Drug Benefit List 2010

20:00 BLOOD FORMATION COAGULATION AND THROMBOSIS

20:04.04 IRON PREPARATIONS

FERROUS FUMARATE

300mg Capsule

2237556 EURO-FER EUR

482064 NEO FER NEO

1923420 PALAFER GSK

300mg/5mL Oral Liquid

2246590 FERRATE O/L EUR

60mg/mL Suspension

1923439 PALAFER GSK

200mg Tablet

2138751 FERROUS FUMARATE VTH

300mg Tablet

31089 FERROUS FUMARATE PED

FERROUS GLUCONATE

300mg Tablet

545031 APO-FERROUS GLUCONATE APX

31097 FERROUS GLUCONATE PED

41157 FERROUS GLUCONATE PMS

21458 NOVO-FERROGLUC NOP

80000435 NOVO-FERROGLUC NOP

324mg Tablet

582727 FERROUS GLUCONATE * VTH

FERROUS SULFATE

15mg/mL Drop

2237385 FERODAN ODN

2232202 PEDIAFER EUR

2222574 PMS-FERROUS SULFATE PMS

75mg/mL Drop

762954 FER-IN-SOL MJO

80008309 JAMP SULFATE FERREUX JMP

6mg/mL Syrup

17884 FER-IN-SOL MJO

2242863 PEDIAFER EUR

30mg/mL Syrup

758469 FERODAN ODN

80008295 JAMP SULFATE FERREUX JMP

792675 PMS-FERROUS SULFATE PMS

300mg Tablet

1912518 APO-FERROUS SULFATE FC APX

2246733 EURO-FERROUS SULFATE EUR

2248699 FERODAN ODN

31100 FERROUS SULFATE PED

179655 FERROUS SULFATE SDR

346918 FERROUS SULFATE PMT

782114 FERROUS SULFATE * VTH

2125471 FERROUS SULFATE PDL

586323 PMS-FERROUS SULFATE PMS

IRON DEXTRAN

50mg/mL Injection

2205963 DEXIRON GEN

2221780 INFUFER SDZ

20:12.04 ANTICOAGULANTS

DALTEPARIN SODIUM

7,500IU/0.3mL Injection

99100159 FRAGMIN PFI

10,000IU/0.4mL Injection

9853790 FRAGMIN * PMJ

99004143 FRAGMIN * PMJ

10,000IU/mL Injection

2132664 FRAGMIN PMJ

12,500IU/0.5mL Injection

99004151 FRAGMIN * PMJ

15,000IU/0.6mL Injection

9853880 FRAGMIN * PMJ

99004178 FRAGMIN * PMJ

18,000IU/0.72mL Injection

9853910 FRAGMIN * PMJ

99004186 FRAGMIN * PMJ

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

2231171 FRAGMIN PMJ

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

2132621 FRAGMIN PMJ

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

2132648 FRAGMIN PMJ

ENOXAPARIN SODIUM

30mg/0.3mL Injection

2012472 LOVENOX SAC

40mg/0.4mL Injection

2236883 LOVENOX SAC

60mg/0.6mL Injection

99002965 LOVENOX * AVT

80mg/0.8mL Injection

99003058 LOVENOX AVT

100mg/1.0mL Injection

99002981 LOVENOX AVT

120mg/0.8mL Injection

99004941 LEVENOX HP AVT

150mg/1.0mL Injection

2242692 LEVONEX HP SAC

300mg/3mL Injection

2236564 LOVENOX SAC

HEPARIN SODIUM

1,000 U/mL Injection

740519 HEPALEAN ORG

10,000 U/mL Injection

740497 HEPALEAN ORG

10U/mL Lock Flush

725323 HEPARIN LOCK FLUSH ABB

HEPARIN SODIUM

100U/mL Lock Flush

740578 HEPALEAN LOK ORG

727520 HEPARIN LEO LEO

725315 HEPARIN LOCK FLUSH HOS

NADROPARIN CALCIUM

9,500IU/mL Injection

2236913 FRAXIPARINE GSK

19,000IU/mL Injection

2240114 FRAXIPARINE FORTE GSK

NICOUMALONE

1mg Tablet

10383 SINTROM PED

4mg Tablet

10391 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

2316986 XARELTO BAY

TINZAPARIN SODIUM

10,000IU/mL Injection

2167840 INNOHEP LEO

14,000IU/mL Injection

99002612 INNOHEP LEO

20,000IU/mL Injection

2229515 INNOHEP LEO

20,000IU/mL Injection (Graduated Syringe)

2231478 INNOHEP LEO

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

2229755 INNOHEP LEO

9853898 INNOHEP * LEO

20,000IU/mL Injection (Pre-filled Syringe)

9853901 INNOHEP * LEO

9853928 INNOHEP * LEO

99002620 INNOHEP * LEO

WARFARIN SODIUM

1mg Tablet

2242924 APO-WARFARIN APX

1918311 COUMADIN BMS

2244462 GEN-WARFARIN GEN

2265273 NOVO-WARFARIN NOP

2242680 TARO-WARFARIN TAR

2mg Tablet

2242925 APO-WARFARIN APX

1918338 COUMADIN BMS

2244463 GEN-WARFARIN GEN

2265281 NOVO-WARFARIN NOP

2242681 TARO-WARFARIN TAR

WARFARIN SODIUM

2.5mg Tablet

2242926 APO-WARFARIN APX

1918346 COUMADIN BMS

2244464 GEN-WARFARIN GEN

2265303 NOVO-WARFARIN NOP

2242682 TARO-WARFARIN TAR

3mg Tablet

2245618 APO-WARFARIN APX

2240205 COUMADIN BMS

2287498 GEN-WARFARIN GEN

2265311 NOVO-WARFARIN NOP

2242683 TARO-WARFARIN TAR

4mg Tablet

2242927 APO-WARFARIN APX

2007959 COUMADIN BMS

2244465 GEN-WARFARIN GEN

2265338 NOVO-WARFARIN NOP

2242684 TARO-WARFARIN TAR

5mg Tablet

2242928 APO-WARFARIN APX

1918354 COUMADIN BMS

2244466 GEN-WARFARIN GEN

2265346 NOVO-WARFARIN NOP

2242685 TARO-WARFARIN TAR

6mg Tablet

2287501 GEN-WARFARIN GEN

2242686 TARO-WARFARIN TAR

7.5mg Tablet

2287528 GEN-WARFARIN GEN

2242697 TARO-WARFARIN TAR

10mg Tablet

2242929 APO-WARFARIN APX

1918362 COUMADIN BMS

2244467 GEN-WARFARIN GEN

2242687 TARO-WARFARIN TAR

20:12.18 PLATELET AGGREGATION INHIBITORS

ANAGRELIDE HCL

0.5mg Capsule

2236859 AGRYLIN SHI

2253054 GEN-ANAGRELIDE GEN

2274949 PMS-ANAGRELIDE PMS

2260107 RHOXAL-ANAGRELIDE RHO

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.

75mg Tablet

2238682 PLAVIX SAC

TICLOPIDINE HCL

250mg Tablet

2237701 APO-TICLOPIDINE APX

2239744 GEN-TICLOPIDINE GEN

2236848 NOVO-TICLOPIDINE NOP

2237560 NU-TICLOPIDINE NXP

2238208 PDL-TICLOPIDINE PDL

2243587 SANDOZ-TICLOPIDINE SDZ

20:16.00 HEMATOPOIETIC AGENTS

FILGRASTIM

300mcg/mL Injection

1968017 NEUPOGEN AMG

99001454 NEUPOGEN * AMG

480mcg/1.6mL Injection

9853464 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

2249790 NEULASTA AMG

20:24.00 HEMORRHEOLOGIC AGENTS

PENTOXIFYLLINE

400mg Sustained Release Tablet

2230090 APO-PENTOXIFYL APX

2230401 NU-PENTOXIFYL NXP

1968432 RATIO-PENTOXIFYLLINE RPH

2221977 TRENTAL SAC

20:28.16 HEMOSTATICS

TRANEXAMIC ACID

500mg Tablet

2064405 CYKLOKAPRON PFI