Drug Benefit List 2012

20:00 BLOOD FORMATION COAGULATION AND THROMBOSIS

20:04.04 IRON PREPARATIONS

FERROUS FUMARATE

ST 300mg Capsule

02237556 EURO-FER EUR

00482064 NEO FER NEO

01923420 PALAFER GSK

ST 300mg/5mL Oral Liquid

02246590 FERRATE O/L EUR

ST 60mg/mL Suspension

01923439 PALAFER GSK

ST 300mg Tablet

31089 FERROUS FUMARATE JMP

FERROUS GLUCONATE

ST 300mg Tablet

00545031 APO-FERROUS GLUCONATE APX

00031097 FERROUS GLUCONATE JMP

00041157 FERROUS GLUCONATE ADA

80000435 NOVO-FERROGLUC NUR

ST 324mg Tablet

00582727 FERROUS GLUCONATE VTH *

FERROUS SULFATE

ST 15mg/mL Drop

02237385 FERODAN ODN

02232202 PEDIAFER EUR

02222574 PMS-FERROUS SULFATE PMS

ST 75mg/mL Drop

00762954 FER-IN-SOL MJO

80008309 JAMP SULFATE FERREUX JMP

ST 6mg/mL Syrup

00017884 FER-IN-SOL MJO

02242863 PEDIAFER EUR

ST 30mg/mL Syrup

00758469 FERODAN ODN

80008295 JAMP SULFATE FERREUX JMP

00792675 PMS-FERROUS SULFATE PMS

ST 300mg Tablet

01912518 APO-FERROUS SULFATE FC APX

02246733 EURO-FERROUS SULFATE EUR

02248699 FERODAN ODN

00031100 FERROUS SULFATE JMP

00346918 FERROUS SULFATE PMT

00782114 FERROUS SULFATE VTH *

00586323 PMS-FERROUS SULFATE PMS

IRON DEXTRAN

50mg/mL Injection

02205963 DEXIRON MYL

02221780 INFUFER SDZ

20:12.04 ANTICOAGULANTS

DALTEPARIN SODIUM

10,000IU/mL Injection (Multi-Dose)

02132664 FRAGMIN PMJ

25,000IU/mL Injection (Multi-Dose)

02231171 FRAGMIN PMJ

2,500IU/0.2mL Injection (Pre-filled Syringe)

02132621 FRAGMIN PMJ

5,000IU/0.2mL Injection (Pre-filled Syringe)

02132648 FRAGMIN PMJ

7,500IU/0.3mL Injection (Pre-filled Syringe)

02352648 FRAGMIN PFI

10,000IU/0.4mL Injection (Pre-filled Syringe)

02352656 FRAGMIN PFI

12,500IU/0.5mL Injection (Pre-filled Syringe)

02352664 FRAGMIN PFI

15,000IU/0.6mL Injection (Pre-filled Syringe)

02352672 FRAGMIN PFI

18,000IU/0.72mL Injection (Pre-filled Syringe)

02352680 FRAGMIN PFI

ENOXAPARIN SODIUM

30mg/0.3mL Injection

02012472 LOVENOX SAC

40mg/0.4mL Injection

02236883 LOVENOX SAC

60mg/0.6mL Injection

99002965 LOVENOX SAC *

80mg/0.8mL Injection

99003058 LOVENOX SAC

100mg/1.0mL Injection

99002981 LOVENOX SAC

120mg/0.8mL Injection

99004941 LOVENEX HP SAC

150mg/1.0mL Injection

02242692 LOVENEX HP SAC

300mg/3mL Injection

02236564 LOVENOX SAC

HEPARIN SODIUM

1,000 U/mL Injection

00740519 HEPALEAN SCH

00453811 HEPARIN LEO INJ 1000UNIT/ML LEO

02303086 HEPARIN SODIUM 1000U/ML SDZ

10,000 U/mL Injection

00579718 HEPARIN LEO INJ 10000UNIT/ML LEO

02303094 HEPARIN SODIUM 10000U/ML SDZ

02303108 HEPARIN SODIUM 10000U/ML SDZ

25,000 U/mL Injection

00453781 HEPARIN LEO INJ 25000UNIT/ML LEO

10 U/mL Lock Flush

00725323 HEPARIN LOCK FLUSH ABB

100 U/mL Lock Flush

00727520 HEPARIN LEO LEO

00725315 HEPARIN LOCK FLUSH HOS

NADROPARIN CALCIUM

9,500IU/mL Injection

02236913 FRAXIPARINE GSK

19,000IU/mL Injection

02240114 FRAXIPARINE FORTE GSK

NICOUMALONE

1mg Tablet

00010383 SINTROM PED

4mg Tablet

00010391 SINTROM PED

RIVAROXABAN

Limited use benefit (prior approval not required).

For the prevention of venous thromboembolism following total knee replacement or total hip replacement surgery, for up to two weeks.

10mg Tablet

02316986 XARELTO BAY

TINZAPARIN SODIUM

10,000IU/mL Injection

02167840 INNOHEP LEO

20,000IU/mL Injection

02229515 INNOHEP LEO

2,500IU Injection (Pre-filled Syringe)

02229755 INNOHEP LEO

3,500IU Injection (Pre-filled Syringe)

02358158 INNOHEP LEO

4,500IU Injection (Pre-filled Syringe)

02358166 INNOHEP LEO

10,000IU Injection (Pre-filled Syringe)

02231478 INNOHEP LEO

14,000IU Injection (Pre-filled Syringe)

02358174 INNOHEP LEO

18,000IU Injection (Pre-filled Syringe)

02358182 INNOHEP LEO

WARFARIN SODIUM

1mg Tablet

02242924 APO-WARFARIN APX

01918311 COUMADIN BMS

02244462 MYLAN-WARFARIN MYL

02265273 NOVO-WARFARIN TEV

02242680 TARO-WARFARIN TAR

02344025 WARFARIN SAN

2mg Tablet

02242925 APO-WARFARIN APX

01918338 COUMADIN BMS

02244463 MYLAN-WARFARIN MYL

02265281 NOVO-WARFARIN TEV

02242681 TARO-WARFARIN TAR

02344033 WARFARIN SAN

2.5mg Tablet

02242926 APO-WARFARIN APX

01918346 COUMADIN BMS

02244464 MYLAN-WARFARIN MYL

02265303 NOVO-WARFARIN TEV

02242682 TARO-WARFARIN TAR

02344041 WARFARIN SAN

3mg Tablet

02245618 APO-WARFARIN APX

02240205 COUMADIN BMS

02287498 MYLAN-WARFARIN MYL

02265311 NOVO-WARFARIN TEV

02242683 TARO-WARFARIN TAR

02344068 WARFARIN SAN

4mg Tablet

02242927 APO-WARFARIN APX

02007959 COUMADIN BMS

02244465 MYLAN-WARFARIN MYL

02265338 NOVO-WARFARIN TEV

02242684 TARO-WARFARIN TAR

02344076 WARFARIN SAN

5mg Tablet

02242928 APO-WARFARIN APX

01918354 COUMADIN BMS

02244466 MYLAN-WARFARIN MYL

02265346 NOVO-WARFARIN TEV

02242685 TARO-WARFARIN TAR

02344084 WARFARIN SAN

6mg Tablet

02240206 COUMADIN BMS

02287501 MYLAN-WARFARIN MYL

02242686 TARO-WARFARIN TAR

02344092 WARFARIN SAN

7.5mg Tablet

02287528 MYLAN-WARFARIN MYL

02242697 TARO-WARFARIN TAR

02344106 WARFARIN SAN

10mg Tablet

02242929 APO-WARFARIN APX

01918362 COUMADIN BMS

02244467 MYLAN-WARFARIN MYL

02242687 TARO-WARFARIN TAR

02344114 WARFARIN SAN

20:12.18 PLATELET AGGREGATION INHIBITORS

ANAGRELIDE HCL

ST 0.5mg Capsule

02236859 AGRYLIN SHI

02253054 MYLAN-ANAGRELIDE MYL

02274949 PMS-ANAGRELIDE PMS

02260107 SANDOZ-ANAGRELIDE SDZ

CLOPIDOGREL BISULFATE

Limited use benefit (one-year duration, prior approval required).

1. Patients with intra-coronary stent implantation following insertion.
2. Patients with acute coronary syndrome (ACS) (unstable angina or non-ST-segment elevation MI), in combination with ASA.

ST 75mg Tablet

02238682 PLAVIX SAC

TICLOPIDINE HCL

ST 250mg Tablet

02237701 APO-TICLOPIDINE APX

02239744 MYLAN-TICLOPIDINE MYL

02237560 NU-TICLOPIDINE NXP

02236848 TEVA-TICLOPIDINE TEV

02343045 TICLOPIDINE SAN

20:16.00 HEMATOPOIETIC AGENTS

FILGRASTIM

300mcg/mL Injection

01968017 NEUPOGEN AMG

PEGFILGRASTIM

Limited use benefit (prior approval required).

1. To decrease the incidence of infection, as manifested by febrile neutropenia, in patients with non-myeloid malignancies receiving myelosuppressive antineoplastic drugs with curative intent.
   and
2. Where access to a health care facility is problematic.

10mg/mL Injection

02249790 NEULASTA AMG

20:24.00 HEMORRHEOLOGIC AGENTS

PENTOXIFYLLINE

ST 400mg Sustained Release Tablet

02230090 APO-PENTOXIFYL APX

02230401 NU-PENTOXIFYL NXP

02221977 TRENTAL SAC

20:28.16 HEMOSTATICS

TRANEXAMIC ACID

500mg Tablet

02064405 CYKLOKAPRON PFI