL 42 NOVO-FOSINOPRIL 62NOVO-ALENDRONATE (EDS) 200 NOVO-FURANTOIN 19NOVO-ALPRAZOL 109 NOVO-GABAPENTIN 89NOVO-AMIODARONE 42 " 90NOVO-AMPICILLIN 8 NOVO-GEMFIBROZIL 53NOVO-ATENOL 43 NOVO-GLYBURIDE 164NOVO-AZATHIOPRINE 201 NOVO-HYDRAZIDE 122NOVO-AZITHROMYCIN (EDS) 6 NOVO-HYDROXYZIN 113NOVO-BISOPROLOL (EDS) 44 NOVO-HYLAZIN 62NOVO-BROMAZEPAM 110 NOVO-INDAPAMIDE 122NOVO-BUSPIRONE 113 NOVO-IPRAMIDE 27NOVO-CAPTORIL 58 NOVO-KETOCONAZOLE (EDS) 4 " 59 NOVO-KETOTIFEN (EDS) 204NOVO-CARBAMAZ 88 NOVO-LAMOTRIGINE 90NOVO-CARVEDILOL (EDS) 44 NOVO-LEFLUNOMIDE (EDS) 205 " 45 NOVO-LEVOBUNOLOL 135NOVO-CHLOROQUINE 17 NOVO-LEVOCARBIDOPA 205NOVO-CHLORPROMAZINE 102 " 206NOVO-CILAZAPRIL 59 NOVO-LEVOFLOXACIN (EDS) 18NOVO-CIMETINE 140 NOVO-LEXIN 5 " 141 NOVOLIN GE 10/90 PENFILL 163NOVO-CIPROFLOXACIN (EDS) 17 NOVOLIN GE 20/80 PENFILL 163 " 18 NOVOLIN GE 30/70 163NOVO-CITALOPRAM 94 NOVOLIN GE 30/70 PENFILL 163NOVO-CLAVAMOXIN (EDS) 8 NOVOLIN GE 40/60 PENFILL 163NOVO-CLINDAMYCIN 10 NOVOLIN GE 50/50 PENFILL 163NOVO-CLOBAZAM 89 NOVOLIN GE NPH 162NOVO-CLOBETASOL 182 NOVOLIN GE NPH PENFILL 162NOVO-CLONAZEPAM 86 NOVOLIN GE TORONTO 162 " 87 NOVOLIN GE TORONTO PENFIL 162NOVO-CLONIDINE 60 NOVO-LOPERAMIDE 138NOVO-CLOPATE 110 NOVO-LORAZEM 111NOVO-CLOXIN 9 " 112NOVO-CYCLOPRINE (EDS) 34 NOVO-LOVASTATIN 54NOVO-CYPROTERONE (EDS) 22 NOVO-MAPROTILINE 97NOVO-DIFENAC 74 NOVO-MEDRONE 168NOVO-DIFENAC SR 74 NOVO-MELOXICAM (EDS) 77NOVO-DIFLUNISAL 75 NOVO-METFORMIN 164NOVO-DILTAZEM 45 " 165NOVO-DILTAZEM CD 45 NOVO-METHACIN 76 " 46 NOVO-METOPROL 47NOVO-DILTIAZEM HCL 46 " 48 " 47 NOVO-METOPROL (UNCOATED) 47NOVO-DIMENATE 140 " 48NOVO-DIPAM 111 NOVO-METOPROL CT 47NOVO-DIVALPROEX 89 NOVO-MEXILETINE 48NOVO-DOMPERIDONE 141 NOVO-MINOCYCLINE (EDS) 10NOVO-DOXAZOSIN 60 NOVO-MIRTAZAPINE 98NOVO-DOXEPIN 95 NOVO-MISOPROSTOL 143 " 96 NOVO-MOCLOBEMIDE 98NOVO-DOXYLIN 9 NOVO-NABUMETONE (EDS) 77NOVO-FAMOTIDINE 142 NOVO-NADOLOL 48NOVO-FENOFIB. MICRO 53 NOVO-NAPROX 78NOVOFINE 12MM 215 NOVO-NAPROX SR 78

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PRODUCT NAME Page PRODUCT NAME PageNOVO-NIZATIDINE 143 NU-AMILZIDE 57NOVO-NORFLOXACIN (EDS) 19 NU-AMOXI 7NOVO-NORTRIPTYLINE 99 " 8NOVO-OXYBUTYNIN 192 NU-ATENOL 43NOVO-PAROXETINE 99 NU-AZATHIOPRINE 201 " 100 NU-BACLO 33NOVO-PEN-VK 9 NU-BECLOMETHASONE 130NOVO-PERIDOL 104 NU-BROMAZEPAM 110NOVO-PINDOL 49 NU-BUSPIRONE 113NOVO-PIROCAM 78 NU-CAPTO 58 " 79 " 59NOVO-PRAMINE 97 NU-CARBAMAZEPINE 88NOVO-PRANOL 50 NU-CARVEDILOL (EDS) 44 " 51 " 45NOVO-PRAVASTATIN 54 NU-CEPHALEX 5 " 55 NU-CIMET 140NOVO-PRAZIN 65 " 141NOVO-PREDNISONE 155 NU-CIPROFLOXACIN (EDS) 17NOVO-PROFEN 76 " 18NOVO-PROPAMIDE 163 NU-CITALOPRAM 94NOVO-PUROL 200 NU-CLONAZEPAM 86NOVO-QUININE 17 " 87NOVO-RANIDINE 144 NU-CLONIDINE 60NOVORAPID (EDS) 162 NU-CLOXI 9NOVO-RYTHRO ESTOLATE 7 NU-COTRIMOX 20NOVO-RYTHRO ETHYLSUCCINATE 7 NU-COTRIMOX DS 20NOVO-SELEGILINE (EDS) 210 NU-CROMOLYN 210NOVO-SEMIDE 121 NU-CYCLOBENZAPRINE (EDS) 34NOVO-SERTRALINE 100 NU-DESIPRAMINE 95 " 101 NU-DICLO 74NOVO-SIMVASTATIN 55 NU-DICLO-SR 74 " 56 NU-DILTIAZ 45 " 57 NU-DILTIAZ-CD 45NOVO-SOTALOL 51 " 46NOVO-SPIROTON 123 NU-DIVALPROEX 89NOVO-SPIROZINE 66 NU-DOMPERIDONE 141NOVO-SUCRALATE 145 NU-DOXYCYCLINE 9NOVO-SUMATRIPTAN (EDS) 32 NU-FAMOTIDINE 142NOVO-SUNDAC 79 NU-FENO-MICRO 53NOVO-TEMAZEPAM 112 NU-FLUOXETINE 96NOVO-TERAZOSIN 67 NU-FLURBIPROFEN 75 " 68 NU-FLUVOXAMINE 97NOVO-TERBINAFINE 4 NU-FUROSEMIDE 121NOVO-THEOPHYL SR 193 NU-GABAPENTIN 89NOVO-TIAPROFENIC 79 " 90NOVO-TICLOPIDINE (EDS) 40 NU-GEMFIBROZIL 53NOVO-TIMOL 52 NU-GLYBURIDE 164NOVO-TOPIRAMATE 91 NU-HYDRO 122 " 92 NU-IBUPROFEN 76NOVO-TRAZODONE 101 NU-INDAPAMIDE 122NOVO-TRIAMZIDE 68 NU-INDO 76NOVO-TRIMEL 20 NU-IPRATROPIUM 27NOVO-TRIMEL DS 20 NU-KETOCON (EDS) 4NOVO-TRIPTYN 93 NU-LEVOCARB 205NOVO-VALPROIC 92 " 206NOVO-VERAMIL SR 69 NU-LORAZ 111NOVO-WARFARIN 38 " 112NOZINAN 114 NU-LOVASTATIN 54NU-ACEBUTOLOL 42 NU-LOXAPINE 104NU-ACYCLOVIR 11 " 105NU-ALPRAZ 109 NU-MEDROXY 168

313

PRODUCT NAME Page PRODUCT NAME PageNU-MEFENAMIC 77 OESCLIM (EDS) 161NU-MEGESTROL (EDS) 23 OFLOXACIN 129NU-METFORMIN 164 OGEN 161 " 165 OLANZAPINE 105NU-METOCLOPRAMIDE 142 OLSALAZINE SODIUM 143NU-METOP 47 OMEPRAZOLE (MAC) 143 " 48 OMEPRAZOLE MAGNESIUM (MAC) 143NU-MOCLOBEMIDE 98 ONE TOUCH 116NU-NAPROX 78 ONE TOUCH ULTRA 116NU-NIFED 49 ONE TOUCH ULTRA SOFT 214NU-NIFEDIPINE-PA 49 ONE-ALPHA (EDS) 197NU-NIZATIDINE 143 OPTIMYXIN PLUS 128NU-NORTRIPTYLINE 99 ORACORT DENTAL PASTE 186NU-OXYBUTYN 192 ORAP 106NU-PAROXETINE 99 ORCIPRENALINE SO4 29 " 100 ORTHO 0.5/35 158NU-PENTOXIFYLLINE-SR 40 ORTHO 1/35 158NU-PEN-VK 9 ORTHO 7/7/7 158NU-PINDOL 49 ORTHO-CEPT 157NU-PIROX 78 OSTOFORTE 197 " 79 OVRAL 157NU-PRAVASTATIN 54 OXAZEPAM 112 " 55 OXCARBAZEPINE 91NU-PROPAFENONE 50 OXEZE TURBUHALER (EDS) 28NU-PROPRANOLOL 50 OXPRENOLOL HCL 65NU-RANIT 144 OXSORALEN (EDS) 190NU-SALBUTAMOL 29 OXSORALEN ULTRA (EDS) 190NU-SELEGILINE (EDS) 210 OXTRIPHYLLINE 193NU-SERTRALINE 100 OXYBUTYN 192 " 101 OXYBUTYNIN CHLORIDE 192NU-SIMVASTATIN 55 OXYCODONE HCL 85 " 56 OXYCONTIN 85 " 57 OXYDERM 188NU-SOTALOL 51 OXY-IR 85NU-SUCRALFATE 145 PAM. DISODIUM OMEGA (EDS) 207NU-SULFINPYRAZONE 123 PAMIDRONATE DISODIUM 207NU-SULINDAC 79 PAMIDRONATE DISODIUM (EDS) 207NU-TEMAZEPAM 112 PANCREASE 138NU-TERAZOSIN 67 PANCREASE MT 10 139 " 68 PANCREASE MT 16 139NU-TERBINAFINE 4 PANCREASE MT 4 138NU-TETRA 10 PANCRELIPASE NU-TIAPROFENIC 79 (LIPASE/AMYLASE/PROTEASE) 138NU-TICLOPIDINE (EDS) 40 PANECTYL 211NU-TRAZODONE 101 PANOXYL 188NU-TRIAZIDE 68 PANOXYL-10 188NU-TRIMIPRAMINE 102 PANOXYL-15 188NUTROPIN (EDS) 167 PANOXYL-20 188NUTROPIN AQ (EDS) 167 PANTOLOC (EDS) 144NUTROPIN AQ PEN (EDS) 167 PANTOPRAZOLE (MAC) 144NU-VALPROIC 92 PARIET (EDS) 144NU-VERAP 69 PARLODEL 201NU-VERAP SR 69 PARNATE 101NYADERM 174 PAROXETINE HCL 99NYSTATIN 4 PARSITAN 26 " 174 PAXIL 99OCTOSTIM (EDS) 167 " 100OCTREOTIDE 207 PCE 6OCTREOTIDE ACETATE (EDS) 207 PEDIAPRED 155OCUFLOX (EDS) 129 PEDIAZOLE 20OESCLIM (EDS) 160 PEGASYS (EDS) 23

314

PRODUCT NAME Page PRODUCT NAME PagePEGASYS RBV (EDS) 208 PMS-BROMOCRIPTINE 201PEGETRON (EDS) 208 PMS-BUSPIRONE 113PEGETRON REDIPEN (EDS) 208 PMS-CAPTOPRIL 58PEGINTERFERON ALFA-2A 23 " 59PEGINTERFERON ALFA-2A/RIBAVIRIN 208 PMS-CARBAMAZEPINE CHEWTAB 88PEGINTERFERON ALFA-2B 23 PMS-CARBAMAZEPINE CR (EDS) 88PEGINTERFERON ALFA-2B/RIBAVIRIN 208 PMS-CARVEDILOL (EDS) 44PENICILLAMINE 150 " 45PENICILLIN V (POTASSIUM) 9 PMS-CEPHALEXIN 5PENTASA 145 PMS-CHLORAL HYDRATE SYRUP 113PENTAZOCINE 85 PMS-CHOLESTYRAMINE 52PENTOSAN POLYSULFATE SO4 208 PMS-CHOLESTYRAMINE LIGHT 52PENTOXIFYLLINE 40 PMS-CIMETIDINE 140PEPCID 142 " 141PERGOLIDE MESYLATE 208 PMS-CIPROFLOXACIN (EDS) 17PERICYAZINE 105 " 18PERINDOPRIL ERBUMINE 65 " 129PERINDOPRIL ERBUMINE/INDAPAMIDE 65 PMS-CITALOPRAM 94PERMAX 208 PMS-CLOBAZAM 89PERMETHRIN 175 PMS-CLOBETASOL 182PERPHENAZINE 106 PMS-CLONAZEPAM 87PERSANTINE (EDS) 70 PMS-CLONAZEPAM-R 86PHENAZO 186 PMS-CODEINE 80PHENAZOPYRIDINE 186 PMS-CYCLOBENZAPRINE (EDS) 34PHENELZINE SO4 100 PMS-DEFEROXAMINE (EDS) 150PHENOBARBITAL 86 PMS-DESIPRAMINE 95 " 109 PMS-DESONIDE 183PHENYLBUTAZONE 78 PMS-DEXAMETHASONE 154PHENYTOIN 87 PMS-DEXAMETHASONE SOD PHO 130PHISOHEX 175 PMS-DIAZEPAM 111PHYLLOCONTIN 193 PMS-DICLOFENAC 74PHYLLOCONTIN-350 193 " 75PILOCARPINE HCL 133 PMS-DICLOFENAC-SR 74PILOPINE-HS 133 PMS-DIPIVEFRIN 133PIMECROLIMUS 190 PMS-DIVALPROEX 89PIMOZIDE 106 PMS-DOMPERIDONE 141PINDOLOL 49 PMS-DOXAZOSIN 60 " 65 PMS-FENOFIBRATE 53PINDOLOL/HYDROCHLOROTHIAZIDE 65 PMS-FLAVOXATE (EDS) 192PIOGLITAZONE HCL 165 PMS-FLUCONAZOLE (EDS) 3PIPORTIL L4 106 PMS-FLUOROMETHOLONE 130PIPOTIAZINE PALMITATE 106 PMS-FLUOXETINE 96PIROXICAM 78 PMS-FLUPHENAZINE DECAN. 103PIZOTYLINE HYDROGEN MALATE 31 PMS-FLUVOXAMINE 97PLAN B 159 PMS-FOSINOPRIL 62PLAQUENIL 17 PMS-FUROSEMIDE 121PLAVIX (EDS) 40 PMS-GABAPENTIN 89PLENDIL 61 " 90PMS-ALENDRONATE (EDS) 200 PMS-GEMFIBROZIL 53PMS-AMANTADINE 12 PMS-GENTAMICIN 128PMS-AMIODARONE 42 PMS-GENTAMYCIN 128PMS-AMITRIPTYLINE 93 PMS-GLYBURIDE 164PMS-AMOXICILLIN 7 PMS-HALOPERIDOL 104 " 8 PMS-HYDROCHLOROTHIAZIDE 122PMS-ANAGRELIDE 201 PMS-HYDROMORPHONE 81PMS-ATENOLOL 43 PMS-HYDROXYZINE 113PMS-AZITHROMYCIN (EDS) 6 PMS-INDAPAMIDE 122PMS-BACLOFEN 33 PMS-IPRATROPIUM 27PMS-BENZTROPINE 26 " 135PMS-BEZAFIBRATE (EDS) 52 PMS-KETOPROFEN 76PMS-BRIMONIDINE 134 PMS-KETOPROFEN-EC 76

315

PRODUCT NAME Page PRODUCT NAME PagePMS-KETOTIFEN (EDS) 204 PMS-SERTRALINE 101PMS-LACTULOSE (EDS) 138 PMS-SIMVASTATIN 55PMS-LAMOTRIGINE 90 " 56PMS-LEVOBUNOLOL 135 " 57PMS-LINDANE 175 PMS-SOD POLY SULF (120ML) 120PMS-LITHIUM CARBONATE 114 PMS-SOD POLYSTYRENE SULF 120PMS-LOPERAMIDE 138 PMS-SODIUM CROMOGLYCATE 210PMS-LOPERAMIDE HCL 138 PMS-SOTALOL 51PMS-LORAZEPAM 111 PMS-SUCRALFATE 145 " 112 PMS-SULFASALAZINE 145PMS-LOVASTATIN 54 PMS-SUMATRIPTAN (EDS) 32PMS-LOXAPINE 104 PMS-TEMAZEPAM 112 " 105 PMS-TERAZOSIN 67PMS-MEDROXYPROGESTERONE 168 " 68PMS-MEFENAMIC ACID 77 PMS-TERBINAFINE 4PMS-MELOXICAM (EDS) 77 PMS-TIAPROFENIC 79PMS-METFORMIN 164 PMS-TICLOPIDINE (EDS) 40 " 165 PMS-TIMOLOL 136PMS-METHOTRIMEPRAZINE 114 PMS-TIMOLOL MALEATE 136PMS-METHYLPHENIDATE 109 PMS-TOBRAMYCIN (EDS) 128PMS-METOCLOPRAMIDE 142 PMS-TOPIRAMATE 91PMS-METOPROLOL-B 47 " 92 " 48 PMS-TRAZODONE 101PMS-METOPROLOL-L 47 PMS-VALPROIC 92 " 48 PMS-VALPROIC ACID 92PMS-MINOCYCLINE (EDS) 10 PMS-VALPROIC ACID E.C. 92PMS-MIRTAZAPINE 98 PMS-VANCOMYCIN (EDS) 11PMS-MISOPROSTOL 143 PMS-VERAPAMIL SR 69PMS-MOCLOBEMIDE 98 PODOFILOX 188PMS-MOMETASONE 185 POLYMYXIN B SO4/BACITRACIN (ZINC)/ PMS-MORPHINE SULFATE SR 83 NEOMYCIN SO4/HYDROCORTISONE 132 " 84 " 186PMS-NAPROXEN 78 POLYMYXIN B SO4/NEOMYCIN SO4/ PMS-NIZATIDINE 143 BACITRACIN(ZINC) 172PMS-NORFLOXACIN (EDS) 19 POLYMYXIN B SO4/NEOMYCIN SO4/ PMS-NORTRIPTYLINE 99 DEXAMETHASONE 132PMS-NYSTATIN 4 POLYMYXIN B SO4/NEOMYCIN SO4/ PMS-OFLOXACIN (EDS) 129 GRAMICIDIN 128PMS-OXTRIPHYLLINE 193 " 172PMS-OXYBUTYNIN 192 POLYMYXIN B SO4/NEOMYCIN SO4/ PMS-PAMIDRONATE (EDS) 207 HYDROCORTISONE 132PMS-PAROXETINE 99 POLYMYXIN B SO4/ " 100 TRIMETHOPRIM SO4 128PMS-PHENOBARBITAL 86 POLYTRIM 128PMS-PINDOLOL 49 POTASSIUM CHLORIDE 120PMS-PIROXICAM 78 POVIDONE-IODINE 176 " 79 PRAMIPEXOLE DIHYDROCHLORIDE 209PMS-POLYTRIMETHOPRIM 128 PRANDASE 163PMS-POTASSIUM CHLORIDE 120 PRAVACHOL 54PMS-PRAVASTATIN 54 " 55 " 55 PRAVASTATIN 54PMS-PREDNISOLONE 155 PRAZIQUANTEL 2PMS-PROCYCLIDINE 26 PRAZOSIN 65PMS-PROPAFENONE 50 PRECISION EASY 116PMS-PROPRANOLOL 50 PRECISION PLUS 116 " 51 PRECISION THIN 214PMS-RANITIDINE 144 PRECISION XTRA 116PMS-SALBUTAMOL 29 PRECISION XTRA KETONE 116PMS-SALBUTAMOL RESP. SOL. 30 PRED FORTE 131PMS-SELEGILINE (EDS) 210 PRED MILD 131PMS-SERTRALINE 100 PREDNISOLONE ACETATE 131

316

PRODUCT NAME Page PRODUCT NAME PagePREDNISOLONE SODIUM PHOSPHATE 155 RAN-CIPROFLOXAXIN (EDS) 18PREDNISONE 155 RAN-CITALOPRAM 94PREMARIN 160 RAN-DOMPERIDONE 141PREMPLUS 160 RANITIDINE 144PREVACID (EDS) 142 RAN-LOVASTATIN 54PREVACID FASTAB (EDS) 142 RAN-METFORMIN 164PRIMIDONE 86 " 165PRINIVIL 63 RAPAMUNE (EDS) 210PRINZIDE 63 RATIO-ACLAVULANATE (EDS) 8PROBENECID 123 RATIO-ACYCLOVIR 11PROCAINAMIDE HCL 50 RATIO-ALENDRONATE (EDS) 200PROCAN-SR 50 RATIO-AMCINONIDE 176PROCHLORPERAZINE 106 RATIO-AMIODARONE 42PROCHLORPERAZINE MESYLATE 106 RATIO-ATENOLOL 43PROCYCLIDINE HCL 26 RATIO-AZITHROMYCIN (EDS) 6PROFASI HP (EDS) 162 RATIO-BACLOFEN 33PROGESTERONE (MICRONIZED) 168 RATIO-BECLOMETHASONE AQ. 130PROGRAF (EDS) 211 RATIO-BRIMONIDINE 134PROLOPA 205 RATIO-BUSPIRONE 113PROMETRIUM (EDS) 168 RATIO-CARVEDILOL (EDS) 44PROPADERM 176 " 45PROPAFENONE HCL 50 RATIO-CEFUROXIME (EDS) 5PROPOXYPHENE 85 RATIO-CIPROFLOXACIN (EDS) 17PROPRANOLOL 31 " 18 " 50 RATIO-CITALOPRAM 94 " 66 RATIO-CLINDAMYCIN 10PROPYLTHIOURACIL 170 RATIO-CLOBAZAM 89PROPYL-THYRACIL 170 RATIO-CLOBETASOL 182PROSCAR 203 RATIO-CLONAZEPAM 86PROSTIGMIN 26 " 87PROTOPIC (EDS) 190 RATIO-CODEINE 80PROVERA 168 RATIO-CYCLOBENZAPRINE(EDS) 34PROZAC 96 RATIO-DESIPRAMINE 95PULMICORT NEBUAMP 153 RATIO-DEXAMETHASONE 154PULMICORT TURBUHALER 153 RATIO-DILTIAZEM CD 45PULMOZYME (EDS) 126 " 46PURINETHOL (EDS) 23 RATIO-DIPIVEFRIN 133PYRANTEL PAMOATE 2 RATIO-DOMPERIDONE 141PYRETHINS/PIPERONYL BUTOXIDE/ RATIO-DOXYCYCLINE 9 PETROLEUM DISTILLATE 175 RATIO-ECTOSONE 182PYRIDOSTIGMINE BROMIDE 26 RATIO-ECTOSONE MILD 182PYRIDOXINE HCL 196 RATIO-EMTEC 80PYRIMETHAMINE 17 RATIO-FENOFIBRATE MC 53PYRVINIUM PAMOATE 2 RATIO-FLUNISOLIDE 130QUETIAPINE 106 RATIO-FLUOXETINE 96QUINAPRIL HCL 66 RATIO-FLURBIPROFEN 75QUINAPRIL HCL/ RATIO-FLUVOXAMINE 97 HYDROCHLOROTHIAZIDE 66 RATIO-FOSINOPRIL 62QUINIDINE BISULFATE 51 RATIO-GABAPENTIN 89QUININE SO4 17 " 90QUININE-ODAN 17 RATIO-GLYBURIDE 164QVAR 153 RATIO-IPRA SAL UDV 27R&C SHAMPOO/CONDITIONER 175 RATIO-IPRATROPIUM 27RABEPRAZOLE SODIUM (MAC) 144 RATIO-IPRATROPIUM UDV 27RALOXIFENE HCL 162 RATIO-KETOROLAC (EDS) 131RAMIPRIL 66 RATIO-LACTULOSE (EDS) 138RAN-ATENOLOL 43 RATIO-LAMOTRIGINE 90RAN-CARVEDILOL (EDS) 44 RATIO-LENOLTEC NO.2 80 " 45 RATIO-LENOLTEC NO.3 80RAN-CIPROFLOXACIN (EDS) 17 RATIO-LENOLTEC NO.4 80 " 18 RATIO-LEVOBUNOLOL 135

317

PRODUCT NAME Page PRODUCT NAME PageRATIO-LOVASTATIN 54 RHINOCORT AQUA 130RATIO-MELOXICAM (EDS) 77 RHINOCORT TURBUHALER 130RATIO-METFORMIN 164 RHODACINE 76 " 165 RHO-NITRO PUMPSPRAY 71RATIO-METHOTREXATE 190 RHOTRAL 42RATIO-MINOCYCLINE (EDS) 10 RIDAURA 148RATIO-MIRTAZAPINE 98 RIFABUTIN 209RATIO-MOMETASONE 185 RISEDRONATE SODIUM 209RATIO-MORPHINE 84 RISPERDAL 107RATIO-MORPHINE SR 83 RISPERDAL CONSTA (EDS) 107 " 84 RISPERDAL M-TAB 107RATIO-MPA 168 RISPERIDONE 107RATIO-NORTRIPTYLINE 99 RITALIN 109RATIO-NYSTATIN 4 RITALIN SR 109 " 174 RITONAVIR 16RATIO-PAROXETINE 99 RIVASTIGMINE 209 " 100 RIVOTRIL 86RATIO-PENTOXIFYLLINE 40 " 87RATIO-PRAVASTATIN 54 RIZATRIPTAN BENZOATE 32 " 55 ROCALTROL (EDS) 197RATIO-PREDNISOLONE 131 ROFERON-A (EDS) 22RATIO-RANITIDINE 144 ROPINIROLE HCL 210RATIO-SALBUTAMOL 29 ROSASOL 175 " 30 ROSIGLITAZONE MALEATE 166RATIO-SALBUTAMOL HFA 29 ROSIGLITAZONE MALEATE/ RATIO-SALBUTAMOL P.F. 29 METFORMIN HCL 166RATIO-SERTRALINE 100 ROSUVASTATIN CALCIUM 55 " 101 RYTHMODAN 47RATIO-SIMVASTATIN 56 RYTHMODAN-LA 47 " 57 RYTHMOL 50RATIO-SOTALOL 51 SAB-DICLOFENAC 75RATIO-SUMATRIPTAN (EDS) 32 SAB-INDOMETHACIN 76RATIO-TEMAZEPAM 112 SAB-NAPROXEN 78RATIO-TERAZOSIN 67 SAB-PROCHLOPERAZINE 106 " 68 SABRIL 92RATIO-TOPILENE 181 SAFE-T-PRO 214RATIO-TOPIRAMATE 91 SAIZEN (EDS) 167 " 92 SALAZOPYRIN 145RATIO-TOPISALIC 181 SALBUTAMOL SO4 29RATIO-TOPISONE 181 SALMETEROL XINAFOATE 30RATIO-TRAZODONE 101 SALMETEROL XINAFOATE/ RATIO-VALPROIC 92 FLUTICASONE PROPIONATE 30REBIF (EDS) 204 SALOFALK 145REMERON 98 SALOFALK RETENTION ENEMA 145REMERON RD 98 SANDOMIGRAN 31REMICADE (EDS) 204 SANDOMIGRAN DS 31REMINYL (EDS) 203 SANDOSTATIN (EDS) 207REMINYL ER (EDS) 203 SANDOSTATIN LAR (EDS) 207RENAGEL (EDS) 210 SANDOZ ACEBUTOLOL 42RENEDIL 61 SANDOZ AMIODARONE 42REPAGLINIDE 165 SANDOZ ANAGRELIDE 201REQUIP 210 SANDOZ ATENOLOL 43RESCRIPTOR (EDS) 12 SANDOZ AZITHROMYCIN (EDS) 6RESONIUM CALCIUM 120 SANDOZ BISOPROLOL (EDS) 44RESTORIL 112 SANDOZ CIPROFLOXACIN (EDS) 17RETIN A 187 " 18RETIN A (EDS) 187 SANDOZ CITALOPRAM 94RETROVIR (EDS) 15 SANDOZ CLONAZEPAM 86REYATAZ (EDS) 15 " 87RHINALAR 130 SANDOZ CORTIMYXIN 132RHINARIS-F 130 SANDOZ DEXAMETHASONE 130

318

PRODUCT NAME Page PRODUCT NAME PageSANDOZ DILTIAZEM CD 45 SINEMET CR 206 " 46 SINEQUAN 95SANDOZ DILTIAZEM T 46 " 96 " 47 SINGULAIR (EDS) 206SANDOZ ESTRADIOL DERM (EDS) 160 SINTROM 36 " 161 SIROLIMUS 210SANDOZ FLUOXETINE 96 SLOW-K 120SANDOZ FLUVOXAMINE 97 SODIUM AUROTHIOMALATE 148SANDOZ GENTAMICIN 128 SODIUM AUROTHIOMALATE 148SANDOZ GLYBURIDE 164 SODIUM CROMOGLYCATE 135SANDOZ LEVOBUNOLOL 135 " 210SANDOZ LOPERAMIDE 138 SODIUM FLUORIDE 210SANDOZ LOVASTATIN 54 SODIUM FUSIDATE 172SANDOZ METFORMIN FC 164 SODIUM NITROPRUSSIDE REAGENT 117 " 165 SODIUM POLYSTYRENE SULFONATE 120SANDOZ METOPROLOL L 47 SOFRACORT 131 " 48 SOFRA-TULLE 172SANDOZ MINOCYCLINE (EDS) 10 SOF-TACT 116SANDOZ MIRTAZAPINE 98 SOFTCLIX 214SANDOZ MIRTAZAPINE FC 98 SOFTCLIX PRO 214SANDOZ NABUMETONE (EDS) 77 SOLU-CORTEF 155SANDOZ NITRAZEPAM 87 SOMATROPIN 167SANDOZ OPTICORT 131 SORIATANE (EDS) 189SANDOZ PAROXETINE 99 SOTALOL HCL 51 " 100 SPIRIVA (EDS) 28SANDOZ PENTASONE 131 SPIRONOLACTONE 123SANDOZ PRAVASTATIN 54 SPIRONOLACTONE/ " 55 HYDROCHLOROTHIAZIDE 66SANDOZ PREDNISOLONE 131 SPORANOX (EDS) 3SANDOZ RANITIDINE 144 STARLIX (EDS) 165SANDOZ SALBUTAMOL RES. SOL 30 STATEX 83SANDOZ SERTRALINE 100 " 84 " 101 " 85SANDOZ SIMVASTATIN 56 STAVUDINE 14 " 57 STIEVA-A 187SANDOZ SOTALOL 51 STIEVA-A FORTE (EDS) 187SANDOZ SUMATRIPTAN (EDS) 32 SUCRALFATE 145SANDOZ TICLOPIDINE (EDS) 40 SULCRATE 145SANDOZ TIMOLOL 136 SULCRATE SUSPENSION PLUS 145SANDOZ TOBRAMYCIN (EDS) 128 SULFACETAMIDE (SODIUM) 129SANDOZ TOPIRAMATE 91 SULFACETAMIDE (SODIUM)/ " 92 COLLOIDAL SULPHUR 176SANDOZ TRIFLURIDINE 129 SULFACETAMIDE SODIUM/SANDOZ VALPROIC 92 PREDNISOLONE ACETATE 132SANSERT (EDS) 31 SULFACET-R 176SAQUINAVIR 16 SULFAMETHOXAZOLE/TRIMETHOPRIMSARNA HC 185 (CO-TRIMOXAZOLE) 20SCOPOLAMINE 140 SULFASALAZINE SECTRAL 42 (SALICYLAZOSULFAPYRIDINE) 145SELECT 1/35 158 SULFINPYRAZONE 39SELEGILINE HCL 210 " 123SERC 70 SULINDAC 79SEREVENT (EDS) 30 SUMATRIPTAN 32SEREVENT DISKUS (EDS) 30 SUPRAX (EDS) 4SEROQUEL 106 SUPREFACT (EDS) 202SERTRALINE HYDROCHLORIDE 100 SURESTEP 116SEVELAMER HCL 210 SURGAM 79SIBELIUM (EDS) 31 SUSTIVA (EDS) 13SIMVASTATIN 55 SYMBICORT TURBUHALER(EDS) 28SINEMET 205 SYMMETREL 12 " 206 SYNACTHEN DEPOT 167

319

PRODUCT NAME Page PRODUCT NAME PageSYNALAR 183 THIOTHIXENE 107SYNALAR REGULAR 183 THYROID 169SYNAREL (EDS) 207 THYROID 169SYNPHASIC 158 TIAPROFENIC ACID 79SYNTHROID 169 TIAZAC 46SYRINGE 215 " 47TACROLIMUS 190 TIAZAC XC 46 " 211 " 47TALWIN 85 TICLOPIDINE HCL 40TAMBOCOR 47 TIMOLOL MALEATE 52TAMSULOSIN HCL 211 " 68TAPAZOLE 170 " 136TARO-AMCINONIDE 176 TIMOPTIC 136TARO-CARBAMAZEPINE 88 TIMOPTIC-XE 136TARO-CARBAMAZEPINE CR (EDS) 88 TINZAPARIN SODIUM 37TARO-CIPROFLOXACIN (EDS) 17 TIOTROPIUM BROMIDE MONOHYDRATE 28 " 18 TIZANIDINE HCL 34TARO-CLINDAMYCIN 172 TOBI (EDS) 3TARO-CLOBETASOL CREAM 182 TOBRADEX (EDS) 132TARO-CLOBETASOL OINTMENT 182 TOBRAMYCIN 3TARO-CLOBETASOL SOLUTION 182 " 128TARO-FLUCONAZOLE (EDS) 3 TOBRAMYCIN/DEXAMETHASONE 132TARO-MOMETASONE OINTMENT 185 TOBREX (EDS) 128TARO-PHENYTOIN 87 TOFRANIL 97TARO-SIMVASTATIN 56 TOLBUTAMIDE 166TARO-SONE 181 TOLTERODINE L-TARTRATE 192TARO-TERCONAZOLE 174 TOPAMAX 91TARO-WARFARIN 38 " 92TAZAROTENE 190 TOPICORT 183TAZORAC 190 TOPICORT MILD 183TEGRETOL 88 TOPIRAMATE 91TEGRETOL CR (EDS) 88 TOPSYN 184TELITHROMYCIN 7 TRACLEER (EDS) 201TELMISARTAN 67 TRANDATE 63TELMISARTAN/ TRANDOLAPRIL 68 HYDROCHLOROTHIAZIDE 67 TRANSDERM-NITRO 0.2 71TELZIR (EDS) 15 TRANSDERM-NITRO 0.4 71TEMAZEPAM 112 TRANSDERM-NITRO 0.6 71TENOFOVIR DISOPROXIL FUMARATE 16 TRANSDERM-V 140TENORETIC 57 TRANYLCYPROMINE SO4 101TENORMIN 43 TRASICOR 65TERAZOL-3 174 TRAVATAN 136TERAZOL-3 DUAL-PAK 174 TRAVOPROST 136TERAZOL-7 174 TRAZODONE 101TERAZOSIN HCL 67 TRAZOREL 101TERBINAFINE HCL 4 TRENTAL 40 " 174 TRETINOIN 187TERBUTALINE SO4 30 TRIADERM 186TERCONAZOLE 174 TRIAMCINOLONE 156TESTOSTERONE CYPIONATE 156 TRIAMCINOLONE ACETONIDE 131TESTOSTERONE CYPIONATE 156 " 156TESTOSTERONE ENANTHATE 156 " 186TESTOSTERONE UNDECANOATE 156 TRIAMCINOLONE ACETONIDE 156TETRABENAZINE 211 TRIAMCINOLONE HEXACETONIDE 156TETRACYCLINE 10 TRIAMTERENE/HYDROCHLOROTHIAZIDE 68TEVETEN 61 TRIAZOLAM 112TEVETEN PLUS 61 TRI-CYCLEN 159THEOLAIR LIQUID 193 TRI-CYCLEN LO 159THEOPHYLLINE (ANHYDROUS) 193 TRIFLUOPERAZINE 108THIAMIJECT 196 TRIFLURIDINE 129THIAMINE HCL 196 TRIHEXYPHENIDYL HCL 26

320

PRODUCT NAME Page PRODUCT NAME PageTRILEPTAL (EDS) 91 VIDEX EC (EDS) 14TRIMEPRAZINE TARTRATE 211 VIGABATRIN 92TRIMETHOPRIM 20 VIGAMOX (EDS) 129TRIMIPRAMINE 102 VIOKASE 139TRINIPATCH 0.2 71 VIRACEPT (EDS) 16TRINIPATCH 0.4 71 VIRAMUNE (EDS) 13TRINIPATCH 0.6 71 VIREAD (EDS) 16TRIPHASIL 157 VIROPTIC 129TRIQUILAR 157 VISKAZIDE 65TRIZIVIR (EDS) 13 VISKEN 49TRUSOPT 132 VITAMIN A ACID 187T-STAT 172 VITAMIN A ACID (EDS) 187TWINJECT 28 VITAMIN B1 196TYLENOL WITH CODEINE ELX 80 VITAMIN B12 196TYLENOL WITH CODEINE NO.2 80 VITAMIN B6 196TYLENOL WITH CODEINE NO.3 80 VITAMIN D 197TYLENOL WITH CODEINE NO.4 80 VIVOL 111ULTICARE 29G 215 VOLTAREN 74ULTICARE 30G 215 " 75ULTRAMOP (EDS) 190 VOLTAREN OPHTHA (EDS) 134ULTRASE MS4 138 VOLTAREN-SR 74ULTRASE MT12 139 VORICONAZOLE 4ULTRASE MT20 139 WARFARIN 38ULTRAVATE (EDS) 184 WARTEC 188UNIFINE 215 WEBCOL ALCOHOL PREP 214UNIPHYL 193 WELLBUTRIN SR (EDS) 93UNITRON PEG (EDS) 23 WELLBUTRIN XL (EDS) 93UREMOL-HC 185 WESTCORT 185URISPAS (EDS) 192 WINPRED 155URSO (EDS) 211 XALACOM 135URSO DS (EDS) 211 XALATAN 135URSODIOL 211 XANAX 109VAGIFEM 160 XATRAL 200VALACYCLOVIR 12 YASMIN 21 157VALCYTE (EDS) 12 YASMIN 28 157VALGANCICLOVIR HCL 12 ZADITEN (EDS) 204VALISONE 182 ZAFIRLUKAST 211VALIUM 111 ZANAFLEX (EDS) 34VALPROATE SODIUM 92 ZANTAC 144VALPROIC ACID 92 ZARONTIN 88VALSARTAN 68 ZAROXOLYN 122VALSARTAN/HYDROCHLOROTHIAZIDE 69 ZERIT (EDS) 14VALTREX 12 ZESTORETIC 63VANCOCIN (EDS) 11 ZESTRIL 63VANCOMYCIN HCL 11 ZIAGEN (EDS) 13VANQUIN 2 ZIDOVUDINE 15VASERETIC 61 ZITHROMAX (EDS) 6VASOTEC 61 ZOCOR 55VENLAFAXINE HCL 102 " 56VENOFER (EDS) 36 " 57VENTODISK 29 ZOLADEX (EDS) 204VENTOLIN 29 ZOLEDRONIC ACID 211VENTOLIN NEBULES P.F. 29 ZOLMITRIPTAN 33VENTOLIN RESPIRATOR SOLN. 30 ZOLOFT 100VERAPAMIL HCL 52 " 101 " 69 ZOMIG (EDS) 33VERMOX 2 ZOMIG RAPIMELT (EDS) 33VFEND (EDS) 4 ZOVIRAX 11VIADERM-KC 186 ZOVIRAX WELLSTAT PAC 11VIBRAMYCIN 9 ZOVIRAX ZOSTAB PAC 11VIBRA-TABS 9 ZUCLOPENTHIXOL ACETATE 108

321

PRODUCT NAME PageZUCLOPENTHIXOL DECANOATE 108ZUCLOPENTHIXOL DIHYDROCHLORIDE 108ZYLOPRIM 200ZYMAR (EDS) 134ZYPREXA (EDS) 105ZYPREXA ZYDIS (EDS) 105ZYVOXAM (EDS) 11

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21


Form

ular

y U

pdat

es

22


334

23


24


Formulary U

pdates

335

25


Form

ular

y U

pdat

es

26


336

27


28


Formulary U

pdates

337

29


Form

ular

y U

pdat

es

30


338

31


32


Formulary U

pdates

339

33


Form

ular

y U

pdat

es

34


340

35


36


Formulary U

pdates

341

37


Form

ular

y U

pdat

es

38


342

343

39


40


Formulary U

pdates

UPDATE INDEX

A


Upd

ate

Inde

x

B


346

C


D


Update Index

347

E


Upd

ate

Inde

x

F


348

G


H


Update Index

349

I


Upd

ate

Inde

x

J


350

K


L


Update Index

351

352

M


Upd

ate

Inde

x

N


TABLE OF CONTENTSSUPPLEMENTARY INFORMATION

TABLE OF CONTENTS

(SUPPLEMENTARY INFORMATION)

Note: This section is provided for information purposes only.Documents contained in this section are not

part of the Formulary or the Drug Plan.

HOSPITAL BENEFIT DRUG LIST..................................................................................... . 2TIPS ON PRESCRIPTION WRITING......................................................................……… . 38PRESCRIPTION REGULATIONS...................................................................................... . 42GUIDELINES FOR REPORTING ADVERSE REACTIONS.....................................……… . 46THE PRESCRIPTION REVIEW PROGRAM………........................................................... . 48

ii


July 2006

NOTIFICATION OF UPDATES TO THE HOSPITAL BENEFIT DRUG LIST WILL BE PROVIDED IN THE DRUG PLAN UPDATE BULLETINS

PLEASE DIRECT INQUIRIES REGARDING THIS LIST TO: (306) 787- 6823

2

1. This list of drug benefits under Saskatchewan Health is supplementary to the annual Saskatchewan Formulary (56th Edition, July 2006). It is intended to expand on the Formulary as required to meet the special requirements of hospitals and health centers.

2. The Benefit Drug List is updated semi-annually by the Advisory Committee on

Institutional Pharmacy Practice. This committee is composed of representatives of: the Canadian Society of Hospital Pharmacists (Saskatchewan Branch); the Saskatchewan Drug Quality Assessment Committee; the Saskatchewan Association of Health Organizations and officials from the Department of Health.

3. In summary, the government is accepting the following items as insured benefits

when administered to patients in hospital and/or health centers. Institutional formularies put in place by Regional Health Authorities and affiliates may affect the availability of some insured drugs:

(a) All products listed in the Saskatchewan Formulary. (Brands other than

those listed are not considered as interchangeable.) (b) Unlisted strengths of products included in the Saskatchewan Formulary or

approved for Exception Drug Status coverage (see item 5). [This applies only to brands manufactured by the same supplier(s).]

(c) Generally accepted nursing treatments, agents such as antiseptics,

disinfectants, mouthwashes, lozenges, lubricants, soaps and emollients. (d) All diagnostic agents. (e) All irrigating solutions. (f) All radioactive agents.

(g) All injectable vitamins and injectable multivitamin preparations when used

to maintain or attain nutritional status. (h) Alcoholic beverages such as beer, stout, brandy and whiskey. (i) All dietary supplements. (j) All antacids and laxatives marketed by approved manufacturers. (k) All hemostatic agents. (l) All agents appearing on the attached supplemental list including all dosage

forms and strengths unless otherwise indicated in the list. Prolonged release, sustained release, and delayed release dosage forms are benefits only when specifically listed.

(m) New dosage forms, drug entities and other products released on the

market after the effective date of this list are not insured hospital/health center benefits. They may be charged to hospital or health center clients until reviewed and approved as an insured benefit by the Saskatchewan Formulary Committee or the Advisory Committee on Institutional Pharmacy Practice.

3

4. Formularies established by Regional Health Authorities and affiliates may not include all insured items. If an insured drug is not included in a health region/affiliate formulary, its provision will be subject to Regional Health Authority/affiliate policy.

5. Only drugs listed in the Saskatchewan Formulary, and not those on the Benefit Drug

List, are an insured benefit when dispensed to ambulatory patients, i.e. through retail pharmacies or an organized hospital dispensing service.

6. For certain patients, the Prescription Drug Services Branch may approve/has

approved Exception Drug Status coverage, on an outpatient basis, for certain products which are not listed in the Saskatchewan Formulary or the Benefit Drug List. Patients with such coverage have been issued a letter of authorization which, upon presentation in a hospital or health center, also entitles the beneficiary to receive the specified drug as an inpatient benefit (notwithstanding Statement 4 above).

In cases where treatment with a product known to be eligible for Exception Drug Status Coverage is initiated in the hospital or health center, it will be recognized as an inpatient benefit providing the patient's case meets the eligibility criteria listed in the Saskatchewan Formulary. The drugs eligible for such coverage and the criteria for patient eligibility are published in the Saskatchewan Formulary as Appendix A.

7. Certain products are benefits only when used according to specific criteria. The

usage criteria or restrictions that apply are shown for each product. When these products are ordered, the ordering physician and/or the pharmacist must determine if the conditions for coverage have been met. When the conditions are met, the patient receives the drug as a benefit. The cost is absorbed by the health region or affiliate. The region/affiliate may choose to charge the patient for administration of drugs in this section that fails to meet the criteria/restrictions listed.

8. Combination products are only benefits if they are specifically included in the Benefit

Drug List. Listing of one ingredient included in a combination product does not make that product a benefit.

9. Products that are not listed in either the Saskatchewan Formulary or this

supplementary benefit drug list, or which have not received special approval, are not insured and therefore chargeable to a patient.

10. Certain products may be granted Restricted Coverage status for non-approved

indications. This is the case only when the Advisory Committee for Institutional Pharmacy Practice has reviewed evidence to demonstrate safety and efficacy and the prescriber is aware the drug is being prescribed for a non-approved indication.

11. Toxoids and Vaccines are to be provided by health regions and affiliates according to

supply and guidelines established by Saskatchewan Health and Canadian Blood Services. Other such products will be reviewed and recommended for approval on a case by case basis by the health regions and affiliates. Serums are listed in Section 80:00.00.

12. EprexTM, AranespTM, InfuferTM and VenoferTM may be billed to the Drug Plan when

used for the treatment of anemia of renal disease if patients receive these drugs in an institution’s dialysis unit as an outpatient. The cost of EprexTM, AranespTM, InfuferTM and VenoferTM for inpatient use is the responsibility of the health region or affiliate.

4

Payment Policy Statement: The Drug Plan will reimburse hospital pharmacies the actual acquisition cost (AAC) of the dose of EprexTM, AranespTM, InfuferTM or VenoferTM that is administered plus a 10% mark-up for each month’s supply. The mark-up will be capped at $20.00 per month, unless there are dosage changes.

•

•

How to bill the Drug Plan:

To ensure consistency in billing for these agents, hospital pharmacy departments are asked to use specific billing forms to submit claims. Please contact (306) 787-3315 or toll free 1-800-667-7578 with any questions.

5

TABLE OF CONTENTS

04:00.00 ANTIHISTAMINE AGENTS 10

08:00.00 ANTI-INFECTIVE AGENTS 10

08:12.00 ANTIBIOTICS 10 08:12.02 AMINOGLYCOSIDES 10 08:12.04 ANTIFUNGALS 10 08:12.06 CEPHALOSPORINS 10 08:12.07 MISCELLANEOUS BETA LACTAM ANTIBIOTICS 11 08:12.08 CHLORAMPHENICOL 11 08:12.12 MACROLIDES 11 08:12.16 PENICILLINS 11 08:12.28 MISCELLANEOUS ANTIBIOTICS 12

08:14.00 ANTIFUNGAL AGENTS 12 08:16.00 ANTITUBERCULOSIS AGENTS 12 08:18.00 ANTIVIRALS 12

08:22.00 QUINOLONES 13

08:40.00 MISCELLANEOUS ANTI INFECTIVES 13

10:00.00 ANTINEOPLASTIC AGENTS (Agents used for non-cancer indications. See the Formulary of the Saskatchewan Cancer Foundation for a complete listing of antineoplastic agents.) 13

12:00.00 AUTONOMIC DRUGS 13

12:04.00 PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS 13 12:08.00 ANTICHOLINERGIC AGENTS 14

12:08.08 ANTIMUSCARINIC/ANTISPASMODICS 14 12:12.00 SYMPATHOMIMETIC (ADRENERGIC) AGENTS 14 12:16.00 SYMPATHOLYTICS 14 12:20.00 SKELETAL MUSCLE RELAXANTS 14

20:00.00 BLOOD FORMATION AND COAGULATION 14

20:04.00 ANTIANEMIA DRUGS 14 20:04.04 IRON PREPARATIONS 15

20:12.00 COAGULANTS AND ANTICOAGULANTS 15 20:12.04 ANTICOAGULANTS 15 20:12.08 ANTIHEPARIN AGENTS 15 20:12.16 HEMOSTATICS 16

6

20:40.00 THROMBOLYTIC AGENTS 16

24:00.00 CARDIOVASCULAR DRUGS 16

24.04.00 CARDIAC DRUGS 16 24:08.00 HYPOTENSIVE AGENTS 17 24:12.00 VASODILATING AGENTS 17

28:00.00 CENTRAL NERVOUS SYSTEM AGENTS 17

28:04.00 GENERAL ANESTHETICS 17 28:08.00 ANALGESICS AND ANTIPYRETICS 18

28:08.04 NON-STEROIDAL ANTI-INFLAMMATORY AGENTS 18 28:08.08 OPIATE AGONISTS 18 28:08.12 OPIATE PARTIAL AGONISTS 18 28:08.92 MISCELLANEOUS ANALGESICS AND ANTIPYRETICS 18

28:10.00 OPIATE ANTAGONISTS 18 28:12.00 ANTICONVULSANTS 18

28:12.12 HYDANTOINS 18 28:12.92 MISCELLANEOUS ANTICONVULSANTS 19

28:16.00 PSYCHOTHERAPEUTIC AGENTS (see the Saskatchewan Formulary) 19 28:20.00 RESPIRATORY AND CEREBRAL STIMULANTS 19 28:24.00 ANXIOLYTICS, SEDATIVES AND HYPNOTICS 19

28:24.04 BARBITURATES (see the Saskatchewan Formulary) 19 28:24.08 BENZODIAZEPINES 19 28:24.92 MISCELLANEOUS ANXIOLYTICS, SEDATIVES, HYPNOTICS 19

28:92.00 MISCELLANEOUS CENTRAL NERVOUS SYSTEM AGENTS 19

36:00.00 DIAGNOSTIC AGENTS 19

36:56.00 MYASTHENIA GRAVIS 19

40:00.00 ELECTROLYTIC, CALORIC AND WATER BALANCE 19

40:08.00 ALKALINIZING AGENTS 19 40:12.00 ELECTROLYTE AND FLUID REPLACEMENT 20 40:20.00 CALORIC AGENTS 20 40:28.00 DIURETICS 21

48:00.00 ANTITUSSIVES, EXPECTORANTS AND MUCOLYTIC AGENTS 21

48:08.00 ANTITUSSIVES 21 48:16.00 EXPECTORANTS 21

7

48:24.00 MUCOLYTIC AGENTS 21

52:00.00 EYE, EAR, NOSE AND THROAT PREPARATIONS 21

52:04.00 ANTI-INFECTIVES 21 52:04.04 ANTIBIOTICS 21

52:16.00 LOCAL ANESTHETICS 21 52:20.00 MIOTICS 22 52:24.00 MYDRIATICS 22 52:32.00 VASOCONSTRICTORS 22 52:36.00 MISCELLANEOUS EYE, EAR, NOSE AND THROAT DRUGS 22

56:00.00 GASTROINTESTINAL DRUGS 22

56:04.00 ANTACIDS AND ADSORBENTS 22 56:08.00 ANTIDIARRHEA AGENTS 22 56:12.00 CATHARTICS AND LAXATIVES 22 56:20.00 EMETICS 23 56:22.00 ANTIEMETICS 23 56:40.00 MISCELLANEOUS GASTROINTESTINAL DRUGS 23

64:00.00 HEAVY METAL ANTAGONISTS 23

68:00.00 HORMONES AND SYNTHETIC SUBSTITUTES 23

68:04.00 ADRENALS 23 68:08.00 ANDROGENS 24 68:24.00 PARATHYROID 24 68:28.00 PITUITARY 24

72:00.00 LOCAL ANESTHETICS 24

76:00.00 OXYTOCICS 25

80:00.00 SERUMS, TOXOIDS AND VACCINES 25

80:04.00 SERUMS 25 80:08.00 TOXOIDS 25 80:12.00 VACCINES 25

8

84:00.00 SKIN AND MUCOUS MEMBRANE AGENTS 26

84:04.00 ANTI INFECTIVES 26 84:04.04 ANTIBIOTICS 26 84:04.08 ANTIFUNGALS 26 84:04.16 MISCELLANEOUS LOCAL ANTI-INFECTIVES 26

84:08.00 ANTIPRURITICS AND LOCAL ANESTHETICS 26 84:24.00 EMOLLIENTS, DEMULCENTS AND PROTECTANTS 26

84:24.12 BASIC CREAMS, OINTMENTS AND PROTECTANTS 26 84:24.16 BASIC POWDERS AND DEMULCENTS 27

84:40:00 HEMORRHOID PREPARATIONS 27

88:00.00 VITAMINS 27

88:16.00 VITAMIN D 27

92:00.00 UNCLASSIFIED THERAPEUTIC AGENTS 27

APPENDIX I: PROCEDURES FOR OBTAINING DRUGS PROVIDED UNDER PROVINCIAL PROGRAMS 29

APPENDIX II: HOME PARENTERAL MEDICATION PROGRAM COVERAGE POLICY 31

9

04:00.00 ANTIHISTAMINE AGENTS CYPROHEPTADINE Tablet 4mg Syrup 0.4mg/mL DIPHENHYDRAMINE (injection only) Injection 50mg/mL PROMETHAZINE Injection 25mg/mL 08:00.00 ANTI-INFECTIVE AGENTS 08:12.00 ANTIBIOTICS

08:12.02 AMINOGLYCOSIDES AMIKACIN Injection 250mg/mL TOBRAMYCIN Injection 10mg/mL, 40mg/mL

08:12.04 ANTIFUNGALS AMPHOTERICIN B Injection 50mg AMPHOTERICIN B LIPID COMPLEX INJECTION (Abelcet) and LIPOSOMAL AMPHOTERICIN B (AmBisome)

Restricted Coverage: When used in consultation with an infectious disease specialist under the following guidelines:

failure of amphotericin B deoxycholate. For adults, this is normally defined as poor clinical response to >500mg cumulative doses;

•

•

•

•

nephrotoxicity due to conventional amphotericin B therapy as evidenced by doubling of baseline serum creatinine or a significant rise from baseline plus concomitant use of other potential nephrotoxins; significant pre-existing renal failure – creatinine >220umol/L or CrCl <25mL/minute or special renal condition (e.g. transplant or single kidney); severe dose-related toxicities which do not resolve with premedication (e.g. fever, rigors, hypotension).

CASPOFUNGIN ACETATE Restricted coverage: when administered in consultation with an infectious disease specialist.

Injection 50mg, 70mg FLUCONAZOLE Restricted Coverage: Injection Injection 2mg/mL FLUCYTOSINE (Health Canada - Special Access Programme) Injection 1g, 5g, 10g Capsules 500mg 08:12.06 CEPHALOSPORINS CEFAZOLIN Injection 500mg, 1g CEFOTAXIME

10

Restricted Coverage: Benefit status is automatic for first 72 hours in severe infections. Long-term use is covered when supported by sensitivity tests.

Injection 500mg, 1g, 2g CEFOTETAN Injection 1g, 2g CEFOXITIN SODIUM Injection 1g, 2g CEFTAZIDIME Restricted Coverage: Benefit status is automatic for first 72 hours in severe infections. Long-term use is covered when supported by sensitivity tests. Injection 500mg, 1g, 2g

CEFTRIAXONE Restricted Coverage: Benefit status is automatic for first 72 hours in severe infections. Long-term use is covered when supported by sensitivity tests.

Injection 250mg, 1g, 2g CEFUROXIME (see Appendix A – Saskatchewan Health Drug Plan Formulary) Injection 750mg, 1.5g CEPHALOTHIN Injection

08:12.07 MISCELLANEOUS BETA LACTAM ANTIBIOTICS ERTAPENEM

Restricted coverage: For the treatment of severe infections on the recommendation of an infectious disease specialist, internist or microbiologist. Injection 1g

IMIPENEM/CILASTATIN Restricted Coverage: For the treatment of severe infections on the recommendation of an infectious disease specialist; internist or medical microbiologist.

Injection 250mg/250mg; 500mg/500mg MEROPENEM

Restricted Coverage: For the treatment of severe infections on the recommendation of an infectious disease specialist; internist or medical microbiologist. Injection

08:12.08 CHLORAMPHENICOL

CHLORAMPHENICOL Injection 1g

08:12.12 MACROLIDES AZITHROMYCIN (see Appendix A - Saskatchewan Health Drug Plan Formulary) Injection ERYTHROMYCIN Injection (lactobionate) 500mg, 1g 08:12.16 PENICILLINS AMPICILLIN Injection 125mg, 250mg, 500mg, 1g, 2g PIPERACILLIN Injection 2g, 3g, 4g PIPERACILLIN/TAZOBACTAM Restricted Coverage: For the treatment of severe infections on the

11

recommendation of an infectious disease specialist; internist or medical microbiologist.

Injection 2g/0.25g; 3g/0.375g; 4g/0.5g TICARCILLIN Injection 3g

08:12.28 MISCELLANEOUS ANTIBIOTICS BACITRACIN STERILE Vial 50,000 units

POLYMYXIN B SULFATE (injection only) (Health Canada - Special Access Programme)

QUINUPRISTIN/DALFOPRISTIN (SynercidTM) Restricted Coverage: Reserved for use against multi-resistant gram positive organisms, including Methicillin Resistant Staph. Aureus (MRSA) and vancomycin resistant E.faecium, on the recommendation of an infectious disease specialist.

Injection VANCOMYCIN Injection

08:14.00 ANTIFUNGAL AGENTS VORICONAZOLE Restricted Coverage: When prescribed by an infectious disease specialist. Injection

08:16.00 ANTITUBERCULOSIS AGENTS ETHAMBUTOL Tablet 100mg, 400mg ISONIAZID Tablet 50mg, 100mg, 300mg Syrup 10mg/mL PYRAZINAMIDE Tablet 500mg RIFAMPIN Capsule 150mg, 300mg

08:18.00 ANTIVIRALS ACYCLOVIR Restricted Coverage:

a) IV form only when used for treatment of initial and recurrent mucosal and cutaneous herpes simplex infections in immunocompromised patients and;

b) IV form when used for severe initial episodes of herpes simplex infections in patients who may not be immunocompromised.

Suspension 40mg/mL Injection 500mg, 1g FOSCARNET (Health Canada - Special Access Programme) Injection 24mg/mL

GANCICLOVIR (see Appendix A - Saskatchewan Health Drug Plan Formulary) Vial 500mg

RIBAVIRIN Restricted Coverage: When used in a Pediatric Intensive Care Unit,

12

preferably on the basis of consultation with an infectious disease specialist, and for proven or seriously ill cases during an outbreak of the Respiratory Syncytial Virus (RSV).

Powder for inhalation solution 6g 08:22.00 QUINOLONES (see Appendix A - Saskatchewan Health Drug Plan Formulary) CIPROFLOXACIN Injection 10mg/mL LEVOFLOXACIN Injection 5mg/mL, 25mg/mL MOXIFLOXACIN Injection, 400mg

08:40.00 MISCELLANEOUS ANTI INFECTIVES LINEZOLID (see Appendix A - Saskatchewan Health Drug Plan Formulary) Injection PENTAMIDINE ISETHIONATE Injection Oral inhalation solution 300mg 10:00.00 ANTINEOPLASTIC AGENTS (Agents used for non-cancer indications.

See the Formulary of the Saskatchewan Cancer Foundation for a complete listing of antineoplastic agents.)

BLEOMYCIN Injection 15 unit CYCLOPHOSPHAMIDE Tablet 25mg, 50mg Injection 200mg, 1g DAUNORUBICIN Injection 20mg DOXORUBICIN Injection 2mg/mL FLUOROURACIL Injection 50mg/mL METHOTREXATE Injection 10mg/mL (2mL), 25mg/mL (2mL, 4mL, 8mL, 20mL, 40mL, 200mL) Powder for injection 20mg 12:00.00 AUTONOMIC DRUGS

12:04.00 PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS EDROPHONIUM Injection 10mg/mL NEOSTIGMINE Injection 0.5mg/mL (1:2000), 1mg/mL (1:1000) Injection 2.5mg/mL (5mL)

13

12:08.00 ANTICHOLINERGIC AGENTS

12:08.08 ANTIMUSCARINIC/ANTISPASMODICS

HYOSCINE BUTYLBROMIDE Also known as SCOPOLAMINE BUTYLBROMIDE

Injection 20mg/Ml HYOSCINE HYDROBROMIDE Also known as SCOPOLAMINE HYDROBROMIDE Injection 0.4mg/mL, 0.6mg/mL

12:12.00 SYMPATHOMIMETIC (ADRENERGIC) AGENTS DOBUTAMINE Injection 12.5mg/mL DOPAMINE Injection 40mg/mL (20mL) IV premixed bag 0.8mg/mL (250mL, 500mL) D5W EPHEDRINE Injection 50mg/1mL Tablet 8mg, 15mg, 25mg, 30mg Capsule 25mg ISOPROTERENOL Injection 0.2mg/mL (1:5000) NOREPINEPHRINE Injection 1mg/mL

PHENYLEPHRINE Injection 10mg/mL

PSEUDOEPHEDRINE Tablet 60mg Syrup 6mg/mL

12:16.00 SYMPATHOLYTICS PHENTOLAMINE MESYLATE Injection

12:20.00 SKELETAL MUSCLE RELAXANTS

ATRACURIUM BESYLATE Injection 10mg/mL (5mL, 10mL) GALLAMINE TRIETHIODIDE Injection 20mg/mL (2mL, 5mL) PANCURONIUM Injection 2mg/mL ROCURONIUM Injection 10mg/mL (10mL)

SUCCINYLCHOLINE Injection 20mg/mL

VECURONIUM Injection 10mg

20:00.00 BLOOD FORMATION AND COAGULATION

20:04.00 ANTIANEMIA DRUGS

14

20:04.04 IRON PREPARATIONS

FERROUS FUMARATE Capsule FERROUS GLUCONATE Tablet FERROUS SULPHATE Tablet Syrup Oral drops Oral solution IRON DEXTRAN Injection 50mg/mL elemental iron

20:12.00 COAGULANTS AND ANTICOAGULANTS

20:12.04 ANTICOAGULANTS

ARGATROBAN

Restricted Coverage: For treatment of heparin-induced thrombocytopenia in consultation with a hematologist.

Injection DALTEPARIN

Restricted Coverage: See Appendix A - Saskatchewan Health Drug Plan Formulary. For in-hospital treatment of acute coronary syndrome to a maximum of eight (8) days.

Injection DANAPAROID Restricted Coverage: For treatment of heparin-induced thrombocytopenia in

consultation with a hematologist. Injection

ENOXAPARIN Restricted Coverage: See Appendix A - Saskatchewan Health Drug Plan Formulary. For in-hospital treatment of acute coronary syndrome to a maximum of eight (8) days.

Injection HEPARIN (not including low molecular weight formulations) Injection 1,000 IU/mL (1mL, 10mL, 30mL) Injection (subcutaneous) 25000 IU/mL (0.2mL, 2mL) Injection (heparin lock flush) 100 IU/mL (2mL, 10mL)

LEPIRUDIN

Restricted Coverage: For treatment of heparin-induced thrombocytopenia in consultation with a hematologist.

Injection NADROPARIN

Restricted Coverage: See Appendix A - Saskatchewan Health Drug Plan Formulary. For in-hospital treatment of acute coronary syndrome to a maximum of eight (8) days.

Injection

20:12.08 ANTIHEPARIN AGENTS PROTAMINE SULPHATE

15

Injection 10mg/mL

20:12.16 HEMOSTATICS

AMINOCAPROIC ACID Tablet 500mg Injection 250mg/mL ANTIHEMOPHILIC FACTOR VIII (HUMAN)

APROTININ Injection 10,000 Kallikrein Inhibitory Units/mL

FACTOR IX TRANEXAMIC ACID

Injection 100mg/mL

20:40.00 THROMBOLYTIC AGENTS STREPTOKINASE Injection 250,000 IU, 750000 IU, 1.5 million IU TENECTEPLASE (TNK) Restricted Coverage: For the treatment of patients with:

larger acute myocardial infarction and presenting within twelve (12) hours; high risk inferior wall myocardial infarctions; patients with significant hypotension or cardiogenic shock.

Injection ALTEPLASE (TISSUE PLASMINOGEN ACTIVATOR or tPA) Restricted Coverage: a) for the treatment of patients with:

larger acute myocardial infarction and presenting within twelve (12) hours. high risk inferior wall myocardial infarctions. patients with significant hypotension or cardiogenic shock.

Injection 50mg, 100mg b) for the treatment of strokes when all the following circumstances are present:

within three (3) hours of the onset of symptoms; under the guidance of a neurologist and a neuro-radiologist; after a CT scan to rule out hemorrhage; and in conjunction with established treatment protocols.

c) Injection, powder for solution, 2mg/vial (Cathflo) For correction of catheter occlusions.

24:00.00 CARDIOVASCULAR DRUGS

24.04.00 CARDIAC DRUGS ADENOSINE

Restricted Coverage: When used as an antiarrhythmic – for conversion to sinus rhythm of paroxysmal supraventricular tachycardia, including those associated with accessory bypass tracts (Wolf-Parkinson-White Syndrome).

Injection 3mg/mL AMIODARONE HCl Injection 50mg/mL BRETYLIUM TOSYLATE Injection 50mg/mL DIGOXIN Injection 0.05mg/mL (1mL), 0.25mg/mL (2mL)

16

DILTIAZEM Injection 5mg/mL (5mL, 10mL) ESMOLOL

Restricted Coverage: For use in Operating Room or Critical Care Areas only for: the perioperative management of tachycardia and hypertension in patients with atrial fibrillation or atrial flutter in acute situations.

Injection 10mg/mL (10mL) MILRINONE Restricted Coverage:

a) When used in the short-term management of ventricular dysfunction unresponsive to digitalis, diuretics and vasodilators or as an aid to weaning off an intra-aortic balloon pump when other inotropes have failed.

b) Must be administered in a critical care setting capable of invasive cardiac monitoring including cardiac output, pulmonary capillary wedge

pressures and systemic vascular resistance. Injection 1mg/mL (10mL, 20mL) PROCAINAMIDE Injection 100mg/mL (10mL)

24:08.00 HYPOTENSIVE AGENTS LABETALOL

Injection 5mg/mL SODIUM NITROPRUSSIDE Injection 50mg

24:12.00 VASODILATING AGENTS ALPROSTADIL Injection 0.5mg/mL NIMODIPINE Injection 0.2mg/mL (250mL) NITROGLYCERIN Injection 5mg/mL (10mL) PAPAVERINE Injection 32.5mg/mL (2mL) NITRIC OXIDE Restricted Coverage: For use in the pediatric population Inhalation Gas 28:00.00 CENTRAL NERVOUS SYSTEM AGENTS

28:04.00 GENERAL ANESTHETICS DESFLURANE Inhalation solution 1mL/mL (240mL) ENFLURANE Solution 250mL HALOTHANE Solution 250mL ISOFLURANE Solution 100mL KETAMINE Injection 10mg/mL, 50mg/mL

17

PROPOFOL Injection 10mg/mL (20mL, 50mL, 100mL) SEVOFLURANE Solution 250mL THIOPENTAL Injection kit 1 g kit and 500mg /2.5% kit

28:08.00 ANALGESICS AND ANTIPYRETICS

28:08.04 NON-STEROIDAL ANTI-INFLAMMATORY AGENTS ACETYLSALICYLIC ACID Tablet Enteric coated tablet Suppository

28:08.08 OPIATE AGONISTS ALFENTANIL Injection 0.05mg/mL, 0.5mg/mL FENTANYL Injection 50ug/mL METHADONE Powder for oral solution

(Use of methadone is restricted to Health Protection Branch authorized prescribers)

SUFENTANIL Injection 50ug/mL

28:08.12 OPIATE PARTIAL AGONISTS NALBUPHINE Ampoule 10mg/mL

28:08.92 MISCELLANEOUS ANALGESICS AND ANTIPYRETICS ACETAMINOPHEN Tablet (chewable) Tablet Oral liquid Elixir Suppository

28:10.00 OPIATE ANTAGONISTS NALOXONE Injection 0.02mg/mL, 0.4mg/mL

28:12.00 ANTICONVULSANTS

28:12.12 HYDANTOINS FOSPHENYTOIN Restricted coverage: for the treatment of status epilepticus.

Injection 25mg (50 PE)

18

28:12.92 MISCELLANEOUS ANTICONVULSANTS MAGNESIUM SULFATE Injection 50mg/mL

28:16.00 PSYCHOTHERAPEUTIC AGENTS (see the Saskatchewan Formulary)

28:20.00 RESPIRATORY AND CEREBRAL STIMULANTS DOXAPRAM (FDA – Special Access Program) Restricted Coverage: When used for approved indications. Injection 20mg/mL (20mL)

28:24.00 ANXIOLYTICS, SEDATIVES AND HYPNOTICS

28:24.04 BARBITURATES (see the Saskatchewan Formulary)

28:24.08 BENZODIAZEPINES MIDAZOLAM Injection 1mg/mL (2mL, 5mL, 10mL), 5mg/mL (1mL, 2mL, 10mL)

28:24.92 MISCELLANEOUS ANXIOLYTICS, SEDATIVES, HYPNOTICS DROPERIDOL Injection 2.5mg/mL PARALDEHYDE Injection 5mL ampoule (1mL is equivalent to approximately 1g)

28:92.00 MISCELLANEOUS CENTRAL NERVOUS SYSTEM AGENTS FLUMAZENIL injection 36:00.00 DIAGNOSTIC AGENTS

36:56.00 MYASTHENIA GRAVIS EDROPHONIUM Injection 10mg/mL 40:00.00 ELECTROLYTIC, CALORIC AND WATER BALANCE

40:08.00 ALKALINIZING AGENTS SODIUM BICARBONATE injectable preparations Injection 0.5mEq/mL (4.2%), 1mEq/mL (8.4%) pre-load syringe Injection 5g/100mL (5%) (500mL) Injection 75mg/mL (7.5%) Injection 1mEq/mL (8.4%) TROMETHAMINE injection Injection 36mg/mL (0.3 Molar)

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40:12.00 ELECTROLYTE AND FLUID REPLACEMENT CALCIUM CHLORIDE Injection 10% - 100mg/mL (27mg elemental calcium/mL) CALCIUM GLUCONATE Injection 10% - 100mg/mL (9mg elemental calcium/mL) CALCIUM ORAL DOSAGE FORMS

Note: 500mg elemental calcium = 12.5mmol or 25mEq elemental calcium DEXTRAN 40 Solution 10% in D5W 500mL Solution 10% in Saline 0.9% 500mL DEXTRAN 70 Solution 32% in D10W 100mL Solution 6% in D5W 500mL Solution 6% in Saline 0.9% 500mL MAGNESIUM ORAL DOSAGE FORMS MAGNESIUM SULPHATE Injection 50% - 500mg/mL (50mg elemental magnesium/mL) Note: 5mg elemental magnesium = 0.2mmol or 0.4mEq elemental magnesium PHOSPHATE Injection potassium phosphate dibasic 236mg/mL Injection potassium phosphate monobasic 224mg/mL Effervescent tablet 500mg

POTASSIUM ACETATE Injection 392mg/mL POTASSIUM CHLORIDE Injection 2mEq elemental potassium/mL POTASSIUM PHOSPHATE Vial 3mmol/mL SODIUM CHLORIDE Injection 2.5mEq/mL Injection 4mEq/mL SODIUM PHOSPHATE Injection 3 mmol/mL ZINC ORAL DOSAGE FORMS

40:20.00 CALORIC AGENTS ABSOLUTE ALCOHOL INJECTION (dehydrated alcohol) Injection 100% (10mL) AMINO ACIDS SOLUTIONS (with or without electrolytes) Includes all single substrate formulations AMINO ACIDS / DEXTROSE SOLUTIONS (with or without electrolytes) Includes all multisubstrate formulations DEXTROSE Injection 5%, 10%, 50% FAT EMULSION PREPARATIONS Injection 10%, 20%, 30%

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40:28.00 DIURETICS MANNITOL Injection 10% (1000mL) Injection 20% (500mL) Injection 25% (50mL) 48:00.00 ANTITUSSIVES, EXPECTORANTS AND MUCOLYTIC AGENTS

48:08.00 ANTITUSSIVES DEXTROMETHORPHAN Syrup 3mg/mL

48:16.00 EXPECTORANTS GUAIFENESIN Oral solution 20mg/mL 48:24.00 MUCOLYTIC AGENTS ACETYLCYSTEINE Antidote for acetaminophen poisoning Injection 20% solution 52:00.00 EYE, EAR, NOSE AND THROAT PREPARATIONS

52:04.00 ANTI-INFECTIVES

52:04.04 ANTIBIOTICS POLYMYXIN B/GRAMICIDIN or BACITRACIN Ophthalmic/otic solution, each mL: 10,000 units/0.25mg (gramicidin) Ophthalmic ointment, each g: 10,000 units/500 units (bacitracin)

52:16.00 LOCAL ANESTHETICS BENZOCAINE Gel, topical 7.5% Spray, 20% Gel, topical 20% COCAINE Topical solution 100mg/mL: 4% (4mL), 10% (5mL) LIDOCAINE (except for lozenges and suppositories) Aerosol, endotracheal Liquid (viscous), topical 2% PROPARACAINE Ophthalmic solution 0.5% TETRACAINE Ophthalmic solution 0.5% Ophthalmic solution minums 0.5% Aerosol 754 mg / 65g (oral)

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52:20.00 MIOTICS ACETYLCHOLINE Solution, intraocular irrigation 10mg/mL

52:24.00 MYDRIATICS PHENYLEPHRINE Ophthalmic solution 2.5% Ophthalmic solution minums 10% TROPICAMIDE Ophthalmic solution 0.5%, 1% Ophthalmic solution minums 1%

52:32.00 VASOCONSTRICTORS NAPHAZOLINE Ophthalmic solution 0.1% XYLOMETAZOLINE Nasal spray 0.05%, 0.1% Nasal solution 0.05%, 0.1%

52:36.00 MISCELLANEOUS EYE, EAR, NOSE AND THROAT DRUGS ALUMINUM ACETATE Solution, otic 0.5% ARTIFICIAL TEARS Ophthalmic solution FLUORESCEIN SODIUM Ophthalmic solution 2%, 10% Ophthalmic solution minums 2% Strip, ophthalmic 1mg Injection 100mg/mL, 250mg/mL SODIUM CHLORIDE Ophthalmic solution, 5% 56:00.00 GASTROINTESTINAL DRUGS

56:04.00 ANTACIDS AND ADSORBENTS ACTIVATED CHARCOAL Suspension (aqueous), oral - 200mg/mL Suspension (in sorbitol), oral - 200mg/mL

56:08.00 ANTIDIARRHEA AGENTS ATTAPULGITE Tablet 300mg, 600mg, 750mg Suspension 40mg/mL, 50mg/mL

56:12.00 CATHARTICS AND LAXATIVES CASTOR OIL FLEET

Enema with monobasic sodium phosphate 16g/100mL, dibasic sodium phosphate 6g/100mL

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Enema with monobasic sodium phosphate 16g/100mL, dibasic sodium phosphate 6g/100mL, & mineral oil

FLEET PHOSPHO - SODA BUFFERED SALINE Oral solution with sodium biphosphate 900mg/5mL, sodium phosphate monobasic 2.4g/5mL

GLYCERIN Suppository - infant 1.63g, adult 2.67g SENNOSIDES (Standardized) Liquid 119mg/70mL Powder 157.5mg/21g pouch Tablet 8.6mg, 12mg, 15mg, 25mg Granules 15mg/3g=1tsp Syrup 1.7mg/mL (70mL, 100mL, 250mL, 500mL) Suppository 30mg

56:20.00 EMETICS IPECAC Syrup

56:22.00 ANTIEMETICS DROPERIDOL Injection 2.5mg/mL

56:40.00 MISCELLANEOUS GASTROINTESTINAL DRUGS

PANTOPRAZOLE IV Restricted Coverage: When ordered in a high dose (80mg IV bolus followed by 8mg/hour x 72 hours) by a gastroenterologist or general surgeon following endoscopic hemostasis for non-variceal upper gastrointestinal bleeding; or when ordered as Pantoprazole 40mg IV q24h for patients who are strict NPO (i.e. not taking any oral medications or oral diet) and have: a) non-variceal upper GI bleeding not requiring endoscopic hemostatis; or b) severe erosive esophagitis; or c) Exception Drug Status (EDS) for a Proton Pump Inhibitor taken prior to

admission. Injection 64:00.00 HEAVY METAL ANTAGONISTS

CALCIUM DISODIUM EDETATE Injection (not for chelation therapy) DEFEROXAMINE MESYLATE Injection 500mg, 2g vial DIMERCAPROL Injection 100mg/mL 68:00.00 HORMONES AND SYNTHETIC SUBSTITUTES

68:04.00 ADRENALS METHYLPREDNISOLONE Plain

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Injection 40mg, 50mg, 125mg, 500mg, 1g Injection (depot) 20mg/mL, 40mg/mL, 80mg/mL (5mL) With Lidocaine Injection 10mg/mL, 40mg/mL (1mL, 2mL, 5mL)

68:08.00 ANDROGENS FLUOXYMESTERONE Tablet 5mg

68:24.00 PARATHYROID CALCITONIN Restricted coverage : For the treatment of non-malignant hypercalcemia.

Note : Requests for the treatment of hypercalcemia of malignancy should be referred to the Saskatchewan Cancer Agency Injection

68:28.00 PITUITARY

ACTH (adrenocorticotropic hormone / corticotropin) Jelly 80 unit/mL (5mL) Powder 80 unit VASOPRESSIN Injection (aqueous) 20 units/mL 72:00.00 LOCAL ANESTHETICS ARTICAINE Cartridge 4% (5ug/mL epinephrine) (1.7mL) BUPIVACAINE Injection 0.25%, 0.5%, 0.75% Injection 0.25% with epinephrine 1:200,000 Injection 0.5% with epinephrine 1:200,000 Injection, spinal 0.75% with dextrose 8.25% (2mL) CHLOROPROCAINE Injection, caudal-epidural 2%, 3% LIDOCAINE (with the exception of lozenges or suppositories) Injection 0.5%, 1%, 2% Injection 0.5% with epinephrine 1:100,000 Injection 0.5% with epinephrine 1:200,000 Injection 1% with epinephrine 1:100,000 Injection 1% with epinephrine 1:200,000 Injection 2% with epinephrine 1:100,000 Injection, epidural 1.5%, 2% Injection, epidural 1.5% with epinephrine 1:200,000 Injection, spinal 5% with glucose 7.5% - 2mL vial MEPIVACAINE Injection 1% Injection, caudal-epidural 1%, 2% PRILOCAINE Solution 4% TETRACAINE Injection 20mg ampoule

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76:00.00 OXYTOCICS CARBOPROST Injection 250mg/mL DINOPROSTONE Tablet 0.5mg Gel 0.5mg/2.5mL, 1mg/2.5mL, 2mg/2.5mL syringe Vaginal insert 10mg DINOPROST TROMETHAMINE Injection 5mg/mL ERGOMETRINE MALEATE Injection 0.25mg/mL OXYTOCIN Injection 10 units/mL 80:00.00 SERUMS, TOXOIDS AND VACCINES Note: * indicates the product is supplied to health regions by Saskatchewan Health **indicates the product is supplied to health regions by the Canadian Blood Services

80:04.00 SERUMS DIGOXIN IMMUNE FAB Restricted Coverage:

a) When used for the treatment of severe, life threatening digoxin toxicity as defined by: (1) severe ventricular tachy or bradyarrhythmias and/or (2) progressive hyperkalemia of greater then 5mmol/L in the setting of severe digoxin toxicity.

b) It is recommended one of the following medical specialties be consulted before this agent is administered: cardiologist; internist; or pediatrician.

Injection 38mg DIPHTHERIA ANTITOXIN* Injection 20,000 IU vial HEPATITIS B IMMUNE GLOBULIN (HUMAN)** IMMUNE GLOBULIN (HUMAN IV)** Injection 0.5%, 10% solution IMMUNE SERUM GLOBULIN (HUMAN IM) Injection 18% TETANUS IMMUNE GLOBULIN (HUMAN) Injection 250 unit

80:08.00 TOXOIDS

To be provided according to supply and guidelines by Saskatchewan Health and Canadian Blood Services. Other such products to be reviewed and approved on a case by case basis by the health regions.

80:12.00 VACCINES To be provided according to supply and guidelines by Saskatchewan Health and Canadian Blood Services. Other such products to be reviewed and approved on a case by case basis by the health regions.

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84:00.00 SKIN AND MUCOUS MEMBRANE AGENTS

84:04.00 ANTI INFECTIVES

84:04.04 ANTIBIOTICS BACITRACIN Ointment 500 IU/g 84:04.08 ANTIFUNGALS TOLNAFTATE Aerosol liquid 0.72mg/g (70g) Aerosol powder 10mg/g Cream 10mg/g Powder 10mg/g Solution 10mg/mL

84:04.16 MISCELLANEOUS LOCAL ANTI-INFECTIVES CHLORHEXIDINE Alcoholic scrub Cleanser 4% Gauze 0.5% Jelly 2%, 4% Liquid 2%, 4%, 20% Ointment 1% Soap 2% SILVER SULFADIAZINE Cream 1% w/w

84:08.00 ANTIPRURITICS AND LOCAL ANESTHETICS CALCIUM FOLINATE (folinic acid) Powder 50mg, 350mg Tablets 5mg Injection 10mg/mL DIBUCAINE Cream 0.5% (30g) Ointment 1% (30g) LIDOCAINE/PRILOCAINE Topical cream 2.5%/2.5% Patch LIDOCAINE (except lozenges and suppositories) Jelly 2% Jelly (urojet) 2% Ointment 5% Topical solution 4% PRAMOXINE Cream, rectal 1%

84:24.00 EMOLLIENTS, DEMULCENTS AND PROTECTANTS 84:24.12 BASIC CREAMS, OINTMENTS AND PROTECTANTS

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ZINC OXIDE Ointment 15%

84:24.16 BASIC POWDERS AND DEMULCENTS

GELATIN, PECTIN, SODIUM CARBOXYMETHYLCELLULOSE Paste 13.3% gelatin, 13.3% pectin, 13.3% sodium carboxymethylcellulose

84:40:00 HEMORRHOID PREPARATIONS PRAMOXINE Ointment, rectal 1%, with zinc sulphate 0.5% Suppository 20mg, with zinc sulphate 10mg

88:00.00 VITAMINS

88:16.00 VITAMIN D ALFACALCIDOL DISODIUM INJECTION Injection 2ug/mL CALCITRIOL (also known as 1,25-DIHYDROXYCHOLECALCIFEROL) Injection 1ug/mL DIHYDROTACHYSTEROL Capsule 0.125mg

92:00.00 UNCLASSIFIED THERAPEUTIC AGENTS

ABCIXMAB INJECTION Restricted Coverage: For use in high risk angioplasties carried out in a cardiac catheterization laboratory as per approved health region/affiliate protocols.

Injection 2 mg/mL (5mL) BASILIXIMAB Restricted Coverage: For prophylaxis of acute rejection in renal transplant patients. Injection BERACTANT Restricted Coverage: When administered in a Neonatal Intensive Care Unit. Powder (reconstituted) 25mg phospholipids/mL COLFOSCERIL PALMITATE Restricted Coverage: When administered in a Neonatal Intensive Care Unit. Powder for tracheal suspension CYANIDE ANTIDOTE KIT

With sodium nitrate injection 30mg/mL (2 x 10mL ampoules), sodium thiosulfate injection 250mg/mL (2 x 50mL ampoules), amyl nitrate inhalant solution (12 x 0.3mL crushable ampoules)

CYCLOSPORINE (see Appendix A - Saskatchewan Health Formulary) Injection 50mg/mL

DACLIZUMAB Restricted Coverage: For prophylaxis of acute rejection in renal transplant patients. Injection 5mg/mL DIMETHYL SULFOXIDE Solution 500mg/g (50mL) DROTRECOGIN ALFA

Restricted coverage: for use when administered in a tertiary care facility on the recommendation of an intensivist.

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Injection 5mg, 20mg EPTIFIBITIDE Restricted Coverage: When used on the recommendation of a cardiologist for the treatment of High Risk Unstable Angina and Non-ST Segment Elevation Myocardial Infarction according to the guidelines of The American College of Cardiology & American Heart Association, Inc. (Circulation, 2000; 102: 1193-1209)

Injection ETANERCEPT (see Appendix A - Saskatchewan Health Formulary)

Injection FOMEPIZOLE

Restricted Coverage: This product should be used in consultation with the Poison and Drug Information Service (PADIS). A contact number for PADIS is 1-866-454-1212. Injection LEVOCARNITINE Restricted Coverage: For the treatment of metabolic disorders with carnitine deficiency and neonates who will be on long term Total Parenteral Nutrition (greater than 14 days).

Injection 200mg/mL Oral solution 100mg/mL Tablet 330mg OCTREOTIDE Restricted Coverage:

a) For the treatment of acute variceal bleeds in patients with acute portal hypertension.

b) For the prevention of fistulas following pancreatic resection to a maximum of 7 days.

Injection 50ug, 100ug, 500ug (1mL) Injection 200ug (5mL) Injection 10mg, 20mg, 30mg (powder for injection) PAMIDRONATE Restricted coverage: For the treatment of non-malignant hypercalcemia.

Note: requests for treatment of hypercalcemia of malignancy should be referred to the Saskatchewan Cancer Agency. Injection

PRALIDOXIME CHLORIDE Injection, 1g vial SOMATOSTATIN Restricted Coverage: For the treatment of acute variceal bleeds. Powder 205ug, 3mg

TIROFIBAN Restricted Coverage: When used on the recommendation of a cardiologist for the treatment of High Risk Unstable Angina and Non-ST Segment Elevation Myocardial Infarction according to the guidelines of The American College of Cardiology & American Heart Association, Inc. (Circulation, 2000; 102: 1193-1209)

Injection TRACE ELEMENTS Chromium 4ug/mL Copper 0.4mg/mL Manganese 0.1mg/mL, 0.5mg/mL Selenium 40ug/mL Zinc 1mg/mL, 5mg/mL

Note: May come as cocktails.(M.T.E.-4 contains: 4.0ug/mL chromium, 0.4mg/mL copper, 0.1mg/mL manganese, and 1.0mg/mL zinc) (Micro 5 contains: 10ug/mL chromium, 1mg/mL copper, 0.5mg/mL manganese, 60ug/mL selenium, 5mg/mL zinc)

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APPENDIX I: PROCEDURES FOR OBTAINING DRUGS PROVIDED UNDER PROVINCIAL PROGRAMS DRUGS USED FOR THE TREATMENT OF TUBERCULOSIS: The following drugs can be obtained for use in the treatment of tuberculosis by contacting the Clinical Director for Tuberculosis Control (933-6171). The drugs will be sent from the TB Pharmacy in Ellis Hall at the Royal University Hospital in Saskatoon. Amikacin injection 500mg/2mL Cycloserine capsules 250mg Ethambutol tablets, 100mg, 400mg Ethionamide tablets 250mg Isoniazid syrup 10mg/mL, tablets 50mg, 300mg Levofloxacin tablet 500mg Pyrazinamide tablet 500mg Rifampin capsule 150mg, 300mg, suspension 25mg/mL DRUGS USED FOR THE TREATMENT OF SEXUALLY TRANSMITTED DISEASES: • The following drugs can be obtained from Saskatchewan Health – Communicable

Disease Control at (306) 787-1460 for the treatment of sexually transmitted diseases:

Azithromycin 1g Erythromycin PCE 333mg or 250mg Cefixime 400mg Doxycycline 100mg Amoxicillin 500mg

• The following medication/vaccines are available on special request from

Saskatchewan Health – Communicable Disease Control (306) 787-1460: Benzathine Penicillin 1.2 MU IM injection Ciprofloxacin 500mg

COVERAGE OF VERTEPORFIN (VISUDYNE) FOR THE TREATMENT OF MACULAR DEGENERATION:

Health regions will provide coverage for Visudyne and the associated laser treatment according to the following criteria:

•

•

for the treatment of age-related macular degeneration with predominately classic subfoveal choroidal neovascularization (CNV)

for the treatment of pathologic myopia for the treatment of ocular histoplasmosis

For patients meeting the above criteria health regions may submit an invoice for the drug cost to the Drug Plan & Extended Benefits Branch, 3475 Albert Street, Regina, Saskatchewan, S4S 6X6.

COVERAGE OF EPOPROSTENOL (FLOLAN):

Health regions may submit requests for coverage of Flolan to the Drug Plan and Extended Benefits Branch. Coverage will be approved on a case by case basis for

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patients with primary and secondary pulmonary hypertension on the recommendation of a specialist. Requests may be submitted via the Exception Drug Status process for approval. Payment will be provided following submission of quarterly invoices.

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APPENDIX II: HOME PARENTERAL MEDICATION PROGRAM COVERAGE POLICY Regional Health Authorities will cover home/nursing home administration of approved parenteral medications when they are prescribed as an acute care replacement measure. The Saskatchewan Prescription Drug Plan will cover approved parenteral medications administered for maintenance therapy of life long or chronic conditions except when the patient is a registered inpatient in an acute care facility. Drugs administered parenterally include sub-cutaneous or intramuscular injections as well as intravenous medications. The Regional Health Authorities will cover supply costs for medications listed below in both the acute and chronic therapy categories. These are purchased through hospital contracts and would have significant cost implications if purchased outside of these contracts. The supplies to be provided to the client without charge include but are not limited to, intravenous solutions, tubing, cathlons, heparin locks and caps, pump cassettes, syringes and needles. Eligibility of drugs for coverage will be subject to the Hospital Benefit Drug List, Saskatchewan Formulary, and/or Regional Health Authority protocols. These policies apply to residents of special care homes as well as community residents. PART I - ACUTE CARE REPLACEMENT MEDICATIONS These are parenteral medications that enable early discharge from the acute care site, or that prevent admission to the acute care site. These medications are to be provided by the Regional Health Authority without charge to the individual. Eligible drugs are listed within this section “Hospital Benefit Drug List” (Supplementary Information - Saskatchewan Health Drug Plan Formulary). Changes to the Hospital Benefit Drug List are through recommendations of the Saskatchewan drug review process and the Advisory Committee on Institutional Pharmacy Practice. Also included in this policy are medications (e.g. low molecular weight heparins) for temporary anticoagulation prior to a surgical procedure. Health regions will also be responsible for the supply of low molecular weight heparins for patients who have been on warfarin or are starting on warfarin until a therapeutic INR is reached. Regional Health Authorities shall establish appropriate guidelines for home parenteral therapy and an appropriate screening mechanism for the services. Considerations when determining if parenteral therapy at home or in a special-care home is appropriate for a particular individual shall include the: • ability to co-ordinate and plan the care with the physician, home care

program/special-care home program, hospital/health centre and pharmacist; • practicality and safety of administering the drug at home or in a special-care home; • ability and motivation of the individual and/or the availability of family support, when

therapy is delivered at home; • availability of more appropriate oral alternatives; • cost-effectiveness of providing the drug at home or in a special-care home. PART II - CHRONIC CONDITION MEDICATIONS Injectable drugs used in the treatment of chronic conditions administered in the community or in hospitals to hospital outpatients where the only purpose in entering a

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hospital is to receive the drug will be covered under the Saskatchewan Drug Plan and subject to a co-payment and deductible where applicable. Eligible drugs are listed in the Saskatchewan Health Drug Plan Formulary. Maintenance of the Formulary is through the formulary approval process via the Saskatchewan drug review process. Where applicable, these medications are subject to Exception Drug Status approval, co-pay, and family deductible. Drugs that have not been approved by the Saskatchewan review process will not be considered benefit drugs under the Drug Plan. Certain drugs require Exception Drug Status (EDS) approval. See Appendix A of the Saskatchewan Health Drug Plan Formulary for EDS Program information, as well as a complete list of EDS drugs. Benefits provided prior to this policy will be grandfathered (e.g. pulse therapy, IV iron, Eprex). Updated November 2005

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INDEX ANTI-INFECTIVE AGENTS............... 10 1,25-

DIHYDROXYCHOLECALCIFEROL...................................................... 27

ANTI-INFECTIVES............................ 21 ANTIMUSCARINIC/

ANTISPASMODICS ...................... 14 ABCIXMAB INJECTION.................... 27 ANTINEOPLASTIC AGENTS............ 13 ABELCET.......................................... 10 ANTIPRURITICS AND LOCAL

ANESTHETICS ............................. 26 ABSOLUTE ALCOHOL INJECTION . 20 ACETAMINOPHEN........................... 18

ANTISPASMODICS .......................... 14 ACETYLCHOLINE ............................ 22 ANTITUBERCULOSIS AGENTS....... 12 ACETYLCYSTEINE .......................... 21 ANTITUSSIVES ................................ 21 ACETYLSALICYLIC ACID ................ 18 ANTITUSSIVES, EXPECTORANTS

AND MUCOLYTIC AGENTS......... 21 ACTH ................................................ 24 ACTIVATED CHARCOAL ................. 22

ANTIVIRALS ..................................... 12 ACYCLOVIR ..................................... 12 ANXIOLYTICS................................... 19 ADENOSINE ..................................... 16 ANXIOLYTICS, SEDATIVES AND

HYPNOTICS ................................. 19 ADRENALS....................................... 23 ADRENERGIC AGENTS................... 14

APROTININ....................................... 16 ADRENOCORTICOTROPIC HORMONE / CORTICOTROPIN... 24 ARGATROBAN ................................. 15

ARTICAINE ....................................... 24 ALFACALCIDOL DISODIUM INJECTION ................................... 27 ARTIFICIAL TEARS .......................... 22

ATRACURIUM BESYLATE............... 14 ALFENTANIL .................................... 18 ATTAPULGITE.................................. 22 ALKALINIZING AGENTS .................. 19 AUTONOMIC DRUGS....................... 13 ALPROSTADIL ................................. 17 AZITHROMYCIN ......................... 11, 29 ALTEPLASE...................................... 16 BACITRACIN..................................... 26 ALUMINUM ACETATE...................... 22 BACITRACIN STERILE..................... 12 AMBISOME....................................... 10 BARBITURATES............................... 19 AMIKACIN................................... 10, 29 BASIC CREAMS, OINTMENTS AND

PROTECTANTS............................ 26 AMINO ACIDS / DEXTROSE

SOLUTIONS ................................. 20 BASIC POWDERS AND

DEMULCENTS.............................. 27 AMINO ACIDS SOLUTIONS............. 20 AMINOCAPROIC ACID..................... 16

BASILIXIMAB .................................... 27 AMINOGLYCOSIDES ....................... 10 BENZATHINE PENICILLIN ............... 29 AMIODARONE HCl........................... 16 BENZOCAINE ................................... 21 AMOXICILLIN ................................... 29 BENZODIAZEPINES......................... 19 AMPHOTERICIN B ........................... 10 BERACTANT..................................... 27 AMPHOTERICIN B LIPID COMPLEX

INJECTION ................................... 10 BETA LACTAM ANTIBIOTICS .......... 11 BLEOMYCIN ..................................... 13 AMPICILLIN ...................................... 11 BLOOD FORMATION AND

COAGULATION ............................ 14 ANALGESICS AND ANTIPYRETICS 18 ANDROGENS ................................... 24

BRETYLIUM TOSYLATE .................. 16 ANESTHETICS ................................. 17 BUPIVACAINE .................................. 24 ANTACIDS AND ADSORBENTS...... 22 CALCITONIN..................................... 24 ANTI INFECTIVES...................... 13, 26 CALCITRIOL ..................................... 27 ANTIANEMIA DRUGS ...................... 14 CALCIUM CHLORIDE....................... 20 ANTIBIOTICS...................10, 12, 21, 26 CALCIUM DISODIUM EDETATE...... 23 ANTICHOLINERGIC AGENTS ......... 14 CALCIUM FOLINATE........................ 26 ANTICOAGULANTS ......................... 15 CALCIUM GLUCONATE................... 20 ANTICONVULSANTS ....................... 18 CALCIUM ORAL DOSAGE FORMS . 20 ANTIDIARRHEA AGENTS................ 22 CALORIC AGENTS........................... 20 ANTIEMETICS .................................. 23 CARBOPROST ................................. 25 ANTIFUNGAL AGENTS.................... 12 CARDIAC DRUGS ............................ 16 ANTIFUNGALS ........................... 10, 26 CARDIOVASCULAR DRUGS ........... 16 ANTIHEMOPHILIC FACTOR VIII...... 16 CASPOFUNGIN ACETATE............... 10 ANTIHEPARIN AGENTS .................. 15 CASTOR OIL..................................... 22 ANTIHISTAMINE AGENTS............... 10

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DOXORUBICIN ................................. 13 CATHARTICS AND LAXATIVES ...... 22 DOXYCYCLINE................................. 29 CEFAZOLIN ...................................... 10 DROPERIDOL............................. 19, 23 CEFIXIME ......................................... 29 DROTRECOGIN ALFA...................... 27 CEFOTAXIME................................... 10 EDROPHONIUM ......................... 13, 19 CEFOTETAN .................................... 11 ELECTROLYTE AND FLUID

REPLACEMENT ........................... 20 CEFOXITIN SODIUM........................ 11 CEFTAZIDIME .................................. 11

ELECTROLYTIC, CALORIC AND WATER BALANCE........................ 19

CEFTRIAXONE................................. 11 CEFUROXIME .................................. 11

EMETICS .......................................... 23 CENTRAL NERVOUS SYSTEM AGENTS ....................................... 17 EMOLLIENTS, DEMULCENTS AND

PROTECTANTS............................ 26 CEPHALOSPORINS......................... 10 CEPHALOTHIN................................. 11 ENFLURANE..................................... 17 CHLORAMPHENICOL...................... 11 ENOXAPARIN................................... 15 CHLORHEXIDINE............................. 26 ENZYMES......................................... 21 CHLOROPROCAINE ........................ 24 EPHEDRINE ..................................... 14 CHOLINERGIC AGENTS.................. 13 EPOPROSTENOL............................. 29 CHROMIUM ...................................... 28 EPTIFIBITIDE.................................... 28 CIPROFLOXACIN....................... 13, 29 ERGOMETRINE MALEATE.............. 25 COAGULANTS AND

ANTICOAGULANTS ..................... 15 ERTAPENEM.................................... 11 ERYTHROMYCIN ....................... 11, 29

COCAINE.......................................... 21 ESMOLOL......................................... 17 COLFOSCERIL PALMITATE ............ 27 ETANERCEPT .................................. 28 COPPER........................................... 28 ETHAMBUTOL............................ 12, 29 CYANIDE ANTIDOTE KIT................. 27 ETHIONAMIDE ................................. 29 CYCLOPHOSPHAMIDE ................... 13 EXPECTORANTS ............................. 21 CYCLOSERINE ................................ 29 EYE, EAR, NOSE AND THROAT

PREPARATIONS .......................... 21 CYCLOSPORINE.............................. 27 FACTOR IX ....................................... 16 CYPROHEPTADINE......................... 10 FAT EMULSION PREPARATIONS... 20 DACLIZUMAB ................................... 27 FENTANYL........................................ 18 DALTEPARIN.................................... 15 FERROUS FUMARATE .................... 15 DANAPAROID .................................. 15 FERROUS GLUCONATE.................. 15 DAUNORUBICIN............................... 13 FERROUS SULPHATE..................... 15 DEFEROXAMINE MESYLATE ......... 23 FLEET ............................................... 22 DEMULCENTS ........................... 26, 27 FLEET PHOSPHO-SODA BUFFERED

SALINE.......................................... 23 DESFLURANE .................................. 17 DEXTRAN 40 .................................... 20

FLOLAN ............................................ 29 DEXTRAN 70 .................................... 20 FLUCONAZOLE................................ 10 DEXTROMETHORPHAN.................. 21 FLUCYTOSINE ................................. 10 DEXTROSE ...................................... 20

DIAGNOSTIC AGENTS .................... 19 FLUMAZENIL .................................... 19 DIBUCAINE....................................... 26 FLUORESCEIN SODIUM.................. 22 DIGOXIN ........................................... 16 FLUOROURACIL .............................. 13 DIGOXIN IMMUNE FAB.................... 25 FLUOXYMESTERONE ..................... 24 DIHYDROTACHYSTEROL ............... 27 FOMEPIZOLE ................................... 28 DILTIAZEM ....................................... 17 FOSCARNET .................................... 12 DIMERCAPROL................................ 23 FOSPHENYTOIN .............................. 18 DIMETHYL SULFOXIDE................... 27 GALLAMINE TRIETHIODIDE............ 14 DINOPROST TROMETHAMINE....... 25 GANCICLOVIR.................................. 12 DINOPROSTONE ............................. 25 GASTROINTESTINAL DRUGS......... 22 DIPHENHYDRAMINE ....................... 10 GELATIN, PECTIN, SODIUM

CARBOXYMETHYLCELLULOSE . 27 DIPHTHERIA ANTITOXIN ................ 25 DIURETICS....................................... 21 GENERAL ANESTHETICS ............... 17 DOBUTAMINE .................................. 14 GLYCERIN........................................ 23 DOPAMINE ....................................... 14 GRAMICIDIN..................................... 21 DOXAPRAM...................................... 19 GUAIFENESIN .................................. 21

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HALOTHANE .................................... 17 MISCELLANEOUS ANXIOLYTICS, SEDATIVES, HYPNOTICS ........... 19 HEAVY METAL ANTAGONISTS ...... 23

HEMORRHOID PREPARATIONS .... 27 MISCELLANEOUS BETA LACTAM ANTIBIOTICS................................ 11 HEMOSTATICS ................................ 16

HEPARIN .......................................... 15 MISCELLANEOUS CENTRAL NERVOUS SYSTEM AGENTS ..... 19 HEPATITIS B IMMUNE GLOBULIN.. 25

HORMONES AND SYNTHETIC SUBSTITUTES.............................. 23

MISCELLANEOUS EYE, EAR, NOSE AND THROAT DRUGS ................. 22

HYDANTOINS................................... 18 MISCELLANEOUS GASTROINTESTINAL DRUGS..... 23 HYOSCINE BUTYLBROMIDE .......... 14

HYOSCINE HYDROBROMIDE......... 14 MISCELLANEOUS LOCAL ANTI-INFECTIVES ................................. 26 HYPNOTICS ..................................... 19

HYPOTENSIVE AGENTS................. 17 MOXIFLOXACIN ............................... 13 IMIPENEM CILASTATIN................... 11 MUCOLYTIC AGENTS...................... 21 IMMUNE GLOBULIN......................... 25 MYASTHENIA GRAVIS..................... 19 IMMUNE SERUM GLOBULIN........... 25 MYDRIATICS .................................... 22 IPECAC............................................. 23 NADROPARIN .................................. 15 IRON DEXTRAN ............................... 15 NALBUPHINE ................................... 18 IRON PREPARATIONS .................... 15 NALOXONE ...................................... 18 ISOFLURANE ................................... 17 NAPHAZOLINE ................................. 22 ISONIAZID .................................. 12, 29 NEOSTIGMINE ................................. 13 ISOPROTERENOL ........................... 14 NIMODIPINE..................................... 17 KETAMINE........................................ 17 NITRIC OXIDE .................................. 17 LABETALOL...................................... 17 NITROGLYCERIN............................. 17 LEPIRUDIN ....................................... 15 NON-STEROIDAL ANTI-

INFLAMMATORY AGENTS .......... 18 LEVOCARNITINE ............................. 28 LEVOFLOXACIN......................... 13, 29 NOREPINEPHRINE .......................... 14 LIDOCAINE........................... 21, 24, 26 OCTREOTIDE................................... 28 LIDOCAINE/PRILOCAINE ................ 26 OINTMENTS ..................................... 26 LINEZOLID........................................ 13 OPIATE AGONISTS.......................... 18 LIPOSOMAL AMPHOTERICIN B...... 10 OPIATE ANTAGONISTS................... 18 LOCAL ANESTHETICS .............. 21, 24 OPIATE PARTIAL AGONISTS.......... 18

OXYTOCICS ..................................... 25 LOCAL ANTI-INFECTIVES............... 26 OXYTOCIN........................................ 25 MACROLIDES .................................. 11 PAMIDRONATE ................................ 28 MAGNESIUM ORAL DOSAGE FORMS

...................................................... 20 PANCURONIUM ............................... 14 PANTOPRAZOLE IV......................... 23 MAGNESIUM SULFATE................... 19 PAPAVERINE ................................... 17 MAGNESIUM SULPHATE ................ 20 PARALDEHYDE................................ 19 MANGANESE ................................... 28 PARASYMPATHOMIMETIC AGENTS

...................................................... 13 MANNITOL........................................ 21 MEPIVACAINE.................................. 24

PARATHYROID ................................ 24 MEROPENEM................................... 11 PENICILLINS .................................... 11 METHADONE ................................... 18 PENTAMIDINE ISETHIONATE......... 13 METHOTREXATE............................. 13 PHENTOLAMINE MESYLATE .......... 14 METHYLPREDNISOLONE ............... 23 PHENYLEPHRINE ...................... 14, 22 MIDAZOLAM..................................... 19 PHOSPHATE .................................... 20 MILRINONE ...................................... 17 PIPERACILLIN .................................. 11 MIOTICS ........................................... 22 PIPERACILLIN/TAZOBACTAM......... 11 MISCELLANEOUS ANALGESICS AND

ANTIPYRETICS ............................ 18 PITUITARY........................................ 24 POLYMYXIN B SULFATE................. 12 MISCELLANEOUS ANTI INFECTIVES

...................................................... 13 POLYMYXIN B/GRAMICIDIN or BACITRACIN................................. 21 MISCELLANEOUS ANTIBIOTICS .... 12

POTASSIUM ACETATE.................... 20 MISCELLANEOUS ANTICONVULSANTS ................... 19 POTASSIUM CHLORIDE.................. 20

POTASSIUM PHOSPHATE .............. 20

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PRALIDOXIME CHLORIDE .............. 28 PRAMOXINE............................... 26, 27 PRILOCAINE .................................... 24 PROCAINAMIDE............................... 17 PROMETHAZINE.............................. 10 PROPARACAINE.............................. 21 PROPOFOL ...................................... 18 PROTAMINE SULPHATE ................. 15 PROTECTANTS ............................... 26 PSEUDOEPHEDRINE ...................... 14 PSYCHOTHERAPEUTIC AGENTS .. 19 PYRAZINAMIDE ......................... 12, 29 QUINOLONES .................................. 13 QUINUPRISTIN/DALFOPRISTIN

(SynercidTM) .................................. 12 RESPIRATORY AND CEREBRAL

STIMULANTS ............................... 19 RIBAVIRIN ........................................ 12 RIFAMPIN ................................... 12, 29 ROCURONIUM ................................. 14 SCOPOLAMINE BUTYLBROMIDE... 14 SCOPOLAMINE HYDROBROMIDE . 14 SEDATIVES ...................................... 19 SELENIUM........................................ 28 SENNOSIDES................................... 23 SERUMS........................................... 25 SERUMS, TOXOIDS AND VACCINES

...................................................... 25 SEVOFLURANE ............................... 18 SILVER SULFADIAZINE................... 26 SKELETAL MUSCLE RELAXANTS.. 14 SKIN AND MUCOUS MEMBRANE

AGENTS ....................................... 26 SODIUM BICARBONATE ................. 19 SODIUM CHLORIDE .................. 20, 22 SODIUM NITROPRUSSIDE ............. 17 SODIUM PHOSPHATE..................... 20 SOMATOSTATIN.............................. 28 STREPTOKINASE ............................ 16

SUCCINYLCHOLINE ........................ 14 SUFENTANIL .................................... 18 SYMPATHOLYTICS.......................... 14 SYMPATHOMIMETIC (ADRENERGIC)

AGENTS........................................ 14 TENECTEPLASE (TNK).................... 16 TETANUS IMMUNE GLOBULIN ....... 25 TETRACAINE.............................. 21, 24 THIOPENTAL.................................... 18 THROMBIN ....................................... 16 THROMBOLYTIC AGENTS .............. 16 TICARCILLIN .................................... 12 TIROFIBAN ....................................... 28 TISSUE PLASMINOGEN ACTIVATOR

(tPA) .............................................. 16 TOBRAMYCIN .................................. 10 TOLNAFTATE................................... 26 TOXOIDS .......................................... 25 TRACE ELEMENTS.......................... 28 TRANEXAMIC ACID ......................... 16 TROMETHAMINE ............................. 19 TROPICAMIDE ................................. 22 UNCLASSIFIED THERAPEUTIC

AGENTS........................................ 27 VACCINES........................................ 25 VANCOMYCIN .................................. 12 VASOCONSTRICTORS.................... 22 VASODILATING AGENTS ................ 17 VASOPRESSIN................................. 24 VECURONIUM.................................. 14 VERTEPORFIN................................. 29 VISUDYNE........................................ 29 VITAMIN D ........................................ 27 VITAMINS ......................................... 27 VORICONAZOLE.............................. 12 XYLOMETAZOLINE.......................... 22 ZINC.................................................. 28 ZINC ORAL DOSAGE FORMS ......... 20 ZINC OXIDE...................................... 27

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TIPS ON PRESCRIPTION WRITING

TIPS ON PRESCRIPTION WRITING

(Adapted from "Tips on Prescription Writing", a pamphlet available from the Saskatchewan College of Pharmacists.) Properly issued prescriptions are in the best interest of the patient, the pharmacist and the prescriber. This information is designed to assist prescribers to issue prescriptions most effectively. These guidelines will help to reduce the time involved in the prescription process, increase patient safety and maximize patient compliance. PRESCRIPTION CONTENT Prescriptions need to be issued clearly and completely to minimize errors. Clear pronunciation or legible writing with accurate spelling is essential. The prescription may be written, or verbal for certain classes of drugs, (for more information refer to the chart Saskatchewan College of Pharmacists – Prescription Regulations also published in this Supplementary Information section) and must include the following information: date physician's name and signature patient's name full name of the medication medication concentration where appropriate medication strength where appropriate dosage amount prescribed or the duration of treatment administration route if other than oral explicit instructions for patient usage of the medication number of refills where refills are authorized

The prescriber's name, address and telephone number should be preprinted on the prescription form, or hand printed beneath the signature. VERBAL PRESCRIPTIONS Federal and Provincial legislation states that a verbal prescription or refill authority must be given by a medical practitioner, duly qualified optometrist, dentist, nurse practitioner (RN-NP) or veterinary surgeon directly to a pharmacist. Having a receptionist or nurse (other than a RN-NP) assume this responsibility is contrary to the law. Direct prescriber/pharmacist communication is necessary to provide the best quality of care for the patient. The pharmacist may wish to discuss an aspect of the drug therapy prior to dispensing the medication. As well, the prescriber may wish to ask the pharmacist about a particular medication, or a patient's medication history, compliance, or pattern of drug use. Both the professionals and the patient will benefit from this direct communication. MEDICATION DIRECTIONS Pharmacists maintain patient profiles, which contain information concerning prescriptions dispensed, directions for use, drug allergies, medical conditions, and other pertinent information. These profiles are used to monitor the patient's drug usage and compliance, and drug interactions. Thus, it is very important that directions on the prescription be consistent with verbal instructions given to the patient. Clear directions enable the pharmacist to effectively counsel the patient and reinforce the prescriber's instructions.

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Prescriptions with closing instructions written "As Directed" create problems for the patient, particularly the elderly or those assisting them. Patients taking more than one medication may become confused if all instructions read "As Directed". Such labelling also makes it impossible for pharmacists to monitor compliance, or assist patients with medication concerns. It is helpful for a patient taking more than one medication, or for the caregiver, to know what the medication is used for. The prescriber may wish to indicate the use of the medication on the prescription (e.g. for heart), to enable the pharmacist to include this information on the label. REFILLS When a patient is stabilized on medication, refills, where permitted by law, should be indicated on the prescription. Authorization should allow for sufficient refills until the patient's next appointment, to a maximum of one year. If refills are not properly indicated on the prescription, the pharmacist must by law, contact the prescriber for refill authorization. Specific regulations apply to various categories of prescription drugs. Your pharmacist would be pleased to review the regulations with you. Please refer to the chart Saskatchewan College of Pharmacists – Prescription Regulations (also published in this Supplementary Information section) for a summary of requirements. SUBSTITUTION Unless the prescriber directs otherwise, the pharmacist may select and dispense an interchangeable pharmaceutical product, other than the one prescribed, according to the Saskatchewan Prescription Drug Plan Formulary. An interchangeable pharmaceutical product is a product containing a drug or drugs in the same amounts, of the same active ingredients, in the same dosage form as that directed by the prescription. Those which conform to the criteria for interchangeability determined by the Saskatchewan Formulary Committee are designated as "interchangeable" in the Saskatchewan Formulary Listing. A prescriber may request that a specific brand of a drug be dispensed by indicating in his own handwriting at the time of issuing a written prescription, or verbally at the time of giving a verbal prescription, No Substitution, No Sub, or N/S. In most cases, the patient is responsible for the incremental cost of "No Sub" prescriptions. TRANSFER OF PRESCRIPTIONS Schedule F drugs may be transferred from one pharmacist to another at the request of a patient. Prescriptions for benzodiazepines and other targeted substances may be transferred once. Prescriptions for Schedule 2 and 3 drugs and Narcotic and Controlled Drugs may NOT be transferred. When a prescription is transferred, the original prescription shall remain on file, and on it shall be entered: 1. the date of the transfer; 2. an indication that no further sales nor transfers may be made under the prescription

(i.e. the word "VOID"); 3. the name of the pharmacy and pharmacist to whom the prescription was transferred; 4. the patient profile, manual or electronic, must also indicate the prescription is "VOID". The pharmacist receiving the transferred prescription shall indicate: 1. the name of the pharmacist transferring the prescription; 2. the name and address of the pharmacy transferring the prescription; 3. the number of authorized repeats remaining, if any; 4. the date of the last fill or refill.

PRESCRIPTION REGULATIONS

Saskatchewan College of PharmacistsPRESCRIPTION REGULATIONS

CLASS DESCRIPTION REQUIREMENTSNARCOTIC DRUG**Examples: Codeine, Demerol, MS Contin, Novahistex DH, Percocet, Tussionex, Tylenol #4, Lomotil, Darvon-N, Talwin, etc.

All straight narcotics, all narcotic drugs or compounds for parenteral use. Compounds containing more than one narcotic or compounds with less than two non-narcotic ingredients. All products containing diacetylmorphine, oxycodone, hydrocodone, methadone, or pentazocine.

Refer to the Controlled Drugs and Substances Act and to the Schedule to the Narcotic Control Regulations.

Written prescription signed and dated by a practitioner.

**Refer to Triplicate Prescription Program.

VERBAL PRESCRIPTION NARCOTIC**Examples: A.C. with Codeine 15, 30, 60 mg, Fiorinal C 1/4, C 1/2, Tylenol #2 and #3, etc.

A combination product not intended for parenteral use, containing one narcotic (only) and two or more non-narcotic drugs in therapeutic dose, except products containing diacetylmorphine, oxycodone, hydrocodone, methadone, or pentazocine.

Refer to the Controlled Drugs and Substances Act and to theSchedule to the Narcotic Control Regulations

Written or verbal prescription** from a practitionerVerbal prescription must be reduced to writing by a pharmacist showing:- name and address of patient;- name, initials and address of prescriber;- name, quantity, and form of drug(s);- directions for use;- date;- prescription number;- name or initials of pharmacist

**Refer to Triplicate Prescription Program

CONTROLLED DRUGS - LEVEL I**Examples: Dexedrine, Ritalin, etc.

Those drugs listed in Part I of the Schedule to Part G of the Food and Drug Regulations and Schedule III of the Controlled Drugs and Substances Act. They include amphetamines, methaqualone, methylphenidate, phendimetrazine, phenmetrazine, pentobarbital and secobarbital.

CONTROLLED DRUG PREPARATION - LEVEL I**

A combination containing a controlled drug - LeveI 1 - as described above, and one or more active medicinal ingredients, in a recognized therapeutic dose, other than a narcotic or controlled drug.

CONTROLLED DRUGS - LEVEL II**Examples: Phenobarb, Tenuate, Ionamin, Anabolic Steroids (i.e. Delatestryl), etc.

Those drugs listed in Parts II & III of the Schedule to Part G of the Food and Drug Regulations and Schedule IV of the Controlled Drugs and Substances Act. They include: butorphanol, chlorphentermine, diethylpropion, nalbuphine, phentermine, thiobarbituric acid, barbituric acid and its salts and derivatives (except secobarbital and pentobarbital).

As immediately above, plus, in the case of verbal prescriptions:- number and frequency of refills (if any) authorized.

CONTROLLED DRUG PREPARATION - LEVEL IIExamples: Fiorinal, Anabolic Steroids (i.e. Climacteron), etc.

A combination containing a controlled drug - Level II - as described above, and one or more active medicinal ingredients, in a recognized therapeutic dose, other than a narcotic or controlled drug.

BENZODIAZEPINES & OTHER TARGETED SUBSTANCESExamples: Benzodiazepines (except for Flunitrazepam, Clozapine & Olanzapine), Mazindol, Pipradol, etc.

Those drugs listed in Schedule I of the Benzodiazepines and Other Targeted Substances Regulations.

Written or verbal prescription from practitioner. Verbal prescriptions must be reduced to writing by a pharmacist showing date, prescription number, patient's name and address, name and quantity of drug(s), directions for use, prescriber's name, name and initials of pharmacist, and number of refills (if any).

TRANSFER OF PRESCRIPTIONS Only prescriptions for Schedule 1 may be transferred from one pharmacist to another at the request of a patient. Prescriptions for Narcotic andControlled Drugs may NOT be transferred. Prescriptions for Targeted Substances may only be transferred ONCE.

The pharmacist receiving the transferred prescription shall indicate:1. the name of the pharmacist transferring the prescription;2. the name and address of the pharmacy transferring the prescription;3. the number of authorized repeats remaining, if any;4. the date of the last fill or refill.

PRESCRIPTION DRUGS Those drugs listed in Schedule I of the Bylaws to the Pharmacy Act, 1996, including drugs listed in Schedule F to the Food and Drug Regulations.

Written or verbal prescription from practitioner. Verbal prescriptions must be reduced to writing by a pharmacist showing date, prescription number, patient's name and address, name and quantity of drug(s), directions for use, prescriber's name, name and initials of pharmacist, and number of refills (if any).

A synopsis* of Federal and Provincial Acts and Regulationsgoverning the Distribution of Drugs by Prescription in Saskatchewan

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REPEATS RECORDS***No Repeats.All re-orders must be new, written prescriptions. However, a prescription may be dispensed in divided portions, subject to professional discretion.

All receipts and all sales (except prescription sales of dextropropoxyphene) entered in Narcotic Register. Prescriptions filed in order of date and number in a special file designated for Narcotics and Controlled Drugs. If a part-fill is made, all records, including the prescription itself, and the Narcotic Register, must reflect the actual amount dispensed. Further part-fills must be documented and cross-referenced to the original prescription.

No Repeats.All orders must be new, written prescriptions. However, a prescription may be dispensed in divided portions, subject to professional discretion.

Receipts - entry required in Narcotic Register.Sales - no entry required for sales pursuant to prescriptions, but emergency supplies provided to another pharmacist and returns to licensed dealers must be recorded in sales portion of Register. Prescriptions filed in order of date and number in a special file designated for Narcotics and Controlled Drugs.

No repeats are allowed if original prescription is verbal. If written, the original prescription may be repeated if the prescriber has indicated in writing the number and frequency of repeats.

**Refer to the Triplicate Prescription Program.

All receipts and all sales entered in Narcotic Register.Prescriptions filed in order of date and number in a special file designated for Narcotics and Controlled Drugs.

Receipts - entry required in Narcotic Register.Sales - no entry required in Narcotic Register for sales pursuant to prescriptions, but emergency supplies provided to another pharmacist and returns to licensed dealers must be recorded in sales portion of Register. Prescriptions filed in order of date and number in a special file designated for Narcotics and Controlled Drugs.

Repeats may be authorized on original prescription whether written or verbal, but authorization must indicate number and frequency of repeats.

Receipts - entry required in Narcotic Register or invoices must be available to substantiate receipt.Sales - no entry required in Narcotic Register for sales pursuant to prescriptions, but emergency supplies provided to another pharmacist and returns to licensed dealers must be recorded in sales portion of Register. Prescriptions filed in order of date and number in special file designated for Narcotics and Controlled Drugs.

Receipts - entry required in Narcotic Register or invoices must be available to substantiate receipt.

Prescriptions filed in the regular Schedule 1 file and must be retained for at least two years from the date of the last fill or refill.

When a prescription is transferred, the original prescription shall remain on file, and on it shall be entered:1. the date of the transfer;2. an indication that no further sales nor transfers may be made under the prescription (i.e. the word "VOID");3. the name of the pharmacy and pharmacist to whom the prescription was transferred;4. the patient profile, manual or electronic, must also indicate the prescription is "VOID".

* This synopsis is a condensation of some of the pertinent Acts and Regulations. Users of the chart are reminded that it has been compiled for convenient reference only and that the official legislation should always be consulted for the purposes of interpreting and applying the laws.** Triplicate Prescription Program: Please refer to the Triplicate Prescription Program in the Pharmacy Reference Manual for details.*** RECORDS - Narcotic Register includes either the approved manual or electronic (i.e. pharmacy computer) version.

August 30, 2004 Saskatchewan College of Pharmacists

Repeats may be authorized on original prescription whether written or verbal, but authorization must be for a specific number of refills. Refills are permitted only if less than 1 year has elapsed since the date on which the prescription was issued.

"PRN" is not valid authority for repeats.

No entries required in Narcotic Register. Prescriptions filed in regular file and must be retained for at least two years from date of last fill or refill.

Repeats may be authorized on original prescription whether written or verbal, but authorization must be for a specific number of refills.

"PRN" is not valid authority for repeats.

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GUIDELINES FOR REPORTINGADVERSE DRUG REACTIONS

GUIDELINES FOR REPORTING ADVERSE REACTIONS DEFINITION OF AN ADVERSE REACTION (AR): “A noxious and unintended response to a drug which occurs with use or testing for the diagnosis, treatment, or prophylaxis of a disease or modification of an organic function. This includes any undesirable patient effect suspected to be associated with drug use.” ARs resulting from any prescription, non-prescription, biological (including blood products), complementary medicines (including herbals), and radiopharmaceutical drug products are monitored. WHICH ADVERSE REACTIONS SHOULD BE REPORTED? AR reports are, for the most part, only SUSPECTED associations. Reporting an AR DOES NOT imply a causal link. Practitioners should report the following suspected ARs to the Saskatchewan AR Monitoring Office: • all suspected adverse reactions that are unexpected. An unexpected adverse

reaction is an undesirable patient effect that is not consistent with product information or labelling;

• all suspected adverse reactions that are serious. A serious adverse reaction is an undesirable patient effect that contributes to significant disability or illness. All adverse drug reactions that result in, or prolong hospitalization or require significant medical intervention should be considered serious;

• all suspected adverse reactions to recently marketed drugs regardless of their nature or severity. A recently marketed drug is considered to be commercially available for 5 (five) years or less.

HOW TO REPORT A SUSPECTED ADVERSE REACTION TO THE REGIONAL AR MONITORING OFFICE IN SASKATCHEWAN: Please report suspected adverse reactions as soon as possible after detection, even if all details are not known at the time. Saskatchewan AR Monitoring Office staff will follow-up for further information if required. Complete a written AR report form (available in the Compendium of Pharmaceuticals and Specialties (CPS) or contact the Saskatchewan AR Monitoring Office. Information may be attached to the report form if insufficient space is available for complete documentation. A form may also be downloaded from the Health Canada website. http://www.hc-sc.gc.ca/dhp-mps/medeff/report-declaration/form/index_e.html. Click “Report of Suspected Adverse Reaction due to Health Products Marketed in Canada” under Forms. Record all information that is available and mail or fax to: Saskatchewan AR Monitoring Office: Canadian Adverse Reaction Monitoring - Saskatchewan 4th Floor, Room 412 101- 22nd Street East Saskatoon SK S7K 0E1 Fax: 1-866-678-6789 OR Telephone report to Saskatchewan AR Monitoring Office: 1-866-234-2345 Office is staffed, Monday to Friday, excluding statutory holidays.

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http://www.hc-sc.gc.ca/dhp-mps/medeff/report-declaration/form/index_e.html

THE PRESCRIPTION REVIEW PROGRAM

THE PRESCRIPTION REVIEW PROGRAM

The Prescription Review Program was formerly known as the Triplicate Prescription Program because the program formerly relied upon specially designed multiple copy prescription pads to gather data regarding a panel of drugs subject to abuse and/or diversion. Use of these special prescription pads is no longer necessary since the data required to operate the program is now captured electronically. PROGRAM PARTNERS:

Saskatchewan College of Pharmacists College of Physicians and Surgeons of Saskatchewan College of Dental Surgeons of Saskatchewan The Saskatchewan Registered Nurses’ Association Saskatchewan Health

OBJECTIVE: To reduce the abuse and diversion of a select panel of prescription drugs. THE PROGRAM:

1. Alerts prescribers to possible inappropriate prescribing or use of medications to which the Prescription Review Program applies.

2. May seek an explanation to the relevant professional regulatory body where the data indicates prescribing and/or dispensing practices not consistent with acceptable professional standards; and

3. Encourages appropriate prescribing and dispensing practices by providing professional guidance to both prescribers and dispensers.

PRESCRIBER PARTICIPATION: Prescribers may prescribe any of the medications on the panel of monitored drugs using an ordinary prescription pad so long as the following information is contained on each prescription:

a) A statement that the prescription is only valid for three days; b) The patient’s date of birth; c) The patient’s address; d) The total quantity of medication prescribed, both numerically and in written

form; e) The patient’s health services number; and, f) The prescriber’s name and address.

Verbal prescriptions cannot be issued for any of the products included in the Prescription Review Program. Faxed prescriptions are acceptable if done according to the published guidelines for faxing prescriptions. DATA COLLECTION: The Drug Plan’s electronic network with pharmacies will receive and store prescription information for benefit and non-benefit monitored drugs, for Drug Plan beneficiaries and non-beneficiaries who have a Saskatchewan Health Service card, and send this information electronically to the College of Physicians and Surgeons. Pharmacists must continue to mail the College a copy of any prescriptions for drugs monitored under the Prescription Review Program that were not successfully “adjudicated” or “captured” by the Drug Plan system. Any College copies should continue to be sent at least once per week. (The Saskatchewan College of Pharmacists

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distributes pre-addressed envelopes for this purpose.) Upon receipt of the prescription copy, the College of Physicians and Surgeons will enter the information into their computer system. ADDITIONAL INFORMATION: The Prescription Review Program does not apply to medication orders for hospital inpatients or residents of licensed long term care facilities. While under federal law many of these drugs can be prescribed verbally, the written prescription requirement continues for all drugs under the new Program, including those that have been added. Part fills of prescriptions are not encouraged. Pharmacists may dispense part fills at their discretion, or prescribers may request part fills if the following information is set out in the prescription:

a) The total quantity; b) The amount to be dispensed each time; and c) The time interval between fills.

Prescribers may issue refills as permitted under federal law. To summarize, prescription refills are NOT permitted for any Narcotic, but are permitted under the Program when issued in writing for:

a) Controlled Drugs Level I and II, including Preparations, if the prescriber has specified the number, and frequency or interval between, refills,

b) Benzodiazepines, if the prescriber has specified the number of refills and less than one year has elapsed since the date the prescription was issued. If the prescriber also specifies the interval between refills, the pharmacist may not dispense the refill until the interval has expired.

c) Chloral hydrate if the prescriber has specified the number of refills. If a prescriber or dispenser is concerned about a patient’s drug utilization history, he or she may contact the College personally for confidential information during weekday daytime hours at (306)244-8778. Patient drug utilization profiles for the drugs in the Prescription Review Program, as well as all other prescription drugs, are accessible electronically through the Pharmaceutical Information Program (PIP) to those prescribers and dispensers actively involved in the professional care of the patient in question. All prescribers and dispensers are strongly encouraged to utilize the information available to them in the PIP when prescribing drugs that are high risk and/or dealing with patients who are high risk. Information about the PIP is accessible at www.health.gov.sk.ca. To inquire about receiving access to PIP, please contact [email protected] or 306-787-9833. DRUGS SUBJECT TO THE PRESCRIPTION REVIEW PROGRAM: The following categories of drugs are included under the Prescription Review Program:

• Drugs previously monitored under the former Triplicate Prescription Program

• Amphetamines • Anabolic Steroids • Barbiturates • Benzodiazepines • Chloral hydrate

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http://www.health.gov.sk.ca/

mailto:[email protected]

DRUGS SUBJECT TO THE PRESCRIPTION REVIEW PROGRAM (con’t): An alphabetical list of generic names included in the above categories is noted below. All brands, strengths, and dosage forms of products with a generic name listed below are subject to the program, except where indicated otherwise. The list is subject to change from time to time. Prescribers and pharmacists will be advised directly of the effective date of any additions or deletions. Questions should be directed to the College of Physicians and Surgeons at (306) 244-8778, or to the Saskatchewan College of Pharmacists at (306) 584-2292.

THE PRESCRIPTION REVIEW PROGRAM PANEL OF DRUGS

(by generic name)*

ACETAMINOPHEN WITH CODEINE - in all dosage forms except those containing 8 mg or less of codeine

ACETYLSALICYLIC ACID (ASA) WITH CODEINE - in all dosage forms except those containing 8 mg or less of codeine

ALPRAZOLAM AMOBARBITAL ANILERIDINE BROMAZEPAM BUTALBITAL BUTALBITAL WITH CODEINE BUTORPHANOL CHLORAL HYDRATE CHLORDIAZEPOXIDE CLOBAZAM CLONAZEPAM CLORAZEPATE COCAINE CODEINE - as the single active ingredient, or in combination with other active ingredients, in

all dosage forms except those containing 20 mg per 30 ml or less of codeine in liquid for oral administration

DEXTROAMPHETAMINE DIAZEPAM DIETHYLPROPION FENTANYL FLURAZEPAM HYDROCODONE - DIHYDROCODEINONE HYDROMORPHONE - DIHYDROMORPHONE LEVORPHANOL LORAZEPAM MEPERIDINE - PETHIDINE METHADONE METHYLPHENIDATE MIDAZOLAM MORPHINE NANDROLONE NITRAZEPAM NORMETHANDONE-P-HYDROXYEPHEDRINE OXAZEPAM OXYCODONE - as the single active ingredient, or in combination with other active ingredients

in all dosage forms PANTOPON PENTAZOCINE PENTOBARBITAL PHENOBARBITAL PHENTERMINE PROPOXYPHENE SECOBARBITAL TEMAZEPAM TESTOSTERONE THIOPENTAL TRIAZOLAM

* Note - The Bylaw contains category names as noted on the previous page. Generic names are provided above for reference only.

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