Drug Benefit List 2012

56:00 GASTROINTESTINAL DRUGS

56:04.00 ANTACIDS AND ADSORBENTS

BISMUTH SUBSALICYLATE

17.6mg/mL Liquid

02097079 PEPTO BISMOL PGI

262mg Tablet

02177994 PEPTO BISMOL PGI

MAG OXIDE

420mg Tablet

00299448 MAGNESIUM OXIDE SWS

56:08.00 ANTIDIARRHEA AGENTS

LOPERAMIDE HCL

ST 0.2mg/mL Liquid

02192667 DIARR-EZE PMS

02016095 PMS-LOPERAMIDE PMS

ST 2mg Tablet

02212005 APO-LOPERAMIDE APX

02229552 DIARR-EZE PMS

02256452 DIARRHEA RELIEF VTH

02239535 DOM-LOPERAMIDE DPC

02183862 IMODIUM MCL

02225182 LOPERAMIDE PDL

02132591 NOVO-LOPERAMIDE TEV

02228351 PMS-LOPERAMIDE PMS

02238211 RIVA-LOPERAMIDE RIV

02257564 SANDOZ-LOPERAMIDE SDZ

56:12.00 CATHARTICS AND LAXATIVES

BISACODYL

ST 5mg Delayed Release Tablet

02273411 BISACODYL-ODAN ODN

ST 5mg Enteric Coated Tablet

00545023 APO-BISACODYL APX

00714488 BISACOLAX ICN

00254142 DULCOLAX BOE

02246039 JAMP-BISACODYL JMP

00587273 PMS-BISACODYL PMS

5mg Suppository

00003867 DULCOLAX BOE

10mg Suppository

00261327 BISACOLAX ICN

00003875 DULCOLAX BOE

00582883 PMS-BISACODYL PMS

00404802 RATIO-BISACODYL RPH

02229743 SOFLAX EX PMS

BISACODYL (POLYETHYLENE GLYCOL BASE)

Limited use benefit (prior approval required).

For treatment of constipation in patients with spinal cord injury.

10mg Suppository

02241091 MAGIC BULLET DCM

CITRIC ACID, MAGNESIUM OXIDE, SODIUM PICOSULFATE

Oral Liquid

02317966 PURG-ODAN ODN

Powder

02254794 PICO-SALAX FEI

DOCUSATE CALCIUM

ST 240mg Capsule

02245080 APO-DOCUSATE CALCIUM APX

00830275 DOCUSATE CALCIUM TAR

02283255 JAMP-DOCUSATE CALCIUM JMP

00842044 NOVO-DOCUSATE CALCIUM TEV

00664553 PMS-DOCUSATE CALCIUM PMS

00809055 RATIO-DOCUSATE CALCIUM RPH

DOCUSATE SODIUM

ST 100mg Capsule

02245079 APO-DOCUSATE SODIUM APX

02106256 COLACE WPC

00794406 DOCUSATE SODIUM SDR

00830267 DOCUSATE SODIUM TRI

02245946 DOCUSATE SODIUM JMP

02246036 DOCUSATE SODIUM RPH

02326086 DOCUSATE SODIUM PDL

02239658 DOM-DOCUSATE SODIUM DPC

02247385 EURO-DOCUSATE EUR

02303825 EURO-DOCUSATE EUR

02020084 NOVO-DOCUSATE TEV

00703494 PMS-DOCUSATE SODIUM PMS

00870196 RATIO-DOCUSATE SODIUM RPH

00514888 SELAX ODN

01994344 SOFLAX PMS

00716731 TARO-DOCUSATE TAR

ST 200mg Capsule

02029529 SOFLAX PMS

ST 250mg Capsule

02006596 SELAX ODN

ST 10mg/mL Drop

02090163 COLACE WPC

00870218 DOCUSATE SODIUM RPH

00880140 PMS-SODIUM DOCUSATE PMS

02006723 SOFLAX PMS

ST 4mg/mL Syrup

02086018 COLACE WPC

00703508 PMS-DOCUSATE SODIUM PMS

00870226 RATIO-DOCUSATE SODIUM RPH

02006758 SOFLAX SYRUP PMS

ST 20mg/mL Syrup

02283239 DOCUSATE SODIUM JMP

ST 50mg/mL Syrup

02283220 DOCUSATE SODIUM JMP

00848417 PMS-DOCUSATE SODIUM PMS

DOCUSATE SODIUM, SENNA

ST 50mg & 187mg Tablet

00026123 SENOKOT S PFR

ST 50mg & 8.6mg Tablet

02247390 EURO-SENNA S EUR

GLYCERINE

Adult Suppository

00873462 GLYCERIN RPH *

01926039 GLYCERIN WLA

Pediatric Suppository

02020815 GLYCERIN INFANT RPH

01926047 GLYCERIN INFANT & CHILD PFI

LACTULOSE

ST 667mg/mL Oral Liquid

02242814 APO-LACTULOSE APX

02247383 EURO-LAC EUR

02295881 LACTULOSE JMP

00703486 PMS-LACTULOSE PMS

00854409 RATIO-LACTULOSE RPH

MACROGOL, POTASSIUM CHLORIDE, SODIUM BICARBONATE, SODIUM CHLORIDE, SODIUM SULFATE

60g & 750mg & 1.68g & 1.46g & 5.68g/L Powder

00677442 COLYTE ZYM

00652512 GOLYTELY BAX

00777838 PEGLYTE PMS

MAGNESIUM HYDROXIDE

80mg/mL Liquid

02150646 MILK OF MAGNESIA BCD

PLAIN/SUGARFREE

311mg Tablet

02150638 MILK OF MAGNESIA BCD

MINERAL OIL

78% Jelly

00608734 LANSOYL GEL AXC

02186926 LANSOYL GEL SUGARFREE AXC

Liquid

01935348 MINERAL OIL (HEAVY) RWP

PLANTAGO SEED

50% Powder

00599875 MUCILLIUM PMS

POLYETHYLENE GLYCOL

Powder

09991007 POLYETHYLENE GLYCOL

POLYETHYLENE GLYCOL 3350

Powder

09991054 POLYETHYLENE GLYCOL

1g/g Powder

02317680 LAX-A-DAY PED

02358034 PEG 3350 MDS

POLYETHYLENE GLYCOL, POTASSIUM CHLORIDE, SODIUM BICARBONATE, SODIUM CHLORIDE, SODIUM SULFATE

Oral Liquid

02147793 KLEAN-PREP RVX

PSYLLIUM HYDROPHILIC MUCILLOID

680mg/g Powder

02174812 METAMUCIL ORIGINAL TEXTURE PGI

02174790 METAMUCIL SM TEXT ORANGE PGI

02174782 METAMUCIL SM TEXT ORANGE S/F PGI

02174804 METAMUCIL SM TEXT PGI

SENNOSIDES

ST 1.7mg/mL Liquid

02144379 SENNALAX PMS

02084651 SENNAPREP PMS

00367729 SENOKOT PFR

ST 8.6mg Tablet

02247389 EURO-SENNA EUR

80009182 JAMP-SENNOSIDES JMP

00896411 PMS-SENNOSIDES PMS

01949292 RIVA-SENNA RIV

02237105 SENNA LAXATIVE SDR

02068109 SENNATAB PMS

00026158 SENOKOT PFR

ST 12MG Tablet

80009183 JAMP-SENNOSIDES JMP

00896403 PMS-SENNOSIDES PMS

SODIUM CITRATE, SODIUM LAURYL SULFOACETATE, SORBITOL

90mg & 9mg & 625mg Enema

02063905 MICROLAX PMS

SODIUM PHOSPHATE

Oral Liquid

80000689 PHOSLAX ODN

SODIUM PHOSPHATE DIBASIC, SODIUM PHOSPHATE MONOBASIC

180mg & 480mg/mL Oral Liquid

02230399 PMS-PHOSPHATES PMS

60mg & 160mg/mL Rectal Liquid

02096900 ENEMOL DPC

00009911 FLEET ENEMA FRS

60mg & 160mg/mL PED Rectal Liquid

00108065 FLEET ENEMA PEDIATRIC JAJ

56:14.00 CHOLELITHOLYTIC AGENTS

URSODIOL

ST 250mg Tablet

02281317 PHL-URSODIOL C PHH

02273497 PMS-URSODIOL PMS

02238984 URSO AXC

ST 500mg Tablet

02281325 PHL-URSODIOL C PHH

02273500 PMS-URSODIOL PMS

02245894 URSO DS AXC

56:16.00 DIGESTANTS

LACTASE

Oral Liquid

99100157 LACTEEZE DROPS GSC

3,000U Tablet

02200384 DAIRY DIGESTIVE PER

02239139 DAIRY DIGESTIVE SDR

01951637 DAIRYAID TAN

02230653 LACTAID JNO

02017512 LACTOMAX STE

4,500U Tablet

02239140 DAIRY DIGESTIVE EXTRA STRENGTH SDR

02230654 LACTAID EXTRA STRENGTH JNO

02224909 LACTOMAX EXTRA STE

LIPASE, AMYLASE, PROTEASE

ST 5,000U & 16,600U & 18,750U Capsule

02239007 CREON 5 MINIMICROSPHERES SPH

ST 8,000U & 30,000U & 30,000U Capsule

00263818 COTAZYM ORG

ST 20,000U & 66,400U & 75,000U Capsule

02239008 CREON 20 MINIMICROSPHERES SPH

ST 4,000U & 11,000U & 11,000U Capsule (Enteric Coated Particles)

02181215 COTAZYM ECS4 ORG

ST 4,000U & 12,000U & 12,000U Capsule (Enteric Coated Particles)

00789445 PANCREASE MT 4 JNO

ST 4,500U & 20,000U & 25,000U Capsule (Enteric Coated Particles)

02203324 ULTRASE MS 4 AXC

ST 8,000U & 30,000U & 30,000U Capsule (Enteric Coated Particles)

00502790 COTAZYM ECS 8 ORG

ST 10,000U & 30,000U & 30,000U Capsule (Enteric Coated Particles)

00789437 PANCREASE MT 10 JNO

ST 10,000U & 33,200U & 37,500U Capsule (Enteric Coated Particles)

02200104 CREON 10 MINIMICROSPHERES SPH

ST 12,000U & 39,000U & 39,000U Capsule (Enteric Coated Particles)

02045834 ULTRASE MT 12 AXC

ST 16,000U & 48,000U & 48,000U Capsule (Enteric Coated Particles)

00789429 PANCREASE MT 16 JNO

ST 20,000U & 55,000U & 55,000U Capsule (Enteric Coated Particles)

00821373 COTAZYM ECS 20 ORG

ST 20,000U & 65,000 & 65,000U Capsule (Enteric Coated Particles)

02045869 ULTRASE MT 20 AXC

ST 25,000U & 74,000U & 62,500U Capsule (Enteric Coated Particles)

01985205 CREON 25 MINIMICROSPHERES SPH

ST 8,000U & 30,000U & 30,000U Tablet

02230019 VIOKASE AXC

ST 16,000U & 60,000U & 60,000U Tablet

02241933 VIOKASE AXC

56:20.00 EMETICS

IPECAC

14mg/mL Syrup

00378801 IPECAC XEN

56:22.08 ANTIHISTAMINES

DIMENHYDRINATE

50mg/mL Injection

00392537 DIMENHYDRINATE SDZ

00013579 GRAVOL HOR

ST 3mg/mL Liquid

00230197 GRAVOL HOR

25mg Suppository

00783595 GRAVOL HOR

50mg Suppository

00392553 DIMENHYDRINATE SDZ

ST 15mg Tablet

00511196 GRAVOL HOR

ST 50mg Tablet

00363766 APO-DIMENHYDRINATE APX

00013803 GRAVOL HOR

00399779 NAUSEATOL SDZ

00586331 PMS-DIMENHYDRINATE PMS

00021423 TEVA-DIMENATE TEV

00605786 TRAVEL AID VTH

02245416 TRAVEL TABLET JMP

DOXYLAMINE SUCCINATE, PYRIDOXINE

10mg & 10mg Tablet

00609129 DICLECTIN DUI

56:22.20 5-HT3 RECEPTOR

DOLASETRON MESYLATE

100mg Tablet

02231379 ANZEMET SAC

GRANISETRON

1mg Tablet

02308894 GRANISETRON AAP

02185881 KYTRIL HLR

ONDANSETRON HCL DIHYDRATE

0.8mg/mL Liquid

02291967 ONDANSETRON AAP

02229639 ZOFRAN GSK

4mg Orally Disintegrating Tablet

02239372 ZOFRAN ODT GSK

8mg Orally Disintegrating Tablet

02239373 ZOFRAN ODT GSK

4mg Tablet

02288184 APO-ONDANSETRON APX

02296349 CO-ONDANSETRON COB

02313685 JAMP ONDANSETRON JMP

02371731 MAR-ONDANSETRON MAR

02305259 MINT-ONDANSETRON MIN

02297868 MYLAN-ONDANSETRON MYL

02264056 NOVO-ONDANSETRON TEV

02306212 ONDANSETRON-ODAN ODN

02278618 PHL-ONDANSETRON PHH

02258188 PMS-ONDANSETRON PMS

02312247 RAN-ONDANSETRON RBY

02278529 RATIO-ONDANSETRON RPH

02274310 SANDOZ-ONDANSETRON SDZ

02213567 ZOFRAN GSK

02344440 ZYM-ONDANSETRON ZYM

8mg Tablet

02288192 APO-ONDANSETRON APX

02296357 CO-ONDANSETRON COB

02313693 JAMP ONDANSETRON JMP

02305267 MINT-ONDANSETRON MIN

02297876 MYLAN-ONDANSETRON MYL

02264064 NOVO-ONDANSETRON TEV

02325160 ONDANSETRON PDL

02306220 ONDANSETRON-ODAN ODN

02278626 PHL-ONDANSETRON PHH

02258196 PMS-ONDANSETRON PMS

02312255 RAN-ONDANSETRON RBY

02278537 RATIO-ONDANSETRON RPH

02274329 SANDOZ-ONDANSETRON SDZ

02213575 ZOFRAN GSK

02344459 ZYM-ONDANSETRON ZYM

56:22.92 MISCELLANEOUS ANTIEMETICS

APREPITANT

Limited use benefit (prior approval required).

When used in combination with a 5-HT3 antagonist and dexamethasone for the prevention of acute and delayed nausea and vomiting due to highly emetogenic cancer chemotherapy (eg. Cisplatin > 70mg/m2) in patients who have experienced emesis despite treatment with a combination of a 5-HT3 antagonist and dexamethasone in a previous cycle of highly emetogenic chemotherapy.

80mg Capsule

02298791 EMEND FRS

125mg Capsule

02298805 EMEND FRS

125mg & 80mg Capsule

02298813 EMEND TRI PACK FRS

DOMPERIDONE MALEATE

10mg Tablet

02103613 APO-DOMPERIDONE APX

02238315 DOM-DOMPERIDONE DPC

02236857 DOMPERIDONE PDL

02350440 DOMPERIDONE SAN

02278669 MYLAN-DOMPERIDONE MYL

02157195 NOVO-DOMPERIDONE TEV

02231477 NU-DOMPERIDONE NXP

02236466 PMS-DOMPERIDONE PMS

02268078 RAN-DOMPERIDONE RBY

01912070 RATIO-DOMPERIDONE RPH

NABILONE

0.25mg Capsule

02312263 CESAMET VAE

0.5mg Capsule

02256193 CESAMET VAE

1mg Capsule

00548375 CESAMET VAE

56:28.12 HISTAMINE H2-ANTAGONISTS

CIMETIDINE

ST 200mg Tablet

00584215 APO-CIMETIDINE APX

00865796 NU-CIMET NXP

02229717 PMS-CIMETIDINE PMS

00582409 TEVA-CIMETINE TEV

ST 300mg Tablet

00487872 APO-CIMETIDINE APX

02231287 DOM-CIMETIDINE DPC

02227444 MYLAN-CIMETIDINE MYL

00865818 NU-CIMET NXP

02229718 PMS-CIMETIDINE PMS

00582417 TEVA-CIMETINE TEV

ST 400mg Tablet

00600059 APO-CIMETIDINE APX

02231288 DOM-CIMETIDINE DPC

02227452 MYLAN-CIMETIDINE MYL

00865826 NU-CIMET NXP

02229719 PMS-CIMETIDINE PMS

00603678 TEVA-CIMETINE TEV

ST 600mg Tablet

00600067 APO-CIMETIDINE APX

00618705 CIMETIDINE PDL

02231290 DOM-CIMETIDINE DPC

02227460 MYLAN-CIMETIDINE MYL

00865834 NU-CIMET NXP

02229720 PMS-CIMETIDINE PMS

00603686 TEVA-CIMETINE TEV

ST 800mg Tablet

00749494 APO-CIMETIDINE APX

02227479 MYLAN-CIMETIDINE MYL

02229721 PMS-CIMETIDINE PMS

00663727 TEVA-CIMETINE TEV

FAMOTIDINE

ST 20mg Tablet

01953842 APO-FAMOTIDINE APX

02351102 FAMOTIDINE SAN

02196018 MYLAN-FAMOTIDINE MYL

02022133 NOVO-FAMOTIDINE TEV

02024195 NU-FAMOTIDINE NXP

00710121 PEPCID FRS

02237148 ULCIDINE VAE

ST 40mg Tablet

01953834 APO-FAMOTIDINE APX

02351110 FAMOTIDINE SAN

02196026 MYLAN-FAMOTIDINE MYL

02022141 NOVO-FAMOTIDINE TEV

02024209 NU-FAMOTIDINE NXP

00710113 PEPCID FRS

02237149 ULCIDINE VAE

NIZATIDINE

ST 150mg Capsule

02220156 APO-NIZATIDINE APX

00778338 AXID PHH

02185814 DOM-NIZATIDINE DPC

02240457 NOVO-NIZATIDINE TEV

02177714 PMS-NIZATIDINE PMS

ST 300mg Capsule

02220164 APO-NIZATIDINE APX

00778346 AXID PHH

02238195 NIZATIDINE PHH

02240458 NOVO-NIZATIDINE TEV

02177722 PMS-NIZATIDINE PMS

RANITIDINE HCL

ST 15mg/mL Oral Solution

02280833 APO-RANITIDINE APX

02242940 NOVO-RANITIDINE TEV

ST 150mg Tablet

00733059 APO-RANITIDINE APX

02248570 CO RANITIDINE COB

02293471 MAXIMUM STRENGTH ACID REDUCER PMS

02207761 MYLAN-RANITIDINE MYL

02367378 MYL-RANITIDINE MYL

00828564 NOVO-RANIDINE TEV

00865737 NU-RANIT NXP

02245782 PHL-RANITIDINE PHH

02242453 PMS-RANITIDINE PMS

00740748 RANITIDINE PDL

02353016 RANITIDINE SAN

02336480 RAN-RANITIDINE RBY

00828823 RATIO-RANITIDINE RPH

02247814 RIVA-RANTIDINE RIV

02243229 SANDOZ-RANITIDINE SDZ

02212331 ZANTAC GSK

ST 300mg Tablet

00733067 APO-RANITIDINE APX

02248571 CO RANITIDINE COB

02207788 MYLAN-RANITIDINE MYL

02367386 MYL-RANITIDINE MYL

00865745 NU-RANIT NXP

02245783 PHL-RANITIDINE PHH

02242454 PMS-RANITIDINE PMS

00740756 RANITIDINE PDL

02353024 RANITIDINE SAN

02336502 RAN-RANITIDINE RBY

00828688 RATIO-RANITIDINE RPH

02247815 RIVA-RANITIDINE RIV

02243230 SANDOZ-RANITIDINE SDZ

02212358 ZANTAC GSK

56:28.28 PROSTAGLANDINS

MISOPROSTOL

ST 100mcg Tablet

02244022 MISOPROSTOL AAP

ST 200mcg Tablet

02244023 MISOPROSTOL AAP

02244125 PMS-MISOPROSTOL PMS

56:28.32 PROTECTANTS

SUCRALFATE

ST 200mg/mL Suspension

02103567 SULCRATE PLUS AXC

ST 1g Tablet

02125250 APO-SUCRALFATE APX

02045702 NOVO-SUCRALATE TEV

02134829 NU-SUCRALFATE NXP

02130939 SUCRALFATE-1 PDL

02100622 SULCRATE AXC

56:28.36 PROTON-PUMP INHIBITORS

AMOXICILLIN, CLARITHROMYCIN, LANSOPRAZOLE

500mg & 500mg & 30mg Kit

02238525 HP-PAC TAK

LANSOPRAZOLE

(Please refer to Appendix A).

Limited use benefit (prior approval not required).

Coverage will be limited to 400 tablets/capsules every 180 days.

ST 15mg Sustained Release Capsule

02293811 APO-LANSOPRAZOLE APX

02357682 LANSOPRAZOLE SAN

02353830 MYLAN-LANSOPRAZOLE MYL

02280515 NOVO-LANSOPRAZOLE TEV

02165503 PREVACID TAK

ST 30mg Sustained Release Capsule

02293838 APO-LANSOPRAZOLE APX

02357690 LANSOPRAZOLE SAN

02366282 LANSOPRAZOLE PDL

02353849 MYLAN-LANSOPRAZOLE MYL

02280523 NOVO-LANSOPRAZOLE TEV

02165511 PREVACID TAK

LANSOPRAZOLE ODT

(Please refer to Appendix A).

Limited use benefit (prior approval required).

Coverage will be limited to 400 tablets/capsules every 180 days.

• For children 12 years of age or under who are unable to swallow the capsule formulation
• For patients with dysphagia or a feeding tube when the use of the capsule formulation is not possible.

ST 15mg Orally Disintegrating Tablet

02249464 PREVACID FASTAB TAK

ST 30mg Orally Disintegrating Tablet

02249472 PREVACID FASTAB TAK

OMEPRAZOLE MAGNESIUM (PA)

(Please refer to Appendix A).

Limited use benefit (prior approval required).

Coverage will be limited to 400 tablets/capsules every 180 days.

Coverage will be provided for the following medical conditions if the patient has tried at least 30 days each of two of the following open benefit PPIs: Omeprazole (Losec^®), Rabeprazole (Pariet^®), Pantoprazole sodium (Pantoloc^®), Lansoprazole (Prevacid^®):

• For treatment of confirmed gastric and duodenal ulcers. OR
• For mild to moderate gastroesophageal reflux disease (GERD) in patients who have failed on or not tolerated a 4- week trial of histamine-2 receptor antagonists. OR
• For severe gastroesophageal reflux disease (GERD) and complications as first-line therapy for a maximum period of 3 months. Patients should be reassessed endoscopically or with step-down therapy using a histamine-2 receptor antagonist. OR
• For treatment of nonsteroidal anti-inflammatory drug (NSAID)-induced ulcers where the NSAID must be continued. OR
• For prevention of NSAID-induced ulcers in patients who have history of ulcer complications, are over the age of 65 years, have comorbid disease such as cardiovascular disease or coagulopathies or are on concomitant medications which increase risk of ulcers or bleeding. OR
• Zollinger-Ellison Syndrome*. OR
• Barrett's Esophagus*. OR
• Esophagitis associated with connective tissue disease.

(*) Diagnosis must be confirmed by a specialist qualified to

ST 10mg Delayed Release Tablet

02230737 LOSEC AZC

02260859 RATIO-OMEPRAZOLE RPH

OMEPRAZOLE, OMEPRAZOLE MAGNESIUM (NO PA)

(Please refer to Appendix A).

Limited use benefit (prior approval not required).

Coverage will be limited to 400 tablets/capsules every 180 days.

ST 10mg Capsule

02119579 LOSEC AZC

02329425 MYLAN-OMEPRAZOLE MYL

02296438 SANDOZ OMEPRAZOLE SDZ

ST 20mg Capsule

02245058 APO-OMEPRAZOLE APX

00846503 LOSEC AZC

02329433 MYLAN-OMEPRAZOLE MYL

02339927 OMEPRAZOLE PDL

02348691 OMEPRAZOLE SAN

02320851 PMS-OMEPRAZOLE PMS

02296446 SANDOZ OMEPRAZOLE SDZ

ST 20mg Delayed Release Tablet

02190915 LOSEC AZC

02310260 PMS-OMEPRAZOLE PMS

02260867 RATIO-OMEPRAZOLE RPH

PANTOPRAZOLE MAGNESIUM

(Please refer to Appendix A).

Limited use benefit (prior approval not required).

Coverage will be limited to 400 tablets/capsules every 180 days.

ST 40mg Enteric Coated Tablet

02267233 TECTA NYC

PANTOPRAZOLE SODIUM

(Please refer to Appendix A).

Limited use benefit (prior approval not required).

Coverage will be limited to 400 tablets/capsules every 180 days.

ST 40mg Delayed Release Tablet

02292920 APO-PANTOPRAZOLE APX

02300486 CO PANTOPRAZOLE COB

02299585 MYLAN-PANTOPRAZOLE MYL

02285487 NOVO-PANTOPRAZOLE TEV

02229453 PANTOLOC NYC

02309866 PANTOPRAZOLE MEL

02310201 PANTOPRAZOLE SOR

02318695 PANTOPRAZOLE PDL

02307871 PMS-PANTOPRAZOLE PMS

02305046 RAN-PANTOPRAZOLE RBY

02316463 RIVA-PANTOPRAZOLE RIV

02301083 SANDOZ-PANTOPRAZOLE SDZ

RABEPRAZOLE SODIUM

(Please refer to Appendix A).

Limited use benefit (prior approval not required).

Coverage will be limited to 400 tablets/capsules every 180 days.

ST 10mg Enteric Coated Tablet

02296632 NOVO-RABEPRAZOLE TEV

02243796 PARIET EC JNO

02310805 PMS-RABEPRAZOLE PMS

02315181 PRO-RABEPRAZOLE PDL

02356511 RABEPRAZOLE EC SAN

02298074 RAN-RABEPRAZOLE RBY

02330083 RIVA-RABEPRAZOLE EC RIV

02314177 SANDOZ-RABEPRAZOLE SDZ

ST 20mg Enteric Coated Tablet

02296640 NOVO-RABEPRAZOLE TEV

02243797 PARIET EC JNO

02310813 PMS-RABEPRAZOLE PMS

02315203 PRO-RABEPRAZOLE PDL

02356538 RABEPRAZOLE EC SAN

02298082 RAN-RABEPRAZOLE RBY

02330091 RIVA-RABEPRAZOLE RIV

02314185 SANDOZ-RABEPRAZOLE SDZ

56:32.00 PROKINETIC AGENTS

METOCLOPRAMIDE HCL

1mg/mL Oral Liquid

02230433 PMS-METOCLOPRAMIDE PMS

5mg Tablet

00842826 APO-METOCLOP APX

02143275 NU-METOCLOPRAMIDE NXP

02230431 PMS-METOCLOPRAMIDE PMS

10mg Tablet

00842834 APO-METOCLOP APX

02143283 NU-METOCLOPRAMIDE NXP

02230432 PMS-METOCLOPRAMIDE PMS

56:36.00 ANTI-INFLAMMATORY AGENTS

5-AMINOSALICYLIC ACID

ST 500mg Delayed Release Tablet

02099683 PENTASA FEI

2g/60g Enema

02112795 SALOFALK AXC

4g/60g Enema

02112809 SALOFALK AXC

ST 400mg Enteric Coated Tablet

01997580 ASACOL PGP

ST 500mg Enteric Coated Tablet

02112787 SALOFALK AXC

ST 800mg Enteric Coated Tablet

02267217 ASACOL WCI

500mg Suppository

02112760 SALOFALK AXC

MESALAZINE

1g/100mL Enema

02153521 PENTASA FEI

4g/100mL Enema

02153556 PENTASA FEI

ST 400mg Enteric Coated Tablet

02351463 5-ASA SAN

02171929 NOVO 5-ASA TEV

ST 500mg Enteric Coated Tablet

01914030 MESASAL GSK

1g Suppository

02153564 PENTASA FEI

1000mg Suppository

02242146 SALOFALK AXC

OLSALAZINE SODIUM

ST 250mg Capsule

02063808 DIPENTUM LUD