Drug Benefit List 2012

86:00 SMOOTH MUSCLE RELAXANTS

86:12.00 GENITOURINARY SMOOTH MUSCLE RELAXANTS

DARIFENACIN HYDROBROMIDE

7.5mg Long Acting Tablet

02273217 ENABLEX NVR

15mg Long Acting Tablet

02273225 ENABLEX NVR

FLAVOXATE HCL

ST 200mg Tablet

00728179 URISPAS PAL

OXYBUTYNIN CHLORIDE

ST 1mg/mL Syrup

02231089 APO-OXYBUTYNIN APX

02223376 PMS-OXYBUTYNIN PMS

ST 2.5mg Tablet

02240549 PMS-OXYBUTYNIN PMS

ST 5mg Tablet

02163543 APO-OXYBUTYNIN APX

02241285 DOM-OXYBUTYNIN DPC

02230800 MYLAN-OXYBUTYNIN MYL

02230394 NOVO-OXYBUTYNIN TEV

02158590 NU-OXYBUTYN NXP

02220059 OXYBUTYN VAE

02350238 OXYBUTYNIN SAN

02220636 OXYBUTYNINE PDL

02240550 PMS-OXYBUTYNIN PMS

02299364 RIVA-OXYBUTYNIN RIV

SOLIFENACIN SUCCINATE

Limited use benefit (prior approval required).

For symptomatic relief in patients with an overactive bladder with symptoms of urinary frequency, urgency or urge incontinence in patients who have failed on or are intolerant of therapy with oxybutynin.

ST 5mg Tablet

02277263 VESICARE AST

ST 10mg Tablet

02277271 VESICARE AST

TOLTERODINE

Limited use benefit (prior approval required).

For the symptomatic relief of patients with an overactive bladder with symptoms of urinary frequency, urgency or urge incontinence or any combination of these in patients who have failed on or are intolerant of therapy with oxybutynin.

ST 2mg Extended Release Capsule

02244612 DETROL LA PFI

ST 4mg Extended Release Capsule

02244613 DETROL LA PFI

ST 1mg Tablet

02239064 DETROL PFI

ST 2mg Tablet

02239065 DETROL PFI

TROSPIUM CHLORIDE

Limited use benefit (prior approval required).

For the symptomatic relief of patients with an overactive bladder with symptoms of urinary frequency, urgency or urge incontinence or any combination of these in patients who have failed on or are intolerant of therapy with oxybutynin.

ST 20mg Tablet

02275066 TROSEC ORY

86:16.00 RESPIRATORY SMOOTH MUSCLE RELAXANTS

OXTRIPHYLLINE

20mg/mL Elixir

00476366 CHOLEDYL PFI

00792942 PMS-OXTRIPHYLLINE PMS

THEOPHYLLINE

5.33mg/mL Elixir

00575151 PMS-THEOPHYLLINE PMS

00466409 PULMOPHYLLIN RIV

00627410 THEOPHYLLINE ATL

5.33mg/mL Solution

01966219 THEOLAIR MMH

100mg Sustained Release Tablet

00692689 APO-THEO APX

02230085 NOVO-THEOPHYL SR TEV

200mg Sustained Release Tablet

00692697 APO-THEO LA APX

02230086 NOVO-THEOPHYL SR TEV

300mg Sustained Release Tablet

00692700 APO-THEO LA APX

02230087 NOVO-THEOPHYL SR TEV

400mg Sustained Release Tablet

02014165 UNIPHYL PFR

600mg Sustained Release Tablet

02014181 UNIPHYL PFR