Drug Benefit List 2012

68:00 HORMONES AND SYNTHETIC SUBSTITUTES

68:04.00 ADRENALS

BECLOMETHASONE DIPROPIONATE

50mcg Inhaler

02242029 QVAR MMH

100mcg Inhaler

02242030 QVAR MMH

BUDESONIDE

0.125mg/mL Inhalation Solution

02229099 PULMICORT NEBUAMP AZC

0.25mg/mL Inhalation Solution

01978918 PULMICORT NEBUAMP AZC

0.5mg/mL Inhalation Solution

01978926 PULMICORT NEBUAMP AZC

100mcg Powder for Inhalation

00852074 PULMICORT TURBUHALER AZC

200mcg Powder for Inhalation

00851752 PULMICORT TURBUHALER AZC

400mcg Powder for Inhalation

00851760 PULMICORT TURBUHALER AZC

CICLESONIDE

100mg/Inhalation Inhaler

02285606 ALVESCO NYC

200mg/Inhalation Inhaler

02285614 ALVESCO NYC

CORTISONE ACETATE

25mg Tablet

00280437 CORTISONE VAE

DEXAMETHASONE

0.1mg/mL Elixir

01946897 PMS-DEXAMETHASONE PMS

0.5mg Tablet

02261081 APO-DEXAMETHASONE APX

02237044 PHL-DEXAMETHASONE PHH

01964976 PMS-DEXAMETHASONE PMS

02240684 RATIO-DEXAMETHASONE RPH

0.75mg Tablet

00285471 DEXASONE VAE

01964968 PMS-DEXAMETHASONE PMS

2mg Tablet

02279363 PMS-DEXAMETHASONE PMS

4mg Tablet

02250055 APO-DEXAMETHASONE APX

00489158 DEXASONE VAE

02237046 PHL-DEXAMETHASONE PHH

01964070 PMS-DEXAMETHASONE PMS

02311267 PRO-DEXAMETHASONE PRO

02240687 RATIO-DEXAMETHASONE RPH

DEXAMETHASONE PHOSPHATE

4mg/mL Injection

00664227 DEXAMETHASONE SDZ

01977547 DEXAMETHASONE CYX

02204266 DEXAMETHASONE-OMEGA OMG

10mg/mL Injection

00874582 DEXAMETHASONE SDZ

00783900 PMS-DEXAMETHASONE PMS

FLUDROCORTISONE ACETATE

0.1mg Tablet

02086026 FLORINEF SHI

FLUTICASONE PROPIONATE

50mcg/Inhalation Inhaler

02244291 FLOVENT HFA 50 GSK

125mcg/Inhalation Inhaler

02244292 FLOVENT HFA 125 GSK

250mcg/Inhalation Inhaler

02244293 FLOVENT HFA 250 GSK

50mcg/Dose Powder Diskus

02237244 FLOVENT DISKUS GSK

100mcg/Dose Powder Diskus

02237245 FLOVENT DISKUS GSK

250mcg/Dose Powder Diskus

02237246 FLOVENT DISKUS GSK

500mcg/Dose Powder Diskus

02237247 FLOVENT DISKUS GSK

HYDROCORTISONE

10mg Tablet

00030910 CORTEF PFI

20mg Tablet

00030929 CORTEF PFI

METHYLPREDNISOLONE

4mg Tablet

00030988 MEDROL PFI

16mg Tablet

00036129 MEDROL PFI

METHYLPREDNISOLONE ACETATE

40mg/mL Suspension for Injection

00030759 DEPO-MEDROL PMJ

02245400 METHYLPREDNISOLONE SDZ

02245407 METHYLPREDNISOLONE SDZ

80mg/mL Suspension for Injection

00030767 DEPO-MEDROL PMJ

02245406 METHYLPREDNISOLONE SDZ

02245408 METHYLPREDNISOLONE SDZ

20mg/mL Suspension for Injection (Multi-Dose)

01934325 DEPO-MEDROL PMJ

40mg/mL Suspension for Injection (Multi-Dose)

01934333 DEPO-MEDROL PMJ

80mg/mL Suspension for Injection (Multi-Dose)

01934341 DEPO-MEDROL PMJ

PREDNISOLONE SODIUM PHOSPHATE

1mg/mL Oral Liquid

02230619 PEDIAPRED SAC

02245532 PMS-PREDNISOLONE PMS

PREDNISONE

1mg Tablet

00598194 APO-PREDNISONE APX

00271373 WINPRED VAE

5mg Tablet

00312770 APO-PREDNISONE APX

00156876 PREDNISONE PRO

50mg Tablet

00550957 APO-PREDNISONE APX

00232378 NOVO-PREDNISONE TEV

00607517 PREDNISONE PRO

TRIAMCINOLONE ACETONIDE

10mg/mL Suspension for Injection

01999761 KENALOG-10 WSB

02229540 TRIAMCINOLONE SDZ

40mg/mL Suspension for Injection

01999869 KENALOG-40 WSB

02229550 TRIAMCINOLONE SDZ

09857128 TRIAMCINOLONE ACETONIDE (5ML) SDZ

TRIAMCINOLONE DIACETATE

40mg/mL Suspension for Injection

01977555 STERILE TRIAMCINOLONE CYX

TRIAMCINOLONE HEXACETONIDE

20mg/mL Suspension for Injection

02194155 ARISTOSPAN VAO

68:08.00 ANDROGENS

DANAZOL

50mg Capsule

02018144 CYCLOMEN SAC

100mg Capsule

02018152 CYCLOMEN SAC

200mg Capsule

02018160 CYCLOMEN SAC

TESTOSTERONE CYPIONATE

100mg/mL Injection

00030783 DEPO-TESTOSTERONE PFI

02246063 TESTOSTERONE CYPIONATE SDZ

TESTOSTERONE ENANTHATE

200mg/mL Injection

00029246 DELATESTRYL BMS

00739944 PMS-TESTOSTERONE PMS

TESTOSTERONE UNDECANOATE

40mg Capsule

00782327 ANDRIOL ORG

02322498 PMS-TESTOSTERONE PMS

68:12.00 CONTRACEPTIVES

ETHINYL ESTRADIOL, DESOGESTREL

25mcg & 150mcg, 125mcg, 100mcg Tablet

02272903 LINESSA 21 ORG

02257238 LINESSA 28 ORG

30mcg & 150mcg Tablet

02317192 APRI 21 BAR

02317206 APRI 28 BAR

02042487 MARVELON 21 ORG

02042479 MARVELON 28 ORG

02042533 ORTHO CEPT 28 JNO

ETHINYL ESTRADIOL, DROSPIRENONE

0.02mg & 3mg Tablet

02321157 YAZ BAY

0.03mg & 3mg Tablet

02261723 YASMIN 21 BAY

02261731 YASMIN 28 BAY

ETHINYL ESTRADIOL, ETHYNODIOL DIACETATE

30mcg & 2mg Tablet

00469327 DEMULEN 30 21 PFI

00471526 DEMULEN 30 28 PFI

ETHINYL ESTRADIOL, ETONOGESTREL

Limited use benefit (prior approval required).

For patients who are intolerant to or unable to take oral contraceptives.

2.6mg & 11.4mg Device

02253186 NUVARING ORG

ETHINYL ESTRADIOL, LEVONORGESTREL

20mcg & 100mcg Tablet

02236974 ALESSE 21 WAY

02236975 ALESSE 28 WAY

02298538 AVIANE 21 BAR

02298546 AVIANE 28 BAR

30mcg & 0.05mg, 40mcg & 0.075mg, 30mcg & 0.125mg Tablet

00707600 TRIQUILAR 21 BEX

00707503 TRIQUILAR 28 BEX

30mcg & 150mcg Tablet

02042320 MIN-OVRAL 21 WAY

02042339 MIN-OVRAL 28 WAY

02295946 PORTIA 21 BAR

02295954 PORTIA 28 BAR

ETHINYL ESTRADIOL, NORETHINDRONE

35mcg & 0.5mg Tablet

02187086 BREVICON 0.5/35 21 PFI

02187094 BREVICON 0.5/35 28 PFI

00340731 ORTHO 0.5/35 28 JNO

00317047 ORTHO 0.5/35 21 JNO

35mcg & 0.5mg, 35mcg & 1mg Tablet

02187108 SYNPHASIC 21 PFI

02187116 SYNPHASIC 28 PFI

35mcg & 1mg Tablet

02189054 BREVICON 1/35 21 PFI

02189062 BREVICON 1/35 28 PFI

00372838 ORTHO 1/35 28 JNO

00372846 ORTHO 1/35 21 JNO

02197502 SELECT 1/35 21 DSP

02199297 SELECT 1/35 28 DSP

35mcg & 500mcg, 35mcg & 750mcg, 35mcg & 1mg Tablet

00602957 ORTHO 7/7/7 21 JNO

00602965 ORTHO 7/7/7 28 JNO

ETHINYL ESTRADIOL, NORETHINDRONE ACETATE

20mcg & 1mg Tablet

00315966 MINESTRIN 1/20 21 GCL

00343838 MINESTRIN 1/20 28 GCL

30mcg & 1.5mg Tablet

00297143 LOESTRIN 1.5/30 21 GCL

00353027 LOESTRIN 1.5/30 28 GCL

ETHINYL ESTRADIOL, NORGESTIMATE

25mcg & 0.180mg, 25mcg & 0.215mg, 25mcg & 0.25mg Tablet

02258560 TRI-CYCLEN LO 21 JNO

02258587 TRI-CYCLEN LO 28 JNO

35mcg & 0.180mg, 35mcg & 0.215mg, 35mcg & 0.25mg Tablet

02028700 TRI-CYCLEN 21 JNO

02029421 TRI-CYCLEN 28 JNO

35mcg & 0.25mg Tablet

01968440 CYCLEN 21 JNO

01992872 CYCLEN 28 JNO

LEVONORGESTREL

0.75mg Tablet

02364905 NEXT CHOICE COB

02285576 NORLEVO HRA

02241674 PLAN B BAR

LEVONORGESTREL INTRAUTERINE INSERT

Limited use benefit with quantity and frequency limits (prior approval is not required).

Coverage is granted for 1 device every 5 years.

52mg Intrauterine Insert

02243005 MIRENA BAY

NORETHINDRONE

0.35mg Tablet

00037605 MICRONOR 28 JNO

68:16.04 ESTROGENS

CONJUGATED ESTROGENS

0.3mg Tablet

02043394 PREMARIN WAY

0.625mg Tablet

00265470 C.E.S. VAE

02043408 PREMARIN WAY

1.25mg Tablet

02043424 PREMARIN WAY

0.625mg/g Vaginal Cream

02043440 PREMARIN WAY

CONJUGATED ESTROGENS, MEDROXYPROGESTERONE ACETATE

0.625mg & 2.5mg Kit

02242878 PREMPLUS WAY

0.625mg & 5mg Kit

02242879 PREMPLUS WAY

ESTRADIOL

0.06% Gel

02238704 ESTROGEL SCH

0.39mg Patch

02245676 ESTRADOT 25 NVR

0.585mg Patch

02243999 ESTRADOT 37.5 NVR

0.78mg Patch

02244000 ESTRADOT 50 NVR

1.17mg Patch

02244001 ESTRADOT 75 NVR

1.56mg Patch

02244002 ESTRADOT 100 NVR

2mg Patch

00756849 ESTRADERM 25 NVR

4mg Patch

02246967 SANDOZ-ESTRADIOL DERM 50 SDZ

5mg Patch

02243722 OESCLIM PAL

6mg Patch

02246968 SANDOZ-ESTRADIOL DERM 75 SDZ

8mg Patch

00756792 ESTRADERM 100 NVR

02246969 SANDOZ-ESTRADIOL DERM 100 SDZ

10mg Patch

02243724 OESCLIM PAL

0.5mg Tablet

02225190 ESTRACE SHI

1mg Tablet

02148587 ESTRACE SHI

2mg Tablet

02148595 ESTRACE SHI

2mg Vaginal Ring

02168898 ESTRING PMJ

ESTRADIOL (ESTRADIOL HEMIHYDRATE)

2mg Patch

02247499 CLIMARA 25 BEX

3.8mg Patch

02231509 CLIMARA 50 BEX

5.7mg Patch

02247500 CLIMARA 75 BEX

7.6mg Patch

02231510 CLIMARA 100 BEX

10mcg Vaginal Tablet

02325462 VAGIFEM NOO

ESTRADIOL, NORETHINDRONE ACETATE

0.51mg & 4.8mg Patch

02241837 ESTALIS 250/50 NVR

0.62mg & 2.7mg Patch

02241835 ESTALIS 140/50 NVR

ESTRONE

1mg/g Vaginal Cream

00727369 ESTRAGYN TRT

ESTROPIPATE

0.75mg Tablet

02089793 OGEN .625 PFI

1.5mg Tablet

02089769 OGEN 1.25 PFI

3mg Tablet

02089777 OGEN 2.5 PFI

ETHINYL ESTRADIOL, NORETHINDRONE ACETATE

5mcg & 1mg Tablet

02242531 FEMHRT WCI

68:16.12 ESTROGEN AGONISTS- ANTAGONISTS

RALOXIFENE HCL

Limited use benefit (prior approval required).

For:

1. secondary prevention of osteoporosis in women who experience failure on bisphosphonates.
2. secondary prevention of osteoporosis in women who have a personal history or a first degree relative with a history of breast cancer.

60mg Tablet

02279215 APO-RALOXIFENE APX

02239028 EVISTA LIL

02312298 NOVO-RALOXIFENE TEV

02358921 PMS-RALOXIFENE PMS

68:18.00 GONADOTROPINS

NAFARELIN ACETATE

2mg/mL Nasal Solution

02188783 SYNAREL PFI

68:20.02 ALPHA-GLUCOSIDASE INHIBITORS

ACARBOSE

ST 50mg Tablet

02190885 GLUCOBAY BAY

ST 100mg Tablet

02190893 GLUCOBAY BAY

68:20.04 BIGUANIDES

METFORMIN HCL

ST 500mg Tablet

02167786 APO-METFORMIN APX

02257726 CO METFORMIN COB

02229994 DOM-METFORMIN DPC

02099233 GLUCOPHAGE SAC

02229516 GLYCON VAE

02242794 METFORMIN MEL

02353377 METFORMIN SAN

02148765 MYLAN-METFORMIN MYL

02045710 NOVO-METFORMIN TEV

02162822 NU-METFORMIN NXP

02223562 PMS-METFORMIN PMS

02314908 PRO-METFORMIN PDL

02269031 RAN-METFORMIN RBY

02242974 RATIO-METFORMIN RPH

02239081 RIVA-METFORMIN RIV

02246820 SANDOZ-METFORMIN FC SDZ

ST 850mg Tablet

02229785 APO-METFORMIN APX

02257734 CO METFORMIN COB

02242726 DOM-METFORMIN DPC

02162849 GLUCOPHAGE SAC

02239214 GLYCON VAE *

02242793 METFORMIN SOR

02353385 METFORMIN SAN

02229656 MYLAN-METFORMIN MYL

02230475 NOVO-METFORMIN TEV

02229517 NU-METFORMIN NXP

02242589 PMS-METFORMIN PMS

02314894 PRO-METFORMIN PDL

02269058 RAN-METFORMIN RBY

02242931 RATIO-METFORMIN RPH

02242783 RIVA-METFORMIN RIV

02246821 SANDOZ-METFORMIN SDZ

SITAGLIPTIN/METFORMIN

Limited use benefit (prior approval required).

Type 2 diabetes mellitus patients who are not adequately controlled by an adequate trial of metformin AND sulfonylureas or for whom these products are contraindicated or not tolerated

ST 50mg & 1000mg Tablet

02333872 JANUMET FRS

ST 50mg & 500mg Tablet

02333856 JANUMET FRS

ST 50mg & 850mg Tablet

02333864 JANUMET FRS

68:20.05

SITAGLIPTIN

Limited use benefit (prior approval required).

Type 2 diabetes mellitus patients who are not adequately controlled by an adequate trial of metformin AND sulfonylureas or for whom these products are contraindicated or not tolerated

ST 100mg Tablet

02303922 JANUVIA FRS

68:20.08 INSULINS

INSULIN (30% NEUTRAL & 70% ISOPHANE) HUMAN BIOSYNTHETIC

100U/mL Injection

02025248 NOVOLIN GE 30/70 PENFILL NOO *

09853812 NOVOLIN GE 30/70 PENFILL (ON) NOO

02024217 NOVOLIN GE 30/70 VIAL NOO

INSULIN (40% NEUTRAL & 60% ISOPHANE) HUMAN BIOSYNTHETIC

100U/mL Injection

02024314 NOVOLIN GE 40/60 PENFILL NOO

INSULIN (50% NEUTRAL & 50% ISOPHANE) HUMAN BIOSYNTHETIC

100U/mL Injection

02024322 NOVOLIN GE 50/50 PENFILL NOO

INSULIN (ISOPHANE) HUMAN

100U/mL Injection

01959239 HUMULIN N CARTRIDGE/KWIKPEN LIL

09853804 HUMULIN N CARTRIDGE/KWIKPEN (ON) LIL

00587737 HUMULIN N VIAL LIL

02024268 NOVOLIN GE NPH PENFILL NOO *

09853782 NOVOLIN GE NPH PENFILL (ON) NOO

02024225 NOVOLIN GE NPH VIAL NOO

INSULIN (ZINC CRYSTALLINE) HUMAN BIOSYNTHETIC (RDNA ORIGIN)

100U/mL Injection

01959220 HUMULIN R CARTRIDGE LIL

09853766 HUMULIN R CARTRIDGE (ON) LIL

00586714 HUMULIN R VIAL LIL

INSULIN ASPART

100U/mL Injection

02244353 NOVORAPID NOO

02245397 NOVORAPID VIAL NOO

INSULIN GLARGINE

100U/mL Injection

02251930 LANTUS CARTRIDGE SAC

02294338 LANTUS SOLOSTAR SAC

02245689 LANTUS VIAL SAC

INSULIN GLULISINE

100U/mL Injection

02279479 APIDRA CARTRIDGE SAC

02294346 APIDRA SOLOSTAR SAC

02279460 APIDRA VIAL SAC

INSULIN HUMAN BIOSYNTHETIC

100U/mL Injection

02024284 NOVOLIN GE TORONTO PENFILL NOO

09853774 NOVOLIN GE TORONTO PENFILL (ON) NOO

02024233 NOVOLIN GE TORONTO VIAL NOO

INSULIN HUMAN BIOSYNTHETIC 30% & ISOPHANE 70%

100U/mL Injection

01959212 HUMULIN 30/70 CARTRIDGE LIL

09853855 HUMULIN 30/70 CARTRIDGE (ON) LIL

00795879 HUMULIN 30/70 VIAL LIL

INSULIN LISPRO

100U/mL Injection

02229705 HUMALOG CARTRIDGE/KWIKPEN LIL

09853715 HUMALOG LIL * CARTRIDGE/KWIKPEN (ON)

02229704 HUMALOG VIAL LIL

68:20.16 MEGLITINIDES

NATEGLINIDE

ST 60mg Tablet

02245438 STARLIX NVR

ST 120mg Tablet

02245439 STARLIX NVR

REPAGLINIDE

ST 0.5mg Tablet

02321475 CO-REPAGLINIDE COB

02239924 GLUCONORM NOO

02354926 PMS-REPAGLINIDE PMS

02357453 SANDOZ REPAGLINIDE SDZ

ST 1mg Tablet

02321483 CO-REPAGLINIDE COB

02239925 GLUCONORM NOO

02354934 PMS-REPAGLINIDE PMS

02357461 SANDOZ REPAGLINIDE SDZ

ST 2mg Tablet

02321491 CO-REPAGLINIDE COB

02239926 GLUCONORM NOO

02354942 PMS-REPAGLINIDE PMS

02357488 SANDOZ REPAGLINIDE PFI

68:20.20 ANTIDIABETIC AGENTS - SULFONYLUREAS

GLICLAZIDE

ST 30mg Tablet

02242987 DIAMICRON MR SEV

02297795 GLICLAZIDE MR AAP

ST 60mg Tablet

02356422 DIAMICRON MR SEV

ST 80mg Tablet

02245247 APO-GLICLAZIDE APX

00765996 DIAMICRON SEV

02155850 GLICLAZIDE PRO

02248453 GLICLAZIDE PDL

02287072 GLICLAZIDE SAN

02229519 MYLAN-GLICLAZIDE MYL

02238103 NOVO-GLICLAZIDE TEV

ST 2.5mg Tablet

01913654 APO-GLYBURIDE APX

02224550 DIABETA SAC

01959352 GLYBURIDE PDL

02350459 GLYBURIDE SAN

00808733 MYLAN-GLYBE MYL

01913670 NOVO-GLYBURIDE TEV

02020734 NU-GLYBURIDE NXP

01900927 RATIO-GLYBURIDE RPH

02248008 SANDOZ-GLYBURIDE SDZ

ST 5mg Tablet

01913662 APO-GLYBURIDE APX

02224569 DIABETA SAC

02234514 DOM-GLYBURIDE DPC

00720941 EUGLUCON PMS

02350467 GLYBURIDE SAN

00808741 MYLAN-GLYBE MYL

01913689 NOVO-GLYBURIDE TEV

02020742 NU-GLYBURIDE NXP

02236734 PMS-GLYBURIDE PMS

02316544 PRO-GLYBURIDE PDL

01900935 RATIO-GLYBURIDE RPH

02236548 RIVA-GLYBURIDE PHH

02248009 SANDOZ-GLYBURIDE SDZ

TOLBUTAMIDE

ST 500mg Tablet

00312762 TOLBUTAMIDE AAP

68:20.28 THIAZOLIDINEDIONES

Limited use benefit (prior approval required).

For treatment of type 2 diabetic patients who are not adequately controlled by or are intolerant to metformin and sulfonylureas or for whom these products are contraindicated.

ST 15mg Tablet

02303442 ACCEL PIOGLITAZONE ACP

02242572 ACTOS LIL

02302942 APO-PIOGLITAZONE APX

02302861 CO PIOGLITAZONE COB

02307634 DOM-PIOGLITAZONE DPC

02326477 MINT-PIOGLITAZONE MIN

02298279 MYLAN-PIOGLITAZONE MYL

02274914 NOVO-PIOGLITAZONE TEV

02307669 PHL-PIOGLITAZONE PHH

02303124 PMS-PIOGLITAZONE PMS

02312050 PRO-PIOGLITAZONE PDL

02301423 RATIO-PIOGLITAZONE RPH

02297906 SANDOZ PIOGLITAZONE SDZ

02320754 ZYM-PIOGLITAZONE ZYM

Limited use benefit (prior approval required).

For treatment of type 2 diabetic patients who are not adequately controlled by or are intolerant to metformin and sulfonylureas or for whom these products are contraindicated.

ST 30mg Tablet

02303450 ACCEL PIOGLITAZONE ACP

02242573 ACTOS LIL

02302950 APO-PIOGLITAZONE APX

02302888 CO PIOGLITAZONE COB

02307642 DOM-PIOGLITAZONE DPC

02326485 MINT-PIOGLITAZONE MIN

02298287 MYLAN-PIOGLITAZONE MYL

02274922 NOVO-PIOGLITAZONE TEV

02307677 PHL-PIOGLITAZONE PHH

02303132 PMS-PIOGLITAZONE PMS

02312069 PRO-PIOGLITAZONE PDL

02301431 RATIO-PIOGLITAZONE RPH

02297914 SANDOZ PIOGLITAZONE SDZ

02320762 ZYM-PIOGLITAZONE ZYM

ST 45mg Tablet

02303469 ACCEL PIOGLITAZONE ACP

02242574 ACTOS LIL

02302977 APO-PIOGLITAZONE APX

02302896 CO PIOGLITAZONE COB

02307650 DOM-PIOGLITAZONE DPC

02326493 MINT-PIOGLITAZONE MIN

02298295 MYLAN-PIOGLITAZONE MYL

02274930 NOVO-PIOGLITAZONE TEV

02307723 PHL-PIOGLITAZONE PHH

02303140 PMS-PIOGLITAZONE PMS

02312077 PRO-PIOGLITAZONE PDL

02301458 RATIO-PIOGLITAZONE RPH

02297922 SANDOZ PIOGLITAZONE SDZ

02320770 ZYM-PIOGLITAZONE ZYM

ROSIGLITAZONE MALEATE

Limited use benefit (prior approval required).

For treatment of type 2 diabetic patients who are not adequately controlled by or are intolerant to metformin and sulfonylureas or for whom these products are contraindicated.

ST 2mg Tablet

02241112 AVANDIA GSK

ST 4mg Tablet

02241113 AVANDIA GSK

ST 8mg Tablet

02241114 AVANDIA GSK

68:22.12 GLYCOGENOLYTIC AGENTS

GLUCAGON RECOMBINANT DNA ORGIN

1mg/mL Injection

02333627 GLUCAGEN HYPOKIT NOO

02333619 GLUCAGEN VIAL NOO

02243297 GLUCAGON LIL

68:24.00 PARATHYROID

CALCITONIN SALMON (MIACALCIN)

Limited use benefit (prior approval required).

For treatment of patients with postmenopausal osteoporosis who have failed therapy, are intolerant to, or who have contraindications to both bisphosphonates and raloxifene.
OR

For treatment of pain due to osteoporotic fractures of the vertebra in patients requiring an alternative pain reliever (eg. due to co-morbidities, intolerance to alternatives or severe pain not controlled by alternatives) for a period of 3 months

200IU/Dose Nasal Spray

02247585 APO-CALCITONIN APX

02240775 MIACALCIN NVR

02261766 SANDOZ-CALCITONIN SDZ

CALCITONIN SALMON (SYNTHETIC)

200IU/mL Injection

01926691 CALCIMAR SAC

68:28.00 PITUITARY

DESMOPRESSIN ACETATE

4mcg/mL Injection

00873993 DDAVP FEI

0.1mg/mL Nasal Solution

00402516 DDAVP FEI

0.1mg/mL Nasal Spray

00836362 DDAVP FEI

02242465 DESMOPRESSIN AAP

0.1mg Tablet

02284030 APO-DESMOPRESSIN APX

00824305 DDAVP FEI

02304368 PMS-DESMOPRESSIN PMS

02287730 TEVA-DESMOPRESSIN TEV

0.2mg Tablet

02284049 APO-DESMOPRESSIN APX

00824143 DDAVP FEI

02304376 PMS-DESMOPRESSIN PMS

02287749 TEVA-DESMOPRESSIN TEV

60mcg Tablet

02284995 DDAVP MELT FEI

120mcg Tablet

02285002 DDAVP MELT FEI

240mcg Tablet

02285010 DDAVP MELT FEI

68:32.00 PROGESTINS

MEDROXYPROGESTERONE ACETATE

50mg/mL Injection

00030848 DEPO-PROVERA PFI

150mg/mL Injection

00585092 DEPO-PROVERA PFI

02322250 MEDROXYPROGESTERONE SDZ

2.5mg Tablet

02244726 APO-MEDROXY APX

02247581 DOM-MEDROXYPROGESTERONE DPC

02253550 MEDROXY PDL

02221284 NOVO-MEDRONE TEV

02252740 NU-MEDROXY NXP

00708917 PROVERA PFI

5mg Tablet

02244727 APO-MEDROXY APX

02247582 DOM-MEDROXYPROGESTERONE DPC

02253577 MEDROXY PDL

02221292 NOVO-MEDRONE TEV

02252759 NU-MEDROXY NXP

00030937 PROVERA PFI

02010739 PROVERA PAK PFI

10mg Tablet

02277298 APO-MEDROXY APX

02247583 DOM-MEDROXYPROGESTERONE DPC

02221306 NOVO-MEDRONE TEV

00729973 PROVERA PFI

02010933 PROVERA PAK PFI

100mg Tablet

02267640 APO-MEDROXY APX

68:36.04 THYROID AGENTS

LEVOTHYROXINE SODIUM

ST 0.025mg Tablet

02264323 EUTHYROX MYL

02172062 SYNTHROID ABB

ST 0.05mg Tablet

02213192 ELTROXIN GSK

02264331 EUTHYROX MYL

02172070 SYNTHROID ABB

ST 0.075mg Tablet

02264358 EUTHYROX MYL

02172089 SYNTHROID ABB

ST 0.088mg Tablet

02172097 SYNTHROID ABB

ST 0.1mg Tablet

02213206 ELTROXIN GSK

02264374 EUTHYROX MYL

02172100 SYNTHROID ABB

ST 0.112mg Tablet

02264390 EUTHYROX MYL

02171228 SYNTHROID ABB

ST 0.125mg Tablet

02264404 EUTHYROX MYL

02172119 SYNTHROID ABB

ST 0.137mg Tablet

02264412 EUTHYROX MYL

02233852 SYNTHROID ABB

ST 0.15mg Tablet

02213214 ELTROXIN GSK

02264420 EUTHYROX MYL

02172127 SYNTHROID ABB

ST 0.175mg Tablet

02264439 EUTHYROX MYL

02172135 SYNTHROID ABB

ST 0.2mg Tablet

02213222 ELTROXIN GSK

02264447 EUTHYROX MYL

02172143 SYNTHROID ABB

ST 0.3mg Tablet

02264455 EUTHYROX MYL

02172151 SYNTHROID ABB

THYROID

ST 30mg Tablet

00023949 THYROID ERF

ST 60mg Tablet

00023957 THYROID ERF

ST 125mg Tablet

00023965 THYROID ERF

68:36.08 ANTITHYROID AGENTS

PROPYLTHIOURACIL

ST 50mg Tablet

00010200 PROPYL THYRACIL SQU

ST 100mg Tablet

00010219 PROPYL THYRACIL SQU

THIAMAZOLE

ST 5mg Tablet

00015741 TAPAZOLE PAL

ST 10mg Tablet

02296039 TAPAZOLE PAL