Drug Benefit List 2010

48:00 RESPIRATORY TRACT AGENTS

48:08.00 ANTITUSSIVES

BROMPHENIRAMINE MALEATE, DEXTROMETHORPHAN HBR, PHENYLEPHRINE HCL

Oral Liquid

2243969 DIMETAPP DM COUGH & COLD WRI

CHLORPHENIRAMINE MALEATE, DEXTROMETHORPHAN HBR, PSEUDOEPHEDRINE HCL

0.2mg & 1.5mg & 3mg/mL Syrup

896179 TRIAMINIC DM NIGHT TIME NVC

DEXTROMETHORPHAN HBR

15mg/mL Oral Liquid

2241495 DM COUGH SYRUP THC

1.5mg/mL Sugar Free Liquid

2215268 BENYLIN DM CHILD WLA

3mg/mL Sugar Free Liquid

1928775 BALMINIL DM * RPH

1944738 BENYLIN DM WLA

511013 DM SANS SUCRE TRI

1928791 KOFFEX DM RPH

6mg/mL Sustained Release Sugar Free Liquid

2231404 BENYLIN DM NIGHTTIME WLA

6mg/mL Sustained Release Suspension

2018403 DELSYM NVC

2231313 TRIAMINIC DM NVC

1.5mg/mL Syrup

1953966 ROBITUSSIN PEDIATRIC WRI

2.5mg/mL Syrup

729655 BUCKLEYS DM BUY

3mg/mL Syrup

522791 BRONCHOPHAN FORTE DM ATL

800813 COUGH SYRUP RPH

833231 COUGH SYRUP DEXTROMETHORPHAN TAN

1928783 KOFFEX DM RPH

DEXTROMETHORPHAN HBR, PSEUDOEPHEDRINE HCL

7.5mg & 15mg Oral Liquid

2243062 TRIAMINIC COUGH & CONGESTION NVC

1.5mg & 3mg/mL Sugar Free Liquid

1944746 BENYLIN DM-D CHILD WLA

3mg & 6mg/mL Sugar Free Liquid

1944711 BENYLIN DM-D WLA

48:10.24 LEUKOTRIENE MODIFIERS

MONTELUKAST

Limited use benefit (prior approval required).

For treatment of:

1. asthma when used in patients on concurrent steroid therapy.
2. asthma patients not well controlled with or intolerant to inhaled corticosteroids.

4mg Chewable Tablet

2243602 SINGULAIR FRS

5mg Chewable Tablet

2238216 SINGULAIR FRS

4mg Granules

2247997 SINGULAIR FRS

10mg Tablet

2238217 SINGULAIR FRS

ZAFIRLUKAST

Limited use benefit (prior approval required).

For treatment of:

1. asthma when used in patients on concurrent steroid therapy.
2. asthma patients not well controlled with or intolerant to inhaled corticosteroids.

20mg Tablet

2236606 ACCOLATE AZC

48:10.32 MAST CELL STABILIZERS

SODIUM CROMOGLYCATE

100mg Capsule

500895 NALCROM AVT

10mg/mL Inhalation Solution (Unit Dose)

2231671 NU-CROMOLYN NXP

2046113 PMS-SOD CROMOGLYCATE PMS

2% Nasal Solution

1950541 CROMOLYN PMS

2% Ophth Solution

2009277 CROMOLYN PMS

2230621 OPTICROM ALL