Drug Benefit List - April 2009

08:00 ANTI-INFECTIVE AGENTS

08:08.00 ANTHELMINTICS

MEBENDAZOLE

100MG Tablet

00556734 VERMOX JNO

PYRANTEL PAMOATE

50MG/ML Suspension

01944355 COMBANTRIN PFI

125MG Tablet

01944363 COMBANTRIN PFI

PYRVINIUM PAMOATE

10MG/ML Suspension

02019809 VANQUIN WLA

08:12.06 CEPHALOSPORINS

CEFACLOR

250MG Capsule

02230263 APO-CEFACLOR APX

00465186 CECLOR PHH

02177633 DOM-CEFACLOR DPC

02231691 NOVO-CEFACLOR NOP

02231432 NU-CEFACLOR NXP

02238200 PDL-CEFACLOR PDL

02237729 SCHEIN-CEFACLOR SCN

500MG Capsule

02230264 APO-CEFACLOR APX

00465194 CECLOR PHH

02177641 DOM-CEFACLOR DPC

02231693 NOVO-CEFACLOR NOP

02231433 NU-CEFACLOR NXP

02238201 PDL-CEFACLOR PDL

02237730 SCHEIN-CEFACLOR SCN

25MG/ML Suspension

02237500 APO-CEFACLOR APX

00465208 CECLOR PHH

02177668 DOM-CEFACLOR DPC

02238202 PDL-CEFACLOR PDL

50MG/ML Suspension

02237501 APO-CEFACLOR APX

00465216 CECLOR PHH

02177676 DOM-CEFACLOR DPC

02238203 PDL-CEFACLOR PDL

75MG/ML Suspension

02237502 APO-CEFACLOR APX

00832804 CECLOR BID PHH

02177684 DOM-CEFACLOR DPC

02238204 PDL-CEFACLOR PDL

CEFADROXIL

500MG Capsule

02240774 APO-CEFADROXIL APX

00507245 DURICEF BMS

02235134 NOVO-CEFADROXIL NOP

02311062 PRO-CEFADROXIL PDL

CEFIXIME

20MG/ML Suspension

00868965 SUPRAX SAC

400MG Tablet

00868981 SUPRAX SAC

CEFPROZIL

25MG/ML Suspension

02293943 APO-CEFPROZIL APX

02163675 CEFZIL BMS

02303426 SANDOZ CEFPROZIL SDZ

50MG/ML Suspension

02293951 APO-CEFPROZIL APX

02163683 CEFZIL BMS

02293579 RAN-CEFPROZIL RBY

02303434 SANDOZ CEFPROZIL SDZ

250MG Tablet

02292998 APO-CEFPROZIL APX

02163659 CEFZIL BMS

02293528 RAN-CEFPROZIL RBY

02302179 SANDOZ CEFPROZIL SDZ

500MG Tablet

02293005 APO-CEFPROZIL APX

02163667 CEFZIL BMS

02293536 RAN-CEFPROZIL RBY

02302187 SANDOZ CEFPROZIL SDZ

CEFUROXIME AXETIL

25MG/ML Suspension

02212307 CEFTIN GSK

250MG Tablet

02244393 APO-CEFUROXIME APX

02212277 CEFTIN GSK

02242656 RATIO-CEFUROXIME RPH

500MG Tablet

02244394 APO-CEFUROXIME APX

02212285 CEFTIN GSK

02311453 PRO-CEFUROXIME PDL

02242657 RATIO-CEFUROXIME RPH

CEPHALEXIN

250MG Capsule

00342084 NOVO-LEXIN NOP

500MG Capsule

00342114 NOVO-LEXIN NOP

25MG/ML Suspension

02177862 DOM-CEPHALEXIN DPC

00342106 NOVO-LEXIN NOP

50MG/ML Suspension

02177870 DOM-CEPHALEXIN DPC

00342092 NOVO-LEXIN NOP

250MG Tablet

00768723 APO-CEPHALEX APX

02177846 DOM-CEPHALEXIN DPC

00583413 NOVO-LEXIN NOP

00865877 NU-CEPHALEX NXP

00828858 PDL-CEPHALEXIN PDL

02177781 PMS-CEPHALEXIN PMS

500MG Tablet

00768715 APO-CEPHALEX APX

02177854 DOM-CEPHALEXIN DPC

00583421 NOVO-LEXIN NOP

00865885 NU-CEPHALEX NXP

00828866 PDL-CEPHALEXIN PDL

02177803 PMS-CEPHALEXIN PMS

08:12.12 MACROLIDES

AZITHROMYCIN

20MG/ML Suspension

02315157 NOVO-AZITHROMYCIN NOP

02274388 PMS-AZITHROMYCIN PMS

02223716 ZITHROMAX PFI

40MG/ML Suspension

02315165 NOVO-AZITHROMYCIN NOP

02274396 PMS-AZITHROMYCIN PMS

02223724 ZITHROMAX PFI

250MG Tablet

02247423 APO-AZITHROMYCIN APX

02255340 CO-AZITHROMYCIN COB

02278359 GEN-AZITHROMYCIN GEN

02267845 NOVO-AZITHROMYCIN NOP

02261634 PMS-AZITHROMYCIN PMS

02310600 PRO-AZITHROMYCIN PDL

02275287 RATIO-AZITHROMYCIN RPH

02275309 RIVA-AZITHROMYCIN RIV

02265826 SANDOZ-AZITHROMYCIN SDZ

02212021 ZITHROMAX PFI

600MG Tablet

02256088 CO-AZITHROMYCIN COB

02261642 PMS-AZITHROMYCIN PMS

02275317 RIVA-AZITHROMYCIN RIV

02231143 ZITHROMAX PFI

CLARITHROMYCIN

500MG Extended Release Tablet

02244756 BIAXIN XL ABB

250MG Film Coated Tablet

02274744 APO-CLARITHROMYCIN APX

01984853 BIAXIN ABB

02248856 GEN-CLARITHROMYCIN GEN

02247573 PMS-CLARITHROMYCIN PMS

02247818 RATIO-CLARITHROMYCIN RPH

02266539 SANDOZ-CLARITHROMYCIN RHO

500MG Film Coated Tablet

02266547 SANDOZ-CLARITHROMYCIN RHO

02274752 APO-CLARITHROMYCIN APX

02126710 BIAXIN ABB

02248857 GEN-CLARITHROMYCIN GEN

02247574 PMS-CLARITHROMYCIN PMS

02247819 RATIO-CLARITHROMYCIN RPH

25MG/ML Suspension

02146908 BIAXIN ABB

50MG/ML Suspension

02244641 BIAXIN ABB

ERYTHROMYCIN

250MG Enteric Coated Capsule

00726672 APO-ERYTHRO APX

00607142 ERYC PFI

333MG Enteric Coated Capsule

01925938 APO-ERYTHRO APX

333MG Enteric Coated Tablet

00873454 ERYC PFI

250MG Tablet

00682020 APO-ERYTHRO BASE APX

ERYTHROMYCIN ESTOLATE

25MG/ML Suspension

00021172 NOVO-RYTHRO ESTOLATE NOP

50MG/ML Suspension

00262595 NOVO-RYTHRO ESTOLATE NOP

ERYTHROMYCIN ETHYLSUCCINATE

40MG/ML Suspension

00605859 NOVO-RYTHRO ETHYLSUCCINATE NOP

80MG/ML Suspension

00652318 NOVO-RYTHRO ETHYLSUCCINATE NOP

600MG Tablet

00637416 APO-ERYTHRO-S APX

00583782 EES-600 ABB

00704377 ERYTHRO-ES PDL

ERYTHROMYCIN STEARATE

250MG Tablet

00545678 APO-ERYTHRO-S APX

00563854 ERYTHROMYCIN PDL

02051850 NU-ERYTHROMYCIN S NXP

500MG Tablet

00688568 APO-ERYTHRO S APX

00704393 ERYTHRO PDL

08:12.16 PENICILLINS

AMOXICILLIN

250MG Capsule

00628115 APO-AMOXI APX

02238171 GEN-AMOXICILLIN GEN

02239761 MED-AMOXICILLIN MEC

00406724 NOVAMOXIN NOP

00865567 NU-AMOXI NXP

02229584 PENTA-AMOXICILLIN PEN

02230243 PMS-AMOXICILLIN PMS

00644307 PRO-AMOX PDL

02241826 SCHEIN-AMOXICILLIN SCN

500MG Capsule

00628123 APO-AMOXI APX

02238172 GEN-AMOXICILLIN GEN

02239762 MED-AMOXICILLIN MEC

00406716 NOVAMOXIN NOP

00865575 NU-AMOXI NXP

02233017 PENTA-AMOXICILLIN PEN

02230244 PMS-AMOXICILLIN PMS

00644315 PRO-AMOX PDL

02241827 SCHEIN-AMOXICILLIN SCN

125MG Chewable Tablet

02036347 NOVAMOXIN NOP

250MG Chewable Tablet

02036355 NOVAMOXIN NOP

25MG/ML Suspension

00628131 APO-AMOXI APX

00452149 NOVAMOXIN NOP

01934171 NOVAMOXIN SUGAR REDUCED NOP

00865540 NU-AMOXI NXP

02229582 PENTA-AMOXICILLIN PEN

02230245 PMS-AMOXICILLIN PMS

00644323 PRO-AMOX PDL

50MG/ML Suspension

00628158 APO-AMOXI APX

00452130 NOVAMOXIN NOP

01934163 NOVAMOXIN SUGAR REDUCED NOP

00865559 NU-AMOXI NXP

02229583 PENTA-AMOXICILLIN PEN

02230246 PMS-AMOXICILLIN PMS

00644331 PRO-AMOX PDL

AMOXICILLIN, CLAVULANIC ACID

25MG & 6.25MG/ML Suspension

02243986 APO-AMOXI CLAV APX

01916882 CLAVULIN-F 125 GSK

40MG & 5.7MG/ML Suspension

02288559 APO-AMOXI CLAV APX

02238831 CLAVULIN 200 GSK

50MG & 12.5MG/ML Suspension

02243987 APO-AMOXI CLAV APX

01916874 CLAVULIN-F 250 GSK

80MG & 11.4MG/ML Suspension

02238830 CLAVULIN 400 GSK

250MG & 125MG Tablet

02243350 APO-AMOXI CLAV APX

500MG & 125MG Tablet

02243351 APO-AMOXI CLAV APX

01916858 CLAVULIN-F GSK

02243771 RATIO-ACLAVULANATE RPH

875MG & 125MG Tablet

02245623 APO-AMOXI CLAV APX

02238829 CLAVULIN GSK

02248138 NOVO-CLAVAMOXIN NOP

02247021 RATIO-ACLAVULANATE RPH

AMPICILLIN

250MG Capsule

00020877 NOVO-AMPICILLIN NOP

500MG Capsule

00020885 NOVO-AMPICILLIN NOP

25MG/ML Suspension

00603260 APO-AMPICILLIN APX

00717495 NU-AMPI NXP

50MG/ML Suspension

00603287 APO-AMPICILLIN APX

00717649 NU-AMPI NXP

02043203 PENBRITIN WAY

CLOXACILLIN

250MG Capsule

00618292 APO-CLOXI APX

02069660 CLOXACILLINE PRO

00337765 NOVO-CLOXIN NOP

00717584 NU-CLOXI NXP

500MG Capsule

00618284 APO-CLOXI APX

02069679 CLOXACILLINE PRO

00337773 NOVO-CLOXIN NOP

00717592 NU-CLOXI NXP

25MG/ML Suspension

00644633 APO-CLOXI APX

00337757 NOVO-CLOXIN NOP

00717630 NU-CLOXI NXP

PENICILLIN V BENZATHINE

36MG/ML Suspension

02229618 PEN VEE PED

60MG/ML Suspension

02229617 PEN VEE PED

PENICILLIN V POTASSIUM

25MG/ML Suspension

00642223 APO-PEN VK APX

60MG/ML Suspension

00642231 APO-PEN VK APX

00391603 NOVO-PEN VK NOP

300MG Tablet

00642215 APO-PEN VK APX

00021202 NOVO-PEN VK NOP

00717568 NU-PEN VK NXP

00468029 PENICILLINE V PDL

PIVAMPICILLIN

35MG/ML Suspension

00582239 PONDOCILLIN LEO

500MG Tablet

00582247 PONDOCILLIN LEO

PIVMECILLINAM HCL

200MG Tablet

00657212 SELEXID LEO

08:12.18 QUINOLONES

CIPROFLOXACIN HCL

250MG Tablet

02229521 APO-CIPROFLOX APX

02155958 CIPRO BAY

02251752 CIPROFLOXCIN PDL

02247339 CO-CIPROFLOXACIN COB

02251272 DOM-CIPROFLOXACIN DPC

02245647 GEN-CIPROFLOXACIN GEN

02161737 NOVO-CIPROFLOXACIN NOP

02249634 NU-CIPROFLOXACIN NXP

02251310 PHL-CIPROFLOXACIN PHH

02248437 PMS-CIPROFLOXACIN PMS

02249960 PREM-CIPROFLOXACIN PRE

02317796 PRO-CIPROFLOXACIN PDL

02303728 RAN-CIPROFLOX RBY

02267934 RAN-CIPROFLOXACIN RBY

02246825 RATIO-CIPROFLOXACIN RPH

02251221 RIVA-CIPROFLOXACIN RIV

02248756 SANDOZ-CIPROFLOXACIN SDZ

02266962 TARO-CIPROFLOXACIN TAR

500MG Tablet

02229522 APO-CIPROFLOX APX

02155966 CIPRO BAY

02251760 CIPROFLOXACIN PDL

02247340 CO-CIPROFLOXACIN COB

02251280 DOM-CIPROFLOXACIN DPC

02245648 GEN-CIPROFLOXACIN GEN

02161745 NOVO-CIPROFLOXACIN NOP

02249642 NU-CIPROFLOXACIN NXP

02251329 PHL-CIPROFLOXACIN PHH

02248438 PMS-CIPROFLOXACIN PMS

02249979 PREM-CIPROFLOXACIN PRE

02317818 PRO-CIPROFLOXACIN PDL

02303736 RAN-CIPROFLOX RBY

02267942 RAN-CIPROFLOXACIN RBY

02246826 RATIO-CIPROFLOXACIN RPH

02248757 RHOXAL-CIPROFLOXACIN RHO

02251248 RIVA-CIPROFLOXACIN RIV

02266970 TARO-CIPROFLOXACIN TAR

750MG Tablet

02229523 APO-CIPROFLOX APX

02155974 CIPRO BAY

02251779 CIPROFLOXACIN PDL

02247341 CO-CIPROFLOXACIN COB

02251299 DOM-CIPROFLOXACIN DPC

02245649 GEN-CIPROFLOXACIN GEN

02161753 NOVO-CIPROFLOXACIN NOP

02249650 NU-CIPROFLOXACIN NXP

02251337 PHL-CIPROFLOXACIN PHH

02248439 PMS-CIPROFLOXACIN PMS

02249987 PREM-CIPROFLOXACIN PRE

02303744 RAN-CIPROFLOX RBY

02267950 RAN-CIPROFLOXACIN RBY

02246827 RATIO-CIPROFLOXACIN RPH

02248758 RHOXAL-CIPROFLOXACIN RHO

02251256 RIVA-CIPROFLOXACIN RIV

NALIDIXIC ACID

500MG Tablet

02017687 NEGGRAM SAC

NORFLOXACIN

400MG Tablet

02229524 APO-NORFLOX APX

02269627 CO-NORFLOXACIN COB

02237682 NOVO-NORFLOXACIN NOP

02239670 PDL-NORFLOXACINE PDL

02246596 PMS-NORFLOXACIN PMS

02241483 RIVA-NORFLOXACIN RIV

02301504 RIVA-NORFLOXACIN RIV

OFLOXACIN

200MG Tablet

02231529 APO-OFLOX APX

02243474 NOVO-OFLOXACIN NOP

300MG Tablet

02231531 APO-OFLOX APX

02243475 NOVO-OFLOXACIN NOP

400MG Tablet

02231532 APO-OFLOX APX

02243476 NOVO-OFLOXACIN NOP

08:12.20 SULFONAMIDES

SULFAMETHOXAZOLE

500MG Tablet

00421480 APO-SULFAMETHOXAZOLE APX

SULFAMETHOXAZOLE, TRIMETHOPRIM

40MG & 8MG/ML Suspension

00846465 APO-SULFATRIM APX

00726540 NOVO-TRIMEL NOP

00865753 NU-COTRIMOX NXP

100MG & 20MG Tablet

00445266 APO-SULFATRIM PED APX

400MG & 80MG Tablet

00445274 APO-SULFATRIM APX

00510637 NOVO-TRIMEL NOP

00865710 NU-COTRIMOX NXP

00512516 PROTRIN PDL

800MG & 160MG Tablet

00445282 APO-SULFATRIM DS APX

00510645 NOVO-TRIMEL DS NOP

00865729 NU-COTRIMOX DS NXP

00512524 PROTRIN DF PRO

SULFASALAZINE

500MG Enteric Coated Tablet

00598488 PMS-SULFASALAZINE PMS

02064472 SALAZOPYRIN PFI

500MG Tablet

00598461 PMS-SULFASALAZINE PMS

02064480 SALAZOPYRIN PFI

08:12.24 TETRACYCLINES

DOXYCYCLINE

100MG Capsule

00740713 APO-DOXY APX

00817120 DOXYCIN RIV

00742562 DOXYCYCLINE PDL

00725250 NOVO-DOXYLIN NOP

02044668 NU-DOXYCYCLINE NXP

02289539 PMS-DOXYCYCLINE PMS

02093103 RATIO-DOXYCYCLINE RPH

100MG Tablet

00874256 APO-DOXY APX

00860751 DOXYCIN RIV

00887064 DOXYTAB PDL

02158574 NOVO-DOXYLIN NOP

02044676 NU-DOXYCYCLINE NXP

02289466 PMS-DOXYCYCLINE PMS

02091232 RATIO-DOXYCYCLINE RPH

00578452 VIBRA-TABS PFI

MINOCYCLINE HCL

50MG Capsule

02084090 APO-MINOCYCLINE APX

02239667 DOM-MINOCYCLINE DPC

02237875 MED-MINOCYCLINE MEC

02173514 MINOCIN STI

02108143 NOVO-MINOCYCLINE NOP

02153394 PDL-MINOCYCLINE PDL

02294419 PMS-MINOCYCLINE PMS

02239238 PMS-MINOCYCLINE PMS

01914138 RATIO-MINOCYCLINE RPH

02242080 RIVA-MINOCYCLINE RIV

02237313 SANDOZ-MINOCYCLINE SDZ

100MG Capsule

02084104 APO-MINOCYCLINE APX

02239668 DOM-MINOCYCLINE DPC

02237876 MED-MINOCYCLINE MEC

02173506 MINOCIN STI

02239982 MINOCYCLINE IVX

02108151 NOVO-MINOCYCLINE NOP

02154366 PDL-MINOCYCLINE PDL

02294427 PMS-MINOCYCLINE PMS

02239239 PMS-MONOCYCLINE PMS

01914146 RATIO-MINOCYCLINE RPH

02242081 RIVA-MINOCYCLINE RIV

02237314 SANDOZ-MINOCYCLINE SDZ

TETRACYCLINE HCL

250MG Capsule

00580929 APO-TETRA APX

00156744 TETRACYCLINE PRO

250MG Tablet

00717606 NU-TETRA NXP

08:12.28 MISCELLANEOUS ANTIBIOTICS

CLINDAMYCIN HCL

150MG Capsule

02245232 APO-CLINDAMYCIN APX

02248525 CLINDAMYCINE PDL

00030570 DALACIN C PFI

02258331 GEN-CLINDAMYCIN GEN

02241709 NOVO-CLINDAMYCIN NOP

02294826 PMS-CLINDAMYCIN PMS

02130033 RATIO-CLINDAMYCIN RPH

02242409 RIVA-CLINDAMYCIN RIV

300MG Capsule

02245233 APO-CLINDAMYCIN APX

02248526 CLINDAMYCINE PDL

02182866 DALACIN C PFI

02258358 GEN-CLINDAMYCIN GEN

02241710 NOVO-CLINDAMYCIN NOP

02294834 PMS-CLINDAMYCIN PMS

02192659 RATIO-CLINDAMYCIN RPH

02242410 RIVA-CLINDAMYCIN RIV

CLINDAMYCIN PALMITATE HCL

15MG/ML Solution

00225851 DALACIN C PFI

FUSIDATE SODIUM

250MG Tablet

01934252 FUCIDIN FC LEO

LINEZOLID

Limited use benefit (prior approval required).

Tablets:

For treatment of proven vancomycin-resistant enterococci (VRE) infections when other antibiotics are not available, and for the treatment of proven Methicillin-Resistant Staphylococcus aureus (MRSA) infections in patients who cannot tolerate or who had an idiosyncratic reaction with Vancomycin.

I.V. solution:

When linezolid cannot be administered orally in the above mentioned situations.

2MG/ML Injection

02243685 ZYVOXAM PFI

600MG Tablet

02243684 ZYVOXAM PFI

08:14.04 ALLYLAMINES

TERBINAFINE HCL

250MG Tablet

02239893 APO-TERBINAFINE APX

02254727 CO-TERBINAFINE COB

02242503 GEN-TERBINAFINE GEN

02031116 LAMISIL NVR

02240346 NOVO-TERBINAFINE NOP

02248845 NU-TERBINAFINE NXP

02240807 PMS-TERBINAFINE PMS

02262924 RIVA-TERBINAFINE RIV

02262177 SANDOZ-TERBINAFINE SDZ

08:14.08 AZOLES

FLUCONAZOLE

150MG Capsule

02241895 APO-FLUCONAZOLE APX

02141442 DIFLUCAN PFI

02245697 GEN-FLUCONAZOLE GEN

02243645 NOVO-FLUCONAZOLE NOP

02246620 PMS-FLUCONAZOLE PMS

02282348 PMS-FLUCONAZOLE PMS

02310694 PRO-FLUCONAZOLE PDL

02255510 RIVA-FLUCONAZOLE RIV

10MG/ML Suspension

02024152 DIFLUCAN PFI

50MG Tablet

02237370 APO-FLUCONAZOLE APX

00891800 DIFLUCAN PFI

02245292 GEN-FLUCONAZOLE GEN

02236978 NOVO-FLUCONAZOLE NOP

02245643 PMS-FLUCONAZOLE PMS

02249294 TARO-FLUCONAZOLE TAR

100MG Tablet

02237371 APO-FLUCONAZOLE APX

02245293 GEN-FLUCONAZOLE GEN

02236979 NOVO-FLUCONAZOLE NOP

02245644 PMS-FLUCONAZOLE PMS

02310686 PRO-FLUCONAZOLE PDL

02271516 RIVA-FLUCONAZOLE RIV

02249308 TAR0-FLUCONAZOLE TAR

ITRACONAZOLE

100MG Capsule

02047454 SPORANOX JNO

10MG/ML Solution

02231347 SPORANOX JNO

KETOCONAZOLE

200MG Tablet

02237235 APO-KETOCONAZOLE APX

02231061 NOVO-KETOCONAZOLE NOP

02122197 NU-KETOCON NXP

VORICONAZOLE

50MG Tablet

02256460 VFEND PFI

200MG Tablet

02256479 VFEND PFI

08:14.28 POLYENES

NYSTATIN

100,000U/ML Suspension

02125145 DOM-NYSTATIN DPC

00792667 PMS-NYSTATIN PMS

02194201 RATIO-NYSTATIN RPH

500,000U Tablet

02194198 RATIO-NYSTATIN RPH

08:16.04 ANTITUBERCULOSIS AGENTS

ETHAMBUTOL HCL

100MG Tablet

00247960 ETIBI VAE

400MG Tablet

00247979 ETIBI VAE

ISONIAZID

10MG/ML Syrup

00265500 ISOTAMINE VAE

00577812 PMS-ISONIAZID PMS

50MG Tablet

00577782 PMS-ISONIAZID PMS

300MG Tablet

00272655 ISOTAMINE VAE

00577804 PMS-ISONIAZID PMS

PYRAZINAMIDE

500MG Tablet

00618810 PMS-PYRAZINAMIDE PMS

00283991 TEBRAZID VAE

RIFABUTIN

150MG Capsule

02063786 MYCOBUTIN PFI

RIFAMPIN

150MG Capsule

02091887 RIFADIN SAC

00393444 ROFACT VAE

300MG Capsule

02092808 RIFADIN SAC

00210463 RIMACTANE NVR

00343617 ROFACT VAE

08:18.04 ADAMANTANES

AMANTADINE HCL

100MG Capsule

02130963 DOM-AMANTADINE DPC

02034468 ENDANTADINE LIN

02139200 GEN-AMANTADINE GEN

02199289 MED-AMANTADINE MEC

01990403 PMS-AMANTADINE PMS

10MG/ML Syrup

02130971 DOM-AMANTADINE DPC

02022826 PMS-AMANTADINE PMS

01913999 SYMMETREL BMS

08:18.08 ANTIRETROVIRALS

ABACAVIR

20MG/ML Oral Liquid

02240358 ZIAGEN GSK

300MG Tablet

02240357 ZIAGEN GSK

ABACAVIR, LAMIVUDINE

600MG & 300MG Tablet

02269341 KIVEXA GSK

ABACAVIR, LAMIVUDINE, ZIDOVUDINE

300MG & 150MG & 300MG Tablet

02244757 TRIZIVIR GSK

AMPRENAVIR

Limited use benefit (prior approval required).

For the management of HIV disease in patients who have failed other protease inhibitor combinations, or for patients who experienced a lack of tolerability to other protease inhibitors.

50MG Capsule

02243541 AGENERASE GSK

150MG Capsule

02243542 AGENERASE GSK

15MG/ML Oral Liquid

02243543 AGENERASE GSK

ATAZANAVIR SULFATE

150MG Capsule

02248610 REYATAZ BMS

200MG Capsule

02248611 REYATAZ BMS

300MG Capsule

02294176 REYATAZ BMS

DARUNAVIR

Limited use benefit (prior approval required).

For the management of HIV in patients who failed or have experienced adverse events to three or more listed protease inhibitors.

300MG Tablet

02284057 PREZISTA JNO

DIDANOSINE

125MG Capsule

02244596 VIDEX EC BMS

200MG Capsule

02244597 VIDEX EC BMS

250MG Capsule

02244598 VIDEX EC BMS

400MG Capsule

02244599 VIDEX EC BMS

EFAVIRENZ

50MG Capsule

02239886 SUSTIVA BMS

100MG Capsule

02239887 SUSTIVA BMS

200MG Capsule

02239888 SUSTIVA BMS

600MG Tablet

02246045 SUSTIVA BMS

EFAVIRENZ, EMTRICITABINE, TENOFOVIR DISOPROXIL FUMARATE

Limited use benefit (prior approval required).

For the treatment of HIV-1 infection adults where the virus is susceptible to each of tenofovir, emtricitabine and efavirenz, and:

1. Atripla is used to replace existing therapy with its component drugs, or
2. the patient is treatment naïve, or
3. the patient has established viral suppression but requires antiretroviral therapy modification due to intolerance or adverse effects.

Note: Criteria will be confirmed against medication history.

600MG/200MG/300MG Tablet

02300699 ATRIPLA BMS

EMTRICITABINE, TENOFOVIR DISOPROXIL FUMARATE

Limited use benefit (prior approval required).

For the treatment of patients with HIV infection where the virus is susceptible to both emtricitabine and tenofovir AND where the triple-entity antiretroviral agent (tenofovir/ emtricitabine/efavirenz) is not indicated due to one of the following:

1. efavirenz resistance;
2. adverse effects secondary to efavirenz.

200MG/300MG Tablet

02274906 TRUVADA GIL

FOSAMPRENAVIR CALCIUM

50MG/ML Oral Suspension

02261553 TELZIR GSK

700MG Tablet

02261545 TELZIR GSK

INDINAVIR SULFATE

200MG Capsule

02229161 CRIXIVAN FRS

400MG Capsule

02229196 CRIXIVAN FRS

LAMIVUDINE

10MG/ML Solution

02192691 3TC GSK

100MG Tablet

02239193 HEPTOVIR GSK

150MG Tablet

02192683 3TC GSK

300MG Tablet

02247825 3TC GSK

LAMIVUDINE, ZIDOVUDINE

150MG & 300MG Tablet

02239213 COMBIVIR GSK

LOPINAVIR, RITONAVIR

80MG & 20MG/ML Oral Solution

02243644 KALETRA ABB

100MG & 25MG Tablet

02312301 KALETRA ABB

200MG & 50MG Tablet

02285533 KALETRA ABB

NELFINAVIR MESYLATE

50MG/G Powder for Suspension

02238618 VIRACEPT PFI

250MG Tablet

02238617 VIRACEPT PFI

625MG Tablet

02248761 VIRACEPT PFI

NEVIRAPINE

200MG Tablet

02238748 VIRAMUNE BOE

RALTEGRAVIR

Limited use benefit (prior approval required).

For the treatment of HIV infection in patients who are antiretroviral experienced and have virologic failure due to resistance to at least one agent from each of the three major classes of antiretroviral agents, nucleoside/tide reverse transcriptase inhibitors, non-nucleoside reverse transcriptase inhibitors and protease inhibitors.

400MG Tablet

02301881 ISENTRESS FRS

RITONAVIR

100MG Capsule

02241480 NORVIR SEC ABB

80MG/ML Liquid

02229145 NORVIR ABB

SAQUINAVIR MESYLATE

200MG Capsule

02216965 INVIRASE HLR

500MG Tablet

02279320 INVIRASE HLR

STAVUDINE

15MG Capsule

02216086 ZERIT BMS

20MG Capsule

02216094 ZERIT BMS

30MG Capsule

02216108 ZERIT BMS

40MG Capsule

02216116 ZERIT BMS

TENOFOVIR DISOPROXIL FUMARATE

Limited use benefit (prior approval required).

For the management of HIV disease in patients who have failed or have experienced adverse events to an alternative nucleoside reverse transcriptase inhibitor.

245MG Tablet

02247128 VIREAD GIL

TIPRANAVIR

250MG Capsule

02273322 APTIVUS BOE

ZIDOVUDINE

100MG Capsule

01946323 APO-ZIDOVUDINE APX

01902660 RETROVIR GSK

10MG/ML Syrup

01902652 RETROVIR GSK

08:18.20 INTERFERONS

PEGINTERFERON ALFA-2A

180MCG/0.5ML Injection

02248077 PEGASYS HLR

180MCG/1ML Injection

02248078 PEGASYS HLR

PEGINTERFERON ALFA-2A, RIBAVIRIN

180MCG/0.5ML & 200MG Injection & Tablet

02253429 PEGASYS RBV HLR

180MCG/1ML & 200MG Injection & Tablet

02253410 PEGASYS RBV HLR

PEGINTERFERON ALFA-2B

74MCG/VIAL Injection

02242966 UNITRON PEG SCH

118.4MCG/VIAL Injection

02242967 UNITRON PEG SCH

177.6MCG/VIAL Injection

02242968 UNITRON PEG SCH

222MCG/VIAL Injection

02242969 UNITRON PEG SCH

PEGINTERFERON ALFA-2B, RIBAVIRIN

50MCG/0.5ML & 200MG Injection & Capsule

02246026 PEGETRON SCH

02254573 PEGETRON REDIPEN SCH

80MCG/0.5ML & 200MG Injection & Capsule

02246027 PEGETRON SCH

02254581 PEGETRON REDIPEN SCH

100MCG/0.5ML & 200MG Injection & Capsule

02246028 PEGETRON SCH

02254603 PEGETRON REDIPEN SCH

120MCG/0.5ML & 200MG Injection & Capsule

02246029 PEGETRON SCH

02254638 PEGETRON REDIPEN SCH

150MCG/0.5ML & 200MG Injection & Capsule

02246030 PEGETRON SCH

02254646 PEGETRON REDIPEN SCH

08:18.32 NUCLEOSIDES AND NUCLEOTIDES

ACYCLOVIR

40MG/ML Suspension

00886157 ZOVIRAX GSK

200MG Tablet

02207621 APO-ACYCLOVIR APX

02242784 GEN-ACYCLOVIR GEN

02285959 NOVO-ACYCLOVIR NOP

02197405 NU-ACYCLOVIR NXP

02237541 PDL-ACYCLOVIR PDL

02078627 RATIO-ACYCLOVIR RPH

00634506 ZOVIRAX GSK

400MG Tablet

02207648 APO-ACYCLOVIR APX

02242463 GEN-ACYCLOVIR GEN

02285967 NOVO-ACYCLOVIR NOP

02197413 NU-ACYCLOVIR NXP

02237542 PDL-ACYCLOVIR PDL

02078635 RATIO-ACYCLOVIR RPH

01911627 ZOVIRAX GSK

800MG Tablet

02207656 APO-ACYCLOVIR APX

02242464 GEN-ACYCLOVIR GEN

02285975 NOVO-ACYCLOVIR NOP

02197421 NU-ACYCLOVIR NXP

02237543 PDL-ACYCLOVIR PDL

02078651 RATIO-ACYCLOVIR RPH

01911635 ZOVIRAX GSK

ADEFOVIR DIPIVOXIL

Limited use benefit (prior approval required).

For the treatment of chronic hepatitis B infection when used in combination with lamivudine in patients who have developed failure to lamivudine, as defined by an increase in HBV DNA of ≥ 1 log10 IU/mL above the nadir, measured on two separate occasions within an interval of at least one month, after the first three months of lamivudine therapy, and when failure to lamivudine is not due to poor adherence to therapy.

10MG Tablet

02247823 HEPSERA GIL

ENTECAVIR

Limited use benefit (prior approval required).

For the treatment of chronic hepatitis B infection in patients with cirrhosis documented on radiologic or histologic grounds and a HBV DNA concentration above 2000IU/mL.

0.5MG Tablet

02282224 BARACLUDE BMS

FAMCICLOVIR

125MG Tablet

02292025 APO-FAMCICLOVIR APX

02305682 CO FAMCICLOVIR COB

02229110 FAMVIR NVR

02278081 PMS-FAMCICLOVIR PMS

02278634 SANDOZ-FAMCICLOVIR SDZ

250MG Tablet

02292041 APO-FAMCICLOVIR APX

02305690 CO FAMCICLOVIR COB

02229129 FAMVIR NVR

02278103 PMS-FAMCICLOVIR PMS

02278642 SANDOZ-FAMCICLOVIR SDZ

500MG Tablet

02292068 APO-FAMCICLOVIR APX

02305704 CO FAMCICLOVIR COB

02177102 FAMVIR NVR

02278111 PMS-FAMCICLOVIR PMS

02278650 SANDOZ-FAMCICLOVIR SDZ

GANCICLOVIR SODIUM

500MG Injection

02162695 CYTOVENE HLR

VALACYCLOVIR HCL

500MG Tablet

02295822 APO-VALACYCLOVIR APX

02298457 PMS-VALACYCLOVIR PMS

02316447 RIVA-VALACYCLOVIR RIV

02219492 VALTREX GSK

VALGANCICLOVIR HCL

450MG Tablet

02245777 VALCYTE HLR

08:30.04 AMEBICIDES

DIIODOHYDROXYQUIN

210MG Tablet

01997769 DIODOQUIN GLE

650MG Tablet

01997750 DIODOQUIN GLE

PAROMOMYCIN SULFATE

250MG Capsule

02078759 HUMATIN ERF

08:30.08 ANTIMALARIALS

CHLOROQUINE PHOSPHATE

250MG Tablet

00021261 NOVO-CHLOROQUINE NOP

HYDROXYCHLOROQUINE SULFATE

200MG Tablet

02246691 APO-HYDROXYQUINE APX

02252600 GEN-HYDROXYCHLOROQUINE GEN

02017709 PLAQUENIL SAC

02311011 PRO-HYDROXYQUINE PDL

PRIMAQUINE PHOSPHATE

26.3MG Tablet

02017776 PRIMAQUINE SAC

PYRIMETHAMINE

25MG Tablet

00004774 DARAPRIM GSK

08:30.92 MISCELLANEOUS ANTIPROTOZOALS

ATOVAQUONE

150MG/ML Suspension

02217422 MEPRON GSK

METRONIDAZOLE

500MG Capsule

02248562 APO-METRONIDAZOLE APX

00783137 TRIKACIDE PMS

250MG Tablet

00545066 APO-METRONIDAZOLE APX

00420409 METRONIDAZOLE PDL

PENTAMIDINE ISETHIONATE

300MG/VIAL Injection

02183080 PENTAMIDINE MAY

TRIMETREXATE GLUCURONATE

25MG/VIAL Injection

02065770 NEUTREXIN MIO

08:36.00 URINARY ANTI-INFECTIVES

NITROFURANTOIN

50MG Capsule

01997637 MACRODANTIN PGP

02231015 NOVO-FURANTOIN NOP

100MG Capsule

02063662 MACROBID PGP

02231016 NOVO-FURANTOIN NOP

50MG Tablet

00319511 APO-NITROFURANTOIN APX

100MG Tablet

00312738 APO-NITROFURANTOIN APX

TRIMETHOPRIM

100MG Tablet

02243116 APO-TRIMETHOPRIM APX

200MG Tablet

02243117 APO-TRIMETHOPRIM APX