Drug Benefit List - April 2009

68:00 HORMONES AND SYNTHETIC SUBSTITUTES

68:04.00 ADRENALS

BECLOMETHASONE DIPROPIONATE

50MCG Inhaler CFC-Free

02242029 QVAR MMH

100MCG Inhaler CFC-Free

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/ACT Inhaler

02285606 ALVESCO NCC

200MG/ACT Inhaler

02285614 ALVESCO NCC

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

02240685 RATIO-DEXAMETHASONE RPH

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 HFA

02244291 FLOVENT HFA 50 GSK

125MCG/INHALATION Inhaler HFA

02244292 FLOVENT HFA 125 GSK

250MCG/INHALATION Inhaler HFA

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 ACETATE SDZ

02245407 METHYLPREDNISOLONE ACETATE SDZ

80MG/ML Suspension for Injection

00030767 DEPO-MEDROL PMJ

02245406 METHYLPREDNISOLONE ACETATE SDZ

02245408 METHYLPREDNISOLONE ACETATE 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 AVT

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 NOP

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) SIL

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

68:12.00 CONTRACEPTIVES

ETHINYL ESTRADIOL, D-NORGESTREL

50MCG & 250MCG (21) Tablet

02043033 OVRAL (21) WAY

50MCG & 250MCG (28) Tablet

02043041 OVRAL (28) WAY

ETHINYL ESTRADIOL, DESOGESTREL

25MCG & 150MCG (21) Tablet

02272903 LINESSA (21) ORG

25MCG & 150MCG (28) Tablet

02257238 LINESSA (28) ORG

30MCG & 150MCG (21) Tablet

02317192 APRI 21 BAR

02042487 MARVELON (21) ORG

30MCG & 150MCG (28) Tablet

02317206 APRI 28 BAR

02042479 MARVELON (28) ORG

02042533 ORTHO CEPT (28) JNO

ETHINYL ESTRADIOL, DROSPIRENONE

30MCG & 3MG (21) Tablet

02261723 YASMIN BEX

30MCG & 3MG (28) Tablet

02261731 YASMIN BEX

ETHINYL ESTRADIOL, ETHYNODIOL DIACETATE

30MCG & 2MG (21) Tablet

00469327 DEMULEN 30 (21) PFI

30MCG & 2MG (28) Tablet

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.

11.4MG & 2.6MG Device

02253186 NUVARING ORG

ETHINYL ESTRADIOL, LEVONORGESTREL

20MCG & 100MCG (21) Tablet

02236974 ALESSE (21) WAY

02298538 AVIANE 21 BAR

20MCG & 100MCG (28) Tablet

02236975 ALESSE (28) WAY

02298546 AVIANE 28 BAR

30MCG & 0.05MG (6), 40MCG & 0.075MG (5), 30MCG & 0.125MG (10) (21) Tablet

00707600 TRIQUILAR (21) BEX

30MCG & 0.05MG (6), 40MCG & 0.075MG (5), 30MCG & 0.125MG (10), (28) Tablet

00707503 TRIQUILAR (28) BEX

30MCG & 150MCG (21) Tablet

02042320 MIN OVRAL (21) WAY

02295946 PORTIA 21 BAR

30MCG & 150MCG (28) Tablet

02042339 MIN OVRAL (28) WAY

02295954 PORTIA 28 BAR

ETHINYL ESTRADIOL, NORETHINDRONE

35MCG & 0.5MG (21) Tablet

02187086 BREVICON 0.5/35 (21) PFI

00317047 ORTHO 0.5/35 (21) JNO

35MCG & 0.5MG (28) Tablet

02187094 BREVICON 0.5/35 (28) PFI

00340731 ORTHO 0.5/35 (28) JNO

35MCG & 0.5MG (7), 35MCG & 1MG (9), 35MCG & 0.5MG (5) (21) Tablet

02187108 SYNPHASIC (21) PFI

35MCG & 0.5MG (7), 35MCG & 1MG (9), 35MCG & 0.5MG (5) (28) Tablet

02187116 SYNPHASIC (28) PFI

35MCG & 1MG (21) Tablet

02189054 BREVICON 1/35 (21) PFI

00372846 ORTHO 1/35 (21) JNO

02197502 SELECT 1/35 (21) DSP

35MCG & 1MG (28) Tablet

02189062 BREVICON 1/35 (28) PFI

00372838 ORTHO 1/35 (28) JNO

02199297 SELECT 1/35 (28) DSP

35MCG & 500MCG (7), 35MCG & 750MCG (7), 35MCG & 1MG (7) (21) Tablet

00602957 ORTHO 7/7/7 (21) JNO

35MCG & 500MCG (7), 35MCG & 750MCG (7), 35MCG & 1MG (7), (28) Tablet

00602965 ORTHO 7/7/7 (28) JNO

ETHINYL ESTRADIOL, NORETHINDRONE ACETATE

20MCG & 1MG (21) Tablet

00315966 MINESTRIN 1/20 (21) GCL

20MCG & 1MG (28) Tablet

00343838 MINESTRIN 1/20 (28) GCL

30MCG & 1.5MG (21) Tablet

00297143 LOESTRIN 1.5/30 (21) GCL

30MCG & 1.5MG (28) Tablet

00353027 LOESTRIN 1.5/30 (28) GCL

ETHINYL ESTRADIOL, NORGESTIMATE

25MCG & 0.180MG (7), 25MCG & 0.215MG (7), 25MCG & 0.25MG (7) (21) Tablet

02258560 TRI-CYCLEN LO JNO

25MCG & 0.180MG (7), 25MCG & 0.215MG (7), 25MCG & 0.25MG (7), (28) Tablet

02258587 TRI-CYCLEN LO JNO

35MCG & 0.180MG (7), 35MCG & 0.215MG (7), 35MCG & 0.25MG (7) (21) Tablet

02028700 TRI-CYCLEN (21) JNO

35MCG & 0.180MG (7), 35MCG & 0.215MG (7), 35MCG & 0.25MG (7), (28) Tablet

02029421 TRI-CYCLEN (28) JNO

35MCG & 0.25MG (21) Tablet

01968440 CYCLEN (21) JNO

35MCG & 0.25MG (28) Tablet

01992872 CYCLEN (28) JNO

LEVONORGESTREL

52MG Intrauterine Insert

02243005 MIRENA BAY

0.75MG Tablet

02241674 PLAN B BAR

NORETHINDRONE

0.35MG (28) Tablet

00037605 MICRONOR (28) JNO

68:16.04 ESTROGENS

CONJUGATED ESTROGENS

0.3MG Tablet

02239654 PMS-CONJUGATED ESTROGENS PMS

02043394 PREMARIN WAY

0.625MG Tablet

00265470 C.E.S. VAE

00830232 CONGEST TRI *

00587281 PMS-CONJUGATED ESTROGENS PMS

02043408 PREMARIN WAY

0.9MG Tablet

00830224 CONGEST TRI *

02239655 PMS-CONJUGATED ESTROGENS PMS

1.25MG Tablet

00830216 CONGEST TRI *

00587303 CONJUGATED ESTROGENS PMS

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

5MG Patch

02243722 OESCLIM PAL

10MG Patch

02243724 OESCLIM PAL

25MCG Patch

00756849 ESTRADERM NVR

50MCG Patch

00756857 ESTRADERM NVR

02246967 SANDOZ-ESTRADIOL DERM SDZ

75MCG Patch

02246968 SANDOZ-ESTRADIOL DERM SDZ

100MCG Patch

00756792 ESTRADERM NVR

02246969 SANDOZ-ESTRADIOL DERM SDZ

0.5MG Tablet

02225190 ESTRACE SHI

1MG Tablet

02148587 ESTRACE SHI

2MG Tablet

02148595 ESTRACE SHI

2MG Vaginal Ring

02168898 ESTRING PMJ

25MCG Vaginal Tablet

02241332 VAGIFEM NOO

ESTRADIOL (ESTRADIOL HEMIHYDRATE)

25MCG Patch

02247499 CLIMARA 25 BEX

50MCG Patch

02231509 CLIMARA 50 BEX

75MCG Patch

02247500 CLIMARA 75 BEX

100MCG Patch

02231510 CLIMARA 100 BEX

ESTRADIOL VALERATE

10MG/ML Injection

00029238 DELESTROGEN BMS

ESTRADIOL, ESTRADIOL, NORETHINDRONE ACETATE

50MCG / 250MCG & 50MCG Patch

02108186 ESTRACOMB NVR

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 NEO-ESTRONE NEO

ESTROPIPATE

0.625MG Tablet

02089793 OGEN PFI

1.25MG Tablet

02089769 OGEN PFI

2.5MG Tablet

02089777 OGEN PFI

ETHINYL ESTRADIOL, NORETHINDRONE ACETATE

1MG/5MCG Tablet

02242531 FEMHRT WCI

68:16.12 ESTROGEN AGONISTS-ANTAGONISTS

RALOXIFENE HCL

60MG Tablet

02239028 EVISTA LIL

68:18.00 GONADOTROPINS

NAFARELIN ACETATE

2MG/ML Nasal Solution

02188783 SYNAREL PFI

68:20.02 ALPHA-GLUCOSIDASE INHIBITORS

ACARBOSE

50MG Tablet

02190885 GLUCOBAY BAY

100MG Tablet

02190893 GLUCOBAY BAY

68:20.04 BIGUANIDES

METFORMIN HCL

500MG Tablet

02167786 APO-METFORMIN APX

02265575 BCI-METFORMIN BCI

02257726 CO-METFORMIN COB

02229994 DOM-METFORMIN DPC

02148765 GEN-METFORMIN GEN

02099233 GLUCOPHAGE SAC

02229516 GLYCON VAE

02230670 MED-METFORMIN MEC

02242794 METFORMIN ZYM

02220628 METFORMIN PDL

02045710 NOVO-METFORMIN NOP

02162822 NU-METFORMIN NXP

02223562 PMS-METFORMIN PMS

02314908 PRO-METFORMIN PDL

02269031 RAN-METFORMIN RBY

02242974 RATIO-METFORMIN RPH

02233999 RHOXAL-METFORMIN RHO

02239081 RIVA-METFORMIN RIV

02246820 SANDOZ-METFORMIN FC SDZ

850MG Tablet

02229785 APO-METFORMIN APX

02265583 BCI-METFORMIN BCI

02257734 CO-METFORMIN COB

02242726 DOM-METFORMIN DPC

02229656 GEN-METFORMIN GEN

02162849 GLUCOPHAGE SAC

02239214 GLYCON VAE *

02242793 METFORMIN ZYM

02231058 METFORMIN PDL

02230475 NOVO-METFORMIN NOP

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

68:20.08 INSULINS

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

100U/ML (3ML) Injection

09853812 NOVOLIN GE 30/70 PENFILL NOO

00908134 NOVOLIN GE 30/70 PENFILL NOO *

00920681 NOVOLIN GE 30/70 PENFILL NOO *

100U/ML Injection

02024217 NOVOLIN GE 30/70 10ML NOO

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

100U/ML (3ML) Injection

02024314 NOVOLIN GE 40/60 PENFILL NOO

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

100U/ML (3ML) Injection

02024322 NOVOLIN GE 50/50 PENFILL NOO

INSULIN (ISOPHANE) HUMAN BIOSYNTHETIC

100U/ML (1.5ML) Injection

01959239 HUMULIN N CARTRIDGE LIL

99000342 NOVOLIN GE NPH PENFILL NOO *

100U/ML (3ML) Injection

09853804 HUMULIN N CARTRIDGE LIL

00908991 HUMULIN N CARTRIDGE LIL

99001586 HUMULIN N CARTRIDGE LIL *

09853782 NOVOLIN GE NPH PENFILL NOO

99000334 NOVOLIN GE NPH PENFILL NOO *

100U/ML Injection

00587737 HUMULIN N 10ML LIL

02024225 NOVOLIN GE NPH 10ML NOO

100U/ML Injection (Pre-filled Pen)

02241310 HUMULIN N LIL

INSULIN (ZINC CRYSTALLINE) HUMAN BIOSYNTHETIC (RDNA ORIGIN)

100U/ML (1.5ML) Injection

01959220 HUMULIN R CARTRIDGE LIL

100U/ML (3ML) Injection

09853766 HUMULIN R CARTRIDGE LIL

99001594 HUMULIN R CARTRIDGE LIL *

100U/ML Injection

00586714 HUMULIN R 10ML LIL

INSULIN ASPART

100U/ML (3ML) Injection

02244353 NOVORAPID NOO

100U/ML Injection

02245397 NOVORAPID NOO

INSULIN HUMAN BIOSYNTHETIC

100U/ML (3ML) Injection

09853774 NOVOLIN GE TORONTO PENFILL NOO

00908746 NOVOLIN GE TORONTO PENFILL NOO *

00921130 NOVOLIN GE TORONTO PENFILL NOO *

100U/ML Injection

02024233 NOVOLIN GE TORONTO NOO

INSULIN HUMAN BIOSYNTHETIC 20% & ISOPHANE 80%

100U/ML (1.5ML) Injection

01962655 HUMULIN 20/80 CARTRIDGE LIL

100U/ML (3ML) Injection

09853847 HUMULIN 20/80 CARTRIDGE LIL

99001616 HUMULIN 20/80 CARTRIDGE LIL *

INSULIN HUMAN BIOSYNTHETIC 30% & ISOPHANE 70%

100U/ML (1.5ML) Injection

01959212 HUMULIN 30/70 CARTRIDGE LIL

00909009 HUMULIN 30/70 CARTRIDGE LIL

100U/ML (3ML) Injection

09853855 HUMULIN 30/70 CARTRIDGE LIL

99001632 HUMULIN 30/70 CARTRIDGE LIL *

100U/ML Injection

00795879 HUMULIN 30/70 LIL

INSULIN LISPRO

100IU/ML Injection

02229704 HUMALOG 10ML LIL

100U/ML (1.5ML) Injection

02229705 HUMALOG CARTRIDGE LIL

100U/ML (3ML) Injection

09853715 HUMALOG CARTRIDGE LIL *

02233562 HUMALOG CARTRIDGE LIL *

99002817 HUMALOG CARTRIDGE LIL *

100IU/ML Injection (Pre-filled Pen)

02241283 HUMALOG LIL

INSULIN LISPRO (25%), INSULIN LISPRO PROTAMINE SUSPENSION (75%)

100U/ML (3ML) Injection

02240294 HUMALOG MIX 25 LIL

100U/ML (3ML) Injection (Pre-filled Pen)

02240295 HUMALOG MIX 25 LIL

INSULIN ZINC SUSPENSION MEDIUM HUMAN BIOSYNTHETIC (RDNA ORIGIN)

100U/ML Injection

00646148 HUMULIN L 10ML LIL

68:20.16 MEGLITINIDES

NATEGLINIDE

60MG Tablet

02245438 STARLIX NVR

120MG Tablet

02245439 STARLIX NVR

180MG Tablet

02245440 STARLIX NVR

REPAGLINIDE

0.5MG Tablet

02239924 GLUCONORM NOO

1MG Tablet

02239925 GLUCONORM NOO

2MG Tablet

02239926 GLUCONORM NOO

68:20.20 ANTIDIABETIC AGENTS - SULFONYLUREAS

GLICLAZIDE

30MG Tablet

02297795 APO-GLICLAZIDE MR APX

02242987 DIAMICRON MR SEV

80MG Tablet

02245247 APO-GLICLAZIDE APX

00765996 DIAMICRON SEV

02229519 GEN-GLICLAZIDE GEN

02248453 GLICLAZIDE PDL

02238103 NOVO-GLICLAZIDE NOP

02294400 PMS-GLICAZIDE PMS

02155850 PROVAL-GLICLAZIDE PRO

GLYBURIDE

2.5MG Tablet

01913654 APO-GLYBURIDE APX

02224550 DIABETA SAC

02234513 DOM-GLYBURIDE DPC

00720933 EUGLUCON PMS

00808733 GEN-GLYBE GEN

01959352 GLYBURIDE PDL

02084341 MED-GLYBE MEC

01913670 NOVO-GLYBURIDE NOP

02020734 NU-GLYBURIDE NXP

02236733 PMS-GLYBURIDE PMS

01900927 RATIO-GLYBURIDE RPH

02236543 RIVA-GLYBURIDE RIV

02248008 SANDOZ-GLYBURIDE SDZ

5MG Tablet

01913662 APO-GLYBURIDE APX

02224569 DIABETA SAC

02234514 DOM-GLYBURIDE DPC

00720941 EUGLUCON PMS

00808741 GEN-GLYBE GEN

01959360 GLYBURIDE PDL

02085887 MED-GLYBE MEC

01913689 NOVO-GLYBURIDE NOP

02020742 NU-GLYBURIDE NXP

02236734 PMS-GLYBURIDE PMS

01900935 RATIO-GLYBURIDE RPH

02236548 RIVA-GLYBURIDE PHH

02248009 SANDOZ-GLYBURIDE SDZ

TOLBUTAMIDE

500MG Tablet

00312762 APO-TOLBUTAMIDE APX

00156663 TOLBUTAMIDE PRO

68:20.28 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

02242572 ACTOS LIL

02302942 APO-PIOGLITAZONE APX

02302861 CO PIOGLITAZONE CBT

02298279 GEN-PIOGLITAZONE GEN

02274914 NOVO-PIOGLITAZONE NOP

02303124 PMS-PIOGLITAZONE PMS

02312050 PRO-PIOGLITAZONE PDL

02301423 RATIO-PIOGLITAZONE RPH

02297906 SANDOZ PIOGLITAZONE SDZ

30MG Tablet

02242573 ACTOS LIL

02302950 APO-PIOGLITAZONE APX

02302888 CO PIOGLITAZONE CBT

02298287 GEN-PIOGLITAZONE GEN

02274922 NOVO-PIOGLITAZONE NOP

02303132 PMS-PIOGLITAZONE PMS

02312069 PRO-PIOGLITAZONE PDL

02301431 RATIO-PIOGLITAZONE RPH

02297914 SANDOZ PIOGLITAZONE SDZ

45MG Tablet

02242574 ACTOS LIL

02302977 APO-PIOGLITAZONE APX

02302896 CO PIOGLITAZONE CBT

02298295 GEN-PIOGLITAZONE GEN

02274930 NOVO-PIOGLITAZONE NOP

02303140 PMS-PIOGLITAZONE PMS

02312077 PRO-PIOGLITAZONE PDL

02301458 RATIO-PIOGLITAZONE RPH

02297922 SANDOZ PIOGLITAZONE SDZ

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

02241112 AVANDIA GSK

4MG Tablet

02241113 AVANDIA GSK

8MG Tablet

02241114 AVANDIA GSK

68:22.12 GLYCOGENOLYTIC AGENTS

GLUCAGON RECOMBINANT DNA ORGIN

1MG/ML Injection

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.

200IU/dose Nasal Spray

02247585 APO-CALCITONIN APX

02240775 MIACALCIN NVR

CALCITONIN SALMON (SYNTHETIC)

200IU/ML Injection

01926691 CALCIMAR SAC

200IU/ML Nasal Spray

02261766 SANDOZ-CALCITONIN SDZ

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

02242465 APO-DESMOPRESSIN APX

00836362 DDAVP FEI

0.1MG Tablet

02284030 APO-DESMOPRESSIN APX

00824305 DDAVP FEI

02287730 NOVO-DESMOPRESSIN NOP

02304368 PMS-DESMOPRESSIN PMS

0.2MG Tablet

02284049 APO-DESMOPRESSIN APX

00824143 DDAVP FEI

02287749 NOVO-DESMOPRESSIN NOP

02304376 PMS-DESMOPRESSIN PMS

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

02229838 GEN-MEDROXY GEN

02221284 NOVO-MEDRONE NOP

02252740 NU-MEDROXY NXP

02253550 PDL-MEDROXY PDL

02246627 PMS-MEDROXYPROGESTERONE PMS

00708917 PROVERA PFI

5MG Tablet

02244727 APO-MEDROXY APX

02247582 DOM-MEDROXYPROGESTERONE DPC

02229839 GEN-MEDROXY GEN

02221292 NOVO-MEDRONE NOP

02252759 NU-MEDROXY NXP

02253577 PDL-MEDROXY PDL

02246628 PMS-MEDROXYPROGESTERONE PMS

00030937 PROVERA PFI

02010739 PROVERA PAK PFI

10MG Tablet

02277298 APO-MEDROXY APX

02247583 DOM-MEDROXYPROGESTERONE DPC

02229840 GEN-MEDROXY GEN

02221306 NOVO-MEDRONE NOP

02246629 PMS-MEDROXYPROGESTERONE PMS

00729973 PROVERA PFI

02010933 PROVERA PFI

100MG Tablet

02267640 APO-MEDROXY APX

00030945 PROVERA PFI

68:36.04 THYROID AGENTS

LEVOTHYROXINE SODIUM

0.025MG Tablet

02264323 EUTHYROX GEN

02187574 LEVO-T PMS

02172062 SYNTHROID ABB

0.05MG Tablet

02213192 ELTROXIN GSK

02264331 EUTHYROX GEN

02187582 LEVO-T PMS

02172070 SYNTHROID ABB

0.075MG Tablet

02264358 EUTHYROX GEN

02187590 LEVO-T PMS

02172089 SYNTHROID ABB

0.088MG Tablet

02264366 EUTHYROX GEN

02172097 SYNTHROID ABB

0.1MG Tablet

02213206 ELTROXIN GSK

02264374 EUTHYROX GEN

02187604 LEVO-T PMS

02172100 SYNTHROID ABB

0.112MG Tablet

02264390 EUTHYROX GEN

02171228 SYNTHROID ABB

0.125MG Tablet

02264404 EUTHYROX GEN

02187612 LEVO-T PMS

02172119 SYNTHROID ABB

0.137MG Tablet

02264412 EUTHYROX GEN

02233852 SYNTHROID ABB

0.15MG Tablet

02213214 ELTROXIN GSK

02264420 EUTHYROX GEN

02187620 LEVO-T PMS

02172127 SYNTHROID ABB

0.175MG Tablet

02264439 EUTHYROX GEN

02172135 SYNTHROID ABB

0.2MG Tablet

02213222 ELTROXIN GSK

02264447 EUTHYROX GEN

02187639 LEVO-T PMS

02172143 SYNTHROID ABB

0.3MG Tablet

02213230 ELTROXIN GSK

02264455 EUTHYROX GEN

02187647 LEVO-T PMS

02172151 SYNTHROID ABB

THYROID

30MG Tablet

00023949 THYROID ERF

60MG Tablet

00023957 THYROID ERF

125MG Tablet

00023965 THYROID ERF

68:36.08 ANTITHYROID AGENTS

PROPYLTHIOURACIL

50MG Tablet

00010200 PROPYL THYRACIL SQU

100MG Tablet

00010219 PROPYL THYRACIL SQU

THIAMAZOLE

5MG Tablet

00015741 TAPAZOLE PAL