Drug Benefit List 2012

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

08:12.06 CEPHALOSPORINS

CEFACLOR

250mg Capsule

02230263 APO-CEFACLOR APX

00465186 CECLOR PHH

02231432 NU-CEFACLOR NXP

02237729 SCHEIN-CEFACLOR SCN

500mg Capsule

02230264 APO-CEFACLOR APX

00465194 CECLOR PHH

02231433 NU-CEFACLOR NXP

02237730 SCHEIN-CEFACLOR SCN

25mg/mL Suspension

00465208 CECLOR PHH

50mg/mL Suspension

00465216 CECLOR PHH

75mg/mL Suspension

02237502 APO-CEFACLOR APX

00832804 CECLOR BID PHH

CEFADROXIL

500mg Capsule

02240774 APO-CEFADROXIL APX

02311062 PRO-CEFADROXIL PDL

02235134 TEVA-CEFADROXIL TEV

CEFIXIME

20mg/mL Suspension

00868965 SUPRAX SAC

400mg Tablet

00868981 SUPRAX SAC

CEFPROZIL

25mg/mL Suspension

02293943 APO-CEFPROZIL APX

02163675 CEFZIL BMS

02329204 RAN-CEFPROZIL RBY

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

08:12.06 CEPHALOSPORINS

CEFPROZIL

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 TEV

500mg Capsule

00342114 NOVO-LEXIN TEV

25mg/mL Suspension

02177862 DOM-CEPHALEXIN DPC

00342106 NOVO-LEXIN TEV

50mg/mL Suspension

02177870 DOM-CEPHALEXIN DPC

00342092 NOVO-LEXIN TEV

250mg Tablet

00768723 APO-CEPHALEX APX

00828858 CEPHALEXIN PDL

02177846 DOM-CEPHALEXIN DPC

00583413 NOVO-LEXIN TEV

00865877 NU-CEPHALEX NXP

02177781 PMS-CEPHALEXIN PMS

500mg Tablet

00768715 APO-CEPHALEX APX

00828866 CEPHALEXIN PDL

02177854 DOM-CEPHALEXIN DPC

00583421 NOVO-LEXIN TEV

00865885 NU-CEPHALEX NXP

02177803 PMS-CEPHALEXIN PMS

08:12.12 MACROLIDES

AZITHROMYCIN

20mg/mL Suspension

02274388 PMS-AZITHROMYCIN PMS

02332388 SANDOZ-AZITHROMYCIN SDZ

02315157 TEVA-AZITHROMYCIN TEV

02223716 ZITHROMAX PFI

40mg/mL Suspension

02274396 PMS-AZITHROMYCIN PMS

02332396 SANDOZ-AZITHROMYCIN SDZ

02315165 TEVA-AZITHROMYCIN TEV

02223724 ZITHROMAX PFI

250mg Tablet

02247423 APO-AZITHROMYCIN APX

02330881 AZITHROMYCIN SAN

02255340 CO AZITHROMYCIN COB

02278359 MYLAN-AZITHROMYCIN MYL

02278588 PHL-AZITHROMYCIN PHH

02261634 PMS-AZITHROMYCIN PMS

02310600 PRO-AZITHROMYCIN PDL

02275287 RATIO-AZITHROMYCIN RPH

02275309 RIVA-AZITHROMYCIN RIV

02265826 SANDOZ-AZITHROMYCIN SDZ

02267845 TEVA-AZITHROMYCIN TEV

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 MYLAN-CLARITHROMYCIN MYL

02247573 PMS-CLARITHROMYCIN PMS

02324482 PRO-CLARITHROMYCIN PDL

02361426 RAN-CLARITHROMYCIN RBY

02247818 RATIO-CLARITHROMYCIN RPH

02346524 RIVA-CLARITHROMYCIN RIV

02266539 SANDOZ-CLARITHROMYCIN SDZ

500mg Film Coated Tablet

02274752 APO-CLARITHROMYCIN APX

02126710 BIAXIN ABB

02351005 DOM-CLARITHROMYCIN SEV

02248857 MYLAN-CLARITHROMYCIN MYL

02247574 PMS-CLARITHROMYCIN PMS

02324490 PRO-CLARITHROMYCIN PDL

02361434 RAN-CLARITHROMYCIN RBY

02247819 RATIO-CLARITHROMYCIN RPH

02346532 RIVA-CLARITHROMYCIN RIV

02266547 SANDOZ-CLARITHROMYCIN SDZ

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

00873454 ERYC PFI

250mg Tablet

00682020 APO-ERYTHRO BASE APX

ERYTHROMYCIN ESTOLATE

50mg/mL Suspension

00262595 NOVO-RYTHRO ESTOLATE TEV

ERYTHROMYCIN ETHYLSUCCINATE

40mg/mL Suspension

00605859 NOVO-RYTHRO ETHYLSUCCINATE TEV

80mg/mL Suspension

00652318 NOVO-RYTHRO ETHYLSUCCINATE TEV

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

02352710 AMOXICILLIN SAN

00628115 APO-AMOXI APX

02238171 MYLAN-AMOXICILLIN MYL

00406724 NOVAMOXIN TEV

00865567 NU-AMOXI NXP

02230243 PMS-AMOXICILLIN PMS

500mg Capsule

02352729 AMOXICILLIN SAN

00628123 APO-AMOXI APX

02238172 MYLAN-AMOXICILLIN MYL

00406716 NOVAMOXIN TEV

00865575 NU-AMOXI NXP

02230244 PMS-AMOXICILLIN PMS

00644315 PRO-AMOX PDL

125mg Chewable Tablet

02036347 NOVAMOXIN TEV

250mg Chewable Tablet

02352737 AMOXICILLIN SAN

02036355 NOVAMOXIN TEV

25mg/mL Oral Solution

01934171 NOVAMOXIN SUGAR TEV

REDUCED

50mg/mL Oral Solution

01934163 NOVAMOXIN SUGAR TEV

REDUCED

25mg/mL Suspension

02352745 AMOXICILLIN SAN

02352761 AMOXICILLIN SUGAR REDUCED SAN

00628131 APO-AMOXI APX

00452149 NOVAMOXIN TEV

00865540 NU-AMOXI NXP

02230245 PMS-AMOXICILLIN PMS

50mg/mL Suspension

02352753 AMOXICILLIN SAN

02352788 AMOXICILLIN SUGAR REDUCED SAN

00628158 APO-AMOXI APX

00452130 NOVAMOXIN TEV

00865559 NU-AMOXI NXP

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

02326515 AMOXI-CLAV PDL

02243351 APO-AMOXI CLAV APX

01916858 CLAVULIN-F GSK

02243771 RATIO-ACLAVULANATE RPH

875mg & 125mg Tablet

02326523 AMOXI-CLAV PDL

02245623 APO-AMOXI CLAV APX

02238829 CLAVULIN GSK

02247021 RATIO-ACLAVULANATE RPH

02248138 TEVA-CLAVAMOXIN TEV

AMPICILLIN

250mg Capsule

00020877 TEVA-AMPICILLIN TEV

500mg Capsule

00020885 TEVA-AMPICILLIN TEV

25mg/mL Suspension

00717495 NU-AMPI NXP

50mg/mL Suspension

00603287 APO-AMPICILLIN APX

00717649 NU-AMPI NXP

CLOXACILLIN

250mg Capsule

02069660 CLOXACILLINE PRO

00717584 NU-CLOXI NXP

00337765 TEVA-CLOXIN TEV

500mg Capsule

02069679 CLOXACILLINE PRO

00717592 NU-CLOXI NXP

00337773 TEVA-CLOXIN TEV

25mg/mL Suspension

00717630 NU-CLOXI NXP

00337757 TEVA-CLOXIN TEV

PENICILLIN V POTASSIUM

25mg/mL Suspension

00642223 APO-PEN VK APX

60mg/mL Suspension

00642231 APO-PEN VK APX

00391603 NOVO-PEN VK TEV

300mg Tablet

00642215 APO-PEN VK APX

00021202 NOVO-PEN VK TEV

00717568 NU-PEN VK NXP

00468029 PENICILLINE V PDL

PIVMECILLINAM HCL

200mg Tablet

00657212 SELEXID LEO

08:12.18 QUINOLONES

CIPROFLOXACIN HCL

250mg Tablet

02229521 APO-CIPROFLOX APX

02155958 CIPRO BAY

02353318 CIPROFLOXACIN SAN

02247339 CO CIPROFLOXACIN COB

02317427 MINT-CIPROFLOXACIN MIN

02245647 MYLAN-CIPROFLOXACIN MYL

02251310 PHL-CIPROFLOXACIN PHH

02248437 PMS-CIPROFLOXACIN PMS

02317796 PRO-CIPROFLOXACIN PDL

02303728 RAN-CIPROFLOX RBY

02246825 RATIO-CIPROFLOXACIN RPH

02251221 RIVA-CIPROFLOXACIN RIV

02248756 SANDOZ-CIPROFLOXACIN SDZ

02266962 TARO-CIPROFLOXACIN TAR

02161737 TEVA-CIPROFLOXACIN TEV

500mg Tablet

02229522 APO-CIPROFLOX APX

02155966 CIPRO BAY

02353326 CIPROFLOXACIN SAN

02247340 CO CIPROFLOXACIN COB

02251280 DOM-CIPROFLOXACIN PMS

02317435 MINT-CIPROFLOXACIN MIN

02245648 MYLAN-CIPROFLOXACIN MYL

02251329 PHL-CIPROFLOXACIN PHH

02248438 PMS-CIPROFLOXACIN PMS

02317818 PRO-CIPROFLOXACIN PDL

02303736 RAN-CIPROFLOX RBY

02246826 RATIO-CIPROFLOXACIN RPH

02251248 RIVA-CIPROFLOXACIN RIV

02248757 SANDOZ-CIPROFLOXACIN SDZ

02266970 TARO-CIPROFLOXACIN TAR

02161745 TEVA-CIPROFLOXACIN TEV

750mg Tablet

02229523 APO-CIPROFLOX APX

02155974 CIPRO BAY

02353334 CIPROFLOXACIN SAN

02247341 CO CIPROFLOXACIN COB

02317443 MINT-CIPROFLOXACIN MIN

02245649 MYLAN-CIPROFLOXACIN MYL

02251337 PHL-CIPROFLOXACIN PHH

02248439 PMS-CIPROFLOXACIN PMS

02303744 RAN-CIPROFLOX RBY

02246827 RATIO-CIPROFLOXACIN RPH

02251256 RIVA-CIPROFLOXACIN RIV

02248758 SANDOZ-CIPROFLOXACIN SDZ

02161753 TEVA-CIPROFLOXACIN TEV

LEVOFLOXACIN

Limited use benefit (prior approval not required).

Coverage will be limited to a maximum of 14 days.

250mg Tablet

02284707 APO-LEVOFLOXACIN APX

02315424 CO-LEVOFLOXACIN COB

02236841 LEVAQUIN JNO

02313979 MYLAN-LEVOFLOXACIN MYL

02248262 NOVO-LEVOFLOXACIN TEV

02284677 PMS-LEVOFLOXACIN PMS

02298635 SANDOZ LEVOFLOXACIN SDZ

500mg Tablet

02284715 APO-LEVOFLOXACIN APX

02315432 CO-LEVOFLOXACIN COB

02236842 LEVAQUIN JNO

02313987 MYLAN-LEVOFLOXACIN MYL

02248263 NOVO-LEVOFLOXACIN TEV

02284685 PMS-LEVOFLOXACIN PMS

02298643 SANDOZ LEVOFLOXACIN SDZ

750mg Tablet

02325942 APO-LEVOFLOXACIN APX

02315440 CO-LEVOFLOXACIN COB

02246804 LEVAQUIN JNO

02285649 NOVO-LEVOFLOXACIN TEV

02305585 PMS-LEVOFLOXACIN PMS

02298651 SANDOZ LEVOFLOXACIN SDZ

NORFLOXACIN

400mg Tablet

02229524 APO-NORFLOX APX

02269627 CO NORFLOXACIN COB

02237682 NOVO-NORFLOXACIN TEV

02246596 PMS-NORFLOXACIN PMS

02241483 RIVA-NORFLOXACIN RIV

02301504 RIVA-NORFLOXACIN RIV

OFLOXACIN

200mg Tablet

02231529 OFLOXACIN AAP

300mg Tablet

02243475 NOVO-OFLOXACIN TEV

02231531 OFLOXACIN AAP

400mg Tablet

02231532 OFLOXACIN AAP

08:12.20 SULFONAMIDES

SULFAMETHOXAZOLE

500mg Tablet

00421480 APO-SULFAMETHOXAZOLE APX

SULFAMETHOXAZOLE, TRIMETHOPRIM

40mg & 8mg/mL Suspension

00726540 NOVO-TRIMEL TEV

100mg & 20mg Tablet

00445266 APO-SULFATRIM PED APX

400mg & 80mg Tablet

00445274 APO-SULFATRIM APX

00510637 NOVO-TRIMEL TEV

00865710 NU-COTRIMOX NXP

800mg & 160mg Tablet

00445282 APO-SULFATRIM DS APX

00510645 NOVO-TRIMEL DS TEV

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

02351234 DOXYCYCLINE SAN

00725250 NOVO-DOXYLIN TEV

02044668 NU-DOXYCYCLINE NXP

100mg Tablet

00874256 APO-DOXY APX

00860751 DOXYCIN RIV

02351242 DOXYCYCLINE SAN

00887064 DOXYTAB PDL

02158574 NOVO-DOXYLIN TEV

02044676 NU-DOXYCYCLINE NXP

MINOCYCLINE HCL

Limited use benefit (prior approval required).

For:

1. patients who cannot tolerate other tetracyclines.
2. patients with severe widespread acne who have failed on tetracycline.

50mg Capsule

02084090 APO-MINOCYCLINE APX

02239667 DOM-MINOCYCLINE DPC

02153394 MINOCYCLINE PDL

02287226 MINOCYCLINE SAN

02230735 MYLAN-MINOCYCLINE MYL

02108143 NOVO-MINOCYCLINE TEV

02239238 PMS-MINOCYCLINE PMS

02294419 PMS-MINOCYCLINE PMS

02242080 RIVA-MINOCYCLINE RIV

02237313 SANDOZ-MINOCYCLINE SDZ

100mg Capsule

02084104 APO-MINOCYCLINE APX

02239668 DOM-MINOCYCLINE DPC

02173506 MINOCIN STI

02154366 MINOCYCLINE PDL

02239982 MINOCYCLINE IVX

02287234 MINOCYCLINE SAN

02230736 MYLAN-MINOCYCLINE MYL

02108151 NOVO-MINOCYCLINE TEV

02294427 PMS-MINOCYCLINE PMS

02239239 PMS-MONOCYCLINE PMS

02242081 RIVA-MINOCYCLINE RIV

02237314 SANDOZ-MINOCYCLINE SDZ

TETRACYCLINE HCL

250mg Capsule

00580929 APO-TETRA APX

00717606 NU-TETRA NXP

00156744 TETRACYCLINE PRO

08:12.28 MISCELLANEOUS ANTIBIOTICS

CLINDAMYCIN HCL

150mg Capsule

02245232 APO-CLINDAMYCIN APX

02248525 CLINDAMYCINE PDL

00030570 DALACIN C PFI

02258331 MYLAN-CLINDAMYCIN MYL

02242409 RIVA-CLINDAMYCIN RIV

02241709 TEVA-CLINDAMYCIN TEV

300mg Capsule

02245233 APO-CLINDAMYCIN APX

02248526 CLINDAMYCINE PDL

02182866 DALACIN C PFI

02258358 MYLAN-CLINDAMYCIN MYL

02242410 RIVA-CLINDAMYCIN RIV

02241710 TEVA-CLINDAMYCIN TEV

CLINDAMYCIN PALMITATE HCL

15mg/mL Solution

00225851 DALACIN C PFI

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

02299275 DOM-TERBINAFINE DPC

02031116 LAMISIL NVR

02242503 MYLAN-TERBINAFINE MYL

02240346 NOVO-TERBINAFINE TEV

02248845 NU-TERBINAFINE NXP

02240807 PMS-TERBINAFINE PMS

02294273 PMS-TERBINAFINE PMS

02262924 RIVA-TERBINAFINE RIV

02262177 SANDOZ-TERBINAFINE SDZ

02242735 TERBINAFINE PDL

02353121 TERBINAFINE SAN

08:14.08 AZOLES

FLUCONAZOLE

150mg Capsule

02241895 APO-FLUCONAZOLE APX

02311690 CANESORAL BAY

02323419 CO FLUCONAZOLE COB

02141442 DIFLUCAN PFI

02243645 NOVO-FLUCONAZOLE TEV

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

02281260 CO FLUCONAZOLE COB

00891800 DIFLUCAN PFI

02245292 MYLAN-FLUCONAZOLE MYL

02236978 NOVO-FLUCONAZOLE TEV

02245643 PMS-FLUCONAZOLE PMS

02249294 TARO-FLUCONAZOLE TAR

100mg Tablet

02237371 APO-FLUCONAZOLE APX

02281279 CO FLUCONAZOLE COB

02245293 MYLAN-FLUCONAZOLE MYL

02236979 NOVO-FLUCONAZOLE TEV

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 TEV

02122197 NU-KETOCON NXP

VORICONAZOLE

Limited use benefit (prior approval required).

For the treatment of:

1. patients with invasive aspergillosis.
2. culture proven invasive candidiasis with documented resistance to fluconazole.

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

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

00343617 ROFACT VAE

08:18.04 ADAMANTANES

AMANTADINE HCL

100mg Capsule

02130963 DOM-AMANTADINE DPC

02139200 MYLAN-AMANTADINE MYL

01990403 PMS-AMANTADINE PMS

10mg/mL Syrup

02022826 PMS-AMANTADINE PMS

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

ATAZANAVIR SULFATE

150mg Capsule

02248610 REYATAZ BMS

200mg Capsule

02248611 REYATAZ BMS

300mg Capsule

02294176 REYATAZ BMS

DARUNAVIR

75mg Tablet

02338432 PREZISTA JNO

DARUNAVIR

400mg Tablet

02324016 PREZISTA JNO

600mg Tablet

02324024 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

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 na�ve, 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

ETRAVIRINE

Limited use benefit (prior approval required).

For use in combination with other antiretroviral agents for treatment-experienced patients with HIV-1 infection who:

1. have failed prior antiretroviral therapy; and
2. have HIV-1 strains resistant to multiple antiretroviral agents, including NNRTIs

100mg Tablet

02306778 INTELENCE JNO

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

MARAVIROC

Limited use benefit (prior approval required).

For the treatment of HIV-1 infection, given in combination with other antiretroviral agents, in patients who have:

1. CR5 tropic viruses; and
2. documented resistance to at least one agent from each of the three major classes of antiretroviral agents (nucleoside reverse transcriptase inhibitors, non-nucleoside reverse transcriptase inhibitors, and protease inhibitors)

150mg Tablet

02299844 CELSENTRI GSK

300mg Tablet

02299852 CELSENTRI GSK

NELFINAVIR MESYLATE

50mg/g Powder for Suspension

02238618 VIRACEPT PFI

NELFINAVIR MESYLATE

250mg Tablet

02238617 VIRACEPT PFI

625mg Tablet

02248761 VIRACEPT PFI

NEVIRAPINE

200mg Tablet

02318601 AURO-NEVIRAPINE AUR

02352893 TEVA-NEVIRAPINE TEV

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

100mg Tablet

02357593 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

Limited use benefit (prior approval required).

For the management of HIV disease in patients

1. who have failed all currently listed protease inhibitors
2. intolerant to all currently listed protease inhibitors

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

Limited use benefit (prior approval required).

For the treatment of chronic hepatitis C in patients who are treatment naïve, upon the written request of a hepatologist or other specialist in this area.

1. For genotypes 1, 4, 5 and 6, an initial 24 week supply will be approved. A further 24 week supply may be approved if patient has a viral reduction of at least 2 logs or HCV is undetectable at 12 weeks (48 weeks total).
2. For genotypes 2 or 3, initial coverage for a maximum of 24 weeks will be approved. Renewals will not be covered

180mcg/0.5mL Injection

02248077 PEGASYS HLR

180mcg/1mL Injection

02248078 PEGASYS HLR

PEGINTERFERON ALFA-2A, RIBAVIRIN

Limited use benefit (prior approval required).

For the treatment of chronic hepatitis C in patients who are treatment naïve, upon the written request of a hepatologist or other specialist in this area.

1. For genotypes 1, 4, 5 and 6, an initial 24 week supply will be approved. A further 24 week supply may be approved if patient has a viral reduction of at least 2 logs or HCV is undetectable at 12 weeks (48 weeks total).
2. For genotypes 2 or 3, initial coverage for a maximum of 24 weeks will be approved. Renewals will not be covered

180mcg/0.5mL & 200mg Injection & Tablet

02253429 PEGASYS RBV HLR

180mcg/1mL & 200mg Injection & Tablet

02253410 PEGASYS RBV HLR

PEGINTERFERON ALFA-2B

Limited use benefit (prior approval required).

For the treatment of chronic hepatitis C in patients who are treatment naïve, upon the written request of a hepatologist or other specialist in this area.

1. For genotypes 1, 4, 5 and 6, an initial 24 week supply will be approved. A further 24 week supply may be approved if patient has a viral reduction of at least 2 logs or HCV is undetectable at 12 weeks (48 weeks total).
2. For genotypes 2 or 3, initial coverage for a maximum of 24 weeks will be approved. Renewals will not be covered.

74mcg/Vial Injection

02242966 UNITRON PEG 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

Limited use benefit (prior approval required).

For the treatment of chronic hepatitis C in patients who are treatment naïve, upon the written request of a hepatologist or other specialist in this area.

1. For genotypes 1, 4, 5 and 6, an initial 24 week supply will be approved. A further 24 week supply may be approved if patient has a viral reduction of at least 2 logs or HCV is undetectable at 12 weeks (48 weeks total).
2. For genotypes 2 or 3, initial coverage for a maximum of 24 weeks will be approved. Renewals will not be covered

50mcg/0.5mL & 200mg Injection & Capsule

02246026 PEGETRON 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

02286556 ACYCLOVIR SAN

02207621 APO-ACYCLOVIR APX

02242784 MYLAN-ACYCLOVIR MYL

02197405 NU-ACYCLOVIR NXP

02078627 RATIO-ACYCLOVIR RPH

02285959 TEVA-ACYCLOVIR TEV

00634506 ZOVIRAX GSK

400mg Tablet

02286564 ACYCLOVIR SAN

02207648 APO-ACYCLOVIR APX

02242463 MYLAN-ACYCLOVIR MYL

02197413 NU-ACYCLOVIR NXP

02078635 RATIO-ACYCLOVIR RPH

02285967 TEVA-ACYCLOVIR TEV

01911627 ZOVIRAX GSK

800mg Tablet

02286572 ACYCLOVIR SAN

02207656 APO-ACYCLOVIR APX

02242464 MYLAN-ACYCLOVIR MYL

02197421 NU-ACYCLOVIR NXP

02078651 RATIO-ACYCLOVIR RPH

02285975 TEVA-ACYCLOVIR TEV

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

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

02324865 FAMCICLOVIR PDL

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

02331748 CO VALACYCLOVIR COB

02307936 DOM-VALACYCLOVIR DPC

02351579 MYLAN-VALACYCLOVIR MYL

02298457 PMS-VALACYCLOVIR PMS

02315173 PRO-VALACYCLOVIR PDL

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

000021261 TEVA-CHLOROQUINE TEV

HYDROXYCHLOROQUINE SULFATE

200mg Tablet

02246691 APO-HYDROXYQUINE APX

02252600 MYLAN-HYDROXYCHLOROQUINE MYL

02017709 PLAQUENIL SAC

02311011 PRO-HYDROXYQUINE PDL

PRIMAQUINE PHOSPHATE

26.3mg Tablet

02017776 PRIMAQUINE SAC

PYRIMETHAMINE

25mg Tablet

4774 DARAPRIM GSK

08:30.92 MISCELLANEOUS ANTIPROTOZOALS

ATOVAQUONE

150mg/mL Suspension

02217422 MEPRON GSK

METRONIDAZOLE

500mg Capsule

02248562 METRONIDAZOLE AAP

250mg Tablet

00420409 METRONIDAZOLE PDL

00545066 METRONIDAZOLE AAP

08:36.00 URINARY ANTI-INFECTIVES

NITROFURANTOIN

50mg Capsule

02231015 NOVO-FURANTOIN TEV

100mg Capsule

02063662 MACROBID PGP

02231016 NOVO-FURANTOIN TEV

50mg Tablet

00319511 NITROFURANTOIN AAP

100mg Tablet

00312738 NITROFURANTOIN AAP

TRIMETHOPRIM

100mg Tablet

02243116 TRIMETHOPRIM AAP

200mg Tablet

02243117 TRIMETHOPRIM AAP