Drug Benefit List 2010

56:00 GASTROINTESTINAL DRUGS

56:04.00 ANTACIDS AND ADSORBENTS

BISMUTH SUBSALICYLATE

17.6mg/mL Liquid

2097079 PEPTO BISMOL PGI

262mg Tablet

2177994 PEPTO BISMOL PGI

MAG OXIDE

420mg Tablet

299448 MAGNESIUM OXIDE SWS

56:08.00 ANTIDIARRHEA AGENTS

LOPERAMIDE HCL

0.2mg/mL Liquid

2192667 DIARR-EZE PMS

2016095 PMS-LOPERAMIDE PMS

2mg Tablet

2212005 APO-LOPERAMIDE APX

2229552 DIARR-EZE PMS

2248994 DIARRHEA RELIEF PMS

2256452 DIARRHEA RELIEF VTH

2239535 DOM-LOPERAMIDE DPC

2183862 IMODIUM MCL

2225182 LOPERAMIDE PDL

2132591 NOVO-LOPERAMIDE NOP

2228351 PMS-LOPERAMIDE PMS

2233998 RHOXAL-LOPERAMIDE RHO

2238211 RIVA-LOPERAMIDE RIV

2257564 SANDOZ-LOPERAMIDE SDZ

56:12.00 CATHARTICS AND LAXATIVES

BISACODYL

5mg Enteric Coated Tablet

545023 APO-BISACODYL APX

420433 BISACODYL PRO

714488 BISACOLAX ICN

254142 DULCOLAX BOE

2246039 JAMP-BISACODYL JMP

587273 PMS-BISACODYL PMS

5mg Suppository

3867 DULCOLAX BOE

10mg Suppository

754595 APO-BISACODYL APX

261327 BISACOLAX ICN

3875 DULCOLAX BOE

582883 PMS-BISACODYL PMS

404802 RATIO-BISACODYL RPH

2229743 SOFLAX EX PMS

BISACODYL (POLYETHYLENE GLYCOL BASE)

Limited use benefit (prior approval required).

For treatment of constipation in patients with spinal cord

10mg Suppository

2241091 MAGIC BULLET DCM

CITRIC ACID, MAGNESIUM OXIDE, SODIUM PICOSULFATE

Oral Liquid

2317966 PURG-ODAN ODN

Powder

2254794 PICO-SALAX FEI

DIOCTYL CALCIUM SULFOSUCCINATE

240mg Capsule

2245080 APO-DOCUSATE CALCIUM APX

830275 DOCUSATE CALCIUM TAR

2283255 JAMP-DOCUSATE CALCIUM JMP

842044 NOVO-DOCUSATE CALCIUM NOP

664553 PMS-DOCUSATE CALCIUM PMS

809055 RATIO-DOCUSATE CALCIUM RPH

DIOCTYL SODIUM SULFOSUCCINATE

100mg Capsule

2245079 APO-DOCUSATE SODIUM APX

2106256 COLACE WPC

716731 DOCUSATE SODIUM TAR

794406 DOCUSATE SODIUM SDR

830267 DOCUSATE SODIUM TRI

2246036 DOCUSATE SODIUM RPH

2239658 DOM-DOCUSATE SODIUM DPC

2247385 EURO-DOCUSATE EUR

2020084 NOVO-DOCUSATE NOP

703494 PMS-DOCUSATE SODIUM PMS

870196 RATIO-DOCUSATE SODIUM RPH

514888 SELAX ODN

1994344 SOFLAX PMS

200mg Capsule

2029529 SOFLAX PMS

250mg Capsule

2006596 SELAX ODN

10mg/mL Drop

2090163 COLACE WPC

870218 DOCUSATE SODIUM RPH

880140 PMS-SODIUM DOCUSATE PMS

2006723 SOFLAX PMS

4mg/mL Syrup

2086018 COLACE WPC

703508 PMS-DOCUSATE SODIUM PMS

870226 RATIO-DOCUSATE SODIUM RPH

2006758 SOFLAX SYRUP PMS

20mg/mL Syrup

2283239 DOCUSATE SODIUM JMP

50mg/mL Syrup

2283220 DOCUSATE SODIUM JMP

848417 PMS-DOCUSATE SODIUM PMS

DIOCTYL SODIUM SULFOSUCCINATE, SENNA

50mg & 187mg Tablet

26123 SENOKOT S PFR

DIOCTYL SODIUM SULFOSUCCINATE, SENNOSIDES

100mg Capsule

2245946 DOCUSATE SODIUM JMP

50mg & 8.6mg Tablet

2247390 EURO-SENNA S EUR

DOCUSATE SODIUM

100mg Capsule

2326086 DOCUSATE SODIUM PDL

2303825 EURO-DOCUSATE EUR

FIBER

469mg Tablet

595829 NOVO-FIBRE NOP

GLYCERINE

Adult Suppository

873462 GLYCERIN * RPH

1926039 GLYCERIN WLA

812250 GLYCERINE * WLA

884022 GLYCERINE * RPH

Pediatric Suppository

2020815 GLYCERIN INFANT RPH

1926047 GLYCERIN INFANT & CHILD PFI

LACTULOSE

667mg/mL Oral Liquid

2242814 APO-LACTULOSE APX

2247383 EURO-LAC EUR

2280078 GPI-LACTULOSE OBP

2295881 LACTULOSE JMP

703486 PMS-LACTULOSE PMS

2311275 PRO-LACTULOSE PRO

690686 RATIO-LACTULOSE RPH

854409 RATIO-LACTULOSE RPH

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

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

677442 COLYTE ZYM

652512 GOLYTELY BAX

777838 PEGLYTE PMS

MAGNESIUM HYDROXIDE

80mg/mL Liquid

2150646 MILK OF MAGNESIA PLAIN/SUGARFREE BCD

311mg Tablet

2150638 MILK OF MAGNESIA BCD

MINERAL OIL

78% Jelly

608734 LANSOYL GEL AXC

2186926 LANSOYL GEL SUGARFREE AXC

MINERAL OIL

Liquid

1935348 MINERAL OIL (HEAVY) 100% USP RWP

PLANTAGO SEED

50% Powder

599875 MUCILLIUM PMS

POLYETHYLENE GLYCOL

Powder

9991007 POLYETHYLENE GLYCOL WIL

POLYETHYLENE GLYCOL 3350

Powder

9991054 POLYETHYLENE GLYCOL 3350 WIL

1g/g Powder

2317680 LAX-A-DAY PED

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

Oral Liquid

2147793 KLEAN-PREP RVX

PSYLLIUM HYDROPHILIC MUCILLOID

680mg/g Powder

2174812 METAMUCIL ORIGINAL TEXTURE PGI

2174790 METAMUCIL SM TEXT ORANGE PGI

2174782 METAMUCIL SM TEXT ORANGE S/F PGI

2174804 METAMUCIL SM TEXT UNFLAV PGI

SENNOSIDES

1.7mg/mL Liquid

2144379 SENNALAX PMS

2084651 SENNAPREP PMS

367729 SENOKOT PFR

367737 X-PREP PFR

8.6mg Tablet

2247389 EURO-SENNA EUR

80009182 JAMP-SENNOSIDES JMP

896411 PMS-SENNOSIDES PMS

1949292 RIVA-SENNA RIV

2089653 SANDOZ-SENNOSIDES SDZ

2237105 SENNA LAXATIVE SDR

2068109 SENNATAB PMS

26158 SENOKOT PFR

12MG Tablet

80009183 JAMP-SENNOSIDES JMP

896403 PMS-SENNOSIDES PMS

2089645 SANDOZ-SENNOSIDES SDZ

SODIUM CITRATE, SODIUM LAURYL SULFOACETATE,

90mg & 9mg & 625mg Enema

2063905 MICROLAX PMS

SODIUM PHOSPHATE DIBASIC, SODIUM PHOSPHATE MONOBASIC

180mg & 480mg/mL Oral Liquid

2206218 PHOSPHO SODA FLEET LAXATIVE JAJ

2230399 PMS-PHOSPHATES SOLUTION PMS

60mg & 160mg/mL Rectal Liquid

2096900 ENEMOL DPC

9911 FLEET ENEMA FRS

60mg & 160mg/mL PED Rectal Liquid

108065 FLEET ENEMA PEDIATRIC JAJ

56:14.00 CHOLELITHOLYTIC AGENTS

URSODIOL

250mg Tablet

2281317 PHL-URSODIOL C PHH

2273497 PMS-URSODIOL PMS

2238984 URSO AXC

500mg Tablet

2281325 PHL-URSODIOL C PHH

2273500 PMS-URSODIOL PMS

2245894 URSO DS AXC

56:16.00 DIGESTANTS

LACTASE

3,550U Capsule

2016478 LACTRASE RIV

Oral Liquid

903981 LACTAID MCL

3,000U Tablet

2200384 DAIRY DIGESTIVE PER

2239139 DAIRY DIGESTIVE SDR

2017512 DAIRY FREE KIN

1951637 DAIRYAID TAN

2230653 LACTAID JNO

4,500U Tablet

2239140 DAIRY DIGESTIVE EXTRA STRENGTH SDR

2224909 DAIRY FREE EXTRA STRENGTH KIN

2230654 LACTAID EXTRA STRENGTH JNO

LIPASE, AMYLASE, PROTEASE

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

2239007 CREON 5 MINIMICROSPHERES SPH

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

263818 COTAZYM ORG

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

2239008 CREON 20 MINIMICROSPHERES SPH

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

2181215 COTAZYM ECS4 ORG

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

789445 PANCREASE MT 4 JNO

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

2203324 ULTRASE MS 4 AXC

LIPASE, AMYLASE, PROTEASE

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

502790 COTAZYM ECS 8 ORG

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

789437 PANCREASE MT 10 JNO

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

2200104 CREON 10 MINIMICROSPHERES SPH

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

2045834 ULTRASE MT 12 AXC

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

789429 PANCREASE MT 16 JNO

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

821373 COTAZYM ECS 20 ORG

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

2045869 ULTRASE MT 20 AXC

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

1985205 CREON 25 MINIMICROSPHERES SPH

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

2230020 VIOKASE AXC

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

2230019 VIOKASE AXC

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

2241933 VIOKASE AXC

56:20.00 EMETICS

IPECAC

7% Syrup

721328 PMS-IPECAC PMS

14mg/mL Syrup

378801 IPECAC XEN

56:22.08 ANTIHISTAMINES

DIMENHYDRINATE

50mg/mL Injection

392537 DIMENHYDRINATE SDZ

13579 GRAVOL HOR

3mg/mL Liquid

230197 GRAVOL HOR

25mg Suppository

783595 GRAVOL HOR

50mg Suppository

392553 DIMENHYDRINATE SDZ

13595 GRAVOL HOR

15mg Tablet

511196 GRAVOL HOR

DIMENHYDRINATE

50mg Tablet

363766 APO-DIMENHYDRINATE APX

156655 DIMENHYDRINATE PRO

13803 GRAVOL HOR

399779 NAUSEATOL SDZ

21423 NOVODIMENATE NOP

586331 PMS-DIMENHYDRINATE PMS

272671 TRAVAMINE ICN

605786 TRAVEL AID VTH

2245416 TRAVEL TABLET JMP

DOXYLAMINE SUCCINATE, PYRIDOXINE HCL

10mg & 10mg Tablet

609129 DICLECTIN DUI

MECLIZINE HCL

25mg Chewable Tablet

220442 BONAMINE JNO

56:22.20 5-HT3 RECEPTOR ANTAGONISTS

DOLASETRON MESYLATE

20mg/mL Injection

2231380 ANZEMET SAC

50mg Tablet

2231378 ANZEMET SAC

100mg Tablet

2231379 ANZEMET SAC

GRANISETRON

1mg Tablet

2308894 APO-GRANISETRON APX

2185881 KYTRIL HLR

ONDANSETRON HCL

4mg Tablet

2296349 CO-ONDANSETRON CBT

2344440 ZYM-ONDANSETRON ZYM

8mg Tablet

2296357 CO-ONDANSETRON CBT

2344459 ZYM-ONDANSETRON ZYM

ONDANSETRON HCL DIHYDRATE

0.8mg/mL Liquid

2291967 APO-ONDANSETRON APX

2229639 ZOFRAN GSK

ONDANSETRON HCL DIHYDRATE

4mg Tablet

2288184 APO-ONDANSETRON APX

2297868 GEN-ONDANSETRON GEN

2313685 JAMP ONDANSETRON JMP

2305259 MINT-ONDANSETRON MIN

2264056 NOVO-ONDANSETRON NOP

2278618 PHL-ONDANSETRON PHH

2258188 PMS-ONDANSETRON PMS

2312247 RAN-ONDANSETRON RBY

2278529 RATIO-ONDANSETRON RPH

2274310 SANDOZ-ONDANSETRON SDZ

2213567 ZOFRAN GSK

2239372 ZOFRAN ODT GSK

8mg Tablet

2288192 APO-ONDANSETRON APX

2297876 GEN-ONDANSETRON 8MG TAB GEN

2313693 JAMP ONDANSETRON JMP

2305267 MINT-ONDANSETRON MIN

2264064 NOVO-ONDANSETRON NOP

2278626 PHL-ONDANSETRON PHH

2258196 PMS-ONDANSETRON PMS

2312255 RAN-ONDANSETRON RBY

2278537 RATIO-ONDANSETRON RPH

2274329 SANDOZ-ONDANSETRON SDZ

2213575 ZOFRAN GSK

2239373 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

2298791 EMEND FRS

125mg Capsule

2298805 EMEND FRS

125mg & 80mg Capsule

2298813 EMEND TRI PACK FRS

DOMPERIDONE MALEATE

10mg Tablet

2103613 APO-DOMPERIDONE APX

2238315 DOM-DOMPERIDONE DPC

2236857 DOMPERIDONE PDL

2278669 GEN-DOMPERIDONE GEN

2157195 NOVO-DOMPERIDONE NOP

2231477 NU-DOMPERIDONE NXP

2236466 PMS-DOMPERIDONE PMS

2268078 RAN-DOMPERIDONE RBY

1912070 RATIO-DOMPERIDONE RPH

NABILONE

0.25mg Capsule

2312263 CESAMET VAE

0.5mg Capsule

2256193 CESAMET VAE

1mg Capsule

548375 CESAMET VAE

56:28.12 HISTAMINE H2-ANTAGONISTS

CIMETIDINE

200mg Tablet

584215 APO-CIMETIDINE APX

2227436 GEN-CIMETIDINE GEN

582409 NOVO-CIMETINE NOP

865796 NU-CIMET NXP

596469 PDL-CIMETIDINE PDL

2229717 PMS-CIMETIDINE PMS

300mg Tablet

487872 APO-CIMETIDINE APX

596477 CIMETIDINE PDL

2231287 DOM-CIMETIDINE DPC

2227444 GEN-CIMETIDINE GEN

582417 NOVO-CIMETINE NOP

865818 NU-CIMET NXP

2229718 PMS-CIMETIDINE PMS

400mg Tablet

600059 APO-CIMETIDINE APX

618691 CIMETIDINE PDL

2231288 DOM-CIMETIDINE DPC

2227452 GEN-CIMETIDINE GEN

603678 NOVO-CIMETINE NOP

865826 NU-CIMET NXP

2229719 PMS-CIMETIDINE PMS

600mg Tablet

600067 APO-CIMETIDINE APX

618705 CIMETIDINE PDL

2231290 DOM-CIMETIDINE DPC

2227460 GEN-CIMETIDINE GEN

603686 NOVO-CIMETINE NOP

865834 NU-CIMET NXP

2229720 PMS-CIMETIDINE PMS

CIMETIDINE

800mg Tablet

749494 APO-CIMETIDINE APX

2227479 GEN-CIMETIDINE GEN

663727 NOVO-CIMETINE NOP

2229721 PMS-CIMETIDINE PMS

FAMOTIDINE

20mg Tablet

1953842 APO-FAMOTIDINE APX

2241372 FAMOTIDINE PDL

2196018 GEN-FAMOTIDINE GEN

2022133 NOVO-FAMOTIDINE NOP

2024195 NU-FAMOTIDINE NXP

2238342 PENTA-FAMOTIDINE PEN

710121 PEPCID FRS

2237148 ULCIDINE VAE

40mg Tablet

1953834 APO-FAMOTIDINE APX

2241373 FAMOTIDINE PDL

2196026 GEN-FAMOTIDINE GEN

2022141 NOVO-FAMOTIDINE NOP

2024209 NU-FAMOTIDINE NXP

2238343 PENTA-FAMOTIDINE PEN

710113 PEPCID FRS

2237149 ULCIDINE VAE

NIZATIDINE

150mg Capsule

2220156 APO-NIZATIDINE APX

778338 AXID PHH

2185814 DOM-NIZATIDINE DPC

2246046 GEN-NIZATIDINE GEN

2239558 NIZATIDINE PDL

2240457 NOVO-NIZATIDINE NOP

2177714 PMS-NIZATIDINE PMS

300mg Capsule

2220164 APO-NIZATIDINE APX

778346 AXID PHH

2246047 GEN-NIZATIDINE GEN

2238195 NIZATIDINE PHH

2239559 NIZATIDINE PDL

2240458 NOVO-NIZATIDINE NOP

2177722 PMS-NIZATIDINE PMS

RANITIDINE HCL

15mg/mL Oral Solution

2280833 APO-RANITIDINE APX

2242940 NOVO-RANITIDINE NOP

2212374 ZANTAC GSK

RANITIDINE HCL

150mg Tablet

733059 APO-RANITIDINE APX

2265591 BCI-RANITIDINE BAK

2248570 CO RANITIDINE COB

2207761 GEN-RANITIDINE GEN

2293471 MAXIMUM STRENGTH ACID REDUCER PMS

2219077 MED-RANITIDINE MEC

828564 NOVO-RANIDINE NOP

865737 NU-RANIT NXP

2242453 PMS-RANITIDINE PMS

740748 RANITIDINE PDL

828823 RATIO-RANITIDINE RPH

2245782 RIVA-RANITIDINE PHH

2247814 RIVA-RANTIDINE RIV

2243229 SANDOZ-RANITIDINE SDZ

2212331 ZANTAC GSK

300mg Tablet

733067 APO-RANITIDINE APX

2265605 BCI-RANITIDINE BAK

2248571 CO RANITIDINE COB

2207788 GEN-RANITIDINE GEN

2219085 MED-RANITIDINE MEC

828556 NOVO-RANIDINE NOP

865745 NU-RANIT NXP

2242454 PMS-RANITIDINE PMS

740756 RANITIDINE PDL

828688 RATIO-RANITIDINE RPH

2245783 RIVA-RANITIDINE PHH

2247815 RIVA-RANITIDINE RIV

2243230 SANDOZ-RANITIDINE SDZ

2212358 ZANTAC GSK

56:28.28 PROSTAGLANDINS

MISOPROSTOL

100mcg Tablet

2244022 APO-MISOPROSTOL APX

200mcg Tablet

2244023 APO-MISOPROSTOL APX

2248846 MISOPROSTOL PDL

2244125 PMS-MISOPROSTOL PMS

56:28.32 PROTECTANTS

SUCRALFATE

200mg/mL Suspension

2103567 SULCRATE PLUS AXC

1g Tablet

2125250 APO-SUCRALFATE APX

2045702 NOVO-SUCRALATE NOP

2134829 NU-SUCRALFATE NXP

2130939 SUCRALFATE-1 PDL

2100622 SULCRATE AXC

56:28.36 PROTON-PUMP INHIBITORS

AMOXICILLIN, CLARITHROMYCIN, LANSOPRAZOLE

500mg & 500mg & 30mg Kit

2238525 HP-PAC ABB

LANSOPRAZOLE

(Please refer to Appendix A).

Limited use benefit (prior approval not required).

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

15mg Sustained Release Capsule

2293811 APO-LANSOPRAZOLE APX

2280515 NOVO-LANSOPRAZOLE NOP

2165503 PREVACID ABB

30mg Sustained Release Capsule

2293838 APO-LANSOPRAZOLE APX

2280523 NOVO-LANSOPRAZOLE NOP

2165511 PREVACID ABB

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.

15MG Orally Disintegrating Tablet

2249464 PREVACID FASTAB TAK

30MG Orally Disintegrating Tablet

2249472 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

10mg Delayed Release Tablet

2230737 LOSEC AZC

2260859 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.

10mg Capsule

2119579 LOSEC AZC

2329425 MYLAN-OMEPRAZOLE GEN

2296438 SANDOZ OMEPRAZOLE SDZ

20mg Capsule

2245058 APO-OMEPRAZOLE APX

846503 LOSEC AZC

2329433 MYLAN-OMEPRAZOLE GEN

2320851 PMS-OMEPRAZOLE PMS

2296446 SANDOZ OMEPRAZOLE SDZ

20mg Delayed Release Tablet

2190915 LOSEC AZC

2310260 PMS-OMEPRAZOLE PMS

2260867 RATIO-OMEPRAZOLE RPH

PANTOPRAZOLE MAGNESIUM

(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

40mg Enteric Coated Tablet

2267233 TECTA NCC

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.

40mg Enteric Coated Tablet

2292920 APO-PANTOPRAZOLE APX

2300486 CO PANTOPRAZOLE COB

2299585 GEN-PANTOPRAZOLE GEN

2285487 NOVO-PANTOPRAZOLE NOP

2229453 PANTOLOC NYC

2318695 PANTOPRAZOLE PDL

2309866 PHL-PANTOPRAZOLE PMI

2307871 PMS-PANTOPRAZOLE PMS

2305046 RAN-PANTOPRAZOLE RBY

2308703 RATIO-PANTOPRAZOLE RPH

2310201 RIVA-PANTOPRAZOLE ZYM

2316463 RIVA-PANTOPRAZOLE RIV

2301083 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.

10mg Enteric Coated Tablet

2296632 NOVO-RABEPRAZOLE NOP

2243796 PARIET EC JNO

2310805 PMS-RABEPRAZOLE PMS

2315181 PRO-RABEPRAZOLE PDL

2298074 RAN-RABEPRAZOLE RBY

2314177 SANDOZ-RABEPRAZOLE SDZ

20mg Enteric Coated Tablet

2296640 NOVO-RABEPRAZOLE NOP

2243797 PARIET EC JNO

2310813 PMS-RABEPRAZOLE PMS

2315203 PRO-RABEPRAZOLE PDL

2298082 RAN-RABEPRAZOLE RBY

2330091 RIVA-RABEPRAZOLE RIV

2314185 SANDOZ-RABEPRAZOLE SDZ

56:32.00 PROKINETIC AGENTS

METOCLOPRAMIDE HCL

1mg/mL Oral Liquid

2230433 PMS-METOCLOPRAMIDE PMS

5mg Tablet

842826 APO-METOCLOP APX

871001 METOCLOPRAMIDE PDL

2143275 NU-METOCLOPRAMIDE NXP

2230431 PMS-METOCLOPRAMIDE PMS

10mg Tablet

842834 APO-METOCLOP APX

870994 METOCLOPRAMIDE PDL

2143283 NU-METOCLOPRAMIDE NXP

2230432 PMS-METOCLOPRAMIDE PMS

56:36.00 ANTI-INFLAMMATORY AGENTS

5-AMINOSALICYLIC ACID

500mg Delayed Release Tablet

2099683 PENTASA FEI

2g/60g Enema

2112795 SALOFALK AXC

4g/60g Enema

2112809 SALOFALK AXC

400mg Enteric Coated Tablet

1997580 ASACOL PGP

500mg Enteric Coated Tablet

2112787 SALOFALK AXC

800mg Enteric Coated Tablet

2267217 ASACOL WAC

500mg Suppository

2112760 SALOFALK AXC

MESALAZINE

1g/100mL Enema

2153521 PENTASA FEI

4g/100mL Enema

2153556 PENTASA FEI

400mg Enteric Coated Tablet

2171929 NOVO 5-ASA NOP

500mg Enteric Coated Tablet

1914030 MESASAL GSK

1g Suppository

2153564 PENTASA FEI

1000mg Suppository

2242146 SALOFALK AXC

OLSALAZINE SODIUM

250mg Capsule

2063808 DIPENTUM LUD