Drug Benefit List 2010

40:00 ELECTROLYTIC, CALORIC, AND WATER BALANCE

40:08.00 ALKALINIZING AGENTS

CITRIC ACID, SODIUM CITRATE

66.8mg & 100mg/mL Solution

721344 DICITRATE PMS

SODIUM BICARBONATE

300mg Tablet

481912 SODIUM BICARBONATE XEN

40:12.00 REPLACEMENT PREPARATIONS

CALCIUM CARBONATE

500mg Tablet

682039 APO-CAL 500 APX

674346 CAL-500 PDL

621722 CALCIUM HAL

2240240 CALCIUM PMT

80003773 CALCIUM TRI

2246040 CALCIUM CARBONATE JMP

2237352 EURO-CAL EUR

645923 NOVO-CALCIUM NOP

618098 NU-CAL ODN

622443 O-CALCIUM 500 VTH

80001122 PMS-CALCIUM PMS

CALCIUM CARBONATE, CHOLECALCIFEROL

500mg & 125IU Tablet

752673 CAL-500-D PRO

80004966 CALCITE D 500 RIV

688770 CALCITE D-500 RIV

2244161 CALCIUM 500 + D 400 TRI

702986 CALCIUM 500MG WITH VIT D HAL

2246041 CALCIUM CARBONATE WITH D JMP

730599 CALCIUM CARBONATE WITH VIT D PMT

688975 CALCIUM D-500 TRI

2237351 EURO-CAL D EUR

720798 NEO CAL-D-500 NEO

2043025 OS-CAL D 500MG WAY

80004281 PMS-CALCIUM/VITAMIN D PMS

500mg & 400IU Tablet

2244130 CALCITE 500 + D 400 RIV

80004963 CALCITE 500 + D 400 RIV

80004969 CALCIUM 500 + D 400 TRI

80002623 CALCIUM 500MG WITH VIT D JMP

2245511 CARBOCAL D EUR

80002901 CARBOCAL D EUR

80002122 JAMP-CALCIUM+VITAM D JMP

CALCIUM LACTOGLUCONATE

20mg/mL Oral Liquid

80002626 CALCIUM WITHOUT SUGAR JMP

CALCIUM LACTOGLUCONATE

20mg/mL Oral Liquid

80006877 WAMPOLE MINERAL CALCIUM JMP

CALCIUM, VITAMIN D

500mg & 400IU Tablet

80015351 PRIVA CAL D FORTE PHA

500mg & 400U Tablet

80003919 BIOCAL-D FORTE BMI

ELECTROLYTE & DEXTROSE

3.56g & 300mg & 470mg & 530mg Powder

1931563 GASTROLYTE REG SAC

25mg & 2.2mg & 2.2mg & 0.9mg/mL Solution

630365 PEDIALYTE ABB

2219883 PEDIATRIC ELECTROLYTE PMS

MAGNESIUM

25mg Oral Liquid

80009357 JAMP-MAGNESIUM GLUCONATE JMP

28mg Tablet

80009539 JAMP-MAGNESIUM GLUCONATE JMP

100mg Tablet

2068400 MAGNESIUM JAM

MAGNESIUM CITRATE

5.40% Oral Liquid

262609 CITRO MAG 15GM/300ML TCH

MAGNESIUM GLUCONATE

100mg/mL Oral Liquid

26697 RATIO-MAGNESIUM RPH

POTASSIUM CHLORIDE

25MEQ Effervescent Tablet

2085992 K LYTE WPC

8mmol Long Acting Capsule

2242291 EURO-K8 EUR

2244068 RIVA-K RIV

8mmol Long Acting Tablet

602884 APO-K APX

2246734 EURO-K 600 EUR

613274 PRO-600K PDL

74225 SLOW K NVR

20mmol Long Acting Tablet

2242261 EURO-K 20 EUR

713376 K-DUR KEY

80004415 ODAN K-20 ODN

2243975 RIVA-K 20 RIV

1.33MEQ/mL Oral Liquid

1918303 K 10 GSK

2238604 PMS-POTASSIUM PMS

25MEQ Powder

2089580 K LYTE WPC

SODIUM CHLORIDE

0.9% Inhalation Diluent

2094657 BACTERIOSTATIC NACL BIO

801267 SODIUM CHLORIDE *

2058235 SODIUM CHLORIDE BDH

0.9% Injection

60208 SODIUM CHLORIDE BAT

402249 SODIUM CHLORIDE ABB

2150204 SODIUM CHLORIDE OMG

99002329 SODIUM CHLORIDE *

40:17.00 CALCIUM-REMOVING RESINS

CALCIUM POLYSTYRENE SULFONATE

1g binds with approx 1.6mmol K Powder

2017741 RESONIUM CALCIUM SAC

40:18.00 ION-REMOVING AGENTS

SODIUM POLYSTYRENE SULFONATE

1g binds with approx 1mmol K Powder

2026961 KAYEXALATE SAC

765252 K-EXIT OMG

755338 PMS-SOD POLYSTYRENE SULFONA PMS

250mg/mL Oral Suspension

769541 PMS-SOD POLYSTYRENE SULF PMS

250mg/mL Retention Enema

769533 PMS-SOD POLYSTYRENE SULF PMS

40:20.00 CALORIC AGENTS

LEVOCARNITINE

Limited use benefit (prior approval required).

For treatment of carnitine deficiency.

100mg/mL Oral Liquid

2144336 CARNITOR SIG

200mg/mL Solution

2144344 CARNITOR IV SIG

330mg Tablet

2144328 CARNITOR SIG

40:28.08 LOOP DIURETICS

ETHACRYNIC ACID

25mg Tablet

2258528 EDECRIN FRS

FUROSEMIDE

10mg/mL Solution

2224720 LASIX SAC

FUROSEMIDE

20mg Tablet

396788 APO-FUROSEMIDE APX

2247371 BIO-FUROSEMIDE BMI

2248124 DOM-FUROSEMIDE BMI

496723 FUROSEMIDE PDL

2224690 LASIX SAC

337730 NOVO-SEMIDE NOP

2239224 NU-FUROSEMIDE NXP

2247493 PMS-FUROSEMIDE PMS

40mg Tablet

362166 APO-FUROSEMIDE APX

2247372 BIO-FUROSEMIDE BMI

2248125 DOM-FUROSEMIDE BMI

397792 FUROSEMIDE PDL

2224704 LASIX SAC

337749 NOVO-SEMIDE NOP

2239225 NU-FUROSEMIDE NXP

2247494 PMS-FUROSEMIDE PMS

80mg Tablet

707570 APO-FUROSEMIDE APX

667080 FUROSEMIDE PDL

765953 NOVO-SEMIDE NOP

500mg Tablet

2224755 LASIX SAC

40:28.16 POTASSIUM SPARING DIURETICS

AMILORIDE HCL

5mg Tablet

2249510 APO-AMILORIDE APX

487805 MIDAMOR OBP

AMILORIDE HCL, HYDROCHLOROTHIAZIDE

5mg & 50mg Tablet

870943 AMI-HYDRO PDL

784400 APO-AMILZIDE APX

2257378 GEN-AMILAZIDE GEN

487813 MODURET OBP

1937219 NOVAMILOR NOP

886106 NU-AMILZIDE NXP

2231254 PENTA-AMILOR HCTZ PEN

TRIAMTERENE, HYDROCHLOROTHIAZIDE

50mg & 25mg Tablet

441775 APO-TRIAZIDE APX

532657 NOVO-TRIAMZIDE NOP

865532 NU-TRIAZIDE NXP

519367 PRO-TRIAZIDE PRO

2240846 RIVA-ZIDE RIV

40:28.20 TIAZIDE DIURETICS

HYDROCHLOROTHIAZIDE

12.5mg Tablet

2327856 APO-HYDRO APX

2274086 PMS-HYDROCHLOROTHIAZIDE BMI

HYDROCHLOROTHIAZIDE

25mg Tablet

326844 APO-HYDROCLOROTHIAZIDE APX

2247170 BIO-HYDROCHLOROTHIAZIDE BMI

2248134 DOM-HYDROCHLOROTHIAZIDE DPC

341975 HYDROCHLOROTHIAZIDE PDL

21474 NOVO-HYDRAZIDE NOP

2250659 NU-HYDRO NXP

2247386 PMS-HYDROCHLOROTHIAZIDE PMS

50mg Tablet

312800 APO-HYDRO APX

2247171 BIO-HYDROCHLOROTHIAZIDE BMI

2248135 DOM-HYDROCHLOROTHIAZIDE DPC

156604 HYDROCHLOROTHIAZIDE PRO

21482 NOVO-HYDRAZIDE NOP

2250667 NU-HYDRO NXP

2247387 PMS-HYDROCHLOROTHIAZIDE PMS

100mg Tablet

644552 APO-HYDRO APX

532088 HYDROCHLOROTHIAZIDE PDL

SPIRONOLACTONE, HYDROCHLOROTHIAZIDE

25mg & 25mg Tablet

180408 ALDACTAZIDE-25 PFI

613231 NOVO-SPIROZINE-25 NOP

50mg & 50mg Tablet

594377 ALDACTAZIDE-50 PFI

657182 NOVO-SPIROZINE-50 NOP

40:28.24 THIAZIDE LIKE DIURETICS

CHLORTHALIDONE

50mg Tablet

360279 APO-CHLORTHALIDONE APX

100mg Tablet

360287 APO-CHLORTHALIDONE APX

INDAPAMIDE

1.25mg Tablet

2245246 APO-INDAPAMIDE APX

2239913 DOM-INDAPAMIDE DPC

2240067 GEN-INDAPAMIDE GEN

2227339 INDAPAMIDE PRO

2179709 LOZIDE SEV

2240349 PHL-INDAPAMIDE PHH

2239619 PMS-INDAPAMIDE PMS

2312530 PRO-INDAPAMIDE PDL

2247245 RIVA-INDAPAMIDE RIV

INDAPAMIDE

2.5mg Tablet

2223678 APO-INDAPAMIDE APX

2239917 DOM-INDAPAMIDE DPC

2153483 GEN-INDAPAMIDE GEN

2049341 INDAPAMIDE PRO

564966 LOZIDE SEV

2231184 NOVO-INDAPAMIDE NOP

2223597 NU-INDAPAMIDE NXP

2239620 PMS-INDAPAMIDE PMS

2312549 PRO-INDAPAMIDE PDL

2242125 RIVA-INDAPAMIDE RIV

METOLAZONE

2.5mg Tablet

888400 ZAROXOLYN AVT

40:36.00 IRRIGATING SOLUTIONS

WATER

Injection

402257 STERILE WATER FOR INJ OMG

2142546 STERILE WATER FOR INJ HOS

40:40.00 URICOSURIC AGENTS

PROBENECID

500mg Tablet

294926 BENURYL VAE

SULFINPYRAZONE

200mg Tablet

441767 APO-SULFINPYRAZONE APX

2045699 NU-SULFINPYRAZONE NXP