Drug Benefit List - April 2009

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

56:08.00 ANTIDIARRHEA AGENTS

LOPERAMIDE HCL

0.2MG/ML Liquid

02192667 DIARR-EZE PMS

02016095 PMS-LOPERAMIDE PMS

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 NOP

02228351 PMS-LOPERAMIDE PMS

02233998 RHOXAL-LOPERAMIDE RHO

02238211 RIVA-LOPERAMIDE RIV

02257564 SANDOZ-LOPERAMIDE SDZ

56:12.00 CATHARTICS AND LAXATIVES

BISACODYL

5MG Enteric Coated Tablet

00545023 APO-BISACODYL APX

00420433 BISACODYL PRO

00714488 BISACOLAX ICN

00254142 DULCOLAX BOE

02246039 JAMP-BISACODYL JMP

00587273 PMS-BISACODYL PMS

5MG Suppository

00003867 DULCOLAX BOE

10MG Suppository

00754595 APO-BISACODYL APX

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

Powder

02254794 PICO-SALAX FEI

DIOCTYL CALCIUM SULFOSUCCINATE

240MG Capsule

02245080 APO-DOCUSATE CALCIUM APX

00830275 DOCUSATE CALCIUM TAR

00842044 NOVO-DOCUSATE CALCIUM NOP

00664553 PMS-DOCUSATE CALCIUM PMS

00809055 RATIO-DOCUSATE CALCIUM RPH

DIOCTYL SODIUM SULFOSUCCINATE

100MG Capsule

02245079 APO-DOCUSATE SODIUM APX

02106256 COLACE WPC

00716731 DOCUSATE SODIUM TAR

02283255 JAMP-DOCUSATE CALCIUM JMP

02246036 DOCUSATE SODIUM RPH

00794406 DOCUSATE SODIUM SDR

00830267 DOCUSATE SODIUM TRI

02239658 DOM-DOCUSATE SODIUM DPC

02247385 EURO-DOCUSATE EUO

02020084 NOVO-DOCUSATE NOP

00703494 PMS-DOCUSATE SODIUM PMS

00870196 RATIO-DOCUSATE SODIUM RPH

00514888 SELAX ODN

01994344 SOFLAX PMS

200MG Capsule

02029529 SOFLAX PMS

250MG Capsule

02006596 SELAX ODN

10MG/ML Drop

02090163 COLACE WPC

00870218 DOCUSATE SODIUM RPH

00880140 PMS-SODIUM DOCUSATE PMS

02006723 SOFLAX PMS

4MG/ML Syrup

02086018 COLACE WPC

00703508 PMS-DOCUSATE SODIUM PMS

00870226 RATIO-DOCUSATE SODIUM RPH

02006758 SOFLAX SYRUP PMS

20MG/ML Syrup

02283239 DOCUSATE SODIUM JMP

50MG/ML Syrup

02283220 DOCUSATE SODIUM JMP

00848417 PMS-DOCUSATE SODIUM PMS

DIOCTYL SODIUM SULFOSUCCINATE, SENNA

100MG Capsule

02245946 DOCUSATE SODIUM JMP

50MG & 187MG Tablet

00026123 SENOKOT S PFR

DIOCTYL SODIUM SULFOSUCCINATE, SENNOSIDES

50MG & 8.6MG Tablet

02247390 EURO-SENNA S EUR

FIBER

469MG Tablet

00595829 NOVO-FIBRE NOP

GLYCERINE

Adult Suppository

00873462 GLYCERIN RPH *

01926039 GLYCERIN WLA

00884022 GLYCERINE RPH *

00812250 GLYCERINE WLA *

Pediatric Suppository

02020815 GLYCERIN INFANT RPH

01926047 GLYCERIN INFANT & CHILD PFI

LACTULOSE

667MG/ML Oral Liquid

02242814 APO-LACTULOSE APX

02247383 EURO-LAC EUR

02143542 GEN-LAC GEN

02280078 GPI-LACTULOSE OBP

02295881 LACTULOSE JMP

00703486 PMS-LACTULOSE PMS

02311275 PRO-LACTULOSE PRO

00690686 RATIO-LACTULOSE RPH

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 PLAIN/SUGARFREE BCD

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) 100% USP RWP

PLANTAGO SEED

50% Powder

00599875 MUCILLIUM PMS

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 UNFLAV PGI

SENNOSIDES

1.7MG/ML Liquid

02144379 SENNALAX PMS

02084651 SENNAPREP PMS

00367729 SENOKOT PFR

00367737 X-PREP PFR

8.6MG Tablet

02247389 EURO-SENNA EUR

00896411 PMS-SENNOSIDES PMS

01949292 RIVA-SENNA RIV

02089653 SANDOZ-SENNOSIDES SDZ

02237105 SENNA LAXATIVE SDR

02068109 SENNATAB PMS

00026158 SENOKOT PFR

12MG Tablet

00896403 PMS-SENNOSIDES PMS

02089645 SANDOZ-SENNOSIDES SDZ

SODIUM CITRATE, SODIUM LAURYL SULFOACETATE, SORBITOL

90MG & 9MG & 625MG Enema

02063905 MICROLAX PMS

SODIUM PHOSPHATE DIBASIC, SODIUM PHOSPHATE MONOBASIC

180MG & 480MG/ML Oral Liquid

02206218 PHOSPHO SODA FLEET LAXATIVE JAJ

02230399 PMS-PHOSPHATES SOLUTION PMS

60MG & 160MG/ML PED Rectal Liquid

00108065 FLEET ENEMA PEDIATRIC JAJ

60MG & 160MG/ML Rectal Liquid

02096900 ENEMOL DPC

00009911 FLEET ENEMA FRS

56:14.00 CHOLELITHOLYTIC AGENTS

URSODIOL

250MG Tablet

02281317 PHL-URSODIOL C PMI

02273497 PMS-URSODIOL PMS

02238984 URSO AXC

500MG Tablet

02281325 PHL-URSODIOL C PMI

02273500 PMS-URSODIOL PMS

02245894 URSO DS AXC

56:16.00 DIGESTANTS

LACTASE

3,550U Capsule

02016478 LACTRASE RIV

Oral Liquid

00903981 LACTAID MCL

50000U Oral Liquid

99003325 DAIRY-FREE KIN

3,000U Tablet

02200384 DAIRY DIGESTIVE PER

02239139 DAIRY DIGESTIVE SDR

02017512 DAIRY FREE KIN

01951637 DAIRYAID TAN

02230653 LACTAID JNO

4,500U Tablet

02239140 DAIRY DIGESTIVE EXTRA STRENGTH SDR

02224909 DAIRY FREE EXTRA STRENGTH KIN

02230113 DAIRYAID EXTRA STRENGTH TAN

02230654 LACTAID EXTRA STRENGTH JNO

LIPASE, AMYLASE, PROTEASE

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

02239007 CREON 5 MINIMICROSPHERES SPH

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

00263818 COTAZYM ORG

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

02239008 CREON 20 MINIMICROSPHERES SPH

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

02181215 COTAZYM ECS4 ORG

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

00789445 PANCREASE MT 4 JNO

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

02203324 ULTRASE MS 4 AXC

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

00502790 COTAZYM ECS 8 ORG

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

00789437 PANCREASE MT 10 JNO

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

02200104 CREON 10 MINIMICROSPHERES SPH

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

02045834 ULTRASE MT 12 AXC

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

00789429 PANCREASE MT 16 JNO

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

00821373 COTAZYM ECS 20 ORG

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

02045869 ULTRASE MT 20 AXC

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

01985205 CREON 25 MINIMICROSPHERES SPH

24,000U & 100,000U & 100,000U/G Powder

02230020 VIOKASE AXC

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

02230019 VIOKASE AXC

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

02241933 VIOKASE AXC

56:20.00 EMETICS

IPECAC

7% Syrup

00721328 PMS-IPECAC PMS

14MG/ML Syrup

00378801 IPECAC XEN

56:22.08 ANTIHISTAMINES

DIMENHYDRINATE

50MG/ML Injection

00392537 DIMENHYDRINATE SDZ

00013579 GRAVOL HOR

3MG/ML Liquid

00230197 GRAVOL HOR

00757705 PMS-DIMENHYDRINATE PMS

25MG Suppository

00783595 GRAVOL HOR

50MG Suppository

00392553 DIMENHYDRINATE SIL

00013595 GRAVOL HOR

15MG Tablet

00511196 GRAVOL HOR

50MG Tablet

00363766 APO-DIMENHYDRINATE APX

00156655 DIMENHYDRINATE PRO

00013803 GRAVOL HOR

00399779 NAUSEATOL SIL

00021423 NOVODIMENATE NOP

00586331 PMS-DIMENHYDRINATE PMS

00272671 TRAVAMINE ICN

00605786 TRAVEL AID VTH

02245416 TRAVEL TABLET JMP

DOXYLAMINE SUCCINATE, PYRIDOXINE HCL

10MG & 10MG Tablet

00609129 DICLECTIN DUI

MECLIZINE HCL

25MG Chewable Tablet

00220442 BONAMINE JNO

56:22.20 5-HT3 RECEPTOR ANTAGONISTS

DOLASETRON MESYLATE

20MG/ML Injection

02231380 ANZEMET SAC

50MG Tablet

02231378 ANZEMET SAC

100MG Tablet

02231379 ANZEMET SAC

GRANISETRON

1MG Tablet

02308894 APO-GRANISETRON APX

02185881 KYTRIL HLR

ONDANSETRON HCL DIHYDRATE

0.8MG/ML Liquid

02291967 APO-ONDANSETRON APX

02229639 ZOFRAN GSK

4MG Tablet

02288184 APO-ONDANSETRON APX

02297868 GEN-ONDANSETRON GEN

02313685 JAMP ONDANSETRON JMP

02305259 MINT-ONDANSETRON MIN

02264056 NOVO-ONDANSETRON NOP

02278618 PHL-ONDANSETRON PMI

02258188 PMS-ONDANSETRON PMS

02312247 RAN-ONDANSETRON RBY

02278529 RATIO-ONDANSETRON RPH

02274310 SANDOZ-ONDANSETRON SDZ

02213567 ZOFRAN GSK

02239372 ZOFRAN ODT GSK

8MG Tablet

02288192 APO-ONDANSETRON APX

02297876 GEN-ONDANSETRON 8MG TAB GEN

02313693 JAMP ONDANSETRON JMP

02305267 MINT-ONDANSETRON MIN

02264064 NOVO-ONDANSETRON NOP

02278626 PHL-ONDANSETRON PMI

02258196 PMS-ONDANSETRON PMS

02312255 RAN-ONDANSETRON RBY

02278537 RATIO-ONDANSETRON RPH

02274329 SANDOZ-ONDANSETRON SDZ

02213575 ZOFRAN GSK

02239373 ZOFRAN ODT GSK

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

02278669 GEN-DOMPERIDONE GEN

02157195 NOVO-DOMPERIDONE NOP

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

200MG Tablet

00584215 APO-CIMETIDINE APX

02227436 GEN-CIMETIDINE GEN

00582409 NOVO-CIMETINE NOP

00865796 NU-CIMET NXP

02229717 PMS-CIMETIDINE PMS

300MG Tablet

00487872 APO-CIMETIDINE APX

00596477 CIMETIDINE PDL

02231287 DOM-CIMETIDINE DPC

02227444 GEN-CIMETIDINE GEN

00582417 NOVO-CIMETINE NOP

00865818 NU-CIMET NXP

00596469 PDL-CIMETIDINE PRO

02229718 PMS-CIMETIDINE PMS

400MG Tablet

00600059 APO-CIMETIDINE APX

00618691 CIMETIDINE PDL

02231288 DOM-CIMETIDINE DPC

02227452 GEN-CIMETIDINE GEN

00603678 NOVO-CIMETINE NOP

00865826 NU-CIMET NXP

02229719 PMS-CIMETIDINE PMS

600MG Tablet

00600067 APO-CIMETIDINE APX

00618705 CIMETIDINE PDL

02231290 DOM-CIMETIDINE DPC

02227460 GEN-CIMETIDINE GEN

00603686 NOVO-CIMETINE NOP

00865834 NU-CIMET NXP

02229720 PMS-CIMETIDINE PMS

800MG Tablet

00749494 APO-CIMETIDINE APX

02227479 GEN-CIMETIDINE GEN

00663727 NOVO-CIMETINE NOP

02229721 PMS-CIMETIDINE PMS

FAMOTIDINE

20MG Tablet

01953842 APO-FAMOTIDINE APX

02241372 FAMOTIDINE PDL

02196018 GEN-FAMOTIDINE GEN

02022133 NOVO-FAMOTIDINE NOP

02024195 NU-FAMOTIDINE NXP

02238342 PENTA-FAMOTIDINE PEN

00710121 PEPCID FRS

02242327 RATIO-FAMOTIDINE RPH

02237148 ULCIDINE VAE

40MG Tablet

01953834 APO-FAMOTIDINE APX

02241373 FAMOTIDINE PDL

02196026 GEN-FAMOTIDINE GEN

02022141 NOVO-FAMOTIDINE NOP

02024209 NU-FAMOTIDINE NXP

02238343 PENTA-FAMOTIDINE PEN

00710113 PEPCID FRS

02242328 RATIO-FAMOTIDINE RPH

02237149 ULCIDINE VAE

NIZATIDINE

150MG Capsule

02220156 APO-NIZATIDINE APX

00778338 AXID PHH

02185814 DOM-NIZATIDINE DPC

02246046 GEN-NIZATIDINE GEN

02239558 NIZATIDINE PDL

02240457 NOVO-NIZATIDINE NOP

02177714 PMS-NIZATIDINE PMS

300MG Capsule

02220164 APO-NIZATIDINE APX

00778346 AXID PHH

02246047 GEN-NIZATIDINE GEN

02238195 NIZATIDINE PHH

02239559 NIZATIDINE PDL

02240458 NOVO-NIZATIDINE NOP

02177722 PMS-NIZATIDINE PMS

RANITIDINE HCL

15MG/ML Oral Solution

02280833 APO-RANITIDINE APX

02242940 NOVO-RANITIDINE NOP

02212374 ZANTAC GSK

150MG Tablet

00733059 APO-RANITIDINE APX

02265591 BCI-RANITIDINE BCI

02248570 CO-RANITIDINE COB

02207761 GEN-RANITIDINE GEN

02219077 MED-RANITIDINE MEC

00828564 NOVO-RANIDINE NOP

00865737 NU-RANIT NXP

02242453 PMS-RANITIDINE PMS

00740748 RANITIDINE PDL

00828823 RATIO-RANITIDINE RPH

02245782 RIVA-RANITIDINE PHH

02247814 RIVA-RANTIDINE RIV

02243229 SANDOZ-RANITIDINE SDZ

02212331 ZANTAC GSK

300MG Tablet

00733067 APO-RANITIDINE APX

02265605 BCI-RANITIDINE BCI

02248571 CO-RANITIDINE COB

02207788 GEN-RANITIDINE GEN

02219085 MED-RANITIDINE MEC

00828556 NOVO-RANIDINE NOP

00865745 NU-RANIT NXP

02242454 PMS-RANITIDINE PMS

00740756 RANITIDINE PDL

00828688 RATIO-RANITIDINE RPH

02245783 RIVA-RANITIDINE PHH

02247815 RIVA-RANITIDINE RIV

02243230 SANDOZ-RANITIDINE SDZ

02212358 ZANTAC GSK

56:28.28 PROSTAGLANDINS

MISOPROSTOL

100MCG Tablet

02244022 APO-MISOPROSTOL APX

200MCG Tablet

02244023 APO-MISOPROSTOL APX

02248846 MISOPROSTOL PDL

02244125 PMS-MISOPROSTOL PMS

56:28.32 PROTECTANTS

SUCRALFATE

200MG/ML Suspension

02103567 SULCRATE PLUS AXC

1G Tablet

02125250 APO-SUCRALFATE APX

02045702 NOVO-SUCRALATE NOP

02134829 NU-SUCRALFATE NXP

02238209 PMS-SUCRALFATE PMS

02130939 SUCRALFATE-1 PDL

02100622 SULCRATE AXC

56:28.36 PROTON-PUMP INHIBITORS

AMOXICILLIN, CLARITHROMYCIN, LANSOPRAZOLE

500MG & 500MG & 30MG Kit

02238525 HP-PAC ABB

LANSOPRAZOLE

(Please refer to Appendix A).

Limited use benefit (prior approval required).

Coverage will be limited to 200 tablets/capsules every 180 days. As part of multi-drug therapy (maximum 7-14 day coverage) for eradication of Helicobacter pylori in individuals with peptic ulcer disease (diagnosed by urea breath test, serology or endoscopically).

Coverage will also be provided if the following prerequisites are met:

• patient has tried at least 30 days of Omeprazole (Losec^®) AND
• patient has tried at least 30 days of Rabeprazole sodium (Pariet^®).

Total trial of 60 days will be confirmed against medication history

PLUS

• 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 to 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 a 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. Or
• other exceptional circumstances, evaluated on an individual basis.

* Diagnosis must be confirmed by a specialist qualified to diagnose and treat condition.

15MG Sustained Release Capsule

02165503 PREVACID ABB

30MG Sustained Release Capsule

02165511 PREVACID ABB

OMEPRAZOLE MAGNESIUM (PA)

(Please refer to Appendix A).

Limited use benefit (prior approval required).

Coverage will be limited to 200 tablets/capsules every 180 days. As part of multi-drug therapy (maximum 7-14 day coverage) for eradication of Helicobacter pylori in individuals with peptic ulcer disease (diagnosed by urea breath test, serology or endoscopically).

Coverage will also be provided if the following prerequisites are met:

• patient has tried at least 30 days of Omeprazole (Losec^®) AND
• patient has tried at least 30 days of Rabeprazole sodium (Pariet^®).

Total trial of 60 days will be confirmed against medication history

PLUS

• 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 to 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 a 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. Or
• other exceptional circumstances, evaluated on an individual basis.

* Diagnosis must be confirmed by a specialist qualified to diagnose and treat condition.

10MG Delayed Release Tablet

02230737 LOSEC AZC

OMEPRAZOLE, OMEPRAZOLE MAGNESIUM (NO PA)

(Please refer to Appendix A).

Limited use benefit (prior approval not required).

Coverage will be limited to 200 tablets/capsules every 180 days.

10MG Capsule

02119579 LOSEC AZC

02296438 SANDOZ OMEPRAZOLE SDZ

20MG Capsule

02245058 APO-OMEPRAZOLE APX

00846503 LOSEC AZC

02296446 SANDOZ OMEPRAZOLE SDZ

10MG Delayed Release Tablet

02260859 RATIO-OMEPRAZOLE RPH

20MG Delayed Release Tablet

02190915 LOSEC AZC

02260867 RATIO-OMEPRAZOLE RPH

PANTOPRAZOLE

(Please refer to Appendix A).

Limited use benefit (prior approval required).

Coverage will be limited to 200 tablets/capsules every 180 days. As part of multi-drug therapy (maximum 7-14 day coverage) for eradication of Helicobacter pylori in individuals with peptic ulcer disease (diagnosed by urea breath test, serology or endoscopically).

Coverage will also be provided if the following prerequisites are met:

• patient has tried at least 30 days of Omeprazole (Losec^®) AND
• patient has tried at least 30 days of Rabeprazole sodium (Pariet^®).

Total trial of 60 days will be confirmed against medication history

PLUS

• 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 to 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 a 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. Or
• other exceptional circumstances, evaluated on an individual basis.

* Diagnosis must be confirmed by a specialist qualified to diagnose and treat condition.

40MG Enteric Coated Tablet

02292920 APO-PANTOPRAZOLE APX

02300486 CO PANTOPRAZOLE CO

02299585 GEN-PANTOPRAZOLE GEN

02285487 NOVO-PANTOPRAZOLE NOP

02229453 PANTOLOC NCC

02307871 PMS-PANTOPRAZOLE PMS

02305046 RAN-PANTOPRAZOLE RBL

02308703 RATIO-PANTOPRAZOLE RPH

02310201 RIVA-PANTOPRAZOLE ZYM

02316463 RIVA-PANTOPRAZOLE RIV

02301083 SANDOZ-PANTOPRAZOLE SDZ

RABEPRAZOLE SODIUM

10MG Enteric Coated Tablet

02296632 NOVO-RABEPRAZOLE NOP

02243796 PARIET EC JNO

02310805 PMS-RABEPRAZOLE PMS

02298074 RAN-RABEPRAZOLE RBY

02314177 SANDOZ-RABEPRAZOLE SDZ

20MG Enteric Coated Tablet

02296640 NOVO-RABEPRAZOLE NOP

02243797 PARIET EC JNO

02310813 PMS-RABEPRAZOLE PMS

02298082 RAN-RABEPRAZOLE RBY

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

00871001 METOCLOPRAMIDE PDL

02143275 NU-METOCLOPRAMIDE NXP

02230431 PMS-METOCLOPRAMIDE PMS

10MG Tablet

00842834 APO-METOCLOP APX

00870994 METOCLOPRAMIDE PDL

02143283 NU-METOCLOPRAMIDE NXP

02230432 PMS-METOCLOPRAMIDE PMS

56:36.00 ANTI-INFLAMMATORY AGENTS

5-AMINOSALICYLIC ACID

500MG Delayed Release Tablet

02099683 PENTASA FEI

2G/60G Enema

02112795 SALOFALK AXC

4G/60G Enema

02112809 SALOFALK AXC

400MG Enteric Coated Tablet

01997580 ASACOL PGP

500MG Enteric Coated Tablet

02112787 SALOFALK AXC

250MG Suppository

02112752 SALOFALK AXC

500MG Suppository

02112760 SALOFALK AXC

MESALAZINE

1G/100ML Enema

02153521 PENTASA FEI

4G/100ML Enema

02153556 PENTASA FEI

400MG Enteric Coated Tablet

02171929 NOVO 5-ASA NOP

500MG Enteric Coated Tablet

01914030 MESASAL GSK

1G Suppository

02153564 PENTASA FEI

1000MG Suppository

02242146 SALOFALK AXC

OLSALAZINE SODIUM

250MG Capsule

02063808 DIPENTUM LUD