Drug Benefit List - April 2009

40:00 ELECTROLYTIC, CALORIC, AND WATER BALANCE

40:08.00 ALKALINIZING AGENTS

CITRIC ACID, SODIUM CITRATE

66.8MG & 100MG/ML Solution

00721344 DICITRATE PMS

SODIUM BICARBONATE

300MG Tablet

00481912 SODIUM BICARBONATE XEN

40:12.00 REPLACEMENT PREPARATIONS

CALCIUM CARBONATE

500MG Tablet

00682039 APO-CAL 500 APX

00674346 CAL-500 PDL

02240240 CALCIUM PMT

00621722 CALCIUM HAL

02240240 CALCIUM PMT

80003773 CALCIUM TRI

00688983 CALCIUM 500 TRI

02246040 CALCIUM CARBONATE JMP

02237352 EURO-CAL EUR

00645923 NOVO-CALCIUM NOP

00618098 NU-CAL ODN

00622443 O-CALCIUM 500 VTH

02042991 OS-CAL WAY

80001122 PMS-CALCIUM PMS

CALCIUM CARBONATE, CHOLECALCIFEROL

500MG & 125IU Tablet

00752673 CAL-500-D PRO

80004966 CALCITE D 500 RIV

00688770 CALCITE D-500 RIV

02244161 CALCIUM 500 + D 400 TRI

00702986 CALCIUM 500MG WITH VIT D HAL

02246041 CALCIUM CARBONATE WITH D JMP

00730599 CALCIUM CARBONATE WITH VIT D PMT

00688975 CALCIUM D-500 TRI

02237351 EURO-CAL D EUR

00720798 NEO CAL-D-500 NEO

02043025 OS-CAL D 500MG WAY

80004281 PMS-CALCIUM/VITAMIN D PMS

500MG & 400IU Tablet

02244130 CALCITE 500 + D 400 RIV

80004969 CALCIUM 500 + D 400 TRI

80002623 CALCIUM 500MG WITH VIT D JMP

80002122 JAMP-CALCIUM+VITAM D JMP

CALCIUM LACTOGLUCONATE

20MG/ML LIQUID

80002626 CALCIUM WITHOUT SUGAR JMP

CALCIUM/VITAMIN D3

500MG & 400IU Tablet

80004963 CALCITE 500 + D 400 RIV

ELECTROLYTE & DEXTROSE

3.56G & 300MG & 470MG & 530MG Powder

01931563 GASTROLYTE REG SAC

25MG & 2.2MG & 2.2MG & 0.9MG/ML Solution

00630365 PEDIALYTE ABB

02219883 PEDIATRIC ELECTROLYTE PMS

POTASSIUM CHLORIDE

25MEQ Effervescent Tablet

02085992 K LYTE WPC

8MMOL Long Acting Capsule

02242291 EURO-K8 EUR

02244068 RIVA-K RIV

8MMOL Long Acting Tablet

00602884 APO-K APX

02246734 EURO-K 600 EUR

00613274 PRO-600K PDL

00074225 SLOW K NVR

20MMOL Long Acting Tablet

02242261 EURO-K 20 EUR

00713376 K-DUR KEY

02243975 RIVA-K 20 RIV

1.33MEQ/ML Oral Liquid

01918303 K 10 GSK

02238604 PMS-POTASSIUM PMS

20MEQ Powder

00481211 K-LOR ABB

25MEQ Powder

02089580 K LYTE WPC

SODIUM CHLORIDE

0.9% Inhalation Diluent

02094657 BACTERIOSTATIC NACL BIO

00801267 SODIUM CHLORIDE UNK *

02058235 SODIUM CHLORIDE BDH

0.9% Injection

00060208 SODIUM CHLORIDE BAT

00402249 SODIUM CHLORIDE ABB

02150204 SODIUM CHLORIDE OMG

99002329 SODIUM CHLORIDE AUT *

40:17.00 CALCIUM-REMOVING RESINS

CALCIUM POLYSTYRENE SULFONATE

1G binds with approx 1.6mmol K Powder

02017741 RESONIUM CALCIUM SAC

40:18.00 ION-REMOVING AGENTS

SODIUM POLYSTYRENE SULFONATE

250MG/ML Oral Suspension

00769541 PMS-SOD POLYSTYRENE SULF PMS

250MG/ML Retention Enema

00769533 PMS-SOD POLYSTYRENE SULF PMS

1G binds with approx 1mmol K Powder

00765252 K-EXIT OMG

02026961 KAYEXALATE SAC

00755338 PMS-SOD POLYSTYRENE SULFONA PMS

40:20.00 CALORIC AGENTS

LEVOCARNITINE

Limited use benefit (prior approval required).

For treatment of carnitine deficiency.

100MG/ML Oral Liquid

02144336 CARNITOR SIG

200MG/ML Solution

02144344 CARNITOR IV SIG

330MG Tablet

02144328 CARNITOR SIG

40:28.08 LOOP DIURETICS

ETHACRYNIC ACID

25MG Tablet

02258528 EDECRIN FRS

FUROSEMIDE

10MG/ML Solution

02224720 LASIX SAC

20MG Tablet

00396788 APO-FUROSEMIDE APX

02247371 BIO-FUROSEMIDE BMI

02248124 DOM-FUROSEMIDE BMI

00496723 FUROSEMIDE PDL

02224690 LASIX SAC

00337730 NOVO-SEMIDE NOP

02239224 NU-FUROSEMIDE NXP

02247493 PMS-FUROSEMIDE PMS

40MG Tablet

00362166 APO-FUROSEMIDE APX

02247372 BIO-FUROSEMIDE BMI

02248125 DOM-FUROSEMIDE BMI

00397792 FUROSEMIDE PDL

02224704 LASIX SAC

00337749 NOVO-SEMIDE NOP

02239225 NU-FUROSEMIDE NXP

02247494 PMS-FUROSEMIDE PMS

80MG Tablet

00707570 APO-FUROSEMIDE APX

00667080 FUROSEMIDE PDL

00765953 NOVO-SEMIDE NOP

500MG Tablet

02224755 LASIX SAC

40:28.16 POTASSIUM SPARING DIURETICS

AMILORIDE HCL

5MG Tablet

02249510 APO-AMILORIDE APX

00487805 MIDAMOR OBP

AMILORIDE HCL, HYDROCHLOROTHIAZIDE

5MG & 50MG Tablet

00870943 AMI-HYDRO PDL

00784400 APO-AMILZIDE APX

02257378 GEN-AMILAZIDE GEN

00487813 MODURET OBP

01937219 NOVAMILOR NOP

00886106 NU-AMILZIDE NXP

02231254 PENTA-AMILOR HCTZ PEN

TRIAMTERENE, HYDROCHLOROTHIAZIDE

50MG & 25MG Tablet

00441775 APO-TRIAZIDE APX

00532657 NOVO-TRIAMZIDE NOP

00865532 NU-TRIAZIDE NXP

02238638 PENTA-TRIAMTERENCE HCTZ PEN

00519367 PRO-TRIAZIDE PRO

02240846 RIVA-ZIDE RIV

40:28.20 TIAZIDE DIURETICS

HYDROCHLOROTHIAZIDE

12.5MG Tablet

02274086 PMS-HYDROCHLOROTHIAZIDE BMI

25MG Tablet

00326844 APO-HYDROCLOROTHIAZIDE APX

02247170 BIO-HYDROCHLOROTHIAZIDE BMI

02248134 DOM-HYDROCHLOROTHIAZIDE DPC

00341975 HYDROCHLOROTHIAZIDE PDL

00021474 NOVO-HYDRAZIDE NOP

02250659 NU-HYDRO NXP

02247386 PMS-HYDROCHLOROTHIAZIDE PMS

50MG Tablet

00312800 APO-HYDRO APX

02247171 BIO-HYDROCHLOROTHIAZIDE BMI

02248135 DOM-HYDROCHLOROTHIAZIDE DPC

00156604 HYDROCHLOROTHIAZIDE PRO

00021482 NOVO-HYDRAZIDE NOP

02250667 NU-HYDRO NXP

02247387 PMS-HYDROCHLOROTHIAZIDE PMS

100MG Tablet

00644552 APO-HYDRO APX

00532088 HYDROCHLOROTHIAZIDE PDL

SPIRONOLACTONE, HYDROCHLOROTHIAZIDE

25MG & 25MG Tablet

00180408 ALDACTAZIDE-25 PFI

00613231 NOVO-SPIROZINE-25 NOP

50MG & 50MG Tablet

00594377 ALDACTAZIDE-50 PFI

00657182 NOVO-SPIROZINE-50 NOP

40:28.24 THIAZIDE LIKE DIURETICS

CHLORTHALIDONE

50MG Tablet

00360279 APO-CHLORTHALIDONE APX

100MG Tablet

00360287 APO-CHLORTHALIDONE APX

INDAPAMIDE

1.25MG Tablet

02245246 APO-INDAPAMIDE APX

02239913 DOM-INDAPAMIDE DPC

02240067 GEN-INDAPAMIDE GEN

02227339 INDAPAMIDE PRO

02179709 LOZIDE SEV

02240349 PHL-INDAPAMIDE PHH

02239619 PMS-INDAPAMIDE PMS

02312530 PRO-INDAPAMIDE PDL

02247245 RIVA-INDAPAMIDE RIV

2.5MG Tablet

02223678 APO-INDAPAMIDE APX

02239917 DOM-INDAPAMIDE DPC

02153483 GEN-INDAPAMIDE GEN

02049341 INDAPAMIDE PRO

00564966 LOZIDE SEV

02231184 NOVO-INDAPAMIDE NOP

02223597 NU-INDAPAMIDE NXP

02229762 PDL-INDAPAMIDE PDL

02239620 PMS-INDAPAMIDE PMS

02312549 PRO-INDAPAMIDE PDL

02242125 RIVA-INDAPAMIDE RIV

METOLAZONE

2.5MG Tablet

00888400 ZAROXOLYN AVT

40:36.00 IRRIGATING SOLUTIONS

WATER

Injection

00402257 STERILE WATER FOR INJ OMG

02142546 STERILE WATER FOR INJ HOS

40:40.00 URICOSURIC AGENTS

PROBENECID

500MG Tablet

00294926 BENURYL VAE

SULFINPYRAZONE

100MG Tablet

02045680 NU-SULFINPYRAZONE NXP

200MG Tablet

00441767 APO-SULFINPYRAZONE APX

02045699 NU-SULFINPYRAZONE NXP