Drug Benefit List 2010

68:00 HORMONES AND SYNTHETIC SUBSTITUTES

68:04.00 ADRENALS

BECLOMETHASONE DIPROPIONATE

50mcg Inhaler

2242029 QVAR MMH

100mcg Inhaler

2242030 QVAR MMH

BUDESONIDE

0.125mg/mL Inhalation Solution

2229099 PULMICORT NEBUAMP AZC

0.25mg/mL Inhalation Solution

1978918 PULMICORT NEBUAMP AZC

0.5mg/mL Inhalation Solution

1978926 PULMICORT NEBUAMP AZC

100mcg Powder for Inhalation

852074 PULMICORT TURBUHALER AZC

200mcg Powder for Inhalation

851752 PULMICORT TURBUHALER AZC

400mcg Powder for Inhalation

851760 PULMICORT TURBUHALER AZC

CICLESONIDE

100mg/Inhalation Inhaler

2285606 ALVESCO NYC

200mg/Inhalation Inhaler

2285614 ALVESCO NYC

CORTISONE ACETATE

25mg Tablet

280437 CORTISONE VAE

DEXAMETHASONE

0.1mg/mL Elixir

1946897 PMS-DEXAMETHASONE PMS

0.5mg Tablet

2261081 APO-DEXAMETHASONE APX

2237044 PHL-DEXAMETHASONE PHH

1964976 PMS-DEXAMETHASONE PMS

2240684 RATIO-DEXAMETHASONE RPH

0.75mg Tablet

285471 DEXASONE VAE

1964968 PMS-DEXAMETHASONE PMS

2240685 RATIO-DEXAMETHASONE RPH

2mg Tablet

2279363 PMS-DEXAMETHASONE PMS

4mg Tablet

2250055 APO-DEXAMETHASONE APX

489158 DEXASONE VAE

2237046 PHL-DEXAMETHASONE PHH

1964070 PMS-DEXAMETHASONE PMS

2311267 PRO-DEXAMETHASONE PRO

2240687 RATIO-DEXAMETHASONE RPH

DEXAMETHASONE PHOSPHATE

4mg/mL Injection

664227 DEXAMETHASONE SDZ

1977547 DEXAMETHASONE CYX

2204266 DEXAMETHASONE-OMEGA OMG

10mg/mL Injection

874582 DEXAMETHASONE SDZ

783900 PMS-DEXAMETHASONE PMS

FLUDROCORTISONE ACETATE

0.1mg Tablet

2086026 FLORINEF SHI

FLUTICASONE PROPIONATE

50mcg/Inhalation Inhaler

2244291 FLOVENT HFA 50 GSK

125mcg/Inhalation Inhaler

2244292 FLOVENT HFA 125 GSK

250mcg/Inhalation Inhaler

2244293 FLOVENT HFA 250 GSK

50mcg/Dose Powder Diskus

2237244 FLOVENT DISKUS GSK

100mcg/Dose Powder Diskus

2237245 FLOVENT DISKUS GSK

250mcg/Dose Powder Diskus

2237246 FLOVENT DISKUS GSK

500mcg/Dose Powder Diskus

2237247 FLOVENT DISKUS GSK

HYDROCORTISONE

10mg Tablet

30910 CORTEF PFI

20mg Tablet

30929 CORTEF PFI

METHYLPREDNISOLONE

4mg Tablet

30988 MEDROL PFI

16mg Tablet

36129 MEDROL PFI

METHYLPREDNISOLONE ACETATE

40mg/mL Suspension for Injection

30759 DEPO-MEDROL PMJ

2245400 METHYLPREDNISOLONE ACETATE SDZ

2245407 METHYLPREDNISOLONE ACETATE SDZ

80mg/mL Suspension for Injection

30767 DEPO-MEDROL PMJ

2245406 METHYLPREDNISOLONE ACETATE SDZ

2245408 METHYLPREDNISOLONE ACETATE SDZ

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

1934325 DEPO-MEDROL PMJ

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

1934333 DEPO-MEDROL PMJ

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

1934341 DEPO-MEDROL PMJ

PREDNISOLONE SODIUM PHOSPHATE

1mg/mL Oral Liquid

2230619 PEDIAPRED AVT

2245532 PMS-PREDNISOLONE PMS

PREDNISONE

1mg Tablet

598194 APO-PREDNISONE APX

271373 WINPRED VAE

5mg Tablet

312770 APO-PREDNISONE APX

156876 PREDNISONE PRO

50mg Tablet

550957 APO-PREDNISONE APX

232378 NOVO-PREDNISONE NOP

607517 PREDNISONE PRO

TRIAMCINOLONE ACETONIDE

10mg/mL Suspension for Injection

1999761 KENALOG-10 WSB

2229540 TRIAMCINOLONE SDZ

40mg/mL Suspension for Injection

1999869 KENALOG-40 WSB

2229550 TRIAMCINOLONE SDZ

9857128 TRIAMCINOLONE ACETONIDE (5ML) SDZ

TRIAMCINOLONE DIACETATE

40mg/mL Suspension for Injection

1977555 STERILE TRIAMCINOLONE CYX

TRIAMCINOLONE HEXACETONIDE

20mg/mL Suspension for Injection

2194155 ARISTOSPAN VAO

68:08.00 ANDROGENS

DANAZOL

50mg Capsule

2018144 CYCLOMEN SAC

100mg Capsule

2018152 CYCLOMEN SAC

200mg Capsule

2018160 CYCLOMEN SAC

TESTOSTERONE CYPIONATE

100mg/mL Injection

30783 DEPO-TESTOSTERONE PFI

2246063 TESTOSTERONE CYPIONATE SDZ

TESTOSTERONE ENANTHATE

200mg/mL Injection

29246 DELATESTRYL BMS

739944 PMS-TESTOSTERONE PMS

TESTOSTERONE UNDECANOATE

40mg Capsule

782327 ANDRIOL ORG

2322498 PMS-TESTOSTERONE PMS

68:12.00 CONTRACEPTIVES

ETHINYL ESTRADIOL, DESOGESTREL

25mcg & 150mcg (21) Tablet

2272903 LINESSA (21) ORG

25mcg & 150mcg (28) Tablet

2257238 LINESSA (28) ORG

30mcg & 150mcg (21) Tablet

2317192 21-Apr BAR

2042487 MARVELON (21) ORG

30mcg & 150mcg (28) Tablet

2317206 28-Apr BAR

2042479 MARVELON (28) ORG

2042533 ORTHO CEPT (28) JNO

ETHINYL ESTRADIOL, D-NORGESTREL

50mcg & 250mcg (21) Tablet

2043033 OVRAL (21) WAY

ETHINYL ESTRADIOL, DROSPIRENONE

3mg/0.02mg Tablet

2321157 YAZ BAY

30mcg & 3mg (21) Tablet

2261723 YASMIN (21) BEX

30mcg & 3mg (28) Tablet

2261731 YASMIN (28) BEX

ETHINYL ESTRADIOL, ETHYNODIOL DIACETATE

30mcg & 2mg (21) Tablet

469327 DEMULEN 30 (21) PFI

30mcg & 2mg (28) Tablet

471526 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.

11.4mg & 2.6mg Device

2253186 NUVARING ORG

ETHINYL ESTRADIOL, LEVONORGESTREL

20mcg & 100mcg (21) Tablet

2236974 ALESSE (21) WAY

2298538 AVIANE 21 BAR

20mcg & 100mcg (28) Tablet

2236975 ALESSE (28) WAY

2298546 AVIANE 28 BAR

30mcg & 0.05mg (6), 40mcg & 0.075mg (5), 30mcg & 0.125mg (10) (21) Tablet

707600 TRIQUILAR (21) BEX

30mcg & 0.05mg (6), 40mcg & 0.075mg (5), 30mcg & 0.125mg (10), (28) Tablet

707503 TRIQUILAR (28) BEX

30mcg & 150mcg (21) Tablet

2042320 MIN OVRAL (21) WAY

2295946 PORTIA 21 BAR

ETHINYL ESTRADIOL, LEVONORGESTREL

30mcg & 150mcg (28) Tablet

2042339 MIN OVRAL (28) WAY

2295954 PORTIA 28 BAR

ETHINYL ESTRADIOL, NORETHINDRONE

35mcg & 0.5mg (21) Tablet

2187086 BREVICON 0.5/35 (21) PFI

317047 ORTHO 0.5/35 (21) JNO

35mcg & 0.5mg (28) Tablet

2187094 BREVICON 0.5/35 (28) PFI

340731 ORTHO 0.5/35 (28) JNO

35mcg & 0.5mg (7), 35mcg & 1mg (9), 35mcg & 0.5mg (5) (21) Tablet

2187108 SYNPHASIC (21) PFI

35mcg & 0.5mg (7), 35mcg & 1mg (9), 35mcg & 0.5mg (5) (28) Tablet

2187116 SYNPHASIC (28) PFI

35mcg & 1mg (21) Tablet

2189054 BREVICON 1/35 (21) PFI

372846 ORTHO 1/35 (21) JNO

2197502 SELECT 1/35 (21) DSP

35mcg & 1mg (28) Tablet

2189062 BREVICON 1/35 (28) PFI

372838 ORTHO 1/35 (28) JNO

2199297 SELECT 1/35 (28) DSP

35mcg & 500mcg (7), 35mcg & 750mcg (7), 35mcg & 1mg (7) (21) Tablet

602957 ORTHO 7/7/7 (21) JNO

35mcg & 500mcg (7), 35mcg & 750mcg (7), 35mcg & 1mg (7), (28) Tablet

602965 ORTHO 7/7/7 (28) JNO

ETHINYL ESTRADIOL, NORETHINDRONE ACETATE

20mcg & 1mg (21) Tablet

315966 MINESTRIN 1/20 (21) GCL

20mcg & 1mg (28) Tablet

343838 MINESTRIN 1/20 (28) GCL

30mcg & 1.5mg (21) Tablet

297143 LOESTRIN 1.5/30 (21) GCL

30mcg & 1.5mg (28) Tablet

353027 LOESTRIN 1.5/30 (28) GCL

ETHINYL ESTRADIOL, NORGESTIMATE

25mcg & 0.180mg (7), 25mcg & 0.215mg (7), 25mcg & 0.25mg (7) (21) Tablet

2258560 TRI-CYCLEN LO JNO

25mcg & 0.180mg (7), 25mcg & 0.215mg (7), 25mcg & 0.25mg (7), (28) Tablet

2258587 TRI-CYCLEN LO JNO

35mcg & 0.180mg (7), 35mcg & 0.215mg (7), 35mcg & 0.25mg (7) (21) Tablet

2028700 TRI-CYCLEN (21) JNO

35mcg & 0.180mg (7), 35mcg & 0.215mg (7), 35mcg & 0.25mg (7), (28) Tablet

2029421 TRI-CYCLEN (28) JNO

35mcg & 0.25mg (21) Tablet

1968440 CYCLEN (21) JNO

35mcg & 0.25mg (28) Tablet

1992872 CYCLEN (28) JNO

LEVONORGESTREL

52mg Intrauterine Insert

2243005 MIRENA BAY

0.75mg Tablet

2285576 NORLEVO LAP

2241674 PLAN B BAR

NORETHINDRONE

0.35mg (28) Tablet

37605 MICRONOR (28) JNO

68:16.04 ESTROGENS

CONJUGATED ESTROGENS

0.3mg Tablet

2043394 PREMARIN WAY

0.625mg Tablet

265470 C.E.S. VAE

2043408 PREMARIN WAY

1.25mg Tablet

2043424 PREMARIN WAY

0.625mg/g Vaginal Cream

2043440 PREMARIN WAY

CONJUGATED ESTROGENS, MEDROXYPROGESTERONE ACETATE

0.625mg & 2.5mg Kit

2242878 PREMPLUS WAY

0.625mg & 5mg Kit

2242879 PREMPLUS WAY

ESTRADIOL

0.06% Gel

2238704 ESTROGEL SCH

0.39mg Patch

2245676 ESTRADOT 25 NVR

0.585mg Patch

2243999 ESTRADOT 37.5 NVR

0.78mg Patch

2244000 ESTRADOT 50 NVR

1.17mg Patch

2244001 ESTRADOT 75 NVR

1.56mg Patch

2244002 ESTRADOT 100 NVR

5mg Patch

2243722 OESCLIM PAL

10mg Patch

2243724 OESCLIM PAL

25mcg Patch

756849 ESTRADERM NVR

50mcg Patch

756857 ESTRADERM NVR

2246967 SANDOZ-ESTRADIOL DERM SDZ

75mcg Patch

2246968 SANDOZ-ESTRADIOL DERM SDZ

ESTRADIOL

100mcg Patch

756792 ESTRADERM NVR

2246969 SANDOZ-ESTRADIOL DERM SDZ

0.5mg Tablet

2225190 ESTRACE SHI

1mg Tablet

2148587 ESTRACE SHI

2mg Tablet

2148595 ESTRACE SHI

2mg Vaginal Ring

2168898 ESTRING PMJ

25mcg Vaginal Tablet

2241332 VAGIFEM NOO

ESTRADIOL (ESTRADIOL HEMIHYDRATE)

25mcg Patch

2247499 CLIMARA 25 BEX

50mcg Patch

2231509 CLIMARA 50 BEX

75mcg Patch

2247500 CLIMARA 75 BEX

100mcg Patch

2231510 CLIMARA 100 BEX

ESTRADIOL, NORETHINDRONE ACETATE

0.51mg & 4.8mg Patch

2241837 ESTALIS 250/50 NVR

0.62mg & 2.7mg Patch

2241835 ESTALIS 140/50 NVR

ESTRONE

1mg/g Vaginal Cream

727369 NEO-ESTRONE NEO

ESTROPIPATE

0.625mg Tablet

2089793 OGEN PFI

1.25mg Tablet

2089769 OGEN PFI

2.5mg Tablet

2089777 OGEN PFI

ETHINYL ESTRADIOL, NORETHINDRONE ACETATE

1mg/5mcg Tablet

2242531 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

2279215 APO-RALOXIFENE APX

2239028 EVISTA LIL

2312298 NOVO-RALOXIFENE NOP

68:18.00 GONADOTROPINS

NAFARELIN ACETATE

2mg/mL Nasal Solution

2188783 SYNAREL PFI

68:20.02 ALPHA-GLUCOSIDASE INHIBITORS

ACARBOSE

50mg Tablet

2190885 GLUCOBAY BAY

100mg Tablet

2190893 GLUCOBAY BAY

68:20.04 BIGUANIDES

METFORMIN HCL

500mg Tablet

2167786 APO-METFORMIN APX

2257726 CO METFORMIN COB

2229994 DOM-METFORMIN DPC

2148765 GEN-METFORMIN GEN

2099233 GLUCOPHAGE SAC

2229516 GLYCON VAE

2230670 MED-METFORMIN MEC

2220628 METFORMIN PDL

2242794 METFORMIN ZYM

2045710 NOVO-METFORMIN NOP

2162822 NU-METFORMIN NXP

2223562 PMS-METFORMIN PMS

2314908 PRO-METFORMIN PDL

2269031 RAN-METFORMIN RBY

2242974 RATIO-METFORMIN RPH

2233999 RHOXAL-METFORMIN RHO

2239081 RIVA-METFORMIN RIV

2246820 SANDOZ-METFORMIN FC SDZ

METFORMIN HCL

850mg Tablet

2229785 APO-METFORMIN APX

2257734 CO METFORMIN COB

2242726 DOM-METFORMIN DPC

2229656 GEN-METFORMIN GEN

2162849 GLUCOPHAGE SAC

2239214 GLYCON * VAE

2231058 METFORMIN PDL

2242793 METFORMIN ZYM

2230475 NOVO-METFORMIN NOP

2229517 NU-METFORMIN NXP

2242589 PMS-METFORMIN PMS

2314894 PRO-METFORMIN PDL

2269058 RAN-METFORMIN RBY

2242931 RATIO-METFORMIN RPH

2242783 RIVA-METFORMIN RIV

2246821 SANDOZ-METFORMIN SDZ

68:20.08 INSULINS

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

100U/mL Injection

2024217 NOVOLIN GE 30/70 10ML NOO

100U/mL (3mL) Injection

908134 NOVOLIN GE 30/70 PENFILL * NOO

920681 NOVOLIN GE 30/70 PENFILL * NOO

9853812 NOVOLIN GE 30/70 PENFILL NOO

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

100U/mL (3mL) Injection

2024314 NOVOLIN GE 40/60 PENFILL NOO

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

100U/mL (3mL) Injection

2024322 NOVOLIN GE 50/50 PENFILL NOO

INSULIN (ISOPHANE) HUMAN BIOSYNTHETIC

100U/mL Injection

587737 HUMULIN N 10ML LIL

2024225 NOVOLIN GE NPH 10ML NOO

100U/mL (1.5mL) Injection

1959239 HUMULIN N CARTRIDGE LIL

99000342 NOVOLIN GE NPH PENFILL * NOO

100U/mL (3mL) Injection

908991 HUMULIN N CARTRIDGE LIL

9853804 HUMULIN N CARTRIDGE LIL

99001586 HUMULIN N CARTRIDGE * LIL

9853782 NOVOLIN GE NPH PENFILL NOO

99000334 NOVOLIN GE NPH PENFILL * NOO

100U/mL Injection (Pre-filled Pen)

2241310 HUMULIN N LIL

INSULIN (ZINC CRYSTALLINE) HUMAN BIOSYNTHETIC (RDNA ORIGIN)

100U/mL Injection

586714 HUMULIN R 10ML LIL

100U/mL (1.5mL) Injection

1959220 HUMULIN R CARTRIDGE LIL

100U/mL (3mL) Injection

9853766 HUMULIN R CARTRIDGE LIL

99001594 HUMULIN R CARTRIDGE * LIL

INSULIN ASPART

100U/mL Injection

2245397 NOVORAPID NOO

100U/mL (3mL) Injection

2244353 NOVORAPID NOO

INSULIN GLULISINE

100U/mL Injection

2279460 APIDRA SAC

2279479 APIDRA SAC

2294346 APIDRA SOLOSTAR SAC

INSULIN HUMAN BIOSYNTHETIC

100U/mL Injection

2024233 NOVOLIN GE TORONTO NOO

100U/mL (3mL) Injection

908746 NOVOLIN GE TORONTO PENFILL * NOO

921130 NOVOLIN GE TORONTO PENFILL * NOO

9853774 NOVOLIN GE TORONTO PENFILL NOO

INSULIN HUMAN BIOSYNTHETIC 20% & ISOPHANE 80%

100U/mL (3mL) Injection

9853847 HUMULIN 20/80 CARTRIDGE LIL

99001616 HUMULIN 20/80 CARTRIDGE * LIL

INSULIN HUMAN BIOSYNTHETIC 30% & ISOPHANE 70%

100U/mL Injection

795879 HUMULIN 30/70 LIL

100U/mL (1.5mL) Injection

909009 HUMULIN 30/70 CARTRIDGE LIL

1959212 HUMULIN 30/70 CARTRIDGE LIL

100U/mL (3mL) Injection

9853855 HUMULIN 30/70 CARTRIDGE LIL

99001632 HUMULIN 30/70 CARTRIDGE * LIL

INSULIN LISPRO

100IU/mL Injection

2229704 HUMALOG 10ML LIL

100U/mL (1.5mL) Injection

2229705 HUMALOG CARTRIDGE LIL

100U/mL (3mL) Injection

2233562 HUMALOG CARTRIDGE * LIL

9853715 HUMALOG CARTRIDGE * LIL

99002817 HUMALOG CARTRIDGE * LIL

100IU/mL Injection (Pre-filled Pen)

2241283 HUMALOG LIL

INSULIN ZINC SUSPENSION MEDIUM HUMAN BIOSYNTHETIC (RDNA ORIGIN)

100U/mL Injection

646148 HUMULIN L 10ML LIL

68:20.16 MEGLITINIDES

NATEGLINIDE

60mg Tablet

2245438 STARLIX NVR

120mg Tablet

2245439 STARLIX NVR

REPAGLINIDE

0.5mg Tablet

2239924 GLUCONORM NOO

1mg Tablet

2239925 GLUCONORM NOO

2mg Tablet

2239926 GLUCONORM NOO

68:20.20 ANTIDIABETIC AGENTS - SULFONYLUREAS

GLICLAZIDE

30mg Tablet

2297795 APO-GLICLAZIDE MR APX

2242987 DIAMICRON MR SEV

80mg Tablet

2245247 APO-GLICLAZIDE APX

765996 DIAMICRON SEV

2229519 GEN-GLICLAZIDE GEN

2248453 GLICLAZIDE PDL

2238103 NOVO-GLICLAZIDE NOP

2294400 PMS-GLICAZIDE PMS

2155850 PROVAL-GLICLAZIDE PRO

GLYBURIDE

2.5mg Tablet

1913654 APO-GLYBURIDE APX

2224550 DIABETA SAC

2234513 DOM-GLYBURIDE DPC

720933 EUGLUCON PMS

808733 GEN-GLYBE GEN

1959352 GLYBURIDE PDL

2084341 MED-GLYBE MEC

1913670 NOVO-GLYBURIDE NOP

2020734 NU-GLYBURIDE NXP

1900927 RATIO-GLYBURIDE RPH

2236543 RIVA-GLYBURIDE RIV

2248008 SANDOZ-GLYBURIDE SDZ

GLYBURIDE

5mg Tablet

1913662 APO-GLYBURIDE APX

2224569 DIABETA SAC

2234514 DOM-GLYBURIDE DPC

720941 EUGLUCON PMS

808741 GEN-GLYBE GEN

1959360 GLYBURIDE PDL

2085887 MED-GLYBE MEC

1913689 NOVO-GLYBURIDE NOP

2020742 NU-GLYBURIDE NXP

2316544 PDL-GLYBURIDE PDL

2236734 PMS-GLYBURIDE PMS

1900935 RATIO-GLYBURIDE RPH

2236548 RIVA-GLYBURIDE PHH

2248009 SANDOZ-GLYBURIDE SDZ

TOLBUTAMIDE

500mg Tablet

312762 APO-TOLBUTAMIDE APX

156663 TOLBUTAMIDE PRO

08:20.28 THIAZOLIDINEDIONES

PIOGLITAZONE HCL

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.

15mg Tablet

2303442 ACCEL PIOGLITAZONE ACP

2242572 ACTOS LIL

2302942 APO-PIOGLITAZONE APX

2302861 CO PIOGLITAZONE COB

2307634 DOM-PIOGLITAZONE DOM

2298279 GEN-PIOGLITAZONE GEN

2326477 MINT-PIOGLITAZONE MIN

2274914 NOVO-PIOGLITAZONE NOP

2307669 PHL-PIOGLITAZONE PMI

2303124 PMS-PIOGLITAZONE PMS

2312050 PRO-PIOGLITAZONE PDL

2301423 RATIO-PIOGLITAZONE RPH

2297906 SANDOZ PIOGLITAZONE SDZ

2320754 ZYM-PIOGLITAZONE ZYM

PIOGLITAZONE HCL

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.

30mg Tablet

2303450 ACCEL PIOGLITAZONE ACP

2242573 ACTOS LIL

2302950 APO-PIOGLITAZONE APX

2302888 CO PIOGLITAZONE COB

2307642 DOM-PIOGLITAZONE DOM

2298287 GEN-PIOGLITAZONE GEN

2326485 MINT-PIOGLITAZONE MIN

2274922 NOVO-PIOGLITAZONE NOP

2307677 PHL-PIOGLITAZONE PMI

2303132 PMS-PIOGLITAZONE PMS

2312069 PRO-PIOGLITAZONE PDL

2301431 RATIO-PIOGLITAZONE RPH

2297914 SANDOZ PIOGLITAZONE SDZ

2320762 ZYM-PIOGLITAZONE ZYM

45mg Tablet

2303469 ACCEL PIOGLITAZONE ACP

2242574 ACTOS LIL

2302977 APO-PIOGLITAZONE APX

2302896 CO PIOGLITAZONE COB

2307650 DOM-PIOGLITAZONE DOM

2298295 GEN-PIOGLITAZONE GEN

2326493 MINT-PIOGLITAZONE MIN

2274930 NOVO-PIOGLITAZONE NOP

2307723 PHL-PIOGLITAZONE PMI

2303140 PMS-PIOGLITAZONE PMS

2312077 PRO-PIOGLITAZONE PDL

2301458 RATIO-PIOGLITAZONE RPH

2297922 SANDOZ PIOGLITAZONE SDZ

2320770 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.

2mg Tablet

2241112 AVANDIA GSK

4mg Tablet

2241113 AVANDIA GSK

8mg Tablet

2241114 AVANDIA GSK

68:22.12 GLYCOGENOLYTIC AGENTS

GLUCAGON RECOMBINANT DNA ORGIN

1mg/mL Injection

2243297 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.

200IU/Dose Nasal Spray

2247585 APO-CALCITONIN APX

2240775 MIACALCIN NVR

2261766 SANDOZ-CALCITONIN SDZ

CALCITONIN SALMON (SYNTHETIC)

200IU/mL Injection

1926691 CALCIMAR SAC

68:28.00 PITUITARY

DESMOPRESSIN ACETATE

4mcg/mL Injection

873993 DDAVP FEI

0.1mg/mL Nasal Solution

402516 DDAVP FEI

0.1mg/mL Nasal Spray

2242465 APO-DESMOPRESSIN APX

836362 DDAVP FEI

0.1mg Tablet

2284030 APO-DESMOPRESSIN APX

824305 DDAVP FEI

2287730 NOVO-DESMOPRESSIN NOP

2304368 PMS-DESMOPRESSIN PMS

0.2mg Tablet

2284049 APO-DESMOPRESSIN APX

824143 DDAVP FEI

2287749 NOVO-DESMOPRESSIN NOP

2304376 PMS-DESMOPRESSIN PMS

60mcg Tablet

2284995 DDAVP MELT FEI

120mcg Tablet

2285002 DDAVP MELT FEI

240mcg Tablet

2285010 DDAVP MELT FEI

68:32.00 PROGESTINS

MEDROXYPROGESTERONE ACETATE

50mg/mL Injection

30848 DEPO-PROVERA PFI

150mg/mL Injection

585092 DEPO-PROVERA PFI

2322250 MEDROXYPROGESTERONE SDZ

MEDROXYPROGESTERONE ACETATE

2.5mg Tablet

2244726 APO-MEDROXY APX

2247581 DOM-MEDROXYPROGESTERONE DPC

2229838 GEN-MEDROXY GEN

2221284 NOVO-MEDRONE NOP

2252740 NU-MEDROXY NXP

2253550 PDL-MEDROXY PDL

708917 PROVERA PFI

5mg Tablet

2244727 APO-MEDROXY APX

2247582 DOM-MEDROXYPROGESTERONE DPC

2229839 GEN-MEDROXY GEN

2221292 NOVO-MEDRONE NOP

2252759 NU-MEDROXY NXP

2253577 PDL-MEDROXY PDL

30937 PROVERA PFI

2010739 PROVERA PAK PFI

10mg Tablet

2277298 APO-MEDROXY APX

2247583 DOM-MEDROXYPROGESTERONE DPC

2229840 GEN-MEDROXY GEN

2221306 NOVO-MEDRONE NOP

729973 PROVERA PFI

2010933 PROVERA PFI

100mg Tablet

2267640 APO-MEDROXY APX

30945 PROVERA PFI

68:36.04 THYROID AGENTS

LEVOTHYROXINE SODIUM

0.025mg Tablet

2264323 EUTHYROX GEN

2172062 SYNTHROID ABB

0.05mg Tablet

2213192 ELTROXIN GSK

2264331 EUTHYROX GEN

2172070 SYNTHROID ABB

0.075mg Tablet

2264358 EUTHYROX GEN

2172089 SYNTHROID ABB

0.088mg Tablet

2172097 SYNTHROID ABB

0.1mg Tablet

2213206 ELTROXIN GSK

2264374 EUTHYROX GEN

2172100 SYNTHROID ABB

0.112mg Tablet

2264390 EUTHYROX GEN

2171228 SYNTHROID ABB

0.125mg Tablet

2264404 EUTHYROX GEN

2172119 SYNTHROID ABB

LEVOTHYROXINE SODIUM

0.137mg Tablet

2264412 EUTHYROX GEN

2233852 SYNTHROID ABB

0.15mg Tablet

2213214 ELTROXIN GSK

2264420 EUTHYROX GEN

2172127 SYNTHROID ABB

0.175mg Tablet

2264439 EUTHYROX GEN

2172135 SYNTHROID ABB

0.2mg Tablet

2213222 ELTROXIN GSK

2264447 EUTHYROX GEN

2172143 SYNTHROID ABB

0.3mg Tablet

2213230 ELTROXIN GSK

2264455 EUTHYROX GEN

2172151 SYNTHROID ABB

THYROID

30mg Tablet

23949 THYROID ERF

60mg Tablet

23957 THYROID ERF

125mg Tablet

23965 THYROID ERF

68:36.08 ANTITHYROID AGENTS

PROPYLTHIOURACIL

50mg Tablet

10200 PROPYL THYRACIL SQU

100mg Tablet

10219 PROPYL THYRACIL SQU

THIAMAZOLE

5mg Tablet

15741 TAPAZOLE PAL

10mg Tablet

2296039 TAPAZOLE PAL