Drug Benefit List 2010

08:00 ANTI-INFECTIVE AGENTS

08:08.00 ANTHELMINTICS

MEBENDAZOLE

100mg Tablet

556734 VERMOX JNO

PYRANTEL PAMOATE

50mg/mL Suspension

1944355 COMBANTRIN PFI

125mg Tablet

1944363 COMBANTRIN PFI

08:12.06 CEPHALOSPORINS

CEFACLOR

250mg Capsule

2230263 APO-CEFACLOR APX

465186 CECLOR PHH

2177633 DOM-CEFACLOR DPC

2231432 NU-CEFACLOR NXP

2238200 PDL-CEFACLOR PDL

2237729 SCHEIN-CEFACLOR SCN

500mg Capsule

2230264 APO-CEFACLOR APX

465194 CECLOR PHH

2177641 DOM-CEFACLOR DPC

2231433 NU-CEFACLOR NXP

2238201 PDL-CEFACLOR PDL

2237730 SCHEIN-CEFACLOR SCN

25mg/mL Suspension

465208 CECLOR PHH

2177668 DOM-CEFACLOR DPC

2238202 PDL-CEFACLOR PDL

50mg/mL Suspension

465216 CECLOR PHH

2177676 DOM-CEFACLOR DPC

2238203 PDL-CEFACLOR PDL

75mg/mL Suspension

2237502 APO-CEFACLOR APX

832804 CECLOR BID PHH

2177684 DOM-CEFACLOR DPC

2238204 PDL-CEFACLOR PDL

CEFADROXIL

500mg Capsule

2240774 APO-CEFADROXIL APX

2235134 NOVO-CEFADROXIL NOP

2311062 PRO-CEFADROXIL PDL

CEFIXIME

20mg/mL Suspension

868965 SUPRAX SAC

400mg Tablet

868981 SUPRAX SAC

CEFPROZIL

25mg/mL Suspension

2293943 APO-CEFPROZIL APX

2163675 CEFZIL BMS

2303426 SANDOZ CEFPROZIL SDZ

50mg/mL Suspension

2293951 APO-CEFPROZIL APX

2163683 CEFZIL BMS

2293579 RAN-CEFPROZIL RBY

2303434 SANDOZ CEFPROZIL SDZ

250mg Tablet

2292998 APO-CEFPROZIL APX

2163659 CEFZIL BMS

2293528 RAN-CEFPROZIL RBY

2302179 SANDOZ CEFPROZIL SDZ

500mg Tablet

2293005 APO-CEFPROZIL APX

2163667 CEFZIL BMS

2293536 RAN-CEFPROZIL RBY

2302187 SANDOZ CEFPROZIL SDZ

CEFPROZIL MONOHYDRATE

125MG/5ML Oral Liquid

2329204 RAN-CEFPROZIL RBY

2329204 RAN-CEFPROZIL RBY

CEFUROXIME AXETIL

25mg/mL Suspension

2212307 CEFTIN GSK

250mg Tablet

2244393 APO-CEFUROXIME APX

2212277 CEFTIN GSK

2242656 RATIO-CEFUROXIME RPH

500mg Tablet

2244394 APO-CEFUROXIME APX

2212285 CEFTIN GSK

2311453 PRO-CEFUROXIME PDL

2242657 RATIO-CEFUROXIME RPH

CEPHALEXIN

250mg Capsule

342084 NOVO-LEXIN NOP

500mg Capsule

342114 NOVO-LEXIN NOP

25mg/mL Suspension

2177862 DOM-CEPHALEXIN DPC

342106 NOVO-LEXIN NOP

50mg/mL Suspension

2177870 DOM-CEPHALEXIN DPC

342092 NOVO-LEXIN NOP

CEPHALEXIN

250mg Tablet

768723 APO-CEPHALEX APX

2177846 DOM-CEPHALEXIN DPC

583413 NOVO-LEXIN NOP

865877 NU-CEPHALEX NXP

828858 PDL-CEPHALEXIN PDL

2177781 PMS-CEPHALEXIN PMS

500mg Tablet

768715 APO-CEPHALEX APX

2177854 DOM-CEPHALEXIN DPC

583421 NOVO-LEXIN NOP

865885 NU-CEPHALEX NXP

828866 PDL-CEPHALEXIN PDL

2177803 PMS-CEPHALEXIN PMS

08:12.12 MACROLIDES

AZITHROMYCIN

100MG/5ML Oral Liquid

2332388 SANDOZ-AZITHROMYCIN SDZ

200MG/5ML Oral Liquid

2332396 SANDOZ-AZITHROMYCIN SDZ

20mg/mL Suspension

2315157 NOVO-AZITHROMYCIN NOP

2274388 PMS-AZITHROMYCIN PMS

2223716 ZITHROMAX PFI

40mg/mL Suspension

2315165 NOVO-AZITHROMYCIN NOP

2274396 PMS-AZITHROMYCIN PMS

2223724 ZITHROMAX PFI

250mg Tablet

2247423 APO-AZITHROMYCIN APX

2255340 CO AZITHROMYCIN COB

2278359 GEN-AZITHROMYCIN GEN

2267845 NOVO-AZITHROMYCIN NOP

2278588 PHL-AZITHROMYCIN PMI

2261634 PMS-AZITHROMYCIN PMS

2310600 PRO-AZITHROMYCIN PDL

2275287 RATIO-AZITHROMYCIN RPH

2275309 RIVA-AZITHROMYCIN RIV

2265826 SANDOZ-AZITHROMYCIN SDZ

2212021 ZITHROMAX PFI

600mg Tablet

2256088 CO AZITHROMYCIN COB

2261642 PMS-AZITHROMYCIN PMS

2275317 RIVA-AZITHROMYCIN RIV

2231143 ZITHROMAX PFI

CLARITHROMYCIN

500mg Extended Release Tablet

2244756 BIAXIN XL ABB

CLARITHROMYCIN

250mg Film Coated Tablet

2274744 APO-CLARITHROMYCIN APX

1984853 BIAXIN ABB

2248856 GEN-CLARITHROMYCIN GEN

2247573 PMS-CLARITHROMYCIN PMS

2247818 RATIO-CLARITHROMYCIN RPH

2266539 SANDOZ-CLARITHROMYCIN RHO

500mg Film Coated Tablet

2266547 SANDOZ-CLARITHROMYCIN RHO

500mg Film Coated Tablet

2274752 APO-CLARITHROMYCIN APX

2126710 BIAXIN ABB

2248857 GEN-CLARITHROMYCIN GEN

2247574 PMS-CLARITHROMYCIN PMS

2247819 RATIO-CLARITHROMYCIN RPH

25mg/mL Suspension

2146908 BIAXIN ABB

50mg/mL Suspension

2244641 BIAXIN ABB

ERYTHROMYCIN

250mg Enteric Coated Capsule

726672 APO-ERYTHRO APX

607142 ERYC PFI

333mg Enteric Coated Capsule

1925938 APO-ERYTHRO APX

333mg Enteric Coated Tablet

873454 ERYC PFI

250mg Tablet

682020 APO-ERYTHRO BASE APX

ERYTHROMYCIN ESTOLATE

50mg/mL Suspension

262595 NOVO-RYTHRO ESTOLATE NOP

ERYTHROMYCIN ETHYLSUCCINATE

40mg/mL Suspension

605859 NOVO-RYTHRO ETHYLSUCCINATE NOP

80mg/mL Suspension

652318 NOVO-RYTHRO ETHYLSUCCINATE NOP

600mg Tablet

637416 APO-ERYTHRO-S APX

583782 EES-600 ABB

704377 ERYTHRO-ES PDL

ERYTHROMYCIN STEARATE

250mg Tablet

545678 APO-ERYTHRO-S APX

563854 ERYTHROMYCIN PDL

2051850 NU-ERYTHROMYCIN S NXP

500mg Tablet

688568 APO-ERYTHRO S APX

704393 ERYTHRO PDL

08:12.16 PENICILLINS

AMOXICILLIN

250mg Capsule

628115 APO-AMOXI APX

2238171 GEN-AMOXICILLIN GEN

2239761 MED-AMOXICILLIN MEC

406724 NOVAMOXIN NOP

865567 NU-AMOXI NXP

2229584 PENTA-AMOXICILLIN PEN

2230243 PMS-AMOXICILLIN PMS

644307 PRO-AMOX PDL

2241826 SCHEIN-AMOXICILLIN SCN

500mg Capsule

628123 APO-AMOXI APX

2238172 GEN-AMOXICILLIN GEN

2239762 MED-AMOXICILLIN MEC

406716 NOVAMOXIN NOP

865575 NU-AMOXI NXP

2233017 PENTA-AMOXICILLIN PEN

2230244 PMS-AMOXICILLIN PMS

644315 PRO-AMOX PDL

2241827 SCHEIN-AMOXICILLIN SCN

125mg Chewable Tablet

2036347 NOVAMOXIN NOP

250mg Chewable Tablet

2036355 NOVAMOXIN NOP

25mg/mL Suspension

628131 APO-AMOXI APX

452149 NOVAMOXIN NOP

1934171 NOVAMOXIN SUGAR REDUCED NOP

865540 NU-AMOXI NXP

2229582 PENTA-AMOXICILLIN PEN

2230245 PMS-AMOXICILLIN PMS

644323 PRO-AMOX PDL

50mg/mL Suspension

628158 APO-AMOXI APX

452130 NOVAMOXIN NOP

1934163 NOVAMOXIN SUGAR REDUCED NOP

865559 NU-AMOXI NXP

2229583 PENTA-AMOXICILLIN PEN

2230246 PMS-AMOXICILLIN PMS

644331 PRO-AMOX PDL

AMOXICILLIN, CLAVULANIC ACID

25mg & 6.25mg/mL Suspension

2243986 APO-AMOXI CLAV APX

1916882 CLAVULIN-F 125 GSK

40mg & 5.7mg/mL Suspension

2288559 APO-AMOXI CLAV APX

2238831 CLAVULIN 200 GSK

50mg & 12.5mg/mL Suspension

2243987 APO-AMOXI CLAV APX

1916874 CLAVULIN-F 250 GSK

AMOXICILLIN, CLAVULANIC ACID

80mg & 11.4mg/mL Suspension

2238830 CLAVULIN 400 GSK

250mg & 125mg Tablet

2243350 APO-AMOXI CLAV APX

500mg & 125mg Tablet

2243351 APO-AMOXI CLAV APX

1916858 CLAVULIN-F GSK

2243771 RATIO-ACLAVULANATE RPH

875mg & 125mg Tablet

2245623 APO-AMOXI CLAV APX

2238829 CLAVULIN GSK

2248138 NOVO-CLAVAMOXIN NOP

2247021 RATIO-ACLAVULANATE RPH

AMPICILLIN

250mg Capsule

20877 NOVO-AMPICILLIN NOP

500mg Capsule

20885 NOVO-AMPICILLIN NOP

25mg/mL Suspension

603260 APO-AMPICILLIN APX

717495 NU-AMPI NXP

50mg/mL Suspension

603287 APO-AMPICILLIN APX

717649 NU-AMPI NXP

2043203 PENBRITIN WAY

CLOXACILLIN

250mg Capsule

618292 APO-CLOXI APX

2069660 CLOXACILLINE PRO

337765 NOVO-CLOXIN NOP

717584 NU-CLOXI NXP

500mg Capsule

618284 APO-CLOXI APX

2069679 CLOXACILLINE PRO

337773 NOVO-CLOXIN NOP

717592 NU-CLOXI NXP

25mg/mL Suspension

644633 APO-CLOXI APX

337757 NOVO-CLOXIN NOP

717630 NU-CLOXI NXP

PENICILLIN V BENZATHINE

36mg/mL Suspension

2229618 PEN VEE PED

60mg/mL Suspension

2229617 PEN VEE PED

PENICILLIN V POTASSIUM

25mg/mL Suspension

642223 APO-PEN VK APX

60mg/mL Suspension

642231 APO-PEN VK APX

391603 NOVO-PEN VK NOP

PENICILLIN V POTASSIUM

300mg Tablet

642215 APO-PEN VK APX

21202 NOVO-PEN VK NOP

717568 NU-PEN VK NXP

468029 PENICILLINE V PDL

PIVMECILLINAM HCL

200mg Tablet

657212 SELEXID LEO

08:12.18 QUINOLONES

CIPROFLOXACIN HCL

250mg Tablet

2229521 APO-CIPROFLOX APX

2155958 CIPRO BAY

2251752 CIPROFLOXCIN PDL

2247339 CO CIPROFLOXACIN COB

2251272 DOM-CIPROFLOXACIN DPC

2245647 GEN-CIPROFLOXACIN GEN

2317427 MINT-CIPROFLOXACIN MIN

2161737 NOVO-CIPROFLOXACIN NOP

2249634 NU-CIPROFLOXACIN NXP

2251310 PHL-CIPROFLOXACIN PHH

2248437 PMS-CIPROFLOXACIN PMS

2249960 PREM-CIPROFLOXACIN PRE

2317796 PRO-CIPROFLOXACIN PDL

2303728 RAN-CIPROFLOX RBY

2267934 RAN-CIPROFLOXACIN RBY

2246825 RATIO-CIPROFLOXACIN RPH

2251221 RIVA-CIPROFLOXACIN RIV

2248756 SANDOZ-CIPROFLOXACIN SDZ

2266962 TARO-CIPROFLOXACIN TAR

500mg Tablet

2229522 APO-CIPROFLOX APX

2155966 CIPRO BAY

2251760 CIPROFLOXACIN PDL

2247340 CO CIPROFLOXACIN COB

2251280 DOM-CIPROFLOXACIN DPC

2245648 GEN-CIPROFLOXACIN GEN

2317435 MINT-CIPROFLOXACIN MIN

2161745 NOVO-CIPROFLOXACIN NOP

2249642 NU-CIPROFLOXACIN NXP

2251329 PHL-CIPROFLOXACIN PHH

2248438 PMS-CIPROFLOXACIN PMS

2249979 PREM-CIPROFLOXACIN PRE

2317818 PRO-CIPROFLOXACIN PDL

2303736 RAN-CIPROFLOX RBY

2267942 RAN-CIPROFLOXACIN RBY

2246826 RATIO-CIPROFLOXACIN RPH

2248757 RHOXAL-CIPROFLOXACIN RHO

2251248 RIVA-CIPROFLOXACIN RIV

2266970 TARO-CIPROFLOXACIN TAR

CIPROFLOXACIN HCL

750mg Tablet

2229523 APO-CIPROFLOX APX

2155974 CIPRO BAY

2251779 CIPROFLOXACIN PDL

2247341 CO CIPROFLOXACIN COB

2251299 DOM-CIPROFLOXACIN DPC

2245649 GEN-CIPROFLOXACIN GEN

2317443 MINT-CIPROFLOXACIN MIN

2161753 NOVO-CIPROFLOXACIN NOP

2249650 NU-CIPROFLOXACIN NXP

2251337 PHL-CIPROFLOXACIN PHH

2248439 PMS-CIPROFLOXACIN PMS

2249987 PREM-CIPROFLOXACIN PRE

2303744 RAN-CIPROFLOX RBY

2267950 RAN-CIPROFLOXACIN RBY

2246827 RATIO-CIPROFLOXACIN RPH

2248758 RHOXAL-CIPROFLOXACIN RHO

2251256 RIVA-CIPROFLOXACIN RIV

LEVOFLOXACIN

Limited use benefit (prior approval not required).

Coverage will be limited to a maximum of 14 days.

250mg Tablet

2284707 APO-LEVOFLOXACIN APX

2315424 CO-LEVOFLOXACIN CBT

2286920 DOM-LEVOFLOXACIN DOM

2313979 GEN-LEVOFLOXACIN GEN

2236841 LEVAQUIN JNO

2307200 LEVOFLOXACIN SOR

2248262 NOVO-LEVOFLOXACIN NOP

2286947 PHL-LEVOFLOXACIN PMI

2284677 PMS-LEVOFLOXACIN PMS

2298635 SANDOZ LEVOFLOXACIN SDZ

500mg Tablet

2284715 APO-LEVOFLOXACIN APX

2315432 CO-LEVOFLOXACIN CBT

2286939 DOM-LEVOFLOXACIN DOM

2313987 GEN-LEVOFLOXACIN GEN

2236842 LEVAQUIN JNO

2307219 LEVOFLOXACIN SOR

2248263 NOVO-LEVOFLOXACIN NOP

2286955 PHL-LEVOFLOXACIN PMI

2284685 PMS-LEVOFLOXACIN PMS

2298643 SANDOZ LEVOFLOXACIN SDZ

NORFLOXACIN

400mg Tablet

2229524 APO-NORFLOX APX

2269627 CO NORFLOXACIN COB

2237682 NOVO-NORFLOXACIN NOP

2239670 PDL-NORFLOXACINE PDL

2246596 PMS-NORFLOXACIN PMS

2241483 RIVA-NORFLOXACIN RIV

2301504 RIVA-NORFLOXACIN RIV

OFLOXACIN

200mg Tablet

2231529 APO-OFLOX APX

300mg Tablet

2231531 APO-OFLOX APX

2243475 NOVO-OFLOXACIN NOP

400mg Tablet

2231532 APO-OFLOX APX

08:12.20 SULFONAMIDES

SULFAMETHOXAZOLE

500mg Tablet

421480 APO-SULFAMETHOXAZOLE APX

SULFAMETHOXAZOLE, TRIMETHOPRIM

40mg & 8mg/mL Suspension

726540 NOVO-TRIMEL NOP

100mg & 20mg Tablet

445266 APO-SULFATRIM PED APX

400mg & 80mg Tablet

445274 APO-SULFATRIM APX

510637 NOVO-TRIMEL NOP

865710 NU-COTRIMOX NXP

512516 PROTRIN PDL

800mg & 160mg Tablet

445282 APO-SULFATRIM DS APX

510645 NOVO-TRIMEL DS NOP

865729 NU-COTRIMOX DS NXP

512524 PROTRIN DF PRO

SULFASALAZINE

500mg Enteric Coated Tablet

598488 PMS-SULFASALAZINE PMS

2064472 SALAZOPYRIN PFI

500mg Tablet

598461 PMS-SULFASALAZINE PMS

2064480 SALAZOPYRIN PFI

08:12.24 TETRACYCLINES

DOXYCYCLINE

100mg Capsule

740713 APO-DOXY APX

817120 DOXYCIN RIV

742562 DOXYCYCLINE PDL

725250 NOVO-DOXYLIN NOP

2044668 NU-DOXYCYCLINE NXP

2289539 PMS-DOXYCYCLINE PMS

2093103 RATIO-DOXYCYCLINE RPH

DOXYCYCLINE

100mg Tablet

874256 APO-DOXY APX

860751 DOXYCIN RIV

887064 DOXYTAB PDL

2158574 NOVO-DOXYLIN NOP

2044676 NU-DOXYCYCLINE NXP

2289466 PMS-DOXYCYCLINE PMS

2091232 RATIO-DOXYCYCLINE RPH

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

2084090 APO-MINOCYCLINE APX

2239667 DOM-MINOCYCLINE DPC

2237875 MED-MINOCYCLINE MEC

2173514 MINOCIN STI

2108143 NOVO-MINOCYCLINE NOP

2153394 PDL-MINOCYCLINE PDL

2239238 PMS-MINOCYCLINE PMS

2294419 PMS-MINOCYCLINE PMS

1914138 RATIO-MINOCYCLINE RPH

2242080 RIVA-MINOCYCLINE RIV

2237313 SANDOZ-MINOCYCLINE SDZ

100mg Capsule

2084104 APO-MINOCYCLINE APX

2239668 DOM-MINOCYCLINE DPC

2237876 MED-MINOCYCLINE MEC

2173506 MINOCIN STI

2239982 MINOCYCLINE IVX

2108151 NOVO-MINOCYCLINE NOP

2154366 PDL-MINOCYCLINE PDL

2294427 PMS-MINOCYCLINE PMS

2239239 PMS-MONOCYCLINE PMS

1914146 RATIO-MINOCYCLINE RPH

2242081 RIVA-MINOCYCLINE RIV

2237314 SANDOZ-MINOCYCLINE SDZ

TETRACYCLINE HCL

250mg Capsule

580929 APO-TETRA APX

156744 TETRACYCLINE PRO

250mg Tablet

717606 NU-TETRA NXP

08:12.28 MISCELLANEOUS ANTIBIOTICS

CLINDAMYCIN HCL

150mg Capsule

2245232 APO-CLINDAMYCIN APX

2248525 CLINDAMYCINE PDL

30570 DALACIN C PFI

2258331 GEN-CLINDAMYCIN GEN

2241709 NOVO-CLINDAMYCIN NOP

2242409 RIVA-CLINDAMYCIN RIV

300mg Capsule

2245233 APO-CLINDAMYCIN APX

2248526 CLINDAMYCINE PDL

2182866 DALACIN C PFI

2258358 GEN-CLINDAMYCIN GEN

2241710 NOVO-CLINDAMYCIN NOP

2242410 RIVA-CLINDAMYCIN RIV

CLINDAMYCIN PALMITATE HCL

15mg/mL Solution

225851 DALACIN C PFI

FUSIDATE SODIUM

250mg Tablet

1934252 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

2243685 ZYVOXAM PFI

600mg Tablet

2243684 ZYVOXAM PFI

08:14.04 ALLYLAMINES

TERBINAFINE HCL

250mg Tablet

2239893 APO-TERBINAFINE APX

2254727 CO TERBINAFINE COB

2242503 GEN-TERBINAFINE GEN

2031116 LAMISIL NVR

2240346 NOVO-TERBINAFINE NOP

2248845 NU-TERBINAFINE NXP

2240807 PMS-TERBINAFINE PMS

2294273 PMS-TERBINAFINE PMS

2262924 RIVA-TERBINAFINE RIV

2262177 SANDOZ-TERBINAFINE SDZ

08:14.08 AZOLES

FLUCONAZOLE

150mg Capsule

2241895 APO-FLUCONAZOLE APX

2311690 CANESORAL BAY

2323419 CO FLUCONAZOLE CBT

2141442 DIFLUCAN PFI

2245697 GEN-FLUCONAZOLE GEN

2243645 NOVO-FLUCONAZOLE NOP

2246620 PMS-FLUCONAZOLE PMS

2282348 PMS-FLUCONAZOLE PMS

2310694 PRO-FLUCONAZOLE PDL

2255510 RIVA-FLUCONAZOLE RIV

10mg/mL Suspension

2024152 DIFLUCAN PFI

50mg Tablet

2237370 APO-FLUCONAZOLE APX

891800 DIFLUCAN PFI

2245292 GEN-FLUCONAZOLE GEN

2236978 NOVO-FLUCONAZOLE NOP

2245643 PMS-FLUCONAZOLE PMS

2249294 TARO-FLUCONAZOLE TAR

100mg Tablet

2237371 APO-FLUCONAZOLE APX

2281279 CO FLUCONAZOLE CBT

2245293 GEN-FLUCONAZOLE GEN

2236979 NOVO-FLUCONAZOLE NOP

2245644 PMS-FLUCONAZOLE PMS

2310686 PRO-FLUCONAZOLE PDL

2271516 RIVA-FLUCONAZOLE RIV

2249308 TAR0-FLUCONAZOLE TAR

ITRACONAZOLE

100mg Capsule

2047454 SPORANOX JNO

10mg/mL Solution

2231347 SPORANOX JNO

KETOCONAZOLE

200mg Tablet

2237235 APO-KETOCONAZOLE APX

2231061 NOVO-KETOCONAZOLE NOP

2122197 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

2256460 VFEND PFI

200mg Tablet

2256479 VFEND PFI

08:14.28 POLYENES

NYSTATIN

100,000U/mL Suspension

2125145 DOM-NYSTATIN DPC

792667 PMS-NYSTATIN PMS

2194201 RATIO-NYSTATIN RPH

500,000U Tablet

2194198 RATIO-NYSTATIN RPH

08:16.04 ANTITUBERCULOSIS AGENTS

ETHAMBUTOL HCL

100mg Tablet

247960 ETIBI VAE

400mg Tablet

247979 ETIBI VAE

ISONIAZID

10mg/mL Syrup

265500 ISOTAMINE VAE

577812 PMS-ISONIAZID PMS

50mg Tablet

577782 PMS-ISONIAZID PMS

300mg Tablet

272655 ISOTAMINE VAE

577804 PMS-ISONIAZID PMS

PYRAZINAMIDE

500mg Tablet

618810 PMS-PYRAZINAMIDE PMS

283991 TEBRAZID VAE

RIFABUTIN

150mg Capsule

2063786 MYCOBUTIN PFI

RIFAMPIN

150mg Capsule

2091887 RIFADIN SAC

393444 ROFACT VAE

RIFAMPIN

300mg Capsule

2092808 RIFADIN SAC

210463 RIMACTANE NVR

343617 ROFACT VAE

08:18.04 ADAMANTANES

AMANTADINE HCL

100mg Capsule

2130963 DOM-AMANTADINE DPC

2139200 GEN-AMANTADINE GEN

2199289 MED-AMANTADINE MEC

1990403 PMS-AMANTADINE PMS

10mg/mL Syrup

2130971 DOM-AMANTADINE DPC

2022826 PMS-AMANTADINE PMS

1913999 SYMMETREL BMS

08:18.08 ANTIRETROVIRALS

ABACAVIR

20mg/mL Oral Liquid

2240358 ZIAGEN GSK

300mg Tablet

2240357 ZIAGEN GSK

ABACAVIR, LAMIVUDINE

600mg & 300mg Tablet

2269341 KIVEXA GSK

ABACAVIR, LAMIVUDINE, ZIDOVUDINE

300mg & 150mg & 300mg Tablet

2244757 TRIZIVIR GSK

ATAZANAVIR SULFATE

150mg Capsule

2248610 REYATAZ BMS

200mg Capsule

2248611 REYATAZ BMS

300mg Capsule

2294176 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

2284057 PREZISTA JNO

400mg Tablet

2324016 PREZISTA JNO

600mg Tablet

2324024 PREZISTA JNO

DIDANOSINE

125mg Capsule

2244596 VIDEX EC BMS

DIDANOSINE

200mg Capsule

2244597 VIDEX EC BMS

250mg Capsule

2244598 VIDEX EC BMS

400mg Capsule

2244599 VIDEX EC BMS

EFAVIRENZ

50mg Capsule

2239886 SUSTIVA BMS

200mg Capsule

2239888 SUSTIVA BMS

600mg Tablet

2246045 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

2300699 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

2274906 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

2306778 INTELENCE JNO

FOSAMPRENAVIR CALCIUM

50mg/mL Oral Suspension

2261553 TELZIR GSK

700mg Tablet

2261545 TELZIR GSK

INDINAVIR SULFATE

200mg Capsule

2229161 CRIXIVAN FRS

400mg Capsule

2229196 CRIXIVAN FRS

LAMIVUDINE

10mg/mL Solution

2192691 3TC GSK

100mg Tablet

2239193 HEPTOVIR GSK

150mg Tablet

2192683 3TC GSK

300mg Tablet

2247825 3TC GSK

LAMIVUDINE, ZIDOVUDINE

150mg & 300mg Tablet

2239213 COMBIVIR GSK

LOPINAVIR, RITONAVIR

80mg & 20mg/mL Oral Solution

2243644 KALETRA ABB

100mg & 25mg Tablet

2312301 KALETRA ABB

200mg & 50mg Tablet

2285533 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

2299844 CELSENTRI VII

300mg Tablet

2299852 CELSENTRI VII

NELFINAVIR MESYLATE

50mg/g Powder for Suspension

2238618 VIRACEPT PFI

250mg Tablet

2238617 VIRACEPT PFI

625mg Tablet

2248761 VIRACEPT PFI

NEVIRAPINE

200mg Tablet

2238748 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

2301881 ISENTRESS FRS

RITONAVIR

100mg Capsule

2241480 NORVIR SEC ABB

80mg/mL Liquid

2229145 NORVIR ABB

SAQUINAVIR MESYLATE

200mg Capsule

2216965 INVIRASE HLR

500mg Tablet

2279320 INVIRASE HLR

STAVUDINE

15mg Capsule

2216086 ZERIT BMS

20mg Capsule

2216094 ZERIT BMS

30mg Capsule

2216108 ZERIT BMS

40mg Capsule

2216116 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

2247128 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

2273322 APTIVUS BOE

ZIDOVUDINE

100mg Capsule

1946323 APO-ZIDOVUDINE APX

1902660 RETROVIR GSK

10mg/mL Syrup

1902652 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

2248077 PEGASYS HLR

180mcg/1mL Injection

2248078 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

2253429 PEGASYS RBV HLR

180mcg/1mL & 200mg Injection & Tablet

2253410 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

2242966 UNITRON PEG SCH

118.4mcg/Vial Injection

2242967 UNITRON PEG SCH

177.6mcg/Vial Injection

2242968 UNITRON PEG SCH

222mcg/Vial Injection

2242969 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

2246026 PEGETRON SCH

2254573 PEGETRON REDIPEN SCH

80mcg/0.5mL & 200mg Injection & Capsule

2246027 PEGETRON SCH

2254581 PEGETRON REDIPEN SCH

100mcg/0.5mL & 200mg Injection & Capsule

2246028 PEGETRON SCH

2254603 PEGETRON REDIPEN SCH

120mcg/0.5mL & 200mg Injection & Capsule

2246029 PEGETRON SCH

2254638 PEGETRON REDIPEN SCH

150mcg/0.5mL & 200mg Injection & Capsule

2246030 PEGETRON SCH

2254646 PEGETRON REDIPEN SCH

08:18.32 NUCLEOSIDES AND NUCLEOTIDES

ACYCLOVIR

40mg/mL Suspension

886157 ZOVIRAX GSK

200mg Tablet

2207621 APO-ACYCLOVIR APX

2242784 GEN-ACYCLOVIR GEN

2285959 NOVO-ACYCLOVIR NOP

2197405 NU-ACYCLOVIR NXP

2237541 PDL-ACYCLOVIR PDL

2078627 RATIO-ACYCLOVIR RPH

634506 ZOVIRAX GSK

400mg Tablet

2207648 APO-ACYCLOVIR APX

2242463 GEN-ACYCLOVIR GEN

2285967 NOVO-ACYCLOVIR NOP

2197413 NU-ACYCLOVIR NXP

2237542 PDL-ACYCLOVIR PDL

2078635 RATIO-ACYCLOVIR RPH

1911627 ZOVIRAX GSK

ACYCLOVIR

800mg Tablet

2207656 APO-ACYCLOVIR APX

2242464 GEN-ACYCLOVIR GEN

2285975 NOVO-ACYCLOVIR NOP

2197421 NU-ACYCLOVIR NXP

2237543 PDL-ACYCLOVIR PDL

2078651 RATIO-ACYCLOVIR RPH

1911635 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

2247823 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

2282224 BARACLUDE BMS

FAMCICLOVIR

125mg Tablet

2292025 APO-FAMCICLOVIR APX

2305682 CO FAMCICLOVIR COB

2229110 FAMVIR NVR

2278081 PMS-FAMCICLOVIR PMS

2278634 SANDOZ-FAMCICLOVIR SDZ

250mg Tablet

2292041 APO-FAMCICLOVIR APX

2305690 CO FAMCICLOVIR COB

2229129 FAMVIR NVR

2278103 PMS-FAMCICLOVIR PMS

2278642 SANDOZ-FAMCICLOVIR SDZ

500mg Tablet

2292068 APO-FAMCICLOVIR APX

2305704 CO FAMCICLOVIR COB

2177102 FAMVIR NVR

2278111 PMS-FAMCICLOVIR PMS

2278650 SANDOZ-FAMCICLOVIR SDZ

GANCICLOVIR SODIUM

500mg Injection

2162695 CYTOVENE HLR

VALACYCLOVIR HCL

500mg Tablet

2295822 APO-VALACYCLOVIR APX

2298457 PMS-VALACYCLOVIR PMS

2316447 RIVA-VALACYCLOVIR RIV

2219492 VALTREX GSK

500mg Tablet

2315173 PRO-VALACYCLOVIR PDL

VALGANCICLOVIR HCL

450mg Tablet

2245777 VALCYTE HLR

08:30.04 AMEBICIDES

DIIODOHYDROXYQUIN

210mg Tablet

1997769 DIODOQUIN GLE

650mg Tablet

1997750 DIODOQUIN GLE

PAROMOMYCIN SULFATE

250mg Capsule

2078759 HUMATIN ERF

08:30.08 ANTIMALARIALS

CHLOROQUINE PHOSPHATE

250mg Tablet

21261 NOVO-CHLOROQUINE NOP

HYDROXYCHLOROQUINE SULFATE

200mg Tablet

2246691 APO-HYDROXYQUINE APX

2252600 GEN-HYDROXYCHLOROQUINE GEN

2017709 PLAQUENIL SAC

2311011 PRO-HYDROXYQUINE PDL

PRIMAQUINE PHOSPHATE

26.3mg Tablet

2017776 PRIMAQUINE SAC

PYRIMETHAMINE

25mg Tablet

4774 DARAPRIM GSK

08:30.92 MISCELLANEOUS ANTIPROTOZOALS

ATOVAQUONE

150mg/mL Suspension

2217422 MEPRON GSK

METRONIDAZOLE

500mg Capsule

2248562 APO-METRONIDAZOLE APX

250mg Tablet

545066 APO-METRONIDAZOLE APX

420409 METRONIDAZOLE PDL

PENTAMIDINE ISETHIONATE

300mg/Vial Injection

2183080 PENTAMIDINE MAY

08:36.00 URINARY ANTI-INFECTIVES

NITROFURANTOIN

50mg Capsule

1997637 MACRODANTIN PGP

2231015 NOVO-FURANTOIN NOP

100mg Capsule

2063662 MACROBID PGP

2231016 NOVO-FURANTOIN NOP

50mg Tablet

319511 APO-NITROFURANTOIN APX

100mg Tablet

312738 APO-NITROFURANTOIN APX

TRIMETHOPRIM

100mg Tablet

2243116 APO-TRIMETHOPRIM APX

200mg Tablet

2243117 APO-TRIMETHOPRIM APX