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Core List F (Diabetes Mellitus) January 2019 ATCLVL5 Non Proprietary Drug Cde Dma Drug Description Pack Size Name Pack Size Typ Illness A10AB01 INSULIN (HUMAN), FAST ACTING 62006 Actrapid Vial 100 IU/ml. 10 ml. Vial 1 1 X 10ML 1 F A10AB01 INSULIN (HUMAN), FAST ACTING 68187 Insuman Rapid Cartridge 100 IU/ml. 3 ml. Cartridge 5 5 X 3 ML 5 F A10AB01 INSULIN (HUMAN), FAST ACTING 69077 Humulin S Vial 100 IU/ml. 10 ml. Vial 1 1 X 10 ML 1 F A10AB01 INSULIN (HUMAN), FAST ACTING 69169 Humulin S Cartridge 100 IU/ml. 3 ml. Cartridge 5 5 X 3 ML 5 F A10AB04 INSULIN LISPRO FAST-ACTING 63500 Humalog Pen 100 IU/ml. 3 ml. Pre-filled Pen 5 5 X 3 ML 5 F A10AB04 INSULIN LISPRO FAST-ACTING 69050 Humalog Vial 100 IU/ml. 10 ml. Vial 1 1 X 10 ML 1 F A10AB04 INSULIN LISPRO FAST-ACTING 69091 Humalog Cartridge 100 IU/ml. 3 ml. Cartridge 5 5 X 3 ML 5 F A10AB04 INSULIN LISPRO FAST-ACTING 69132 Humalog Kwikpen 100 IU/ml. 3 ml. Pre-filled Pen 5 3 ML X 5 5 F A10AB04 INSULIN LISPRO FAST-ACTING 41045 Humalog KwikPen (P.C.O. Mfg.) 100 IU/ml. 3 ml. Pre-filled Pen 5 3 ML X 5 5 F A10AB04 Insulin Lispro Fast-Acting 69184 Humalog Kwikpen 200 IU/ml. 3 ml. Pre-filled Pen 5 3 ML X 5 5 F A10AB05 Insulin Aspart 43903 Fiasp FlexTouch Soln. for Inj. Prefilled Pen 100 IU/ml. 3 ml. 5 3 ML X 5 5 F A10AB05 Insulin Aspart 43911 Fiasp Penfill Soln. for Inj. Cartridge 100 IU/ml. 3 ml. 5 3 ML X 5 5 F A10AB05 Insulin Aspart 43918 Fiasp Soln. for Inj. Vial 100 IU/ml. 10 ml. 1 1 X 10 ML 1 F A10AB05 INSULIN ASPART FAST-ACTING 62710 NovoRapid (P.C.O. Mfg.) Soln. for Inj. 100 IU/ml. 10 ml. Vial 1 1 X 10 ML 1 F A10AB05 INSULIN ASPART FAST-ACTING 73541 NovoRapid Vial 100 IU/ml. 10 ml. Vial 1 1X 10 ML 1 F A10AB05 INSULIN ASPART, FAST-ACTING 62709 NovoRapid FlexPen 100 IU/ml. 3 ml. Pre-filled Pen 5 5 X 3 ML 5 F A10AB05 INSULIN ASPART, FAST-ACTING 62720 NovoRapid (P.C.O. Mfg.) FlexPen 100 IU/ml. 3 ml. Pre-filled Pen 5 5 X 3ML 5 F A10AB05 INSULIN ASPART, FAST-ACTING 62730 NovoRapid (P.C.O. Mfg.) Penfill Cartidge 100 IU/ml. 3 ml. Cartridge 5 5 X 3ML 5 F A10AB05 INSULIN ASPART, FAST-ACTING 63121 NovoRapid Penfill Cartridge 100 IU/ml. 3 ml. Cartridge 5 5 X 3 ML 5 F A10AB06 INSULIN GLULISINE FAST-ACTING 69335 Apidra Cartridge 100 IU/ml. 3 ml. 1 5 X 3 ML 5 F A10AB06 INSULIN GLULISINE FAST-ACTING 69376 Apidra Vial 100 IU/ml. 10 ml. 1 X 10 ML 1 F A10AB06 INSULIN GLULISINE FAST-ACTING 69398 Apidra SoloStar Soln. for Inj. 100 units/ml. 3 ml. 5 5 X 3 ML 5 F A10AB06 INSULIN GLULISINE FAST-ACTING 53489 Apidra SoloStar (P.C.O. Mfg.) Soln. for Inj. 100 units/ml. 3 ml. 5 5 X 3 ML 5 F A10AC01 INSULIN (HUMAN) INTERMEDIATE-ACTING 61786 Insulatard Vial 100 IU/ml. 10 ml. Vial 1 1 X 10 ML 1 F A10AC01 INSULIN (HUMAN) INTERMEDIATE-ACTING 68032 Insuman Comb 50 Cartridge 100 IU/ml. 3 ml. Cartridge 5 5 X 3 ML 5 F A10AC01 INSULIN (HUMAN) INTERMEDIATE-ACTING 69069 Humulin I Vial 100 IU/ml. 10 ml. Vial 1 1 X 10 ML 1 F A10AC01 INSULIN (HUMAN) INTERMEDIATE-ACTING 69100 Humulin I Cartridge 100 IU/ml. 3 ml. Cartridge 5 5 X 3 ML 5 F A10AC01 INSULIN (HUMAN) INTERMEDIATE-ACTING 69337 Humulin I kwikpen 100 iu/ml. 3 ml. Pre-filled Pen 5 5 X 3 ML 5 F A10AC01 INSULIN (HUMAN) INTERMEDIATE-ACTING 71512 Insulatard InnoLet Pre-filled Syringe 100 IU/ml. 3 ml. Syringe 5 5 X 3 ML 5 F A10AC01 INSULIN (HUMAN) INTERMEDIATE-ACTING 71580 Insulatard Penfill Cartridge 100 IU/ml. 3 ml. Cartridge 5 5 X 3 ML 5 F A10AD01 INSULIN (HUMAN) INTERMEDIATE-ACTING COMBINED WITH FAST-ACTING 68047 Insuman Comb 25 Cartridge 100 IU/ml. 3 ml. Cartridge 5 5 X 3 ML 5 F A10AD01 INSULIN (HUMAN) INTERMEDIATE-ACTING COMBINED WITH FAST-ACTING 68241 Insuman Comb 25 Vial 100 IU/ml. 5 ml. Vial 1 1 X 5 ML 1 F A10AD01 INSULIN (HUMAN) INTERMEDIATE-ACTING COMBINED WITH FAST-ACTING 69137 Humulin M3 Cartridge 100 IU/ml. 3 ml. Cartridge 5 5 X 3 ML 5 F A10AD01 INSULIN (HUMAN) INTERMEDIATE-ACTING COMBINED WITH FAST-ACTING 69183 Humulin M3 Vial 100 IU/ml. 10 ml. Vial 1 1 X 10ML 1 F A10AD01 INSULIN (HUMAN) INTERMEDIATE-ACTING COMBINED WITH FAST-ACTING 69312 Humulin M3 Kwikpen 100 IU/ml. 3 ml. Pre-filled Pen 5 3 ML. X 5 5 F A10AD05 INSULIN ASPART INTERMEDIATE-ACTING COMBINED WITH FAST-ACTING 68927 NovoMix 30 Penfill Cartridge 100 IU/ml. 3 ml. Cartridge 5 5 X 3 ML 5 F A10AD05 INSULIN ASPART INTERMEDIATE-ACTING COMBINED WITH FAST-ACTING 64275 NovoMix (P.C.O. Mfg.) 30 Penfill 100 IU/ml. 3 ml. Cartridge 5 5 X 3 ML 5 F A10AD05 INSULIN ASPART INTERMEDIATE-ACTING COMBINED WITH FAST-ACTING 68930 NovoMix 30 (P.C.O. Mfg.) FlexPen 100 IU/ml. 3 ml. Pre-filled Pen 5 5 X 3ML 5 F A10AD05 INSULIN ASPART INTERMEDIATE-ACTING COMBINED WITH FAST-ACTING 76140 NovoMix 30 FlexPen 100 IU/ml. 3 ml. Pre-filled Pen 5 5 X 3 ML 5 F A10AD30 INSULIN COMBINATIONS, INTERMEDIATE ACTING COMBINED WITH FAST-ACTING 69105 Humalog Kwikpen Mix 25 100 IU/ml. 3 ml. Pre-filled Pen 5 3 ML X 5 5 F A10AD30 INSULIN COMBINATIONS, INTERMEDIATE ACTING COMBINED WITH FAST-ACTING 69148 Humalog Kwikpen Mix 50 100 IU/ml. 3 ml. Pre-filled Pen 5 3 ML X 5 5 F A10AD30 INSULIN COMBINATIONS, INTERMEDIATE-ACTING COMBINED WITH FAST-ACTING 69001 Humalog Mix 25 Cartridge 100 IU/ml. 3 ml. Cartridge 5 5 X 3 ML 5 F A10AD30 INSULIN COMBINATIONS, INTERMEDIATE-ACTING COMBINED WITH FAST-ACTING 69057 Humalog Mix 50 Cartridge 100 IU/ml. 3 ml. Cartridge 5 5 x 3 ML. 5 F A10AE01 INSULIN (HUMAN) LONG-ACTING 68063 Insuman Basal Cartridge 100 IU/ml. 3 ml. Cartridge 5 5 X 3 ML 5 F A10AE01 INSULIN (HUMAN) LONG-ACTING 68233 Insuman Basal Vial 100 IU/ml. 5 ml. Vial 1 1 X 5 ML 1 F A10AE04 Insulin Aspart 43698 Fiasp FlexTouch Soln. for Inj. Pre-filled Pen 100 IU/ml. 3 ml. 5 5 X 3 ML 5 F A10AE04 Insulin Aspart 43741 Fiasp Penfill Soln. for Inj. Cartridge 100 IU/ml. 3 ml. 5 5 X 3 ML 5 F A10AE04 Insulin Aspart 43810 Fiasp Soln. for Inj. Vial 100 IU/ml. 10 ml. 1 1 X 10ML 1 F A10AE04 INSULIN GLARGINE LONG-ACTING 69238 Abasaglar Soln. For Inj., Cartridge 100 units/ml. 3 ml. 5 5 X 3 ML 5 F A10AE04 Insulin Glargine 69486 Abasaglar KwikPen Soln. for Inj., Pre-Filled Pen 100 units/ml. 3 ml. 5 (1 - 80 Units) 5 X 3 ML 5 F A10AE04 INSULIN GLARGINE LONG-ACTING 41752 Toujeo Solostar Soln. for Inj. in Pre-filled Pen 300 units/ml. 1.5 ml. 5 5 X 1.5 ML 5 F A10AE04 INSULIN GLARGINE LONG-ACTING 69158 Lantus Cartridge 100 IU/ml. 3 ml. Cartridge 5 5 X 3 ML 5 F A10AE04 INSULIN GLARGINE LONG-ACTING 69252 Lantus SoloStar Soln. for Inj. 100 units/ml. 3 ml. 5 5 X 3 ML 5 F

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Page 1: S 'PD 1DPH 6L]H ,OOQHVV $FWUDSLG 9LDO ,8 PO PO 9LDO ; 0 ... · &ruh /lvw ) 'ldehwhv 0hoolwxv -dqxdu\ $7&/9/ 1rq 3ursulhwdu\ 'uxj &gh 'pd 'uxj 'hvfulswlrq 3dfn 6l]h 1dph 3dfn 6l]h

Core List F(Diabetes Mellitus)

January 2019

ATCLVL5 Non Proprietary Drug Cde Dma

Drug Description Pack Size Name

PackSize

Typ Illness

A10AB01 INSULIN (HUMAN), FAST ACTING 62006 Actrapid Vial 100 IU/ml. 10 ml. Vial 1 1 X 10ML 1 FA10AB01 INSULIN (HUMAN), FAST ACTING 68187 Insuman Rapid Cartridge 100 IU/ml. 3 ml. Cartridge 5 5 X 3 ML 5 FA10AB01 INSULIN (HUMAN), FAST ACTING 69077 Humulin S Vial 100 IU/ml. 10 ml. Vial 1 1 X 10 ML 1 FA10AB01 INSULIN (HUMAN), FAST ACTING 69169 Humulin S Cartridge 100 IU/ml. 3 ml. Cartridge 5 5 X 3 ML 5 FA10AB04 INSULIN LISPRO FAST-ACTING 63500 Humalog Pen 100 IU/ml. 3 ml. Pre-filled Pen 5 5 X 3 ML 5 FA10AB04 INSULIN LISPRO FAST-ACTING 69050 Humalog Vial 100 IU/ml. 10 ml. Vial 1 1 X 10 ML 1 FA10AB04 INSULIN LISPRO FAST-ACTING 69091 Humalog Cartridge 100 IU/ml. 3 ml. Cartridge 5 5 X 3 ML 5 FA10AB04 INSULIN LISPRO FAST-ACTING 69132 Humalog Kwikpen 100 IU/ml. 3 ml. Pre-filled Pen 5 3 ML X 5 5 FA10AB04 INSULIN LISPRO FAST-ACTING 41045 Humalog KwikPen (P.C.O. Mfg.) 100 IU/ml. 3 ml. Pre-filled Pen 5 3 ML X 5 5 FA10AB04 Insulin Lispro Fast-Acting 69184 Humalog Kwikpen 200 IU/ml. 3 ml. Pre-filled Pen 5 3 ML X 5 5 FA10AB05 Insulin Aspart 43903 Fiasp FlexTouch Soln. for Inj. Prefilled Pen 100 IU/ml. 3 ml. 5 3 ML X 5 5 FA10AB05 Insulin Aspart 43911 Fiasp Penfill Soln. for Inj. Cartridge 100 IU/ml. 3 ml. 5 3 ML X 5 5 FA10AB05 Insulin Aspart 43918 Fiasp Soln. for Inj. Vial 100 IU/ml. 10 ml. 1 1 X 10 ML 1 FA10AB05 INSULIN ASPART FAST-ACTING 62710 NovoRapid (P.C.O. Mfg.) Soln. for Inj. 100 IU/ml. 10 ml. Vial 1 1 X 10 ML 1 FA10AB05 INSULIN ASPART FAST-ACTING 73541 NovoRapid Vial 100 IU/ml. 10 ml. Vial 1 1X 10 ML 1 FA10AB05 INSULIN ASPART, FAST-ACTING 62709 NovoRapid FlexPen 100 IU/ml. 3 ml. Pre-filled Pen 5 5 X 3 ML 5 FA10AB05 INSULIN ASPART, FAST-ACTING 62720 NovoRapid (P.C.O. Mfg.) FlexPen 100 IU/ml. 3 ml. Pre-filled Pen 5 5 X 3ML 5 FA10AB05 INSULIN ASPART, FAST-ACTING 62730 NovoRapid (P.C.O. Mfg.) Penfill Cartidge 100 IU/ml. 3 ml. Cartridge 5 5 X 3ML 5 FA10AB05 INSULIN ASPART, FAST-ACTING 63121 NovoRapid Penfill Cartridge 100 IU/ml. 3 ml. Cartridge 5 5 X 3 ML 5 FA10AB06 INSULIN GLULISINE FAST-ACTING 69335 Apidra Cartridge 100 IU/ml. 3 ml. 1 5 X 3 ML 5 FA10AB06 INSULIN GLULISINE FAST-ACTING 69376 Apidra Vial 100 IU/ml. 10 ml. 1 X 10 ML 1 FA10AB06 INSULIN GLULISINE FAST-ACTING 69398 Apidra SoloStar Soln. for Inj. 100 units/ml. 3 ml. 5 5 X 3 ML 5 FA10AB06 INSULIN GLULISINE FAST-ACTING 53489 Apidra SoloStar (P.C.O. Mfg.) Soln. for Inj. 100 units/ml. 3 ml. 5 5 X 3 ML 5 FA10AC01 INSULIN (HUMAN) INTERMEDIATE-ACTING 61786 Insulatard Vial 100 IU/ml. 10 ml. Vial 1 1 X 10 ML 1 FA10AC01 INSULIN (HUMAN) INTERMEDIATE-ACTING 68032 Insuman Comb 50 Cartridge 100 IU/ml. 3 ml. Cartridge 5 5 X 3 ML 5 FA10AC01 INSULIN (HUMAN) INTERMEDIATE-ACTING 69069 Humulin I Vial 100 IU/ml. 10 ml. Vial 1 1 X 10 ML 1 FA10AC01 INSULIN (HUMAN) INTERMEDIATE-ACTING 69100 Humulin I Cartridge 100 IU/ml. 3 ml. Cartridge 5 5 X 3 ML 5 FA10AC01 INSULIN (HUMAN) INTERMEDIATE-ACTING 69337 Humulin I kwikpen 100 iu/ml. 3 ml. Pre-filled Pen 5 5 X 3 ML 5 FA10AC01 INSULIN (HUMAN) INTERMEDIATE-ACTING 71512 Insulatard InnoLet Pre-filled Syringe 100 IU/ml. 3 ml. Syringe 5 5 X 3 ML 5 FA10AC01 INSULIN (HUMAN) INTERMEDIATE-ACTING 71580 Insulatard Penfill Cartridge 100 IU/ml. 3 ml. Cartridge 5 5 X 3 ML 5 FA10AD01

INSULIN (HUMAN) INTERMEDIATE-ACTING COMBINED WITH FAST-ACTING

68047 Insuman Comb 25 Cartridge 100 IU/ml. 3 ml. Cartridge 5 5 X 3 ML 5 FA10AD01

INSULIN (HUMAN) INTERMEDIATE-ACTING COMBINED WITH FAST-ACTING

68241 Insuman Comb 25 Vial 100 IU/ml. 5 ml. Vial 1 1 X 5 ML 1 FA10AD01

INSULIN (HUMAN) INTERMEDIATE-ACTING COMBINED WITH FAST-ACTING

69137 Humulin M3 Cartridge 100 IU/ml. 3 ml. Cartridge 5 5 X 3 ML 5 FA10AD01

INSULIN (HUMAN) INTERMEDIATE-ACTING COMBINED WITH FAST-ACTING

69183 Humulin M3 Vial 100 IU/ml. 10 ml. Vial 1 1 X 10ML 1 FA10AD01

INSULIN (HUMAN) INTERMEDIATE-ACTING COMBINED WITH FAST-ACTING

69312 Humulin M3 Kwikpen 100 IU/ml. 3 ml. Pre-filled Pen 5 3 ML. X 5 5 FA10AD05

INSULIN ASPART INTERMEDIATE-ACTING COMBINED WITH FAST-ACTING

68927 NovoMix 30 Penfill Cartridge 100 IU/ml. 3 ml. Cartridge 5 5 X 3 ML 5 FA10AD05

INSULIN ASPART INTERMEDIATE-ACTING COMBINED WITH FAST-ACTING

64275 NovoMix (P.C.O. Mfg.) 30 Penfill 100 IU/ml. 3 ml. Cartridge 5 5 X 3 ML 5 FA10AD05

INSULIN ASPART INTERMEDIATE-ACTING COMBINED WITH FAST-ACTING

68930 NovoMix 30 (P.C.O. Mfg.) FlexPen 100 IU/ml. 3 ml. Pre-filled Pen 5 5 X 3ML 5 FA10AD05

INSULIN ASPART INTERMEDIATE-ACTING COMBINED WITH FAST-ACTING

76140 NovoMix 30 FlexPen 100 IU/ml. 3 ml. Pre-filled Pen 5 5 X 3 ML 5 FA10AD30

INSULIN COMBINATIONS, INTERMEDIATE ACTING COMBINED WITH FAST-ACTING

69105 Humalog Kwikpen Mix 25 100 IU/ml. 3 ml. Pre-filled Pen 5 3 ML X 5 5 FA10AD30

INSULIN COMBINATIONS, INTERMEDIATE ACTING COMBINED WITH FAST-ACTING

69148 Humalog Kwikpen Mix 50 100 IU/ml. 3 ml. Pre-filled Pen 5 3 ML X 5 5 FA10AD30

INSULIN COMBINATIONS, INTERMEDIATE-ACTING COMBINED WITH FAST-ACTING

69001 Humalog Mix 25 Cartridge 100 IU/ml. 3 ml. Cartridge 5 5 X 3 ML 5 FA10AD30

INSULIN COMBINATIONS, INTERMEDIATE-ACTING COMBINED WITH FAST-ACTING

69057 Humalog Mix 50 Cartridge 100 IU/ml. 3 ml. Cartridge 5 5 x 3 ML. 5 FA10AE01 INSULIN (HUMAN) LONG-ACTING 68063 Insuman Basal Cartridge 100 IU/ml. 3 ml. Cartridge 5 5 X 3 ML 5 FA10AE01 INSULIN (HUMAN) LONG-ACTING 68233 Insuman Basal Vial 100 IU/ml. 5 ml. Vial 1 1 X 5 ML 1 FA10AE04 Insulin Aspart 43698 Fiasp FlexTouch Soln. for Inj. Pre-filled Pen 100 IU/ml. 3 ml. 5 5 X 3 ML 5 FA10AE04 Insulin Aspart 43741 Fiasp Penfill Soln. for Inj. Cartridge 100 IU/ml. 3 ml. 5 5 X 3 ML 5 FA10AE04 Insulin Aspart 43810 Fiasp Soln. for Inj. Vial 100 IU/ml. 10 ml. 1 1 X 10ML 1 FA10AE04 INSULIN GLARGINE LONG-ACTING 69238 Abasaglar Soln. For Inj., Cartridge 100 units/ml. 3 ml. 5 5 X 3 ML 5 FA10AE04 Insulin Glargine 69486 Abasaglar KwikPen Soln. for Inj., Pre-Filled Pen 100 units/ml. 3 ml. 5 (1 - 80 Units) 5 X 3 ML 5 FA10AE04 INSULIN GLARGINE LONG-ACTING 41752 Toujeo Solostar Soln. for Inj. in Pre-filled Pen 300 units/ml. 1.5 ml. 5 5 X 1.5 ML 5 FA10AE04 INSULIN GLARGINE LONG-ACTING 69158 Lantus Cartridge 100 IU/ml. 3 ml. Cartridge 5 5 X 3 ML 5 FA10AE04 INSULIN GLARGINE LONG-ACTING 69252 Lantus SoloStar Soln. for Inj. 100 units/ml. 3 ml. 5 5 X 3 ML 5 F

Page 2: S 'PD 1DPH 6L]H ,OOQHVV $FWUDSLG 9LDO ,8 PO PO 9LDO ; 0 ... · &ruh /lvw ) 'ldehwhv 0hoolwxv -dqxdu\ $7&/9/ 1rq 3ursulhwdu\ 'uxj &gh 'pd 'uxj 'hvfulswlrq 3dfn 6l]h 1dph 3dfn 6l]h

Core List F(Diabetes Mellitus)

January 2019

ATCLVL5 Non Proprietary Drug Cde Dma

Drug Description Pack Size Name

PackSize

Typ Illness

A10AE04 INSULIN GLARGINE LONG-ACTING 69277 Lantus Vial 100 IU/ml. 10 ml. Vial 1 1 X 10 ML 1 FA10AE04 INSULIN GLARGINE, LONG-ACTING 26953 Lantus (P.C.O. Mfg.) Soln. for Inj. 100 units/ml. 3 ml. 5 5 X 3ML 5 FA10AE04 INSULIN GLARGINE, LONG-ACTING 69207 Lantus Solostar (P.C.O. Mfg.) Soln for Inj. 100 units/ml. 3 ml. 5 5 X 3ML 5 FA10AE04 INSULIN GLARGINE, LONG-ACTING 69254 Lantus OptiSet (Waymade Healthcare Plc) 100 IU/ml. 3 ml. Pre-filled Pen 5 3 ML. X 5 5 FA10AE05 INSULIN DETEMIR LONG-ACTING 63109 Levemir InnoLet 100 units/ml. 3 ml. 5 5 X 3 ML 5 FA10AE05 INSULIN DETEMIR, LONG-ACTING 63003 Levemir Flexpen Pre-Filled Pen 100 units/ml. 3 ml. 5 5 X 3 ML 5 FA10AE05 INSULIN DETEMIR, LONG-ACTING 63005 Levemir (P.C.O. Mfg.) Penfill Cartridge 100 units/ml. 3 ml. 5 5 X 3ML 5 FA10AE05 INSULIN DETEMIR, LONG-ACTING 63015 Levemir (P.C.O. Mfg.) Flexpen Pre-Filled Pen 100 units/ml. 3 ml. 5 5 X 3ML 5 FA10AE05 INSULIN DETEMIR, LONG-ACTING 63082 Levemir Penfill Cartridge 100 units/ml. 3 ml. 5 5 X 3 ML. 5 FA10AE06 Insulin Degludec 72386 Tresiba U100 FlexTouch Pre-filled Pen 100 iu/ml. 3 ml. 5 5 X 3 ML. 5 FA10AE06 Insulin Degludec 72390 Tresiba U200 FlexTouch Pre-filled Pen 200 iu/ml. 3 ml. 3 5 X 3 ML. 3 FA10BA02 METFORMIN 36823 Metformin (AuroBindo Pharma) Film Coated Tabs. 500 mg. 90 90 90 FA10BA02 METFORMIN 36824 Metformin (AuroBindo Pharma) Film Coated Tabs. 850 mg. 60 60 60 FA10BA02 METFORMIN 36820 Metformin (AuroBindo Pharma) Film Coated Tabs. 1000 mg. 60 60 60 FA10BA02 METFORMIN 18832 Metophage Film Coated Tabs. 500 mg. 90 90 90 FA10BA02 METFORMIN 18895 Metophage Film Coated Tabs. 850 mg. 60 60 60 FA10BA02 METFORMIN 27723 Glucophage Tabs. 500 mg. 84 84 84 FA10BA02 METFORMIN 27731 Glucophage Tabs. 850 mg. 56 56 56 FA10BA02 METFORMIN 27742 Glucophage Tabs. 1000 mg. 60 60 60 FA10BA02 METFORMIN 30396 Glucophage Powder Sachets 500 mg. 30 30 30 FA10BA02 METFORMIN 33690 Metformin (Rosemont) Oral Soln. 500 mg./5 ml. 150 ml. 1 X 150 ML 150 FA10BA02 METFORMIN 36815 Metformin (Bluefish) Tabs. 500 mg. 84 84 84 FA10BA02 METFORMIN 36816 Metformin (Bluefish) Tabs. 850 mg. 56 56 56 FA10BA02 METFORMIN 36817 Metformin (Bluefish) Tabs. 1000 mg. 30 30 30 FA10BA02 METFORMIN 36832 Metformin (Bluefish) Film Coated Tabs. 1000 mg. 60 60 60 FA10BA02 METFORMIN 36825 Metformin TEVA Film Coated Tabs. 500 mg. 84 84 84 FA10BA02 METFORMIN 36826 Metformin TEVA Film Coated Tabs. 850 mg. 56 56 56 FA10BA02 METFORMIN 36827 Metformin TEVA Film Coated Tabs. 1000 mg. 60 60 60 FA10BB01 GLIBENCLAMIDE 19731 Daonil (P.C.O. Mfg.) Tabs. 5 mg. 30 30 30 FA10BB09 GLICLAZIDE 14096 Diaclide MR Tabs. 30 mg. 60 60 60 FA10BB09 GLICLAZIDE 21123 Diabrezide Tabs. 80 mg. 60 60 60 FA10BB09 GLICLAZIDE 21215 Diaglyc Modified Release Tabs. 30 mg. 60 60 60 FA10BB09 GLICLAZIDE 46902 Diacronal MR Modified Release Tabs. 30 mg. 60 60 60 FA10BB09 GLICLAZIDE 46903 Diacronal MR Modified Release Tabs. 60 mg. 30 30 30 FA10BB09 GLICLAZIDE 46985 Diamicron MR Tabs. 60 mg. 30 30 30 FA10BB09 GLICLAZIDE 69515 Diamicron MR Tabs. 30 mg. 60 60 60 FA10BB09 GLICLAZIDE 69540 Diamicron MR (Imbat Ltd.) Tabs. 30 mg. 60 60 60 FA10BB09 GLICLAZIDE 23251 Vitile MR Modified Release Tabs. 30 mg. 60 60 60 FA10BB12 GLIMEPIRIDE 12576 Amaryl Tabs. 3 mg. 30 30 30 FA10BB12 GLIMEPIRIDE 12706 Amaryl Tabs. 1 mg. 30 30 30 FA10BB12 GLIMEPIRIDE 12707 Amaryl (B & S Healthcare) Tabs. 2 mg. 30 30 30 FA10BB12 GLIMEPIRIDE 12713 Amaryl (Imbat Ltd.) Tabs. 1 mg. 30 30 30 FA10BB12 GLIMEPIRIDE 12738 Amaryl (Imbat Ltd.) Tabs. 4 mg. 30 30 30 FA10BB12 GLIMEPIRIDE 12749 Amaryl (P.C.O. Mfg.) Tabs. 4 mg. 30 30 30 FA10BB12 GLIMEPIRIDE 12803 Amaryl (P.C.O. Mfg.) Tabs. 1 mg. 60 60 60 FA10BB12 GLIMEPIRIDE 12827 Amaryl (P.C.O. Mfg.) Tabs. 2 mg. 30 30 30 FA10BB12 GLIMEPIRIDE 12891 Amaryl (P.C.O. Mfg.) Tabs. 3 mg. 60 60 60 FA10BB12 GLIMEPIRIDE 12916 Amaryl (Imbat Ltd.) Tabs. 2 mg. 30 30 30 FA10BB12 GLIMEPIRIDE 12918 Amaryl (B & S Healthcare) Tabs. 2 mg. 60 60 60 FA10BB12 GLIMEPIRIDE 12922 Amaryl (B & S Healthcare) Tabs. 3 mg. 30 30 30 FA10BB12 GLIMEPIRIDE 23432 Glimepiride (Accord Healthcare Ltd.) Tabs. 1 mg. 30 30 30 FA10BB12 GLIMEPIRIDE 23433 Glimepiride (Accord Healthcare Ltd.) Tabs. 2 Mg. 30 30 30 FA10BB12 GLIMEPIRIDE 23434 Glimepiride (Accord Healthcare Ltd.) Tabs. 3 Mg. 30 30 30 F

Page 3: S 'PD 1DPH 6L]H ,OOQHVV $FWUDSLG 9LDO ,8 PO PO 9LDO ; 0 ... · &ruh /lvw ) 'ldehwhv 0hoolwxv -dqxdu\ $7&/9/ 1rq 3ursulhwdu\ 'uxj &gh 'pd 'uxj 'hvfulswlrq 3dfn 6l]h 1dph 3dfn 6l]h

Core List F(Diabetes Mellitus)

January 2019

ATCLVL5 Non Proprietary Drug Cde Dma

Drug Description Pack Size Name

PackSize

Typ Illness

A10BB12 GLIMEPIRIDE 23435 Glimepiride (Accord Healthcare Ltd.) Tabs. 4 mg. 30 30 30 FA10BD05 METFORMIN AND PIOGLITAZONE 18301 Competact Tabs. 15 mg./850 mg. 56 56 56 FA10BD05 METFORMIN AND PIOGLITAZONE 30456 Competact (P.C.O. Mfg.) Film Coated Tabs. 15 mg./850 mg. 56 56 56 FA10BD05 METFORMIN AND PIOGLITAZONE 13245 Competact (B & S Healthcare) Tabs. 15 mg./850 mg. 60 60 60 FA10BD05 METFORMIN AND PIOGLITAZONE 18306 Competact (Doncaster Ltd.) Tabs. 15 mg./850 mg. 56 56 56 FA10BD07 METFORMIN AND SITAGLIPTIN 29705 Janumet (P.C.O. Mfg.) Tabs. 50 mg./1000 mg. 56 56 56 FA10BD07 METFORMIN AND SITAGLIPTIN 29710 Janumet (P.C.O. Mfg.) Tabs. 50 mg./850 mg. 56 56 56 FA10BD07 METFORMIN AND SITAGLIPTIN 29751 Janumet Tabs. 50 mg./850 mg. 56 56 56 FA10BD07 METFORMIN AND SITAGLIPTIN 29765 Janumet Tabs. 50 mg./1000 mg. 56 56 56 FA10BD07 METFORMIN AND SITAGLIPTIN 19035 Janumet (Lexon UK) Film Coated Tabs. 50 mg./1000 mg. 56 56 56 FA10BD08 METFORMIN AND VILDAGLIPTIN 24314 Eucreas Tabs. 50 mg./850 mg. 60 60 60 FA10BD08 METFORMIN AND VILDAGLIPTIN 24352 Eucreas Tabs. 50 mg./1000 mg. 60 60 60 FA10BD10 METFORMIN AND SAXAGLIPTIN 16739 Komboglyze Film Coated Tabs. 2.5 mg./850 mg. 56 56 56 FA10BD10 METFORMIN AND SAXAGLIPTIN 16768 Komboglyze Film Coated Tabs. 2.5 mg./1000 mg. 56 56 56 FA10BD11 METFORMIN AND LINAGLIPTIN 53875 Jentadueto Film Coated Tabs. 2.5 mg./850 mg. 56 56 56 FA10BD11 METFORMIN AND LINAGLIPTIN 53876 Jentadueto Film Coated Tabs. 2.5 mg./1000 mg. 56 56 56 FA10BD15 METFORMIN AND DAPAGLIFLOZIN 36850 Xigduo Film Coated Tabs. 5 mg./850 mg. 56 56 56 FA10BD15 METFORMIN AND DAPAGLIFLOZIN 36851 Xigduo Film Coated Tabs. 5 mg./1000 mg. 56 56 56 FA10BD16 Metformin And Canagliflozin 36958 Vokanamet Film Coated Tabs. 150 mg./1000 mg. 60 60 60 FA10BD16 Metformin And Canagliflozin 36957 Vokanamet Film Coated Tabs. 150 mg./850 mg. 60 60 60 FA10BD16 Metformin And Canagliflozin 36956 Vokanamet Film Coated Tabs. 50 mg./1000 mg. 60 60 60 FA10BD16 Metformin And Canagliflozin 36955 Vokanamet Film Coated Tabs. 50 mg./850 mg. 60 60 60 FA10BD20 Metformin And Empagliflozin 32647 Synjardy Film Coated Tabs. 5 mg./850 mg. 56 56 56 FA10BD20 Metformin And Empagliflozin 32648 Synjardy Film Coated Tabs. 5 mg./1000 mg. 56 56 56 FA10BD20 Metformin And Empagliflozin 32649 Synjardy Film Coated Tabs. 12.5 mg./850 mg. 56 56 56 FA10BD20 Metformin And Empagliflozin 32650 Synjardy Film Coated Tabs. 12.5 mg./1000 mg. 56 56 56 FA10BD24 Sitagliptin And Ertugliflozin 43771 Steglujan Film Coated Tabs. 15 mg./100 mg. 28 28 28 FA10BD24 Sitagliptin And Ertugliflozin 43770 Steglujan Film Coated Tabs. 5 mg./100 mg. 28 28 28 FA10BF01 ACARBOSE 27745 Glucobay Tabs. 50 mg. 90 90 90 FA10BF01 ACARBOSE 27780 Glucobay Tabs. 100 mg. 90 90 90 FA10BG03 PIOGLITAZONE 10330 Actos Tabs. 45 mg. 28 28 28 FA10BG03 PIOGLITAZONE 10378 Actos Tabs. 15 mg. 28 28 28 FA10BG03 PIOGLITAZONE 10506 Actos (BR Lewis Pharmaceuticals) Tabs. 15 mg. 28 28 28 FA10BG03 PIOGLITAZONE 10568 Actos (BR Lewis Pharmaceuticals) Tabs. 30 mg. 28 28 28 FA10BG03 PIOGLITAZONE 10579 Actos (B & S Healthcare) Tabs. 30 mg. 28 28 28 FA10BG03 PIOGLITAZONE 10594 Actos Tabs. 30 mg. 28 28 28 FA10BG03 PIOGLITAZONE 10609 Actos (Doncaster Ltd.) Tabs. 15 mg. 28 28 28 FA10BG03 PIOGLITAZONE 10661 Actos (Doncaster Ltd.) Tabs. 30 mg. 28 28 28 FA10BG03 PIOGLITAZONE 10690 Actos (B & S Healthcare) Tabs. 15 mg. 28 28 28 FA10BG03 PIOGLITAZONE 10756 Actos (P.C.O. Mfg.) Tabs. 15 mg. 28 28 28 FA10BG03 PIOGLITAZONE 10761 Actos (P.C.O. Mfg.) Tabs. 30 mg. 28 28 28 FA10BG03 PIOGLITAZONE 10797 Actos (Lexon UK) Tabs. 15 mg. 28 28 28 FA10BG03 PIOGLITAZONE 10798 Actos (Lexon UK) Tabs. 30 mg. 28 28 28 FA10BG03 PIOGLITAZONE 15530 Actos (Lexon UK) Tabs. 45 mg. 28 28 28 FA10BG03 PIOGLITAZONE 15590 Actos (Doncaster Ltd.) Tabs. 45 mg. 28 28 28 FA10BG03 PIOGLITAZONE 34512 Pioglitazone (Actavis) Tabs. 15 mg. 28 28 28 FA10BG03 PIOGLITAZONE 34687 Pioglitazone (Actavis) Tabs. 30 mg. 28 28 28 FA10BG03 PIOGLITAZONE 34875 Pioglitazone (Accord Healthcare Ltd.) Tabs. 15 mg. 28 28 28 FA10BG03 PIOGLITAZONE 34876 Pioglitazone (Accord Healthcare Ltd.) Tabs. 30 mg. 28 28 28 FA10BG03 PIOGLITAZONE 34877 Pioglitazone (Accord Healthcare Ltd.) Tabs. 45 mg. 28 28 28 FA10BG03 PIOGLITAZONE 34858 Pioglitazone (Actavis) Tabs. 45 mg. 28 28 28 FA10BH01 SITAGLIPTIN 48043 Januvia (P.C.O. Mfg.) Film Coated Tabs. 25 mg. 28 28 28 FA10BH01 SITAGLIPTIN 48057 Januvia (P.C.O. Mfg.) Film Coated Tabs. 50 mg. 28 28 28 F

Page 4: S 'PD 1DPH 6L]H ,OOQHVV $FWUDSLG 9LDO ,8 PO PO 9LDO ; 0 ... · &ruh /lvw ) 'ldehwhv 0hoolwxv -dqxdu\ $7&/9/ 1rq 3ursulhwdu\ 'uxj &gh 'pd 'uxj 'hvfulswlrq 3dfn 6l]h 1dph 3dfn 6l]h

Core List F(Diabetes Mellitus)

January 2019

ATCLVL5 Non Proprietary Drug Cde Dma

Drug Description Pack Size Name

PackSize

Typ Illness

A10BH01 SITAGLIPTIN 13263 Januvia (B & S Healthcare) Film Coated Tabs. 100 mg. 28 28 28 FA10BH01 SITAGLIPTIN 19675 Januvia (Doncaster Ltd.) Tabs. 100 mg. 28 28 28 FA10BH01 SITAGLIPTIN 23521 Januvia Film Coated Tabs. 25 mg. 28 28 28 FA10BH01 SITAGLIPTIN 23569 Januvia Film Coated Tabs. 50 mg. 28 28 28 FA10BH01 SITAGLIPTIN 29714 Januvia Tabs. 100 mg. 28 28 28 FA10BH01 SITAGLIPTIN 29720 Januvia (P.C.O. Mfg.) Tabs. 100 mg. 28 28 28 FA10BH01 SITAGLIPTIN 29725 Januvia (Pharmaram Ltd.) Tabs. 100 mg. 28 28 28 FA10BH01 SITAGLIPTIN 15547 Januvia (Lexon UK) Film Coated Tabs. 50 mg. 2828 28 FA10BH01 SITAGLIPTIN 15682 Januvia (Lexon UK) Film Coated Tabs. 100 mg. 2828 28 FA10BH01 SITAGLIPTIN 13117 Januvia (LTT Pharma Ltd.) Film Coated Tabs. 25 mg. 28 28 28 FA10BH02 VILDAGLIPTIN 71711 Galvus Tabs. 50 mg. 56 56 56 FA10BH03 SAXAGLIPTIN 37526 Onglyza Tabs. 5 mg. 28 28 28 FA10BH03 SAXAGLIPTIN 37535 Onglyza Tabs. 2.5 mg. 28 28 28 FA10BH03 SAXAGLIPTIN 42941 Onglyza (P.C.O. Mfg.) Film Coated 5 mg. 28 28 28 FA10BH05 LINAGLIPTIN 65482 Trajenta Tabs. 5 mg. 28 28 28 FA10BK02 CANAGLIFLOZIN 13489 Invokana Film Coated Tabs. 100 mg. 30 30 30 FA10BK02 CANAGLIFLOZIN 13490 Invokana Film Coated Tabs. 300 mg. 30 30 30 FA10BK02 CANAGLIFLOZIN 47851 Invokana (P.C.O. Mfg.) Film Coated Tabs. 100 mg. 30 30 30 FA10BK02 CANAGLIFLOZIN 47858 Invokana (P.C.O. Mfg.) Film Coated Tabs. 300 mg. 30 30 30 F

A10BK04 Ertugliflozin 27573 Steglatro Film Coated Tabs. 5 mg. 28 28 28 FA10BK04 Ertugliflozin 27698 Steglatro Film Coated Tabs. 15 mg. 28 28 28 F

A10BX02 REPAGLINIDE 76424 Repaglinide (Accord Healthcare Ltd.) Tabs. 0.5 mg. 30 30 30 FA10BX02 REPAGLINIDE 76425 Repaglinide (Accord Healthcare Ltd.) Tabs. 0.5 mg. 90 90 90 FA10BX02 REPAGLINIDE 76426 Repaglinide (Accord Healthcare Ltd.) Tabs. 1 mg. 90 90 90 FA10BX02 REPAGLINIDE 76427 Repaglinide (Accord Healthcare Ltd.) Tabs. 2 mg. 90 90 90 FA10BX02 REPAGLINIDE 76453 NovoNorm Tabs. 0.5 mg. 120 120 120 FA10BX02 REPAGLINIDE 76474 NovoNorm Tabs. 1 mg. 120 120 120 FA10BX02 REPAGLINIDE 76497 NovoNorm Tabs. 2 mg. 120 120 120 FA10BX02 REPAGLINIDE 76407 Novonorm (Lexon UK) Tabs. 1 mg. 90 90 90 FA10BX02 REPAGLINIDE 13282 NovoNorm (B & S Healthcare) Tabs. 0.5 mg. 90 90 90 FA10BX02 REPAGLINIDE 13283 NovoNorm (B & S Healthcare) Tabs. 1 mg. 90 90 90 FA10BX02 REPAGLINIDE 13284 NovoNorm (B & S Healthcare) Tabs. 2 mg. 90 90 90 FA10BX03 NATEGLINIDE 45428 Starlix (BR Lewis Pharmaceuticals) Tabs. 120 mg. 84 84 84 FA10BX03 NATEGLINIDE 62094 Starlix Tabs. 180 mg. 84 84 84 FA10BJ01 EXENATIDE 47510 Byetta Soln. for Inj., Pre-filled Pen 5 mcg. 60 Dose Pack 1 1 X 60 DOSE 1 FA10BJ01 EXENATIDE 47515 Byetta Soln. for Inj., Pre-filled Pen 10 mcg. 60 Dose Pack 1 1 X 60 DOSE 1 FA10BJ01 EXENATIDE 47522 Byetta (P.C.O. Mfg.) Soln. for Inj., Pre-filled Pen 5 mcg. 60 Dose Pack 1 1 X 60 DOSE PACK 1 FA10BJ01 EXENATIDE 47523 Byetta (P.C.O. Mfg.) Soln. for Inj., Pre-filled Pen 10 mcg. 60 Dose Pack 1 1 X 60 DOSE PACK 1 FA10BJ01 EXENATIDE 47530 Bydureon Pdr. & Solv. for Prolonged Release Susp. for Inj. 2 mg. 4 4 4 FA10BJ01 EXENATIDE 54347 Bydrureon Pdr. & Solv. for Prolonged Release Susp. for Inj. in Pre-filled Pen 2 mg. 4 4 4 FA10BJ01 EXENATIDE 13106 Bydureon (P.C.O. Mfg.) Pdr. and Solv. for Prolonged Release Susp. for Inj. 2 mg. 4 4 4 FA10BJ02 LIRAGLUTIDE 47980 Victoza Soln. for Inj., Pre-filled Pen 6 mg./ml. 3 ml. 2 2 X 3ML 2 FA10BJ02 LIRAGLUTIDE 47981 Victoza Soln. for Inj., Pre-filled Pen 6 mg./ml. 3 ml. 3 3 X 3ML 3 FA10BJ02 LIRAGLUTIDE 13221 Victoza (P.C.O. Mfg.) Soln. for Inj., Pre-filled Pen 6 mg./ml. 3 ml. 2 2 X 3ML 2 FA10BJ02 LIRAGLUTIDE 47989 Victoza (Originalis B.V.) Soln. for Inj. in Pre-filled Pen 6 mg./ml. 3 ml. 3 3 X 3ML 3 FA10BK01 DAPAFLIGLOZIN 18921 Forxiga Film Coated Tabs. 5 mg. 28 28 28 FA10BK01 DAPAFLIGLOZIN 18954 Forxiga Film Coated Tabs. 10 mg. 28 28 28 FA10BK03 EMPAGLIFLOZIN 13256 Jardiance Film Coated Tabs. 10 mg. 28 28 28 FA10BK03 EMPAGLIFLOZIN 13257 Jardiance Film Coated Tabs. 25 mg. 28 28 28 FA10BJ05 DULAGLUTIDE 73580 Trulicity Once Weekly Soln. for Inj. in Pre-filled Pen 0.75 mg./0.5 ml. 4 4 X .05ML 4 FA10BJ05 DULAGLUTIDE 73583 Trulicity Once Weekly Soln. for Inj. in Pre-filled Pen 1.5 mg./0.5 ml. 4 4 X .05ML 4 FA10BJ06 Semaglutide 33700 Ozempic Once Weekly Soln. for Inj. in Pre-filled Pen 0.25 mg. (1 pre-filled pen, 4 needles) Pack 1 1 1 FA10BJ06 Semaglutide 33701 Ozempic Once Weekly Soln. for Inj. in Pre-filled Pen 0.5 mg. (1 pre-filled pen, 4 needles) Pack 1 1 1 F

Page 5: S 'PD 1DPH 6L]H ,OOQHVV $FWUDSLG 9LDO ,8 PO PO 9LDO ; 0 ... · &ruh /lvw ) 'ldehwhv 0hoolwxv -dqxdu\ $7&/9/ 1rq 3ursulhwdu\ 'uxj &gh 'pd 'uxj 'hvfulswlrq 3dfn 6l]h 1dph 3dfn 6l]h

Core List F(Diabetes Mellitus)

January 2019

ATCLVL5 Non Proprietary Drug Cde Dma

Drug Description Pack Size Name

PackSize

Typ Illness

A10BJ06 Semaglutide 33702 Ozempic Once Weekly Soln. for Inj. in Pre-filled Pen 1 mg. (1 pre-filled pen, 4 needles) Pack 1 1 1 FB01AA03 WARFARIN 61701 Warfarin Teva Tabs. 1 mg. 100 100 100 FB01AA03 WARFARIN 61717 Warfarin Teva Tabs. 3 mg. 100 100 100 FB01AA03 WARFARIN 61721 Warfant Tabs. 1 mg. 100 100 100 FB01AA03 WARFARIN 61728 Warfarin Teva Tabs 5 mg. 100 100 100 FB01AA03 WARFARIN 61736 Warfant Tabs. 3 mg. 100 100 100 FB01AA03 WARFARIN 61748 Warfant Tabs. 5 mg. 100 100 100 FB01AC04 CLOPIDOGREL 65045 Clopidogrel (Clonmel) Film Coated Tabs. 75 mg. 28 28 28 FB01AC04 CLOPIDOGREL 65123 Clopidogrel (Actavis) Film Coated Tabs. 75 mg. 100 100 100 FB01AC04 CLOPIDOGREL 65105 Clopidogrel Mylan Tabs. 75 mg. 28 28 28 FB01AC04 CLOPIDOGREL 65118 Clopidogrel (KRKA Pharma) Film Coated Tabs. 75 mg. 28 28 28 FB01AC04 CLOPIDOGREL 12546 Clopidogrel (Actavis) Tabs. 75 mg. 28 28 28 FB01AC04 CLOPIDOGREL 65038 Clopidogrel TEVA Film Coated Tabs. 75 mg. 28 28 28 FB01AC04 CLOPIDOGREL 65032 Clopidogrel TAD Tabs. 75 mg. 28 28 28 FB01AC04 CLOPIDOGREL 65112 Clopidogrel (Niche) Tabs. 75 mg. 30 30 30 FB01AC04 CLOPIDOGREL 59203 Clodel Film Coated Tabs. 75 mg. 28 28 28 FB01AC04 CLOPIDOGREL 41095 Plavix (Lexon UK) Tabs. 75 mg. 28 28 28 FB01AC04 CLOPIDOGREL 40213 Plavix (B & S Healthcare) Tabs. 75 mg. 28 28 28 FB01AC04 CLOPIDOGREL 40115 Plavix (P.C.O. Mfg.) Tabs. 75 mg. 28 28 28 FB01AC04 CLOPIDOGREL 41012 Plavix (Waymade Healthcare Plc) Tabs. 75 Mg. 28 28 28 FB01AC04 CLOPIDOGREL 40901 Plavix (BR Lewis Pharmaceuticals) Tabs. 75 mg. 28 28 28 FB01AC04 CLOPIDOGREL 41021 Plavix (Doncaster Ltd.) Tabs. 75 mg. 28 28 28 FB01AC04 CLOPIDOGREL 41090 Plavix (Pharmaram Ltd.) Tabs. 75 mg. 28 28 28 FB01AC04 CLOPIDOGREL 41059 Plavix Tabs. 75 mg. 28 28 28 FB01AC04 CLOPIDOGREL 41072 Plavix (B & S Healthcare) Tabs. 75 mg. 30 30 30 FB01AC04 CLOPIDOGREL 41080 Plavix (iMED Healthcare Ltd.) Film Coated Tabs. 75 mg. 30 30 30 FB01AC04 CLOPIDOGREL 41086 Plavix (Doncaster Ltd.) Tabs. 75 mg. 30 30 30 FB01AC04 CLOPIDOGREL 27519 Grepid Film Coated Tabs. 75 mg. 28 28 28 FB01AC06 ACETYLSALICYLIC ACID 77170 Aspirin (KRKA Pharma) Gastro-Resistant Tabs. 75 mg. 28 28 28 FB01AC06 ACETYLSALICYLIC ACID 13103 Aspirin (Clonmel) Gastro-Resistant Tabs. 75 mg. 28 28 28 FB01AC06 ACETYLSALICYCLIC ACID-ASPIRIN (ANTITHROMBOTIC)) 37350 Nu-Seals (Imbat Ltd.) Aspirin Tabs. 75 mg. 28 28 28 FB01AC06 ACETYLSALICYLIC ACID 18672 Nu-Seal Gastro-Resistant Tabs. 75 mg. 100 100 100 FB01AC06 ACETYLSALICYLIC ACID 43704 Nuprin Gastro Resistant Tabs. 75 mg. 28 28 28 FB01AC06 ACETYLSALICYLIC ACID 43705 Nuprin Gastro Resistant Tabs. 75 mg. 56 56 56 FB01AC06 ACETYLSALICYLIC ACID - ASPIRIN (ANTITHROMBOTIC) 43747 Nuprin Gastro-Resistant Tabs. 75 mg. 100 100 100 FB01AC06 ACETYLSALICYLIC ACID-ASPIRIN (ANTITHROMBOTIC) 28647 Nuasa 75 mg. Gastro Resistant Tabs. 30 30 30 FB01AC06 ACETYLSALICYLIC ACID-ASPIRIN (ANTITHROMBOTIC) 37308 Nu-Seals Aspirin Tabs. 75 mg. 28 28 28 FB01AC06 ACETYLSALICYLIC ACID-ASPIRIN (ANTITHROMBOTIC) 77103 Nu-Seals Aspirin Tabs. 75 mg. 56 56 56 FB01AC06 ASPIRIN 10855 Caprin Enteric Coated Tabs. 75 mg. 100 100 100 FB01AC06 ASPIRIN 37317 Nu-Seals (P.C.O. Mfg.) Aspirin Tabs. 75 mg. 56 56 56 FB01AF03 Edoxaban 36930 Lixiana Film Coated Tabs. 15 mg. 10 10 10 FB01AF03 Edoxaban 36931 Lixiana Film Coated Tabs. 30 mg. 28 28 28 FB01AF03 Edoxaban 36932 Lixiana Film Coated Tabs. 60 mg. 28 28 28 FB01AE07 DABIGATRAN ETEXILATE 36882 Pradaxa (LTT Pharma) Hard Caps. 110 mg. 60 (30 Day Dose) 60 60 FB01AE07 DABIGATRAN ETEXILATE 36883 Pradaxa (LTT Pharma) Hard Caps. 150 mg. 60 (30 Day Dose) 60 60 FB01AE07 DABIGATRAN ETEXILATE 60633 Pradaxa (Lexon UK) Hard Caps. 110 mg. 60 (30 Day Dose) 60 60 FB01AE07 DABIGATRAN ETEXILATE 60634 Pradaxa (Lexon UK) Hard Caps. 150 mg. 60 (30 Day Dose) 60 60 FB01AE07 DABIGATRAN ETEXILATE 60681 Pradaxa (iMED Healthcare Ltd.) Hard Caps. 110 mg. 60 60 60 FB01AE07 DABIGATRAN ETEXILATE 60685 Pradaxa (iMED Healthcare Ltd.) Hard Caps. 150 mg. 60 60 60 FB01AE07 DABIGATRAN ETEXILATE 60603 Pradaxa Hard Caps. 150 mg. 10 10 10 FB01AE07 DABIGATRAN ETEXILATE 60602 Pradaxa Hard Caps. 150 mg. 60 (30 Day Dose) 60 60 FB01AE07 DABIGATRAN ETEXILATE 60616 Pradaxa (P.C.O. Mfg.) Hard Caps. 110 mg. 60 (30 Day Dose) 60 60 FB01AE07 DABIGATRAN ETEXILATE 60617 Pradaxa (P.C.O. Mfg.) Hard Caps. 150 mg. 60 (30 Day Dose) 60 60 F

Page 6: S 'PD 1DPH 6L]H ,OOQHVV $FWUDSLG 9LDO ,8 PO PO 9LDO ; 0 ... · &ruh /lvw ) 'ldehwhv 0hoolwxv -dqxdu\ $7&/9/ 1rq 3ursulhwdu\ 'uxj &gh 'pd 'uxj 'hvfulswlrq 3dfn 6l]h 1dph 3dfn 6l]h

Core List F(Diabetes Mellitus)

January 2019

ATCLVL5 Non Proprietary Drug Cde Dma

Drug Description Pack Size Name

PackSize

Typ Illness

B01AE07 DABIGATRAN ETEXILATE 60659 Pradaxa Caps. 110 mg. 10 (5 Day Dose) 10 10 FB01AE07 DABIGATRAN ETEXILATE 60684 Pradaxa Caps. 110 mg. 60 (30 Day Dose) 60 60 FB01AF02 APIXABAN 14024 Eliquis Film Coated Tabs. 2.5 mg. 20 20 20 FB01AF02 APIXABAN 14025 Eliquis Film Coated Tabs. 2.5 mg. 60 60 60 FB01AF02 APIXABAN 14047 Eliquis Film Coated Tabs. 5 mg. 56 56 56 FB01AF02 APIXABAN 36834 Eliquis Film Coated Tabs. 5 mg. 28 28 28 FB01AF02 APIXABAN 36807 Eliquis (Lexon UK) Film Coated Tabs. 2.5 mg. 60 60 60 FB01AF02 APIXABAN 36814 Eliquis (Lexon UK) Film Coated Tabs. 5 mg. 60 60 60 FB01AF01 RIVAROXABAN 53335 Xarelto Film Coated Tabs. 15 mg. 28 28 28 FB01AF01 RIVAROXABAN 53336 Xarelto Film Coated Tabs. 15 mg. 42 (A) 42 42 FB01AF01 RIVAROXABAN 53337 Xarelto Film Coated Tabs. 20 mg. 28 28 28 FC01DA02 GLYCERYL TRINITRATE 26700 Glytrin Spray 400 mcg. 200 Dose Aerosol 1 200 Dose Aerosol 1 FC01DA02 GLYCERYL TRINITRATE 42442 Nitrolingual (LTT Pharma D.P.R.) Pump Spray 400 mcg. 200 Dose Pack 1 200 Dose Pack 1 FC01DA02 GLYCERYL TRINITRATE 42449 Nitrolingual (P.C.O. Mfg. D.P.R.) Pump Spray 400 mcg. 200 Dose Pack 1 200 Dose Pack 1 FC01DA02 GLYCERYL TRINITRATE 42433 Nitrolingual (Eurodrug Ltd. D.P.R.) Pump Spray 200 Dose Pack 1 200 Dose Pack 1 FC01DA02 GLYCERYL TRINITRATE 40664 Nitrolingual Pump Spray 200 Dose Pack 1 200 Dose Pack 1 FC01DA02 GLYCERYL TRINITRATE 47287 Suscard Buccal Tabs. 2 mg. 100 100 100 FC01DA02 GLYCERYL TRINITRATE 47309 Suscard Buccal Tabs. 3 mg. 100 100 100 FC01DA02 GLYCERYL TRINITRATE 57673 Suscard Buccal Tabs. 5 mg. 100 100 100 FC01DA02 GLYCERYL TRINITRATE 51261 Transiderm-Nitro 5 Patches 28 28 28 FC01DA02 GLYCERYL TRINITRATE 51544 Transiderm-Nitro 10 Patches 28 28 28 FC01DA02 GLYCERYL TRINITRATE 50040 Transiderm-Nitro 15 Patches 30 30 30 FC01DA14 ISOSORBIDE MONONITRATE 31672 Isomel SR Tabs. 60 mg. 28 28 28 FC01DA14 ISOSORBIDE MONONITRATE 72058 Sormon PR Tabs. 60 mg. 28 28 28 FC01DA14 ISOSORBIDE MONONITRATE 31688 Isomonit Retard Tabs. 60 mg. 30 30 30 FC01DA14 ISOSORBIDE MONONITRATE 31410 Imdur Tabs. 60 mg. 28 28 28 FC01DA14 ISOSORBIDE MONONITRATE 31441 Imdur (Imbat Ltd.) Tabs. 60 mg. 28 28 28 FC01DA14 ISOSORBIDE MONONITRATE 23247 Elantan 10 Tabs. 10 mg. 56 56 56 FC01DA14 ISOSORBIDE MONONITRATE 28233 Elantan 20 Tabs. 20 mg. 56 56 56 FC01DA14 ISOSORBIDE MONONITRATE 28205 Elantan LA 25 (B & S Healthcare) Caps. 25 mg. 28 28 28 FC01DA14 ISOSORBIDE MONONITRATE 28260 Elantan LA (Imbat Ltd.) Caps. 25 mg. 28 28 28 FC01DA14 ISOSORBIDE MONONITRATE 22208 Elantan LA 25 Caps. 25 mg. 28 28 28 FC01DA14 ISOSORBIDE MONONITRATE 22081 Elantan 40 Tabs. 40 mg. 56 56 56 FC01DA14 ISOSORBIDE MONONITRATE 28206 Elantan LA 50 (B & S Healthcare) Caps. 50 mg. 28 28 28 FC01DA14 ISOSORBIDE MONONITRATE 22144 Elantan LA 50 Caps. 50 mg. 28 28 28 FC01DA14 ISOSORBIDE MONONITRATE 22108 Elantan LA (Imbat Ltd.) Caps. 50 mg. 28 28 28 FC02AC01 CLONIDINE 16690 Catapres Tabs. 0.1 mg. 100 100 100 FC02AC01 CLONIDINE 82872 Catapres Inj. 0.15 mg./ml. 1 ml. 5 1ML 5 5 FC02CA01 PRAZOSIN 28570 Hypovase Tabs. 0.5 mg. 60 60 60 FC02CA01 PRAZOSIN 28580 Hypovase Tabs. 1 mg. 60 60 60 FC02CA02 INDORAMIN 76003 Indoramin (Chemidex Pharma Ltd.) Film Coated Tabs. 20 mg. 60 60 60 FC02CA02 INDORAMIN 79723 Baratol Tabs. 50 mg. 100 100 100 FC02CA04 DOXAZOSIN 14585 Kamiren Prolonged Release Tabs. 4 mg. 28 28 28 FC02CA04 DOXAZOSIN 16101 Cardura XL Tabs. 4 mg. 28 28 28 FC02CA04 DOXAZOSIN 16122 Cardura XL Tabs. 8 mg. 28 28 28 FC02CA04 DOXAZOSIN 16160 Cardura Tabs. 1 mg. 28 28 28 FC02CA04 DOXAZOSIN 16179 Cardura Tabs. 2 mg. 28 28 28 FC02CA04 DOXAZOSIN 16202 Cardura XL (Imbat Ltd.) Tabs. 4 mg. 28 28 28 FC02CA04 DOXAZOSIN 16236 Cardura XL (P.C.O. Mfg.) Tabs. 4 mg. 28 28 28 FC02CA04 DOXAZOSIN 16257 Cardura XL (Imbat Ltd.) Tabs. 8 mg. 28 28 28 FC02CA04 DOXAZOSIN 16350 Cardura XL (P.C.O. Mfg.) Tabs. 4 mg. 30 30 30 FC02CA04 DOXAZOSIN 16385 Cardura XL (B & S Healthcare) Tabs. 4 mg. 28 28 28 FC02CA04 DOXAZOSIN 16389 Cardura XL (B & S Healthcare) Tabs. 8 mg. 28 28 28 F

Page 7: S 'PD 1DPH 6L]H ,OOQHVV $FWUDSLG 9LDO ,8 PO PO 9LDO ; 0 ... · &ruh /lvw ) 'ldehwhv 0hoolwxv -dqxdu\ $7&/9/ 1rq 3ursulhwdu\ 'uxj &gh 'pd 'uxj 'hvfulswlrq 3dfn 6l]h 1dph 3dfn 6l]h

Core List F(Diabetes Mellitus)

January 2019

ATCLVL5 Non Proprietary Drug Cde Dma

Drug Description Pack Size Name

PackSize

Typ Illness

C02CA04 DOXAZOSIN 16392 Cardura XL (P.C.O. Mfg.) Tabs. 8 mg. 30 30 30 FC02CA04 DOXAZOSIN 16395 Cardura (B & S Healthcare) Tabs. 2 mg. 30 30 30 FC02CA04 DOXAZOSIN 16399 Cardura XL (Primecrown 2010 Ltd.) Tabs. 8 mg. 28 28 28 FC02CA04 DOXAZOSIN 16405 Cardura XL (LTT Pharma Ltd.) Tabs. 8 mg. 28 28 28 FC02CA04 DOXAZOSIN 16408 Cardura (LTT Pharma Ltd.) XL Tabs. 4 mg. 28 28 28 FC02CA04 DOXAZOSIN 16427 Cardura XL (Clear Pharmacy) Tabs. 4 mg. 28 28 28 FC02CA04 DOXAZOSIN 16428 Cardura XL (Clear Pharmacy) Tabs. 8 mg. 28 28 28 FC02CA04 DOXAZOSIN 19823 Doxatan Tabs. 2 mg. 28 28 28 FC02CA04 DOXAZOSIN 20040 Carsem XL Prolonged Release Tabs. 4 mg. 28 28 28 FC02CA04 DOXAZOSIN 22072 Doxatan Prolonged Release Tabs. 4 mg. 28 28 28 FC02CA04 DOXAZOSIN 37622 Doxatan Tabs. 1 mg. 28 28 28 FC02CA04 DOXAZOSIN 53915 Raporsin Prolonged Release Tabs. 8 mg. 28 28 28 FC02CA04 DOXAZOSIN 53922 Raporsin Prolonged Release Tabs. 4 mg. 28 28 28 FC02CA04 DOXAZOSIN 68414 Doxatan Tabs. 4 mg. 28 28 28 FC02CA04 DOXAZOSIN 68420 Doxacar Prolonged Release Tabs. 4 mg. 28 28 28 FC02CA04 DOXAZOSIN 68903 Doxane XL Prolonged Release Tabs. 4 mg. 28 28 28 FC02DB02 HYDRALAZINE 12831 Apresoline Inj. 20 mg. 5 5 5 FC02DC01 MINOXIDIL 77213 Loniten Tabs. 5 mg. 60 60 60 FC03AA01 BENDROFLUMETHIAZIDE 55584 Bendroflumethiazide (Actavis) Tabs. 2.5 Mg. 28 28 28 FC03AA01 BENDROFLUMETHIAZIDE 55585 Bendroflumethiazide (Actavis) Tabs. 5 Mg. 28 28 28 FC03AB01 BENDROFLUMETHIAZIDE AND POTASSIUM 17162 Centyl K Tabs. 250 250 250 FC03AB01 BENDROFLUMETHIAZIDE AND POTASSIUM 31950 Low Centyl K Tabs. 250 250 250 FC03BA11 INDAPAMIDE 37133 Icorvida SR Prolonged Release Tabs. 1.5 mg. 30 30 30 FC03BA11 INDAPAMIDE 67363 Natrilix SR Tabs. 30 30 30 FC03BA11 INDAPAMIDE 67370 Natrilix SR (Imbat Ltd.) Tabs. 1.5 mg. 30 30 30 FC09BX01 PERINDOPRIL, AMLODIPINE AND INDAPAMIDE 13347 Coverdine Film Coated Tabs. 10 mg./2.5 mg./10 mg. 30 30 30 FC09BX01 PERINDOPRIL, AMLODIPINE AND INDAPAMIDE 13346 Coverdine Film Coated Tabs. 10 mg./2.5 mg./5 mg. 30 30 30 FC09BX01 PERINDOPRIL, AMLODIPINE AND INDAPAMIDE 13344 Coverdine Film Coated Tabs. 5 mg./1.25 mg./10 mg. 30 30 30 FC09BX01 PERINDOPRIL, AMLODIPINE AND INDAPAMIDE 13343 Coverdine Film Coated Tabs. 5 mg./1.25 mg./5 mg. 30 30 30 FC09BX02 Perindopril And Bisoprolol 22501 Cosimprel Film Coated Tabs. 5 mg./5 mg. 30 30 30 FC09BX02 Perindopril And Bisoprolol 22502 Cosimprel Film Coated Tabs. 5 mg./10 mg. 30 30 30 FC09BX02 Perindopril And Bisoprolol 22503 Cosimprel Film Coated Tabs. 10 mg./5 mg. 30 30 30 FC09BX02 Perindopril And Bisoprolol 22504 Cosimprel Film Coated Tabs. 10 mg./10 mg. 30 30 30 FC03CA01 FUROSEMIDE 30856 Lasix Inj. 10 mg./ml. 2 ml. 5 2ML 5 5 FC03CA01 FUROSEMIDE 66284 Fruside Tabs. 40 mg. 500 500 500 FC03CA01 FUROSEMIDE 74543 Furosemide (Clonmel) Tabs. 20 mg. 100 100 100 FC03CA01 FUROSEMIDE 74551 Frusemide (Clonmel) Tabs. 40 mg. 500 500 500 FC03CA02 BUMETANIDE 61033 Burinex Tabs. 1 mg. 28 28 28 FC03CA02 BUMETANIDE 31596 Burinex Tabs. 1 mg. 30 30 30 FC03CA02 BUMETANIDE 61045 Burinex Tabs. 5 mg. 28 28 28 FC03CA03 PIRETANIDE 65770 Arelix Tabs. 6 mg. 20 20 20 FC03DA01 SPIRONOLACTONE 56601 Aldactone (LTT Pharma Ltd.) Film Coated Tabs. 25 mg. 100 100 100 FC03DA01 SPIRONOLACTONE 70174 Spironolactone (Accord Healthcare Ltd.) Film Coated Tabs. 100 mg. 28 28 28 FC03DA01 SPIRONOLACTONE 10510 Aldactone Tabs. 50 mg. 100 100 100 FC03DA01 SPIRONOLACTONE 11053 Aldactone Tabs. 25 mg. 100 100 100 FC03DA01 SPIRONOLACTONE 79596 Aldactone Tabs. 100 mg. 100 100 100 FC03DA01 SPIRONOLACTONE 79782 Aldactone Tabs. 100 mg. 28 28 28 FC03DA01 SPIRONOLACTONE 72813 Spironolactone (Accord Healthcare Ltd.) Film Coated Tabs. 25 mg. 100 100 100 FC03DA01 SPIRONOLACTONE 72814 Spironolactone (Accord Healthcare Ltd.) Film Coated Tabs. 50 mg. 100 100 100 FC03DA01 SPIRONOLACTONE 72815 Spironolactone (Accord Healthcare Ltd.) Film Coated Tabs. 100 mg. 30 30 30 FC03DA01 SPIRONOLACTONE 72816 Spironolactone (Accord Healthcare Ltd.) Film Coated Tabs. 100 mg. 100 100 100 FC03DA04 EPLERENONE 30503 Eplerenone (KRKA Pharma) Film Coated Tabs. 25 mg. 30 30 30 FC03DA04 EPLERENONE 30504 Eplerenone (KRKA Pharma) Film Coated Tabs. 50 mg. 30 30 30 F

Page 8: S 'PD 1DPH 6L]H ,OOQHVV $FWUDSLG 9LDO ,8 PO PO 9LDO ; 0 ... · &ruh /lvw ) 'ldehwhv 0hoolwxv -dqxdu\ $7&/9/ 1rq 3ursulhwdu\ 'uxj &gh 'pd 'uxj 'hvfulswlrq 3dfn 6l]h 1dph 3dfn 6l]h

Core List F(Diabetes Mellitus)

January 2019

ATCLVL5 Non Proprietary Drug Cde Dma

Drug Description Pack Size Name

PackSize

Typ Illness

C03DA04 EPLERENONE 19337 Eplerenone (Accord Healthcare Ltd.) Film Coated Tabs. 25 mg. 28 28 28 FC03DA04 EPLERENONE 19345 Eplerenone (Accord Healthcare Ltd.) Film Coated Tabs. 50 mg. 28 28 28 FC03DA04 EPLERENONE 24987 Eplerenone (Bluefish) Film Coated Tabs. 25 mg. 28 28 28 FC03DA04 EPLERENONE 25130 Eplerenone (Bluefish) Film Coated Tabs. 50 mg. 28 28 28 FC03DA04 EPLERENONE 36897 Eplerenone Mylan (Gerard Labs.) Film Coated Tabs. 25 mg. 28 28 28 FC03DA04 EPLERENONE 13175 Eplerenone (Rowex) Film Coated Tabs. 25 mg. 28 28 28 FC03DA04 EPLERENONE 13176 Eplerenone (Rowex) Film Coated Tabs. 50 mg. 28 28 28 FC03DA04 EPLERENONE 30502 Inspra (Clear Pharmacy) Tabs. 25 mg. 30 30 30 FC03DA04 EPLERENONE 30507 Inspra Tabs. 25 mg. 28 28 28 FC03DA04 EPLERENONE 30530 Eplerenone (Actavis) Film Coated Tabs. 25 mg. 30 30 30 FC03DA04 EPLERENONE 30531 Eplerenone (Actavis) Film Coated Tabs. 50 mg. 30 30 30 FC03DA04 EPLERENONE 30542 Inspra Tabs. 50 mg. 28 28 28 FC03DA04 EPLERENONE 30557 Inspra (Imbat Ltd.) Tabs. 25 mg. 28 28 28 FC03DA04 EPLERENONE 30565 Inspra (B & S Healthcare D.P.R.) Tabs. 25 mg. 28 28 28 FC03DA04 EPLERENONE 30566 Inspra (B & S Healthcare D.P.R.) Tabs. 50 mg. 28 28 28 FC03EA01

HYDROCHLOROTHIAZIDE AND POTASSIUM-SPARING AGENTS

54946 Moduret 25 Tabs. 28 28 28 FC03EB01 FUROSEMIDE AND POTASSIUM-SPARING AGENTS 25429 Frumil Tabs. 28 28 28 FC03EB01 FUROSEMIDE AND POTASSIUM-SPARING AGENTS 25518 Frumil Tabs. Low Strength 28 28 28 FC03EB01 FUROSEMIDE AND POTASSIUM-SPARING AGENTS 25534 Frumil Tabs. 56 56 56 FC07AA05 PROPRANOLOL 28980 Half-Inderal LA (P.C.O. Mfg.) Caps. 80 mg. 28 28 28 FC07AA05 PROPRANOLOL 29068 Inderal Tabs. 10 mg. 100 100 100 FC07AA05 PROPRANOLOL 67320 Beta-Prograne Caps. 160 mg. 28 28 28 FC07AA05 PROPRANOLOL 67321 Beta-Prograne (LTT Pharma Ltd.) Caps. 160 mg. 28 28 28 FC07AA05 PROPRANOLOL 67340 Half Beta-Prograne Caps. 80 mg. 28 28 28 FC07AA05 PROPRANOLOL 67300 Half Beta-Prograne (Lexon UK) PR Caps. 80 mg. 28 28 28 FC07AA05 PROPRANOLOL 73610 Inderal LA (B & S Healthcare) Caps. 160 mg. 28 28 28 FC07AA05 PROPRANOLOL 73620 Inderal LA (P.C.O. Mfg.) Caps. 160 mg. 28 28 28 FC07AA07 SOTALOL 46725 Sotacor (Imbat Ltd.) Tabs. 80 mg. 30 30 30 FC07AA07 SOTALOL 46740 Sotacor Tabs. 80 mg. 30 30 30 FC07AA07 SOTALOL 62446 Sotager Tabs. 80 mg. 28 28 28 FC07AB02 METOPROLOL 61525 Metocor Tabs. 50 mg. 100 100 100 FC07AB02 METOPROLOL 61544 Metocor Tabs. 100 mg. 100 100 100 FC07AB03 ATENOLOL 10707 Atecor Tabs. 50 mg. 30 30 30 FC07AB03 ATENOLOL 10723 Atecor Tabs. 100 mg. 30 30 30 FC07AB03 ATENOLOL 11235 Atenomel Tabs. 25 mg. 30 30 30 FC07AB03 ATENOLOL 11436 Atecor Tabs. 25 mg. 30 30 30 FC07AB03 ATENOLOL 11947 Atenomel Tabs. 50 mg. 30 30 30 FC07AB03 ATENOLOL 11961 Atenomel Tabs. 100 mg. 30 30 30 FC07AB03 ATENOLOL 12637 Ateni Tabs. 50 mg. 28 28 28 FC07AB03 ATENOLOL 12645 Ateni Tabs. 100 mg. 28 28 28 FC07AB03 ATENOLOL 33634 Amolin New Formula Tabs. 25 mg. 30 30 30 FC07AB03 ATENOLOL 33645 Nortenolol Tabs. 100 mg. 30 30 30 FC07AB03 ATENOLOL 33758 Amolin New Formula Tabs. 100 mg. 30 30 30 FC07AB03 ATENOLOL 36624 Nortenolol Tabs. 25 mg. 30 30 30 FC07AB03 ATENOLOL 36636 Nortenolol Tabs. 50 mg. 30 30 30 FC07AB03 ATENOLOL 48879 Tenormin-50 Tabs. 28 28 28 FC07AB03 ATENOLOL 48902 Trantalol Tabs. 25 mg. 30 30 30 FC07AB03 ATENOLOL 48947 Trantalol Tabs. 50 mg. 30 30 30 FC07AB03 ATENOLOL 48950 Trantalol Tabs. 100 mg. 30 30 30 FC07AB03 ATENOLOL 69264 Tenormin Tabs. 25 mg. 28 28 28 FC07AB03 ATENOLOL 69299 Tenormin Tabs. 100 mg. 28 28 28 FC07AB03 ATENOLOL 69306 Tenormin (B & S Healthcare) Tabs. 25 mg. 28 28 28 FC07AB03 ATENOLOL 69341 Tenormin (B & S Healthcare) Film Coated Tabs. 50 mg. 28 28 28 F

Page 9: S 'PD 1DPH 6L]H ,OOQHVV $FWUDSLG 9LDO ,8 PO PO 9LDO ; 0 ... · &ruh /lvw ) 'ldehwhv 0hoolwxv -dqxdu\ $7&/9/ 1rq 3ursulhwdu\ 'uxj &gh 'pd 'uxj 'hvfulswlrq 3dfn 6l]h 1dph 3dfn 6l]h

Core List F(Diabetes Mellitus)

January 2019

ATCLVL5 Non Proprietary Drug Cde Dma

Drug Description Pack Size Name

PackSize

Typ Illness

C07AB07 BISOPROLOL 27690 Bisoprolol Fumarate (Accord Healthcare Ltd.) Tabs. 5 mg. 28 28 28 FC07AB07 BISOPROLOL 27691 Bisoprolol Fumarate (Accord Healthcare Ltd.) Tabs. 10 mg. 28 28 28 FC07AB07 BISOPROLOL 21658 Bisoprolol Fumarate (Clonmel) Tabs. 1.25 mg. 28 28 28 FC07AB07 BISOPROLOL 27136 Bisoprolol Fumarate (Clonmel) Tabs. 2.5 mg. 28 28 28 FC07AB07 BISOPROLOL 27415 Bisoprolol Fumarate (Clonmel) Tabs. 3.75 mg. 28 28 28 FC07AB07 BISOPROLOL 27681 Bisoprolol Fumarate (Clonmel) Tabs. 5 mg. 28 28 28 FC07AB07 BISOPROLOL 27685 Bisoprolol Fumarate (Clonmel) Tabs. 10 mg. 28 28 28 FC07AB07 BISOPROLOL 13801 BISOPROLOL FUMARATE (NICHE GENERICS) TABS. 2.5 MG. 28 28 28 FC07AB07 BISOPROLOL 13813 Bisoprolol Fumarate (Actavis) Tabs. 5 mg. 28 28 28 FC07AB07 BISOPROLOL 13814 Bisoprolol Fumarate (Actavis) Tabs. 10 mg. 28 28 28 FC07AB07 BISOPROLOL 13827 Bisoprolol Mylan (Gerard Labs.) Film Coated Tabs. 1.25 mg. 28 28 28 FC07AB07 BISOPROLOL 13828 Bisoprolol Mylan (Gerard Labs.) Film Coated Tabs. 2.5 mg. 28 28 28 FC07AB07 BISOPROLOL 13830 Bisoprolol Mylan (Gerard Labs.) Film Coated Tabs. 5 mg. 28 28 28 FC07AB07 BISOPROLOL 13831 Bisoprolol Mylan (Gerard Labs.) Film Coated Tabs. 7.5 mg. 28 28 28 FC07AB07 BISOPROLOL 13832 Bisoprolol Mylan (Gerard Labs.) Film Coated Tabs. 10 mg. 28 28 28 FC07AB07 BISOPROLOL 13880 Bisoprolol Fumarate (Niche) Tabs. 5 mg. 28 28 28 FC07AB07 BISOPROLOL 13881 Bisoprolol Fumarate (Niche) Tabs. 10 mg. 28 28 28 FC07AB07 BISOPROLOL 15304 Bisop Film Coated Tabs. 1.25 mg. 28 28 28 FC07AB07 BISOPROLOL 15311 Bisopine Tabs. 5 mg. 28 28 28 FC07AB07 BISOPROLOL 15316 Bisop Film Coated Tabs. 2.5 mg. 28 28 28 FC07AB07 BISOPROLOL 15322 Bisop Film Coated Tabs. 3.75 mg. 28 28 28 FC07AB07 BISOPROLOL 15334 Bisopine Tabs. 10 mg. 28 28 28 FC07AB07 BISOPROLOL 15338 Bisop Film Coated Tabs. 5 mg. 28 28 28 FC07AB07 BISOPROLOL 15346 Bisop Film Coated Tabs. 7.5 mg. 28 28 28 FC07AB07 BISOPROLOL 15360 Bisop Film Coated Tabs. 10 mg. 28 28 28 FC07AB07 BISOPROLOL 15366 Bisocor Tabs. 5 mg. 28 28 28 FC07AB07 BISOPROLOL 15415 Bisocor Tabs. 10 mg. 28 28 28 FC07AB07 BISOPROLOL 16104 Cardicor (iMED Healthcare Ltd.) Film Coated Tabs. 1.25 mg. 28 28 28 FC07AB07 BISOPROLOL 16105 Cardicor (iMED Healthcare Ltd.) Film Coated Tabs. 2.5 mg. 28 28 28 FC07AB07 BISOPROLOL 16103 Cardicor (Imbat Ltd.) Tabs. 1.25 mg. 28 28 28 FC07AB07 BISOPROLOL 16114 Cardicor (Imbat Ltd.) Tabs. 2.5 mg. 28 28 28 FC07AB07 BISOPROLOL 16120 Cardicor (Imbat Ltd.) Tabs. 3.75 mg. 28 28 28 FC07AB07 BISOPROLOL 16131 Cardicor (Imbat Ltd.) Tabs. 5 mg. 28 28 28 FC07AB07 BISOPROLOL 16148 Cardicor (Imbat Ltd.) Tabs. 7.5 mg. 28 28 28 FC07AB07 BISOPROLOL 16152 Cardicor (Imbat Ltd.) Tabs. 10 mg. 28 28 28 FC07AB07 BISOPROLOL 16188 Cardicor (B & S Healthcare) Tabs. 10 mg. 28 28 28 FC07AB07 BISOPROLOL 16907 Cardicor Tabs. 1.25 mg. 28 28 28 FC07AB07 BISOPROLOL 16912 Cardicor Tabs. 2.5 mg. 28 28 28 FC07AB07 BISOPROLOL 16934 Cardicor Tabs. 3.75 mg. 28 28 28 FC07AB07 BISOPROLOL 16941 Cardicor Tabs. 5 mg. 28 28 28 FC07AB07 BISOPROLOL 16978 Cardicor Tabs. 7.5 mg. 28 28 28 FC07AB07 BISOPROLOL 16999 Cardicor Tabs. 10 mg. 28 28 28 FC07AB07 BISOPROLOL 17403 Cardicor (LTT Pharma D.P.R.) Tabs. 1.25 mg. 28 28 28 FC07AB07 BISOPROLOL 17404 Cardicor (LTT Pharma D.P.R.) Tabs. 2.5 mg. 28 28 28 FC07AB07 BISOPROLOL 17405 Cardicor (LTT Pharma D.P.R.) Tabs. 3.75 mg. 28 28 28 FC07AB07 BISOPROLOL 17406 Cardicor (LTT Pharma D.P.R.) Tabs. 7.5 mg. 28 28 28 FC07AB07 BISOPROLOL 17409 Cardicor (P.C.O. Mfg.) Tabs. 1.25 mg. 28 28 28 FC07AB07 BISOPROLOL 17429 Cardicor (P.C.O. Mfg.) Tabs. 7.5 mg. 28 28 28 FC07AB07 BISOPROLOL 17430 Cardicor (P.C.O. Mfg.) Tabs. 10 mg. 28 28 28 FC07AB07 BISOPROLOL 17448 Cardicor (P.C.O. Mfg.) Tabs. 2.5 mg. 28 28 28 FC07AB07 BISOPROLOL 19324 Bisoprolol (KRKA Pharma) Film Coated Tabs. 2.5 mg. 28 28 28 FC07AB07 BISOPROLOL 19465 Bisoprolol (KRKA Pharma) Film Coated Tabs. 5 mg. 28 28 28 FC07AB07 BISOPROLOL 19530 Bisoprolol (KRKA Pharma) Film Coated Tabs. 10 mg. 28 28 28 F

Page 10: S 'PD 1DPH 6L]H ,OOQHVV $FWUDSLG 9LDO ,8 PO PO 9LDO ; 0 ... · &ruh /lvw ) 'ldehwhv 0hoolwxv -dqxdu\ $7&/9/ 1rq 3ursulhwdu\ 'uxj &gh 'pd 'uxj 'hvfulswlrq 3dfn 6l]h 1dph 3dfn 6l]h

Core List F(Diabetes Mellitus)

January 2019

ATCLVL5 Non Proprietary Drug Cde Dma

Drug Description Pack Size Name

PackSize

Typ Illness

C07AB07 BISOPROLOL 22470 Emcor Tabs. 5 mg. 28 28 28 FC07AB07 BISOPROLOL 22489 Emcor Tabs. 10 mg. 28 28 28 FC07AB07 BISOPROLOL 22545 Emcor (P.C.O. Mfg.) Tabs. 10 mg. 30 30 30 FC07AB07 BISOPROLOL 22553 Emcor (B & S Healthcare) Tabs. 5 mg. 30 30 30 FC07AB07 BISOPROLOL 22554 Emcor (B & S Healthcare) Tabs. 10 mg. 30 30 30 FC07AB08 CELIPROLOL 45500 Selectol Tabs. 200 mg. 28 28 28 FC07AB08 CELIPROLOL 45509 Selectol (P.C.O. Mfg.) Tabs. 200 mg. 28 28 28 FC07AB08 CELIPROLOL 45516 Selectol (LTT Pharma Ltd.) Tabs. 200 mg. 28 28 28 FC07AB08 CELIPROLOL 45517 Selectol (LTT Pharma Ltd.) Tabs. 400 mg. 28 28 28 FC07AB08 CELIPROLOL 45554 Selectol Tabs. 400 mg. 28 28 28 FC07AB08 CELIPROLOL 45562 Selectol (P.C.O. Mfg.) Tabs. 400 mg. 28 28 28 FC07AB12 NEBIVOLOL 35608 Nebilet (Imbat Ltd.) Tabs. 5 mg. 28 28 28 FC07AB12 NEBIVOLOL 54373 Nebilet (P.C.O. Mfg.) Tabs. 5 mg. 28 28 28 FC07AB12 NEBIVOLOL 35653 Nebilet Tabs. 5 mg. 28 28 28 FC07AB12 NEBIVOLOL 35658 Nelet Tabs. 5 mg. 28 28 28 FC07AB12 NEBIVOLOL 35690 Nebivolol TEVA Tabs. 5 mg. 28 28 28 FC07AB12 NEBIVOLOL 35692 Nebilet (Clear Pharmacy) Tabs. 5 mg. 28 28 28 FC07AB12 NEBIVOLOL 53634 Nebol Tabs. 5 mg. 28 28 28 FC07AB12 NEBIVOLOL 67101 Nebimel Tabs. 5 mg. 28 28 28 FC07AG01 LABETALOL 69787 Trandate Tabs. 100 mg. 50 50 50 FC07AG01 LABETALOL 69795 Trandate Tabs. 100 mg. 250 250 250 FC07AG01 LABETALOL 69809 Trandate Tabs. 200 mg. 50 50 50 FC07AG01 LABETALOL 69817 Trandate Tabs. 200 mg. 250 250 250 FC07AG01 LABETALOL 69833 Trandate Tabs. 100 mg. 56 56 56 FC07AG01 LABETALOL 69841 Trandate Tabs. 200 mg. 56 56 56 FC07AG02 CARVEDILOL 15501 Carvedilol (KRKA Pharma) Tabs. 3.125 mg. 28 28 28 FC07AG02 CARVEDILOL 15536 Carvedilol (KRKA Pharma) Tabs. 6.25 mg. 28 28 28 FC07AG02 CARVEDILOL 15578 Carvedilol (KRKA Pharma) Tabs. 12.5 mg. 28 28 28 FC07AG02 CARVEDILOL 15597 Carvedilol (KRKA Pharma) Tabs. 25 mg. 28 28 28 FC07AG02 CARVEDILOL 24233 Eucardic Tabs. 6.25 mg. 28 28 28 FC07AG02 CARVEDILOL 24256 Eucardic Tabs. 12.5 mg. 28 28 28 FC07AG02 CARVEDILOL 24279 Eucardic Tabs. 25 mg. 28 28 28 FC07BA06 TIMOLOL AND THIAZIDES 70920 Prestim Tabs. 100 100 100 FC07BA06 TIMOLOL AND THIAZIDES 70939 Prestim Tabs. 30 30 30 FC07BB12 NEBIVOLOL AND THIAZIDES 35672 Nebilet Plus Film Coated Tabs. 5 mg./12.5 mg. 28 28 28 FC07BB12 NEBIVOLOL AND THIAZIDES 35673 Nebilet Plus Film coated Tabs. 5 mg/.25 mg. 28 28 28 FC07CB03 ATENOLOL AND OTHER DIURETICS 13664 Atecor CT Tabs. 50/12.5mg. 30 30 30 FC07CB03 ATENOLOL AND OTHER DIURETICS 13688 Atecor CT Tabs. 100/25mg. 30 30 30 FC07CB03 ATENOLOL AND OTHER DIURETICS 16446 Atenetic Tabs. 50/12.5 mg. 28 28 28 FC07CB03 ATENOLOL AND OTHER DIURETICS 16454 Atenetic Tabs. 100/25 mg. 28 28 28 FC07CB03 ATENOLOL AND OTHER DIURETICS 48712 Tenoret 50 Tabs. 28 28 28 FC07CB03 ATENOLOL AND OTHER DIURETICS 75370 Tenoret 50 (B & S Healthcare) Film Coated Tabs. 50 mg./12.5 mg. 28 28 28 FC07CB03 ATENOLOL AND OTHER DIURETICS 75390 Tenoretic (B & S Healthcare) Tabs. 100 mg./25 mg. 28 28 28 FC07CB03 ATENOLOL AND OTHER DIURETICS 75396 Tenoretic Tabs. 28 28 28 FC07FB03 ATENOLOL AND OTHER ANTIHYPERTENSIVES 36714 Nif-Ten Caps. 28 28 28 FC08CA01 AMLODIPINE 38902 Amlodipine (Pinewood) Tabs. 5 mg. 30 30 30 FC08CA01 AMLODIPINE 38904 Amlodipine (Pinewood) Tabs. 10 mg. 30 30 30 FC08CA01 AMLODIPINE 36812 Amlodipine (WPR Healthcare) Tabs. 5 mg. 28 28 28 FC08CA01 AMLODIPINE 36813 Amlodipine (WPR Healthcare) Tabs. 10 mg. 28 28 28 FC08CA01 AMLODIPINE 36802 Amlodipine (Clonmel) Tabs. 5 mg. 28 28 28 FC08CA01 AMLODIPINE 36803 Amlodipine (Clonmel) Tabs. 10 mg. 28 28 28 FC08CA01 AMLODIPINE 10372 Amlode Tabs. 5 mg. 28 28 28 FC08CA01 AMLODIPINE 10389 Amlode Tabs. 10 mg. 28 28 28 F

Page 11: S 'PD 1DPH 6L]H ,OOQHVV $FWUDSLG 9LDO ,8 PO PO 9LDO ; 0 ... · &ruh /lvw ) 'ldehwhv 0hoolwxv -dqxdu\ $7&/9/ 1rq 3ursulhwdu\ 'uxj &gh 'pd 'uxj 'hvfulswlrq 3dfn 6l]h 1dph 3dfn 6l]h

Core List F(Diabetes Mellitus)

January 2019

ATCLVL5 Non Proprietary Drug Cde Dma

Drug Description Pack Size Name

PackSize

Typ Illness

C08CA01 AMLODIPINE 11226 Amlodipine Mylan (Gerard Labs.) Tabs. 5 mg. 28 28 28 FC08CA01 AMLODIPINE 11227 Amlodipine Mylan (Gerard Labs.) Tabs. 10 mg. 28 28 28 FC08CA01 AMLODIPINE 15073 Amlodipine (Bluefish) Tabs. 5 mg. 28 28 28 FC08CA01 AMLODIPINE 15074 Amlodipine (Bluefish) Tabs. 10 mg. 28 28 28 FC08CA01 AMLODIPINE 15078 Amlodipine TEVA Tabs. 5 mg. 28 28 28 FC08CA01 AMLODIPINE 15079 Amlodipine TEVA Tabs. 10 mg. 28 28 28 FC08CA01 AMLODIPINE 15082 Amlodipine (KRKA Pharma) Tabs. 5 mg. 28 28 28 FC08CA01 AMLODIPINE 15093 Amlodipine (KRKA Pharma) Tabs. 10 mg. 28 28 28 FC08CA01 AMLODIPINE 16542 Amlodipine (Pfizer) Tabs. 5 mg. 28 28 28 FC08CA01 AMLODIPINE 16587 Amlodipine (Pfizer) Tabs. 10 mg. 28 28 28 FC08CA01 AMLODIPINE 22760 Istolde Tabs. 5 mg. 28 28 28 FC08CA01 AMLODIPINE 22761 Istolde Tabs. 10 mg. 28 28 28 FC08CA01 AMLODIPINE 28901 Istin (Imbat Ltd.) Tabs. 5 mg. 28 28 28 FC08CA01 AMLODIPINE 28959 Istin Tabs. 5 mg. 28 28 28 FC08CA01 AMLODIPINE 28967 Istin Tabs. 10 mg. 28 28 28 FC08CA01 AMLODIPINE 29025 Istin (P.C.O. Mfg.) Tabs. 5 mg. 30 30 30 FC08CA01 AMLODIPINE 29047 Istin (P.C.O. Mfg.) Tabs. 5 mg. 28 28 28 FC08CA01 AMLODIPINE 29058 Istin (P.C.O. Mfg.) Tabs. 10 mg. 28 28 28 FC08CA01 AMLODIPINE 29064 Istin (B & S Healthcare) Tabs. 5 mg. 28 28 28 FC08CA01 AMLODIPINE 13259 Istin (B & S Healthcare) Tabs. 10 mg. 28 28 28 FC08CA01 AMLODIPINE 29081 Istin (P.C.O. Mfg.) Tabs. 10 mg. 30 30 30 FC08CA01 AMLODIPINE 29090 Istin (Imbat Ltd.) Tabs. 10 mg. 28 28 28 FC08CA01 AMLODIPINE 29140 Istin (iMED Healthcare Ltd.) Tabs. 5 mg. 28 28 28 FC08CA01 AMLODIPINE 29185 Istin (LTT Pharma Ltd.) Tabs. 5 mg. 28 28 28 FC08CA01 AMLODIPINE 29186 Istin (LTT Pharma Ltd.) Tabs. 10 mg. 28 28 28 FC08CA02 FELODIPINE 40035 Plendil Tabs. 5 mg. 28 28 28 FC08CA02 FELODIPINE 40041 Plendil Tabs. 10 mg. 28 28 28 FC08CA05 NIFEDIPINE 10310 Adalat LA (B & S Healthcare) Tabs. 30 mg. 28 28 28 FC08CA05 NIFEDIPINE 10347 Adalat LA Tabs. 20 mg. 28 28 28 FC08CA05 NIFEDIPINE 10356 Adalat LA (P.C.O. Mfg.) Tabs. 20 mg. 28 28 28 FC08CA05 NIFEDIPINE 10362 Adalat LA (B & S Healthcare) Tabs. 60 mg. 28 28 28 FC08CA05 NIFEDIPINE 10391 Adalat Retard Tabs. 10 mg. 56 56 56 FC08CA05 NIFEDIPINE 10433 Adalat LA Tabs. 30 mg. 28 28 28 FC08CA05 NIFEDIPINE 10467 Adalat LA Tabs. 60 mg. 28 28 28 FC08CA05 NIFEDIPINE 10601 Adalat LA (B & S Healthcare) Tabs. 20 mg. 14 14 14 FC08CA05 NIFEDIPINE 10629 Adalat Caps. 5 mg. 90 90 90 FC08CA05 NIFEDIPINE 10644 Adalat Retard Tabs. 20 mg. 56 56 56 FC08CA05 NIFEDIPINE 10647 Adalat Caps. 10 mg. 90 90 90 FC08CA05 NIFEDIPINE 10657 Adalat LA (B & S Healthcare) Tabs. 20 mg. 28 28 28 FC08CA05 NIFEDIPINE 10743 Adalat LA (B & S Healthcare) Tabs. 30 mg. 14 14 14 FC08CA05 NIFEDIPINE 10773 Adalat (Imbat Ltd.) Retard Tabs. 20 mg. 60 60 60 FC08CA05 NIFEDIPINE 10779 Adalat LA (B & S Healthcare) Tabs. 60 mg. 14 14 14 FC08CA05 NIFEDIPINE 10813 Adalat (B & S Healthcare) Retard Tabs. 20 mg. 30 30 30 FC08CA05 NIFEDIPINE 10842 Adalat (B & S Healthcare) Retard Tabs. 20 mg. 60 60 60 FC08CA05 NIFEDIPINE 56031 Adalat LA (P.C.O. Mfg.) Tabs. 30 mg. 28 28 28 FC08CA05 NIFEDIPINE 56059 Adalat LA (Clear Pharmacy) Tabs. 20 mg. 28 28 28 FC08CA05 NIFEDIPINE 56060 Adalat LA (Clear Pharmacy) Tabs. 60 mg. 28 28 28 FC08CA05 NIFEDIPINE 56185 Adalat (P.C.O. Mfg.) Retard Tabs. 20 mg. 60 60 60 FC08CA05 NIFEDIPINE 56301 Adalat LA (Clear Pharmacy) Tabs. 30 mg. 28 28 28 FC08CA05 NIFEDIPINE 56335 Adalat LA (iMED Healthcare Ltd.) Tabs. 20 mg. 28 28 28 FC08CA05 NIFEDIPINE 56336 Adalat LA (iMED Healthcare Ltd.) Tabs. 30 mg. 28 28 28 FC08CA05 NIFEDIPINE 56337 Adalat LA (iMED Healthcare Ltd.) Tabs. 60 mg. 28 28 28 FC08CA05 NIFEDIPINE 56355 Adalat LA (LTT Pharma Ltd.) Tabs. 30 mg. 28 28 28 F

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Core List F(Diabetes Mellitus)

January 2019

ATCLVL5 Non Proprietary Drug Cde Dma

Drug Description Pack Size Name

PackSize

Typ Illness

C08CA05 NIFEDIPINE 56372 Adalat LA (P.C.O. Mfg.) Tabs. 60 mg. 28 28 28 FC08CA05 NIFEDIPINE 56378 Adalat LA (LTT Pharma Ltd.) Tabs. 20 mg. 28 28 28 FC08CA05 NIFEDIPINE 56380 Adalat LA (LTT Pharma Ltd.) Tabs. 60 mg. 28 28 28 FC08CA05 NIFEDIPINE 56385 Adalat Retard (LTT Pharma Ltd.) Tabs. 10 mg. 56 56 56 FC08CA05 NIFEDIPINE 56386 Adalat Retard (LTT Pharma Ltd.) Tabs. 20 mg. 60 60 60 FC08CA05 NIFEDIPINE 56393 Adalat (Imbat Ltd.) Retard Tabs. 20 mg. 56 56 56 FC08CA05 NIFEDIPINE 56395 Adalat LA (Imbat Ltd.) Tabs. 30 mg. 28 28 28 FC08CA06 NIMODIPINE 36517 Nimotop Tabs. 30 mg. 100 100 100 FC08CA13 LERCANIDIPINE 26004 Lecalpin Tabs. 10 mg. 28 28 28 FC08CA13 LERCANIDIPINE 26005 Lecalpin Tabs. 20 mg. 28 28 28 FC08CA13 LERCANIDIPINE 41032 Lercanidipine (Clonmel) Tabs. 10 mg. 28 28 28 FC08CA13 LERCANIDIPINE 41665 Lercanidipine (Clonmel) Tabs. 20 mg. 28 28 28 FC08CA13 LERCANIDIPINE 51414 Lercanidipine TEVA Film Coated Tabs. 10 mg. 28 28 28 FC08CA13 LERCANIDIPINE 51415 Lercanidipine TEVA Film Coated Tabs. 20 mg. 28 28 28 FC08CA13 LERCANIDIPINE 13357 Lercanidipine Mylan (Gerard Labs.) Film Coated Tabs. 10 mg. 28 28 28 FC08CA13 LERCANIDIPINE 13359 Lercanidipine Mylan (Gerard Labs.) Film Coated Tabs. 20 mg. 28 28 28 FC08CA13 LERCANIDIPINE 55849 Zanidip Tabs. 10 mg. 28 28 28 FC08CA13 LERCANIDIPINE 63804 Zanidip Tabs. 20 mg. 28 28 28 FC08CA13 LERCANIDIPINE 63808 Zanidip (B & S Healthcare) Tabs. 10 mg. 28 28 28 FC08CA13 LERCANIDIPINE 63811 Zanidip (P.C.O. Mfg.) Tabs. 10 mg. 28 28 28 FC08CA13 LERCANIDIPINE 63815 Zanidip (Imbat Ltd.) Tabs. 10 mg. 28 28 28 FC08CA13 LERCANIDIPINE 63817 Zanidip (LTT Pharma Ltd.) Tabs. 10 mg. 28 28 28 FC08CA13 LERCANIDIPINE 63818 Zanidip (LTT Pharma Ltd.) Tabs. 20 mg. 28 28 28 FC08CA13 LERCANIDIPINE 63821 Zanidip (iMED Healthcare Ltd.) Film Coated Tabs. 10 mg. 28 28 28 FC08CA13 LERCANIDIPINE 63830 ZANIDIP (iMED HEALTHCARE LTD.) TABS. 20 MG. 28 28 28 FC08CA13 LERCANIDIPINE 63834 Zanidip (P.C.O. Mfg.) Tabs. 20 mg. 28 28 28 FC08CA13 LERCANIDIPINE 63884 Zanidip (G & A Licensing Ltd.) Film Coated Tabs. 10 mg. 28 28 28 FC08CA13 LERCANIDIPINE 63890 Zanidip (B & S Healthcare) Tabs. 20 mg. 28 28 28 FC08CA13 LERCANIDIPINE 63892 Zanidip (Imbat Ltd.) Tabs. 20 mg. 28 28 28 FC08CA13 LERCANIDIPINE 63897 Zanidip (Clear Pharmacy) Tabs. 10 mg. 28 28 28 FC08CA13 LERCANIDIPINE 63898 Zanidip (Clear Pharmacy) Tabs 20 mg. 28 28 28 FC08DA01 VERAPAMIL 13258 Isoptin SR (LTT Pharma Ltd.) Tabs. 240 mg. 30 30 30 FC08DA01 VERAPAMIL 29424 Isoptin Tabs. 120 mg. 100 100 100 FC08DA01 VERAPAMIL 29521 Isoptin Soln. for Inj. Or Inf. 2.5 mg/ml. 2 ml. 5 5 5 FC08DA01 VERAPAMIL 29548 Isoptin Tabs. 40 mg. 100 100 100 FC08DA01 VERAPAMIL 38933 Isoptin Tabs. 80 mg. 100 100 100 FC08DA01 VERAPAMIL 39470 Isoptin SR Tabs. 240 mg. 28 28 28 FC08DA01 VERAPAMIL 45272 Verap Prolonged Release Tabs. 120 mg. 30 30 30 FC08DA01 VERAPAMIL 49522 Veramil Tabs. 40 mg. 100 100 100 FC08DA01 VERAPAMIL 49557 Veramil Tabs. 80 mg. 100 100 100 FC08DA01 VERAPAMIL 59978 Veramil Tabs. 120 mg. 100 100 100 FC08DA01 VERAPAMIL 63628 Verap Prolonged Release Tabs. 240 mg. 30 30 30 FC08DB01 DILTIAZEM 16023 Dilzem SR (Eurodrug Ltd. D.P.R.) Caps. 60 mg. 56 56 56 FC08DB01 DILTIAZEM 16256 Dilzem SR (Eurodrug ltd. D.P.R.) Caps. 90 mg. 56 56 56 FC08DB01 DILTIAZEM 16387 Dilzem SR (Eurodrug Ltd. D.P.R.) Caps. 120 mg. 56 56 56 FC08DB01 DILTIAZEM 16390 Dilzem SR (B & S Healthcare D.P.R.) Caps. 60 mg. 56 56 56 FC08DB01 DILTIAZEM 20024 Diltam 90 Retard Tabs. 90 mg. 60 60 60 FC08DB01 DILTIAZEM 21615 Dilzem XL Once Daily Caps. 120 mg. 28 28 28 FC08DB01 DILTIAZEM 21713 Dilzem XL (P.C.O. Mfg.) Caps. 240 mg. 28 28 28 FC08DB01 DILTIAZEM 21719 Dilzem XL (B & S Healthcare D.P.R.) Caps. 240 mg. 56 56 56 FC08DB01 DILTIAZEM 21727 Dilzem XL (Eurodrug Ltd. D.P.R.) Caps. 120 mg. 28 28 28 FC08DB01 DILTIAZEM 21728 Dilzem XL (Eurodrug Ltd. D.P.R.) Caps. 180 mg. 28 28 28 FC08DB01 DILTIAZEM 21744 Dilzem XL Once Daily Caps. 180 mg. 28 28 28 F

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Core List F(Diabetes Mellitus)

January 2019

ATCLVL5 Non Proprietary Drug Cde Dma

Drug Description Pack Size Name

PackSize

Typ Illness

C08DB01 DILTIAZEM 21756 Dilzem XL Once Daily Caps. 240 mg. 28 28 28 FC08DB01 DILTIAZEM 21758 Dilzem XL (Eurodrug Ltd. D.P.R.) Once Daily Caps. 240 mg. 28 28 28 FC08DB01 DILTIAZEM 49003 Tildiem LA (B & S Healthcare) Caps. 200 mg. 28 28 28 FC08DB01 DILTIAZEM 49004 Tildiem LA (B & S Healthcare) Caps. 300 mg. 28 28 28 FC08DB01 DILTIAZEM 49575 Tildiem Retard (B & S Healthcare) Tabs. 90 mg. 56 56 56 FC08DB01 DILTIAZEM 49576 Tildiem Retard (B & S Healthcare) Tabs. 120 mg. 56 56 56 FC08DB01 DILTIAZEM 56839 Adizem SR Caps. 90 mg. 56 56 56 FC08DB01 DILTIAZEM 56847 Adizem SR Caps. 120 mg. 56 56 56 FC08DB01 DILTIAZEM 56855 Adizem SR Caps. 180 mg. 56 56 56 FC08DB01 DILTIAZEM 60402 Adizem XL Caps. 120 mg. 28 28 28 FC08DB01 DILTIAZEM 60424 Adizem XL Caps. 180 mg. 28 28 28 FC08DB01 DILTIAZEM 60436 Adizem XL Caps. 240 mg. 28 28 28 FC08DB01 DILTIAZEM 60487 Adizem XL Caps. 300 mg. 28 28 28 FC09AA01 CAPTOPRIL 13763 Aceomel Tabs. 12.5 mg. 60 60 60 FC09AA01 CAPTOPRIL 13782 Aceomel Tabs. 25 mg. 60 60 60 FC09AA01 CAPTOPRIL 13795 Aceomel Tabs. 50 mg. 60 60 60 FC09AA01 CAPTOPRIL 16725 Capoten (B & S Healthcare) Tabs. 25 mg. 60 60 60 FC09AA01 CAPTOPRIL 16793 Capoten (B & S Healthcare) Tabs. 50 mg. 14 14 14 FC09AA01 CAPTOPRIL 16841 Capoten (P.C.O. Mfg.) Tabs. 25 mg. 30 30 30 FC09AA01 CAPTOPRIL 16897 Capoten (P.C.O. Mfg.) Tabs. 50 mg. 30 30 30 FC09AA01 CAPTOPRIL 56750 Capoten Tabs. 25 mg. 28 28 28 FC09AA01 CAPTOPRIL 56768 Capoten Tabs. 50 mg. 28 28 28 FC09AA01 CAPTOPRIL 68556 Captor Tabs. 12.5 mg. 60 60 60 FC09AA01 CAPTOPRIL 68653 Captor Tabs. 25 mg. 60 60 60 FC09AA01 CAPTOPRIL 68677 Captor Tabs. 50 mg. 60 60 60 FC09AA02 ENALAPRIL 24041 Enap Tabs. 5 mg. 30 30 30 FC09AA02 ENALAPRIL 24052 Enap Tabs. 10 mg. 30 30 30 FC09AA02 ENALAPRIL 24073 Enap Tabs. 20 mg. 30 30 30 FC09AA02 ENALAPRIL 29696 Innovace Tabs. 5 mg. 28 28 28 FC09AA02 ENALAPRIL 29722 Innovace Tabs. 2.5 mg. 28 28 28 FC09AA02 ENALAPRIL 29793 Innovace Tabs. 10 mg. 28 28 28 FC09AA02 ENALAPRIL 29807 Innovace Tabs. 20 mg. 28 28 28 FC09AA02 ENALAPRIL 29819 Innovace (Imbat Ltd.) Tabs. 20 mg. 28 28 28 FC09AA02 ENALAPRIL 29827 Innovace (Imbat Ltd.) Tabs. 5 mg. 28 28 28 FC09AA03 LISINOPRIL 52378 Lisinopril (WPR Healthcare) Tabs. 5 mg. 28 28 28 FC09AA03 LISINOPRIL 14710 ByZestra Tabs. 2.5 mg. 28 28 28 FC09AA03 LISINOPRIL 14757 ByZestra Tabs. 10 mg. 28 28 28 FC09AA03 LISINOPRIL 17690 Lestace Tabs. 2.5 mg. 28 28 28 FC09AA03 LISINOPRIL 17691 Lestace Tabs. 5 mg. 28 28 28 FC09AA03 LISINOPRIL 17692 Lestace Tabs. 10 mg. 28 28 28 FC09AA03 LISINOPRIL 17693 Lestace Tabs. 20 mg. 28 28 28 FC09AA03 LISINOPRIL 23947 Zesger Tabs. 5 mg. 28 28 28 FC09AA03 LISINOPRIL 25270 Bellisin Tabs. 10 mg. 28 28 28 FC09AA03 LISINOPRIL 25287 Bellisin Tabs. 20 mg. 28 28 28 FC09AA03 LISINOPRIL 31702 Lispril Tabs. 5 mg. 30 30 30 FC09AA03 LISINOPRIL 31735 Lispril Tabs. 10 mg. 30 30 30 FC09AA03 LISINOPRIL 31781 Lispril Tabs. 20 mg. 30 30 30 FC09AA03 LISINOPRIL 39817 Lisopress Tabs. 2.5 mg. 28 28 28 FC09AA03 LISINOPRIL 47975 Lisopress Tabs. 5 mg. 28 28 28 FC09AA03 LISINOPRIL 52287 Zestan Tabs. 2.5 mg. 28 28 28 FC09AA03 LISINOPRIL 52335 Zesger Tabs. 2.5 mg. 28 28 28 FC09AA03 LISINOPRIL 52361 Zestril Tabs. 5 mg. 28 28 28 FC09AA03 LISINOPRIL 52388 Zestril Tabs. 10 mg. 28 28 28 F

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Core List F(Diabetes Mellitus)

January 2019

ATCLVL5 Non Proprietary Drug Cde Dma

Drug Description Pack Size Name

PackSize

Typ Illness

C09AA03 LISINOPRIL 52396 Zestril Tabs. 20 mg. 28 28 28 FC09AA03 LISINOPRIL 52690 Zestan Tabs. 5 mg. 28 28 28 FC09AA03 LISINOPRIL 53689 Zestan Tabs. 10 mg. 28 28 28 FC09AA03 LISINOPRIL 53814 Zestan Tabs. 20 mg. 28 28 28 FC09AA03 LISINOPRIL 53826 Zestril (P.C.O. Mfg.) Tabs. 20 mg. 30 30 30 FC09AA03 LISINOPRIL 53851 Zestril (P.C.O. Mfg.) Tabs. 10 mg. 30 30 30 FC09AA03 LISINOPRIL 53867 Zestril (P.C.O. Mfg.) Tabs. 5 mg. 30 30 30 FC09AA03 LISINOPRIL 54756 Lisopress Tabs. 20 mg. 28 28 28 FC09AA03 LISINOPRIL 58410 Zestril (LTT Pharma Ltd.) Tabs. 5 mg. 28 28 28 FC09AA03 LISINOPRIL 58411 Zestril (LTT Pharma Ltd.) Tabs. 20 mg. 28 28 28 FC09AA03 LISINOPRIL 58457 Zestril (B & S Healthcare) Tabs. 5 mg. 28 28 28 FC09AA03 LISINOPRIL 58458 Zestril (B & S Healthcare) Tabs. 10 mg. 28 28 28 FC09AA03 LISINOPRIL 58459 Zestril (B & S Healthcare) Tabs. 20 mg. 28 28 28 FC09AA03 LISINOPRIL 58496 Zestril (P.C.O. Mfg.) Tabs. 2.5 mg. 28 28 28 FC09AA03 LISINOPRIL 79677 Lisopress Tabs. 10 mg. 28 28 28 FC09AA03 LISNIOPRIL 58456 Zestril (B & S Healthcare) Tabs. 2.5 mg. 28 28 28 FC09AA04 PERINDOPRIL 18428 Coversyl Arginine (P.C.O. Mfg.) Tabs. 5 mg. 30 30 30 FC09AA04 PERINDOPRIL 18481 Coversyl Arginine (P.C.O. Mfg.) Tabs. 10 mg. 30 30 30 FC09AA04 PERINDOPRIL 19407 Coversyl Arginine Tabs. 5 mg. 30 30 30 FC09AA04 PERINDOPRIL 68306 Coversyl Arginine Orodispersible Tabs. 5 mg. 30 30 30 FC09AA04 PERINDOPRIL 19433 Coversyl Arginine (Imbat Ltd.) Tabs. 5 mg. 30 30 30 FC09AA04 PERINDOPRIL 19441 Coversyl Arginine (Imbat Ltd.) Tabs. 10 mg. 30 30 30 FC09AA04 PERINDOPRIL 19471 Coversyl Arginine (B & S Healthcare) Tabs. 5 mg. 30 30 30 FC09AA04 PERINDOPRIL 19475 Coversyl Arginine (B & S Healthcare) Tabs. 10 mg. 30 30 30 FC09AA04 PERINDOPRIL 19492 Coversyl Arginine Tabs. 10 mg. 30 30 30 FC09AA04 PERINDOPRIL 68307 Coversyl Arginine Orodispersible Tabs. 10 mg. 30 30 30 FC09AA04 PERINDOPRIL 19500 Coversyl Arginine (iMED Healthcare Ltd.) Tabs. 5 mg. 30 30 30 FC09AA04 PERINDOPRIL 19501 Coversyl Arginine (iMED Healthcare Ltd.) Tabs. 10 mg. 30 30 30 FC09AA04 PERINDOPRIL 39117 Perindopril (KRKA Pharma) Tabs. 2 mg. 30 30 30 FC09AA04 PERINDOPRIL 39103 Perindopril (KRKA Pharma) Tabs. 4 mg. 30 30 30 FC09AA04 PERINDOPRIL 39104 Perindopril (KRKA Pharma) Tabs. 8 mg. 30 30 30 FC09AA04 PERINDOPRIL 39109 Perindopril Tosilate TEVA Film Coated Tabs. 5 mg. 30 30 30 FC09AA04 PERINDOPRIL 68336 Coversyl Arginine (Clear Pharmacy) Tabs. 5 mg. 30 30 30 FC09AA04 PERINDOPRIL 68337 Coversyl Arginine (Clear Pharmacy) Tabs. 10 mg. 30 30 30 FC09AA04 PERINDOPRIL 68346 Coversyl Arginine (LTT Pharma Ltd.) Film Coated Tabs. 5 mg. 30 30 30 FC09AA04 PERINDOPRIL 68347 Coversyl Arginine (LTT Pharma Ltd.) Film Coated Tabs. 10 mg. 30 30 30 FC09AA04 PERINDOPRIL 76800 Pendrex Tabs. 2 mg. 30 30 30 FC09AA04 PERINDOPRIL 76830 Pendrex Tabs. 8 mg 30 30 30 FC09AA04 PERINDOPRIL 76883 Pendrex Tabs. 4 mg. 30 30 30 FC09AA04 PERINDOPRIL 39110 Perindopril Tosilate TEVA Film Coated Tabs. 10 mg. 30 30 30 FC09AA05 RAMIPRIL 49308 Ramipril (Accord Healthcare Ltd.) Hard Caps. 5 mg. 28 28 28 FC09AA05 RAMIPRIL 49309 Ramipril (Accord Healthcare Ltd.) Hard Caps. 10 mg. 28 28 28 FC09AA05 RAMIPRIL 31404 Loavel Tabs. 1.25 mg. 28 28 28 FC09AA05 RAMIPRIL 31418 Loavel Tabs. 2.5 mg. 28 28 28 FC09AA05 RAMIPRIL 31423 Loavel Tabs. 5 mg. 28 28 28 FC09AA05 RAMIPRIL 31434 Loavel Tabs. 10 mg. 28 28 28 FC09AA05 RAMIPRIL 43008 Ramic Caps. 2.5 mg. 28 28 28 FC09AA05 RAMIPRIL 43025 Ramic Caps. 5 mg. 28 28 28 FC09AA05 RAMIPRIL 43059 Ramic Caps. 10 mg. 28 28 28 FC09AA05 RAMIPRIL 43065 Ramitace Tabs. 2.5 mg. 28 28 28 FC09AA05 RAMIPRIL 43074 Ramitace Tabs. 5 mg. 28 28 28 FC09AA05 RAMIPRIL 43082 Ramitace Tabs. 10 mg. 28 28 28 FC09AA05 RAMIPRIL 43201 Ramilo Tabs. 1.25 mg. 30 30 30 F

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Core List F(Diabetes Mellitus)

January 2019

ATCLVL5 Non Proprietary Drug Cde Dma

Drug Description Pack Size Name

PackSize

Typ Illness

C09AA05 RAMIPRIL 43212 Ramilo Tabs. 2.5 mg. 30 30 30 FC09AA05 RAMIPRIL 43230 Ramilo Tabs. 5 mg. 30 30 30 FC09AA05 RAMIPRIL 43255 Ramilo Tabs. 10 mg. 30 30 30 FC09AA05 RAMIPRIL 48017 Tritace Tabs. 1.25 mg. 28 28 28 FC09AA05 RAMIPRIL 48023 Tritace Tabs. 2.5 mg. 28 28 28 FC09AA05 RAMIPRIL 48042 Tritace Tabs. 5 mg. 28 28 28 FC09AA05 RAMIPRIL 48061 Tritace Tabs. 10 mg. 28 28 28 FC09AA05 RAMIPRIL 48122 Tritace (Imbat Ltd.) Tabs. 10 mg. 28 28 28 FC09AA05 RAMIPRIL 48166 Tritace (Imbat Ltd.) Tabs. 1.25 mg. 28 28 28 FC09AA05 RAMIPRIL 48175 Tritace (Imbat Ltd.) Tabs. 2.5 mg. 28 28 28 FC09AA05 RAMIPRIL 48189 Tritace (Imbat Ltd.) Tabs. 5 mg. 28 28 28 FC09AA05 RAMIPRIL 49365 Ramipril (Actavis) Caps. 2.5 mg. 28 28 28 FC09AA05 RAMIPRIL 49366 Ramipril (Actavis) Caps. 5 mg. 28 28 28 FC09AA05 RAMIPRIL 49367 Ramipril (Actavis) Caps. 10 mg. 28 28 28 FC09AA05 RAMIPRIL 50017 Ramipril (KRKA Pharma) Tabs. 1.25 mg. 30 30 30 FC09AA05 RAMIPRIL 50018 Ramipril (KRKA Pharma) Tabs. 2.5 mg. 30 30 30 FC09AA05 RAMIPRIL 50019 Ramipril (KRKA Pharma) Tabs. 5 mg. 30 30 30 FC09AA05 RAMIPRIL 50020 Ramipril (KRKA Pharma) Tabs. 10 mg. 30 30 30 FC09AA05 RAMIPRIL 50034 Ramipril TEVA Pharma Tabs. 1.25 mg. 28 28 28 FC09AA05 RAMIPRIL 50035 Ramipril TEVA Pharma Tabs. 2.5 mg. 28 28 28 FC09AA05 RAMIPRIL 50036 Ramipril TEVA Pharma Tabs. 5 mg. 28 28 28 FC09AA05 RAMIPRIL 50037 Ramipril TEVA Pharma Tabs. 10 mg. 28 28 28 FC09AA06 QUINAPRIL 10077 Accupro Tabs. 40 mg. 28 28 28 FC09AA06 QUINAPRIL 10219 Accupro (B & S Healthcare) Tabs. 5 mg. 28 28 28 FC09AA06 QUINAPRIL 13233 Accupro (B & S Healthcare) Tabs. 10 mg. 30 30 30 FC09AA06 QUINAPRIL 10241 Accupro (B & S Healthcare) Tabs. 20 mg. 14 14 14 FC09AA06 QUINAPRIL 10251 Accupro Tabs. 5 mg. 28 28 28 FC09AA06 QUINAPRIL 10278 Accupro Tabs. 10 mg. 28 28 28 FC09AA06 QUINAPRIL 10294 Accupro Tabs. 20 mg. 28 28 28 FC09AA06 QUINAPRIL 10327 Accupro (P.C.O. Mfg.) Tabs. 5 mg. 28 28 28 FC09AA06 QUINAPRIL 10462 Accupro (P.C.O. Mfg.) Tabs. 20 mg. 28 28 28 FC09AA06 QUINAPRIL 10614 Accupro (P.C.O. Mfg.) Tabs. 10 mg. 30 30 30 FC09AA07 BENAZEPRIL 17526 Cibacen Tabs. 5 mg. 28 28 28 FC09AA07 BENAZEPRIL 17530 Cibacen Tabs. 10 mg. 28 28 28 FC09AA10 TRANDOLAPRIL 26740 Gopten (B & S Healthcare) Caps. 2 mg. 28 28 28 FC09AA10 TRANDOLAPRIL 66508 Odrik Caps. 0.5 mg. 28 28 28 FC09AA10 TRANDOLAPRIL 66516 Odrik Caps. 1 mg. 28 28 28 FC09AA10 TRANDOLAPRIL 66524 Odrik Caps. 2 mg. 28 28 28 FC09AA15 ZOFENOPRIL 53965 Zofenil Tabs. 30 mg. 28 28 28 FC09AA15 ZOFENOPRIL 53972 Zofenil Tabs. 7.5 mg. 12 12 12 FC09BA01 CAPTOPRIL AND DIURETICS 17287 Capozide (B & S Healthcare) Tabs. 50/25 mg. 28 28 28 FC09BA01 CAPTOPRIL AND DIURETICS 27105 Capozide Tabs. 50/25 mg. 30 30 30 FC09BA01 CAPTOPRIL AND DIURETICS 68624 Captor-HCT Tabs. 25/12.5 mg. 30 30 30 FC09BA01 CAPTOPRIL AND DIURETICS 68690 Captor-HCT Tabs. 50/25 mg. 30 30 30 FC09BA02 ENALAPRIL AND DIURETICS 29939 Innozide Tabs. 28 28 28 FC09BA03 LISINOPRIL AND DIURETICS 31857 Lispril-Hydrochlorothiazide Tabs. 20 mg./12.5 mg. 30 30 30 FC09BA03 LISINOPRIL AND DIURETICS 31918 Lispril-Hydrochlorothiazide Tabs. 10 mg./12.5 mg. 30 30 30 FC09BA03 LISINOPRIL AND DIURETICS 52207 Zestoretic (LTT Pharma Ltd.) Tabs. 10 mg./12.5 mg. 28 28 28 FC09BA03 LISINOPRIL AND DIURETICS 52208 Zestoretic (LTT Pharma Ltd.) Tabs. 20 mg./12.5 mg. 28 28 28 FC09BA03 LISINOPRIL AND DIURETICS 52270 Zestoretic Tabs. 10 mg./12.5 mg. 28 28 28 FC09BA03 LISINOPRIL AND DIURETICS 52299 Zestoretic Tabs. 20 mg./12.5 mg. 28 28 28 FC09BA03 LISINOPRIL AND DIURETICS 53811 Zesger Plus Tabs. 20/12.5 mg. 28 28 28 FC09BA04 PERINDOPRIL AND DIURETICS 19415 Coversyl Arginine Plus Film Coated Tabs. 5 mg./1.25 mg. 30 30 30 F

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Core List F(Diabetes Mellitus)

January 2019

ATCLVL5 Non Proprietary Drug Cde Dma

Drug Description Pack Size Name

PackSize

Typ Illness

C09BA04 PERINDOPRIL AND DIURETICS 19505 Coversyl Arginine Plus Film Coated Tabs. 10 mg./2.5 mg. 30 30 30 FC09BA04 PERINDOPRIL AND DIURETICS 19509 Coversyl Arginine Plus (B & S Healthcare) Film Coated Tabs. 5 mg./1.25 mg. 30 30 30 FC09BA04 PERINDOPRIL AND DIURETICS 19512 Coversyl Arginine Plus (Imbat Ltd.) Film Coated Tabs. 5 mg./1.25 mg. 30 30 30 FC09BA04 PERINDOPRIL AND DIURETICS 39114 Perindopril Tosilate/Indapamide TEVA Film Coated Tabs. 2.5 mg./0.625 mg. 30 30 30 FC09BA04 PERINDOPRIL AND DIURETICS 39115 Perindopril Tosilate/Indapamide TEVA Film Coated Tabs. 5 mg./1.25 mg. 30 30 30 FC09BA04 PERINDOPRIL AND DIURETICS 39122 Perindopril Tostilate/Indapamide Teva Film Coated Tabs. 10 mg./2.5 mg. 30 30 30 FC09BA04 PERINDOPRIL AND DIURETICS 68304 Coversyl Arginine Tabs. 2.5 mg./0.625 mg. 30 30 30 FC09BA04 PERINDOPRIL AND DIURETICS 68311 Coversyl Arginine Plus (LTT Pharma Ltd.) Film Coated Tabs. 5 mg./1.25 mg. 30 30 30 FC09BA04 PERINDOPRIL AND DIURETICS 68338 Coversyl Arginine Plus (Clear Pharmacy) Film Coated Tabs. 5 mg./1.25 mg. 30 30 30 FC09BA04 PERINDOPRIL AND DIURETICS 76804 Pendrex Plus Tabs. 4 mg./1.25 mg. 30 30 30 FC09BA05 RAMIPRIL AND DIURETICS 53636 Trialix Tabs. 28 28 28 FC09BA06 QUINAPRIL AND DIURETICS 10092 Accuretic Tabs. 20/12.5 mg. 28 28 28 FC09BB02 ENALAPRIL AND LERCANIDIPINE 31470 Lercaril Film Coated Tabs. 10 mg./10 mg. 28 28 28 FC09BB02 ENALAPRIL AND LERCANIDIPINE 31482 Lercaril Film Coated Tabs. 20 mg./10 mg. 28 28 28 FC09BB02 ENALAPRIL AND LERCANIDIPINE 13484 Enalapril/Lercanidipine (KRKA Pharma) Film Coated Tabs. 10 mg./10 mg. 28 28 28 FC09BB02 ENALAPRIL AND LERCANIDIPINE 13485 Enalapril/Lercanidipine (KRKA Pharma) Film Coated Tabs. 20 mg./10 mg. 28 28 28 FC09BB04 PERINDOPRIL AND AMLODIPINE 36844 Perindopril Tosilate/Amlodipine TEVA Tabs. 5 mg./5 mg. 30 30 30 FC09BB04 PERINDOPRIL AND AMLODIPINE 36845 Perindopril Tosilate/Amlodipine TEVA Tabs. 10 mg./10 mg. 30 30 30 FC09BB04 PERINDOPRIL AND AMLODIPINE 36847 Perindopril Tosilate/Amlodipine TEVA Tabs. 5 mg./10 mg. 30 30 30 FC09BB04 PERINDOPRIL AND AMLODIPINE 36848 Perindopril Tosilate/Amlodipine TEVA Tabs. 10 mg./5 mg. 30 30 30 FC09BB04 PERINDOPRIL AND AMLODIPINE 11803 Acerycal Tabs. 5 mg./5 mg. 30 30 30 FC09BB04 PERINDOPRIL AND AMLODIPINE 11828 Acerycal Tabs. 5 mg./10 mg. 30 30 30 FC09BB04 PERINDOPRIL AND AMLODIPINE 11829 Acerycal (Clear Pharmacy) Tabs. 5 mg./5 mg. 30 30 30 FC09BB04 PERINDOPRIL AND AMLODIPINE 11830 Acerycal (Clear Pharmacy) Tabs. 5 mg./10 mg. 30 30 30 FC09BB04 PERINDOPRIL AND AMLODIPINE 11831 Acerycal (Clear Pharmacy) Tabs. 10 mg./5 mg. 30 30 30 FC09BB04 PERINDOPRIL AND AMLODIPINE 11832 Acerycal (Clear Pharmacy) Tabs. 10 mg./10 mg. 30 30 30 FC09BB04 PERINDOPRIL AND AMLODIPINE 11849 Acerycal Tabs. 10 mg./5 mg. 30 30 30 FC09BB04 PERINDOPRIL AND AMLODIPINE 11887 Acerycal Tabs. 10 mg./10 mg. 30 30 30 FC09BB04 PERINDOPRIL AND AMLODIPINE 13536 Acerycal (Imbat Ltd.) Tabs. 5 mg./5 mg. 30 30 30 FC09BB04 PERINDOPRIL AND AMLODIPINE 13538 Acerycal (Imbat Ltd.) Tabs. 10 mg./5 mg. 30 30 30 FC09BB04 PERINDOPRIL AND AMLODIPINE 13539 ACERYCAL (IMBAT LTD.) TABS. 10 MG./10 MG. 30 30 30 FC09BB04 PERINDOPRIL AND AMLODIPINE 13555 Acerycal (LTT Pharma Ltd.) Tabs. 5 mg./5 mg. 30 30 30 FC09BB04 PERINDOPRIL AND AMLODIPINE 13556 Acerycal (LTT Pharma Ltd.) Tabs. 5 mg./10 mg. 30 30 30 FC09BB04 PERINDOPRIL AND AMLODIPINE 13557 Acerycal (LTT Pharma Ltd.) Tabs. 10 mg./5 mg. 30 30 30 FC09BB04 PERINDOPRIL AND AMLODIPINE 13558 Acerycal (LTT Pharma Ltd.) Tabs. 10 mg./10 mg. 30 30 30 FC09BB04 PERINDOPRIL AND AMLODIPINE 13572 Acerycal (P.C.O. Mfg.) Tabs. 5 mg./5 mg. 30 30 30 FC09BB04 PERINDOPRIL AND AMLODIPINE 13573 Acerycal (P.C.O. Mfg.) Tabs. 5 mg./10 mg. 30 30 30 FC09BB04 PERINDOPRIL AND AMLODIPINE 13574 Acerycal (P.C.O. Mfg.) Tabs. 10 mg./5 mg. 30 30 30 FC09BB04 PERINDOPRIL AND AMLODIPINE 13575 Acerycal (P.C.O. Mfg.) Tabs. 10 mg./10 mg. 30 30 30 FC09BB04 PERINDOPRIL AND AMLODIPINE 13580 Acerycal (iMED Healthcare Ltd.) Tabs. 5 mg./5 mg. 30 30 30 FC09BB04 PERINDOPRIL AND AMLODIPINE 13581 Acerycal (iMED Healthcare Ltd.) Tabs. 5 mg./10 mg. 30 30 30 FC09BB04 PERINDOPRIL AND AMLODIPINE 13582 Acerycal (iMED Healthcare Ltd.) Tabs. 10 mg./5 mg. 30 30 30 FC09BB04 PERINDOPRIL AND AMLODIPINE 13583 Acerycal (iMED Healthcare Ltd.) Tabs. 10 mg./10 mg. 30 30 30 FC09BB04 PERINDOPRIL AND AMLOPIDINE 13537 ACERYCAL (IMBAT LTD.) TABS. 5 MG./10 MG. 30 30 30 FC09BB05 RAMIPRIL AND FELODIPINE 50117 Triapin Tabs. 2.5/2.5 mg. 28 28 28 FC09BB05 RAMIPRIL AND FELODIPINE 72085 Triapin (P.C.O. Mfg.) Prolonged Release Tabs. 2.5 mg./2.5 mg. 30 30 30 FC09BB05 RAMIPRIL AND FELODIPINE 50134 Triapin Tabs. 5/5 mg. 28 28 28 FC09BB05 RAMIPRIL AND FELODIPINE 50190 Triapin (P.C.O. Mfg.) Tabs. 5/5 mg. 28 28 28 FC09BB05 RAMIPRIL AND FELODIPINE 50114 Triapin (iMED Healthcare Ltd.) Prolonged Release Tabs. 5 mg./5 mg. 28 28 28 FC09BB05 RAMIPRIL AND FELODIPINE 50107 Triapin (LTT Pharma Ltd.) Prolonged ReleaseTabs. 5/5 mg. 28 28 28 FC09CA01 LOSARTAN 32637 Losartan Potassium (Accord Healtcare Ltd.) Film Coated Tabs. 25 mg. 28 28 28 FC09CA01 LOSARTAN 19020 Cozaar Tabs. 50 mg. 28 28 28 FC09CA01 LOSARTAN 19042 Cozaar (P.C.O. Mfg.) Tabs. 100 mg. 28 28 28 F

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Core List F(Diabetes Mellitus)

January 2019

ATCLVL5 Non Proprietary Drug Cde Dma

Drug Description Pack Size Name

PackSize

Typ Illness

C09CA01 LOSARTAN 19051 Cozaar (Imbat Ltd.) Tabs. 100 mg. 28 28 28 FC09CA01 LOSARTAN 19065 Cozaar (Imbat Ltd.) Tabs. 50 mg. 28 28 28 FC09CA01 LOSARTAN 19252 Cozaar (P.C.O. Mfg.) Tabs. 50 mg. 30 30 30 FC09CA01 LOSARTAN 19257 Cozaar Tabs. 12.5 mg. 28 28 28 FC09CA01 LOSARTAN 31912 Lotanos Film Coated Tabs. 50 mg. 28 28 28 FC09CA01 LOSARTAN 31913 Lotanos Film Coated Tabs. 100 mg. 28 28 28 FC09CA01 LOSARTAN 32509 Losartan TEVA Film Coated Tabs. 50 mg. 28 28 28 FC09CA01 LOSARTAN 32510 Losartan TEVA Film Coated Tabs. 100 mg. 28 28 28 FC09CA01 LOSARTAN 32612 Losartan (KRKA Pharma) Film Coated Tabs. 50 mg. 28 28 28 FC09CA01 LOSARTAN 32613 Losartan (KRKA Pharma) Film Coated Tabs. 100 mg. 28 28 28 FC09CA01 LOSARTAN 32624 Losartan Potassium (Accord Healthcare Ltd.) Tabs. 50 mg. 28 28 28 FC09CA01 LOSARTAN 32625 Losartan Potassium (Accord Healthcare Ltd.) Tabs. 100 mg. 28 28 28 FC09CA01 LOSARTAN 32664 Losartan Potassium (Pinewood) Film Coated Tabs. 12.5 mg. 28 28 28 FC09CA01 LOSARTAN 32665 Losartan Potassium (Pinewood) Film Coated Tabs. 50 mg. 28 28 28 FC09CA01 LOSARTAN 32666 Losartan Potassium (Pinewood) Film Coated Tabs. 100 mg. 28 28 28 FC09CA01 LOSARTAN 32630 Myzaar Film Coated Tabs. 50 mg. 28 28 28 FC09CA01 LOSARTAN 32631 Myzaar Film Coated Tabs. 100 mg. 28 28 28 FC09CA01 LOSARTAN 65036 Cozatan Tabs. 100 mg. 28 28 28 FC09CA01 LOSARTAN 76510 COZAAR (iMED HEALTHCARE LTD.) TABS. 50 MG. 28 28 28 FC09CA01 LOSARTAN 76511 COZAAR (iMED HEALTHCARE LTD..) TABS. 100 MG. 28 28 28 FC09CA01 LOSARTAN 76513 Cozaar (Clear Pharmacy) Tabs. 100 mg. 28 28 28 FC09CA01 LOSARTAN 76529 Cozaar Tabs. 100 mg. 28 28 28 FC09CA01 LOSARTAN 76580 Cozaar (B & S Healthcare) Tabs. 50 mg. 28 28 28 FC09CA01 LOSARTAN 76581 Cozaar (B & S Healthcare) Tabs. 100 mg. 28 28 28 FC09CA01 LOSARTAN 76584 Cozaar (Primecrown 2010 Ltd.) Tabs. 50 mg. 28 28 28 FC09CA01 LOSARTAN 76585 Cozaar (Primecrown 2010 Ltd.) Tabs. 100 mg. 28 28 28 FC09CA01 LOSARTAN 76594 Cozaar (Clear Pharmacy) Tabs. 50 mg. 28 28 28 FC09CA01 LOSARTAN 91090 Cozaar Pdr. & Solv. for Oral Susp. 2.5 mg./ml Pack 1 1 1 FC09CA01 LOSARTAN 65008 Cosartal Tabs. 50 mg. 28 28 28 FC09CA01 LOSARTAN 65009 Cosartal Tabs. 100 mg. 28 28 28 FC09CA01 LOSARTAN 65035 Cozatan Tabs. 50 mg. 28 28 28 FC09CA02 EPROSARTAN 49420 Teveten Tabs. 600 mg. 28 28 28 FC09CA02 EPROSARTAN 49480 Teveten (iMED Healthcare Ltd.) Film Coated Tabs. 600 mg. 28 28 28 FC09CA02 EPROSARTAN 49422 Teveten (Imbat Ltd.) Tabs. 600 mg. 28 28 28 FC09CA02 EPROSARTAN 49461 Teveten (P.C.O. Mfg.) Tabs. 600 mg. 28 28 28 FC09CA02 EPROSARTAN 49468 Teveten Tabs. 400 mg. 56 56 56 FC09CA02 EPROSARTAN 49472 Teveten (P.C.O. Mfg.) Tabs. 400 mg. 28 28 28 FC09CA02 EPROSARTAN 49502 Teveten (LTT Pharma Ltd.) Film Coated Tabs. 400 mg. 56 56 56 FC09CA02 EPROSARTAN 49503 Teveten (LTT Pharma Ltd.) Film Coated Tabs. 600 mg. 28 28 28 FC09CA02 EPROSARTAN 49512 Teveten (G & A Licensing Ltd.) Tabs. 600 mg. 30 30 30 FC09CA03 VALSARTAN 73702 Diovan Tabs. 80 mg. 28 28 28 FC09CA03 VALSARTAN 73704 Valsartan (Actavis) Tabs. 40 mg. 28 28 28 FC09CA03 VALSARTAN 73705 Valsartan (Actavis) Tabs. 80 mg. 28 28 28 FC09CA03 VALSARTAN 73706 Valsartan (Actavis) Tabs. 160 mg. 28 28 28 FC09CA03 VALSARTAN 73708 Diovan (Imbat Ltd.) Film Coated Tabs. 40 mg. 28 28 28 FC09CA03 VALSARTAN 73712 Diovan (P.C.O. Mfg.) Film Coated Tabs. 80 mg. 28 28 28 FC09CA03 VALSARTAN 73713 Diovan (P.C.O. Mfg.) Film Coated Tabs. 160 mg. 28 28 28 FC09CA03 VALSARTAN 73728 Diovan Tabs. 40 mg. 28 28 28 FC09CA03 VALSARTAN 73733 Valsartan TEVA Tabs. 40 mg. 28 28 28 FC09CA03 VALSARTAN 73734 Valsartan TEVA Tabs. 80 mg. 28 28 28 FC09CA03 VALSARTAN 73735 Valsartan TEVA Tabs. 160 mg. 28 28 28 FC09CA03 VALSARTAN 73738 Valsartan (KRKA Pharma) Film Coated Tabs. 40 mg. 28 28 28 FC09CA03 VALSARTAN 73739 Valsartan (KRKA Pharma) Film Coated Tabs. 80 mg. 28 28 28 F

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Core List F(Diabetes Mellitus)

January 2019

ATCLVL5 Non Proprietary Drug Cde Dma

Drug Description Pack Size Name

PackSize

Typ Illness

C09CA03 VALSARTAN 73740 Valsartan (KRKA Pharma) Film Coated Tabs. 160 mg. 28 28 28 FC09CA03 VALSARTAN 73755 Diovan Tabs. 160 mg. 28 28 28 FC09CA03 VALSARTAN 73762 Diovan Tabs. 320 mg. 28 28 28 FC09CA03 VALSARTAN 73766 Diovan Oral Soln. 3 mg./ml. 160 ml. 160ML 160 FC09CA03 VALSARTAN 73770 Diovan (Imbat Ltd.) Tabs. 80 mg. 28 28 28 FC09CA03 VALSARTAN 73775 Diovan (Imbat Ltd.) Tabs. 160 mg. 28 28 28 FC09CA03 VALSARTAN 73777 Valtan Tabs. 40 mg. 28 28 28 FC09CA03 VALSARTAN 73778 Valtan Tabs. 80 mg. 28 28 28 FC09CA03 VALSARTAN 73779 Valtan Tabs. 160 mg. 28 28 28 FC09CA03 VALSARTAN 73780 Valsartan Mylan (Gerard Labs.) Film Coated Tabs. 40 mg. 28 28 28 FC09CA03 VALSARTAN 73781 Valsartan Mylan (Gerard Labs.) Film Coated Tabs. 80 mg. 28 28 28 FC09CA03 VALSARTAN 73782 Valsartan Mylan (Gerard Labs.) Film Coated Tabs. 160 mg. 28 28 28 FC09CA03 VALSARTAN 73783 Valsartan Mylan (Gerard Labs.) Film Coated Tabs. 320 mg. 28 28 28 FC09CA03 VALSARTAN 73794 Valsartan (Rowa) Film Coated Tabs. 40 mg. 28 28 28 FC09CA03 VALSARTAN 73795 Valsartan (Rowa) Film Coated Tabs. 80 mg. 28 28 28 FC09CA03 VALSARTAN 73796 Valsartan (Rowa) Film Coated Tabs. 160 mg. 28 28 28 FC09CA04 IRBESARTAN 12015 Aprovel (B & S Healthcare) Tabs. 150 mg. 28 28 28 FC09CA04 IRBESARTAN 12027 Aprovel (B & S Healthcare) Tabs. 75 mg. 28 28 28 FC09CA04 IRBESARTAN 12053 Aprovel Tabs. 75 mg. 28 28 28 FC09CA04 IRBESARTAN 12059 Aprovel (B & S Healthcare) Tabs. 300 mg. 28 28 28 FC09CA04 IRBESARTAN 12064 Aprovel Tabs. 150 mg. 28 28 28 FC09CA04 IRBESARTAN 12077 Aprovel Tabs. 300 mg. 28 28 28 FC09CA04 IRBESARTAN 12100 Aprovel (Doncaster Ltd.) Tabs. 75 mg. 28 28 28 FC09CA04 IRBESARTAN 12118 Aprovel (BR Lewis Pharmaceuticals) Tabs. 75 mg. 28 28 28 FC09CA04 IRBESARTAN 12124 Aprovel (BR Lewis Pharmaceuticals) Tabs. 150 mg. 28 28 28 FC09CA04 IRBESARTAN 12125 Aprovel (Doncaster Ltd.) Tabs. 150 mg. 28 28 28 FC09CA04 IRBESARTAN 12142 Aprovel (Doncaster Ltd.) Tabs. 300 mg 28 28 28 FC09CA04 IRBESARTAN 12193 Aprovel (BR Lewis Pharmaceuticals) Tabs. 300 mg. 28 28 28 FC09CA04 IRBESARTAN 12209 Aprovel (Lexon UK) Tabs. 75 mg. 28 28 28 FC09CA04 IRBESARTAN 12210 Aprovel (Lexon UK) Tabs. 300 mg. 28 28 28 FC09CA04 IRBESARTAN 12242 Aprovel (P.C.O. Mfg.) Film Coated Tabs. 75 mg. 28 28 28 FC09CA04 IRBESARTAN 12258 Aprovel (P.C.O. Mfg.) Film Coated Tabs. 150 mg. 28 28 28 FC09CA04 IRBESARTAN 12266 Aprovel (P.C.O. Mfg.) Film Coated Tabs. 300 mg. 28 28 28 FC09CA04 IRBESARTAN 12271 Aprovel (Waymade Healthcare PLC) Tabs. 75 mg. 28 28 28 FC09CA04 IRBESARTAN 12272 Aprovel (Waymade Healthcare Plc) Tabs. 150 Mg. 28 28 28 FC09CA04 IRBESARTAN 12273 Aprovel (Waymade Healthcare Plc) Tabs. 300 Mg. 28 28 28 FC09CA04 IRBESARTAN 54317 Ifirmasta Film Coated Tabs. 75 mg. 28 28 28 FC09CA04 IRBESARTAN 54318 Ifirmasta Film Coated Tabs. 150 mg. 28 28 28 FC09CA04 IRBESARTAN 54319 Ifirmasta Film Coated Tabs. 300 mg. 28 28 28 FC09CA04 IRBESARTAN 54324 Irbesartan (ROWA) Tabs. 75 mg. 28 28 28 FC09CA04 IRBESARTAN 54325 Irbesartan (ROWA) Tabs. 150 mg. 28 28 28 FC09CA04 IRBESARTAN 54326 Irbesartan (Rowa) Tabs. 300 mg. 28 28 28 FC09CA04 IRBESARTAN 54330 Irbesartan (Accord Healthcare Ltd.) Film Coated Tabs. 75 mg. 28 28 28 FC09CA04 IRBESARTAN 54331 Irbesartan (Accord Healthcare Ltd.) Film Coated Tabs. 150 mg. 28 28 28 FC09CA04 IRBESARTAN 54332 Irbesartan (Accord Healthcare Ltd.) Film Coated Tabs. 300 mg. 28 28 28 FC09CA04 IRBESARTAN 54340 Irbesartan (Clonmel) Film Coated Tabs. 75 mg. 28 28 28 FC09CA04 IRBESARTAN 54341 Irbesartan (Clonmel) Film Coated Tabs. 150 mg. 28 28 28 FC09CA04 IRBESARTAN 54342 Irbesartan (Clonmel) Film Coated Tabs. 300 mg. 28 28 28 FC09CA04 IRBESARTAN 54358 Irprestan Film Coated Tabs. 75 mg. 28 28 28 FC09CA04 IRBESARTAN 54359 Irprestan Film Coated Tabs. 150 mg. 28 28 28 FC09CA04 IRBESARTAN 54360 Irprestan Film Coated Tabs. 300 mg. 28 28 28 FC09CA06 CANDESARTAN 13048 Atacand Tabs. 4 mg. 28 28 28 FC09CA06 CANDESARTAN 13050 Atacand (B & S Healthcare) Tabs. 16 mg. 14 14 14 F

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Core List F(Diabetes Mellitus)

January 2019

ATCLVL5 Non Proprietary Drug Cde Dma

Drug Description Pack Size Name

PackSize

Typ Illness

C09CA06 CANDESARTAN 13068 Atacand (B & S Healthcare) Tabs. 4 mg. 14 14 14 FC09CA06 CANDESARTAN 13070 Atacand (B & S Healthcare) Tabs. 4 mg. 28 28 28 FC09CA06 CANDESARTAN 13071 Atacand (B & S Healthcare) Tabs. 16 mg. 28 28 28 FC09CA06 CANDESARTAN 13088 Atacand (Profind Wholesale Ltd.) Tabs. 4 mg. 28 28 28 FC09CA06 CANDESARTAN 13090 Atacand (Profind Wholesale Ltd.) Tabs. 8 mg. 28 28 28 FC09CA06 CANDESARTAN 13092 Atacand (Profind Wholesale Ltd.) Tabs. 16 mg. 28 28 28 FC09CA06 CANDESARTAN 13123 Atacand Tabs. 8 mg. 28 28 28 FC09CA06 CANDESARTAN 13219 Atacand (P.C.O. Mfg.) Tabs. 4 mg. 15 15 15 FC09CA06 CANDESARTAN 13442 ATACAND (iMED HEALTHCARE LTD.) TABS. 8 MG. 28 28 28 FC09CA06 CANDESARTAN 13443 ATACAND (iMED HEALTHCARE Ltd.) TABS. 16 MG. 28 28 28 FC09CA06 CANDESARTAN 13705 Atacand (P.C.O. Mfg.) Tabs. 8 mg. 28 28 28 FC09CA06 CANDESARTAN 13707 Atacand (Imbat Ltd.) Tabs. 16 mg. 28 28 28 FC09CA06 CANDESARTAN 13737 Atacand (P.C.O. Mfg.) Tabs. 16 mg. 28 28 28 FC09CA06 CANDESARTAN 14689 Candesartan (KRKA Pharma) Tabs. 4 mg. 28 28 28 FC09CA06 CANDESARTAN 14765 Candesartan (KRKA Pharma) Tabs. 8 mg. 28 28 28 FC09CA06 CANDESARTAN 14822 Candesartan (KRKA Pharma) Tabs. 16 mg. 28 28 28 FC09CA06 CANDESARTAN 15409 Candist Tabs. 4 mg. 28 28 28 FC09CA06 CANDESARTAN 15410 Candist Tabs. 8 mg. 28 28 28 FC09CA06 CANDESARTAN 15411 Candist Tabs. 16 mg. 28 28 28 FC09CA06 CANDESARTAN 15417 Candesartan (Actavis) Tabs. 4 mg. 28 28 28 FC09CA06 CANDESARTAN 15418 Candesartan (Actavis) Tabs. 8 mg. 28 28 28 FC09CA06 CANDESARTAN 15419 Candesartan (Actavis) Tabs. 16 mg. 28 28 28 FC09CA06 CANDESARTAN 15427 Atacand (Imbat Ltd.) Tabs. 4 mg. 28 28 28 FC09CA06 CANDESARTAN 15428 Atacand (Imbat Ltd.) Tabs. 8 mg. 28 28 28 FC09CA06 CANDESARTAN 15433 Candesartan Mylan (Gerard Labs.) Tabs. 4 mg. 28 28 28 FC09CA06 CANDESARTAN 15434 Candesartan Mylan (Gerard Labs.) Tabs. 8 mg. 28 28 28 FC09CA06 CANDESARTAN 15435 Candesartan Mylan (Gerard Labs.) Tabs. 16 mg. 28 28 28 FC09CA06 CANDESARTAN 15491 Catasart Tabs. 4 mg. 28 28 28 FC09CA06 CANDESARTAN 15492 Catasart Tabs. 8 mg. 28 28 28 FC09CA06 CANDESARTAN 15493 Catasart Tabs. 16 mg. 28 28 28 FC09CA06 CANDESARTAN 21306 Candesartan TEVA Tabs. 8 mg. 28 28 28 FC09CA06 CANDESARTAN 21498 Candesartan TEVA Tabs. 16 mg. 28 28 28 FC09CA06 CANDESARTAN 13084 Atacand (B & S Healthcare) Tabs. 8 mg. 28 28 28 FC09CA06 CANDESARTAN 13439 Atacand Tabs. 16 mg. 28 28 28 FC09CA06 CANDESARTAN 63900 Blopress Tabs. 2 mg. 7 7 7 FC09CA06 CANDESARTAN 63901 Blopress Tabs. 2 mg. 28 28 28 FC09CA06 CANDESARTAN 63902 Blopress Tabs. 4 mg. 7 7 7 FC09CA06 CANDESARTAN 63903 Blopress Tabs. 4 mg. 28 28 28 FC09CA06 CANDESARTAN 63904 Blopress Tabs. 8 mg. 28 28 28 FC09CA06 CANDESARTAN 63905 Blopress Tabs.16 mg. 28 28 28 FC09CA06 CANDESARTAN 63906 Blopress Tabs. 32 mg. 28 28 28 FC09CA07 TELMISARTAN 34412 Micardis Tabs. 40 mg. 28 28 28 FC09CA07 TELMISARTAN 34487 Micardis Tabs. 80 mg. 28 28 28 FC09CA07 TELMISARTAN 34501 Micardis (B & S Healthcare) Tabs. 20 mg. 28 28 28 FC09CA07 TELMISARTAN 34502 Micardis (Doncaster Ltd.) Tabs. 20 mg. 28 28 28 FC09CA07 TELMISARTAN 34522 Micardis (BR Lewis Pharmaceuticals) Tabs. 20 mg. 28 28 28 FC09CA07 TELMISARTAN 34530 Micardis (Doncaster Ltd.) Tabs. 40 mg. 28 28 28 FC09CA07 TELMISARTAN 34541 Micardis (BR Lewis Pharmaceuticals) Tabs. 40 mg. 28 28 28 FC09CA07 TELMISARTAN 34552 Micardis (B & S Healthcare) Tabs. 40 mg. 28 28 28 FC09CA07 TELMISARTAN 34562 Micardis (BR Lewis Pharmaceuticals) Tabs. 80 mg. 28 28 28 FC09CA07 TELMISARTAN 34567 Micardis (B & S Healthcare) Tabs. 80 mg. 28 28 28 FC09CA07 TELMISARTAN 34570 Micardis (P.C.O. Mfg.) Tabs. 20 mg. 28 28 28 FC09CA07 TELMISARTAN 34582 Micardis (P.C.O. Mfg.) Tabs. 40 mg. 28 28 28 F

Page 20: S 'PD 1DPH 6L]H ,OOQHVV $FWUDSLG 9LDO ,8 PO PO 9LDO ; 0 ... · &ruh /lvw ) 'ldehwhv 0hoolwxv -dqxdu\ $7&/9/ 1rq 3ursulhwdu\ 'uxj &gh 'pd 'uxj 'hvfulswlrq 3dfn 6l]h 1dph 3dfn 6l]h

Core List F(Diabetes Mellitus)

January 2019

ATCLVL5 Non Proprietary Drug Cde Dma

Drug Description Pack Size Name

PackSize

Typ Illness

C09CA07 TELMISARTAN 34591 Micardis (P.C.O. Mfg.) Tabs. 80 mg. 28 28 28 FC09CA07 TELMISARTAN 34593 Micardis (Doncaster Ltd.) Tabs. 80 mg. 28 28 28 FC09CA07 TELMISARTAN 40271 Tolura Tabs. 40 mg. 28 28 28 FC09CA07 TELMISARTAN 40288 Tolura Tabs. 80 mg. 28 28 28 FC09CA07 TELMISARTAN 63075 Telmisartan (Rowex) Tabs. 20 mg. 28 28 28 FC09CA07 TELMISARTAN 63289 Telmisartan (Rowex) Tabs. 40 mg. 28 28 28 FC09CA07 TELMISARTAN 63759 Telmisartan (Rowex) Tabs. 80 mg. 28 28 28 FC09CA07 TELMISARTAN 64404 MICARDIS (iMED Heathcare Ltd.) TABS. 20 MG. 28 28 28 FC09CA07 TELMISARTAN 64413 Micardis Tabs. 20 mg. 28 28 28 FC09CA07 TELMISARTAN 64414 Telmisartan (Actavis) Tabs. 20 mg. 28 28 28 FC09CA07 TELMISARTAN 64415 Telmisartan (Actavis) Tabs. 40 mg. 28 28 28 FC09CA07 TELMISARTAN 64416 Telmisartan (Actavis) Tabs. 80 mg. 28 28 28 FC09CA07 TELMISARTAN 64418 Micardis (Waymade Healthcare Plc) Tabs. 20 Mg. 28 28 28 FC09CA07 TELMISARTAN 64419 Micardis (Waymade Healthcare Plc) Tabs. 40 Mg. 28 28 28 FC09CA07 TELMISARTAN 64420 Micardis (Waymade Healthcare Plc) Tabs. 80 mg. 28 28 28 FC09CA07 TELMISARTAN 64422 Telmisartan (Clonmel) Film Coated Tabs. 20 mg. 28 28 28 FC09CA07 TELMISARTAN 64423 Telmisartan (Clonmel) Film Coated Tabs. 40 mg. 28 28 28 FC09CA07 TELMISARTAN 64424 Telmisartan (Clonmel) Film Coated Tabs. 80 mg. 28 28 28 FC09CA07 TELMISARTAN 64428 Telmisartan Mylan (Gerard Labs.) Tabs. 20 mg. 28 28 28 FC09CA07 TELMISARTAN 64429 Telmisartan Mylan (Gerard Labs.) Tabs. 40 mg. 28 28 28 FC09CA07 TELMISARTAN 64430 Telmisartan Mylan (Gerard Labs.) Tabs. 80 mg. 28 28 28 FC09CA07 TELMISARTAN 64434 Telmisartan TEVA Pharma Tabs. 20 mg. 28 28 28 FC09CA07 TELMISARTAN 64435 Telmisartan TEVA Pharma Tabs. 40 mg. 28 28 28 FC09CA07 TELMISARTAN 64436 Telmisartan TEVA Pharma Tabs. 80 mg. 28 28 28 FC09CA07 TELMISARTAN 64470 Micardis (Pharmaram Ltd.) Tabs. 40 mg. 28 28 28 FC09CA07 TELMISARTAN 64475 Micardis (iMED Healthcare Ltd.) Tabs. 40 mg. 28 28 28 FC09CA07 TELMISARTAN 64476 Micardis (iMED Healthcare Ltd.) Tabs. 80 mg. 28 28 28 FC09CA07 TELMISARTAN 64480 Micardis (Lexon UK) Tabs. 20 mg. 28 28 28 FC09CA07 TELMISARTAN 64481 Micardis (Lexon UK) Tabs. 40 mg. 28 28 28 FC09CA07 TELMISARTAN 64482 Micardis (Lexon UK) Tabs. 80 mg. 28 28 28 FC09CA07 TELMISARTAN 64471 Micardis (Pharmaram Ltd.) Tabs. 80 mg. 28 28 28 FC09CA08 OLMESARTAN MEDOXOMIL 37623 Olmesartan Medoxomil (Accord Healthcare Ltd.) Film Coated Tabs. 10 mg. 28 28 28 FC09CA08 OLMESARTAN MEDOXOMIL 37624 Olmesartan Medoxomil (Accord Healthcare Ltd.) Film Coated Tabs. 20 mg. 28 28 28 FC09CA08 OLMESARTAN MEDOXOMIL 37625 Olmesartan Medoxomil (Accord Healthcare Ltd.) Film Coated Tabs. 40 mg. 28 28 28 FC09CA08 OLMESARTAN MEDOXOMIL 37637 Olmesartan Medoxomil (Generics UK) Mylan Film Coated Tabs. 10 mg. 28 28 28 FC09CA08 OLMESARTAN MEDOXOMIL 37638 Olmesartan Medoxomil (Generics UK) Mylan Film Coated Tabs. 20 mg. 28 28 28 FC09CA08 OLMESARTAN MEDOXOMIL 37639 Olmesartan Medoxomil (Generics UK) Mylan Film Coated Tabs. 40 mg. 28 28 28 FC09CA08 OLMESARTAN MEDOXOMIL 37601 Olmesartan Medoxomil Teva Film Coated Tabs. 10 mg. 28 28 28 FC09CA08 OLMESARTAN MEDOXOMIL 37603 Olmesartan Medoxomil Teva Film Coated Tabs. 20 mg. 28 28 28 FC09CA08 OLMESARTAN MEDOXOMIL 34856 Olmesartan (Rowex) Film Coated Tabs. 10 mg. 28 28 28 FC09CA08 OLMESARTAN MEDOXOMIL 34857 Olmesartan (Rowex) Film Coated Tabs. 20 mg. 28 28 28 FC09CA08 OLMESARTAN MEDOXOMIL 34860 Olmesartan (Rowex) Film Coated Tabs. 40 mg. 28 28 28 FC09CA08 OLMESARTAN MEDOXOMIL 34853 Olmesartan (KRKA Pharma) Film Coated Tabs. 10 mg. 28 28 28 FC09CA08 OLMESARTAN MEDOXOMIL 34854 Olmesartan (KRKA Pharma) Film Coated Tabs. 20 mg. 28 28 28 FC09CA08 OLMESARTAN MEDOXOMIL 34855 Olmesartan (KRKA Pharma) Film Coated Tabs. 40 mg. 28 28 28 FC09CA08 OLMESARTAN MEDOXOMIL 46987 Olmesartan Medoxomil (Clonmel) Film Coated Tabs. 10 mg. 28 28 28 FC09CA08 OLMESARTAN MEDOXOMIL 47298 Olmesartan Medoxomil (Clonmel) Film Coated Tabs. 20 mg. 28 28 28 FC09CA08 OLMESARTAN MEDOXOMIL 47685 Olmesartan Medoxomil (Clonmel) Film Coated Tabs. 40 mg. 28 28 28 FC09CA08 OLMESARTAN MEDOXOMIL 14408 Benetor Film Coated Tabs. 10 mg. 28 28 28 FC09CA08 OLMESARTAN MEDOXOMIL 14412 Benetor Film Coated Tabs. 20 mg. 28 28 28 FC09CA08 OLMESARTAN MEDOXOMIL 14483 Benetor Film Coated Tabs. 40 mg. 28 28 28 FC09CA08 OLMESARTAN MEDOXOMIL 37602 Omesar Film Coated Tabs. 10 mg. 28 28 28 FC09CA08 OLMESARTAN MEDOXOMIL 37617 Omesar Film Coated Tabs. 20 mg. 28 28 28 F

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Core List F(Diabetes Mellitus)

January 2019

ATCLVL5 Non Proprietary Drug Cde Dma

Drug Description Pack Size Name

PackSize

Typ Illness

C09CA08 OLMESARTAN MEDOXOMIL 37620 Omesar (Imbat Ltd.) Film Coated Tabs. 40 mg. 28 28 28 FC09CA08 OLMESARTAN MEDOXOMIL 37628 Omesar (P.C.O. Mfg.) Film Coated Tabs. 10 mg. 28 28 28 FC09CA08 OLMESARTAN MEDOXOMIL 21493 Omesar (iMED Healthcare Ltd.) Film Coated Tabs. 10 mg. 28 28 28 FC09CA08 OLMESARTAN MEDOXOMIL 37631 Omesar Film Coated Tabs. 40 mg. 28 28 28 FC09CA08 OLMESARTAN MEDOXOMIL 40751 Omesar (iMED Healthcare Ltd.) Film Coated Tabs. 20 mg. 28 28 28 FC09CA08 OLMESARTAN MEDOXOMIL 40852 Omesar (iMED Healthcare Ltd.) Film Coated Tabs. 40 mg. 28 28 28 FC09CA08 OLMESARTAN MEDOXOMIL 41857 Omesar (P.C.O. Mfg.) Film Coated Tabs. 20 mg. 28 28 28 FC09CA08 OLMESARTAN MEDOXOMIL 41978 Omesar (P.C.O. Mfg.) Film Coated Tabs. 40 mg. 28 28 28 FC09CA09 AZILSARTAN MEDOXOMIL 51002 Edarbi Tabs. 20 mg. 28 28 28 FC09CA09 AZILSARTAN MEDOXOMIL 51003 Edarbi Tabs. 40 mg. 28 28 28 FC09CA09 AZILSARTAN MEDOXOMIL 51004 Edarbi Tabs. 80 mg. 28 28 28 FC09DA01 LOSARTAN AND DIURETICS 15465 COZATAN COMP TABS. 50 MG./12.5 MG. 28 28 28 FC09DA01 LOSARTAN AND DIURETICS 15746 Cosartal Plus Film Coated Tabs. 100 mg./12.5 mg. 28 28 28 FC09DA01 LOSARTAN AND DIURETICS 15789 Cozatan Comp Tabs. 100 mg./25 mg. 28 28 28 FC09DA01 LOSARTAN AND DIURETICS 19025 Cozaar Comp Tabs. 100/25 mg. 28 28 28 FC09DA01 LOSARTAN AND DIURETICS 19032 Cozaar Comp Tabs. 50/12.5 mg. 28 28 28 FC09DA01 LOSARTAN AND DIURETICS 19061 Cozaar-Comp (P.C.O. Mfg.) Tabs. 100 mg./25 mg. 28 28 28 FC09DA01 LOSARTAN AND DIURETICS 19108 Cozaar-Comp (P.C.O. Mfg.) Tabs. 50/12.5 mg. 28 28 28 FC09DA01 LOSARTAN AND DIURETICS 19211 Cozaar Comp (B & S Healthcare) Tabs. 50 mg./12.5 mg. 28 28 28 FC09DA01 LOSARTAN AND DIURETICS 19212 Cozaar Comp (B & S Healthcare) Tabs. 100 mg./25 mg. 28 28 28 FC09DA01 LOSARTAN AND DIURETICS 19218 Cozaar Comp Tabs. 100 mg./12.5 mg. 28 28 28 FC09DA01 LOSARTAN AND DIURETICS 19220 Cozaar Comp (Imbat Ltd.) Tabs. 100 mg./25 mg. 28 28 28 FC09DA01 LOSARTAN AND DIURETICS 19269 Cozaar Comp (Clear Pharmacy) Tabs. 50 mg./12.5 mg. 28 28 28 FC09DA01 LOSARTAN AND DIURETICS 19270 Cozaar Comp (Clear Pharmacy) Tabs. 100 mg./25 mg. 28 28 28 FC09DA01 LOSARTAN AND DIURETICS 19280 Cozaar Comp (Imbat Ltd.) Tabs. 50 mg./12.5 mg. 28 28 28 FC09DA01 LOSARTAN AND DIURETICS 23456 Losartan/Hydrochlorothiazide (KRKA Pharma) Film Coated Tabs. 50 mg./12.5 mg. 28 28 28 FC09DA01 LOSARTAN AND DIURETICS 23710 Losartan/Hydrochlorothiazide (KRKA Pharma) Film Coated Tabs. 100 mg./12.5 mg. 28 28 28 FC09DA01 LOSARTAN AND DIURETICS 23842 Losartan/Hydrochlorothiazide (KRKA Pharma) Film Coated Tabs. 100 mg./25 mg. 28 28 28 FC09DA01 LOSARTAN AND DIURETICS 28912 Losartan and Hydrochlorothiazide (Bluefish) Film Coated Tabs. 50 mg./12.5 mg. 28 28 28 FC09DA01 LOSARTAN AND DIURETICS 29658 Losartan and Hydrochlorothiazide (Bluefish) Film Coated Tabs. 100 mg./25 mg. 28 28 28 FC09DA01 LOSARTAN AND DIURETICS 31920 Lotanos Comp Tabs. 50 mg./12.5 mg. 28 28 28 FC09DA01 LOSARTAN AND DIURETICS 31921 Lotanos Comp Tabs. 100 mg./25 mg. 28 28 28 FC09DA01 LOSARTAN AND DIURETICS 32580 Losartan and Hydrochlorothiazide TEVA Film Coated Tabs. 50 mg./12.5 mg. 28 28 28 FC09DA01 LOSARTAN AND DIURETICS 32581 Losartan and Hydrochlorothiazide TEVA Film Coated Tabs. 100 mg./25 mg. 28 28 28 FC09DA01 LOSARTAN AND DIURETICS 65042 Cosartal Plus Tabs. 50 mg./12.5 mg. 28 28 28 FC09DA01 LOSARTAN AND DIURETICS 65043 Cosartal Plus Tabs. 100 mg./25 mg. 28 28 28 FC09DA02 ESPROSARTAN AND DIURETICS 49457 Teveten Plus Tabs. 600/12.5 mg. 28 28 28 FC09DA03 VALSARTAN AND DIURETICS 13187 Valsartan/Hydrochlorothiazide (KRKA Pharma) Film Coated Tabs. 320 mg./12.5 mg. 28 28 28 FC09DA03 VALSARTAN AND DIURETICS 13189 Valsartan/Hydrochlorothiazide (KRKA Pharma) Film Coated Tabs. 320 mg./25 mg. 28 28 28 FC09DA03 VALSARTAN AND DIURETICS 17442 Co-Diovan Tabs. 80/12.5 mg. 28 28 28 FC09DA03 VALSARTAN AND DIURETICS 17913 Co-Diovan Tabs. 320 mg./12.5 mg. 28 28 28 FC09DA03 VALSARTAN AND DIURETICS 17985 Co-Diovan Tabs. 160/25 mg. 28 28 28 FC09DA03 VALSARTAN AND DIURETICS 17992 Co-Diovan Tabs. 320 mg./25 mg. 28 28 28 FC09DA03 VALSARTAN AND DIURETICS 18705 Co-Diovan Film Coated Tabs. 160/12.5 mg. 28 28 28 FC09DA03 VALSARTAN AND DIURETICS 18708 Co-Diovan (P.C.O. Mfg.) Tabs. 80/12.5 mg. 28 28 28 FC09DA03 VALSARTAN AND DIURETICS 18709 Co-Diovan (P.C.O. Mfg.) Tabs. 160/12.5 mg 28 28 28 FC09DA03 VALSARTAN AND DIURETICS 18710 Co-Diovan (P.C.O. Mfg.) Tabs. 160 mg./25 mg. 28 28 28 FC09DA03 VALSARTAN AND DIURETICS 18723 Co-Diovan (Clear Pharmacy) Tabs. 80 mg./12.5 mg. 28 28 28 FC09DA03 VALSARTAN AND DIURETICS 18724 Co-Diovan (Clear Pharmacy) Tabs. 160 mg./12.5 mg. 28 28 28 FC09DA03 VALSARTAN AND DIURETICS 18725 Co-Diovan (Clear Pharmacy) Tabs. 160 mg./25 mg. 28 28 28 FC09DA03 VALSARTAN AND DIURETICS 18727 Co-Diovan (Imbat Ltd.) Film Coated Tabs. 80 mg./12.5 mg. 28 28 28 FC09DA03 VALSARTAN AND DIURETICS 18728 Co-Diovan (Imbat Ltd.) Film Coated Tabs. 160 mg./12.5 mg. 28 28 28 FC09DA03 VALSARTAN AND DIURETICS 18729 Co-Diovan (Imbat Ltd.) Film Coated Tabs. 160 mg./25 mg. 28 28 28 F

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Core List F(Diabetes Mellitus)

January 2019

ATCLVL5 Non Proprietary Drug Cde Dma

Drug Description Pack Size Name

PackSize

Typ Illness

C09DA03 VALSARTAN AND DIURETICS 18735 Co-Diovan (P.C.O. Mfg.) Film Coated Tabs. 320 mg./25 mg. 28 28 28 FC09DA03 VALSARTAN AND DIURETICS 18750 Co-Diovan (iMED Healthcare Ltd.) Film Coated Tabs. 80 mg./12.5 mg. 28 28 28 FC09DA03 VALSARTAN AND DIURETICS 18751 Co-Diovan (iMED Healthcare Ltd.) Film Coated Tabs. 160 mg./12.5 mg. 28 28 28 FC09DA03 VALSARTAN AND DIURETICS 18752 Co-Diovan (iMED Healthcare Ltd.) Film Coated Tabs. 160 mg./25 mg. 28 28 28 FC09DA03 VALSARTAN AND DIURETICS 32446 Co-Vatan Tabs. 80 mg./12.5 mg. 28 28 28 FC09DA03 VALSARTAN AND DIURETICS 32447 Co-Vatan Tabs. 160 mg./12.5 mg. 28 28 28 FC09DA03 VALSARTAN AND DIURETICS 32448 Co-Vatan Tabs. 160 mg./25 mg. 28 28 28 FC09DA03 VALSARTAN AND DIURETICS 73720 Valsartan/Hydrochlorothiazide (KRKA Pharma) FC Tabs. 80 mg./12.5 mg. 28 28 28 FC09DA03 VALSARTAN AND DIURETICS 73721 Valsartan/Hydrochlorothiazide (KRKA Pharma) FC Tabs. 160 mg./12.5 mg. 28 28 28 FC09DA03 VALSARTAN AND DIURETICS 73722 Valsartan/Hydrochlorothiazide (KRKA Pharma) FC Tabs. 160 mg./25 mg. 28 28 28 FC09DA03 VALSARTAN AND DIURETICS 73745 Valsartan/HCTZ (Actavis) Tabs. 80 mg./12.5 mg. 28 28 28 FC09DA03 VALSARTAN AND DIURETICS 73746 Valsartan/HCTZ (Actavis) Tabs. 160 mg./12.5 mg. 28 28 28 FC09DA03 VALSARTAN AND DIURETICS 73747 Valsartan/HCTZ (Actavis) Tabs. 160 mg./25 mg. 28 28 28 FC09DA03 VALSARTAN AND DIURETICS 73757 Valsartan/HCTZ TEVA Tabs. 80 mg./12.5 mg. 28 28 28 FC09DA03 VALSARTAN AND DIURETICS 73758 Valsartan/HCTZ TEVA Tabs. 160 mg./12.5 mg. 28 28 28 FC09DA03 VALSARTAN AND DIURETICS 73759 Valsartan/HCTZ TEVA Tabs. 160 mg./25 mg. 28 28 28 FC09DA03 VALSARTAN AND DIURETICS 73788 Valtan Comp Tabs. 80 mg./12.5 mg. 28 28 28 FC09DA04 IRBESARTAN AND DIURETICS 17182 Co-Aprovel (BR Lewis Pharmaceuticals) Tabs. 150/12.5 mg. 28 28 28 FC09DA04 IRBESARTAN AND DIURETICS 17190 Co-Aprovel (BR Lewis Pharmaceuticals) Tabs. 300/12.5 mg. 28 28 28 FC09DA04 IRBESARTAN AND DIURETICS 17923 Co-Aprovel (Doncaster Ltd.) Tabs. 150/12.5 mg. 28 28 28 FC09DA04 IRBESARTAN AND DIURETICS 17961 Co-Aprovel (Doncaster Ltd.) Tabs. 300/12.5 mg. 28 28 28 FC09DA04 IRBESARTAN AND DIURETICS 17970 Co-Aprovel (B & S Healthcare) Tabs. 150/12.5 mg. 28 28 28 FC09DA04 IRBESARTAN AND DIURETICS 19630 Ifirmacombi Film Coated Tabs. 150 mg./12.5 mg. 28 28 28 FC09DA04 IRBESARTAN AND DIURETICS 19671 Ifirmacombi Film Coated Tabs. 300 mg./12.5 mg. 28 28 28 FC09DA04 IRBESARTAN AND DIURETICS 19723 Ifirmacombi Film Coated Tabs. 300 mg./25 mg. 28 28 28 FC09DA04 IRBESARTAN AND DIURETICS 50160 Co-Aprovel Tabs. 300/25 mg. 28 28 28 FC09DA04 IRBESARTAN AND DIURETICS 54307 Co-Aprovel (Lexon UK) Tabs. 150/12.5 mg. 28 28 28 FC09DA04 IRBESARTAN AND DIURETICS 54308 Co-Aprovel (Lexon UK) Tabs. 300/12.5 mg. 28 28 28 FC09DA04 IRBESARTAN AND DIURETICS 54315 Co-Aprovel (Waymade Healthcare Plc) Tabs. 300/12.5 mg. 28 28 28 FC09DA04 IRBESARTAN AND DIURETICS 54321 Co-Aprovel Tabs. 150/12.5 mg. 28 28 28 FC09DA04 IRBESARTAN AND DIURETICS 54356 Co-Aprovel Tabs. 300/12.5 mg. 28 28 28 FC09DA04 IRBESARTAN AND DIURETICS 54367 Co-Aprovel (P.C.O. Mfg.) Tabs. 150 mg./12.5 mg. 28 28 28 FC09DA04 IRBESARTAN AND DIURETICS 54375 CoAprovel (P.C.O. Mfg.) Tabs. 300 mg./12.5 mg. 28 28 28 FC09DA04 IRBESARTAN AND DIURETICS 54380 CoAprovel (B & S Healthcare) Tabs. 300/12.5 mg. 28 28 28 FC09DA04 IRBESARTAN AND DIURETICS 54390 Irprezide Film Coated Tabs. 150 mg./12.5 mg. 28 28 28 FC09DA04 IRBESARTAN AND DIURETICS 54391 Irprezide Film Coated Tabs. 300 mg./12.5 mg. 28 28 28 FC09DA04 IRBESARTAN AND DIURETICS 54392 Irprezide Film Coated Tabs. 300 mg./25 mg. 28 28 28 FC09DA06 CANDESARTAN AND DIURETICS 13479 Atacand Plus (B & S Healthcare) Tabs. 16/12.5 mg. 14 14 14 FC09DA06 CANDESARTAN AND DIURETICS 13818 Atacand Plus (P.C.O. Mfg.) Tabs. 16/12.5 mg. 30 30 30 FC09DA06 CANDESARTAN AND DIURETICS 14013 Atacand Plus Tabs. 16/12.5 mg. 28 28 28 FC09DA06 CANDESARTAN AND DIURETICS 15402 Atacand Plus (G & A Licensing Ltd.) Tabs. 16/12.5 mg. 28 28 28 FC09DA06 CANDESARTAN AND DIURETICS 15405 Atacand Plus (Imbat Ltd) Tabs. 16/12.5 mg. 28 28 28 FC09DA06 CANDESARTAN AND DIURETICS 15412 Candist Plus Tabs. 16 mg./12.5 mg. 28 28 28 FC09DA06 CANDESARTAN AND DIURETICS 15425 Candesartan Hydrochlorothiazide (KRKA Pharma) Tabs. 16 mg./12.5 mg. 28 28 28 FC09DA06 CANDESARTAN AND DIURETICS 15437 Atacand Plus (iMED Healthcare Ltd.) Tabs. 16 mg./12.5 mg. 28 28 28 FC09DA06 CANDESARTAN AND DIURETICS 17564 Candesartan Hydrochlorothiazide (Actavis) Tabs. 16 mg./12.5 mg. 28 28 28 FC09DA06 CANDESARTAN AND DIURETICS 17570 Candesartan/Hydrochlorothiazide TEVA Tabs. 16 mg./12.5 mg. 28 28 28 FC09DA06 CANDESARTAN AND DIURETICS 63907 Blopress Plus Tabs. 8 mg./12.5 mg. 28 28 28 FC09DA06 CANDESARTAN AND DIURETICS 63908 Blopress Plus Tabs. 16 mg./12.5 mg 28 28 28 FC09DA06 CANDESARTAN AND DIURETICS 63909 Blopress Plus Tabs. 32 mg./12.5mg. 28 28 28 FC09DA06 CANDESARTAN AND DIURETICS 63910 Blopress Plus Tabs. 32 mg./25 mg. 28 28 28 FC09DA06 CANDESARTAN AND DIURETICS 15494 Catasart Plus Tabs. 16 mg./12.5 mg. 28 28 28 FC09DA07 TELMISARTAN AND DIURETICS 13309 Telmisartan/Hydrochlorothiazide (Clonmel) Tabs. 40 mg./12.5 mg. 28 28 28 F

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Core List F(Diabetes Mellitus)

January 2019

ATCLVL5 Non Proprietary Drug Cde Dma

Drug Description Pack Size Name

PackSize

Typ Illness

C09DA07 TELMISARTAN AND DIURETICS 13310 Telmisartan/Hydrochlorothiazide (Clonmel) Tabs. 80 mg./12.5 mg. 28 28 28 FC09DA07 TELMISARTAN AND DIURETICS 13311 Telmisartan/Hydrochlorothiazide (Clonmel) Tabs. 80 mg./25 mg. 28 28 28 FC09DA07 TELMISARTAN AND DIURETICS 13422 Telmisartan/Hydrochlorothiazide Teva Tabs. 80 mg./12.5 mg. 28 28 28 FC09DA07 TELMISARTAN AND DIURETICS 13423 Telmisartan/Hydrochlorothiazide Teva Tabs. 80 mg./25 mg. 28 28 28 FC09DA07 TELMISARTAN AND DIURETICS 18132 Actelsar HCT Tabs. 40 mg./12.5 mg. 28 28 28 FC09DA07 TELMISARTAN AND DIURETICS 18765 Actelsar HCT Tabs. 80 mg./12.5 mg. 28 28 28 FC09DA07 TELMISARTAN AND DIURETICS 18943 Actelsar HCT Tabs. 80 mg./25 mg. 28 28 28 FC09DA07 TELMISARTAN AND DIURETICS 34554 Micardis Plus Tabs. 80 mg./25 mg. 28 28 28 FC09DA07 TELMISARTAN AND DIURETICS 34611 Micardis Plus (Doncaster Ltd.) Tabs. 40 mg./12.5 mg. 28 28 28 FC09DA07 TELMISARTAN AND DIURETICS 34629 Micardis Plus (Doncaster Ltd.) Tabs. 80 mg./12.5 mg. 28 28 28 FC09DA07 TELMISARTAN AND DIURETICS 34631 Micardis Plus (B & S Healthcare) Tabs. 80/12.5 mg. 28 28 28 FC09DA07 TELMISARTAN AND DIURETICS 34700 Micardis Plus (P.C.O. Mfg.) Tabs. 40/12.5 mg. 28 28 28 FC09DA07 TELMISARTAN AND DIURETICS 34742 Micardis Plus (P.C.O. Mfg.) Tabs. 80/12.5 mg. 28 28 28 FC09DA07 TELMISARTAN AND DIURETICS 34811 Micardis Plus (BR Lewis Pharmaceuticals) Tabs. 80/12.5 mg. 28 28 28 FC09DA07 TELMISARTAN AND DIURETICS 34820 Micardis Plus (Clear Pharmacy) Tabs. 40 mg./12.5 mg. 28 28 28 FC09DA07 TELMISARTAN AND DIURETICS 34821 Micardis Plus (Clear Pharmacy) Tabs. 80 mg./12.5 mg. 28 28 28 FC09DA07 TELMISARTAN AND DIURETICS 39320 Micardis Plus (iMED Healthcare Ltd.) Tabs. 80/12.5 mg. 28 28 28 FC09DA07 TELMISARTAN AND DIURETICS 61075 Tolucombi Tabs. 40 mg./12.5 mg. 28 28 28 FC09DA07 TELMISARTAN AND DIURETICS 61132 Tolucombi Tabs. 80 mg./12.5 mg. 28 28 28 FC09DA07 TELMISARTAN AND DIURETICS 61453 Tolucombi Tabs. 80 mg./25 mg. 28 28 28 FC09DA07 TELMISARTAN AND DIURETICS 64406 Micardis Plus (Doncaster Ltd.) Tabs. 80/25 mg. 28 28 28 FC09DA07 TELMISARTAN AND DIURETICS 64410 Micardis Plus (Clear Pharmacy) Tabs. 80 mg./25 mg. 28 28 28 FC09DA07 TELMISARTAN AND DIURETICS 64421 Micardis Plus (Waymade Healthcare Plc) Tabs. 80 Mg./12.5 Mg. 28 28 28 FC09DA07 TELMISARTAN AND DIURETICS 64444 Micardis Plus Tabs. 40/12.5 mg. 28 28 28 FC09DA07 TELMISARTAN AND DIURETICS 64450 Micardis Plus Tabs. 80/12.5 mg. 28 28 28 FC09DA07 TELMISARTAN AND DIURETICS 64493 Micardis Plus (Lexon UK) Tabs. 40/12.5 mg. 28 28 28 FC09DA07 TELMISARTAN AND DIURETICS 64494 Micardis Plus (Lexon UK) Tabs. 80/12.5 mg. 28 28 28 FC09DA07 TELMISARTAN AND DIURETICS 13163 Telmisartan/Hydrochlorothiazide (Rowa) Tabs. 40 mg./12.5 mg. 28 28 28 FC09DA07 TELMISARTAN AND DIURETICS 13164 Telmisartan/Hydrochlorothiazide (Rowa) Tabs. 80 mg./12.5 mg. 28 28 28 FC09DA07 TELMISARTAN AND DIURETICS 13165 Telmisartan/Hydrochlorothiazide (Rowa) Tabs. 80 mg./25 mg. 28 28 28 FC09DA08 OLMESARTAN MEDOXOMIL AND DIURETICS 34866 Olmesartan Hydrochlorothiazide (Rowex) Film Coated Tabs. 20 mg./12.5 mg. 28 28 28 FC09DA08 OLMESARTAN MEDOXOMIL AND DIURETICS 34867 Olmesartan Hydrochlorothiazide (Rowex) Film Coated Tabs. 20 mg./25 mg. 28 28 28 FC09DA08 OLMESARTAN MEDOXOMIL AND DIURETICS 34868 Olmesartan Hydrochlorothiazide (Rowex) Film Coated Tabs. 40 mg./12.5 mg. 28 28 28 FC09DA08 OLMESARTAN MEDOXOMIL AND DIURETICS 34870 Olmesartan Hydrochlorothiazide (Rowex) Film Coated Tabs. 40 mg./25 mg. 28 28 28 FC09DA08 OLMESARTAN MEDOXOMIL AND DIURETICS 34862 Olmesartan Hydrochlorothiazide (KRKA Pharma) Film Coated Tabs. 20 mg./12.5 mg. 28 28 28 FC09DA08 OLMESARTAN MEDOXOMIL AND DIURETICS 34863 Olmesartan Hydrochlorothiazide (KRKA Pharma) Film Coated Tabs. 20 mg./25 mg. 28 28 28 FC09DA08 OLMESARTAN MEDOXOMIL AND DIURETICS 34864 Olmesartan Hydrochlorothiazide (KRKA Pharma) Film Coated Tabs. 40 mg./12.5 mg. 28 28 28 FC09DA08 OLMESARTAN MEDOXOMIL AND DIURETICS 34865 Olmesartan Hydrochlorothiazide (KRKA Pharma) Film Coated Tabs. 40 mg./25 mg. 28 28 28 FC09DA08 OLMESARTAN MEDOXOMIL AND DIURETICS 13179 Omesar Plus (P.C.O. Mfg.) Film Coated Tabs. 20 mg./25 mg. 28 28 28 FC09DA08 Olmesartan Medoxomil And Hydrochlorothiazide 34852 Olmesartan Hydrochlorothiazide (Clonmel) Film Coated Tabs. 20 mg./12.5 mg. 28 28 28 FC09DA08 Olmesartan Medoxomil And Hydrochlorothiazide 34861 Olmesartan Hydrochlorothiazide (Clonmel) Film Coated Tabs. 20 mg./25 mg. 28 28 28 FC09DA08 Olmesartan Medoxomil And Hydrochlorothiazide 34883 Olmesartan Hydrochlorothiazide (Clonmel) Film Coated Tabs. 40 mg./12.5 mg. 28 28 28 FC09DA08 Olmesartan Medoxomil And Hydrochlorothiazide 34892 Olmesartan Hydrochlorothiazide (Clonmel) Film Coated Tabs. 40 mg./25 mg. 28 28 28 FC09DA08 OLMESARTAN MEDOXOMIL AND DIURETICS 14425 Benetor Plus Tabs. 20/12.5 mg. 28 28 28 FC09DA08 OLMESARTAN MEDOXOMIL AND DIURETICS 14436 Benetor Plus Tabs. 20/25 mg. 28 28 28 FC09DA08 OLMESARTAN MEDOXOMIL AND DIURETICS 37640 Omesar Plus Tabs. 20/12.5 mg. 28 28 28 FC09DA08 OLMESARTAN MEDOXOMIL AND DIURETICS 37648 Omesar Plus Tabs. 20/25 mg. 28 28 28 FC09DA08 OLMESARTAN MEDOXOMIL AND DIURETICS 37682 Omesar Plus Tabs. 40 mg./12.5 mg. 28 28 28 FC09DA08 OLMESARTAN MEDOXOMIL AND DIURETICS 37683 Omesar Plus Tabs. 40 mg./25 mg. 28 28 28 FC09DA08 OLMESARTAN MEDOXOMIL AND DIURETICS 42103 Omesar Plus (P.C.O. Mfg.) Film Coated Tabs. 20 mg./12.5 mg. 28 28 28 FC09DA08 OLMESARTAN MEDOXOMIL AND DIURETICS 13179 Omesar Plus (P.C.O. Mfg.) Film Coated Tabs. 20 mg./25 mg. 28 28 28 FC09DB01 VALSARTAN AND AMLODIPINE 23401 Exforge (BR Lewis Pharmaceuticals) Tabs. 5 mg./80 mg. 28 28 28 FC09DB01 VALSARTAN AND AMLODIPINE 23410 Exforge Tabs. 5 mg./80 mg. 28 28 28 F

Page 24: S 'PD 1DPH 6L]H ,OOQHVV $FWUDSLG 9LDO ,8 PO PO 9LDO ; 0 ... · &ruh /lvw ) 'ldehwhv 0hoolwxv -dqxdu\ $7&/9/ 1rq 3ursulhwdu\ 'uxj &gh 'pd 'uxj 'hvfulswlrq 3dfn 6l]h 1dph 3dfn 6l]h

Core List F(Diabetes Mellitus)

January 2019

ATCLVL5 Non Proprietary Drug Cde Dma

Drug Description Pack Size Name

PackSize

Typ Illness

C09DB01 VALSARTAN AND AMLODIPINE 23419 Exforge Tabs. 5 mg./160 mg. 28 28 28 FC09DB01 VALSARTAN AND AMLODIPINE 23423 Exforge Tabs. 10 mg./160 mg. 28 28 28 FC09DB01 VALSARTAN AND AMLODIPINE 23425 Exforge (BR Lewis Pharmaceuticals) Tabs. 10/160 mg. 28 28 28 FC09DB01 VALSARTAN AND AMLODIPINE 32406 Exforge (Clear Pharma Ltd.) Film Coated Tabs. 5 mg./160 mg. 28 28 28 FC09DB01 VALSARTAN AND AMLODIPINE 32407 Exforge (Clear Pharma Ltd.) Film Coated Tabs. 10 mg./160 mg. 28 28 28 FC09DB01 VALSARTAN AND AMLODIPINE 32460 Exforge (B & S Healthcare) Tabs. 5 mg./160 mg. 28 28 28 FC09DB01 VALSARTAN AND AMLODIPINE 32462 Exforge (B & S Healthcare) Tabs. 10 mg./160 mg. 30 30 30 FC09DB01 VALSARTAN AND AMLODIPINE 32627 Exforge (iMED Healthcare Ltd.) Film Coated Tabs. 5 mg./160 mg. 28 28 28 FC09DB01 VALSARTAN AND AMLODIPINE 32628 Exforge (iMED Healthcare Ltd.) Film Coated Tabs. 10 mg./160 mg. 28 28 28 FC09DB01 VALSARTAN AND AMLODIPINE 32651 Exforge (Doncaster Ltd.) Tabs. 5 mg./160 mg. 28 28 28 FC09DB01 VALSARTAN AND AMLODIPINE 32661 Exforge (P.C.O. Mfg.) Film Coated Tabs. 5 mg./80 mg. 28 28 28 FC09DB01 VALSARTAN AND AMLODIPINE 32662 Exforge (P.C.O. Mfg.) Film Coated Tabs. 5 mg./160 mg. 28 28 28 FC09DB01 VALSARTAN AND AMLODIPINE 32663 Exforge (P.C.O. Mfg.) Film Coated Tabs. 10 mg./160 mg. 28 28 28 FC09DB02 OLMESARTAN MEDOXOMIL AND AMLODIPINE 38942 Olmesartan/Amlodipine (KRKA Pharma) Film Coated Tabs. 20 mg./5 mg. 28 28 28 FC09DB02 OLMESARTAN MEDOXOMIL AND AMLODIPINE 38943 Olmesartan/Amlodipine (KRKA Pharma) Film Coated Tabs. 40 mg./5 mg. 28 28 28 FC09DB02 OLMESARTAN MEDOXOMIL AND AMLODIPINE 38944 Olmesartan/Amlodipine (KRKA Pharma) Film Coated Tabs. 40 mg./10 mg. 28 28 28 FC09DB02 OLMESARTAN MEDOXOMIL AND AMLODIPINE 24954 Olmesartan/Amlodipine (Clonmel) Film Coated Tabs. 20 mg./5 mg. 28 28 28 FC09DB02 OLMESARTAN MEDOXOMIL AND AMLODIPINE 24956 Olmesartan/Amlodipine (Clonmel) Film Coated Tabs. 40 mg./5 mg. 28 28 28 FC09DB02 OLMESARTAN MEDOXOMIL AND AMLODIPINE 24960 Olmesartan/Amlodipine (Clonmel) Film Coated Tabs. 40 mg./10 mg. 28 28 28 FC09DB02 OLMESARTAN MEDOXOMIL AND AMLODIPINE 38930 Olmesartan/Amlodipine Mylan (Gerard Labs.) Film Coated Tabs. 20 mg./5 mg. 28 28 28 FC09DB02 OLMESARTAN MEDOXOMIL AND AMLODIPINE 38934 Olmesartan/Amlodipine Mylan (Gerard Labs.) Film Coated Tabs. 40 mg./5 mg. 28 28 28 FC09DB02 OLMESARTAN MEDOXOMIL AND AMLODIPINE 38936 Olmesartan/Amlodipine Mylan (Gerard Labs.) Film Coated Tabs. 40 mg./10 mg. 28 28 28 FC09DB02 OLMESARTAN MEDOXOMIL AND AMLODIPINE 38938 Olmesartan Medoxomil/Amlodipine (Accord Healthcare) Film Coated Tabs. 20 mg./5 mg. 28 28 28 FC09DB02 OLMESARTAN MEDOXOMIL AND AMLODIPINE 38940 Olmesartan Medoxomil/Amlodipine (Accord Healthcare) Film Coated Tabs. 40 mg./5 mg. 28 28 28 FC09DB02 OLMESARTAN MEDOXOMIL AND AMLODIPINE 38941 Olmesartan Medoxomil/Amlodipine (Accord Healthcare) Film Coated Tabs. 40 mg./10 mg. 28 28 28 FC09DB02 OLMESARTAN MEDOXOMIL AND AMLODIPINE 30486 Konverge Tabs. 20 mg./5 mg. 28 28 28 FC09DB02 OLMESARTAN MEDOXOMIL AND AMLODIPINE 30487 Konverge Tabs. 40 mg./5 mg. 28 28 28 FC09DB02 OLMESARTAN MEDOXOMIL AND AMLODIPINE 30488 Konverge Tabs. 40 mg./10 mg. 28 28 28 FC09DB02 OLMESARTAN MEDOXOMIL AND AMLODIPINE 50421 Konverge (P.C.O. Mfg.) Film Coated Tabs. 20 mg./5 mg. 28 28 28 FC09DB02 OLMESARTAN MEDOXOMIL AND AMLODIPINE 50790 Konverge (P.C.O. Mfg.) Film Coated Tabs. 40 mg./5 mg. 28 28 28 FC09DB02 OLMESARTAN MEDOXOMIL AND AMLODIPINE 51384 Konverge (P.C.O. Mfg.) Film Coated Tabs. 40 mg./10 mg. 28 28 28 FC09DB02 OLMESARTAN MEDOXOMIL AND AMLODIPINE 21463 Konverge (iMED Healthcare Ltd.) Film Coated Tabs. 20 mg./5 mg. 28 28 28 FC09DB02 OLMESARTAN MEDOXOMIL AND AMLODIPINE 21470 Konverge (iMED Healthcare Ltd.) Film Coated Tabs. 40 mg./5 mg. 28 28 28 FC09DB02 OLMESARTAN MEDOXOMIL AND AMLODIPINE 21486 Konverge (iMED Healthcare Ltd.) Film Coated Tabs. 40 mg./10 mg. 28 28 28 FC09DB04 TELMISARTAN AND AMLODIPINE 42422 Twynsta Tabs. 40 mg./5 mg. 28 28 28 FC09DB04 TELMISARTAN AND AMLODIPINE 42423 Twynsta Tabs. 80 mg./5 mg. 28 28 28 FC09DB04 TELMISARTAN AND AMLODIPINE 42424 Twynsta Tabs. 80 mg./10 mg. 28 28 28 FC09DB04 TELMISARTAN AND AMLODIPINE 42425 Twynsta (Lexon UK) Tabs. 40 mg./5 mg. 28 28 28 FC09DB04 TELMISARTAN AND AMLODIPINE 42426 Twynsta (Lexon UK) Tabs. 80 mg./5 mg. 28 28 28 FC09DB04 TELMISARTAN AND AMLODIPINE 42434 Twynsta (Lexon UK) Tabs. 80 mg./10 mg. 28 28 28 FC09DX01 VALSARTAN, AMLODIPINE AND HYDROCHLOROTHIAZIDE 14359 ExforgeHCT Film Coated Tabs. 5 mg./160 mg./12.5 mg. 28 28 28 FC09DX01 VALSARTAN, AMLODIPINE AND HYDROCHLOROTHIAZIDE 14463 ExforgeHCT Film Coated Tabs. 5 mg./160 mg./25 mg. 28 28 28 FC09DX01 VALSARTAN, AMLODIPINE AND HYDROCHLOROTHIAZIDE 14572 ExforgeHCT Film Coated Tabs. 10 mg./160 mg./12.5 mg. 28 28 28 FC09DX01 VALSARTAN, AMLODIPINE AND HYDROCHLOROTHIAZIDE 14578 ExforgeHCT (P.C.O. Mfg.) Film Coated 5 mg./160 mg./12.5 mg. 28 28 28 FC09DX01 VALSARTAN, AMLODIPINE AND HYDROCHLOROTHIAZIDE 14579 ExforgeHCT (P.C.O. Mfg.) Film Coated Tabs. 10 mg./160 mg./12.5 mg. 28 28 28 FC09DX01 VALSARTAN, AMLODIPINE AND HYDROCHLOROTHIAZIDE 13191 ExforgeHCT (Clear Pharma Ltd.) Film Coated Tabs. 5 mg./160 mg./12.5 mg. 28 28 28 FC09DX01 VALSARTAN, AMLODIPINE AND HYDROCHLOROTHIAZIDE 13193 ExforgeHCT (Clear Pharma Ltd.) Film Coated Tabs. 10 mg./160 mg./12.5 mg. 28 28 28 FC09DX03

OLMESARTAN MEDOXOMIL, AMLODIPINE AND HYDROCHLOROTHIAZIDE

30424 Konverge Plus Tabs. 40 mg./5 mg./12.5 mg. 28 28 28 FC09DX03

OLMESARTAN MEDOXOMIL, AMLODIPINE AND HYDROCHLOROTHIAZIDE

30425 Konverge Plus Tabs. 40 mg./10 mg./12.5 mg. 28 28 28 FC09DX03

OLMESARTAN MEDOXOMIL, AMLODIPINE AND HYDROCHLOROTHIAZIDE

30443 Konverge Plus Tabs. 20 mg./5 mg./12.5 mg. 28 28 28 FC09DX03

OLMESARTAN MEDOXOMIL, AMLODIPINE AND HYDROCHLOROTHIAZIDE

30445 Konverge Plus Tabs. 40 mg./10 mg./25 mg. 28 28 28 FC09DX03

OLMESARTAN, MEDOXOMIL, AMLODIPINE AND HYDROCHLOROTHIAZIDE

30444 Konverge Plus 40 mg./5 mg./25 mg. 28 28 28 FC09XA02 ALISKIREN 13291 Rasilez (B & S Healthcare) Tabs. 150 mg. 28 28 28 F

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Core List F(Diabetes Mellitus)

January 2019

ATCLVL5 Non Proprietary Drug Cde Dma

Drug Description Pack Size Name

PackSize

Typ Illness

C09XA02 ALISKIREN 48963 Rasilez (P.C.O. Mfg.) Film Coated Tabs. 300 mg. 28 28 28 FC09XA02 ALISKIREN 68204 Rasilez (Clear Pharmacy) 150 mg. 28 28 28 FC09XA02 ALISKIREN 68205 Rasilez (Clear Pharmacy) Tabs. 300 mg. 28 28 28 FC09XA02 ALISKIREN 68210 Rasilez (Lexon UK) Tabs. 150 mg. 28 28 28 FC09XA02 ALISKIREN 68211 Rasilez (Lexon UK) Tabs. 300 mg. 28 28 28 FC09XA02 ALISKIREN 68230 Rasilez (P.C.O. Mfg.) Tabs. 150 mg. 28 28 28 FC09XA02 ALISKIREN 68250 Rasilez Tabs. 150 mg. 28 28 28 FC09XA02 ALISKIREN 68255 Rasilez Tabs. 300 mg. 28 28 28 FC09XA02 ALISKIREN 68260 Rasilez (Waymade Healthcare Plc) Tabs. 150 Mg. 28 28 28 FC09XA02 ALISKIREN 68261 Rasilez (Waymade Healthcare Plc) Tabs. 300 Mg. 28 28 28 FC09XA02 ALISKIREN 68280 Rasilez (Doncaster Ltd.) Tabs. 150 mg. 28 28 28 FC09XA02 ALISKIREN 68281 Rasilez (Doncaster Ltd.) Tabs. 300 mg. 28 28 28 FC09XA52 ALISKIREN AND HYDROCHLOROTHIAZIDE 68273 Rasilez HCT Tabs. 150 mg./12.5 mg. 28 28 28 FC09XA52 ALISKIREN AND HYDROCHLOROTHIAZIDE 68274 Rasilez HCT Tabs. 150/25 mg. 28 28 28 FC09XA52 ALISKIREN AND HYDROCHLOROTHIAZIDE 68275 Rasilez HCT Tabs. 300 mg../12.5 mg. 28 28 28 FC09XA52 ALISKIREN AND HYDROCHLOROTHIAZIDE 68276 Rasilez HCT Tabs. 300 mg./25 mg. 28 28 28 FC10AA01 SIMVASTATIN 32657 Simvastatin (Actavis) Film Coated Tabs. 10 Mg. 28 28 28 FC10AA01 SIMVASTATIN 32658 Simvastatin (Actavis) Film Coated Tabs. 20 Mg. 28 28 28 FC10AA01 SIMVASTATIN 32659 Simvastatin (Actavis) Film Coated Tabs. 40 Mg. 28 28 28 FC10AA01 SIMVASTATIN 38230 Simvastatin TEVA Film Coated Tabs. 10 mg. 28 28 28 FC10AA01 SIMVASTATIN 38247 Simvastatin TEVA Film Coated Tabs. 20 mg. 28 28 28 FC10AA01 SIMVASTATIN 38256 Simvastatin TEVA Film Coated Tabs. 40 mg. 28 28 28 FC10AA01 SIMVASTATIN 44301 Simvastatin (KRKA Pharma) Film Coated Tabs. 10 mg. 28 28 28 FC10AA01 SIMVASTATIN 44336 Simvastatin (KRKA Pharma) Film Coated Tabs. 20 mg. 28 28 28 FC10AA01 SIMVASTATIN 44354 Simvastatin (KRKA Pharma) Film Coated Tabs. 40 mg. 28 28 28 FC10AA01 SIMVASTATIN 46307 Sivatin Tabs. 10 mg. 30 30 30 FC10AA01 SIMVASTATIN 46368 Sivatin Tabs. 40 mg. 30 30 30 FC10AA01 SIMVASTATIN 46492 Sivatin Tabs. 20 mg. 30 30 30 FC10AA01 SIMVASTATIN 52092 Zocor Tabs. 40 mg. 28 28 28 FC10AA01 SIMVASTATIN 52126 Zocor (P.C.O. Mfg.) Tabs. 10 mg. 28 28 28 FC10AA01 SIMVASTATIN 52138 Zocor (P.C.O. Mfg.) Tabs. 20 mg. 28 28 28 FC10AA01 SIMVASTATIN 52183 Zocor Tabs. 10 mg. 28 28 28 FC10AA01 SIMVASTATIN 52191 Zocor Tabs. 20 mg. 28 28 28 FC10AA01 SIMVASTATIN 52236 Zocor (P.C.O. Mfg.) Tabs. 40 mg. 28 28 28 FC10AA01 SIMVASTATIN 52241 Zocor (Imbat Ltd.) Tabs. 10 mg. 28 28 28 FC10AA01 SIMVASTATIN 52268 Zocor (Imbat Ltd.) Tabs. 20 mg. 28 28 28 FC10AA01 SIMVASTATIN 52290 ZOCOR (B & S HEALTHCARE) TABS. 20 MG. 28 28 28 FC10AA01 SIMVASTATIN 76307 Simvastatin (Bentley) Tabs. 10 mg. 28 28 28 FC10AA01 SIMVASTATIN 76321 Simvastatin (Bentley) Tabs. 20 mg. 28 28 28 FC10AA01 SIMVASTATIN 76329 Simvastatin (Gerard Labs.) Tabs. 10 mg. 30 30 30 FC10AA01 SIMVASTATIN 76330 Simvastatin (Gerard Labs.) Tabs. 20 mg. 30 30 30 FC10AA01 SIMVASTATIN 76331 Simvastatin (Gerard Labs.) Tabs. 40 mg. 30 30 30 FC10AA01 SIMVASTATIN 76346 Simvastatin (Bentley) Tabs. 40 mg. 28 28 28 FC10AA01 SIMVASTATIN 76352 Simvastatin (Bluefish) Tabs. 10 mg. 28 28 28 FC10AA01 SIMVASTATIN 76353 Simvastatin (Bluefish) Tabs. 20 mg. 28 28 28 FC10AA01 SIMVASTATIN 76354 Simvastatin (Bluefish) Tabs. 40 mg. 28 28 28 FC10AA01 SIMVASTATIN 76418 Simtan Caps. 5 mg. 28 28 28 FC10AA01 SIMVASTATIN 76602 Simtan Caps. 20 mg. 28 28 28 FC10AA01 SIMVASTATIN 76627 Simtan Caps. 10 mg. 28 28 28 FC10AA01 SIMVASTATIN 76680 Simtan Caps. 40 mg. 28 28 28 FC10AA03 PRAVASTATIN 31504 Lipostat (Imbat Ltd.) Tabs. 10 mg. 28 28 28 FC10AA03 PRAVASTATIN 31549 Lipostat (Imbat Ltd.) Tabs. 20 mg. 28 28 28 FC10AA03 PRAVASTATIN 31704 Lipostat Tabs. 10 mg. 28 28 28 F

Page 26: S 'PD 1DPH 6L]H ,OOQHVV $FWUDSLG 9LDO ,8 PO PO 9LDO ; 0 ... · &ruh /lvw ) 'ldehwhv 0hoolwxv -dqxdu\ $7&/9/ 1rq 3ursulhwdu\ 'uxj &gh 'pd 'uxj 'hvfulswlrq 3dfn 6l]h 1dph 3dfn 6l]h

Core List F(Diabetes Mellitus)

January 2019

ATCLVL5 Non Proprietary Drug Cde Dma

Drug Description Pack Size Name

PackSize

Typ Illness

C10AA03 PRAVASTATIN 31712 Lipostat Tabs. 20 mg. 28 28 28 FC10AA03 PRAVASTATIN 31725 Lipostat (P.C.O. Mfg.) Tabs. 10 mg. 28 28 28 FC10AA03 PRAVASTATIN 31786 Lipostat Tabs. 40 mg. 28 28 28 FC10AA03 PRAVASTATIN 31811 Lipostat (Imbat Ltd.) Tabs. 40 mg. 28 28 28 FC10AA03 PRAVASTATIN 31815 Lipostat (B & S Healthcare) Tabs. 20 mg. 28 28 28 FC10AA03 PRAVASTATIN 31847 Lipostat (B & S Healthcare) Tabs. 40 mg. 28 28 28 FC10AA03 PRAVASTATIN 60501 Pravitin Tabs. 10 mg. 30 30 30 FC10AA03 PRAVASTATIN 60508 Pravamel Tabs. 10 mg. 30 30 30 FC10AA03 PRAVASTATIN 60512 Pravitin (Imbat Ltd.) Tabs. 20 mg. 30 30 30 FC10AA03 PRAVASTATIN 60517 Pravamel Tabs. 20 mg. 30 30 30 FC10AA03 PRAVASTATIN 60520 Pravitin Tabs. 20 mg. 30 30 30 FC10AA03 PRAVASTATIN 60505 Pravastatin Sodium (WPR Healthcare) Tabs. 10 mg. 28 28 28 FC10AA03 PRAVASTATIN 60506 Pravastatin Sodium (WPR Healthcare) Tabs. 20 mg. 28 28 28 FC10AA03 PRAVASTATIN 60507 Pravastatin Sodium (WPR Healthcare) Tabs. 40 mg. 28 28 28 FC10AA03 PRAVASTATIN 60525 Pravastatin Sodium TEVA Tabs. 10 mg. 28 28 28 FC10AA03 PRAVASTATIN 60527 Pravastatin Sodium TEVA Tabs. 40 mg. 28 28 28 FC10AA03 PRAVASTATIN 60545 Pravastatin Sodium (Accord Healthcare Ltd.) Tabs. 10 mg. 28 28 28 FC10AA03 PRAVASTATIN 60557 Pravitin Tabs. 40 mg. 30 30 30 FC10AA03 PRAVASTATIN 60561 Pravamel Tabs. 40 mg. 30 30 30 FC10AA03 PRAVASTATIN 60564 Pravastatin Sodium (Actavis) Tabs. 10 mg. 28 28 28 FC10AA03 PRAVASTATIN 60565 Pravastatin Sodium (Actavis) Tabs. 20 mg. 28 28 28 FC10AA03 PRAVASTATIN 60566 Pravastatin Sodium (Actavis) Tabs. 40 mg. 28 28 28 FC10AA03 PRAVASTATIN 60576 Pravastatin Mylan (Gerard Labs.) Tabs. 20 mg. 28 28 28 FC10AA03 PRAVASTATIN 60577 Pravastatin Mylan (Gerard Labs.) Tabs. 40 mg. 28 28 28 FC10AA03 PRAVASTATIN 60607 Pravat Tabs. 10 mg. 28 28 28 FC10AA03 PRAVASTATIN 60649 Pravat Tabs. 20 mg. 28 28 28 FC10AA03 PRAVASTATIN 60672 Pravat Tabs. 40 mg. 28 28 28 FC10AA03 PRAVASTATIN 60526 Pravastatin Sodium Teva Tabs. 20 mg. 28 28 28 FC10AA03 PRAVASTATIN 60546 Pravastatin Sodium (Accord Healthcare Ltd.) Tabs. 20 mg. 28 28 28 FC10AA03 PRAVASTATIN 60547 Pravastatin Sodium (Accord Healthcare Ltd.) Tabs. 40 mg. 28 28 28 FC10AA03 PRAVASTATIN 60575 Pravastatin Mylan (Gerard Labs.) Tabs. 10 mg. 28 28 28 FC10AA04 FLUVASTATIN 39256 Lescol XL Tabs. 80 mg. 28 28 28 FC10AA04 FLUVASTATIN 77104 Lescol XL (P.C.O. Mfg.) Tabs. 80 mg. 28 28 28 FC10AA04 FLUVASTATIN 77106 Lescol XL (LTT Pharma Ltd.) Tabs. 80 mg. 28 28 28 FC10AA05 ATORVASTATIN 42027 Atorvastatin (Clonmel) Film Coated Tabs. 10 mg. 28 28 28 FC10AA05 ATORVASTATIN 42028 Atorvastatin (Clonmel) Film Coated Tabs. 20 mg. 28 28 28 FC10AA05 ATORVASTATIN 42029 Atorvastatin (Clonmel) Film Coated Tabs. 40 mg. 28 28 28 FC10AA05 ATORVASTATIN 42030 Atorvastatin (Clonmel) Film Coated Tabs. 80 mg. 28 28 28 FC10AA05 ATORVASTATIN 36974 Atorvastatin (WPR Healthcare) Film Coated Tabs. 10 mg. 28 28 28 FC10AA05 ATORVASTATIN 36975 Atorvastatin (WPR Healthcare) Film Coated Tabs. 20 mg. 28 28 28 FC10AA05 ATORVASTATIN 36976 Atorvastatin (WPR Healthcare) Film Coated Tabs. 40 mg. 28 28 28 FC10AA05 ATORVASTATIN 36977 Atorvastatin (WPR Healthcare) Film Coated Tabs. 80 mg. 28 28 28 FC10AA05 ATORVASTATIN 36917 Atorvastatin (Ranbaxy) Film Coated Tabs. 10 mg. 30 30 30 FC10AA05 ATORVASTATIN 36918 Atorvastatin (Ranbaxy) Film Coated Tabs. 20 mg. 30 30 30 FC10AA05 ATORVASTATIN 36920 Atorvastatin (Ranbaxy) Film Coated Tabs. 40 mg. 30 30 30 FC10AA05 ATORVASTATIN 36921 Atorvastatin (Ranbaxy) Film Coated Tabs. 80 mg. 30 30 30 FC10AA05 ATORVASTATIN 15451 Atorvastatin (Actavis) Film Coated Tabs. 10 mg. 100 100 100 FC10AA05 ATORVASTATIN 15486 Atorvastatin (Actavis) Film Coated Tabs. 20 mg. 100 100 100 FC10AA05 ATORVASTATIN 15593 Atorvastatin (Actavis) Film Coated Tabs. 40 mg. 100 100 100 FC10AA05 ATORVASTATIN 25398 Atorvastatin (Actavis) Film Coated Tabs. 80 mg. 28 28 28 FC10AA05 ATORVASTATIN 31710 Lipitor (Imbat Ltd.) Tabs. 20 mg. 28 28 28 FC10AA05 ATORVASTATIN 31731 Lipitor (Imbat Ltd.) Tabs. 40 mg. 28 28 28 FC10AA05 ATORVASTATIN 31752 Lipitor (Imbat Ltd.) Tabs. 80 mg. 28 28 28 F

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Core List F(Diabetes Mellitus)

January 2019

ATCLVL5 Non Proprietary Drug Cde Dma

Drug Description Pack Size Name

PackSize

Typ Illness

C10AA05 ATORVASTATIN 31798 Lipitor Tabs. 20 mg. 28 28 28 FC10AA05 ATORVASTATIN 31819 Lipitor Tabs. 40 mg. 28 28 28 FC10AA05 ATORVASTATIN 31892 Lipitor Tabs. 10 mg. 28 28 28 FC10AA05 ATORVASTATIN 31903 Lipitor (B & S Healthcare) Tabs. 40 mg. 28 28 28 FC10AA05 ATORVASTATIN 31905 Lipitor (B & S Healthcare) Tabs. 80 mg. 28 28 28 FC10AA05 ATORVASTATIN 32001 Lipitor Tabs. 80 mg. 28 28 28 FC10AA05 ATORVASTATIN 32038 Lipitor (P.C.O. Mfg.) Tabs. 20 mg. 28 28 28 FC10AA05 ATORVASTATIN 32359 Lipitor (P.C.O. Mfg.) Tabs. 40 mg. 28 28 28 FC10AA05 ATORVASTATIN 32363 Lipitor (P.C.O. Mfg.) Tabs. 80 mg. 28 28 28 FC10AA05 ATORVASTATIN 32378 Lipitor (B & S Healthcare) Tabs. 20 mg. 28 28 28 FC10AA05 ATORVASTATIN 32399 Lipitor (P.C.O. Mfg.) Tabs. 10 mg. 28 28 28 FC10AA05 ATORVASTATIN 32551 Lipitor (Imbat Ltd.) Tabs. 10 mg. 28 28 28 FC10AA05 ATORVASTATIN 32584 Lipitor (B & S Healthcare) Film Coated Tabs. 10 mg. 28 28 28 FC10AA05 ATORVASTATIN 41835 Lipitor (Primecrown 2010 Ltd.) Tabs. 10 mg. 28 28 28 FC10AA05 ATORVASTATIN 41836 Lipitor (Primecrown 2010 Ltd.) Tabs. 20 mg. 28 28 28 FC10AA05 ATORVASTATIN 41837 Lipitor (Primecrown 2010 Ltd.) Tabs. 40 mg. 28 28 28 FC10AA05 ATORVASTATIN 41838 Lipitor (Primecrown 2010 Ltd.) Tabs. 80 mg. 28 28 28 FC10AA05 ATORVASTATIN 41864 Lipitor (LTT Pharma Ltd.) Tabs. 20 mg. 28 28 28 FC10AA05 ATORVASTATIN 41865 Lipitor (LTT Pharma Ltd.) Tabs. 40 mg. 28 28 28 FC10AA05 ATORVASTATIN 41866 Lipitor (LTT Pharma Ltd.) Tabs. 80 mg. 28 28 28 FC10AA05 ATORVASTATIN 41876 Lipitor (Clear Pharmacy) Tabs. 10 mg. 28 28 28 FC10AA05 ATORVASTATIN 41877 Lipitor (Clear Pharmacy) Tabs. 20 mg. 28 28 28 FC10AA05 ATORVASTATIN 41878 Lipitor (Clear Pharmacy) Tabs. 40 mg. 28 28 28 FC10AA05 ATORVASTATIN 41879 Lipitor (Clear Pharmacy) Tabs. 80 mg. 28 28 28 FC10AA05 ATORVASTATIN 41884 Lipitor Chewable Tabs. 10 mg. 30 30 30 FC10AA05 ATORVASTATIN 41885 Lipitor Chewable Tabs. 20 mg. 30 30 30 FC10AA05 ATORVASTATIN 41906 Atorvastatin (Pfizer) Film Coated Tabs. 10 mg. 30 30 30 FC10AA05 ATORVASTATIN 41908 Atorvastatin (Pfizer) Film Coated Tabs. 40 mg. 30 30 30 FC10AA05 ATORVASTATIN 41909 Atorvastatin (Pfizer) Film Coated Tabs. 80 mg. 30 30 30 FC10AA05 ATORVASTATIN 41930 Atorvas Film Coated Tabs. 10 mg. 28 28 28 FC10AA05 ATORVASTATIN 41931 Atorvas Film Coated Tabs. 20 mg. 28 28 28 FC10AA05 ATORVASTATIN 41932 Atorvas Film Coated Tabs. 40 mg. 28 28 28 FC10AA05 ATORVASTATIN 41933 Atorvas Film Coated Tabs. 80 mg. 28 28 28 FC10AA05 ATORVASTATIN 41937 Atorvastatin (Actavis) Film Coated Tabs. 10 mg. 28 28 28 FC10AA05 ATORVASTATIN 41938 Atorvastatin (Actavis) Film Coated Tabs. 20 mg. 28 28 28 FC10AA05 ATORVASTATIN 41939 Atorvastatin (Actavis) Film Coated Tabs. 40 mg. 28 28 28 FC10AA05 ATORVASTATIN 41958 Atorvastatin (Dexcel Pharma) Film Coated Tabs. 10 mg. 28 28 28 FC10AA05 ATORVASTATIN 41959 Atorvastatin (Dexcel Pharma) Film Coated Tabs. 20 mg. 28 28 28 FC10AA05 ATORVASTATIN 41960 Atorvastatin (Dexcel Pharma) Film Coated Tabs. 40 mg. 28 28 28 FC10AA05 ATORVASTATIN 41965 Atorvastatin Mylan (Gerard Labs.) Film Coated Tabs. 10 mg. 28 28 28 FC10AA05 ATORVASTATIN 41966 Atorvastatin Mylan (Gerard Labs.) Film Coated Tabs. 20 mg. 28 28 28 FC10AA05 ATORVASTATIN 41967 Atorvastatin Mylan (Gerard Labs.) Film Coated Tabs. 40 mg. 28 28 28 FC10AA05 ATORVASTATIN 41968 Atorvastatin Mylan (Gerard Labs.) Film Coated Tabs. 80 mg. 28 28 28 FC10AA05 ATORVASTATIN 41990 Atorvastatin TEVA Film Coated Tabs. 10 mg. 28 28 28 FC10AA05 ATORVASTATIN 41991 Atorvastatin TEVA Film Coated Tabs. 20 mg. 28 28 28 FC10AA05 ATORVASTATIN 41992 Atorvastatin TEVA Film Coated Tabs. 40 mg. 28 28 28 FC10AA05 ATORVASTATIN 41993 Atorvastatin TEVA Film Coated Tabs. 80 mg. 28 28 28 FC10AA05 ATORVASTATIN 42000 Torvacol Film Coated Tabs. 10 mg. 28 28 28 FC10AA05 ATORVASTATIN 42001 Torvacol Film Coated Tabs. 20 mg. 28 28 28 FC10AA05 ATORVASTATIN 42003 Torvacol Film Coated Tabs. 80 mg 28 28 28 FC10AA05 ATORVASTATIN 42016 Atorvastatin (KRKA Pharma) Film Coated Tabs. 20 mg. 28 28 28 FC10AA05 ATORVASTATIN 42017 Atorvastatin (KRKA Pharma) Film Coated Tabs. 40 mg. 28 28 28 FC10AA05 ATORVASTATIN 42018 Atorvastatin (KRKA Pharma) Film Coated Tabs. 80 mg. 28 28 28 F

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Core List F(Diabetes Mellitus)

January 2019

ATCLVL5 Non Proprietary Drug Cde Dma

Drug Description Pack Size Name

PackSize

Typ Illness

C10AA05 ATORVASTATIN 42020 Atorvastatin (Pinewood Healthcare) Film Coated Tabs. 10 mg. 28 28 28 FC10AA05 ATORVASTATIN 42021 Atorvastatin (Pinewood Healthcare) Film Coated Tabs. 20 mg. 28 28 28 FC10AA05 ATORVASTATIN 42022 Atorvastatin (Pinewood Healthcare) Film Coated Tabs. 40 mg. 28 28 28 FC10AA05 ATORVASTATIN 42023 Atorvastatin (Pinewood Healthcare) Film Coated Tabs. 80 mg. 28 28 28 FC10AA05 ATORVASTATIN 41863 Lipitor (LTT Pharma Ltd.) Tabs. 10 mg. 28 28 28 FC10AA05 ATORVASTATIN 41907 Atorvastatin (Pfizer) Film Coated Tabs. 20 mg. 30 30 30 FC10AA05 ATORVASTATIN 42015 Atorvastatin (KRKA Pharma) Film Coated Tabs. 10 mg. 28 28 28 FC10AA07 ROSUVASTATIN 26975 Rosuvastatin (Pinewood) Film Coated Tabs. 5 mg. 28 28 28 FC10AA07 ROSUVASTATIN 27285 Rosuvastatin (Pinewood) Film Coated Tabs. 10 mg. 28 28 28 FC10AA07 ROSUVASTATIN 27290 Rosuvastatin (Pinewood) Film Coated Tabs. 20 mg. 28 28 28 FC10AA07 ROSUVASTATIN 27498 Rosuvastatin (Pinewood) Film Coated Tabs. 40 mg. 28 28 28 FC10AA07 ROSUVASTATIN 22632 Rosuvastatin (Accord Healthcare Ltd.) Film Coated Tabs. 5 mg. 98 98 98 FC10AA07 ROSUVASTATIN 22633 Rosuvastatin (Accord Healthcare Ltd.) Film Coated Tabs. 5 mg. 500 500 500 FC10AA07 ROSUVASTATIN 22634 Rosuvastatin (Accord Healthcare Ltd.) Film Coated Tabs. 10 mg. 500 500 500 FC10AA07 ROSUVASTATIN 22635 Rosuvastatin (Accord Healthcare Ltd.) Film Coated Tabs. 20 mg. 500 500 500 FC10AA07 ROSUVASTATIN 62869 Rosuvastatin (Clonmel) Film Coated Tabs. 5 mg. 28 28 28 FC10AA07 ROSUVASTATIN 62870 Rosuvastatin (Clonmel) Film Coated Tabs. 10 mg. 28 28 28 FC10AA07 ROSUVASTATIN 62872 Rosuvastatin (Clonmel) Film Coated Tabs. 20 mg. 28 28 28 FC10AA07 ROSUVASTATIN 62873 Rosuvastatin (Clonmel) Film Coated Tabs. 40 mg. 28 28 28 FC10AA07 ROSUVASTATIN 18905 Crestor Tabs. 5 mg. 28 28 28 FC10AA07 ROSUVASTATIN 19078 Crestor (B & S Healthcare) Tabs. 20 mg. 28 28 28 FC10AA07 ROSUVASTATIN 19105 Crestor (P.C.O. Mfg.) Tabs. 10 mg. 28 28 28 FC10AA07 ROSUVASTATIN 19114 Crestor (P.C.O. Mfg.) Tabs. 20 mg. 28 28 28 FC10AA07 ROSUVASTATIN 19140 Crestor (P.C.O. Mfg.) Tabs. 40 mg. 28 28 28 FC10AA07 ROSUVASTATIN 19164 Crestor Tabs. 10 mg. 28 28 28 FC10AA07 ROSUVASTATIN 19202 Crestor (Imbat Ltd.) Tabs. 20 mg. 28 28 28 FC10AA07 ROSUVASTATIN 19207 Crestor Tabs. 20 mg. 28 28 28 FC10AA07 ROSUVASTATIN 19226 Crestor (Eurodrug LTD. D.P.R.) Tabs. 20 mg. 28 28 28 FC10AA07 ROSUVASTATIN 19238 Crestor Tabs. 40 mg. 28 28 28 FC10AA07 ROSUVASTATIN 19243 Crestor (B & S Healthcare) Tabs. 10 mg. 28 28 28 FC10AA07 ROSUVASTATIN 19245 Crestor (Primecrown 2010 Ltd.) Tabs. 10 mg. 28 28 28 FC10AA07 ROSUVASTATIN 19246 Crestor (Primecrown 2010 Ltd.) Tabs. 20 mg. 28 28 28 FC10AA07 ROSUVASTATIN 19247 Crestor (Primecrown 2010 Ltd.) Tabs. 40 mg. 28 28 28 FC10AA07 ROSUVASTATIN 19260 Crestor (Eurodrug Ltd. D.P.R.) Tabs. 5 mg. 28 28 28 FC10AA07 ROSUVASTATIN 19261 Crestor (Eurodrug Ltd. D.P.R.) Tabs. 10 mg. 28 28 28 FC10AA07 ROSUVASTATIN 19262 Crestor (Eurodrug Ltd. D.P.R.) Tabs. 40 mg. 28 28 28 FC10AA07 ROSUVASTATIN 19264 Crestor (B & S Healthcare) Tabs. 40 mg. 28 28 28 FC10AA07 ROSUVASTATIN 19285 Crestor (Clear Pharmacy) Tabs. 10 mg. 28 28 28 FC10AA07 ROSUVASTATIN 19286 Crestor (Clear Pharmacy) Tabs. 20 mg. 28 28 28 FC10AA07 ROSUVASTATIN 62840 Rosuvastatin (Accord Healthcare Ltd.) Film Coated Tabs. 5 mg. 28 28 28 FC10AA07 ROSUVASTATIN 62841 Rosuvastatin (Accord Healthcare Ltd.) Film Coated Tabs. 10 mg. 28 28 28 FC10AA07 ROSUVASTATIN 62842 Rosuvastatin (Accord Healthcare Ltd.) Film Coated Tabs. 20 mg. 28 28 28 FC10AA07 ROSUVASTATIN 62843 Rosuvastatin (Accord Healthcare Ltd.) Film Coated Tabs. 40 mg. 28 28 28 FC10AA07 ROSUVASTATIN 62810 Rosuvastatin TEVA Tabs. 5 mg. 28 28 28 FC10AA07 ROSUVASTATIN 62811 Rosuvastatin TEVA Tabs. 10 mg. 28 28 28 FC10AA07 ROSUVASTATIN 62812 Rosuvastatin TEVA Tabs. 20 mg. 28 28 28 FC10AA07 ROSUVASTATIN 62813 Rosuvastatin TEVA Tabs. 40 mg. 28 28 28 FC10AA07 ROSUVASTATIN 62822 Rosuva Film Coated Tabs. 5 mg. 28 28 28 FC10AA07 ROSUVASTATIN 62823 Rosuva Film Coated Tabs. 10 mg. 28 28 28 FC10AA07 ROSUVASTATIN 62824 Rosuva Film Coated Tabs. 20 mg. 28 28 28 FC10AA07 ROSUVASTATIN 62825 Rosuva Film Coated Tabs. 40 mg. 28 28 28 FC10AA07 ROSUVASTATIN 62830 Rosuvastatin (Actavis) Film Coated Tabs. 5 mg. 28 28 28 FC10AA07 ROSUVASTATIN 62832 Rosuvastatin (Actavis) Film Coated Tabs. 20 mg. 28 28 28 F

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Core List F(Diabetes Mellitus)

January 2019

ATCLVL5 Non Proprietary Drug Cde Dma

Drug Description Pack Size Name

PackSize

Typ Illness

C10AA07 ROSUVASTATIN 62833 Rosuvastatin (Actavis) Film Coated Tabs. 40 mg. 28 28 28 FC10AA07 ROSUVASTATIN 62857 Rosuvastatin (KRKA Pharma) Film Coated Tabs. 5 mg. 28 28 28 FC10AA07 ROSUVASTATIN 62858 Rosuvastatin (KRKA Pharma) Film Coated Tabs. 10 mg. 28 28 28 FC10AA07 ROSUVASTATIN 62859 Rosuvastatin (KRKA Pharma) Film Coated Tabs. 20 mg. 28 28 28 FC10AA07 ROSUVASTATIN 62860 Rosuvastatin (KRKA Pharma) Film Coated Tabs. 40 mg. 28 28 28 FC10AA07 ROSUVASTATIN 62865 Rosuvastatin Mylan (Gerard Labs.) Film Coated Tabs. 5 mg. 28 28 28 FC10AA07 ROSUVASTATIN 62866 Rosuvastatin Mylan (Gerard Labs.) Film Coated Tabs. 10 mg. 28 28 28 FC10AA07 ROSUVASTATIN 62867 Rosuvastatin Mylan (Gerard Labs.) Film Coated 20 mg. 28 28 28 FC10AA07 ROSUVASTATIN 62868 Rosuvastatin Mylan (Gerard Labs.) Film Coated Tabs. 40 mg. 28 28 28 FC10AA07 ROSUVASTATIN 62831 Rosuvastatin (Actavis) Film Coated Tabs. 10 mg. 28 28 28 FC10AB04 GEMFIBROZIL 31941 Lopid Tabs. 600 mg. 56 56 56 FC10AB04 GEMFIBROZIL 54369 Lopid Tabs. 600 mg. 60 60 60 FC10AB04 GEMFIBROZIL 32150 Lopid Caps. 300 mg. 100 100 100 FC10AB05 FENOFIBRATE 31620 Lipantil Micro 67 Caps. 90 90 90 FC10AB05 FENOFIBRATE 31657 Lipantil Micro 200 Caps. 30 30 30 FC10AB05 FENOFIBRATE 31683 Lipantil Micro 200 (P.C.O. Mfg.) Caps. 200 mg. 30 30 30 FC10AB05 FENOFIBRATE 31669 Lipantil Supra Tabs. 145 mg. 30 30 30 FC10AB05 FENOFIBRATE 31607 Lipantil Supra (LTT Pharma Ltd.) Film Coated Tabs. 145 mg. 30 30 30 FC10AB05 FENOFIBRATE 31605 Lipantil Supra (Imbat Ltd.) Film Coated Tabs. 145 mg. 30 30 30 FC10AC01 COLESTYRAMINE 44329 Questran Sachets 4 G. 50 50 50 FC10AC04 COLESEVELAM 73107 Cholestagel Tabs. 625 mg. 180 180 180 FC10AX09 EZETIMIBE 36760 Ezetimibe (Accord Healthcare Ltd.) Tabs. 10 mg. 28 28 28 FC10AX09 EZETIMIBE 36766 Ezetimibe (Apotex) Tabs. 10 mg. 28 28 28 FC10AX09 EZETIMIBE 36773 Ezetimibe (KRKA Pharma) Tabs. 10 mg. 28 28 28 FC10AX09 EZETIMIBE 36787 Ezetimibe Teva Tabs. 10 mg. 28 28 28 FC10AX09 EZETIMIBE 36871 Ezetimibe (Gerard Labs.) Tabs. 10 mg. 28 28 28 FC10AX09 EZETIMIBE 36888 Ezetimibe (Rowa) Tabs. 10 mg. 28 28 28 FC10AX09 EZETIMIBE 17025 Ezetrol (Eurodrug Ltd. D.P.R.) Tabs. 10 mg. 28 28 28 FC10AX09 EZETIMIBE 23252 Ezetrol (Clear Pharmacy D.P.R.) Tabs. 10 mg. 28 28 28 FC10AX09 EZETIMIBE 23263 Ezetrol Tabs. 10 mg. 28 28 28 FC10AX09 EZETIMIBE 23275 Ezetrol (P.C.O. Mfg.) Tabs. 10 mg. 28 28 28 FC10BA02 SIMVASTATIN AND EZETIMIBE 29845 Inegy Tabs. 10/20 mg. 28 28 28 FC10BA02 SIMVASTATIN AND EZETIMIBE 19562 Inegy (Eurodrug Ltd. D.P.R.) Tabs. 10 mg./20 mg. 28 28 28 FC10BA02 SIMVASTATIN AND EZETIMIBE 19635 Inegy (Eurodrug Ltd. D.P.R.) Tabs. 10 mg./40 mg. 28 28 28 FC10BA02 SIMVASTATIN AND EZETIMIBE 29803 Inegy (Eurodrug Ltd. D.P.R.) Tabs. 10/80 mg. 28 28 28 FC10BA02 SIMVASTATIN AND EZETIMIBE 29869 Inegy Tabs. 10/40 mg. 28 28 28 FC10BA02 SIMVASTATIN AND EZETIMIBE 29885 Inegy (P.C.O. Mfg.) Tabs. 10/20 mg. 28 28 28 FC10BA02 SIMVASTATIN AND EZETIMIBE 29906 Inegy (B & S Healthcare D.P.R.) Tabs. 10 mg./20 mg. 28 28 28 FC10BA02 SIMVASTATIN AND EZETIMIBE 29907 Inegy (B & S Healthcare D.P.R.) Tabs. 10 mg./40 mg. 28 28 28 FC10BA02 SIMVASTATIN AND EZETIMIBE 29908 Inegy (B & S Healthcare D.P.R.) Tabs. 10 mg./80 mg. 28 28 28 FC10BA02 SIMVASTATIN AND EZETIMIBE 29914 Inegy (Clear Pharmacy D.P.R.) Tabs. 10 mg./20 mg. 28 28 28 FC10BA02 SIMVASTATIN AND EZETIMIBE 29915 Inegy (Clear Pharmacy D.P.R.) Tabs. 10 mg./40 mg. 28 28 28 FC10BA02 SIMVASTATIN AND EZETIMIBE 29916 Inegy (Clear Pharmacy D.P.R.) Tabs. 10 mg./80 mg. 28 28 28 FC10BA02 SIMVASTATIN AND EZETIMIBE 29876 Inegy Tabs. 10/80 mg. 28 28 28 FC10BA02 SIMVASTATIN AND EZETIMIBE 37024 Ezetimibe/Simvastatin (Clonmel) Tabs. 10 mg./10 mg. 28 28 28 FC10BA02 SIMVASTATIN AND EZETIMIBE 37025 Ezetimibe/Simvastatin (Clonmel) Tabs. 10 mg./20 mg. 28 28 28 FC10BA02 SIMVASTATIN AND EZETIMIBE 37026 Ezetimibe/Simvastatin (Clonmel) Tabs. 10 mg./40 mg. 28 28 28 FC10BA02 SIMVASTATIN AND EZETIMIBE 37027 Ezetimibe/Simvastatin (Clonmel) Tabs. 10 mg./80 mg. 28 28 28 FC10BA05 ATORVASTATIN AND EZETIMIBE 36858 Atozet Film Coated Tabs. 10 mg./10 mg. 30 30 30 FC10BA05 ATORVASTATIN AND EZETIMIBE 36859 Atozet Film Coated Tabs. 10 mg./20 mg. 30 30 30 FC10BA05 ATORVASTATIN AND EZETIMIBE 36862 Atozet Film Coated Tabs. 10 mg./40 mg. 30 30 30 FC10BA05 ATORVASTATIN AND EZETIMIBE 36863 Atozet Film Coated Tabs. 10 mg./80 mg. 30 30 30 FC10BX06 Atorvastatin, Acetylsalicylic Acid And Ramipril 43726 Trinomia Hard Caps. 100 mg./40 mg./5 mg. 28 28 28 F

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Core List F(Diabetes Mellitus)

January 2019

ATCLVL5 Non Proprietary Drug Cde Dma

Drug Description Pack Size Name

PackSize

Typ Illness

C10BX06 Atorvastatin, Acetylsalicylic Acid And Ramipril 43727 Trinomia Hard Caps. 100 mg./40 mg./10 mg. 28 28 28 FC10BX06 Atorvastatin, Acetylsalicylic Acid And Ramipril 43713 Trinomia Hard Caps. 100 mg./20 mg./2.5 mg. 28 28 28 FC10BX06 Atorvastatin, Acetylsalicylic Acid And Ramipril 43714 Trinomia Hard Caps. 100 mg./20 mg./5 mg. 28 28 28 FC10BX06 Atorvastatin, Acetylsalicylic Acid And Ramipril 43715 Trinomia Hard Caps. 100 mg./20 mg./10 mg. 28 28 28 FC10BX06 Atorvastatin, Acetylsalicylic Acid And Ramipril 43725 Trinomia Hard Caps. 100 mg./40 mg./2.5 mg. 28 28 28 FC10BX06 Atorvastatin, Acetylsalicylic Acid And Ramipril 43726 Trinomia Hard Caps. 100 mg./40 mg./5 mg. 28 28 28 FC10BX06 Atorvastatin, Acetylsalicylic Acid And Ramipril 43727 Trinomia Hard Caps. 100 mg./40 mg./10 mg. 28 28 28 FH04AA01 GLUCAGON 27027 GlucaGen Hypokit 1 mg. Pack 1 PACK 1 FH04AA01 GLUCAGON 53492 GlucaGen Hypokit (P.C.O. Mfg.) 1 mg. Pack 1 1 1 FN03AX12 GABAPENTIN 58601 Gabapentin (Accord Healthcare Ltd.) Hard Caps. 100 mg. 100 100 100 FN03AX12 GABAPENTIN 58603 Gabapentin (Accord Healthcare Ltd.) Hard Caps. 300 mg. 100 100 100 FN03AX12 GABAPENTIN 58604 Gabapentin (Accord Healthcare Ltd.) Hard Caps. 400 mg. 100 100 100 FN03AX12 GABAPENTIN 58619 Gabapentin (Gerard Labs.) Caps. 100 mg. 100 100 100 FN03AX12 GABAPENTIN 36772 Neurostil Caps. 100 mg. 100 100 100 FN03AX12 GABAPENTIN 76704 Gabin Caps. 100 mg. 100 100 100 FN03AX12 GABAPENTIN 36269 Neurontin Caps. 100 mg. 100 100 100 FN03AX12 GABAPENTIN 36359 Neurontin (P.C.O. Mfg.) Caps. 100 mg. 90 90 90 FN03AX12 GABAPENTIN 61448 NEURONTIN (iMED Healthcare Ltd.) Hard Caps. 100 mg. 100 100 100 FN03AX12 GABAPENTIN 61449 Neurontin (iMED Healthcare Ltd.) 300 mg. 100 100 100 FN03AX12 GABAPENTIN 58625 Gabapentin (Gerard Labs.) Caps. 300 mg. 100 100 100 FN03AX12 GABAPENTIN 36783 Neurostil Caps. 300 mg. 100 100 100 FN03AX12 GABAPENTIN 76720 Gabin Caps. 300 mg. 100 100 100 FN03AX12 GABAPENTIN 36390 Neurontin Caps. 300 mg. 100 100 100 FN03AX12 GABAPENTIN 36207 Neurontin (P.C.O. Mfg.) Caps 300 mg. 50 50 50 FN03AX12 GABAPENTIN 36341 Neurontin (B & S Healthcare) Caps. 300 mg. 50 50 50 FN03AX12 GABAPENTIN 76732 Gabin Caps. 400 mg. 100 100 100 FN03AX12 GABAPENTIN 28670 Gabapentin (Gerard Labs.) Caps. 400 mg. 100 100 100 FN03AX12 GABAPENTIN 36794 Neurostil Caps. 400 mg. 100 100 100 FN03AX12 GABAPENTIN 36455 Neurontin Caps. 400 mg. 100 100 100 FN03AX12 GABAPENTIN 36396 Neurontin (B & S Healthcare) Caps. 400 mg. 50 50 50 FN03AX12 GABAPENTIN 36254 Neurontin (P.C.O. Mfg.) Caps. 400 mg. 50 50 50 FN03AX12 GABAPENTIN 58653 Gabapentin TEVA Film Coated Tabs. 800 mg. 100 100 100 FN03AX12 GABAPENTIN 58606 Gabapentin (Accord Healthcare Ltd.) Film Coated Tabs. 800 mg. 100 100 100 FN03AX12 GABAPENTIN 62154 Neurontin Tabs. 800 mg. 100 100 100 FN03AX12 GABAPENTIN 58605 Gabapentin (Accord Healthcare Ltd.) Film Coated Tabs. 600 mg. 100 100 100 FN03AX12 GABAPENTIN 58652 Gabapentin TEVA Film Coated Tabs. 600 mg. 100 100 100 FN03AX12 GABAPENTIN 44539 Neurontin Tabs. 600 mg. 100 100 100 FN03AX12 GABAPENTIN 62167 Neurontin (P.C.O. Mfg.) Tabs. 600 mg. 100 100 100 FN03AX12 GABAPENTIN 61452 Neurontin (iMED Healthcare Ltd.) Film Coated Tabs. 600 mg. 100 100 100 FN03AX12 GABAPENTIN 36252 Gabapentin (Rosemont) Oral Soln. 50 mg./ml. 150 ml. 150 ML. 150 FN06AA09 AMITRIPTYLINE 77895 Amitriptyline (Clonmel) Tabs. 25 mg. 500 500 500 FN06AA09 AMITRIPTYLINE 20261 Amitriptyline (ULM) Tabs 10 mg 28 28 28 FV04BW95 URINALYSIS - MULITPLE TEST STRIPS 15784 Combur-5-Test D Test Strips 50 50 50 FV04BW95 URINALYSIS - MULTIPLE TEST STRIPS 10150 Uriflet S 9UB Test Strips 100 100 100 FV04BW95 URINALYSIS - MULTIPLE TEST STRIPS 10045 vChem 6 Test Strips 100 100 100 FV04BW95 URINALYSIS - MULTIPLE TEST STRIPS 10054 Aution 10EA Test Strips 100 100 100 FV04BW95 URINALYSIS - MULTIPLE TEST STRIPS 10160 vChem 10+ Test Strips 100 100 100 FV04BW95 URINALYSIS - MULTIPLE TEST STRIPS 31003 Keto-Diabur Test 5000 Test Strips 50 50 50 FV04BW95 URINALYSIS - MULTIPLE TEST STRIPS 34916 Multistix SG Test Strips 100 100 100 FV04BW95 URINALYSIS - MULTIPLE TEST STRIPS 35343 N-Multistix SG Test Strips 100 100 100 FV04BW95 URINALYSIS - MULTIPLE TEST STRIPS 39246 Multistix GP Test Strips 25 25 25 FV04BW95 URINALYSIS - MULTIPLE TEST STRIPS 39292 Multistix 10 SG Test Strips 100 100 100 FV04BW95 URINALYSIS - MULTIPLE TEST STRIPS 39398 Multistix 8 SG Test Strips 100 100 100 F

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Core List F(Diabetes Mellitus)

January 2019

ATCLVL5 Non Proprietary Drug Cde Dma

Drug Description Pack Size Name

PackSize

Typ Illness

V04BW95 URINALYSIS - MULTIPLE TEST STRIPS 57703 Labstix SG Test Strips 100 100 100 FV04BW95 URINALYSIS - MULTIPLE TEST STRIPS 57711 Labstix Test Strips 100 100 100 FV04BW95 URINALYSIS - MULTIPLE TEST STRIPS 61050 Uristix Test Strips 50 50 50 FV04BW95 URINALYSIS - MULTIPLE TEST STRIPS 61867 Hema-Combistix Test Strips 50 50 50 FV04BW95 URINALYSIS - MULTIPLE TEST STRIPS 64157 N-Labstix Test Strips 100 100 100 FV04BW95 URINALYSIS - MULTIPLE TEST STRIPS 64173 Keto-Diastix Test Strips 50 50 50 FV04BW95 URINALYSIS - MULTIPLE TEST STRIPS 81624 Combur-9-Test Test Strips 50 50 50 FV04BW95 URINALYSIS - MULTIPLE TEST STRIPS 81653 Combur-9-Test Test Strips 100 100 100 FV04BW95 URINALYSIS - MULTIPLE TEST STRIPS 81670 Microalbustix Test Strips 25 25 25 FV04BW95 URINALYSIS - MULTIPLE TEST STRIPS 85214 Combur-10-Test Test Strips 100 100 100 FV04BW95 URINALYSIS - MULTIPLE TEST STRIPS 85269 Combur-7-Test Test Strips 100 100 100 FV04BW96 URINALYSIS - SINGLE TEST STRIPS 10136 Micral-Test Test Strips 30 30 30 FV04BW96 URINALYSIS - SINGLE TEST STRIPS 10185 Ketur-Test Test Strips 50 50 50 FV04BW96 URINALYSIS - SINGLE TEST STRIPS 10979 Albustix Test Strips 50 50 50 FV04BW96 URINALYSIS - SINGLE TEST STRIPS 17825 Clinistix Test Strips 50 50 50 FV04BW96 URINALYSIS - SINGLE TEST STRIPS 20508 Diabur-Test 5000 Test Strips 50 50 50 FV04BW96 URINALYSIS - SINGLE TEST STRIPS 64149 Ketostix Test Strips 50 50 50 FV04BW96 URINALYSIS - SINGLE TEST STRIPS 64211 Diastix Test Strips 50 50 50 FV04CA91 BLOOD GLUCOSE TEST STRIPS 85135 Element Blood Glucose Test Strips 8809115901743 Strips (2 x 25) 50 50 50 FV04CA91 BLOOD GLUCOSE TEST STRIPS 85131 Finetest Lite Blood Glucose Test Strips 8809115901743 Strips (2 x 25) 50 50 50 FV04CA91 BLOOD GLUCOSE TEST STRIPS 85120 Gluco RX Nexus Test Strips 50 50 50 FV04CA91 BLOOD GLUCOSE TEST STRIPS 97607 mylife Unio Test Strip 700000532 50 50 50 FV04CA91 BLOOD GLUCOSE TEST STRIPS 97622 Dexcom G4 Platinum/G5 Mobile Sensor STS-GF-001 1 1 1 FV04CA91 BLOOD GLUCOSE TEST STRIPS 97626 Dexcom G4 Platinum/G5 Mobile Sensor STS-GF-004 4 4 4 FV04CA91 BLOOD GLUCOSE TEST STRIPS 10020 Accu-Chek Active Test Strips 50 50 50 FV04CA91 BLOOD GLUCOSE TEST STRIPS 10028 Accu-Chek Compact Test Strips 51 51 51 FV04CA91 BLOOD GLUCOSE TEST STRIPS 10035 One Touch Ultra Test Strips 50 50 50 FV04CA91 BLOOD GLUCOSE TEST STRIPS 10051 FreeStyle Optium Test Strips 50 50 50 FV04CA91 BLOOD GLUCOSE TEST STRIPS 10650 BM-Accutest Test Strips 50 50 50 FV04CA91 BLOOD GLUCOSE TEST STRIPS 15403 Breeze 2 Disc Test Strips 50 50 50 FV04CA91 BLOOD GLUCOSE TEST STRIPS 15858 PocketScan Test Strips 50 50 50 FV04CA91 BLOOD GLUCOSE TEST STRIPS 29238 Hypoguard Supreme Test Strips 50 50 50 FV04CA91 BLOOD GLUCOSE TEST STRIPS 63435 Accu-Chek Advantage Plus Test Strips 50 50 50 FV04CA91 BLOOD GLUCOSE TEST STRIPS 68321 One Touch Verio Test Strips 50 50 50 FV04CA91 BLOOD GLUCOSE TEST STRIPS 81516 Ascensia Autodisc Test Strips 50 50 50 FV04CA91 BLOOD GLUCOSE TEST STRIPS 81537 Contour Test Strips 50 50 50 FV04CA91 BLOOD GLUCOSE TEST STRIPS 81601 FreeStyle Test Strips 50 50 50 FV04CA91 BLOOD GLUCOSE TEST STRIPS 85001 FreeStyle Lite Test Strips 50 50 50 FV04CA91 BLOOD GLUCOSE TEST STRIPS 85015 GlucoMen LX Sensor Test Strips 50 50 50 FV04CA91 BLOOD GLUCOSE TEST STRIPS 85102 SensoCard Test Strips 50 50 50 FV04CA91 BLOOD GLUCOSE TEST STRIPS 85104 Accu-Chek Aviva Test Strips 50 50 50 FV04CA91 BLOOD GLUCOSE TEST STRIPS 85110 GlucoMen Areo Sensor Test Strips 50 50 50 FV04CA91 BLOOD GLUCOSE TEST STRIPS 85124 GlucoMen Visio Sensor Test Strips 50 50 50 FV04CA91 BLOOD GLUCOSE TEST STRIPS 85158 GlucoMen Sensor Test Strips 50 50 50 FV04CA91 BLOOD GLUCOSE TEST STRIPS 85501 HemoCue Monitor Microcuvette Test Strips 50 50 50 FV04CA91 BLOOD GLUCOSE TEST STRIPS 86392 SuperCheck2 Blood Glucose Test Strips 50 50 50 FV04CA91 BLOOD GLUCOSE TESTS 12003 TRUEresult Blood Glucose Test Strips 50 50 50 FV04CA91 BLOOD GLUCOSE TESTS 85540 Accu-Chek Mobile Test Cassette 100 100 (2 x 50 strips) 100 FV04CA91 BLOOD GLUCOSE TESTS 86308 Microdot+ Blood Glucose Test Strips 50 50 50 FV04CA91 BLOOD GLUCOSE TESTS 15963 Contour NEXT Blood Glucose Test Strips 50 50 50 FV04CA91 BLOOD GLUCOSE TESTS 83204 Medtronic Glucose Enlite Sensor BNENSENS 10 10 10 FV04CA91 Test Strips 97603 Gluco RX Test Strips 381-0942 50 50 50 FV04CA92 BLOOD KETONE TEST STRIPS 85113 GlucoMen LX B-Ketone Sensor 10 10 10 F

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Core List F(Diabetes Mellitus)

January 2019

ATCLVL5 Non Proprietary Drug Cde Dma

Drug Description Pack Size Name

PackSize

Typ Illness

V04CA92 BLOOD KETONE TEST STRIPS 85106 Freestyle Optium B-Ketone Test Strips 10 10 10 FV04CA92 Test Strips 85140 GlucoMen Areo B Ketone Sensor 48106 10 10 10 FV04CA92 Test Strips 97601 Gluco RX HCT Ketone Test Strips 394-8734 10 10 10 FV07AY01 DISP. INSULIN SYRINGES & NEEDLES 85197 Insulin Syringe and Needle 50 Units 0.5 ml. 100 100 100 FV07AY01 DISP. INSULIN SYRINGES & NEEDLES 85200 Insulin Syringe and Needle 100 Units 1 ml. 100 100 100 FV07AY01 DISP. INSULIN SYRINGES & NEEDLES 85294 Insulin Paed. Syringe and Needle 30 Units 0.3 ml. 100 100 100 FV07AY02 Disposable Insulin Needle 85149 Gluco RX Carepoint Insulin Pen Needles 31 G., 4 mm. 367-6582 100 100 100 FV07AY02 Disposable Insulin Needle 85123 Gluco RX Carepoint Insulin Pen Needles 32 G., 4 mm. 405-9143 100 100 100 FV07AY02 Disposable Insulin Needle 85150 Gluco RX Carepoint Insulin Pen Needles 31 G., 5 mm. 385-1979 100 100 100 FV07AY02 Disposable Insulin Needle 85151 Gluco RX Carepoint Insulin Pen Needles 31 G., 6 mm. 319-0550 100 100 100 FV07AY02 Disposable Insulin Needle 85152 Gluco RX Carepoint Insulin Pen Needles 31 G., 8 mm. 319-0568 100 100 100 FV07AY02 Disposable Insulin Needle 85115 NeonVerifine Insulin Pen Needle 31 G., 4 mm. 6284511680584 100 100 100 FV07AY02 Disposable Insulin Needle 85116 NeonVerifine Insulin Pen Needle 31 G., 5 mm. 6284511680652 100 100 100 FV07AY02 Disposable Insulin Needle 85119 NeonVerifine Insulin Pen Needle 31 G., 6 mm. 6284511680720 100 100 100 FV07AY02 Disposable Insulin Needle 85121 NeonVerifine Insulin Pen Needle 31 G., 8 mm. 6284511680898 100 100 100 FV07AY02 Disposable Insulin Needle 85122 NeonVerifine Ultra Insulin Pen Needle 32 G., 4 mm. 6284511680898 100 100 100 FV07AY02 Needles 85354 Tricare Pen Needle 4 mm AN8004 100 100 100 FV07AY02 Needle 85355 Tricare Pen Needle 5 mm AN8005 100 100 100 FV07AY02 Needles 85357 Tricare Pen Needle 6 mm AN8006 100 100 100 FV07AY02 Needles 85358 Tricare Pen Needle 8 mm AN8008 100 100 100 FV07AY02 Needles 85361 Unifine Pentips Pen Needle 4 mm AN3540 100 100 100 FV07AY02 Needles 85363 Unifine Pentips Pen Needle 5 mm AN3550 100 100 100 FV07AY02 DISPOSABLE INSULIN NEEDLE 85026 Glucoject Pen Needles 4mm, 5mm, 6mm, 8mm, 10mm, 12mm 100 100 100 FV07AY02 DISPOSABLE INSULIN NEEDLE 85377 Microdot Droplet Insulin Pen Needles; 32 G., 4 mm. 100 100 100 FV07AY02 DISPOSABLE INSULIN NEEDLE 85378 Microdot Droplet Insulin Pen Needles; 31 G., 6 mm. 100 100 100 FV07AY02 DISPOSABLE INSULIN NEEDLE 85379 Microdot Droplet Insulin Pen Needles; 31 G., 8 mm. 100 100 100 FV07AY02 DISPOSABLE INSULIN NEEDLES 85078 Micro-Fine+ Pen Needle 31G 5 mm. 100 100 100 FV07AY02 DISPOSABLE INSULIN NEEDLES 85141 Micro-Fine+ Pen Needle 31G 8 mm. 100 100 100 FV07AY02 DISPOSABLE INSULIN NEEDLES 85262 NovoFine Needle 30G 8 mm. 100 100 100 FV07AY02 DISPOSABLE INSULIN NEEDLES 85305 NovoFine Needle 31G 6 mm. 100 100 100 FV07AY02 DISPOSABLE INSULIN NEEDLES 85332 Micro-Fine+ Pen Needle 29G 12.7 mm. 100 100 100 FV07AY02 DISPOSABLE INSULIN NEEDLES 85337 Unifine Pentips 31G 6 mm. 100 100 100 FV07AY02 DISPOSABLE INSULIN NEEDLES 85345 Clickfine Needle 31G 6 mm. 100 100 100 FV07AY02 DISPOSABLE INSULIN NEEDLES 85353 Clickfine Needle 31G 8 mm. 100 100 100 FV07AY02 DISPOSABLE INSULIN NEEDLES 85381 Unifine Pentips 29G 12 mm. 100 100 100 FV07AY02 DISPOSABLE INSULIN NEEDLES 85393 Unifine Pentips 31G 8 mm. 100 100 100 FV07AY02 DISPOSABLE INSULIN NEEDLES 85503 NovoFine Autocover Needle 30G 8 mm. 100 100 100 FV07AY03 INSULIN INFUSION SET 83175 Animas ADR Cartridge Insulin Pump Syringe Reservoir 1.8 ml. 100-505-00 - 10 Pieces 10 PIECES 10 FV07AY03 INSULIN INFUSION SET 83176 Animas ADR Cartridge Insulin Pump Syringe Reservoir 3.0 ml. 100-505-01 - 10 Pieces 10 PIECES 10 FV07AY03 INSULIN INFUSION SET 83177 Animas COMFORT 23" 13 MM. 100-240-01 - 10 Pieces 10 PIECES 10 FV07AY03 INSULIN INFUSION SET 83178 Animas COMFORT 43" 13 mm. 100-240-03 - 10 Pieces 10 PIECES 10 FV07AY03 INSULIN INFUSION SET 83179 Animas DETACH 23" 6 mm. 100-905-00 - 10 Pieces 10 PIECES 10 FV07AY03 INSULIN INFUSION SET 83180 Animas DETACH 23" 8 mm. 100-905-01 - 10 Pieces 10 PIECES 10 FV07AY03 INSULIN INFUSION SET 83181 Animas DETACH 43" 6 mm. 100-905-02 - 10 Pieces 10 PIECES 10 FV07AY03 INSULIN INFUSION SET 83183 Animas DETACH 43" 8 mm. 100-905-03 - 10 Pieces 10 PIECES 10 FV07AY03 INSULIN INFUSION SET 83184 Animas Inset 30 Grey 60 cm. 13 mm. 100-396-00 - 10 Pieces 10 PIECES 10 FV07AY03 INSULIN INFUSION SET 83185 Animas Inset 30 Blue 60 cm. 13 mm. 100-396-01 - 10 Pieces 10 PIECES 10 FV07AY03 INSULIN INFUSION SET 83186 Animas Inset 30 Pink 60 cm. 13 mm. 100-396-02 - 10 Pieces 10 PIECES 10 FV07AY03 INSULIN INFUSION SET 83187 Animas Inset 30 Grey 110 cm. 13 mm. 100-396-03 - 10 Pieces 10 PIECES 10 FV07AY03 INSULIN INFUSION SET 83188 Medtronic Mio Pink 45 cm. 6 mm. MMT-921 - 10 Pieces 10 PIECES 10 FV07AY03 INSULIN INFUSION SET 83189 Medtronic Mio Pink 60 cm. 6 mm. MMT-923 - 10 Pieces 10 PIECES 10 FV07AY03 INSULIN INFUSION SET 83192 Medtronic Mio Pink 80 cm. 6 mm. MMT-925 - 10 Pieces 10 PIECES 10 FV07AY03 INSULIN INFUSION SET 83193 Medtronic Mio Blue 45 cm. 6 mm. MMT-941 10 Pieces 10 PIECES 10 F

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Core List F(Diabetes Mellitus)

January 2019

ATCLVL5 Non Proprietary Drug Cde Dma

Drug Description Pack Size Name

PackSize

Typ Illness

V07AY03 INSULIN INFUSION SET 83194 Medtronic Mio Blue 60 cm. 6 mm. MMT-943 - 10 Pieces 10 PIECES 10 FV07AY03 INSULIN INFUSION SET 83195 Medtronic Mio Blue 80 cm. 6 mm. MMT-945 - 10 Pieces 10 PIECES 10 FV07AY03 INSULIN INFUSION SET 83196 Medtronic Mio Grey 80 cm. 6 mm. MMT-965 - 10 Pieces 10 PIECES 10 FV07AY03 INSULIN INFUSION SET 83197 Medtronic Mio Grey 80 cm. 9 mm. MMT-975 - 10 Pieces 10 PIECES 10 FV07AY03 INSULIN INFUSION SET 85142 Medtronic MiniMed Mio Advance 60 cm. 6 mm. MMT-242 - 10 Pieces 10 PIECES 10 FV07AY03 INSULIN INFUSION SET 85143 Medtronic MiniMed Mio Advance 60 cm. 6 mm. MMT-247 - 10 Pieces 10 PIECES 10 FV07AY03 INSULIN INFUSION SET 85148 Medtronic MiniMed Mio 30 60 cm. 13 mm. MMT-905 - 10 Pieces 10 PIECES 10 FV07AY03 INSULIN INFUSION SET 85145 Medtronic MiniMed Mio 30 110 cm. 13 mm. MMT-906 - 10 Pieces 10 PIECES 10 FV07AY03 INSULIN INFUSION SET 83198 Medtronic Quick-set Paradigm 45 cm. 6 mm. MMT-394 - 10 Pieces 10 PIECES 10 FV07AY03 INSULIN INFUSION SET 83199 Medtronic Silhouette Paradigm 45 cm. 13 mm. MMT-368 - 10 Pieces 10 PIECES 10 FV07AY03 INSULIN INFUSION SET 83200 Medtronic Silhouette Paradigm 80 cm. 13 mm. MMT-383 - 10 Pieces 10 PIECES 10 FV07AY03 INSULIN INFUSION SET 83201 Medtronic Silhouette Paradigm 80 cm. 17 mm. MMT-384 - 10 Pieces 10 PIECES 10 FV07AY03 INSULIN INFUSION SET 83203 Medtronic Sure-T Paradigm 45 cm. 6 mm. MMT-862 - 10 Pieces 10 PIECES 10 FV07AY03 INSULIN INFUSION SET 85128 Accu-Chek FlexLink I 6/30 06593844001 - 10 Pieces 10 PIECES 10 FV07AY03 INSULIN INFUSION SET 85130 Accu-Chek FlexLink I 6/60 06593909001 - 10 Pieces 10 PIECES 10 FV07AY03 INSULIN INFUSION SET 85126 Accu-Chek FlexLink Cannula 6 06593941001 - 10 Pieces 10 PIECES 10 FV07AY03 INSULIN INFUSION SET 85002 Accu-Chek Spirit 3.15 ml. Cartridge System 04949935001 5 5 PIECES 5 FV07AY03 INSULIN INFUSION SET 85003 Accu-Chek Tenderlink Cannula 13 05015260001 10 10 PIECES 10 FV07AY03 INSULIN INFUSION SET 85004 Accu-Chek Tenderlink Cannula 17 05015251001 10 10 PIECES 10 FV07AY03 INSULIN INFUSION SET 85005 Accu-Chek TenderLink I 13/30 04541596001 10 10 PIECES 10 FV07AY03 INSULIN INFUSION SET 85007 Accu-Chek TenderLink I 13/60 04541600001 10 10 PIECES 10 FV07AY03 INSULIN INFUSION SET 85008 Accu-Chek TenderLink I 13/80 04541618001 10 10 PIECES 10 FV07AY03 INSULIN INFUSION SET 85009 Accu-Chek TenderLink I 17/60 04541642001 10 10 PIECES 10 FV07AY03 INSULIN INFUSION SET 85010 Accu-Chek TenderLink I 17/80 04541669001 - 10 10 PIECES 10 FV07AY03 INSULIN INFUSION SET 85011 Accu-Chek TenderLink I 17/110 04541626001 10 10 PIECES 10 FV07AY03 INSULIN INFUSION SET 85012 Accu-Chek TenderLink I 17/30 04541634001 10 10 PIECES 10 FV07AY03 INSULIN INFUSION SET 85013 Accu-Chek TenderLink I 13/110 04541588001 10 10 PIECES 10 FV07AY03 INSULIN INFUSION SET 85016 Animas Inset II Infusion Set 60 cm. Grey 6 mm. 100-410-00 10 10 PIECES 10 FV07AY03 INSULIN INFUSION SET 85017 Animas Inset II Infusion Set 60 cm. Blue 6 mm. 100-410-01 10 10 PIECES 10 FV07AY03 INSULIN INFUSION SET 85018 Animas Inset II Infusion Set 60 cm. Pink 6 mm. 100-410-02 10 10 PIECES 10 FV07AY03 INSULIN INFUSION SET 85019 Animas Inset II Infusion Set 60 cm. Grey 9 mm. 100-411-00 10 10 PIECES 10 FV07AY03 INSULIN INFUSION SET 85020 Animas Inset II Infusion Set 60 cm. Blue 9 mm. 100-411-01 10 10 PIECES 10 FV07AY03 INSULIN INFUSION SET 85021 Animas Inset II Infusion Set 60 cm. Pink 9 mm. 100-411-02 10 10 PIECES 10 FV07AY03 INSULIN INFUSION SET 85023 Animas Inset II Infusion Set 110 cm. Grey 6 mm. 100-412-00 10 10 PIECES 10 FV07AY03 INSULIN INFUSION SET 85024 Animas Inset II Infusion Set 110 cm. Grey 9 mm. 100-413-00 10 10 PIECES 10 FV07AY03 INSULIN INFUSION SETS 83153 Medtronic Quick-Set Paradigm 110 cm. 9 mm. MMT-396 - 10 Pieces 10 10 FV07AY03 INSULIN INFUSION SETS 83408 Medtronic Quick-Set Paradigm 110 cm. 6 mm. MMT-398 - 10 Pieces 10 10 FV07AY03 INSULIN INFUSION SETS 83447 Medtronic Quick-Set Paradigm 60 cm. 9 mm. MMT-397 - 10 Pieces 10 10 FV07AY03 INSULIN INFUSION SETS 83492 Medtronic Quick-Set Paradigm 60 cm. 6 mm. MMT-399 - 10 Pieces 10 10 FV07AY03 INSULIN INFUSION SETS 85025 Animas 2020 Cartridges 2020-100-124-11 - 10 Pieces 10 PIECES 10 FV07AY03 INSULIN INFUSION SETS 85117 Accu-Chek TenderLink II 13/30 04541685001 - 20 Pieces 20 20 FV07AY03 INSULIN INFUSION SETS 85118 Medtronic Paradigm Reservoir 1.8 ml. MMT-326A - 10 Pieces 10 10 FV07AY03 INSULIN INFUSION SETS 85127 Medtronic Paradigm Reservoir 3.0 ml. MMT-332A - 10 Pieces 10 10 FV07AY03 INSULIN INFUSION SETS 85129 Accu-Chek Tenderlink II 13/60 04541693001 - 20 Pieces 20 20 FV07AY03 INSULIN INFUSION SETS 85134 Accu-Chek TenderLink II 13/80 04541707001 - 20 Pieces 20 20 FV07AY03 INSULIN INFUSION SETS 85147 Accu-Chek D-Tron Adapter 04572432001 - 10 Pieces 10 10 FV07AY03 INSULIN INFUSION SETS 85179 Accu-Chek Cartridge and Needle for 3 ml. H-Tron Pump 04567528001 - 25 Pieces 25 25 FV07AY03 INSULIN INFUSION SETS 85201 Medtronic MiniMed Paradigm Sof-Set Ultimate QR 107 cm. MMT-317 - 12 Pieces 12 12 FV07AY03 INSULIN INFUSION SETS 85210 Medtronic MiniMed Paradigm Sof-Set Ultimate QR 61 cm. 9 mm. MMT-318 - 12 Pieces 12 12 FV07AY03 INSULIN INFUSION SETS 85215 Medtronic MiniMed Paradigm Sof-Set Micro QR 107 cm. MMT-324 - 12 Pieces 12 12 FV07AY03 INSULIN INFUSION SETS 85221 Medtronic MiniMed Paradigm Sof-Set Micro QR 61 cm. MMT-325 - 12 Pieces 12 12 FV07AY03 INSULIN INFUSION SETS 85237 Medtronic MiniMed Paradigm Silhouette 110 cm. Full Set MMT-377 - 10 Pieces 10 10 FV07AY03 INSULIN INFUSION SETS 85239 Accu-Chek RapidLink 8/60 04541294001 - 25 Pieces 25 25 F

Page 34: S 'PD 1DPH 6L]H ,OOQHVV $FWUDSLG 9LDO ,8 PO PO 9LDO ; 0 ... · &ruh /lvw ) 'ldehwhv 0hoolwxv -dqxdu\ $7&/9/ 1rq 3ursulhwdu\ 'uxj &gh 'pd 'uxj 'hvfulswlrq 3dfn 6l]h 1dph 3dfn 6l]h

Core List F(Diabetes Mellitus)

January 2019

ATCLVL5 Non Proprietary Drug Cde Dma

Drug Description Pack Size Name

PackSize

Typ Illness

V07AY03 INSULIN INFUSION SETS 85247 Accu-Chek RapidLink 8/80 04541332001 - 25 Pieces 25 25 FV07AY03 INSULIN INFUSION SETS 85253 Medtronic MiniMed Paradigm Silhouette 60 cm. Full Set MMT-378 - 10 Pieces 10 10 FV07AY03 INSULIN INFUSION SETS 85260 Accu-Chek RapidLink 8/110 04541316001 - 25 Pieces 25 25 FV07AY03 INSULIN INFUSION SETS 85281 Accu-Chek RapidLink 10/60 04541243001 - 25 Pieces 25 25 FV07AY03 INSULIN INFUSION SETS 85303 Accu-Chek RapidLink 10/80 04541251001 - 25 Pieces 25 25 FV07AY03 INSULIN INFUSION SETS 85304 Medtronic MiniMed Paradigm Silhouette 60 cm. 13mm MMT-381 - 10 Pieces 10 10 FV07AY03 INSULIN INFUSION SETS 85306 Medtronic MiniMed Paradigm Silhouette 110 cm. 13mm MMT-382 - 10 Pieces 10 10 FV07AY03 INSULIN INFUSION SETS 85310 Medtronic Sure-T Paradigm 80 cm. 6 mm. MMT-866 - 10 Pieces 10 10 FV07AY03 INSULIN INFUSION SETS 85311 Medtronic Sure-T Paradigm 80 cm. 8 mm. MMT-876 - 10 Pieces 10 10 FV07AY03 INSULIN INFUSION SETS 85313 Medtronic Sure-T Paradigm 80 cm. 10 mm. MMT-886 - 10 Pieces 10 10 FV07AY03 INSULIN INFUSION SETS 85314 Accu-Chek RapidLink 10/110 04541740001 - 25 Pieces 25 25 FV07AY03 INSULIN INFUSION SETS 85315 Medtronic Sure-T Paradigm 60 cm. 6 mm. MMT-864 - 10 Pieces 10 10 FV07AY03 INSULIN INFUSION SETS 85319 Medtronic Sure-T Paradigm 60 cm. 10 mm. MMT-884 - 10 Pieces 10 10 FV07AY03 INSULIN INFUSION SETS 85321 Medtronic MiniMed 508 Reservoir MMT-103A - 10 Pieces 10 10 FV07AY03 INSULIN INFUSION SETS 85356 Medtronic MiniMed 508 Quick-Set 110 cm. 9mm MMT-390 - 10 Pieces 10 10 FV07AY03 INSULIN INFUSION SETS 85360 Medtronic MiniMed 508 Quick-Set 110 cm. 6mm MMT-391 - 10 Pieces 10 10 FV07AY03 INSULIN INFUSION SETS 85368 Medtronic MiniMed 508 Quick-Set 60 cm. 9mm MMT-392 - 10 Pieces 10 10 FV07AY03 INSULIN INFUSION SETS 85373 Medtronic MiniMed 508 Quick-Set 60 cm. 6mm MMT-393 - 10 Pieces 10 10 FV07AY03 INSULIN INFUSION SETS 85376 Medtronic MiniMed 508 Silhouette 60 cm. Full Set MMT-373 - 10 Pieces 10 10 FV07AY03 INSULIN INFUSION SETS 85380 Medtronic MiniMed 508 Silhouette 110 cm. Full Set MMT-371 - 10 Pieces 10 10 FV07AY03 INSULIN INFUSION SETS 85397 Accu-Chek RapidLink 6/60 04541324001 - 25 Pieces 25 25 FV07AY03 INSULIN INFUSION SETS 85402 Accu-Chek RapidLink 6/80 04541308001 - 25 Pieces 25 25 FV07AY03 INSULIN INFUSION SETS 85423 Accu-Chek TenderLink II 17/60 04541731001 - 20 Pieces 20 20 FV07AY03 INSULIN INFUSION SETS 85445 Accu-Chek TenderLink II 17/80 04541235001 - 20 Pieces 20 20 FV07AY03 INSULIN INFUSION SETS 85468 Accu- Chek TenderLink II 17/110 04541715001 - 20 Pieces 20 20 FV07AY03 INSULIN INFUSION SETS 85475 Accu-Chek TenderLink II 17/30 04541723001 - 20 Pieces 20 20 FV07AY03 INSULIN INFUSION SETS 85505 Accu-Chek FlexLink 1 8/30 04626427001 - 10 Pieces 10 10 FV07AY03 INSULIN INFUSION SETS 85506 Accu-Chek FlexLink 1 8/60 04626435001 - 10 Pieces 10 10 FV07AY03 INSULIN INFUSION SETS 85507 Accu-Chek FlexLink 1 8/80 04626478001 - 10 Pieces 10 10 FV07AY03 INSULIN INFUSION SETS 85508 Accu-Chek FlexLink 1 10/80 04626524001 - 10 Pieces 10 10 FV07AY03 INSULIN INFUSION SETS 85509 Accu-Chek FlexLink 8 04626567001 - 10 Pieces 10 10 FV07AY03 INSULIN INFUSION SETS 85511 Accu-Chek FlexLink 10 04626575001 - 10 Pieces 10 10 FV07AY03 INSULIN INFUSION SETS 85513 Accu-Chek Rapid-D Link Cannula 6 04541006001 - 25 Pieces 25 25 FV07AY03 INSULIN INFUSION SETS 85514 Accu-Chek Rapid-D Link Cannula 8 04541014001 - 25 Pieces 25 25 FV07AY03 INSULIN INFUSION SETS 85515 Accu-Chek Rapid-D Link Cannula 10 04541022001 - 25 Pieces 25 25 FV07AY03 INSULIN INFUSION SETS 85516 Accu-Chek Rapid-D Link Transfer Set 50 04541065001 - 10 Pieces 10 10 FV07AY03 INSULIN INFUSION SETS 85517 Accu-Chek Rapid-D Link Transfer Set 70 04541073001 - 10 Pieces 10 10 FV07AY03 INSULIN INFUSION SETS 85518 Accu-Chek Rapid-D Link Transfer Set 100 04541081001 - 10 Pieces 10 10 FV07AY03 INSULIN INFUSION SETS 85519 Accu-Chek Rapid-D Link Protective Cap 04540999001 - 10 Pieces 10 10 FV07AY03 INSULIN INFUSION SETS 85520 Smiths Medical Deltec Cozmo 3 ml. Insulin Cartridge Unfilled 21-7450-24 - 25 Pieces 25 25 FV07AY03 INSULIN INFUSION SETS 85530 Cleo 90 Infusion Set 6mm 61 cm. 21-7220-24 - 20 Pieces 20 20 FV07AY03 INSULIN INFUSION SETS 85531 Cleo 90 Infusion Set 6mm 77 cm. 21-7221-24 - 20 Pieces 20 20 FV07AY03 INSULIN INFUSION SETS 85532 Cleo 90 Infusion Set 6mm 105 cm. 21-7222-24 - 20 Pieces 20 20 FV07AY03 INSULIN INFUSION SETS 85533 Cleo 90 Infusion Set 9mm 61 cm. 21-7230-24 - 20 Pieces 20 20 FV07AY03 INSULIN INFUSION SETS 85534 Cleo 90 Infusion Set 9mm 77 cm. 21-7231-24 - 20 Pieces 20 20 FV07AY03 INSULIN INFUSION SETS 85535 Cleo 90 Infusion Set 9mm 105 cm. 21-7232-24 - 20 Pieces 20 20 FV07AY03 INSULIN INFUSION SETS 93257 Neria Soft Unomedical Tubing 60 cm. 76-060-2652 - 10 Pieces 10 10 FV07AY03 INSULIN INFUSION SETS 93259 Neria Soft Unomedical Tubing 110 cm. 76-110-2652 - 10 Pieces 10 10 FV07AY03 INSULIN INFUSION SETS 93260 Neria Soft Unomedical Infusion Set 60 cm. 13 mm. 79-060-2522 - 10 Pieces 10 10 FV07AY03 INSULIN INFUSION SETS 93261 Neria Soft Unomedical Infusion Set 60 cm. 17 mm. 79-060-2622 - 10 Pieces 10 10 FV07AY03 INSULIN INFUSION SETS 93263 Neria Soft Unomedical Infusion Set 80 cm. 13 mm. 79-080-2522 - 10 Pieces 10 10 FV07AY03 INSULIN INFUSION SETS 93264 Neria Soft Unomedical Infusion Set 80 cm. 17 mm. 79-080-2622 - 10 Pieces 10 10 FV07AY03 INSULIN INFUSION SETS 93266 Neria Soft Unomedical Infusion Set 110 cm. 13 mm. 79-110-2522 - 10 Pieces 10 10 F

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Drug Description Pack Size Name

PackSize

Typ Illness

V07AY03 INSULIN INFUSION SETS 93268 Neria Soft Unomedical Infusion Set 110 cm. 17 mm. 79-110-2622 - 10 Pieces 10 10 FV07AY03 INSULIN INFUSION SETS 95413 Medtronic MiniMed 508 QR Sof-Set Micro 61 cm. MMT-321 - 12 Pieces 12 12 FV07AY03 INSULIN INFUSION SETS 95417 Medtronic MiniMed 508 QR Sof-Set Micro 107 cm. MMT-320 - 12 Pieces 12 12 FV07AY03 INSULIN INFUSION SETS 95437 Medtronic MiniMed 508 QR Sof-Set 61 cm. MMT-316 - 12 Pieces 12 12 FV07AY03 INSULIN INFUSION SETS 95440 Medtronic MiniMed 508 QR Sof-Set 107 cm. MMT-315 - 12 Pieces 12 12 FV07AY03 INUSLIN INFUSION SETS 85318 Medtronic Sure-T Paradigm 60 cm. 8 mm. MMT-874 - 10 Pieces 10 10 FV07AY03 INUSLIN INFUSION SETS 97609 mylife Orbitmicro Infusion Set 5.5 mm./45 cm. MYOYP1851 10 10 10 FV07AY03 INUSLIN INFUSION SETS 97610 mylife Orbitmicro Infusion Set 5.5 mm./60 cm. MYOYP2451 10 10 10 FV07AY03 INUSLIN INFUSION SETS 97611 mylife Orbitmicro Infusion Set 5.5 mm./80 cm. MYOYP3151 10 10 10 FV07AY03 INUSLIN INFUSION SETS 97612 mylife Orbitmicro Infusion Set 5.5 mm./110 cm. MYOYP4351 10 10 10 FV07AY03 INUSLIN INFUSION SETS 97613 mylife Orbitsoft Infusion Set 6 mm./45 cm. MYOYP1861 10 10 10 FV07AY03 INUSLIN INFUSION SETS 97614 mylife Orbitsoft Infusion Set 6 mm./60 cm. MYOYP2461 10 10 10 FV07AY03 INUSLIN INFUSION SETS 97615 mylife Orbitsoft Infusion Set 6 mm./80 cm. MYOYP3161 10 10 FV07AY03 INUSLIN INFUSION SETS 97617 mylife Orbitsoft Infusion Set 6 mm./110 cm. MYOYP4361 10 10 10 FV07AY03 INUSLIN INFUSION SETS 97618 mylife Orbitsoft Infusion Set 9 mm./45 cm. MYOYP1891 10 10 10 FV07AY03 INUSLIN INFUSION SETS 97619 mylife Orbitsoft Infusion Set 9 mm./60 cm. MYOYP2491 10 10 FV07AY03 INUSLIN INFUSION SETS 97620 mylife Orbitsoft Infusion Set 9 mm./80 cm. MYOYP3191 10 10 10 FV07AY03 INUSLIN INFUSION SETS 97621 mylife Orbitsoft Infusion Set 9 mm./110 cm. MYOYP4391 10 10 10 FV07AY03 Insulin Infusion Sets 97604 mylife YpsoPump Reservoir 700001181 10 10 10 FV07AY08 LANCETS 85541 Accu-Chek FastClix Lancets 204 204 204 FV07AY08 LANCETS 86315 Microdot Lancets, 30 G. 100 100 100 FV07AY08 LANCETS 86391 Apollo Twist Lancets 28 G. 0.36 mm 200 200 200 FV07AY08 LANCETS FOR FINGER PRICKING DEVICES 85055 Lancet Type C (cylindrical mount fluted longitudinally Fine Gauge Minimum 28 G.) 200 200 200 FV07AY08 LANCETS FOR FINGER PRICKING DEVICES 85086 Lancet Type D (Flat, Non-Ribbed) 200 200 200 FV07AY08 LANCETS FOR FINGER PRICKING DEVICES 85405 Lancet Type A (cylindrical mount fluted longitudinally) 200 200 200 FV07AY08 LANCETS FOR FINGER PRICKING DEVICES 85413 Lancet Type B (cylindrical mount with concentric ribs) 200 200 200 FV07AY08 Lancets 97602 Gluco Rx Lancets 30 G., 0.31 mm. 394-1354 200 200 200 FV07AY08 LANCETS 86316 OneTouch Delica Lancets, 30 G. 0.32 mm. 200 200 200 FV07AY08 Lancets 86317 Unilet Eco Lancet AT0935 100 100 100 FV07AY91 Blood Glucose Tests 85543 Accu-Chek Mobile Test Cassette 50 50 50 F


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