Drug Benefit List 2012

48:00 RESPIRATORY TRACT AGENTS

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

02354977 PMS-MONTELUKAST PMS

02330385 SANDOZ MONTELUKAST SDZ

02243602 SINGULAIR FRS

02355507 TEVA-MONTELUKAST TEV

5mg Chewable Tablet

02354985 PMS-MONTELUKAST PMS

02330393 SANDOZ MONTELUKAST SDZ

02238216 SINGULAIR FRS

02355515 TEVA-MONTELUKAST TEV

4mg Granules

02358611 SANDOZ MONTELUKAST SDZ

02247997 SINGULAIR FRS

10mg Tablet

02374609 APO-MONTELUKAST APX

02368226 MYLAN-MONTELUKAST MYL

02373947 PMS-MONTELUKAST PMS

02328593 SANDOZ MONTELUKAST SDZ

02238217 SINGULAIR FRS

02355523 TEVA-MONTELUKAST TEV

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

02236606 ACCOLATE AZC

48:10.32 MAST CELL STABILIZERS

SODIUM CROMOGLYCATE

100mg Capsule

00500895 NALCROM SAC

10mg/mL Inhalation Solution (Unit Dose)

02231671 NU-CROMOLYN NXP

02046113 PMS-SOD CROMOGLYCATE PMS

2% Nasal Solution

02231390 APO-CROMOLYN APX

01950541 RHINARIS-CS PMS

2% Ophth Solution

02009277 CROMOLYN PMS

02230621 OPTICROM ALL