Formulary
February 2016
July 2011 was the last printed
publication of
the Nova Scotia Formulary
Monthly updates of the Nova Scotia
Formulary
are published online and can be
accessed
at:
www.nspharmacare.ca
Copyright ©1996 Nova Scotia Department of Health. All rights reserved. No part of this publication may be reproduced,
photocopied, stored on a retrieval system, or transmitted without the express written consent of the publisher.
TABLE OF CONTENTS
INTRODUCTION
How to Use the Formulary
Legend
ATC CLASSIFICATION OF DRUGS
A - Alimentary Tract and Metabolism
B - Blood and Blood Forming Organs
C - Cardiovascular System
D - Dermatologicals
G - Genito-Urinary System & Sex Hormones
H - Systemic Hormonal Preparations, Excluding Sex Hormones
J - General Antiinfectives, Systemic
L - Antineoplastics and Immunomodulating Agents
M - Musculo-Skeletal System
N - Nervous System
P - Antiparasitic Products, Insecticides and Repellents
R - Respiratory System
S - Sensory Organs
V - Various
MISCELLANEOUS
Diabetic Supplies Benefit List
Ostomy Supplies Benefit List
Compounds
APPENDICES
Appendix I - Abbreviations
Appendix II - Abbreviations of Manufacturers' Names
Appendix III - Criteria for Coverage of Exception Status Drugs
PRODUCT INDEX
1-23
24-31
32-77
78-88
89-100
101-107
108-129
130-143
144-155
156-215
216-217
218-226
227-234
235-237
INTRODUCTION
The Nova Scotia Formulary details which drugs and supplies are benefits under the Nova Scotia Seniors'
Pharmacare Program, Family Pharmacare Program, Diabetes Assistance Program, Community Services
Pharmacare Programs and Drug Assistance for Cancer Patients.
The Formulary is provided on our website at www.nspharmacare.ca in PDF.
The ATC Classification System
All medications are classified according to the Anatomical Therapeutic Chemical (ATC) Classification System which
is used by the World Health Organization for pharmacoepidemiological purposes and by the Patented Medicine
Prices Review Board for pricing purposes.
The ATC Classification System groups chemically similar products according to their site of action and facilitates the
comparison of new medicines with previously available medicines. There are fourteen main groups in the ATC
system:
A
B
C
D
G
H
J
L
M
N
P
R
S
V
Alimentary tract and metabolism
Blood and blood forming organs
Cardiovascular system
Dermatologicals
Genito-urinary system and sex hormones
Systemic hormonal preparations, excluding sex hormones
General antiinfectives, systemic
Antineoplastic and immunomodulating agents
Musculo-skeletal system
Nervous system
Antiparasitic products, insecticides and repellents
Respiratory system
Sensory organs
Various
Each group is subdivided into anatomical, therapeutic and chemical subgroups as shown in the Legend.
A drug may be given more than one ATC code. If it is available in two or more strengths or formulations with clearly
different therapeutic uses, the drug would appear in various categories depending on its different forms. If a drug
has more than one clinical indication, the main indication is chosen for the listing of the various brands and strengths
of this drug.
February 2016
Page i
Interchangeability, Maximum Reimbursable Price (MRP) and Pharmacare Reimbursement Price (PRP)
The Formulary indicates those products which have been deemed interchangeable by the Drugs and Therapeutics
Committee of the Nova Scotia Department of Health and Wellness (see the Legend). For generic products that
meet the criteria for interchangeability a Maximum Reimbursable Price (MRP) may be applied. MRP is the maximum
price established by the Pharmacare Programs for an interchangeable generic drug. MRP is applied to those drugs
which are Pharmacare benefits, and have been deemed interchangeable (e.g., brand name drugs and their generic
equivalents) The MRP is the maximum amount that the Pharmacare Programs will reimburse providers for one unit
(tablet, capsule, millilitre, etc.) of a drug.
For each interchangeable, generic drug category, a maximum reimbursable price per unit (e.g., tablet, capsule,
millilitre) is determined by calculating a percentage of the cost of the equivalent brand name drug. The percentage of the
MRP is reimbursed at 25% of the cost of the manufacturer list price of the equivalent brand drug.
Some generic drugs may have exceptions to the MRP formula, and their MRP will also be included in the
Reimbursement List. Exemptions to the MRP are available for beneficiaries who have experienced a severe or life
threatening reaction with lower cost alternatives. A request must be received from the prescriber detailing the reaction.
Providers shall not charge any cost difference between the MRP of the drug and amount reimbursed by the
Pharmacare Programs unless the beneficiary requests the higher priced drug. If the beneficiary requests the higher
priced drug the extra cost is not counted toward their annual maximum copayment or annual maximum deductible.
In addition, a Pharmacare Reimbursement Price (PRP) is the maximum cost assigned to:
-
certain groups of drugs that are similar in effect;
specific services for which coverage is established;
certain unit dose and special delivery formats that are also available in less expensive bulk formats; and
certain supplies that are used for the same function.
The PRP is the maximum amount the Pharmacare Program reimburses providers for one unit of a drug (tablet,
capsule, millilitre, etc.) supply or service.
Providers may charge the beneficiary the portion of their AAC that exceeds the PRP. The extra cost is not counted
toward the beneficiary's annual maximum copayment or annual maximum deductible.
In all pricing categories, except AAC, the Pharmacare Programs will reimburse pharmacies the lesser of the amount
submitted, or as applicable, MLP, MRP, or PRP.
All Manufacturer List Prices (MLPs) will be updated on a quarterly basis unless otherwise notified directly by the
manufacturer.
Prescriber
The Formulary provides prescriber codes (see Legend) associated with each benefit under the Pharmacare
Programs. These codes indicate which benefits will be reimbursed when prescribed by a specific prescriber.
February 2016
Page ii
The Nova Scotia Government Pharmacare Programs
1.
Seniors' Pharmacare Program - available to all Nova Scotia seniors 65 years or older who have a valid
Nova Scotia Health Card, and do not have private drug coverage.
2.
Community Services Pharmacare Programs - The Department of Community Services provides drug
benefits as part of the Income Assistance Programs (including Special Needs Pharmacare and Transitional
Pharmacare), the Low Income Pharmacare Program for Children, Services for Persons with Disabilities and
the Children in Care Programs. Eligibility is determined by the Department of Community Services.
3.
Drug Assistance for Cancer Patients, an income based assistance program covering medication for the
treatment of cancer.
4.
Diabetes Assistance Program, an income based assistance program covering medication and supplies
needed for diabetes treatment.
5.
Under 65-Long Term Care (LTC) Pharmacare, provides drug coverage for long term care residents under
65 years of age who have no drug insurance.
6.
Family Pharmacare Program, an income based program available to all Nova Scotians with a valid Nova
Scotia Health Card who are not currently receiving drug benefits through Seniors', Community Services,
Diabetes Assistance or the Under 65-Long Term Care Pharmacare Programs.
The benefit status of medications reimbursed under these programs are indicated, in the fourth column of the ATC
classification, by the letters S (Seniors' Pharmacare), F (Community Services Pharmacare / Under 65-Long Term
Care Pharmacare / Family Pharmacare), C (Drug Assistance for Cancer Patients), D (Diabetes Assistance) or E
(Exception Status Drug - see Appendix III). If this column is blank, the product is not a benefit under any of these
programs.
February 2016
Page iii
Miscellaneous Section
Diabetes and ostomy supplies are listed in this section. These products are benefits under the Seniors' and
Community Services Pharmacare Programs and are cross-referenced in the appropriate ATC classification.
Diabetes supplies are also benefits under the Diabetes Assistance Program.
Legend
1. Therapeutic Main Group
2. Therapeutic Subgroup
3. Chemical/Therapeutic Subgroup
4. Subgroup for Chemical Substance
5. Brand or Manufacturer's Name of the Drug, including dosage form
and/or route and strength
6. Interchangeable Product Heading
7. Prescriber Codes:
D - Physician / Dentist
N - Nurse Practitioner
P - Pharmacist
M - Midwife
O - Prescribing Optometrist
8. Unit Price
9. M = Maximum Reimbursement Price
P = Pharmacare Reimbursement Price
L = Manufacturer's List Price
10. Benefit Status (plans for which the product is a benefit):
S - Seniors' Pharmacare
F - Community Services Pharmacare
- Under 65-Long Term Care Pharmacare
- Family Pharmacare
C - Drug Assistance for Cancer Patients
D - Diabetes Assistance Program
E - Exception status applies (see Appendix III)
11. Drug Identification Number (DIN)
12. Abbreviation of Manufacturer (see Appendix II)
13. Interchangeable Product Indicator
February 2016
Page iv
CA
Alimentary Tract and Metabolism
A01
STOMATOLOGICALS, MOUTH PREPARATIONS
A01A
STOMATOLOGICALS, MOUTH PREPARATIONS
A01AB
ANTIINFECTIVES FOR LOCAL ORAL TREATMENT
A01AB03
CHLORHEXIDINE
chlorhexidine 0.12% oral rinse
Perichlor 0.12% Oral Rinse
Peridex 0.12% Oral Rinse
A01AB22
DNP
1.4040
M
SF
01964054
01999788
TAR Y
BRI Y
DNP
0.0618
M
E
02229777
PDP Y
01966065
MDS Y
02135620
AUR N
01966529
CHU N
Diovol Plus O/L
00116815
CHU N
Diovol Plus Tab
Mylanta Double St Tab
00116882
02019787
CHU N
JNJ N
00584215
APX
OTHER DRUGS FOR LOCAL ORAL TREATMENT
A01AD02
BENZYDAMINE
benzydamine 0.15% oral rinse
Pharixia 1.5mg/mL Oral Rinse
Tantum Oral Rinse (discontinued)
A02
DRUGS FOR ACID RELATED DISORDERS
A02A
ANTACIDS
A02AB
ALUMINIUM COMPOUNDS
A02AB01
ALUMINIUM HYDROXIDE
Basaljel 500mg Cap
DNP
0.1500
L
SF
COMB OF ALUMINIUM,CALCIUM AND MAGNESIUM COMPOUNDS
A02AD01
ANTACIDS, ORDINARY SALT COMBINATIONS
Diovol Regular O/L
A02AF
PDP N
TRIAMCINOLONE
triamcinolone acetonide 0.1% oral paste
Oracort 0.1% Oral Paste
Kenalog 0.1% in Orabase (discontinued)
A02AD
02247104
CORTICOSTEROIDS FOR LOCAL ORAL TREATMENT
A01AC01
A01AD
PMS Y
ZIA Y
DOXYCYCLINE
Periostat 20mg Cap
A01AC
02240433
02237452
ANTACIDS WITH ANTIFLATULENTS
A02AF02
ANTACIDS, ORDINARY SALT COMBINATIONS AND ANTIFLATULENTS
A02B
DRUGS FOR PEPTIC ULCER AND GASTROESOPHAGEAL REFLUX DISEASE(GERD)
A02BA
H2-RECEPTOR ANTAGONISTS
A02BA01
CIMETIDINE
cimetidine 200mg tab
Apo-Cimetidine 200mg Tab
February 2016
DNP
0.3284
M
SF
1
Y
A
Alimentary Tract and Metabolism
Tagamet 200mg Tab (discontinued)
cimetidine 300mg tab
Apo-Cimetidine 300mg Tab
MYLAN-Cimetidine 300mg Tab
Tagamet 300mg Tab (discontinued)
cimetidine 400mg tab
Apo-Cimetidine 400mg Tab
MYLAN-Cimetidine 400mg Tab
MYLAN-Cimetidine 600mg Tab
Tagamet 600mg Tab (discontinued)
A02BA02
0.1791
M
SF
00487872
APX
DNP
0.1791
M
SF
02227444
01916815
MYL Y
GSK Y
DNP
DNP
0.2930
0.2930
M
M
SF
SF
00600059
02227452
APX Y
MYL Y
01916785
GSK Y
Y
DNP
0.3405
M
SF
00600067
APX
DNP
0.3405
M
SF
02227460
01916777
MYL Y
GSK Y
Y
02280833
APX
DNP
0.0932
M
SFC
02242940
02212374
TEV Y
GSK Y
DNP
DNP
1.3976
1.3976
M
M
SFC
SFC
02256711
02212366
SDZ Y
GSK Y
02230507
02230287
APX
JNJ
Y
Y
Y
Y
RANITIDINE
ranitidine 15mg/mL o/l
Apo-Ranitidine 15mg/mL O/L
Novo-Ranitidine 15mg/mL O/L
Zantac 15mg/mL O/L (discontinued)
ranitidine 25mg/mL inj
Ranitidine 25mg/mL Inj
Zantac 25mg/mL Inj
ranitidine 75mg tab
Apo-Ranitidine 75mg Tab
Zantac 75mg Tab (discontinued)
February 2016
SKR Y
DNP
Tagamet 400mg Tab (discontinued)
cimetidine 600mg tab
Apo-Cimetidine 600mg Tab
01916793
Y
ranitidine 150mg tab
Apo-Ranitidine 150mg Tab
CO Ranitidine 150mg Tab
DNP
DNP
0.1800
0.1800
M
M
SFC
SFC
00733059
02248570
APX
ATV
Myl-Ranitidine 150mg Tab (discontinued)
MYLAN-Ranitidine 150mg Tab
DNP
0.1800
M
SFC
02367378
02207761
MYL Y
MYL Y
Novo-Ranidine 150mg Tab
pms-Ranitidine 150mg Tab
DNP
DNP
0.1800
0.1800
M
M
SFC
SFC
00828564
02242453
TEV Y
PMS Y
RAN-Ranitidine 150mg Tab
Ranitidine 150mg Tab
DNP
DNP
0.1800
0.1800
M
M
SFC
SFC
02336480
02353016
RAN Y
SAS Y
Ranitidine-150mg Tab
Sandoz Ranitidine 150mg Tab
DNP
DNP
0.1800
0.1800
M
M
SFC
SFC
02385953
02243229
SIV
SDZ
Zantac 150mg Tab
DNP
0.1800
M
SFC
02212331
GSK Y
ranitidine 300mg tab
Apo-Ranitidine 300mg Tab
DNP
0.3600
M
SFC
00733067
APX
CO Ranitidine 300mg Tab
Myl-Ranitidine 300mg Tab (discontinued)
DNP
0.3600
M
SFC
02248571
02367386
ATV Y
MYL Y
MYLAN-Ranitidine 300mg Tab
Novo-Ranidine 300mg Tab
DNP
DNP
0.3600
0.3600
M
M
SFC
SFC
02207788
00828556
MYL Y
TEV Y
pms-Ranitidine 300mg Tab
RAN-Ranitidine 300mg Tab
DNP
DNP
0.3600
0.3600
M
M
SFC
SFC
02242454
02336502
PMS Y
RAN Y
Ranitidine 300mg Tab
Ranitidine-300mg Tab
DNP
DNP
0.3600
0.3600
M
M
SFC
SFC
02353024
02385961
SAS
SIV
2
Y
Y
Y
Y
Y
A
Alimentary Tract and Metabolism
Sandoz Ranitidine 300mg Tab
Zantac 300mg Tab
A02BA03
DNP
DNP
0.3600
0.3600
M
M
SFC
SFC
02243230
02212358
SDZ Y
GSK Y
DNP
1.9850
M
SF
02247745
OMG Y
00728128
FRS
02247735
OMG Y
00728128
FRS
Y
Y
FAMOTIDINE
famotidine 10mg/mL inj
Famotidine Omega 10mg/mL Inj
Pepcid 10mg/mL Inj (discontinued)
famotidine 10mg/mL inj (pf)
Famotidine Omega (PF) 10mg/mL Inj
DNP
1.9850
M
SF
Pepcid (PF) 10mg/mL Inj (discontinued)
famotidine 20mg tab
Apo-Famotidine 20mg Tab
DNP
0.1800
P
SF
01953842
APX
Famotidine 20mg Tab
MYLAN-Famotidine 20mg Tab
DNP
DNP
0.1800
0.1800
P
P
SF
SF
02351102
02196018
SAS Y
MYL Y
Novo-Famotidine 20mg Tab
Pepcid 20mg Tab (discontinued)
DNP
0.1800
P
SF
02022133
00710121
TEV
FRS
Y
Y
famotidine 40mg tab
Apo-Famotidine 40mg Tab
Famotidine 40mg Tab
DNP
DNP
0.3600
0.3600
P
P
SF
SF
01953834
02351110
APX
SAS
Y
Y
MYLAN-Famotidine 40mg Tab
Novo-Famotidine 40mg Tab
DNP
DNP
0.3600
0.3600
P
P
SF
SF
02196026
02022141
MYL Y
TEV Y
00710113
FRS
02220156
00778338
APX Y
PDP Y
02220164
00778346
APX Y
PDP Y
02244022
AAP
Y
00813966
PFI
Y
02244023
AAP
Y
00632600
PFI
Y
02329425
02296438
MYL Y
SDZ Y
02119579
AZE
Pepcid 40mg Tab (discontinued)
A02BA04
DNP
0.1800
P
SF
nizatidine 300mg cap
Apo-Nizatidine 300mg Cap (discontinued)
Axid 300mg Cap (discontinued)
PROSTAGLANDINS
A02BB01
MISOPROSTOL
misoprostol 100mcg tab
Misoprostol 100mcg Tab
DNPM
0.2804
M
SF
Cytotec 100mcg Tab (discontinued)
misoprostol 200mcg tab
Misoprostol 200mcg Tab
DNPM
0.4669
M
SF
Cytotec 200mcg Tab (discontinued)
A02BC
Y
NIZATIDINE
nizatidine 150mg cap
Apo-Nizatidine 150mg Cap (discontinued)
Axid 150mg Cap
A02BB
Y
PROTON PUMP INHIBITORS
A02BC01
OMEPRAZOLE
omeprazole 10mg cap
MYLAN-Omeprazole 10mg Cap
Sandoz Omeprazole 10mg Cap
Losec 10mg Cap (discontinued)
*exception status when daily dose exceeds once daily
February 2016
DNP
DNP
0.2059
0.2059
P
P
SFC*
SFC*
3
Y
A
Alimentary Tract and Metabolism
omeprazole 10mg cap/tab
MYLAN-Omeprazole 10mg Cap
DNP
0.2059
P
SFC*
02329425
MYL Y
Teva-Omeprazole 10mg Tab
Losec 10mg Tab
DNP
DNP
0.2059
0.2059
P
P
SFC*
SFC*
02295407
02230737
TEV
AZE
Y
Y
omeprazole 20mg cap
Apo-Omeprazole 20mg Cap
DNP
0.4117
M
SFC*
02245058
APX
Y
MYLAN-Omeprazole 20mg Cap
Omeprazole 20mg Cap
DNP
DNP
0.4117
0.4117
M
M
SFC*
SFC*
02329433
02348691
MYL Y
SAS Y
Omeprazole-20mg Cap
pms-Omeprazole 20mg Cap
DNP
DNP
0.4117
0.4117
M
M
SFC*
SFC*
02411857
02320851
SIV Y
PMS Y
RAN-Omeprazole 20mg Cap
Sandoz Omeprazole 20mg Cap
DNP
DNP
0.4117
0.4117
M
M
SFC*
SFC*
02403617
02296446
RAN Y
SDZ Y
Losec 20mg Cap
*exception status when daily dose exceeds once daily.
DNP
0.4117
M
SFC*
00846503
AZE
Y
omeprazole 20mg cap/tab
Apo-Omeprazole 20mg Cap
Jamp-Omeprazole DR 20mg Tab
DNP
DNP
0.4117
0.4117
M
M
SFC*
SFC*
02245058
02420198
APX
JPC
Y
Y
MYLAN-Omeprazole 20mg Cap
Novo-Omeprazole Delayed-Release 20mg Tab
DNP
DNP
0.4117
0.4117
M
M
SFC*
SFC*
02329433
02295415
MYL Y
TEV Y
Omeprazole 20mg Cap
Omeprazole DR 20mg Tab
DNP
DNP
0.4117
0.4117
M
M
SFC*
SFC*
02348691
02416549
SAS
AHI
pms-Omeprazole DR 20mg Tab
RAN-Omeprazole 20mg tab
DNP
DNP
0.4117
0.4117
M
M
SFC*
SFC*
02310260
02374870
PMS Y
RAN Y
Losec 20mg Tab
*exception status when daily dose exceeds once daily.
DNP
0.4117
M
SFC*
02190915
AZE
Y
pantoprazole sodium 20mg EC tab
Apo-Pantoprazole 20mg DR Tab
DNP
0.3246
M
SFC*
02292912
APX
Y
Jamp-Pantoprazole 20mg Tab
Pantoprazole-20mg Tab
DNP
DNP
0.3246
0.3246
M
M
SFC*
SFC*
02408414
02385740
JPC
SIV
Y
Y
RAN-Pantoprazole 20mg Tab
Sandoz Pantoprazole 20mg DR Tab
DNP
DNP
0.3246
0.3246
M
M
SFC*
SFC*
02305038
02301075
RAN Y
SDZ Y
Teva-Pantoprazole 20mg DR Tab
Pantoloc 20mg Tab
DNP
DNP
0.3246
0.3246
M
M
SFC*
SFC*
02285479
02241804
TEV
TAK
pantoprazole magnesium 40mg EC tab
Pantoprazole Magnesium 40mg Tab
DNP
0.3750
M
E
02441853
APR Y
Teva-Pantoprazole Magnesium 40mg Tab
Tecta 40mg Tab
DNP
DNP
0.3750
0.3750
M
M
E
E
02440628
02267233
TEV
TAK
Y
Y
pantoprazole sodium 40mg EC tab
Abbott-Pantoprazole 40mg Tab (discontinued)
Apo-Pantoprazole 40mg DR Tab
DNP
0.3628
M
SFC*
02412969
02292920
ABB
APX
Y
Y
Auro-Pantoprazole 40mg Tab
CO Pantoprazole 40mg DR Tab
DNP
DNP
0.3628
0.3628
M
M
SFC*
SFC*
02415208
02300486
ARO Y
ATV Y
Jamp-Pantoprazole 40mg Tab
Mar-Pantoprazole 40mg DR Tab
DNP
DNP
0.3628
0.3628
M
M
SFC*
SFC*
02357054
02416565
JPC Y
MAR Y
*exception status when daily dose exceeds once daily.
A02BC02
Y
Y
PANTOPRAZOLE
Y
Y
*exception status when daily dose exceeds once daily.
February 2016
4
A
Alimentary Tract and Metabolism
MINT-Pantoprazole 40mg DR Tab
MYLAN-Pantoprazole 40mg DR Tab
DNP
DNP
0.3628
0.3628
M
M
SFC*
SFC*
02417448
02299585
MNT Y
MYL Y
Pantoprazole 40mg DR Tab
Pantoprazole 40mg Tab
DNP
DNP
0.3628
0.3628
M
M
SFC*
SFC*
02437945
02370808
PMS Y
SAS Y
Pantoprazole-40mg Tab
pms-Pantoprazole 40mg DR Tab
DNP
DNP
0.3628
0.3628
M
M
SFC*
SFC*
02385759
02307871
SIV Y
PMS Y
RAN-Pantoprazole 40mg Tab
Sandoz Pantoprazole 40mg DR Tab
DNP
DNP
0.3628
0.3628
M
M
SFC*
SFC*
02305046
02301083
RAN Y
SDZ Y
Teva-Pantoprazole 40mg DR Tab
Pantoloc 40mg Tab
DNP
DNP
0.3628
0.3628
M
M
SFC*
SFC*
02285487
02229453
TEV
TAK
lansoprazole 15mg cap
Apo-Lansoprazole 15mg DR Cap
Lansoprazole 15mg Cap
DNP
DNP
0.2500
0.2500
P
P
E
E
02293811
02433001
APX Y
PMS Y
Lansoprazole 15mg Cap
Lansoprazole 15mg DR Cap
DNP
DNP
0.2500
0.2500
P
P
E
E
02385767
02357682
SIV
SAS
MYLAN-Lansoprazole 15mg DR Cap
Novo-Lansoprazole 15mg DR Cap
DNP
DNP
0.2500
0.2500
P
P
E
E
02353830
02280515
MYL Y
TEV Y
pms-Lansoprazole 15mg Cap (discontinued)
RAN-Lansoprazole 15mg Cap
DNP
0.2500
P
E
02395258
02402610
PMS Y
RAN Y
Sandoz Lansoprazole 15mg DR Cap
Prevacid 15mg Cap
DNP
DNP
0.2500
0.2500
P
P
E
E
02385643
02165503
SDZ
ABB
Y
Y
Prevacid FasTab 15mg Tab
DNP
2.0000
L
E
02249464
ABB
N
lansoprazole 30mg cap
Apo-Lansoprazole 30mg DR Cap
Lansoprazole 30mg Cap
DNP
DNP
0.5000
0.5000
M
M
E
E
02293838
02433028
APX Y
PMS Y
Lansoprazole 30mg DR Cap
Lansoprazole-30mg Cap
DNP
DNP
0.5000
0.5000
M
M
E
E
02357690
02410389
SAS
SIV
MYLAN-Lansoprazole 30mg DR Cap
Novo-Lansoprazole 30mg DR Cap
DNP
DNP
0.5000
0.5000
M
M
E
E
02353849
02280523
MYL Y
TEV Y
pms-Lansoprazole 30mg DR Cap (discontinued)
RAN-Lansoprazole 30mg Cap
DNP
0.5000
M
E
02395266
02402629
PMS Y
RAN Y
Sandoz Lansoprazole 30mg DR Cap
Prevacid 30mg Cap
DNP
DNP
0.5000
0.5000
M
M
E
E
02385651
02165511
SDZ
ABB
Y
Y
Prevacid FasTab 30mg Tab
DNP
2.0000
L
E
02249472
ABB
N
02422638
ABB
Y
Apo-Rabeprazole 10mg EC Tab
MYLAN-Rabeprazole 10mg Tab
DNP
DNP
0.1204
0.1204
M
M
SFC
SFC
02345579
02408392
APX Y
MYL Y
pms-Rabeprazole 10mg EC Tab
Rabeprazole EC 10mg Tab
DNP
DNP
0.1204
0.1204
M
M
SFC
SFC
02310805
02356511
PMS Y
SAS Y
Rabeprazole-10mg Tab
RAN-Rabeprazole 10mg Tab
DNP
DNP
0.1204
0.1204
M
M
SFC
SFC
02385449
02298074
SIV Y
RAN Y
Sandoz Rabeprazole 10mg EC Tab
Teva-Rabeprazole-EC 10mg Tab
DNP
DNP
0.1204
0.1204
M
M
SFC
SFC
02314177
02296632
SDZ
TEV
Y
Y
*exception status when daily dose exceeds once daily.
A02BC03
A02BC04
LANSOPRAZOLE
Y
Y
RABEPRAZOLE
rabeprazole 10mg EC tab
Abbott-Rabeprazole 10mg DR Tab (discontinued)
February 2016
Y
Y
5
Y
Y
A
Alimentary Tract and Metabolism
Pariet 10mg Tab
DNP
0.1204
M
SFC
rabeprazole 20mg EC tab
Abbott-Rabeprazole 20mg DR Tab (discontinued)
A02BC05
A02BD
JAN
Y
02422646
ABB
Y
Apo-Rabeprazole 20mg EC Tab
MYLAN-Rabeprazole 20mg Tab
DNP
DNP
0.2408
0.2408
M
M
SFC
SFC
02345587
02408406
APX Y
MYL Y
pms-Rabeprazole 20mg EC Tab
Rabeprazole EC 20mg Tab
DNP
DNP
0.2408
0.2408
M
M
SFC
SFC
02310813
02356538
PMS Y
SAS Y
Rabeprazole-20mg Tab
RAN-Rabeprazole 20mg Tab
DNP
DNP
0.2408
0.2408
M
M
SFC
SFC
02385457
02298082
SIV Y
RAN Y
Sandoz Rabeprazole 20mg EC Tab
Teva-Rabeprazole-EC 20mg Tab
DNP
DNP
0.2408
0.2408
M
M
SFC
SFC
02314185
02296640
SDZ
TEV
Y
Y
Pariet 20mg Tab
DNP
0.2408
M
SFC
02243797
JAN
Y
esomeprazole 20mg tab
Apo-Esomeprazole 20mg DR Tab
MYLAN-Esomeprazole 20mg DR Tab
02339099
02383039
APX Y
MYL Y
RAN-Esomeprazole 20mg Tab
Nexium 20mg Tab
02423979
02244521
RAN Y
AZE Y
esomeprazole 20mg tab
Esomeprazole 20mg Tab
02442493
SIV
Y
esomeprazole 40mg cap/tab
Apo-Esomeprazole 40mg DR Tab
02339102
APX
Y
Esomeprazole 40mg DR Tab
Esomeprazole 40mg Tab
02431173
02442507
SAS
SIV
Y
Y
MYLAN-Esomeprazole 40mg DR Tab
pms-Esomeprazole DR 40mg Cap
02383047
02379171
MYL Y
PMS Y
RAN-Esomeprazole 40mg Tab
Nexium 40mg Tab
02423987
02244522
RAN Y
AZE Y
ESOMEPRAZOLE
COMBINATIONS FOR ERADICATION OF HELICOBACTER PYLORI
A02BD07
LANSOPRAZOLE, CLARITHROMYCIN AND AMOXICILLIN
Hp-PAC
*quantity limit of one pack per year
A02BX
02243796
DNP
86.6500
L
SF*
02238525
ABB
N
Y
DRUGS FOR PEPTIC ULCER AND GASTROESOPHAGEAL REFLUX DISEASE(GERD)
A02BX02
SUCRALFATE
sucralfate 1g tab
Apo-Sucralfate 1g Tab
DNP
0.1924
M
SF
02125250
APX
Novo-Sucralate 1g Tab
Sulcrate 1g Tab
DNP
DNP
0.1924
0.1924
M
M
SF
SF
02045702
02100622
TEV Y
AXC Y
Sulcrate 1g/5mL Plus Susp
DNP
0.1122
L
SF
02103567
AXC N
A03
DRUGS FOR FUNCTIONAL GASTROINTESTINAL DISORDERS
A03A
DRUGS FOR FUNCTIONAL BOWEL DISORDERS
A03AA
SYNT ANTICHOLIN ESTERS WITH TERTIARY AMINO GROUP
A03AA05
February 2016
TRIMEBUTINE
6
A
Alimentary Tract and Metabolism
A03AA07
A03AB
Trimebutine 100mg Tab
DNP
0.2690
L
SFC
02245663
AAP
N
trimebutine 200mg tab
Trimebutine 200mg Tab
DNP
0.5680
M
SFC
02245664
AAP
Y
Modulon 200mg Tab
DNP
0.5680
M
SFC
00803499
AXC Y
Jamp-Dicyclomine 10mg Tab
DNP
0.1128
L
SFC
02391619
JPC
Bentylol 10mg Tab
Dicyclomine 10mg/mL Inj
DNP
0.1265
L
SFC
02103087
00392812
AXC N
SDZ N
Bentylol 10mg/5mL Syr
DNP
0.0677
L
SFC
02102978
AXC N
Jamp-Dicyclomine 20mg Tab
DNP
0.2207
L
SFC
02366088
JPC
Bentylol 20mg Tab
DNP
0.2388
L
SFC
02103095
AXC N
DNP
3.9775
L
SFC
02039508
SDZ
N
00009881
SDZ
N
DICYCLOVERINE (DICYCLOMINE)
GLYCOPYRROLATE (GLYCOPYRRONIUM)
Glycopyrrolate 0.2mg/mL Inj
PAPAVERINE AND DERIVATIVES
A03AD01
PAPAVERINE
Papaverine HCl 32.5mg/mL Inj
A03AX
N
SYNT ANTICHOLINERGICS,ESTERS,QUATER AMMONIUM COMP
A03AB02
A03AD
N
OTHER DRUGS FOR FUNCTIONAL BOWEL DISORDERS
A03AX04
A03AX13
PINAVERIUM
Dicetel 50mg Tab
DNP
0.3533
L
SFC
01950592
ABB
N
Dicetel 100mg Tab
DNP
0.6160
L
SFC
02230684
ABB
N
00292990
CHU N
SILICONES
Ovol 80 (80mg) Tab
A03B
BELLADONNA AND DERIVATIVES, PLAIN
A03BA
BELLADONNA ALKALOIDS, TERTIARY AMINES
A03BA01
A03BA03
ATROPINE
Atropine Sulfate 0.4mg/mL Inj
DNP
2.2880
L
SFC
00392782
SDZ
N
Atropine Sulfate 0.6mg/mL Inj
DNP
2.4880
L
SFC
00392693
SDZ
N
DNP
0.4935
L
SFC
00125857
AXS
N
DN
DN
0.2330
0.2330
M
M
SFC
SFC
00618454
00115630
AAP
VLN
Y
Y
HYOSCYAMINE
Levsin 0.125mg SL Tab
A03C
ANTISPASMODICS IN COMBINATION WITH PSYCHOLEPTICS
A03CA
SYNTHETICS,PSYCHOLEPTICS COMBINATIONS
A03CA02
CLIDINIUM AND PSYCHOLEPTICS
chlordiazepoxide HCl 5mg & clidinium Br 2.5mg cap
Apo-Chlorax 5/2.5mg Cap
Librax Cap
February 2016
7
A
Alimentary Tract and Metabolism
A03E
ANTISPASMODICS,ANTICHOLINERGICS WITH ANALGESICS
A03ED
ANTISPASMODICS IN COMBINATION WITH OTHER DRUGS
A03ED99
ANTISPASMODICS, COMBINATIONS
DN
1.4919
L
SFC
00176141
PAL
metoclopramide HCl 1mg o/l
Metonia 1mg/mL Liq
Maxeran 1mg/mL O/L (discontinued)
DNP
0.0475
M
SFC
02230433
00314714
PDP Y
NRD Y
metoclopramide HCl 5mg tab
Metonia 5mg Tab
Maxeran 5mg Tab (discontinued)
DNP
0.0590
M
SFC
02230431
02099195
PDP Y
MRR Y
Metoclopramide 5mg/mL Inj
DNP
2.9500
L
SFC
02185431
SDZ
metoclopramide HCl 10mg tab
Metonia 10mg Tab
Maxeran 10mg Tab (discontinued)
DNP
0.0618
M
SFC
02230432
02099209
PDP Y
MRR Y
domperidone maleate 10mg tab
Apo-Domperidone 10mg Tab
DNPM
0.0594
M
SFC
02103613
APX
Y
Domperidone 10mg Tab
Domperidone-10mg Tab
DNPM
DNPM
0.0594
0.0594
M
M
SFC
SFC
02350440
02238341
SAS
SIV
Y
Y
Jamp-Domperidone 10mg Tab
Mar-Domperidone 10mg Tab
DNPM
DNPM
0.0594
0.0594
M
M
SFC
SFC
02369206
02403870
JPC Y
MAR Y
MYL Y
PMS Y
Bellergal Spacetabs
A03F
PROPULSIVES
A03FA
PROPULSIVES
A03FA01
A03FA03
METOCLOPRAMIDE
MYLAN-Domperidone 10mg Tab (discontinued)
pms-Domperidone 10mg Tab
DNPM
0.0594
M
SFC
02278669
02236466
RAN-Domperidone 10mg Tab
ratio-Domperidone 10mg Tab
DNPM
DNPM
0.0594
0.0594
M
M
SFC
SFC
02268078
01912070
RAN Y
TEV Y
Teva-Domperidone 10mg Tab
Motilium 10mg Tab (discontinued)
DNPM
0.0594
M
SFC
02157195
00855820
TEV
JAN
Y
Y
ondansetron 4mg tab
Apo-Ondansetron 4mg Tab
DNP
2.5556
P
E
02288184
APX
Y
CO Ondansetron 4mg Tab
Jamp-Ondansetron 4mg Tab
DNP
DNP
2.5556
2.5556
P
P
E
E
02296349
02313685
ATV
JPC
Y
Y
Mar-Ondansetron 4mg Tab
MINT-Ondansetron 4mg Tab
DNP
DNP
2.5556
2.5556
P
P
E
E
02371731
02305259
MAR Y
MNT Y
MYLAN-Ondansetron 4mg Tab
NAT-Ondansetron 4mg Tab
DNP
DNP
2.5556
2.5556
P
P
E
E
02297868
02417839
MYL Y
NAT Y
ANTIEMETICS AND ANTINAUSEANTS
A04A
ANTIEMETICS AND ANTINAUSEANTS
A04AA
SEROTONIN (5HT3) ANTAGONISTS
February 2016
N
DOMPERIDONE
A04
A04AA01
N
ONDANSETRON
8
A
Alimentary Tract and Metabolism
A04AA02
Novo-Ondansetron 4mg Tab
Ondansetron 4mg Tab
DNP
DNP
2.5556
2.5556
P
P
E
E
02264056
02421402
TEV
SAS
Ondansetron-Odan 4mg Tab (discontinued)
pms-Ondansetron 4mg Tab
DNP
2.5556
P
E
02306212
02258188
ODN Y
PMS Y
RAN-Ondansetron 4mg Tab
ratio-Ondansetron 4mg Tab (discontinued)
DNP
2.5556
P
E
02312247
02278529
RAN Y
TEV Y
Sandoz Ondansetron 4mg Tab
Septa-Ondansetron 4mg Tab
DNP
DNP
2.5556
2.5556
P
P
E
E
02274310
02376091
SDZ
SPT
Zofran 4mg Tab
DNP
2.5556
P
E
02213567
NVR Y
ondansetron 4mg/5mL o/l
Ondansetron 4mg/5mL O/L
DNP
1.5856
M
E
02291967
AAP
Zofran 4mg/5mL O/L
DNP
1.5856
M
E
02229639
NVR Y
ondansetron OD 4mg tab/film
Ondissolve ODF 4mg Film
DNP
2.5556
P
E
02389983
TAK
Sandoz Ondansetron ODT 4mg Tab
Zofran ODT 4mg Tab
DNP
DNP
2.5556
2.5556
P
P
E
E
02444674
02239372
SDZ Y
NVR Y
ondansetron 8mg tab
Apo-Ondansetron 8mg Tab
CO Ondansetron 8mg Tab
DNP
DNP
5.1111
5.1111
M
M
E
E
02288192
02296357
APX
ATV
Jamp-Ondansetron 8mg Tab
Mar-Ondansetron 8mg Tab
DNP
DNP
5.1111
5.1111
M
M
E
E
02313693
02371758
JPC Y
MAR Y
MINT-Ondansetron 8mg Tab
MYLAN-Ondansetron 8mg Tab
DNP
DNP
5.1111
5.1111
M
M
E
E
02305267
02297876
MNT Y
MYL Y
NAT-Ondansetron 8mg Tab
Ondansetron 8mg Tab
DNP
DNP
5.1111
5.1111
M
M
E
E
02417847
02421410
NAT Y
SAS Y
pms-Ondansetron 8mg Tab
RAN-Ondansetron 8mg Tab
DNP
DNP
5.1111
5.1111
M
M
E
E
02258196
02312255
PMS Y
RAN Y
ratio-Ondansetron 8mg Tab (discontinued)
Sandoz Ondansetron 8mg Tab
DNP
5.1111
M
E
02278537
02274329
TEV
SDZ
Y
Y
Septa-Ondansetron 8mg Tab
Teva-Ondansetron 8mg Tab
DNP
DNP
5.1111
5.1111
M
M
E
E
02376105
02264064
SPT
TEV
Y
Y
Zofran 8mg Tab
DNP
5.1111
M
E
02213575
NVR Y
ondansetron OD 8mg tab/film
Ondissolve ODF 8mg Film
DNP
4.9930
M
E
02389991
TAK
Sandoz Ondansetron ODT 8mg Tab
Zofran ODT 8mg Tab
DNP
DNP
4.9930
4.9930
M
M
E
E
02444682
02239373
SDZ Y
NVR Y
DNP
14.6475
M
E
02308894
AAP
Y
02185881
HLR
Y
Aloxi 0.25/5mL Inj
02381710
EIS
N
Aloxi 0.5mg Cap
02381729
EIS
N
Kytril 1mg Tab (discontinued)
A04AD
February 2016
Y
Y
Y
Y
Y
PALONOSETRON
OTHER ANTIEMETICS
A04AD01
Y
Y
GRANISETRON
granisetron 1mg tab
Granisetron 1mg Tab
A04AA05
Y
Y
SCOPOLAMINE
9
A
Alimentary Tract and Metabolism
Scopolamine 0.4mg/mL Inj
Scopolamine 0.6mg/mL Inj
DNP
DNP
4.8900
5.3600
L
L
SFC
SFC
Transderm-V 1.5mg Patch
A04AD11
A04AD12
A04AD99
HOS N
HOS N
80024336
NVR N
Buscopan 10mg Tab
DNP
0.3383
L
SF
00363812
BOE N
hyoscine butylbromide 20mg/mL inj
Hyoscine Butylbromide 20mg/mL Inj
Buscopan 20mg/mL Inj (discontinued)
DNP
4.5150
M
SF
02229868
00363839
SDZ Y
BOE Y
nabilone 0.25mg cap
RAN-Nabilone 0.25mg Cap
DN
1.0471
M
E
02358077
RAN Y
Teva-Nabilone 0.25mg Cap
Cesamet 0.25mg Cap
DN
DN
1.0471
1.0471
M
M
E
E
02392925
02312263
TEV
VLN
nabilone 0.5mg cap
CO Nabilone 0.5mg Cap
pms-Nabilone 0.5mg Cap
DN
DN
0.7756
0.7756
M
M
E
E
02393581
02380900
ATV Y
PMS Y
RAN-Nabilone 0.5mg Cap
Teva-Nabilone 0.5mg Cap
DN
DN
0.7756
0.7756
M
M
E
E
02358085
02384884
RAN Y
TEV Y
Cesamet 0.5mg Cap
DN
0.7756
M
E
02256193
VLN
Y
nabilone 1mg cap
CO Nabilone 1mg Cap
DN
1.5513
M
E
02393603
ATV
Y
pms-Nabilone 1mg Cap
RAN-Nabilone 1mg Cap
DN
DN
1.5513
1.5513
M
M
E
E
02380919
02358093
PMS Y
RAN Y
Teva-Nabilone 1mg Cap
Cesamet 1mg Cap
DN
DN
1.5513
1.5513
M
M
E
E
02384892
00548375
TEV
VLN
Y
Y
Emend Tri-Pack Cap
DNP
31.8633
L
E
02298813
FRS
N
Emend 80mg Cap
DNP
31.8600
L
E
02298791
FRS
N
Emend 125mg Cap
DNP
31.8617
L
E
02298805
FRS
N
dimenhydrinate 10mg/mL IV inj
Dimenhydrinate 10mg/mL IV Amp
Gravol 10mg/mL IV Amp (discontinued)
00392731
00013560
SDZ Y
CHU Y
Gravol 15mg/5mL O/L
00230197
CHU N
Gravol 25mg Supp
00783595
CHU N
00392537
00013579
SDZ Y
CHU Y
Dimenhydrinate 50mg Supp
00392553
SDZ
Gravol 50mg Tab
00013803
CHU N
Dimenhydrinate 100mg (Adult) Supp
Gravol 100mg Supp
00392545
00013609
SDZ N
CHU N
NABILONE (CANNABINOID (THC) DERIVATIVES)
DIMENHYDRINATE
DNP
DNP
1.3800
1.3800
M
M
SFC
SFC
BILE AND LIVER THERAPY
February 2016
Y
Y
APREPITANT
dimenhydrinate 50mg/mL IM inj
Dimenhydrinate 50mg/mL IM Inj
Gravol l 50mg/mL IM Inj
A05
00541869
00541877
10
N
A
Alimentary Tract and Metabolism
A05A
BILE THERAPY
A05AA
BILE ACID PREPARATIONS
A05AA02
A05AA99
URSODIOL (URSODEOXYCHOLIC ACID)
ursodiol 250mg tab
pms-Ursodiol C 250mg Tab
DN
1.0043
M
E
02273497
PMS Y
Urso 250mg Tab
DN
1.0043
M
E
02238984
AXC Y
ursodiol 500mg tab
pms-Ursodiol C 500mg Tab
DN
1.9050
M
E
02273500
PMS Y
Urso DS 500mg Tab
DN
1.9050
M
E
02245894
AXC Y
DN
0.3905
L
SF
02162148
NNC N
pms-Docusate Sodium 4mg/mL Syr
DNP
0.0254
L
C
00703508
PMS N
pms-Docusate Sodium 10mg Drp
Colace 10mg/mL Drp
DNP
DNP
0.1996
0.1770
L
L
C
C
00880140
02090163
PMS N
WLS N
Colace 20mg/5mL Syrup
DNP
0.0232
L
C
02086018
WLS N
ratio-Docusate Sodium 20mg/5mL Syr
DNP
0.0523
L
C
00870226
TEV
Selax 20mg/5mL USP Syr
DNP
0.0220
L
C
00695033
ODN N
docusate sodium 100mg cap
Docusate Sodium 100mg Cap
DNP
0.0378
M
C
02426838
SAS
pms-Docusate Sodium 100mg Cap
DNP
0.0378
M
C
00703494
PMS Y
Docusate Sodium 100mg Cap
Jamp-Docusate Sodium 100mg Cap
DNP
DNP
0.0383
0.0250
L
L
C
C
00716731
02245946
TAR N
JPC N
Novo-Docusate 100mg Cap
ratio-Docusate Sodium 100mg Cap
DNP
0.0258
L
C
02020084
00870196
TEV
TEV
Colace 100mg Cap
Selax 100mg Cap
DNP
DNP
0.1567
0.0383
L
L
C
C
02106256
00514888
WLS N
ODN N
Apo-Bisacodyl 5mg Tab
DNP
0.0450
L
C
00545023
APX
Jamp-Bisacodyl 5mg Tab
Bisacodyl-ODAN 5mg Tab
DNP
DNP
0.0405
0.0550
L
L
C
C
02246039
02273411
JPC N
ODN N
Dulcolax ECT 5mg Tab
Jamp-Bisacodyl 5mg Supp
DNP
DNP
0.1950
0.4500
L
L
C
C
00254142
02410893
BOE N
JPC N
pms-Bisacodyl 10mg Supp
DNP
0.5014
L
C
00582883
PMS N
Dulcolax 10mg Supp
Jamp-Bisacodyl 10mg Supp
DNP
DNP
1.1667
0.5014
L
L
C
C
00003875
02361450
BOE N
JPC N
DEHYDROCHOLIC ACID
Dycholium 300mg Tab
A06
LAXATIVES
A06A
LAXATIVES
A06AA
SOFTENERS, EMOLLIENTS
A06AA02
A06AB
DOCUSATE SODIUM
N
Y
N
N
CONTACT LAXATIVES
A06AB02
A06AB06
February 2016
BISACODYL
SENNA GLYCOSIDES
11
N
A
Alimentary Tract and Metabolism
A06AB56
Senokot 1.7mg/mL Syr
DNP
0.0477
L
C
00367729
PFR
N
Jamp-Sennosides 8.6mg Tab
Senokot 8.6mg Tab
DNP
DNP
0.0488
0.1740
L
L
C
C
80009595
00026158
JPC
PFR
N
N
DNP
0.1910
L
C
00026123
PFR
N
CoLyte Powder for Solution
DNP
0.0048
L
C
00677442
PDP N
Peglyte Powder for Solution
DNP
0.0048
L
C
00777838
PDP N
DNP
DNP
0.0145
0.0145
M
M
E
E
02242814
02295881
APX
JPC
Y
Y
DNP
0.0145
M
E
00854409
02331551
TEV
TEV
Y
Y
00534528
MER Y
SENNA GLYCOSIDES, COMBINATIONS
Senokot S 8.6mg/50mg Tab
A06AD
OSMOTICALLY ACTING LAXATIVES
A06AD10
A06AD11
MINERAL SALTS IN COMBINATION
LACTULOSE
lactulose 667mg/mL o/l
Apo-Lactulose 667mg/mL O/L
Jamp-Lactulose 667mg/mL O/L
ratio-Lactulose 667mg/mL O/L
Teva-Lactulose 667mg/mL O/L
Chronulac 667mg/mL O/L (discontinued)
A06AD15
lactulose 667mg/mL syrup
Lactulose 667mg/5mL Syr
DNP
0.0145
M
E
02412268
SAS
pms-Lactulose 667mg/mL Syr
DNP
0.0145
M
E
00703486
PMS Y
02358034
MSC N
00262609
80001809
ROG N
ODN N
02308215
PFI
N
Resotran 1mg Tab
02377012
JAN
N
Resotran 2mg Tab
02377020
JAN
N
02194201
TEV
Y
00248169
BRI
Y
MACROGOL
PEG 3350 Pwd Sol
A06AD19
MAGNESIUM CITRATE
Citro Mag 50mg/mL O/L
Citrodan 50mg/mL O/L
A06AH
DNP
DNP
0.0134
0.0133
L
L
C
C
PERIPHERAL OPIOID RECEPTOR ANTAGONISTS
A06AH01
METHYLNALTREXONE BROMIDE
Relistor 20mg/mL Inj
A06AX
Y
OTHER DRUGS FOR CONSTIPATION
A06AX05
PRUCALOPRIDE
A07
ANTIDIARRHEALS, INTESTINAL ANTIINFLAMMATORY/ANTIINFECTIVE AGENTS
A07A
INTESTINAL ANTIINFECTIVES
A07AA
ANTIBIOTICS
A07AA02
NYSTATIN
nystatin 100,000iu o/l
ratio-Nystatin 100,000iu/mL Oral Drops
Mycostatin 100,000iu/mL Oral Susp (discontinued)
February 2016
DNP
0.0740
M
SFC
12
A
Alimentary Tract and Metabolism
pms-Nystatin 100,000iu/mL Oral Susp
A07AA06
DNP
0.0592
L
SFC
A07B
INTESTINAL ADSORBENTS
A07BB
BISMUTH PREPARATIONS
A07D
ANTIPROPULSIVES
A07DA
ANTIPROPULSIVES
loperamide 2mg caplet
Apo-Loperamide 2mg Caplet
Novo-Loperamide 2mg Caplet
pms-Loperamide 2mg Caplet
Diarr-eze 2mg Caplet (discontinued)
DN
0.4607
L
SFC
00036323
PFI
N
DN
4.3467
L
SFC
01901869
SDZ
N
DNP
0.1063
M
SFC
02016095
02183323
PMS Y
JNJ Y
DNP
DNP
0.0953
0.0953
M
M
SFC
SFC
02212005
02132591
APX
TEV
DNP
0.0953
M
SFC
02228351
02229552
PMS Y
PDP Y
02183862
JNJ
Y
Imodium 2mg Caplet (discontinued)
Jamp-Loperamide 2mg Tab
0.2508
L
SFC
02256452
JPC
N
Cortifoam
DNP
6.6740
L
SF
00579335
PAL
N
Cortenema 100mg/60mL Susp
DNP
0.1212
L
SF
02112736
AXC N
DNP
0.1035
L
SF
02060884
PAL
N
Entocort 0.02mg/mL Enema
DNP
8.6800
L
SF
02052431
AZE
N
Entocort 3mg Cap
DNP
1.6671
L
SF
02229293
AZE
N
INTESTINAL ANTIINFLAMMATORY AGENTS
A07EA
CORTICOSTEROIDS ACTING LOCALLY
HYDROCORTISONE
BETAMETHASONE
Betnesol 5mg/100mL Retention Enema
A07EA06
A07EB
BUDESONIDE
ANTIALLERGIC AGENTS, EXCL CORTICOSTEROIDS
A07EB01
February 2016
Y
Y
DNP
A07E
A07EA04
PGA N
LOPERAMIDE
loperamide HCl 0.2mg/mL o/l
pms-Loperamide 0.2mg/mL O/L
Imodium 0.2mg/mL O/L (discontinued)
A07EA02
02097079
N
OPIUM
Sandoz Opium & Belladonna 65mg/15mg Supp
A07DA03
ERF
DIPHENOXYLATE
Lomotil 2.5mg Tab
A07DA02
02078759
BISMUTH SUBSALICYLATE
PeptoBismol 17.6mg/mL O/L
A07DA01
PMS N
PAROMOMYCIN
Humatin 250mg Cap
A07BB99
00792667
CROMOGLYCATE SODIUM
13
A
Alimentary Tract and Metabolism
Nalcrom 100mg Cap
A07EC
DNP
1.4824
L
SF
00500895
SAV
pms-Sulfasalazine 500mg Tab
DNP
0.2322
L
SF
00598461
PMS N
pms-Sulfasalazine EC 500mg Tab
Salazopyrin 500mg Entabs
DNP
DNP
0.3536
0.4038
L
L
SF
SF
00598488
02064472
PMS N
PFI N
Salazopyrin 500mg Tab
DNP
0.2647
L
SF
02064480
PFI
N
Pentasa 1g Supp
DNP
1.6480
L
SF
02153564
FEI
N
Salofalk 1g Supp
DNP
1.8887
L
SF
02242146
AXC N
Pentasa 1g/100mL Rectal Susp
DNP
0.0381
L
SF
02153521
FEI
N
Mezavant 1.2g Tab
DNP
1.6253
L
SF
02297558
SHI
N
Salofalk 2g/60g Rectal Susp
DNP
0.0690
L
SF
02112795
AXC N
Salofalk 4g/60g Rectal Susp
DNP
0.1173
L
SF
02112809
AXC N
Pentasa 4g/100mL Rectal Susp
DNP
0.0459
L
SF
02153556
FEI
N
5-aminosalicylic acid 400mg tab
Novo-5-ASA 400mg EC Tab
DNP
0.4666
M
SF
02171929
TEV
Y
Asacol 400mg Tab
DNP
0.4666
M
SF
01997580
ATV
Y
Mesasal 500mg Tab
Pentasa 500mg Tab
DNP
DNP
0.6368
0.5796
L
L
SF
SF
01914030
02099683
GSK N
FEI N
Salofalk 500mg Supp
Salofalk 500mg Tab
DNP
DNP
1.2857
0.5817
L
L
SF
SF
02112760
02112787
AXC N
AXC N
Asacol 800 (800mg) Tab
DNP
1.0938
L
SF
02267217
ATV
N
DNP
0.5585
L
SF
02063808
SLP
N
DNP
0.9600
L
SF
80017987
ERF
N
02240325
HLR
N
N
AMINOSALICYLIC ACID AND SIMILAR AGENTS
A07EC01
A07EC02
A07EC03
SULFASALAZINE
5-AMINOSALICYLIC ACID (MESALAMINE)
OLSALAZINE (5-ASA)
Dipentum 250mg Cap
A07F
ANTIDIARRHOEAL MICROORGANISMS
A07FA
ANTIDIARRHOEAL MICROORGANISMS
A07FA01
LACTIC ACID PRODUCING ORGANISMS
Bacid Cap
A08
ANTIOBESITY PREPARATIONS, EXCL DIET PRODUCTS
A08A
ANTIOBESITY PREPARATIONS, EXCL DIET PRODUCTS
A08AB
PERIPHERALLY ACTING ANTIOBESITY PRODUCTS
A08AB01
ORLISTAT
Xenical 120mg Cap
A09
DIGESTIVES, INCL ENZYMES
A09A
DIGESTIVES, INCL ENZYMES
A09AA
ENZYME PREPARATIONS
February 2016
14
A
Alimentary Tract and Metabolism
A09AA02
MULTIENZYMES (LIPASE, PROTEASE, ETC)
Cotazym Cap
Ultrase MT20 Cap
DNP
DNP
0.2141
0.8067
L
L
SF
SF
00263818
02045869
FRS N
AXC N
Viokase Tab
DNP
0.2431
L
SF
02230019
AXC N
Cotazym ECS 4 Cap (discontinued)
Pancrease MT 4 Cap
DNP
0.6284
L
SF
02181215
00789445
SCH N
JAN N
02203324
AXC N
Ultrase MS4 Cap (discontinued)
Creon 6 Minimicrospheres
DNP
0.1703
L
SF
02415194
ABB
Cotazym ECS 8 Cap
DNP
0.3864
L
SF
00502790
SCH N
Creon 10 Minimicrospheres
Pancrease MT 10 Cap
DNP
DNP
0.2723
1.5711
L
L
SF
SF
02200104
00789437
ABB
JAN
Ultrase MT12 Cap
DNP
0.4656
L
SF
02045834
AXC N
Pancrease MT 16 Cap
DNP
2.5137
L
SF
00789429
JAN
Viokase 16 Tab
DNP
0.3731
L
SF
02241933
AXC N
Cotazym ECS 20 Cap
DNP
1.0132
L
SF
00821373
SCH N
Creon 25 Minimicrospheres
DNP
0.8507
L
SF
01985205
ABB
00456233
SCH N
Cotazym-65B Cap (discontinued)
A09AA03
N
0.0130
L
SF
00378739
CHU N
Humulin R Cartridges
Humulin R Insulin
DNP
DNP
3.0080
2.2990
L
L
SFD
SFD
01959220
00586714
LIL
LIL
Novolin GE Toronto Insulin
Novolin GE Toronto Penfill
DNP
DNP
2.1640
2.8313
L
L
SFD
SFD
02024233
02024284
NNO N
NNO N
Humalog Cartridges
Humalog Insulin
DNP
DNP
3.7587
2.8020
L
L
E*
E*
02229705
02229704
LIL
LIL
N
N
Humalog KwikPen
*full benefit for children 18 years and younger.
DNP
3.6847
L
E*
02403412
LIL
N
02265435
NNO N
DRUGS USED IN DIABETES
A10A
INSULINS AND ANALOGUES
A10AB
INSULINS & ANALOGUES FOR INJECTION, FAST-ACTING
A10AB05
N
DNP
A10
A10AB04
N
N
PEPSIN
Fermentol 100mg/30mL Liq
A10AB01
N
INSULIN (HUMAN)
N
N
INSULIN LISPRO
INSULIN ASPART
NovoMix 30 Penfill
NovoRapid 100iu/mL Penfill Ins
NovoRapid 100iu/mL Vial Ins
DNP
DNP
3.9207
2.9000
L
L
E*
E*
02244353
02245397
NNO N
NNO N
DNP
3.3333
L
E*
02279479
SAV
*full benefit for children 18 years and younger.
A10AB06
INSULIN GLULISINE
Apidra 3mL Cartridges
February 2016
15
N
A
A10AC
Alimentary Tract and Metabolism
3.3567
L
E*
02294346
SAV
N
Apidra 10mL Vial
*full benefit for children 18 years and younger.
DNP
2.5230
L
E*
02279460
SAV
N
Humulin N Cartridges
Humulin N Insulin
DNP
DNP
3.0080
2.2990
L
L
SFD
SFD
01959239
00587737
LIL
LIL
N
N
Humulin N KwikPen
Novolin GE NPH Insulin
DNP
DNP
3.0080
2.2130
L
L
SFD
SFD
02403447
02024225
LIL
N
NNO N
Novolin GE NPH Penfill
DNP
2.8993
L
SFD
02024268
NNO N
INSULIN (HUMAN)
INSULINS & ANALOGUES FOR INJEC. INTERMEDIATE-ACTING + FAST-ACTING
A10AD01
A10AD04
A10AE
DNP
INSULINS & ANALOGUES FOR INJECTION, INTERMEDIATE-ACTING
A10AC01
A10AD
Apidra 3mL Prefilled Pen
INSULIN (HUMAN)
Humulin 30/70 Cartridges
DNP
3.0080
L
SFD
01959212
LIL
Humulin 30/70 Insulin
Novolin GE 30/70 Insulin
DNP
DNP
2.2990
2.2240
L
L
SFD
SFD
00795879
02024217
LIL
N
NNO N
N
Novolin GE 30/70 Penfill
DNP
2.8660
L
SFD
02025248
NNO N
Novolin GE 40/60 Penfill
DNP
2.8867
L
SFD
02024314
NNO N
Novolin GE 50/50 Penfill
DNP
2.8867
L
SFD
02024322
NNO N
Humalog Mix25 Cartridges
02240294
LIL
N
Humalog Mix25 KwikPen
Humalog Mix25 Vial
02403420
02240296
LIL
LIL
N
N
Humalog Mix50 Cartridges
02240297
LIL
N
Humalog Mix50 KwikPen
02403439
LIL
N
INSULIN LISPRO
INSULINS & ANALOGUES, FOR INJECTION LONG-ACTING
A10AE04
A10AE05
INSULIN GLARGINE
Lantus 100iu/mL Cartridge
DNP
6.1900
L
E
02251930
SAV
N
Lantus 100iu/mL Solostar Pre-Filled Pen
Lantus 100iu/mL Vial
DNP
DNP
6.1900
6.1690
L
L
E
E
02294338
02245689
SAV
SAV
N
N
DNP
DNP
6.9140
7.1527
L
L
E
E
02271842
02412829
NNO N
NNO N
metformin HCl 500mg tab
Apo-Metformin 500mg Tab
DNP
0.0444
M
SFD
02167786
APX
Y
CO Metformin 500mg Tab
Jamp-Metformin 500mg Tab
DNP
DNP
0.0444
0.0444
M
M
SFD
SFD
02257726
02380196
ATV
JPC
Y
Y
Jamp-Metformin Blackberry 500mg Tab
DNP
0.0444
M
SFD
02380722
JPC
Y
INSULIN DETEMIR
Levemir 100iu/mL Penfill
Levemir FlexTouch 100iu/mL Pre-Filled Pen
A10B
BLOOD GLUCOSE LOWERING DRUGS, EXCL. INSULINS
A10BA
BIGUANIDES
A10BA02
February 2016
METFORMIN
16
A
A10BB
Alimentary Tract and Metabolism
Mar-Metformin 500mg Tab
Metformin 500mg Tab (MAR)
DNP
DNP
0.0444
0.0444
M
M
SFD
SFD
02378620
02378841
MAR Y
MAR Y
Metformin 500mg Tab (SAS)
Metformin FC 500mg Tab
DNP
DNP
0.0444
0.0444
M
M
SFD
SFD
02353377
02385341
SAS
SIV
MINT-Metformin 500mg Tab
MYLAN-Metformin 500mg Tab
DNP
DNP
0.0444
0.0444
M
M
SFD
SFD
02388766
02148765
MNT Y
MYL Y
pms-Metformin 500mg Tab
RAN-Metformin 500mg Tab Tab
DNP
DNP
0.0444
0.0444
M
M
SFD
SFD
02223562
02269031
PMS Y
RAN Y
ratio-Metformin 500mg Tab
Sandoz Metformin FC 500mg Tab
DNP
DNP
0.0444
0.0444
M
M
SFD
SFD
02242974
02246820
TEV
SDZ
Y
Y
Septa-Metformin 500mg Tab
Teva-Metformin 500mg Tab
DNP
DNP
0.0444
0.0444
M
M
SFD
SFD
02379767
02045710
SPT
TEV
Y
Y
Glucophage 500mg Tab
DNP
0.0444
M
SFD
02099233
SAV
Y
metformin HCl 850mg tab
Apo-Metformin 850mg Tab
DNP
0.0610
M
SFD
02229785
APX
Y
CO Metformin 850mg Tab
Jamp-Metformin 850mg Tab
DNP
DNP
0.0610
0.0610
M
M
SFD
SFD
02257734
02380218
ATV
JPC
Y
Y
Jamp-Metformin Blackberry 850mg Tab
Mar-Metformin 850mg Tab
DNP
DNP
0.0610
0.0610
M
M
SFD
SFD
02380730
02378639
JPC Y
MAR Y
Metformin 850mg Tab (MAR)
Metformin 850mg Tab (SAS)
DNP
DNP
0.0610
0.0610
M
M
SFD
SFD
02378868
02353385
MAR Y
SAS Y
Metformin FC 850mg Tab
MINT-Metformin 850mg Tab
DNP
DNP
0.0610
0.0610
M
M
SFD
SFD
02385368
02388774
SIV Y
MNT Y
MYLAN-Metformin 850mg Tab
pms-Metformin 850mg Tab
DNP
DNP
0.0610
0.0610
M
M
SFD
SFD
02229656
02242589
MYL Y
PMS Y
RAN-Metformin 850mg Tab
ratio-Metformin 850mg Tab
DNP
DNP
0.0610
0.0610
M
M
SFD
SFD
02269058
02242931
RAN Y
TEV Y
Sandoz Metformin FC 850mg Tab
Septa-Metformin 850mg Tab
DNP
DNP
0.0610
0.0610
M
M
SFD
SFD
02246821
02379775
SDZ
SPT
Y
Y
Teva-Metformin 850mg Tab
Glucophage 850mg Tab
DNP
DNP
0.0610
0.0610
M
M
SFD
SFD
02230475
02162849
TEV
SAV
Y
Y
Y
Y
Y
SULFONAMIDES, UREA DERIVATIVES
A10BB01
GLYBURIDE (GLIBENCLAMIDE)
glyburide 2.5mg tab
Apo-Glyburide 2.5mg Tab
February 2016
DNP
0.0321
M
SFD
01913654
APX
Glyburide 2.5mg Tab
MYLAN-Glybe 2.5mg Tab (discontinued)
DNP
0.0321
M
SFD
02350459
00808733
SAS Y
MYL Y
Sandoz Glyburide 2.5mg Tab
Teva-Glyburide 2.5mg Tab
DNP
DNP
0.0321
0.0321
M
M
SFD
SFD
02248008
01913670
SDZ
TEV
Diabeta 2.5mg Tab
Euglucon 2.5mg Tab (discontinued)
DNP
0.0321
M
SFD
02224550
00720933
SAV Y
PMS Y
glyburide 5mg tab
Apo-Glyburide 5mg Tab
Glyburide 5mg Tab
DNP
DNP
0.0573
0.0573
M
M
SFD
SFD
01913662
02350467
APX
SAS
MYLAN-Glybe 5mg Tab (discontinued)
pms-Glyburide 5mg Tab
DNP
0.0573
M
SFD
00808741
02236734
MYL Y
PMS Y
Sandoz Glyburide 5mg Tab
Teva-Glyburide 5mg Tab
DNP
DNP
0.0573
0.0573
M
M
SFD
SFD
02248009
01913689
SDZ
TEV
17
Y
Y
Y
Y
Y
Y
A
Alimentary Tract and Metabolism
Diabeta 5mg Tab
Euglucon 5mg Tab (discontinued)
A10BB02
A10BB03
02224569
00720941
SAV Y
PMS Y
A10BB12
February 2016
0.0573
M
SFD
Apo-Chlorpropamide 100mg Tab
00399302
APX
N
chlorpropamide 250mg tab
Apo-Chlorpropamide 250mg Tab
00312711
APX
Y
Diabinese 250mg Tab (discontinued)
00024716
PFI
Y
CHLORPROPAMIDE
TOLBUTAMIDE
tolbutamide 500mg tab
Tolbutamide 500mg Tab
Mobenol 500mg Tab (discontinued)
A10BB09
DNP
DNP
0.1182
M
SFD
00312762
00013889
AAP Y
HOR Y
gliclazide 30mg MR tab
ACT Gliclazide MR 30mg Tab
DNP
0.0931
M
SFD
02429764
ATV
Apo-Gliclazide MR 30mg Tab
MINT-Gliclazide MR 30mg Tab
DNP
DNP
0.0931
0.0931
M
M
SFD
SFD
02297795
02423286
APX Y
MNT Y
Diamicron MR 30mg Tab
DNP
0.0931
M
SFD
02242987
SEV
Y
gliclazide 60mg MR tab
Apo-Gliclazide MR 60mg Tab
DNP
0.2150
M
SFD
02407124
APX
Y
Diamicron MR 60mg Tab
DNP
0.2150
M
SFD
02356422
SEV
Y
gliclazide 80mg tab
Apo-Gliclazide 80mg Tab
DNP
0.0931
M
SFD
02245247
APX
Y
Gliclazide 80mg Tab
MYLAN-Gliclazide 80mg Tab
DNP
DNP
0.0931
0.0931
M
M
SFD
SFD
02287072
02229519
SAS Y
MYL Y
Novo-Gliclazide 80mg Tab
Diamicron 80mg Tab
DNP
DNP
0.0931
0.0931
M
M
SFD
SFD
02238103
00765996
TEV
SEV
Y
Y
glimepiride 1mg tab
Apo-Glimepiride 1mg Tab
02295377
APX
Y
Novo-Glimepiride 1mg Tab (discontinued)
ratio-Glimepiride 1mg Tab
02273756
02273101
TEV
TEV
Y
Y
Sandoz Glimepiride 1mg Tab
Amaryl 1mg Tab
02269589
02245272
SDZ
SAV
Y
Y
glimepiride 2mg tab
Apo-Glimepiride 2mg Tab
Novo-Glimepiride 2mg Tab (discontinued)
02295385
02273764
APX
TEV
Y
Y
ratio-Glimepiride 2mg Tab
Sandoz Glimepiride 2mg Tab
02273128
02269597
TEV
SDZ
Y
Y
Amaryl 2mg Tab
02245273
SAV
Y
glimepiride 4mg tab
Apo-Glimepiride 4mg Tab
02295393
APX
Y
Novo-Glimepiride 4mg Tab (discontinued)
ratio-Glimepiride 4mg Tab
02273772
02273136
TEV
TEV
Y
Y
Sandoz Glimepiride 4mg Tab
02269619
SDZ
Y
GLICLAZIDE
Y
GLIMEPIRIDE
18
A
Alimentary Tract and Metabolism
Amaryl 4mg Tab
A10BD
A10BD07
A10BD10
A10BD13
Y
Avandamet 2/500mg Tab
02247086
GSK N
Avandamet 2/1000mg Tab
02248440
GSK N
Avandamet 4/500mg Tab
02247087
GSK N
Avandamet 4/1000mg Tab
02248441
GSK N
METFORMIN AND ROSIGLITAZONE
METFORMIN AND SITAGLIPTIN
Janumet 50/500mg Tab
DNP
1.6158
L
E
02333856
FRS
N
Janumet 50/850mg Tab
DNP
1.6158
L
E
02333864
FRS
N
Janumet 50/1000mg Tab
Janumet 50/1000mg XR Tab
DNP
DNP
1.6158
1.6158
L
L
E
E
02333872
02416794
FRS
FRS
N
N
Komboglyze 2.5mg/500mg Tab
DNP
1.2700
L
E
02389169
AZE
N
Komboglyze 2.5mg/850mg Tab
DNP
1.2700
L
E
02389177
AZE
N
Komboglyze 2.5mg/1000mg Tab
DNP
1.2700
L
E
02389185
AZE
N
Kazano 500/12.5mg Tab
02417219
TAK
N
Kazano 850/12.5mg Tab
02417227
TAK
N
Kazano 1000/12.5mg Tab
02417235
TAK
N
METFORMIN AND SAXAGLIPTIN
METFORMIN AND ALOGLIPTIN
ALPHA GLUCOSIDASE INHIBITORS
A10BF01
A10BG
SAV
COMBINATIONS OF ORAL BLOOD GLUCOSE LOWERING DRUGS
A10BD03
A10BF
02245274
ACARBOSE
Glucobay 50mg Tab
DNP
0.2695
L
SFD
02190885
BAY
N
Glucobay 100mg Tab
DNP
0.3733
L
SFD
02190893
BAY
N
Avandia 2mg Tab
02241112
GSK N
Avandia 4mg Tab
02241113
GSK N
Avandia 8mg Tab
02241114
GSK N
02303442
ACC Y
THIAZOLINEDIONES
A10BG02
A10BG03
ROSIGLITAZONE
PIOGLITAZONE
pioglitazone 15mg tab
Accel Pioglitazone 15mg Tab
February 2016
Apo-Pioglitazone 15mg Tab
Auro-Pioglitiazone 15mg Tab
DNP
DNP
0.5946
0.5946
M
M
E
E
02302942
02384906
APX Y
ARO Y
CO Pioglitazone 15mg Tab
Jamp-Pioglitazone 15mg Tab
DNP
DNP
0.5946
0.5946
M
M
E
E
02302861
02397307
ATV
JPC
MINT-Pioglitazone 15mg Tab
MYLAN-Pioglitazone 15mg Tab
DNP
DNP
0.5946
0.5946
M
M
E
E
02326477
02298279
MNT Y
MYL Y
19
Y
Y
A
Alimentary Tract and Metabolism
Novo-Pioglitazone 15mg Tab
Pioglitazone 15mg Tab
DNP
DNP
0.5946
0.5946
M
M
E
E
02274914
02391600
TEV
AHI
pms-Pioglitazone 15mg Tab
RAN-Pioglitazone 15mg Tab
DNP
DNP
0.5946
0.5946
M
M
E
E
02303124
02375850
PMS Y
RAN Y
Sandoz Pioglitazone 15mg Tab
Actos 15mg Tab
DNP
DNP
0.5946
0.5946
M
M
E
E
02297906
02242572
SDZ
TAK
pioglitazone 30mg tab
Accel Pioglitazone 30mg Tab
Apo-Pioglitazone 30mg Tab
DNP
0.8330
M
E
02303450
02302950
ACC Y
APX Y
Auro-Pioglitazone 30mg Tab
CO Pioglitazone 30mg Tab
DNP
DNP
0.8330
0.8330
M
M
E
E
02384914
02302888
ARO Y
ATV Y
Jamp-Pioglitazone 30mg Tab
MINT-Pioglitazone 30mg Tab
DNP
DNP
0.8330
0.8330
M
M
E
E
02365529
02326485
JPC Y
MNT Y
MYLAN-Pioglitazone 30mg Tab
Novo-Pioglitazone 30mg Tab
DNP
DNP
0.8330
0.8330
M
M
E
E
02298287
02274922
MYL Y
TEV Y
Pioglitazone 30mg Tab
pms-Pioglitazone 30mg Tab
DNP
DNP
0.8330
0.8330
M
M
E
E
02339587
02303132
AHI Y
PMS Y
RAN-Pioglitazone 30mg Tab
Sandoz Pioglitazone 30mg Tab
DNP
DNP
0.8330
0.8330
M
M
E
E
02375869
02297914
RAN Y
SDZ Y
Actos 30mg Tab
DNP
0.8330
M
E
02242573
TAK
02303469
ACC Y
pioglitazone 45mg tab
Accel Pioglitazone 45mg Tab
A10BH
Y
Y
Y
Y
Y
Apo-Pioglitazone 45mg Tab
Auro-Pioglitazone 45mg Tab
DNP
DNP
1.2525
1.2525
M
M
E
E
02302977
02384922
APX Y
ARO Y
CO Pioglitazone 45mg Tab
Jamp-Pioglitazone 45mg Tab
DNP
DNP
1.2525
1.2525
M
M
E
E
02302896
02365537
ATV
JPC
MINT-Pioglitazone 45mg Tab
MYLAN-Pioglitazone 45mg Tab
DNP
DNP
1.2525
1.2525
M
M
E
E
02326493
02298295
MNT Y
MYL Y
Novo-Pioglitazone 45mg Tab
Pioglitazone 45mg Tab
DNP
DNP
1.2525
1.2525
M
M
E
E
02274930
02339595
TEV
AHI
pms-Pioglitazone 45mg Tab
RAN-Pioglitazone 45mg Tab
DNP
DNP
1.2525
1.2525
M
M
E
E
02303140
02375877
PMS Y
RAN Y
Sandoz Pioglitazone 45mg Tab
Actos 45mg Tab
DNP
DNP
1.2525
1.2525
M
M
E
E
02297922
02242574
SDZ
TAK
Y
Y
Januvia 25mg Tab
DNP
2.9790
L
E
02388839
FRS
N
Januvia 50mg Tab
DNP
2.9790
L
E
02388847
FRS
N
Januvia 100mg Tab
DNP
2.9790
L
E
02303922
FRS
N
Onglyza 2.5mg Tab
DNP
2.3997
L
E
02375842
AZE
N
Onglyza 5mg Tab
DNP
2.8640
L
E
02333554
AZE
N
02417189
TAK
N
Y
Y
Y
Y
DIPEPTIDYL PEPTIDASE 4 (DPP-4) INHIBITORS
A10BH01
A10BH03
A10BH04
SITAGLIPTIN
SAXAGLIPTIN
ALOGLIPTIN
Nesina 6.25mg Tab
February 2016
20
A
Alimentary Tract and Metabolism
A10BH05
Nesina 12.5mg Tab
02417197
TAK
N
Nesina 25mg Tab
02417200
TAK
N
02370921
BOE N
repaglinide 0.5mg tab
Apo-Repaglinide 0.5mg Tab
02355663
APX
Auro-Repaglinide 0.5mg Tab
CO Repaglinide 0.5mg Tab
02424258
02321475
ARO Y
ATV Y
pms-Repaglinide 0.5mg Tab
Sandoz Repaglinide 0.5mg Tab
02354926
02357453
PMS Y
SDZ Y
GlucoNorm 0.5mg Tab
02239924
NNO Y
repaglinide 1mg tab
Apo-Repaglinide 1mg Tab
02355671
APX
Auro-Repaglinide 1mg Tab
CO Repaglinide 1mg Tab
02424266
02321483
ARO Y
ATV Y
pms-Repaglinide 1mg Tab
Sandoz Repaglinide 1mg Tab
02354934
02357461
PMS Y
SDZ Y
GlucoNorm 1mg Tab
02239925
NNO Y
repaglinide 2mg tab
Apo-Repaglinide 2mg Tab
02355698
APX
Auro-Repaglinide 2mg Tab
CO Repaglinide 2mg Tab
02424274
02321491
ARO Y
ATV Y
pms-Repaglinide 2mg Tab
Sandoz Repaglinide 2mg Tab
02354942
02357488
PMS Y
SDZ Y
GlucoNorm 2mg Tab
02239926
NNO Y
Starlix 60mg Tab (discontinued)
02245438
NVR N
Starlix 120mg Tab (discontinued)
02245439
NVR N
Byetta 1.2mL Prefilled Pen
02361809
AZE
N
Byetta 2.4mL Prefilled Pen
02361817
AZE
N
02351064
NNO N
LINAGLIPTIN
Trajenta 5mg Tab
A10BX
DNP
2.2500
L
E
OTHER BLOOD GLUCOSE LOWERING DRUGS, EXCL INSULINS
A10BX02
A10BX03
A10BX04
A10BX07
REPAGLINIDE
Y
EXENATIDE
LIRAGLUTIDE
CANAGLIFLOZIN
Invokana 100mg Tab
DNP
2.6960
L
E
02425483
JAN
N
Invokana 300mg Tab
DNP
2.6960
L
E
02425491
JAN
N
A11
VITAMINS
A11C
VIT A AND D, INCL COMBINATIONS OF THE TWO
February 2016
Y
NATEGLINIDE
Victoza 6mg/mL Inj
A10BX11
Y
21
A
Alimentary Tract and Metabolism
A11CC
VITAMIN D AND ANALOGUES
A11CC01
ERGOCALCIFEROL
Erdol 8,288iu/mL Sol
A11CC03
A11CC04
DNP
0.3917
L
SF
80003615
ODN N
One-Alpha 0.25mcg Cap
DNP
0.4890
L
SF
00474517
LEO
N
One-Alpha 1mcg Cap
DNP
1.4637
L
SF
00474525
LEO
N
One-Alpha 2mcg O/L
DNP
5.5920
L
SF
02240329
LEO
N
calcitriol 0.25mcg cap
Calcitriol-ODAN 0.25mcg Cap
DNP
0.6960
M
SF
02431637
ODN Y
Rocaltrol 0.25mcg Cap
DNP
0.6960
M
SF
00481823
HLR
Y
Rocaltrol 0.5mcg Cap
DNP
1.4891
L
SF
00481815
HLR
N
DNP
1.1880
M
SF
02243525
00816078
CYI
SDZ
Y
Y
HOS Y
OMG Y
ALFACALCIDOL
CALCITRIOL
A11D
VIT B1,PLAIN AND IN COMB WITH VITAMIN B6 AND B12
A11DA
THIAMINE (VIT B1), PLAIN
A11DA01
THIAMINE (VIT B1)
thiamine (vit B1) 100mg/mL inj
Thiamine 100mg/mL Inj
Vitamin B1 100mg/mL Inj
Betaxin 100mg/mL Inj (discontinued)
Thiamiject 100mg/mL Inj (Omega)
DNP
1.1880
M
SF
02241983
02193221
potassium chloride 1.33mEq/mL o/l
pms-Potassium Chloride 20mEq/15mL
DNP
0.0158
M
SFC
02238604
PMS Y
K-10 Sol 20mEq/15mL
DNP
0.0158
M
SFC
80024360
GSK Y
Apo-K 8mEq Tab
Micro-K 8mEq Extencap
DNP
DNP
0.0899
0.0930
L
L
SFC
SFC
00602884
02042304
APX
PAL
Slow-K 8mEq Tab
DNP
0.1803
L
SFC
80040226
NVR N
Jamp-K8 600mg Tab
DNP
0.0899
L
SFC
80013005
JPC
Jamp-K20 1500mg SR Tab
Odan-K20 1500mg SR Tab
DNP
DNP
0.1995
0.2050
L
L
SFC
SFC
80013007
80004415
JPC N
ODN N
DNP
0.5717
L
SFC
02085992
WLS N
A12
MINERAL SUPPLEMENTS
A12B
POTASSIUM
A12BA
POTASSIUM
A12BA01
A12BA02
POTASSIUM CHLORIDE
N
POTASSIUM CITRATE
K-Lyte 25mEq Eff Tab
A12C
OTHER MINERAL SUPPLEMENTS
A12CC
MAGNESIUM
February 2016
N
N
22
A
Alimentary Tract and Metabolism
A12CC99
A12CX
MAGNESIUM GLUCOHEPTONATE
Jamp-Magnesium 5mg/mL O/L
Magnesium-Odan 5mg/mL O/L
DNP
DNP
0.0200
0.0200
L
L
E
E
80009357
80004109
JPC N
ODN N
Rougier-Magnesium 5mg/mL O/L
DNP
0.0200
L
E
00026697
ROG N
DNP
0.8240
L
SF
80027202
NVR N
Carnitor 1g/5mL Inj
DNP
12.5220
L
E
02144344
QGT N
Carnitor 100mg/mL O/L
DNP
0.3961
L
E
02144336
QGT N
Carnitor 330mg Tab
DNP
1.3078
L
E
02144328
QGT N
02238526
ORP N
02254506
GZM N
02284863
GZM N
02296314
PAL
02250519
ACT N
VARIOUS MINERAL PRODUCTS
A12CX99
SODIUM PHOSPHATE
Phosphate-Novartis 500mg Eff Tab
A16
OTHER ALIMENTARY TRACT AND METABOLISM PRODUCTS
A16A
OTHER ALIMENTARY TRACT AND METABOLISM PRODUCTS
A16AA
AMINO ACIDS AND DERIVATIVES
A16AA01
A16AA06
LEVOCARNITINE
BETAINE
Cystadane 1g Powder for Oral Sol
A16AB
ENZYMES
A16AB05
LARONIDASE
Aldurazyme 0.58mg/mL Inj
A16AB07
ALGLUCOSIDASE ALFA
Myozyme 50mg Pdr for Inj
A16AB09
840.3100
L
E
IDURSULFASE
Elaprase 2mg/mL Inj
A16AX
DNP
N
VARIOUS ALIMENTARY TRACT & METABOLISM PRODUCTS
A16AX06
MIGLUSTAT
Zavesca 100mg Cap
February 2016
23
B
Blood and Blood Forming Organs
B01
ANTICOAGULANTS
B01A
ANTICOAGULANTS
B01AA
VITAMIN K ANTAGONISTS
B01AA03
February 2016
WARFARIN
warfarin 1mg tab
Apo-Warfarin 1mg Tab
MYLAN-Warfarin 1mg Tab
DNP
DNP
0.0796
0.0796
M
M
SFC
SFC
02242924
02244462
APX Y
MYL Y
Taro-Warfarin 1mg Tab
Coumadin 1mg Tab
DNP
DNP
0.0796
0.0796
M
M
SFC
SFC
02242680
01918311
TAR Y
BRI Y
warfarin 2mg tab
Apo-Warfarin 2mg Tab
MYLAN-Warfarin 2mg Tab
DNP
DNP
0.0841
0.0841
M
M
SFC
SFC
02242925
02244463
APX Y
MYL Y
TEV Y
TAR Y
Novo-Warfarin 2mg Tab (discontinued)
Taro-Warfarin 2mg Tab
DNP
0.0841
M
SFC
02265281
02242681
Coumadin 2mg Tab
DNP
0.0841
M
SFC
01918338
BRI
Y
warfarin 2.5mg tab
Apo-Warfarin 2.5mg Tab
Y
DNP
0.0674
M
SFC
02242926
APX
MYLAN-Warfarin 2.5mg Tab
Novo-Warfarin 2.5mg Tab (discontinued)
DNP
0.0674
M
SFC
02244464
02265303
MYL Y
TEV Y
Taro-Warfarin 2.5mg Tab
Coumadin 2.5mg Tab
DNP
DNP
0.0674
0.0674
M
M
SFC
SFC
02242682
01918346
TAR Y
BRI Y
warfarin 3mg tab
Apo-Warfarin 3mg Tab
MYLAN-Warfarin 3mg Tab
DNP
DNP
0.1043
0.1043
M
M
SFC
SFC
02245618
02287498
APX Y
MYL Y
Taro-Warfarin 3mg Tab
Coumadin 3mg Tab
DNP
DNP
0.1043
0.1043
M
M
SFC
SFC
02242683
02240205
TAR Y
BRI Y
warfarin 4mg tab
Apo-Warfarin 4mg Tab
MYLAN-Warfarin 4mg Tab
DNP
DNP
0.1043
0.1043
M
M
SFC
SFC
02242927
02244465
APX Y
MYL Y
Taro-Warfarin 4mg Tab
Coumadin 4mg Tab
DNP
DNP
0.1043
0.1043
M
M
SFC
SFC
02242684
02007959
TAR Y
BRI Y
warfarin 5mg tab
Apo-Warfarin 5mg Tab
MYLAN-Warfarin 5mg Tab
DNP
DNP
0.0675
0.0675
M
M
SFC
SFC
02242928
02244466
APX Y
MYL Y
Novo-Warfarin 5mg Tab (discontinued)
Taro-Warfarin 5mg Tab
DNP
0.0675
M
SFC
02265346
02242685
TEV Y
TAR Y
Coumadin 5mg Tab
DNP
0.0675
M
SFC
01918354
BRI
warfarin 6mg tab
MYLAN-Warfarin 6mg Tab
DNP
0.1753
M
SFC
02287501
MYL Y
TAR Y
BRI Y
Y
Taro-Warfarin 6mg Tab
Coumadin 6mg Tab
DNP
0.1753
M
SFC
02242686
02240206
warfarin 7.5mg tab
MYLAN-Warfarin 7.5 Tab
Taro-Warfarin 7.5mg Tab
DNP
DNP
0.3014
0.3014
M
M
SFC
SFC
02287528
02242697
MYL Y
TAR Y
warfarin 10mg tab
Apo-Warfarin 10mg Tab
DNP
0.1211
M
SFC
02242929
APX
24
Y
B
Blood and Blood Forming Organs
B01AA07
B01AB
MYLAN-Warfarin 10mg Tab
Taro-Warfarin 10mg Tab
DNP
DNP
0.1211
0.1211
M
M
SFC
SFC
02244467
02242687
MYL Y
TAR Y
Coumadin 10mg Tab
DNP
0.1211
M
SFC
01918362
BRI
Y
Sintrom 1mg Tab
DNP
0.5578
L
SFC
00010383
PAL
N
Sintrom 4mg Tab
DNP
1.7399
L
SFC
00010391
PAL
N
Heparin 100iu/mL Inj
DNP
0.4794
L
SFC
00727520
LEO
N
Heparin 1,000iu/mL Inj
DNP
0.5637
L
SFC
00453811
LEO
N
00579718
LEO
N
ACENOCOUMAROL
HEPARIN GROUP
B01AB01
HEPARIN
Heparin 10,000iu/mL Inj (discontinued)
B01AB04
B01AB05
B01AB10
February 2016
DALTEPARIN
Fragmin 2,500iu [anti-Xa] 0.2/mL Syringe Inj
DNP
26.1100
L
SFC
02132621
PFI
N
Fragmin 5,000iu [anti-Xa] 0.2/mL Syringe Inj
DNP
52.2200
L
SFC
02132648
PFI
N
Fragmin 7,500iu [anti-Xa] 0.3/mL Syringe Inj
DNP
52.2200
L
SFC
02352648
PFI
N
Fragmin 10,000iu [anti-Xa]/mL Amp Inj
DNP
16.4920
L
SFC
02132664
PFI
N
Fragmin 10,000iu [anti-Xa] 0.4/mL Syringe Inj
DNP
52.2200
L
SFC
02352656
PFI
N
Fragmin 12,500iu [anti-Xa] 0.5/mL Syringe Inj
DNP
52.2200
L
SFC
02352664
PFI
N
Fragmin 15,000iu [anti-Xa] 0.6/mL Syringe Inj
DNP
52.2233
L
SFC
02352672
PFI
N
Fragmin 18,000iu [anti-Xa] 0.72/mL Syringe Inj
DNP
52.2194
L
SFC
02352680
PFI
N
Fragmin 25,000iu [anti-Xa]/mL Vial Inj
DNP
41.2289
L
SFC
02231171
PFI
N
Lovenox 30mg/0.3mL Syringe Inj
DNP
21.6233
L
SFC
02012472
SAV
N
Lovenox 40mg/0.4mL Syringe Inj
DNP
21.6225
L
SFC
02236883
SAV
N
Lovenox 60mg/0.6mL Syringe Inj
DNP
21.6233
L
SFC
02378426
SAV
N
Lovenox 80mg/0.8mL Syringe Inj
DNP
21.6238
L
SFC
02378434
SAV
N
Lovenox 100mg/mL Prefilled Syringe Inj
Lovenox 100mg/mL Vial Inj
DNP
DNP
21.6240
21.6233
L
L
SFC
SFC
02378442
02236564
SAV
SAV
N
N
Lovenox 120mg/0.8mL Syringe Inj
DNP
32.4350
L
SFC
02242692
SAV
N
Lovenox HP 150mg/mL Syringe Inj
DNP
32.4360
L
SFC
02378469
SAV
N
Innohep 2,500iu/0.25mL Inj
DNP
19.6560
L
SFC
02229755
LEO
N
Innohep 3,500iu/0.35mL Inj
DNP
19.6343
L
SFC
02358158
LEO
N
Innohep 4,500iu/0.45mL Inj
DNP
19.6400
L
SFC
02358166
LEO
N
Innohep 8,000iu/0.4mL Inj
DNP
40.1225
L
SFC
02429462
LEO
N
Innohep 10,000iu/0.5mL Inj
DNP
40.0860
L
SFC
02231478
LEO
N
Innohep 10,000iu/mL Inj
DNP
19.4765
L
SFC
02167840
LEO
N
ENOXAPARIN
TINZAPARIN
25
B
B01AC
Blood and Blood Forming Organs
Innohep 12,000iu/0.6mL Inj
DNP
40.1233
L
SFC
02429470
LEO
N
Innohep 14,000iu/0.7mL Inj
DNP
40.1229
L
SFC
02358174
LEO
N
Innohep 16,000iu/0.8mL Inj
DNP
40.1238
L
SFC
02429489
LEO
N
Innohep 18,000iu/0.9mL Inj
DNP
40.1189
L
SFC
02358182
LEO
N
Innohep 20,000iu/mL Inj
DNP
39.5650
L
SFC
02229515
LEO
N
ABB
APX
Y
Y
PLATELET AGGREGATION INHIBITORS EXCL. HEPARIN
B01AC04
B01AC05
CLOPIDOGREL
clopidogrel 75mg tab
Abbott-Clopidogrel 75mg Tab (discontinued)
Apo-Clopidogrel 75mg Tab
DNP
0.4735
M
E
02412942
02252767
Auro-Clopidogrel 75mg Tab
Clopidogrel 75mg Tab
DNP
DNP
0.4735
0.4735
M
M
E
E
02416387
02400553
ARO Y
SAS Y
Clopidogrel-75mg Tab
CO Clopidogrel 75mg Tab
DNP
DNP
0.4735
0.4735
M
M
E
E
02385813
02303027
SIV
ATV
Jamp-Clopidogrel 75mg Tab
Mar-Clopidogrel 75mg Tab
DNP
DNP
0.4735
0.4735
M
M
E
E
02415550
02422255
JPC Y
MAR Y
MINT-Clopidogrel 75mg Tab
MYLAN-Clopidogrel 75mg Tab
DNP
DNP
0.4735
0.4735
M
M
E
E
02408910
02351536
MNT Y
MYL Y
pms-Clopidogrel 75mg Tab
RAN-Clopidogrel 75mg Tab
DNP
DNP
0.4735
0.4735
M
M
E
E
02348004
02379813
PMS Y
RAN Y
Sandoz Clopidogrel 75mg Tab
Teva-Clopidogrel 75mg Tab
DNP
DNP
0.4735
0.4735
M
M
E
E
02359316
02293161
SDZ
TEV
Y
Y
Plavix 75mg Tab
DNP
0.4735
M
E
02238682
SAV
Y
clopidogrel 300mg tab
Apo-Clopidogrel 300mg Tab
02398591
APX
Y
Teva-Clopidogrel 300mg Tab
Plavix 300mg Tab
02388065
02330555
TEV
SAV
Y
Y
02237701
APX
Y
02162776
SYN Y
TICLOPIDINE
ticlopidine 250mg tab
Apo-Ticlopidine 250mg Tab
DNP
0.4398
M
E
Ticlid 250mg Tab (discontinued)
B01AC07
B01AC21
DIPYRIDAMOLE
dipyridamole 25mg tab
Apo-Dipyridamole-FC 25mg Tab
Persantine 25mg Tab (discontinued)
DNP
0.2633
M
SF
00895644
00067385
APX Y
BOE Y
dipyridamole 50mg tab
Apo-Dipyridamole-FC 50mg Tab
Persantine 50mg Tab (discontinued)
DNP
0.3685
M
SF
00895652
00067393
APX Y
BOE Y
dipyridamole 75mg tab
Apo-Dipyridamole-FC 75mg Tab
Persantine 75mg Tab (discontinued)
DNP
0.4963
M
SF
00895660
00452092
APX Y
BOE Y
02246552
UTC N
TREPROSTINIL
Remodulin 1mg/mL Inj
February 2016
Y
Y
26
B
Blood and Blood Forming Organs
B01AC22
Remodulin 2.5mg/mL Inj
02246553
UTC N
Remodulin 5mg/mL Inj
02246554
UTC N
Remodulin 10mg/mL Inj
02246555
UTC N
PRASUGREL
Effient 10mg Tab
B01AC24
L
E
02349124
LIL
N
DNP
1.4992
L
E
02368544
AZE
N
DNP
0.8492
L
E
02242119
BOE N
02312433
BOE N
PLATELET AGGREGATION INHIBITORS, COMBINATIONS
Aggrenox 200/25mg Cap
B01AE
2.7377
TICAGRELOR
Brilinta 90mg Tab
B01AC30
DNP
DIRECT THROMBIN INHIBITORS
B01AE07
DABIGATRAN ETEXILATE
Pradaxa 75mg Cap
B01AF
Pradaxa 110mg Cap
DNP
1.6000
L
E
02312441
BOE N
Pradaxa 150mg Cap
DNP
1.6000
L
E
02358808
BOE N
DNP
2.8400
L
E
02316986
BAY
N
Eliquis 2.5mg Tab
DNP
1.6000
L
E
02377233
BRI
N
Eliquis 5mg Tab
DNP
1.6000
L
E
02397714
BRI
N
fondaparinux sodium 2.5mg/0.5mL Inj
Fondaparinux Sodium 2.5mg/0.5mL Inj
Arixtra 2.5mg/0.5mL Inj
02406853
02245531
RCH Y
APR Y
fondapariunux sodium 12.5mg/mL Inj
Fondaparinux Sodium 12.5mg/mL Inj
Arixtra 12.5mg/mL
02406896
02258056
RCH Y
APR Y
DIRECT FACTOR XA INHIBITORS
B01AF01
RIVAROXABAN
Xarelto 10mg Tab
B01AF02
B01AX
APIXABAN
OTHER ANTITHROMBOTIC AGENTS
B01AX05
B01AX06
FONDAPARINUX
RIVAROXABAN
Xarelto 15mg Tab
DNP
2.8400
L
E
02378604
BAY
N
Xarelto 20mg Tab
DNP
2.8400
L
E
02378612
BAY
N
B02
ANTIHAEMORRHAGICS
B02A
ANTIFIBRINOLYTICS
B02AA
AMINO ACIDS
B02AA02
TRANEXAMIC ACID
tranexamic acid 100mg/mL inj
February 2016
27
B
Blood and Blood Forming Organs
Tranexamic Acid 100mg/mL Inj
Cyklokapron 100mg/mL Inj
0.5934
0.5934
M
M
SF
SF
02409097
02401231
GMD Y
STR Y
Cyklokapron 500mg Tab
DNP
0.5934
M
SF
02064405
PFI
Y
Vitamin K1 10mg/mL Inj
DNPM
3.7490
L
SF
00804312
SDZ
N
Vitamin K1 2mg/mL Inj
DNPM
9.2600
L
SF
00781878
SDZ
N
Nplate 250mcg/0.5mL Inj
02322854
AGA N
Nplate 500mcg/mL Inj
02322862
AGA N
Revolade 25mg Tab
02361825
GSK N
Revolade 50mg Tab
02361833
GSK N
Palafer 300mg Cap
01923420
MVL N
Palafer 300mg/5mL Susp
01923439
MVL N
ferrous gluconate 300mg tab
APC-Ferrous Gluconate 300mg Tab
Apo-Ferrous Gluconate 300mg Tab
00545031
00545031
APX
APX
Y
Y
Novo-Ferrogluc 300mg Tab
80000435
TEV
Y
Ferodan 75mg/mL Infant Drops
02237385
ODN N
pms-Ferrous Sulfate 75mg/0.6mL Drops
02222574
PMS N
Ferodan 150mg5/mL Syrup
00758469
ODN N
02205963
BHC N
B02BA
VITAMIN K
PHYTONADIONE
OTHER SYSTEMIC HAEMOSTATICS
B02BX04
B02BX05
ROMIPLOSTIM
ELTROMBOPAG
B03
ANTIANAEMIC PREPARATIONS
B03A
IRON PREPARATIONS
B03AA
IRON BIVALENT, ORAL PREPARATIONS
B03AA02
B03AA03
B03AA07
B03AC
Y
Y
DNP
DNP
VITAMIN K AND OTHER HEMOSTATICS
B02BX
SDZ
PFI
tranexamic acid 500mg tab
GD-Tranexamic Acid 500mg Tab
Tranexamic Acid 500mg Tab
B02B
B02BA01
02246365
02064413
FERROUS FUMARATE
FERROUS GLUCONATE
FERROUS SULFATE
IRON TRIVALENT, PARENTERAL PREPARATIONS
B03AC01
DEXTRIFERRON (IRON DEXTRAN)
DexIron 50mg/mL Inj
February 2016
DNP
13.7500
L
E
28
B
Blood and Blood Forming Organs
B03AC02
SACCHARATED IRON OXIDE
Venofer 20mg/mL Inj
B03AC07
DNP
7.5000
L
E
02243716
BHC N
DNP
5.2720
L
E
02243333
SAV
N
02377217
TAK
N
01923455
MVL N
02246067
DUI
cyanocobalamin 100mcg/mL inj
Vitamin B12 100mcg/mL Inj
Vitamin B12 100mcg/mL Inj (discontinued)
02241500
00497533
SDZ Y
HOS Y
Vitamin B12 250mcg Tab
00502758
SWS N
FERRIC SODIUM GLUCONATE COMPLEX
Ferrlecit 12.5mg/mL Inj
B03AC99
FERUMOXYTOL
Feraheme 30mg/mL Inj (discontinued)
B03AE
IRON IN OTHER COMBINATIONS
B03AE02
IRON, MULTIVITAMINS AND FOLIC ACID
Palafer CF Cap
B03AE04
IRON, MULTIVITAMINS AND MINERALS
PregVit Tab
B03B
VITAMIN B12 AND FOLIC ACID
B03BA
VITAMIN B12 (CYANOCOBALAMIN AND DERIVATIVES)
B03BA01
B03BA51
CYANOCOBALAMIN
Vitamin B12 500mcg Tab
DNP
0.0687
L
SE
00689726
VLN
cyancocobalamin 1000mcg/mL inj
Cyanocobalamin 1,000mcg/mL Inj
Cyanocobalamin 1,000mcg/mL Inj
DNP
0.2783
L
E
02413795
01987003
MYL Y
CYI Y
Vitamin B12 1,000mcg/mL Inj
DNP
2.0770
L
E
00521515
SDZ
N
Vitamin B12 1,000mcg Tab
DNP
0.0840
L
SE
02237736
VLN
N
N
DNP
0.0840
L
SE
02243119
VLN
N
02236747
WAM N
CYANOCOBALAMIN, COMBINATIONS
Vitamin B12 1,000mcg Tab w Folic Acid
B03BB
N
FOLIC ACID AND DERIVATIVES
B03BB01
FOLIC ACID
Folic Acid 1mg Tab
Apo-Folic Acid 5mg Tab
Euro-Folic Acid 5mg Tab
DNPM
DNPM
0.0404
0.0198
L
L
SFC
SFC
00426849
02285673
APX N
EUR N
Folic Acid 5mg/mL Inj
Jamp-Folic Acide 5mg Tab
DNPM
DNPM
2.2180
0.0363
L
L
SFC
SFC
00816086
02366061
SDZ
JPC
B03X
OTHER ANTIANEMIC PREPARATIONS
B03XA
OTHER ANTIANEMIC PREPARATIONS
B03XA01
February 2016
ERYTHROPOIETIN
29
N
N
B
Blood and Blood Forming Organs
Eprex 1,000iu/0.5mL Syringe Inj
DNP
28.5000
L
E
02231583
JAN
N
Eprex 2,000iu/0.5mL Syringe Inj
DNP
57.0000
L
E
02231584
JAN
N
Eprex 3,000iu/0.3mL Syringe Inj
DNP
142.5000
L
E
02231585
JAN
N
Eprex 4,000iu/0.4mL Syringe Inj
DNP
142.5000
L
E
02231586
JAN
N
Eprex 5,000iu/0.5mL Syringe Inj
DNP
142.5000
L
E
02243400
JAN
N
Eprex 6,000iu/0.6mL Syringe Inj
DNP
142.5000
L
E
02243401
JAN
N
Eprex 8,000iu/0.8mL Syringe Inj
DNP
142.5000
L
E
02243403
JAN
N
Eprex 10,000iu/mL Syringe Inj
DNP
142.5000
L
E
02231587
JAN
N
Eprex 20,000iu/0.5mL Syringe Inj
DNP
602.5200
L
E
02243239
JAN
N
Eprex 30,000iu/0.75mL Syringe Inj
Eprex 30,000iu/0.75mL Syringe Inj*
DNP
DNP
476.2533
476.2533
L
L
E
E
02288680
00903993
JAN
JAN
N
N
DNP
451.8900
L
E
02240722
JAN
N
Aranesp 10mcg/0.4mL Syringe Inj
DNP
67.0000
L
E
02392313
AGA N
Aranesp 20mcg/0.5mL Syringe Inj
DNP
107.2000
L
E
02392321
AGA N
02246355
AGA N
*use when drug cost in excess of CPhA maximum
Eprex 40,000iu/mL Syringe Inj
B03XA02
DARBEPOETIN
Aranesp 40mcg/mL Syringe Inj (discontinued)
Aranesp 100mcg/mL Syringe Inj (discontinued)
Aranesp 30mcg/0.3mL Syringe Inj
DNP
268.0000
L
E
02246357
02392348
AGA N
AGA N
Aranesp 40mcg/0.4mL Syringe Inj
Aranesp 50mcg/0.5mL Syringe Inj
DNP
DNP
268.0000
268.0000
L
L
E
E
02391740
02391759
AGA N
AGA N
Aranesp 100mcg/0.5mL Syringe Inj
DNP
536.0000
L
E
02391775
AGA N
Aranesp 130mcg/0.65mL Syringe Inj
Aranesp 200mcg/mL Syringe Inj (discontinued)
DNP
536.0000
L
E
02391783
02246358
AGA N
AGA N
Aranesp 60mcg/0.3mL Syringe Inj
Aranesp 80mcg/0.4mL Syringe Inj
DNP
DNP
536.0000
536.0000
L
L
E
E
02392356
02391767
AGA N
AGA N
Aranesp 150mcg/0.3mL Syringe Inj
DNP
1340.0000 L
E
02391791
AGA N
Aranesp 200mcg/0.4mL Syringe Inj
Aranesp 300mcg/0.6mL Syringe Inj
DNP
DNP
1525.9250 L
1571.4667 L
E
E
02391805
02391821
AGA N
AGA N
Aranesp 500mcg/mL Syringe Inj
DNP
1571.4900 L
E
02392364
AGA N
DNPM
0.5460
SF
00037974
HOS N
00666157
GSK N
B05
BLOOD SUBSTITUTES AND PERFUSION SOLUTIONS
B05B
I.V. SOLUTIONS
B05BA
SOLUTIONS FOR PARENTERAL NUTRITION
B05BA03
CARBOHYDRATES
Dextrose 50% Inj
B05C
IRRIGATING SOLUTIONS
B05CA
ANTIINFECTIVES
B05CA10
ANTIINFECTIVES, COMBINATIONS
Neosporin Irrigating Sol (discontinued)
February 2016
L
30
B
Blood and Blood Forming Organs
B05CB
SALT SOLUTIONS
B05CB01
SODIUM CHLORIDE
Sodium Chloride Irr Sol
DNP
0.0049
L
SF
00786160
BAX
Sodium Chloride 9mg/mL Inj
DNPM
0.1690
L
SF
00037796
HOS N
Sodium Chloride 146mg/mL Inj
DNPM
0.5320
L
SF
00262005
HOS N
B05X
I.V. SOLUTION ADDITIVES
B05XA
ELECTROLYTE SOLUTIONS
B05XA03
February 2016
N
SODIUM CHLORIDE
31
C
Cardiovascular System
C01
CARDIAC THERAPY
C01A
CARDIAC GLYCOSIDES
C01AA
DIGITALIS GLYCOSIDES
C01AA05
DIGOXIN
digoxin 0.05mg/mL inj
Digoxin 0.05mg/mL Inj
Lanoxin 0.05mg/mL Inj (discontinued)
1.1377
L
SF
02242320
PDP N
digoxin 0.0625mg tab
Toloxin 0.0625mg Tab
Lanoxin 0.0625mg Tab (discontinued)
DNP
0.2617
L
SF
02335700
02242321
PDP Y
PMS Y
digoxin 0.125mg tab
Toloxin 0.125mg Tab
Lanoxin 0.125mg Tab (discontinued)
DNP
0.2617
L
SF
02335719
02242322
PDP Y
PMS Y
digoxin 0.25mg tab
Toloxin 0.25mg Tab
Lanoxin 0.25mg Tab (discontinued)
DNP
0.2617
L
SF
02335727
02242323
PDP Y
PMS Y
02048264
02242319
SDZ Y
VCO Y
procainamide 100mg/mL inj
Procainamide 100mg/mL Inj
02184486
SDZ
Pronestyl 100mg/mL Inj (discontinued)
00029181
SQU Y
00638692
ERF
N
Procan SR 500mg Tab (discontinued)
00638676
ERF
N
Procan SR 750mg Tab (discontinued)
00638684
ERF
N
02224801
SAV
N
Rythmodan 150mg Cap (discontinued)
02224828
SAV
N
Rythmodan-LA 250mg Tab (discontinued)
02224836
SAV
N
02230359
TEV
Y
00599956
BOE Y
02230360
TEV
ANTIARRHYTHMICS, CLASS I AND III
C01BA
ANTIARRHYTHMICS, CLASS IA
PROCAINAMIDE
Procan SR 250mg Tab
DNP
0.4705
L
SF
Y
DISOPYRAMIDE
Rythmodan 100mg Cap
C01BB
Y
Y
DNP
C01B
C01BA03
SDZ
GLA
Toloxin 0.05mg/mL Sol
digoxin 0.25mg/mL inj
Digoxin 0.25mg/mL Inj
Lanoxin 0.25mg/mL Inj (discontinued)
C01BA02
02048272
00004456
DNP
0.2776
L
SF
ANTIARRHYTHMICS, CLASS IB
C01BB02
MEXILETINE
mexiletine 100mg cap
Novo-Mexiletine 100mg Cap
DNP
1.3529
M
SF
Mexitil 100mg Cap (discontinued)
mexiletine 200mg cap
Novo-Mexiletine 200mg Cap
February 2016
DNP
1.8117
M
SF
32
Y
C
Cardiovascular System
Mexitil 200mg Cap (discontinued)
C01BC
BOE Y
ANTIARRHYTHMICS, CLASS IC
C01BC03
C01BC04
PROPAFENONE
propafenone 150mg tab
Apo-Propafenone 150mg Tab
MYLAN-Propafenone 150mg Tab
DNP
DNP
0.3019
0.3019
M
M
SF
SF
02243324
02245372
APX Y
MYL Y
pms-Propafenone 150mg Tab
Propafenone 150mg Tab
DNP
DNP
0.3019
0.3019
M
M
SF
SF
02294559
02343053
PMS Y
SAS Y
Rythmol 150mg Tab
DNP
0.3019
M
SF
00603708
BGP Y
propafenone 300mg tab
Apo-Propafenone 300mg Tab
DNP
0.5321
M
SF
02243325
APX
MYLAN-Propafenone 300mg Tab
pms-Propafenone 300mg Tab
DNP
DNP
0.5321
0.5321
M
M
SF
SF
02245373
02294575
MYL Y
PMS Y
Propafenone 300mg Tab
Rythmol 300mg Tab
DNP
DNP
0.5321
0.5321
M
M
SF
SF
02343061
00603716
SAS Y
BGP Y
DNP
0.4292
M
SF
02275538
AAP
01966197
GWP Y
02275546
AAP
01966200
GWP Y
02242325
02163616
SDZ Y
WAY Y
Y
FLECAINIDE
flecainide 50mg tab
Flecainide 50mg Tab
Tambocor 50mg Tab (discontinued)
flecainide 100mg tab
Flecainide 100mg Tab
DNP
0.8585
M
SF
Tambocor 100mg Tab (discontinued)
C01BD
00599964
Y
Y
ANTIARRHYTHMICS, CLASS III
C01BD01
AMIODARONE
amiodarone HCl 50mg/mL inj
Amiodarone 50mg/mL Inj
Cordarone 50mg/mL Inj (discontinued)
C01BD02
C01BD07
pms-Amiodarone 100mg Tab
DNP
0.7713
L
SF
02292173
PMS N
amiodarone 200mg tab
Amiodarone 200mg Tab
Amiodarone-200mg Tab
DNP
DNP
0.5147
0.5147
M
M
SF
SF
02364336
02385465
SAS
SIV
Apo-Amiodarone 200mg Tab
MYLAN-Amiodarone 200mg Tab
DNP
DNP
0.5147
0.5147
M
M
SF
SF
02246194
02240604
APX Y
MYL Y
pms-Amiodarone 200mg Tab
Sandoz Amiodarone 200mg Tab
DNP
DNP
0.5147
0.5147
M
M
SF
SF
02242472
02243836
PMS Y
SDZ Y
Teva-Amiodarone 200mg Tab
Cordarone 200mg Tab
DNP
DNP
0.5147
0.5147
M
M
SF
SF
02239835
02036282
TEV
PFI
Y
Y
bretylium tosylate 50mg/mL inj
Bretylate 50mg/mL Inj (discontinued)
00519243
GLA
Y
Bretylium Tosylate 50mg/mL Inj
02185377
SDZ
Y
02330989
SAV
N
BRETYLIUM TOSYLATE
DRONEDARONE
Multaq 400mg Tab
February 2016
Y
Y
33
C
Cardiovascular System
C01C
CARDIAC STIMULANTS EXCL.CARDIAC GLYCOSIDES
C01CA
ADRENERGIC AND DOPAMINERGIC AGENTS
C01CA03
C01CA06
NOREPINEPHRINE
norepinephrine 1mg/mL inj
Norepinephrine Bitartrate 1mg/mL Inj
00893285
SDZ
Levophed 1mg/mL Inj
02241981
HOS Y
PHENYLEPHRINE
phenylephrine 10mg/mL inj
Phenylephrine 10mg/mL Inj
Neo-Synephrine 10mg/mL Inj
C01CA07
DNP
4.4300
L
SF
01953583
02241980
SDZ Y
HOS Y
DNP
1.7950
M
SF
02242010
SDZ
00759538
PPC Y
DOBUTAMINE
dobutamine 12.5mg/mL inj
Dobutamine 12.5mg/mL Inj
Dobutrex 12.5mg/mL Inj (discontinued)
C01CA17
C01CA24
Y
Y
MIDODRINE
midodrine 2.5mg tab
Midodrine 2.5mg Tab
Amatine 2.5mg Tab (discontinued)
DNP
0.3665
M
SF
02278677
01934392
AAP
SHI
Y
Y
midodrine 5mg tab
Midodrine 5mg Tab
Amatine 5mg Tab (discontinued)
DNP
0.6109
M
SF
02278685
01934406
AAP
SHI
Y
Y
Allerject 0.15mg/0.15ml Inj
Twinject 0.15mg Auto-Injector (discontinued)
DNPM
83.3500
L
SF*
02382059
02268205
SAV
PAL
N
N
Allerject 0.3mg/0.3ml Inj
DNPM
83.3500
L
SF*
02382067
SAV
N
02247310
PAL
N
EPINEPHRINE
Twinject 0.3mg Auto-Injector (discontinued)
Epinephrine 1:1000 Inj
DNPM
3.8500
L
SF
00721891
HOS N
Epipen 1:1000 (0.3mg/dose) Inj
DNPM
86.8200
L
SF*
00509558
KNG N
Epipen Jr. 1:2000 (0.15mg/dose) Inj
DNPM
86.8200
L
SF*
00578657
KNG N
02421933
02338327
APX
LIL
*quantity limit of two injections per fiscal year. The prescriber
can submit a request for consideration should beneficiaries
require more than two injections per fiscal year.
C01CE
PHOSPHODIESTERASE INHIBITORS
C01CE99
TADALAFIL
tadalafil 20mg tab
Apo-Tadalafil PAH 20mg Tab
Adcirca 20mg Tab
C01D
VASODILATORS USED IN CARDIAC DISEASES
C01DA
ORGANIC NITRATES
February 2016
34
Y
Y
C
Cardiovascular System
C01DA02
C01DA08
NITROGLYCERIN (GLYCERYL TRINITRATE)
nitroglycerin 0.2mg/hr patch
MYLAN-Nitro 0.2mg/hr Patch
DNPM
0.4463
M
SF
02407442
MYL Y
Nitro-Dur 0.2mg/hr Patch
DNPM
0.4463
M
SF
01911910
FRS
Minitran 0.2mg/hr Patch
Transderm-Nitro 0.2mg/hr Patch
DNPM
DNPM
0.6260
0.8097
L
L
SF
SF
02162806
00584223
VLN N
NVR N
Trinipatch 0.2mg/hr Patch
DNPM
0.6070
L
SF
02230732
PAL
N
Nitrostat 0.3mg Tab
DNPM
0.1211
L
SF
00037613
PFI
N
nitroglycerin 0.4mg/dose pumpspray
Apo-Nitroglycerin Pumpspray 0.4mg/dose
DNPM
0.0423
M
SF
02393433
APX
Y
Rho-Nitro Pumpspray 0.4mg/dose
Nitrolingual Pumpspray 0.4mg/dose
DNPM
DNPM
0.0423
0.0423
M
M
SF
SF
02238998
02231441
SDZ
SAV
Y
Y
nitroglycerin 0.4mg/hr patch
MYLAN-Nitro 0.4mg/hr Patch
Nitro-Dur 0.4mg/hr Patch
DNPM
DNPM
0.4704
0.4704
M
M
SF
SF
02407450
01911902
MYL Y
FRS Y
MYLAN-Nitro 0.4mg/dose SL Spray
DNPM
0.0423
L
SF
02243588
MYL N
Minitran 0.4mg/hr Patch
Transderm-Nitro 0.4mg/hr Patch
DNPM
DNPM
0.7073
0.9143
L
L
SF
SF
02163527
00852384
VLN N
NVR N
Trinipatch 0.4mg/hr Patch
DNPM
0.6989
L
SF
02230733
PAL
nitroglycerin 0.6mg/hr patch
MYLAN-Nitro 0.6mg/hr Patch
DNPM
0.4704
M
SF
02407469
MYL Y
Nitro-Dur 0.6mg/hr Patch
DNPM
0.4704
M
SF
01911929
FRS
Y
Minitran 0.6mg/hr Patch
Nitrostat 0.6mg Tab
DNPM
DNPM
0.7077
0.1211
L
L
SF
SF
02163535
00037621
VLN
PFI
N
N
Transderm-Nitro 0.6mg/hr Patch
Trinipatch 0.6mg/hr Patch
DNPM
DNPM
0.9143
0.6989
L
L
SF
SF
02046156
02230734
NVR N
PAL N
nitroglycerin 0.8mg/hr patch
MYLAN-Nitro 0.8mg/hr Patch
Nitro-Dur 0.8mg/hr Patch
DNPM
DNPM
0.8743
0.8743
M
M
SF
SF
02407477
02011271
MYL Y
FRS Y
Nitrol 2% Oint
DNPM
0.6950
L
SF
01926454
PAL
N
Nitroglycerin 5mg/mL Inj
DNPM
1.0170
L
SF
00860778
SDZ
N
DNP
0.0674
M
SF
00670944
AAP
Y
02042606
WAY Y
00441686
AAP
02042622
WAY Y
00441694
AAP
02042614
WAY Y
Isordil Sublingual 5mg Tab (discontinued)
isosorbide dinitrate 10mg tab
ISDN 10mg Tab
DNP
0.0397
M
SF
Isordil 10mg Tab (discontinued)
isosorbide dinitrate 30mg tab
ISDN 30mg Tab
Isordil 30mg Tab (discontinued)
DNP
0.0930
M
SF
ISOSORBIDE MONONITRATE
isosorbide mononitrate 60mg SR tab
February 2016
N
ISOSORBIDE DINITRATE
isosorbide dinitrate 5mg SL tab
ISDN 5mg Tab
C01DA14
Y
35
Y
Y
C
Cardiovascular System
Apo-ISMN 60mg Tab
pms-ISMN 60mg SR Tab
DNP
DNP
0.3523
0.3523
M
M
SF
SF
02272830
02301288
APX Y
PMS Y
Imdur 60mg ER Tab
DNP
0.3523
M
SF
02126559
AZE
Y
methyldopa 125mg tab
Methyldopa 125mg Tab
Aldomet 125mg Tab (discontinued)
DNP
0.1074
M
SF
00360252
00016551
AAP
LIH
Y
Y
methyldopa 250mg tab
Methyldopa 250mg Tab
Aldomet 250mg Tab (discontinued)
DNP
0.1555
M
SF
00360260
00016578
AAP
LIH
Y
Y
methyldopa 500mg tab
Methyldopa 500mg Tab
Aldomet 500mg Tab (discontinued)
DNP
0.2753
M
SF
00426830
00016586
AAP
LIH
Y
Y
DNP
0.2584
M
SF
02304163
TEV
Y
00519251
BOE Y
02046121
TEV
00259527
BOE Y
02046148
TEV
00291889
BOE Y
00882801
01934198
APX
TEV
Y
Y
00560952
PFI
Y
C02
ANTIHYPERTENSIVES
C02A
ANTIADRENERGIC AGENTS, CENTRALLY ACTING
C02AB
METHYLDOPA
C02AB02
C02AC
METHYLDOPA (RACEMIC)
CLONIDINE AND ANALOGUES
C02AC01
CLONIDINE
clonidine HCl 0.025mg tab
Novo-Clonidine 0.025mg Tab
Dixarit 0.025mg Tab (discontinued)
clonidine HCl 0.1mg tab
Novo-Clonidine 0.1mg Tab
DNP
0.1765
M
SF
Catapres 0.1mg Tab (discontinued)
clonidine HCl 0.2mg tab
Novo-Clonidine 0.2mg Tab
DNP
0.3149
M
SF
Catapres 0.2mg Tab (discontinued)
C02C
ANTIADRENERGIC AGENTS, PERIPHERALLY ACTING
C02CA
ALPHA-ADRENOCEPTOR BLOCKING AGENTS
C02CA01
Y
PRAZOSIN
prazosin HCl 1mg tab
Apo-Prazo 1mg Tab
Novo-Prazin 1mg Tab
DNP
DNP
0.1371
0.1371
M
M
SF
SF
Minipres 1mg Tab (discontinued)
prazosin HCl 2mg tab
Apo-Prazo 2mg Tab
Novo-Prazin 2mg Tab
Minipres 2mg Tab (discontinued)
prazosin HCl 5mg tab
Apo-Prazo 5mg Tab
Novo-Prazin 5mg Tab
February 2016
Y
DNP
0.1862
M
SF
00882828
APX
Y
DNP
0.1862
M
SF
01934201
00560960
TEV
PFI
Y
Y
DNP
DNP
0.2560
0.2560
M
M
SF
SF
00882836
01934228
APX
TEV
Y
Y
36
C
Cardiovascular System
Minipres 5mg Tab (discontinued)
C02CA04
Y
doxazosin 1mg tab
Apo-Doxazosin 1mg Tab
MYLAN-Doxazosin 1mg Tab (discontinued)
DNP
0.1421
M
SF
02240588
02240498
APX Y
MYL Y
Novo-Doxazosin 1mg Tab
pms-Doxazosin 1mg Tab
DNP
DNP
0.1421
0.1421
M
M
SF
SF
02242728
02244527
TEV Y
PMS Y
Cardura-1 1mg Tab
DNP
0.1421
M
SF
01958100
PFI
Y
doxazosin 2mg tab
Apo-Doxazosin 2mg Tab
DNP
0.1704
M
SF
02240589
APX
Y
MYLAN-Doxazosin 2mg Tab (discontinued)
Novo-Doxazosin 2mg Tab
DNP
0.1704
M
SF
02240499
02242729
MYL Y
TEV Y
pms-Doxazosin 2mg Tab
Cardura-2 2mg Tab
DNP
DNP
0.1704
0.1704
M
M
SF
SF
02244528
01958097
PMS Y
PFI Y
doxazosin 4mg tab
Apo-Doxazosin 4mg Tab
MYLAN-Doxazosin 4mg Tab (discontinued)
DNP
0.2216
M
SF
02240590
02240500
APX Y
MYL Y
Novo-Doxazosin 4mg Tab
pms-Doxazosin 4mg Tab
DNP
DNP
0.2216
0.2216
M
M
SF
SF
02242730
02244529
TEV Y
PMS Y
Cardura-4 4mg Tab
DNP
0.2216
M
SF
01958119
PFI
hydralazine HCl 10mg tab
Hydralazine 10mg Tab
Apresoline 10mg Tab (discontinued)
DNP
0.1347
M
SF
00441619
00005525
AAP Y
STR Y
Apresoline 20mg/mL Inj
DNP
11.6500
L
SF
00723754
STR N
hydralazine HCl 25mg tab
Hydralazine 25mg Tab
Apresoline 25mg Tab (discontinued)
DNP
0.2314
M
SF
00441627
00005533
AAP Y
STR Y
hydralazine HCl 50mg tab
Hydralazine 50mg Tab
Apresoline 50mg Tab (discontinued)
DNP
0.3633
M
SF
00441635
00005541
AAP Y
STR Y
Loniten 2.5mg Tab
DNP
0.3553
L
SF
00514497
PFI
N
Loniten 10mg Tab
DNP
0.7832
L
SF
00514500
PFI
N
ARTERIOLAR SMOOTH MUSCLE, AGENTS ACTING ON
C02DB
HYDRAZINOPHTHALAZINE DERIVATIVES
C02DC
PFI
DOXAZOSIN
C02D
C02DB02
00560979
Y
HYDRALAZINE
PYRIMIDINE DERIVATIVES
C02DC01
MINOXIDIL
C02K
OTHER ANTIHYPERTENSIVES
C02KX
OTHER ANTIHYPERTENSIVES
C02KX01
BOSENTAN
bosentan 62.5mg tab
February 2016
37
C
Cardiovascular System
C02KX02
C02KX05
C02KX99
CO Bosentan 62.5mg Tab
MYLAN-Bosentan 62.5mg Tab
DNP
16.0447
M
E
02386194
02383497
ATV Y
MYL Y
pms-Bosentan 62.5mg Tab
Sandoz Bosentan 62.5mg Tab
DNP
DNP
16.0447
16.0447
M
M
E
E
02383012
02386275
PMS Y
SDZ Y
Teva-Bosentan 62.5mg Tab (discontinued)
Tracleer 62.5mg Tab
DNP
16.0447
M
E
02398400
02244981
TEV Y
ACT Y
bosentan 125mg tab
CO Bosentan 125mg Tab
MYLAN-Bosentan 125mg Tab
DNP
16.0447
M
E
02386208
02383500
ATV Y
MYL Y
pms-Bosentan 125mg Tab
Sandoz Bosentan 125mg Tab
DNP
DNP
16.0447
16.0447
M
M
E
E
02383020
02386283
PMS Y
SDZ Y
Teva-Bosentan 125mg Tab (discontinued)
Tracleer 125mg Tab
DNP
16.0447
M
E
02398419
02244982
TEV Y
ACT Y
Volibris 5mg Tab
DNP
122.5200
L
E
02307065
GSK N
Volibris 10mg Tab
DNP
122.5200
L
E
02307073
GSK N
Adempas 0.5mg Tab
DNP
42.7500
L
E
02412764
BAY
N
Adempas 1mg Tab
DNP
42.7500
L
E
02412772
BAY
N
Adempas 1.5mg Tab
DNP
42.7500
L
E
02412799
BAY
N
Adempas 2mg Tab
DNP
42.7500
L
E
02412802
BAY
N
Adempas 2.5mg Tab
DNP
42.7500
L
E
02412810
BAY
N
sildenafil 20mg tab
Apo-Sildenafil R 20mg Tab
DNP
6.2520
M
E
02418118
APX
Y
pms-Sildenafil-R 20mg Tab
ratio-Sildenafil-R 20mg Tab
DNP
6.2520
M
E
02412179
02319500
PMS Y
TEV Y
Revatio 20mg Tab
DNP
6.2520
M
E
02279401
PFI
hydrochlorothiazide 12.5mg tab
Apo-Hydro 12.5mg Tab
pms-Hydrochlorothiazide 12.5mg Tab
DNP
DNP
0.0322
0.0322
M
M
SF
SF
02327856
02274086
APX Y
PMS Y
hydrochlorothiazide 25mg tab
Apo-Hydro 25mg Tab
Hydrochlorothiazide 25mg Tab
DNP
DNP
0.0184
0.0184
M
M
SF
SF
00326844
02360594
APX
SAS
pms-Hydrochlorothiazide 25mg Tab
Teva-Hydrochlorothiazide 25mg Tab
DNP
DNP
0.0184
0.0184
M
M
SF
SF
02247386
00021474
PMS Y
TEV Y
00016500
FRS
AMBRISENTAN
RIOCIGUAT
SILDENAFIL
C03
DIURETICS
C03A
LOW-CEILING DIURETICS, THIAZIDES
C03AA
THIAZIDES, PLAIN
C03AA03
HYDROCHLOROTHIAZIDE
Hydrodiuril 25mg Tab (discontinued)
February 2016
Y
38
Y
Y
Y
C
Cardiovascular System
hydrochlorothiazide 50mg tab
Apo-Hydro 50mg Tab
DNP
0.0256
M
SF
00312800
APX
Y
Hydrochlorothiazide 50mg Tab
Novo-Hydrazide 50mg Tab
DNP
DNP
0.0256
0.0256
M
M
SF
SF
02360608
00021482
SAS
TEV
Y
Y
pms-Hydrochlorothiazide 50mg Tab
Hydrodiuril 50mg Tab (discontinued)
DNP
0.0256
M
SF
02247387
00016519
PMS Y
MSD Y
DNP
0.1232
M
SF
00644552
00354317
APX
LIH
Y
Y
DNP
0.1242
L
SF
00360279
AAP
N
DNP
0.2010
L
SF
00888400
SAV
N
indapamide 1.25mg tab
Apo-Indapamide 1.25mg Tab
02245246
APX
Y
Jamp-Indapamide 1.25mg Tab
MYLAN-Indapamide 1.25mg Tab
02373904
02240067
JPC Y
MYL Y
pms-Indapamide 1.25mg Tab
Lozide 1.25mg Tab
02239619
02179709
PMS Y
SEV Y
indapamide 2.5mg tab
Apo-Indapamide 2.5mg Tab
Jamp-Indapamide 2.5mg Tab
02223678
02373912
APX
JPC
MYLAN-Indapamide 2.5mg Tab
Novo-Indapamide 2.5mg Tab
02153483
02231184
MYL Y
TEV Y
pms-Indapamide 2.5mg Tab
Lozide 2.5mg Tab
02239620
00564966
PMS Y
SEV Y
hydrochlorothiazide 100mg tab
Apo-Hydro 100mg Tab
Hydrodiuril 100mg Tab (discontinued)
C03B
LOW-CEILING DIURETICS, EXCL THIAZIDES
C03BA
SULFONAMIDES, PLAIN
C03BA04
CHLORTHALIDONE
Chlorthalidone 50mg Tab
C03BA08
METOLAZONE
Zaroxolyn 2.5mg Tab
C03BA11
INDAPAMIDE
C03C
HIGH-CEILING DIURETICS
C03CA
SULFONAMIDES, PLAIN
C03CA01
February 2016
Y
Y
FUROSEMIDE
Furosemide 10mg/mL Inj
Furosemide 10mg/mL Inj
DNP
DNP
0.8650
0.8650
L
L
SF
SF
00527033
02382539
SDZ
SDZ
N
N
Lasix 10mg/mL Sol
DNP
0.2861
L
SF
02224720
SAV
N
furosemide 20mg tab
Apo-Furosemide 20mg Tab
DNP
0.0373
M
SF
00396788
APX
Y
Furosemide 20mg Tab
Novo-Semide 20mg Tab
DNP
DNP
0.0373
0.0373
M
M
SF
SF
02351420
00337730
SAS
TEV
Y
Y
Lasix 20mg Tab (discontinued)
02224690
SAV
Y
furosemide 40mg tab
Apo-Furosemide 40mg Tab
00362166
APX
Y
39
C
Cardiovascular System
Furosemide 40mg Tab
Novo-Semide 40mg Tab
DNP
DNP
0.0558
0.0558
M
M
SF
SF
Lasix 40mg Tab (discontinued)
02224704
SAV
Y
DNP
0.1220
M
SF
00707570
APX
Y
DNP
DNP
0.1220
0.1220
M
M
SF
SF
02351447
00765953
SAS
TEV
Y
Y
02224712
SAV
Y
DNP
3.1305
L
SF
02224755
SAV
N
Burinex 1mg Tab
DNP
0.7907
L
SF
00728284
LEO
N
Burinex 5mg Tab
DNP
3.0183
L
SF
00728276
LEO
N
DNP
0.9005
L
SF
02258528
VLN
N
spironolactone 25mg tab
Novo-Spiroton 25mg Tab
Aldactone 25mg Tab
DNP
DNP
0.1223
0.1223
M
M
SF
SF
00613215
00028606
TEV
PFI
Y
Y
spironolactone 100mg tab
Novo-Spiroton 100mg Tab
Aldactone 100mg Tab
DNP
DNP
0.2847
0.2847
M
M
SF
SF
00613223
00285455
TEV
PFI
Y
Y
Inspra 25mg Tab
DNP
2.6530
L
E
02323052
PFI
N
Inspra 50mg Tab
DNP
2.6530
L
E
02323060
PFI
N
DNP
0.2948
M
SF
02249510
00487805
AAP Y
ORB Y
BUMETANIDE
ARYLOXYACETIC ACID DERIVATIVES
C03CC01
ETHACRYNIC ACID
Edecrin 25mg Tab
C03D
POTASSIUM-SPARING DRUGS
C03DA
ALDOSTERONE ANTAGONISTS
C03DA01
C03DA04
C03DB
Y
Y
Furosemide 80mg Tab
Novo-Semide 80mg Tab
Lasix Special 500mg Tab
C03CC
SAS
TEV
furosemide 80mg tab
Apo-Furosemide 80mg Tab
Lasix 80mg Tab (discontinued)
C03CA02
02351439
00337749
SPIRONOLACTONE
EPLERENONE
OTHER POTASSIUM-SPARING DRUGS
C03DB01
AMILORIDE
amiloride 5mg tab
Midamor 5mg Tab
Midamor 5mg Tab (discontinued)
C03E
DIURETICS AND POTASSIUM-SPARING DRUGS IN COMBINATION
C03EA
LOW-CEILING DIURETICS AND POTASSIUM-SPARING DRUGS
C03EA01
February 2016
HYDROCHLOROTHIAZIDE AND POTASSIUM-SPARING AGENTS
hydrochlorothiazide 25mg & spironolactone 25mg tab
Novo-Spirozine 25mg Tab
DNP
0.1245
M
SF
00613231
TEV
Y
Aldactazide 25mg Tab
DNP
0.1245
M
SF
00180408
PFI
Y
40
C
Cardiovascular System
hydrochlorothiazide 25mg & triamterene 50mg tab
Apo-Triazide 50-25 Tab
Novo-Triamzide 50/25 Tab
Dyazide 50/25 Tab (discontinued)
hydrochlorothiazide 50mg & amiloride HCl 5mg tab
Apo-Amilzide 5-50 Tab
Novamilor 5/50 Tab
DNP
0.0608
M
SF
00441775
APX
DNP
0.0608
M
SF
00532657
01919547
TEV Y
SKR Y
DNP
DNP
0.1293
0.1293
M
M
SF
SF
00784400
01937219
APX
TEV
00487813
PRE Y
Moduret 5/50 Tab (discontinued)
DNP
0.2633
M
SF
00657182
TEV
Y
Aldactazide 50mg Tab
DNP
0.2633
M
SF
00594377
PFI
Y
Samsca 15mg Tab
02370468
OTS N
Samsca 30mg Tab
02370476
OTS N
02243737
SDZ
N
02230090
02221977
AAP
SAV
Y
Y
00176176
STR N
OTHER DIURETICS
C03XA
VASOPRESSIN ANTAGONISTS
TOLVAPTAN
C04
PERIPHERAL VASODILATORS
C04A
PERIPHERAL VASODILATORS
C04AB
IMIDAZOLINE DERIVATIVES
C04AB01
PHENTOLAMINE
Phentolamine Mesylate 5mg/mL Inj
C04AD
PURINE DERIVATIVES
C04AD03
PENTOXIFYLLINE
pentoxifylline 400mg tab
Pentoxifylline SR 400mg Tab
Trental 400mg Tab (discontinued)
C04AE
Y
Y
hydrochlorothiazide 50mg & spironolactone 50mg tab
Novo-Spirozine 50mg Tab
C03X
C03XA01
Y
DNP
0.5846
M
E
ERGOT ALKALOIDS
C04AE01
ERGOLOID MESYLATES
Hydergine 1mg Tab
C05
VASOPROTECTIVES
C05A
AGENTS FOR TREATMENT OF HEMORRHOIDS & ANAL FISSURES / TOPICAL USE
C05AA
CORTICOSTEROIDS
C05AA01
February 2016
HYDROCORTISONE
hydrocortisone, framycetin sulfate & cinchocaine HCl oint
Proctol Oint
DNPM
ratio-Proctosone Oint
DNPM
0.5960
0.5960
M
M
SF
SF
02247322
02226383
ODN Y
TEV Y
Sandoz Proctomyxin HC Oint
Proctosedyl Oint
0.5960
0.5960
M
M
SF
SF
02242527
02223252
SDZ Y
AXC Y
DNPM
DNPM
41
C
Cardiovascular System
hydrocortisone, framycetin sulfate & cinchocaine HCl supp
Proctol Supp
DNPM
0.7925
M
SF
02247882
ODN Y
ratio-Proctosone Supp
Sandoz Proctomyxin HC Supp
DNPM
DNPM
0.7925
0.7925
M
M
SF
SF
02226391
02242528
TEV
SDZ
Proctosedyl Supp
DNPM
0.7925
M
SF
02223260
AXC Y
hydrocortisone, pramoxine oint
Proctodan-HC Oint
DNPM
0.7317
M
SF
02234466
ODN Y
Anugesic-HC Oint
DNPM
0.7317
M
SF
00505781
JNJ
hydrocortisone, pramoxine supp
Proctodan-HC Supp
DNPM
1.0875
M
SF
02240851
ODN Y
Sandoz Anuzinc HC Plus Supp
Anugesic-HC Supp
DNPM
DNPM
1.0875
1.0875
M
M
SF
SF
02242797
00476242
SDZ
JNJ
Y
Y
ratio-Hemcort HC Oint
DNPM
0.4160
L
SF
00607789
TEV
N
ratio-Hemcort HC Supp
Proctofoam HC Aer
DNPM
DNPM
0.6075
1.7056
L
L
SF
SF
00607797
00363014
TEV
DUI
N
N
hydrocortisone 0.5% oint
Anodan-HC Oint
Sandoz Anuzinc HC Oint
DNPM
DNPM
0.4130
0.4130
M
M
SF
SF
02128446
02247691
ODN Y
SDZ Y
Anusol-HC Oint
DNPM
0.4130
M
SF
00505773
JNJ
hydrocortisone 10mg supp
Anodan-HC Supp
DNPM
0.6075
M
SF
02236399
ODN Y
Sandoz Anuzinc HC Supp
Anusol-HC Supp
DNPM
DNPM
0.6075
0.6075
M
M
SF
SF
02242798
00476285
SDZ
JNJ
Y
Y
DNP
2.7300
L
SF
02029448
JAN
N
pindolol 5mg tab
Apo-Pindol 5mg Tab
Novo-Pindol 5mg Tab
DNP
DNP
0.1464
0.1464
M
M
SF
SF
00755877
00869007
APX
TEV
Y
Y
pms-Pindolol 5mg Tab (discontinued)
Visken 5mg Tab
DNP
0.1464
M
SF
02231536
00417270
PMS Y
TRB Y
pindolol 10mg tab
Apo-Pindol 10mg Tab
Novo-Pindol 10mg Tab
DNP
DNP
0.2500
0.2500
M
M
SF
SF
00755885
00869015
APX
TEV
pms-Pindolol 10mg Tab (discontinued)
Visken 10mg Tab
DNP
0.2500
M
SF
02231537
00443174
PMS Y
TRB Y
C05B
ANTIVARICOSE THERAPY
C05BA
HEPARINS OR HEPARINOIDS FOR TOPICAL USE
C05BA04
C07
BETA BLOCKING AGENTS
C07A
BETA BLOCKING AGENTS, PLAIN
C07AA
BETA BLOCKING AGENTS, PLAIN, NON-SELECTIVE
Y
PINDOLOL
pindolol 15mg tab
February 2016
Y
PENTOSAN POLYSULFATE SODIUM
Elmiron 100mg Cap
C07AA03
Y
Y
42
Y
Y
C
Cardiovascular System
C07AA05
Apo-Pindol 15mg Tab
Novo-Pindol 15mg Tab
DNP
DNP
0.3627
0.3627
M
M
SF
SF
00755893
00869023
APX
TEV
pms-Pindolol 15mg Tab (discontinued)
Sandoz Pindolol 15mg Tab
DNP
0.3627
M
SF
02231539
02261804
PMS Y
SDZ Y
Visken 15mg Tab
DNP
0.3627
M
SF
00417289
TRB Y
02225883
SDZ
PROPRANOLOL
Propranolol HCL 1mg/mL Inj
DNP
0.0689
M
SF
00496480
02042177
TEV Y
WAY Y
propranolol 20mg tab
Novo-Pranol 20mg Tab
Inderal 20mg Tab (discontinued)
DNP
0.1107
M
SF
00740675
02042193
TEV Y
WAY Y
propranolol 40mg tab
Novo-Pranol 40mg Tab
Inderal 40mg Tab (discontinued)
DNP
0.1225
M
SF
00496499
02042207
TEV Y
WAY Y
Inderal-LA 60mg Cap
DNP
0.5758
L
SF
02042231
PFI
propranolol 80mg tab
Novo-Pranol 80mg Tab
Inderal 80mg Tab (discontinued)
DNP
0.2034
M
SF
00496502
02042215
TEV Y
WAY Y
Inderal-LA 80mg Cap
DNP
0.6493
L
SF
02042258
PFI
00504335
02042223
APX Y
WAY Y
N
DNP
0.9997
L
SF
02042266
PFI
N
Inderal-LA 160mg Cap
DNP
1.1823
L
SF
02042274
PFI
N
DNP
0.1649
M
SF
00755842
APX
Y
00353914
LIH
Y
00755850
APX
Y
00353922
FRS
Y
00755869
APX
Y
00495611
FRS
Y
02210428
02368617
APX
JPC
Y
Y
02229778
02231181
MYL Y
TEV Y
02238326
PMS Y
TIMOLOL
Blocadren 5mg Tab (discontinued)
timolol maleate 10mg tab
Apo-Timol 10mg Tab
DNP
0.2572
M
SF
Blocadren 10mg Tab (discontinued)
timolol maleate 20mg tab
Apo-Timol 20mg Tab
DNP
0.5005
M
SF
Blocadren 20mg Tab (discontinued)
SOTALOL
sotalol 80mg tab
Apo-Sotalol 80mg Tab
Jamp-Sotalol 80mg Tab
DNP
DNP
0.2966
0.2966
M
M
SF
SF
MYLAN-Sotalol 80mg Tab (discontinued)
Novo-Sotalol 80mg Tab (discontinued)
pms-Sotalol 80mg Tab
February 2016
N
Inderal-LA 120mg Cap
timolol maleate 5mg tab
Apo-Timol 5mg Tab
C07AA07
N
propranolol 10mg tab
Novo-Pranol 10mg Tab
Inderal 10mg Tab (discontinued)
propranolol 120mg tab
Apo-Propranolol 120mg Tab (discontinued)
Inderal 120mg Tab (discontinued)
C07AA06
Y
Y
DNP
0.2966
M
SF
43
C
Cardiovascular System
ratio-Sotalol 80mg Tab
Sandoz Sotalol 80mg Tab
DNP
DNP
0.2966
0.2966
M
M
SF
SF
02084228
02257831
TEV
SDZ
Y
Y
Sotalol-80mg Tab
Sotacor 80mg Tab (discontinued)
DNP
0.2966
M
SF
02385988
00897272
SIV
BRI
Y
Y
DNP
DNP
0.1624
0.1624
M
M
SF
SF
02167794
02368625
APX
JPC
Y
Y
02229779
02231182
MYL Y
TEV Y
sotalol 160mg tab
Apo-Sotalol 160mg Tab
Jamp-Sotalol 160mg Tab
MYLAN-Sotalol 160mg Tab (discontinued)
Novo-Sotalol 160mg Tab (discontinued)
pms-Sotalol 160mg Tab
ratio-Sotalol 160mg Tab
DNP
DNP
0.1624
0.1624
M
M
SF
SF
02238327
02084236
PMS Y
TEV Y
Sandoz Sotalol 160mg Tab
Sotalol-160mg Tab
DNP
0.1624
M
SF
02257858
02385996
SDZ
SIV
Y
Y
00483923
BRI
Y
Sotacor 160mg Tab (discontinued)
C07AA12
C07AB
NADOLOL
nadolol 40mg tab
Apo-Nadol 40mg Tab
Corgard 40mg Tab (discontinued)
DNP
0.4512
M
SF
00782505
00607126
AAP
BRI
Y
Y
nadolol 80mg tab
Apo-Nadol 80mg Tab
Corgard 80mg Tab (discontinued)
DNP
0.3710
M
SF
00782467
00463256
AAP
BRI
Y
Y
nadolol 160mg tab
Apo-Nadol 160mg Tab
Corgard 160mg Tab (discontinued)
DNP
1.2046
M
SF
00782475
00523372
AAP
BRI
Y
Y
02442116
SIV
Y
pms-Metoprolol-L 25mg Tab
DNP
0.0643
M
SF
02248855
PMS Y
Apo-Metoprolol 25mg Tab
MYLAN-Metoprolol (Type L) 25mg Tab
DNP
DNP
0.0643
0.0643
L
L
SF
SF
02246010
02302055
APX N
MYL N
metoprolol tartrate 50mg tab
Apo-Metoprolol 50mg Tab
Apo-Metoprolol-L 50mg Tab
DNP
DNP
0.0671
0.0671
M
M
SF
SF
00618632
00749354
APX
APX
Y
Y
Jamp-Metoprolol-L 50mg Tab
Metoprolol Film-Coated 50mg Tab
DNP
DNP
0.0671
0.0671
M
M
SF
SF
02356821
02350394
JPC
SAS
Y
Y
Metoprolol-L 50mg Tab
MYLAN-Metoprolol (Type L) 50mg Tab
DNP
DNP
0.0671
0.0671
M
M
SF
SF
02442124
02174545
SIV Y
MYL Y
pms-Metoprolol-L 50mg Tab
Sandoz Metoprolol (Type L) 50mg Tab
DNP
DNP
0.0671
0.0671
M
M
SF
SF
02230803
02354187
PMS Y
SDZ Y
Teva-Metoprol 50mg Tab (pink)
Betaloc 50mg Tab (discontinued)
DNP
0.0671
M
SF
00648035
00402605
TEV
AZE
Lopresor 50mg Tab
DNP
0.0671
M
SF
00397423
NVR Y
Teva-Metoprol 50mg Tab (white)
DNP
0.1225
L
SF
00842648
TEV
BETA BLOCKING AGENTS, PLAIN, SELECTIVE
C07AB02
METOPROLOL
metoprolol 25mg tab
Metoprolol-L 25mg Tab
metoprolol tartrate 100mg SR tab
February 2016
44
Y
Y
N
C
Cardiovascular System
Apo-Metoprolol SR 100mg Tab
Sandoz Metoprolol SR 100mg Tab
DNP
DNP
0.1248
0.1248
M
M
SF
SF
02285169
02303396
APX
SDZ
Lopresor SR 100mg Tab
DNP
0.1248
M
SF
00658855
NVR Y
metoprolol tartrate 100mg tab
Apo-Metoprolol 100mg Tab
DNP
0.1464
M
SF
00618640
APX
Y
Apo-Metoprolol-L 100mg Tab
Jamp-Metoprolol-L 100mg Tab
DNP
DNP
0.1464
0.1464
M
M
SF
SF
00751170
02356848
APX
JPC
Y
Y
Metoprolol Film-Coated 100mg Tab
Metoprolol-L 100mg Tab
DNP
DNP
0.1464
0.1464
M
M
SF
SF
02350408
02442132
SAS
SIV
Y
Y
MYLAN-Metoprolol (Type L) 100mg Tab
pms-Metoprolol-L 100mg Tab
DNP
DNP
0.1464
0.1464
M
M
SF
SF
02174553
02230804
MYL Y
PMS Y
Sandoz Metoprolol (Type L) 100mg Tab
Teva-Metoprol 100mg Tab (blue)
DNP
DNP
0.1464
0.1464
M
M
SF
SF
02354195
00648043
SDZ
TEV
AZE Y
NVR Y
February 2016
Y
Y
Betaloc 100mg Tab (discontinued)
Lopresor 100mg Tab
DNP
0.1464
M
SF
00402540
00397431
Teva-Metoprol 100mg Tab (white)
DNP
0.2223
L
SF
00842656
TEV
N
metoprolol tartrate 200mg SR tab
Apo-Metoprolol SR 200mg Tab
Sandoz Metoprolol SR 200mg Tab
DNP
DNP
0.2499
0.2499
M
M
SF
SF
02285177
02303418
APX
SDZ
Y
Y
Lopresor SR 200mg Tab
DNP
0.2499
M
SF
00534560
NVR Y
00497827
AZE
Betaloc Durules 200mg Tab (discontinued)
C07AB03
Y
Y
N
ATENOLOL
atenolol 25mg tab
Atenolol-25mg Tab
pms-Atenolol 25mg Tab
DNP
DNP
0.0946
0.0946
M
M
SF
SF
02247182
02246581
SIV Y
PMS Y
Jamp-Atenolol 25mg Tab
DNP
0.0946
L
SF
02367556
JPC
Mar-Atenolol 25mg Tab
MINT-Atenol 25mg Tab
DNP
DNP
0.0946
0.0946
L
L
SF
SF
02371979
02368013
MAR N
MNT N
MYLAN-Atenolol 25mg Tab
RAN-Atenolol 25mg Tab
DNP
DNP
0.1758
0.0946
L
L
SF
SF
02303647
02373963
MYL N
RAN N
Teva-Atenolol 25mg Tab
DNP
0.1758
L
SF
02266660
TEV
N
atenolol 50mg tab
Apo-Atenol 50mg Tab
DNP
0.1478
M
SF
00773689
APX
Y
Atenolol-50mg Tab
CO Atenolol 50mg Tab
DNP
DNP
0.1478
0.1478
M
M
SF
SF
02238316
02255545
SIV
ATV
Y
Y
Jamp-Atenolol 50mg Tab
Mar-Atenolol 50mg Tab
DNP
DNP
0.1478
0.1478
M
M
SF
SF
02367564
02371987
JPC Y
MAR Y
MINT-Atenol 50mg tab
MYLAN-Atenolol 50mg Tab
DNP
DNP
0.1478
0.1478
M
M
SF
SF
02368021
02146894
MNT Y
MYL Y
pms-Atenolol 50mg Tab
RAN-Atenolol 50mg Tab
DNP
DNP
0.1478
0.1478
M
M
SF
SF
02237600
02267985
PMS Y
RAN Y
ratio-Atenolol 50mg Tab
Septa-Atenolol 50mg Tab
DNP
DNP
0.1478
0.1478
M
M
SF
SF
02171791
02368641
TEV
SPT
Y
Y
Tenormin 50mg Tab
DNP
0.1478
M
SF
02039532
AZE
Y
atenolol 100mg tab
Apo-Atenol 100mg Tab
DNP
0.2429
M
SF
00773697
APX
Y
45
N
C
Cardiovascular System
C07AB04
Atenolol-100mg Tab
CO Atenolol 100mg Tab
DNP
DNP
0.2429
0.2429
M
M
SF
SF
02238318
02255553
SIV
ATV
Jamp-Atenolol 100mg Tab
Mar-Atenolol 100mg Tab
DNP
DNP
0.2429
0.2429
M
M
SF
SF
02367572
02371995
JPC Y
MAR Y
MINT-Atenol 100mg tab
MYLAN-Atenolol 100mg Tab
DNP
DNP
0.2429
0.2429
M
M
SF
SF
02368048
02147432
MNT Y
MYL Y
pms-Atenolol 100mg Tab
RAN-Atenolol 100mg Tab
DNP
DNP
0.2429
0.2429
M
M
SF
SF
02237601
02267993
PMS Y
RAN Y
ratio-Atenolol 100mg Tab
Septa-Atenolol 100mg Tab
DNP
DNP
0.2429
0.2429
M
M
SF
SF
02171805
02368668
TEV
SPT
Y
Y
Teva-Atenolol 100mg Tab (discontinued)
Tenormin 100mg Tab
DNP
0.2429
M
SF
01912054
02039540
TEV
AZE
Y
Y
acebutolol HCl 100mg tab
Acebutolol 100mg Tab
DNP
0.0839
M
SF
02286246
SAS
Y
Apo-Acebutolol 100mg Tab
MYLAN-Acebutolol (Type S) 100mg Tab
DNP
DNP
0.0839
0.0839
M
M
SF
SF
02147602
02237885
APX Y
MYL Y
MYLAN-Acebutolol 100mg Tab
Novo-Acebutolol 100mg Tab
DNP
DNP
0.0839
0.0839
M
M
SF
SF
02237721
02204517
MYL Y
TEV Y
Monitan 100mg Tab (discontinued)
Sectral 100mg Tab
DNP
0.0839
M
SF
02036290
01926543
WAY Y
SAV Y
acebutolol HCl 200mg tab
Acebutolol 200mg Tab
Apo-Acebutolol 200mg Tab
DNP
DNP
0.1259
0.1259
M
M
SF
SF
02286254
02147610
SAS
APX
MYLAN-Acebutolol (Type S) 200mg Tab
MYLAN-Acebutolol 200mg Tab
DNP
DNP
0.1259
0.1259
M
M
SF
SF
02237886
02237722
MYL Y
MYL Y
Novo-Acebutolol 200mg Tab
Monitan 200mg Tab (discontinued)
DNP
0.1259
M
SF
02204525
02036436
TEV Y
WAY Y
Sectral 200mg Tab
DNP
0.1259
M
SF
01926551
SAV
Y
acebutolol HCl 400mg tab
Acebutolol 400mg
DNP
0.2505
M
SF
02286262
SAS
Y
Apo-Acebutolol 400mg Tab
MYLAN-Acebutolol (Type S) 400mg Tab
DNP
DNP
0.2505
0.2505
M
M
SF
SF
02147629
02237887
APX Y
MYL Y
MYLAN-Acebutolol 400mg Tab
Novo-Acebutolol 400mg Tab
DNP
DNP
0.2505
0.2505
M
M
SF
SF
02237723
02204533
MYL Y
TEV Y
02036444
01910167
WAY Y
SDZ Y
ACEBUTOLOL
Monitan 400mg Tab (discontinued)
Rhotral 400mg Tab (discontinued)
Sectral 400mg Tab
C07AB07
February 2016
Y
Y
Y
Y
DNP
0.2505
M
SF
01926578
SAV
Y
bisoprolol 5mg tab
Apo-Bisoprolol 5mg Tab
Bisoprolol 5mg Tab
DNP
DNP
0.0994
0.0994
M
M
SF
SF
02256134
02391589
APX
SAS
Y
Y
Bisoprolol-5mg Tab
MYLAN-Bisoprolol 5mg Tab
DNP
DNP
0.0994
0.0994
M
M
SF
SF
02383055
02384418
SIV Y
MYL Y
Novo-Bisoprolol 5mg Tab
pms-Bisoprolol 5mg Tab
DNP
DNP
0.0994
0.0994
M
M
SF
SF
02267470
02302632
TEV Y
PMS Y
Sandoz Bisoprolol 5mg Tab
DNP
0.0994
M
SF
02247439
SDZ
BISOPROLOL
46
Y
C
Cardiovascular System
Monocor 5mg Tab (discontinued)
C07AG
BVL
Y
bisoprolol 10mg tab
Apo-Bisoprolol 10mg Tab
DNP
0.1450
M
SF
02256177
APX
Y
Bisoprolol 10mg Tab
Bisoprolol-10mg Tab
DNP
DNP
0.1450
0.1450
M
M
SF
SF
02391597
02383063
SAS
SIV
Y
Y
MYLAN-Bisoprolol 10mg Tab
Novo-Bisoprolol 10mg Tab
DNP
DNP
0.1450
0.1450
M
M
SF
SF
02384426
02267489
MYL Y
TEV Y
pms-Bisoprolol 10mg Tab
Sandoz Bisoprolol 10mg Tab
DNP
DNP
0.1450
0.1450
M
M
SF
SF
02302640
02247440
PMS Y
SDZ Y
02241149
BVL
Y
Bystolic 2.5mg Tab
02398990
FLC
N
Bystolic 5mg Tab
02399008
FLC
N
Bystolic 10mg Tab
02399016
FLC
N
Bystolic 20mg Tab
02399024
FLC
N
labetalol 5mg/mL inj
Labetalol 5mg/mL Inj
02231689
SDZ
Y
Trandate 5mg/mL Inj (discontinued)
02091518
SHI
Y
Monocor 10mg Tab (discontinued)
C07AB12
02241148
NEBIVOLOL
ALPHA AND BETA BLOCKING AGENTS
C07AG01
C07AG02
LABETALOL
Trandate 100mg Tab
DNP
0.3360
L
SF
02106272
PAL
N
Trandate 200mg Tab
DNP
0.5939
L
SF
02106280
PAL
N
carvedilol 3.125mg tab
Apo-Carvedilol 3.125mg Tab
Carvedilol 3.125mg Tab
DNP
DNP
0.3377
0.3377
M
M
E
E
02247933
02364913
APX
SAS
Y
Y
Carvedilol-3.125mg Tab
Jamp-Carvedilol 3.125mg Tab
DNP
DNP
0.3377
0.3377
M
M
E
E
02248752
02368897
SIV
JPC
Y
Y
MYLAN-Carvedilol 3.125mg Tab
pms-Carvedilol 3.125mg Tab
DNP
DNP
0.3377
0.3377
M
M
E
E
02347512
02245914
MYL Y
PMS Y
RAN-Carvedilol 3.125mg Tab
ratio-Carvedilol 3.125mg Tab
DNP
DNP
0.3377
0.3377
M
M
E
E
02268027
02252309
RAN Y
TEV Y
02229650
GSK Y
CARVEDILOL
Coreg 3.125mg Tab (discontinued)
carvedilol 6.25mg tab
Apo-Carvedilol 6.25mg Tab
DNP
0.3377
M
E
02247934
APX
Y
Carvedilol 6.25mg Tab
Carvedilol-6.25mg Tab
DNP
DNP
0.3377
0.3377
M
M
E
E
02364921
02248753
SAS
SIV
Y
Y
Jamp-Carvedilol 6.25mg Tab
MYLAN-Carvedilol 6.25mg Tab
DNP
DNP
0.3377
0.3377
M
M
E
E
02368900
02347520
JPC Y
MYL Y
pms-Carvedilol 6.25mg Tab
RAN-Carvedilol 6.25mg Tab
DNP
DNP
0.3377
0.3377
M
M
E
E
02245915
02268035
PMS Y
RAN Y
ratio-Carvedilol 6.25mg Tab
Coreg 6.25mg Tab (discontinued)
DNP
0.3377
M
E
02252317
02229651
TEV Y
GSK Y
carvedilol 12.5mg tab
February 2016
47
C
Cardiovascular System
Apo-Carvedilol 12.5mg Tab
Carvedilol 12.5mg Tab
DNP
DNP
0.3377
0.3377
M
M
E
E
02247935
02364948
APX
SAS
Y
Y
Carvedilol-12.5mg Tab
Jamp-Carvedilol 12.5mg Tab
DNP
DNP
0.3377
0.3377
M
M
E
E
02248754
02368919
SIV
JPC
Y
Y
MYLAN-Carvedilol 12.5mg Tab
pms-Carvedilol 12.5mg Tab
DNP
DNP
0.3377
0.3377
M
M
E
E
02347555
02245916
MYL Y
PMS Y
RAN-Carvedilol 12.5mg Tab
ratio-Carvedilol 12.5mg Tab
DNP
DNP
0.3377
0.3377
M
M
E
E
02268043
02252325
RAN Y
TEV Y
02229652
GSK Y
Coreg 12.5mg Tab (discontinued)
carvedilol 25mg tab
Apo-Carvedilol 25mg Tab
DNP
0.3377
M
E
02247936
APX
Y
Carvedilol 25mg Tab
Carvedilol-25mg Tab
DNP
DNP
0.3377
0.3377
M
M
E
E
02364956
02248755
SAS
SIV
Y
Y
Jamp-Carvedilol 25mg Tab
MYLAN-Carvedilol 25mg Tab
DNP
DNP
0.3377
0.3377
M
M
E
E
02368927
02347571
JPC Y
MYL Y
pms-Carvedilol 25mg Tab
RAN-Carvedilol 25mg Tab
DNP
DNP
0.3377
0.3377
M
M
E
E
02245917
02268051
PMS Y
RAN Y
ratio-Carvedilol 25mg Tab
Coreg 25mg Tab (discontinued)
DNP
0.3377
M
E
02252333
02229653
TEV Y
GSK Y
DNP
DNP
1.0006
1.0006
L
L
SF
SF
00568627
00568635
TRB N
TRB N
atenolol 50mg & chlorthalidone 25mg tab
Apo-Atenidone 50/25 Tab
DNP
0.3195
M
SF
02248763
APX
Y
Teva-Atenolol/Chlorthalidone 50/25mg Tab
Tenoretic 50/25 Tab
DNP
DNP
0.3195
0.3195
M
M
SF
SF
02302918
02049961
TEV
AZE
Y
Y
atenolol 100mg & chlorthalidone 25mg tab
Apo-Atenidone 100/25 Tab
Teva-Atenolol/Chlorthalidone 100/25mg Tab
DNP
DNP
0.5236
0.5236
M
M
SF
SF
02248764
02302926
APX
TEV
Y
Y
Tenoretic 100/25 Tab
DNP
0.5236
M
SF
02049988
AZE
Y
N
C07C
BETA BLOCKING AGENTS AND OTHER DIURETICS
C07CA
BETA BLOCKING AGENTS,NON-SELECTIVE,OTHER DIURETICS
C07CA03
PINDOLOL AND OTHER DIURETICS
Viskazide 10/25 Tab
Viskazide 10/50 Tab
C07CB
BETA BLOCKING AGENTS,SELECTIVE,AND OTHER DIURETICS
C07CB03
ATENOLOL AND OTHER DIURETICS
C08
CALCIUM CHANNEL BLOCKERS
C08C
SELECTIVE CALCIUM CHANNEL BLOCKERS WITH MAINLY VASCULAR EFFECTS
C08CA
DIHYDROPYRIDINE DERIVATIVES
C08CA01
February 2016
AMLODIPINE
ACT-Amlodipine 2.5mg Tab
DNP
0.1380
L
SF
02297477
ATV
pms-Amlodipine 2.5mg Tab
DNP
0.1380
L
SF
02295148
PMS N
amlodipine 5mg tab
Amlodipine 5mg Tab
DNP
0.2417
M
SF
02331284
SAS
48
Y
C
Cardiovascular System
C08CA02
Amlodipine 5mg Tab
Amlodipine-5mg Tab
DNP
DNP
0.2417
0.2417
M
M
SF
SF
02429217
02385791
JPC
SIV
Amlodipine-ODAN 5mg Tab (discontinued)
Apo-Amlodipine 5mg Tab
DNP
0.2417
M
SF
02378760
02273373
ODN Y
APX Y
Auro-Amlodipine 5mg Tab
CO Amlodipine 5mg Tab
DNP
DNP
0.2417
0.2417
M
M
SF
SF
02397072
02297485
ARO Y
ATV Y
GD-Amlodipine 5mg Tab
Jamp-Amlodipine 5mg Tab (discontinued)
DNP
0.2417
M
SF
02280132
02357194
GMD Y
JPC Y
Mar-Amlodipine 5mg Tab
MINT-Amlodipine 5mg Tab
DNP
DNP
0.2417
0.2417
M
M
SF
SF
02371715
02362651
MAR Y
MNT Y
MYLAN-Amlodipine 5mg Tab
pms-Amlodipine 5mg Tab
DNP
DNP
0.2417
0.2417
M
M
SF
SF
02272113
02284065
MYL Y
PMS Y
RAN-Amlodipine 5mg Tab
ratio-Amlodipine 5mg Tab (discontinued)
DNP
0.2417
M
SF
02321858
02259605
RAN Y
TEV Y
Sandoz Amlodipine 5mg Tab
Septa-Amlodipine 5mg Tab
DNP
DNP
0.2417
0.2417
M
M
SF
SF
02284383
02357712
SDZ
SPT
Y
Y
Teva-Amlodipine 5mg Tab
Norvasc 5mg Tab
DNP
DNP
0.2417
0.2417
M
M
SF
SF
02250497
00878928
TEV
PFI
Y
Y
amlodipine 10mg tab
Amlodipine 10mg Tab
Amlodipine 10mg Tab
DNP
DNP
0.3587
0.3587
M
M
SF
SF
02331292
02429225
SAS
JPC
Y
Y
Amlodipine-10mg Tab
Amlodipine-ODAN 10mg Tab (discontinued)
DNP
0.3587
M
SF
02385805
02378779
SIV Y
ODN Y
Apo-Amlodipine 10mg Tab
Auro-Amlodipine 10mg Tab
DNP
DNP
0.3587
0.3587
M
M
SF
SF
02273381
02397080
APX Y
ARO Y
CO Amlodipine 10mg Tab
GD-Amlodipine 10mg Tab
DNP
DNP
0.3587
0.3587
M
M
SF
SF
02297493
02280140
ATV Y
GMD Y
Jamp-Amlodipine 10mg Tab (discontinued)
Mar-Amlodipine 10mg Tab
DNP
0.3587
M
SF
02357208
02371723
JPC Y
MAR Y
MINT-Amlodipine 10mg Tab
MYLAN-Amlodipine 10mg Tab
DNP
DNP
0.3587
0.3587
M
M
SF
SF
02362678
02272121
MNT Y
MYL Y
pms-Amlodipine 10mg Tab
RAN-Amlodipine 10mg Tab
DNP
DNP
0.3587
0.3587
M
M
SF
SF
02284073
02321866
PMS Y
RAN Y
ratio-Amlodipine 10mg Tab (discontinued)
Sandoz Amlodipine 10mg Tab
DNP
0.3587
M
SF
02259613
02284391
TEV
SDZ
Y
Y
Septa-Amlodipine 10mg Tab
Teva-Amlodipine 10mg Tab
DNP
DNP
0.3587
0.3587
M
M
SF
SF
02357720
02250500
SPT
TEV
Y
Y
Norvasc 10mg Tab
DNP
0.3587
M
SF
00878936
PFI
Y
Plendil 2.5mg ER Tab
DNP
0.5297
L
SF
02057778
AZE
N
felodipine 5mg tab (Plendil)
Sandoz Felodipine 5mg Tab
Plendil 5mg Tab
DNP
DNP
0.5593
0.5593
M
M
SF
SF
02280264
00851779
SDZ
AZE
Y
Y
DNP
0.5593
M
SF
02280264
02221993
SDZ
SAV
Y
Y
FELODIPINE
felodipine 5mg tab (Renedil)
Sandoz Felodipine 5mg Tab
Renedil 5mg Tab (discontinued)
felodipine 10mg tab (Plendil)
February 2016
Y
Y
49
C
Cardiovascular System
C08CA05
Sandoz Felodipine 10mg Tab
Plendil 10mg Tab
DNP
DNP
0.8390
0.8390
M
M
SF
SF
02280272
00851787
SDZ
AZE
Y
Y
felodipine 10mg tab (Renedil)
Sandoz Felodipine 10mg Tab
Renedil 10mg Tab (discontinued)
DNP
0.8390
M
SF
02280272
02222000
SDZ
SAV
Y
Y
DNP
0.3992
M
SF
00725110
AAP
Y
00613258
MIP
Y
00755907
AAP
Y
00557633
MIP
Y
N
NIFEDIPINE
nifedipine 5mg cap
Nifedipine 5mg Cap
Adalat 5mg Cap (discontinued)
nifedipine 10mg cap
Nifedipine 10mg Cap
DNP
0.5292
M
SF
Adalat 10mg Cap (discontinued)
C08CA06
Adalat XL 20mg Tab
DNP
1.2600
L
SF
02237618
TEV
nifedipine 30mg ER tab
MYLAN-Nifedipine ER 30mg Tab
DNP
0.6171
M
SF
02349167
MYL Y
pms-Nifedipine ER 30mg Tab
Adalat XL 30mg Tab
DNP
0.6171
M
SF
02418630
02155907
PMS Y
TEV Y
nifedipine 60mg ER tab
MYLAN-Nifedipine ER 60mg Tab
pms-Nifedipine ER 60mg Tab
DNP
0.9374
M
SF
02321149
02416301
MYL Y
PMS Y
Adalat XL 60mg Tab
DNP
0.9374
M
SF
02155990
TEV
Y
DNP
10.0776
L
SF
02325926
BAY
N
verapamil 2.5mg/mL inj
Verapamil 2.5mg/mL Inj
02166739
SDZ
Y
Isoptin IV 2.5mg/mL Inj (discontinued)
00630535
ABB
Y
Y
NIMODIPINE
Nimotop 30mg Tab
C08D
SELECTIVE CALCIUM CHANNEL BLOCKERS WITH DIRECT CARDIAC EFFECTS
C08DA
PHENYLALKYLAMINE DERIVATIVES
C08DA01
VERAPAMIL
verapamil HCl 80mg tab
Apo-Verap 80mg Tab
DNP
0.2735
M
SF
00782483
APX
DNP
0.2735
M
SF
02237921
00554316
MYL Y
ABB Y
verapamil 120mg SR tab
Apo-Verap SR 120mg Tab
MYLAN-Verapamil SR 120mg Tab
02246893
02210347
APX Y
MYL Y
Isoptin SR 120mg Tab
01907123
BGP Y
MYLAN-Verapamil 80mg Tab
Isoptin 80mg Tab (discontinued)
verapamil HCl 120mg tab
Apo-Verap 120mg Tab
MYLAN-Verapamil 120mg Tab
Isoptin 120mg Tab (discontinued)
DNP
0.4250
M
SF
00782491
APX
DNP
0.4250
M
SF
02237922
00554324
MYL Y
ABB Y
verapamil 180mg SR tab
February 2016
50
Y
C
C08DB
Cardiovascular System
Apo-Verap SR 180mg Tab
MYLAN-Verapamil SR 180mg Tab
DNP
DNP
0.5424
0.5424
M
M
SF
SF
02246894
02210355
APX Y
MYL Y
Isoptin SR 180mg Tab
DNP
0.5424
M
SF
01934317
BGP Y
verapamil 240mg SR tab
Apo-Verap SR 240mg Tab
DNP
0.5166
M
SF
02246895
APX
MYLAN-Verapamil SR 240mg Tab
pms-Verapamil SR 240mg Tab
DNP
DNP
0.5166
0.5166
M
M
SF
SF
02210363
02237791
MYL Y
PMS Y
Isoptin SR 240mg Tab
DNP
0.5166
M
SF
00742554
BGP Y
02244728
02099691
SDZ
BVL
Y
Y
00771376
00862924
APX
TEV
Y
Y
02097370
BVL
Y
00771384
APX
Y
00862932
02097389
TEV
BVL
Y
Y
Y
BENZOTHIAZEPINE DERIVATIVES
C08DB01
DILTIAZEM
diltiazem 5mg/mL inj
Diltiazem Hydrochloride 5mg/mL Inj
Cardizem 5mg/mL Inj (discontinued)
diltiazem HCl 30mg tab
Apo-Diltiaz 30mg Tab
Novo-Diltazem 30mg Tab
DNP
DNP
0.1866
0.1866
M
M
SF
SF
Cardizem 30mg Tab (discontinued)
diltiazem HCl 60mg tab
Apo-Diltiaz 60mg Tab
DNP
0.3273
M
SF
Novo-Diltazem 60mg Tab (discontinued)
Cardizem 60mg Tab (discontinued)
February 2016
diltiazem 120mg CD cap
Apo-Diltiaz CD 120mg Cap
CO Diltiazem CD 120mg Cap
DNP
DNP
0.3696
0.3696
M
M
SF
SF
02230997
02370611
APX
ATV
Y
Y
Diltiazem CD 120mg Cap
Novo-Diltazem CD 120mg Cap
DNP
DNP
0.3696
0.3696
M
M
SF
SF
02400421
02242538
SAS
TEV
Y
Y
pms-Diltiazem CD 120mg Cap
Sandoz Diltiazem CD 120mg Cap
DNP
DNP
0.3696
0.3696
M
M
SF
SF
02355752
02243338
PMS Y
SDZ Y
Cardizem CD 120mg Cap
DNP
0.3696
M
SF
02097249
VLN
Y
diltiazem 120mg ER cap
CO Diltiazem T 120mg Cap
DNP
0.2134
M
SF
02370441
ATV
Y
Novo-Diltazem ER 120mg Cap
Sandoz Diltiazem T 120mg Cap
DNP
DNP
0.2134
0.2134
M
M
SF
SF
02271605
02245918
TEV
SDZ
Y
Y
Tiazac ER 120mg Cap
DNP
0.2134
M
SF
02231150
VLN
Y
Tiazac XC 120mg Tab
DNP
0.8590
L
SF
02256738
VLN
N
diltiazem 180mg CD cap
Apo-Diltiaz CD 180mg Cap
DNP
0.4906
M
SF
02230998
APX
Y
CO Diltiazem CD 180mg Cap
Diltiazem CD 180mg Cap
DNP
DNP
0.4906
0.4906
M
M
SF
SF
02370638
02400448
ATV
SAS
Y
Y
Novo-Diltazem CD 180mg Cap
pms-Diltiazem CD 180mg Cap
DNP
DNP
0.4906
0.4906
M
M
SF
SF
02242539
02355760
TEV Y
PMS Y
Sandoz Diltiazem CD 180mg Cap
Cardizem CD 180mg Cap
DNP
DNP
0.4906
0.4906
M
M
SF
SF
02243339
02097257
SDZ
VLN
Y
Y
diltiazem 180mg ER cap
CO Diltiazem T 180mg Cap
Novo-Diltazem ER 180mg Cap
DNP
DNP
0.2889
0.2889
M
M
SF
SF
02370492
02271613
ATV
TEV
Y
Y
51
C
Cardiovascular System
Sandoz Diltiazem T 180mg Cap
Tiazac ER 180mg Cap
DNP
DNP
0.2889
0.2889
M
M
SF
SF
02245919
02231151
SDZ
VLN
Y
Y
Tiazac XC 180mg Tab
DNP
1.1418
L
SF
02256746
VLN
N
diltiazem 240mg CD cap
Apo-Diltiaz CD 240mg Cap
CO Diltiazem CD 240mg Cap
DNP
DNP
0.6508
0.6508
M
M
SF
SF
02230999
02370646
APX
ATV
Y
Y
Diltiazem CD 240mg Cap
Novo-Diltazem CD 240mg Cap
DNP
DNP
0.6508
0.6508
M
M
SF
SF
02400456
02242540
SAS
TEV
Y
Y
pms-Diltiazem CD 240mg Cap
Sandoz Diltiazem CD 240mg Cap
DNP
DNP
0.6508
0.6508
M
M
SF
SF
02355779
02243340
PMS Y
SDZ Y
Cardizem CD 240mg Cap
DNP
0.6508
M
SF
02097265
VLN
Y
diltiazem 240mg ER cap
CO Diltiazem T 240mg Cap
DNP
0.3832
M
SF
02370506
ATV
Y
Novo-Diltazem ER 240mg Cap
Sandoz Diltiazem T 240mg Cap
DNP
DNP
0.3832
0.3832
M
M
SF
SF
02271621
02245920
TEV
SDZ
Y
Y
Tiazac ER 240mg Cap
DNP
0.3832
M
SF
02231152
VLN
Y
Tiazac XC 240mg Tab
DNP
1.5162
L
SF
02256754
VLN
N
diltiazem 300mg CD cap
Apo-Diltiaz CD 300mg Cap
DNP
0.8134
M
SF
02229526
APX
Y
CO Diltiazem CD 300mg Cap
Diltiazem CD 300mg Cap
DNP
DNP
0.8134
0.8134
M
M
SF
SF
02370654
02400464
ATV
SAS
Y
Y
Novo-Diltazem CD 300mg Cap
pms-Diltiazem CD 300mg Cap
DNP
DNP
0.8134
0.8134
M
M
SF
SF
02242541
02355787
TEV Y
PMS Y
Sandoz Diltiazem CD 300mg Cap
Cardizem CD 300mg Cap
DNP
DNP
0.8134
0.8134
M
M
SF
SF
02243341
02097273
SDZ
VLN
Y
Y
diltiazem 300mg ER cap
CO Diltiazem T 300mg Cap
Novo-Diltazem ER 300mg Cap
DNP
DNP
0.4719
0.4719
M
M
SF
SF
02370514
02271648
ATV
TEV
Y
Y
Sandoz Diltiazem T 300mg Cap
Tiazac ER 300mg Cap
DNP
DNP
0.4719
0.4719
M
M
SF
SF
02245921
02231154
SDZ
VLN
Y
Y
Tiazac XC 300mg Tab
DNP
1.5117
L
SF
02256762
VLN
N
diltiazem 360mg ER cap
CO Diltiazem T 360mg Cap
Novo-Diltazem ER 360mg Cap
DNP
DNP
0.5778
0.5778
M
M
SF
SF
02370522
02271656
ATV
TEV
Y
Y
Sandoz Diltiazem T 360mg Cap
Tiazac ER 360mg Cap
DNP
DNP
0.5778
0.5778
M
M
SF
SF
02245922
02231155
SDZ
VLN
Y
Y
Tiazac XC 360mg Tab
DNP
1.5161
L
SF
02256770
VLN
N
Apo-Capto 6.25mg Tab
DNP
0.1237
L
SF
01999559
APX
N
captopril 12.5mg tab
Apo-Capto 12.5mg Tab
DNP
0.1060
M
SF
00893595
APX
Y
C09
AGENTS ACTING ON THE RENIN-ANGIOTENSIN SYSTEM
C09A
ACE-INHIBITORS, PLAIN
C09AA
ACE-INHIBITORS, PLAIN
C09AA01
February 2016
CAPTOPRIL
52
C
Cardiovascular System
Novo-Captoril 12.5mg Tab
Capoten 12.5mg Tab (discontinued)
captopril 25mg tab
Apo-Capto 25mg Tab
MYLAN-Captopril 25mg Tab (discontinued)
Novo-Captoril 25mg Tab
Capoten 25mg Tab (discontinued)
captopril 50mg tab
Apo-Capto 50mg Tab
Novo-Captoril 50mg Tab
DNP
0.1060
M
SF
01942964
00695661
TEV
BRI
DNP
0.1500
M
SF
00893609
02163578
APX Y
MYL Y
DNP
0.1500
M
SF
01942972
00546283
TEV
BRI
Y
Y
DNP
DNP
0.2795
0.2795
M
M
SF
SF
00893617
01942980
APX
TEV
Y
Y
00546291
BRI
Y
Capoten 50mg Tab (discontinued)
captopril 100mg tab
Apo-Capto 100mg Tab
DNP
0.5198
M
SF
00893625
APX
Y
DNP
0.5198
M
SF
01942999
00546305
TEV
BRI
Y
Y
enalapril 2.5mg tab
Apo-Enalapril 2.5mg Tab
DNP
0.1955
M
SF
02020025
APX
Y
CO Enalapril 2.5mg Tab
Enalapril 2.5mg Tab
DNP
DNP
0.1955
0.1955
M
M
SF
SF
02291878
02400650
ATV
SAS
Y
Y
MYLAN-Enalapril 2.5mg Tab
Novo-Enalapril 2.5mg Tab (discontinued)
DNP
0.1955
M
SF
02300036
02300680
MYL Y
TEV Y
pms-Enalapril 2.5mg Tab
RAN-Enalapril 2.5mg Tab
DNP
DNP
0.1955
0.1955
M
M
SF
SF
02300079
02352230
PMS Y
RAN Y
Sandoz Enalapril 2.5mg Tab
Vasotec 2.5mg Tab
DNP
DNP
0.1955
0.1955
M
M
SF
SF
02299933
00851795
SDZ
FRS
Y
Y
enalapril 5mg tab
Apo-Enalapril 5mg Tab
CO Enalapril 5mg Tab
DNP
DNP
0.2314
0.2314
M
M
SF
SF
02019884
02291886
APX
ATV
Y
Y
Enalapril 5mg Tab
MYLAN-Enalapril 5mg Tab
DNP
DNP
0.2314
0.2314
M
M
SF
SF
02400669
02300044
SAS Y
MYL Y
Novo-Enalapril 5mg Tab
pms-Enalapril 5mg Tab
DNP
DNP
0.2314
0.2314
M
M
SF
SF
02233005
02300087
TEV Y
PMS Y
RAN-Enalapril 5mg Tab
Sandoz Enalapril 5mg Tab
DNP
DNP
0.2314
0.2314
M
M
SF
SF
02352249
02299941
RAN Y
SDZ Y
Vasotec 5mg Tab
DNP
0.2314
M
SF
00708879
FRS
Y
enalapril 10mg tab
Apo-Enalapril 10mg Tab
DNP
0.2779
M
SF
02019892
APX
Y
CO Enalapril 10mg Tab
Enalapril 10mg Tab
DNP
DNP
0.2779
0.2779
M
M
SF
SF
02291894
02400677
ATV
SAS
Y
Y
MYLAN-Enalapril 10mg Tab
Novo-Enalapril 10mg Tab
DNP
DNP
0.2779
0.2779
M
M
SF
SF
02300052
02233006
MYL Y
TEV Y
pms-Enalapril 10mg Tab
RAN-Enalapril 10mg Tab
DNP
DNP
0.2779
0.2779
M
M
SF
SF
02300095
02352257
PMS Y
RAN Y
Sandoz Enalapril 10mg Tab
Vasotec 10mg Tab
DNP
DNP
0.2779
0.2779
M
M
SF
SF
02299968
00670901
SDZ
FRS
Novo-Captoril 100mg Tab
Capoten 100mg Tab (discontinued)
C09AA02
ENALAPRIL
enalapril 20mg tab
February 2016
Y
Y
53
Y
Y
C
Cardiovascular System
C09AA03
February 2016
Apo-Enalapril 20mg Tab
CO Enalapril 20mg Tab
DNP
DNP
0.3354
0.3354
M
M
SF
SF
02019906
02291908
APX
ATV
Y
Y
Enalapril 20mg Tab
MYLAN-Enalapril 20mg Tab
DNP
DNP
0.3354
0.3354
M
M
SF
SF
02400685
02300060
SAS Y
MYL Y
Novo-Enalapril 20mg Tab
pms-Enalapril 20mg Tab
DNP
DNP
0.3354
0.3354
M
M
SF
SF
02233007
02300109
TEV Y
PMS Y
RAN-Enalapril 20mg Tab
Sandoz Enalapril 20mg Tab
DNP
DNP
0.3354
0.3354
M
M
SF
SF
02352265
02299976
RAN Y
SDZ Y
Vasotec 20mg Tab
DNP
0.3354
M
SF
00670928
FRS
lisinopril 5mg tab
Apo-Lisinopril 5mg Tab
Auro-Lisinopril 5mg Tab
DNP
DNP
0.1500
0.1500
M
M
SF
SF
02217481
02394472
APX Y
ARO Y
CO Lisinopril 5mg Tab
Jamp-Lisinopril 5mg Tab
DNP
DNP
0.1500
0.1500
M
M
SF
SF
02271443
02361531
ATV
JPC
Lisinopril-5mg Tab
MYLAN-Lisinopril 5mg Tab
DNP
DNP
0.1500
0.1500
M
M
SF
SF
02386232
02274833
SIV Y
MYL Y
Novo-Lisinopril P 5mg Tab
Novo-Lisinopril Z 5mg Tab
DNP
DNP
0.1500
0.1500
M
M
SF
SF
02285061
02285118
TEV
TEV
pms-Lisinopril 5mg Tab
RAN-Lisinopril 5mg Tab
DNP
DNP
0.1500
0.1500
M
M
SF
SF
02292203
02294230
PMS Y
RAN Y
Sandoz Lisinopril 5mg Tab
Prinivil 5mg Tab
DNP
DNP
0.1500
0.1500
M
M
SF
SF
02289199
00839388
SDZ
FRS
Y
Y
Zestril 5mg Tab
DNP
0.1500
M
SF
02049333
AZE
Y
lisinopril 10mg tab
Apo-Lisinopril 10mg Tab
DNP
0.1801
M
SF
02217503
APX
Y
Auro-Lisinopril 10mg Tab
CO Lisinopril 10mg Tab
DNP
DNP
0.1801
0.1801
M
M
SF
SF
02394480
02271451
ARO Y
ATV Y
Jamp-Lisinopril 10mg Tab
Lisinopril-10mg Tab
DNP
DNP
0.1801
0.1801
M
M
SF
SF
02361558
02386240
JPC
SIV
MYLAN-Lisinopril 10mg Tab
Novo-Lisinopril Z 10mg Tab
DNP
DNP
0.1801
0.1801
M
M
SF
SF
02274841
02285126
MYL Y
TEV Y
pms-Lisinopril 10mg Tab
RAN-Lisinopril 10mg Tab
DNP
DNP
0.1801
0.1801
M
M
SF
SF
02292211
02294249
PMS Y
RAN Y
Sandoz Lisinopril 10mg Tab
Teva-Lisinopril (Type P) 10mg Tab
DNP
DNP
0.1801
0.1801
M
M
SF
SF
02289202
02285088
SDZ
TEV
Y
Y
Prinivil 10mg Tab
Zestril 10mg Tab
DNP
DNP
0.1801
0.1801
M
M
SF
SF
00839396
02049376
FRS
AZE
Y
Y
lisinopril 20mg tab
Apo-Lisinopril 20mg Tab
Auro-Lisinopril 20mg Tab
DNP
DNP
0.2166
0.2166
M
M
SF
SF
02217511
02394499
APX Y
ARO Y
CO Lisinopril 20mg Tab
Jamp-Lisinopril 20mg Tab
DNP
DNP
0.2166
0.2166
M
M
SF
SF
02271478
02361566
ATV
JPC
Lisinopril-20mg Tab
MYLAN-Lisinopril 20mg Tab
DNP
DNP
0.2166
0.2166
M
M
SF
SF
02386259
02274868
SIV Y
MYL Y
Novo-Lisinopril Z 20mg Tab
pms-Lisinopril 20mg Tab
DNP
DNP
0.2166
0.2166
M
M
SF
SF
02285134
02292238
TEV Y
PMS Y
RAN-Lisinopril 20mg Tab
DNP
0.2166
M
SF
02294257
RAN Y
Y
LISINOPRIL
54
Y
Y
Y
Y
Y
Y
Y
Y
C
Cardiovascular System
C09AA04
Sandoz Lisinopril 20mg Tab
Teva-Lisinopril (Type P) 20mg Tab
DNP
DNP
0.2166
0.2166
M
M
SF
SF
02289229
02285096
SDZ
TEV
Y
Y
Prinivil 20mg Tab
Zestril 20mg Tab
DNP
DNP
0.2166
0.2166
M
M
SF
SF
00839418
02049384
FRS
AZE
Y
Y
02123274
SEV
N
PERINDOPRIL
Coversyl 2mg Tab
C09AA05
February 2016
Coversyl 4mg Tab
DNP
0.8867
L
SF
02123282
SEV
N
Coversyl 8mg Tab
DNP
1.1980
L
SF
02246624
SEV
N
ramipril 1.25mg cap/tab
Apo-Ramipril 1.25mg Cap
Auro-Ramipril 1.25mg Cap
DNP
DNP
0.1274
0.1274
M
M
SF
SF
02251515
02387387
APX Y
ARO Y
CO Ramipril 1.25mg Cap
Jamp-Ramipril 1.25mg Cap
DNP
DNP
0.1274
0.1274
M
M
SF
SF
02295482
02331101
ATV
JPC
Mar-Ramipril 1.25mg Cap
MYLAN-Ramipril 1.25mg Cap
DNP
DNP
0.1274
0.1274
M
M
SF
SF
02420457
02301148
MAR Y
MYL Y
pms-Ramipril 1.25mg Cap
RAN-Ramipril 1.25mg Cap
DNP
DNP
0.1274
0.1274
M
M
SF
SF
02295369
02310503
PMS Y
RAN Y
Sandoz Ramipril 1.25mg Tab
Altace 1.25mg Cap
DNP
DNP
0.1274
0.1274
M
M
SF
SF
02291398
02221829
SDZ
SAV
ramipril 2.5mg cap/tab
Apo-Ramipril 2.5mg Cap
Auro-Ramipril 2.5mg Cap
DNP
DNP
0.1470
0.1470
M
M
SF
SF
02251531
02387395
APX Y
ARO Y
CO Ramipril 2.5mg Cap
Jamp-Ramipril 2.5mg Cap
DNP
DNP
0.1470
0.1470
M
M
SF
SF
02295490
02331128
ATV
JPC
Mar-Ramipril 2.5mg Cap
MINT-Ramipril 2.5mg Cap
DNP
DNP
0.1470
0.1470
M
M
SF
SF
02420465
02421305
MAR Y
MNT Y
MYLAN-Ramipril 2.5mg Cap
pms-Ramipril 2.5mg Cap
DNP
DNP
0.1470
0.1470
M
M
SF
SF
02301156
02247917
MYL Y
PMS Y
Ramipril 2.5mg Cap
Ramipril-2.5mg Cap
DNP
DNP
0.1470
0.1470
M
M
SF
SF
02374846
02411563
SAS
SIV
RAN-Ramipril 2.5mg Cap
Sandoz Ramipril 2.5mg Tab
DNP
DNP
0.1470
0.1470
M
M
SF
SF
02310511
02291401
RAN Y
SDZ Y
Teva-Ramipril 2.5mg Cap
Altace 2.5mg Cap
DNP
DNP
0.1470
0.1470
M
M
SF
SF
02247945
02221837
TEV
SAV
ramipril 5mg cap/tab
Apo-Ramipril 5mg Cap
Auro-Ramipril 5mg Cap
DNP
DNP
0.1470
0.1470
M
M
SF
SF
02251574
02387409
APX Y
ARO Y
CO Ramipril 5mg Cap
Jamp-Ramipril 5mg Cap
DNP
DNP
0.1470
0.1470
M
M
SF
SF
02295504
02331136
ATV
JPC
Mar-Ramipril 5mg Cap
MINT-Ramipril 5mg Cap
DNP
DNP
0.1470
0.1470
M
M
SF
SF
02420473
02421313
MAR Y
MNT Y
MYLAN-Ramipril 5mg Cap
pms-Ramipril 5mg Cap
DNP
DNP
0.1470
0.1470
M
M
SF
SF
02301164
02247918
MYL Y
PMS Y
Ramipril 5mg Cap
Ramipril-5mg Cap
DNP
DNP
0.1470
0.1470
M
M
SF
SF
02374854
02411571
SAS
SIV
RAMIPRIL
55
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
C
Cardiovascular System
RAN-Ramipril 5mg Cap
Sandoz Ramipril 5mg Tab
DNP
DNP
0.1470
0.1470
M
M
SF
SF
02310538
02291428
RAN Y
SDZ Y
Teva-Ramipril 5mg Cap
Altace 5mg Cap
DNP
DNP
0.1470
0.1470
M
M
SF
SF
02247946
02221845
TEV
SAV
ramipril 10mg cap/tab
Apo-Ramipril 10mg Cap
Auro-Ramipril 10mg Cap
DNP
DNP
0.1862
0.1862
M
M
SF
SF
02251582
02387417
APX Y
ARO Y
CO Ramipril 10mg Cap
Jamp-Ramipril 10mg Cap
DNP
DNP
0.1862
0.1862
M
M
SF
SF
02295512
02331144
ATV
JPC
Mar-Ramipril 10mg Cap
MINT-Ramipril 10mg Cap
DNP
DNP
0.1862
0.1862
M
M
SF
SF
02420481
02421321
MAR Y
MNT Y
MYLAN-Ramipril 10mg Cap
pms-Ramipril 10mg Cap
DNP
DNP
0.1862
0.1862
M
M
SF
SF
02301172
02247919
MYL Y
PMS Y
Ramipril 10mg Cap
Ramipril-10mg Cap
DNP
DNP
0.1862
0.1862
M
M
SF
SF
02374862
02411598
SAS
SIV
RAN-Ramipril 10mg Cap
Sandoz Ramipril 10mg Tab
DNP
DNP
0.1862
0.1862
M
M
SF
SF
02310546
02291436
RAN Y
SDZ Y
Teva-Ramipril 10mg Cap
Altace 10mg Cap
DNP
DNP
0.1862
0.1862
M
M
SF
SF
02247947
02221853
TEV
SAV
ramipril 15mg cap
Apo-Ramipril 15mg Cap
Mar-Ramipril 15mg Cap
02325381
02420503
APX Y
MAR Y
MINT-Ramipril 15mg Cap
RAN-Ramipril 15mg Cap
02421348
02425548
MNT Y
RAN Y
Altace 15mg Cap
C09AA06
C09AA07
February 2016
Y
Y
Y
Y
Y
Y
Y
Y
DNP
0.4410
P
SF
02281112
SAV
Y
quinapril 5mg tab
Apo-Quinapril 5mg Tab
GD-Quinapril 5mg Tab
DNP
DNP
0.2321
0.2321
M
M
SF
SF
02248499
02290987
APX Y
GMD Y
Accupril 5mg Tab
DNP
0.2321
M
SF
01947664
PFI
Y
quinapril 10mg tab
Apo-Quinapril 10mg Tab
DNP
0.2321
M
SF
02248500
APX
Y
GD-Quinapril 10mg Tab
Accupril 10mg Tab
DNP
DNP
0.2321
0.2321
M
M
SF
SF
02290995
01947672
GMD Y
PFI Y
quinapril 20mg tab
Apo-Quinapril 20mg Tab
GD-Quinapril 20mg Tab
DNP
DNP
0.2321
0.2321
M
M
SF
SF
02248501
02291002
APX Y
GMD Y
Accupril 20mg Tab
DNP
0.2321
M
SF
01947680
PFI
Y
quinapril 40mg tab
Apo-Quinapril 40mg Tab
DNP
0.2321
M
SF
02248502
APX
Y
GD-Quinapril 40mg Tab
Accupril 40mg Tab
DNP
DNP
0.2321
0.2321
M
M
SF
SF
02291010
01947699
GMD Y
PFI Y
benazepril 5mg tab
Benazepril 5mg Tab
DNP
0.6051
M
SF
02290332
AAP
Lotensin 5mg Tab
DNP
0.6051
M
SF
00885835
NVR Y
QUINAPRIL
BENAZEPRIL
56
Y
C
Cardiovascular System
benazepril 10mg tab
Benazepril 10mg Tab
DNP
0.7156
M
SF
Lotensin 10mg Tab (discontinued)
C09AA08
Y
DNP
0.8210
M
SF
02273918
AAP
DNP
0.8210
M
SF
00885851
NVR Y
cilazapril 1mg tab
Apo-Cilazapril 1mg Tab
MYLAN-Cilazapril 1mg Tab
DNP
DNP
0.1780
0.1780
M
M
SF
SF
02291134
02283778
APX Y
MYL Y
Novo-Cilazapril 1mg Tab
pms-Cilazapril 1mg Tab
DNP
DNP
0.1780
0.1780
M
M
SF
SF
02266350
02280442
TEV Y
PMS Y
01911465
HLR
Y
Y
Y
CILAZAPRIL
cilazapril 2.5mg tab
Apo-Cilazapril 2.5mg Tab
DNP
0.1795
M
SF
02291142
APX
Cilazapril 2.5mg Tab
MYLAN-Cilazapril 2.5mg Tab
DNP
DNP
0.1795
0.1795
M
M
SF
SF
02350971
02283786
SAS Y
MYL Y
Novo-Cilazapril 2.5mg Tab
pms-Cilazapril 2.5mg Tab
DNP
DNP
0.1795
0.1795
M
M
SF
SF
02266369
02280450
TEV Y
PMS Y
Inhibace 2.5mg Tab
DNP
0.1795
M
SF
01911473
HLR
Y
cilazapril 5mg tab
Apo-Cilazapril 5mg Tab
Y
DNP
0.2085
M
SF
02291150
APX
MYLAN-Cilazapril 5mg Tab
Novo-Cilazapril 5mg Tab (discontinued)
DNP
0.2085
M
SF
02283794
02266377
MYL Y
TEV Y
pms-Cilazapril 5mg Tab
Inhibace 5mg Tab
DNP
DNP
0.2085
0.2085
M
M
SF
SF
02280469
01911481
PMS Y
HLR Y
fosinopril 10mg tab
Apo-Fosinopril 10mg Tab
DNP
0.2178
M
SF
02266008
APX
Jamp-Fosinopril 10mg Tab
MYLAN-Fosinopril 10mg Tab
DNP
DNP
0.2178
0.2178
M
M
SF
SF
02331004
02262401
JPC Y
MYL Y
Teva-Fosinopril 10mg Tab
Monopril 10mg Tab (discontinued)
DNP
0.2178
M
SF
02247802
01907107
TEV
BRI
Y
Y
fosinopril 20mg tab
Apo-Fosinopril 20mg Tab
Jamp-Fosinopril 20mg Tab
DNP
DNP
0.2619
0.2619
M
M
SF
SF
02266016
02331012
APX
JPC
Y
Y
MYLAN-Fosinopril 20mg Tab
Teva-Fosinopril 20mg Tab
DNP
DNP
0.2619
0.2619
M
M
SF
SF
02262428
02247803
MYL Y
TEV Y
01907115
BRI
02231457
BGP N
FOSINOPRIL
Y
Y
TRANDOLAPRIL
Mavik 0.5mg Cap
February 2016
NVR Y
Lotensin 20mg Tab
Monopril 20mg Tab (discontinued)
C09AA10
AAP
00885843
benazepril 20mg tab
Benazepril 20mg Tab
Inhibace 1mg Tab (discontinued)
C09AA09
02290340
Mavik 1mg Cap
DNP
0.6901
L
SF
02231459
BGP N
Mavik 2mg Cap
DNP
0.7931
L
SF
02231460
BGP N
Mavik 4mg Cap
DNP
0.9785
L
SF
02239267
BGP N
57
C
Cardiovascular System
C09B
ACE-INHIBITORS, COMBINATIONS
C09BA
ACE-INHIBITORS AND DIURETICS
C09BA02
ENALAPRIL AND DIURETICS
enalapril 5mg & hydrochlorothiazide 12.5mg tab
Apo-Enalapril Maleate/HCTZ 5/12.5mg Tab
DNP
0.4941
M
SF
Vaseretic 5/12.5mg Tab (discontinued)
C09BA03
C09BA04
February 2016
APX
Y
02242826
FRS
Y
enalapril 10mg & hydrochlorothiazide 25mg tab
Apo-Enalapril Maleate/HCTZ 10/25mg Tab
DNP
0.6108
M
SF
02352931
APX
Y
Vaseretic 10/25mg Tab
DNP
0.6108
M
SF
00657298
FRS
Y
lisinopril 10mg & hydrochlorothiazide 12.5mg tab
Lisinopril/HCTZ 10mg/12.5mg Tab (Type Z)
MYLAN-Lisinopril/HCTZ 10/12.5mg Tab (discontinued)
DNP
0.2144
M
SF
02362945
02297736
SAS Y
MYL Y
Novo-Lisinopril/HCTZ 10/12.5mg Tab (Type P)
Novo-Lisinopril/HCTZ 10/12.5mg Tab (Type Z)
DNP
DNP
0.2144
0.2144
M
M
SF
SF
02302136
02301768
TEV
TEV
Y
Y
Sandoz Lisinopril 10/12.5mg Tab
Prinzide 10/12.5mg Tab (discontinued)
DNP
0.2144
M
SF
02302365
02108194
SDZ
FRS
Y
Y
Zestoretic 10/12.5mg Tab
DNP
0.2144
M
SF
02103729
AZE
Y
lisinopril 20mg & hydrochlorothiazide 12.5mg tab
Lisinopril/HCTZ 20mg/12.5mg Tab (Type Z)
DNP
0.2575
M
SF
02362953
SAS
Y
MYLAN-Lisinopril/HCTZ 20/12.5mg Tab (discontinued)
Novo-Lisinopril/HCTZ 20/12.5mg Tab (Type P)
DNP
0.2575
M
SF
02297744
02302144
MYL Y
TEV Y
Sandoz Lisinopril 20/12.5mg Tab
Teva-Lisinopril/HCTZ (Type Z) 20/12.5mg Tab
DNP
DNP
0.2575
0.2575
M
M
SF
SF
02302373
02301776
SDZ
TEV
Y
Y
Zestoretic 20/12.5mg Tab
DNP
0.2575
M
SF
02045737
AZE
Y
lisinopril 20mg & hydrochlorothiazide 25mg tab
Lisinopril/HCTZ 20mg/25mg Tab (Type Z)
DNP
0.2575
M
SF
02362961
SAS
Y
MYLAN-Lisinopril/HCTZ 20/25mg Tab (discontinued)
Novo-Lisinopril/HCTZ 20/25mg Tab (Type P)
DNP
0.2575
M
SF
02297752
02302152
MYL Y
TEV Y
Novo-Lisinopril/HCTZ 20/25mg Tab (Type Z)
Sandoz Lisinopril 20/25mg Tab
DNP
DNP
0.2575
0.2575
M
M
SF
SF
02301784
02302381
TEV
SDZ
Y
Y
Prinzide 20/25mg Tab (discontinued)
Zestoretic 20/25mg Tab
DNP
0.2575
M
SF
00884421
02045729
FRS
AZE
Y
Y
02246568
SEV
N
LISINOPRIL AND DIURETICS
PERINDOPRIL AND DIURETICS
Coversyl Plus LD 2/0.625mg Tab
C09BA05
02352923
Coversyl Plus 4/1.25mg Tab
DNP
1.0827
L
SF
02246569
SEV
N
Coversyl Plus HD 8/2.5mg Tab
DNP
1.2110
L
SF
02321653
SEV
N
ramipril 2.5mg & hydrochlorothiazide 12.5mg tab
pms-Ramipril-HCTZ 2.5/12.5mg Tab
Teva-Ramipril/HCTZ 2.5/5mg Tab (discontinued)
DNP
0.2093
M
SF
02342138
02388332
PMS Y
TEV Y
Altace HCT 2.5/12.5mg Tab
DNP
0.2093
M
SF
02283131
SAV
ramipril 5mg & hydrochlorothiazide 12.5mg tab
pms-Ramipril-HCTZ 5/12.5mg Tab
DNP
0.2067
M
SF
02342146
PMS Y
RAMIPRIL AND DIURETICS
58
Y
C
Cardiovascular System
C09BA06
C09BA08
C09BB
Ramipril-HCTZ 5mg/12.5mg Tab
Teva-Ramipril/HCTZ 5/12.5mg Tab (discontinued)
DNP
0.2067
M
SF
02412640
02388340
SAS
TEV
Y
Y
Altace HCT 5/12.5mg Tab
DNP
0.2067
M
SF
02283158
SAV
Y
ramipril 5mg & hydrochlorothiazide 25mg tab
pms-Ramipril-HCTZ 5/25mg Tab
DNP
0.2067
M
SF
02342162
PMS Y
Ramipril-HCTZ 5mg/25mg Tab
Teva-Ramipril/HCTZ 5/25mg Tab (discontinued)
DNP
0.2067
M
SF
02412667
02388367
SAS
TEV
Y
Y
Altace HCT 5/25mg Tab
DNP
0.2067
M
SF
02283174
SAV
Y
ramipril 10mg & hydrochlorothiazide 12.5mg tab
pms-Ramipril-HCTZ 10/12.5mg Tab
DNP
0.2633
M
SF
02342154
PMS Y
Ramipril-HCTZ 10mg/12.5mg Tab
Teva-Ramipril/HCTZ 10/12.5mg Tab (discontinued)
DNP
0.2633
M
SF
02412659
02388359
SAS
TEV
Y
Y
Altace HCT 10/12.5mg Tab
DNP
0.2633
M
SF
02283166
SAV
Y
ramipril 10mg & hydrochlorothiazide 25mg tab
pms-Ramipril-HCTZ 10/25mg Tab
DNP
0.2633
M
SF
02342170
PMS Y
Ramipril-HCTZ 10mg/25mg Tab
Teva-Ramipril/HCTZ 10/25mg Tab (discontinued)
DNP
0.2633
M
SF
02412675
02388375
SAS
TEV
Y
Y
Altace HCT 10/25mg Tab
DNP
0.2633
M
SF
02283182
SAV
Y
quinapril 10mg & hydrochlorothiazide 12.5mg tab
Apo-Quinapril/HCTZ 10/12.5mg Tab
Accuretic 10/12.5mg Tab
DNP
DNP
0.6865
0.6865
M
M
SF
SF
02408767
02237367
APX
PFI
Y
Y
quinapril 20mg & hydrochlorothiazide 12.5mg tab
Apo-Quinapril/HCTZ 20/12.5mg Tab
Accuretic 20/12.5mg Tab
DNP
DNP
0.6865
0.6865
M
M
SF
SF
02408775
02237368
APX
PFI
Y
Y
quinapril 20mg & hydrochlorothiazide 25mg tab
Apo-Quinapril/HCTZ 20/25mg Tab
Accuretic 20/25mg Tab
DNP
DNP
0.6512
0.6512
M
M
SF
SF
02408783
02237369
APX
PFI
Y
Y
cilazapril 5mg & hydrochlorothiazide 12.5mg tab
Apo-Cilazapril/HCTZ 5/12.5mg Tab
DNP
0.4170
M
SF
02284987
APX
Y
Novo-Cilazapril/HCTZ 5mg/12.5mg Tab
Inhibace Plus 5/12.5mg Tab
DNP
DNP
0.4170
0.4170
M
M
SF
SF
02313731
02181479
TEV
HLR
Y
Y
Tarka 2/240mg Tab
02240946
BGP N
Tarka 4/240mg Tab
02238097
BGP N
02379058
APX
QUINAPRIL AND DIURETICS
CILAZAPRIL AND DIURETICS
ACE-INHIBITORS AND CALCIUM CHANNEL BLOCKERS
C09BB10
TRANDOLAPRIL AND VERAPAMIL
C09C
ANGIOTENSIN II ANTAGONISTS
C09CA
ANGIOTENSIN II ANTAGONISTS, PLAIN
C09CA01
LOSARTAN
losartan 25mg tab
Apo-Losartan 25mg Tab
February 2016
DNP
0.3148
M
SF
59
Y
C
Cardiovascular System
C09CA02
C09CA03
February 2016
Auro-Losartan 25mg Tab
CO Losartan 25mg Tab
DNP
DNP
0.3148
0.3148
M
M
SF
SF
02403323
02354829
ARO Y
ATV Y
Jamp-Losartan 25mg Tab
Losartan 25mg Tab
DNP
DNP
0.3148
0.3148
M
M
SF
SF
02398834
02388863
JPC
SAS
Losartan-25mg Tab
MINT-Losartan 25mg Tab
DNP
DNP
0.3148
0.3148
M
M
SF
SF
02388790
02405733
SIV Y
MNT Y
MYLAN-Losartan 25mg Tab
pms-Losartan 25mg Tab
DNP
DNP
0.3148
0.3148
M
M
SF
SF
02368277
02309750
MYL Y
PMS Y
RAN Y
SDZ Y
Y
Y
RAN-Losartan 25mg Tab (discontinued)
Sandoz Losartan 25mg Tab
DNP
0.3148
M
SF
02404451
02313332
Septa-Losartan 25mg Tab
Teva-Losartan 25mg Tab
DNP
DNP
0.3148
0.3148
M
M
SF
SF
02424967
02380838
SPT
TEV
Y
Y
Cozaar 25mg Tab
DNP
0.3148
M
SF
02182815
FRS
Y
losartan 50mg tab
Apo-Losartan 50mg Tab
DNP
0.3148
M
SF
02353504
APX
Y
Auro-Losartan 50mg Tab
CO Losartan 50mg Tab
DNP
DNP
0.3148
0.3148
M
M
SF
SF
02403331
02354837
ARO Y
ATV Y
Jamp-Losartan 50mg Tab
Losartan 50mg Tab
DNP
DNP
0.3148
0.3148
M
M
SF
SF
02398842
02388871
JPC
SAS
Losartan-50mg Tab
MINT-Losartan 50mg Tab
DNP
DNP
0.3148
0.3148
M
M
SF
SF
02388804
02405741
SIV Y
MNT Y
MYLAN-Losartan 50mg Tab
pms-Losartan 50mg Tab
DNP
DNP
0.3148
0.3148
M
M
SF
SF
02368285
02309769
MYL Y
PMS Y
RAN-Losartan 50mg Tab (discontinued)
Sandoz Losartan 50mg Tab
DNP
0.3148
M
SF
02404478
02313340
RAN Y
SDZ Y
Septa-Losartan 50mg Tab
Teva-Losartan 50mg Tab
DNP
DNP
0.3148
0.3148
M
M
SF
SF
02424975
02357968
SPT
TEV
Y
Y
Cozaar 50mg Tab
DNP
0.3148
M
SF
02182874
FRS
Y
losartan 100mg tab
Apo-Losartan 100mg Tab
DNP
0.3148
M
SF
02353512
APX
Y
Auro-Losartan 100mg Tab
CO Losartan 100mg Tab
DNP
DNP
0.3148
0.3148
M
M
SF
SF
02403358
02354845
ARO Y
ATV Y
Jamp-Losartan 100mg Tab
Losartan 100mg Tab
DNP
DNP
0.3148
0.3148
M
M
SF
SF
02398850
02388898
JPC
SAS
Losartan-100mg Tab
MINT-Losartan 100mg Tab
DNP
DNP
0.3148
0.3148
M
M
SF
SF
02388812
02405768
SIV Y
MNT Y
MYLAN-Losartan 100mg Tab
pms-Losartan 100mg Tab
DNP
DNP
0.3148
0.3148
M
M
SF
SF
02368293
02309777
MYL Y
PMS Y
RAN-Losartan 100mg Tab (discontinued)
Sandoz Losartan 100mg Tab
DNP
0.3148
M
SF
02404486
02313359
RAN Y
SDZ Y
Septa-Losartan 100mg Tab
Teva-Losartan 100mg Tab
DNP
DNP
0.3148
0.3148
M
M
SF
SF
02424983
02357976
SPT
TEV
Y
Y
Cozaar 100mg Tab
DNP
0.3148
M
SF
02182882
FRS
Y
Teveten 400mg Tab
DNP
0.7246
L
SF
02240432
BGP N
Teveten 600mg Tab
DNP
1.1079
L
SF
02243942
BGP N
Y
Y
Y
Y
EPROSARTAN
VALSARTAN
60
C
Cardiovascular System
C09CA04
valsartan 40mg tab
Apo-Valsartan 40mg Tab
DNP
0.2911
M
SF
02371510
APX
Auro-Valsartan 40mg Tab
CO Valsartan 40mg Tab
DNP
DNP
0.2911
0.2911
M
M
SF
SF
02414201
02337487
ARO Y
ATV Y
MYLAN-Valsartan 40mg Tab
pms-Valsartan 40mg Tab
DNP
DNP
0.2911
0.2911
M
M
SF
SF
02383527
02312999
MYL Y
PMS Y
RAN-Valsartan 40mg Tab
Sandoz Valsartan 40mg Tab
DNP
DNP
0.2911
0.2911
M
M
SF
SF
02363062
02356740
RAN Y
SDZ Y
Teva-Valsartan 40mg Tab
Valsartan 40mg Tab
DNP
DNP
0.2911
0.2911
M
M
SF
SF
02356643
02366940
TEV
SAS
Valsartan-40mg Tab
Diovan 40mg Tab
DNP
DNP
0.2911
0.2911
M
M
SF
SF
02384523
02270528
SIV Y
NVR Y
valsartan 80mg tab
ACT Valsartan 80mg Tab
Apo-Valsartan 80mg Tab
DNP
DNP
0.2991
0.2991
M
M
SF
SF
02337495
02371529
ATV
APX
Auro-Valsartan 80mg Tab
MYLAN-Valsartan 80mg Tab
DNP
DNP
0.2991
0.2991
M
M
SF
SF
02414228
02383535
ARO Y
MYL Y
pms-Valsartan 80mg Tab
RAN-Valsartan 80mg Tab
DNP
DNP
0.2991
0.2991
M
M
SF
SF
02313006
02363100
PMS Y
RAN Y
Sandoz Valsartan 80mg Tab
Teva-Valsartan 80mg Tab
DNP
DNP
0.2991
0.2991
M
M
SF
SF
02356759
02356651
SDZ
TEV
Y
Y
Valsartan 80mg Tab
Valsartan-80mg Tab
DNP
DNP
0.2991
0.2991
M
M
SF
SF
02366959
02384531
SAS
SIV
Y
Y
Diovan 80mg Tab
DNP
0.2991
M
SF
02244781
NVR Y
valsartan 160mg tab
ACT Valsartan 160mg Tab
DNP
0.2999
M
SF
02337509
ATV
Apo-Valsartan 160mg Tab
Auro-Valsartan 160mg Tab
DNP
DNP
0.2999
0.2999
M
M
SF
SF
02371537
02414236
APX Y
ARO Y
MYLAN-Valsartan 160mg Tab
pms-Valsartan 160mg Tab
DNP
DNP
0.2999
0.2999
M
M
SF
SF
02383543
02313014
MYL Y
PMS Y
RAN-Valsartan 160mg Tab
Sandoz Valsartan 160mg Tab
DNP
DNP
0.2999
0.2999
M
M
SF
SF
02363119
02356767
RAN Y
SDZ Y
Teva-Valsartan 160mg Tab
Valsartan 160mg Tab
DNP
DNP
0.2999
0.2999
M
M
SF
SF
02356678
02366967
TEV
SAS
Valsartan-160mg Tab
Diovan 160mg Tab
DNP
DNP
0.2999
0.2999
M
M
SF
SF
02384558
02244782
SIV Y
NVR Y
valsartan 320mg tab
ACT Valsartan 320mg Tab
Apo-Valsartan 320mg Tab
DNP
DNP
0.2914
0.2914
M
M
SF
SF
02337517
02371545
ATV
APX
MYLAN-Valsartan 320mg Tab
pms-Valsartan 320mg Tab
DNP
DNP
0.2914
0.2914
M
M
SF
SF
02383551
02344564
MYL Y
PMS Y
Sandoz Valsartan 320mg Tab
Teva-Valsartan 320mg Tab
DNP
DNP
0.2914
0.2914
M
M
SF
SF
02356775
02356686
SDZ
TEV
Y
Y
Valsartan 320mg Tab
Valsartan-320mg Tab
DNP
DNP
0.2914
0.2914
M
M
SF
SF
02366975
02384566
SAS
SIV
Y
Y
Diovan 320mg Tab
DNP
0.2914
M
SF
02289504
NVR Y
IRBESARTAN
irbesartan 75mg tab
February 2016
61
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
C
Cardiovascular System
C09CA06
February 2016
Apo-Irbesartan 75mg Tab
Auro-Irbesartan 75mg Tab
DNP
DNP
0.3025
0.3025
M
M
SF
SF
02386968
02406098
APX Y
ARO Y
CO Irbesartan 75mg Tab
Irbesartan 75mg Tab
DNP
DNP
0.3025
0.3025
M
M
SF
SF
02328070
02372347
ATV
SAS
Y
Y
Irbesartan-75mg Tab
Jamp-Irbesartan 75mg Tab
DNP
DNP
0.3025
0.3025
M
M
SF
SF
02385287
02418193
SIV
JPC
Y
Y
MYLAN-Irbesartan 75mg Tab
pms-Irbesartan 75mg Tab
DNP
DNP
0.3025
0.3025
M
M
SF
SF
02347296
02317060
MYL Y
PMS Y
RAN-Irbesartan 75mg Tab
ratio-Irbesartan 75mg Tab
DNP
DNP
0.3025
0.3025
M
M
SF
SF
02406810
02316390
RAN Y
TEV Y
Sandoz Irbesartan 75mg
Avapro 75mg Tab
DNP
DNP
0.3025
0.3025
M
M
SF
SF
02328461
02237923
SDZ
SAV
irbesartan 150mg tab
Apo-Irbesartan 150mg Tab
Auro-Irbesartan 150mg Tab
DNP
DNP
0.3025
0.3025
M
M
SF
SF
02386976
02406101
APX Y
ARO Y
CO Irbesartan 150mg Tab
Irbesartan 150mg Tab
DNP
DNP
0.3025
0.3025
M
M
SF
SF
02328089
02372371
ATV
SAS
Y
Y
Irbesartan-150mg Tab
Jamp-Irbesartan 150mg Tab
DNP
DNP
0.3025
0.3025
M
M
SF
SF
02385295
02418207
SIV
JPC
Y
Y
MINT-Irbesartan 150mg Tab
MYLAN-Irbesartan 150mg Tab
DNP
DNP
0.3025
0.3025
M
M
SF
SF
02422999
02347318
MNT Y
MYL Y
pms-Irbesartan 150mg Tab
RAN-Irbesartan 150mg Tab
DNP
DNP
0.3025
0.3025
M
M
SF
SF
02317079
02406829
PMS Y
RAN Y
ratio-Irbesartan 150mg Tab
Sandoz Irbesartan 150mg
DNP
DNP
0.3025
0.3025
M
M
SF
SF
02316404
02328488
TEV
SDZ
Y
Y
Teva-Irbesartan 150mg Tab
Avapro 150mg Tab
DNP
DNP
0.3025
0.3025
M
M
SF
SF
02315998
02237924
TEV
SAV
Y
Y
irbesartan 300mg tab
Apo-Irebsartan 300mg Tab
Auro-Irbesartan 300mg Tab
DNP
DNP
0.3025
0.3025
M
M
SF
SF
02386984
02406128
APX Y
ARO Y
CO Irbesartan 300mg Tab
Irbesartan 300mg Tab
DNP
DNP
0.3025
0.3025
M
M
SF
SF
02328100
02372398
ATV
SAS
Y
Y
Irbesartan-300mg Tab
Jamp-Irbesartan 300mg Tab
DNP
DNP
0.3025
0.3025
M
M
SF
SF
02385309
02418215
SIV
JPC
Y
Y
MINT-Irbesartan 300mg Tab
MYLAN-Irbesartan 300mg Tab
DNP
DNP
0.3025
0.3025
M
M
SF
SF
02423006
02347326
MNT Y
MYL Y
pms-Irbesartan 300mg Tab
RAN-Irbesartan 300mg Tab
DNP
DNP
0.3025
0.3025
M
M
SF
SF
02317087
02406837
PMS Y
RAN Y
ratio-Irbesartan 300mg Tab
Sandoz Irbesartan 300mg
DNP
DNP
0.3025
0.3025
M
M
SF
SF
02316412
02328496
TEV
SDZ
Y
Y
Avapro 300mg Tab
DNP
0.3025
M
SF
02237925
SAV
Y
candesartan 4mg tab
Apo-Candesartan 4mg Tab
Candesartan 4mg Tab
02365340
02388901
APX
SAS
Y
Y
Candesartan Cilexetil 4mg Tab
Candesartan-4mg Tab
02379260
02388693
AHI
SIV
Y
Y
CO Candesartan 4mg Tab
02376520
ATV
Y
Y
Y
CANDESARTAN
62
C
Cardiovascular System
C09CA07
Jamp-Candesartan 4mg Tab
MYLAN-Candesartan 4mg Tab
02386496
02379120
JPC Y
MYL Y
pms-Candesartan 4mg Tab
RAN-Candesartan 4mg Tab
02391171
02380684
PMS Y
RAN Y
Sandoz Candesartan 4mg Tab
Atacand 4mg Tab
02326957
02239090
SDZ
AZE
Y
Y
candesartan 8mg tab
Apo-Candesartan 8mg Tab
Candesartan 8mg Tab
DNP
DNP
0.2929
0.2929
M
M
SF
SF
02365359
02388928
APX
SAS
Y
Y
Candesartan Cilexetil 8mg Tab
Candesartan-8mg Tab
DNP
DNP
0.2929
0.2929
M
M
SF
SF
02379279
02388707
AHI
SIV
Y
Y
CO Candesartan 8mg Tab
Jamp-Candesartan 8mg Tab
DNP
DNP
0.2929
0.2929
M
M
SF
SF
02376539
02386518
ATV
JPC
Y
Y
MYLAN-Candesartan 8mg Tab
pms-Candesartan 8mg Tab
DNP
DNP
0.2929
0.2929
M
M
SF
SF
02379139
02391198
MYL Y
PMS Y
RAN-Candesartan 8mg Tab
Sandoz Candesartan 8mg Tab
DNP
DNP
0.2929
0.2929
M
M
SF
SF
02380692
02326965
RAN Y
SDZ Y
Teva-Candesartan 8mg Tab
Atacand 8mg Tab
DNP
DNP
0.2929
0.2929
M
M
SF
SF
02366312
02239091
TEV
AZE
Y
Y
candesartan 16mg tab
Apo-Candesartan 16mg Tab
Cabdesartan-16mg Tab
DNP
DNP
0.2929
0.2929
M
M
SF
SF
02365367
02388715
APX
SIV
Y
Y
Candesartan 16mg Tab
Candesartan Cilexetil 16mg Tab
DNP
DNP
0.2929
0.2929
M
M
SF
SF
02388936
02379287
SAS
AHI
Y
Y
CO Candesartan 16mg Tab
Jamp-Candesartan 16mg Tab
DNP
DNP
0.2929
0.2929
M
M
SF
SF
02376547
02386526
ATV
JPC
Y
Y
MYLAN-Candesartan 16mg Tab
pms-Candesartan 16mg Tab
DNP
DNP
0.2929
0.2929
M
M
SF
SF
02379147
02391201
MYL Y
PMS Y
RAN-Candesartan 16mg Tab
Sandoz Candesartan 16mg Tab
DNP
DNP
0.2929
0.2929
M
M
SF
SF
02380706
02326973
RAN Y
SDZ Y
Teva-Candesartan 16mg Tab
Atacand 16mg Tab
DNP
DNP
0.2929
0.2929
M
M
SF
SF
02366320
02239092
TEV
AZE
Y
Y
candesartan 32mg tab
Apo-Candesartan 32mg Tab
Candesartan 32mg Tab
DNP
DNP
0.2995
0.2995
M
M
SF
SF
02399105
02435845
APX
SAS
Y
Y
Candesartan Cilexetil 32mg Tab
CO Candesartan 32mg Tab
DNP
DNP
0.2995
0.2995
M
M
SF
SF
02379295
02376555
AHI
ATV
Y
Y
Jamp-Candesartan 32mg Tab
MYLAN-Candesartan 32mg Tab
DNP
DNP
0.2995
0.2995
M
M
SF
SF
02386534
02379155
JPC Y
MYL Y
pms-Candesartan 32mg Tab
RAN-Candesartan 32mg Tab
DNP
DNP
0.2995
0.2995
M
M
SF
SF
02391228
02380714
PMS Y
RAN Y
Sandoz Candesartan 32mg Tab
Sandoz-Candesartan 32mg Tab
DNP
DNP
0.2995
0.2995
M
M
SF
SF
02392267
02417340
SDZ
SDZ
Y
Y
Teva-Candesartan 32mg Tab
Atacand 32mg Tab
DNP
DNP
0.2995
0.2995
M
M
SF
SF
02366339
02311658
TEV
AZE
Y
Y
DNP
0.2824
M
SF
02420082
APX
Y
TELMISARTAN
telmisartan 40mg tab
Apo-Telmisartan 40mg Tab
February 2016
63
C
Cardiovascular System
C09CA08
C09CA09
CO Telmisartan 40mg Tab
MYLAN-Telmisartan 40mg Tab
DNP
DNP
0.2824
0.2824
M
M
SF
SF
02393247
02376717
ATV Y
MYL Y
pms-Telmisartan 40mg Tab (discontinued)
Sandoz Telmisartan 40mg Tab
DNP
0.2824
M
SF
02391236
02375958
PMS Y
SDZ Y
Telmisartan 40mg Tab
Telmisartan 40mg Tab
DNP
DNP
0.2824
0.2824
M
M
SF
SF
02388944
02407485
SAS
AHI
Telmisartan 40mg Tab
Telmisartan-40mg Tab
DNP
DNP
0.2824
0.2824
M
M
SF
SF
02432897
02390345
PMS Y
SIV Y
Teva-Telmisartan 40mg Tab
Micardis 40mg Tab
DNP
DNP
0.2824
0.2824
M
M
SF
SF
02320177
02240769
TEV Y
BOE Y
telmisartan 80mg tab
Apo-Telmisartan 80mg Tab
CO Telmisartan 80mg Tab
DNP
DNP
0.2824
0.2824
M
M
SF
SF
02420090
02393255
APX
ATV
MYLAN-Telmisartan 80mg Tab
pms-Telmisartan 80mg Tab (discontinued)
DNP
0.2824
M
SF
02376725
02391244
MYL Y
PMS Y
Sandoz Telmisartan 80mg Tab
Telmisartan 80mg Tab
DNP
DNP
0.2824
0.2824
M
M
SF
SF
02375966
02432900
SDZ Y
PMS Y
Telmisartan 80mg Tab
Telmisartan 80mg Tab
DNP
DNP
0.2824
0.2824
M
M
SF
SF
02407493
02388952
AHI
SAS
Y
Y
Telmisartan-80mg Tab
Teva-Telmisartan 80mg Tab
DNP
DNP
0.2824
0.2824
M
M
SF
SF
02390353
02320185
SIV
TEV
Y
Y
Micardis 80mg Tab
DNP
0.2824
M
SF
02240770
BOE Y
Olmetec 20mg Tab
DNP
1.1500
L
SF
02318660
FRS
N
Olmetec 40mg Tab
DNP
1.1500
L
SF
02318679
FRS
N
Edarbi 40mg Tab
02381389
VLN
N
Edarbi 80mg Tab
02381397
VLN
N
ASILSARTAN MEDOXOMIL
ANGIOTENSIN II ANTAGONISTS, COMBINATIONS
C09DA
ANGIOTENSIN II ANTAGONISTS AND DIURETICS
LOSARTAN AND DIURETICS
losartan 50mg & hydrochlorothiazide 12.5mg tab
Apo-Losartan/HCTZ 50/12.5mg Tab
CO Losartan/HCT 50/12.5mg Tab
DNP
DNP
0.3148
0.3148
M
M
SF
SF
02371235
02388251
APX
ATV
Y
Y
Jamp-Losartan HCTZ 50/12.5mg Tab
Losartan/HCT-50-12.5mg Tab
DNP
DNP
0.3148
0.3148
M
M
SF
SF
02408244
02388960
JPC
SIV
Y
Y
Losartan/HCTZ 50mg/12.5mg Tab
MINT-Losartan/HCTZ 50/12.5mg Tab
DNP
DNP
0.3148
0.3148
M
M
SF
SF
02427648
02389657
SAS Y
MNT Y
MYLAN-Losartan HCTZ 50/12.5mg Tab
pms-Losartan-HCTZ 50/12.5mg Tab
DNP
DNP
0.3148
0.3148
M
M
SF
SF
02378078
02392224
MYL Y
PMS Y
Sandoz Losartan HCT 50/12.5mg Tab
Teva-Losartan/HCTZ 50/12.5mg Tab
DNP
DNP
0.3148
0.3148
M
M
SF
SF
02313375
02358263
SDZ
TEV
Y
Y
Hyzaar 50/12.5mg Tab
DNP
0.3148
M
SF
02230047
FRS
Y
losartan 100mg & hydrochlorothiazide 12.5mg tab
February 2016
Y
Y
OLMESARTAN MEDOXOMIL
C09D
C09DA01
Y
Y
64
C
Cardiovascular System
C09DA02
Apo-Losartan/HCTZ 100/12.5mg Tab
CO Losartan/HCT 100/12.5mg Tab
DNP
DNP
0.3082
0.3082
M
M
SF
SF
02371243
02388278
APX
ATV
Y
Y
Losartan/HCT-100/12.5mg Tab
Losartan/HCTZ 100mg/12.5mg Tab
DNP
DNP
0.3082
0.3082
M
M
SF
SF
02388979
02427656
SIV
SAS
Y
Y
MINT-Losartan/HCTZ 100/12.5mg Tab
MYLAN-Losartan HCTZ 100/12.5mg Tab
DNP
DNP
0.3082
0.3082
M
M
SF
SF
02389665
02378086
MNT Y
MYL Y
pms-Losartan-HCTZ 100/12.5mg Tab
Sandoz Losartan HCT 100/12.5mg Tab
DNP
DNP
0.3082
0.3082
M
M
SF
SF
02392232
02362449
PMS Y
SDZ Y
Teva-Losartan/HCTZ 100/12.5mg Tab
Hyzaar 100/12.5mg Tab
DNP
DNP
0.3082
0.3082
M
M
SF
SF
02377144
02297841
TEV
FRS
Y
Y
losartan 100mg & hydrochlorothiazide 25mg tab
Apo-Losartan/HCTZ 100/25mg Tab
CO Losartan/HCT 100/25mg Tab
DNP
DNP
0.3148
0.3148
M
M
SF
SF
02371251
02388286
APX
ATV
Y
Y
Jamp-Losartan HCTZ 100/25mg Tab
Losartan/HCT-100/25mg Tab
DNP
DNP
0.3148
0.3148
M
M
SF
SF
02408252
02388987
JPC
SIV
Y
Y
Losartan/HCTZ 100mg/25mg Tab
MINT-Losartan/HCTZ DS 100/25mg Tab
DNP
DNP
0.3148
0.3148
M
M
SF
SF
02427664
02389673
SAS Y
MNT Y
MYLAN-Losartan HCTZ 100/25mg Tab
pms-Losartan-HCTZ 100/25mg Tab
DNP
DNP
0.3148
0.3148
M
M
SF
SF
02378094
02392240
MYL Y
PMS Y
Sandoz Losartan HCT DS 100/25mg Tab
Teva-Losartan/HCTZ 100/25mg Tab
DNP
DNP
0.3148
0.3148
M
M
SF
SF
02313383
02377152
SDZ
TEV
Y
Y
Hyzaar DS 100/25mg Tab
DNP
0.3148
M
SF
02241007
FRS
Y
DNP
1.1079
L
SF
02253631
BGP N
valsartan 80mg & hydrochlorothiazide 12.5mg tab
Apo-Valsartan/HCTZ 80/12.5mg Tab
DNP
0.2983
M
SF
02382547
APX
Auro-Valsartan HCT 80/12.5mg Tab
MYLAN-Valsartan HCTZ 80/12.5mg Tab
DNP
DNP
0.2983
0.2983
M
M
SF
SF
02408112
02373734
ARO Y
MYL Y
Sandoz Valsartan/HCT 80/12.5mg Tab
Teva-Valsartan/HCTZ 80/12.5mg Tab
DNP
DNP
0.2983
0.2983
M
M
SF
SF
02356694
02356996
SDZ
TEV
Y
Y
Valsartan HCT 80/12.5mg Tab
Valsartan HCT-80mg/12.5mg Tab
DNP
DNP
0.2983
0.2983
M
M
SF
SF
02367009
02384736
SAS
SIV
Y
Y
Diovan-HCT 80/12.5mg Tab
DNP
0.2983
M
SF
02241900
NVR Y
valsartan 160mg & hydrochlorothiazide 12.5mg tab
Apo-Valsartan/HCTZ 160/12.5mg Tab
DNP
0.2993
M
SF
02382555
APX
Auro-Valsartan HCT 160/12.6mg Tab
MYLAN-Valsartan HCTZ 160/12.5mg Tab
DNP
DNP
0.2993
0.2993
M
M
SF
SF
02408120
02373742
ARO Y
MYL Y
Sandoz Valsartan/HCT 160/12.5mg Tab
Teva-Valsartan/HCTZ 160/12.5mg Tab
DNP
DNP
0.2993
0.2993
M
M
SF
SF
02356708
02357003
SDZ
TEV
Y
Y
Valsartan HCT 160/12.5mg Tab
Valsartan HCT-160mg/12.5mg Tab
DNP
DNP
0.2993
0.2993
M
M
SF
SF
02367017
02384744
SAS
SIV
Y
Y
Diovan-HCT 160/12.5mg Tab
DNP
0.2993
M
SF
02241901
NVR Y
valsartan 160mg & hydrochlorothiazide 25mg tab
Apo-Valsartan/HCTZ 160/25mg Tab
DNP
0.2985
M
SF
02382563
APX
Auro-Valsartan HCT 160/25mg Tab
MYLAN-Valsartan HCTZ 160/25mg Tab
DNP
DNP
0.2985
0.2985
M
M
SF
SF
02408139
02373750
ARO Y
MYL Y
EPROSARTAN AND DIURETICS
Teveten Plus 600mg/12.5mg Tab
C09DA03
February 2016
VALSARTAN AND DIURETICS
65
Y
Y
Y
C
Cardiovascular System
C09DA04
February 2016
Sandoz Valsartan/HCT 160/25mg Tab
Teva-Valsartan/HCTZ 160/25mg Tab
DNP
DNP
0.2985
0.2985
M
M
SF
SF
02356716
02357011
SDZ
TEV
Y
Y
Valsartan HCT 160/25mg Tab
Valsartan HCT-160mg/25mg Tab
DNP
DNP
0.2985
0.2985
M
M
SF
SF
02367025
02384752
SAS
SIV
Y
Y
Diovan-HCT 160/25mg Tab
DNP
0.2985
M
SF
02246955
NVR Y
valsartan 320mg & hydrochlorothiazide 12.5mg tab
Apo-Valsartan/HCTZ 320/12.5mg Tab
DNP
0.3003
M
SF
02382571
APX
Auro-Valsartan HCT 230/12.5mg Tab
MYLAN-Valsartan HCTZ 320/12.5mg Tab
DNP
DNP
0.3003
0.3003
M
M
SF
SF
02408147
02373769
ARO Y
MYL Y
Sandoz Valsartan/HCT 320/12.5mg Tab
Teva-Valsartan/HCTZ 320/12.5mg Tab
DNP
DNP
0.3003
0.3003
M
M
SF
SF
02356724
02357038
SDZ
TEV
Valsartan HCT 320/12.5mg Tab
Diovan-HCT 320/12.5mg Tab
DNP
DNP
0.3003
0.3003
M
M
SF
SF
02367033
02308908
SAS Y
NVR Y
valsartan 320mg & hydrochlorothiazide 25mg tab
Apo-Valsartan/HCTZ 320/25mg Tab
Auro-Valsartan HCT 320/25mg Tab
DNP
DNP
0.2985
0.2985
M
M
SF
SF
02382598
02408155
APX Y
ARO Y
MYLAN-Valsartan HCTZ 320/25mg Tab
Sandoz Valsartan/HCT 320/25mg Tab
DNP
DNP
0.2985
0.2985
M
M
SF
SF
02373777
02356732
MYL Y
SDZ Y
Teva-Valsartan/HCTZ 320/25mg Tab
Valsartan HCT 320/25mg Tab
DNP
DNP
0.2985
0.2985
M
M
SF
SF
02357046
02367041
TEV
SAS
Diovan-HCT 320/25mg Tab
DNP
0.2985
M
SF
02308916
NVR Y
irbesartan 150mg & hydrochlorothiazide 12.5mg tab
Apo-Irbesartan/HCTZ 150/12.5mg Tab
CO Irbesartan/HCT 150/12.5mg Tab
DNP
DNP
0.3024
0.3024
M
M
SF
SF
02387646
02357399
APX
ATV
Y
Y
Irbesartan HCT-150/12.5mg Tab
Irbesartan/HCTZ 150/12.5mg Tab
DNP
DNP
0.3024
0.3024
M
M
SF
SF
02385317
02372886
SIV
SAS
Y
Y
Jamp-Irbesartan/Hydrochlorothiazide 150/12.5mg Tab
MINT-Irbesartan/HCTZ 150/12.5mg Tab
DNP
DNP
0.3024
0.3024
M
M
SF
SF
02418223
02392992
JPC Y
MNT Y
pms-Irbesartan-HCTZ 150/12.5 mg Tab
RAN-Irbesartan HCTZ 150/12.5mg Tab
DNP
DNP
0.3024
0.3024
M
M
SF
SF
02328518
02363208
PMS Y
RAN Y
ratio-Irbesartan HCTZ 150/12.5 mg Tab
Sandoz Irbesartan HCT 150/12.5mg Tab
DNP
DNP
0.3024
0.3024
M
M
SF
SF
02330512
02337428
TEV
SDZ
Y
Y
Teva-Irbesartan/HCTZ 150/12.5mg Tab
Avalide 150/12.5mg Tab
DNP
DNP
0.3024
0.3024
M
M
SF
SF
02316013
02241818
TEV
SAV
Y
Y
irbesartan 300mg & hydrochlorothiazide 12.5mg tab
Apo-Irbesartan/HCTZ 300/12.5mg Tab
CO Irbesartan/HCT 300/12.5mg Tab
DNP
DNP
0.3024
0.3024
M
M
SF
SF
02387654
02357402
APX
ATV
Y
Y
Irbesartan HCT-300/12.5mg Tab
Irbesartan/HCTZ 300/12.5mg Tab
DNP
DNP
0.3024
0.3024
M
M
SF
SF
02385325
02372894
SIV
SAS
Y
Y
Jamp-Irbesartan/Hydrochlorothiazide 300/12.5mg Tab
MINT-Irbesartan/HCTZ 300/12.5mg Tab
DNP
DNP
0.3024
0.3024
M
M
SF
SF
02418231
02393018
JPC Y
MNT Y
pms-Irbesartan-HCTZ 300/12.5 mg Tab
RAN-Irbesartan HCTZ 300/12.5mg Tab
DNP
DNP
0.3024
0.3024
M
M
SF
SF
02328526
02363216
PMS Y
RAN Y
ratio-Irbesartan HCTZ 300/12.5 mg Tab
Sandoz Irbesartan HCT 300/12.5mg Tab
DNP
DNP
0.3024
0.3024
M
M
SF
SF
02330520
02337436
TEV
SDZ
Y
Y
Teva-Irbesartan/HCTZ 300/12.5mg Tab
Avalide 300/12.5mg Tab
DNP
DNP
0.3024
0.3024
M
M
SF
SF
02316021
02241819
TEV
SAV
Y
Y
Y
Y
Y
Y
Y
IRBESARTAN AND DIURETICS
66
C
Cardiovascular System
irbesartan 300mg & hydrochlorothiazide 25mg tab
Apo-Irbesartan/HCTZ 300/25mg Tab
DNP
0.3004
M
SF
02387662
APX
Y
CO Irbesartan/HCT 300/25mg Tab
Irbesartan HCT-300/25mg Tab
DNP
DNP
0.3004
0.3004
M
M
SF
SF
02357410
02385333
ATV
SIV
Y
Y
Irbesartan/HCTZ 300/25mg Tab
Jamp-Irbesartan/Hydrochlorothiazide 300/25mg Tab
DNP
DNP
0.3004
0.3004
M
M
SF
SF
02372908
02418258
SAS
JPC
Y
Y
MINT-Irbesartan/HCTZ 300/25mg Tab
pms-Irbesartan-HCTZ 300/25 mg Tab
DNP
DNP
0.3004
0.3004
M
M
SF
SF
02393026
02328534
MNT Y
PMS Y
RAN-Irbesartan HCTZ 300/25mg Tab
ratio-Irbesartan HCTZ 300/25 mg Tab
DNP
DNP
0.3004
0.3004
M
M
SF
SF
02363224
02330539
RAN Y
TEV Y
Sandoz Irbesartan HCT 300/25mg Tab
Teva-Irbesartan/HCTZ 300/25mg Tab
DNP
DNP
0.3004
0.3004
M
M
SF
SF
02337444
02316048
SDZ
TEV
Y
Y
02280213
BRI
Y
Avalide 300/25mg Tab (discontinued)
C09DA06
C09DA07
CANDERSARTAN AND DIURETICS
candesartan 16mg & hydrochlorothiazide 12.5mg tab
Apo-Candesartan/HCTZ 16/12.5mg Tab
Candesartan HCT-16/12.5mg Tab
DNP
DNP
0.2995
0.2995
M
M
SF
SF
02367866
02394812
APX
SIV
Y
Y
Candesartan/HCTZ 16/12.5mg Tab
CO Candesartan/HCTZ 16/12.5mg Tab
DNP
DNP
0.2995
0.2995
M
M
SF
SF
02394804
02388650
SAS
ATV
Y
Y
MYLAN-Candesartan/HCTZ 16/12.5mg Tab
pms-Candesartan HCTZ 16/12.5mg Tab
DNP
DNP
0.2995
0.2995
M
M
SF
SF
02374897
02391295
MYL Y
PMS Y
Sandoz Candesartan Plus 16/12.5mg Tab
Teva-Candesartan/HCTZ 16/12.5mg Tab
DNP
DNP
0.2995
0.2995
M
M
SF
SF
02327902
02395541
SDZ
TEV
Y
Y
Atacand Plus 16/12.5mg Tab
DNP
0.2995
M
SF
02244021
AZE
Y
candesartan 32mg & hydrochlorothiazide 12.5mg tab
Apo-Candesartan/HCTZ 32/12.5mg Tab
DNP
0.4212
M
SF
02395126
APX
Y
Sandoz Candesartan Plus 32/12.5mg Tab
Teva-Candesartan/HCTZ 32/12.5mg
DNP
DNP
0.4212
0.4212
M
M
SF
SF
02420732
02395568
SDZ
TEV
Y
Y
Atacand Plus 32/12.5mg Tab
DNP
0.4212
M
SF
02332922
AZE
Y
candesartan 32mg & hydrochlorothiazide 25mg tab
Apo-Candesartan/HCTZ 32/25mg Tab
DNP
0.4212
M
SF
02395134
APX
Y
Sandoz Candesartan Plus 32/25mg Tab
Atacand Plus 32/25mg Tab
DNP
DNP
0.4212
0.4212
M
M
SF
SF
02420740
02332957
SDZ
AZE
Y
Y
DNP
0.2824
M
SF
02393263
ATV
Y
MYLAN-Telmisartan HCTZ 80/12.5mg Tab
pms-Telmisartan-HCTZ 80/12.5mg Tab (discontinued)
DNP
0.2824
M
SF
02373564
02401665
MYL Y
PMS Y
Sandoz Telmisartan HCT 80/12.5mg Tab
Telmisartan HCTZ-80mg/12.5mg Tab
DNP
DNP
0.2824
0.2824
M
M
SF
SF
02393557
02390302
SDZ
SIV
Telmisartan-HCTZ 80mg/12.5mg Tab
Telmisartan/HCTZ 80/12.5mg Tab
DNP
DNP
0.2824
0.2824
M
M
SF
SF
02433214
02395355
PMS Y
SAS Y
Teva-Telmisartan HCTZ 80/12.5mg tab
Micardis Plus 80/12.5mg Tab
DNP
DNP
0.2824
0.2824
M
M
SF
SF
02330288
02244344
TEV Y
BOE Y
telmisartan 80mg & hydrochlorothiazide 25mg tab
CO Telmisartan/HCT 80/25mg Tab
MYLAN-Telmisartan HCTZ 80/25mg Tab
DNP
DNP
0.2824
0.2824
M
M
SF
SF
02393271
02373572
ATV Y
MYL Y
TELMISARTAN AND DIURETICS
telmisartan 80mg & hydrochlorothiazide 12.5mg tab
CO Telmisartan/HCT 80/12.5mg Tab
February 2016
67
Y
Y
C
Cardiovascular System
C09DA08
C09DA99
C09DB
pms-Telmisartan-HCTZ 80/25mg Tab
Sandoz Telmisartan HCT 80/25mg Tab
DNP
DNP
0.2824
0.2824
M
M
SF
SF
02401673
02393565
PMS Y
SDZ Y
Telmisartan HCTZ-80mg/25mg Tab
Telmisartan/HCTZ 80/25mg Tab
DNP
DNP
0.2824
0.2824
M
M
SF
SF
02390310
02395363
SIV
SAS
Teva-Telmisartan HCTZ 80/25mg tab
Micardis Plus 80/25mg Tab
DNP
DNP
0.2824
0.2824
M
M
SF
SF
02379252
02318709
TEV Y
BOE Y
Olmetec Plus 20mg/12.5mg Tab
DNP
1.1500
L
SF
02319616
FRS
N
Olmetec Plus 40mg/12.5mg Tab
DNP
1.1500
L
SF
02319624
FRS
N
Olmetec Plus 40mg/25mg Tab
DNP
1.1500
L
SF
02319632
FRS
N
Edarbyclor 40/12.5mg Tab
02397749
TAK
N
Edarbyclor 40/25mg Tab
02397765
TAK
N
Edarbyclor 80/12.5mg Tab
02397757
TAK
N
Y
Y
OLMESARTAN MEDOXOMIL AND DIURETICS
ASILSARTAN MEDOXOMIL AND CHLORTHALIDONE
ANGIOTENSIN II ANTAGONISTS AND CALCIUM CHANNEL BLOCKERS
C09DB04
TELMISARTAN AND AMLODIPINE
Twynsta 40/5mg Tab
DNP
0.6818
L
SF
02371022
BOE N
Twynsta 40/10mg Tab
DNP
0.6818
L
SF
02371030
BOE N
Twynsta 80/5mg Tab
DNP
0.6818
L
SF
02371049
BOE N
Twynsta 80/10mg Tab
DNP
0.6818
L
SF
02371057
BOE N
Rasilez 150mg Tab
02302063
NVR N
Rasilez 300mg Tab
02302071
NVR N
C09X
OTHER AGENTS ACTING ON THE RENIN-ANGIOTENSIN SYSTEM
C09XA
RENIN INHIBITORS
C09XA02
ALISKIREN
C10
LIPID MODIFYING AGENTS
C10A
LIPID MODIFYING AGENTS, PLAIN
C10AA
HMG COA REDUCTASE INHIBITORS
C10AA01
February 2016
SIMVASTATIN
simvastatin 5mg tab
Apo-Simvastatin 5mg Tab
DNP
0.1841
M
SF
02247011
APX
Auro-Simvastatin 5mg Tab
CO Simvastatin 5mg Tab
DNP
DNP
0.1841
0.1841
M
M
SF
SF
02405148
02248103
ARO Y
ATV Y
Jamp-Simvastatin 5mg Tab
Mar-Simvastatin 5mg Tab
DNP
DNP
0.1841
0.1841
M
M
SF
SF
02375591
02375036
JPC Y
MAR Y
MINT-Simvastatin 5mg Tab
MYLAN-Simvastatin 5mg Tab
DNP
DNP
0.1841
0.1841
M
M
SF
SF
02372932
02246582
MNT Y
MYL Y
pms-Simvastatin 5mg Tab
RAN-Simvastatin 5mg Tab
DNP
DNP
0.1841
0.1841
M
M
SF
SF
02269252
02329131
PMS Y
RAN Y
68
Y
C
Cardiovascular System
Simvastatin 5mg Tab
Simvastatin-5mg Tab
DNP
DNP
0.1841
0.1841
M
M
SF
SF
02284723
02386291
SAS
SIV
Simvastatin-ODAN 5mg Tab (discontinued)
Teva-Simvastatin 5mg Tab
DNP
0.1841
M
SF
02378884
02250144
ODN Y
TEV Y
Zocor 5mg Tab
DNP
0.1841
M
SF
00884324
FRS
Y
simvastatin 10mg tab
Apo-Simvastatin 10mg Tab
DNP
0.3642
M
SF
02247012
APX
Y
Auro-Simvastatin 10mg Tab
CO Simvastatin 10mg Tab
DNP
DNP
0.3642
0.3642
M
M
SF
SF
02405156
02248104
ARO Y
ATV Y
Jamp-Simvastatin 10mg Tab
Mar-Simvastatin 10mg Tab
DNP
DNP
0.3642
0.3642
M
M
SF
SF
02375605
02375044
JPC Y
MAR Y
MINT-Simvastatin 10mg Tab
MYLAN-Simvastatin 10mg Tab
DNP
DNP
0.3642
0.3642
M
M
SF
SF
02372940
02246583
MNT Y
MYL Y
Novo-Simvastatin 10mg Tab
pms-Simvastatin 10mg Tab
DNP
DNP
0.3642
0.3642
M
M
SF
SF
02250152
02269260
TEV Y
PMS Y
RAN-Simvastatin 10mg Tab
Sandoz Simvastatin 10mg Tab (discontinued)
DNP
0.3642
M
SF
02329158
02247828
RAN Y
SDZ Y
Simvastatin 10mg Tab
Simvastatin-10mg Tab
DNP
DNP
0.3642
0.3642
M
M
SF
SF
02284731
02386305
SAS
SIV
Simvastatin-ODAN 10mg Tab (discontinued)
Zocor 10mg Tab
DNP
0.3642
M
SF
02378892
00884332
ODN Y
FRS Y
simvastatin 20mg tab
Apo-Simvastatin 20mg Tab
Auro-Simvastatin 20mg Tab
DNP
DNP
0.4501
0.4501
M
M
SF
SF
02247013
02405164
APX Y
ARO Y
CO Simvastatin 20mg Tab
Jamp-Simvastatin 20mg Tab
DNP
DNP
0.4501
0.4501
M
M
SF
SF
02248105
02375613
ATV
JPC
Mar-Simvastatin 20mg Tab
MINT-Simvastatin 20mg Tab
DNP
DNP
0.4501
0.4501
M
M
SF
SF
02375052
02372959
MAR Y
MNT Y
MYLAN-Simvastatin 20mg Tab
Novo-Simvastatin 20mg Tab
DNP
DNP
0.4501
0.4501
M
M
SF
SF
02246737
02250160
MYL Y
TEV Y
pms-Simvastatin 20mg Tab
RAN-Simvastatin 20mg Tab
DNP
DNP
0.4501
0.4501
M
M
SF
SF
02269279
02329166
PMS Y
RAN Y
Sandoz Simvastatin 20mg Tab (discontinued)
Simvastatin 20mg Tab
DNP
0.4501
M
SF
02247830
02284758
SDZ
SAS
Simvastatin-20mg Tab
Simvastatin-ODAN 20mg Tab (discontinued)
DNP
0.4501
M
SF
02386313
02378906
SIV Y
ODN Y
Zocor 20mg Tab
DNP
0.4501
M
SF
00884340
FRS
Y
simvastatin 40mg tab
Apo-Simvastatin 40mg Tab
DNP
0.4501
M
SF
02247014
APX
Y
Auro-Simvastatin 40mg Tab
CO Simvastatin 40mg Tab
DNP
DNP
0.4501
0.4501
M
M
SF
SF
02405172
02248106
ARO Y
ATV Y
Jamp-Simvastatin 40mg Tab
Mar-Simvastatin 40mg Tab
DNP
DNP
0.4501
0.4501
M
M
SF
SF
02375621
02375060
JPC Y
MAR Y
MINT-Simvastatin 40mg Tab
MYLAN-Simvastatin 40mg Tab
DNP
DNP
0.4501
0.4501
M
M
SF
SF
02372967
02246584
MNT Y
MYL Y
pms-Simvastatin 40mg Tab
RAN-Simvastatin 40mg Tab
DNP
DNP
0.4501
0.4501
M
M
SF
SF
02269287
02329174
PMS Y
RAN Y
SF
02247831
02284766
SDZ
SAS
Sandoz Simvastatin 40mg Tab (discontinued)
Simvastatin 40mg Tab
February 2016
DNP
0.4501
M
69
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
C
Cardiovascular System
Simvastatin-40mg Tab
Simvastatin-ODAN 40mg Tab (discontinued)
DNP
0.4501
M
SF
02386321
02378914
SIV Y
ODN Y
Teva-Simvastatin 40mg Tab
Zocor 40mg Tab
DNP
DNP
0.4501
0.4501
M
M
SF
SF
02250179
00884359
TEV
FRS
simvastatin 80mg tab
Apo-Simvastatin 80mg Tab
Auro-Simvastatin 80mg Tab
DNP
DNP
0.4501
0.4501
M
M
SF
SF
02247015
02405180
APX Y
ARO Y
CO Simvastatin 80mg Tab
Jamp-Simvastatin 80mg Tab
DNP
DNP
0.4501
0.4501
M
M
SF
SF
02248107
02375648
ATV
JPC
Mar-Simvastatin 80mg Tab
MINT-Simvastatin 80mg Tab
DNP
DNP
0.4501
0.4501
M
M
SF
SF
02375079
02372975
MAR Y
MNT Y
MYLAN-Simvastatin 80mg Tab
pms-Simvastatin 80mg Tab
DNP
DNP
0.4501
0.4501
M
M
SF
SF
02246585
02269295
MYL Y
PMS Y
RAN-Simvastatin 80mg Tab
Sandoz Simvastatin 80mg Tab (discontinued)
DNP
0.4501
M
SF
02329182
02247833
RAN Y
SDZ Y
Simvastatin 80mg Tab
Simvastatin-80mg Tab
DNP
DNP
0.4501
0.4501
M
M
SF
SF
02284774
02386348
SAS
SIV
Simvastatin-ODAN 80mg Tab (discontinued)
Teva-Simvastatin 80mg Tab
DNP
0.4501
M
SF
02378922
02250187
ODN Y
TEV Y
02240332
FRS
Y
Y
Y
Zocor 80mg Tab (discontinued)
C10AA02
February 2016
Y
Y
Y
Y
LOVASTATIN
lovastatin 20mg tab
Apo-Lovastatin 20mg Tab
CO Lovastatin 20mg Tab
DNP
DNP
0.5165
0.5165
M
M
SF
SF
02220172
02248572
APX
ATV
Lovastatin 20mg Tab
MYLAN-Lovastatin 20mg Tab
DNP
DNP
0.5165
0.5165
M
M
SF
SF
02353229
02243127
SAS Y
MYL Y
Novo-Lovastatin 20mg Tab (discontinued)
pms-Lovastatin 20mg Tab
DNP
0.5165
M
SF
02246542
02246013
TEV Y
PMS Y
00795860
FRS
Y
Mevacor 20mg Tab (discontinued)
C10AA03
Y
Y
lovastatin 40mg tab
Apo-Lovastatin 40mg Tab
DNP
0.9434
M
SF
02220180
APX
Y
CO Lovastatin 40mg Tab
Lovastatin 40mg Tab
DNP
DNP
0.9434
0.9434
M
M
SF
SF
02248573
02353237
ATV
SAS
Y
Y
MYLAN-Lovastatin 40mg Tab
Novo-Lovastatin 40mg Tab (discontinued)
DNP
0.9434
M
SF
02243129
02246543
MYL Y
TEV Y
pms-Lovastatin 40mg Tab
Mevacor 40mg Tab (discontinued)
DNP
0.9434
M
SF
02246014
00795852
PMS Y
FRS Y
pravastatin 10mg tab
Apo-Pravastatin 10mg Tab
DNP
0.4050
M
SF
02243506
APX
Y
CO Pravastatin 10mg Tab
Jamp-Pravastatin 10mg Tab
DNP
DNP
0.4050
0.4050
M
M
SF
SF
02248182
02330954
ATV
JPC
Y
Y
MINT-Pravastatin 10mg Tab
MYLAN-Pravastatin 10mg Tab
DNP
DNP
0.4050
0.4050
M
M
SF
SF
02317451
02257092
MNT Y
MYL Y
pms-Pravastatin 10mg Tab
Pravastatin 10mg Tab (SAS)
DNP
DNP
0.4050
0.4050
M
M
SF
SF
02247655
02356546
PMS Y
SAS Y
Pravastatin-10mg
DNP
0.4050
M
SF
02389703
SIV
PRAVASTATIN
70
Y
C
Cardiovascular System
RAN-Pravastatin 10mg Tab
Teva-Pravastatin 10mg Tab
DNP
DNP
0.4050
0.4050
M
M
SF
SF
Pravachol 10mg Tab (discontinued)
C10AA04
C10AA05
February 2016
02284421
02247008
RAN Y
TEV Y
00893749
BRI
Y
pravastatin 20mg tab
Apo-Pravastatin 20mg Tab
DNP
0.4778
M
SF
02243507
APX
Y
CO Pravastatin 20mg Tab
Jamp-Pravastatin 20mg Tab
DNP
DNP
0.4778
0.4778
M
M
SF
SF
02248183
02330962
ATV
JPC
Y
Y
MINT-Pravastatin 20mg Tab
MYLAN-Pravastatin 20mg Tab
DNP
DNP
0.4778
0.4778
M
M
SF
SF
02317478
02257106
MNT Y
MYL Y
pms-Pravastatin 20mg Tab
Pravastatin 20mg Tab (SAS)
DNP
DNP
0.4778
0.4778
M
M
SF
SF
02247656
02356554
PMS Y
SAS Y
Pravastatin-20mg Tab
RAN-Pravastatin 20mg Tab
DNP
DNP
0.4778
0.4778
M
M
SF
SF
02389738
02284448
SIV Y
RAN Y
Teva-Pravastatin 20mg Tab
Pravachol 20mg Tab
DNP
DNP
0.4778
0.4778
M
M
SF
SF
02247009
00893757
TEV
BRI
Y
Y
pravastatin 40mg tab
Apo-Pravastatin 40mg Tab
CO Pravastatin 40mg Tab
DNP
DNP
0.5755
0.5755
M
M
SF
SF
02243508
02248184
APX
ATV
Y
Y
Jamp-Pravastatin 40mg Tab
MINT-Pravastatin 40mg Tab
DNP
DNP
0.5755
0.5755
M
M
SF
SF
02330970
02317486
JPC Y
MNT Y
MYLAN-Pravastatin 40mg Tab
pms-Pravastatin 40mg Tab
DNP
DNP
0.5755
0.5755
M
M
SF
SF
02257114
02247657
MYL Y
PMS Y
Pravastatin 40mg Tab (SAS)
Pravastatin-40mg Tab
DNP
DNP
0.5755
0.5755
M
M
SF
SF
02356562
02389746
SAS
SIV
RAN-Pravastatin 40mg Tab
Sandoz Pravastatin 40mg Tab
DNP
DNP
0.5755
0.5755
M
M
SF
SF
02284456
02247858
RAN Y
SDZ Y
Teva-Pravastatin 40mg Tab
Pravachol 40mg Tab
DNP
DNP
0.5755
0.5755
M
M
SF
SF
02247010
02222051
TEV
BRI
Y
Y
fluvastatin 20mg cap
Sandoz Fluvastatin 20mg Cap
DNP
0.3155
M
SF
02400235
SDZ
Y
Teva-Fluvastatin 20mg Cap
Lescol 20mg Cap
DNP
DNP
0.3155
0.3155
M
M
SF
SF
02299224
02061562
TEV Y
NVR Y
fluvastatin 40mg cap
Sandoz Fluvastatin 40mg Cap
Teva-Fluvastatin 40mg Cap
DNP
DNP
0.4433
0.4433
M
M
SF
SF
02400243
02299232
SDZ
TEV
Lescol 40mg Cap
DNP
0.4433
M
SF
02061570
NVR Y
Lescol XL 80mg Cap
DNP
1.5514
L
SF
02250527
NVR N
atorvastatin 10mg tab
Apo-Atorvastatin 10mg Tab
Atorvastatin 10mg Tab (SAS)
DNP
DNP
0.3138
0.3138
M
M
SF
SF
02295261
02348705
APX
SAS
Y
Y
Atorvastatin-10mg Tab
CO Atorvastatin 10mg Tab
DNP
DNP
0.3138
0.3138
M
M
SF
SF
02411350
02310899
SIV
ATV
Y
Y
GD-Atorvastatin 10mg Tab
Jamp-Atorvastatin 10mg Tab
DNP
DNP
0.3138
0.3138
M
M
SF
SF
02288346
02391058
GMD Y
JPC Y
Y
Y
FLUVASTATIN
Y
Y
ATORVASTATIN
71
C
Cardiovascular System
MYLAN-Atorvastatin 10mg Tab
MYLAN-Atorvastin 10mg Tab (discontinued)
DNP
0.3138
M
SF
02392933
02373203
MYL Y
MYL Y
Novo-Atorvastatin 10mg Tab (discontinued)
pms-Atorvastatin 10mg Tab
DNP
0.3138
M
SF
02302675
02399377
TEV Y
PMS Y
RAN-Atorvastatin 10mg Tab
ratio-Atorvastatin 10mg Tab
DNP
DNP
0.3138
0.3138
M
M
SF
SF
02313707
02350297
RAN Y
TEV Y
Reddy-Atorvastatin 10mg Tab
Sandoz Atorvastatin 10mg Tab
DNP
DNP
0.3138
0.3138
M
M
SF
SF
02417936
02324946
RCH Y
SDZ Y
Lipitor 10mg Tab
DNP
0.3138
M
SF
02230711
PFI
Y
atorvastatin 20mg tab
Apo-Atorvastatin 20mg Tab
DNP
0.3922
M
SF
02295288
APX
Y
Atorvastatin 20mg Tab (SAS)
Atorvastatin-20mg Tab
DNP
DNP
0.3922
0.3922
M
M
SF
SF
02348713
02411369
SAS
SIV
Y
Y
CO Atorvastatin 20mg Tab
GD-Atorvastatin 20mg Tab
DNP
DNP
0.3922
0.3922
M
M
SF
SF
02310902
02288354
ATV Y
GMD Y
Jamp-Atorvastatin 20mg Tab
MYLAN-Atorvastatin 20mg Tab
DNP
DNP
0.3922
0.3922
M
M
SF
SF
02391066
02392941
JPC Y
MYL Y
02373211
02302683
MYL Y
TEV Y
MYLAN-Atorvastin 20mg Tab (discontinued)
Novo-Atorvastatin 20mg Tab (discontinued)
February 2016
pms-Atorvastatin 20mg Tab
RAN-Atorvastatin 20mg Tab
DNP
DNP
0.3922
0.3922
M
M
SF
SF
02399385
02313715
PMS Y
RAN Y
ratio-Atorvastatin 20mg Tab
Reddy-Atorvastatin 20mg Tab
DNP
DNP
0.3922
0.3922
M
M
SF
SF
02350319
02417944
TEV Y
RCH Y
Sandoz Atorvastatin 20mg Tab
Lipitor 20mg Tab
DNP
DNP
0.3922
0.3922
M
M
SF
SF
02324954
02230713
SDZ
PFI
Y
Y
atorvastatin 40mg tab
Apo-Atorvastatin 40mg Tab
Atorvastatin 40mg Tab (SAS)
DNP
DNP
0.4216
0.4216
M
M
SF
SF
02295296
02348721
APX
SAS
Y
Y
Atorvastatin-40mg Tab
CO Atorvastatin 40mg Tab
DNP
DNP
0.4216
0.4216
M
M
SF
SF
02411377
02310910
SIV
ATV
Y
Y
GD-Atorvastatin 40mg Tab
Jamp-Atorvastatin 40mg Tab
DNP
DNP
0.4216
0.4216
M
M
SF
SF
02288362
02391074
GMD Y
JPC Y
MYLAN-Atorvastatin 40mg Tab
MYLAN-Atorvastin 40mg Tab (discontinued)
DNP
0.4216
M
SF
02392968
02373238
MYL Y
MYL Y
TEV Y
PMS Y
Novo-Atorvastatin 40mg Tab (discontinued)
pms-Atorvastatin 40mg Tab
DNP
0.4216
M
SF
02302691
02399393
RAN-Atorvastatin 40mg Tab
ratio-Atorvastatin 40mg Tab
DNP
DNP
0.4216
0.4216
M
M
SF
SF
02313723
02350327
RAN Y
TEV Y
Reddy-Atorvastatin 40mg Tab
Sandoz Atorvastatin 40mg Tab
DNP
DNP
0.4216
0.4216
M
M
SF
SF
02417952
02324962
RCH Y
SDZ Y
Lipitor 40mg Tab
DNP
0.4216
M
SF
02230714
PFI
Y
atorvastatin 80mg tab
Apo-Atorvastatin 80mg Tab
DNP
0.4216
M
SF
02295318
APX
Y
Atorvastatin 80mg Tab (SAS)
Atorvastatin-80mg Tab
DNP
DNP
0.4216
0.4216
M
M
SF
SF
02348748
02411385
SAS
SIV
Y
Y
CO Atorvastatin 80mg Tab
GD-Atorvastatin 80mg Tab
DNP
DNP
0.4216
0.4216
M
M
SF
SF
02310929
02288370
ATV Y
GMD Y
Jamp-Atorvastatin 80mg Tab
MYLAN-Atorvastatin 80mg Tab
DNP
DNP
0.4216
0.4216
M
M
SF
SF
02391082
02392976
JPC Y
MYL Y
72
C
Cardiovascular System
MYLAN-Atorvastin 80mg Tab (discontinued)
Novo-Atorvastatin 80mg Tab (discontinued)
C10AA07
February 2016
02373246
02302713
MYL Y
TEV Y
pms-Atorvastatin 80mg Tab
RAN-Atorvastatin 80mg Tab
DNP
DNP
0.4216
0.4216
M
M
SF
SF
02399407
02313758
PMS Y
RAN Y
ratio-Atorvastatin 80mg Tab
Reddy-Atorvastatin 80mg Tab
DNP
DNP
0.4216
0.4216
M
M
SF
SF
02350335
02417960
TEV Y
RCH Y
Sandoz Atorvastatin 80mg Tab
Lipitor 80mg Tab
DNP
DNP
0.4216
0.4216
M
M
SF
SF
02324970
02243097
SDZ
PFI
Y
Y
rosuvastatin 5mg tab
Apo-Rosuvastatin 5mg Tab
DNP
0.2311
M
SF
02337975
APX
Y
CO Rosuvastatin 5mg Tab
Jamp-Rosuvastatin 5mg Tab
DNP
DNP
0.2311
0.2311
M
M
SF
SF
02339765
02391252
ATV
JPC
Y
Y
Mar-Rosuvastatin 5mg Tab
MINT-Rosuvastatin 5mg Tab
DNP
DNP
0.2311
0.2311
M
M
SF
SF
02413051
02397781
MAR Y
MNT Y
MYLAN-Rosuvastatin 5mg Tab
pms-Rosuvastatin 5mg Tab
DNP
DNP
0.2311
0.2311
M
M
SF
SF
02381265
02378523
MYL Y
PMS Y
RAN-Rosuvastatin 5mg Tab
Rosuvastatin 5mg Tab
DNP
DNP
0.2311
0.2311
M
M
SF
SF
02382644
02405628
RAN Y
SAS Y
Rosuvastatin-5mg Tab
Sandoz Rosuvastatin 5mg Tab
DNP
DNP
0.2311
0.2311
M
M
SF
SF
02411628
02338726
SIV
SDZ
Y
Y
Teva-Rosuvastatin 5mg Tab
Crestor 5mg Tab
DNP
DNP
0.2311
0.2311
M
M
SF
SF
02354608
02265540
TEV
AZE
Y
Y
rosuvastatin 10mg tab
Apo-Rosuvastatin 10mg Tab
CO Rosuvastatin 10mg Tab
DNP
DNP
0.2437
0.2437
M
M
SF
SF
02337983
02339773
APX
ATV
Y
Y
Jamp-Rosuvastatin 10mg Tab
Mar-Rosuvastatin 10mg Tab
DNP
DNP
0.2437
0.2437
M
M
SF
SF
02391260
02413078
JPC Y
MAR Y
MINT-Rosuvastatin 10mg Tab
MYLAN-Rosuvastatin 10mg Tab
DNP
DNP
0.2437
0.2437
M
M
SF
SF
02397803
02381273
MNT Y
MYL Y
pms-Rosuvastatin 10mg Tab
RAN-Rosuvastatin 10mg Tab
DNP
DNP
0.2437
0.2437
M
M
SF
SF
02378531
02382652
PMS Y
RAN Y
Rosuvastatin 10mg Tab
Rosuvastatin-10mg Tab
DNP
DNP
0.2437
0.2437
M
M
SF
SF
02405636
02411636
SAS
SIV
Y
Y
Sandoz Rosuvastatin 10mg Tab
Teva-Rosuvastatin 10mg Tab
DNP
DNP
0.2437
0.2437
M
M
SF
SF
02338734
02354616
SDZ
TEV
Y
Y
Crestor 10mg Tab
DNP
0.2437
M
SF
02247162
AZE
Y
rosuvastatin 20mg tab
Apo-Rosuvastatin 20mg Tab
DNP
0.3046
M
SF
02337991
APX
Y
CO Rosuvastatin 20mg Tab
Jamp-Rosuvastatin 20mg Tab
DNP
DNP
0.3046
0.3046
M
M
SF
SF
02339781
02391279
ATV
JPC
Y
Y
Mar-Rosuvastatin 20mg Tab
MINT-Rosuvastatin 20mg Tab
DNP
DNP
0.3046
0.3046
M
M
SF
SF
02413086
02397811
MAR Y
MNT Y
MYLAN-Rosuvastatin 20mg Tab
pms-Rosuvastatin 20mg Tab
DNP
DNP
0.3046
0.3046
M
M
SF
SF
02381281
02378558
MYL Y
PMS Y
RAN-Rosuvastatin 20mg Tab
Rosuvastatin 20mg Tab
DNP
DNP
0.3046
0.3046
M
M
SF
SF
02382660
02405644
RAN Y
SAS Y
Rosuvastatin-20mg Tab
DNP
0.3046
M
SF
02411644
SIV
ROSUVASTATIN
73
Y
C
C10AB
Cardiovascular System
Sandoz Rosuvastatin 20mg Tab
Teva-Rosuvastatin 20mg Tab
DNP
DNP
0.3046
0.3046
M
M
SF
SF
02338742
02354624
SDZ
TEV
Y
Y
Crestor 20mg Tab
DNP
0.3046
M
SF
02247163
AZE
Y
rosuvastatin 40mg tab
Apo-Rosuvastatin 40mg Tab
DNP
0.3582
M
SF
02338009
APX
Y
CO Rosuvastatin 40mg Tab
Jamp-Rosuvastatin 40mg Tab
DNP
DNP
0.3582
0.3582
M
M
SF
SF
02339803
02391287
ATV
JPC
Y
Y
Mar-Rosuvastatin 40mg Tab
MINT-Rosuvastatin 40mg Tab
DNP
DNP
0.3582
0.3582
M
M
SF
SF
02413108
02397838
MAR Y
MNT Y
MYLAN-Rosuvastatin 40mg Tab
pms-Rosuvastatin 40mg Tab
DNP
DNP
0.3582
0.3582
M
M
SF
SF
02381303
02378566
MYL Y
PMS Y
RAN-Rosuvastatin 40mg Tab
Rosuvastatin 40mg Tab
DNP
DNP
0.3582
0.3582
M
M
SF
SF
02382679
02405652
RAN Y
SAS Y
Rosuvastatin-40mg Tab
Sandoz Rosuvastatin 40mg Tab
DNP
DNP
0.3582
0.3582
M
M
SF
SF
02411652
02338750
SIV
SDZ
Y
Y
Teva-Rosuvastatin 40mg Tab
Crestor 40mg Tab
DNP
DNP
0.3582
0.3582
M
M
SF
SF
02354632
02247164
TEV
AZE
Y
Y
02083523
TRB N
01979574
02241704
APX
TEV
Y
Y
00599026
PFI
Y
Y
FIBRATES
C10AB02
BEZAFIBRATE
Bezalip 400mg SR Tab
C10AB04
GEMFIBROZIL
gemfibrozil 300mg cap
Apo-Gemfibrozil 300mg Cap
Novo-Gemfibrozil 300mg Cap
DNP
DNP
0.1288
0.1288
M
M
SF
SF
Lopid 300mg Cap (discontinued)
gemfibrozil 600mg tab
Apo-Gemfibrozil 600mg Tab
DNP
0.5157
M
SF
01979582
APX
MYLAN-Gemfibrozil 600mg Tab
Novo-Gemfibrozil 600mg Tab
DNP
DNP
0.5157
0.5157
M
M
SF
SF
02230476
02142074
MYL Y
TEV Y
02230183
00659606
PMS Y
PFI Y
fenofibrate 48mg tab
Sandoz Fenofibrate E 48mg Tab
02390698
SDZ
Lipidil EZ 48mg Tab
02269074
BGP Y
02243180
APX
02230283
FOU Y
pms-Gemfibrozil 600mg Tab (discontinued)
Lopid 600mg Tab (discontinued)
C10AB05
FENOFIBRATE
fenofibrate 67mg cap
Apo-Feno-Micro 67mg Cap
DNP
0.5479
M
SF
Lipidil Micro 67mg Cap (discontinued)
February 2016
Y
Y
fenofibrate 100mg tab
Apo-Feno-Super 100mg Tab
DNP
0.5407
M
SF
02246859
APX
Y
Fenofibrate-S 100mg Tab
Novo-Fenofibrate-S 100mg Tab
DNP
DNP
0.5407
0.5407
M
M
SF
SF
02356570
02289083
SAS
TEV
Y
Y
Sandoz Fenofibrate S 100mg Tab
Lipidil Supra 100mg Tab (discontinued)
DNP
0.5407
M
SF
02288044
02241601
SDZ
ABB
Y
Y
Apo-Fenofibrate 100mg Cap
DNP
0.6105
L
SF
02225980
APX
N
74
C
Cardiovascular System
fenofibrate 145mg tab
Sandoz Fenofibrate E 145mg tab
02390701
SDZ
Lipidil EZ 145mg Tab
02269082
BGP Y
fenofibrate 160mg tab
Apo-Feno-Super 160mg Tab
DNP
0.3116
M
SF
02246860
APX
Y
Fenofibrate-S 160mg Tab
Sandoz Fenofibrate S 160mg Tab
DNP
DNP
0.3116
0.3116
M
M
SF
SF
02356589
02288052
SAS
SDZ
Y
Y
Lipidil Supra 160mg Tab
DNP
0.3116
M
SF
02241602
ABB
Y
fenofibrate 200mg cap
Apo-Feno-Micro 200mg Cap
DNP
0.2723
M
SF
02239864
APX
Y
SAS Y
MYL Y
Fenofibrate Micro 200mg Cap (discontinued)
MYLAN-Fenofibrate Micro 200mg Cap
DNP
0.2723
M
SF
02286092
02240210
Novo-Fenofibrate Micronized 200mg Cap (discontinued)
ratio-Fenofibrate MC 200mg Cap
DNP
0.2723
M
SF
02243552
02250039
TEV
TEV
Y
Y
02146959
ABB
Y
00890960
02210320
PDP Y
PDP Y
01918486
00464880
BRI
BRI
Y
Y
Lipidil Micro 200mg Cap (discontinued)
C10AC
BILE ACID SEQUESTRANTS
C10AC01
CHOLESTYRAMINE
cholestyramine powder pouches
Olestyr Light 4g/9g Pdr (Sugar Reduced)
Olestyr Regular 4g/9g Pdr
DNP
DNP
0.3802
0.3802
L
L
SF
SF
Questran Light Pdr 4g/dose (discontinued)
Questran Pdr4g/dose (discontinued)
C10AC02
C10AC04
COLESTIPOL
Colestid 1g Tab
DNP
0.2690
L
SF
02132680
PFI
N
Colestid Granules 5g/pack
Colestid Orange Gran 5g/pack
DNP
DNP
0.1919
0.1280
L
L
SF
SF
00642975
02132699
PFI
PFI
N
N
DNP
1.1154
L
SF
02373955
VLN
N
Ni-ODAN 500mg ER Tab
00779806
ODN N
Niaspan 500mg Tab
Niaspan FCT 500mg ER Tab
02262347
02309254
SNV N
SNV N
Niaspan FCT 750mg ER Tab
02309262
SNV N
Niaspan 1,000mg Tab
02262339
SNV N
Niaspan FCT 1000mg ER Tab
02309289
SNV N
COLESEVELAM
Lodalis 625mg Tab
C10AD
NICOTINIC ACID AND DERIVATIVES
C10AD02
C10AX
Y
NICOTINIC ACID
OTHER LIPID MODIFYING AGENTS
C10AX09
February 2016
EZETIMIBE
ezetimibe 10mg tab
ACH-Ezetimibe 10mg Tab
ACT Ezetimibe 10mg Tab
DNP
DNP
0.4612
0.4612
M
M
E
E
02425610
02414716
AHI
ATV
Y
Y
Apo-Ezetimibe 10mg Tab
DNP
0.4612
M
E
02427826
APX
Y
75
C
Cardiovascular System
Ezetimibe 10mg Tab
Ezetimibe 10mg Tab
DNP
DNP
0.4612
0.4612
M
M
E
E
02431300
02429659
SAS
SIV
Jamp-Ezetimibe 10mg Tab
Mar-Ezetimibe 10mg Tab
DNP
DNP
0.4612
0.4612
M
M
E
E
02423235
02422662
JPC Y
MAR Y
MINT-Ezetimibe 10mg Tab
MYLAN-Ezetimibe 10mg Tab
DNP
DNP
0.4612
0.4612
M
M
E
E
02423243
02378035
MNT Y
MYL Y
pms-Ezetimibe 10mg Tab
RAN-Ezetimibe 10mg Tab
DNP
DNP
0.4612
0.4612
M
M
E
E
02416409
02419548
PMS Y
RAN Y
Sandoz Ezetimibe 10mg Tab
Teva-Ezetimibe 10mg Tab
DNP
DNP
0.4612
0.4612
M
M
E
E
02416778
02354101
SDZ
TEV
Y
Y
Ezetrol 10mg Tab
DNP
0.4612
M
E
02247521
FRS
Y
amlodipine 5mg & atorvastatin 10mg tab
Apo-Amlodipine/Atorvastatin 5/10mg Tab
GD-Amlodipine/Atorvastatin 5/10mg Tab
DNP
DNP
0.5802
0.5802
M
M
SF
SF
02411253
02362759
APX Y
GMD Y
pms-Amlodipine-Atorvastatin 5/10mg Tab
Caduet 5/10mg Tab
DNP
DNP
0.5802
0.5802
M
M
SF
SF
02404222
02273233
PMS Y
PFI Y
amlodipine 5mg & atorvastatin 20mg tab
Apo-Amlodipine/Atorvastatin 5/20mg Tab
GD-Amlodipine/Atorvastatin 5/20mg Tab
DNP
DNP
0.6842
0.6842
M
M
SF
SF
02411261
02362767
APX Y
GMD Y
pms-Amlodipine-Atorvastatin 5/20mg Tab
Caduet 5/20mg Tab
DNP
DNP
0.6842
0.6842
M
M
SF
SF
02404230
02273241
PMS Y
PFI Y
amlodipine 5mg & atorvastatin 40mg tab
Apo-Amlodipine/Atorvastatin 5/40mg Tab
GD-Amlodipine/Atorvastatin 5/40mg Tab
DNP
DNP
1.0124
1.0124
M
M
SF
SF
02411288
02362775
APX Y
GMD Y
Caduet 5/40mg Tab
DNP
1.0124
M
SF
02273268
PFI
Y
amlodipine 5mg & atorvastatin 80mg tab
Apo-Amlodipine/Atorvastatin 5/80mg Tab
DNP
1.0124
M
SF
02411296
APX
Y
GD-Amlodipine/Atorvastatin 5/80mg Tab
Caduet 5/80mg Tab
DNP
DNP
1.0124
1.0124
M
M
SF
SF
02362783
02273276
GMD Y
PFI Y
amlodipine 10mg & atorvastatin 10mg tab
Apo-Amlodipine/Atorvastatin 10/10mg Tab
GD-Amlodipine/Atorvastatin 10/10mg Tab
DNP
DNP
0.6125
0.6125
M
M
SF
SF
02411318
02362791
APX Y
GMD Y
pms-Amlodipine-Atorvastatin 10/10mg Tab
Caduet 10/10mg Tab
DNP
DNP
0.6125
0.6125
M
M
SF
SF
02404249
02273284
PMS Y
PFI Y
amlodipine 10mg & atorvastatin 20mg tab
Apo-Amlodipine/Atorvastatin 10/20mg Tab
GD-Amlodipine/Atorvastatin 10/20mg Tab
DNP
DNP
0.7636
0.7636
M
M
SF
SF
02411326
02362805
APX Y
GMD Y
pms-Amlodipine-Atorvastatin 10/20mg Tab
Caduet 10/20mg Tab
DNP
DNP
0.7636
0.7636
M
M
SF
SF
02404257
02273292
PMS Y
PFI Y
amlodipine 10mg & atorvastatin 40mg tab
Apo-Amlodipine/Atorvastatin 10/40mg Tab
GD-Amlodipine/Atorvastatin 10/40mg Tab
DNP
DNP
1.1200
1.1200
M
M
SF
SF
02411334
02362813
APX Y
GMD Y
C10B
LIPID MODIFYING AGENTS, COMBINATIONS
C10BX
HMG COA REDUCTASE INHIBITORS, OTHER COMBINATIONS
C10BX03
February 2016
Y
Y
ATORVASTATIN AND AMLODIPINE
76
C
Cardiovascular System
February 2016
Caduet 10/40mg Tab
DNP
1.1200
M
SF
02273306
PFI
Y
amlodipine 10mg & atorvastatin 80mg tab
Apo-Amlodipine/Atorvastatin 10/80mg Tab
DNP
1.1200
M
SF
02411342
APX
Y
GD-Amlodipine/Atorvastatin 10/80mg Tab
Caduet 10/80mg Tab
DNP
DNP
1.1200
1.1200
M
M
SF
SF
02362821
02273314
GMD Y
PFI Y
77
D
Dermatologicals
D01
ANTIFUNGALS, DERMATOLOGICAL
D01A
ANTIFUNGALS, TOPICAL PREPARATIONS
D01AA
ANTIBIOTICS
D01AA01
D01AC
NYSTATIN
ratio-Nystatin 100,000 iu/g Cr
DNPM
0.0700
L
SFC
02194236
TEV
ratio-Nystatin 100,000 iu/g Oint
Mycostatin 100,000 iu/g Pdr (discontinued)
DNPM
0.1147
L
SFC
02194228
02004674
TEV N
CON N
Nyaderm 100,000 iu/g Cr
DNPM
0.0667
L
SFC
00716871
TAR N
DNPM
DNPM
0.2233
0.2233
M
M
SFC
SFC
00812382
02150867
TAR Y
YNO Y
DNPM
DNPM
0.2973
0.3933
L
L
SFC
SFC
02085852
02126567
WLS N
JNJ N
DNP
0.3597
M
SFC
02245662
TPH Y
00703974
JNJ
Y
00611174
FRS
N
00594601
VAL
N
IMIDAZOLE AND TRIAZOLE DERIVATIVES
D01AC01
CLOTRIMAZOLE
clotrimazole 1% cr
Clotrimaderm 1% Cr
Canesten 1% Cr
D01AC02
MICONAZOLE
Micatin 2% Cr
Monistat 2% Derm Cr
D01AC08
KETOCONAZOLE
ketoconazole 2% cr
Ketoderm 2% Cr
Nizoral 2% Cr (discontinued)
D01AC20
IMIDAZOLE DERIVATIVES, COMBINATIONS
Lotriderm Cr
D01AE
N
DNP
1.0442
L
SFC
OTHER TOPICAL ANTIFUNGALS
D01AE13
SELENIUM SULFIDE
Versel 2.5% Lot
D01AE14
D01AE15
CICLOPIROX
Loprox 1% Cr
DNP
0.3017
L
SFC
02221802
VLN
N
Loprox 1% Lot
DNP
0.3022
L
SFC
02221810
VLN
N
Stieprox 1.5% Shampoo
02247228
STI
N
ciclopirox 8% w/w top sol
Apo-Ciclopirox 8% w/w Top Sol
02298953
APX
Y
Ciclopirox 8% w/w Top Sol
pms-Ciclopirox 8% w/w Top Sol
02410346
02413574
STR Y
PMS Y
Taro-Ciclopirox 8% w/w Top Sol
Penlac 8% w/w Top Sol
02353288
02250535
TAR Y
VLN Y
02031094
02238703
NVR N
NVR N
TERBINAFINE
Lamisil 1% Cr
Lamisil 1% Top Spray
D01AE18
February 2016
DNP
DNP
0.5283
0.5367
L
L
SFC
SFC
TOLNAFTATE
78
D
Dermatologicals
Tinactin 10mg/g Cr
D01B
ANTIFUNGALS, SYSTEMIC PREPARATIONS
D01BA
ANTIFUNGALS FOR SYSTEMIC USE
D01BA02
terbinafine 250mg tab
Apo-Terbinafine 250mg Tab
Auro-Terbinafine 250mg Tab
DNP
DNP
1.8525
1.8525
M
M
E
E
02239893
02320134
APX Y
ARO Y
CO Terbinafine 250mg Tab
Jamp-Terbinafine 250mg Tab
DNP
DNP
1.8525
1.8525
M
M
E
E
02254727
02357070
ATV
JPC
MYLAN-Terbinafine 250mg Tab (discontinued)
Novo-Terbinafine 250mg Tab
DNP
1.8525
M
E
02242503
02240346
MYL Y
TEV Y
pms-Terbinafine 250mg Tab
Terbinafine 250mg Tab
DNP
DNP
1.8525
1.8525
M
M
E
E
02294273
02353121
PMS Y
SAS Y
Terbinafine-250mg Tab
Lamisil 250mg Tab
DNP
DNP
1.8525
1.8525
M
M
E
E
02385279
02031116
SIV Y
NVR Y
02063670
TMI
PREPARATIONS FOR TREATMENT OF WOUNDS AND ULCERS
D03B
ENZYMES
D03BA
PROTEOLYTIC ENZYMES
D04
ANTIPRURITICS,INCL ANTIHIST,ANAESTHET,ETC.
D04A
ANTIPRURITICS,INCL ANTIHIST,ANAESTHET,ETC.
D04AB
ANAESTHETICS, TOPICAL
Lidodan 2% Viscous Liq
DNPM
0.0900
L
SFC
01968823
ODN N
pms-Lidocaine 2% Viscous Liq
Xylocaine 2% Jelly
DNPM
DNPM
0.0950
0.4833
L
L
SFC
SFC
00811874
00001694
PMS N
AZE N
Xylocaine 2% Viscous Liq
DNPM
0.1000
L
SFC
00001686
AZE
N
00049816
AZE
N
lidocaine 5% oint
Lidodan 5% Oint
DNPM
0.3967
M
SFC
02083795
ODN Y
Xylocaine 5% Oint
DNPM
0.3967
M
SFC
00001961
AZE
Y
02003767
AZE
N
01907476
VLN
N
Xylocaine 12mg/dose Endotracheal Spray
D05
ANTIPSORIATICS
D05A
ANTIPSORIATICS FOR TOPICAL USE
D05AD
PSORALENS FOR TOPICAL USE
METHOXSALEN
Oxsoralen 1% Lot (discontinued)
February 2016
N
LIDOCAINE
Xylocaine 4% Topical Liq (discontinued)
D05AD02
Y
Y
COLLAGENASE (CLOSTRIDIOPEPITIDASE)
Santyl 250u/g Oint
D04AB01
SCH N
TERBINAFINE
D03
D03BA02
00576034
79
D
Dermatologicals
D05AX
OTHER ANTIPSORIATICS FOR TOPICAL USE
D05AX02
CALCIPOTRIOL
Dovonex 50mcg/g Cr (discontinued)
Dovonex 50mcg/g Oint
DNP
0.8063
L
E
Dovonex 50mcg/mL Scalp Sol (discontinued)
D05AX03
D05AX52
02230784
ALL
N
Tazorac 0.1% Gel
DNP
1.3600
L
E
02230785
ALL
N
DNP
1.5377
L
E
02319012
LEO
N
02244126
LEO
N
CALCIPOTRIOL, COMBINATIONS
ACITRETIN
Soriatane 10mg Cap
DNP
2.3573
L
SF
02070847
TRB N
Soriatane 25mg Cap
DNP
4.1400
L
SF
02070863
TRB N
Fucidin 2% Cr
DNP
0.6957
L
SF
00586668
LEO
N
Fucidin 2% Oint
DNP
0.6957
L
SF
00586676
LEO
N
DNP
0.4680
L
SF
00666122
GSK N
DNP
11.5200
L
SF
00030708
PFI
mupirocin 2% oint
Taro-Mupirocin 2% Oint
Bactroban 2% Oint
DNPM
DNPM
0.4125
0.4125
M
M
SF
SF
02279983
01916947
TAR Y
GCH Y
Bactroban 2% Cr
DNPM
0.5500
L
SF
02239757
GCH N
DNP
1.0893
L
SF
02224879
ERF
D06
ANTIBIOTICS AND CHEMOTHERAPEUTICS, DERMATOLOGICALS
D06A
ANTIBIOTICS, TOPICAL PREPARATIONS
D06AX
VARIOUS TOPICAL ANTIBIOTICS
FUSIDIC ACID
NEOMYCIN
Neosporin Oint
BACITRACIN
Bacitracin 50,000iu Pdr/Vial
N
MUPIROCIN
ANTIBIOTICS, COMBINATIONS
Soframycin Oint
February 2016
GAC N
E
RETINOIDS FOR TREATMENT OF PSORIASIS
D06AX30
02338572
L
D05BB
D06AX09
N
1.3600
ANTIPSORIATICS FOR SYSTEMIC USE
D06AX05
LEO
DNP
D05B
D06AX04
02194341
Tazorac 0.05% Gel
Dovobet 50mcg/0.5mg/g Oint
D06AX01
N
N
TAZAROTENE
Dovobet 0.5mg/g/50mcg/g Gel
D05BB02
LEO
LEO
CALCITRIOL
Silkis 3ug/G oint
D05AX05
02150956
01976133
80
N
D
Dermatologicals
D06B
CHEMOTHERAPEUTICS, TOPICAL PREPARATIONS
D06BA
SULFONAMIDES
D06BA01
SILVER SULFADIAZINE
Flamazine 1% Cr
D06BB
DNP
0.2478
L
SFC
D06BB03
D06BB04
D06BB10
00569771
VLN
N
PODOPHYLLOTOXIN
Condyline 0.5% Top Sol
Wartec 0.5% Top Sol (discontinued)
DNP
11.5771
L
SF
01945149
02074788
SAV
PAL
N
N
Podofilm 250mg/mL Liq
DNP
1.3804
L
SF
00598208
PAL
N
imiquimod 5% cr
Apo-Imiquimod 5% Cr
DNP
0.0441
M
E
02407825
APX
Y
Aldara 5% Cr
DNP
0.0441
M
E
02239505
VLN
Y
MetroCream 0.75% Cr
DNP
0.6600
L
SFC
02226839
GAC N
MetroLotion 0.75% Lot
DNP
0.6600
L
SFC
02248206
GAC N
MetroGel 1% Gel
Noritate 1% Cr
DNP
DNP
0.6287
0.5904
L
L
SFC
SFC
02297809
02156091
GAC N
VLN N
DNP
0.1667
M
SF
02242984
TPH Y
01910124
WSQ Y
IMIQUIMOD
OTHER CHEMOTHERAPEUTICS
D06BX01
METRONIDAZOLE
D07
CORTICOSTEROIDS, DERMATOLOGICAL PREPARATIONS
D07A
CORTICOSTEROIDS, PLAIN
D07AA
CORTICOSTEROIDS, WEAK (GROUP I)
D07AA02
HYDROCORTISONE
hydrocortisone valerate 0.2% cr
Hydroval 0.2% Cr
Westcort 0.2% Cr (discontinued)
Hydroval 0.2% Oint
DNP
0.1667
L
SF
02242985
TPH N
Cortoderm 1% Oint
Emo-Cort 1% Cr (discontinued)
DNP
0.1289
L
SF
00716693
00192597
TAR N
STI N
DNP
0.2133
L
SF
00192600
00716839
STI N
TAR N
00804533
00578541
GSK N
STI N
Emo-Cort 1% Lot (discontinued)
Hyderm 1% Cr
Prevex HC 1% Cr (discontinued)
Sarna HC 1% Lot (discontinued)
D07AB
SNE N
ACYCLOVIR
Zovirax 5% Oint
D06BX
00323098
ANTIVIRALS
Emo-Cort 2.5% Cr
DNP
0.2347
L
SF
00595799
GSK N
Emo-Cort 2.5% Lot
DNP
0.2100
L
SF
00595802
GSK N
CORTICOSTEROIDS, MODERATELY POTENT (GROUP II)
D07AB01
February 2016
CLOBETASONE
81
D
Dermatologicals
Spectro Eczemacare Medicated Cream
D07AB08
D07AB09
DNP
0.3817
L
SF
02214415
GCH N
desonide 0.05% cr
PDP-Desonide 0.05% Cr
Tridesilon 0.05% Cr (discontinued)
DNP
0.3275
M
SF
02229315
02154862
PDP Y
PMS Y
desonide 0.05% oint
PDP-Desonide 0.05% Oint
Tridesilon 0.05% Oint (discontinued)
DNP
0.3107
M
SF
02229323
02154870
PDP Y
PMS Y
Triaderm 0.1% Cr
Aristocort R 0.1% Cr
DNP
DNP
0.0506
0.1347
L
L
SF
SF
00716960
02194058
TAR N
VLN N
Aristocort R 0.1% Oint
DNP
0.1347
L
SF
02194031
VLN
N
02194066
VLN
N
00716618
02357860
TAR Y
VLN Y
00027898
SCH Y
DESONIDE
TRIAMCINOLONE
Aristocort C 0.5% Cr
D07AC
CORTICOSTEROIDS, POTENT (GROUP III)
D07AC01
BETAMETHASONE
betamethasone 17 valerate 0.05% cr
Betaderm 0.05% Cr
Celestoderm-V/2 0.05% Cr
DNPM
DNPM
0.0596
0.0596
M
M
SF
SF
Celestoderm-V/2 0.05% Cr (discontinued)
betamethasone dipropionate 0.05% cr
Taro-Sone 0.05% Cr
DNPM
0.2048
M
SF
01925350
TAR Y
Diprosone 0.05% Cr
DNPM
0.2048
M
SF
00323071
FRS
Y
betamethasone dipropionate 0.05% glycol cr
ratio-Topilene 0.05% Glycol Cr
DNPM
0.5187
M
SF
00849650
TEV
Y
Diprolene 0.05% Glycol Cr
DNPM
0.5187
M
SF
00688622
FRS
Y
betamethasone dipropionate 0.05% glycol lot
ratio-Topilene 0.05% Glycol Lot
DNPM
0.5620
M
SF
01927914
TEV
Y
Diprolene 0.05% Glycol Lot
DNPM
0.5620
M
SF
00862975
FRS
Y
betamethasone dipropionate 0.05% glycol oint
ratio-Topilene 0.05% Glycol Oint
DNPM
0.5187
M
SF
00849669
TEV
Y
Diprolene 0.05% Glycol Oint
DNPM
0.5187
M
SF
00629367
FRS
Y
betamethasone dipropionate 0.05% lot
ratio-Topisone 0.05% Lot
DNPM
0.1980
M
SF
00809187
TEV
Y
Diprosone 0.05% Lot
DNPM
0.1980
M
SF
00417246
FRS
Y
betamethasone dipropionate 0.05% oint
ratio-Topisone 0.05% Oint
DNPM
0.2152
M
SF
00805009
TEV
Y
Diprosone 0.05% Oint
DNPM
0.2152
M
SF
00344923
FRS
Y
Betaderm 0.05% Oint
ratio-Ectosone 0.05% Cr
DNPM
DNPM
0.0606
0.0611
L
L
SF
SF
00716642
00535427
TAR N
TEV N
ratio-Ectosone 0.05% Lot
ratio-Topisone 0.05% Cr
DNPM
DNPM
0.2582
0.2048
L
L
SF
SF
00653209
00804991
TEV
TEV
N
N
Celestoderm-V/2 0.05% Oint
DNPM
0.0611
L
SF
02357879
VLN
N
betamethasone 17 valerate 0.1% cr
February 2016
82
D
Dermatologicals
Betaderm 0.1% Cr
Celestoderm-V 0.1% Cr
DNPM
DNPM
0.0889
0.0889
M
M
SF
SF
Celestoderm-V 0.1% Cr (discontinued)
D07AC03
D07AC04
D07AC11
February 2016
00027901
SCH Y
DNPM
DNPM
0.0903
0.0852
L
L
SF
SF
00716650
00716634
TAR N
TAR N
ratio-Ectosone 0.1% Cr
ratio-Ectosone 0.1% Scalp Lot
DNPM
DNPM
0.0911
0.0853
L
L
SF
SF
00535435
00653217
TEV
TEV
Celestoderm-V 0.1% Oint
Prevex B 0.1% Cr
DNPM
DNPM
0.0911
0.3640
L
L
SF
SF
02357852
00804541
VLN N
GSK N
Valisone 0.1% Scalp Lotion
DNPM
0.0853
L
SF
00027944
VLN
N
ratio-Ectosone 1% Lot
DNPM
0.3202
L
SF
00750050
TEV
N
Topicort 0.05% Gel
DNP
0.5037
L
SF
02221926
VLN
N
Topicort Mild 0.05% Cr
DNP
0.5085
L
SF
02221918
VLN
N
Topicort 0.25% Cr
Topicort 0.25% Oint
DNP
DNP
0.7335
0.6493
L
L
SF
SF
02221896
02221934
VLN
VLN
N
N
DNP
0.2803
L
SF
00873292
HLZ
N
DNP
0.3947
L
SF
00587818
STI
N
fluocinonide 0.05% cr
Lyderm 0.05% Cr
DNP
0.2444
M
SF
00716863
TPH Y
Lidex 0.05% Cr
DNP
0.2444
M
SF
02161923
VLN
fluocinonide 0.05% gel
Lyderm 0.05% Gel
DNP
0.3322
M
SF
02236997
TPH Y
Lidex 0.05% Gel
DNP
0.3322
M
SF
02161974
VLN
fluocinonide 0.05% oint
Lyderm 0.05% Oint
DNP
0.3278
M
SF
02236996
TPH Y
Lidex 0.05% Oint
DNP
0.3278
M
SF
02161966
VLN
Lidemol 0.05% Cr
Tiamol 0.05% Cr
DNP
DNP
0.2036
0.2180
L
L
SF
SF
02163152
00598933
VLN N
TPH N
amcinonide 0.1% cr
ratio-Amcinonide 0.1% Cr
DNP
0.1953
M
SF
02247098
TEV
Taro-Amcinonide 0.1% Cr
Cyclocort 0.1% Cr
DNP
DNP
0.1953
0.1953
M
M
SF
SF
02246714
02192284
TAR Y
STI Y
amcinonide 0.1% lot
ratio-Amcinonide 0.1% Lot
Cyclocort 0.1% Lot
DNP
DNP
0.4027
0.4027
M
M
SF
SF
02247097
02192276
TEV
STI
Y
Y
amcinonide 0.1% oint
ratio-Amcinonide 0.1% Oint
DNP
0.4787
M
SF
02247096
TEV
Y
N
N
DESOXIMETASONE
FLUOCINOLONE ACETONIDE
DIFLUCORTOLONE
Nerisone 0.1% Oily Cr
D07AC08
TAR Y
VLN Y
Betaderm 0.1% Oint
Betaderm 0.1% Scalp Lot
Derma-Smoothe FS 0.01% Top Oil
D07AC06
00716626
02357844
FLUOCINONIDE
Y
Y
Y
AMCINONIDE
83
Y
D
Dermatologicals
Cyclocort 0.1% Oint
D07AC13
D07AD
DNP
0.4787
M
SF
02192268
STI
mometasone 0.1% cr
Taro-Mometasone 0.1% Cr
Elocom 0.1% Cr
DNP
DNP
0.5262
0.5262
M
M
SF
SF
02367157
00851744
TAR Y
FRS Y
mometasone 0.1% lot
Taro-Mometasone 0.1% Lot
Elocom 0.1% Lot
DNP
DNP
0.3678
0.3678
M
M
SF
SF
02266385
00871095
TAR Y
FRS Y
mometasone 0.1% oint
ratio-Mometasone 0.1% Oint
Taro-Mometasone 0.1% Oint
DNP
DNP
0.6014
0.6014
M
M
SF
SF
02248130
02264749
TEV Y
TAR Y
Elocom 0.1% Oint
DNP
0.6014
M
SF
00851736
FRS
clobetasol 17-propionate 0.05% cr
MYLAN-Clobetasol 0.05% Cr
Novo-Clobetasol 0.05% Cr
DNP
DNP
0.2279
0.2279
M
M
SF
SF
02024187
02093162
MYL Y
TEV Y
pms-Clobetasol 0.05% Cr
ratio-Clobetasol 0.05% Cr
DNP
DNP
0.2279
0.2279
M
M
SF
SF
02309521
01910272
PMS Y
TEV Y
Taro-Clobetasol 0.05% Cr
Dermovate 0.05% Cr
DNP
DNP
0.2279
0.2279
M
M
SF
SF
02245523
02213265
TAR Y
TPH Y
clobetasol 17-propionate 0.05% oint
MYLAN-Clobetasol 0.05% Oint
Novo-Clobetasol 0.05% Oint
DNP
DNP
0.2279
0.2279
M
M
SF
SF
02026767
02126192
MYL Y
TEV Y
pms-Clobetasol 0.05% Oint
ratio-Clobetasol 0.05% Oint
DNP
DNP
0.2279
0.2279
M
M
SF
SF
02309548
01910280
PMS Y
TEV Y
Taro-Clobetasol 0.05% Oint
Dermovate 0.05% Oint
DNP
DNP
0.2279
0.2279
M
M
SF
SF
02245524
02213273
TAR Y
TPH Y
clobetasol 17-propionate 0.05% scalp lot
MYLAN-Clobetasol 0.05% Scalp Lot
pms-Clobetasol 0.05% Scalp Lot
DNP
DNP
0.1990
0.1990
M
M
SF
SF
02216213
02232195
MYL Y
PMS Y
ratio-Clobetasol 0.05% Scalp Lot
Taro-Clobetasol 0.05% Scalp Lot
DNP
DNP
0.1990
0.1990
M
M
SF
SF
01910299
02245522
TEV Y
TAR Y
Dermovate 0.05% Scalp Lot
DNP
0.1990
M
SF
02213281
TPH Y
Cortisporin Oint (discontinued)
00666246
GSK N
Vioform HC Cr
00074500
PAL
N
Fucidin H 1% Cr
02238578
LEO
N
MOMETASONE
Y
CORTICOSTEROIDS, VERY POTENT (GROUP IV)
D07AD01
CLOBETASOL
D07C
CORTICOSTEROIDS, COMB WITH ANTIBIOTICS
D07CA
CORTICOSTEROIDS, WEAK, COMB WITH ANTIBIOTICS
D07CA01
D07CB
Y
HYDROCORTISONE AND ANTIBIOTICS
CORTICOSTEROIDS, MODERAT. POTENT, COMB W/ANTIBIOT.
D07CB01
February 2016
TRIAMCINOLONE AND ANTIBIOTICS
84
D
Dermatologicals
D07CB05
triamcinolone 0.1%, nystatin, neomycin & gramicidin cr
Viaderm KC Cr
00717002
TAR Y
Kenacomb Cr (discontinued)
01999850
WSQ Y
triamcinolone 0.1%, nystatin, neomycin & gramicidin oint
Viaderm KC Oint
00717029
TAR Y
Kenacomb Oint (discontinued)
01999826
WSQ Y
00074462
PAL
N
00177016
00232351
VLN
VLN
N
N
FLUMETASONE AND ANTIBIOTICS
Locacorten Vioform Cr
D07CC
CORTICOSTEROIDS, POTENT, COMB WITH ANTIBIOTICS
D07CC01
BETAMETHASONE AND ANTIBIOTICS
Valisone G Cream
Valisone G Oint
D07X
CORTICOSTEROIDS, OTHER COMBINATIONS
D07XA
CORTICOSTEROIDS, WEAK, OTHER COMBINATIONS
D07XA01
HYDROCORTISONE
Pramox HC 1% Cr
Pramox HC 1% Lot
D07XC
DNP
DNP
0.4444
0.1833
L
L
SF
SF
00770957
01954210
DPT N
DPT N
DNP
1.1700
L
SF
00578436
FRS
N
bethamethasone dipropionate 0.05% & salicylic acid 2% lot
ratio-Topisalic Lot
DNP
0.4228
M
SF
02245688
TEV
Y
Diprosalic Lot
0.4228
M
SF
00578428
FRS
Y
02017733
SAV
N
CORTICOSTEROIDS, POTENT, OTHER COMBINATIONS
D07XC01
BETAMETHASONE
Diprosalic Oint
D08
ANTISEPTICS AND DISINFECTANTS
D08A
ANTISEPTICS AND DISINFECTANTS
D08AE
PHENOL AND DERIVATIVES
D08AE01
DNP
HEXACHLOROPHENE
pHisoHex 3% Liq (discontinued)
D08AJ
QUATERNARY AMMONIUM COMPOUNDS
D08AJ58
BENZETHONIUM CHLORIDE, COMBINATIONS
Buro-Sol 2.36g/Pack Pdr
D09
MEDICATED DRESSINGS
D09A
MEDICATED DRESSINGS
D09AA
OINTMENT DRESSINGS WITH ANTIINFECTIVES
D09AA01
0.7510
L
SF
00579947
TCD N
DNP
1.5500
L
SF
01988840
ERF
FRAMYCETIN
Sofra-Tulle 1% 10cm x 10cm
February 2016
DNP
85
N
D
Dermatologicals
DNP
3.6000
L
SF
01987682
ERF
N
DNP
0.2604
L
F
00195057
PFI
N
DNP
1.0300
L
F
02220407
VLN
N
Stieva-A 0.01% Cr
DNP
0.3024
L
FE*
00657204
STI
N
Retin-A 0.025% Gel
DNP
0.4070
L
FE*
00443816
VLN
N
Stieva-A 0.025% Cr
DNP
0.3024
L
FE*
00578576
STI
N
Retin-A 0.05% Cr
Stieva-A 0.05% Cr
DNP
DNP
0.4070
0.3024
L
L
FE*
FE*
00443794
00518182
VLN
STI
N
N
Vitamin A Acid 0.05% Gel
DNP
0.3228
L
FE*
01926489
VLN
N
Stieva-A 0.1% Forte Cr
DNP
0.3022
L
FE*
00662348
STI
N
02019825
STI
N
Sofra-Tulle 1% 10cm x 30cm
D10
ANTI-ACNE PREPARATIONS
D10A
ANTI-ACNE PREPARATIONS
D10AA
CORTICOSTEROIDS, COMBINATIONS FOR ACNE
D10AA02
METHYLPREDNISOLONE
Neo-Medrol Acne Lot
D10AB
PREPARATIONS CONTAINING SULPHUR
D10AB02
SULPHUR
Sulfacet-R Lot
D10AD
RETINOIDS FOR TOPICAL USE IN ACNE
D10AD01
TRETINOIN
*full benefit for beneficiaries 30 years and under
D10AE
PEROXIDES
D10AE01
BENZOYL PEROXIDE
Solugel 8% Gel
D10AF
ANTIINFECTIVES FOR TREATMENT OF ACNE
D10AF01
CLINDAMYCIN
clindamycin 1% top sol
Taro-Clindamycin 1% Sol
0.2260
M
F
02266938
TAR Y
0.2260
M
F
00582301
PFI
Y
BenzaClin Gel
02248472
VLN
N
clindamycin 1% & benzoyl peroxide 5% gel
Taro-Clindamycin/Benzoyl Peroxide 1%/5% Gel
Clindoxyl Gel
02243158
02243158
TAR Y
STI Y
Dalacin T 1% Sol
D10AF51
D10AF52
D10AX
DNP
DNP
CLINDAMYCIN, COMBINATIONS
ERYTHROMYCIN, COMBINATIONS
Stievamycin Forte Gel (discontinued)
Stievamycin Mild Gel
DNP
0.8427
L
F
01945262
02015994
STI
STI
N
N
Stievamycin Regular Gel
DNP
0.8427
L
F
01905112
STI
N
OTHER ANTI ACNE PREPARATIONS FOR TOPICAL USE
February 2016
86
D
Dermatologicals
D10AX03
AZELAIC ACID
Finacea 15% Gel
DNP
0.6000
L
SFC
02270811
BAY
isotretinoin 10mg cap
Clarus 10mg Cap
Accutane 10mg Cap
DNP
DNP
0.9313
0.9313
M
M
F
F
02257955
00582344
MYL Y
HLR Y
Epuris 10mg Tab
DNP
1.0710
L
F
02396971
CIP
N
Epuris 20mg Tab
DNP
1.4423
L
F
02396998
CIP
N
Epuris 30mg Tab
DNP
1.8140
L
F
02397005
CIP
N
isotretinoin 40mg cap
Clarus 40mg Cap
Accutane 40mg Cap
DNP
DNP
1.9003
1.9003
M
M
F
F
02257963
00582352
MYL Y
HLR Y
Epuris 40mg Tab
DNP
2.1853
L
F
02397013
CIP
N
Protopic 0.03% Oint
DNP
2.2147
L
E
02244149
ASL
N
Protopic 0.1% Oint
DNP
2.3690
L
E
02244148
ASL
N
02247238
VLN
N
Toctino 10mg Cap
02337630
GSK N
Toctino 30mg Cap
02337649
GSK N
00885754
00708925
APX
JNJ
finasteride 1mg tab
MYLAN-Finasteride HG 1mg tab
02392631
MYL Y
pms-Finasteride 1mg Tab
Sandoz Finasteride A 1mg Tab
02320169
02339471
PMS Y
SDZ Y
Propecia 1mg Tab
02238213
FRS
D10B
ANTI ACNE PREPARATIONS FOR SYSTEMIC USE
D10BA
RETINOIDS FOR TREATMENT OF ACNE
D10BA01
ISOTRETINOIN
D11
OTHER DERMATOLOGICAL PREPARATIONS
D11A
OTHER DERMATOLOGICAL PREPARATIONS
D11AH
AGENTS FOR DERMATITIS, EXCLUDING CORTICOSTEROIDS
D11AH01
D11AH02
TACROLIMUS
PIMECROLIMUS
Elidel 1% Cr
D11AH04
D11AX
N
ALITRETINOIN
OTHER DERMATOLOGICALS
D11AX01
MINOXIDIL
minoxidil 20mg/mL top sol
Apo-Gain 20mg/mL Top Sol
Rogaine 20mg/mL Top Sol (discontinued)
D11AX10
February 2016
Y
Y
FINASTERIDE
87
Y
D
Dermatologicals
D11AX99
AMINOBENZOATE POTASSIUM, SYSTEMIC
Potaba 500mg Cap (discontinued)
February 2016
00611271
GLE
88
N
G
Genito-Urinary System & Sex Hormones
G01
GYNECOLOGICAL ANTIINFECTIVES AND ANTISEPTICS
G01A
ANTIINFECTIVES/ANTISEPT.,EXCL COMB WITH CORTICOST.
G01AA
ANTIBIOTICS
G01AA01
G01AA10
NYSTATIN
Nyaderm 100,000iu/dose Vag Cr
DNP
0.1250
L
SFC
00716901
TAR N
ratio-Nystatin 500,000iu/dose Vag Cr
DNP
0.3191
L
SFC
02194163
TEV
N
DNP
0.7705
L
FC
02060604
PAL
N
Flagystatin Vag Cr
DNP
0.5893
L
SFC
01926845
SAV
N
Flagystatin Vag Ovules
DNP
3.2410
L
SFC
01926829
SAV
N
NidaGel 0.75% Vag Gel
DNP
0.3017
L
SFC
02125226
VLN
N
Flagyl 10% Vag Cr
DNP
0.2407
L
SFC
01926861
SAV
N
clotrimazole 1% vag cr
Clotrimaderm 1% Vag Cr
DNP
0.1750
M
SFC
00812366
TAR Y
Canesten 6 Vag Cr (6 day)
DNP
0.1750
M
SFC
02150891
YNO Y
Canesten 1 Comfortab Combi-Pak (1 day)
Canesten 1 Vag Cr
DNP
DNP
13.3100
12.1900
L
L
SFC
SFC
02264102
02150883
YNO N
YNO N
Canesten 1 Vag Cr Combi-Pak
DNP
13.3100
L
SFC
02230509
YNO N
clotrimazole 2% vag cr
Clotrimaderm 2% Vag Cr
DNP
0.3500
M
SFC
00812374
TAR Y
Canesten 3 Vag Cr (3 day)
DNP
0.3500
M
SFC
02150905
YNO Y
Canesten 3 Comfortab Combi-Pak (3 day)
DNP
13.3100
L
SFC
02264099
YNO N
miconazole 2% vag cr
Micozole 2% Vag Cr
Monistat 7 (2%) Vag Cr
DNP
DNP
0.2576
0.2576
M
M
SFC
SFC
02231106
02084309
TAR Y
JNJ Y
Monistat 3 (400mg) Vag Ovules
DNP
4.0067
L
SFC
02126605
JNJ
N
Monistat 3 Dual-Pak
DNP
13.7600
L
SFC
02126249
JNJ
N
Monistat 7 Dual-Pak
DNP
13.7600
L
SFC
02126257
JNJ
N
DNPM
4.4210
L
SF
00400688
PAL
N
CLINDAMYCIN
Dalacin 100mg/dose Vag Cr
G01AA51
G01AF
NYSTATIN, COMBINATIONS
IMIDAZOLE DERIVATIVES
G01AF01
G01AF02
G01AF04
METRONIDAZOLE
CLOTRIMAZOLE
MICONAZOLE
G02
OTHER GYNAECOLOGICALS
G02A
OXYTOCICS
G02AD
PROSTAGLANDINS
G02AD02
DINOPROSTONE
Prostin E2 0.5mg Tab
February 2016
89
G
Genito-Urinary System & Sex Hormones
G02B
TOPICAL CONTRACEPTIVES
G02BA
INTRAUTERINE CONTRACEPTIVES
G02BA03
G02BB
PLASTIC IUD WITH PROGESTOGEN
Jaydess IUD 13.5mg/insert
DNP
270.6800
L
F
02408295
BAY
N
Mirena IUD 52mg/insert
DNP
337.9000
L
F
02243005
BAY
N
DNP
15.3633
L
F
02253186
FRS
N
DNP
0.9782
M
SFC
02087324
AAP
Y
00371033
NVR Y
02230454
AAP
00568643
NVR Y
E
E
02301407
02242471
ATV
PAL
Y
Y
INTRAVAGINAL CONTRACEPTIVES
G02BB01
ETHINYL ESTRADIOL AND ETONOGESTREL
NuvaRing
G02C
OTHER GYNAECOLOGICALS
G02CB
PROLACTINE INHIBITORS
G02CB01
BROMOCRIPTINE
bromocriptine mesylate 2.5mg tab
Bromocriptine 2.5mg Tab
Parlodel 2.5mg Tab (discontinued)
bromocriptine mesylate 5mg cap
Bromocriptine 5mg Cap
DNP
1.4644
M
SFC
Parlodel 5mg Cap (discontinued)
G02CB03
CABERGOLINE
cabergoline 0.5mg tab
CO Cabergoline 0.5mg Tab
Dostinex 0.5mg Tab
G02CB04
M
M
DNP
E
02223740
FEI
N
Norprolac 0.05mg Tab
DNP
E
02223759
FEI
N
Norprolac 0.075mg Tab
DNP
1.1227
L
E
02223767
FEI
N
Norprolac 0.15mg Tab
DNP
1.6790
L
E
02223775
FEI
N
Demulen 30 Tab 21 Day
DNP
0.6529
L
F
00469327
PFI
N
Demulen 30 Tab 28 Day
DNP
0.5236
L
F
00471526
PFI
N
Brevicon 1/35 Tab 28 Day
DNP
0.4486
L
F
02189062
PFI
N
Brevicon 0.5/35 Tab 21 Day
Brevicon 0.5/35 Tab 28 Day
DNP
DNP
0.5981
0.4486
L
L
F
F
02187086
02187094
PFI
PFI
N
N
Ortho 0.5/35 Tab 21 Day
DNP
1.0990
L
F
00317047
JAN
N
G03A
HORMONAL CONTRACEPTIVES, SYSTEMIC
G03AA
PROGESTOGENS AND ESTROGENS, FIXED COMBINATIONS
February 2016
10.6182
10.6182
Norprolac 0.025mg Tab
SEX HORMONES AND MODULATORS OF THE GENITAL SYSTEM
G03AA05
DNP
DNP
QUINAGOLIDE
G03
G03AA01
Y
ETHYNODIOL AND ESTROGEN
NORETHINDRONE AND ESTROGEN
90
G
Genito-Urinary System & Sex Hormones
G03AA07
Ortho 0.5/35 Tab 28 Day
DNP
0.8243
L
F
00340731
JAN
N
MinEstrin 1/20 Tab 21 Day
MinEstrin 1/20 Tab 28 Day
DNP
DNP
0.6614
0.4961
L
L
F
F
00315966
00343838
TEV
TEV
N
N
Brevicon 1/35 Tab 21 Day
DNP
0.5981
L
F
02189054
PFI
N
Ortho 1/35 Tab 21 Day
Ortho 1/35 Tab 28 Day
DNP
DNP
1.0990
0.8243
L
L
F
F
00372846
00372838
JAN
JAN
N
N
Select 1/35 Tab 21 Day
Select 1/35 Tab 28 Day
DNP
DNP
0.3981
0.2986
L
L
F
F
02197502
02199297
PFI
PFI
N
N
LoEstrin 1.5/30 Tab 21 Day
DNP
0.6614
L
F
00297143
TEV
N
LoEstrin 1.5/30 Tab 28 Day
DNP
0.4961
L
F
00353027
TEV
N
02296659
WNC N
LEVONORGESTREL AND ESTROGEN
Seasonale Tab (91 Day)
G03AA09
levonorgestrel 0.10mg & ethinyl estradiol 0.02mg tab (21)
Alysena Tab 21 Day
DNP
Aviane Tab 21 Day
DNP
0.3629
0.3629
M
M
F
F
02387875
02298538
APX
TEV
ESME Tab 21 Day
Lutera Tab 21 Day
DNP
DNP
0.3629
0.3629
M
M
F
F
02388138
02401185
MYL Y
COB Y
Alesse Tab 21 Day
DNP
0.3629
M
F
02236974
PFI
Y
levonorgestrel 0.10mg & ethinyl estradiol 0.02mg tab (28)
Alysena Tab 28 Day
DNP
0.2721
M
F
02387883
APX
Y
Aviane Tab 28 Day
ESME Tab 28 Day
DNP
DNP
0.2721
0.2721
M
M
F
F
02298546
02388146
TEV Y
MYL Y
Lutera Tab 28 Day
Alesse Tab 28 Day
DNP
DNP
0.2721
0.2721
M
M
F
F
02401207
02236975
COB Y
PFI Y
levonorgestrel 0.15mg & ethinyl estradiol 0.03mg tab (21)
Ovima Tab 21 Day
DNP
Portia Tab 21 Day
DNP
0.5075
0.5075
M
M
F
F
02387085
02295946
APX
TEV
Y
Y
Min-Ovral Tab 21 Day
DNP
0.5075
M
F
02042320
PFI
Y
levonorgestrel 0.15mg & ethinyl estradiol 0.03mg tab (28)
Ovima Tab 28 Day
DNP
0.3806
M
F
02387093
APX
Y
Portia Tab 28 Day
Min-Ovral Tab 28 Day
DNP
DNP
0.3806
0.3806
M
M
F
F
02295954
02042339
TEV
PFI
Y
Y
DNP
DNP
0.7429
0.5571
L
L
F
F
02272903
02257238
APR N
APR N
02042533
JAN
N
F
02317192
TEV
Y
MYL Y
APX Y
DESOGESTREL AND ESTROGEN
Linessa Tab 21 Day
Linessa Tab 28 Day
Orthocept Tab 28 Day (discontinued)
desogestrel 150mcg and ethiny estradiol 30mcg tab (21)
Apri Tab 21 Day
DNP
February 2016
Y
Y
0.5032
M
Freya Tab 21 Day
Mirvala Tab 21 Day
DNP
0.5032
M
F
02396491
02410249
Reclipsen Tab 21 Day
Marvelon Tab 21 Day
DNP
0.5032
M
F
02420813
02042487
ATV
FRS
desogestrel 150mcg and ethiny estradiol 30mcg tab (28)
Apri Tab 28 Day
DNP
Freya Tab 28 Day
0.3774
M
F
02317206
02396610
TEV Y
MYL Y
91
Y
Y
G
Genito-Urinary System & Sex Hormones
G03AA11
G03AA12
Mirvala Tab 28 Day
Reclipsen Tab 28 Day
DNP
0.3774
M
F
02410257
02417464
APX
ATV
Y
Y
Marvelon Tab 28 Day
DNP
0.3774
M
F
02042479
FRS
Y
Cyclen Tab 21 Day
DNP
1.0990
L
F
01968440
JAN
N
Cyclen Tab 28 Day
DNP
0.8243
L
F
01992872
JAN
N
drospirenone 3mg & ethinyl estradiol 0.03mg tab (21)
Zamine Tab 21 Day
Zarah Tab 21 Day
DNP
0.4293
M
F
02410788
02385058
APX
ATV
Y
Y
Yasmin Tab 21 Day
DNP
0.4293
M
F
02261723
BAY
Y
02410796
APX
Y
DNP
DNP
0.3220
0.3220
M
M
F
F
02385066
02261731
ATV
BAY
Y
Y
02415380
02321157
APX
BAY
Y
Y
02248297
JAN
N
NORGESTIMATE AND ESTROGEN
DROSPIRENONE AND ESTROGEN
drospirenone 3mg & ethinyl estradiol 0.03mg tab (28)
Zamine Tab 28 Day
Zarah Tab 28 Day
Yasmin Tab 28 Day
drospirenone 3mg & ethinyl estradiol 0.02mg tab (28)
MYA 3mg/0.02mg Tab
Yaz 3mg/0.02mg Tab
G03AA13
NORELGESTROMIN AND ESTROGEN
Evra 0.6/6mg Patch
G03AB
PROGESTOGENS AND ESTROGENS,SEQUENTIAL PREPARATIONS
G03AB03
G03AB04
G03AB11
G03AC
LEVONORGESTREL AND ESTROGEN
Triquilar Tab 21 Day
DNP
0.7224
L
F
00707600
BAY
N
Triquilar Tab 28 Day
DNP
0.5418
L
F
00707503
BAY
N
Ortho 7/7/7 Tab 21 Day
DNP
1.0990
L
F
00602957
JAN
N
Ortho 7/7/7 Tab 28 Day
Synphasic Tab 21 Day
DNP
DNP
0.8243
0.5495
L
L
F
F
00602965
02187108
JAN
PFI
N
N
Synphasic Tab 28 Day
DNP
0.4121
L
F
02187116
PFI
N
norgestimate & ethinylestradiol 3 phase tab (21)
Tricira Lo (21 Day)
Tri-Cyclen Lo Tab 21 Day
DNP
DNP
0.4511
0.4511
M
M
F
F
02401967
02258560
APX
JAN
Y
Y
norgestimate & ethinylestradiol 3 phase tab (28)
Tricira Lo (28 Day)
Tri-Cyclen Lo Tab 28 Day
DNP
DNP
0.3383
0.3383
M
M
F
F
02401975
02258587
APX
JAN
Y
Y
Tri-Cyclen Tab 21 Day
DNP
1.0990
L
F
02028700
JAN
N
Tri-Cyclen Tab 28 Day
DNP
0.8243
L
F
02029421
JAN
N
NORETHINDRONE AND ESTROGEN
NORGESTIMATE AND ESTROGEN
PROGESTOGENS
G03AC01
NORETHINDRONE
norethindrone 0.35mg tab (28)
February 2016
92
G
Genito-Urinary System & Sex Hormones
Movisse Tab 28 Day
Micronor Tab 28 Day
G03AC06
G03AD03
DNP
DNP
0.5888
0.5888
M
M
SF
SF
02410303
00037605
MYL Y
JAN Y
Depo-Provera 50mg/mL Inj
DNP
5.4180
L
SFC
00030848
PFI
N
medroxyprogesterone acetate 150mg/mL inj
Medroxyprogesterone Acetate 150mg/mL Inj
DNP
22.0000
M
SFC
02322250
SDZ
Y
Depo-Provera 150mg/mL Inj
DNP
22.0000
M
SFC
00585092
PFI
Y
DNP
DNP
6.4500
6.4500
M
M
F
F
02364905
02241674
ATV
PAL
Y
Y
Testim 1% Top Gel
DN
0.7307
L
E
02280248
PAL
N
Androgel 2.5g/pkt Top Gel
DN
0.8920
L
E
02245345
BGP N
Androderm 2.5mg (12.2mg)/24 hr Patch
DN
2.1645
L
E
02239653
ASP
Androgel 5g/pkt Top Gel
DN
0.7887
L
E
02245346
BGP N
Androderm 5mg (24.3mg)/24 hr Patch
DN
4.3290
L
E
02245972
ASP
testosterone undercanoate 40mg cap
pms-Testosterone 40mg Cap
DN
0.4700
M
SFC
02322498
PMS Y
Taro-Testosterone 40mg Cap
Andriol 40mg Cap
DN
DN
0.4700
0.4700
M
M
SFC
SFC
02421186
00782327
TAR Y
FRS Y
testosterone cypionate 100mg/mL inj
Testosterone Cypionate 100mg/mL Inj
Depo-Testosterone 100mg/mL Inj
DN
DN
2.4760
2.4760
M
M
SFC
SFC
02246063
00030783
SDZ
PFI
Y
Y
Delatestryl 200mg/mL Inj
DN
10.0240
L
SFC
00029246
VLN
N
Estrogel 0.06% Top Gel
DNP
0.4659
L
E
02238704
FRS
N
Estrace 0.5mg Tab
DNP
0.1410
L
SFC
02225190
TML N
Estrace 1mg Tab
DNP
0.2721
L
SFC
02148587
TML N
Estrace 2mg Tab
DNP
0.4804
L
SFC
02148595
TML N
Estring 7.5mcg/24 hr Vag Ring
DNP
71.1200
L
SFC
02168898
PAL
Vagifem 10mcg Vag Tab
DNP
3.7189
L
SFC
02325462
NNO N
Estradot Patch (25mcg/day)
DNP
2.6713
L
E
02245676
NVR N
Climara 25 (25mcg/day, 2mg/patch)
DNP
5.2150
L
E
02247499
BAY
MEDROXYPROGESTERONE
LEVONORGESTREL
levonorgestrel 0.75mg tab
Next Choice 0.75mg Tab
Plan B 0.75mg Tab
G03B
ANDROGENS AND COMBINATIONS, EXCL G03E
G03BA
3-OXOANDROSTEN (4) DERIVATIVES
G03BA03
TESTOSTERONE
G03C
ESTROGENS AND COMBINATIONS, EXCL G03E,G03F,G03HB
G03CA
NATURAL AND SEMISYNTHETIC ESTROGENS, PLAIN
G03CA03
February 2016
N
N
ESTRADIOL
93
N
N
G
Genito-Urinary System & Sex Hormones
Oesclim (25mcg/day, 5mg/patch)
2.6888
L
E
02243999
NVR N
estradiol 50mcg/day patch (Estradot)
Sandoz Estradiol Derm 50 (50mcg/day patch)
DNP
2.4125
M
E
02246967
SDZ
Estradot Patch (50mcg/day)
DNP
2.4125
M
E
02244000
NVR Y
estradiol 50mcg/day patch (Vivelle)
Sandoz Estradiol Derm 50 (50mcg/day patch)
DNP
2.4125
M
E
02246967
SDZ
02204428
NVR Y
02231509
BAY
N
02243724
SLP
N
Y
DNP
5.5704
L
E
Oesclim (50mcg/day, 10mg/patch)
Y
DNP
2.5875
M
E
02246968
SDZ
Estradot Patch (75mcg/day)
DNP
2.5875
M
E
02244001
NVR Y
estradiol 75mcg/day patch (Vivelle)
Sandoz Estradiol Derm 75 (75mcg/day patch)
DNP
2.5875
M
E
02246968
SDZ
02204436
NVR Y
Y
Climara 75 (75mcg/day, 5.7mg/patch)
DNP
5.9388
L
E
02247500
BAY
N
estradiol 100mcg/day patch (Estradot)
Sandoz Estradiol Derm 100 (100mcg/day patch)
DNP
2.7375
M
E
02246969
SDZ
Y
Estradot Patch (100mcg/day)
DNP
2.7375
M
E
02244002
NVR Y
estradiol 100mcg/day patch (Vivelle)
Sandoz Estradiol Derm 100 (100mcg/day patch)
DNP
2.7375
M
E
02246969
SDZ
02204444
NVR Y
Vivelle Patch (100mcg/day) (discontinued)
Climara 100 (100mcg/day, 7.8mg/patch)
Y
DNP
6.2800
L
E
02231510
BAY
N
DNP
0.5367
L
SFC
00727369
SLP
N
Premarin 0.3mg Tab
DNP
0.3107
L
SFC
02414678
PFI
N
Premarin 0.625mg Tab
Premarin 0.625mg/g Vag Cr
DNP
DNP
0.3107
0.6700
L
L
SFC
SFC
02414686
02043440
PFI
PFI
N
N
Premarin 1.25mg Tab
DNP
0.3107
L
SFC
02414694
PFI
N
Premarin 25mg/vial Inj
DNP
42.1500
L
SFC
02043386
PFI
N
medroxyprogesterone acetate 2.5mg tab
Apo-Medroxy 2.5mg Tab
DNP
0.0642
M
SFC
02244726
APX
Y
Novo-Medrone 2.5mg Tab
Provera 2.5mg Tab
DNP
DNP
0.0642
0.0642
M
M
SFC
SFC
02221284
00708917
TEV
PFI
Y
Y
ESTRONE
Estragyn Vag Cr
CONJUGATED ESTROGENS
G03D
PROGESTOGENS AND COMBINATIONS, EXCL G03E AND G03F
G03DA
PREGNEN (4) DERIVATIVES
MEDROXYPROGESTERONE
medroxyprogesterone acetate 5mg tab
February 2016
Y
estradiol 75mcg/day patch (Estradot)
Sandoz Estradiol Derm 75 (75mcg/day patch)
Vivelle Patch (75mcg/day) (discontinued)
G03DA02
N
DNP
Climara 50 (50mcg/day, 3.9mg/patch)
G03CA57
SLP
Estradot Patch (37.5mcg/day)
Vivelle Patch (50mcg/day) (discontinued)
G03CA07
02243722
94
G
Genito-Urinary System & Sex Hormones
G03DA04
G03DB
Apo-Medroxy 5mg Tab
Novo-Medrone 5mg Tab
DNP
DNP
0.1270
0.1270
M
M
SFC
SFC
02244727
02221292
APX
TEV
Y
Y
Provera 5mg Tab
DNP
0.1270
M
SFC
00030937
PFI
Y
medroxyprogesterone acetate 10mg tab
Apo-Medroxy 10mg Tab
DNP
0.2577
M
SFC
02277298
APX
Y
Novo-Medrone 10mg Tab
Provera 10mg Tab
DNP
DNP
0.2577
0.2577
M
M
SFC
SFC
02221306
00729973
TEV
PFI
Y
Y
medroxyprogesterone acetate 100mg tab
Apo-Medroxy 100mg Tab
Provera 100mg Tab (discontinued)
DNP
1.2057
M
SFC
02267640
00030945
APX
PFI
Y
Y
progesterone 100mg cap
Teva-Progesterone 100mg Cap
02439913
TEV
Y
Prometrium 100mg Cap
02166704
FRS
Y
N
PROGESTERONE
PREGNADIEN DERIVATIVES
G03DB08
DIENOGEST
DNP
1.9643
L
E
02374900
BAY
Estalis 140/50mcg Transdermal Patch
DNP
3.2725
L
E
02241835
NVR N
Estalis 250/50mcg Transdermal Patch
DNP
3.2725
L
E
02241837
NVR N
Clomid 50mg Tab
02091879
SAV
Serophene 50mg Tab
00893722
EMD N
Visanne 2mg tab
G03F
PROGESTOGENS AND ESTROGENS IN COMBINATION
G03FA
PROGESTROGENS AND ESTROGENS COMBINATIONS
G03FA01
NORETHINDRONE AND ESTROGEN
G03G
GONADOTROPHINS AND OTHER OVULATION STIMULANTS
G03GB
OVULATION STIMULANTS, SYNTHETICS
G03GB02
CLOMIFENE
G03H
ANTIANDROGENS AND COMBINATIONS
G03HA
ANTIANDROGENS, PLAIN PREPARATIONS
G03HA01
G03HB
N
CYPROTERONE
cyproterone 50mg tab
Cyproterone 50mg Tab
MED-Cyproterone 50mg Tab
DNP
DNP
1.5283
1.5283
M
M
SFC
SFC
02245898
02390760
AAP Y
GMP Y
Androcur 50mg Tab
DNP
1.5283
M
SFC
00704431
PMS Y
02290308
PAL
ANTIANDROGENS AND ESTROGENS
G03HB01
CYPROTERONE AND ESTROGEN
cyproterone acetate 2mg & ethinyl estradiol 0.035mg tab
Cyestra-35 Tab
February 2016
95
Y
G
Genito-Urinary System & Sex Hormones
Novo-Cyproterone/Ethinyl Estradiol 2mg/0.035mg Tab
RAN-Cyproterone/Ethinyl Estradiol 2mg/0.035mg Tab
02309556
02425017
TEV Y
RAN Y
Diane-35 Tab
02233542
BAY
Y
G03X
OTHER SEX HORMONES
G03XA
ANTIGONADOTROPHINS
G03XA01
G03XC
DANAZOL
Cyclomen 50mg Cap
DNP
0.9393
L
SF
02018144
SAV
N
Cyclomen 100mg Cap
DNP
1.3940
L
SF
02018152
SAV
N
Cyclomen 200mg Cap
DNP
2.2276
L
SF
02018160
SAV
N
DNP
0.6041
M
E
02279215
APX
Y
CO Raloxifene 60mg Tab
Novo-Raloxifene 60mg Tab (discontinued)
DNP
0.6041
M
E
02358840
02312298
ATV
TEV
Y
Y
pms-Raloxifene 60mg Tab
Evista 60mg Tab
DNP
DNP
0.6041
0.6041
M
M
E
E
02358921
02239028
PMS Y
LIL
Y
Myrbetriq 25mg ER Tab
DNP
1.4600
L
E
02402874
ASL
N
Myrbetriq 50mg ER Tab
DNP
1.4600
L
E
02402882
ASL
N
DNP
0.1369
M
SF
02223376
01924753
PMS Y
JAN Y
02254735
ASP
SELECTIVE ESTROGEN RECEPTOR MODULATORS
G03XC01
RALOXIFENE
raloxifene 60mg tab
Apo-Raloxifene 60mg Tab
G04
UROLOGICALS
G04B
OTHER UROLOGICALS, INCL ANTISPASMODICS
G04BD
URINARY ANTISPASMODICS
B04BD12
G04BD04
MIRABEGRON
OXYBUTYNIN
oxybutynin 1mg/mL o/l
pms-Oxybutynin 1mg/mL O/L
Ditropan 1mg/mL O/L (discontinued)
Oxytrol Patch (3.9mg/day 36mg/patch)
oxybutynin 5mg tab
Apo-Oxybutynin 5mg Tab
MYLAN-Oxybutynin 5mg Tab
DNP
DNP
0.1077
0.1077
M
M
SF
SF
02163543
02230800
APX Y
MYL Y
Novo-Oxybutynin 5mg Tab
Oxybutynin 5mg Tab
DNP
DNP
0.1077
0.1077
M
M
SF
SF
02230394
02350238
TEV
SAS
pms-Oxybutynin 5mg Tab
Ditropan 5mg Tab (discontinued)
DNP
0.1077
M
SF
02240550
01924761
PMS Y
JAN Y
Ditropan XL 5mg Tab
DNP
2.3292
L
E
02243960
JAN
N
Ditropan XL 10mg Tab
DNP
2.3292
L
E
02243961
JAN
N
02366150
ASP
N
Gelnique 100mg/g Gel
G04BD07
February 2016
N
TOLTERODINE
96
Y
Y
G
Genito-Urinary System & Sex Hormones
G04BD08
G04BD09
tolterodine 1mg tab
MINT-Tolterodine 1mg Tab
DNP
0.4910
M
E
02423308
MNT Y
Teva-Tolterodine 1mg Tab
Detrol 1mg Tab
DNP
DNP
0.4910
0.4910
M
M
E
E
02299593
02239064
TEV
PFI
tolterodine 2mg ER cap
MYLAN-Tolterodine ER 2mg Cap
Sandoz Tolterodine LA 2mg Cap
DNP
DNP
0.4911
0.4911
M
M
E
E
02404184
02413140
MYL Y
SDZ Y
Teva-Tolterodine LA 2mg Cap
Detrol LA 2mg Cap
DNP
DNP
0.4911
0.4911
M
M
E
E
02412195
02244612
TEV
PFI
tolterodine 2mg tab
MINT-Tolterodine 2mg Tab
Teva-Tolterodine 2mg Tab
DNP
DNP
0.4910
0.4910
M
M
E
E
02423316
02299607
MNT Y
TEV Y
Detrol 2mg Tab
DNP
0.4910
M
E
02239065
PFI
tolterodine 4mg ER cap
MYLAN-Tolterodine ER 4mg Cap
DNP
0.4911
M
E
02404192
MYL Y
Sandoz Tolterodine LA 4mg Cap
Teva-Tolterodine LA 4mg Cap
DNP
DNP
0.4911
0.4911
M
M
E
E
02413159
02412209
SDZ
TEV
Y
Y
Detrol LA 4mg Cap
DNP
0.4911
M
E
02244613
PFI
Y
solifenacin 5mg tab
ACT-Solifenacin 5mg Tab
Jamp-Solifenacin 5mg Tab
DNP
DNP
0.4223
0.4223
M
M
E
E
02422239
02424339
ATV
JPC
Y
Y
pms-Solifenacin 5mg Tab
RAN-Solifenacin 5mg Tab
DNP
DNP
0.4223
0.4223
M
M
E
E
02417723
02437988
PMS Y
RAN Y
Sandoz Solifenacin 5mg Tab
Teva-Solifenacin 5mg Tab
DNP
DNP
0.4223
0.4223
M
M
E
E
02399032
02397900
SDZ
TEV
Y
Y
Vesicare 5mg Tab
DNP
0.4223
M
E
02277263
ASL
Y
solifenacin 10mg tab
ACT-Solifenacin 10mg Tab
DNP
0.4223
M
E
02422247
ATV
Y
Jamp-Solifenacin 10mg Tab
pms-Solifenacin 10mg Tab
DNP
DNP
0.4223
0.4223
M
M
E
E
02424347
02417731
JPC Y
PMS Y
RAN-Solifenacin 10mg Tab
Sandoz Solifenacin 10mg Tab
DNP
DNP
0.4223
0.4223
M
M
E
E
02437996
02399040
RAN Y
SDZ Y
Teva-Solifenacin 10mg Tab
Vesicare 10mg Tab
DNP
DNP
0.4223
0.4223
M
M
E
E
02397919
02277271
TEV
ASL
DNP
0.7635
L
E
02275066
SNV N
Enablex 7.5mg Tab
DNP
1.5600
L
E
02273217
MRS N
Enablex 15mg Tab
DNP
1.5600
L
E
02273225
MRS N
G04BD11
Toviaz 4mg Tab
DNP
1.5000
L
E
02380021
PFI
N
Toviaz 8mg Tab
DNP
1.5000
L
E
02380048
PFI
N
G04BE
Y
Y
Y
TROSPIUM
DARIFENACIN
FESOTERODINE
DRUGS USED IN ERECTILE DYSFUNCTION
February 2016
Y
Y
SOLIFENACIN
Trosec 20mg Tab
G04BD10
Y
Y
97
G
Genito-Urinary System & Sex Hormones
G04BE03
G04BX
SILDENAFIL
sildenafil 25mg tab
Apo-Sildenafil 25mg Tab
02248201
APX
Y
CO Sildenafil 25mg Tab
Jamp-Sildenafil 25mg Tab
02372053
02405660
ATV
JPC
Y
Y
MINT-Sildenafil 25mg Tab
Myl-Sildenafil 25mg Tab
02393069
02392577
MNT Y
MYL Y
Novo-Sildenafil 25mg Tab
pms-Sildenafil 25mg Tab
02308738
02371626
TEV Y
PMS Y
RAN-Sildenafil 25mg Tab
Sandoz Sildenafil 25mg Tab
02383101
02318806
RAN Y
SDZ Y
Sildenafil 25mg Tab
Viagra 25mg Tab
02317559
02239766
PMS Y
PFI Y
sildenafil 50mg tab
Apo-Sildenafil 50mg Tab
CO Sildenafil 50mg Tab
02248202
02372061
APX
ATV
Jamp-Sildenafil 50mg Tab
MINT-Sildenafil 50mg Tab
02405679
02393077
JPC Y
MNT Y
Myl-Sildenafil 50mg Tab
Novo-Sildenafil 50mg Tab
02392585
02308746
MYL Y
TEV Y
pms-Sildenafil 50mg Tab
RAN-Sildenafil 50mg Tab
02371634
02383128
PMS Y
RAN Y
Sandoz Sildenafil 50mg Tab
Sildenafil 50mg Tab
02318814
02317575
SDZ Y
PMS Y
Sildenafil 50mg Tab
Viagra 50mg Tab
02406152
02239767
SAS
PFI
Y
Y
sildenafil 100mg tab
Apo-Sildenafil 100mg Tab
CO Sildenafil 100mg Tab
02248203
02372088
APX
ATV
Y
Y
Jamp-Sildenafil 100mg Tab
MINT-Sildenafil 100mg Tab
02405687
02393085
JPC Y
MNT Y
Myl-Sildenafil 100mg Tab
Novo-Sildenafil 100mg Tab
02392593
02308754
MYL Y
TEV Y
pms-Sildenafil 100mg Tab
RAN-Sildenafil 100mg Tab
02371642
02383136
PMS Y
RAN Y
Sandoz Sildenafil 100mg Tab
Sildenafil 100mg Tab
02318822
02406160
SDZ
SAS
Sildenafil 100mg Tab
Viagra 100mg Tab
02317583
02239768
PMS Y
PFI Y
Y
Y
OTHER UROLOGICAL
G04BX01
MAGNESIUM HYDROXIDE
Urologic G Irr Sol
G04BX13
DNP
0.0350
L
SF
00039373
HOS N
DNP
2.3000
L
SF
00493392
BCH N
DIMETHYL SULFOXIDE
Rimso-50 (50%) Irr Sol
G04C
Y
Y
DRUGS USED IN BENIGN PROSTATIC HYPERTROPHY
February 2016
98
G
Genito-Urinary System & Sex Hormones
G04CA
ALPHA-ADRENORECEPTOR ANTAGONISTS
G04AC04
G04CA01
G04CA02
G04CA03
February 2016
SILDOSIN
Rapaflo 4mg Cap
02361663
ASP
N
Rapaflo 8mg Cap
02361671
ASP
N
alfuzosin 10mg extended release tab
Apo-Alfuzosin 10mg Tab
Sandoz Alfuzosin 10mg Tab
02315866
02304678
APX
SDZ
Y
Y
Xatral 10mg Tab
02245565
SAV
Y
tamsulosin 0.4mg sustained release cap
MYLAN-Tamsulosin 0.4mg Cap
Novo-Tamsulosin 0.4mg Cap
02298570
02281392
MYL Y
TEV Y
ratio-Tamsulosin 0.4mg Cap
Sandoz Tamsulosin 0.4mg Cap
02294265
02319217
TEV
SDZ
Flomax 0.4mg Cap (discontinued)
02238123
BOE Y
ALFUZOSIN
TAMSULOSIN
Y
Y
tamsulosin 0.4mg sustained release cap/tab
Apo-Tamsulosin CR 0.4mg Tab
DNP
0.1549
M
SF
02362406
APX
Y
Sandoz Tamsulosin CR 0.4mg Tab
Tamsulosin CR 0.4mg Tab
DNP
DNP
0.1549
0.1549
M
M
SF
SF
02340208
02427117
SDZ
SAS
Y
Y
Tamsulosin CR 0.4mg Tab
Teva-Tamsulosin CR 0.4mg Tab
DNP
DNP
0.1549
0.1549
M
M
SF
SF
02429667
02368242
SIV
TEV
Y
Y
Flomax 0.4mg CR Tab
DNP
0.1549
M
SF
02270102
BOE Y
terazosin 1mg tab
Apo-Terazosin 1mg Tab
MYLAN-Terazosin 1mg Tab (discontinued)
DNP
0.1869
M
SF
02234502
02396289
APX Y
MYL Y
pms-Terazosin 1mg Tab
Terazosin 1mg Tab
DNP
DNP
0.1869
0.1869
M
M
SF
SF
02243518
02350475
PMS Y
SAS Y
Teva-Terazosin 1mg Tab
Hytrin 1mg Tab
DNP
DNP
0.1869
0.1869
M
M
SF
SF
02230805
00818658
TEV Y
BGP Y
terazosin 2mg tab
Apo-Terazosin 2mg Tab
MYLAN-Terazosin 2mg Tab (discontinued)
DNP
0.2375
M
SF
02234503
02396297
APX Y
MYL Y
pms-Terazosin 2mg Tab
Terazosin 2mg Tab
DNP
DNP
0.2375
0.2375
M
M
SF
SF
02243519
02350483
PMS Y
SAS Y
Teva-Terazosin 2mg Tab
Hytrin 2mg Tab
DNP
DNP
0.2375
0.2375
M
M
SF
SF
02230806
00818682
TEV Y
BGP Y
terazosin 5mg tab
Apo-Terazosin 5mg Tab
MYLAN-Terazosin 5mg Tab (discontinued)
DNP
0.3225
M
SF
02234504
02396300
APX Y
MYL Y
pms-Terazosin 5mg Tab
Terazosin 5mg Tab
DNP
DNP
0.3225
0.3225
M
M
SF
SF
02243520
02350491
PMS Y
SAS Y
Teva-Terazosin 5mg Tab
Hytrin 5mg Tab
DNP
DNP
0.3225
0.3225
M
M
SF
SF
02230807
00818666
TEV Y
BGP Y
TERAZOSIN
99
G
Genito-Urinary System & Sex Hormones
terazosin 10mg tab
Apo-Terazosin 10mg Tab
G04CB
DNP
0.4721
SF
02234505
APX
M
SF
02396319
02243521
MYL Y
PMS Y
0.4721
0.4721
M
M
SF
SF
02350505
02230808
SAS
TEV
DNP
0.4721
M
SF
00818674
BGP Y
finasteride 5mg tab
Apo-Finasteride 5mg Tab
Auro-Finasteride 5mg Tab
DNP
DNP
0.4665
0.4665
M
M
SF
SF
02365383
02405814
APX Y
ARO Y
CO Finasteride 5mg Tab
Finasteride 5mg Tab
DNP
DNP
0.4665
0.4665
M
M
SF
SF
02354462
02355043
ATV
AHI
Jamp-Finasteride 5mg Tab
MINT-Finasteride 5mg Tab
DNP
DNP
0.4665
0.4665
M
M
SF
SF
02357224
02389878
JPC Y
MNT Y
MYLAN-Finasteride 5mg Tab
Novo-Finasteride 5mg Tab
DNP
DNP
0.4665
0.4665
M
M
SF
SF
02356058
02348500
MYL Y
TEV Y
pms-Finasteride 5mg Tab
RAN-Finasteride 5mg Tab
DNP
DNP
0.4665
0.4665
M
M
SF
SF
02310112
02371820
PMS Y
RAN Y
Sandoz Finasteride 5mg Tab
Proscar 5mg Tab
DNP
DNP
0.4665
0.4665
M
M
SF
SF
02322579
02010909
SDZ
FRS
Y
Y
dutasteride 0.5mg cap
ACT Dutasteride 0.5mg Cap
DNP
0.4205
M
SF
02412691
ATV
Y
Apo-Dutasteride 0.5mg Cap
Dutasteride 0.5mg Cap
DNP
DNP
0.4205
0.4205
M
M
SF
SF
02404206
02429012
APX
SIV
Y
Y
Dutasteride 0.5mg Cap
MED-Dutasteride 0.5mg Cap
DNP
DNP
0.4205
0.4205
M
M
SF
SF
02443058
02416298
SAS Y
GMP Y
MINT-Dutasteride 0.5mg Tab
pms-Dutasteride 0.5mg Cap
DNP
0.4205
M
SF
02428873
02393220
MNT Y
PMS Y
Sandoz Dutasteride 0.5mg Cap
Teva-Dutasteride 0.5mg Cap
DNP
DNP
0.4205
0.4205
M
M
SF
SF
02424444
02408287
SDZ
TEV
Avodart 0.5mg Cap
DNP
0.4205
M
SF
02247813
GSK Y
MYLAN-Terazosin 10mg Tab (discontinued)
pms-Terazosin 10mg Tab
DNP
0.4721
Terazosin 10mg Tab
Teva-Terazosin 10mg Tab
DNP
DNP
Hytrin 10mg Tab
M
Y
Y
Y
TESTOSTERONE-5-ALPHA REDUCTASE INHIBITORS
G04CB01
G04CB02
February 2016
FINASTERIDE
Y
Y
DUTASTERIDE
100
Y
Y
H
Systemic Hormonal Preparations, Excluding Sex Hormones
H01
PITUITARY AND HYPOTHALAMIC HORMONES
H01A
ANTERIOR PITUITARY LOBE HORMONES
H01AC
SOMATROPIN AND SOMATROPIN AGONISTS
H01AC01
SOMATROPIN
Nutropin AQ Pen Cartridge
DNP
197.7350
L
E
02249002
HLR
N
Genotropin MiniQuick 0.6mg/syr
DNP
16.7400
L
E
02401762
PFI
N
Genotropin MiniQuick 0.8mg/syr
DNP
22.3200
L
E
02401770
PFI
N
Genotropin MiniQuick 1mg/syr
DNP
27.9000
L
E
02401789
PFI
N
Humatrope 1mg/mL Inj
DNP
233.3500
L
E
00745626
LIL
N
Genotropin MiniQuick 1.2mg/syr
DNP
33.4800
L
E
02401797
PFI
N
Genotropin MiniQuick 1.4mg/syr
DNP
39.0600
L
E
02401800
PFI
N
Genotropin MiniQuick 1.6mg/syr
DNP
44.6400
L
E
02401819
PFI
N
Genotropin MiniQuick 1.8mg/syr
DNP
50.2200
L
E
02401827
PFI
N
Genotropin MiniQuick 2mg/syr
DNP
55.8000
L
E
02401835
PFI
N
Saizen 3.33mg/vial Inj
DNP
149.2500
L
E
02215136
EMD N
Saizen 5mg/vial Inj
DNP
224.0500
L
E
02237971
EMD N
02325063
SDZ
N
02401703
PFI
N
02325055
SDZ
N
Omnitrope 5mg/1.5mL
Genotropin GoQuick 5.3mg/pen
DNP
147.8700
L
E
Omnitrope 5.8mg/vial
Humatrope 6mg/vial Inj
Saizen 6mg Cart
DNP
DNP
280.0200
268.8300
L
L
E
E
02243077
02350122
LIL
N
EMD N
Saizen 8.8mg/vial Inj
DNP
358.4700
L
E
02272083
EMD N
02325071
SDZ
N
N
Omnitrope 10mg/1.5mL
H01AX
Genotropin GoQuick 12mg/pen
DNP
334.8000
L
E
02401711
PFI
Humatrope 12mg/vial Inj
Saizen 12mg Cart
DNP
DNP
560.0400
537.6600
L
L
E
E
02243078
02350130
LIL
N
EMD N
Saizen 20mg Cart
DNP
896.1000
L
E
02350149
EMD N
Humatrope 24mg/vial Inj
DNP
1120.0800 L
E
02243079
LIL
N
Somavert 10mg/vial Inj
02272199
PFI
N
Somavert 15mg/vial Inj
02272202
PFI
N
Somavert 20mg/vial Inj
02272210
PFI
N
02247938
SDZ
Y
OTHER ANTERIOR PITUITARY HORMONES AND ANALOGUES
H01AX01
PEGVISOMANT
H01B
POSTERIOR PITUITARY LOBE HORMONES
H01BA
VASOPRESSIN AND ANALOGUES
H01BA01
VASOPRESSIN
vasopressin 20units/mL usp inj
Vasopressin 20units/mL USP Inj
February 2016
101
H
Systemic Hormonal Preparations, Excluding Sex Hormones
Pressyn 20units/mL USP Inj (discontinued)
Pressyn AR 20units/mL USP Inj
H01BA02
00693820
02246133
FEI
FEI
Y
Y
Y
DESMOPRESSIN
desmopressin 0.1mg tab
Apo-Desmopressin 0.1mg Tab
DNP
0.3304
M
F*
02284030
APX
Novo-Desmopressin 0.1mg Tab
pms-Desmopressin 0.1mg Tab
DNP
DNP
0.3304
0.3304
M
M
F*
F*
02287730
02304368
TEV Y
PMS Y
DDAVP 0.1mg Tab
*full benefit for children 16 years and under.
DNP
0.3304
M
F*
00824305
FEI
Y
02246500
FEI
N
Y
Y
Minirin 0.1mg Tab (discontinued)
desmopressin 0.2mg tab
Apo-Desmopressin 0.2mg Tab
Novo-Desmopressin 0.2mg Tab
DNP
DNP
0.6608
0.6608
M
M
F*
F*
02284049
02287749
APX
TEV
pms-Desmopressin 0.2mg Tab
DDAVP 0.2mg Tab
DNP
DNP
0.6608
0.6608
M
M
F*
F*
02304376
00824143
PMS Y
FEI Y
Octostim 1.5mg/mL Nasal Spray
02237860
FEI
N
DDAVP 4mcg/mL Inj
00873993
FEI
N
desmopressin 10mcg/dose nasal sp
Desmopressin 10mcg/dose Nasal Sp
02242465
AAP
Y
DDAVP 10mcg/dose Nasal Sp
00836362
FEI
Y
Octostim 15mcg/mL Inj
02024179
FEI
N
02284995
FEI
N
00402516
FEI
N
*full benefit for children 16 years and under.
DDAVP MELT 60mcg Tab
DNP
0.3304
P
F*
DDAVP 100mcg/mL Rhinyle Drops
DDAVP MELT 120mcg Tab
DNP
0.6608
P
F*
02285002
FEI
N
DDAVP MELT 240mcg Tab
DNP
1.3216
P
F*
02285010
FEI
N
DNP
4.9332
L
SFC
02188783
PFI
N
02278383
PAL
N
*full benefit for children 16 years and under.
H01C
HYPOTHALAMIC HORMONES
H01CA
GONADOTROPIN-RELEASING HORMONES
H01CA02
NAFARELIN
Synarel 2mg/mL Sol
H01CA03
HISTRELIN
Vantas 50mg/vial Inj
H01CB
SOMATOSTATIN AND ANALOGUES
H01CB02
OCTREOTIDE
Sandostatin LAR 10mg/vial Inj
DNP
1320.9300 L
SFC
02239323
NVR N
Sandostatin LAR 20mg/vial Inj
DNP
1706.5800 L
SFC
02239324
NVR N
Sandostatin LAR 30mg/vial Inj
DNP
2189.5200 L
SFC
02239325
NVR N
octreotide 50mcg/mL inj
February 2016
102
H
Systemic Hormonal Preparations, Excluding Sex Hormones
H01CB03
Ocphyl 50mcg/mL Inj
Octreotide Acetate Omega 50mcg/mL Inj
DNP
DNP
1.7500
1.7500
M
M
SFC
SFC
02413191
02248639
PDP Y
OMG Y
Sandostatin 50mcg/mL Inj
DNP
1.7500
M
SFC
00839191
NVR Y
octreotide 100mcg/mL inj
Ocphyl 100mcg/mL Inj
DNP
3.3000
M
SFC
02413205
PDP Y
Octreotide Acetate Omega 100mcg/mL Inj
Sandostatin 100mcg/mL Inj
DNP
DNP
3.3000
3.3000
M
M
SFC
SFC
02248640
00839205
OMG Y
NVR Y
octreotide 200mcg/mL inj
Octreotide Acetate Omega 200mcg/mL Inj
Sandostatin 200mcg/mL Inj
DNP
DNP
8.0220
8.0220
M
M
SFC
SFC
02248642
02049392
OMG Y
NVR Y
octreotide 500mcg/mL inj
Ocphyl 500mcg/mL Inj
Octreotide Acetate Omega 500mcg/mL Inj
DNP
DNP
15.5000
15.5000
M
M
SFC
SFC
02413213
02248641
PDP Y
OMG Y
Sandostatin 500mcg/mL Inj
DNP
15.5000
M
SFC
00839213
NVR Y
Somatuline Autogel 60mg/0.3mL Syringe Inj
DNP
3874.8667 L
SFC
02283395
IPS
N
Somatuline Autogel 90mg/0.3mL Syringe Inj
DNP
5168.8333 L
SFC
02283409
IPS
N
Somatuline Autogel 120mg/0.5mL Syringe Inj
DNP
3881.9000 L
SFC
02283417
IPS
N
DNP
0.2685
L
SFC
02086026
PAL
N
DNP
DNP
10.4830
10.4830
M
M
SFC
SFC
02237835
00028096
SDZ
FRS
Y
Y
DNP
0.1095
M
SFC
02261081
APX
Y
DNP
0.1095
M
SFC
01964976
00016462
PMS Y
FRS Y
dexamethasone 0.75mg tab
pms-Dexamethasone 0.75mg Tab
Decadron 0.75mg Tab (discontinued)
DNP
0.4944
M
SFC
01964968
00016470
PMS Y
FRS Y
pms-Dexamethasone 2mg Tab
DNP
0.4658
L
SFC
02279363
PMS N
dexamethasone 4mg tab
Apo-Dexamethasone 4mg Tab
pms-Dexamethasone 4mg Tab
DNP
DNP
0.4265
0.4265
M
M
SFC
SFC
02250055
01964070
APX Y
PMS Y
00354309
FRS
LANREOTIDE
H02
SYSTEMIC CORTICOSTEROIDS
H02A
SYSTEMIC CORTICOSTEROIDS, PLAIN
H02AA
MINERALOCORTICOIDS
H02AA02
FLUDROCORTISONE
Florinef 0.1mg Tab
H02AB
GLUCOCORTICOIDS
H02AB01
BETAMETHASONE
betamethasone 6mg/mL inj
Betaject 6mg/mL Inj
Celestone 6mg/mL Soluspan Inj
H02AB02
DEXAMETHASONE
dexamethasone 0.5mg tab
Apo-Dexamethasone 0.5mg Tab
pms-Dexamethasone 0.5mg Tab
Decadron 0.5mg Tab (discontinued)
Decadron 4mg Tab (discontinued)
February 2016
103
Y
H
Systemic Hormonal Preparations, Excluding Sex Hormones
H02AB04
Dexasone 4mg Tab
DNP
0.4265
M
SFC
00489158
VLN
Y
dexamethasone 4mg/mL inj
Dexamethasone 4mg/mL Inj
DNP
1.6900
M
SFC
00664227
SDZ
Y
Dexamethasone 4mg/mL Inj
Decadron 4mg/mL Inj (discontinued)
DNP
1.6900
M
SFC
01977547
00213624
CYI
FRS
Y
Y
Dexamethasone 10mg/mL Inj
DNP
4.5600
L
SFC
00874582
SDZ
N
Dexamethasone 10mg/mL Inj
pms-Dexamethasone 10mg/mL Inj
DNP
DNP
6.5000
1.2830
L
L
SFC
SFC
02204274
00783900
OMG N
PMS N
methylprednisolone sodium succinate 1g/vial inj
Methylprednisolone Sod. Succ. 1g/vial Inj
DNP
34.4100
M
SFC
02241229
TEV
Y
Solu-Medrol 1g/vial Inj
DNP
34.4100
M
SFC
00036137
PFI
Y
Medrol 4mg Tab
DNP
0.3576
L
SFC
00030988
PFI
N
Medrol 16mg Tab
DNP
1.0305
L
SFC
00036129
PFI
N
Depo-Medrol 20mg/mL Aq Multidose Inj
DNP
2.5020
L
SFC
01934325
PFI
N
methylprednisolone acetate 40mg/vial inj
Methylprednisolone Acetate 40mg/vial Inj
DNP
4.5150
M
SFC
02245407
SDZ
Y
Depo-Medrol 40mg/mL Aq Multidose Inj
DNP
4.5150
M
SFC
01934333
PFI
Y
methylprednisolone acetate 40mg/vial inj (pf)
Methylprednisolone Acetate 40mg/vial Inj (PF)
DNP
4.7250
M
SFC
02245400
SDZ
Y
Depo-Medrol 40mg/mL Aq Multidose Inj (PF)
DNP
4.7250
M
SFC
00030759
PFI
Y
methylprednisolone sodium succinate 40mg/vial inj
Methylprednisolone Sod. Succ. 40mg/vial Inj
DNP
4.3360
M
SFC
02231893
TEV
Y
02230211
PFI
Y
METHYLPREDNISOLONE
Solu-Medrol 40mg/vial Inj (discontinued)
methylprednisolone acetate 80mg/vial inj
Depo-Medrol 80mg/mL Aq Multidose Inj
DNP
6.9900
M
SFC
01934341
PFI
Y
Methylprednisolone Acetate 80mg/vial Inj
DNP
6.9900
M
SFC
02245408
SDZ
Y
methylprednisolone acetate 80mg/vial inj (pf)
Methylprednisolone Acetate 80mg/vial Inj (PF)
DNP
9.0300
M
SFC
02245406
SDZ
Y
Depo-Medrol 80mg/mL Aq Multidose Inj (PF)
DNP
9.0300
M
SFC
00030767
PFI
Y
methylprednisolone sodium succinate 125mg/vial inj
Methylprednisolone Sod. Succ. 125mg/vial Inj
DNP
9.4340
M
SFC
02231894
TEV
Y
02230210
PFI
Y
Solu-Medrol 125mg/vial Inj (discontinued)
H02AB06
methylprednisolone sodium succinate 500mg/vial inj
Methylprednisolone Sod. Succ. 500mg/vial Inj
DNP
22.4000
M
SFC
02231895
TEV
Y
Solu-Medrol 500mg/vial Inj
DNP
22.4000
M
SFC
00030678
PFI
Y
DNP
DNP
0.0997
0.0997
M
M
SFC
SFC
02245532
02230619
PMS Y
SAV Y
DNP
0.1072
L
SFC
00271373
AAP
PREDNISOLONE
prednisolone sodium phosphare 1mg/mL o/l
pms-Prednisolone 1mg/mL O/L
Pediapred 1mg/mL O/L
H02AB07
PREDNISONE
Winpred 1mg Tab
February 2016
104
N
H
Systemic Hormonal Preparations, Excluding Sex Hormones
prednisone 5mg tab
Apo-Prednisone 5mg Tab
Novo-Prednisone 5mg Tab
Deltasone 5mg Tab (discontinued)
prednisone 50mg tab
Apo-Prednisone 50mg Tab
Novo-Prednisone 50mg Tab
DNP
0.0401
M
SFC
00312770
APX
DNP
0.0401
M
SFC
00021695
00210188
TEV Y
PUP Y
DNP
DNP
0.1735
0.1735
M
M
SFC
SFC
00550957
00232378
APX
TEV
00252417
PUP Y
Deltasone 50mg Tab (discontinued)
H02AB08
H02AB09
H02AB10
triamcinolone 10mg/mL inj
Triamcinolone 10mg/mL Inj
Kenalog-10 (10mg/mL) Inj
DNP
DNP
2.8600
2.8600
M
M
SFC
SFC
02229540
01999761
SDZ Y
WSQ Y
triamcinolone 40mg/mL inj
Triamcinolone 40mg/mL Inj
Kenalog-40 (40mg/mL) Inj
DNP
DNP
5.2000
5.2000
M
M
SFC
SFC
01977563
01999869
CYI Y
WSQ Y
Solu-Cortef 1g/vial Inj
DNP
16.4260
L
SFC
00030635
PFI
N
Cortef 10mg Tab
DNP
0.1581
L
SFC
00030910
PFI
N
Cortef 20mg Tab
DNP
0.2853
L
SFC
00030929
PFI
N
Solu-Cortef 100mg/vial Inj
DNP
3.7370
L
SFC
00030600
PFI
N
Solu-Cortef 250mg/vial Inj
DNP
6.4850
L
SFC
00030619
PFI
N
Solu-Cortef 500mg/vial Inj
DNP
9.8020
L
SFC
00030627
PFI
N
DNP
0.3402
L
SFC
00280437
VLN
N
DNP
6.1300
L
SFC
00260428
PFI
N
Synthroid 0.025mg Tab
DNP
0.0902
L
SF
02172062
BGP N
Synthroid 0.05mg Tab
DNP
0.0620
L
SF
02172070
BGP N
Synthroid 0.075mg Tab
DNP
0.0976
L
SF
02172089
BGP N
Synthroid 0.088mg Tab
DNP
0.0976
L
SF
02172097
BGP N
Synthroid 0.1mg Tab
DNP
0.0764
L
SF
02172100
BGP N
Synthroid 0.112mg Tab
DNP
0.1029
L
SF
02171228
BGP N
HYDROCORTISONE
CORTISONE
H02B
SYSTEMIC CORTICOSTEROIDS, COMBINATIONS
H02BX
SYSTEMIC CORTICOSTEROIDS, COMBINATIONS
METHYLPREDNISOLONE, COMBINATIONS
Depo-Medrol 40mg/mL w Lidocaine Inj
H03
THYROID THERAPY
H03A
THYROID PREPARATIONS
H03AA
THYROID HORMONES
H03AA01
February 2016
Y
Y
TRIAMCINOLONE
Cortisone Acetate 25mg Tab
H02BX01
Y
LEVOTHYROXINE SODIUM
105
H
Systemic Hormonal Preparations, Excluding Sex Hormones
H03AA02
H03AA05
Synthroid 0.125mg Tab
DNP
0.1041
L
SF
02172119
BGP N
Synthroid 0.137mg Tab
DNP
0.1761
L
SF
02233852
BGP N
Synthroid 0.15mg Tab
DNP
0.0819
L
SF
02172127
BGP N
Synthroid 0.175mg Tab
DNP
0.1118
L
SF
02172135
BGP N
Synthroid 0.2mg Tab
DNP
0.0873
L
SF
02172143
BGP N
Synthroid 0.3mg Tab
DNP
0.1204
L
SF
02172151
BGP N
Eltroxin 50mcg Tab
DNP
0.0302
L
SF
02213192
APR N
Eltroxin 100mcg Tab
DNP
0.0371
L
SF
02213206
APR N
Eltroxin 150mcg Tab
DNP
0.0411
L
SF
02213214
APR N
Eltroxin 200mcg Tab
DNP
0.0435
L
SF
02213222
APR N
Eltroxin 300mcg Tab
DNP
0.0645
L
SF
02213230
APR N
Cytomel 5mcg Tab
DNP
1.0317
L
SF
01919458
PFI
N
Cytomel 25mcg Tab
DNP
1.1215
L
SF
01919466
PFI
N
Thyroid 30mg Tab
DNP
0.1390
L
SF
00023949
ERF
N
Thyroid 60mg Tab
DNP
0.2820
L
SF
00023957
ERF
N
Thyroid 125mg Tab
DNP
0.4400
L
SF
00023965
ERF
N
Propyl-Thyracil 50mg Tab
DNP
0.2350
L
SF
00010200
PAL
N
Propyl-Thyracil 100mg Tab
DNP
0.3676
L
SF
00010219
PAL
N
Tapazole 5mg Tab
DNP
0.2722
L
SF
00015741
PAL
N
Tapazole 10mg Tab
DNP
0.5446
L
SF
02296039
PAL
N
GlucaGen 1mg/vial
DNP
79.2700
L
SFD
02333619
PAL
N
GlucaGen Hypokit 1mg/vial
Glucagon 1mg/vial Inj
DNP
DNP
79.2700
86.3500
L
L
SFD
SFD
02333627
02243297
PAL
LIL
N
N
LIOTHYRONINE SODIUM
THYROID GLAND PREPARATIONS
H03B
ANTITHYROID PREPARATIONS
H03BA
THIOURACILS
H03BA02
H03BB
PROPYLTHIOURACIL
SULPHUR-CONTAINING IMIDAZOLE DERIVATIVES
H03BB02
METHIMAZOLE (THIAMAZOLE)
H04
PANCREATIC HORMONES
H04A
GLYCOGENOLYTIC HORMONES
H04AA
GLYCOGENOLYTIC HORMONES
H04AA01
H05
GLUCAGON
CALCIUM HOMEOSTASIS
February 2016
106
H
Systemic Hormonal Preparations, Excluding Sex Hormones
H05B
ANTI-PARATHYROID AGENTS
H05BA
CALCITONIN PREPARATIONS
H05BA01
CALCITONIN (SALMON SYNTHETIC)
Calcimar 200iu/mL Inj
H05BX
DNP
28.6800
L
SFC
01926691
SAV
N
Sensipar 30mg Tab
DNP
10.9673
L
E
02257130
AGA N
Sensipar 60mg Tab
DNP
19.9980
L
E
02257149
AGA N
Sensipar 90mg Tab
DNP
29.1007
L
E
02257157
AGA N
OTHER ANTI-PARATHYROID AGENTS
H05BX01
February 2016
CINACALET
107
J
General Antiinfectives, Systemic
J01
ANTIBACTERIALS FOR SYSTEMIC USE
J01A
TETRACYCLINES
J01AA
TETRACYCLINES
J01AA02
DOXYCYCLINE
Apprilon XR 40mg Cap
DNPM
DNPM
0.5860
0.5860
M
M
SFC
SFC
00740713
02351234
APX
SAS
Y
Y
Novo-Doxylin 100mg Cap
Vibramycin 100mg Cap
DNPM
DNPM
0.5860
0.5860
M
M
SFC
SFC
00725250
00024368
TEV
PFI
Y
Y
doxycycline 100mg tab (Vibra-tabs)
Apo-Doxy 100mg Tab
Doxycycline 100mg Tab
DNPM
DNPM
0.5860
0.5860
M
M
SFC
SFC
00874256
02351242
APX
SAS
Y
Y
DNPM
0.5860
M
SFC
02158574
00578452
TEV
PFI
Y
Y
00817120
RIV
N
DNPM
0.6330
L
SFC
00860751
RIV
N
DNP
0.0713
M
SFC
00580929
00024422
AAP
PFI
Y
Y
minocycline HCl 50mg cap
Apo-Minocycline 50mg Cap
DNP
0.3064
M
SFC
02084090
APX
Y
Minocycline 50mg Cap
MYLAN-Minocycline 50mg Cap
DNP
DNP
0.3064
0.3064
M
M
SFC
SFC
02287226
02230735
SAS Y
MYL Y
Novo-Minocycline 50mg Cap
pms-Minocycline 50mg Cap
DNP
DNP
0.3064
0.3064
M
M
SFC
SFC
02108143
02294419
TEV Y
PMS Y
02237313
02173514
SDZ Y
GSK Y
Doxycin 100mg Cap
Doxycin 100mg Tab
TETRACYCLINE
tetracycline 250mg cap
Tetra 250mg Cap
Tetracyn 250mg Cap (discontinued)
J01AA08
MINOCYCLINE
Sandoz Minocycline 50mg Cap (discontinued)
Minocin 50mg Cap (discontinued)
minocycline HCl 100mg cap
Apo-Minocycline 100mg Cap
Minocycline 100mg Cap
DNP
DNP
0.5912
0.5912
M
M
SFC
SFC
02084104
02287234
APX
SAS
MYLAN-Minocycline 100mg Cap
Novo-Minocycline 100mg Cap
DNP
DNP
0.5912
0.5912
M
M
SFC
SFC
02230736
02108151
MYL Y
TEV Y
pms-Minocycline 100mg Cap
Sandoz Minocycline 100mg Cap (discontinued)
DNP
0.5912
M
SFC
02294427
02237314
PMS Y
SDZ Y
02173506
GSK Y
02409356
02285401
APX
PFI
Minocin 100mg Cap (discontinued)
J01AA12
AMPHENICOLS
February 2016
Y
Y
TIGECYCLINE
tigecycline 50mg/vial inj
Tigecycline 50mg/vial Pws IV
Tygacil 50mg/vial Pws IV
J01B
GAC N
doxycycline 100mg cap
Apo-Doxy 100mg Cap
Doxycycline 100mg Cap
Novo-Doxylin 100mg Tab
Vibra-Tabs C-Pak (discontinued)
J01AA07
02375885
108
Y
Y
J
General Antiinfectives, Systemic
J01BA
AMPHENICOLS
J01BA01
CHLORAMPHENICOL
Chloromycetin Succinate 1g/vial Inj
DNP
26.5000
L
SFC
00312363
ERF
ampicillin 250mg cap
Novo-Ampicillin 250mg Cap
Penbritin 250mg Cap (discontinued)
DNPM
0.3830
M
SFC
00020877
02043122
TEV Y
WAY Y
ampicillin 500mg cap
Novo-Ampicillin 500mg Cap
Penbritin 500mg Cap (discontinued)
DNPM
0.7262
M
SFC
00020885
02043130
TEV Y
WAY Y
amoxicillin 25mg/mL o/l
Amoxicillin 125mg Susp
DNP
0.0353
M
SFC
02352745
SAS
Y
Amoxicillin Sugar Reduced 25mg/mL O/L
Apo-Amoxi 125mg Susp
DNP
DNP
0.0353
0.0353
M
M
SFC
SFC
02352761
00628131
SAS
APX
Y
Y
Apo-Amoxi Sugar Free 125mg Susp
Novamoxin 125mg Susp
DNP
DNP
0.0353
0.0353
M
M
SFC
SFC
00628131
00452149
APX
TEV
Y
Y
Novamoxin Sugar Reduced 25mg/mL O/L
pms-Amoxicillin 25mg/mL Susp
DNP
DNP
0.0353
0.0353
M
M
SFC
SFC
01934171
02230245
TEV Y
PMS Y
02041316
WAY Y
J01C
BETA LACTAM ANTIBACTERIALS,PENICILLINS
J01CA
PENICILLIN WITH EXTENDED SPECTRUMS
J01CA01
J01CA04
AMPICILLIN
AMOXICILLIN
Amoxil 25mg/mL Susp (discontinued)
amoxicillin 50mg/mL o/l
Amoxicillin 250mg Susp
DNP
0.0540
M
SFC
02352753
SAS
Y
Amoxicillin Sugar Reduced 50mg/mL O/L
Amoxicillin Sugar-Reduced 250mg/5mL Susp
DNP
DNP
0.0540
0.0540
M
M
SFC
SFC
02352788
02401576
SAS
SIV
Y
Y
Amoxicillin-250mg/5mL Susp
Apo-Amoxi 250mg Susp
DNP
DNP
0.0540
0.0540
M
M
SFC
SFC
02401541
00628158
SIV
APX
Y
Y
Apo-Amoxi Sugar Free 250mg Susp
Novamoxin 250mg Susp
DNP
DNP
0.0540
0.0540
M
M
SFC
SFC
00628158
00452130
APX
TEV
Y
Y
Novamoxin Sugar Reduced 50mg/mL O/L
pms-Amoxicillin 50mg/mL Susp
DNP
DNP
0.0540
0.0540
M
M
SFC
SFC
01934163
02230246
TEV Y
PMS Y
02042592
WAY Y
Amoxil 50mg/mL Susp (discontinued)
amoxicillin 250mg cap
Amoxicillin 250mg Cap
DNP
0.1750
M
SFC
02352710
SAS
Y
Amoxicillin-250mg Cap
Apo-Amoxi 250mg Cap
DNP
DNP
0.1750
0.1750
M
M
SFC
SFC
02401495
00628115
SIV
APX
Y
Y
Auro-Amoxicillin 250mg Cap
MYLAN-Amoxicillin 250mg Cap
DNP
DNP
0.1750
0.1750
M
M
SFC
SFC
02388073
02238171
ARO Y
MYL Y
Novamoxin 250mg Cap
pms-Amoxicillin 250mg Cap
DNP
DNP
0.1750
0.1750
M
M
SFC
SFC
00406724
02230243
TEV Y
PMS Y
02041294
WAY Y
02036355
TEV
Amoxil 250mg Cap (discontinued)
amoxicillin 250mg chewable tab
Novamoxin 250mg Chew Tab
February 2016
N
DNP
0.6813
M
SFC
109
Y
J
General Antiinfectives, Systemic
Amoxil 250mg Chew Tab (discontinued)
DNP
0.3417
M
SFC
02352729
SAS
Y
Amoxicillin-500mg Cap
Apo-Amoxi 500mg Cap
DNP
DNP
0.3417
0.3417
M
M
SFC
SFC
02401509
00628123
SIV
APX
Y
Y
Auro-Amoxicillin 500mg Cap
MYLAN-Amoxicillin 500mg Cap
DNP
DNP
0.3417
0.3417
M
M
SFC
SFC
02388081
02238172
ARO Y
MYL Y
Novamoxin 500mg Cap
pms-Amoxicillin 500mg Cap
DNP
DNP
0.3417
0.3417
M
M
SFC
SFC
00406716
02230244
TEV Y
PMS Y
02041308
WAY Y
00642223
APX
02229618
PDP N
BETA-LACTAMASE SENSITIVE PENICILLINS
J01CE02
PHENOXYMETHYLPENICILLIN (PENICILLIN V)
Apo-Pen VK 125mg/5mL Susp
DNP
0.0535
L
SFC
Pen-Vee 180mg/5mL Susp (discontinued)
J01CF
N
penicillin V potassium 300mg tab
Apo-Pen VK 300mg Tab
PVF K 300mg Tab (discontinued)
DNP
0.1873
M
SFC
00642215
00248843
AAP
FRS
Y
Y
penicillin V potassium 60mg/mL o/l
Apo-Pen VK 300mg/5mL Susp
PVF 500 (300mg/5mL) Susp (discontinued)
DNP
0.0618
M
SFC
00642231
00248835
APX
FRS
Y
Y
DNPM
0.0919
M
SFC
00337757
TEV
Y
02042975
WAY Y
00337765
TEV
02042924
WAY Y
00337773
TEV
02042932
WAY Y
BETA-LACTAMASE RESISTANT PENICILLINS\
J01CF02
CLOXACILLIN
cloxacillin 25mg/mL o/l
Novo-Cloxin 125mg/5mL Susp
Orbenin 125mg/5mL Susp (discontinued)
cloxacillin 250mg cap
Novo-Cloxin 250mg Cap
DNPM
0.3692
M
SFC
Orbenin 250mg Cap (discontinued)
cloxacillin 500mg cap
Novo-Cloxin 500mg Cap
DNPM
0.6982
M
SFC
Orbenin 500mg Cap (discontinued)
J01CR
WAY Y
amoxicillin 500mg cap
Amoxicillin 500mg Cap
Amoxil 500mg Cap (discontinued)
J01CE
02041286
Y
Y
COMBINATIONS PENICILLINS INCL BETA LACTAMASE INHIB
J01CR02
February 2016
AMOXICILLIN AND ENZYME INHIBITOR
amoxicillin & enzyme inhibitor 125mg/5mL susp
Apo-Amoxi Clav 125mg/5mL Susp
ratio-Aclavulanate 125mg/5mL Susp (discontinued)
DNPM
0.0517
M
SFC
02243986
02244646
APX
TEV
Clavulin-125F (125mg/5mL) Susp
DNPM
0.0517
M
SFC
01916882
GSK Y
Clavulin-200 (200mg/5mL) Susp
DNPM
0.1440
L
SFC
02238831
GSK N
amoxicillin & enzyme inhibitor 250mg tab
Apo-Amoxi Clav 250mg Tab
DNPM
0.9375
M
SFC
02243350
APX
Clavulin-250 (250mg) Tab (discontinued)
01916866
GSK Y
amoxicillin & enzyme inhibitor 250mg/5mL susp
Apo-Amoxi Clav 250mg/5mL Susp
02243987
APX
110
Y
Y
Y
Y
J
General Antiinfectives, Systemic
ratio-Aclavulanate 250mg/5mL Susp (discontinued)
Clavulin-250F (250mg/5mL) Susp
SFC
02244647
01916874
TEV Y
GSK Y
DNPM
0.0869
M
amoxicillin & enzyme inhibitor 400mg/5mL susp
Apo-Amoxi Clav 400mg/5mL Susp
Clavulin-400 (400mg/5mL) Susp
DNPM
DNPM
0.1969
0.1969
M
M
SFC
SFC
02288559
02238830
APX Y
GSK Y
amoxicillin & enzyme inhibitor 500mg tab
Apo-Amoxi Clav 500mg Tab
ratio-Aclavulanate 500mg Tab
DNPM
DNPM
0.6673
0.6673
M
M
SFC
SFC
02243351
02243771
APX
TEV
Clavulin-500F (500mg) Tab
DNPM
0.6673
M
SFC
01916858
GSK Y
amoxicillin & enzyme inhibitor 875mg tab
Apo-Amoxi Clav 875mg Tab
DNPM
0.7771
M
SFC
02245623
APX
Y
02248138
02247021
TEV
TEV
Y
Y
02238829
GSK Y
piperacillin sodium & enzyme inhibitor 2g/vial inj
Piperacillin & Tazobactam 2g/vial Inj (Apotex)
Tazocin 2g/vial Inj (discontinued)
02308444
02170817
APX
PFI
piperacillin sodium & enzyme inhibitor 3g/vial inj
Piperacillin/Tazobactam 3g/0.375g Vial
Teva-Piperacillin/Tazobactam 3g/0.375g Vial
02391538
02370166
MYL Y
TEV Y
Piperacillin & Tazobactam 3g/vial Inj (Apotex)
Tazocin 3g/vial Inj (discontinued)
02308452
02170795
APX
PFI
piperacillin sodium & enzyme inhibitor 4g/vial inj
Piperacillin/Tazobactam 4g/0.5g Vial
Teva-Piperacillin/Tazobactam 4g/0.5g Vial
02391546
02370174
MYL Y
TEV Y
Piperacillin & Tazobactam 4g/vial Inj (Apotex)
Tazocin 4g/vial Inj (discontinued)
02308460
02170809
APX
PFI
Y
Y
00342106
TEV
Y
00015547
PDP Y
Novo-Clavamoxin 875 (875mg) Tab (discontinued)
ratio-Aclavulanate 875mg Tab (discontinued)
Clavulin-875 (875mg) Tab
J01CR05
0.7771
M
SFC
PIPERACILLIN AND ENZYME INHIBITOR
J01D
OTHER BETA LACTAM ANTIBACTERIALS
J01DB
FIRST GENERATION CEPHALOSPORINS
J01DB01
DNPM
Y
Y
Y
Y
CEPHALEXIN
cephalexin monohydrate 25mg o/l
Novo-Lexin 125mg/5mL Susp
DNPM
0.2150
M
SFC
Keflex 125mg/5mL Susp (discontinued)
cephalexin monohydrate 250mg tab
Apo-Cephalex 250mg Tab
DNPM
0.2250
M
SFC
00768723
APX
Novo-Lexin 250mg Tab
Keflex 250mg Tab (discontinued)
DNPM
0.2250
M
SFC
00583413
00403628
TEV Y
PDP Y
Novo-Lexin 250mg Cap
DNPM
0.3653
L
SFC
00342084
TEV
cephalexin monohydrate 50mg o/l
Novo-Lexin 250mg/5mL Susp
Keflex 250mg/5mL Susp (discontinued)
DNPM
0.3500
M
SFC
00342092
00035645
TEV Y
PDP Y
cephalexin monohydrate 500mg tab
February 2016
Y
Y
111
Y
N
J
General Antiinfectives, Systemic
Apo-Cephalex 500mg Tab
Novo-Lexin 500mg Tab
DNPM
DNPM
0.4500
0.4500
M
M
SFC
SFC
Keflex 500mg Tab (discontinued)
Novo-Lexin 500mg Cap
J01DB04
J01DB05
APX
TEV
Y
Y
00244392
PDP Y
DNPM
0.6907
L
SFC
00342114
TEV
N
cefazolin sodium 1g/vial inj
Cefazolin Sodium 1g/vial Inj
Cefazolin Sodium 1g/vial Inj
DNPM
DNPM
6.0000
6.0000
M
M
SFC
SFC
02108127
02308959
TEV
SDZ
Y
Y
Cefazolin Sodium 1g/vial Inj
DNPM
6.0000
M
SFC
02297205
APX
Y
cefazolin sodium 10g/vial inj
Cefazolin Sodium 10g/vial Inj
02108135
TEV
Y
Cefazolin Sodium 10g/vial Inj
02297213
APX
Y
CEFAZOLIN
cefazolin sodium 500mg/vial inj
Cefazolin Sodium 500mg/vial Inj
DNPM
4.0000
M
SFC
02108119
TEV
Y
Cefazolin Sodium 500mg/vial Inj
DNPM
4.0000
M
SFC
02308932
SDZ
Y
DNP
DNP
0.8421
0.8421
M
M
SFC
SFC
02240774
02235134
APX
TEV
Y
Y
00507245
BRI
Y
CEFADROXIL
cefadroxil 500mg cap
Apo-Cefadroxil 500mg Cap
Novo-Cefadroxil 500mg Cap
Duricef 500mg Cap (discontinued)
J01DC
00768715
00583421
SECOND GENERATION CEPHALOSPORINS
J01DC02
J01DC04
J01DC10
CEFUROXIME
Ceftin 125mg/5mL O/L
DNP
0.1700
L
SFC
02212307
GSK N
cefuroxime axetil 250mg tab
Apo-Cefuroxime 250mg Tab
Auro-Cefuroxime 250mg Tab
DNP
DNP
0.7237
0.7237
M
M
SFC
SFC
02244393
02344823
APX Y
ARO Y
ratio-Cefuroxime 250mg Tab
Ceftin 250mg Tab
DNP
DNP
0.7237
0.7237
M
M
SFC
SFC
02242656
02212277
TEV Y
GSK Y
cefuroxime axetil 500mg tab
Apo-Cefuroxime 500mg Tab
Auro-Cefuroxime 500mg Tab
DNP
DNP
1.4337
1.4337
M
M
SFC
SFC
02244394
02344831
APX Y
ARO Y
ratio-Cefuroxime 500mg Tab (discontinued)
Ceftin 500mg Tab
DNP
1.4337
M
SFC
02242657
02212285
TEV Y
GSK Y
Ceclor 125mg/5mL Susp
DNP
0.1156
L
SFC
00465208
PDP N
Ceclor 250mg Cap
DNP
1.0513
L
SFC
00465186
PDP N
Ceclor 250mg/5mL Susp
DNP
0.2115
L
SFC
00465216
PDP N
Ceclor 500mg Cap
DNP
2.0641
L
SFC
00465194
PDP N
DNP
DNP
0.1410
0.1410
M
M
SFC
SFC
02329204
02163675
RAN Y
BRI Y
CEFACLOR
CEFPROZIL
cefprozil 25mg/mL o/l
RAN-Cefprozil 125mg/5mL O/L
Cefzil 125mg/5mL O/L
February 2016
112
J
J01DD
General Antiinfectives, Systemic
cefprozil 250mg tab
Apo-Cefprozil 250mg Tab
DNP
0.4332
M
SFC
02292998
APX
Auro-Cefprozil 250mg Tab
RAN-Cefprozil 250mg Tab
DNP
DNP
0.4332
0.4332
M
M
SFC
SFC
02347245
02293528
ARO Y
RAN Y
Sandoz Cefprozil 250mg Tab
Cefzil 250mg Tab
DNP
DNP
0.4332
0.4332
M
M
SFC
SFC
02302179
02163659
SDZ
BRI
cefprozil 50mg/mL o/l
RAN-Cefprozil 250mg/5mL O/L
Cefzil 250mg/5mL O/L
DNP
DNP
0.2822
0.2822
M
M
SFC
SFC
02293579
02163683
RAN Y
BRI Y
cefprozil 500mg tab
Apo-Cefprozil 500mg Tab
Auro-Cefprozil 500mg Tab
DNP
DNP
0.8494
0.8494
M
M
SFC
SFC
02293005
02347253
APX Y
ARO Y
RAN-Cefprozil 500mg Tab
Sandoz-Cefprozil 500mg Tab
DNP
DNP
0.8494
0.8494
M
M
SFC
SFC
02293536
02302187
RAN Y
SDZ Y
Cefzil 500mg Tab
DNP
0.8494
M
SFC
02163667
BRI
DNP
DNP
8.3300
8.3300
M
M
SFC
SFC
02434091
02225093
STR Y
SAV Y
02434105
02225107
STR Y
SAV Y
Y
Y
Y
Y
THIRD GENERATION CEPHALOSPORINS
J01DD01
CEFOTAXIME
cefotaxime 1g/vial inj
Cefotaxime Sodium 1g/vial Inj
Claforan 1g/vial Inj
cefotaxime 2g/vial inj
Cefotaxime Sodium 2g/vial Inj
Claforan 2g/vial Inj
J01DD02
J01DD04
CEFTAZIDIME
Fortaz 1g/vial Inj
DNP
22.9270
L
SFC
02212218
GSK N
Fortaz 2g/vial Inj
DNP
45.0770
L
SFC
02212226
GSK N
Fortaz 6g/vial Inj
DNP
135.2967
L
SFC
02212234
GSK N
DNP
DNP
7.5250
7.5250
M
M
SFC
SFC
02292866
02325594
APX Y
STR Y
00657387
HLR
Y
CEFTRIAXONE
ceftriaxone 0.25g/vial inj
Ceftriaxone 0.25g/vial Inj
Ceftriaxone Sodium 0.25g/vial Inj
Rocephin 0.25g/vial Inj (discontinued)
ceftriaxone 1g/vial inj
Ceftriaxone 1g/vial Inj
DNP
12.4950
M
SFC
02292874
APX
Y
Ceftriaxone 1g/vial Inj
Ceftriaxone 1g/vial Inj
DNP
DNP
12.4950
12.4950
M
M
SFC
SFC
02287633
02292270
TEV
SDZ
Y
Y
Ceftroaxone Sodium 1g/vial Inj
Rocephin 1g/vial Inj (discontinued)
DNP
12.4950
M
SFC
02325616
00657417
STR Y
HLR Y
DNP
DNP
24.1400
24.1400
M
M
SFC
SFC
02292289
02292882
SDZ
APX
DNP
24.1400
M
SFC
02325624
00657409
STR Y
HLR Y
ceftriaxone 2g/vial inj
Ceftriaxone 2g/vial Inj
Ceftriaxone 2g/vial Inj
Ceftriaxone Sodium 2g/vial Inj
Rocephin 2g/vial Inj (discontinued)
ceftriaxone 10g/vial inj
February 2016
113
Y
Y
J
General Antiinfectives, Systemic
J01DD08
J01DE
02292904
02325632
APX Y
STR Y
Rocephin 10g/vial Inj (discontinued)
00851957
HLR
Y
N
CEFIXIME
Suprax 100mg/5mL Susp
DNP
0.4266
L
SFC
00868965
SAV
cefixime 400mg tab
Auro-Cefixime 400mg Tab
Suprax 400mg Tab
DNP
DNP
3.0796
3.0796
M
M
SFC
SFC
02432773
00868981
ARO Y
SAV Y
cefepime 2g/vial inj
Cefepime for injection 2g/vial Inj
02319039
APX
Y
Maxipime 2g/vial Inj (discontinued)
02163640
BRI
Y
02329840
GIL
N
N
FOURTH GENERATION AND OTHER CEPHALOSPORINS
J01DE01
J01DF
Ceftriaxone 10g/vial Inj
Ceftriaxone Sodium 10g/vial Inj
CEFEPIME (HYDROCHLORIDE)
MONOBACTAMS
J01DF01
AZTREONAM
Cayston 75mg vial Pdr for Sol
J01DH
CARBAPENEMS
J01DH51
IMIPENEM AND ENZYME INHIBITOR
Primaxin 500mg/vial Inj
DNP
31.1336
L
SFC
00717282
FRS
trimethoprim 100mg tab
Trimethoprim 100mg Tab
Proloprim 100mg Tab (discontinued)
DNPM
0.2785
M
SFC
02243116
00675229
AAP Y
GSK Y
trimethoprim 200mg tab
Trimethoprim 200mg Tab
Proloprim 200mg Tab (discontinued)
DNPM
0.5722
M
SFC
02243117
00677590
AAP Y
GSK Y
DNPM
0.0977
M
SFC
00726540
TEV
00270644
GSK Y
J01E
SULFONAMIDES AND TRIMETHOPRIM
J01EA
TRIMETHOPRIM PREPARATIONS
J01EA01
J01EE
TRIMETHOPRIM
COMBINATIONS SULFONAMIDES,TRIMETHOPRIM DERIV
J01EE01
SULFAMETHOXAZOLE AND TRIMETHOPRIM
sulfamethoxazole 40mg & trimethoprim 8mg/mL o/l
Novo-Trimel 40/8mg Susp
Septra 40/8mg Susp (discontinued)
Apo-Sulfatrim 100/20mg Tab
DNPM
0.0911
L
SFC
00445266
APX
N
sulfamethoxazole 400mg & trimethoprim 80mg tab
Apo-Sulfatrim 400/80mg Tab
DNPM
0.0482
M
SFC
00445274
APX
Y
DNPM
0.0482
M
SFC
00510637
00270636
TEV Y
GSK Y
Novo-Trimel 400/80mg Tab
Septra 400/80mg Tab (discontinued)
sulfamethoxazole 800mg & trimethoprim 160mg tab
February 2016
Y
114
J
General Antiinfectives, Systemic
Apo-Sulfatrim DS 800/160mg Tab
Novo-Trimel 800/160mg Tab
DNPM
DNPM
0.1221
0.1221
M
M
SFC
SFC
Septra 800/160mg Tab (discontinued)
J01F
MACROLIDES,LINCOSAMIDES & STREPTOGRAMINS
J01FA
MACROLIDES
J01FA01
February 2016
Y
Y
00368040
GSK Y
00605859
00000299
TEV Y
AMD Y
Apo-Erythro Base 250mg Tab
DNPM
0.1828
L
SFC
00682020
AAP
N
Erythro-S 250mg Tab
ERYC 250mg Cap
DNPM
DNPM
0.2118
0.2211
L
L
SFC
SFC
00545678
00607142
AAP
PFI
N
N
Novo-Rythro EST 250mg/5mL Susp
DNPM
0.1301
L
SFC
00262595
TEV
N
ERYC 333mg Cap
DNPM
0.5674
L
SFC
00873454
PFI
N
00652318
00453617
TEV Y
AMD Y
erythromycin ethylsuccinate 80mg/mL o/l
Novo-Rythro EES 400mg/5mL Susp (discontinued)
EES-400 (400mg/5mL) Granules (discontinued)
J01FA09
APX
TEV
ERYTHROMYCIN
erythromycin ethylsuccinate 40mg/mL o/l
Novo-Rythro EES 200mg/5mL Susp (discontinued)
EES-200 (200mg/5mL) Granules (discontinued)
J01FA02
00445282
00510645
Erythro-S 500mg Tab
DNPM
0.5425
L
SFC
00688568
AAP
N
erythromycin ethylsuccinate 600mg tab
Erythro-ES 600mg Tab
EES-600 (600mg) Tab (discontinued)
DNPM
0.3649
M
SFC
00637416
00583782
AAP Y
AMD Y
Rovamycine 250mg Cap
DNP
1.3640
L
SFC
01927825
ODN N
Rovamycine 500mg Cap
DNP
2.7240
L
SFC
01927817
ODN N
clarithromycin 25mg/mL o/l
Accel-Clarithromycin 125mg/5mL O/L
Clarithromycin 125mg/5mL O/L
DNP
DNP
0.2047
0.2047
M
M
SFC
SFC
02390442
02408988
ACC Y
SAS Y
Biaxin 125mg/5mL O/L
DNP
0.2047
M
SFC
02146908
ABB
Y
clarithromycin 250mg tab
Apo-Clarithromycin 250mg Tab
DNP
0.4122
M
SFC
02274744
APX
Y
Clarithromycin 250mg Tab
MYLAN-Clarithromycin 250mg Tab
DNP
DNP
0.4122
0.4122
M
M
SFC
SFC
02442469
02248856
SIV Y
MYL Y
pms-Clarithromycin 250mg Tab
RAN-Clarithromycin 250mg Tab
DNP
DNP
0.4122
0.4122
M
M
SFC
SFC
02247573
02361426
PMS Y
RAN Y
Sandoz Clarithromycin 250mg Tab
Teva-Clarithromycin 250mg Tab
DNP
DNP
0.4122
0.4122
M
M
SFC
SFC
02266539
02248804
SDZ
TEV
Y
Y
Biaxin BID 250mg Tab
DNP
0.4122
M
SFC
01984853
ABB
Y
clarithromycin 50mg/mL o/l
Accel-Clarithromycin 250mg/5mL O/L
DNP
0.3998
M
SFC
02390450
ACC Y
Clarithromycin 250mg/5mL O/L
Biaxin 250mg/5mL O/L
DNP
DNP
0.3998
0.3998
M
M
SFC
SFC
02408996
02244641
SAS
ABB
SPIRAMYCIN
CLARITHROMYCIN
115
Y
Y
J
General Antiinfectives, Systemic
J01FA10
clarithromycin 500mg XL tab
ACT-Clarithromycin XL 500mg Tab
DNP
1.2572
M
SFC
02403196
ATV
Y
Apo-Clarithromycin XL 500mg Tab
Biaxin XL 500mg Tab
DNP
DNP
1.2572
1.2572
M
M
SFC
SFC
02413345
02244756
APX
ABB
Y
Y
clarithromycin 500mg tab
Apo-Clarithromycin 500mg Tab
Clarithromycin 500mg Tab
DNP
DNP
1.6292
1.6292
M
M
SFC
SFC
02274752
02442485
APX
SIV
Y
Y
MYLAN-Clarithromycin 500mg Tab
pms-Clarithromycin 500mg Tab
DNP
DNP
1.6292
1.6292
M
M
SFC
SFC
02248857
02247574
MYL Y
PMS Y
RAN-Carithromycin 500mg Tab
Sandoz Clarithromycin 500mg Tab
DNP
DNP
1.6292
1.6292
M
M
SFC
SFC
02361434
02266547
RAN Y
SDZ Y
Teva-Clarithromycin 500mg Tab
Biaxin BID 500mg Tab
DNP
DNP
1.6292
1.6292
M
M
SFC
SFC
02248805
02126710
TEV
ABB
azithromycin pos 20mg/mL susp
Azithromycin POS 100mg/5mL Susp
DNPM
0.3956
M
E
02274388
PMS Y
Azithromycin POS 100mg/5mL Susp
GD-Azithromycine 100mg/5mL Susp
DNPM
DNPM
0.3956
0.3956
M
M
E
E
02332388
02274566
SDZ Y
GMD Y
Novo-Azithromycin POS 100mg/5mL Susp
pms-Azithromycin 100mg/5mL Susp
DNPM
DNPM
0.3956
0.3956
M
M
E
E
02315157
02418452
TEV Y
PMS Y
Zithromax POS 100mg/5mL Susp
DNPM
0.3956
M
E
02223716
PFI
Y
azithromycin pos 40mg/mL susp
Azithromycin POS 200mg/5mL Susp
DNPM
0.5604
M
E
02332396
SDZ
Y
Azithromycin POS 200mg/5mL Susp
GD-Azithromycine 200mg/5mL Susp
DNPM
DNPM
0.5604
0.5604
M
M
E
E
02274396
02274574
PMS Y
GMD Y
Novo-Azithromycin POS 200mg/5mL Susp
pms-Azithromycin 200mg/5mL Susp
DNPM
DNPM
0.5604
0.5604
M
M
E
E
02315165
02418460
TEV Y
PMS Y
Zithromax POS 200mg/5mL Susp
DNPM
0.5604
M
E
02223724
PFI
Y
azithromycin 250mg tab
Apo-Azithromycin Z 250mg Tab
DNPM
1.2350
M
E
02415542
APX
Y
Azithromycin 250mg Tab
Azithromycin 250mg Tab
DNPM
DNPM
1.2350
1.2350
M
M
E
E
02442434
02330881
SIV
SAS
Y
Y
CO Azithromycin 250mg Tab
GD-Azithromycin 250mg Tab
DNPM
DNPM
1.2350
1.2350
M
M
E
E
02255340
02274531
ATV Y
GMD Y
MYLAN-Azithromycin 250mg Tab
Novo-Azithromycin 250mg Tab
DNPM
DNPM
1.2350
1.2350
M
M
E
E
02278359
02267845
MYL Y
TEV Y
pms-Azithromycin 250mg Tab
ratio-Azithromycin 250mg Tab (discontinued)
DNPM
1.2350
M
E
02261634
02275287
PMS Y
TEV Y
Sandoz Azithromycin 250mg Tab
Zithromax 250mg Tab
DNPM
DNPM
1.2350
1.2350
M
M
E
E
02265826
02212021
SDZ
PFI
Y
Y
02239952
PFI
N
02256088
02261642
ATV Y
PMS Y
02231143
PFI
AZITHROMYCIN
Zithromax 500mg/vial Inj
azithromycin 600mg tab
CO Azithromycin 600mg Tab
pms-Azithromycin 600mg Tab
Zithromax 600mg Tab (discontinued)
J01FF
DNPM
DNPM
6.0000
6.0000
M
M
E
E
LINCOSAMIDES
February 2016
Y
Y
116
Y
J
General Antiinfectives, Systemic
J01FF01
J01FF02
CLINDAMYCIN
Dalacin C 75mg/5mL Granules
DNPM
0.1287
L
SFC
00225851
PFI
N
clindamycin 150mg cap
Apo-Clindamycin 150mg Cap
DNPM
0.2353
M
SFC
02245232
APX
Y
Clindamycin 150mg Cap
MYLAN-Clindamycin 150mg Cap
DNPM
DNPM
0.2353
0.2353
M
M
SFC
SFC
02400529
02258331
SAS Y
MYL Y
Teva-Clindamycin 150mg Cap
Dalacin C 150mg Cap
DNPM
DNPM
0.2353
0.2353
M
M
SFC
SFC
02241709
00030570
TEV
PFI
Y
Y
clindamycin 150mg/mL (bulk) inj
Clindamycin 150mg/mL Inj
Dalacin C Phos 150mg/mL Inj
DNPM
DNPM
3.6550
3.6550
M
M
SFC
SFC
02230535
00260436
SDZ
PFI
Y
Y
clindamycin 150mg/mL inj
Clindamycin 150mg/mL Inj
Dalacin C Phos 150mg/mL Inj
DNPM
DNPM
3.6550
3.6550
M
M
SFC
SFC
02230540
00260436
SDZ
PFI
Y
Y
clindamycin 300mg cap
Apo-Clindamycin 300mg Cap
Clindamycin 300mg Cap
DNPM
DNPM
0.4706
0.4706
M
M
SFC
SFC
02245233
02400537
APX
SAS
Y
Y
MYLAN-Clindamycin 300mg Cap
Novo-Clindamycin 300mg Cap
DNPM
DNPM
0.4706
0.4706
M
M
SFC
SFC
02258358
02241710
MYL Y
TEV Y
Dalacin C 300mg Cap
DNPM
0.4706
M
SFC
02182866
PFI
Y
00030732
PFI
N
tobramycin 10mg/mL inj
Tobramycin 10mg/mL Inj
02241209
SDZ
Y
Nebcin 10mg/mL Inj (discontinued)
00325457
LIL
Y
TOBI Podhaler 28mg Cap
02365154
NVR N
LINCOMYCIN
Lincocin 300mg/mL Inj
J01G
AMINOGLYCOSIDE ANTIBACTERIALS
J01GB
OTHER AMINOGLYCOSIDES
J01GB01
TOBRAMYCIN
tobramycin 40mg/mL inj
Jamp-Tobramycin 40mg/mL Inj
DNP
3.7070
M
SFC
02420287
JPC
Tobramycin 40mg/mL Inj
Tobramycin 40mg/mL Inj (SDZ)
DNP
DNP
3.7070
3.7070
M
M
SFC
SFC
02382814
02241210
MYL Y
SDZ Y
00325449
LIL
Y
Nebcin 40mg/mL Inj (discontinued)
tobramycin 40mg/mL inj (pf)
Tobramycin 40mg/mL Inj (PF)
J01GB03
02241210
SDZ
Y
Nebcin 40mg/mL Inj (discontinued)
00325449
LIL
Y
TOBI 300mg/5mL Sol
02239630
NVR N
3.7070
M
SFC
02242652
00223824
SDZ Y
SCH Y
GENTAMICIN
gentamicin 40mg/mL inj
Gentamicin 40mg/mL Inj
Garamycin 40mg/mL Inj (discontinued)
February 2016
DNP
Y
DNP
7.7780
M
SFC
117
J
General Antiinfectives, Systemic
J01GB06
AMIKACIN
amikacin 250mg/mL inj
Amikacin 250mg/mL Inj
02242971
SDZ
Y
Amikin 250mg/mL Inj (discontinued)
00397415
BRI
Y
ofloxacin 200mg tab
Ofloxacin 200mg Tab (discontinued)
Floxin 200mg Tab (discontinued)
02231529
01968424
AAP
JAN
Y
Y
ofloxacin 300mg tab
Ofloxacin 300mg Tab (discontinued)
Floxin 300mg Tab (discontinued)
02231531
01968416
AAP
JAN
Y
Y
ofloxacin 400mg tab
Ofloxacin 400mg Tab (discontinued)
Floxin 400mg Tab (discontinued)
02231532
01968408
AAP
JAN
Y
Y
J01M
QUINOLONE ANTIBACTERIALS
J01MA
FLOUROQUINOLONES
J01MA01
J01MA02
February 2016
OFLOXACIN
CIPROFLOXACIN
Cipro 100mg/mL O/L
DNPM
0.5756
L
E
02237514
BAY
N
ciprofloxacin 250mg tab
Apo-Ciproflox 250mg Tab
DNPM
0.6186
M
E
02229521
APX
Y
Auro-Ciprofloxacin 250mg Tab
Ciprofloxacin 250mg Tab
DNPM
DNPM
0.6186
0.6186
M
M
E
E
02381907
02353318
ARO Y
SAS Y
Ciprofloxacin-250mg Tab
CO Ciprofloxacin 250mg Tab
DNPM
DNPM
0.6186
0.6186
M
M
E
E
02386119
02247339
SIV
ATV
Jamp-Ciprofloxacin 250mg Tab
Mar-Ciprofloxacin 250mg Tab
DNPM
DNPM
0.6186
0.6186
M
M
E
E
02380358
02379686
JPC Y
MAR Y
MINT-Ciprofloxacin 250mg Tab
MYLAN-Ciprofloxacin 250mg Tab
DNPM
DNPM
0.6186
0.6186
M
M
E
E
02317427
02245647
MNT Y
MYL Y
Novo-Ciprofloxacin 250mg Tab
pms-Ciprofloxacin 250mg Tab
DNPM
DNPM
0.6186
0.6186
M
M
E
E
02161737
02248437
TEV Y
PMS Y
RAN-Ciproflox 250mg Tab
Sandoz Ciprofloxacin 250mg Tab
DNPM
DNPM
0.6186
0.6186
M
M
E
E
02303728
02248756
RAN Y
SDZ Y
Septa-Ciprofloxacin 250mg Tab
Cipro 250mg Tab
DNPM
DNPM
0.6186
0.6186
M
M
E
E
02379627
02155958
SPT
BAY
ciprofloxacin 500mg tab
Apo-Ciproflox 500mg Tab
Auro-Ciprofloxacin 500mg Tab
DNPM
DNPM
0.6979
0.6979
M
M
E
E
02229522
02381923
APX Y
ARO Y
Ciprofloxacin 500mg Tab
Ciprofloxacin-500mg Tab
DNPM
DNPM
0.6979
0.6979
M
M
E
E
02353326
02386127
SAS
SIV
Y
Y
CO Ciprofloxacin 500mg Tab
Jamp-Ciprofloxcin 500mg Tab
DNPM
DNPM
0.6979
0.6979
M
M
E
E
02247340
02380366
ATV
JPC
Y
Y
Mar-Ciprofloxacin 500mg Tab
MINT-Ciproflox 500mg Tab
DNPM
DNPM
0.6979
0.6979
M
M
E
E
02379694
02423561
MAR Y
MNT Y
MINT-Ciprofloxacin 500mg Tab
MYLAN-Ciprofloxacin 500mg Tab
DNPM
DNPM
0.6979
0.6979
M
M
E
E
02317435
02245648
MNT Y
MYL Y
118
Y
Y
Y
Y
J
General Antiinfectives, Systemic
Novo-Ciprofloxacin 500mg Tab
pms-Ciprofloxacin 500mg Tab
DNPM
DNPM
0.6979
0.6979
M
M
E
E
02161745
02248438
TEV Y
PMS Y
RAN-Ciproflox 500mg Tab
Sandoz Ciprofloxacin 500mg Tab
DNPM
DNPM
0.6979
0.6979
M
M
E
E
02303736
02248757
RAN Y
SDZ Y
Septa-Ciprofloxacin 500mg Tab
Cipro 500mg Tab
DNPM
DNPM
0.6979
0.6979
M
M
E
E
02379635
02155966
SPT
BAY
02416433
02247916
PMS Y
BAY Y
ciprofloxacin XL 500mg tab
pms-Ciprofloxacin XL 500mg Tab
Cipro XL 500mg Tab
J01MA06
ciprofloxacin 750mg tab
Apo-Ciproflox 750mg Tab
Auro-Ciprofloxacin 750mg Tab
DNPM
DNPM
1.2780
1.2780
M
M
E
E
02229523
02381931
APX Y
ARO Y
Ciprofloxacin 750mg Tab
CO Ciprofloxacin 750mg Tab
DNPM
DNPM
1.2780
1.2780
M
M
E
E
02353334
02247341
SAS
ATV
Jamp-Ciprofloxacin 750mg Tab
Mar-Ciprofloxacin 750mg Tab
DNPM
DNPM
1.2780
1.2780
M
M
E
E
02380374
02379708
JPC Y
MAR Y
MINT-Ciprofloxacin 750mg Tab
MYLAN-Ciprofloxacin 750mg Tab
DNPM
DNPM
1.2780
1.2780
M
M
E
E
02317443
02245649
MNT Y
MYL Y
Novo-Ciprofloxacin 750mg Tab
pms-Ciprofloxacin 750mg Tab
DNPM
DNPM
1.2780
1.2780
M
M
E
E
02161753
02248439
TEV Y
PMS Y
RAN-Ciproflox 750mg Tab
Sandoz Ciprofloxacin 750mg Tab
DNPM
DNPM
1.2780
1.2780
M
M
E
E
02303744
02248758
RAN Y
SDZ Y
Septa-Ciprofloxacin 750mg Tab
Cipro 750mg Tab
DNPM
DNPM
1.2780
1.2780
M
M
E
E
02379643
02155974
SPT
BAY
Y
Y
Cipro XL 1,000mg Tab
DNPM
3.1120
L
E
02251787
BAY
N
norfloxacin 400mg tab
Apo-Norflox 400mg Tab
DNP
0.7934
M
E
02229524
APX
Y
CO Norfloxacin 400mg Tab
Novo-Norfloxacin 400mg Tab
DNP
DNP
0.7934
0.7934
M
M
E
E
02269627
02237682
ATV
TEV
Y
Y
00643025
FRS
Y
Y
Y
LEVOFLOXACIN
levofloxacin 250mg tab
Apo-Levofloxacin 250mg Tab
CO Levofloxacin 250mg Tab
DNP
DNP
1.3241
1.3241
M
M
E
E
02284707
02315424
APX
ATV
MYLAN-Levofloxacin 250mg Tab
Novo-Levofloxacin 250mg Tab
DNP
DNP
1.3241
1.3241
M
M
E
E
02313979
02248262
MYL Y
TEV Y
pms-Levofloxacin 250mg Tab
Sandoz Levofloxacin 250mg Tab
DNP
DNP
1.3241
1.3241
M
M
E
E
02284677
02298635
PMS Y
SDZ Y
02236841
JAN
Y
Y
Levaquin 250mg Tab (discontinued)
February 2016
Y
Y
NORFLOXACIN
Noroxin 400mg Tab (discontinued)
J01MA12
Y
Y
levofloxacin 500mg tab
Apo-Levofloxacin 500mg Tab
DNP
1.5089
M
E
02284715
APX
CO Levofloxacin 500mg Tab
MYLAN-Levofloxacin 500mg Tab
DNP
DNP
1.5089
1.5089
M
M
E
E
02315432
02313987
ATV Y
MYL Y
Novo-Levofloxacin 500mg Tab
pms-Levofloxacin 500mg Tab
DNP
DNP
1.5089
1.5089
M
M
E
E
02248263
02284685
TEV Y
PMS Y
119
J
General Antiinfectives, Systemic
Sandoz Levofloxacin 500mg Tab
Levaquin 500mg Tab (discontinued)
J01MA14
02298643
02236842
SDZ
JAN
Y
Y
levofloxacin 750mg tab
Apo-Levofloxacin 750mg Tab
CO Levofloxacin 750mg Tab
02325942
02315440
APX
ATV
Y
Y
Novo-Levaquin 750mg Tab
pms-Levofloxacin 750mg Tab
02285649
02305585
TEV Y
PMS Y
Sandoz Levofloxacin 750mg Tab
Levaquin 750mg Tab (discontinued)
02298651
02246804
SDZ
JAN
Y
Y
1.5089
M
E
Y
MOXIFLOXACIN
moxifloxacin 400mg tab
Apo-Moxifloxacain 400mg Tab
DNP
1.5230
M
E
02404923
APX
Auro-Moxifloxacin 400mg Tab
Jamp-Moxifloxacin 400mg Tab
DNP
DNP
1.5230
1.5230
M
M
E
E
02432242
02443929
ARO Y
JPC Y
Mar-Moxifloxacin 400mg Tab
Teva-Moxifloxacin 400mg Tab
DNP
DNP
1.5230
1.5230
M
M
E
E
02447053
02375702
MAR Y
TEV Y
Avelox 400mg Tab
DNP
1.5230
M
E
02242965
BAY
Y
vancomycin 125mg cap
Jamp-Vancomycin 125mg Cap
Vancomycin HCl 125mg Cap
DNPM
6.1090
M
E
02407744
02377470
JPC
FKB
Y
Y
Vancocin 125mg Cap
DNPM
6.1090
M
E
00800430
MRS Y
02407752
JPC
02377489
00788716
FKB Y
MRS Y
vancomycin 500mg vial inj
Vancomycin HCl 500mg/Vial Inj
Vancomycin 500mg/Vial Inj
02394626
02139375
SDZ
FKB
vancomycin 500mg/vial inj
pms-Vancomycin 500mg/vial Inj (discontinued)
Vancocin CP 500mg/vial Inj (discontinued)
02241820
00803510
PMS Y
LIL
Y
J01X
OTHER ANTIBACTERIALS
J01XA
GLYCOPEPTIDE ANTIBACTERIALS
J01XA01
DNP
VANCOMYCIN
vancomycin 250mg cap
Jamp-Vancomycin 250mg Cap
Vancomycin HCl 250mg Cap
Vancocin 250mg Cap
February 2016
DNPM
DNPM
12.2065
12.2065
M
M
E
E
Y
Y
Y
vancomycin HCl 500mg/vial inj
Val-Vancomycin 500mg/vial Inj
Vancomycin HCl 500mg/vial Inj
DNPM
33.6893
M
SFC
02342855
02411032
VLN Y
STR Y
Sterile Vancomycin HCl 500mg/vial Inj
DNPM
33.6893
M
SFC
02230191
HOS Y
vancomycin 1g vial inj
Vancomycin HCl 1g/Vial Inj
02394634
SDZ
Y
Vancomycin 1g/Vial Inj
02139383
FKB
Y
vancomycin 1g/vial inj
pms-Vancomycin 1g/vial Inj (discontinued)
02241821
PMS Y
Vancocin CP 1g/vial Inj (discontinued)
00722146
FKB
120
Y
J
General Antiinfectives, Systemic
vancomycin HCl 1g/vial inj
Val-Vancomycin 1000mg/vial Inj
Vancomycin HCl 1g/vial Inj
Sterile Vancomycin HCl 1g/vial Inj
J01XD
64.0042
M
SFC
02342863
VLN
STR Y
HOS Y
DNPM
64.0042
M
SFC
DNPM
0.0749
M
SFC
00545066
AAP
Flagyl 250mg Tab (discontinued)
01926896
RPR Y
metronidazole 500mg cap
Metronidazole 500mg Cap
02248562
AAP
pms-Metronidazole 500mg Cap
Flagyl 500mg Cap
00783137
01926853
PMS Y
SAV Y
02231015
TEV
01997637
PGA Y
00319511
AAP
N
nitrofurantoin 100mg cap
Novo-Furantoin 100mg Cap
02231016
TEV
Y
Macrodantin 100mg Cap (discontinued)
01997645
PGA Y
METRONIDAZOLE
metronidazole 250mg tab
Metronidazole 250mg Tab
Y
Y
NITROFURAN DERIVATIVES
J01XE01
NITROFURANTOIN
nitrofurantoin 50mg cap
Novo-Furantoin 50mg Cap
DNPM
0.3484
M
SFC
Macrodantin 50mg Cap (discontinued)
Nitrofurantoin 50mg Tab
Nitrofurantoin 100mg Tab
Macrobid 100mg Cap
J01XX
Y
02396386
02230192
IMIDAZOLE DERIVATIVES
J01XD01
J01XE
DNPM
DNPM
0.1670
L
SFC
Y
DNPM
0.7289
L
SFC
00312738
02063662
AAP
ATV
N
N
DNP
5.8367
L
E
02240335
APR N
DNP
0.3800
L
SFC
00499013
ERF
N
linezolid 600mg tab
Apo-Linezolid 600mg Tab
DNP
38.6083
M
E
02426552
APX
Y
Sandoz Linezolid 600mg Tab
Zyvoxam 600mg Tab
DNP
DNP
38.6083
38.6083
M
M
E
E
02422689
02243684
SDZ
PFI
Y
Y
02299909
SEP
N
OTHER ANTIBACTERIALS
J01XX01
FOSFOMYCIN
Monurol 3g Sachet
J01XX05
METHENAMINE
Mandelamine 500mg Tab
J01XX08
J01XX09
LINEZOLID
DAPTOMYCIN
Cubicin 500mg Vial
J02
SYSTEMIC ANTIMYCOTICS
J02A
SYSTEMIC ANTIMYCOTICS
J02AA
ANTIBIOTICS
February 2016
121
J
General Antiinfectives, Systemic
J02AA01
AMPHOTERICIN
Fungizone 50mg/vial Inj
J02AB
DNP
82.0500
L
SFC
00029149
BRI
N
DNP
DNP
0.9393
0.9393
M
M
SFC
SFC
02237235
02231061
APX
TEV
Y
Y
00633836
JNJ
Y
fluconazole 2mg/mL inj
Fluconazole 2mg/mL Inj
Fluconazole 2mg/mL Vial Inj
02248443
02388448
SDZ
SDZ
Y
Y
Diflucan 2mg/mL Inj
00891835
PFI
Y
IMIDAZOLE DERIVATIVES
J02AB02
KETOCONAZOLE
ketoconazole 200mg tab
Apo-Ketoconazole 200mg Tab
Novo-Ketoconazole 200mg Tab
Nizoral 200mg Tab (discontinued)
J02AC
TRIAZOLE DERIVATIVES
J02AC01
FLUCONAZOLE
Diflucan POS 10mg/mL
DNP
1.0257
L
E
02024152
PFI
N
fluconazole 50mg tab
Apo-Fluconazole 50mg Tab
DNP
1.2904
M
SFC
02237370
APX
Y
CO Fluconazole 50mg Tab
MYLAN-Fluconazole 50mg Tab
DNP
DNP
1.2904
1.2904
M
M
SFC
SFC
02281260
02245292
ATV Y
MYL Y
Novo-Fluconazole 50mg Tab
pms-Fluconazole 50mg Tab
DNP
DNP
1.2904
1.2904
M
M
SFC
SFC
02236978
02245643
TEV Y
PMS Y
00891800
PFI
Y
Y
Diflucan 50mg Tab (discontinued)
fluconazole 100mg tab
Apo-Fluconazole 100mg Tab
DNP
2.2891
M
SFC
02237371
APX
CO Fluconazole 100mg Tab
MYLAN-Fluconazole 100mg Tab
DNP
DNP
2.2891
2.2891
M
M
SFC
SFC
02281279
02245293
ATV Y
MYL Y
Novo-Fluconazole 100mg Tab
pms-Fluconazole 100mg Tab
DNP
DNP
2.2891
2.2891
M
M
SFC
SFC
02236979
02245644
TEV Y
PMS Y
00891819
PFI
Y
Y
Diflucan 100mg Tab (discontinued)
fluconazole 150mg cap
Apo-Fluconazole 150mg Cap
DNP
5.0518
M
SFC
02241895
APX
DNP
5.0518
M
SFC
02282348
02141442
PMS Y
PFI Y
DNP
3.9425
M
SFC
02432471
02141442
JPC
PFI
Y
Y
DNP
4.6200
L
E
02047454
JAN
N
voriconazole 50mg tab
Apo-Voriconazole 50mg Tab
Sandoz Voriconazole 50mg Tab
DNP
DNP
3.2465
3.2465
M
M
E
E
02409674
02399245
APX
SDZ
Y
Y
Teva-Voriconazole 50mg Tab
DNP
3.2465
M
E
02396866
TEV
Y
pms-Fluconazole 150mg Cap
Diflucan 150mg Cap (discontinued)
fluconazole 150mg cap (otc)
Jamp-Fluconazole 150mg Cap
Diflucan One 150mg Cap
J02AC02
ITRACONAZOLE
Sporanox 100mg Cap
J02AC03
February 2016
VORICONAZOLE
122
J
General Antiinfectives, Systemic
J02AC04
Vfend 50mg Tab
DNP
3.2465
M
E
02256460
PFI
Y
voriconazole 200mg tab
Apo-Voriconazole 200mg Tab
DNP
12.9808
M
E
02409682
APX
Y
Sandoz Voriconazole 200mg Tab
Teva-Voriconazole 200mg Tab
DNP
DNP
12.9808
12.9808
M
M
E
E
02399253
02396874
SDZ
TEV
Y
Y
Vfend 200mg Tab
DNP
12.9808
M
E
02256479
PFI
Y
02293404
FRS
N
POSACONAZOLE
Posanol 40mg/mL Susp
J04
ANTIMYCOBACTERIALS
J04A
DRUGS FOR TREATMENT OF TUBERCULOSIS
J04AB
ANTIBIOTICS
J04AB02
J04AB04
RIFAMPIN (RIFAMPICIN)
rifampin 150mg cap
Rifadin 150mg Cap
DNP
0.6748
M
SFC
02091887
SAV
Y
Rofact 150mg Cap
DNP
0.6748
M
SFC
00393444
VLN
Y
rifampin 300mg cap
Rifadin 300mg Cap
DNP
1.0620
M
SFC
02092808
SAV
Y
Rofact 300mg Cap
DNP
1.0620
M
SFC
00343617
VLN
Y
DNP
4.1844
L
SFC
02063786
PFI
N
DNP
0.6545
L
SFC
00577804
PDP N
Etibi 100mg Tab
DNP
0.2058
L
SFC
00247960
VLN
N
Etibi 400mg Tab
DNP
0.6175
L
SFC
00247979
VLN
N
02148625
SAV
N
02041510
JCB
N
RIFABUTIN
Mycobutin 150mg Cap
J04AC
HYDRAZIDES
J04AC01
ISONIAZID
pdp-Isoniazid 300mg Tab
J04AK
OTHER DRUGS FOR TREATMENT OF TUBERCULOSIS
J04AK02
J04AM
ETHAMBUTOL
COMB. OF DRUGS FOR TREATMENT OF TUBERCULOSIS
J04AM02
RIFAMPIN AND ISONIAZID
Rifater Tab
J04B
DRUGS FOR TREATMENT OF LEPRA
J04BA
DRUGS FOR TREATMENT OF LEPRA
J04BA02
DAPSONE
Dapsone 100mg Tab
J05
SYSTEMIC ANTIVIRALS
J05A
DIRECT ACTING ANTIVIRALS
February 2016
DNP
1.3391
L
SFC
123
J
General Antiinfectives, Systemic
J05AB
NUCLEOSIDES AND NUCLEOTIDES EXCL.REVERSE TRANSCRIPTASE INHIBITORS
J05AB01
ACYCLOVIR
acyclovir 200mg tab
Apo-Acyclovir 200mg Tab
DNPM
0.6397
M
SFC
02207621
APX
MYLAN-Acyclovir 200mg Tab
Novo-Acyclovir 200mg Tab
DNPM
DNPM
0.6397
0.6397
M
M
SFC
SFC
02242784
02285959
MYL Y
TEV Y
ratio-Acyclovir 200mg Tab
Zovirax 200mg Tab
DNPM
DNPM
0.6397
0.6397
M
M
SFC
SFC
02078627
00634506
TEV Y
GSK Y
Zovirax 200mg/5mL O/L
DNPM
0.2596
L
SFC
00886157
GSK N
acyclovir 400mg tab
Acyclovir 400mg Tab
Apo-Acyclovir 400mg Tab
DNPM
DNPM
1.2700
1.2700
M
M
SFC
SFC
02286564
02207648
SAS
APX
MYLAN-Acyclovir 400mg Tab
Novo-Acyclovir 400mg Tab
DNPM
DNPM
1.2700
1.2700
M
M
SFC
SFC
02242463
02285967
MYL Y
TEV Y
01911627
GSK Y
Zovirax 400mg Tab (discontinued)
DNPM
1.2673
M
SFC
02207656
APX
MYLAN-Acyclovir 800mg Tab
Novo-Acyclovir 800mg Tab
DNPM
DNPM
1.2673
1.2673
M
M
SFC
SFC
02242464
02285975
MYL Y
TEV Y
01911635
GSK Y
02162695
HLR
N
Y
J05AB11
FAMCICLOVIR
famciclovir 125mg tab
Apo-Famciclovir 125mg Tab
DNP
1.3940
M
SFC
02292025
APX
CO Famciclovir 125mg Tab
pms-Famciclovir 125mg Tab
DNP
DNP
1.3940
1.3940
M
M
SFC
SFC
02305682
02278081
ATV Y
PMS Y
Sandoz Famciclovir 125mg Tab
Famvir 125mg Tab
DNP
DNP
1.3940
1.3940
M
M
SFC
SFC
02278634
02229110
SDZ Y
NVR Y
famciclovir 250mg tab
Apo-Famciclovir 250mg Tab
CO Famciclovir 250mg Tab
DNP
DNP
1.8733
1.8733
M
M
SFC
SFC
02292041
02305690
APX
ATV
pms-Famciclovir 250mg Tab
Sandoz Famciclovir 250mg Tab
DNP
DNP
1.8733
1.8733
M
M
SFC
SFC
02278103
02278642
PMS Y
SDZ Y
Famvir 250mg Tab
DNP
1.8733
M
SFC
02229129
NVR Y
famciclovir 500mg tab
Apo-Famciclovir 500mg Tab
DNP
1.7329
M
SFC
02292068
APX
CO Famciclovir 500mg Tab
pms-Famciclovir 500mg Tab
DNP
DNP
1.7329
1.7329
M
M
SFC
SFC
02305704
02278111
ATV Y
PMS Y
Sandoz Famciclovir 500mg Tab
Famvir 500mg Tab
DNP
DNP
1.7329
1.7329
M
M
SFC
SFC
02278650
02177102
SDZ Y
NVR Y
DNPM
0.8609
M
SFC
02295822
APX
Y
Y
Y
VALACYCLOVIR
valacyclovir 500mg tab
Apo-Valacyclovir 500mg Tab
February 2016
Y
GANCICLOVIR
Cytovene 500mg/vial Inj
J05AB09
Y
Y
acyclovir 800mg tab
Apo-Acyclovir 800mg Tab
Zovirax Zostab 800mg Tab (discontinued)
J05AB06
Y
124
Y
J
General Antiinfectives, Systemic
J05AB14
J05AE
Auro-Valacyclovir 500mg Tab
CO Valacyclovir 500mg Tab
DNPM
DNPM
0.8609
0.8609
M
M
SFC
SFC
02405040
02331748
ARO Y
ATV Y
Jamp-Valacyclovir 500mg Tab
Mar-Valacyclovir 500mg Tab
DNPM
DNPM
0.8609
0.8609
M
M
SFC
SFC
02441454
02441586
JPC Y
MAR Y
MYLAN-Valacyclovir 500mg Tab
pms-Valacyclovir 500mg Tab
DNPM
DNPM
0.8609
0.8609
M
M
SFC
SFC
02351579
02298457
MYL Y
PMS Y
Sandoz Valacyclovir 500mg Tab
Teva-Valacyclovir 500mg Tab
DNPM
DNPM
0.8609
0.8609
M
M
SFC
SFC
02347091
02357534
SDZ
TEV
Valacyclovir 500mg Tab
Valtrex 500mg Tab
DNPM
DNPM
0.8609
0.8609
M
M
SFC
SFC
02442000
02219492
SIV Y
GSK Y
valacyclovir 1000mg tab
Apo-Valacyclovir 1000mg Tab
pms-Valacyclovir 1000mg Tab
02354705
02381230
APX Y
PMS Y
Valacyclovir 1000mg Tab
Valtrex 1000mg Tab
02442019
02246559
SIV Y
GSK Y
Y
Y
VALGANCICLOVIR
valganciclovir 450mg tab
Apo-Valganciclovir 450mg Tab
DNP
5.8553
M
E
02393824
APX
Auro-Valganciclovir 450mg Tab
Teva-Valganciclovir 450mg Tab
DNP
DNP
5.8553
5.8553
M
M
E
E
02435179
02413825
ARO Y
TEV Y
Valcyte 450mg Tab
DNP
5.8553
M
E
02245777
HLR
Y
Invirase 200mg Cap
02216965
HLR
N
Invirase 500mg Tab
02279320
HLR
N
02229196
FRS
N
Norvir 80mg/mL O/L
02229145
ABV
N
Norvir FCT 100mg Tab
02357593
ABV
N
02248761
VIV
N
Telzir 50mg/mL Susp
02261553
VIV
N
Telzir 700mg Tab
02261545
VIV
N
Reyataz 150mg Cap
02248610
BRI
N
Reyataz 200mg Cap
02248611
BRI
N
Reyataz 300mg Cap
02294176
BRI
N
Y
PROTEASE INHIBITORS
J05AE01
J05AE02
SAQUINAVIR
INDINAVIR
Crixivan 400mg Cap
J05AE03
J05AE04
RITONAVIR
NELFINAVIR
Viracept 625mg Tab
J05AE07
J05AE08
J05AE09
February 2016
FOSAMPRENAVIR
ATAZANAVIR
TIPRANAVIR
125
J
General Antiinfectives, Systemic
02273322
BOE N
Prezista 75mg Tab
02338432
JAN
N
Prezista 400mg Tab (discontinued)
02324016
JAN
N
02371553
00999627
VTX
VTX
N
N
02370816
FRS
N
02416441
JAN
N
Keletra 100/25mg Pediatric Tab
02312301
ABV
N
Kaletra 200/50mg Tab
02285533
ABV
N
zidovudine 100mg cap
Apo-Zidovudine 100mg Cap
01946323
APX
Y
Retrovir 100mg Cap
01902660
VIV
Y
Zerit 15mg Cap
02216086
BRI
N
Zerit 20mg Cap
02216094
BRI
N
Zerit 30mg Cap
02216108
BRI
N
Zerit 40mg Cap
02216116
BRI
N
02192691
VIV
N
Y
Aptivus 250mg Cap
J05AE10
J05AE11
DARUNAVIR
TELAPREVIR
Incivek 375mg Tab (discontinued)
Incivek 375mg Tab* (discontinued)
*use when drug cost in excess of CPhA maximum
J05AE12
BOCEPREVIR
Victrelis 200mg Cap (discontinued)
J05AE14
SIMEPREVIR
Galexos 150mg Cap
J05AE30
J05AF
DNP
434.5500
L
E
PROTEASE INHIBITORS, COMBINATIONS
NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS
J05AF01
J05AF04
J05AF05
ZIDOVUDINE
STAVUDINE
LAMIVUDINE
3TC 10mg/mL O/L
J05AF07
lamivudine 100mg tab
Apo-Lamivudine HBV 100mg Tab
DNP
3.5316
M
E
02393239
APX
Heptovir 100mg Tab
DNP
3.5316
M
E
02239193
GSK Y
lamivudine 150mg tab
Apo-Lamivudine 150mg Tab
02369052
APX
Y
3TC 150mg Tab
02192683
VIV
Y
lamivudine 300mg tab
Apo-Lamivudine 300mg Tab
02369060
APX
Y
3TC 300mg Tab
02247825
VIV
Y
02247128
GIL
N
TENOFOVIR DISOPROXIL
Viread 300mg Tab
February 2016
DNP
19.1263
L
E
126
J
General Antiinfectives, Systemic
J05AF08
J05AF10
J05AF11
ADEFOVIR DIPIVOXIL
adefovir 10mg tab
Apo-Adefovir 10mg Tab
DNP
20.4400
M
E
02420333
APX
Y
Hepsera 10mg Tab
DNP
20.4400
M
E
02247823
GIL
Y
entecavir 0.5mg tab
Apo-Entecavir 0.5mg Tab
pms-Entecavir 0.5mg Tab
DNP
DNP
11.0000
11.0000
M
M
E
E
02396955
02430576
APX Y
PMS Y
Baraclude 0.5mg Tab
DNP
11.0000
M
E
02282224
BRI
02288389
NVR N
nevirapine 200mg tab
Auro-Nevirapine 200mg Tab
02318601
ARO Y
MYLAN-Nevirapine 200mg Tab
pms-Nevirapine 200mg Tab
02387727
02405776
MYL Y
PMS Y
Teva-Nevirapine 200mg Tab
Viramune 200mg Tab
02352893
02238748
TEV Y
BOE Y
nevirapine 400mg ER tab
Apo-Nevirapine ER 400mg Tab
Viramune XR 400mg Tab
02427931
02367289
APX Y
BOE Y
efavirenz 600mg tab
Auro-Efavirenz 600mg Tab
02418428
ARO Y
MYLAN-Efavirenz 600mg Tab
Teva-Efavirenz 600mg Tab
02381524
02389762
MYL Y
TEV Y
Sustiva 600mg Tab
02246045
BRI
Y
02306778
JAN
N
02370603
JAN
N
ENTECAVIR
TELBIVUDINE
Sebivo 600mg Tab
J05AG
NON-NUCLEOSIDES REVERSE TRANSCRIPTASE INHIBITORS
J05AG01
J05AG03
J05AG04
NEVIRAPINE
EFAVIRENZ
ETRAVIRINE
Intelence 100mg Tab
J05AG05
RILPIVIRINE
Edurant 25mg Tab
J05AH
Y
NEURAMINIDASE INHIBITORS
J05AH01
ZANAMIVIR
Relenza 5mg Pdr for Inhalation
J05AH02
February 2016
DNP
7.3080
L
E
02240863
GSK N
Tamiflu 6mg/mL Susp
DNP
0.3134
L
E
02381842
HLR
N
Tamiflu 30mg Cap
DNP
2.0370
L
E
02304848
HLR
N
Tamiflu 45mg Cap
DNP
3.1350
L
E
02304856
HLR
N
OSELTAMIVIR
127
J
General Antiinfectives, Systemic
Tamiflu 75mg Cap
J05AR
DNP
4.0750
L
E
02241472
HLR
lamivudine 150mg & zidovudine 300mg tab
Apo-Lamivudine-Zidovudine 150/300mg Tab
Auro-Lamivudine/Zidovudine 150/300mg Tab
02375540
02414414
APX Y
ARO Y
Teva-Lamivudine/Zidovudine 150/300mg Tab
Combivir 150/300mg Tab
02387247
02239213
TEV
VIV
Y
Y
02269341
VIV
N
02274906
GIL
N
02300699
GIL
N
02374129
GIL
N
02397137
GIL
N
02430932
VIV
N
N
ANTIVIRALS FOR TREATMENT OF HIV INFECTIONS, COMBINATIONS
J05AR01
J05AR02
ZIDOVUDINE AND LAMIVUDINE
LAMIVUDINE AND ABACAVIR
Kivexa Tab
J05AR03
TENOFOVIR DISOPROXIL AND EMTRICITABINE
Truvada Tab
J05AR06
EMTRICITABINE, TENOFOVIR DISOPROXIL AND EFAVIRENZ
Atripla Tab
J05AR08
EMTRICITABINE, TENOFOVIR DISOPROXIL AND RILPIVIRINE
Complera 200/25/300mg Tab
J05AR09
EMTRICITABINE, TENOFOVIR DISOPROXIL, ELVITEGRAVIR AND COBICISTAT
Stribild 150mg/150mg/200mg/300mg Tab
J05AR13
DULOTEGRAVIR, ABACAVIR, LAMIVUDINE
Triumeq 50mg/600mg/300mg Tab
J05AX
N
OTHER ANTIVIRALS
J05AB04
J05AX07
RIBAVIRIN
Moderiba 200mg Tab
DNP
0.0000
L
E
02436396
ABV
Ibavyr 400mg Tab
Moderiba 400mg Tab
DNP
DNP
14.5000
0.0000
L
L
E
E
02425890
02436418
PDP N
ABV N
Ibavyr 600mg Tab
DNP
21.7500
L
E
02425904
PDP N
Moderiba 600mg Tab
DNP
0.0000
L
E
02436426
ABV
N
02247725
HLR
N
02301881
FRS
N
Celsentri 150mg Tab
02299844
VIV
N
Celsentri 300mg Tab
02299852
VIV
N
02414945
VIV
N
ENFUVIRTIDE
Fuzeon 108mg/vial Inj
J05AX08
RALTEGRAVIR
Isentress 400mg Tab
J05AX09
J05AX12
MARAVIROC
DOLUTEGRAVIR
Tivicay 50mg Tab
February 2016
128
J
General Antiinfectives, Systemic
J05AX15
J05AX65
J05AX66
February 2016
SOFOSBUVIR
Sovaldi 400mg Tab
Sovaldi 400mg Tab*
DNP
DNP
654.7618
654.7618
L
L
E
E
02418355
00904042
GIL
GIL
N
N
Sovaldi 400mg Tab*
*use when drug cost in excess of CPhA maximum
DNP
654.7618
L
E
00904041
GIL
N
Harvoni 90/400mg Tab
Harvoni 90/400mg Tab*
DNP
DNP
797.6189
797.6189
L
L
E
E
02432226
00904032
GIL
GIL
N
N
Harvoni 90/400mg Tab*
*use when drug cost in excess of CPhA maximum
DNP
797.6189
L
E
00904033
GIL
N
LEDIPASVIR AND SOFOSBUVIR
DASABUVIR, OMBITASVIR, PARITAPREVIR AND RITONAVIR
Holkira Pak Tab
Holkira Pak Tab*
DNP
DNP
166.2500
166.2500
L
L
E
E
02436027
00904082
ABV
ABV
N
N
Holkira Pak Tab*
*use when drug cost in excess of CPhA maximum
DNP
166.2500
L
E
00904081
ABV
N
129
L
Antineoplastics and Immunomodulating Agents
L01
ANTINEOPLASTIC AGENTS
L01A
ALKYLATING AGENTS
L01AA
NITROGEN MUSTARD ANALOGUES
L01AA01
L01AA02
CYCLOPHOSPHAMIDE
Procytox 25mg Tab
DNP
0.5385
L
SFC
02241795
BAX
N
Procytox 50mg Tab
DNP
0.7225
L
SFC
02241796
BAX
N
DNP
1.4680
L
SFC
00004626
APR N
DNP
1.6846
L
SFC
00004715
APR N
DNP
1.5576
L
SFC
00004618
APR N
CeeNU 10mg Cap
DNP
7.2950
L
SFC
00360430
BRI
N
CeeNU 40mg Cap
DNP
12.5775
L
SFC
00360422
BRI
N
CeeNU 100mg Cap
DNP
20.7625
L
SFC
00360414
BRI
N
temozolomide 5mg cap
ACT Temozolomide 5mg Cap
DNP
3.9000
M
E
02441160
ATV
Y
Taro-Temozolomide 5mg Cap
Temodal 5mg Cap
DNP
DNP
3.9000
3.9000
M
M
E
E
02443473
02241093
TAR Y
FRS Y
temozolomide 20mg cap
CO Temozolomide 20mg Cap
Taro-Temozolomide 20mg Cap
DNP
DNP
15.6000
15.6000
M
M
E
E
02395274
02443481
COB Y
TAR Y
Temodal 20mg Cap
DNP
15.6000
M
E
02241094
FRS
temozolomide 100mg cap
CO Temozolomide 100mg Cap
DNP
78.0030
M
E
02395282
COB Y
Taro-Temozolomide 100mg Cap
Temodal 100mg Cap
DNP
DNP
78.0030
78.0030
M
M
E
E
02443511
02241095
TAR Y
FRS Y
temozolomide 140mg cap
CO Temozolomide 140mg Cap
Taro-Temozolomide 140mg Cap
DNP
DNP
109.2050
109.2050
M
M
E
E
02395290
02443538
COB Y
TAR Y
Temodal 140mg Cap
DNP
109.2050
M
E
02312794
FRS
temozolomide 250mg cap
CO Temozolomide 250mg Cap
DNP
195.0020
M
E
02395312
COB Y
Taro-Temozolomide 250mg Cap
Temodal 250mg Cap
DNP
DNP
195.0020
195.0020
M
M
E
E
02443554
02241096
TAR Y
FRS Y
CHLORAMBUCIL
Leukeran 2mg Tab
L01AA03
MELPHALAN
Alkeran 2mg Tab
L01AB
ALKYL SULPHONATES
L01AB01
BUSULFAN
Myleran 2mg Tab
L01AD
NITROSOUREAS
L01AD02
L01AX
LOMUSTINE
OTHER ALKYLATING AGENTS
L01AX03
February 2016
TEMOZOLOMIDE
130
Y
Y
L
Antineoplastics and Immunomodulating Agents
L01B
ANTIMETABOLITES
L01BA
FOLIC ACID ANALOGUES
L01BA01
L01BB
METHOTREXATE
methotrexate 2.5mg tab
Apo-Methotrexate 2.5mg Tab
DNP
0.6325
M
SFC
02182963
APX
Y
ratio-Methotrexate Sodium 2.5mg Tab
Methotrexate 2.5mg Tab
DNP
DNP
0.6325
0.6325
M
M
SFC
SFC
02244798
02170698
TEV
PFI
Y
Y
Methotrexate 10mg Tab
DNP
2.7067
L
SFC
02182750
HOS N
Methotrexate 10mg/mL Inj
DNP
8.2650
L
SFC
02182947
HOS N
methotrexate 25mg/mL inj
Methotrexate 25mg/mL Inj
DNP
4.4600
M
SFC
02398427
SDZ
Methotrexate 25mg/mL Inj
DNP
4.4600
M
SFC
02182777
HOS Y
methotrexate 25mg/mL inj (pf)
Jamp-Methotrexate 25mg/mL Inj (PF) (2mL)
DNP
6.0750
M
SFC
02419173
JPC
Methotrexate 25mg/mL Inj (PF) (2mL)
Methotrexate 25mg/mL Inj (PF)
DNP
DNP
6.0750
6.0750
M
M
SFC
SFC
02417626
02182955
MYL Y
HOS Y
Methotrexate 25mg/mL Inj
DNP
6.2500
L
SFC
02099705
TEV
Methotrexate 25mg/mL Inj (PF)
DNP
7.8755
L
SFC
02182971
HOS N
DNP
DNP
2.8610
2.8610
M
M
SFC
SFC
02415275
00004723
STR Y
TEV Y
DNP
4.5380
L
SFC
00282081
APR N
DNP
40.0760
L
E
02246226
SAV
N
Efudex 5% Cr
DNP
0.8620
L
SFC
00330582
VLN
N
Fluorouracil 50mg/vial Inj
DNP
1.6090
L
SFC
00012882
SDZ
N
gemcitabine hydrochloride 1g/vial inj
Gemcitabine 38mg/mL Inj (1g Vial)
Gemcitabine 1g/vial Inj
02402831
02324210
HOS Y
AHI Y
Gemzar 1g/vial Inj (discontinued)
02230309
LIL
gemcitabine hydrochloride 200mg/vial inj
Gemcitabine 38mg/mL Inj (200mg Vial)
02402831
HOS Y
Gemzar 200mg/vial Inj (discontinued)
02230308
LIL
Y
N
PURINE ANALOGUES
L01BB02
MERCAPTOPURINE
mercaptopurine 50mg tab
Mercaptopurine 50mg Tab
Purinethol 50mg Tab
L01BB03
THIOGUANINE
Lanvis 40mg Tab
L01BB05
FLUDARABINE
Fludara 10mg Tab
L01BC
Y
PYRIMIDINE ANALOGUES
L01BC02
L01BC05
L01BC06
February 2016
FLUOROURACIL
GEMCITABINE
CAPECITABINE
131
Y
Y
L
Antineoplastics and Immunomodulating Agents
capecitabine 150mg tab
ACH-Capecitabine 150mg Tab
DNP
0.4575
M
E
02426757
AHI
Y
Sandoz Capecitabine 150mg Tab
Teva-Capecitabine 150mg Tab
DNP
DNP
0.4575
0.4575
M
M
E
E
02421917
02400022
SDZ
TEV
Y
Y
Xeloda 150mg Tab
DNP
0.4575
M
E
02238453
HLR
Y
capecitabine 500mg tab
ACH-Capecitabine 500mg Tab
DNP
1.5250
M
E
02426765
AHI
Y
Sandoz Capecitabine 500mg Tab
Teva-Capecitabine 500mg Tab
DNP
DNP
1.5250
1.5250
M
M
E
E
02421925
02400030
SDZ
TEV
Y
Y
Xeloda 500mg Tab
DNP
1.5250
M
E
02238454
HLR
Y
DNP
38.4525
L
SFC
00616192
BRI
N
paclitaxel 6mg/mL inj
Paclitaxel 6mg/mL Inj
02391465
AHI
Y
Taxol 6mg/mL Inj (discontinued)
02016796
BRI
Y
docetaxel 10mg/mL (2mL)
Docetaxel 10mg/mL Inj (2mL)
Docetaxel 20mg/vial Inj
02361957
02412225
HOS Y
TEV Y
Taxotere 20mg/vial Inj
02177099
SAV
docetaxel 10mg/mL (8mL)
Docetaxel 10mg/mL Inj (8mL)
02361957
HOS Y
Docetaxel 80mg/vial Inj
Taxotere 80mg/vial Inj
02412233
02177080
TEV
SAV
Y
Y
02065703
PFI
Y
cisplatin 1mg/mL inj
Cisplatin 1mg/mL
Teva-Cisplatin 1mg/mL Inj
02355183
02403188
AHI
TEV
Y
Y
Cisplatin 1mg/mL
02126613
HOS Y
L01C
PLANT ALKALOIDS AND OTHER NATURAL PRODUCTS
L01CB
PODOPHYLLOTOXIN DERIVATIVES
L01CB01
ETOPOSIDE
Vepesid 50mg Cap
L01CD
TAXANES
L01CD01
L01CD02
PACLITAXEL
DOCETAXEL
L01D
CYTOTOXIC ANTIBIOTICS AND RELATED SUBSTANCES
L01DB
ANTHRACYCLINES AND RELATED SUBSTANCES
L01DB03
EPIRUBICIN
Pharmorubicin PFS 2mg/mL inj
L01X
OTHER ANTINEOPLASTIC AGENTS
L01XA
PLATINUM COMPOUNDS
L01XA01
L01XB
CISPLATIN
METHYLHYDRAZINES
February 2016
Y
132
L
Antineoplastics and Immunomodulating Agents
L01XB01
PROCARBAZINE
DNP
56.7958
L
SFC
00012750
QGT N
Rituxan 10mg/mL Inj
DNP
45.7180
L
E
02241927
HLR
N
Rituxan 10mg/mL Inj*
*use when drug cost in excess of CPhA maximum
DNP
45.7180
L
E
00903777
HLR
N
imatinib 100mg tab
Apo-Imatinib 100mg Tab
DNP
6.8187
M
E
02355337
APX
Y
CO Imatinib 100mg Tab
pms-Imatinib 100mg Tab
DNP
DNP
6.8187
6.8187
M
M
E
E
02397285
02431114
ATV Y
PMS Y
Teva-Imatinib 100mg Tab
Gleevec 100mg Tab
DNP
DNP
6.8187
6.8187
M
M
E
E
02399806
02253275
TEV Y
NVR Y
imatinib 400mg tab
Apo-Imatinib 400mg Tab
CO Imatinib 400mg Tab
DNP
DNP
27.9886
27.9886
M
M
E
E
02355345
02397293
APX
ATV
pms-Imatinib 400mg Tab
Teva-Imatinib 400mg Tab
DNP
DNP
27.9886
27.9886
M
M
E
E
02431122
02399814
PMS Y
TEV Y
Gleevec 400mg Tab
DNP
27.9886
M
E
02253283
NVR Y
02248676
AZE
N
erlotinib 25mg tab
Teva-Erlotinib 25mg Tab
02377691
TEV
Y
Tarceva 25mg Tab
02269007
HLR
Y
Matulane 50mg Cap
L01XC
MONOCLONAL ANTIBODIES
L01XC02
L01XE
RITUXIMAB
PROTEIN KINASE INHIBITORS
L01XE01
L01XE02
IMATINIB
GEFITINIB
Iressa 250mg Tab
L01XE03
L01XE04
L01XE05
ERLOTINIB
erlotinib 100mg tab
Teva-Erlotinib 100mg Tab
DNP
45.3333
M
E
02377705
TEV
Y
Tarceva 100mg Tab
DNP
45.3333
M
E
02269015
HLR
Y
erlotinib 150mg tab
Teva-Erlotinib 150mg Tab
DNP
68.0000
M
E
02377713
TEV
Y
Tarceva 150mg Tab
DNP
68.0000
M
E
02269023
HLR
Y
Sutent 12.5mg Cap
DNP
64.4157
L
E
02280795
PFI
N
Sutent 25mg Cap
DNP
128.8304
L
E
02280809
PFI
N
Sutent 50mg Cap
DNP
257.6611
L
E
02280817
PFI
N
Sutent 50mg Cap*
*use when drug cost in excess of CPhA maximum
DNP
257.6611
L
E
00904007
PFI
N
DNP
46.4689
L
E
02284227
BAY
N
SUNITINIB
SORAFENIB
Nexavar 200mg Tab
February 2016
Y
Y
133
L
Antineoplastics and Immunomodulating Agents
L01XE06
DASATINIB
Sprycel 20mg Cap
DNP
38.6850
L
E
02293129
BRI
N
Sprycel 50mg Cap
DNP
77.8567
L
E
02293137
BRI
N
Sprycel 70mg Cap
DNP
85.8042
L
E
02293145
BRI
N
Sprycel 100mg Cap
Sprycel 100mg Cap*
DNP
DNP
155.6083
155.6083
L
L
E
E
02320193
00903855
BRI
BRI
N
N
DNP
23.5000
L
E
02326442
GSK N
DNP
DNP
28.7161
28.7161
L
L
E
E
02368250
00904004
NVR N
NVR N
DNP
39.7213
L
E
02315874
NVR N
DNP
34.4100
L
E
02352303
GSK N
Giotrif 20mg Tab
DNP
80.0000
L
E
02415666
BOE N
Giotrif 30mg Tab
DNP
80.0000
L
E
02415674
BOE N
Giotrif 40mg Tab
DNP
80.0000
L
E
02415682
BOE N
Zelboraf 240mg Tab
DNP
46.5420
L
E
02380242
HLR
N
Zelboraf 240mg Tab*
*use when drug cost in excess of CPhA maximum
DNP
46.5420
L
E
00903786
HLR
N
Xalkori 200mg Cap
DNP
146.6667
L
E
02384256
PFI
N
Xalkori 250mg Cap
DNP
146.6667
L
E
02384264
PFI
N
Inlyta 1mg Tab
DNP
18.8603
L
E
02389630
PFI
N
Inlyta 5mg Tab
DNP
94.3020
L
E
02389649
PFI
N
Jakavi 5mg Tab
Jakavi 5mg Tab*
DNP
DNP
82.1918
82.1918
L
L
E
E
02388006
00903985
NVR N
NVR N
Jakavi 15mg Tab
DNP
82.1918
L
E
02388014
NVR N
Jakavi 15mg Tab*
DNP
82.1918
L
E
00904003
NVR N
Jakavi 20mg Tab
*use when drug cost in excess of CPhA maximum
DNP
82.1918
L
E
02388022
NVR N
*use when drug cost in excess of CPhA maximum
L01XE07
LAPATINIB
Tykerb 250mg Tab
L01XE08
NILOTINIB
Tasigna 150mg Cap
Tasigna 150mg Cap*
*use when drug cost in excess of CPhA maximum
Tasigna 200mg Cap
L01XE11
PAZOPANIB
Votrient 200mg tab
L01XE13
L01XE15
L01XE16
L01XE17
L01XE18
L01XE21
February 2016
AFATINIB
VEMURAFENIB
CRIZOTINIB
AXITINIB
RUXOLITINIB
REGORAFENIB
134
L
Antineoplastics and Immunomodulating Agents
Stivarga 40mg Tab
L01XE27
L01XX
DNP
72.6200
L
E
02403390
BAY
N
Imbruvica 140mg Cap
DNP
90.6500
L
E
02434407
JAN
N
Imbruvica 140mg Cap*
*use when drug cost in excess of CPhA maximum
DNP
90.6500
L
E
00904083
JAN
N
hydroxyurea 500mg cap
MYLAN-Hydroxyurea 500mg Cap
DNP
1.0203
M
SFC
02242920
MYL Y
Hydrea 500mg Cap
DNP
1.0203
M
SFC
00465283
BRI
Y
DNP
3.6471
L
SFC
02063794
PFI
N
topotecan 1mg/mL inj
Topotecan 1mg/mL Inj (4mL Vial)
02396378
AHI
Y
Topotecan HCl 1mg/mL Inj (4mL Vial)
Topotecan PWS 4mg/vial Inj
02379422
02344009
HOS Y
AHI Y
Hycamtin 4mg/Vial Inj
02231116
GSK Y
IBRUTINIB
OTHER ANTINEOPLASTIC AGENTS
L01XX05
L01XX11
HYDROXYUREA (HYDROXYCARBAMIDE)
ESTRAMUSTINE
Emcyt 140mg Tab
L01XX17
L01XX35
L01XX43
TOPOTECAN
ANAGRELIDE
anagrelide 0.5mg cap
MYLAN-Anagrelide 0.5mg Cap (discontinued)
Sandoz Anagrelide 0.5mg Cap
DNP
2.6361
M
E
02253054
02260107
MYL Y
SDZ Y
Agrylin 0.5mg Cap
DNP
2.6361
M
E
02236859
SHI
Y
DNP
294.2238
L
E
02409267
HLR
N
DNP
1.0929
M
SFC
02195917
AAP
Y
00386391
BRI
Y
VISMODEGIB
Erivedge 150mg Cap
L02
ENDOCRINE THERAPY
L02A
HORMONES AND RELATED AGENTS
L02AB
PROGESTOGENS
L02AB01
MEGESTROL
megestrol 40mg tab
Megestrol 40mg Tab
Megace 40mg Tab (discontinued)
Megace OS 40mg/mL O/L
DNP
1.8550
L
SFC
02168979
BRI
N
megestrol 160mg tab
Megestrol 160mg Tab
DNP
4.6254
M
SFC
02195925
AAP
Y
00731323
BRI
Y
02225158
SAV
N
Megace 160mg Tab (discontinued)
L02AE
GONADOTROPHIN RH ANALOGUES
L02AE01
BUSERELIN
Suprefact 1mg/mL Nasal Sol
February 2016
DNP
8.0480
L
SFC
135
L
Antineoplastics and Immunomodulating Agents
L02AE02
L02AE03
L02AE04
Suprefact Depot 6.3mg (2 month) Implant
DNP
778.9100
L
SFC
02228955
SAV
N
Suprefact Depot 9.45mg (3 month) Implant
DNP
1154.3100 L
SFC
02240749
SAV
N
Lupron Depot 3.75mg (monthly) Inj Kit
DNP
347.1800
L
SF
00884502
ABV
N
Lupron 5mg/mL Inj
DNP
189.4100
L
SFC
00727695
ABV
N
Lupron Depot 7.5mg (monthly) Inj Kit
DNP
387.9700
L
SFC
00836273
ABV
N
Lupron Depot 11.25mg (3 month) SR Inj Kit
DNP
1034.4100 L
SF
02239834
ABV
N
Eligard 22.5mg (3 month) Inj Kit
DNP
891.0000
L
SFC
02248240
SAV
N
Lupron Depot 22.5mg (3 month) SR Inj Kit
DNP
1071.0000 L
SFC
02230248
ABV
N
Lupron Depot 30mg (4 month) SR Inj Kit
DNP
1428.0000 L
SFC
02239833
ABV
N
Eligard 45mg (6 month) Inj Kit
DNP
1450.0000 L
SFC
02268892
SAV
N
Zoladex Depot 3.6mg/syringe Inj
DNP
406.2600
L
SFC
02049325
AZE
N
Zoladex LA 10.8mg/syringe (3 month) Inj
DNP
1157.9500 L
SFC
02225905
AZE
N
Trelstar Depot 3.75mg/vial Inj
DNP
347.3300
L
SFC
02240000
ASP
N
Trelstar LA 11.25mg/vial Inj
DNP
1042.0300 L
SFC
02243856
ASP
N
Trelstar 22.5mg/vial Inj
DNP
1650.0000 L
SFC
02412322
ASP
N
DNP
DNP
0.1750
0.1750
M
M
SFC
SFC
00812404
02088428
APX Y
MYL Y
DNP
0.1750
M
SFC
00851965
02048477
TEV
AZE
Y
Y
01926624
SAV
Y
Y
LEUPROLIDE (LEUPRORELIN)
GOSERELIN
TRIPTORELIN
L02B
HORMONE ANTAGONISTS AND RELATED AGENTS
L02BA
ANTI-ESTROGENS
L02BA01
TAMOXIFEN
tamoxifen citrate 10mg tab
Apo-Tamox 10mg Tab
MYLAN-Tamoxifen 10mg Tab
Novo-Tamoxifen 10mg Tab
Nolvadex 10mg Tab (discontinued)
Tamofen 10mg Tab (discontinued)
L02BB
tamoxifen citrate 20mg tab
Apo-Tamox 20mg Tab
DNP
0.3500
M
SFC
00812390
APX
MYLAN-Tamoxifen 20mg Tab
Novo-Tamoxifen 20mg Tab
DNP
DNP
0.3500
0.3500
M
M
SFC
SFC
02089858
00851973
MYL Y
TEV Y
Nolvadex-D 20mg Tab
Tamofen 20mg Tab (discontinued)
DNP
0.3500
M
SFC
02048485
01926632
AZE
SAV
Y
Y
DNP
1.3530
M
SFC
02238560
APX
Y
02230089
00637726
TEV
FRS
Y
Y
ANTI-ANDROGENS
L02BB01
FLUTAMIDE
flutamide 250mg tab
Apo-Flutamide 250mg Tab
Novo-Flutamide 250mg Tab (discontinued)
Euflex 250mg Tab (discontinued)
February 2016
136
L
Antineoplastics and Immunomodulating Agents
L02BB02
NILUTAMIDE
Anandron 50mg Tab
L02BB03
L02BB04
DNP
2.2719
L
SFC
02221861
SAV
N
bicalutamide 50mg tab
Apo-Bicalutamide 50mg Tab
Bicalutamide 50mg Tab
DNP
DNP
1.6563
1.6563
M
M
SFC
SFC
02296063
02325985
APX
AHI
Y
Y
Bicalutamide-50mg Tab
CO Bicalutamide 50mg Tab
DNP
DNP
1.6563
1.6563
M
M
SFC
SFC
02382423
02274337
SIV
ATV
Y
Y
Jamp-Bicalutamide 50mg Tab
MYLAN-Bicalutamide 50mg Tab (discontinued)
DNP
1.6563
M
SFC
02357216
02302403
JPC Y
MYL Y
Novo-Bicalutamide 50mg Tab
pms-Bicalutamide 50mg Tab
DNP
DNP
1.6563
1.6563
M
M
SFC
SFC
02270226
02275589
TEV Y
PMS Y
RAN-Bicalutamide 50mg Tab
Sandoz Bicalutamide 50mg Tab
DNP
DNP
1.6563
1.6563
M
M
SFC
SFC
02371324
02276089
RAN Y
SDZ Y
Casodex 50mg Tab
DNP
1.6563
M
SFC
02184478
AZE
Y
DNP
28.3450
L
E
02407329
ASL
N
anastrozole 1mg tab
Anastrozole 1mg Tab
DNP
1.2729
M
SFC
02351218
AHI
Y
Apo-Anastrozole 1mg Tab
Auro-Anastrozole 1mg Tab
DNP
DNP
1.2729
1.2729
M
M
SFC
SFC
02374420
02404990
APX Y
ARO Y
CO Anastrozole 1mg Tab
Jamp-Anastrozole 1mg Tab
DNP
DNP
1.2729
1.2729
M
M
SFC
SFC
02394898
02339080
ATV
JPC
Mar-Anastrozole 1mg Tab
MED-Anastrozole 1mg Tab
DNP
DNP
1.2729
1.2729
M
M
SFC
SFC
02379562
02379104
MAR Y
GMP Y
MINT-Anastrozole 1mg Tab
MYLAN-Anastrozole 1mg Tab
DNP
DNP
1.2729
1.2729
M
M
SFC
SFC
02393573
02361418
MNT Y
MYL Y
NAT-Anastrozole 1mg Tab
pms-Anastrozole 1mg Tab
DNP
DNP
1.2729
1.2729
M
M
SFC
SFC
02417855
02320738
NAT Y
PMS Y
RAN-Anastrozole 1mg Tab
Sandoz Anastrozole 1mg Tab
DNP
DNP
1.2729
1.2729
M
M
SFC
SFC
02328690
02338467
RAN Y
SDZ Y
Taro-Anastrozole 1mg Tab
Teva-Anastrozole 1mg Tab (discontinued)
DNP
1.2729
M
SFC
02365650
02313049
TAR Y
TEV Y
Zinda-Anastrozole 1mg Tab
Arimidex 1mg Tab
DNP
DNP
1.2729
1.2729
M
M
SFC
SFC
02326035
02224135
MCK Y
AZE Y
letrozole 2.5mg tab
Apo-Letrozole 2.5mg Tab
DNP
1.4759
M
SFC
02358514
APX
Auro-Letrozole 2.5mg Tab
Jamp-Letrozole 2.5mg Tab
DNP
DNP
1.4759
1.4759
M
M
SFC
SFC
02404400
02373009
ARO Y
JPC Y
Letrozole 2.5mg Tab
Letrozole 2.5mg Tab
DNP
DNP
1.4759
1.4759
M
M
SFC
SFC
02338459
02348969
AHI
ATV
Mar-Letrozole 2.5mg Tab
DNP
1.4759
M
SFC
02373424
MAR Y
BICALUTAMIDE
ENZALUTAMIDE
Xtandi 40mg Cap
L02BG
AROMATASE INHIBITORS
L02BG03
L02BG04
February 2016
ANASTROZOLE
Y
Y
LETROZOLE
137
Y
Y
Y
L
Antineoplastics and Immunomodulating Agents
L02BG06
L02BX
MED-Letrozole 2.5mg Tab
NAT-Letrozole 2.5mg Tab
DNP
DNP
1.4759
1.4759
M
M
SFC
SFC
02322315
02421585
GMP Y
NAT Y
pms-Letrozole 2.5mg Tab
RAN-Letrozole 2.5mg Tab
DNP
DNP
1.4759
1.4759
M
M
SFC
SFC
02309114
02372282
PMS Y
RAN Y
Sandoz Letrozole 2.5mg Tab
Teva-Letrozole 2.5mg Tab
DNP
DNP
1.4759
1.4759
M
M
SFC
SFC
02344815
02343657
SDZ
TEV
Zinda-Letrozole 2.5mg Tab
Femara 2.5mg Tab
DNP
DNP
1.4759
1.4759
M
M
SFC
SFC
02378213
02231384
MCK Y
NVR Y
exemestane 25mg tab
Apo-Exemestane 25mg Tab
DNP
1.3263
M
SFC
02419726
APX
CO Exemestane 25mg Tab
MED-Exemestane 25mg Tab
DNP
DNP
1.3263
1.3263
M
M
SFC
SFC
02390183
02407841
ATV Y
GMP Y
Teva-Exemestane 25mg Tab
Aromasin 25mg Tab
DNP
DNP
1.3263
1.3263
M
M
SFC
SFC
02408473
02242705
TEV
PFI
Y
Y
Firmagon 80mg/vial Inj
DNP
255.000
L
SFC
02337029
FEI
N
Firmagon 120mg/vial Inj
DNP
345.0000
L
SFC
02337037
FEI
N
DNP
29.5910
L
E
02371065
JAN
N
01968017
AGA N
02249790
AGA N
EXEMESTANE
Y
OTHER HORMONE ANTAGONISTS AND RELATED AGENTS
L02BX02
L02BX03
DEGARELIX
ABIRATERONE
Zytiga 250mg tab
L03
IMMUNOMODULATORS/-STIMULANTS
L03A
IMMUNOSTIMULANTS
L03AA
COLONY STIMULATING FACTORS
L03AA02
FILGRASTIM
Neupogen 300mcg/mL Inj
L03AA13
PEGFILGRASTIM
Neulasta 10mg/mL Inj
L03AB
Y
Y
INTERFERONS
L03AB05
L03AB07
INTERFERON ALPHA-2B
Intron A 6,000,000iu/mL Inj (albumin free)
DNP
72.9200
L
E
02238674
SCH N
Intron A 10,000,000iu/mL Inj (albumin free)
Intron A 10,000,000iu/vial Inj
DNP
DNP
121.5320
125.8200
L
L
E
E
02238675
02223406
SCH N
SCH N
Intron A 15,000,000iu Multidose Pen
DNP
182.3000
L
E
02240693
SCH N
Intron A 25,000,000iu Multidose Pen
DNP
303.8333
L
E
02240694
FRS
Intron A 50,000,000iu Multidose Pen
DNP
607.6583
L
E
02240695
SCH N
02318253
EMD N
INTERFERON BETA-1A
Rebif 22mcg Multidose Cartridges
February 2016
N
138
L
Antineoplastics and Immunomodulating Agents
L03AB08
L03AB11
L03AB60
Rebif 22mcg/0.5mL Inj
02237319
EMD N
Avonex PS 30mcg/0.5mL Inj
02269201
BIG
Rebif 44mcg Mulitdose Cartridges
02318261
EMD N
Rebif 44mcg/0.5mL Inj
02237320
EMD N
Betaseron Initiation Pack
02169649
BAY
N
Betaseron 0.3mg/vial Inj
02169649
BAY
N
Extavia 0.3mg/vial Inj
02337819
NVR N
INTERFERON BETA-1B
PEGINTERFERON ALFA-2A
Pegasys 180mcg/0.5mL Syr Inj
DNP
798.8000
L
E
02248077
HLR
N
Pegasys Proclick Autoinjector 180mcg/0.5mL Syr Inj
DNP
798.8000
L
E
02248077
HLR
N
02246026
SCH N
02254581
FRS
N
02371448
FRS
N
02254603
FRS
N
02371456
FRS
N
02254638
FRS
N
Victrelis Triple 120mcg Inj/200mg/200mg Cap (discontinued)
02371464
FRS
N
Victrelis Triple 120mcg Inj/200mg/200mg Cap* (discontinued)
*use when drug cost in excess of CPhA maximum
00903838
FRS
N
02254646
FRS
N
02371472
FRS
N
PEGINTERFERON ALFA-2B, COMBINATIONS
Pegetron 50mcg/mL Inj/200mg Cap (discontinued)
Pegetron Clearclick 80mcg/0.5mL Inj/200mg Cap
DNP
793.4700
L
E
Victrelis Triple 80mcg Inj/200mg/200mg Cap (discontinued)
Pegetron Clearclick 100mcg/0.5mL Inj/200mg Cap
DNP
793.4700
L
E
Victrelis Triple 100mcg Inj/200mg/200mg Cap (discontinued)
Pegetron Clearclick 120mcg/0.5mL Inj/200mg Cap
Pegetron Clearclick 150mcg/0.5mL Inj/200mg Cap
DNP
DNP
876.7800
876.7800
L
L
E
E
Victrelis Triple 150mcg Inj/200mg/200mg Cap (discontinued)
L03AB61
L03AX
PEGINTERFERON ALFA-2A, COMBINATIONS
Pegasys RBV 180mcg/0.5mL Inj/200mg Tab (1 Kit)
Pegasys RBV 180mcg/0.5mL Inj/200mg Tab (4 Kit)
DNP
DNP
399.4025 L
1597.6100 L
E
E
02253429
00999450
HLR
HLR
N
N
Pegasys RBV Proclick 180mcg/0.5mL Inj/200mg Tab
DNP
399.4025
L
E
02253429
HLR
N
DNP
218.7100
L
SFC
02194376
AVP
N
02245619
TMP N
OTHER IMMUNOSTIMULANTS
L03AX03
BCG VACCINE
ImmuCyst BCG Therapeutic 3.5CFU/vial Inj
L03AX13
GLATIRAMER ACETATE
Copaxone 20mg/mL Syr Inj
L03AX16
PLERIXAFOR
Mozobil 24mg/1.2mL (20mg/mL) Single Use Vial
DNP
6295.8333 L
E
02377225
SAV
N
Mozobil 24mg/1.2mL (20mg/mL) Single Use Vial*
Mozobil 24mg/1.2mL (20mg/mL) Single Use Vial*
DNP
DNP
6295.8333 L
6295.8333 L
E
E
00903774
00903773
SAV
SAV
N
N
*use when drug cost in excess of CPhA maximum
L04
N
IMMUNOSUPPRESSANTS
February 2016
139
L
Antineoplastics and Immunomodulating Agents
L04A
IMMUNOSUPPRESSANTS
L04AA
SELECTIVE IMMUNOSUPPRESSANTS
L04AA06
L04AA13
L04AA18
February 2016
MYCOPHENOLIC ACID
mycophenolic acid 180mg tab
Apo-Mycophenolic Acid 180mg Tab
02372738
APX
Myfortic 180mg Tab
02264560
NVR Y
mycophenolic acid 250mg cap
Apo-Mycophenolate 250mg Cap
02352559
APX
Jamp-Mycophenolate 250mg Cap
MYLAN-Mycophenolate 250mg Cap
02386399
02371154
JPC Y
MYL Y
Novo-Mycophenolate 250mg Cap
Sandoz Mycophenolate Mofetil 250mg Cap
02364883
02320630
TEV
SDZ
Y
Y
Cellcept 250mg Cap
02192748
HLR
Y
mycophenolic acid 360mg tab
Apo-Mycophenolic Acid 360mg Tab
02372746
APX
Y
Myfortic 360mg Tab
02264579
NVR Y
mycophenolic acid 500mg tab
Apo-Mycophenolate 500mg Tab
02352567
APX
Jamp-Mycophenolate Mofetil 500mg Tab
MYLAN-Mycophenolate 500mg Tab
02380382
02370549
JPC Y
MYL Y
Novo-Mycophenolate 500mg Tab
Sandoz Mycophenolate Mofetil 500mg Tab
02348675
02313855
TEV
SDZ
Y
Y
Cellcept 500mg Tab
02237484
HLR
Y
Y
Y
Y
Y
Y
LEFLUNOMIDE
leflunomide 10mg tab
Apo-Leflunomide 10mg Tab
Leflunomide 10mg Tab
DNP
DNP
2.6855
2.6855
M
M
SF
SF
02256495
02351668
APX
SAS
MYLAN-Leflunomide 10mg Tab
Novo-Leflunomide 10mg Tab
DNP
DNP
2.6855
2.6855
M
M
SF
SF
02319225
02261251
MYL Y
TEV Y
pms-Leflunomide 10mg Tab
Sandoz Leflunomide 10mg Tab
DNP
DNP
2.6855
2.6855
M
M
SF
SF
02288265
02283964
PMS Y
SDZ Y
Arava 10mg Tab
DNP
2.6855
M
SF
02241888
SAV
Y
leflunomide 20mg tab
Apo-Leflunomide 20mg Tab
DNP
2.6855
M
SF
02256509
APX
Y
Leflunomide 20mg Tab
MYLAN-Leflunomide 20mg Tab
DNP
DNP
2.6855
2.6855
M
M
SF
SF
02351676
02319233
SAS Y
MYL Y
Novo-Leflunomide 20mg Tab
pms-Leflunomide 20mg Tab
DNP
DNP
2.6855
2.6855
M
M
SF
SF
02261278
02288273
TEV Y
PMS Y
Sandoz Leflunomide 20mg Tab
Arava 20mg Tab
DNP
DNP
2.6855
2.6855
M
M
SF
SF
02283972
02241889
SDZ
SAV
Afinitor 2.5mg Tab
Afinitor 2.5mg Tab*
DNP
DNP
196.5473
196.5473
L
L
E
E
02369257
00903881
NVR N
NVR N
Afinitor 5mg Tab
DNP
196.5473
L
E
02339501
NVR N
Afinitor 5mg Tab*
DNP
196.5473
L
E
00903822
NVR N
Y
Y
EVEROLIMUS
140
L
Antineoplastics and Immunomodulating Agents
Afinitor 10mg Tab
Afinitor 10mg Tab*
DNP
DNP
196.5473
196.5473
L
L
E
E
02339528
00903882
NVR N
NVR N
DNP
215.4187
L
E
02286386
BIG
N
DNP
490.0500
L
E
02282097
BRI
N
Benlysta 120mg/vial
02370050
GSK N
Benlysta 400mg/vial
02370069
GSK N
*use when drug cost in excess of CPhA maximum
L04AA23
NATALIZUMAB
Tysabri 300mg/15mL Vial Inj
L04AA24
ABATACEPT
Orencia 250mg/vial Inj
L04AA26
L04AA27
BELIMUMAB
FINGOLIMOD
Gilenya 0.5mg Cap
L04AA31
DNP
85.1650
L
E
02365480
NVR N
DNP
53.4250
L
E
02416328
GZM N
Enbrel 25mg Pdr for Inj
DNP
202.9300
L
E
02242903
AGA N
Enbrel 50mg/mL Inj
Enbrel 50mg/mL Inj*
DNP
DNP
405.9850
405.9850
L
L
E
E
02274728
00903810
AGA N
AGA N
Enbrel Sureclick 50mg/mL Autoinject (PIN 00999655)
*use when drug cost in excess of CPhA maximum
DNP
405.9850
L
E
02274728
AGA N
DNP
DNP
987.5600
987.5600
L
L
E
E
02244016
00903607
JAN
JAN
N
N
Humira 40mg/0.8mL Pen (PIN 97799757)
DNP
925.4500
L
E
02258595
ABV
N
Humira 40mg/0.8mL Syringe Inj (PIN 97799756)
Humira 40mg/0.8mL Syringe Inj*
DNP
DNP
925.4500
925.4500
L
L
E
E
02258595
00903684
ABV
ABV
N
N
DNP
664.5100
L
E
02331675
UCB N
DNP
DNP
3110.3400 L
3110.3400 L
E
E
02324784
02324776
JAN
JAN
TERIFLUNOMIDE
Aubagio 14mg Tab
L04AB
TUMOR NECROSIS FACTOR ALPHA (TNF-ALPHA) INHIBITORS
L04AB01
L04AB02
ETANERCEPT
INFLIXIMAB
Remicade 100mg Pdr for Inj
Remicade 100mg Pdr for Inj*
*use when drug cost in excess of CPhA maximum
L04AB04
ADALIMUMAB
*use when drug cost in excess of CPhA maximum
L04AB05
CERTOLIZUMAB PEGOL
Cimzia 200mg/mL SC Inj
L04AB06
GOLIMUMAB
Simponi 50mg/0.5mL Autoinjector
Simponi 50mg/0.5mL Pre-filled Syringe
L04AC
INTERLEUKIN INHIBITORS
L04AC03
February 2016
ANAKINRA
141
N
N
L
Antineoplastics and Immunomodulating Agents
Kineret 100mg/syringe Inj
L04AC05
L04AC07
L04AC08
BVT
N
USTEKINUMAB
Stelara 45mg/0.5mL Syringe Inj
DNP
9186.2800 L
E
02320673
JAN
N
Stelara 45mg/0.5mL Syringe Inj*
Stelara 90mg/1.0mL Syringe Inj
DNP
DNP
9186.2800 L
4593.1400 L
E
E
00903860
02320681
JAN
JAN
N
N
Stelara 90mg/1.0mL Syringe Inj*
*use when drug cost in excess of CPhA maximum
DNP
4593.1400 L
E
00999746
JAN
N
Actemra 80mg/4mL Inj
DNP
45.2025
L
E
02350092
HLR
N
Actemra 200mg/10mL Inj
DNP
45.2030
L
E
02350106
HLR
N
Actemra 400mg/20mL Inj
DNP
45.2030
L
E
02350114
HLR
N
02344939
NVR N
TOCILIZUMAB
CANAKINUMAB
Ilaris 150mg/vial Inj
L04AD
02245913
CALCINEURIN INHIBITORS
L04AD01
L04AD02
February 2016
CYCLOSPORINE
Neoral 10mg Cap
DNP
0.6238
L
E
02237671
NVR N
cyclosporine 25mg cap
Sandoz Cyclosporine 25mg Cap
DNP
1.3050
M
E
02247073
SDZ
Neoral 25mg Cap
DNP
1.3050
M
E
02150689
NVR Y
cyclosporine 50mg cap
Sandoz Cyclosporine 50mg Cap
DNP
2.5450
M
E
02247074
SDZ
Neoral 50mg Cap
DNP
2.5450
M
E
02150662
NVR Y
cyclosporine 100mg cap
Sandoz Cyclosporine 100mg Cap
DNP
5.0900
M
E
02242821
SDZ
Neoral 100mg Cap
DNP
5.0900
M
E
02150670
NVR Y
cyclosporine 100mg/mL o/l
Apo-Cyclosporine 100mg/mL O/L
DNP
3.7708
M
E
02244324
APX
Neoral 100mg/mL O/L
DNP
3.7708
M
E
02150697
NVR Y
tacrolimus 0.5mg cap
Sandoz Tacrolimus 0.5mg Cap
Prograf 0.5mg Cap
02416816
02243144
SDZ
ASL
Y
Y
Advagraf 0.5mg ER Cap
02296462
ASL
N
tacrolimus 1mg cap
Sandoz Tacrolimus 1mg Cap
Prograf 1mg Cap
02416824
02175991
SDZ
ASL
Y
Y
Advagraf 1mg ER Cap
02296470
ASL
N
Advagraf 3mg Cap
02331667
ASL
N
tacrolimus 5mg cap
Sandoz Tacrolimus 5mg Cap
Prograf 5mg Cap
02416832
02175983
SDZ
ASL
Y
Y
Y
Y
Y
Y
TACROLIMUS
142
L
Antineoplastics and Immunomodulating Agents
Advagraf 5mg ER Cap
L04AX
02296489
ASL
N
Y
Y
OTHER IMMUNOSUPPRESSANTS
L04AX01
L04AX04
AZATHIOPRINE
azathioprine 50mg tab
Apo-Azathioprine 50mg Tab
Azathioprine 50mg Tab
DNP
DNP
0.2405
0.2405
M
M
SFC
SFC
02242907
02343002
APX
SAS
MYLAN-Azathioprine 50mg Tab
Teva-Azathioprine 50mg Tab
DNP
DNP
0.2405
0.2405
M
M
SFC
SFC
02231491
02236819
MYL Y
TEV Y
Imuran 50mg Tab
DNP
0.2405
M
SFC
00004596
APR Y
Revlimid 5mg Cap
DNP
340.0000
L
E
02304899
CEL
N
Revlimid 5mg Cap*
DNP
340.0000
L
E
00903913
CEL
N
Revlimid 10mg Cap
Revlimid 10mg Cap*
DNP
DNP
361.0000
361.0000
L
L
E
E
02304902
00903984
CEL
CEL
N
N
Revlimid 10mg Cap*
DNP
361.0000
L
E
00903791
CEL
N
Revlimid 15mg Cap
Revlimid 15mg Cap*
DNP
DNP
382.0000
382.0000
L
L
E
E
02317699
00903918
CEL
CEL
N
N
Revlimid 25mg Cap
DNP
424.0000
L
E
02317710
CEL
N
Revlimid 25mg Cap*
Revlimid 25mg Cap*
DNP
DNP
424.0000
424.0000
L
L
E
E
00903928
00904065
CEL
CEL
N
N
DNP
13.0302
L
E
02393751
ITM
N
Pomalyst 1mg Cap
Pomalyst 1mg Cap*
DNP
DNP
500.0000
500.0000
L
L
E
E
02419580
00904028
CEL
CEL
N
N
Pomalyst 2mg Cap
DNP
500.0000
L
E
02419599
CEL
N
Pomalyst 2mg Cap*
DNP
500.0000
L
E
00904029
CEL
N
Pomalyst 3mg Cap
Pomalyst 3mg Cap*
DNP
DNP
500.0000
500.0000
L
L
E
E
02419602
00904030
CEL
CEL
N
N
Pomalyst 4mg Cap
DNP
500.0000
L
E
02419610
CEL
N
Pomalyst 4mg Cap*
*use when drug cost in excess of CPhA maximum
DNP
500.0000
L
E
00904031
CEL
N
LENALIDOMIDE
*use when drug cost in excess of CPhA maximum
L04AX05
PIRFENIDONE
Esbriet 267mg Cap
L04AX06
February 2016
POMALIDOMIDE
143
M
Musculo-Skeletal System
M01
ANTIINFLAMMATORY AND ANTIRHEUMATIC PRODUCTS
M01A
ANTIINFLAMMATORY/ANTIRHEUMATIC PROD.,NON-STEROIDS
M01AB
ACETIC ACID AND ACETAMIDE DERIVATIVES
M01AB01
INDOMETHACIN
indomethacin 25mg cap
Novo-Methacin 25mg Cap
Indocid 25mg Cap (discontinued)
DNPM
0.2275
M
SFC
00337420
00016039
TEV
FRS
Y
Y
indomethacin 50mg cap
Novo-Methacin 50mg Cap
Indocid 50mg Cap (discontinued)
DNPM
0.4549
M
SFC
00337439
00016047
TEV
LIH
Y
Y
indomethacin 50mg supp
Sandoz Indomethacin 50mg Supp
Indocid 50mg Supp (discontinued)
DNPM
0.8840
M
SFC
02231799
00594466
SDZ
FRS
Y
Y
01934139
02231800
TEV
SDZ
Y
Y
00016233
FRS
Y
indomethacin 100mg supp
ratio-Indomethacin 100mg Supp (discontinued)
Sandoz Indomethacin 100mg Supp
DNPM
0.8920
M
SFC
Indocid 100mg Supp (discontinued)
M01AB02
M01AB05
February 2016
SULINDAC
sulindac 150mg tab
Novo-Sundac 150mg Tab
Clinoril 150mg Tab (discontinued)
DNP
0.3500
P
SF
00745588
00456888
TEV
LIH
Y
Y
sulindac 200mg tab
Novo-Sundac 200mg Tab
Clinoril 200mg Tab (discontinued)
DNP
0.3500
P
SF
00745596
00432369
TEV
LIH
Y
Y
diclofenac sodium 25mg EC tab
Apo-Diclo 25mg Tab
DNPM
0.0781
M
SF
00839175
APX
Y
Novo-Difenac 25mg Tab
pms-Diclofenac 25mg Tab
DNPM
DNPM
0.0781
0.0781
M
M
SF
SF
00808539
02302616
TEV Y
PMS Y
Sandoz Diclofenac 25mg Tab
Voltaren 25mg Tab (discontinued)
DNPM
0.0781
M
SF
02261952
00514004
SDZ Y
NVR Y
diclofenac potassium 50mg tab
Apo-Diclo Rapide 50mg Tab
Diclofenac Potassium 50mg Tab
02243433
02351684
APX
SAS
pms-Diclofenac-K 50mg Tab
Sandoz Diclofenac Rapide 50mg Tab
02239753
02261774
PMS Y
SDZ Y
Teva-Diclofenac-K 50mg Tab
Voltaren Rapide 50mg Tab
02239355
00881635
TEV Y
NVR Y
DICLOFENAC
Y
Y
diclofenac sodium 50mg EC tab
Apo-Diclo 50mg Tab
Diclofenac Sodium 50mg Tab
DNPM
DNPM
0.2333
0.2333
P
P
SF
SF
00839183
02352397
APX
SAS
Novo-Difenac 50mg Tab
pms-Diclofenac 50mg Tab
DNPM
DNPM
0.2333
0.2333
P
P
SF
SF
00808547
02302624
TEV Y
PMS Y
Sandoz Diclofenac 50mg Tab
Voltaren 50mg Tab
DNPM
DNPM
0.2333
0.2333
P
P
SF
SF
02261960
00514012
SDZ Y
NVR Y
144
Y
Y
M
Musculo-Skeletal System
M01AB08
diclofenac sodium 50mg supp
pms-Diclofenac 50mg Supp
DNPM
0.4670
M
SF
02231506
PMS Y
Sandoz Diclofenac 50mg Supp
Voltaren 50mg Supp
DNPM
DNPM
0.4670
0.4670
M
M
SF
SF
02261928
00632724
SDZ Y
NVR Y
diclofenac sodium 75mg SR tab
Apo-Diclo SR 75mg Tab
Diclofenac Sodium SR 75mg Tab
DNPM
DNPM
0.3500
0.3500
P
P
SF
SF
02162814
02352400
APX
SAS
Novo-Difenac SR 75mg Tab
pms-Diclofenac SR 75mg Tab
DNPM
DNPM
0.3500
0.3500
P
P
SF
SF
02158582
02231504
TEV Y
PMS Y
Sandoz Diclofenac SR 75mg Tab
Voltaren SR 75mg Tab
DNPM
DNPM
0.3500
0.3500
P
P
SF
SF
02261901
00782459
SDZ Y
NVR Y
diclofenac sodium 100mg SR tab
Apo-Diclo SR 100mg Tab
Novo-Difenac SR 100mg Tab
DNPM
DNPM
0.4134
0.4134
M
M
SF
SF
02091194
02048698
APX
TEV
pms-Diclofenac SR 100mg Tab
Sandoz Diclofenac SR 100mg Tab
DNPM
DNPM
0.4134
0.4134
M
M
SF
SF
02231505
02261944
PMS Y
SDZ Y
Voltaren SR 100mg Tab
DNPM
0.4134
M
SF
00590827
NVR Y
diclofenac sodium 100mg supp
pms-Diclofenac 100mg Supp
DNPM
0.6286
M
SF
02231508
PMS Y
Sandoz Diclofenac 100mg Supp
Voltaren 100mg Supp
DNPM
DNPM
0.6286
0.6286
M
M
SF
SF
02261936
00632732
SDZ Y
NVR Y
DNP
0.3500
P
SF
02232317
AAP
02142023
PGA Y
02232318
AAP
02142031
PGA Y
02229080
02162660
AAP
HLR
Y
Y
Ultradol 200mg Cap (discontinued)
etodolac 300mg cap
Etodolac 300mg Cap
DNP
0.3500
P
SF
Ultradol 300mg Cap (discontinued)
Y
Toradol 10mg/mL Inj
DNP
1.2460
L
SF
02162644
HLR
N
ketorolac 30mg/mL inj
Ketorolac 30mg/mL Inj
Toradol 30mg/mL Inj (discontinued)
DNP
4.4100
M
SF
02239944
02162652
SDZ
HLR
Y
Y
02397145
ATV
Y
DICLOFENAC, COMBINATIONS
diclofenac 50mg & misoprostol 200mcg tab
CO Diclo-Miso 50mg Tab
February 2016
Y
KETOROLAC
ketorolac 10mg tab
Apo-Ketorolac 10mg Tab
Toradol 10mg Tab
M01AB55
Y
Y
ETODOLAC
etodolac 200mg cap
Etodolac 200mg Cap
M01AB15
Y
Y
GD-Diclofenac/Misoprostol 50mg Tab
Arthrotec 50mg Tab
DNP
DNP
0.3149
0.3149
M
M
SF
SF
02341689
01917056
GMD Y
PFI Y
diclofenac 75mg & misoprostol 200mcg tab
CO Diclo-Miso 75mg Tab
GD-Diclofenac/Misoprostol 75mg Tab
DNP
0.4286
M
SF
02397153
02341697
ATV Y
GMD Y
145
M
Musculo-Skeletal System
Arthrotec 75mg Tab
M01AC
DNP
0.4286
M
SF
02229837
PFI
Y
DNP
DNP
0.3211
0.3211
M
M
SF
SF
00642886
00695718
APX
TEV
Y
Y
00525596
PFI
Y
OXICAMS
M01AC01
PIROXICAM
piroxicam 10mg cap
Apo-Piroxicam 10mg Cap
Novo-Pirocam 10mg Cap
Feldene 10mg Cap (discontinued)
piroxicam 20mg cap
Apo-Piroxicam 20mg Cap
Novo-Pirocam 20mg Cap
Feldene 20mg Cap (discontinued)
M01AC02
DNP
0.5196
M
SF
00642894
APX
Y
DNP
0.5196
M
SF
00695696
00525618
TEV
PFI
Y
Y
DNP
0.7000
P
SF
02230661
AAP
Y
00884367
HLR
Y
TENOXICAM
tenoxicam 20mg tab
Tenoxicam 20mg Tab
Mobiflex 20mg Tab (discontinued)
M01AC06
M01AE
MELOXICAM
meloxicam 7.5mg tab
Apo-Meloxicam 7.5mg Tab
Auro-Meloxicam 7.5mg Tab
DNP
DNP
0.2003
0.2003
M
M
SF
SF
02248973
02390884
APX Y
ARO Y
CO Meloxicam 7.5mg Tab
Meloxicam 7.5mg Tab
DNP
DNP
0.2003
0.2003
M
M
SF
SF
02250012
02353148
ATV
SAS
MYLAN-Meloxicam 7.5mg Tab
Novo-Meloxicam 7.5mg Tab
DNP
DNP
0.2003
0.2003
M
M
SF
SF
02255987
02258315
MYL Y
TEV Y
pms-Meloxicam 7.5mg Tab
Mobicox 7.5mg Tab
DNP
DNP
0.2003
0.2003
M
M
SF
SF
02248267
02242785
PMS Y
BOE Y
meloxicam 15mg tab
Apo-Meloxicam 15mg Tab
Auro-Meloxicam 15mg Tab
DNP
DNP
0.2311
0.2311
M
M
SF
SF
02248974
02390892
APX Y
ARO Y
CO Meloxicam 15mg Tab
Meloxicam 15mg Tab
DNP
DNP
0.2311
0.2311
M
M
SF
SF
02250020
02353156
ATV
SAS
MYLAN-Meloxicam 15mg Tab
pms-Meloxicam 15mg Tab
DNP
DNP
0.2311
0.2311
M
M
SF
SF
02255995
02248268
MYL Y
PMS Y
Teva-Meloxicam 15mg Tab
Mobicox 15mg Tab
DNP
DNP
0.2311
0.2311
M
M
SF
SF
02258323
02242786
TEV Y
BOE Y
00441643
APX
N
Y
Y
Y
Y
PROPIONIC ACID DERIVATIVES
M01AE01
IBUPROFEN
Apo-Ibuprofen 200mg Tab
ibuprofen 300mg tab
Apo-Ibuprofen 300mg Tab
DNP
0.1377
M
SFC
00441651
APX
Y
Motrin IB 300mg Tab
DNP
0.1377
M
SFC
02242632
JNJ
Y
00506052
APX
Y
DNP
DNP
0.0372
0.0372
M
M
SFC
SFC
02317338
00629340
JPC
TEV
Y
Y
ibuprofen 400mg tab
Apo-Ibuprofen 400mg Tab
Jamp-Ibuprofen 400mg Tab
Novo-Profen 400mg Tab
February 2016
146
M
Musculo-Skeletal System
Motrin IB 400mg Tab
DNP
0.0372
M
SFC
02242658
JNJ
Y
ibuprofen 600mg tab
Apo-Ibuprofen 600mg Tab
DNP
0.1313
M
SFC
00585114
APX
Y
DNP
0.1313
M
SFC
00629359
00484911
TEV
JNJ
Y
Y
DNPM
0.0781
M
SFC
00522678
APX
Y
00299413
HLR
Y
Novo-Profen 600mg Tab
Motrin 600mg Tab (discontinued)
M01AE02
NAPROXEN
naproxen 125mg tab
Apo-Naproxen 125mg Tab
Naprosyn 125mg Tab (discontinued)
naproxen 250mg EC tab
Apo-Naproxen 250mg EC Tab
DNPM
0.1434
M
SFC
02246699
APX
Y
Naproxen 250mg EC Tab
Novo-Naprox 250mg EC Tab
DNPM
DNPM
0.1434
0.1434
M
M
SFC
SFC
02350785
02243312
SAS
TEV
Y
Y
02162792
HLR
Y
Naprosyn-E 250mg EC Tab (discontinued)
naproxen 250mg tab
Apo-Naproxen 250mg Tab
DNPM
0.1068
M
SFC
00522651
APX
Y
Naproxen 250mg Tab
Teva-Naproxen 250mg Tab
DNPM
DNPM
0.1068
0.1068
M
M
SFC
SFC
02350750
00565350
SAS
TEV
Y
Y
02162474
HLR
Y
Naprosyn 250mg Tab (discontinued)
naproxen sodium 275mg tab
Apo-Napro-Na 275mg Tab
DNPM
0.1750
P
SF
00784354
APX
Y
Naproxen Sodium 275mg Tab
Teva-Naprox Sodium 275mg Tab
DNPM
DNPM
0.1750
0.1750
P
P
SF
SF
02351013
00778389
SAS
TEV
Y
Y
Anaprox 275mg Tab
DNPM
0.1750
P
SF
02162725
HLR
Y
naproxen 375mg EC tab
Apo-Naproxen 375mg EC Tab
DNPM
0.1458
M
SFC
02246700
APX
Y
MYLAN-Naproxen 375mg EC Tab
Naproxen 375mg EC Tab
DNPM
DNPM
0.1458
0.1458
M
M
SFC
SFC
02243432
02350793
MYL Y
SAS Y
pms-Naproxen 375mg EC Tab
Teva-Naproxen EC 375mg Tab
DNPM
DNPM
0.1458
0.1458
M
M
SFC
SFC
02294702
02243313
PMS Y
TEV Y
Naprosyn-E 375mg EC Tab
DNPM
0.1458
M
SFC
02162415
HLR
Y
naproxen 375mg tab
Apo-Naproxen 375mg Tab
DNPM
0.1458
M
SFC
00600806
APX
Y
Naproxen 375mg Tab
Teva-Naproxen 375mg Tab
DNPM
DNPM
0.1458
0.1458
M
M
SFC
SFC
02350769
00627097
SAS
TEV
Y
Y
02162482
HLR
Y
Y
Naprosyn 375mg Tab (discontinued)
naproxen 500mg EC tab
Apo-Naproxen 500mg EC Tab
DNPM
0.2426
M
SFC
02246701
APX
MYLAN-Naproxen 500mg EC Tab
Naproxen 500mg EC Tab
DNPM
DNPM
0.2426
0.2426
M
M
SFC
SFC
02241024
02350807
MYL Y
SAS Y
Novo-Naprox 500mg EC Tab
pms-Naproxen 500mg EC Tab
DNPM
DNPM
0.2426
0.2426
M
M
SFC
SFC
02243314
02294710
TEV Y
PMS Y
Naprosyn-E 500mg EC Tab
DNPM
0.2426
M
SFC
02162423
HLR
naproxen 500mg supp
pms-Naproxen 500mg Supp
DNPM
0.9567
M
SFC
02017237
PMS Y
02162458
HLR
Naprosyn 500mg Supp (discontinued)
February 2016
147
Y
Y
M
Musculo-Skeletal System
naproxen 500mg tab
Apo-Naproxen 500mg Tab
DNPM
0.2110
M
SFC
00592277
APX
Y
Naproxen 500mg Tab
Teva-Naproxen 500mg Tab
DNPM
DNPM
0.2110
0.2110
M
M
SFC
SFC
02350777
00589861
SAS
TEV
Y
Y
02162490
HLR
Y
Naprosyn 500mg Tab (discontinued)
M01AE03
M01AE09
naproxen sodium 550mg tab
Apo-Napro-Na DS 550mg Tab
DNPM
0.3500
P
SF
01940309
APX
Y
Naproxen Sodium DS 550mg Tab
Teva-Naprox Sodium DS 550mg Tab
DNPM
DNPM
0.3500
0.3500
P
P
SF
SF
02351021
02026600
SAS
TEV
Y
Y
Anaprox DS 550mg Tab
DNPM
0.3500
P
SF
02162717
HLR
Y
Naprosyn SR 750mg Tab
DNPM
1.4757
L
SFC
02162466
HLR
N
ketoprofen 50mg EC tab
Apo-Keto-E 50mg Tab
Orudis-E 50mg Tab (discontinued)
DNP
0.1750
P
SFC
00790435
01926381
AAP
SAV
Y
Y
ketoprofen 50mg cap
Apo-Keto 50mg Cap
Orudis 50mg Cap (discontinued)
DNP
0.1750
P
SFC
00790427
01926403
AAP
SAV
Y
Y
ketoprofen 100mg EC tab
Apo-Keto-E 100mg Tab
Orudis-E 100mg Tab (discontinued)
DNP
0.3500
P
SFC
00842664
01926365
AAP
SAV
Y
Y
pms-Ketoprofen 100mg supp
DNP
1.2153
L
SFC
02015951
PMS N
ketoprofen 200mg SR tab
Ketoprofen SR 200mg Tab
Orudis-SR 200mg Tab (discontinued)
DNP
0.7000
P
SFC
02172577
01926373
AAP
SAV
Y
Y
DNP
0.1750
P
SF
01912046
APX
Y
DNP
0.1750
P
SF
02100509
00647942
TEV
PFI
Y
Y
DNP
DNP
0.3039
0.3039
M
M
SF
SF
01912038
02100517
APX
TEV
Y
Y
00600792
PFI
Y
KETOPROFEN
FLURBIPROFEN
flurbiprofen 50mg tab
Apo-Flurbiprofen 50mg Tab
Novo-Flurprofen 50mg Tab
Ansaid 50mg Tab (discontinued)
flurbiprofen 100mg tab
Apo-Flurbiprofen 100mg Tab
Novo-Flurprofen 100mg Tab
Ansaid 100mg Tab (discontinued)
M01AE11
M01AE12
TIAPROFENIC ACID
tiaprofenic acid 200mg tab
Novo-Tiaprofenic 200mg Tab
Surgam 200mg Tab (discontinued)
DNP
0.5455
P
SF
02179679
02221942
TEV
SAV
Y
Y
tiaprofenic acid 300mg tab
Novo-Tiaprofenic 300mg Tab
Surgam 300mg Tab (discontinued)
DNP
0.7542
M
SF
02179687
02221950
TEV
SAV
Y
Y
OXAPROZIN
oxaprozin 600mg tab
February 2016
148
M
Musculo-Skeletal System
Apo-Oxaprozin 600mg Tab
Daypro 600mg Tab (discontinued)
M01AG
Y
Y
MEFENAMIC ACID
mefenamic acid 250mg cap
Apo-Mefenamic 250mg Cap
DNP
0.5412
M
F
02229452
AAP
Y
Ponstan 250mg Cap
DNP
0.5412
M
F
00155225
ERF
Y
celecoxib 100mg cap
Apo-Celecoxib 100mg Cap
Celecoxib 100mg Cap
DNP
DNP
0.1759
0.1759
M
M
SF
SF
02418932
02436299
APX
SAS
Y
Y
Celecoxib 100mg Cap
CO Celecoxib 100mg Cap
DNP
DNP
0.1759
0.1759
M
M
SF
SF
02429675
02420155
SIV
ATV
Y
Y
GD-Celecoxib 100mg Cap
Jamp-Celecoxib 100mg Cap
DNP
DNP
0.1759
0.1759
M
M
SF
SF
02291975
02424533
GMD Y
JPC Y
Mar-Celecoxib 100mg Cap
MINT-Celecoxib 100mg Cap
DNP
DNP
0.1759
0.1759
M
M
SF
SF
02420058
02412497
MAR Y
MNT Y
MYLAN-Celecoxib 100mg Cap
pms-Celecoxib 100mg Cap
DNP
DNP
0.1759
0.1759
M
M
SF
SF
02423278
02355442
MYL Y
PMS Y
RAN-Celecoxib 100mg Cap
Sandoz Celecoxib 100mg Cap
DNP
DNP
0.1759
0.1759
M
M
SF
SF
02412373
02321246
RAN Y
SDZ Y
Teva-Celecoxib 100mg Cap
Celebrex 100mg Cap
DNP
DNP
0.1759
0.1759
M
M
SF
SF
02288915
02239941
TEV
PFI
Y
Y
celecoxib 200mg cap
Apo-Celecoxib 200mg Cap
Celecoxib 200mg Cap
DNP
DNP
0.3518
0.3518
M
M
SF
SF
02418940
02436302
APX
SAS
Y
Y
Celecoxib 200mg Cap
CO Celecoxib 200mg Cap
DNP
DNP
0.3518
0.3518
M
M
SF
SF
02429683
02420163
SIV
ATV
Y
Y
GD-Celecoxib 200mg Cap
Jamp-Celecoxib 200mg Cap
DNP
DNP
0.3518
0.3518
M
M
SF
SF
02291983
02424541
GMD Y
JPC Y
Mar-Celecoxib 200mg Cap
MINT-Celecoxib 200mg Cap
DNP
DNP
0.3518
0.3518
M
M
SF
SF
02420066
02412500
MAR Y
MNT Y
MYLAN-Celecoxib 200mg Cap
pms-Celecoxib 200mg Cap
DNP
DNP
0.3518
0.3518
M
M
SF
SF
02399881
02355450
MYL Y
PMS Y
RAN-Celecoxib 200mg Cap
Sandoz Celecoxib 200mg Cap
DNP
DNP
0.3518
0.3518
M
M
SF
SF
02412381
02321254
RAN Y
SDZ Y
Teva-Celecoxib 200mg Cap
Celebrex 200mg Cap
DNP
DNP
0.3518
0.3518
M
M
SF
SF
02288923
02239942
TEV
PFI
Y
Y
DNP
0.1750
P
SF
02238639
APX
Y
SF
02343282
02240867
SAS
TEV
Y
Y
COXIBS
M01AH01
M01AX
APX
PFI
FENEMATES
M01AG01
M01AH
02243661
02027860
CELECOXIB
OTHER ANTIINFLAMMATORY/ANTIRHEUMATICS,NON-STEROIDS
M01AX01
NABUMETONE
nabumetone 500mg tab
Apo-Nabumetone 500mg Tab
Nabumetone 500mg Tab
Novo-Nabumetone 500mg Tab
February 2016
DNP
0.1750
P
149
M
Musculo-Skeletal System
Relafen 500mg Tab (discontinued)
nabumetone 750mg tab
Novo-Nabumetone 750mg Tab
DNP
0.3500
P
SF
Relafen 750mg Tab (discontinued)
M01C
SPECIFIC ANTIRHEUMATIC AGENTS
M01CB
GOLD PREPARATIONS
M01CB01
02240868
TEV
02083558
GSK Y
Y
DNP
DNP
9.6600
9.6600
M
M
SF
SF
02245456
01927620
SDZ
SAV
Y
Y
sodium aurothiomalate 25mg/mL inj
Sodium Aurothiomalate 25mg/mL Inj
Myochrysine 25mg/mL Inj (discontinued)
DNP
11.7100
M
SF
02245457
01927612
SDZ
SAV
Y
Y
Myochrysine 50mg/mL Inj
DNP
23.3300
L
SF
01927604
SAV
N
DNP
6.0142
L
SF
01916823
XPI
N
DNP
3.5990
L
SF
00016055
VLN
N
diclofenac 1.5% w/w top sol
Diclofenac 1.5% Top Sol
02434571
STR Y
pms-Diclofenac 1.5% Top Sol
Taro-Diclofenac 1.5% Top Sol
02356783
02420988
PMS Y
TAR Y
Pennsaid 1.5% Top Sol
02247265
PAL
AURANOFIN
Ridaura 3mg Cap
M01CC
GSK Y
SODIUM AUROTHIOMALATE
sodium aurothiomalate 10mg/mL inj
Sodium Aurothiomalate 10mg/mL Inj
Myochrysine 10mg/mL Inj
M01CB03
02083531
PENICILLAMINE AND SIMILAR AGENTS
M01CC01
PENICILLAMINE
Cuprimine 250mg Cap
M02
TOPICAL PRODUCTS FOR JOINT AND MUSCULAR PAIN
M02A
TOPICAL PRODUCTS FOR JOINT AND MUSCULAR PAIN
M02AA
ANTIINFLAMMATORY PREPS,NON-STEROIDS TOPICAL USE
M02AA15
DICLOFENAC
M03
MUSCLE RELAXANTS
M03A
PERIPHERALLY ACTING AGENTS,MUSCLE RELAXANTS
M03AX
OTHER MUSCLE RELAXANTS,PERIPHERALLY ACTING
M03AX01
M03AX01
February 2016
Y
INCOBOTULINUMTOXIN-A
Xeomin 50iu/vial inj
DNP
165.0000
L
E
02371081
MRZ N
Xeomin 100iu/vial Inj
DNP
330.0000
L
E
02324032
MRZ N
Botox 50iu/vial Inj
DNP
178.5000
L
E
00999443
ALL
N
Botox 100iu/vial Inj
DNP
357.0000
L
E
01981501
ALL
N
ONABOTULINUMTOXIN-A
150
M
Musculo-Skeletal System
Botox 200iu/vial Inj
00999505
ALL
Robaxin 500mg Tab
01930990
WCH N
Robaxin 750mg Tab
01932187
WCH N
Methoxacet Caplet (discontinued)
Methoxacet-C1/8 Caplet
02230521
02236872
ROG N
ROG N
Methoxisal-C1/2 Caplet
Methoxisal-C1/4 Caplet
01966375
01966367
ROG N
ROG N
Methoxisal-C1/8 Caplet
Robaxacet Caplet
01941895
02026805
ROG N
WCH N
Robaxacet-8 Tab
Robaxisal C1/2 Tab
01934767
01934791
WCH N
WCH N
Robaxisal C1/4 Tab
01934783
WCH N
orphenadrine 100mg tab
Sandoz Orphenadrine 100mg Tab
Norflex 100mg Tab (discontinued)
02243559
01966154
SDZ Y
GWP Y
Orfenace 100mg Tab
02047535
STR N
Lioresal Intrathecal 0.05mg/mL
02131048
NVR N
Lioresal Intrathecal 0.5mg/mL
02131056
NVR N
Lioresal Intrathecal 2mg/mL
02131064
NVR N
M03B
CENTRALLY ACTING AGENTS
M03BA
CARBAMIC ACID ESTERS
M03BA03
M03BA53
M03BC
714.0000
L
E
N
METHOCARBAMOL
METHOCARBAMOL, COMBINATIONS EXCLUDING PSYCHOLEPTICS
ETHERS, CHEMICALLY CLOSE TO ANTIHISTAMINES
M03BC01
M03BX
DNP
ORPHENADRINE (CITRATE)
OTHER CENTRALLY ACTING AGENTS
M03BX01
February 2016
BACLOFEN
baclofen 10mg tab
Apo-Baclofen 10mg Tab
DNP
0.1716
M
SF
02139332
APX
Baclofen 10mg Tab
MYLAN-Baclofen 10mg Tab
DNP
DNP
0.1716
0.1716
M
M
SF
SF
02287021
02088398
SAS Y
MYL Y
pms-Baclofen 10mg Tab
ratio-Baclofen 10mg Tab
DNP
DNP
0.1716
0.1716
M
M
SF
SF
02063735
02236507
PMS Y
TEV Y
Lioresal 10mg Tab
DNP
0.1716
M
SF
00455881
NVR Y
baclofen 20mg tab
Apo-Baclofen 20mg Tab
DNP
0.3340
M
SF
02139391
APX
Baclofen 20mg Tab
MYLAN-Baclofen 20mg Tab
DNP
DNP
0.3340
0.3340
M
M
SF
SF
02287048
02088401
SAS Y
MYL Y
pms-Baclofen 20mg Tab
ratio-Baclofen 20mg Tab
DNP
DNP
0.3340
0.3340
M
M
SF
SF
02063743
02236508
PMS Y
TEV Y
Lioresal DS 20mg Tab
DNP
0.3340
M
SF
00636576
NVR Y
151
Y
Y
M
Musculo-Skeletal System
M03BX02
M03BX08
TIZANIDINE
tizanidine 4mg tab
Apo-Tizanidine 4mg Tab
DNP
0.3686
M
E
02259893
AAP
Y
Zanaflex 4mg Tab
DNP
0.3686
M
E
02239170
PAL
Y
cyclobenzaprine HCl 10mg tab
Apo-Cyclobenzaprine 10mg Tab
Auro-Cyclobenzaprine 10mg Tab
DNP
DNP
0.3727
0.3727
M
M
SF
SF
02177145
02348853
APX Y
ARO Y
Cyclobenzaprine 10mg Tab
Cyclobenzaprine 10mg Tab
DNP
DNP
0.3727
0.3727
M
M
SF
SF
02424584
02287064
SIV
SAS
Jamp-Cyclobenzaprine 10mg Tab
MYLAN-Cyclobenzaprine 10mgTab
DNP
DNP
0.3727
0.3727
M
M
SF
SF
02357127
02231353
JPC Y
MYL Y
Novo-Cycloprine 10mg Tab
pms-Cyclobenzaprine 10mg Tab
DNP
DNP
0.3727
0.3727
M
M
SF
SF
02080052
02212048
TEV Y
PMS Y
00782742
JAN
CYCLOBENZAPRINE
Flexeril 10mg Tab (discontinued)
M03C
DIRECTLY ACTING AGENTS
M03CA
DANTROLENE AND DERIVATIVES
M03CA01
Dantrium 25mg Cap
DNP
0.3940
L
SF
01997602
MTP N
Dantrium 100mg Cap
DNP
0.7684
L
SF
01997653
MTP N
allopurinol 100mg tab
Apo-Allopurinol 100mg Tab
DNP
0.0780
M
SFC
02402769
APX
Mar-Allopurinol 100mg Tab
Zyloprim 100mg Tab
DNP
DNP
0.0780
0.0780
M
M
SFC
SFC
02396327
00402818
MAR Y
AAP Y
00004588
GSK Y
ANTIGOUT PREPARATIONS
M04A
ANTIGOUT PREPARATIONS
M04AA
PREPARATIONS INHIBITING URIC ACID PRODUCTION
ALLOPURINOL
Zyloprim 100mg Tab (discontinued)
DNP
0.1300
M
SFC
02402777
APX
Mar-Allopurinol 200mg Tab
Zyloprim 200mg Tab
DNP
DNP
0.1300
0.1300
M
M
SFC
SFC
02396335
00479799
MAR Y
AAP Y
00506370
GSK Y
Y
allopurinol 300mg tab
Apo-Allopurinol 300mg Tab
DNP
0.2125
M
SFC
02402785
APX
Mar-Allopurinol 300mg Tab
Zyloprim 300mg Tab
DNP
DNP
0.2125
0.2125
M
M
SFC
SFC
02396343
00402796
MAR Y
AAP Y
00294322
GSK Y
02357380
TAK
Zyloprim 300mg Tab (discontinued)
Y
FEBUXOSTAT
Uloric 80mg Tab
February 2016
Y
allopurinol 200mg tab
Apo-Allopurinol 200mg Tab
Zyloprim 200mg Tab (discontinued)
M04AA03
Y
DANTROLENE
M04
M04AA01
Y
Y
DNP
1.5900
L
E
152
N
M
Musculo-Skeletal System
M04AB
PREPARATIONS INCREASING URIC ACID EXCRETION
M04AB02
SULFINPYRAZONE
sulfinpyrazone 200mg tab
Sulfinpyrazone 200mg Tab
DNP
0.3252
M
SFC
Anturan 200mg Tab (discontinued)
M04AC
00441767
AAP
00010529
NVR Y
Y
PREPARATION WITH NO EFFECT ON URIC ACID METABOLISM
M04AC01
COLCHICINE
colchicine 0.6mg tab
Colchicine 0.6mg Tab
Euro-Colchicine 0.6mg Tab
DNP
0.2565
M
SF
00572349
00287873
ODN Y
EUR Y
pms-Colchicine 0.6mg Tab
Colchicine 0.6mg Tab (discontinued)
DNP
0.2565
M
SF
02402181
00000396
PMS Y
ABB Y
Jamp-Colchicine 0.6mg Tab
DNP
0.2565
L
SF
02373823
JPC
N
DNP
0.4997
M
E
02248686
ATV
Y
DNP
0.4997
M
E
02245330
01997629
MYL Y
PGA Y
01984837
BAY
N
01984845
BAY
N
pamidronate disodium 30mg/vial inj
Pamidronate Disodium Omega 30mg/vial Inj
Aredia 30mg/vial Inj
02249669
02059762
OMG Y
NVR Y
pamidronate disodium 90mg/vial inj
Pamidronate Disodium Omega 90mg/mL Inj
Aredia 90mg/vial Inj
02249685
02059789
OMG Y
NVR Y
alendronate 5mg tab
Alendronate Sodium 5mg Tab
02381478
AHI
Apo-Alendronate 5mg Tab
RAN-Alendronate 5mg Tab
02248727
02384698
APX Y
RAN Y
Sandoz Alendronate 5mg Tab
Fosamax 5mg Tab (discontinued)
02288079
02233055
SDZ
FRS
Y
Y
02381486
02248728
AHI
APX
Y
Y
M05
DRUGS FOR TREATMENT OF BONE DISEASES
M05B
DRUGS AFFECTING BONE STRUCTURE AND MINERALIZATION
M05BA
BISPHOSPHONATES
M05BA01
ETIDRONIC ACID (ETIDRONATE)
etidronate 200mg tab
CO Etidronate 200mg Tab
MYLAN-Etidronate 200mg Tab
Didronel 200mg Tab (discontinued)
M05BA02
CLODRONIC ACID (CLODRONATE)
Bonefos 60mg/mL Inj
Bonefos 400mg Cap
M05BA03
M05BA04
1.9582
L
SFC
PAMIDRONIC ACID (PAMIDRONATE)
ALENDRONIC ACID (ALENDRONATE)
alendronate 10mg tab
Alendronate Sodium 10mg Tab
Apo-Alendronate 10mg Tab
February 2016
DNP
DNP
DNP
0.4986
0.4986
M
M
SFC
SFC
153
Y
M
Musculo-Skeletal System
Auro-Alendronate 10mg Tab
MINT-Alendronate 10mg Tab
DNP
DNP
0.4986
0.4986
M
M
SFC
SFC
02388545
02394863
ARO Y
MNT Y
MYLAN-Alendronate 10mg Tab (discontinued)
RAN-Alendronate 10mg Tab
DNP
0.4986
M
SFC
02270129
02384701
MYL Y
RAN Y
Sandoz Alendronate 10mg Tab
Teva-Alendronate 10mg Tab
DNP
DNP
0.4986
0.4986
M
M
SFC
SFC
02288087
02247373
SDZ
TEV
Y
Y
02201011
FRS
Y
02258102
ATV
Y
02201038
FRS
Y
Fosamax 10mg Tab (discontinued)
alendronate 40mg tab
CO Alendronate 40mg Tab
DNP
3.0832
M
E
Fosamax 40mg Tab (discontinued)
M05BA07
February 2016
alendronate 70mg tab
Alendronate 70mg Tab
DNP
2.5144
M
SFC
02352966
SAS
Y
Alendronate Sodium 70mg Tab
Alendronate-FC 70mg Tab
DNP
DNP
2.5144
2.5144
M
M
SFC
SFC
02381494
02299712
AHI
SIV
Y
Y
Apo-Alendronate 70mg Tab
Auro-Alendronate 70mg Tab
DNP
DNP
2.5144
2.5144
M
M
SFC
SFC
02248730
02388553
APX Y
ARO Y
CO Alendronate 70mg Tab
Jamp-Alendronate 70mg Tab
DNP
DNP
2.5144
2.5144
M
M
SFC
SFC
02258110
02385031
ATV
JPC
MINT-Alendronate 70mg Tab
MYLAN-Alendronate 70mg Tab
DNP
DNP
2.5144
2.5144
M
M
SFC
SFC
02394871
02286335
MNT Y
MYL Y
pms-Alendronate-FC 70mg Tab
RAN-Alendronate 70mg Tab
DNP
DNP
2.5144
2.5144
M
M
SFC
SFC
02284006
02384728
PMS Y
RAN Y
Sandoz Alendronate 70mg Tab
Teva-Alendronate 70mg Tab
DNP
DNP
2.5144
2.5144
M
M
SFC
SFC
02288109
02261715
SDZ
TEV
Y
Y
Fosamax 70mg Tab
DNP
2.5144
M
SFC
02245329
FRS
Y
risedronate 5mg tab
Teva-Risedronate 5mg Tab
Actonel 5mg Tab
DNP
DNP
1.5620
1.5620
M
M
SFC
SFC
02298376
02242518
TEV
ATV
Y
Y
risedronate 30mg tab
Teva-Risedronate 30mg Tab
Actonel 30mg Tab
DNP
DNP
10.1203
10.1203
M
M
E
E
02298384
02239146
TEV
ATV
Y
Y
risedronate 35mg tab
Apo-Risedronate 35mg Tab
Auro-Risedronate 35mg Tab
DNP
DNP
2.9500
2.9500
M
M
SFC
SFC
02353687
02406306
APX Y
ARO Y
Jamp-Risedronate 35mg Tab
MYLAN-Risedronate 35mg Tab
DNP
DNP
2.9500
2.9500
M
M
SFC
SFC
02368552
02357984
JPC Y
MYL Y
pms-Risedronate 35mg Tab
ratio-Risedronate 35mg Tab (discontinued)
DNP
2.9500
M
SFC
02302209
02319861
PMS Y
TEV Y
Risedronate 35mg Tab
Risedronate-35mg Tab
DNP
DNP
2.9500
2.9500
M
M
SFC
SFC
02370255
02411407
SAS
SIV
Y
Y
Sandoz Risedronate 35mg Tab
Teva-Risedronate 35mg Tab
DNP
DNP
2.9500
2.9500
M
M
SFC
SFC
02327295
02298392
SDZ
TEV
Y
Y
Actonel 35mg Tab
DNP
2.9500
M
SFC
02246896
WNC Y
risedronate 150mg tab
Apo-Risedronate 150mg Tab
02377721
APX
MYLAN-Risedronate 150mg Tab
02397773
MYL Y
Y
Y
RISEDRONIC ACID (RISEDRONATE)
154
Y
M
Musculo-Skeletal System
M05BA08
pms-Risedronate 150mg Tab
Teva-Risedronate 150mg Tab
02424177
02413809
PMS Y
TEV Y
Actonel 150mg Tab
02316838
WNC Y
zoledronic acid 4mg inj
pms-Zoledronic Acid 4mg/5mL Inj (discontinued)
Taro-Zoledronic Acid 4mg/5mL Inj
02403056
02415186
PMS Y
TAR Y
Teva-Zoledronic Acid 4mg/5mL Inj
Zoledronic Acid 4mg/5mL Inj
02407639
02413701
TEV Y
OMG Y
Zoledronic Acid 4mg/5mL Inj
Zoledronic Acid Z 4mg/5mL Inj
02422425
02401606
RCH Y
SDZ Y
Zometa 4mg/vial Inj
02248296
NVR Y
ZOLEDRONIC ACID
zoledronic acid 5mg inj
Taro-Zoledronic Acid 5mg/100mL Inj
M05BB
DNP
3.3540
M
E
02415100
TAR Y
Teva-Zoledronic Acid 5mg/100mL Inj
Zoledronic Acid 5mg/100mL Inj
DNP
3.3540
M
E
02408082
02422433
TEV Y
RCH Y
Aclasta 5mg/100mL Inj
DNP
3.3540
M
E
02269198
NVR Y
M
E
02263866
02353210
ATV
SAS
02176017
WNC Y
02403633
02276429
TEV
FRS
Y
Y
BISPHOSPHONATES, COMBINATIONS
M05BB01
ETIDRONIC ACID AND CALCIUM, SEQUENTIAL
etidronic disodium 400mg & calcium carbonate 500mg tab, sequential kit
CO Etidrocal Kit
DNP
19.9900
Etidrocal Kit (discontinued)
Didrocal Kit (discontinued)
M05BB03
ALENDRONIC ACID AND CHOLECALCIFEROL
alendronic acid 70mg & cholecalciferol 2800 IU tab
Alendronate/Cholecalciferol 70mg/2800 IU Tab
Fosavance 70mg/2800 IU Tab
M05BX
Y
Y
alendronic acid 70mg & cholecalciferol 5600 IU tab
Alendronate/Cholecalciferol 70mg/5600 IU Tab
Sandoz Alendronate/Cholecalciferol 70mg/140mcg Tab
DNP
DNP
2.3312
2.3312
M
M
SFC
SFC
02403641
02429160
TEV
SDZ
Y
Y
Fosavance 70mg/5600 IU Tab
DNP
2.3312
M
SFC
02314940
FRS
Y
Prolia 60mg/mL Inj
DNP
361.9000
L
E
02343541
AGA N
Xgeva 120mg/1.7mL Sol
DNP
333.7235
L
E
02368153
AGA N
OTHER DRUGS AFFECTING MINERALIZATION
M05BX04
February 2016
DENOSUMAB
155
N
Nervous System
N01
ANAESTHETICS
N01A
ANAESTHETICS, GENERAL
N01AH
OPIOID ANESTHETICS
N01AH01
FENTANYL
fentanyl citrate 50mcg/mL inj
Fentanyl Citrate 50mcg/mL Inj
Fentanyl Citrate 50mcg/mL Inj
N01AH02
N01AH03
02240434
00888346
SDZ Y
HOS Y
alfentanil 500mcg/mL inj
Alfentanil 500mcg/mL Inj (discontinued)
02248181
SDZ
Y
Alfenta 500mcg/mL Inj (discontinued)
00755818
JAN
Y
02244147
01951319
SDZ
JAN
Y
Y
ketamine 10mg/mL inj
Ketamine 10mg/mL Inj
02246795
SDZ
Y
Ketalar 10mg/mL Inj
00224391
ERF
Y
ketamine 50mg/mL inj
Ketamine 50mg/mL Inj
02246796
SDZ
Y
Ketalar 50mg/mL Inj
00224405
ERF
Y
ALFENTANIL
SUFENTANIL
sufentanil citrate 50mcg/mL inj
Sufentanil Citrate 50mcg/mL Inj
Sufenta 50mcg/mL Inj (discontinued)
N01AX
DN
11.7830
M
SFC
VARIOUS GENERAL ANAESTHETICS
N01AX03
KETAMINE
N01B
LOCAL ANAESTHETICS, EXCL DERMATOLOGICALS
N01BB
AMIDES
N01BB01
N01BB02
BUPIVACAINE
Marcaine 0.25% Inj
DNPM
0.7505
L
SFC
02241918
HOS N
Sensorcaine 0.25% Inj
DNPM
0.5100
L
SFC
01976141
AZE
Marcaine 0.5% Inj
Sensorcaine 0.5% Inj
DNPM
DNPM
0.8930
0.5980
L
L
SFC
SFC
02241919
01976168
HOS N
AZE N
Xylocaine 1% (with perservative)
Xylocaine 1% Inj
DNPM
DNPM
0.2185
0.9250
L
L
SFC
SFC
02302411
00001732
AZE
AZE
N
N
Xylocaine 2% (with perservative)
DNPM
0.2320
L
SFC
02302438
AZE
N
Xylocaine 2% Inj
Xylocaine 2% Jelly Inj
DNPM
DNPM
1.1080
0.9170
L
L
SFC
SFC
00036641
00385484
AZE
AZE
N
N
02231147
ODN N
00284106
AZE
LIDOCAINE
Lidodan Endotracheal 10mg/ACT Liq
N01BB52
LIDOCAINE, COMBINATIONS
Xylocaine 2% W Epine Inj
February 2016
N
DNPM
0.4325
L
SFC
156
N
N
Nervous System
N02
ANALGESICS
N02A
OPIOIDS
N02AA
NATURAL OPIUM ALKALOIDS
N02AA01
MORPHINE
Morphine LP Epidural 0.5mg/mL Inj
Morphine LP Epidural 1mg/mL Inj
SDZ
N
02021048
SDZ
N
ratio-Morphine 1mg/mL Syr
Statex 1mg/mL Syr
DN
DN
0.0306
0.0200
L
L
SFC
SFC
00607762
00591467
TEV
PAL
N
N
Morphine Sulfate 2mg/mL Inj
DN
0.2528
L
SFC
01964437
SDZ
N
Morphine Sulfate 2mg/mL Inj
DN
1.9490
L
SFC
02242484
SDZ
N
ratio-Morphine 5mg/mL Syr
MOS Sulphate 5mg Tab
DN
DN
0.1061
0.1166
L
L
SFC
SFC
00607770
02009773
TEV
VLN
N
N
MS-IR 5mg Tab
Statex 5mg Tab
DN
DN
0.1240
0.1420
L
L
SFC
SFC
02014203
00594652
PFR
PAL
N
N
Statex 5mg/mL Syr
DN
0.0803
L
SFC
00591475
PAL
N
morphine sulfate 10mg/mL inj
Morphine Sulfate 10mg/mL Inj
DN
2.0648
M
SFC
00392588
SDZ
Y
00497355
ABB
Y
Morphine Sulfate 10mg/mL Inj (ABB) (discontinued)
ratio-Morphine 10mg/mL Syr
Kadian 10mg Cap
DN
DN
0.2008
0.3841
L
L
SFC
SFC
00690783
02242163
TEV
ABB
N
N
M-Eslon ER 10mg Cap
MOS Sulphate 10mg Tab
DN
DN
0.3070
0.1803
L
L
SFC
SFC
02019930
02009765
SAV
VLN
N
N
MS-IR 10mg Tab
Statex 10mg Supp
DN
DN
0.1930
1.9310
L
L
SFC
SFC
02014211
00632201
PFR
PAL
N
N
Statex 10mg Tab
DN
0.1860
L
SFC
00594644
PAL
N
morphine sulfate 15mg SR tab
Morphine SR 15mg Tab
DN
0.2317
M
SFC
02350815
SAS
Y
Novo-Morphine SR 15mg Tab
Sandoz Morphine SR 15mg Tab
DN
DN
0.2317
0.2317
M
M
SFC
SFC
02302764
02244790
TEV
SDZ
Y
Y
MS Contin 15mg Tab
DN
0.2317
M
SFC
02015439
PFR
Y
morphine sulfate 15mg/mL inj
Morphine Sulfate 15mg/mL Inj
DN
1.5162
M
SFC
00392561
SDZ
Y
00497363
ABB
Y
Morphine Sulfate 15mg/mL Inj (ABB - discontinued)
February 2016
02021056
M-Eslon ER 15mg Cap
DN
0.3540
L
SFC
02177749
SAV
N
Kadian 20mg Cap
MS-IR 20mg Tab
DN
DN
0.8266
0.3440
L
L
SFC
SFC
02184435
02014238
ABB
PFR
N
N
Statex 20mg Supp
Statex 20mg/mL Drops
DN
DN
2.3080
0.5080
L
L
SFC
SFC
00596965
00621935
PAL
PAL
N
N
Morphine HP 25mg/mL Inj
DN
2.8900
L
SFC
00676411
SDZ
N
MOS Sulphate 25mg Tab
Statex 25mg Tab
DN
DN
0.2386
0.2250
L
L
SFC
SFC
02009749
00594636
VLN
PAL
N
N
morphine sulfate 30mg SR tab
Morphine SR 30mg Tab
Novo-Morphine SR 30mg Tab
DN
DN
0.3500
0.3500
M
M
SFC
SFC
02350890
02302772
SAS
TEV
Y
Y
Sandoz Morphine SR 30mg Tab
DN
0.3500
M
SFC
02244791
SDZ
Y
157
N
Nervous System
MS Contin 30mg Tab
DN
0.3500
M
SFC
02014297
PFR
Y
M-Eslon ER 30mg Cap
MOS-SR 30mg Tab (discontinued)
DN
0.5290
L
SFC
02019949
00776181
SAV
VLN
N
N
MS-IR 30mg Tab
Statex 30mg Supp
DN
DN
0.4410
2.5330
L
L
SFC
SFC
02014254
00639389
PFR
PAL
N
N
Morphine HP 50mg/mL Inj
DN
5.2994
L
SFC
00617288
SDZ
N
Kadian 50mg Cap
MOS Sulphate 50mg Tab
DN
DN
1.5111
0.3659
L
L
SFC
SFC
02184443
02009706
ABB
VLN
N
N
Statex 50mg Tab
Statex 50mg/mL Drops
DN
DN
0.3450
0.9654
L
L
SFC
SFC
00675962
00705799
PAL
PAL
N
N
morphine sulfate 60mg SR tab
Morphine SR 60mg Tab
Novo-Morphine SR 60mg Tab
DN
DN
0.6167
0.6167
M
M
SFC
SFC
02350912
02302780
SAS
TEV
Y
Y
Sandoz Morphine SR 60mg Tab
MS Contin 60mg Tab
DN
DN
0.6167
0.6167
M
M
SFC
SFC
02244792
02014300
SDZ
PFR
Y
Y
M-Eslon ER 60mg Cap
DN
0.9390
L
SFC
02019957
SAV
N
00776203
VLN
N
MOS-SR 60mg Tab (discontinued)
N02AA03
February 2016
morphine sulfate 100mg SR tab
Novo-Morphine SR 100mg Tab
DN
2.4822
M
SFC
02302799
TEV
Y
MS Contin 100mg Tab
DN
2.4822
M
SFC
02014319
PFR
Y
Kadian 100mg Cap
M-Eslon ER 100mg Cap
DN
DN
2.6518
2.0220
L
L
SFC
SFC
02184451
02019965
ABB
SAV
N
N
morphine sulfate 200mg SR tab
Novo-Morphine SR 200mg Tab
MS Contin 200mg Tab
DN
DN
4.6150
4.6150
M
M
SFC
SFC
02302802
02014327
TEV
PFR
Y
Y
M-Eslon ER 200mg Cap
DN
4.0450
L
SFC
02177757
SAV
N
hydromorphone 1mg/mL oral sol
pms-Hydromorphone 1mg/mL Oral Sol
DN
0.0717
M
SFC
01916386
PMS Y
Dilaudid 1mg/mL Oral Sol
DN
0.0717
M
SFC
00786535
PFR
Y
hydromorphone HCl 1mg tab
Apo-Hydromorphone 1mg Tab
DN
0.0959
M
SFC
02364115
APX
Y
pms-Hydromorphone 1mg Tab
Teva-Hydromorphone 1mg Tab
DN
DN
0.0959
0.0959
M
M
SFC
SFC
00885444
02319403
PMS Y
TEV Y
Dilaudid 1mg Tab
DN
0.0959
M
SFC
00705438
PFR
Y
hydromorphone 2mg/mL inj
Hydromorphone 2mg/mL Inj
DN
1.7825
M
SFC
02145901
SDZ
Y
Dilaudid 2mg/mL Inj
DN
1.7825
M
SFC
00627100
PFR
Y
hydromorphone HCl 2mg tab
Apo-Hydromorphone 2mg Tab
DN
0.1417
M
SFC
02364123
APX
Y
pms-Hydromorphone 2mg Tab
Teva-Hydromorphone 2mg Tab
DN
DN
0.1417
0.1417
M
M
SFC
SFC
00885436
02319411
PMS Y
TEV Y
Dilaudid 2mg Tab
DN
0.1417
M
SFC
00125083
PFR
Y
Hydromorph Contin 3mg Cap
DN
0.6950
L
SFC
02125323
PFR
N
HYDROMORPHONE
158
N
Nervous System
hydromorphone HCl 4mg tab
Apo-Hydromorphone 4mg Tab
DN
0.2240
M
SFC
02364131
APX
pms-Hydromorphone 4mg Tab
Teva-Hydromorphone 4mg Tab
DN
DN
0.2240
0.2240
M
M
SFC
SFC
00885401
02319438
PMS Y
TEV Y
Dilaudid 4mg Tab
DN
0.2240
M
SFC
00125121
PFR
Y
02337266
JAN
N
Jurnista 4mg Tab
Hydromorph Contin 4.5mg Cap
DN
0.8390
L
SFC
02359502
PFR
N
Hydromorph Contin 6mg Cap
DN
1.0420
L
SFC
02125331
PFR
N
hydromorphone HCl 8mg tab
Apo-Hydromorphone 8mg Tab
DN
0.3528
M
SFC
02364158
APX
Y
pms-Hydromorphone 8mg Tab
Teva-Hydromorphone 8mg Tab
DN
DN
0.3528
0.3528
M
M
SFC
SFC
00885428
02319446
PMS Y
TEV Y
Dilaudid 8mg Tab
DN
0.3528
M
SFC
00786543
PFR
Y
02337274
JAN
N
Junista 8mg Tab
Hydromoprh Contin 9mg Cap
DN
1.3760
L
SFC
02359510
PFR
N
hydromorphone 10mg/mL inj
Hydromorphone HP 10mg/mL Inj
DN
3.9680
M
SFC
02145928
SDZ
Y
Dilaudid HP 10mg/mL Inj
DN
3.9680
M
SFC
00622133
PFR
Y
Hydromorph Contin 12mg Cap
DN
1.8060
L
SFC
02125366
PFR
N
02337282
JAN
N
Junista 16mg Tab
Hydromorph Contin 18mg Cap
DN
2.6060
L
SFC
02243562
PFR
N
hydromorphone 20mg/mL inj
Hydromorphone HP 20mg/mL Inj
DN
6.7223
M
SFC
02145936
SDZ
Y
02146118
PFR
Y
Dilaudid HP Plus 20mg/mL Inj (discontinued)
Hydromorph Contin 24mg Cap
DN
3.3350
L
SFC
02125382
PFR
N
Hydromorph Contin 30mg Cap
DN
3.9950
L
SFC
02125390
PFR
N
02337290
JAN
N
02146126
SDZ
Y
02145863
PFR
Y
02387425
PFR
N
Junista 32mg Tab
hydromorphone 50mg/mL inj
Hydromorphone HP 50mg/mL Inj
DN
16.7013
M
SFC
Dilaudid XP 50mg/mL Inj (discontinued)
N02AA05
OXYCODONE
Targin 2.5/5mg Tab
oxycodone 5mg tab (Oxy-IR)
pms-Oxycodone 5mg Tab
Oxy-IR 5mg Tab
DN
DN
0.1776
0.1776
M
M
SFC
SFC
02319977
02231934
PMS Y
PFR Y
oxycodone 5mg tab (Supeudol)
pms-Oxycodone 5mg Tab
Supeudol 5mg Tab
DN
DN
0.1776
0.1776
M
M
SFC
SFC
02319977
00789739
PMS Y
SDZ Y
02339609
PFR
02319985
02240131
PMS Y
PFR Y
Targin 5/10mg Tab
oxycodone 10mg tab (Oxy-IR)
pms-Oxycodone 10mg Tab
Oxy-IR 10mg Tab
February 2016
Y
DN
DN
0.2760
0.2760
M
M
SFC
SFC
159
N
N
Nervous System
oxycodone 10mg tab (Supeudol)
pms-Oxycodone 10mg Tab
DN
0.2760
M
SFC
02319985
PMS Y
Supeudol 10mg Tab
DN
0.2760
M
SFC
00443948
SDZ
Y
OxyNeo 10mg Tab
Supeudol 10mg Supp
DN
3.1442
L
SFC
02372525
00392480
PFR
SDZ
N
N
Targin 10/20mg Tab
02339617
PFR
N
OxyNeo 15mg Tab
02372533
PFR
N
oxycodone 20mg tab (Oxy-IR)
pms-Oxycodone 20mg Tab
Oxy-IR 20mg Tab
DN
DN
0.4538
0.4538
M
M
SFC
SFC
02319993
02240132
PMS Y
PFR Y
DN
0.4538
M
SFC
02319993
02262983
PMS Y
SDZ Y
02372797
PFR
N
DN
4.5383
L
SFC
00392472
SDZ
N
Targin 20/40mg Tab
02339625
PFR
N
OxyNeo 30mg Tab
02372541
PFR
N
OxyNeo 40mg Tab
02372568
PFR
N
OxyNeo 60mg Tab
02372576
PFR
N
OxyNeo 80mg Tab
02372584
PFR
N
oxycodone 20mg tab (Supeudol)
pms-Oxycodone 20mg Tab
Supeudol 20mg Tab
OxyNeo 20mg Tab
Supeudol 20mg Supp
N02AA59
N02AB
CODEINE, COMBINATIONS EXCL. PSYCHOLEPTICS
ratio-Emtec Tab
DN
0.1300
L
SFC
00608882
TEV
N
ratio-Lenoltec #3 Tab
ratio-Lenoltec #4 Tab
DN
DN
0.0889
0.1605
L
L
SFC
SFC
00653276
00621463
TEV
TEV
N
N
292 Tab
Atasol 30 Tab
DN
DN
0.1730
0.1338
L
L
SFC
SFC
02238645
00293512
PDP N
CHU N
Tylenol #3 Tab
Tylenol #4 Tab
DN
DN
0.1241
0.2623
L
L
SFC
SFC
02163926
02163918
JAN
JAN
N
N
DN
1.8630
M
SFC
00725765
SDZ
Y
Demerol 50mg/mL Inj (discontinued)
02139022
SAV
Y
Demerol 50mg Tab
02138018
SAV
N
00725757
SDZ
Y
02139049
SAV
Y
00725749
SDZ
Y
02242005
HOS Y
PHENYLPIPERIDINE DERIVATIVES
N02AB02
PETHIDINE (MEPERIDINE)
pethidine 50mg/mL inj
Meperidine 50mg/mL Inj
pethidine 75mg/mL inj
Meperidine 75mg/mL Inj
DN
1.0100
M
SFC
Demerol 75mg/mL Inj (discontinued)
pethidine 100mg/mL inj
Meperidine 100mg/mL Inj
Demerol 100mg/mL Inj (discontinued)
N02AB03
DN
1.0700
M
SFC
FENTANYL
fentanyl 12mcg/hr patch
February 2016
160
N
Nervous System
CO Fentanyl 12mcg/hr Patch
MYLAN-Fentanyl Matrix 12mcg/hr Patch
DN
DN
2.2300
2.2300
M
M
E
E
02386844
02396696
COB Y
MYL Y
pms-Fentanyl MTX 12mcg/hr Patch
RAN-Fentanyl MTX 12mcg/hr Patch
DN
DN
2.2300
2.2300
M
M
E
E
02341379
02330105
PMS Y
RAN Y
Sandoz Fentanyl 12mcg/hr Patch
Teva-Fentanyl 12mcg/hr Patch
DN
DN
2.2300
2.2300
M
M
E
E
02327112
02311925
SDZ
TEV
Y
Y
02280345
JAN
Y
Y
Duragesic 12mcg/hr Patch (discontinued)
fentanyl 25mcg/hr patch
Apo-Fentanyl 25mcg/hr Patch
DN
4.0236
M
E
02314630
APX
CO Fentanyl 25mcg/hr Patch
MYLAN-Fentanyl Matrix 25mcg/hr Patch
DN
DN
4.0236
4.0236
M
M
E
E
02386852
02396718
COB Y
MYL Y
pms-Fentanyl MTX 25mcg/hr Patch
RAN-Fentanyl MTX 25mcg/hr Patch
DN
DN
4.0236
4.0236
M
M
E
E
02341387
02330113
PMS Y
RAN Y
Sandoz Fentanyl 25mcg/hr Patch
Teva-Fentanyl 25mcg/hr Patch
DN
DN
4.0236
4.0236
M
M
E
E
02327120
02282941
SDZ
TEV
Y
Y
Duragesic 25mcg/hr Patch (discontinued)
Duragesic MAT 25mcg/hr Patch
DN
4.0236
M
E
01937383
02275813
JAN
JAN
Y
Y
fentanyl 50mcg/hr patch
Apo-Fentanyl 50mcg/hr Patch
CO Fentanyl 50mcg/hr Patch
DN
DN
7.5719
7.5719
M
M
E
E
02314649
02386879
APX Y
COB Y
MYLAN-Fentanyl Matrix 50mcg/hr Patch
pms-Fentanyl 50mcg/hr Patch
DN
DN
7.5719
7.5719
M
M
E
E
02396726
02341395
MYL Y
PMS Y
RAN-Fentanyl MTX 50mcg/hr Patch
Sandoz Fentanyl 50mcg/hr Patch
DN
DN
7.5719
7.5719
M
M
E
E
02330121
02327147
RAN Y
SDZ Y
Teva-Fentanyl 50mcg/hr Patch
Duragesic 50mcg/hr Patch (discontinued)
DN
7.5719
M
E
02282968
01937391
TEV
JAN
Y
Y
Duragesic MAT 50mcg/hr Patch
DN
7.5719
M
E
02275821
JAN
Y
fentanyl 75mcg/hr patch
Apo-Fentanyl 75mcg/hr Patch
DN
10.6498
M
E
02314657
APX
Y
CO Fentanyl 75mcg/hr Patch
MYLAN-Fentanyl Matrix 75mcg/hr Patch
DN
DN
10.6498
10.6498
M
M
E
E
02386887
02396734
COB Y
MYL Y
pms-Fentanyl 75mcg/hr Patch
RAN-Fentanyl MTX 75mcg/hr Patch
DN
DN
10.6498
10.6498
M
M
E
E
02341409
02330148
PMS Y
RAN Y
Sandoz Fentanyl 75mcg/hr Patch
Teva-Fentanyl 75mcg/hr Patch
DN
DN
10.6498
10.6498
M
M
E
E
02327155
02282976
SDZ
TEV
Y
Y
Duragesic 75mcg/hr Patch (discontinued)
Duragesic MAT 75mcg/hr Patch
DN
10.6498
M
E
01937405
02275848
JAN
JAN
Y
Y
fentanyl 100mcg/hr patch
Apo-Fentanyl 100mcg/hr Patch
CO Fentanyl 100mcg/hr Patch
DN
DN
13.2559
13.2559
M
M
E
E
02314665
02386895
APX Y
COB Y
MYLAN-Fentanyl Matrix 100mcg/hr Patch
pms-Fentanyl 100mcg/hr Patch
DN
DN
13.2559
13.2559
M
M
E
E
02396742
02341417
MYL Y
PMS Y
RAN-Fentanyl MTX 100mcg/hr Patch
Sandoz Fentanyl 100mcg/hr Patch
DN
DN
13.2559
13.2559
M
M
E
E
02330156
02327163
RAN Y
SDZ Y
Teva-Fentanyl 100mcg/hr Patch
Duragesic 100mcg/hr Patch (discontinued)
DN
13.2559
M
E
02282984
01937413
TEV
JAN
Y
Y
Duragesic MAT 100mcg/hr Patch
DN
13.2559
M
E
02275856
JAN
Y
02364174
PAL
N
Abstral 100mcg SL Tab
February 2016
161
N
N02AD
Nervous System
PAL
N
Abstral 300mcg SL Tab
02364190
PAL
N
Abstral 400mcg SL Tab
02364204
PAL
N
Abstral 600mcg SL Tab
02364212
PAL
N
Talwin 30mg/mL Inj
02241976
HOS N
Talwin 50mg Tab
02137984
SAV
N
Butrans-5 5mcg/hr Patch
02341174
PFR
N
Butrans-10 10mcg/hr Patch
02341212
PFR
N
Butrans-20 20mcg/hr Patch
02341220
PFR
N
02242504
02113031
AAP Y
BMN Y
tramadol 50mg Tab
Apo-Tramadol 50mg Tab
02426153
APX
Y
Ultram 50mg Tab
02349469
JAN
Y
Ralivia 100mg Tab
02299194
VLN
N
Zytram XL 150mg Tab
02286424
PFR
N
Ralivia 200mg Tab
Zytram XL 200mg Tab
02299208
02286432
VLN
PFR
N
N
Ralivia 300mg Tab
02299216
VLN
N
Zytram XL 300mg Tab
02286440
PFR
N
Zytram XL 400mg Tab
02286459
PFR
N
tramadol 37.5mg & acetaminophen 325mg tab
Apo-Tramadol/Acet 37.5/325mg Tab
CO Tramadol/Acet 37.5/325mg Tab
02336790
02383209
APX
ATV
Y
Y
Jamp-Acet-Tramadol 325/37.5mg Tab
Mar-Tramadol/Acet 37.5/325mg Tab
02388308
02388324
JPC Y
MAR Y
MINT-Tramadol/Acet 37.5/325mg Tab
MYLAN-Tramadol/Acet 37.5/325mg Tab
02389800
02425599
MNT Y
MYL Y
pms-Tramadol/Acet 37.5/325mg Tab
RAN-Tramadol/Acet 37.5/325mg Tab
02401657
02388197
PMS Y
RAN Y
DEXTROPROPOXYPHENE
ORIPAVINE DERIVATIVES
N02AE01
N02AF
02364182
BENZOMORPHAN DERIVATIVES
N02AD01
N02AE
Abstral 200mcg SL Tab
BUPRENORPHINE
MORPHINAN DERIVATIVES
N02AF01
BUTORPHANOL
butorphanol 10mg/mL nasal sp
Apo-Butorphanol Nasal Sp
Stadol NS 10mg/mL Nasal Sp (discontinued)
N02AX
DN
3.7683
M
E
OTHER OPIOIDS
N02AX02
N02AX52
February 2016
TRAMADOL
TRAMADOL, COMBINATIONS
162
N
Nervous System
Teva-Tramadol/Acetaminophen 37.5/325mg Tab
Tramadol/Acet 37.5/325mg Tab
02347180
02429969
TEV
SIV
Y
Y
Tramadol/Acet 37.5/325mg Tab
Tramacet 37.5/325mg Tab
02426803
02264846
SAS
JAN
Y
Y
ASATAB 80mg Chewable Tab
02280167
ODN N
acetylsalicylic acid 325mg EC tab
Entrophen 325mg Tab
00010332
PDP Y
Novasen 325mg Tab
pms-ASA EC 325mg Tab
00216666
02284529
TEV Y
PMS Y
ASATAB EC 325mg Tab
02352427
ODN N
Enteric Coated ASA 325mg Tab
02010526
JPC
N
00229296
TEV
Y
00010340
PDP Y
N02B
OTHER ANALGESICS AND ANTIPYRETICS
N02BA
SALICYLIC ACID AND DERIVATIVES
N02BA01
ACETYLSALICYLIC ACID
acetylsalicylic acid 650mg EC tab
Novasen 650mg Tab
DNP
0.0352
M
SFC
Entrophen 650mg Tab (discontinued)
Enteric Coated ASA 650mg Tab
N02BA11
DNP
0.0550
L
SFC
00794244
JPC
N
DNP
0.1750
P
SFC
02039486
02048493
AAP
TEV
Y
Y
Dolobid 250mg Tab (discontinued)
00587699
LIH
Y
diflunisal 500mg tab
Apo-Diflunisal 500mg Tab (discontinued)
02039494
APX
Y
Dolobid 500mg Tab (discontinued)
00576131
LIH
Y
DIFLUNISAL
diflunisal 250mg tab
Apo-Diflunisal 250mg Tab (discontinued)
Novo-Diflunisal 250mg Tab
N02BA51
ACETYLSALICYLIC ACID (ASA) COMBINATIONS EXCL. PSYCHOLEPTICS
ratio-Oxycodan Tab
N02BA71
DN
0.3972
L
SFC
00608157
TEV
N
L
SFC
00608211
TEV
N
Y
ACETYLSALICYLIC ACID (ASA) COMBINATIONS WITH PSYCHOLEPTICS
ratio-Tecnal Tab
DN
1.0492
acetylsalicylic acid 330mg, butalbital 50mg, caffeine 40mg & codeine phosphate 15mg cap
ratio-Tecnal C1/4 Cap
DN
1.4999
M
SFC
00608203
TEV
Fiorinal C1/4 Cap
DN
1.4999
M
SFC
00176192
NVR Y
acetylsalicylic acid 330mg, butalbital 50mg, caffeine 40mg & codeine phosphate 30mg cap
ratio-Tecnal C1/2 Cap
Fiorinal C1/2 Cap
DN
DN
acetylsalicylic acid 330mg, butalbital 50mg & caffeine 40mg cap
ratio-Tecnal Cap
DN
Fiorinal Cap
DN
N02BE
1.8367
1.8367
M
M
SFC
SFC
00608181
00176206
TEV Y
NVR Y
1.3988
1.3988
M
M
SFC
SFC
00608238
00226327
TEV Y
NVR Y
ANILIDES
February 2016
163
N
Nervous System
N02BE01
ACETAMINOPHEN (PARACETAMOL)
Assorted Generic Brands
N02BE51
N02BG
N
Tylenol 325mg Caplets
Tylenol 325mg Tab
00723894
00559393
JNJ
JNJ
N
N
Tylenol 500mg Caplets
00723908
JNJ
N
Tylenol 500mg Tab
00559407
JNJ
N
ACETAMINOPHEN, COMB. EXCL. PSYCHOLEPTICS
pms-Acetaminophen W Codeine Elx
DN
0.0932
L
SFC
00816027
PMS N
ratio-Lenoltec #2 Tab
Atasol 15 Tab
DN
DN
0.0807
0.1150
L
L
SFC
SFC
00653241
00293504
TEV N
CHU N
Percocet Demi Tab
Tylenol #2 Tab
DN
DN
0.7125
0.1127
L
L
SFC
SFC
01916491
02163934
BRI
JAN
N
N
acetaminophen 325mg & oxycodone 5mg tab
Apo-Oxycodone/Acet 5/325mg Tab
Oxycodone/Acet 5/325mg Tab
DN
DN
0.1285
0.1285
M
M
SFC
SFC
02324628
02361361
APX
SAS
Y
Y
ratio-Oxycocet Tab
Sandoz Oxycodone Acet 5/325mg Tab
DN
DN
0.1285
0.1285
M
M
SFC
SFC
00608165
02307898
TEV
SDZ
Y
Y
Endocet Tab
Percocet Tab
DN
DN
0.1285
0.1285
M
M
SFC
SFC
01916548
01916475
BRI
BRI
Y
Y
DNP
0.1167
P
SFC
02244680
AAP
Y
02017628
SAV
Y
02244681
AAP
Y
02017636
SAV
Y
02266121
BAY
N
00027243
STR N
OTHERS,ANALGESICS AND ANTIPYRETICS
N02BG04
FLOCTAFENINE
floctafenine 200mg tab
Floctafenine 200mg Tab
Idarac 200mg Tab (discontinued)
floctafenine 400mg tab
Floctafenine 400mg Tab
DNP
0.2333
P
SFC
Idarac 400mg Tab (discontinued)
N02BG99
CANNABINOID DERIVATIVES, COMBINATIONS
Sativex Spray
N02C
ANTIMIGRAINE PREPARATIONS
N02CA
ERGOT ALKALOIDS
N02CA01
DIHYDROERGOTAMINE
Dihydroergotamine 1mg/mL Inj
Migranal 4mg/mL Nasal Spray
N02CC
DNP
9.9167
L
SF
02228947
STR N
Imitrex 5mg Nasal Spray
DNP
14.6000
L
E
02230418
GSK N
sumatriptan 12mg/mL inj
Taro-Sumatriptan 6mg/0.5mL Auto Injector
Imitrex 6mg/0.5mL Inj
DNP
DNP
66.3500
66.3500
M
M
E
E
02361698
02212188
TAR Y
GSK Y
SELECTIVE 5HT1-RECEPTOR AGONISTS
N02CC01
February 2016
SUMATRIPTAN
164
N
Nervous System
N02CC02
N02CC03
February 2016
Imitrex Stat Dose Kit With Case Inj 12mg/mL Liq
Imitrex Unit Dose Inj 12mg/mL Liq
DNP
DNP
66.3500
66.3500
M
M
E
E
00999446
00901886
GSK Y
GSK Y
Imitrex 20mg Nasal Spray
DNP
15.0250
L
E
02230420
GSK N
sumatriptan 25mg tab
CO Sumatriptan 25mg Tab
MYLAN-Sumatriptan 25mg Tab
02257882
02268906
ATV Y
MYL Y
Novo-Sumatriptan DF 25mg Tab
pms-Sumatriptan 25mg Tab
02286815
02256428
TEV Y
PMS Y
Imitrex DF 25mg Tab (discontinued)
02239738
GSK Y
sumatriptan 50mg tab
Apo-Sumatriptan 50mg Tab
DNP
7.1350
M
E
02268388
APX
CO Sumatriptan 50mg Tab
MYLAN-Sumatriptan 50mg Tab
DNP
DNP
7.1350
7.1350
M
M
E
E
02257890
02268914
ATV Y
MYL Y
Novo-Sumatriptan DF 50mg Tab
pms-Sumatriptan 50mg Tab
DNP
DNP
7.1350
7.1350
M
M
E
E
02286823
02256436
TEV Y
PMS Y
Sandoz Sumatriptan 50mg Tab
Sumatriptan 50mg Tab
DNP
DNP
7.1350
7.1350
M
M
E
E
02263025
02286521
SDZ
SAS
Sumatriptan DF-50mg Tab
Imitrex DF 50mg Tab
DNP
DNP
7.1350
7.1350
M
M
E
E
02385570
02212153
SIV Y
GSK Y
sumatriptan 100mg tab
Apo-Sumatriptan 100mg Tab
CO Sumatriptan 100mg Tab
DNP
DNP
7.8600
7.8600
M
M
E
E
02268396
02257904
APX
ATV
MYLAN-Sumatriptan 100mg Tab
Novo-Sumatriptan 100mg Tab
DNP
DNP
7.8600
7.8600
M
M
E
E
02268922
02239367
MYL Y
TEV Y
Novo-Sumatriptan DF 100mg Tab
pms-Sumatriptan 100mg Tab
DNP
DNP
7.8600
7.8600
M
M
E
E
02286831
02256444
TEV Y
PMS Y
Sandoz Sumatriptan 100mg Tab
Sumatriptan 100mg Tab
DNP
DNP
7.8600
7.8600
M
M
E
E
02263033
02286548
SDZ
SAS
Sumatriptan DF-100mg Tab
Imitrex DF 100mg Tab
DNP
DNP
7.8600
7.8600
M
M
E
E
02385589
02212161
SIV Y
GSK Y
naratriptan 1mg tab
Novo-Naratriptan 1mg Tab
DNP
11.3375
M
E
02314290
TEV
Amerge 1mg Tab
DNP
11.3375
M
E
02237820
GSK Y
naratriptan 2.5mg tab
Novo-Naratriptan 2.5mg Tab
DNP
6.1438
M
E
02314304
TEV
Sandoz-Naratriptan 2.5mg Tab
Amerge 2.5mg Tab
DNP
DNP
6.1438
6.1438
M
M
E
E
02322323
02237821
SDZ Y
GSK Y
zolmitriptan 2.5mg tab
Jamp-Zolmitriptan 2.5mg Tab
DNP
3.5375
M
SF
02421623
JPC
Mar-Zolmitriptan 2.5mg Tab
MINT-Zolmitriptan 2.5mg Tab
DNP
DNP
3.5375
3.5375
M
M
SF
SF
02399458
02419521
MAR Y
MNT Y
MYLAN-Zolmitriptan 2.5mg Tab
pms-Zolmitriptan 2.5mg Tab
DNP
DNP
3.5375
3.5375
M
M
SF
SF
02369036
02324229
MYL Y
PMS Y
Sandoz Zolmitriptan 2.5mg Tab
DNP
3.5375
M
SF
02362988
SDZ
Y
Y
Y
Y
Y
Y
Y
NARATRIPTAN
Y
Y
ZOLMITRIPTAN
165
Y
Y
N
Nervous System
N02CC04
Teva-Zolmitriptan 2.5mg Tab
Zomig 2.5mg Tab
DNP
DNP
3.5375
3.5375
M
M
SF
SF
02313960
02238660
TEV
AZE
zolmitriptan ODT 2.5mg tab
Jamp-Zolmitriptan ODT 2.5mg Tab
MINT-Zolmitriptan ODT 2.5mg Tab
DNP
DNP
3.5375
3.5375
M
M
SF
SF
02428237
02419513
JPC Y
MNT Y
MYL Y
PMS Y
MYLAN-Zolmitriptan ODT 2.5mg Tab
pms-Zolmitriptan ODT 2.5mg Tab
DNP
3.5375
M
SF
02387158
02324768
Sandoz Zolmitriptan ODT 2.5mg Tab
Septa-Zolmitriptan ODT 2.5mg Tab
DNP
DNP
3.5375
3.5375
M
M
SF
SF
02362996
02428474
SDZ
SPT
Y
Y
Teva-Zolmitriptan OD 2.5mg Tab
Zomig Rapimelt 2.5mg Tab
DNP
DNP
3.5375
3.5375
M
M
SF
SF
02342545
02243045
TEV
AZE
Y
Y
Zomig 2.5mg Nasal Spray
DNP
14.3300
L
E
02248992
AZE
N
Zomig 5mg Nasal Spray
DNP
14.3333
L
E
02248993
AZE
N
DNP
3.7050
M
SF
02393468
APX
Y
DNP
3.7050
M
SF
02380455
02240520
JPC
FRS
Y
Y
rizatriptan ODT 5mg tab
Apo-Rizatriptan RPD 5mg Tab
CO Rizatriptan ODT 5mg Tab
DNP
DNP
3.7050
3.7050
M
M
SF
SF
02393484
02374730
APX
ATV
Y
Y
MINT-Rizatriptan ODT 5mg Tab
MYLAN-Rizatriptan ODT 5mg Tab
DNP
DNP
3.7050
3.7050
M
M
SF
SF
02439573
02379198
MNT Y
MYL Y
NAT-Rizatriptan ODT 5mg Tab
pms-Rizatriptan RDT 5mg Tab
DNP
DNP
3.7050
3.7050
M
M
SF
SF
02436604
02393360
NAT Y
PMS Y
Rizatriptan ODT 5mg Tab
Sandoz Rizatriptan ODT 5mg Tab
DNP
DNP
3.7050
3.7050
M
M
SF
SF
02442906
02351870
SAS
SDZ
Y
Y
Teva-Rizatriptn ODT 5mg Tab
Maxalt RPD 5mg Wafers
DNP
DNP
3.7050
3.7050
M
M
SF
SF
02396661
02240518
TEV
FRS
Y
Y
rizatriptan 10mg tab
Apo-Rizatriptan 10mg Tab
CO Rizatriptan 10mg Tab
DNP
DNP
3.7050
3.7050
M
M
SF
SF
02393476
02381702
APX
ATV
Y
Y
Jamp-Rizatriptan 10mg Tab
Mar-Rizatriptan 10mg Tab
DNP
DNP
3.7050
3.7050
M
M
SF
SF
02380463
02379678
JPC Y
MAR Y
Maxalt 10mg Tab
DNP
3.7050
M
SF
02240521
FRS
Y
rizatriptan ODT 10mg tab
Apo-Rizatriptan RPD 10mg Tab
DNP
3.7050
M
SF
02393492
APX
Y
CO Rizatriptan ODT 10mg Tab
MINT-Rizatriptan ODT 10mg Tab
DNP
DNP
3.7050
3.7050
M
M
SF
SF
02374749
02439581
ATV Y
MNT Y
MYLAN-Rizatriptan ODT 10mg Tab
NAT-Rizatriptan ODT 10mg Tab
DNP
DNP
3.7050
3.7050
M
M
SF
SF
02379201
02436612
MYL Y
NAT Y
pms-Rizatriptan RDT 10mg Tab
Rizatriptan ODT 10mg Tab
DNP
DNP
3.7050
3.7050
M
M
SF
SF
02393379
02442914
PMS Y
SAS Y
Sandoz Rizatriptan ODT 10mg Tab
Teva-Rizatriptan ODT 10mg Tab
DNP
DNP
3.7050
3.7050
M
M
SF
SF
02351889
02396688
SDZ
TEV
Y
Y
Maxalt RPD 10mg Wafers
DNP
3.7050
M
SF
02240519
FRS
Y
RIZATRIPTAN
rizatriptan 5mg tab
Apo-Rizatriptan 5mg Tab
Jamp-Rizatriptan 5mg Tab
Maxalt 5mg Tab (discontinued)
February 2016
Y
Y
166
N
Nervous System
N02CC05
ALMOTRIPTAN
almotriptan 6.25mg tab
Apo-Almotriptan 6.25mg Tab
N02CC06
N02CC07
N02CX
02405792
APX
Y
MYLAN-Almotriptan 6.25mg Tab
Axert 6.25mg Tab
DNP
DNP
7.0434
7.0434
M
M
E
E
02398435
02248128
MYL Y
JNJ Y
almotriptan 12.5mg tab
Apo-Almotriptan 12.5mg Tab
MYLAN-Almotriptan 12.5mg Tab
DNP
7.0434
M
E
02405806
02398443
APX Y
MYL Y
Sandoz Almotriptan 12.5mg Tab
Axert 12.5mg Tab
DNP
DNP
7.0434
7.0434
M
M
E
E
02405334
02248129
SDZ
JNJ
Y
Y
eletriptan 20mg tab
Apo-Eletriptan 20mg Tab
02386054
APX
Y
GD-Eletriptan 20mg Tab
pms-Eletriptan 20mg Tab
02342235
02434342
GMD Y
PMS Y
Teva-Eletriptan 20mg Tab
Relpax 20mg Tab
02382091
02256290
TEV
PFI
eletriptan 40mg tab
Apo-Eletriptan 40mg Tab
GD-Eletriptan 40mg Tab
02386062
02342243
APX Y
GMD Y
pms-Eletriptan 40mg Tab
Teva-Eletriptan 40mg Tab
02434350
02382105
PMS Y
TEV Y
Relpax 40mg Tab
02256304
PFI
Y
frovatriptan 2.5mg tab
Apo-Frovatriptan 2.5mg Tab
Teva-Frovatriptan 2.5mg Tab
02426471
02415844
APX
TEV
Y
Y
Frova 2.5mg Tab
02257084
TMP Y
ELETRIPTAN
Y
Y
FROVATRIPTAN
VARIOUS ANTIMIGRAINE PREPARATIONS
N02CX01
PIZOTIFEN
Sandomigran 0.5mg Tab
DNP
0.3894
L
SF
00329320
PAL
N
Sandomigran DS 1mg Tab
DNP
0.6998
L
SF
00511552
PAL
N
Phenobarb 5mg/mL Elixir
DN
0.1275
L
SFC
00645575
PDP N
Phenobarb 15mg Tab
DN
0.0955
L
SFC
00178799
PDP N
Phenobarb 30mg Tab
DN
0.1136
L
SFC
00178802
PDP N
Phenobarb 60mg Tab
DN
0.1541
L
SFC
00178810
PDP N
Phenobarb 100mg Tab
DN
0.2109
L
SFC
00178829
PDP N
N03
ANTIEPILEPTICS
N03A
ANTIEPILEPTICS
N03AA
BARBITURATES AND DERIVATIVES
N03AA02
February 2016
PHENOBARBITAL
167
N
Nervous System
N03AA03
PRIMIDONE
primidone 125mg tab
Primidone 125mg Tab
DN
0.0600
M
SF
Mysoline 125mg Tab (discontinued)
primidone 250mg tab
Primidone 250mg Tab
DN
0.0944
M
SF
Mysoline 250mg Tab (discontinued)
N03AB
Y
02042363
DRH Y
00396761
AAP
02042355
DRH Y
Y
PHENYTOIN
Dilantin-30 (6mg/mL) Susp
DNP
0.0419
L
SFC
00023442
PFI
N
phenytoin 25mg/mL susp
Taro-Phenytoin 25mg/mL Susp
Dilantin-125 (25mg/mL) Susp
DNP
DNP
0.0371
0.0371
M
M
SFC
SFC
02250896
00023450
TAR Y
PFI Y
Dilantin 30mg Cap
DNP
0.0544
L
SFC
00022772
PFI
N
Dilantin 50mg Infatabs
DNP
0.0761
L
SFC
00023698
PFI
N
Dilantin 100mg Cap
DNP
0.0756
L
SFC
00022780
PFI
N
Zarontin 250mg Cap
DNP
0.3518
L
SF
00022799
ERF
N
Zarontin 250mg/5mL Syr
DNP
0.0704
L
SF
00023485
ERF
N
00022802
ERF
N
02442027
SIV
Y
SUCCINIMIDE DERIVATIVES
N03AD01
N03AD03
ETHOSUXIMIDE
METHSUXIMIDE (MESUXIMIDE)
Celontin 300mg Cap (discontinued)
N03AE
AAP
HYDANTOIN DERIVATIVES
N03AB02
N03AD
00399310
BENZODIAZEPINE DERIVATIVES AS ANTIEPILEPTICS
N03AE01
CLONAZEPAM
clonazepam 0.25mg tab
Clonazepam 0.25mg Tab
pms-Clonazepam 0.25mg Tab
DN
0.0774
M
SF
02179660
PMS Y
clonazepam 0.5mg tab
Apo-Clonazepam 0.5mg Tab
DN
0.0496
M
SF
02177889
APX
Clonazepam 0.5mg Tab
MYLAN-Clonazepam 0.5mg Tab
DN
DN
0.0496
0.0496
M
M
SF
SF
02442035
02230950
SIV Y
MYL Y
Novo-Clonazepam 0.5mg Tab
pms-Clonazepam 0.5mg Tab
DN
DN
0.0496
0.0496
M
M
SF
SF
02239024
02048701
TEV Y
PMS Y
pms-Clonazepam-R 0.5mg Tab
Sandoz Clonazepam 0.5mg Tab (discontinued)
DN
0.0496
M
SF
02207818
02233960
PMS Y
SDZ Y
Rivotril 0.5mg Tab
DN
0.0496
M
SF
00382825
HLR
Y
02442043
SIV
Y
02048728
PMS Y
02233982
SDZ
clonazepam 1mg tab
Clonazepam 1mg Tab
pms-Clonazepam 1mg Tab
Sandoz Clonazepam 1mg Tab (discontinued)
DN
0.1487
M
SF
clonazepam 2mg tab
February 2016
168
Y
N
N
N03AF
Nervous System
Apo-Clonazepam 2mg Tab
Clonazepam 2mg Tab
DN
DN
0.0854
0.0854
M
M
SF
SF
02177897
02442051
APX
SIV
Y
Y
CO Clonazepam 2mg Tab (discontinued)
MYLAN-Clonazepam 2mg Tab
DN
0.0854
M
SF
02270676
02230951
ATV Y
MYL Y
Novo-Clonazepam 2mg Tab
pms-Clonazepam 2mg Tab
DN
DN
0.0854
0.0854
M
M
SF
SF
02239025
02048736
TEV Y
PMS Y
Rivotril 2mg Tab
DN
0.0854
M
SF
00382841
HLR
carbamazepine 100mg chewable tab
pms-Carbamazepine 100mg Chewtab
Sandoz Carbamazepine 100mg Chewtab (discontinued)
DNP
0.1188
M
SFC
02231542
02261855
PMS Y
SDZ Y
Taro-Carbamazepine 100mg Chewtab
Tegretol 100mg Chewtab
DNP
DNP
0.1188
0.1188
M
M
SFC
SFC
02244403
00369810
TAR Y
NVR Y
02367394
02194333
TAR Y
NVR Y
Y
CARBOXAMIDE DERIVATIVES
N03AF01
CARBAMAZEPINE
carbamazepine 20mg/mL o/l
Taro-Carbamazepine 100mg/5mL O/L
Tegretol 100mg/5mL O/L
N03AF02
February 2016
carbamazepine 200mg CR tab
MYLAN-Carbamazepine CR 200mg Tab (discontinued)
pms-Carbamazepine CR 200mg Tab
DNP
0.1001
M
SFC
02241882
02231543
MYL Y
PMS Y
Sandoz Carbamazepine CR 200mg Tab
Tegretol CR 200mg Tab
DNP
DNP
0.1001
0.1001
M
M
SFC
SFC
02261839
00773611
SDZ Y
NVR Y
carbamazepine 200mg chewable tab
pms-Carbamazepine 200mg Chewtab
Taro-Carbamazepine 200mg Chewtab
DNP
0.0806
M
SFC
02231540
02244404
PMS Y
TAR Y
Tegretol 200mg Chewtab
DNP
0.0806
M
SFC
00665088
NVR Y
carbamazepine 200mg tab
Taro-Carbamazepine 200mg Tab
DNP
0.0795
M
SFC
02407515
TAR Y
Teva-Carbamazepine 200mg Tab
Tegretol 200mg Tab
DNP
DNP
0.0795
0.0795
M
M
SFC
SFC
00782718
00010405
TEV Y
NVR Y
carbamazepine 400mg CR tab
MYLAN-Carbamazepine CR 400mg Tab (discontinued)
pms-Carbamazepine CR 400mg Tab
DNP
0.2001
M
SFC
02241883
02231544
MYL Y
PMS Y
Sandoz Carbamazepine CR 400mg Tab
Tegretol CR 400mg Tab
DNP
DNP
0.2001
0.2001
M
M
SFC
SFC
02261847
00755583
SDZ Y
NVR Y
Trileptal 60mg/mL O/L
DNP
0.3310
L
E
02244673
NVR N
oxcarbazepine 150mg tab
Apo-Oxcarbazepine 150mg Tab
DNP
0.6209
M
E
02284294
AAP
Trileptal 150mg Tab
DNP
0.6209
M
E
02242067
NVR Y
oxcarbazepine 300mg tab
Apo-Oxcarbazepine 300mg Tab
DNP
0.9102
M
E
02284308
AAP
Trileptal 300mg Tab
DNP
0.9102
M
E
02242068
NVR Y
oxcarbazepine 600mg tab
Apo-Oxcarbazepine 600mg Tab
DNP
1.8204
M
E
02284316
AAP
OXCARBAZEPINE
169
Y
Y
Y
N
Nervous System
Trileptal 600mg Tab
N03AF03
N03AG
1.8204
M
E
02242069
NVR Y
Banzel 100mg Tab
DNP
0.7183
L
E
02369613
EIS
N
Banzel 200mg Tab
DNP
1.4364
L
E
02369621
EIS
N
Banzel 400mg Tab
DNP
3.1298
L
E
02369648
EIS
N
valproic acid 50mg/mL syr
Apo-Valproic 50mg/mL Syr
DNP
0.0605
M
SF
02238370
APX
Y
pms-Valproic 50mg/mL Syr
Depakene 50mg/mL Syr
DNP
DNP
0.0605
0.0605
M
M
SF
SF
02236807
00443832
PMS Y
BGP Y
divalproex sodium 125mg tab
Apo-Divalproex 125mg Tab
Divalproex 125mg Tab
DNP
DNP
0.0737
0.0737
M
M
SF
SF
02239698
02400499
APX
SAS
Novo-Divalproex 125mg Tab
Epival 125mg Tab
DNP
DNP
0.0737
0.0737
M
M
SF
SF
02239701
00596418
TEV Y
BGP Y
divalproex sodium 250mg tab
Apo-Divalproex 250mg Tab
Divalproex 250mg Tab
DNP
DNP
0.1325
0.1325
M
M
SF
SF
02239699
02400502
APX
SAS
Novo-Divalproex 250mg Tab
Epival 250mg Tab
DNP
DNP
0.1325
0.1325
M
M
SF
SF
02239702
00596426
TEV Y
BGP Y
valproic acid 250mg cap
Apo-Valproic 250mg Cap
Novo-Valproic 250mg Cap (discontinued)
DNP
0.1947
M
SF
02238048
02100630
APX
TEV
pms-Valproic 250mg Cap
Depakene 250mg Cap
DNP
DNP
0.1947
0.1947
M
M
SF
SF
02230768
00443840
PMS Y
BGP Y
divalproex sodium 500mg tab
Apo-Divalproex 500mg Tab
Divalproex 500mg Tab
DNP
DNP
0.2651
0.2651
M
M
SF
SF
02239700
02400510
APX
SAS
Novo-Divalproex 500mg Tab
Epival 500mg Tab
DNP
DNP
0.2651
0.2651
M
M
SF
SF
02239703
00596434
TEV Y
BGP Y
valproic acid 500mg EC cap
pms-Valproic EC 500mg Cap
Depakene 500mg Cap (discontinued)
DNP
0.5597
M
SF
02229628
00507989
PMS Y
ABB Y
Sabril 0.5g Sachets
DNP
0.9110
L
E
02068036
LBK
N
Sabril 500mg Tab
DNP
0.9110
L
E
02065819
LBK
N
Lamictal 5mg Chewable Tab
DNP
0.1654
L
SF
02240115
GSK N
lamotrigine 25mg tab
Apo-Lamotrigine 25mg Tab
DNP
0.0936
M
SF
02245208
APX
RUFINAMIDE
FATTY ACID DERIVATIVES
N03AG01
N03AG04
N03AX
DNP
VALPROIC ACID (DIVALPROEX SODIUM)
Y
Y
Y
Y
Y
Y
Y
Y
VIGABATRIN
VARIOUS ANTIEPILEPTICS
N03AX09
February 2016
LAMOTRIGINE
170
Y
N
Nervous System
N03AX11
February 2016
Auro-Lamotrigine 25mg Tab
Lamotrigine 25mg Tab
DNP
DNP
0.0936
0.0936
M
M
SF
SF
02381354
02343010
ARO Y
SAS Y
Lamotrigine 25mg Tab
MYLAN-Lamotrigine 25mg Tab
DNP
DNP
0.0936
0.0936
M
M
SF
SF
02428202
02265494
SIV Y
MYL Y
Novo-Lamotrigine 25mg Tab
pms-Lamotrigine 25mg Tab
DNP
DNP
0.0936
0.0936
M
M
SF
SF
02248232
02246897
TEV Y
PMS Y
Lamictal 25mg Tab
DNP
0.0936
M
SF
02142082
GSK Y
lamotrigine 100mg tab
Apo-Lamotrigine 100mg Tab
DNP
0.3735
M
SF
02245209
APX
Auro-Lamotrigine 100mg Tab
Lamotrigine 100mg Tab
DNP
DNP
0.3735
0.3735
M
M
SF
SF
02381362
02343029
ARO Y
SAS Y
Lamotrigine 100mg Tab
MYLAN-Lamotrigine 100mg Tab
DNP
DNP
0.3735
0.3735
M
M
SF
SF
02428210
02265508
SIV Y
MYL Y
Novo-Lamotrigine 100mg Tab
pms-Lamotrigine 100mg Tab
DNP
DNP
0.3735
0.3735
M
M
SF
SF
02248233
02246898
TEV Y
PMS Y
Lamictal 100mg Tab
DNP
0.3735
M
SF
02142104
GSK Y
lamotrigine 150mg tab
Apo-Lamotrigine 150mg Tab
DNP
0.5505
M
SF
02245210
APX
Auro-Lamotrigine 150mg Tab
Lamotrigine 150mg Tab
DNP
DNP
0.5505
0.5505
M
M
SF
SF
02381370
02428229
ARO Y
SIV Y
Lamotrigine 150mg Tab
MYLAN-Lamotrigine 150mg Tab
DNP
DNP
0.5505
0.5505
M
M
SF
SF
02343037
02265516
SAS Y
MYL Y
Novo-Lamotrigine 150mg Tab
pms-Lamotrigine 150mg Tab
DNP
DNP
0.5505
0.5505
M
M
SF
SF
02248234
02246899
TEV Y
PMS Y
Lamictal 150mg Tab
DNP
0.5505
M
SF
02142112
GSK Y
Topamax 15mg Sprinkle Cap
DNP
1.2407
L
E
02239907
JAN
N
topiramate 25mg tab
Abbott-Topiramate 25mg Tab (discontinued)
Apo-Topiramate 25mg Tab
DNP
0.3128
M
SF
02414600
02279614
ABB
APX
Y
Y
Auro-Topiramate 25mg Tab
CO Topiramate 25mg Tab
DNP
DNP
0.3128
0.3128
M
M
SF
SF
02345803
02287765
ARO Y
ATV Y
MINT-Topiramate 25mg Tab
MYLAN-Topiramate 25mg Tab
DNP
DNP
0.3128
0.3128
M
M
SF
SF
02315645
02263351
MNT Y
MYL Y
Novo-Topiramate 25mg Tab
pms-Topiramate 25mg Tab
DNP
DNP
0.3128
0.3128
M
M
SF
SF
02248860
02262991
TEV Y
PMS Y
RAN-Topiramate 25mg Tab
Sandoz Topiramate 25mg Tab
DNP
DNP
0.3128
0.3128
M
M
SF
SF
02396076
02431807
RAN Y
SDZ Y
SDZ
AHI
Y
Y
Y
Y
TOPIRAMATE
Sandoz Topiramate 25mg Tab (discontinued)
Topiramate 25mg Tab
DNP
0.3128
M
SF
02260050
02395738
Topiramate 25mg Tab
Topiramate-25mg Tab
DNP
DNP
0.3128
0.3128
M
M
SF
SF
02356856
02389460
SAS
SIV
Y
Y
Topamax 25mg Tab
DNP
0.3128
M
SF
02230893
JAN
Y
Topamax 25mg Sprinkle Cap
DNP
1.3020
L
E
02239908
JAN
N
pms-Topiramate 50mg Tab
02312085
PMS N
topiramate 100mg tab
Abbott-Topiramate 100mg Tab (discontinued)
02414619
ABB
171
Y
N
Nervous System
N03AX12
February 2016
Apo-Topiramate 100mg Tab
Auro-Topiramate 100mg Tab
DNP
DNP
0.5929
0.5929
M
M
SF
SF
02279630
02345838
APX Y
ARO Y
CO Topiramate 100mg Tab
MINT-Topiramate 100mg Tab
DNP
DNP
0.5929
0.5929
M
M
SF
SF
02287773
02315653
ATV Y
MNT Y
MYLAN-Topiramate 100mg Tab
Novo-Topiramate 100mg Tab
DNP
DNP
0.5929
0.5929
M
M
SF
SF
02263378
02248861
MYL Y
TEV Y
pms-Topiramate 100mg Tab
RAN-Topiramate 100mg Tab
DNP
DNP
0.5929
0.5929
M
M
SF
SF
02263009
02396084
PMS Y
RAN Y
Sandoz Topiramate 100mg Tab
Sandoz Topiramate 100mg Tab (discontinued)
DNP
0.5929
M
SF
02431815
02260069
SDZ
SDZ
Y
Y
Topiramate 100mg Tab
Topiramate 100mg Tab
DNP
DNP
0.5929
0.5929
M
M
SF
SF
02395746
02356864
AHI
SAS
Y
Y
Topiramate-100mg Tab
Topamax 100mg Tab
DNP
DNP
0.5929
0.5929
M
M
SF
SF
02389487
02230894
SIV
JAN
Y
Y
topiramate 200mg tab
Abbott-Topiramate 200mg Tab (discontinued)
Apo-Topiramate 200mg Tab
DNP
0.8854
M
SF
02414627
02279649
ABB
APX
Y
Y
Auro-Topiramate 200mg Tab
CO Topiramate 200mg Tab
DNP
DNP
0.8854
0.8854
M
M
SF
SF
02345846
02287781
ARO Y
ATV Y
MINT-Topiramate 200mg Tab
MYLAN-Topiramate 200mg Tab
DNP
DNP
0.8854
0.8854
M
M
SF
SF
02315661
02263386
MNT Y
MYL Y
Novo-Topiramate 200mg Tab
pms-Topiramate 200mg Tab
DNP
DNP
0.8854
0.8854
M
M
SF
SF
02248862
02263017
TEV Y
PMS Y
RAN-Topiramate 200mg Tab
Sandoz Topiramate 200mg Tab
DNP
DNP
0.8854
0.8854
M
M
SF
SF
02396092
02431823
RAN Y
SDZ Y
Sandoz Topiramate 200mg Tab (discontinued)
Topiramate 200mg Tab
DNP
0.8854
M
SF
02267837
02395754
SDZ
AHI
Y
Y
Topiramate 200mg Tab
Topamax 200mg Tab
DNP
DNP
0.8854
0.8854
M
M
SF
SF
02356872
02230896
SAS
JAN
Y
Y
gabapentin 100mg cap
Apo-Gabapentin 100mg Cap
DNP
0.0749
M
E
02244304
APX
Y
Auro-Gabapentin 100mg Cap
CO Gabapentin 100mg Cap
DNP
DNP
0.0749
0.0749
M
M
E
E
02321203
02256142
ARO Y
ATV Y
Gabapentin 100mg Cap (SAS)
Gabapentin-100mg Cap
DNP
DNP
0.0749
0.0749
M
M
E
E
02353245
02246314
SAS
SIV
GD-Gabapentin 100mg Cap
Jamp-Gabapentin 100mg Cap
DNP
DNP
0.0749
0.0749
M
M
E
E
02285819
02361469
GMD Y
JPC Y
Mar-Gabapentin 100mg Cap
MYLAN-Gabapentin 100mg Cap
DNP
DNP
0.0749
0.0749
M
M
E
E
02391473
02248259
MAR Y
MYL Y
pms-Gabapentin 100mg Cap
RAN-Gabapentin 100mg Cap
DNP
DNP
0.0749
0.0749
M
M
E
E
02243446
02319055
PMS Y
RAN Y
Teva-Gabapentin 100mg Cap
Neurontin 100mg Cap
DNP
DNP
0.0749
0.0749
M
M
E
E
02244513
02084260
TEV
PFI
gabapentin 300mg cap
Apo-Gabapentin 300mg Cap
Auro-Gabapentin 300mg Cap
DNP
DNP
0.1821
0.1821
M
M
E
E
02244305
02321211
APX Y
ARO Y
CO Gabapentin 300mg Cap
DNP
0.1821
M
E
02256150
ATV
GABAPENTIN
172
Y
Y
Y
Y
Y
N
Nervous System
N03AX14
Gabapentin 300mg Cap (SAS)
Gabapentin-300mg Cap
DNP
DNP
0.1821
0.1821
M
M
E
E
02353253
02246315
SAS
SIV
GD-Gabapentin 300mg Cap
Jamp-Gabapentin 300mg Cap
DNP
DNP
0.1821
0.1821
M
M
E
E
02285827
02361485
GMD Y
JPC Y
Mar-Gabapentin 300mg Cap
MYLAN-Gabapentin 300mg Cap
DNP
DNP
0.1821
0.1821
M
M
E
E
02391481
02248260
MAR Y
MYL Y
pms-Gabapentin 300mg Cap
RAN-Gabapentin 300mg Cap
DNP
DNP
0.1821
0.1821
M
M
E
E
02243447
02319063
PMS Y
RAN Y
Teva-Gabapentin 300mg Cap
Neurontin 300mg Cap
DNP
DNP
0.1821
0.1821
M
M
E
E
02244514
02084279
TEV
PFI
gabapentin 400mg cap
Apo-Gabapentin 400mg Cap
Auro-Gabapentin 400mg Cap
DNP
DNP
0.2171
0.2171
M
M
E
E
02244306
02321238
APX Y
ARO Y
CO Gabapentin 400mg Cap
Gabapentin 400mg Cap (SAS)
DNP
DNP
0.2171
0.2171
M
M
E
E
02256169
02353261
ATV
SAS
Gabapentin-400mg Cap
GD-Gabapentin 400mg Cap
DNP
DNP
0.2171
0.2171
M
M
E
E
02246316
02285835
SIV Y
GMD Y
Jamp-Gabapentin 400mg Cap
Mar-Gabapentin 400mg Cap
DNP
DNP
0.2171
0.2171
M
M
E
E
02361493
02391503
JPC Y
MAR Y
MYLAN-Gabapentin 400mg Cap
pms-Gabapentin 400mg Cap
DNP
DNP
0.2171
0.2171
M
M
E
E
02248261
02243448
MYL Y
PMS Y
RAN-Gabapentin 400mg Cap
Teva-Gabapentin 400mg Cap
DNP
DNP
0.2171
0.2171
M
M
E
E
02319071
02244515
RAN Y
TEV Y
Neurontin 400mg Cap
DNP
0.2171
M
E
02084287
PFI
Y
gabapentin 600mg tab
Apo-Gabapentin 600mg Tab
DNP
0.3256
M
E
02293358
APX
Y
Gabapentin 600mg Tab
Gabapentin 600mg Tab
DNP
DNP
0.3256
0.3256
M
M
E
E
02431289
02392526
SAS
AHI
Y
Y
Gabapentin-600mg Tab
GD-Gabapentin 600mg Tab
DNP
DNP
0.3256
0.3256
M
M
E
E
02388200
02285843
SIV Y
GMD Y
Jamp-Gabapentin 600mg Tab
MYLAN-Gabapentin 600mg Tab
DNP
DNP
0.3256
0.3256
M
M
E
E
02402289
02397471
JPC Y
MYL Y
pms-Gabapentin 600mg Tab
Teva-Gabapentin 600mg Tab
DNP
DNP
0.3256
0.3256
M
M
E
E
02255898
02248457
PMS Y
TEV Y
Neurontin 600mg Tab
DNP
0.3256
M
E
02239717
PFI
Y
gabapentin 800mg tab
Apo-Gabapentin 800mg Tab
DNP
0.4341
M
E
02293366
APX
Y
Gabapentin 800mg Tab
Gabapentin 800mg Tab
DNP
DNP
0.4341
0.4341
M
M
E
E
02392534
02431297
AHI
SAS
Y
Y
Gabapentin-800mg Tab
GD-Gabapentin 800mg Tab
DNP
DNP
0.4341
0.4341
M
M
E
E
02388219
02285851
SIV Y
GMD Y
Jamp-Gabapentin 800mg Tab
MYLAN-Gabapentin 800mg Tab
DNP
DNP
0.4341
0.4341
M
M
E
E
02402297
02397498
JPC Y
MYL Y
pms-Gabapentin 800mg Tab
Teva-Gabapentin 800mg Tab
DNP
DNP
0.4341
0.4341
M
M
E
E
02255901
02247346
PMS Y
TEV Y
Neurontin 800mg Tab
DNP
0.4341
M
E
02239718
PFI
LEVETIRACETAM
levetiracetam 250mg tab
February 2016
173
Y
Y
Y
Y
Y
Y
Y
N
Nervous System
Abbott-Levetiracetam 250mg Tab (discontinued)
Apo-Levetiracetam 250mg Tab
E
02414805
02285924
ABB
APX
DNP
0.8000
M
Auro-Levetiracetam 250mg tab
CO Levetiracetam 250mg Tab
DNP
DNP
0.8000
0.8000
M
M
Jamp-Levetiracetam 250mg Tab
Levetiracetam 250mg Tab
DNP
DNP
0.8000
0.8000
Levetiracetam 250mg Tab
pms-Levetiracetam 250mg Tab
DNP
DNP
RAN-Levetiracetam 250mg Tab
Keppra 250mg Tab
E
E
02375249
02274183
ARO Y
ATV Y
M
M
E
E
02403005
02353342
JPC
SAS
0.8000
0.8000
M
M
E
E
02399776
02296101
AHI Y
PMS Y
DNP
DNP
0.8000
0.8000
M
M
E
E
02396106
02247027
RAN Y
UCB Y
levetiracetam 500mg tab
Abbott-Levetiracetam 500mg Tab (discontinued)
Apo-Levetiracetam 500mg Tab
DNP
0.9750
M
E
02414791
02285932
ABB
APX
Auro-Levetiracetam 500mg tab
CO Levetiracetam 500mg Tab
DNP
DNP
0.9750
0.9750
M
M
E
E
02375257
02274191
ARO Y
ATV Y
Jamp-Levetiracetam 500mg Tab
Levetiracetam 500mg Tab
DNP
DNP
0.9750
0.9750
M
M
E
E
02403021
02353350
JPC
SAS
Levetiracetam 500mg Tab
pms-Levetiracetam 500mg Tab
DNP
DNP
0.9750
0.9750
M
M
E
E
02399784
02296128
AHI Y
PMS Y
RAN-Levetiracetam 500mg Tab
Keppra 500mg Tab
DNP
DNP
0.9750
0.9750
M
M
E
E
02396114
02247028
RAN Y
UCB Y
levetiracetam 750mg tab
Abbott-Levetiracetam 750mg Tab (discontinued)
Apo-Levetiracetam 750mg Tab
DNP
1.3500
M
E
02414783
02285940
ABB
APX
Auro-Levetiracetam 750mg tab
CO Levetiracetam 750mg Tab
DNP
DNP
1.3500
1.3500
M
M
E
E
02375265
02274205
ARO Y
ATV Y
Jamp-Levetiracetam 750mg Tab
Levetiracetam 750mg Tab
DNP
DNP
1.3500
1.3500
M
M
E
E
02403048
02353369
JPC
SAS
pms-Levetiracetam 750mg Tab
RAN-Levetiracetam 750mg Tab
DNP
DNP
1.3500
1.3500
M
M
E
E
02296136
02396122
PMS Y
RAN Y
Keppra 750mg Tab
DNP
1.3500
M
E
02247029
UCB Y
02399792
AHI
Levetiracetam 750mg Tab
N03AX16
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
PREGABALIN
pregabalin 25mg cap
Apo-Pregabalin 25mg Cap
Auro-Pregabalin 25mg Cap
February 2016
Y
Y
DNP
DNP
0.2058
0.2058
M
M
E
E
02394235
02433869
APX Y
ARO Y
CO Pregabalin 25mg Cap
GD-Pregabalin 25mg Cap (discontinued)
DNP
0.2058
M
E
02402912
02360136
ATV Y
GMD Y
Mar-Pregabalin 25mg Cap
MINT-Pregabalin 25mg Cap
DNP
DNP
0.2058
0.2058
M
M
E
E
02417529
02423804
MAR Y
MNT Y
Myl-Pregabalin 25mg Cap
pms-Pregabalin 25mg Cap
DNP
DNP
0.2058
0.2058
M
M
E
E
02408651
02359596
MYL Y
PMS Y
Pregabalin 25mg Cap
Pregabalin 25mg Cap
DNP
DNP
0.2058
0.2058
M
M
E
E
02403692
02405539
SIV
SAS
Pregabalin-25mg Cap
RAN-Pregabalin 25mg Cap
DNP
DNP
0.2058
0.2058
M
M
E
E
02411725
02392801
SIV Y
RAN Y
Sandoz Pregabalin 25mg Cap
Teva-Pregabalin 25mg Cap
DNP
DNP
0.2058
0.2058
M
M
E
E
02390817
02361159
SDZ
TEV
174
Y
Y
Y
Y
N
Nervous System
February 2016
Lyrica 25mg Cap
DNP
0.2058
M
E
02268418
PFI
Y
pregabalin 50mg cap
Apo-Pregabalin 50mg Cap
DNP
0.3228
M
E
02394243
APX
Y
Auro-Pregablain 50mg Cap
CO Pregabalin 50mg Cap
DNP
DNP
0.3228
0.3228
M
M
E
E
02433877
02402920
ARO Y
ATV Y
GMD Y
MAR Y
GD-Pregabalin 50mg Cap (discontinued)
Mar-Pregabalin 50mg Cap
DNP
0.3228
M
E
02360144
02417537
MINT-Pregabalin 50mg Cap
Myl-Pregabalin 50mg Cap
DNP
DNP
0.3228
0.3228
M
M
E
E
02423812
02408678
MNT Y
MYL Y
pms-Pregabalin 50mg Cap
Pregabalin 50mg Cap
DNP
DNP
0.3228
0.3228
M
M
E
E
02359618
02403706
PMS Y
SIV Y
Pregabalin 50mg Cap
Pregabalin-50mg Cap
DNP
DNP
0.3228
0.3228
M
M
E
E
02405547
02411733
SAS
SIV
RAN-Pregabalin 50mg Cap
Sandoz Pregabalin 50mg Cap
DNP
DNP
0.3228
0.3228
M
M
E
E
02392828
02390825
RAN Y
SDZ Y
Teva-Pregablin 50mg Cap
Lyrica 50mg Cap
DNP
DNP
0.3228
0.3228
M
M
E
E
02361175
02268426
TEV
PFI
pregabalin 75mg cap
Apo-Pregabalin 75mg Cap
Auro-Pregabalin 75mg Cap
DNP
DNP
0.4176
0.4176
M
M
E
E
02394251
02433885
APX Y
ARO Y
CO Pregabalin 75mg Cap
GD-Pregabalin 75mg Cap (discontinued)
DNP
0.4176
M
E
02402939
02360152
ATV Y
GMD Y
Mar-Pregabalin 75mg Cap
MINT-Pregabalin 75mg Cap
DNP
DNP
0.4176
0.4176
M
M
E
E
02417545
02424185
MAR Y
MNT Y
Myl-Pregabalin 75mg Cap
pms-Pregablin 75mg Cap
DNP
DNP
0.4176
0.4176
M
M
E
E
02408686
02359626
MYL Y
PMS Y
Pregabalin 75mg Cap
Pregabalin 75mg Cap
DNP
DNP
0.4176
0.4176
M
M
E
E
02403714
02405555
SIV
SAS
Pregabalin-75mg Cap
RAN-Pregabalin 75mg Cap
DNP
DNP
0.4176
0.4176
M
M
E
E
02411741
02392836
SIV Y
RAN Y
Sandoz Pregabalin 75mg Cap
Teva-Pregabalin 75mg Cap
DNP
DNP
0.4176
0.4176
M
M
E
E
02390833
02361183
SDZ
TEV
Y
Y
Lyrica 75mg Cap
DNP
0.4176
M
E
02268434
PFI
Y
pregabalin 150mg cap
Apo-Pregabalin 150mg Cap
DNP
0.5757
M
E
02394278
APX
Y
Auro-Pregabalin 150mg Cap
CO Pregabalin 150mg Cap
DNP
DNP
0.5757
0.5757
M
M
E
E
02433907
02402955
ARO Y
ATV Y
GD-Pregabalin 150mg Cap (discontinued)
Mar-Pregabalin 150mg Cap
DNP
0.5757
M
E
02360179
02417561
GMD Y
MAR Y
MINT-Pregabalin 150mg Cap
Myl-Pregabalin 150mg Cap
DNP
DNP
0.5757
0.5757
M
M
E
E
02424207
02408694
MNT Y
MYL Y
pms-Pregabalin 150mg Cap
Pregabalin 150mg Cap
DNP
DNP
0.5757
0.5757
M
M
E
E
02359634
02403722
PMS Y
SIV Y
Pregabalin 150mg Cap
Pregabalin-150mg Cap
DNP
DNP
0.5757
0.5757
M
M
E
E
02405563
02411768
SAS
SIV
RAN-Pregabalin 150mg Cap
Sandoz Pregabalin 150mg Cap
DNP
DNP
0.5757
0.5757
M
M
E
E
02392844
02390841
RAN Y
SDZ Y
Teva-Pregabalin 150mg Cap
Lyrica 150mg Cap
DNP
DNP
0.5757
0.5757
M
M
E
E
02361205
02268450
TEV
PFI
175
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
Nervous System
pregabalin 225mg cap
Apo-Pregabalin 225mg Cap
N03AX18
N03AX22
DNP
0.5757
M
E
02394286
APX
CO Pregabalin 225mg Cap
GD-Pregabalin 225mg Cap (discontinued)
DNP
0.5757
M
E
02402971
02360195
ATV Y
GMD Y
pms-Pregabalin 225mg Cap
RAN-Pregabalin 225mg Cap
DNP
DNP
0.5757
0.5757
M
M
E
E
02398079
02392852
PMS Y
RAN Y
Teva-Pregabalin 225mg Cap
Lyrica 225mg Cap
DNP
DNP
0.5757
0.5757
M
M
E
E
02361221
02268477
TEV
PFI
Y
Y
pregabalin 300mg cap
Apo-Pregabalin 300mg Cap
CO Pregabalin 300mg Cap
DNP
DNP
0.5757
0.5757
M
M
E
E
02394294
02402998
APX
ATV
Y
Y
GD-Pregabalin 300mg Cap (discontinued)
Myl-Pregabalin 300mg Cap
DNP
0.5757
M
E
02360209
02408708
GMD Y
MYL Y
pms-Pregabalin 300mg Cap
Pregabalin 300mg Cap
DNP
DNP
0.5757
0.5757
M
M
E
E
02359642
02403730
PMS Y
SIV Y
Pregabalin 300mg Cap
RAN-Pregabalin 300mg Cap
DNP
DNP
0.5757
0.5757
M
M
E
E
02405598
02392860
SAS Y
RAN Y
Sandoz Pregabalin 300mg Cap
Teva-Pregabalin 300mg Cap
DNP
DNP
0.5757
0.5757
M
M
E
E
02390868
02361248
SDZ
TEV
Y
Y
Lyrica 300mg Cap
DNP
0.5757
M
E
02268485
PFI
Y
Vimpat 50mg Tab
DNP
2.5000
L
E
02357615
UCB N
Vimpat 100mg Tab
DNP
3.4793
L
E
02357623
UCB N
Vimpat 150mg Tab
DNP
4.6600
L
E
02357631
UCB N
Vimpat 200mg Tab
DNP
5.7500
L
E
02357658
UCB N
Fycompa 2mg Tab
DNP
9.4500
L
E
02404516
EIS
N
Fycompa 4mg Tab
DNP
9.4500
L
E
02404524
EIS
N
Fycompa 6mg Tab
DNP
9.4500
L
E
02404532
EIS
N
Fycompa 8mg Tab
DNP
9.4500
L
E
02404540
EIS
N
Fycompa 10mg Tab
DNP
9.4500
L
E
02404559
EIS
N
Fycompa 12mg Tab
DNP
9.4500
L
E
02404567
EIS
N
Trihexyphenidyl 2mg Tab
DNP
0.0369
L
SF
00545058
AAP
N
Trihexyphenidyl 5mg Tab
DNP
0.0668
L
SF
00545074
AAP
N
DNP
0.2670
M
SF
00587362
PDP Y
LACOSAMIDE
PERAMPANEL
N04
ANTI-PARKINSON DRUGS
N04A
ANTI-CHOLINERGIC AGENTS
N04AA
TERTIARY AMINES WITH CARBON CHAIN
N04AA01
N04AA04
TRIHEXYPHENIDYL
PROCYCLIDINE
procyclidine HCl 0.5mg/mL o/l
pdp-Procyclidine 0.5mg/mL Elx
February 2016
Y
176
N
Nervous System
Kemadrin 0.5mg/mL O/L (discontinued)
procyclidine HCl 5mg tab
pdp-Procyclidine 5mg Tab
DNP
0.1366
M
SF
Kemadrin 5mg Tab (discontinued)
N04AA05
GSK Y
00587354
PDP Y
00004758
GSK Y
ETHOPROPAZINE (PROFENAMINE)
Parsitan 50mg Tab
N04AC
00004405
DNP
0.2345
L
SF
01927744
ERF
N
pms-Benztropine 1mg Tab
DNP
0.0477
L
SF
00706531
PMS N
benztropine mesylate 2mg tab
Benztropine 2mg Tab
DNP
0.0534
M
SF
00426857
PMS Y
00016357
FRS
Y
ETHERS OF TROPINE OR TROPINE DERIVATIVES
N04AC01
BENZTROPINE
Cogentin 2mg Tab (discontinued)
N04B
DOPAMINERGIC AGENTS
N04BA
DOPA AND DOPA DERIVATIVES
N04BA02
LEVODOPA AND DECARBOXYLASE INHIBITOR
Prolopa 100-25 Cap
DNP
0.4701
L
SF
00386464
HLR
N
Prolopa 200-50 Cap
Prolopa 50-12.5 Cap
DNP
DNP
0.7891
0.2855
L
L
SF
SF
00386472
00522597
HLR
HLR
N
N
02292165
ABV
N
Duodopa 5mg/20mg/mL Inj
N04BA03
levodopa 100mg & carbidopa 10mg tab
Apo-Levocarb 100/10 Tab
Novo-Levocarbidopa 100/10 Tab
DNP
DNP
0.1877
0.1877
M
M
SF
SF
02195933
02244494
APX
TEV
Y
Y
Sinemet 100/10 Tab
DNP
0.1877
M
SF
00355658
FRS
Y
levodopa 100mg & carbidopa 25mg CR tab
Apo-Levocarb CR 100/25mg Tab
DNP
0.5126
M
SF
02272873
APX
Y
pms-Levocarb CR 100mg/25mg Tab
Sinemet CR 100/25mg Tab
DNP
DNP
0.5126
0.5126
M
M
SF
SF
02421488
02028786
PMS Y
FRS Y
levodopa 100mg & carbidopa 25mg tab
Apo-Levocarb 100/25 Tab
Novo-Levocarbidopa 100/25 Tab
DNP
DNP
0.2803
0.2803
M
M
SF
SF
02195941
02244495
APX
TEV
Y
Y
Sinemet 100/25 Tab
DNP
0.2803
M
SF
00513997
FRS
Y
levodopa 200mg & carbidopa 50mg CR tab
Apo-Levocarb CR 200/50 Tab
DNP
1.0850
M
SF
02245211
APX
Y
PMS N
FRS Y
pms-Levocarb CR 200mg/50mg Tab
Sinemet CR 200/50mg Tab
DNP
1.0850
M
SF
02421496
00870935
levodopa 250mg & carbidopa 25mg tab
Apo-Levocarb 250/25 Tab
Novo-Levocarbidopa 250/25 Tab
DNP
DNP
0.3129
0.3129
M
M
SF
SF
02195968
02244496
APX
TEV
Y
Y
Sinemet 250/25 Tab
DNP
0.3129
M
SF
00328219
FRS
Y
1.6882
L
E
02305933
NVR N
LEVODOPA, DECARBOXYLASE INHIBITOR AND COMT INHIBITOR
Stalevo 50mg Tab
February 2016
DNP
177
N
N04BB
Nervous System
Stalevo 75mg Tab
DNP
1.6882
L
E
02337827
NVR N
Stalevo 100mg Tab
DNP
1.6882
L
E
02305941
NVR N
Stalevo 125mg Tab
DNP
1.6882
L
E
02337835
NVR N
Stalevo 150mg Tab
DNP
1.6882
L
E
02305968
NVR N
amantadine HCl 10mg/mL o/l
pms-Amantadine 10mg/mL Syr
Symmetrel 10mg/mL Syr (discontinued)
DNP
0.1066
M
SF
02022826
01913999
PDP Y
BRI Y
amantadine HCl 100mg cap
pms-Amantadine 100mg Cap
Endantadine 100mg Cap (discontinued)
DNP
0.5334
M
SF
01990403
02034468
PDP Y
BRI Y
01914006
BRI
Y
Y
Y
ADAMANTINE DERIVATIVES
N04BB01
AMANTADINE
Symmetrel 100mg Cap (discontinued)
N04BC
DOPAMINE AGONISTS
N04BC04
N04BC05
ROPINIROLE
ropinirole 0.25mg tab
CO Ropinirole 0.25mg Tab
Jamp-Ropinirole 0.25mg Tab
DNP
DNP
0.0709
0.0709
M
M
SF
SF
02316846
02352338
ATV
JPC
pms-Ropinirole 0.25mg Tab
RAN-Ropinirole 0.25mg Tab
DNP
DNP
0.0709
0.0709
M
M
SF
SF
02326590
02314037
PMS Y
RAN Y
Ropinirole 0.25mg Tab
ReQuip 0.25mg Tab
DNP
DNP
0.0709
0.0709
M
M
SF
SF
02353040
02232565
SAS Y
GSK Y
ropinirole 1mg tab
CO Ropinirole 1mg Tab
Jamp-Ropinirole 1mg Tab
DNP
DNP
0.2839
0.2839
M
M
SF
SF
02316854
02352346
ATV
JPC
pms-Ropinirole 1mg Tab
RAN-Ropinirole 1mg Tab
DNP
DNP
0.2839
0.2839
M
M
SF
SF
02326612
02314053
PMS Y
RAN Y
Ropinirole 1mg Tab
ReQuip 1mg Tab
DNP
DNP
0.2839
0.2839
M
M
SF
SF
02353059
02232567
SAS Y
GSK Y
ropinirole 2mg tab
CO Ropinirole 2mg Tab
Jamp-Ropinirole 2mg Tab
DNP
DNP
0.3122
0.3122
M
M
SF
SF
02316862
02352354
ATV
JPC
pms-Ropinirole 2mg Tab
RAN-Ropinirole 2mg Tab
DNP
DNP
0.3122
0.3122
M
M
SF
SF
02326620
02314061
PMS Y
RAN Y
ReQuip 2mg Tab
DNP
0.3122
M
SF
02232568
GSK Y
ropinirole 5mg tab
CO Ropinirole 5mg Tab
DNP
0.8596
M
SF
02316870
ATV
Jamp-Ropinirole 5mg Tab
pms-Ropinirole 5mg Tab
DNP
DNP
0.8596
0.8596
M
M
SF
SF
02352362
02326639
JPC Y
PMS Y
RAN-Ropinirole 5mg Tab
Ropinirole 5mg Tab
DNP
DNP
0.8596
0.8596
M
M
SF
SF
02314088
02353075
RAN Y
SAS Y
ReQuip 5mg Tab
DNP
0.8596
M
SF
02232569
GSK Y
PRAMIPEXOLE
pramipexole 0.25mg tab
February 2016
178
Y
Y
Y
Y
Y
N
N04BD
Nervous System
ACT Pramipexole 0.25mg Tab
Apo-Pramipexole 0.25mg Tab
DNP
DNP
0.2629
0.2629
M
M
SF
SF
02297302
02292378
ATV
APX
Y
Y
MYLAN-Pramipexole 0.25mg Tab
Novo-Pramipexole 0.25mg Tab
DNP
DNP
0.2629
0.2629
M
M
SF
SF
02376350
02269309
MYL Y
TEV Y
pms-Pramipexole 0.25mg Tab
Pramipexole 0.25mg Tab
DNP
DNP
0.2629
0.2629
M
M
SF
SF
02290111
02367602
PMS Y
SAS Y
Pramipexole-0.25mg Tab
Sandoz Pramipexole 0.25mg Tab
DNP
DNP
0.2629
0.2629
M
M
SF
SF
02309122
02315262
SIV
SDZ
Mirapex 0.25mg Tab
DNP
0.2629
M
SF
02237145
BOE Y
pramipexole 0.5mg tab
ACT Pramipexole 0.5mg Tab
02297310
ATV
Apo-Pramipexole 0.5mg Tab
MYLAN-Pramipexole 0.5mg Tab
02292386
02376369
APX Y
MYL Y
Novo-Pramipexole 0.5mg Tab
pms-Pramipexole 0.5mg Tab
02269317
02290138
TEV Y
PMS Y
Pramipexole 0.5mg Tab
Pramipexole-0.5mg Tab
02367610
02309130
SAS
SIV
Sandoz Pramipexole 0.5mg Tab
Mirapex 0.5mg Tab
02315270
02241594
SDZ Y
BOE Y
Y
Y
Y
Y
Y
pramipexole 1mg tab
ACT Pramipexole 1mg Tab
Apo-Pramipexole 1mg Tab
DNP
DNP
0.5257
0.5257
M
M
SF
SF
02297329
02292394
ATV
APX
MYLAN-Pramipexole 1mg Tab
Novo-Pramipexole 1mg Tab
DNP
DNP
0.5257
0.5257
M
M
SF
SF
02376377
02269325
MYL Y
TEV Y
pms-Pramipexole 1mg Tab
Pramipexole 1mg Tab
DNP
DNP
0.5257
0.5257
M
M
SF
SF
02290146
02367629
PMS Y
SAS Y
Pramipexole-1mg Tab
Sandoz Pramipexole 1mg Tab
DNP
DNP
0.5257
0.5257
M
M
SF
SF
02309149
02315289
SIV
SDZ
Mirapex 1mg Tab
DNP
0.5257
M
SF
02237146
BOE Y
pramipexole 1.5mg tab
ACT Pramipexole 1.5mg Tab
DNP
0.5257
M
SF
02297337
ATV
Apo-Pramipexole 1.5mg Tab
MYLAN-Pramipexole 1.5mg Tab
DNP
DNP
0.5257
0.5257
M
M
SF
SF
02292408
02376385
APX Y
MYL Y
Novo-Pramipexole 1.5mg Tab
pms-Pramipexole 1.5mg Tab
DNP
DNP
0.5257
0.5257
M
M
SF
SF
02269333
02290154
TEV Y
PMS Y
Pramipexole-1.5mg Tab
Sandoz Pramipexole 1.5mg Tab
DNP
DNP
0.5257
0.5257
M
M
SF
SF
02309157
02315297
SIV
SDZ
Mirapex 1.5mg Tab
DNP
0.5257
M
SF
02237147
BOE Y
DNP
DNP
0.5022
0.5022
M
M
SF
SF
02230641
02231036
APX Y
MYL Y
DNP
0.5022
M
SF
02068087
02123312
TEV Y
DRH Y
Y
Y
Y
Y
Y
Y
Y
MONOAMINE OXIDASE TYPE B INHIBITORS
N04BD01
SELEGILINE
selegiline 5mg tab
Apo-Selegiline 5mg Tab
MYLAN-Selegiline 5mg Tab
Novo-Selegiline 5mg Tab
Eldepryl 5mg Tab (discontinued)
N04BD02
February 2016
RASAGILINE
179
N
N04BX
Nervous System
Azilect 0.5mg Tab
02284642
TMP N
Azilect 1mg Tab
02284650
TMP N
OTHER DOPAMINERGIC AGENTS
N04BX02
ENTACAPONE
entacapone 200mg tab
MYLAN-Entacapone 200mg Tab
Sandoz Entacapone 200mg Tab
DNP
DNP
0.4062
0.4062
M
M
E
E
02390337
02380005
MYL Y
SDZ Y
Teva-Entacapone 200mg Tab
Comtan 200mg Tab
DNP
DNP
0.4062
0.4062
M
M
E
E
02375559
02243763
TEV Y
NVR Y
chlorpromazine 25mg/mL inj
Chlorpromazine 25mg/mL Inj
00743518
SDZ
Y
Largactil 25mg/5mL Inj (discontinued)
01929968
SAV
Y
N05
PSYCHOLEPTICS
N05A
ANTIPSYCHOTICS
N05AA
PHENOTHIAZINE WITH ALIPHATIC SIDE CHAIN
N05AA01
N05AA02
N05AB
CHLORPROMAZINE
Teva-Chlorpromazine 25mg Tab
DNP
0.2226
L
SFC
00232823
TEV
N
Teva-Chlorpromazine 50mg Tab
DNP
0.2547
L
SFC
00232807
TEV
N
Teva-Chlorpromazine 100mg Tab
DNP
0.6780
L
SFC
00232831
TEV
N
methotrimeprazine 2mg tab
Methoprazine 2mg Tab
Nozinan 2mg Tab (discontinued)
DNP
0.0685
M
SFC
02238403
01927647
AAP
SAV
Y
Y
methotrimeprazine 5mg tab
Methoprazine 5mg Tab
Nozinan 5mg Tab (discontinued)
DNP
0.0991
M
SFC
02238404
01927655
AAP
SAV
Y
Y
methotrimeprazine 25mg tab
Methoprazine 25mg Tab
Nozinan 25mg Tab (discontinued)
DNP
0.2547
M
SFC
02238405
01927663
AAP
SAV
Y
Y
Nozinan 25mg/mL Inj
DNP
3.4640
L
SFC
01927698
SAV
N
methotrimeprazine 50mg tab
Methoprazine 50mg Tab
Nozinan 50mg Tab (discontinued)
DNP
0.3857
M
SFC
02238406
01927671
AAP
SAV
Y
Y
Fluphenazine 1mg Tab
DNP
0.1739
L
SFC
00405345
AAP
N
Fluphenazine 2mg Tab
DNP
0.2252
L
SFC
00410632
AAP
N
Fluphenazine 5mg Tab
pms-Fluphenazine 5mg Tab
DNP
DNP
0.1720
0.1720
L
L
SFC
SFC
00405361
00726354
AAP N
PMS N
Modecate Concentrate 100mg/mL Inj
DNP
29.7800
L
SFC
00755575
BRI
METHOTRIMEPRAZINE (LEVOMEPROMAZINE)
PHENOTHIAZINE WITH PIPERAZINE STRUCTURE
N05AB02
February 2016
FLUPHENAZINE
180
N
N
Nervous System
N05AB03
PERPHENAZINE
Perphenazine 2mg Tab
DNP
0.0626
L
SFC
00335134
AAP
N
perphenazine 4mg tab
Perphenazine 4mg Tab
DNP
0.0823
M
SFC
00335126
AAP
Y
00028304
SCH Y
Trilafon 4mg Tab (discontinued)
N05AB04
N05AB06
Perphenazine 8mg Tab
DNP
0.0832
L
SFC
00335118
AAP
N
Perphenazine 16mg Tab
DNP
0.1274
L
SFC
00335096
AAP
N
prochlorperazine 5mg tab
Prochlorazine 5mg Tab
Stemetil 5mg Tab (discontinued)
DNP
0.1659
M
SFC
00886440
01927752
AAP Y
ROP Y
prochlorperazine 5mg/mL inj
Prochlorperazine 5mg/mL Inj
Stemetil 5mg/mL Inj (discontinued)
DNP
1.5020
M
SFC
00789747
01927779
SDZ Y
ROP Y
prochlorperazine 10mg tab
Prochlorazine 10mg Tab
Stemetil 10mg Tab (discontinued)
DNP
0.2025
M
SFC
00886432
01927760
AAP Y
ROP Y
Prochlorperazine 10mg Supp
DNP
1.5180
L
SFC
00789720
SDZ
N
DNP
0.1454
M
SFC
00345539
AAP
Y
01918206
GSK Y
00312754
AAP
01918214
GSK Y
00312746
AAP
01918222
GSK Y
00326836
AAP
01918230
GSK Y
PROCHLORPERAZINE
TRIFLUOPERAZINE
trifluoperazine 1mg tab
Trifluoperazine 1mg Tab
Stelazine 1mg Tab (discontinued)
trifluoperazine 2mg tab
Trifluoperazine 2mg Tab
DNP
0.1908
M
SFC
Stelazine 2mg Tab (discontinued)
trifluoperazine 5mg tab
Trifluoperazine 5mg Tab
DNP
0.2526
M
SFC
Stelazine 5mg Tab (discontinued)
trifluoperazine 10mg tab
Trifluoperazine 10mg Tab
DNP
0.3028
M
SFC
Stelazine 10mg Tab (discontinued)
Trifluoperazine 20mg Tab
N05AB08
Y
0.5580
L
SFC
00595942
AAP
N
DNP
0.6929
L
SFC
01927639
ERF
N
Neuleptil 5mg Cap
01926780
ERF
N
Neuleptil 10mg Cap
Neuleptil 10mg/mL Oral Drops
01926772
01926756
ERF
ERF
N
N
Neuleptil 20mg Cap
01926764
ERF
N
THIOPROPERAZINE
PHENOTHIAZINE WITH PIPERIDINE STRUCTURE
N05AC01
N05AD
Y
DNP
Majeptil 10mg Tab
N05AC
Y
PERICYAZINE (PROPERICYAZINE)
BUTYROPHENONE DERIVATIVES
February 2016
181
N
Nervous System
N05AD01
HALOPERIDOL
haloperidol 0.5mg tab
Novo-Peridol 0.5mg Tab
DNP
0.0360
M
SFC
Haldol 0.5mg Tab (discontinued)
haloperidol 1mg tab
Novo-Peridol 1mg Tab
DNP
0.0614
M
SFC
Haldol 1mg Tab (discontinued)
haloperidol 2mg tab
Novo-Peridol 2mg Tab
DNP
0.2773
M
SFC
Haldol 2mg Tab (discontinued)
haloperidol 5mg tab
Novo-Peridol 5mg Tab
DNP
0.4424
M
SFC
Haldol 5mg Tab (discontinued)
00017655
OMC Y
00363677
TEV
00017663
OMC Y
00363669
TEV
00017671
OMC Y
00363650
TEV
00017698
OMC Y
Y
Y
Y
4.8300
L
SFC
00808652
SDZ
N
haloperidol 10mg tab
Novo-Peridol 10mg Tab
DNP
0.1330
M
SFC
Y
00713449
TEV
Haldol 10mg Tab (discontinued)
00381772
OMC Y
haloperidol 20mg tab
Novo-Peridol 20mg Tab
00768820
TEV
Haldol 20mg Tab (discontinued)
00499579
OMC Y
02130297
SDZ
Y
00599085
JAN
Y
02130300
SDZ
Y
00599093
JAN
Y
02167832
SDZ
N
haloperidol LA 100mg/mL inj
Haloperidol LA 100mg/mL Inj
DNP
8.4640
M
SFC
DNP
16.9233
M
SFC
Haldol LA 100mg/mL Inj (discontinued)
Y
DROPERIDOL
Droperidol 2.5mg/mL Inj
INDOLE DERIVATIVES
N05AE04
N05AE05
N05AF
Y
DNP
Haldol LA 50mg/mL Inj (discontinued)
N05AE
TEV
Haloperidol 5mg/mL Inj
haloperidol LA 50mg/mL inj
Haloperidol LA 50mg/mL Inj
N05AD08
00363685
ZIPRASIDONE
Zeldox 20mg Cap
DNP
1.7492
L
E
02298597
PFI
N
Zeldox 40mg Cap
DNP
2.0037
L
E
02298600
PFI
N
Zeldox 60mg Cap
DNP
2.0037
L
E
02298619
PFI
N
Zeldox 80mg Cap
DNP
2.0037
L
E
02298627
PFI
N
Latuda 20mg Tab
DNP
4.0800
L
E
02422050
SNV N
Latuda 40mg Tab
DNP
4.0800
L
E
02387751
SNV N
Latuda 60mg Tab
DNP
4.0800
L
E
02413361
SNV N
Latuda 80mg Tab
DNP
4.0800
L
E
02387778
SNV N
Latuda 120mg Tab
DNP
4.0800
L
E
02387786
SNV N
LURASIDONE
THIOXANTHENE DERIVATIVES
February 2016
182
N
Nervous System
N05AF01
N05AF04
FLUPENTHIXOL
Fluanxol 0.5mg Tab
DNP
0.2608
L
SFC
02156008
VLH
N
Fluanxol Depot 2% Inj
DNP
7.5500
L
SFC
02156032
VLH
N
Fluanxol 3mg Tab
DNP
0.5633
L
SFC
02156016
VLH
N
Fluanxol Depot 10% Inj
DNP
37.7480
L
SFC
02156040
VLH
N
00024430
ERF
N
00024449
ERF
N
00024457
ERF
N
Clopixol 10mg Tab
02230402
VLH
N
Clopixol 25mg Tab
02230403
VLH
N
Clopixol-Acuphase 50mg/mL Inj
02230405
VLH
N
N
THIOTHIXENE
Navane 2mg Cap (discontinued)
Navane 5mg Cap
DNP
0.4738
L
SFC
Navane 10mg Cap (discontinued)
N05AF05
ZUCLOPENTHIXOL
Clopixol-Depot 200mg/mL Inj
N05AG
N05AG02
N05AH
DNP
15.6690
L
SF
02230406
VLH
pimozide 2mg tab
Apo-Pimozide 2mg Tab
Orap 2mg Tab
DNP
DNP
0.3093
0.3093
M
M
SFC
SFC
02245432
00313815
AAP Y
PMS Y
pimozide 4mg tab
Apo-Pimozide 4mg Tab
Orap 4mg Tab
DNP
DNP
0.4136
0.4136
M
M
SFC
SFC
02245433
00313823
AAP Y
PMS Y
Xylac 2.5mg Tab
DNP
0.1866
L
SFC
02242868
PDP N
loxapine 5mg tab
Xylac 5mg Tab
DNP
0.1749
M
SFC
02230837
PDP Y
02170019
WAY Y
02230838
PDP Y
02170027
WAY Y
02230839
PDP Y
02170132
WAY Y
02230840
PDP Y
02170035
WAY Y
02169991
SDZ
DIPHENYLBUTYLPIPERIDINE DERIVATIVES
PIMOZIDE
DIAZEPINES, OXAZEPINES, THIAZEPINES AND OXEPINES
N05AH01
LOXAPINE
Loxapac 5mg Tab (discontinued)
loxapine 10mg tab
Xylac10mg Tab
DNP
0.2912
M
SFC
Loxapac 10mg Tab (discontinued)
loxapine 25mg tab
Xylac 25mg Tab
DNP
0.4514
M
SFC
Loxapac 25mg Tab (discontinued)
loxapine 50mg tab
Xylac 50mg Tab
DNP
0.6017
M
SFC
Loxapac 50mg Tab (discontinued)
Loxapac 50mg/mL IM Inj
N05AH02
February 2016
DNP
15.2350
L
SFC
CLOZAPINE
183
N
N
Nervous System
N05AH03
February 2016
clozapine 25mg tab
Apo-Clozapine 25mg Tab
02248034
APX
Gen-Clozapine 25mg Tab
Clozaril 25mg Tab
02247243
00894737
MYL Y
NVR Y
Gen-Clozapine 50mg Tab
02305003
MYL N
clozapine 100mg tab
Apo-Clozapine 100mg Tab
Gen-Clozapine 100mg Tab
02248035
02247244
APX Y
MYL Y
Clozaril 100mg Tab
00894745
NVR Y
Gen-Clozapine 200mg Tab
02305011
MYL N
Y
OLANZAPINE
olanzapine 2.5mg tab
Apo-Olanzapine 2.5mg Tab
CO Olanzapine 2.5mg Tab
DNP
DNP
0.3189
0.3189
M
M
E
E
02281791
02325659
APX
ATV
Jamp-Olanzapine FC 2.5mg Tab
Mar-Olanzapine 2.5mg Tab
DNP
DNP
0.3189
0.3189
M
M
E
E
02417243
02421232
JPC Y
MAR Y
MYLAN-Olanzapine 2.5mg Tab
Olanzapine 2.5mg Tab
DNP
DNP
0.3189
0.3189
M
M
E
E
02337878
02372819
MYL Y
SAS Y
Olanzapine-2.5mg Tab
pms-Olanzapine 2.5mg Tab
DNP
0.3189
M
E
02385864
02303116
SIV N
PMS Y
RAN-Olanzapine 2.5mg Tab
Sandoz Olanzapine 2.5mg Tab
DNP
DNP
0.3189
0.3189
M
M
E
E
02403064
02310341
RAN Y
SDZ Y
Teva-Olanzapine 2.5mg Tab
Zyprexa 2.5mg Tab
DNP
DNP
0.3189
0.3189
M
M
E
E
02276712
02229250
TEV
LIL
Y
Y
olanzapine 5mg tab
Apo-Olanzapine 5mg Tab
CO Olanzapine 5mg Tab
DNP
DNP
0.6379
0.6379
M
M
E
E
02281805
02325667
APX
ATV
Y
Y
Jamp-Olanzapine FC 5mg Tab
Mar-Olanzapine 5mg Tab
DNP
DNP
0.6379
0.6379
M
M
E
E
02417251
02421240
JPC Y
MAR Y
MYLAN-Olanzapine 5mg Tab
Olanzapine 5mg Tab
DNP
DNP
0.6379
0.6379
M
M
E
E
02337886
02372827
MYL Y
SAS Y
Olanzapine-5mg Tab
pms-Olanzapine 5mg Tab
DNP
DNP
0.6379
0.6379
M
M
E
E
02385872
02303159
SIV Y
PMS Y
RAN-Olanzapine 5mg Tab
Sandoz Olanzapine 5mg Tab
DNP
DNP
0.6379
0.6379
M
M
E
E
02403072
02310368
RAN Y
SDZ Y
Teva-Olanzapine 5mg Tab
Zyprexa 5mg Tab
DNP
DNP
0.6379
0.6379
M
M
E
E
02276720
02229269
TEV
LIL
Y
Y
olanzapine ODT 5mg tab
Apo-Olanzapine ODT 5mg Tab
CO Olanzapine ODT 5mg Tab
DNP
DNP
0.6434
0.6434
M
M
E
E
02360616
02327562
APX
ATV
Y
Y
Jamp-Olanzapine ODT 5mg Tab
Mar-Olanzapine ODT 5mg Tab
DNP
DNP
0.6434
0.6434
M
M
E
E
02406624
02389088
JPC Y
MAR Y
MYLAN-Olanzapine ODT 5mg Tab
Novo-Olanzapine OD 5mg Tab
DNP
DNP
0.6434
0.6434
M
M
E
E
02382709
02321343
MYL Y
TEV Y
Olanzapine ODT 5mg Tab
Olanzapine-ODT 5mg Tab
DNP
DNP
0.6434
0.6434
M
M
E
E
02352974
02343665
SAS
SIV
pms-Olanzapine ODT 5mg Tab
DNP
0.6434
M
E
02303191
PMS Y
184
Y
Y
Y
Y
N
Nervous System
RAN-Olanzapine ODT 5mg Tab
Sandoz Olanzapine ODT 5mg Tab
DNP
DNP
0.6434
0.6434
M
M
E
E
02414090
02327775
RAN Y
SDZ Y
Zyprexa Zydis 5mg Tab
DNP
0.6434
M
E
02243086
LIL
Y
olanzapine 7.5mg tab
Apo-Olanzapine 7.5mg Tab
DNP
0.9568
M
E
02281813
APX
Y
CO Olanzapine 7.5mg Tab
Jamp-Olanzapine FC 7.5mg Tab
DNP
DNP
0.9568
0.9568
M
M
E
E
02325675
02417278
ATV
JPC
Y
Y
Mar-Olanzapine 7.5mg Tab
MYLAN-Olanzapine 7.5mg Tab
DNP
DNP
0.9568
0.9568
M
M
E
E
02421259
02337894
MAR Y
MYL Y
Olanzapine 7.5mg Tab
Olanzapine-7.5mg Tab
DNP
DNP
0.9568
0.9568
M
M
E
E
02372835
02385880
SAS
SIV
pms-Olanzapine 7.5mg Tab
RAN-Olanzapine 7.5mg Tab
DNP
DNP
0.9568
0.9568
M
M
E
E
02303167
02403080
PMS Y
RAN Y
Sandoz Olanzapine 7.5mg Tab
Teva-Olanzapine 7.5mg Tab
DNP
DNP
0.9568
0.9568
M
M
E
E
02310376
02276739
SDZ
TEV
Y
Y
Zyprexa 7.5mg Tab
DNP
0.9568
M
E
02229277
LIL
Y
olanzapine 10mg tab
Apo-Olanzapine 10mg Tab
DNP
1.2758
M
E
02281821
APX
Y
CO Olanzapine 10mg Tab
Jamp-Olanzapine FC 10mg Tab
DNP
DNP
1.2758
1.2758
M
M
E
E
02325683
02417286
ATV
JPC
Y
Y
Mar-Olanzapine 10mg Tab
MYLAN-Olanzapine 10mg Tab
DNP
DNP
1.2758
1.2758
M
M
E
E
02421267
02337908
MAR Y
MYL Y
Olanzapine 10mg Tab
Olanzapine-10mg Tab
DNP
DNP
1.2758
1.2758
M
M
E
E
02372843
02385899
SAS
SIV
pms-Olanzapine 10mg Tab
RAN-Olanzapine 10mg Tab
DNP
DNP
1.2758
1.2758
M
M
E
E
02303175
02403099
PMS Y
RAN Y
Sandoz Olanzapine 10mg Tab
Teva-Olanzapine 10mg Tab
DNP
DNP
1.2758
1.2758
M
M
E
E
02310384
02276747
SDZ
TEV
Y
Y
Zyprexa 10mg Tab
DNP
1.2758
M
E
02229285
LIL
Y
olanzapine ODT 10mg tab
Apo-Olanzapine ODT 10mg Tab
DNP
1.2857
M
E
02360624
APX
Y
CO Olanzapine ODT 10mg Tab
Jamp-Olanzapine ODT 10mg Tab
DNP
DNP
1.2857
1.2857
M
M
E
E
02327570
02406632
ATV
JPC
Y
Y
Mar-Olanzapine ODT 10mg Tab
MYLAN-Olanzapine ODT 10mg Tab
DNP
DNP
1.2857
1.2857
M
M
E
E
02389096
02382717
MAR Y
MYL Y
Novo-Olanzapine OD 10mg Tab
Olanzapine ODT 10mg Tab
DNP
DNP
1.2857
1.2857
M
M
E
E
02321351
02352982
TEV
SAS
Olanzapine-ODT 10mg Tab
pms-Olanzapine ODT 10mg Tab
DNP
DNP
1.2857
1.2857
M
M
E
E
02343673
02303205
SIV Y
PMS Y
RAN-Olanzapine ODT 10mg Tab
Sandoz Olanzapine ODT 10mg Tab
DNP
DNP
1.2857
1.2857
M
M
E
E
02414104
02327783
RAN Y
SDZ Y
Zyprexa Zydis 10mg Tab
DNP
1.2857
M
E
02243087
LIL
Y
02247099
LIL
N
Zyprexa 10mg/vial Inj
February 2016
Y
Y
Y
Y
Y
Y
olanzapine 15mg tab
Apo-Olanzapine 15mg Tab
DNP
1.9136
M
E
02281848
APX
Y
CO Olanzapine 15mg Tab
Jamp-Olanzapine FC 15mg Tab
DNP
DNP
1.9136
1.9136
M
M
E
E
02325691
02417294
ATV
JPC
Y
Y
Mar-Olanzapine 15mg Tab
DNP
1.9136
M
E
02421275
MAR Y
185
N
Nervous System
N05AH04
February 2016
MYLAN-Olanzapine 15mg Tab
Olanzapine 15mg Tab
DNP
DNP
1.9136
1.9136
M
M
E
E
02337916
02372851
MYL Y
SAS Y
Olanzapine-15mg Tab
pms-Olanzapine 15mg Tab
DNP
DNP
1.9136
1.9136
M
M
E
E
02385902
02303183
SIV Y
PMS Y
RAN-Olanzapine 15mg Tab
Sandoz Olanzapine 15mg Tab
DNP
DNP
1.9136
1.9136
M
M
E
E
02403102
02310392
RAN N
SDZ Y
Teva-Olanzapine 15mg Tab
Zyprexa 15mg Tab
DNP
DNP
1.9136
1.9136
M
M
E
E
02276755
02238850
TEV
LIL
Y
Y
olanzapine ODT 15mg tab
Apo-Olanzapine ODT 15mg Tab
CO Olanzapine ODT 15mg Tab
DNP
DNP
1.9280
1.9280
M
M
E
E
02360632
02327589
APX
ATV
Y
Y
Jamp-Olanzapine ODT 15mg Tab
Mar-Olanzapine ODT 15mg Tab
DNP
DNP
1.9280
1.9280
M
M
E
E
02406640
02389118
JPC Y
MAR Y
MYLAN-Olanzapine ODT 15mg Tab
Novo-Olanzapine OD 15mg Tab
DNP
DNP
1.9280
1.9280
M
M
E
E
02382725
02321378
MYL Y
TEV Y
Olanzapine ODT 15mg Tab
Olanzapine-ODT 15mg Tab
DNP
DNP
1.9280
1.9280
M
M
E
E
02352990
02343681
SAS
SIV
pms-Olanzapine ODT 15mg Tab
RAN-Olanzapine ODT 15mg Tab
DNP
DNP
1.9280
1.9280
M
M
E
E
02303213
02414112
PMS Y
RAN Y
Sandoz Olanzapine ODT 15mg Tab
Zyprexa Zydis 15mg Tab
DNP
DNP
1.9280
1.9280
M
M
E
E
02327791
02243088
SDZ
LIL
Y
Y
olanzapine 20mg tab
Apo-Olanzapine 20mg Tab
CO Olanzapine 20mg Tab
02333015
02325713
APX
ATV
Y
Y
Jamp-Olanzapine FC 20mg Tab
pms-Olanzapine 20mg Tab
02417308
02367483
JPC Y
PMS Y
Teva-Olanzapine 20mg
Zyprexa 20mg Tab
02359707
02238851
TEV
LIL
Y
Y
Y
Y
Y
Y
olanzapine ODT 20mg tab
Apo-Olanzapine ODT 20mg Tab
CO Olanzapine ODT 20mg Tab
DNP
DNP
2.5447
2.5447
M
M
E
E
02360640
02327597
APX
ATV
Jamp-Olanzapine ODT 20mg Tab
Mar-Olanzapine ODT 20mg Tab
DNP
DNP
2.5447
2.5447
M
M
E
E
02406659
02389126
JPC Y
MAR Y
MYLAN-Olanzapine ODT 20mg Tab
Novo-Olanzapine OD 20mg Tab
DNP
DNP
2.5447
2.5447
M
M
E
E
02382733
02321386
MYL Y
TEV Y
Olanzapine-ODT 20mg Tab
pms-Olanzapine ODT 20mg Tab
DNP
DNP
2.5447
2.5447
M
M
E
E
02343703
02423944
SIV Y
PMS Y
RAN-Olanzapine ODT 20mg Tab
Sandoz Olanzapine ODT 20mg Tab
DNP
DNP
2.5447
2.5447
M
M
E
E
02414120
02327805
RAN Y
SDZ Y
Zyprexa Zydis 20mg Tab
DNP
2.5447
M
E
02243089
LIL
Y
quetiapine 25mg tab
Abbott-Quetiapine 25mg Tab (discontinued)
Apo-Quetiapine 25mg Tab
DNP
0.1271
M
SF
02412977
02313901
ABB
APX
Y
Y
Auro-Quetiapine 25mg Tab
CO Quetiapine 25mg Tab
DNP
DNP
0.1271
0.1271
M
M
SF
SF
02390205
02316080
ARO Y
ATV Y
Jamp-Quetiapine 25mg Tab
Mar-Quetiapine 25mg Tab
DNP
DNP
0.1271
0.1271
M
M
SF
SF
02330415
02399822
JPC Y
MAR Y
QUETIAPINE
186
N
Nervous System
MYLAN-Quetiapine 25mg Tab
Novo-Quetiapine 25mg Tab
DNP
DNP
0.1271
0.1271
M
M
SF
SF
02307804
02284235
MYL Y
TEV Y
pms-Quetiapine 25mg Tab
Quetiapine 25mg Tab
DNP
DNP
0.1271
0.1271
M
M
SF
SF
02296551
02353164
PMS Y
SAS Y
Quetiapine-25mg Tab
Quetiapine-25mg Tab
DNP
DNP
0.1271
0.1271
M
M
SF
SF
02317893
02387794
SIV
AHI
RAN-Quetiapine 25mg Tab
Sandoz Quetiapine 25mg Tab
DNP
DNP
0.1271
0.1271
M
M
SF
SF
02397099
02313995
RAN Y
SDZ Y
Seroquel 25mg Tab
DNP
0.1271
M
SF
02236951
AZE
Y
quetiapine 50mg ER tab
Sandoz Quetiapine XRT 50mg Tab
02407671
SDZ
Y
Teva-Quetiapine XR 50mg Tab
Seroquel XR 50mg Tab
02395444
02300184
TEV
AZE
Y
Y
SF
02361892
PMS N
ABB
APX
pms-Quetiapine 50mg Tab
DNP
0.6437
L
quetiapine 100mg tab
Abbott-Quetiapine 100mg Tab (discontinued)
Apo-Quetiapine 100mg Tab
DNP
0.3390
M
SF
02412985
02313928
Auro-Quetiapine 100mg Tab
CO Quetiapine 100mg Tab
DNP
DNP
0.3390
0.3390
M
M
SF
SF
02390213
02316099
ARO Y
ATV Y
Jamp-Quetiapine 100mg Tab
Mar-Quetiapine 100mg Tab
DNP
DNP
0.3390
0.3390
M
M
SF
SF
02330423
02399830
JPC Y
MAR Y
MYLAN-Quetiapine 100mg Tab
Novo-Quetiapine 100mg Tab
DNP
DNP
0.3390
0.3390
M
M
SF
SF
02307812
02284243
MYL Y
TEV Y
pms-Quetiapine 100mg Tab
Quetiapine 100mg Tab
DNP
DNP
0.3390
0.3390
M
M
SF
SF
02296578
02353172
PMS Y
SAS Y
Quetiapine-100mg Tab
Quetiapine-100mg Tab
DNP
DNP
0.3390
0.3390
M
M
SF
SF
02387808
02317907
AHI
SIV
RAN-Quetiapine 100mg Tab
Sandoz Quetiapine 100mg Tab
DNP
DNP
0.3390
0.3390
M
M
SF
SF
02397102
02314002
RAN Y
SDZ Y
Seroquel 100mg Tab
DNP
0.3390
M
SF
02236952
AZE
Y
quetiapine 150mg ER tab
Sandoz Quetiapine XRT 150mg Tab
02407698
SDZ
Y
Teva-Quetiapine XR 150mg Tab
Seroquel XR 150mg Tab
02395452
02321513
TEV
AZE
Y
Y
02284251
02240862
TEV
AZE
Y
Y
quetiapine 200mg ER tab
Sandoz Quetiapine XRT 200mg Tab
Teva-Quetiapine XR 200mg Tab
02407701
02395460
SDZ
TEV
Y
Y
Seroquel XR 200mg Tab
02300192
AZE
Y
Y
quetiapine 150mg tab
Novo-Quetiapine 150mg Tab
Seroquel 150mg Tab (discontinued)
DNP
1.6222
M
SF
quetiapine 200mg tab
Abbott-Quetiapine 200mg Tab (discontinued)
February 2016
Y
Y
Y
Y
Y
Y
02412993
ABB
Apo-Quetiapine 200mg Tab
Auro-Quetiapine 200mg Tab
DNP
DNP
0.6807
0.6807
M
M
SF
SF
02313936
02390248
APX Y
ARO Y
CO Quetiapine 200mg Tab
Jamp-Quetiapine 200mg Tab
DNP
DNP
0.6807
0.6807
M
M
SF
SF
02316110
02330458
ATV
JPC
187
Y
Y
N
Nervous System
N05AH05
N05AN
Mar-Quetiapine 200mg Tab
MYLAN-Quetiapine 200mg Tab
DNP
DNP
0.6807
0.6807
M
M
SF
SF
02399849
02307839
MAR Y
MYL Y
Novo-Quetiapine 200mg Tab
pms-Quetiapine 200mg Tab
DNP
DNP
0.6807
0.6807
M
M
SF
SF
02284278
02296594
TEV Y
PMS Y
Quetiapine 200mg Tab
Quetiapine-200mg Tab
DNP
DNP
0.6807
0.6807
M
M
SF
SF
02353199
02317923
SAS
SIV
Quetiapine-200mg Tab
RAN-Quetiapine 200mg Tab
DNP
DNP
0.6807
0.6807
M
M
SF
SF
02387824
02397110
AHI Y
RAN Y
Sandoz Quetiapine 200mg Tab
Seroquel 200mg Tab
DNP
DNP
0.6807
0.6807
M
M
SF
SF
02314010
02236953
SDZ
AZE
Y
Y
quetiapine 300mg ER tab
Sandoz Quetiapine XRT 300mg Tab
Teva-Quetiapine XR 300mg Tab
02407728
02395479
SDZ
TEV
Y
Y
Seroquel XR 300mg Tab
02300206
AZE
Y
quetiapine 300mg tab
Abbott-Quetiapine 300mg Tab (discontinued)
02413000
ABB
Y
Y
Y
Apo-Quetiapine 300mg Tab
Auro-Quetiapine 300mg Tab
DNP
DNP
0.9933
0.9933
M
M
SF
SF
02313944
02390256
APX Y
ARO Y
CO Quetiapine 300mg Tab
Jamp-Quetiapine 300mg Tab
DNP
DNP
0.9933
0.9933
M
M
SF
SF
02316129
02330466
ATV
JPC
Mar-Quetiapine 300mg Tab
MYLAN-Quetiapine 300mg Tab
DNP
DNP
0.9933
0.9933
M
M
SF
SF
02399857
02307847
MAR Y
MYL Y
Novo-Quetiapine 300mg Tab
pms-Quetiapine 300mg Tab
DNP
DNP
0.9933
0.9933
M
M
SF
SF
02284286
02296608
TEV Y
PMS Y
Quetiapine 300mg Tab
Quetiapine-300mg Tab
DNP
DNP
0.9933
0.9933
M
M
SF
SF
02353202
02387832
SAS
AHI
Quetiapine-300mg Tab
RAN-Quetiapine 300mg Tab
DNP
DNP
0.9933
0.9933
M
M
SF
SF
02317931
02397129
SIV Y
RAN Y
Sandoz Quetiapine 300mg Tab
Seroquel 300mg Tab
DNP
DNP
0.9933
0.9933
M
M
SF
SF
02314029
02244107
SDZ
AZE
Y
Y
quetiapine 400mg ER tab
Sandoz Quetiapine XRT 400mg Tab
Teva-Quetiapine XR 400mg Tab
02407736
02395487
SDZ
TEV
Y
Y
Seroquel XR 400mg Tab
02300214
AZE
Y
Y
Y
Y
Y
ASENAPINE
Saphris 5mg SL Tab
DNP
1.4500
L
E
02374803
FRS
N
Saphris 10mg SL Tab
DNP
1.4500
L
E
02374811
FRS
N
lithium 150mg cap (Carbolith)
Apo-Lithium Carbonate 150mg Cap
DNP
0.0667
M
SFC
02242837
APX
Y
pms-Lithium Carbonate 150mg Cap
Carbolith 150mg Cap
DNP
DNP
0.0667
0.0667
M
M
SFC
SFC
02216132
00461733
PMS Y
VLN Y
lithium 150mg cap (Lithane)
Apo-Lithium Carbonate 150mg Cap
Lithane 150mg Cap
DNP
DNP
0.0667
0.0667
M
M
SFC
SFC
02242837
02013231
APX
ERF
LITHIUM
N05AN01
February 2016
LITHIUM
188
Y
Y
N
Nervous System
lithium 300mg SR tab
Lithmax SR 300mg Tab
DNP
0.2708
M
SFC
Duralith 300mg Tab (discontinued)
N05AX
02266695
AAP
Y
00590665
JAN
Y
Y
lithium 300mg cap (Carbolith)
Apo-Lithium Carbonate 300mg Cap
DNP
0.0657
M
SFC
02242838
APX
pms-Lithium Carbonate 300mg Cap
Carbolith 300mg Cap
DNP
DNP
0.0657
0.0657
M
M
SFC
SFC
02216140
00236683
PMS Y
VLN Y
lithium 300mg cap (Lithane)
Apo-Lithium Carbonate 300mg Cap
Lithane 300mg Cap
DNP
DNP
0.0657
0.0657
M
M
SFC
SFC
02242838
00406775
APX
ERF
lithium 600mg cap
pms-Lithium Carbonate 600mg Cap
Carbolith 600mg Cap
DNP
DNP
0.1576
0.1576
M
M
SFC
SFC
02216159
02011239
PMS Y
VLN Y
risperidone 0.25mg tab
Apo-Risperidone 0.25mg Tab
DNP
0.1314
M
SF
02282119
APX
Y
CO Risperidone 0.25mg Tab
Jamp-Risperidone 0.25mg Tab
DNP
DNP
0.1314
0.1314
M
M
SF
SF
02282585
02359529
ATV
JPC
Y
Y
Mar-Risperidone 0.25mg Tab
MINT-Risperidon 0.25mg Tab
DNP
DNP
0.1314
0.1314
M
M
SF
SF
02371766
02359790
MAR Y
MNT Y
MYLAN-Risperidone 0.25mg Tab
Novo-Risperidone 0.25mg Tab
DNP
DNP
0.1314
0.1314
M
M
SF
SF
02282240
02282690
MYL Y
TEV Y
pms-Risperidone 0.25mg Tab
RAN-Risperidone 0.25mg Tab
DNP
DNP
0.1314
0.1314
M
M
SF
SF
02252007
02328305
PMS Y
RAN Y
Risperidone 0.25mg Tab
Sandoz Risperidone 0.25mg Tab
DNP
DNP
0.1314
0.1314
M
M
SF
SF
02356880
02303655
SAS
SDZ
Y
Y
Risperdal 0.25mg Tab
DNP
0.1314
M
SF
02240551
JAN
Y
risperidone 0.5mg tab
Apo-Risperidone 0.5mg Tab
DNP
0.2201
M
SF
02282127
APX
Y
CO Risperidone 0.5mg Tab
Jamp-Risperidone 0.5mg Tab
DNP
DNP
0.2201
0.2201
M
M
SF
SF
02282593
02359537
ATV
JPC
Y
Y
Mar-Risperidone 0.5mg Tab
MINT-Risperidon 0.5mg Tab
DNP
DNP
0.2201
0.2201
M
M
SF
SF
02371774
02359804
MAR Y
MNT Y
MYLAN-Risperidone 0.5mg Tab
Novo-Risperidone 0.5mg Tab
DNP
DNP
0.2201
0.2201
M
M
SF
SF
02282259
02264188
MYL Y
TEV Y
pms-Risperidone 0.5mg Tab
RAN-Risperidone 0.5mg Tab
DNP
DNP
0.2201
0.2201
M
M
SF
SF
02252015
02328313
PMS Y
RAN Y
Risperidone 0.5mg Tab
Sandoz Risperidone 0.5mg Tab
DNP
DNP
0.2201
0.2201
M
M
SF
SF
02356899
02303663
SAS
SDZ
Y
Y
Risperdal 0.5mg Tab
DNP
0.2201
M
SF
02240552
JAN
Y
risperidone ODT 0.5mg tab
MYLAN-Risperidone ODT 0.5mg
DNP
0.5588
M
SF
02413485
MYL Y
Risperdal M-Tab (0.5mg)
DNP
0.5588
M
SF
02247704
JAN
Y
risperidone 1mg tab
Apo-Risperidone 1mg Tab
DNP
0.3041
M
SF
02282135
APX
Y
Y
Y
OTHER NEUROLEPTICS
N05AX08
February 2016
RISPERIDONE
189
N
Nervous System
February 2016
CO Risperidone 1mg Tab
Jamp-Risperidone 1mg Tab
DNP
DNP
0.3041
0.3041
M
M
SF
SF
02282607
02359545
ATV
JPC
Mar-Risperidone 1mg Tab
MINT-Risperidon 1mg Tab
DNP
DNP
0.3041
0.3041
M
M
SF
SF
02371782
02359812
MAR Y
MNT Y
MYLAN-Risperidone 1mg Tab
Novo-Risperidone 1mg Tab
DNP
DNP
0.3041
0.3041
M
M
SF
SF
02282267
02264196
MYL Y
TEV Y
pms-Risperidone 1mg Tab
RAN-Risperidone 1mg Tab
DNP
DNP
0.3041
0.3041
M
M
SF
SF
02252023
02328321
PMS Y
RAN Y
Risperidone 1mg Tab
Sandoz Risperidone 1mg Tab
DNP
DNP
0.3041
0.3041
M
M
SF
SF
02356902
02279800
SAS
SDZ
Y
Y
Risperdal 1mg Tab
DNP
0.3041
M
SF
02025280
JAN
Y
risperidone 1mg/mL o/l
Apo-Risperidone 1mg/mL O/L
DNP
0.4802
M
SF
02280396
APX
Y
pms-Risperidone 1mg/mL O/L
Risperdal 1mg/mL O/L
DNP
DNP
0.4802
0.4802
M
M
SF
SF
02279266
02236950
PMS Y
JAN Y
risperidone ODT 1mg tab
MYLAN-Risperidone ODT 1mg Tab
pms-Risperidone ODT 1mg Tab
DNP
DNP
0.5150
0.5150
M
M
SF
SF
02413493
02291789
MYL Y
PMS Y
Risperdal M-Tab (1mg)
DNP
0.5150
M
SF
02247705
JAN
Y
risperidone 2mg tab
Apo-Risperidone 2mg Tab
DNP
0.6071
M
SF
02282143
APX
Y
CO Risperidone 2mg Tab
Jamp-Risperidone 2mg Tab
DNP
DNP
0.6071
0.6071
M
M
SF
SF
02282615
02359553
ATV
JPC
Y
Y
Mar-Risperidone 2mg Tab
MINT-Risperidon 2mg Tab
DNP
DNP
0.6071
0.6071
M
M
SF
SF
02371790
02359820
MAR Y
MNT Y
MYLAN-Risperidone 2mg Tab
Novo-Risperidone 2mg Tab
DNP
DNP
0.6071
0.6071
M
M
SF
SF
02282275
02264218
MYL Y
TEV Y
pms-Risperidone 2mg Tab
RAN-Risperidone 2mg Tab
DNP
DNP
0.6071
0.6071
M
M
SF
SF
02252031
02328348
PMS Y
RAN Y
Risperidone 2mg Tab
Sandoz Risperidone 2mg Tab
DNP
DNP
0.6071
0.6071
M
M
SF
SF
02356910
02279819
SAS
SDZ
Y
Y
Risperdal 2mg Tab
DNP
0.6071
M
SF
02025299
JAN
Y
risperidone ODT 2mg tab
MYLAN-Risperidone ODT 2mg Tab
DNP
1.0188
M
SF
02413507
MYL Y
pms-Risperidone ODT 2mg Tab
Risperdal M-Tab (2mg)
DNP
DNP
1.0188
1.0188
M
M
SF
SF
02291797
02247706
PMS Y
JAN Y
risperidone 3mg tab
Apo-Risperidone 3mg Tab
CO Risperidone 3mg Tab
DNP
DNP
0.9108
0.9108
M
M
SF
SF
02282151
02282623
APX
ATV
Jamp-Risperidone 3mg Tab
Mar-Risperidone 3mg Tab
DNP
DNP
0.9108
0.9108
M
M
SF
SF
02359561
02371804
JPC Y
MAR Y
MINT-Risperidon 3mg Tab
MYLAN-Risperidone 3mg Tab
DNP
DNP
0.9108
0.9108
M
M
SF
SF
02359839
02282283
MNT Y
MYL Y
Novo-Risperidone 3mg Tab
pms-Risperidone 3mg Tab
DNP
DNP
0.9108
0.9108
M
M
SF
SF
02264226
02252058
TEV Y
PMS Y
RAN-Risperidone 3mg Tab
Risperidone 3mg Tab
DNP
DNP
0.9108
0.9108
M
M
SF
SF
02328364
02356929
RAN Y
SAS Y
Sandoz Risperidone 3mg Tab
DNP
0.9108
M
SF
02279827
SDZ
190
Y
Y
Y
Y
Y
N
Nervous System
N05AX12
N05AX13
N05B
Risperdal 3mg Tab
DNP
0.9108
M
SF
02025302
JAN
risperidone ODT 3mg tab
MYLAN-Risperidone ODT 3mg Tab
DNP
1.5275
M
SF
02413515
MYL Y
pms-Risperidone ODT 3mg Tab
Risperdal M-Tab (3mg)
DNP
DNP
1.5275
1.5275
M
M
SF
SF
02370697
02268086
PMS Y
JAN Y
risperidone 4mg tab
Apo-Risperidone 4mg Tab
CO Risperidone 4mg Tab
DNP
DNP
1.2144
1.2144
M
M
SF
SF
02282178
02282631
APX
ATV
Jamp-Risperidone 4mg Tab
Mar-Risperidone 4mg Tab
DNP
DNP
1.2144
1.2144
M
M
SF
SF
02359588
02371812
JPC Y
MAR Y
MINT-Risperidon 4mg Tab
MYLAN-Risperidone 4mg Tab
DNP
DNP
1.2144
1.2144
M
M
SF
SF
02359847
02282291
MNT Y
MYL Y
Novo-Risperidone 4mg Tab
pms-Risperidone 4mg Tab
DNP
DNP
1.2144
1.2144
M
M
SF
SF
02264234
02252066
TEV Y
PMS Y
RAN-Risperidone 4mg Tab
Risperidone 4mg Tab
DNP
DNP
1.2144
1.2144
M
M
SF
SF
02328372
02356937
RAN Y
SAS Y
Sandoz Risperidone 4mg Tab
Risperdal 4mg Tab
DNP
DNP
1.2144
1.2144
M
M
SF
SF
02279835
02025310
SDZ
JAN
risperidone ODT 4mg tab
MYLAN-Risperidone ODT 4mg Tab
pms-Risperidone ODT 4mg Tab
DNP
DNP
2.0425
2.0425
M
M
SF
SF
02413523
02370700
MYL Y
PMS Y
Risperdal M-Tab (4mg)
DNP
2.0425
M
SF
02268094
JAN
Y
Risperdal Consta 12.5mg/2mL Inj
DNP
80.9500
L
E
02298465
JAN
N
Risperdal Consta 25mg/2mL Inj
DNP
168.0700
L
E
02255707
JAN
N
Risperdal Consta 37.5mg/2mL Inj
DNP
252.0900
L
E
02255723
JAN
N
Risperdal Consta 50mg/2mL Inj
DNP
336.1300
L
E
02255758
JAN
N
Abilify 2mg Tab
DNP
3.0917
L
E
02322374
BRI
N
Abilify 5mg Tab
DNP
3.4800
L
E
02322382
BRI
N
Abilify 10mg Tab
DNP
3.9717
L
E
02322390
BRI
N
Abilify 15mg Tab
DNP
4.0500
L
E
02322404
BRI
N
Abilify 20mg Tab
DNP
4.0900
L
E
02322412
BRI
N
Abilify 30mg Tab
DNP
4.0900
L
E
02322455
BRI
N
Abilify Maintena 300mg/Vial Inj
DNP
456.1800
L
E
02420864
BRI
N
Abilify Maintena 400mg/Vial Inj
DNP
456.1800
L
E
02420872
BRI
N
Invega Sustenna 50mg/0.5mL Kit
DNP
317.9100
L
E
02354217
JAN
N
Invega Sustenna 75mg/0.75mL Kit
DNP
476.8700
L
E
02354225
JAN
N
Invega Sustenna 100mg/1mL Kit
DNP
476.8700
L
E
02354233
JAN
N
Invega Sustenna 150mg/1.5mL Kit
DNP
635.8300
L
E
02354241
JAN
N
Y
Y
Y
Y
ARIPIPRAZOLE
PALIPERIDONE
ANXIOLYTICS
February 2016
Y
191
N
Nervous System
N05BA
BENZODIAZEPINE DERIVATIVES
N05BA01
DIAZEPAM
pms-Diazepam 1mg/mL O/L
DN
0.1053
L
SFC
00891797
PMS N
Apo-Diazepam 2mg Tab
pms-Diazepam 2mg Tab
DN
DN
0.0508
0.0508
L
L
SFC
SFC
00405329
02247490
APX N
PMS N
diazepam 5mg tab
Apo-Diazepam 5mg Tab
Valium 5mg Tab
DN
DN
0.0650
0.0650
M
M
SFC
SFC
00362158
00013285
APX
HLR
Y
Y
00013765
AXS
Y
00399728
SDZ
Y
00012874
HLR
Y
Vivol 5mg Tab (discontinued)
diazepam 5mg/mL inj
Diazepam 5mg/mL Inj
DN
1.2415
M
SFC
Valium 5mg/mL Inj (discontinued)
pms-Diazepam 5mg Tab
Diastat 5mg/mL Rectal Gel
DN
0.0650
L
SFC
02247491
02238162
PMS N
VLN N
Diazemuls 5mg/mL Inj
DN
1.1520
L
SFC
02065614
PFI
N
diazepam 10mg tab
Apo-Diazepam 10mg Tab
DN
0.0867
M
SFC
00405337
APX
Y
00013293
00013773
HLR
AXS
Y
Y
Valium 10mg Tab (discontinued)
Vivol 10mg Tab (discontinued)
pms-Diazepam 10mg Tab
N05BA02
N05BA04
N05BA05
DN
0.0867
L
SFC
02247492
PMS N
Chlordiazepoxide 5mg Cap
DN
0.0679
L
SFC
00522724
AAP
N
Chlordiazepoxide 10mg Cap
DN
0.1070
L
SFC
00522988
AAP
N
Chlordiazepoxide 25mg Cap
DN
0.1659
L
SFC
00522996
AAP
N
oxazepam 10mg tab
Apo-Oxazepam 10mg Tab
Serax 10mg Tab (discontinued)
DN
0.0420
M
SFC
00402680
02043653
APX Y
WAY Y
oxazepam 15mg tab
Apo-Oxazepam 15mg Tab
Serax 15mg Tab (discontinued)
DN
0.0560
M
SFC
00402745
02043661
APX Y
WAY Y
oxazepam 30mg tab
Apo-Oxazepam 30mg Tab
Serax 30mg Tab (discontinued)
DN
0.0764
M
SFC
00402737
02043688
APX Y
WAY Y
DN
0.1476
M
SFC
00860689
AAP
Y
00264938
ABB
Y
00860700
AAP
Y
00264946
ABB
Y
CHLORDIAZEPOXIDE
OXAZEPAM
CLORAZEPATE DIPOTASSIUM
clorazepate dipotassium 3.75mg cap
Clorazepate 3.75mg Cap
Tranxene 3.75mg Cap (discontinued)
clorazepate dipotassium 7.5mg cap
Clorazepate 7.5mg Cap
Tranxene 7.5mg Cap (discontinued)
DN
0.1810
M
SFC
clorazepate dipotassium 15mg cap
February 2016
192
N
Nervous System
Clorazepate 15mg Cap
Tranxene 15mg Cap (discontinued)
N05BA06
DN
0.3933
M
SFC
00860697
00264911
AAP
ABB
Y
Y
lorazepam 0.5mg SL tab
Apo-Lorazepam 0.5mg SL Tab
02410745
APX
Y
Ativan 0.5mg SL Tab
02041456
PFI
Y
LORAZEPAM
lorazepam 0.5mg tab
Apo-Lorazepam 0.5mg Tab
DN
0.0359
M
SFC
00655740
APX
Y
Lorazepam 0.5mg Tab
Novo-Lorazem 0.5mg Tab
DN
DN
0.0359
0.0359
M
M
SFC
SFC
02351072
00711101
SAS
TEV
Y
Y
pms-Lorazepam 0.5mg Tab
Ativan 0.5mg Tab
DN
DN
0.0359
0.0359
M
M
SFC
SFC
00728187
02041413
PMS Y
PFI Y
02410753
02041464
APX
PFI
Y
Y
Y
Y
lorazepam 1mg SL tab
Apo-Lorazepam 1mg SL Tab
Ativan 1mg SL Tab
N05BA08
lorazepam 1mg tab
Apo-Lorazepam 1mg Tab
Lorazepam 1mg Tab
DN
DN
0.0447
0.0447
M
M
SFC
SFC
00655759
02351080
APX
SAS
Novo-Lorazem 1mg Tab
pms-Lorazepam 1mg Tab
DN
DN
0.0447
0.0447
M
M
SFC
SFC
00637742
00728195
TEV Y
PMS Y
Ativan 1mg Tab
DN
0.0447
M
SFC
02041421
PFI
Y
lorazepam 2mg SL tab
Apo-Lorazepam 2mg SL Tab
02410761
APX
Y
Ativan 2mg SL Tab
02041472
PFI
Y
lorazepam 2mg tab
Apo-Lorazepam 2mg Tab
DN
0.0699
M
SFC
00655767
APX
Y
Lorazepam 2mg Tab
Novo-Lorazem 2mg Tab
DN
DN
0.0699
0.0699
M
M
SFC
SFC
02351099
00637750
SAS
TEV
Y
Y
pms-Lorazepam 2mg Tab
Ativan 2mg Tab
DN
DN
0.0699
0.0699
M
M
SFC
SFC
00728209
02041448
PMS Y
PFI Y
lorazepam 4mg/mL inj
Lorazepam 4mg/mL Inj
Ativan 4mg/mL Inj (discontinued)
DN
21.2000
M
SFC
02243278
02041405
SDZ Y
WAY Y
DN
0.1028
M
SFC
02177153
APX
Y
00682314
HLR
Y
BROMAZEPAM
bromazepam 1.5mg tab
Apo-Bromazepam 1.5mg Tab
Lectopam 1.5mg Tab (discontinued)
February 2016
bromazepam 3mg tab
Apo-Bromazepam 3mg Tab
DN
0.0776
M
SFC
02177161
APX
Y
Novo-Bromazepam 3mg Tab
Lectopam 3mg Tab
DN
DN
0.0776
0.0776
M
M
SFC
SFC
02230584
00518123
TEV
HLR
Y
Y
bromazepam 6mg tab
Apo-Bromazepam 6mg Tab
Novo-Bromazepam 6mg Tab
DN
DN
0.1134
0.1134
M
M
SFC
SFC
02177188
02230585
APX
TEV
Y
Y
Lectopam 6mg Tab
DN
0.1134
M
SFC
00518131
HLR
Y
193
N
Nervous System
N05BA09
CLOBAZAM
clobazam 10mg tab
Apo-Clobazam 10mg Tab
N05BA12
N05BB
DN
0.1538
M
SF
02244638
APX
Y
Novo-Clobazam 10mg Tab
pms-Clobazam 10mg Tab (discontinued)
DN
0.1538
M
SF
02238334
02244474
TEV Y
PMS Y
Frisium 10mg Tab
DN
0.1538
M
SF
02221799
LBK
Y
alprazolam 0.25mg tab
Alprazolam 0.25mg Tab
Apo-Alpraz 0.25mg Tab
DN
DN
0.0609
0.0609
M
M
SFC
SFC
02349191
00865397
SAS
APX
Y
Y
Jamp-Alprazolam 0.25mg Tab
MYLAN-Alprazolam 0.25mg Tab
DN
DN
0.0609
0.0609
M
M
SFC
SFC
02400111
02137534
JPC Y
MYL Y
NAT-Alprazolam 0.25mg Tab
Teva-Alprazolam 0.25mg Tab
DN
DN
0.0609
0.0609
M
M
SFC
SFC
02417634
01913484
NAT Y
TEV Y
Xanax 0.25mg Tab
DN
0.0609
M
SFC
00548359
PFI
Y
alprazolam 0.5mg tab
Alprazolam 0.5mg Tab
DN
0.0728
M
SFC
02349205
SAS
Y
Apo-Alpraz 0.5mg Tab
MYLAN-Alprazolam 0.5mg Tab
DN
DN
0.0728
0.0728
M
M
SFC
SFC
00865400
02137542
APX Y
MYL Y
NAT-Alprazolam 0.5mg Tab
Teva-Alprazolam 0.5mg Tab
DN
DN
0.0728
0.0728
M
M
SFC
SFC
02417642
01913492
NAT Y
TEV Y
Jamp-Alprazolam 0.5mg Tab
Xanax 0.5mg Tab
DN
DN
0.0728
0.0728
M
M
SFC
SFC
02400138
00548367
JPC
PFI
Y
Y
alprazolam 1mg tab
Apo-Alpraz 1mg Tab
Jamp-Alprazolam 1mg Tab
02243611
02400146
APX
JPC
Y
Y
MYLAN-Alprazolam 1mg Tab
NAT-Alprazolam 1mg Tab
02229813
02417650
MYL Y
NAT Y
Xanax 1mg Tab
00723770
PFI
Y
alprazolam 2mg tab
Apo-Alpraz 2mg Tab
02243612
APX
Y
Jamp-Alprazolam 2mg Tab
MYLAN-Alprazolam 2mg Tab
02400154
02229814
JPC Y
MYL Y
Xanax 2mg Tab
00813958
PFI
Y
ALPRAZOLAM
DIPHENYLMETHANE DERIVATIVES
N05BB01
HYDROXYZINE
Atarax 2mg/mL Syr
DNP
0.0563
L
E
00024694
ERF
N
hydroxyzine HCl 10mg cap
Apo-Hydroxyzine 10mg Cap
Novo-Hydroxyzin 10mg Cap
DNP
DNP
0.1116
0.1116
M
M
E
E
00646059
00738824
APX
TEV
Y
Y
00024376
ERF
Y
Atarax 10mg Cap (discontinued)
hydroxyzine HCl 25mg cap
Apo-Hydroxyzine 25mg Cap
Novo-Hydroxyzin 25mg Cap
Atarax 25mg Cap (discontinued)
February 2016
DNP
0.1425
M
E
00646024
APX
Y
DNP
0.1425
M
E
00738832
00024384
TEV
ERF
Y
Y
194
N
Nervous System
hydroxyzine 50mg/mL inj
Hydroxyzine 50mg/mL Inj
00742813
SDZ
Y
Atarax 50mg/mL Inj (discontinued)
00024589
ERF
Y
hydroxyzine HCl 50mg cap
Apo-Hydroxyzine 50mg Cap
DNP
0.2068
M
E
00646016
APX
Y
DNP
0.2068
M
E
00738840
00024392
TEV
ERF
Y
Y
buspirone HCl 10mg tab
Apo-Buspirone 10mg Tab
DNP
0.3517
M
SFC
02211076
APX
Y
Novo-Buspirone 10mg Tab
pms-Buspirone 10mg Tab
DNP
DNP
0.3517
0.3517
M
M
SFC
SFC
02231492
02230942
TEV Y
PMS Y
00603821
BRI
Novo-Hydroxyzin 50mg Cap
Atarax 50mg Cap (discontinued)
N05BE
AZASPIRODECANEDIONE DERIVATIVES
N05BE01
BUSPIRONE
Buspar 10mg Tab (discontinued)
N05C
HYPNOTICS AND SEDATIVES
N05CC
ALDEHYDES AND DERIVATIVES
N05CC01
N05CD
Y
CHLORAL HYDRATE
Chloral Hydrate-ODAN 100mg/mL Syr
DNP
0.0433
L
SFC
02247621
ODN N
pms-Chloral Hydrate 100mg/mL Syr
DNP
0.0469
L
SFC
00792659
PMS N
flurazepam 15mg cap
Apo-Flurazepam 15mg Cap
Dalmane 15mg Cap (discontinued)
00521698
00012696
AAP
VLN
Y
Y
flurazepam 30mg cap
Apo-Flurazepam 30mg Cap
Dalmane 30mg Cap (discontinued)
00521701
00012718
AAP
VLN
Y
Y
nitrazepam 5mg tab
Mogadon 5mg Tab
00511528
AAP
Y
Nitrazadon 5mg Tab (discontinued)
02229654
VLN
Y
nitrazepam 10mg tab
Mogadon 10mg Tab
00511536
AAP
Y
Nitrazadon 10mg Tab (discontinued)
02229655
VLN
Y
00808563
AAP
N
BENZODIAZEPINE DERIVATIVES
N05CD01
N05CD02
N05CD05
FLURAZEPAM
NITRAZEPAM
TRIAZOLAM
Triazolam 0.125mg Tab (discontinued)
Triazolam 0.25mg Tab
N05CD07
0.2501
L
SFC
00808571
AAP
N
DN
0.0499
M
SFC
02225964
APX
Y
TEMAZEPAM
temazepam 15mg cap
Apo-Temazepam 15mg Cap
February 2016
DN
195
N
Nervous System
Novo-Temazepam 15mg Cap (discontinued)
Restoril 15mg Cap
N05CD08
TEV Y
SNV Y
DN
0.0499
M
SFC
temazepam 30mg cap
Apo-Temazepam 30mg Cap
Novo-Temazepam 30mg Cap (discontinued)
DN
0.0605
M
SFC
02225972
02230102
APX
TEV
Restoril 30mg Cap
DN
0.0605
M
SFC
00604461
SNV Y
DN
DN
0.7800
0.7800
M
M
E
E
02240285
02382873
SDZ
SDZ
Y
Y
00784516
HLR
Y
Y
Y
MIDAZOLAM
midazolam 1mg/mL inj
Midazolam 1mg/mL Inj
Midazolam 1mg/mL Inj
Versed 1mg/mL Inj (discontinued)
midazolam 5mg/mL inj
Midazolam 5mg/mL Inj
DN
4.1000
M
E
02382903
SDZ
Y
DN
4.1000
M
E
02240286
00766011
SDZ
HLR
Y
Y
zopiclone 5mg tab
Apo-Zopiclone 5mg Tab
DNP
0.2199
M
SFC
02245077
APX
Y
CO Zopiclone 5mg Tab
Jamp-Zopiclone 5mg Tab
DNP
DNP
0.2199
0.2199
M
M
SFC
SFC
02271931
02406969
ATV
JPC
Y
Y
Mar-Zopiclone 5mg Tab
MINT-Zopiclone 5mg Tab
DNP
DNP
0.2199
0.2199
M
M
SFC
SFC
02386771
02391716
MAR Y
MNT Y
MYLAN-Zopiclone 5mg Tab
Novo-Zopiclone 5mg Tab (discontinued)
DNP
0.2199
M
SFC
02296616
02251450
MYL Y
TEV Y
pms-Zopiclone 5mg Tab
RAN-Zopiclone 5mg Tab
DNP
DNP
0.2199
0.2199
M
M
SFC
SFC
02243426
02267918
PMS Y
RAN Y
ratio-Zopiclone 5mg Tab
Sandoz Zopiclone 5mg Tab
DNP
DNP
0.2199
0.2199
M
M
SFC
SFC
02246534
02257572
TEV
SDZ
Y
Y
Septa-Zopiclone 5mg Tab
Zopiclone 5mg Tab
DNP
DNP
0.2199
0.2199
M
M
SFC
SFC
02386909
02344122
SPT
SAS
Y
Y
Zopiclone-5mg Tab
Imovane 5mg Tab
DNP
DNP
0.2199
0.2199
M
M
SFC
SFC
02385821
02216167
SIV
SAV
Y
Y
zopiclone 7.5mg tab
Apo-Zopiclone 7.5mg Tab
CO Zopiclone 7.5mg Tab
02218313
02271958
APX
ATV
Y
Y
Jamp-Zopiclone 7.5mg Tab
Jamp-Zopiclone 7.5mg Tab
02406977
02356805
JPC
JPC
Y
Y
Mar-Zopiclone 7.5mg Tab
MINT-Zopiclone 7.5mg Tab
02386798
02391724
MAR Y
MNT Y
MYLAN-Zopiclone 7.5mg Tab
Novo-Zopiclone 7.5mg Tab (discontinued)
02238596
02251469
MYL Y
TEV Y
pms-Zopiclone 7.5mg Tab
RAN-Zopiclone 7.5mg Tab
02240606
02267926
PMS Y
RAN Y
ratio-Zopiclone 7.5mg Tab
Sandoz Zopiclone 7.5mg Tab
02242481
02257580
TEV
SDZ
Midazolam 5mg/mL Inj
Versed 5mg/mL Inj (discontinued)
N05CF
02230095
00604453
BENZODIAZEPINE RELATED DRUGS
N05CF01
February 2016
ZOPICLONE
196
Y
Y
N
Nervous System
N05CF02
Septa-Zopiclone 7.5mg Tab
Zopiclone 7.5mg Tab
02386917
02282445
SPT
SAS
Y
Y
Zopiclone-7.5mg Tab
Imovane 7.5mg Tab
02385848
01926799
SIV
SAV
Y
Y
Rhovane 7.5mg Tab
02008203
SDZ
Y
zolpidem ODT 5mg tab
Apo-Zolpidem ODT 5mg Tab
Sublinox 5mg SL Tab
02436159
02391678
APX Y
MVL Y
zolpidem ODT 10mg tab
Apo-Zolpidem ODT 10mg Tab
Sublinox 10mg SL Tab
02434946
02370433
APX Y
MVL Y
02216248
AAP
Y
02103583
SAV
Y
02216256
AAP
Y
02099128
SAV
Y
02216264
AAP
Y
02099136
SAV
Y
02216272
AAP
Y
02099144
SAV
Y
02216280
AAP
Y
02103591
SAV
Y
ZOLPIDEM
N06
PSYCHOANALEPTICS
N06A
ANTIDEPRESSANTS
N06AA
TRICYCLIC DERIVATIVES
N06AA01
DESIPRAMINE
desipramine 10mg tab
Desipramine 10mg Tab
DNP
0.3804
M
SFC
Norpramin 10mg Tab (discontinued)
desipramine 25mg tab
Desipramine 25mg Tab
DNP
0.3804
M
SFC
Norpramin 25mg Tab (discontinued)
desipramine 50mg tab
Desipramine 50mg Tab
DNP
0.6704
M
SFC
Norpramin 50mg Tab (discontinued)
desipramine 75mg tab
Desipramine 75mg Tab
DNP
0.8915
M
SFC
Norpramin 75mg Tab (discontinued)
desipramine 100mg tab
Desipramine 100mg Tab
DNP
0.8915
M
SFC
Norpramin 100mg Tab (discontinued)
N06AA02
February 2016
IMIPRAMINE
imipramine 10mg tab
Imipramine 10mg Tab
Tofranil 10mg Tab (discontinued)
DNP
0.1370
M
SFC
00360201
00010464
AAP Y
NVR Y
imipramine 25mg tab
Imipramine 25mg Tab
Tofranil 25mg Tab (discontinued)
DNP
0.2682
M
SFC
00312797
00010472
AAP Y
NVR Y
imipramine 50mg tab
Imipramine 50mg Tab
Tofranil 50mg Tab (discontinued)
DNP
0.5232
M
SFC
00326852
00010480
AAP Y
NVR Y
Imipramine 75mg Tab
DNP
0.6308
L
SFC
00644579
AAP
197
N
N
Nervous System
N06AA04
CLOMIPRAMINE
clomipramine 10mg tab
Apo-Clomipramine 10mg Tab (discontinued)
0.2863
L
SFC
02244816
00330566
ATV Y
APR Y
clomipramine 25mg tab
Apo-Clomipramine 25mg Tab (discontinued)
CO Clomipramine 25mg Tab
DNP
0.1758
M
SFC
02040778
02244817
APX
ATV
Anafranil 25mg Tab
DNP
0.1758
M
SFC
00324019
APR Y
02040751
APX
Y
Y
Y
DNP
0.7107
L
SFC
02244818
00402591
ATV Y
APR Y
DNP
0.2339
M
SFC
00740799
AAP
Y
01926357
SAV
Y
00740802
AAP
Y
01926322
SAV
Y
00740810
AAP
Y
01926330
SAV
Y
02070987
AAP
Y
01926349
SAV
Y
00740829
AAP
Y
01926284
SAV
Y
Y
Y
TRIMIPRAMINE
trimipramine 12.5mg tab
Trimipramine 12.5mg Tab
Surmontil 12.5mg Tab (discontinued)
trimipramine 25mg tab
Trimipramine 25mg Tab
DNP
0.3012
M
SFC
Surmontil 25mg Tab (discontinued)
trimipramine 50mg tab
Trimipramine 50mg Tab
DNP
0.5896
M
SFC
Surmontil 50mg Tab (discontinued)
trimipramine 75mg cap
Trimipramine 75mg Cap
DNP
0.7936
M
SFC
Surmontil 75mg Cap (discontinued)
trimipramine 100mg tab
Trimipramine 100mg Tab
DNP
1.0061
M
SFC
Surmontil 100mg Tab (discontinued)
AMITRIPTYLINE
amitriptyline 10mg tab
Apo-Amitriptyline 10mg Tab
Elavil 10mg Tab
DNP
0.0435
M
SFC
02403137
00335053
APX
AAP
Mar-Amitriptyline 10mg Tab
pms-Amitriptyline 10mg Tab
DNP
DNP
0.0435
0.0435
M
M
SFC
SFC
02429861
00654523
MAR Y
PMS Y
Teva-Amitriptyline 10mg Tab
Elavil 10mg Tab (discontinued)
DNP
0.0435
M
SFC
02326043
00016322
TEV
FRS
Y
Y
amitriptyline 25mg tab
Apo-Amitritpyline 25mg Tab
Elavil 25mg Tab
DNP
0.0829
M
SFC
02403145
00335061
APX
AAP
Y
Y
Mar-Amitriptyline 25mg Tab
pms-Amitriptyline 25mg Tab
DNP
DNP
0.0829
0.0829
M
M
SFC
SFC
02429888
00654515
MAR Y
PMS Y
Teva-Amitriptyline 25mg Tab
Elavil 25mg Tab (discontinued)
DNP
0.0829
M
SFC
02326051
00016330
TEV
FRS
amitriptyline 50mg tab
February 2016
Y
DNP
CO Clomipramine 50mg Tab (discontinued)
Anafranil 50mg Tab
N06AA09
APX
CO Clomipramine 10mg Tab (discontinued)
Anafranil 10mg Tab
clomipramine 50mg tab
Apo-Clomipramine 50mg Tab (discontinued)
N06AA06
02040786
198
Y
Y
N
Nervous System
Apo-Amitriptyline 50mg Tab
Elavil 50mg Tab
DNP
0.1540
M
SFC
02403153
00335088
APX
AAP
Mar-Amitriptyline 50mg Tab
pms-Amitriptyline 50mg Tab
DNP
DNP
0.1540
0.1540
M
M
SFC
SFC
02429896
00654507
MAR Y
PMS Y
Teva-Amitriptyline 50mg Tab
Elavil 50mg Tab (discontinued)
DNP
0.1540
M
SFC
02326078
00016349
TEV
FRS
Y
Y
DNP
0.3634
M
SFC
02403161
00754129
APX
AAP
Y
Y
DNP
0.3634
M
SFC
02429918
00354295
MAR Y
FRS Y
Aventyl 10mg Cap
DNP
0.2517
L
SFC
00015229
AAP
N
Aventyl 25mg Cap
DNP
0.5086
L
SFC
00015237
AAP
N
doxepin HCl 10mg cap
Apo-Doxepin 10mg Cap
Sinequan 10mg Cap
DNP
DNP
0.2397
0.2397
M
M
SFC
SFC
02049996
00024325
APX
ERF
Y
Y
doxepin HCl 25mg cap
Apo-Doxepin 25mg Cap
Sinequan 25mg Cap
DNP
DNP
0.2940
0.2940
M
M
SFC
SFC
02050005
00024333
APX
ERF
Y
Y
doxepin HCl 50mg cap
Apo-Doxepin 50mg Cap
Sinequan 50mg Cap
DNP
DNP
0.5455
0.5455
M
M
SFC
SFC
02050013
00024341
APX
ERF
Y
Y
doxepin HCl 75mg cap
Apo-Doxepin 75mg Cap
Sinequan 75mg Cap (discontinued)
DNP
0.8066
M
SFC
02050021
00400750
APX
ERF
Y
Y
doxepin HCl 100mg cap
Apo-Doxepin 100mg Cap
Sinequan 100mg Cap (discontinued)
DNP
1.3438
M
SFC
02050048
00326925
APX
ERF
Y
Y
DNP
0.5687
M
SFC
02158612
TEV
Y
00360481
NVR Y
02158620
TEV
00360503
NVR Y
02158639
TEV
00360511
PMS Y
amitriptyline 75mg tab
Apo-Amitriptyline 75mg Tab
Elavil 75mg Tab
Mar-Amitriptyline 75mg Tab
Elavil 75mg Tab (discontinued)
N06AA10
N06AA12
N06AA21
NORTRIPTYLINE
DOXEPIN
MAPROTILINE
maprotiline 25mg tab
Novo-Maprotiline 25mg Tab
Ludiomil 25mg Tab (discontinued)
maprotiline 50mg tab
Novo-Maprotiline 50mg Tab
DNP
1.0769
M
SFC
Ludiomil 50mg Tab (discontinued)
maprotiline 75mg tab
Novo-Maprotiline 75mg Tab
Ludiomil 75mg Tab (discontinued)
N06AB
DNP
1.4707
M
SFC
SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRI'S)
N06AB03
FLUOXETINE
fluoxetine 10mg cap
February 2016
Y
Y
199
Y
Y
N
Nervous System
Apo-Fluoxetine 10mg Cap
Auro-Fluoxetine 10mg Cap
DNP
DNP
0.6179
0.6179
M
M
SFC
SFC
02216353
02385627
APX Y
ARO Y
CO Fluoxetine 10mg Cap
Fluoxetine 10mg Cap
DNP
DNP
0.6179
0.6179
M
M
SFC
SFC
02242177
02286068
ATV
SAS
Y
Y
Fluoxetine BP 10mg Cap
Fluoxetine-10mg Cap
DNP
DNP
0.6179
0.6179
M
M
SFC
SFC
02393441
02374447
AHI
SIV
Y
Y
Jamp-Fluoxetine 10mg Cap
Mar-Fluoxetine 10mg Cap
DNP
DNP
0.6179
0.6179
M
M
SFC
SFC
02401894
02392909
JPC Y
MAR Y
MINT-Fluoxetine 10mg Cap
MYLAN-Fluoxetine 10mg Cap
DNP
DNP
0.6179
0.6179
M
M
SFC
SFC
02380560
02237813
MNT Y
MYL Y
pms-Fluoxetine 10mg Cap
RAN-Fluoxetine 10mg Cap
DNP
DNP
0.6179
0.6179
M
M
SFC
SFC
02177579
02405695
PMS Y
RAN Y
Teva-Fluoxetine 10mg Cap
Prozac 10mg Cap
DNP
DNP
0.6179
0.6179
M
M
SFC
SFC
02216582
02018985
TEV
LIL
fluoxetine 20mg cap
Apo-Fluoxetine 20mg Cap
Auro-Fluoxetine 20mg Cap
DNP
DNP
0.4599
0.4599
M
M
SFC
SFC
02216361
02385635
APX Y
ARO Y
CO Fluoxetine 20mg Cap
Fluoxetin-20mg Cap
DNP
DNP
0.4599
0.4599
M
M
SFC
SFC
02242178
02374455
ATV
SIV
Y
Y
Fluoxetine 20mg Cap
Fluoxetine BP 20mg Cap
DNP
DNP
0.4599
0.4599
M
M
SFC
SFC
02286076
02383241
SAS
AHI
Y
Y
Jamp-Fluoxetine 20mg Cap
Mar-Fluoxetine 20mg Cap
DNP
DNP
0.4599
0.4599
M
M
SFC
SFC
02386402
02392917
JPC Y
MAR Y
MINT-Fluoxetine 20mg Cap
MYLAN-Fluoxetine 20mg Cap
DNP
DNP
0.4599
0.4599
M
M
SFC
SFC
02380579
02237814
MNT Y
MYL Y
pms-Fluoxetine 20mg Cap
RAN-Fluoxetine 20mg Cap
DNP
DNP
0.4599
0.4599
M
M
SFC
SFC
02177587
02405709
PMS Y
RAN Y
Teva-Fluoxetine 20mg Cap
Prozac 20mg Cap
DNP
DNP
0.4599
0.4599
M
M
SFC
SFC
02216590
00636622
TEV
LIL
Y
Y
02231328
01917021
AAP
LIL
Y
Y
ABB N
MNT N
fluoxetine 4mg/mL syr
Apo-Fluoxetine 20mg/5mL Syr
Prozac 20mg/5mL Syr (discontinued)
N06AB04
February 2016
Y
Y
CITALOPRAM
Abbott Citalopram 10mg Tab (discontinued)
MINT-Citalopram 10mg tab
DNP
0.1432
L
SFC
02414570
02370077
NAT-Citalopram 10mg Tab
pms-Citalopram 10mg Tab
DNP
DNP
0.1432
0.1432
L
L
SFC
SFC
02409003
02270609
NAT N
PMS N
ABB
APX
citalopram 20mg tab
Abbott Citalopram 20mg Tab (discontinued)
Apo-Citalopram 20mg Tab
DNP
0.2397
M
SFC
02414589
02246056
Auro-Citalopram 20mg Tab
Citalopram 20mg Tab
DNP
DNP
0.2397
0.2397
M
M
SFC
SFC
02275562
02430541
ARO Y
JPC Y
Citalopram 20mg Tab
Citalopram-20mg Tab
DNP
DNP
0.2397
0.2397
M
M
SFC
SFC
02353660
02387956
SAS
SIV
Citalopram-Odan 20mg Tab (discontinued)
CO Citalopram 20mg Tab
DNP
0.2397
M
SFC
02306239
02248050
ODN Y
ATV Y
Jamp-Citalopram 20mg Tab
Mar-Citalopram 20mg Tab
DNP
DNP
0.2397
0.2397
M
M
SFC
SFC
02313405
02371898
JPC Y
MAR Y
200
Y
Y
Y
Y
N
Nervous System
MINT-Citalopram 20mg Tab
MYLAN-Citalopram 20mg Tab
DNP
DNP
0.2397
0.2397
M
M
SFC
SFC
02304686
02246594
MNT Y
MYL Y
NAT-Citalopram 20mg Tab
Novo-Citalopram 20mg Tab
DNP
DNP
0.2397
0.2397
M
M
SFC
SFC
02409011
02293218
NAT Y
TEV Y
pms-Citalopram 20mg Tab
RAN-Citalo 20mg Tab
DNP
DNP
0.2397
0.2397
M
M
SFC
SFC
02248010
02285622
PMS Y
RAN Y
Sandoz Citalopram 20mg Tab
Septa-Citalopram 20mg Tab
DNP
DNP
0.2397
0.2397
M
M
SFC
SFC
02248170
02355272
SDZ
SPT
Y
Y
Celexa 20mg Tab
DNP
0.2397
M
SFC
02239607
VLH
Y
CTP30 (30mg) Tab
DNP
0.8750
L
SFC
02296152
SNV N
02414597
ABB
Apo-Citalopram 40mg Tab
Auro-Citalopram 40mg Tab
DNP
DNP
0.2397
0.2397
M
M
SFC
SFC
02246057
02275570
APX Y
ARO Y
Citalopram 40mg Tab
Citalopram 40mg Tab
DNP
DNP
0.2397
0.2397
M
M
SFC
SFC
02430568
02353679
JPC
SAS
Citalopram-40mg Tab
Citalopram-Odan 40mg Tab (discontinued)
DNP
0.2397
M
SFC
02387964
02306247
SIV Y
ODN Y
CO Citalopram 40mg Tab
Jamp-Citalopram 40mg Tab
DNP
DNP
0.2397
0.2397
M
M
SFC
SFC
02248051
02313413
ATV
JPC
Mar-Citalopram 40mg Tab
MINT-Citalopram 40mg Tab
DNP
DNP
0.2397
0.2397
M
M
SFC
SFC
02371901
02304694
MAR Y
MNT Y
MYLAN-Citalopram 40mg Tab
NAT-Citalopram 40mg Tab
DNP
DNP
0.2397
0.2397
M
M
SFC
SFC
02246595
02409038
MYL Y
NAT Y
Novo-Citalopram 40mg Tab
pms-Citalopram 40mg Tab
DNP
DNP
0.2397
0.2397
M
M
SFC
SFC
02293226
02248011
TEV Y
PMS Y
RAN-Citalo 40mg Tab
Sandoz Citalopram 40mg Tab
DNP
DNP
0.2397
0.2397
M
M
SFC
SFC
02285630
02248171
RAN Y
SDZ Y
Septa-Citalopram 40mg Tab
Celexa 40mg Tab
DNP
DNP
0.2397
0.2397
M
M
SFC
SFC
02355280
02239608
SPT
VLH
Y
Y
paroxetine 10mg tab
Apo-Paroxetine 10mg Tab
02240907
APX
Y
CO Paroxetine 10mg Tab
Jamp-Paroxetine 10mg Tab
02262746
02368862
ATV
JPC
Y
Y
Mar-Paroxetine 10mg Tab
MINT-Paroxetine 10mg Tab
02411946
02421372
MAR Y
MNT Y
MYLAN-Paroxetine 10mg Tab
Paroxetine 10mg Tab
02248012
02282844
MYL Y
SAS Y
Paroxetine-10mg Tab
pms-Paroxetine 10mg Tab
02388227
02247750
SIV Y
PMS Y
Sandoz Paroxetine 10mg Tab
Sandoz Paroxetine 10mg Tab (discontinued)
02431777
02269422
SDZ
SDZ
Teva-Paroxetine 10mg Tab
Paxil 10mg Tab
02248556
02027887
TEV Y
GSK Y
02240908
02383284
APX Y
ARO Y
citalopram 40mg tab
Abbott Citalopram 40mg Tab (discontinued)
N06AB05
Y
Y
Y
Y
PAROXETINE
paroxetine 20mg tab
Apo-Paroxetine 20mg Tab
Auro-Paroxetine 20mg Tab
February 2016
Y
DNP
DNP
0.4514
0.4514
M
M
SFC
SFC
201
Y
Y
N
Nervous System
CO Paroxetine 20mg Tab
Jamp-Paroxetine 20mg Tab
DNP
DNP
0.4514
0.4514
M
M
SFC
SFC
02262754
02368870
ATV
JPC
Mar-Paroxetine 20mg Tab
MINT-Paroxetine 20mg Tab
DNP
DNP
0.4514
0.4514
M
M
SFC
SFC
02411954
02421380
MAR Y
MNT Y
MYLAN-Paroxetine 20mg Tab
Paroxetine 20mg Tab (SAS)
DNP
DNP
0.4514
0.4514
M
M
SFC
SFC
02248013
02282852
MYL Y
SAS Y
Paroxetine-20mg Tab
pms-Paroxetine 20mg Tab
DNP
DNP
0.4514
0.4514
M
M
SFC
SFC
02388235
02247751
SIV Y
PMS Y
Sandoz Paroxetine 20mg Tab
Teva-Paroxetine 20mg Tab
DNP
DNP
0.4514
0.4514
M
M
SFC
SFC
02269430
02248557
SDZ
TEV
Paxil 20mg Tab
DNP
0.4514
M
SFC
01940481
GSK Y
paroxetine 30mg tab
Apo-Paroxetine 30mg Tab
DNP
0.4796
M
SFC
02240909
APX
Auro-Paroxetine 30mg Tab
CO Paroxetine 30mg Tab
DNP
DNP
0.4796
0.4796
M
M
SFC
SFC
02383292
02262762
ARO Y
ATV Y
Jamp-Paroxetine 30mg Tab
Mar-Paroxetine 30mg Tab
DNP
DNP
0.4796
0.4796
M
M
SFC
SFC
02368889
02411962
JPC Y
MAR Y
MINT-Paroxetine 30mg Tab
MYLAN-Paroxetine 30mg Tab
DNP
DNP
0.4796
0.4796
M
M
SFC
SFC
02421399
02248014
MNT Y
MYL Y
Paroxetine 30mg Tab (SAS)
Paroxetine-30mg Tab
DNP
DNP
0.4796
0.4796
M
M
SFC
SFC
02282860
02388243
SAS
SIV
pms-Paroxetine 30mg Tab
Sandoz Paroxetine 30mg Tab
DNP
DNP
0.4796
0.4796
M
M
SFC
SFC
02247752
02431793
PMS Y
SDZ Y
Sandoz Paroxetine 30mg Tab (discontinued)
Teva-Paroxetine 30mg Tab
DNP
0.4796
M
SFC
02269449
02248558
SDZ
TEV
Paxil 30mg Tab
DNP
0.4796
M
SFC
01940473
GSK Y
02293749
PMS N
pms-Paroxetine 40mg Tab
N06AB06
Y
Y
Y
Y
Y
Y
Y
SERTRALINE
sertraline 25mg cap
Apo-Sertraline 25mg Cap
Auro-Sertraline 25mg Cap
February 2016
Y
Y
DNP
DNP
0.2010
0.2010
M
M
SFC
SFC
02238280
02390906
APX Y
ARO Y
CO Sertraline 25mg Cap
GD-Sertraline 25mg Cap
DNP
0.2010
M
SFC
02287390
02273683
ATV Y
GMD Y
Jamp-Sertaline 25mg Cap
Mar-Sertraline 25mg Cap
DNP
DNP
0.2010
0.2010
M
M
SFC
SFC
02357143
02399415
JPC Y
MAR Y
MINT-Sertraline 25mg Cap
MYLAN-Sertraline 25mg Cap
DNP
DNP
0.2010
0.2010
M
M
SFC
SFC
02402378
02242519
MNT Y
MYL Y
Novo-Sertraline 25mg Cap
pms-Sertraline 25mg Cap
DNP
DNP
0.2010
0.2010
M
M
SFC
SFC
02240485
02244838
TEV Y
PMS Y
RAN-Sertraline 25mg cap
Sandoz Sertraline 25mg Cap
DNP
DNP
0.2010
0.2010
M
M
SFC
SFC
02374552
02245159
RAN Y
SDZ Y
Sertraline 25mg Cap
Sertraline-25mg Cap
DNP
DNP
0.2010
0.2010
M
M
SFC
SFC
02353520
02386070
SAS
SIV
Y
Y
Zoloft 25mg Cap
DNP
0.2010
M
SFC
02132702
PFI
Y
sertraline 50mg cap
Apo-Sertraline 50mg Cap
DNP
0.4020
M
SFC
02238281
APX
Y
Auro-Sertraline 50mg Cap
CO Sertraline 50mg Cap
DNP
DNP
0.4020
0.4020
M
M
SFC
SFC
02390914
02287404
ARO Y
ATV Y
202
N
Nervous System
N06AB08
N06AB10
February 2016
GD-Sertraline 50mg Cap
Jamp-Sertaline 50mg Cap
DNP
DNP
0.4020
0.4020
M
M
SFC
SFC
02273691
02357151
GMD Y
JPC Y
Mar-Sertraline 50mg Cap
MINT-Sertraline 50mg Cap
DNP
DNP
0.4020
0.4020
M
M
SFC
SFC
02399423
02402394
MAR Y
MNT Y
MYLAN-Sertraline 50mg Cap
Novo-Sertraline 50mg Cap
DNP
DNP
0.4020
0.4020
M
M
SFC
SFC
02242520
02240484
MYL Y
TEV Y
pms-Sertraline 50mg Cap
RAN-Sertraline 50mg cap
DNP
DNP
0.4020
0.4020
M
M
SFC
SFC
02244839
02374560
PMS Y
RAN Y
Sandoz Sertraline 50mg Cap
Sertraline 50mg Cap
DNP
DNP
0.4020
0.4020
M
M
SFC
SFC
02245160
02353539
SDZ
SAS
Y
Y
Sertraline-50mg Cap
Zoloft 50mg Cap
DNP
DNP
0.4020
0.4020
M
M
SFC
SFC
02386089
01962817
SIV
PFI
Y
Y
sertraline 100mg cap
Apo-Sertraline 100mg Cap
Auro-Sertraline 100mg Cap
DNP
DNP
0.4213
0.4213
M
M
SFC
SFC
02238282
02390922
APX Y
ARO Y
CO Sertraline 100mg Cap
GD-Sertraline 100mg Cap
DNP
0.4213
M
SFC
02287412
02273705
ATV Y
GMD Y
Jamp-Sertraline 100mg Cap
Mar-Sertraline 100mg Cap
DNP
DNP
0.4213
0.4213
M
M
SFC
SFC
02357178
02399431
JPC Y
MAR Y
MINT-Sertraline 100mg Cap
MYLAN-Sertraline 100mg Cap
DNP
DNP
0.4213
0.4213
M
M
SFC
SFC
02402408
02242521
MNT Y
MYL Y
pms-Sertraline 100mg Cap
RAN-Sertraline 100mg cap
DNP
DNP
0.4213
0.4213
M
M
SFC
SFC
02244840
02374579
PMS Y
RAN Y
Sandoz Sertraline 100mg Cap
Sertraline 100mg Cap
DNP
DNP
0.4213
0.4213
M
M
SFC
SFC
02245161
02353547
SDZ
SAS
Y
Y
Sertraline-100mg Cap
Teva-Sertraline 100mg Cap
DNP
DNP
0.4213
0.4213
M
M
SFC
SFC
02386097
02240481
SIV
TEV
Y
Y
Zoloft 100mg Cap
DNP
0.4213
M
SFC
01962779
PFI
Y
fluvoxamine 50mg tab
Apo-Fluvoxamine 50mg Tab
CO Fluvoxamine 50mg Tab
DNP
DNP
0.2143
0.2143
M
M
SFC
SFC
02231329
02255529
APX
ATV
Y
Y
Novo-Fluvoxamine 50mg Tab
ratio-Fluvoxamine 50mg Tab
DNP
DNP
0.2143
0.2143
M
M
SFC
SFC
02239953
02218453
TEV
TEV
Y
Y
Luvox 50mg Tab
DNP
0.2143
M
SFC
01919342
BGP Y
fluvoxamine 100mg tab
Apo-Fluvoxamine 100mg Tab
DNP
0.3851
M
SFC
02231330
APX
Y
CO Fluvoxamine 100mg Tab
Novo-Fluvoxamine 100mg Tab
DNP
DNP
0.3851
0.3851
M
M
SFC
SFC
02255537
02239954
ATV
TEV
Y
Y
Luvox 100mg Tab
DNP
0.3851
M
SFC
01919369
BGP Y
escitalopram 10mg tab
Apo-Escitalopram 10mg Tab
Auro-Escitalopram 10mg Tab
DNP
DNP
0.4318
0.4318
M
M
SFC
SFC
02295016
02397358
APX Y
ARO Y
CO Escitalopram 10mg Tab
Escitalopram 10mg Tab
DNP
DNP
0.4318
0.4318
M
M
SFC
SFC
02313561
02429039
ATV
SIV
Y
Y
Escitalopram 10mg Tab
DNP
0.4318
M
SFC
02430118
SAS
Y
FLUVOXAMINE
ESCITALOPRAM
203
N
Nervous System
Jamp-Escitalopram 10mg Tab
Mar-Escitalopram 10mg Tab
DNP
DNP
0.4318
0.4318
M
M
SFC
SFC
02429780
02423480
JPC Y
MAR Y
MYLAN-Escitalopram 10mg Tab
pms-Escitalopram 10mg Tab
DNP
DNP
0.4318
0.4318
M
M
SFC
SFC
02309467
02303949
MYL Y
PMS Y
RAN-Escitalopram 10mg Tab
Sandoz Escitalopram 10mg Tab
DNP
DNP
0.4318
0.4318
M
M
SFC
SFC
02385481
02364077
RAN Y
SDZ Y
Teva-Escitalopram 10mg Tab
Cipralex 10mg Tab
DNP
DNP
0.4318
0.4318
M
M
SFC
SFC
02318180
02263238
TEV
VLH
escitalopram 20mg tab
Apo-Escitalopram 20mg Tab
Auro-Escitalopram 20mg Tab
DNP
DNP
0.4597
0.4597
M
M
SFC
SFC
02295024
02397374
APX Y
ARO Y
CO Escitalopram 20mg Tab
Escitalopram 20mg Tab
DNP
DNP
0.4597
0.4597
M
M
SFC
SFC
02313588
02429047
ATV
SIV
Y
Y
Escitalopram 20mg Tab
Jamp-Escitalopram 20mg Tab
DNP
DNP
0.4597
0.4597
M
M
SFC
SFC
02430126
02429799
SAS
JPC
Y
Y
Mar-Escitalopram 20mg Tab
MYLAN-Escitalopram 20mg Tab
DNP
DNP
0.4597
0.4597
M
M
SFC
SFC
02423502
02309475
MAR Y
MYL Y
RAN-Escitalopram 20mg Tab
Sandoz Escitalopram 20mg Tab
DNP
DNP
0.4597
0.4597
M
M
SFC
SFC
02385503
02364085
RAN Y
SDZ Y
Teva-Escitalopram 20mg Tab
Cipralex 20mg Tab
DNP
DNP
0.4597
0.4597
M
M
SFC
SFC
02318202
02263254
TEV
VLH
02303965
PMS N
pms-Escitalopram 20mg Tab
N06AF
PHENELZINE
Nardil 15mg Tab
N06AF04
DNP
0.3908
L
SFC
00476552
ERF
N
DNP
0.3816
L
SFC
01919598
GSK N
DNP
0.2520
M
SFC
02232148
APX
Y
DNP
0.2520
M
SFC
02239746
00899348
TEV
HLR
Y
Y
moclobemide 150mg tab
Apo-Moclobemide 150mg Tab
Novo-Moclobemide 150mg Tab
DNP
DNP
0.3120
0.3120
M
M
SFC
SFC
02232150
02239747
APX
TEV
Y
Y
Manerix 150mg Tab
DNP
0.3120
M
SFC
00899356
MVL Y
moclobemide 300mg tab
Apo-Moclobemide 300mg Tab
DNP
0.6126
M
SFC
02240456
APX
Novo-Moclobemide 300mg Tab (discontinued)
Manerix 300mg Tab
DNP
0.6126
M
SFC
02239748
02166747
TEV Y
MVL Y
TRANYLCYPROMINE
Parnate 10mg Tab
MONOAMINE OXIDASE TYPE A INHIBITORS
N06AG02
MOCLOBEMIDE
moclobemide 100mg tab
Apo-Moclobemide 100mg Tab
Novo-Moclobemide 100mg Tab
Manerix 100mg Tab (discontinued)
N06AX
Y
Y
MONOAMINE OXIDASE INHIBITORS,NON-SELECTIVE
N06AF03
N06AG
Y
Y
OTHER ANTIDEPRESSANTS
N06AX02
February 2016
TRYPTOPHAN
204
Y
N
Nervous System
N06AX05
tryptophan 1g tab
Apo-Tryptophan 1g Tab
DNP
0.7126
M
E
02248539
APX
Y
ratio-Tryptophan 1g Tab
Tryptan 1g Tab
DNP
DNP
0.7126
0.7126
M
M
E
E
02237250
00654531
TEV
VLN
Y
Y
Tryptan 250mg Tab
DNP
0.3876
L
E
02239326
VLN
N
tryptophan 500mg cap
Apo-Tryptophan 500mg Cap
ratio-Tryptophan 500mg Cap
DNP
DNP
0.3563
0.3563
M
M
E
E
02248540
02240334
APX
TEV
Y
Y
Tryptan 500mg Cap
DNP
0.3563
M
E
00718149
VLN
Y
tryptophan 500mg tab
Apo-Tryptophan 500mg Tab
DNP
0.3563
M
E
02248538
APX
Y
ratio-Tryptophan 500mg Tab
Tryptan 500mg Tab
DNP
DNP
0.3563
0.3563
M
M
E
E
02240333
02029456
TEV
VLN
Y
Y
Tryptan 750mg Tab
DNP
1.1634
L
E
02239327
VLN
N
trazodone 50mg tab
Apo-Trazodone 50mg Tab
DNP
0.0554
M
SFC
02147637
APX
Y
MYLAN-Trazodone 50mg Tab (discontinued)
pms-Trazodone 50mg Tab
DNP
0.0554
M
SFC
02231683
01937227
MYL Y
PMS Y
Teva-Trazodone 50mg Tab
Trazodone 50mg Tab
DNP
DNP
0.0554
0.0554
M
M
SFC
SFC
02144263
02348772
TEV
SAS
Y
Y
00579351
BRI
Y
TRAZODONE
Desyrel 50mg Tab (discontinued)
pms-Trazodone 75mg Tab
DNP
0.3775
L
SFC
02237339
PMS N
trazodone 100mg tab
Apo-Trazodone 100mg Tab
DNP
0.0989
M
SFC
02147645
APX
pms-Trazodone 100mg Tab
Teva-Trazodone 100mg Tab
DNP
DNP
0.0989
0.0989
M
M
SFC
SFC
01937235
02144271
PMS Y
TEV Y
Trazodone 100mg Tab
Desyrel 100mg Tab (discontinued)
DNP
0.0989
M
SFC
02348780
00579378
SAS
BRI
Y
Y
DNP
0.1454
M
SFC
02147653
02144298
APX
TEV
Y
Y
DNP
0.1454
M
SFC
02348799
00702277
SAS
BRI
Y
Y
mirtazapine 15mg RD tab
Auro-Mirtazapine OD 15mg Tab
DNP
0.1406
M
SFC
02299801
ARO Y
Novo-Mirtazapine OD 15mg Tab
Remeron RD 15mg Tab
DNP
DNP
0.1406
0.1406
M
M
SFC
SFC
02279894
02248542
TEV
FRS
pms-Mirtazapine 15mg Tab
DNP
0.3750
L
SFC
02273942
PMS N
Sandoz Mirtazapine 15mg Tab
DNP
0.3750
L
SFC
02250594
SDZ
mirtazapine 30mg RD tab
Auro-Mirtazapine OD 30mg Tab
DNP
0.2812
M
SFC
02299828
ARO Y
Novo-Mirtazapine OD 30mg Tab
Remeron RD 30mg Tab
DNP
DNP
0.2812
0.2812
M
M
SFC
SFC
02279908
02248543
TEV
FRS
trazodone 150mg tab
Apo-Trazodone 150mg Tab
Teva-Trazodone 150mg Tab
Trazodone 150mg Tab
Desyrel 150mg Tab (discontinued)
N06AX11
February 2016
Y
MIRTAZAPINE
205
Y
Y
N
Y
Y
N
Nervous System
N06AX12
N06AX16
mirtazapine 30mg tab
Apo-Mirtazapine 30mg Tab
DNP
0.3255
M
SFC
02286629
APX
Auro-Mirtazapine 30mg Tab
Mirtazapine 30mg Tab (SAS)
DNP
DNP
0.3255
0.3255
M
M
SFC
SFC
02411709
02370689
ARO Y
SAS Y
MYLAN-Mirtazapine 30mg Tab
Novo-Mirtazapine 30mg Tab
DNP
DNP
0.3255
0.3255
M
M
SFC
SFC
02256118
02259354
MYL Y
TEV Y
pms-Mirtazapine 30mg Tab
Sandoz Mirtazapine 30mg Tab
DNP
DNP
0.3255
0.3255
M
M
SFC
SFC
02248762
02250608
PMS Y
SDZ Y
Remeron 30mg Tab
DNP
0.3255
M
SFC
02243910
FRS
mirtazapine 45mg RD tab
Auro-Mirtazapine OD 45mg Tab
DNP
0.4218
M
SFC
02299836
ARO Y
Novo-Mirtazapine OD 45mg Tab
Remeron RD 45mg Tab
DNP
DNP
0.4218
0.4218
M
M
SFC
SFC
02279916
02248544
TEV
FRS
Y
Y
bupropion 100mg SR tab
Bupropion SR 100mg Tab
DNP
0.1548
M
SFC
02391562
SAS
Y
pms-Bupropion SR 100mg Tab
ratio-Bupropion SR 100mg Tab
DNP
DNP
0.1548
0.1548
M
M
SFC
SFC
02325373
02285657
PMS Y
TEV Y
Sandoz Bupropion SR 100mg Tab
Wellbutrin SR 100mg Tab (discontinued)
DNP
0.1548
M
SFC
02275074
02237824
SDZ
BVL
bupropion 150mg SR tab
Bupropion SR 150mg Tab
pms-Bupropion SR 150mg Tab
DNP
DNP
0.2311
0.2311
M
M
SFC
SFC
02391570
02313421
SAS Y
PMS Y
ratio-Bupropion SR 150mg Tab
Sandoz Bupropion SR 150mg Tab
DNP
DNP
0.2311
0.2311
M
M
SFC
SFC
02285665
02275082
TEV
SDZ
Y
Y
Wellbutrin SR 150mg Tab
DNP
0.2311
M
SFC
02237825
VLN
Y
bupropion 150mg XL tab
MYLAN-Bupropion XL 150mg Tab
DNP
0.3982
M
SFC
02382075
MYL Y
Wellbutrin XL 150mg Tab
DNP
0.3982
M
SFC
02275090
VLN
bupropion 300mg XL tab
MYLAN-Bupropion XL 300mg Tab
DNP
0.7963
M
SFC
02382083
MYL Y
Wellbutrin XL 300mg Tab
DNP
0.7963
M
SFC
02275104
VLN
Y
venlafaxine 37.5mg ER cap
Apo-Venlafaxine XR 37.5mg Cap
CO Venlafaxine XR 37.5mg Cap
DNP
DNP
0.1643
0.1643
M
M
SFC
SFC
02331683
02304317
APX
ATV
Y
Y
GD-Venlafaxine XR 37.5mg Cap
MYLAN-Venlafaxine XR 37.5mg Cap
DNP
DNP
0.1643
0.1643
M
M
SFC
SFC
02360020
02310279
GMD Y
MYL Y
pms-Venlafaxine XR 37.5mg Cap
RAN-Venlafaxine XR 37.5mg Cap
DNP
DNP
0.1643
0.1643
M
M
SFC
SFC
02278545
02380072
PMS Y
RAN Y
Sandoz Venlafaxine XR 37.5mg Cap
Teva-Venlafaxine XR 37.5mg Cap
DNP
DNP
0.1643
0.1643
M
M
SFC
SFC
02310317
02275023
SDZ
TEV
Y
Y
Venlafaxine XR 37.5mg Cap
Venlafaxine-XR 37.5mg Cap
DNP
DNP
0.1643
0.1643
M
M
SFC
SFC
02354713
02385929
SAS
SIV
Y
Y
Effexor XR 37.5mg Cap
DNP
0.1643
M
SFC
02237279
PFI
Y
Y
BUPROPION
Y
Y
Y
VENLAFAXINE
venlafaxine 75mg ER cap
February 2016
Y
206
N
Nervous System
N06AX21
N06AX23
Apo-Venlafaxine XR 75mg Cap
CO Venlafaxine XR 75mg Cap
DNP
DNP
0.3285
0.3285
M
M
SFC
SFC
02331691
02304325
APX
ATV
GD-Venlafaxine XR 75mg Cap
MYLAN-Venlafaxine XR 75mg Cap
DNP
DNP
0.3285
0.3285
M
M
SFC
SFC
02360039
02310287
GMD Y
MYL Y
Novo-Venlafaxine XR 75mg Cap
pms-Venlafaxine XR 75mg Cap
DNP
DNP
0.3285
0.3285
M
M
SFC
SFC
02275031
02278553
TEV Y
PMS Y
RAN-Venlafaxine XR 75mg Cap
Sandoz Venlafaxine XR 75mg Cap
DNP
DNP
0.3285
0.3285
M
M
SFC
SFC
02380080
02310325
RAN Y
SDZ Y
Venlafaxine XR 75mg Cap
Venlafaxine-XR 75mg Cap
DNP
DNP
0.3285
0.3285
M
M
SFC
SFC
02354721
02385937
SAS
SIV
Y
Y
Effexor XR 75mg Cap
DNP
0.3285
M
SFC
02237280
PFI
Y
venlafaxine 150mg ER cap
Apo-Venlafaxine XR 150mg Cap
DNP
0.3469
M
SFC
02331705
APX
Y
CO Venlafaxine XR 150mg Cap
GD-Venlafaxine XR 150mg Cap
DNP
DNP
0.3469
0.3469
M
M
SFC
SFC
02304333
02360047
ATV Y
GMD Y
MYLAN-Venlafaxine XR 150mg Cap
pms-Venlafaxine XR 150mg Cap
DNP
DNP
0.3469
0.3469
M
M
SFC
SFC
02310295
02278561
MYL Y
PMS Y
RAN-Venlafaxine XR 150mg Cap
Sandoz Venlafaxine XR 150mg Cap
DNP
DNP
0.3469
0.3469
M
M
SFC
SFC
02380099
02310333
RAN Y
SDZ Y
Teva-Venlafaxine XR 150mg Cap
Venlafaxine XR 150mg Cap
DNP
DNP
0.3469
0.3469
M
M
SFC
SFC
02275058
02354748
TEV
SAS
Y
Y
Venlafaxine-XR 150mg Cap
Effexor XR 150mg Cap
DNP
DNP
0.3469
0.3469
M
M
SFC
SFC
02385945
02237282
SIV
PFI
Y
Y
Cymbalta 30mg Cap
DNP
1.9254
L
E
02301482
LIL
N
Cymbalta 60mg Cap
DNP
3.9075
L
E
02301490
LIL
N
Pristiq 50mg ER Tab
02321092
PFI
N
Pristiq 100mg ER Tab
02321106
PFI
N
Adderall XR 5mg Cap
02248808
SHI
N
Adderall XR 10mg Cap
02248809
SHI
N
Adderall XR 15mg Cap
02248810
SHI
N
Adderall XR 20mg Cap
02248811
SHI
N
Adderall XR 25mg Cap
02248812
SHI
N
Adderall XR 30mg Cap
02248813
SHI
N
02443236
01924516
APX
PAL
Y
Y
DULOXETINE
DESVENLAFAXINE
N06B
PSYCHOSTIMULANTS, AGENTS USED FOR ADHD AND NOOTROPICS
N06BA
CENTRALLY ACTING SYMPATHOMIMETICS
N06BA01
N06BA02
AMPHETAMINES
DEXAMPHETAMINE
dextroamphetamine 5mg tab
Apo-Dextroamphetamine 5mg Tab
Dexedrine 5mg Tab
February 2016
Y
Y
DN
DN
0.5081
0.5081
M
M
SFC
SFC
207
N
Nervous System
N06BA04
N06BA07
February 2016
Dexedrine Spansule 10mg Cap
DN
0.9911
L
SFC
01924559
PAL
N
Dexedrine Spansule 15mg Cap
DN
1.2117
L
SFC
01924567
PAL
N
Apo-Methylphenidate 5mg Tab
DN
0.0947
L
SFC
02273950
APX
N
pms-Methylphenidate 5mg Tab
DN
0.0947
L
SFC
02234749
PMS N
methylphenidate 10mg tab
Apo-Methylphenidate 10mg Tab
DN
0.1271
M
SFC
02249324
APX
pms-Methylphenidate 10mg Tab
Ritalin 10mg Tab
DN
DN
0.1271
0.1271
M
M
SFC
SFC
00584991
00005606
PMS Y
NVR Y
Biphentin 10mg Cap
DN
0.7030
L
E
02277166
PFR
N
Biphentin 15mg Cap
DN
1.0060
L
E
02277131
PFR
N
methylphenidate 18mg ER tab
Novo-Methylphenidate ER-C 18mg Tab
pms-Methylphenidate ER 18mg Tab
DN
DN
1.0197
1.0197
M
M
E
E
02315068
02413728
TEV Y
PMS Y
Concerta 18mg Tab
DN
1.0197
M
E
02247732
JAN
Y
methylphenidate 20mg SR tab
Apo-Methylphenidate SR 20mg Tab
DN
0.2820
M
SFC
02266687
APX
Y
Sandoz Methylphenidate SR 20mg Tab
Ritalin SR 20mg Tab
DN
DN
0.2820
0.2820
M
M
SFC
SFC
02320312
00632775
SDZ Y
NVR Y
methylphenidate 20mg tab
Apo-Methylphenidate 20mg Tab
pms-Methylphenidate 20mg Tab
DN
DN
0.2359
0.2359
M
M
SFC
SFC
02249332
00585009
APX Y
PMS Y
Ritalin 20mg Tab
DN
0.2359
M
SFC
00005614
NVR Y
Biphentin 20mg Cap
DN
1.3000
L
E
02277158
PFR
N
methylphenidate 27mg ER tab
Novo-Methylphenidate ER-C 27mg Tab
DN
1.1768
M
E
02315076
TEV
Y
pms-Methylphenidate ER 27mg Tab
Concerta 27mg Tab
DN
DN
1.1768
1.1768
M
M
E
E
02413736
02250241
PMS Y
JAN Y
Biphentin 30mg Cap
DN
1.7840
L
E
02277174
PFR
methylphenidate 36mg ER tab
Novo-Methylphenidate ER-C 36mg Tab
pms-Methylphenidate ER 36mg Tab
DN
DN
1.3339
1.3339
M
M
E
E
02315084
02413744
TEV Y
PMS Y
Concerta 36mg Tab
DN
1.3339
M
E
02247733
JAN
Y
Biphentin 40mg Cap
DN
2.2730
L
E
02277182
PFR
N
Biphentin 50mg Cap
DN
2.7560
L
E
02277190
PFR
N
methylphenidate 54mg ER tab
Novo-Methylphenidate ER-C 54mg Tab
DN
1.6480
M
E
02315092
TEV
Y
pms-Methylphenidate ER 54mg Tab
Concerta 54mg Tab
DN
DN
1.6480
1.6480
M
M
E
E
02413752
02247734
PMS Y
JAN Y
Biphentin 60mg Cap
DN
3.2080
L
E
02277204
PFR
N
Biphentin 80mg Cap
DN
4.2330
L
E
02277212
PFR
N
METHYLPHENIDATE
MODAFINIL
208
Y
N
N
Nervous System
modafinil 100mg tab
Auro-Modafinil 100mg Tab
N06BA09
February 2016
DNP
0.9293
E
02430487
ARO Y
M
E
02432560
02285398
MAR Y
APX Y
M
E
02420260
02239665
TEV
SHI
Y
Y
atomoxetine 10mg cap
Apo-Atomoxetine 10mg Cap
02318024
APX
Y
Novo-Atomoxetine 10mg Cap
pms-Atomoxetine 10mg Cap
02314541
02381028
TEV Y
PMS Y
Sandoz Atomoxetine 10mg Cap
Strattera 10mg Cap
02386410
02262800
SDZ
LIL
atomoxetine 18mg cap
Apo-Atomoxetine 18mg Cap
MYLAN-Atomoxetine 18mg cap
02318032
02378930
APX Y
MYL Y
Novo-Atomoxetine 18mg Cap
pms-Atomoxetine 18mg Cap
02314568
02381036
TEV Y
PMS Y
Sandoz Atomoxetine 18mg Cap
Strattera 18mg Cap
02386429
02262819
SDZ
LIL
atomoxetine 25mg cap
Apo-Atomoxetine 25mg Cap
MYLAN-Atomoxetine 25mg cap
02318040
02378949
APX Y
MYL Y
Novo-Atomoxetine 25mg Cap
pms-Atomoxetine 25mg Cap
02314576
02381044
TEV Y
PMS Y
Sandoz Atomoxetine 25mg Cap
Strattera 25mg Cap
02386437
02262827
SDZ
LIL
atomoxetine 40mg cap
Apo-Atomoxetine 40mg Cap
MYLAN-Atomoxetine 40mg cap
02318059
02378957
APX Y
MYL Y
Novo-Atomoxetine 40mg Cap
pms-Atomoxetine 40mg Cap
02314584
02381052
TEV Y
PMS Y
Sandoz Atomoxetine 40mg Cap
Strattera 40mg Cap
02386445
02262835
SDZ
LIL
atomoxetine 60mg cap
Apo-Atomoxetine 60mg Cap
MYLAN-Atomoxetine 60mg cap
02318067
02378965
APX Y
MYL Y
Novo-Atomoxetine 60mg Cap
pms-Atomoxetine 60mg Cap
02314592
02381060
TEV Y
PMS Y
Sandoz Atomoxetine 60mg Cap
Strattera 60mg Cap
02386453
02262843
SDZ
LIL
atomoxetine 80mg cap
Apo-Atomoxetine 80mg Cap
MYLAN-Atomoxetine 80mg Cap
02318075
02378973
APX Y
MYL Y
Sandoz Atomoxetine 80mg Cap
Teva-Atomoxetine 80mg Cap
02386461
02362511
SDZ
TEV
Y
Y
Strattera 80mg Cap
02279347
LIL
Y
Mar-Modafinil 100mg Tab
Modafinil 100mg Tab
DNP
0.9293
Teva-Modafinil 100mg Tab
Alertec 100mg Tab
DNP
0.9293
M
ATOMOXETINE
209
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
Nervous System
N06BA12
atomoxetine 100mg cap
Apo-Atomoxetine 100mg Cap
02318083
APX
MYLAN-Atomoxetine 100mg Cap
Sandoz Atomoxetine 100mg Cap
02378981
02386488
MYL Y
SDZ Y
Teva-Atomoxetine 100mg Cap
Strattera 100mg Cap
02362538
02279355
TEV
LIL
Y
Y
LISDEXAMFETAMINE
Vyvanse 10mg Cap
DNP
2.1411
L
E
02439603
SHI
N
Vyvanse 20mg Cap
DNP
2.6633
L
E
02347156
SHI
N
Vyvanse 30mg Cap
DNP
3.1855
L
E
02322951
SHI
N
Vyvanse 40mg Cap
DNP
3.7077
L
E
02347164
SHI
N
Vyvanse 50mg Cap
DNP
4.2299
L
E
02322978
SHI
N
Vyvanse 60mg Cap
DNP
4.7521
L
E
02347172
SHI
N
donepezil 5mg tab
Apo-Donepezil 5mg Tab
Auro-Donepezil 5mg Tab
DNP
DNP
1.1806
1.1806
M
M
E
E
02362260
02400561
APX Y
ARO Y
CO Donepezil 5mg Tab
Donepezil HCl 5mg Tab
DNP
DNP
1.1806
1.1806
M
M
E
E
02397595
02402645
ATV
AHI
Y
Y
Donepezil-5mg Tab
Jamp-Donepezil 5mg Tab
DNP
DNP
1.1806
1.1806
M
M
E
E
02420597
02404419
SIV
JPC
Y
Y
Jamp-Donepezil 5mg Tab
Mar-Donepezil 5mg Tab
DNP
DNP
1.1806
1.1806
M
M
E
E
02416948
02402092
JPC Y
MAR Y
MYLAN-Donepezil 5mg Tab
pms-Donepezil 5mg Tab
DNP
DNP
1.1806
1.1806
M
M
E
E
02359472
02322331
MYL Y
PMS Y
RAN-Donepezil 5mg Tab
Sandoz Donepezil 5mg Tab
DNP
DNP
1.1806
1.1806
M
M
E
E
02381508
02328666
RAN Y
SDZ Y
Septa-Donepezil 5mg Tab
Teva-Donepezil 5mg Tab
DNP
DNP
1.1806
1.1806
M
M
E
E
02428482
02340607
SPT
TEV
Y
Y
Aricept 5mg Tab
DNP
1.1806
M
E
02232043
PFI
Y
donepezil OD 5mg tab
CO Donepezil ODT 5mg Tab
02397617
ATV
Y
Sandoz Donepezil 5mg Tab
Aricept RDT 5mg Tab
02367688
02269457
SDZ
PFI
Y
Y
N06D
ANTI-DEMENTIA DRUGS
N06DA
ANTICHOLINESTERASES
N06DA02
February 2016
Y
DONEPEZIL
donepezil 10mg tab
Apo-Donepezil 10mg Tab
Auro-Donepezil 10mg Tab
DNP
DNP
1.1806
1.1806
M
M
E
E
02362279
02400588
APX Y
ARO Y
CO Donepezil 10mg Tab
Donepezil HCl 10mg Tab
DNP
DNP
1.1806
1.1806
M
M
E
E
02397609
02402653
ATV
AHI
Y
Y
Donepezil-10mg Tab
Jamp-Donepezil 10mg tab
DNP
DNP
1.1806
1.1806
M
M
E
E
02420600
02416956
SIV
JPC
Y
Y
Jamp-Donepezil 10mg Tab
DNP
1.1806
M
E
02404427
JPC
Y
210
N
Nervous System
N06DA03
Mar-Donepezil 10mg Tab
MYLAN-Donepezil 10mg Tab
DNP
DNP
1.1806
1.1806
M
M
E
E
02402106
02359480
MAR Y
MYL Y
pms-Donepezil 10mg Tab
RAN-Donepezil 10mg Tab
DNP
DNP
1.1806
1.1806
M
M
E
E
02322358
02381516
PMS Y
RAN Y
Sandoz Donepezil 10mg Tab
Septa-Donepezil 10mg tab
DNP
DNP
1.1806
1.1806
M
M
E
E
02328682
02428490
SDZ
SPT
Y
Y
Teva-Donepezil 10mg Tab
Aricept 10mg Tab
DNP
DNP
1.1806
1.1806
M
M
E
E
02340615
02232044
TEV
PFI
Y
Y
donepezil OD 10mg tab
CO Donepezil ODT 10mg Tab
Sandoz Donepezil 10mg Tab
02397625
02367696
ATV
SDZ
Y
Y
Aricept RDT 10mg Tab
02269465
PFI
Y
RIVASTIGMINE
rivastigmine 1.5mg cap
Apo-Rivastigmine 1.5mg Cap
MED-Rivastigmine 1.5mg Cap
DNP
DNP
0.6515
0.6515
M
M
E
E
02336715
02401614
APX Y
GMP Y
MINT-Rivastigmine 1.5mg Cap
Novo-Rivastigmine 1.5mg Cap
DNP
DNP
0.6515
0.6515
M
M
E
E
02406985
02305984
MNT Y
TEV Y
pms-Rivastigmine 1.5mg Cap
ratio-Rivastigmine 1.5mg Cap (discontinued)
DNP
0.6515
M
E
02306034
02311283
PMS Y
TEV Y
Sandoz Rivastigmine 1.5mg Cap
Exelon 1.5mg Cap
DNP
DNP
0.6515
0.6515
M
M
E
E
02324563
02242115
SDZ Y
NVR Y
Exelon 2mg/mL O/L
DNP
1.3823
L
E
02245240
NVR N
rivastigmine 3mg cap
Apo-Rivastigmine 3mg Cap
MED-Rivastigmine 3mg Cap
DNP
DNP
0.6515
0.6515
M
M
E
E
02336723
02401622
APX Y
GMP Y
MINT-Rivastigmine 3mg Cap
Novo-Rivastigmine 3mg Cap
DNP
DNP
0.6515
0.6515
M
M
E
E
02406993
02305992
MNT Y
TEV Y
pms-Rivastigmine 3mg Cap
ratio-Rivastigmine 3mg Cap (discontinued)
DNP
0.6515
M
E
02306042
02311291
PMS Y
TEV Y
Sandoz Rivastigmine 3mg Cap
Exelon 3mg Cap
DNP
DNP
0.6515
0.6515
M
M
E
E
02324571
02242116
SDZ Y
NVR Y
rivastigmine 4.5mg cap
Apo-Rivastigmine 4.5mg Cap
MED-Rivastigmine 4.5mg Cap
DNP
DNP
0.6515
0.6515
M
M
E
E
02336731
02401630
APX Y
GMP Y
MINT-Rivastigmine 4.5mg Cap
Novo-Rivastigmine 4.5mg Cap
DNP
DNP
0.6515
0.6515
M
M
E
E
02407000
02306018
MNT Y
TEV Y
pms-Rivastigmine 4.5mg Cap
ratio-Rivastigmine 4.5mg Cap (discontinued)
DNP
0.6515
M
E
02306050
02311305
PMS Y
TEV Y
Sandoz Rivastigmine 4.5mg Cap
Exelon 4.5mg Cap
DNP
DNP
0.6515
0.6515
M
M
E
E
02324598
02242117
SDZ Y
NVR Y
02302845
NVR N
Exelon Patch 5 (4.6mg/24hr)
February 2016
rivastigmine 6mg cap
Apo-Rivastigmine 6mg Cap
MED-Rivastigmine 6mg Cap
DNP
DNP
0.6515
0.6515
M
M
E
E
02336758
02401649
APX Y
GMP Y
MINT-Rivastigmine 6mg Cap
Novo-Rivastigmine 6mg Cap
DNP
DNP
0.6515
0.6515
M
M
E
E
02407019
02306026
MNT Y
TEV Y
211
N
Nervous System
ratio-Rivastigmine 6mg Cap (discontinued)
Sandoz Rivastigmine 6mg Cap
DNP
0.6515
M
Exelon 6mg Cap
DNP
0.6515
M
E
02311313
02324601
TEV
SDZ
E
02242118
NVR Y
02302853
NVR N
Exelon Patch 10 (9.5mg/24hr)
N06DA04
N06DX
Y
Y
GALANTAMINE
galantamine 8mg ER cap
Mar-Galantamine ER 8mg Cap
MYLAN-Galantamine ER 8mg Cap
DNP
DNP
1.2467
1.2467
M
M
E
E
02420821
02339439
MAR Y
MYL Y
PAT-Galantamine ER 8mg Cap
pms-Galantamine ER 8mg Cap
DNP
DNP
1.2467
1.2467
M
M
E
E
02316943
02398370
PPH Y
PMS Y
Reminyl ER 8mg Cap
DNP
1.2467
M
E
02266717
JAN
galantamine 16mg ER cap
Mar-Galantamine ER 16mg Cap
DNP
1.2467
M
E
02420848
MAR Y
MYLAN-Galantamine ER 16mg Cap
PAT-Galantamine ER 16mg Cap
DNP
DNP
1.2467
1.2467
M
M
E
E
02339447
02316951
MYL Y
PPH Y
pms-Galantamine ER 16mg Cap
Reminyl ER 16mg Cap
DNP
DNP
1.2467
1.2467
M
M
E
E
02398389
02266725
PMS Y
JAN Y
galantamine 24mg ER cap
Mar-Galantamine ER 24mg Cap
MYLAN-Galantamine ER 24mg Cap
DNP
DNP
1.2467
1.2467
M
M
E
E
02420856
02339455
MAR Y
MYL Y
PAT-Galantamine ER 24mg Cap
pms-Glanatamine ER 24mg Cap
DNP
DNP
1.2467
1.2467
M
M
E
E
02316978
02398397
PPH Y
PMS Y
Reminyl ER 24mg Cap
DNP
1.2467
M
E
02266733
JAN
Y
memantine 10mg tab
Apo-Memantine 10mg Tab
CO Memantine 10mg Tab
02366487
02324067
APX
ATV
Y
Y
MED-Memantine 10mg Tab
Memantine 10mg Tab
02409895
02443082
GMP Y
SAS Y
MYLAN-Memantine 10mg Tab
pms-Memantine 10mg Tab
02430371
02321130
MYL Y
PMS Y
RAN-Memantine 10mg Tab
ratio-Memantine 10mg Tab
02421364
02320908
RAN Y
TEV Y
Sandoz Memantine 10mg Tab
Sandoz Memantine FCT 10mg Tab
02344807
02375532
SDZ
SDZ
Y
Y
Ebixa 10mg Tab
02260638
VLH
Y
Neostigmine Methylsulfate 0.5mg/mL Inj
00874957
SDZ
N
Neostigmine Methylsulfate 1mg/mL Inj
00885282
SDZ
N
Y
OTHER ANTI-DEMENTIA DRUGS
N06DX01
MEMANTINE
N07
OTHER NERVOUS SYSTEM DRUGS
N07A
PARASYMPATHOMIMETICS
N07AA
ANTICHOLINESTERASES
N07AA01
February 2016
NEOSTIGMINE
212
N
Nervous System
Neostigmine Methylsulfate 2.5mg/mL Inj
Prostigmin 15mg Tab
N07AA02
N07AB
0.4851
L
SF
00869945
VLN
N
Mestinon 60mg Tab
DNP
0.4767
L
SF
00869961
VLN
N
Mestinon 180mg SR Tab
DNP
1.0423
L
SF
00869953
VLN
N
DNP
0.3033
L
SF
01947958
PAL
N
00349739
FRS
Y
PYRIDOSTIGMINE
BETHANECHOL
bethanechol chloride 25mg tab
Urecholine 25mg Tab (discontinued)
Duvoid 25mg Tab
DNP
0.4914
L
SF
01947931
PAL
N
Duvoid 50mg Tab
DNP
0.6473
L
SF
01947923
PAL
N
02402483
STR Y
DNP
1.1543
L
E
02216345
PFI
Y
02238441
VLN
N
OTHER PARASYMPATHOMIMETICS
N07AX01
PILOCARPINE
pilocarpine 5mg tab
Pilocarpine 5mg Tab (discontinued)
Salagen 5mg Tab
N07B
DRUGS USED IN ADDICTIVE DISORDERS
N07BA
DRUGS USED IN NICOTINE DEPENDENCE
N07BA02
BUPROPION
Zyban 150mg Tab
DRUGS USED IN ALCOHOL DEPENDENCE
N07BB03
ACAMPROSATE
Campral 333mg Tab
N07BB04
DNP
0.8000
L
E
02293269
MYL N
DNP
5.6150
L
E
02213826
TEV
Methadone Pdr (o/l compound)
DN
0.0050
P
E
00999734
VAR N
Metadol 1mg Tab
Metadol 1mg/mL O/L
DN
0.1800
L
E
02247698
02247694
PAL
PAL
N
N
Metadol 5mg Tab
DN
0.6148
L
E
02247699
PAL
N
Metadol 10mg Tab
DN
0.9836
L
E
02247700
PAL
N
02241377
PAL
N
02247701
PAL
N
NALTREXONE
ReVia 50mg Tab
N07BC
N
DNP
Duvoid 10mg Tab
N07BB
SDZ
CHOLINE ESTERS
N07AB02
N07AX
01915436
N
DRUGS USED IN OPIOID DEPENDENCE
N07BC02
METHADONE
Metadol 10mg/mL O/L
Metadol 25mg Tab
N07BC51
February 2016
DN
1.7300
L
E
BUPRENORPHINE, COMBINATIONS
213
N
Nervous System
buprenorphine 2mg & naloxone 0.5mg tab
MYLAN-Buprenorphine/Naloxone 2mg/0.5mg Tab
DN
1.3350
M
E
02408090
MYL Y
Teva-Buprenorphine/Naloxone 2mg/0.5mg Tab
Suboxone 2mg/0.5mg SL Tab
DN
DN
1.3350
1.3350
M
M
E
E
02424851
02295695
TEV
ICL
buprenorphine 8mg & naloxone 2mg tab
MYLAN-Buprenorphine/Naloxone 8mg/2mg Tab
Teva-Buprenorphine/Naloxone 8mg/2mg Tab
DN
DN
2.3650
2.3650
M
M
E
E
02408104
02424878
MYL Y
TEV Y
Suboxone 8mg/2mg SL Tab
DN
2.3650
M
E
02295709
ICL
Y
betahistine 16mg tab
CO Betahistine 16mg Tab
Novo-Betahistine 16mg Tab
DNP
DNP
0.1770
0.1770
M
M
E
E
02374757
02280191
ATV
TEV
Y
Y
pms-Betahistine 16mg Tab
Serc 16mg Tab
DNP
0.1770
M
E
02330210
02243878
PMS Y
BGP Y
betahistine 24mg tab
CO Betahistine 24mg Tab
Novo-Betahistine 24mg Tab
DNP
DNP
0.3040
0.3040
M
M
E
E
02374765
02280205
ATV
TEV
pms-Betahistine 24mg Tab
Serc 24mg Tab
DNP
DNP
0.3040
0.3040
M
M
E
E
02330237
02247998
PMS Y
BGP Y
DNP
0.7817
M
SF
02246082
AAP
00846341
PMS Y
N07C
ANTIVERTIGO PREPARATIONS
N07CA
ANTIVERTIGO PREPARATIONS
N07CA01
N07CA03
BETAHISTINE
Sibelium 5mg Cap (discontinued)
N07X
OTHER NERVOUS SYSTEM DRUGS
N07XX
OTHER NERVOUS SYSTEM DRUGS
N07XX06
N07XX07
February 2016
Y
RILUZOLE
riluzole 50mg tab
Apo-Riluzole 50mg Tab
MYLAN-Riluzole 50mg Tab
DNP
DNP
3.4361
3.4361
M
M
E
E
02352583
02390299
APX Y
MYL Y
Rilutek 50mg Tab
DNP
3.4361
M
E
02242763
SAV
tetrabenazine 25mg tab
Apo-Tetrabenazine 25mg Tab
pms-Tetrabenazine 25mg Tab
DNP
3.3746
M
SF
02407590
02402424
APX Y
PMS Y
Tetrabenazine 25mg Tab
Nitoman 25mg Tab
DNP
DNP
3.3746
3.3746
M
M
SF
SF
02410338
02199270
STR Y
VLN Y
02379910
BIG
Y
TETRABENAZINE
FAMPRIDINE
Fampyra 10mg SR Tab
N07XX09
Y
Y
FLUNARIZINE
flunarizine 5mg cap
Flunarizine 5mg Cap
N07XX02
Y
Y
DIMETHYL FUMARATE
214
N
N
Nervous System
February 2016
Tecfidera 120mg DR Cap
DNP
16.5164
L
E
02404508
BIG
N
Tecfidera 240mg DR Cap
DNP
33.0329
L
E
02420201
BIG
N
215
P
Antiparasitic Products, Insecticides and Repellents
P01
ANTIPROTOZOALS
P01A
AGENTS VS.AMOEBIASIS & OTHER PROTOZOAL DISEASES
P01AX
OTHER AGENTS VS AMOEBIASIS & OTHER PROTOZOAL DIS.
P01AX06
ATOVAQUONE
Mepron 150mg/mL Oral Susp
P01B
ANTIMALARIALS
P01BA
AMINOQUINOLINES
P01BA01
DNP
2.6554
L
SF
02217422
GSK N
DNP
1.2240
M
SF
00021261
TEV
Y
02017539
SAV
Y
CHLOROQUINE
chloroquine phosphate 250mg tab
Novo-Chloroquine 250mg Tab
Aralen 250mg Tab (discontinued)
P01BA02
P01BA03
HYDROXYCHLOROQUINE
hydroxychloroquine 200mg tab
Apo-Hydroxyquine 200mg Tab
MINT-Hydroxychloroquine 200mg Tab
DNP
DNP
0.2620
0.2620
M
M
SF
SF
02246691
02424991
APX Y
MNT Y
MYLAN-Hydroxychloroquine 200mg Tab
Plaquenil 200mg Tab
DNP
DNP
0.2620
0.2620
M
M
SF
SF
02252600
02017709
MYL Y
SAV Y
DNP
0.4140
L
SF
02017776
SAV
atovaquone 250mg & proguanil HCl 100mg tab
Atovaquone Proguanil 250/100mg Tab
MYLAN-Atovaquone/Proguanil 250mg/100mg Tab
02421429
02402165
SAS Y
MYL Y
Teva-Atovaquone Proguanil 250/100mg Tab
Malarone 250/100mg Tab
02380927
02238151
TEV Y
GSK Y
00021008
TEV
00022837
PDA Y
PRIMAQUINE
Primaquine 15mg Tab
P01BB51
P01BC
N
PROGUANIL, COMBINATIONS
METHANOLQUINOLINES
P01BC01
QUININE
quinine sulfate 200mg cap
Novo-Quinine 200mg Cap
DNP
0.2481
M
SF
Quinine 200mg Cap (discontinued)
P01BC02
Apo-Quinine 200mg Cap
Quinine-Odan 200mg Cap
DNP
DNP
0.2481
0.2390
L
L
SF
SF
02254514
00695440
APX N
ODN N
quinine sulfate 300mg cap
Novo-Quinine 300mg Cap
Quinine 300mg Cap (discontinued)
DNP
0.3893
M
SF
00021016
00022845
TEV Y
PDA Y
Apo-Quinine 300mg Cap
DNP
0.3893
L
SF
02254522
APX
Quinine-Odan 300mg Cap
Quinine-Odan 300mg Tab
DNP
DNP
0.3750
0.3750
L
L
SF
SF
00695459
00695432
ODN N
ODN N
MEFLOQUINE
mefloquine 250mg tab
February 2016
Y
216
N
P
Antiparasitic Products, Insecticides and Repellents
Mefloquine 250mg Tab
Larium 250mg Tab (discontinued)
P02
ANTHELMINTICS
P02C
ANTINEMATODAL AGENTS
P02CA
BENZIMIDAZOLE AGENTS
P02CA01
P03
ECTOPARASITICIDES,INCL SCABICIDES,INSECT.&REPELLAN
P03A
ECTOPARASITICIDES, INCL SCABICIDES
P03AX
OTHER ECTOPARACITICIDES, INCL SCABICIDES
Y
Y
DNP
5.4700
L
SF
00556734
JAN
N
02279592
MDF N
ISOPROPYL MYRISTATE
Resultz 50% Top Sol
February 2016
AAP
HLR
MEBENDAZOLE
Vermox 100mg Tab
P03AX99
02244366
02018055
217
R
Respiratory System
R01
NASAL PREPARATIONS
R01A
DECONGESTANTS & OTHER NASAL PREPS,TOPICAL USE
R01AB
SYMPATHOMIMETICS,COMBINATIONS EXCL CORTICOSTEROIDS
R01AB01
PHENYLEPHRINE
Soframycin Nasal Spray
R01AC
DNP
2.8667
L
SF
02224860
ERF
DNP
0.5292
M
SF
01950541
PDP Y
00605255
RPR Y
ANTIALLERGIC AGENTS, EXCL CORTICOSTEROIDS
R01AC01
CROMOGLYCATE SODIUM
cromoglycate sodium 2% nasal sol
Rhinaris-CS Anti-Allergic Nasal Mist
Rynacrom 2% Nasal Sol (discontinued)
R01AC02
LEVOCABASTINE
Livostin 0.5mg/mL Nasal Spray
R01AD
N
DNP
1.9667
L
SF
02020017
JAN
N
0.0613
M
SFC
02238796
APX
Y
0.0613
M
SFC
02172712
01923935
MYL Y
GLA Y
flunisolide 25mcg/dose nasal mist
Apo-Flunisolide 25mcg/dose Nasal Spray
02239288
APX
Rhinalar 25mcg/dose Nasal Mist (discontinued)
02162687
ORX Y
CORTICOSTEROIDS
R01AD01
BECLOMETHASONE
beclomethasone dipropionate 50mcg/dose aqueous nasal spray
Apo-Beclo 50mcg/dose Acq Nasal Sp
DNP
MYLAN-Beclo 50mcg/dose Acq Nasal Spray
Beconase 50mcg/dose Acq Nasal Sp (discontinued)
R01AD04
R01AD05
R01AD08
R01AD09
DNP
FLUNISOLIDE
Y
BUDESONIDE
budesonide 64mcg/dose aqueous nasal spray
MYLAN-Budesonide AQ 64mcg/dose Nasal Spray
Rhinocort 64mcg/dose Aqua Nasal Spray
DNP
DNP
0.0843
0.0843
M
M
SF
SF
02241003
02231923
MYL Y
AZE Y
MYLAN-Budesonide AQ 100mcg/dose Nasal Spray
DNP
0.0958
L
SF
02230648
MYL N
Rhinocort 100mcg/dose Turbuhaler
DNP
0.1223
L
SF
02035324
AZE
N
fluticasone 50mcg/dose nasal spray
Apo-Fluticasone 50mcg/dose Nasal Spray
ratio-Fluticasone 50mcg/dose Nasal Spray
02294745
02296071
APX
TEV
Y
Y
Flonase 50mcg/dose Nasal Spray
02213672
GSK Y
02403587
02238465
APX
FRS
Y
Y
02213834
SAV
N
FLUTICASONE
MOMETASONE
mometasone 50mcg/mL nasal spray
Apo-Mometasone 0.05% Nasal Spray
Nasonex 0.05% Nasal Spray
DNP
DNP
0.1549
0.1549
M
M
F*
F*
*full benefit for children aged 3 to 11 years.
R01AD11
TRIAMCINOLONE
Nasacort AQ 55mcg/dose Nasal Spray
February 2016
218
R
Respiratory System
R01AX
OTHER NASAL PREPARATIONS
R01AX03
R01AX10
IPRATROPIUM BROMIDE
ipratropium bromide 0.3% nasal spray (21mcg/dose)
pms-Ipratropium 21mcg/dose Nasal Spray
DNP
0.0668
M
SF
02239627
PMS Y
Atrovent 21mcg/dose Nasal Spray
DNP
0.0668
M
SF
02163705
BOE Y
ipratropium bromide 0.6% nasal spray (42mcg/dose)
Apo-Ipravent 42mcg/dose Nasal Spray
DNP
0.1355
M
SF
02246084
AAP
Atrovent 42mcg/dose Nasal Spray
DNP
0.1355
M
SF
02163713
BOE Y
DNP
0.0567
L
SF
02058235
DLU
DNPM
0.0293
P
E
02208245
PMS Y
DNPM
0.0293
P
E
02239365
02213400
TEV Y
GSK Y
salbutamol 1mg/mL unit dose inh sol
pms-Salbutamol 1mg/mL Polynebs
ratio-Salbutamol 1mg/mL Nebules
DNPM
DNPM
0.0585
0.0585
P
P
E
E
02208229
01986864
PMS Y
TEV Y
Ventolin 1mg/mL Nebules
DNPM
0.0585
P
E
02213419
GSK Y
salbutamol 2mg/mL unit dose inh sol
pms-Salbutamol 2mg/mL Polynebs
DNPM
0.1170
P
E
02208237
PMS Y
TEV Y
GSK Y
VARIOUS NASAL PREPARATIONS
Dey-Pak Sodium Chloride Inhalation Sol 0.9%
R03
DRUGS FOR OBSTRUCTIVE AIRWAY DISEASES
R03A
ADRENERGICS, INHALANTS
R03AC
SELECTIVE BETA-2-ADRENOCEPTOR AGONISTS
R03AC02
ratio-Salbutamol 0.5mg/mL Nebules
Ventolin 0.5mg/mL Nebules (discontinued)
ratio-Salbutamol 2mg/mL Nebules (discontinued)
Ventolin 2mg/mL Nebules
DNPM
0.1170
P
E
02239366
02213427
salbutamol 5mg/mL inh sol
pms-Salbutamol 5mg/mL Resp Sol (discontinued)
ratio-Salbutamol 5mg/mL Resp Sol
DNPM
0.3511
M
E
02069571
00860808
PMS Y
TEV Y
Sandoz Salbutamol 5mg/mL Resp Sol
Ventolin 5mg/mL Resp Sol
DNPM
DNPM
0.3511
0.3511
M
M
E
E
02154412
02213486
SDZ Y
GSK Y
salbutamol 100mcg/dose oral inh
Apo-Salvent 100mcg/dose CFC Free Inh
Novo-Salbutamol HFC 100mcg/act Inh
DNPM
DNPM
0.0325
0.0325
M
M
SFC
SFC
02245669
02326450
APX
TEV
Y
Y
Salbutamol HFA 100mcg/dose Inh
Airomir 100mcg/act Inh
DNPM
DNPM
0.0325
0.0325
M
M
SFC
SFC
02419858
02232570
SAS
VLN
Y
Y
Ventolin HFA 100mcg/dose Inh
DNPM
0.0325
M
SFC
02241497
GSK Y
Ventolin 200mcg/dose Diskus
DNPM
0.1928
L
SFC
02243115
GSK N
DNP
0.0773
L
SF
00786616
AZE
TERBUTALINE
Bricanyl 0.5mg/dose Turbuhaler
R03AC12
February 2016
N
SALBUTAMOL
salbutamol 0.5mg/mL unit dose inh sol
pms-Salbutamol 0.5mg/mL Polynebs
R03AC03
Y
SALMETEROL
219
N
R
Respiratory System
Serevent 50mcg/dose Diskhaler
Serevent 50mcg/dose Diskus
R03AC13
R03AC18
DNP
DNP
0.9350
0.9350
L
L
E
E
02214261
02231129
GSK N
GSK N
Oxeze 6mcg/dose Turbuhaler
DNP
0.5608
L
E
02237225
AZE
Foradil 12mcg Cap for Inhalation
Oxeze 12mcg/dose Turbuhaler
DNP
DNP
0.8422
0.7467
L
L
E
E
02230898
02237224
NVR N
AZE N
DNP
1.5500
L
E
02376938
NVR N
02148633
BOE N
FORMOTEROL
INDACATEROL
Onbrez 75mcg Micronized Pwd for Inhilation
R03AK
N
ADRENERGICS AND OTHER DRUGS FOR OBSTRUCTIVE AIRWAY DISEASES
R03AK03
FENOTEROL AND OTHER DRUGS FOR OBSTRUCTIVE AIRWAY DISEASES
Duovent UDV Inh Sol
R03AK04
SALBUTAMOL AND OTHER DRUGS FOR OBSTRUCTIVE AIRWAY DISEASES
ipratropium bromide 200mcg/mL & salbutamol 1mg/mL unit dose inh sol
R03AK06
R03AK07
Teva-Combo Sterinebs
DNP
0.5126
M
E
02272695
TEV
Combivent UDV Inh Sol
DNP
0.5126
M
E
02231675
BOE Y
SALMETEROL AND OTHER DRUGS FOR OBSTRUCTIVE AIRWAY DISEASES
Advair HFA 25/125mcg/dose Inh
DNP
0.7999
L
E
02245126
GSK N
Advair HFA 25/250mcg/dose Inh
DNP
1.1356
L
E
02245127
GSK N
Advair 50/100mcg Diskus
DNP
1.3365
L
E
02240835
GSK N
Advair 50/250mcg Diskus
DNP
1.5998
L
E
02240836
GSK N
Advair 50/500mcg Diskus
DNP
2.2712
L
E
02240837
GSK N
02361744
FRS
N
FORMOTEROL AND OTHER DRUGS FOR OBSTRUCTIVE AIRWAY DISEASES
Zenhale 5/50mcg Inh (discontinued)
R03AK10
Zenhale 5/100mcg Inh
DNP
0.7246
L
E
02361752
FRS
N
Zenhale 5/200mcg Inh
DNP
0.8783
L
E
02361760
FRS
N
Symbicort 100/6mcg Turbuhaler
DNP
0.5380
L
E
02245385
AZE
N
Symbicort 200/6mcg Turbuhaler
DNP
0.6991
L
E
02245386
AZE
N
DNP
4.0000
L
E
02408872
GSK N
DNP
0.2392
L
SFC
02419106
BOE N
DNP
2.7000
L
E
02418401
GSK N
DNP
2.6800
L
E
02418282
NVR N
VILANTEROL AND FLUTICASONE FUROATE
Breo Ellipta 100mcg/25mcg Pwd for Inh
R03AL
Y
ADRENERGICS IN COMBINATION WITH ANTICHOLINERGICS
R03AL02
SALBUTAMOL AND IPATROPRIUM BROMIDE
Combivent 100/20mcg Respimat
R03AL03
VILANTEROL AND UMECLIDINIUM BROMIDE
Anoro Ellipta 62.5/25mcg Pwd for Inh
R03AL04
INDACATEROL AND GLYCOPYRRONIUM BROMIDE
Ultibro Breezhaler 110/50mcg Cap for Inh
February 2016
220
R
Respiratory System
R03B
OTHER DRUGS FOR OBSTRUCTIVE AIRWAY DISEASES, INHALANTS
R03BA
GLUCOCORTICOIDS, ANTI-ASTHMATICS, INHALED
R03BA01
R03BA02
R03BA05
R03BA07
R03BA08
BECLOMETHASONE
QVAR 50mcg/dose Inh
DNP
0.1591
L
SFC
02242029
VLN
N
QVAR 100mcg/dose Inh
DNP
0.3172
L
SFC
02242030
VLN
N
Pulmicort 0.125mg/mL Nebuamps
DNP
0.2203
L
E
02229099
AZE
N
Pulmicort 0.25mg/mL Nebuamps
DNP
0.4405
L
E
01978918
AZE
N
Pulmicort 0.5mg/mL Nebuamps
DNP
0.8795
L
E
01978926
AZE
N
Pulmicort 100mcg/dose Turbuhaler
DNP
0.1564
L
SF
00852074
AZE
N
Pulmicort 200mcg/dose Turbuhaler
DNP
0.3193
L
SF
00851752
AZE
N
Pulmicort 400mcg/dose Turbuhaler
DNP
0.4650
L
SF
00851760
AZE
N
Flovent Diskus 50mcg (discontinued)
Flovent HFA 50mcg/act Inh
DNP
0.1994
L
SF
02237244
02244291
GSK N
GSK N
Flovent Diskus 100mcg
DNP
0.3988
L
SF
02237245
GSK N
Flovent HFA 125mcg/act Inh
DNP
0.3440
L
SF
02244292
GSK N
Flovent Diskus 250mcg
DNP
0.6880
L
SF
02237246
GSK N
Flovent HFA 250mcg/act Inh
DNP
0.6878
L
SF
02244293
GSK N
Flovent Diskus 500mcg
DNP
1.0700
L
SF
02237247
GSK N
Asmanex 200mcg/act Twisthaler
DNP
0.5913
L
SF
02243595
FRS
N
Asmanex 400mcg/act Twisthaler
DNP
1.1827
L
SF
02243596
FRS
N
02303671
TAK
N
BUDESONIDE
FLUTICASONE
MOMETASONE
CICLESONIDE
Omnaris 50mcg/dose Nasal Spray
R03BB
Alvesco 100mcg/dose Inh
DNP
0.3795
L
SF
02285606
NYC N
Alvesco 200mcg/dose Inh
DNP
0.6273
L
SF
02285614
NYC N
DNP
0.0946
L
SFC
02247686
BOE N
ipratropium bromide 125mcg/mL unit dose inh sol (2mL)
pms-Ipratropium 125mcg/mL Polynebs
DNP
Atrovent 125mcg/mL UDV (discontinued)
0.1579
P
E
02231135
02026759
PMS Y
BOE Y
ANTICHOLINERGICS
R03BB01
IPRATROPIUM BROMIDE
Atrovent HFA 20mcg/dose Inhaler
February 2016
ipratropium bromide 250mcg/mL inh sol (20mL)
Apo-Ipravent 250mcg/mL Inh Sol
MYLAN-Ipratropium 250mcg/mL Inh Sol
DNP
DNP
0.3157
0.3157
M
M
E
E
02126222
02239131
APX Y
MYL Y
Novo-Ipramide 250mcg/mL Inh Sol (discontinued)
pms-Ipratropium 250mcg/mL Inh Sol
DNP
0.3157
M
E
02210479
02231136
TEV Y
PMS Y
221
R
Respiratory System
Atrovent 250mcg/mL Inh Sol (discontinued)
0.3157
P
E
02231244
PMS Y
ratio-Ipratropium 250mcg/mL Nebules
Teva-Ipratropium 250mcg/mL Sterinebs
0.3157
0.3157
P
P
E
E
02097168
02216221
TEV
TEV
00731439
BOE Y
DNP
DNP
ipratropium bromide 250mcg/mL unit dose inh sol (2mL)
pms-Ipratropium 250mcg/mL Polynebs
DNP
ratio-Ipratropium 250mcg/mL Nebules
Atrovent 250mcg/mL UDV (discontinued)
P
E
02231245
PMS Y
DNP
0.3157
P
E
02097168
01950681
TEV Y
BOE Y
DNP
2.1667
L
E
02246793
BOE N
DNP
0.8850
L
E
02409720
ALM N
DNP
1.7700
L
E
02394936
NVR N
DNP
0.8601
M
E
02046113
00534609
PMS Y
SAV Y
DNP
0.0574
M
SF
02236783
AAP
00249920
BOE Y
GLYCOPYRRONIUM BROMIDE
Seebri 50mcg Cap for Inh
R03BC
0.3157
ACLIDINIUM BROMIDE
Tudorza Genuair 400mcg Pwd for Inh
R03BB06
ANTIALLERGIC AGENTS, EXCL CORTICOSTEROIDS
R03BC01
CROMOGLYCATE SODIUM
cromoglycate sodium 1% unit dose inh sol
pms-Sodium Cromoglycate 1% Neb Sol
Intal 1% Neb Sol (discontinued)
R03C
ADRENERGICS, SYSTEMIC PREPARATIONS
R03CB
NON-SELECTIVE BETA-ADRENOCEPTOR AGONISTS
R03CB03
ORCIPRENALINE
orciprenaline 2mg/mL syr
Apo-Orciprenaline 2mg/mL Syr
Alupent 2mg/mL Syr (discontinued)
R03CC
Y
Y
TIOTROPIUM BROMIDE
Spiriva 18mcg Cap for Inh
R03BB05
BOE Y
ipratropium bromide 250mcg/mL unit dose inh sol (1mL)
pms-Ipratropium 250mcg/mL Polynebs
DNP
Atrovent 250mcg/mL UDV (discontinued)
R03BB04
01950681
Y
SELECTIVE BETA-2-ADRENOCEPTOR AGONISTS
R03CC02
SALBUTAMOL
salbutamol 2mg tab
Apo-Salvent 2mg Tab
Ventolin 2mg Tab (discontinued)
DNP
0.1274
M
SFC
02146843
01961039
APX
GLA
Y
Y
salbutamol 4mg tab
Apo-Salvent 4mg Tab
Ventolin 4mg Tab (discontinued)
DNP
0.2134
M
SFC
02146851
01932691
APX
GLA
Y
Y
R03D
OTHER SYSTEMIC DRUGS FOR OBSTRUCTIVE AIRWAY DISEASES
R03DA
XANTINES
R03DA02
February 2016
OXTRIPHYLLINE (CHOLINE THEOPHYLLINATE)
222
R
Respiratory System
Choledyl 20mg/mL Elx
R03DA04
DNP
0.0399
L
SF
00476366
ERF
N
Theolair 80mg/15mL Liq
DNP
0.0267
L
SF
01966219
VLN
N
Apo-Theo LA 100mg Tab
DNP
0.1300
L
SF
00692689
APX
N
Novo-Theophyl SR 100mg Tab
DNP
0.1300
L
SF
02230085
TEV
N
theophylline 200mg SR tab
Novo-Theophyl SR 200mg Tab
DNP
0.1350
M
SF
02230086
TEV
Y
00460990
AZE
Y
THEOPHYLLINE
Theo-DUR 200mg Tab (discontinued)
Apo-Theo LA 200mg Tab
DNP
0.1350
L
SF
00692697
APX
N
theophylline 300mg SR tab
Novo-Theophyl SR 300mg Tab
DNP
0.1817
M
SF
02230087
TEV
Y
00461008
AZE
Y
00692700
APX
N
02360101
AAP
Y
02014165
PFR
Y
Theo-DUR 300mg Tab (discontinued)
Apo-Theo LA 300mg Tab
DNP
0.1817
L
SF
DNP
0.5030
L
SF
02360128
AAP
Y
DNP
0.6090
L
SF
02014181
PFR
Y
DNP
0.1050
L
SF
00476374
ERF
N
DNP
0.7773
L
E
02236606
AZE
N
montelukast 4mg chewtab
Apo-Montelukast 4mg Chewtab
Auro-Montelukast 4mg Chewtab
DNP
DNP
0.3647
0.3647
M
M
E
E
02377608
02422867
APX Y
ARO Y
Mar-Montelukast 4mg Chewtab
MINT-Montelukast 4mg Chewtab
DNP
DNP
0.3647
0.3647
M
M
E
E
02399865
02408627
MAR Y
MNT Y
Montelukast 4mg Chewtab
Montelukast-4mg Chewtab
DNP
DNP
0.3647
0.3647
M
M
E
E
02379317
02382458
SAS
SIV
MYLAN-Montelukast 4mg Chewtab
pms-Montelukast 4mg Chewtab
DNP
DNP
0.3647
0.3647
M
M
E
E
02380749
02354977
MYL Y
PMS Y
RAN-Montelukast 4mg Chewtab
Sandoz Montelukast 4mg Chewtab
DNP
DNP
0.3647
0.3647
M
M
E
E
02402793
02330385
RAN Y
SDZ Y
Teva-Montelukast 4mg Chewtab
Singulair 4mg Chewtab
DNP
DNP
0.3647
0.3647
M
M
E
E
02355507
02243602
TEV
FRS
Y
Y
montelukast 4mg granules
Sandoz Montelukast 4mg Granules
Singulair 4mg/pkt Granules
DNP
DNP
0.2100
0.2100
M
M
E
E
02358611
02247997
SDZ
FRS
Y
Y
theophylline 400mg ER tab
Theo ER 400mg Tab
Uniphyl 400mg Tab
theophylline 600mg ER tab
Theo ER 600mg Tab
Uniphyl 600mg Tab
R03DA54
THEOPHYLLINE, COMBINATIONS EXCLUDING PSYCHOLEPTICS
Choledyl Expectorant
R03DC
LEUKOTRIENE RECEPTOR ANTAGONISTS
R03DC01
ZAFIRLUKAST
Accolate 20mg Tab
R03DC03
MONTELUKAST
montelukast 5mg chewtab
February 2016
223
Y
Y
R
R03DX
Respiratory System
Apo-Montelukast 5mg Chewtab
Auro-Montelukast 5mg Chewtab
DNP
DNP
0.4280
0.4280
M
M
E
E
02377616
02422875
APX Y
ARO Y
Mar-Montelukast 5mg Chewtab
MINT-Montelukast 5mg Chewtab
DNP
DNP
0.4280
0.4280
M
M
E
E
02399873
02408635
MAR Y
MNT Y
Montelukast 5mg Chewtab
Montelukast 5mg Chewtab
DNP
DNP
0.4280
0.4280
M
M
E
E
02379325
02382466
SAS
SIV
MYLAN-Montelukast 5mg Chewtab
pms-Montelukast 5mg Chewtab
DNP
0.4280
M
E
02380757
02354985
MYL Y
PMS Y
RAN-Montelukast 5mg Chewtab
Sandoz Montelukast 5mg Chewtab
DNP
DNP
0.4280
0.4280
M
M
E
E
02402807
02330393
RAN Y
SDZ Y
Teva-Montelukast 5mg Chewtab
Singulair 5mg Chewtab
DNP
DNP
0.4280
0.4280
M
M
E
E
02355515
02238216
TEV
FRS
montelukast 10mg tab
Apo-Montelukast 10mg Tab
Auro-Montelukast 10mg Tab
DNP
DNP
0.8195
0.8195
M
M
E
E
02374609
02401274
APX Y
ARO Y
Jamp-Montelukast 10mg Tab
Mar-Montelukast 10mg Tab
DNP
DNP
0.8195
0.8195
M
M
E
E
02391422
02399997
JPC Y
MAR Y
MINT-Montelukast 10mg Tab
Montelukast 10mg Tab
DNP
DNP
0.8195
0.8195
M
M
E
E
02408643
02382474
MNT Y
SIV Y
Montelukast 10mg Tab (AHI)
Montelukast 10mg Tab (SAS)
DNP
DNP
0.8195
0.8195
M
M
E
E
02379236
02379333
AHI
SAS
MYLAN-Montelukast 10mg Tab
pms-Montelukast FC 10mg Tab
DNP
DNP
0.8195
0.8195
M
M
E
E
02368226
02373947
MYL Y
PMS Y
RAN-Montelukast 10mg Tab
Sandoz Montelukast 10mg Tab
DNP
DNP
0.8195
0.8195
M
M
E
E
02389517
02328593
RAN Y
SDZ Y
Teva-Montelukast 10mg Tab
Singulair 10mg Tab
DNP
DNP
0.8195
0.8195
M
M
E
E
02355523
02238217
TEV
FRS
02260565
NVR N
02359456
TAK
01931032
WCH N
02243098
02091526
SDZ Y
WLS Y
Y
Y
Y
Y
Y
Y
OHTER SYSTEMIC DRUGS FOR OBSTRUCTIVE AIRWAY DISEASES
R03DX05
OMALIZUMAB
Xolair 150mg/vial Inj
R03DX07
ROFLUMILAST
Daxas 500mcg Tab
R05
COUGH AND COLD PREPARATIONS
R05C
EXPECTORANTS,EXCL COMBINATIONS WITH ANTITUSSIVES
R05CA
EXPECTORANTS
R05CA03
N
GUAIFENESIN
Robitussin 20mg/mL O/L
R05CB
Y
Y
MUCOLYTICS
R05CB01
ACETYLCYSTEINE
acetylcysteine 200mg/mL inj
Acetylcysteine 200mg/mL Inj
Mucomyst 20% Inj (discontinued)
February 2016
DNP
0.7000
M
SF
224
R
Respiratory System
R05D
ANTITUSSIVES, EXCL COMBINATIONS WITH EXPECTORANTS
R05DA
OPIUM ALKALOIDS AND DERIVATIVES
R05DA04
CODEINE
Linctus Codeine Blanc 0.2% Liq
DN
0.0615
L
SFC
00380571
ATL
N
Codeine Phosphate 4.7mg/mL Syr
DN
0.0569
L
SFC
00050024
ATL
N
ratio-Codeine 15mg Tab
DN
0.0783
L
SFC
00593435
TEV
N
SDZ
TEV
N
N
Codeine Phosphate 30mg/mL Inj
ratio-Codeine 30mg Tab
DN
0.1412
L
SFC
00544884
00593451
Codeine Contin 50mg Tab
DN
0.3330
L
E
02230302
PFR
N
Codeine Contin 100mg Tab
DN
0.6660
L
E
02163748
PFR
N
Codeine Contin 150mg Tab
DN
0.9990
L
E
02163780
PFR
N
Codeine Contin 200mg Tab
DN
1.3320
L
E
02163799
PFR
N
Benadryl 12.5mg/5mL Elx
02019736
JNJ
N
Benadryl 25mg Caplets
02017849
JNJ
N
Diphenhydramine 50mg/mL Inj
00596612
SDZ
N
R06
SYSTEMIC ANTIHISTAMINES
R06A
SYSTEMIC ANTIHISTAMINES
R06AA
AMINOALKYL ETHERS
R06AA02
R06AA09
DIPHENHYDRAMINE
DOXYLAMINE
Diclectin Tab
R06AE
DNPM
1.2803
L
SFC
00609129
DUI
N
Reactine 5mg Tab
DNP
0.4981
L
E
02223546
JNJ
N
cetirizine 10mg tab
Apo-Cetirizine 10mg Tab
DNP
0.4083
M
E
02231603
APX
Y
Extra Strength Allergy Relief 10mg Tab
Reactine 10mg Tab
DNP
DNP
0.4083
0.4083
M
M
E
E
02315955
02223554
PDP Y
JNJ Y
02315963
01900978
PMS Y
JNJ Y
PIPERAZINE DERIVATIVES
R06AE07
CETIRIZINE
cetirizine 20mg tab
pms-Cetirizine 20mg Tab
Reactine 20mg Tab
R06AX
VARIOUS SYSTEMIC ANTIHISTAMINES
R06AX13
R06AX17
February 2016
LORATADINE
loratadine 10mg tab
APC-Loratadine 10mg Tab
DNP
0.6267
M
E
02366444
APX
Apo-Loratadine 10mg Tab
Claritin 10mg Tab
DNP
DNP
0.6267
0.6267
M
M
E
E
02243880
00782696
APX Y
SCH Y
KETOTIFEN
225
Y
R
Respiratory System
Zaditen 1mg Tab
R06AX26
R06AX27
00577308
TEV
N
ketotifen fumarate 1mg/5mL syr
Novo-Ketotifen 1mg/5mL Syr (discontinued)
02176084
TEV
Y
Zaditen 1mg/5mL Syr
00600784
TEV
Y
Allegra 60mg Tab
02231462
SAV
N
Allegra 120mg Tab
02242819
SAV
N
desloratadine 5mg tab
Desloratadine Allergy Control 5mg Tab
02298155
PDP Y
Aerius 5mg Tab
02243919
SCH Y
R07A
OTHER RESPIRATORY SYSTEM PRODUCTS
R07AX
OTHER RESPIRATORY SYSTEM PRODUCTS
February 2016
L
SF
DESLORATADINE
OTHER RESPIRATORY SYSTEM PRODUCTS
R07AX02
1.7245
FEXOFENADINE
R07
R07AX01
DNP
OTHER RESPIRATORY SYSTEM PRODUCTS
AC Boyz Chamber
DNP
23.5500
L
FC
96899962
TMI
N
AC Girlz Chamber
AeroChamber Max Pediatric with Mask
DNP
DNP
23.5500
37.6700
L
L
FC
FC
96899963
96899995
TMI
TMI
N
N
AeroChamber Plus Flow-Vu with Mask (Lg)
AeroChamber Plus Flow-Vu with Mask (Med)
DNP
DNP
39.8600
37.6700
L
L
SFC
SFC
96899969
96899970
TMI
TMI
N
N
AeroChamber Plus Flow-Vu with Mask (Sm)
AeroChamber Plus Flow-Vu with Mouthpiece
DNP
DNP
37.6700
23.5500
L
L
FC
SFC
96899971
96899968
TMI
TMI
N
N
AreoChamber AC-Boyz
AreoChamber AC-Girlz
DNP
DNP
21.5400
21.5400
L
L
FC
FC
96899976
96899975
TMI
TMI
N
N
Kalydeco 150mg Tab
Kalydeco 150mg Tab*
DNP
DNP
420.0000
420.0000
L
L
E
E
02397412
00903964
VTX
VTX
N
N
Kalydeco 150mg Tab*
*use when drug cost in excess of CPhA maximum
DNP
420.0000
L
E
00903963
VTX
N
IVACAFTOR
226
S
Sensory Organs
S01
OPHTHALMOLOGICALS
S01A
ANTIINFECTIVES
S01AA
ANTIBIOTICS(OPHTHALMOLOGICALS)
S01AA07
FRAMYCETIN
Soframycin 0.5% Oph Sol
S01AA12
S01AA13
DNPO
1.3663
L
SF
02224887
ERF
N
tobramycin 0.3% oph sol
Sandoz Tobramycin 0.3% Oph Sol
DNPO
1.2576
M
SF
02241755
SDZ
Y
Tobrex 0.3% Oph Sol
DNPO
1.2576
M
SF
00513962
ALC
Y
Tobrex 0.3% Oph Oint
DNPO
2.6400
L
SF
00614254
ALC
N
02243862
LEO
N
TOBRAMYCIN
FUSIDIC ACID
Fucithalmic 1% Oph Sol
S01AA17
S01AA30
ERYTHROMYCIN
pms-Erythromycin 0.5% Oph Oint
DNPMO
3.8380
L
SF
01912755
PMS N
Erythromycin 5mg/g Oph Oint
DNPMO
3.6000
L
SF
02326663
SGQ N
02239234
02011956
SDZ
ALL
Y
Y
00028053
SDZ
N
ANTIBIOTICS (OPHTHALMIC), COMBINATIONS
polymyxin B 10,000u/mL & trimethoprim 1mg/mL oph sol
Sandozy Polytrimethoprim Oph Sol
Polytrim Oph Sol
S01AB
SULFONAMIDES
S01AB04
SULFACETAMIDE
Sodium Sulamyd 10% Oph Sol (discontinued)
S01AD
ANTIVIRALS
S01AD02
TRIFLURIDINE
Viroptic 1% Oph Sol
S01AE
DNPO
3.3147
L
SF
00687456
VLN
N
ofloxacin 0.3% oph sol
Apo-Ofloxacin 0.3% Oph Sol
DNPO
1.4680
M
E
02248398
APX
Y
Ocuflox 0.3% Oph Sol
DNPO
1.4680
M
E
02143291
ALL
Y
APX
SDZ
Y
Y
FLUOROQUINOLONES
S01AE01
S01AE03
S01AE06
OFLOXACIN
CIPROFLOXACIN
ciprofloxacin 0.3% oph sol
Apo-Ciproflox 0.3% Oph Sol
Sandoz Ciprofloxacin 0.3% Oph Sol
DNPO
1.7600
M
E
02263130
02387131
Ciloxan 0.3% Oph Sol
DNPO
1.7600
M
E
01945270
ALC
Y
Ciloxan 0.3% Oph Oint
DNPO
3.0943
L
E
02200864
ALC
N
02257270
ALL
N
GATIFLOXACIN
Zymar 0.3% Oph Sol
February 2016
227
S
Sensory Organs
S01AE07
MOXIFLOXACIN
moxifloxacin 0.5% oph sol
ACT Moxifloxacin 0.5% Oph Sol
02404656
ATV
Y
Apo-Moxifloxacin 0.5% Oph Sol
Sandoz Moxifloxacin 0.5% Oph Sol
02406373
02411520
APX
SDZ
Y
Y
Vigamox 0.5% Oph Sol
02252260
ALC
Y
S01B
ANTIINFLAMMATORY AGENTS
S01BA
CORTICOSTEROIDS, PLAIN
S01BA01
DEXAMETHASONE
Maxidex 0.1% Oph Oint
DNPO
2.6657
L
SF
00042579
ALC
N
Maxidex 0.1% Oph Susp
DNPO
1.7200
L
SF
00042560
ALC
N
02363445
ALL
N
Ozurdex 0.7mg Intravitreal Implant
S01BA04
S01BA07
S01BA14
PREDNISOLONE
prednisolone acetate 0.12% oph susp
Sandoz Prednisolone 0.12% Oph Susp (discontinued)
Pred Mild 0.12% Oph Susp
DNPO
1.8320
L
SF
01916181
00299405
SDZ
ALL
Y
Y
prednisolone acetate 1% oph susp
ratio-Prednisolone 1% Oph Susp
Sandoz Prednisolone 1% Oph Susp
DNPO
DNPO
1.9400
1.9400
M
M
SF
SF
00700401
01916203
TEV
SDZ
Y
Y
Pred Forte 1% Oph Susp
DNPO
1.9400
M
SF
00301175
ALL
Y
fluorometholone 0.1% oph susp
Sandoz Fluorometholone 0.1% Oph Susp
FML 0.1% Liquifilm Oph Susp
DNPO
DNPO
1.7880
1.7880
M
M
SF
SF
00432814
00247855
SDZ
ALL
Y
Y
Flarex 0.1% Oph Sol
DNPO
1.9440
L
SF
00756784
ALC
N
FML Forte 0.25% Oph Sol
DNPO
2.7580
L
SF
00707511
ALL
N
02321114
BSH N
FLUOROMETHOLONE
LOTEPREDNOL
Lotemax 0.5% Oph Susp
S01BC
ANTIINFLAMMATORY AGENTS,NON STEROIDS
S01BC03
DICLOFENAC
diclofenac 0.1% oph sol
Apo-Diclofenac 0.1% Oph Sol
Voltaren 0.1% Oph Sol
S01BC05
S01C
DNPO
DNPO
2.6565
2.6565
M
M
SF
SF
02441020
01940414
APX
ALC
Y
Y
Acuvail 0.45% Oph Sol
DNPO
0.6042
L
SF
02369362
ALL
N
ketorolac 0.5% oph sol
Apo-Ketorolac 0.5% Oph Sol
DNPO
2.5960
M
SF
02245821
AAP
Y
Acular 0.5% Oph Sol
DNPO
2.5960
M
SF
01968300
ALL
Y
KETOROLAC
ANTIINFLAMMATORY AGENTS & ANTIINFECTIVES IN COMB.
February 2016
228
S
Sensory Organs
S01CA
CORTICOSTEROIDS AND ANTIINFECTIVES IN COMBINATION
S01CA01
S01CA02
DEXAMETHASONE AND ANTIINFECTIVES
Maxitrol Oph Oint
Maxitrol Oph Susp
DNPO
DNPO
2.9657
2.1260
L
L
SF
SF
00358177
00042676
ALC
ALC
N
N
Tobradex Oph Oint
Tobradex Oph Sol
DNPO
DNPO
3.1829
2.1600
L
L
SF
SF
00778915
00778907
ALC
ALC
N
N
DNPO
DNPO
3.5714
2.7980
L
L
SF
SF
00307246
00807788
ALL
ALL
N
N
DNP
4.7540
L
SF
02076306
ALC
N
02301334
02248151
AAP
ALL
Y
Y
PREDNISOLONE AND ANTIINFECTIVES
Blephamide Oph Oint
Blephamide Oph Sol
S01E
ANTIGLAUCOMA PREPARATIONS AND MIOTICS
S01EA
SYMPATHOMIMETICS IN GLAUCOMA THERAPY
S01EA03
APRACLONIDINE
Iopidine 0.5% Oph Sol
S01EA05
BRIMONIDINE
brimonidine 0.15% oph sol
Apo-Brimonidine P 0.15% Oph Sol
Alphagan P 0.15% Oph Sol
S01EB
DNP
DNP
1.1550
1.1550
M
M
SF
SF
02260077
02246284
APX Y
PMS Y
ratio-Brimonidine 0.2% Oph Sol (discontinued)
Sandoz Brimonidine 0.2% Oph Sol
DNP
1.1550
M
SF
02243026
02305429
TEV
SDZ
Y
Y
Alphagan 0.2% Oph Sol
DNP
1.1550
M
SF
02236876
ALL
Y
Isopto Carpine 1% Oph Sol
DNP
0.2280
L
SF
00000841
ALC
N
Isopto Carpine 2% Oph Sol
DNP
0.2633
L
SF
00000868
ALC
N
Isopto Carpine 4% Oph Sol
DNP
0.2987
L
SF
00000884
ALC
N
DNP
0.1343
M
SF
00545015
AAP
Y
02238072
WAY Y
02316307
02216205
SDZ
FRS
Y
Y
02269090
FRS
N
PARASYMPATHOMIMETICS
S01EB01
S01EC
brimonidine 0.2% oph sol
Apo-Brimonidine 0.2% Oph Sol
pms-Brimonidine 0.2% Oph Sol
PILOCARPINE
CARBONIC ANHYDRASE INHIBITORS
S01EC01
ACETAZOLAMIDE
acetazolamide 250mg tab
Acetazolamide 250mg Tab
Diamox 250mg Tab (discontinued)
S01EC03
DORZOLAMIDE
dorzolamide HCI 2% oph sol
Sandoz Dorzolamide 2% Oph Sol
Trusopt 2% Oph Sol
Trusopt 2% (PF) Oph Sol
S01EC04
February 2016
DNP
DNP
3.0700
3.0700
M
M
SF
SF
BRINZOLAMIDE
229
S
Sensory Organs
Azopt 1% Oph Sol
S01EC05
DNP
3.4680
L
SF
02238873
ALC
N
DNP
0.4817
L
SF
02245882
AAP
N
DNP
4.5670
L
SF
02435411
ALC
N
DNP
DNP
3.2160
3.2160
M
M
SF
SF
02242275
02171880
SDZ
FRS
Y
Y
DNP
0.9678
M
SF
00755826
02083353
APX Y
PMS Y
DNP
0.9678
M
SF
02166712
00451193
SDZ
FRS
Y
Y
timolol maleate 0.5% oph gel
Timolol Maleate-EX 0.5% Oph Gel
Timoptic-XE 0.5% Oph Gel
DNP
DNP
3.8480
3.8480
M
M
SF
SF
02242276
02171899
SDZ
FRS
Y
Y
timolol maleate 0.5% oph sol
Apo-Timop 0.5% Oph Sol
pms-Timolol 0.5% Oph Sol
DNP
DNP
1.2754
1.2754
M
M
SF
SF
00755834
02083345
APX Y
PMS Y
Sandoz Timolol 0.5% Oph Sol
Timoptic 0.5% Oph Sol
DNP
DNP
1.2754
1.2754
M
M
SF
SF
02166720
00451207
SDZ
FRS
Y
Y
Apo-Timop 0.5% Oph Gel
DNP
2.7300
L
SF
02290812
APX
N
DNP
2.4540
L
SF
01908448
ALC
N
levobunolol HCl 0.25% oph sol
ratio-Levobunolol 0.25% Oph Sol (discontinued)
Betagan 0.25% Oph Sol (discontinued)
02031159
00751286
TEV
ALL
Y
Y
levobunolol HCl 0.5% oph sol
pms-Levobunolol 0.5% Oph Sol (discontinued)
ratio-Levobunolol 0.5% Oph Sol (discontinued)
02237991
02031167
PMS Y
TEV Y
METHAZOLAMIDE
Methazolamide 50mg Tab
S01EC54
BRINZOLAMIDE, COMBINATIONS
Simbrinza 10mg/2mg/mL Oph Susp
S01ED
BETA BLOCKING AGENTS
S01ED01
TIMOLOL
timolol maleate 0.25% oph gel
Timolol Maleate-EX 0.25% Oph Gel
Timoptic-XE 0.25% Oph Gel
timolol maleate 0.25% oph sol
Apo-Timop 0.25% Oph Sol
pms-Timolol 0.25% Oph Sol (discontinued)
Sandoz Timolol 0.25% Oph Sol
Timoptic 0.25% Oph Sol (discontinued)
S01ED02
BETAXOLOL
Betoptic-S 0.25% Oph Susp
S01ED03
LEVOBUNOLOL
Betagan 0.5% Oph Sol
S01ED51
DNP
3.3560
L
SF
00637661
ALL
Y
Azarga Oph Susp
DNP
4.5560
L
SF
02331624
ALC
N
Combigan Oph Sol
Cosopt (PF) Oph Sol
DNP
4.2300
L
SF
02248347
02258692
ALL
FRS
N
N
DNP
DNP
9.9600
9.9600
M
M
SF
SF
02413817
02278251
SDZ
ALC
Y
Y
TIMOLOL, COMBINATIONS
travaprost 0.004% & timolol maleate 0.5% oph sol
Sanodz Travaprost-Timolol 0.004%/0.5% Oph Sol
DuoTrav PQ Oph Sol
February 2016
230
S
S01EE
Sensory Organs
dorzolamide HCI 2% & timolol maleate 0.5% oph sol
Apo-Dorzo-Timop 2%/0.5% Oph Sol
DNP
2.0097
M
SF
02299615
APX
CO DorzoTimolol 2%/0.5% Oph Sol
pms-Dorzolamide-Timolol 2%/0.5% Oph Sol
DNP
DNP
2.0097
2.0097
M
M
SF
SF
02404389
02442426
ATV Y
PMS Y
Sandoz Dorzolamide/Timolol 2/0.5% Oph Sol
Teva-Dorzotimol 2%/0.5% Oph Sol
DNP
DNP
2.0097
2.0097
M
M
SF
SF
02344351
02320525
SDZ
TEV
Y
Y
Cosopt Oph Sol
DNP
2.0097
M
SF
02240113
FRS
Y
latanoprost 50mcg/mL & timolol maleate 5mg/mL oph sol
ACT-Latanoprost/Timolol 50mcg/5mg/mL Oph Sol
DNP
4.4268
M
SF
02436256
ATV
Y
Apo-Latanoprost/Timolol 50mcg/5mg/mL Oph Sol
GD-Latanoprost/Timolol 50mcg/5mg/mL Oph Sol
DNP
DNP
4.4268
4.4268
M
M
SF
SF
02414155
02373068
APX Y
GMD Y
Sandoz Latanoprost/Timolol 50mcg/5mg/mL Oph Sol
Xalacom Oph Sol
DNP
DNP
4.4268
4.4268
M
M
SF
SF
02394685
02246619
SDZ
PFI
Y
Y
latanoprost 50mcg/mL oph sol
Apo-Latanoprost 0.005% Oph Sol
DNP
3.8542
M
SF
02296527
APX
Y
CO Latanoprost 0.005% Oph Sol
GD-Latanoprost 0.005% Oph Sol
DNP
DNP
3.8542
3.8542
M
M
SF
SF
02254786
02373041
ATV Y
GMD Y
pms-Latanoprost 0.005% Oph Sol
Xalatan 0.005% Oph Sol
DNP
DNP
3.8542
3.8542
M
M
SF
SF
02317125
02231493
PMS Y
PFI Y
DNP
11.4000
L
SF
02324997
ALL
N
travoprost 0.004% oph sol
Apo-Travoprost Z 0.004% Oph Sol
Sandoz Travoprost 0.004% Oph Sol
DNP
DNP
4.0264
4.0264
M
M
SF
SF
02415739
02413167
APX
SDZ
Y
Y
Teva-Travoprost Z 0.004% Ops Sol
Travatan Z 0.004% Oph Sol
DNP
DNP
4.0264
4.0264
M
M
SF
SF
02412063
02318008
TEV
ALC
Y
Y
DNPO
0.6700
L
SF
00035017
ALC
N
DNPO
0.9007
L
SF
00252506
ALC
N
Isopto Homatropine 2% Sol
DNPO
0.6813
L
SF
00000779
ALC
N
Isopto Homatropine 5% Sol
DNPO
0.8120
L
SF
00000787
ALC
N
DNPO
0.9340
L
SF
00000981
ALC
N
Y
PROSTAGLANDIN ANALOGUES
S01EE01
S01EE03
LATANOPROST
BIMATOPROST
Lumigan RC 0.01% Oph Sol
S01EE04
TRAVOPROST
S01F
MYDRIATICS AND CYCLOPLEGICS
S01FA
ANTICHOLINERGICS
S01FA01
ATROPINE
Isopto Atropine 1% Oph Sol
S01FA04
CYCLOPENTOLATE
Cyclogyl 1.0% Oph Sol
S01FA05
S01FA06
HOMATROPINE
TROPICAMIDE
Mydriacyl 0.5% Oph Sol
February 2016
231
S
Sensory Organs
Mydriacyl 1% Oph Sol
DNPO
1.2027
L
SF
00001007
ALC
N
DNPO
1.0840
L
SF
00465763
ALC
N
cromoglycate sodium 2% oph sol
Cromolyn 2% Oph Sol
DNPO
0.9500
M
SF
02009277
PDP Y
Opticrom 2% Oph Sol
DNPO
0.9500
M
SF
02230621
ALL
DNPO
5.2920
L
SF
02400871
02242324
STR Y
NVO Y
olopatadine 0.1% oph sol
Apo-Olopatadine 0.1% Oph Sol
02305054
APX
CO Olopatadine 0.1% Oph Sol
MINT-Olopatadine 0.1% Oph Sol
02403986
02422727
COB Y
MNT Y
02358913
02233143
SDZ
ALC
Y
Y
02404095
02402823
ATV
APX
Y
Y
S01G
DECONGESTANTS AND ANTIALLERGICS
S01GA
SYMPATHOMIMETICS USED AS DECONGESTANTS
S01GA05
PHENYLEPHRINE
Mydfrin 2.5% Oph Sol
S01GX
OTHER ANTIALLERGICS
S01GX01
S01GX08
CROMOGLYCATE SODIUM
KETOTIFEN
ketotifen 0.25% oph sol
Ketotifen 0.25% Oph Sol
Zaditor 0.25% Oph Sol
S01GX09
OLOPATADINE
Sandoz Olopatadine 0.1% Oph Sol
Patanol 0.1% Oph Sol
DNPO
6.0520
L
SF
olopatadine 0.2% oph sol
ACT Olopatadine 0.2% Oph Sol
Apo-Olopatadine 0.2% Oph Sol
Sandoz Olopatadine 0.2% Oph Sol
Pataday 0.2% Oph Sol
S01H
LOCAL ANESTHETICS
S01HA
LOCAL ANESTHETICS
S01HA04
S01L
OCULAR VASCULAR DISORDER AGENTS
S01LA
ANTINEOVASCULARISATION AGENTS
12.1040
L
SF
02420171
02362171
SDZ
ALC
Y
Y
DNPO
0.7440
L
SF
00035076
ALC
N
DNP
1703.10
L
E
02242367
VLN
N
02267225
PFI
N
PEGAPTANIB
Macugen 0.3mg/90mcl Pre-filled Syringe (discontinued)
S01X
DNPO
VERTEPORFIN
Visudyne 15mg/vial Inj
S01LA03
OTHER OPHTHALMOLOGICALS
February 2016
Y
PROXYMETACAINE
Alcaine 0.5% Drops
S01LA01
Y
232
S
Sensory Organs
S01XA
OTHER OPHTHALMOLOGICALS
S01XA03
S01XA18
SODIUM CHLORIDE, HYPERTONIC
ODAN-Sodium Chloride 5% Oph Oint
Muro 128 (5%) Oph Oint
DNPO
DNPO
2.3857
2.8086
L
L
SF
SF
80046696
00750816
ODN N
BSH N
ODAN-Sodium Chloride 5% Oph sol
DNPO
0.6553
L
SF
80046737
ODN N
Muro 128 (5%) Oph Sol
DNPO
0.6553
L
SF
00750824
BSH N
02355655
ALL
02216051
02125706
ALC N
BSH N
02231289
02133288
ALC
ALC
ALL N
NVO N
CICLOSPORIN
Restasis 0.05% Oph Sol
S01XA20
ARTIFICIAL TEARS AND OTHER INDIFFERENT PREPARATIONS
Bion Tears Oph Sol
Duolube Oph Oint
GenTeal 3mg/g Oph Sol
Hypotears Oph Oint (discontinued)
DNPO
1.4771
L
SF
DNPO
0.4327
L
SF
DNPO
0.7800
L
SF
00210889
00999491
Tears Naturale Free Oph Sol
Tears Naturale II Oph Sol
DNPO
DNPO
0.4944
0.4220
L
L
E
SF
01943308
00743445
ALC
ALC
N
N
Tears Naturale Oph Sol
Tears Naturale P.M. Oph Oint
00390291
02082519
ALC
ALC
N
N
Hylashield 0.15%/0.4% Allets
00999176
IMD
N
02242977
ALC
N
00889806
00000809
SDZ
ALC
Y
Y
DNPO
0.8110
L
SF
artificial tears 0.5% oph sol
Sandoz Eyelube 0.5% Oph Sol
Isopto Tears 0.5% Oph Sol
Refresh Plus 0.5% Oph Sol
DNPO
0.7592
L
E
02049260
ALL
N
Refresh Tears 0.5% Oph Sol
DNPO
0.4167
L
E
02231008
ALL
N
artificial tears 1% oph sol
Sandoz Eyelube 1% Oph Sol
00874965
SDZ
Y
Isopto Tears 1% Oph Sol
00000817
ALC
Y
02244650
00870153
ALL
ALL
N
N
Refresh 1% Liquigel
Refresh Celluvisc 1% Liq
DNPO
0.8217
L
E
02229570
PDP N
DNPO
0.8533
L
E
02138670
00579408
ALL
ALL
N
N
DNP
3950.0000 L
E
02410818
ALC
N
DNP
1.6091
SF
00074454
PAL
N
Artificial Tears 1.4% Oph Sol
Refresh 1.4% Oph Sol
Tears Plus 1.4% Oph Sol
OCRIPLASMIN
Jetrea 2.5mg/mL Inj
S02
OTOLOGICALS
S02C
CORTICOSTEROIDS AND ANTIINFECTIVES IN COMBINATION
S02CA
CORTICOSTEROIDS AND ANTIINFECTIVES IN COMBINATION
S02CA02
FLUMETASONE AND ANTIINFECTIVES
Locacorten Vioform Otic Sol
February 2016
N
N
Refresh Lacri-Lube Oph Oint
TearGel Oph Oint
GenTeal 0.3% Oph Gel
S01XA22
N
L
233
S
Sensory Organs
S02CA06
DEXAMETHASONE AND ANTIINFECTIVES
Ciprodex Otic Susp
S03
OPHTHALMOLOGICAL AND OTOLOGICAL PREPARATIONS
S03B
CORTICOSTEROIDS
S03BA
CORTICOSTEROIDS, PLAIN
S03BA01
S03C
CORTICOSTEROIDS AND ANTIINFECTIVES IN COMBINATION
S03CA
CORTICOSTEROIDS AND ANTIINFECTIVES IN COMBINATION
L
E
02252716
ALC
N
DNPO
1.4060
M
SF
00739839
00016217
SDZ
FRS
Y
Y
DNPO
1.9363
L
SF
02224623
SAV
N
DEXAMETHASONE AND ANTIINFECTIVES
Sofracort Oph/Otic Sol
February 2016
3.7520
DEXAMETHASONE
dexamethasone 0.1% oph/otic sol
Sandoz Dexamethasone 0.1% Oph/Otic Sol
Decadron 0.1% Oph/Otic Sol (discontinued)
S03CA01
DNP
234
V
Various
V01
ALLERGENS
V01A
ALLERGENS
V01AA
ALLERGEN EXTRACTS
V01AA02
V01AA20
GRASS POLLEN
Pollinex-R Inj
DNP
367.5000
L
E
00464988
NYC N
Oralair 100iu IR S/L Tab
DNP
1.2600
L
E
02381885
STA
N
Oralair 300iu IR S/L Tab
DNP
3.8000
L
E
02381893
STA
N
DNP
99.9900
L
E
00999938
VAR N
naloxone 0.4mg/mL inj
Naloxone 0.4mg/mL Inj
Narcan 0.4mg/mL Inj (discontinued)
02148706
01913956
SDZ
BRI
Y
Y
naloxone 1mg/mL inj
Naloxone 1mg/mL Inj
Narcan 1mg/mL Inj (discontinued)
02148714
01913964
SDZ
BRI
Y
Y
flumazenil 0.1mg/mL inj
Flumazenil 0.1mg/mL Inj
02249561
SDZ
Y
Anexate 0.1mg/mL Inj (discontinued)
00874019
HLR
Y
VARIOUS
Allergy Serum
V03
ALL OTHER THERAPEUTIC PRODUCTS
V03A
ALL OTHER THERAPEUTIC PRODUCTS
V03AB
ANTIDOTES
V03AB15
V03AB25
V03AC
FLUMAZENIL
IRON CHELATING AGENTS
V03AC01
V03AC03
V03AE
NALOXONE
DEFEROXAMINE
Desferal 2g/vial Inj
DNP
60.99
L
SF
01981250
NVR N
deferoxamine 500mg/vial inj
Desferrioxamine 500mg/vial Inj
Desferal 500mg/vial Inj
DNP
DNP
7.4800
7.4800
M
M
SF
SF
02241600
01981242
HOS Y
NVR Y
Exjade 125mg Tab for Susp
DNP
10.6064
L
E
02287420
NVR N
Exjade 250mg Tab for Susp
DNP
21.2125
L
E
02287439
NVR N
Exjade 500mg Tab for Susp
DNP
42.4254
L
E
02287447
NVR N
pms-Sodium Polystyrene Sulfonate Pd
DNP
0.1799
L
SF
00755338
PMS N
Solystat Oral
Kayexalate Powder
DNP
DNP
0.1595
0.1851
L
L
SF
SF
00769541
02026961
PDP N
SAV N
DEFERASIROX
FOR TREATMENT OF HYPERKALEMIA AND HYPERPHOSPHATEMIA
V03AE01
February 2016
POLYSTYRENE SULFONATE
235
V
Various
V03AE02
SEVELAMER
Renagel 800mg Tab
V03AE03
V03AE99
DNP
1.6426
L
E
02244310
SAV
N
Fosrenol 250mg Tab
DNP
1.1338
L
E
02287145
SHI
N
Fosrenol 500mg Tab
DNP
2.2678
L
E
02287153
SHI
N
Fosrenol 750mg Tab
DNP
3.4126
L
E
02287161
SHI
N
Fosrenol 1,000mg Tab
DNP
4.5243
L
E
02287188
SHI
N
02229437
FRE
N
LANTHANUM CARBONATE
CALCIUM ACETATE
Phoslo 667mg Tab (discontinued)
V03AF
DETOXIFYING AGENTS FOR CYTOSTATIC TREATMENT
V03AF03
CALCIUM FOLINATE
Lederle Leucovorin 5mg Tab
V03AH
V04
DIAGNOSTIC AGENTS
V04C
OTHER DIAGNOSTIC AGENTS
V04CA
TESTS FOR DIABETES
V04CA02
SFC
02170493
PFI
N
DNP
1.8568
L
SF
00503347
FRS
N
GLUCOSE
*Diabetic Supplies Benefit List (Testing Strips)
DNP
SFD
TESTS FOR THYREOIDEA FUNCTION
V04CJ01
THYROTROPIN
Thyrogen 0.9mg/mL Inj
DNP
833.7750
L
E
02246016
GZM N
Bacteriostatic Water for Inj
DNP
0.1193
L
SF
00038202
HOS N
Sterile Water for Inj (WP)
DNP
0.1850
L
SF
02142546
HOS N
V07
ALL OTHER NON-THERAPEUTIC PRODUCTS
V07A
ALL OTHER NON-THERAPEUTIC PRODUCTS
V07AB
SOLVENTS AND DILUTING AGENTS,INCL IRRIGAT SOLUT
V07AB99
STERILE WATER
STOMI EQUIPMENT
V07AS01
STOMI EQUIPMENT
*Ostomy Supplies Benefit List
V07AY
L
DIAZOXIDE
Proglycem 100mg Cap
V07AS
6.1958
DRUGS FOR TREATMENT OF HYPOGLYCEMIA
V03AH01
V04CJ
DNP
DNP
SFC
VARIOUS NON-THERAPEUTIC AUXILLIARY PRODUCTS
V07AY03
February 2016
MISCELLANEOUS DEVICES
236
V
Various
CADD Pump Cassette
V07AY04
00999970
VAR N
DNP
SFD
DNP
SFD
DNP
SFD
00501190
ODN N
PLACEBO
Placebo Tab (discontinued)
February 2016
SFC
DIABETIC LANCETS
*Diabetic Supplies Benefit List
V07AY90
L
INSULIN PEN NEEDLES
*Diabetic Supplies Benefit List
V07AY06
41.3600
INSULIN SYRINGES
*Diabetic Supplies Benefit List
V07AY05
DNP
237
Diabetic Supplies Benefit List
INSULIN PEN NEEDLES
PRODUCT DESCRIPTION
PIN
97799897
97799896
BD Ultra-Fine II Pen Needles, 12.7mm, 29g
BD Ultra-Fine III Mini Pen Needles, 5mm, 31g
PKG SIZE
100
100
PRODUCT #
320223
320145
MFR
BTD
BTD
PRICE
0.3234
0.2910
97799895
97799527
BD Ultra-Fine III Short Pen Needles. 8mm, 31g
BD Ultra-Fine Nano Pen Needles 32g x 4mm
100
100
320108
320144
BTD
BTD
0.2910
0.2993
L
L
97799429
97799428
Global Ease Pen Inject Needle 29g x 9mm
Global Ease Pen Inject Needle 31g x 5mm
100
100
90166-0121-22
90166-0631-32
CMP
CMP
0.2337
0.2337
L
L
97799430
97799566
Global Ease Pen Inject Needle 31g x 8mm
Insupen, 29g x 12mm
100
100
90166-0831-52
22988
CMP
DOM
0.2337
0.2100
L
L
97799567
97799569
Insupen, 30g x 8mm
Insupen, 31g x 6mm
100
100
22987
22989
DOM
DOM
0.2100
0.2100
L
L
97799568
97799571
Insupen, 31g x 8mm
Insupen, 32g x 6mm
100
100
22990
22983
DOM
DOM
0.2100
0.2500
L
L
97799570
97799334
Insupen, 32g x 8mm
MontKiddy Pen Needles,4mm, 32g, Blue
100
100
22984
11002007
DOM
MTD
0.2500
0.2799
L
L
97799337
97799335
MontKiddy Pen Needles,4mm, 32g, Green
MontKiddy Pen Needles,4mm, 32g, Pink
100
100
11002008
11002009
MTD
MTD
0.2799
0.2799
L
L
97799336
97799367
MontKiddy Pen Needles,4mm, 32g, Yellow
Montméd Pen Needles, 4mm, 32g
100
100
11002010
11002005
MTD
MTD
0.2799
0.2750
L
L
97799368
97799364
Montméd Pen Needles, 5mm, 31g
Montméd Pen Needles, 6mm, 32g
100
100
11002006
11002002
MTD
MTD
0.2799
0.2799
L
L
97799363
97799366
Montméd Pen Needles, 6mm, 32g
Montméd Pen Needles, 8mm, 31g
100
100
11002001
11002004
MTD
MTD
0.2799
0.2799
L
L
97799365
97799764
Montméd Pen Needles, 8mm, 32g
Novofine ETW Pen Needles 32g
100
100
11002003
86601
MTD
NNO
0.2999
0.3610
L
L
97799909
97799911
Novofine Pen Needles 28g X 12mm
Novofine Pen Needles 30g X 6mm
100
100
890037
890237
NNO
NNO
0.3502
0.3502
L
L
97799910
97799386
Novofine Pen Needles 30g X 8mm
Novofine Plus 32g x 4mm
100
100
890187
591072
NNO
NNO
0.3502
0.3610
L
L
97799467
97799468
NovoTwist 30g (8mm) Tip Needles
NovoTwist 32g (5mm) Tip Needles
100
100
14533
14634
NNO
NNO
0.3502
0.3610
L
L
97799561
97799563
SUPER-FINE Pen Needles (Micro 29g 12.7mm)
SUPER-FINE Pen Needles (Micro 31g 5mm)
100
100
933000000
933000000
PMS
PMS
0.2440
0.2440
L
L
97799562
97799280
SUPER-FINE Pen Needles (XTRA 31g 8mm)
SureComfort Pen Needles, 12.7mm, 29g
100
100
933000000
24-1010
PMS
BBM
0.2440
0.2414
L
L
97799267
97799279
SureComfort Pen Needles, 4mm, 32g
SureComfort Pen Needles, 5mm, 31g
100
100
24-1308
24-1210
BBM
BBM
0.2414
0.2414
L
L
97799278
97799269
SureComfort Pen Needles, 6mm, 31g
SureComfort Pen Needles, 8mm, 30g
100
100
24-1305
24-1115
BBM
BBM
0.2414
0.2414
L
L
97799268
97799545
SureComfort Pen Needles, 8mm, 31g
Ulticare Pen Needles 31g x 6mm
100
100
24-1215
9563
BBM
DRX
0.2414
0.2540
L
L
97799544
97799440
Ulticare Pen Needles 31g x 8mm
Ulticare Pen Needles 32g x 4mm
100
100
9583
00543
DRX
DRX
0.2450
0.2800
L
L
97799991
97799993
Unifine Pen Needles 29g x 12mm
Unifine Pen Needles 31g x 6mm
100
100
OMAM3529
OMAM3590
AUT
AUT
0.1680
0.1895
L
L
97799992
Unifine Pen Needles 31g x 8mm
100
OMAM3530
AUT
0.1895
L
PRODUCT #
320440
MFR
BTD
PRICE
0.3246
INSULIN SYRINGES
PRODUCT DESCRIPTION
PIN
97799760
February 2016
PKG SIZE
BD Ultra-Fine II Short Half-Unit Syringes, 0.3cc, 31g 100
TYPE
L
L
TYPE
L
238
Diabetic Supplies Benefit List
INSULIN SYRINGES
PRODUCT DESCRIPTION
PIN
97799886
97799425
BD Ultra-Fine II Syringes, 0.3cc, 30g
BD Ultra-Fine II Syringes, 0.3cc, 31g
PKG SIZE
100
100
PRODUCT #
320438
324919
MFR
BTD
BTD
PRICE
0.3246
0.3555
97799885
97799890
BD Ultra-Fine II Syringes, 0.5cc. 30g
BD Ultra-Fine II Syringes, 1cc, 30g
100
100
320468
320469
BTD
BTD
0.3246
0.3246
L
L
97799887
97799888
BD Ultra-Fine Syringes, 0.3cc, 29g
BD Ultra-Fine Syringes, 0.5cc, 29g
100
100
320431
320466
BTD
BTD
0.3246
0.3246
L
L
97799385
97799384
BD Ultra-Fine Syringes, 0.5cc, 31g
BD Ultra-Fine Syringes, 1.0cc, 31g
100
100
324920
32921
BTD
BTD
0.3555
0.3555
L
L
97799889
97799786
BD Ultra-Fine Syringes, 1cc, 29g
Monoject Syringes 0.3cc, 29 x 1/2"
100
100
320411
8881600145
BTD
TYC
0.3246
0.2884
L
L
97799783
97799780
Monoject Syringes 0.3cc, 30g x 5/16"
Monoject Syringes 0.5cc, 25g x 5/8"
100
100
8881600800
1188528012
TYC
TYC
0.2884
0.2266
L
L
97799788
97799785
Monoject Syringes 0.5cc, 28g x 1/2"
Monoject Syringes 0.5cc, 29g x 1/2"
100
100
8881600004
8881600350
TYC
TYC
0.2884
0.2884
L
L
97799782
97799778
Monoject Syringes 0.5cc, 30g x 5/16"
Monoject Syringes 1cc, 27g x 1/2"
100
100
8881600700
1188127012
TYC
TYC
0.2884
0.2472
L
L
97799787
97799777
Monoject Syringes 1cc, 28g x 1/2"
Monoject Syringes 1cc, 28g x 1/2"
100
100
8881601101
1188128012
TYC
TYC
0.2884
0.2266
L
L
97799784
97799781
Monoject Syringes 1cc, 29g x 1/2"
Monoject Syringes 1cc, 30g x 5/16"
100
100
8881601358
8881601600
TYC
TYC
0.2884
0.2884
L
L
97799369
97799370
Montméd Syringes 0.3cc, 31g
Montméd Syringes 0.5cc, 31g
100
100
11001003
11001002
MTD
MTD
0.3110
0.3090
L
L
97799371
97799273
Montméd Syringes 1cc, 31g
SureComfort Half-Unit Syringe, 0.3cc, 31g
100
100
11001001
22-6504
MTD
BBM
0.3090
0.1411
L
L
97799260
97799264
SureComfort Syringe, 0.3cc, 29g x 1/2"
SureComfort Syringe, 0.3cc, 30g x 1/2"
100
100
22-9003
22-6203
BBM
BBM
0.1221
0.1347
L
L
97799261
97799274
SureComfort Syringe, 0.3cc, 30g x 5/16"
SureComfort Syringe, 0.3cc, 31g x 5/16"
100
100
22-6003
22-6503
BBM
BBM
0.1347
0.1411
L
L
97799257
97799259
SureComfort Syringe, 0.5cc, 28g x 1/2"
SureComfort Syringe, 0.5cc, 29g x 1/2"
100
100
22-8005
22-9005
BBM
BBM
0.1221
0.1221
L
L
97799270
97799272
SureComfort Syringe, 0.5cc, 30g x 1/2"
SureComfort Syringe, 0.5cc, 30g x 5/16"
100
100
22-6205
22-6005
BBM
BBM
0.1347
0.1347
L
L
97799263
97799275
SureComfort Syringe, 0.5cc, 31g x 5/16"
SureComfort Syringe, 1cc, 28g x 1/2"
100
100
22-6505
22-8010
BBM
BBM
0.1411
0.1221
L
L
97799258
97799271
SureComfort Syringe, 1cc, 29g x 1/2"
SureComfort Syringe, 1cc, 30g x 1/2"
100
100
22-9010
22-6210
BBM
BBM
0.1221
0.1347
L
L
97799265
97799262
SureComfort Syringe, 1cc, 30g x 5/16"
SureComfort Syringe, 1cc, 31g x 5/16"
100
100
22-6010
22-6510
BBM
BBM
0.1347
0.1411
L
L
97799999
97799996
UltiCare Syringes 0.3cc, 29g
UltiCare Syringes 0.3cc, 30g
100
100
UC09239
UC09339
AUT
AUT
0.1980
0.2080
L
L
97799998
97799995
UltiCare Syringes 0.5cc, 29g
UltiCare Syringes 0.5cc, 30g
100
100
UC09259
UC09359
AUT
AUT
0.1980
0.2080
L
L
97799997
97799994
UltiCare Syringes 1cc, 29g
UltiCare Syringes 1cc, 30g
100
100
UC09219
UC09319
AUT
AUT
0.1980
0.2080
L
L
PRODUCT DESCRIPTION
Abbott Thin 28g Lancets
Abbott Thin 28g Lancets
PKG SIZE
200
100
PRODUCT #
9868203
7004302
MFR
MID
MID
PRICE
0.0445
0.0500
LANCETS
PIN
97799689
97799691
February 2016
TYPE
L
L
TYPE
P
P
239
Diabetic Supplies Benefit List
LANCETS
PIN
97799495
97799494
PRODUCT DESCRIPTION
Accu-Chek Fastclix Lancets
Accu-Chek Fastclix Lancets
PKG SIZE
204
102
PRODUCT #
05353815001
05353807001
MFR
BOM
BOM
PRICE
0.0500
0.0500
97799816
97799817
Accu-Chek Multiclix Lancets
Accu-Chek Multiclix Lancets
204
102
4470000000
4470000000
BOM
BOM
0.0500
0.0500
P
P
97799945
97799946
Accu-Chek Softclix Lancets
Accu-Chek Softclix Lancets
200
100
3146693
3146707
BOM
BOM
0.0500
0.0500
P
P
97799942
97799918
Accu-Chek Softclix Pro Lancets
Ascensia Microlet Lancets
200
100
3038157
6546BA
BOM
BDD
0.0500
0.0500
P
P
97799917
97799883
Ascensia Microlet Lancets
BD Ultra-Fine Lancets
200
200
6550PC
326572
BDD
BTD
0.0500
0.0495
P
P
97799882
97799466
BD Ultra-Fine Lancets
BGStar Lanets
100
100
326571
86476
BTD
SAV
0.0500
0.0500
P
P
97799540
97799825
EZ Health Lancets
Finger Stix Lancets
100
200
GMH-L3
5965
THI
BDD
0.0500
0.0500
P
P
97799312
97799826
FORA TD-Thin Lancet
FreeStyle Lancets
200
100
TD-5084
83001
FRA
MID
0.0500
0.0500
P
P
97799766
97799767
iTest Lancets 28g
iTest Lancets 33g
100
100
IT31005
IT31003
AUT
AUT
0.0465
0.0404
P
P
97799388
97799389
Medi+Sure Soft 30G Twist Lancet (Purple)
Medi+Sure Soft 33G Twist Lancet (Beige)
100
100
DG030N
DG033N
MSR
MSR
0.0490
0.0490
P
P
97799592
97799591
Medlance Plus Lite Lancets 25g
Medlance Plus Universal Lancets 21g
200
200
1381
1382
MPD
MPD
0.0500
0.0500
P
P
97799810
97799807
MPD Thin Lancets
MPD Ultra Thin Lancets
100
100
P0555/P0455
P0465/P0565
MPD
MPD
0.0318
0.0318
P
P
97799501
97799431
OneTouch Delica Lancet 33G
OneTouch Delica Lancets 30G
100
100
022-142
022631
LFS
LFS
0.0500
0.0500
P
P
97799765
97799970
OneTouch SureSoft Lancets 21g
OneTouch UltraSoft
200
100
021-139
020432
LFS
LFS
0.0500
0.0500
P
P
97799948
97799348
Safe-T-Pro Lancets
Ultilet Classic Lancets 20g
200
100
2210916
598428
BOM
BMP
0.0500
0.0500
P
P
TESTING STRIPS
PRODUCT DESCRIPTION
PIN
TYPE
P
P
97799823
97799824
Accu-Chek Advantage Glucose Test Strips
Accu-Chek Advantage Glucose Test Strips
PKG SIZE
50
100
PRODUCT #
2030578
2030551
MFR
BOM
BOM
PRICE
0.7400
0.7400
97799814
97799815
Accu-Chek AVIVA Test Strips
Accu-Chek AVIVA Test Strips
100
50
4540000000
4450000000
BOM
BOM
0.7400
0.7400
P
P
97799962
97799963
Accu-Chek Compact Test Strips
Accu-Chek Compact Test Strips
102
51
3021475/102
3021475
BOM
BOM
0.7400
0.7400
P
P
97799496
97799497
Accu-Chek Mobile BG Test Strip Cassette
Accu-Chek Mobile BG Test Strip Cassette
50
100
05127670119
05190843119
BOM
BOM
0.7400
0.7400
P
P
97799916
97799851
Acetest
Albustix
100
100
2381
2870U
BDD
BDD
0.1640
0.2750
L
L
97799749
97799748
Ascensia Breeze 2 Test Strip Disc
Ascensia Breeze 2 Test Strip Disc
50
100
1469
1470
BDD
BDD
0.7400
0.7400
P
P
97799703
97799702
Ascensia Contour Test Strip
Ascensia Contour Test Strip
50
100
7081B
7091B
BDD
BDD
0.7400
0.7400
P
P
97799465
97799294
BGStar Test Strips
CareSens N BG Test Strip
100
100
86366
180144
SAV
ISN
0.6750
0.6400
P
P
February 2016
TYPE
P
P
240
Diabetic Supplies Benefit List
TESTING STRIPS
PRODUCT DESCRIPTION
PIN
97799956
97799953
Chemstrip uGK Glucose and Ketone Strips
Chemstrip-9
PKG SIZE
50
100
PRODUCT #
647705
398411
MFR
BOM
BOM
PRICE
0.1280
0.4125
97799958
97799957
Chemstrip-BG (Accu-Chek)
Chemstrip-BG Glucose Strips (Visual Testing)
50
25
1179446
318710
BOM
BOM
0.7220
0.6888
L
L
97799951
97799915
Chemstrip-GP
Clinitest
100
100
200743
2101
BOM
BDD
0.2545
0.0966
L
L
97799459
97799460
Contour NEXT Blood Glucose Test Strips
Contour NEXT Blood Glucose Test Strips
100
50
7322
7321
BDD
BDD
0.6989
0.7400
P
P
97799914
97799564
Diastix
EZ Oracle Test Strips
50
100
2806
GMH-B1S100
BDD
THI
0.1094
0.7381
L
P
97799313
97799829
FORA Test n' Go BG Strip
FreeStyle Blood Glucose Test Strips
100
100
TD-4365
82058
FRA
MID
0.7000
0.7335
P
P
97799827
97799597
FreeStyle Blood Glucose Test Strips
FreeStyle Lite Test Strips
50
100
82055
6.99E+11
MID
MID
0.7400
0.7335
P
P
97799596
97799841
FreeStyle Lite Test Strips
Freestyle Precision Strips
50
50
6.99E+11
99786
MID
MID
0.7400
0.7400
P
P
97799840
97799372
Freestyle Precisions Strips
GE200 Glucose Test Strip
100
50
99059
589829
MID
BNM
0.7325
0.5200
P
L
97799373
97799849
GE200 Glucose Test Strip
Hemastix
100
50
589829
2524A
BNM
BDD
0.5100
0.4078
L
L
97799770
97799912
iTest Blood Glucose Test Strips
Keto-Diastix
50
100
IT31002
2882U
AUT
BDD
0.6910
0.1311
P
L
97799913
97799854
Ketostix
Labstix
50
100
2880U
2810A
BDD
BDD
0.1218
0.3775
L
L
97799403
97799853
Medi+Sure BG Test Strip
Multistix
100
100
DG001S
2820A
MSR
BDD
0.6990
0.5438
P
L
97799458
97799583
MyGlucoHealth Glucose Test Strips
NovaMax Test Strips
50
100
CAN-MGH-TS50
43955
EHS
NBM
0.6730
0.7400
P
P
97799584
97799581
NovaMax Test Strips
On-Call Plus Test Strips
50
50
43894
1130000000
NBM
ACO
0.7400
0.6700
P
P
97799582
97799580
On-Call Plus Test Strips
On-Call Plus Test Strips
100
25
1130000000
1130000000
ACO
ACO
0.6300
0.7000
P
P
97799983
97799982
One-Touch FastTake Blood Glucose Test Strips
One-Touch FastTake Blood Glucose Test Strips
50
100
010-455
010-456
LFS
LFS
0.7400
0.7381
P
P
97799976
97799977
One-Touch Test Strips
One-Touch Test Strips
100
50
010-638
010-501
LFS
LFS
0.7381
0.7400
P
P
97799986
97799985
One-Touch Ultra Test Strips
One-Touch Ultra Test Strips
50
100
020-383
020-384
LFS
LFS
0.7400
0.7381
P
P
97799476
97799475
One-Touch Verio Test Strips
One-Touch Verio Test Strips
50
100
022279
022439
LFS
LFS
0.7400
0.6943
P
P
97799451
97799479
Rapid Response Blood Glucose Test Strips
Rightest GS100 Test Strips
50
50
04GLU-68
8539105202
BTX
BNM
0.7100
0.5730
P
P
97799478
97799601
Rightest GS100 Test Strips
Sidekick Blood Glucose Testing System
100
50
8539110202
K-05011-47/D-4120-81
BNM
HOM
0.4500
0.4444
P
P
97799355
97799531
Suretest Blood Glucose Test Strips
TRUEtest Blood Glucose Test Strips
50
50
83865
E3i20-81
SKM
HOM
0.7290
0.5742
P
P
97799532
97799603
TRUEtest Blood Glucose Test Strips
TrueTrack Blood Glucose Test Strip
100
50
E3i20-80
A-3120-81
HOM
HOM
0.5741
0.4444
P
P
February 2016
TYPE
L
L
241
Diabetic Supplies Benefit List
TESTING STRIPS
PRODUCT DESCRIPTION
PIN
97799602
97799852
February 2016
TrueTrack Blood Glucose Test Strip
Uristix
PKG SIZE
100
100
PRODUCT #
A-3120-80
2855U
MFR
HOM
BDD
PRICE
0.3859
0.2647
TYPE
P
L
242
Ostomy Supplies Benefit List
MISCELLANEOUS
PIN
95098862
95098861
PRODUCT DESCRIPTION
Assura Irrigation Sleeve
Assura Irrigation Sleeve
PRODUCT #
1003
12834
MFR
COL
COL
95098859
95098860
Assura Irrigation Sleeve
Assura Irrigation Sleeve
12836
12835
COL
COL
95099427
95099424
CenterPointLock Irrig Sleeve
CenterPointLock Irrig Sleeve
3827
3824
HOL
HOL
95099426
95099425
CenterPointLock Irrig Sleeve
CenterPointLock Irrig Sleeve
3822
3823
HOL
HOL
95099423
95099163
CenterPointLock Irrig Sleeve
Cone Irrigator Kit
3826
7721
HOL
HOL
95098038
95098039
Confidence Comfort Dr Pouch
Confidence Comfort Dr Pouch
DLT013
DT013
ARG
ARG
95099866
95098244
ConvaTec Pouch Closure
Dermacol Stoma Collar
175635
DC23
CON
ARG
95098245
95098243
Dermacol Stoma Collar
Dermacol Stoma Collar
DC20
DC26
ARG
ARG
95098242
95098241
Dermacol Stoma Collar
Dermacol Stoma Collar
DC29
DC32
ARG
ARG
95098240
95098239
Dermacol Stoma Collar
Dermacol Stoma Collar
DC35
DC38
ARG
ARG
95098238
95098857
Dermacol Stoma Collar
Drainable Pouch Clamp
DC41
9500
ARG
COL
95099123
95099865
Drainable Pouch Clamp
DuoLock Pouch Closure
8770
175652
HOL
CON
95099160
95099161
Irrigator Sleeve w Closure
Irrigator Sleeve w Closure
7724
7728
HOL
HOL
95099547
95099546
New Image Irrigation Sleeve
New Image Irrigation Sleeve
18153
18154
HOL
HOL
95099548
95099799
New Image Irrigation Sleeve
Sur-Fit AutoLock Convex Insrt
18152
401614
HOL
CON
95099795
95099684
Sur-Fit AutoLock Convex Insrt
Sur-Fit Natura Convex Inserts
401618
404006
CON
CON
95099682
95099683
Sur-Fit Natura Convex Inserts
Sur-Fit Natura Convex Inserts
404008
404007
CON
CON
95099681
95099680
Sur-Fit Natura Convex Inserts
Sur-Fit Natura Convex Inserts
404009
404010
CON
CON
95099679
95099677
Sur-Fit Natura Convex Inserts
Sur-Fit Natura Convex Inserts
404011
404013
CON
CON
95099678
95099766
Sur-Fit Natura Convex Inserts
Sur-Fit Natura Irrig Closure
404012
175650
CON
CON
95099695
95099694
Sur-Fit Natura Irrig Sleeve
Sur-Fit Natura Irrig Sleeve
401911
401912
CON
CON
95099692
95099693
Sur-Fit Natura Irrig Sleeve
Sur-Fit Natura Irrig Sleeve
401914
401913
CON
CON
PRODUCT #
650408
650422
MFR
CON
CON
ONE-PIECE SYSTEMS
PIN
95099977
95099976
February 2016
PRODUCT DESCRIPTION
Active Life Closed-End
Active Life Closed-End
243
Ostomy Supplies Benefit List
ONE-PIECE SYSTEMS
PIN
95099952
95098781
PRODUCT DESCRIPTION
Active Life Dr Durahesive
Active Life Dr Durahesive
PRODUCT #
175780
125353
MFR
CON
CON
95098780
95098778
Active Life Dr Durahesive
Active Life Dr Durahesive
125354
125356
CON
CON
95098776
95098774
Active Life Dr Durahesive
Active Life Dr Durahesive
125358
125360
CON
CON
95098772
95098771
Active Life Dr Durahesive
Active Life Dr Durahesive
125362
125363
CON
CON
95098769
95098767
Active Life Dr Durahesive
Active Life Dr Durahesive
125365
125367
CON
CON
95098765
95099955
Active Life Dr Durahesive
Active Life Dr Durahesive
125369
175777
CON
CON
95099953
95098782
Active Life Dr Durahesive
Active Life Dr Durahesive
175779
125352
CON
CON
95098779
95098777
Active Life Dr Durahesive
Active Life Dr Durahesive
125355
125357
CON
CON
95098775
95098773
Active Life Dr Durahesive
Active Life Dr Durahesive
125359
125361
CON
CON
95098770
95098768
Active Life Dr Durahesive
Active Life Dr Durahesive
125364
125366
CON
CON
95098766
95099954
Active Life Dr Durahesive
Active Life Dr Durahesive
125368
175778
CON
CON
95099986
95098783
Active Life Drainable
Active Life Drainable
22765
125343
CON
CON
95098785
95098788
Active Life Drainable
Active Life Drainable
125341
125338
CON
CON
95098790
95098792
Active Life Drainable
Active Life Drainable
125335
125333
CON
CON
95098795
95099983
Active Life Drainable
Active Life Drainable
125330
22768
CON
CON
95099985
95099987
Active Life Drainable
Active Life Drainable
22766
22764
CON
CON
95099978
95099980
Active Life Drainable
Active Life Drainable
650803
400598
CON
CON
95098784
95098786
Active Life Drainable
Active Life Drainable
125342
125340
CON
CON
95098787
95098789
Active Life Drainable
Active Life Drainable
125339
125336
CON
CON
95098791
95098794
Active Life Drainable
Active Life Drainable
125334
125331
CON
CON
95099981
95099982
Active Life Drainable
Active Life Drainable
22771
22769
CON
CON
95099979
95099984
Active Life Drainable
Active Life Drainable
400599
22767
CON
CON
95099946
95099945
Active Life Durahesive
Active Life Durahesive
650828
650829
CON
CON
95099943
95099944
Active Life Durahesive
Active Life Durahesive
650831
650830
CON
CON
February 2016
244
Ostomy Supplies Benefit List
ONE-PIECE SYSTEMS
PIN
95099856
95099857
PRODUCT DESCRIPTION
Active Life Little Ones
Active Life Little Ones
PRODUCT #
20922
20917
MFR
CON
CON
95099973
95099974
Active Life Pre-Cut Closed
Active Life Pre-Cut Closed
175770
175769
CON
CON
95099972
95099971
Active Life Pre-Cut Closed
Active Life Pre-Cut Closed
175771
175772
CON
CON
95099970
95099965
Active Life Pre-Cut Closed
Active Life Pre-Cut Closed
175773
413146
CON
CON
95099966
95099967
Active Life Pre-Cut Closed
Active Life Pre-Cut Closed
413145
413144
CON
CON
95099968
95099969
Active Life Pre-Cut Closed
Active Life Pre-Cut Closed
413143
413142
CON
CON
95099975
95099940
Active Life Stoma Cap
Active Life Uros Durahesive
175611
64927
CON
CON
95099942
95099941
Active Life Uros Durahesive
Active Life Uros Durahesive
650832
650833
CON
CON
95098995
95098994
Assura Drainable
Assura Drainable
14173
14174
COL
COL
95098993
95098992
Assura Drainable
Assura Drainable
14175
14176
COL
COL
95098991
95098990
Assura Drainable
Assura Drainable
13874
13875
COL
COL
95098989
95099064
Assura Drainable
Assura Drainable
13876
14106
COL
COL
95099007
95098802
Assura Drainable w Easiclose
Assura Drainable w Easiclose
14196
14414
COL
COL
95098800
95098797
Assura Drainable w Easiclose
Assura Drainable w Easiclose
14421
14424
COL
COL
95098996
95098801
Assura Drainable w Easiclose
Assura Drainable w Easiclose
13870
14415
COL
COL
95098799
95098798
Assura Drainable w Easiclose
Assura Drainable w Easiclose
14422
14423
COL
COL
95099015
95099012
Assura E-E Wear Drainable
Assura E-E Wear Drainable
12416
12432
COL
COL
95099011
95099017
Assura E-E Wear Drainable
Assura E-E Wear Drainable
12433
12419
COL
COL
95099009
95099010
Assura E-E Wear Urostomy
Assura E-E Wear Urostomy
12472
12471
COL
COL
95098881
95098883
Assura Pediatric Closed
Assura Pediatric Drainable
2125
2115
COL
COL
95098880
95098899
Assura Pediatric Urostomy
Assura Std Wear Closed
8009
12130
COL
COL
95098918
95098901
Assura Std Wear Closed
Assura Std Wear Closed
12140
14454
COL
COL
95098902
95098903
Assura Std Wear Closed
Assura Std Wear Closed
14453
14452
COL
COL
95098914
95098915
Assura Std Wear Closed
Assura Std Wear Closed
14445
14444
COL
COL
February 2016
245
Ostomy Supplies Benefit List
ONE-PIECE SYSTEMS
PIN
95098894
95098895
PRODUCT DESCRIPTION
Assura Std Wear Closed
Assura Std Wear Closed
PRODUCT #
14442
14441
MFR
COL
COL
95098916
95098917
Assura Std Wear Closed
Assura Std Wear Closed
14435
14434
COL
COL
95098905
95098907
Assura Std Wear Closed
Assura Std Wear Closed
12177
12175
COL
COL
95098908
95098910
Assura Std Wear Closed
Assura Std Wear Closed
12174
12147
COL
COL
95098906
95098898
Assura Std Wear Closed
Assura Std Wear Closed
12176
12170
COL
COL
95098911
95098912
Assura Std Wear Closed
Assura Std Wear Closed
12146
12144
COL
COL
95098919
95098913
Assura Std Wear Closed
Assura Std Wear Closed
12110
12145
COL
COL
95099006
95098805
Assura Std Wear Dr Easiclose
Assura Std Wear Dr Easiclose
13840
14405
COL
COL
95098804
95098803
Assura Std Wear Dr Easiclose
Assura Std Wear Dr Easiclose
14411
14412
COL
COL
95098806
95098997
Assura Std Wear Dr Easiclose
Assura Std Wear Dr Easiclose
14404
14166
COL
COL
95098998
95098999
Assura Std Wear Dr Easiclose
Assura Std Wear Dr Easiclose
14165
14164
COL
COL
95099000
95099002
Assura Std Wear Dr Easiclose
Assura Std Wear Dr Easiclose
14163
14103
COL
COL
95099001
95099003
Assura Std Wear Dr Easiclose
Assura Std Wear Dr Easiclose
13860
13846
COL
COL
95099004
95099005
Assura Std Wear Dr Easiclose
Assura Std Wear Dr Easiclose
13845
13844
COL
COL
95098963
95098959
Assura Std Wear Drainable
Assura Std Wear Drainable
12533
2490
COL
COL
95098960
95098962
Assura Std Wear Drainable
Assura Std Wear Drainable
13706
2520
COL
COL
95098920
95098930
Assura Std Wear Urostomy
Assura Std Wear Urostomy
12997
12595
COL
COL
95098921
95098922
Assura Std Wear Urostomy
Assura Std Wear Urostomy
12996
12995
COL
COL
95098931
95098927
Assura Std Wear Urostomy
Assura Std Wear Urostomy
5580
5585
COL
COL
95098929
95098926
Assura Std Wear Urostomy
Assura Std Wear Urostomy
12596
12991
COL
COL
95098925
95098924
Assura Std Wear Urostomy
Assura Std Wear Urostomy
12992
12993
COL
COL
95098923
95099021
Assura Std Wear Urostomy
Assura Stoma Cap
12994
2802
COL
COL
95099022
95098889
Assura Stoma Cap
Assura Stoma Cap
2801
2501
COL
COL
95098206
95098169
Confidence Convex Supersoft
Confidence Convex Supersoft
CCSS1325
CUSS38
ARG
ARG
February 2016
246
Ostomy Supplies Benefit List
ONE-PIECE SYSTEMS
PIN
95098204
95098203
PRODUCT DESCRIPTION
Confidence Convex Supersoft
Confidence Convex Supersoft
PRODUCT #
CCSS1352
CCSS21
MFR
ARG
ARG
95098202
95098201
Confidence Convex Supersoft
Confidence Convex Supersoft
CCSS25
CCSS28
ARG
ARG
95098200
95098199
Confidence Convex Supersoft
Confidence Convex Supersoft
CCSS32
CCSS35
ARG
ARG
95098198
95098197
Confidence Convex Supersoft
Confidence Convex Supersoft
CCSS38
CCSS41
ARG
ARG
95098196
95098195
Confidence Convex Supersoft
Confidence Convex Supersoft
CCSSL1325
CCSSL1338
ARG
ARG
95098194
95098193
Confidence Convex Supersoft
Confidence Convex Supersoft
CCSSL1352
CDSS1325
ARG
ARG
95098192
95098191
Confidence Convex Supersoft
Confidence Convex Supersoft
CDSS1338
CDSS1352
ARG
ARG
95098190
95098189
Confidence Convex Supersoft
Confidence Convex Supersoft
CDSS21
CDSS25
ARG
ARG
95098188
95098187
Confidence Convex Supersoft
Confidence Convex Supersoft
CDSS28
CDSS32
ARG
ARG
95098186
95098185
Confidence Convex Supersoft
Confidence Convex Supersoft
CDSS35
CDSS38
ARG
ARG
95098184
95098183
Confidence Convex Supersoft
Confidence Convex Supersoft
CDSS41
CDSSL1325
ARG
ARG
95098182
95098181
Confidence Convex Supersoft
Confidence Convex Supersoft
CDSSL1338
CDSSL1352
ARG
ARG
95098180
95098179
Confidence Convex Supersoft
Confidence Convex Supersoft
CDSSS1325
CDSSS1338
ARG
ARG
95098178
95098177
Confidence Convex Supersoft
Confidence Convex Supersoft
CDSSS1352
CUSS1325
ARG
ARG
95098176
95098175
Confidence Convex Supersoft
Confidence Convex Supersoft
CUSS1338
CUSS1352
ARG
ARG
95098174
95098173
Confidence Convex Supersoft
Confidence Convex Supersoft
CUSS21
CUSS25
ARG
ARG
95098172
95098171
Confidence Convex Supersoft
Confidence Convex Supersoft
CUSS28
CUSS32
ARG
ARG
95098170
95098205
Confidence Convex Supersoft
Confidence Convex Supersoft
CUSS35
CCSS1338
ARG
ARG
95098231
95098230
Confidence Natural
Confidence Natural
N25
N28
ARG
ARG
95098229
95098228
Confidence Natural
Confidence Natural
N32
N35
ARG
ARG
95098227
95098226
Confidence Natural
Confidence Natural
N38
N41
ARG
ARG
95098225
95098224
Confidence Natural
Confidence Natural
NL13
NLT13
ARG
ARG
95098223
95098222
Confidence Natural
Confidence Natural
NM13
NT13
ARG
ARG
95098221
95098220
Confidence Natural
Confidence Natural
ND13
ND25
ARG
ARG
February 2016
247
Ostomy Supplies Benefit List
ONE-PIECE SYSTEMS
PIN
95098219
95098218
PRODUCT DESCRIPTION
Confidence Natural
Confidence Natural
PRODUCT #
ND28
ND32
MFR
ARG
ARG
95098217
95098216
Confidence Natural
Confidence Natural
ND35
NDL13
ARG
ARG
95098215
95098214
Confidence Natural
Confidence Natural
NDLT13
NDS13
ARG
ARG
95098213
95098212
Confidence Natural
Confidence Natural
NDT13
NU13
ARG
ARG
95098211
95098210
Confidence Natural
Confidence Natural
NU25
NU28
ARG
ARG
95098209
95098208
Confidence Natural
Confidence Natural
NU32
NU35
ARG
ARG
95098207
95098232
Confidence Natural
Confidence Natural
NUS13
N13
ARG
ARG
95099290
95098089
Contour Stoma Cap
Esteem + Closed Pouch
1796
416724
HOL
CON
95098100
95098117
Esteem + Closed Pouch
Esteem + Closed Pouch
416733
416702
CON
CON
95098118
95098119
Esteem + Closed Pouch
Esteem + Closed Pouch
416701
416700
CON
CON
95098078
95098079
Esteem + Closed Pouch
Esteem + Closed Pouch
416750
416748
CON
CON
95098080
95098081
Esteem + Closed Pouch
Esteem + Closed Pouch
416746
416744
CON
CON
95098115
95098114
Esteem + Closed Pouch
Esteem + Closed Pouch
416704
416705
CON
CON
95098113
95098112
Esteem + Closed Pouch
Esteem + Closed Pouch
416706
416707
CON
CON
95098111
95098110
Esteem + Closed Pouch
Esteem + Closed Pouch
416708
416709
CON
CON
95098109
95098108
Esteem + Closed Pouch
Esteem + Closed Pouch
416710
416711
CON
CON
95098107
95098106
Esteem + Closed Pouch
Esteem + Closed Pouch
416712
416713
CON
CON
95098105
95098104
Esteem + Closed Pouch
Esteem + Closed Pouch
416714
416715
CON
CON
95098103
95098102
Esteem + Closed Pouch
Esteem + Closed Pouch
416719
416725
CON
CON
95098101
95098116
Esteem + Closed Pouch
Esteem + Closed Pouch
416729
416703
CON
CON
95098099
95098098
Esteem + Closed Pouch
Esteem + Closed Pouch
416737
416739
CON
CON
95098097
95098096
Esteem + Closed Pouch
Esteem + Closed Pouch
416741
416743
CON
CON
95098095
95098094
Esteem + Closed Pouch
Esteem + Closed Pouch
416745
416747
CON
CON
95098093
95098092
Esteem + Closed Pouch
Esteem + Closed Pouch
416749
416751
CON
CON
February 2016
248
Ostomy Supplies Benefit List
ONE-PIECE SYSTEMS
PIN
95098091
95098090
PRODUCT DESCRIPTION
Esteem + Closed Pouch
Esteem + Closed Pouch
PRODUCT #
416718
416721
MFR
CON
CON
95098088
95098087
Esteem + Closed Pouch
Esteem + Closed Pouch
416728
416732
CON
CON
95098086
95098084
Esteem + Closed Pouch
Esteem + Closed Pouch
416736
416738
CON
CON
95098082
95098083
Esteem + Closed Pouch
Esteem + Closed Pouch
416742
416740
CON
CON
95097918
95097917
Esteem + Drainable Pouch
Esteem + Drainable Pouch
413510
413509
CON
CON
95097916
95097915
Esteem + Drainable Pouch
Esteem + Drainable Pouch
413522
412521
CON
CON
95097919
95097921
Esteem + Drainable Pouch
Esteem + Drainable Pouch
413519
413518
CON
CON
95097920
95097930
Esteem + Drainable Pouch
Esteem + Drainable Pouch
413516
413515
CON
CON
95099197
95099199
Hollister Closed
Hollister Closed
3143
3142
HOL
HOL
95099196
95099194
Hollister Closed
Hollister Closed
3149
3145
HOL
HOL
95099198
95099195
Hollister Closed
Hollister Closed
3148
3144
HOL
HOL
95099181
95099179
Lo-Profile Urostomy
Lo-Profile Urostomy
1432
1433
HOL
HOL
95099178
95099180
Lo-Profile Urostomy
Lo-Profile Urostomy
1439
1438
HOL
HOL
95099177
95098045
Lo-Profile Urostomy
Pouchkins Pediatric
1434
3795
HOL
HOL
95098378
95099174
Pouchkins Pediatric
Pouchkins Pediatric
3796
3777
HOL
HOL
95099173
95098595
Pouchkins Pediatric
Premier Closed
3778
82335
HOL
HOL
95098597
95098596
Premier Closed
Premier Closed
82325
82330
HOL
HOL
95098593
95098641
Premier Closed
Premier Closed
82100
82300
HOL
HOL
95098592
95099399
Premier Closed
Premier Drainable
82125
8639
HOL
HOL
95099409
95099410
Premier Drainable
Premier Drainable
8642
8647
HOL
HOL
95099406
95098588
Premier Drainable
Premier Drainable
8649
88300
HOL
HOL
95099389
95099386
Premier Drainable
Premier Drainable
8614
8617
HOL
HOL
95099384
95099395
Premier Drainable
Premier Drainable
8619
8628
HOL
HOL
95099402
95099400
Premier Drainable
Premier Drainable
8632
8633
HOL
HOL
February 2016
249
Ostomy Supplies Benefit List
ONE-PIECE SYSTEMS
PIN
95099397
95099401
PRODUCT DESCRIPTION
Premier Drainable
Premier Drainable
PRODUCT #
8635
8638
MFR
HOL
HOL
95099411
95099407
Premier Drainable
Premier Drainable
8641
8643
HOL
HOL
95099405
95099408
Premier Drainable
Premier Drainable
8644
8648
HOL
HOL
95099394
95098586
Premier Drainable
Premier Drainable
86211
88700
HOL
HOL
95099393
95099391
Premier Drainable
Premier Drainable
8610
8612
HOL
HOL
95099403
95099398
Premier Drainable
Premier Drainable
8637
8634
HOL
HOL
95099404
95099396
Premier Drainable
Premier Drainable
8631
8624
HOL
HOL
95099385
95099387
Premier Drainable
Premier Drainable
8618
8616
HOL
HOL
95099390
95099392
Premier Drainable
Premier Drainable
8613
8611
HOL
HOL
95098046
95098043
Premier Drainable
Premier Drainable
8450
8031
HOL
HOL
95099388
95098044
Premier Drainable
Premier Drainable Lock'n Roll
8615
88402
HOL
HOL
95098609
95098606
Premier Drainable Lock'n Roll
Premier Drainable Lock'n Roll
88325
88340
HOL
HOL
95098600
95098598
Premier Drainable Lock'n Roll
Premier Drainable Lock'n Roll
88730
88740
HOL
HOL
95098608
95098607
Premier Drainable Lock'n Roll
Premier Drainable Lock'n Roll
88330
88335
HOL
HOL
95098601
95098599
Premier Drainable Lock'n Roll
Premier Drainable Lock'n Roll
88725
88735
HOL
HOL
95098665
95098369
Premier Lock'n Roll
Premier Lock'n Roll
8513
85118
HOL
HOL
95098371
95098372
Premier Lock'n Roll
Premier Lock'n Roll
85116
8599
HOL
HOL
95098374
95098654
Premier Lock'n Roll
Premier Lock'n Roll
8597
8595
HOL
HOL
95097820
95098042
Premier Lock'n Roll
Premier Lock'n Roll
8588
8331
HOL
HOL
95098668
95098666
Premier Lock'n Roll
Premier Lock'n Roll
8510
8512
HOL
HOL
95098675
95098672
Premier Lock'n Roll
Premier Lock'n Roll
8552
8559
HOL
HOL
95098658
95098656
Premier Lock'n Roll
Premier Lock'n Roll
8591
8593
HOL
HOL
95098375
95098662
Premier Lock'n Roll
Premier Lock'n Roll
8596
85011
HOL
HOL
95098671
95098661
Premier Lock'n Roll
Premier Lock'n Roll
85211
8504
HOL
HOL
February 2016
250
Ostomy Supplies Benefit List
ONE-PIECE SYSTEMS
PIN
95098660
95098667
PRODUCT DESCRIPTION
Premier Lock'n Roll
Premier Lock'n Roll
PRODUCT #
8508
8511
MFR
HOL
HOL
95098368
95098664
Premier Lock'n Roll
Premier Lock'n Roll
85119
8514
HOL
HOL
95098663
95098670
Premier Lock'n Roll
Premier Lock'n Roll
8515
8524
HOL
HOL
95098669
95098681
Premier Lock'n Roll
Premier Lock'n Roll
8528
8531
HOL
HOL
95098680
95098679
Premier Lock'n Roll
Premier Lock'n Roll
8532
8533
HOL
HOL
95098678
95098677
Premier Lock'n Roll
Premier Lock'n Roll
8538
8539
HOL
HOL
95098676
95098674
Premier Lock'n Roll
Premier Lock'n Roll
8551
8553
HOL
HOL
95098673
95098659
Premier Lock'n Roll
Premier Lock'n Roll
8558
8590
HOL
HOL
95098657
95098655
Premier Lock'n Roll
Premier Lock'n Roll
8592
8594
HOL
HOL
95097819
95097818
Premier Soft Convexity
Premier Soft Convexity
8663
8662
HOL
HOL
95097817
95097814
Premier Soft Convexity
Premier Soft Convexity
8661
86711
HOL
HOL
95097816
95097815
Premier Soft Convexity
Premier Soft Convexity
8678
8674
HOL
HOL
95099369
95099367
Premier Urostomy
Premier Urostomy
8484
8486
HOL
HOL
95099366
95099364
Premier Urostomy
Premier Urostomy
8487
8489
HOL
HOL
95099381
95099377
Premier Urostomy
Premier Urostomy
8462
8464
HOL
HOL
95099380
95099375
Premier Urostomy
Premier Urostomy
8468
8478
HOL
HOL
95099372
95099370
Premier Urostomy
Premier Urostomy
8481
8483
HOL
HOL
95099368
95099365
Premier Urostomy
Premier Urostomy
8485
8488
HOL
HOL
95099374
95099383
Premier Urostomy
Premier Urostomy
84711
8460
HOL
HOL
95099379
95099382
Premier Urostomy
Premier Urostomy
8463
8467
HOL
HOL
95099378
95099376
Premier Urostomy
Premier Urostomy
8469
8474
HOL
HOL
95099373
95099371
Premier Urostomy
Premier Urostomy
8480
8482
HOL
HOL
95099274
95099275
Premium Closed
Premium Closed
3553
3558
HOL
HOL
95099272
95099273
Premium Closed
Premium Closed
3554
3559
HOL
HOL
February 2016
251
Ostomy Supplies Benefit List
ONE-PIECE SYSTEMS
PIN
95099280
95099278
PRODUCT DESCRIPTION
Premium Drainable
Premium Drainable
PRODUCT #
3663
3664
MFR
HOL
HOL
95099281
95099279
Premium Drainable
Premium Drainable
3668
3669
HOL
HOL
95099285
95099283
Premium Drainable
Premium Drainable
3604
3606
HOL
HOL
95099282
95099286
Premium Drainable
Premium Drainable
3662
3609
HOL
HOL
95099288
95099284
Premium Drainable
Premium Drainable
3608
3605
HOL
HOL
95099287
95099277
Premium Drainable
Premium Drainable
3603
3665
HOL
HOL
95098379
95098426
Sensura Easiclose
Sensura Maxi
15821
15607
COL
COL
95098428
95098432
Sensura Maxi
Sensura Maxi
15605
15533
COL
COL
95098434
95098435
Sensura Maxi
Sensura Maxi
15531
15524
COL
COL
95098437
95098423
Sensura Maxi
Sensura Maxi
15522
15633
COL
COL
95098424
95098421
Sensura Maxi
Sensura Maxi
15632
15635
COL
COL
95098422
95098425
Sensura Maxi
Sensura Maxi
15634
15608
COL
COL
95098427
95098431
Sensura Maxi
Sensura Maxi
15606
15534
COL
COL
95098433
95098436
Sensura Maxi
Sensura Maxi
15532
15523
COL
COL
95098438
95098446
Sensura Maxi
Sensura Maxi Closed
15521
15473
COL
COL
95098455
95098448
Sensura Maxi Closed
Sensura Maxi Closed
15408
15470
COL
COL
95098447
95098457
Sensura Maxi Closed
Sensura Maxi Closed
15472
15406
COL
COL
95098458
95098456
Sensura Maxi Closed
Sensura Maxi Closed
15405
15407
COL
COL
95098443
95098441
Sensura Maxi Closed
Sensura Maxi Closed
15482
15484
COL
COL
95098445
95098444
Sensura Maxi Closed
Sensura Maxi Closed
15474
15480
COL
COL
95098442
95098430
Sensura Maxi Closed
Sensura Midi
15483
15603
COL
COL
95098440
95098439
Sensura Midi
Sensura Midi
15501
15511
COL
COL
95098429
95098451
Sensura Midi
Sensura Midi Closed
15604
15415
COL
COL
95098453
95098454
Sensura Midi Closed
Sensura Midi Closed
15413
15412
COL
COL
February 2016
252
Ostomy Supplies Benefit List
ONE-PIECE SYSTEMS
PIN
95098459
95098460
PRODUCT DESCRIPTION
Sensura Midi Closed
Sensura Midi Closed
PRODUCT #
15404
15403
MFR
COL
COL
95098449
95098452
Sensura Midi Closed
Sensura Midi Closed
15450
15414
COL
COL
95098450
95098022
Sensura Midi Closed
Sensura Mio Maxi
15441
10489
COL
COL
95098023
95098024
Sensura Mio Maxi
Sensura Mio Maxi
10487
10484
COL
COL
95098026
95098027
Sensura Mio Maxi
Sensura Mio Maxi
10483
10482
COL
COL
95098028
95098029
Sensura Mio Maxi
Sensura Mio Maxi
10481
10478
COL
COL
95098030
95097950
Sensura Mio Maxi
Sensura Mio Maxi
10477
10479
COL
COL
95098032
95098031
Sensura Mio Maxi
Sensura Mio Maxi
10476
10474
COL
COL
95098033
95098035
Sensura Mio Maxi
Sensura Mio Maxi
10472
10471
COL
COL
95098034
95099185
Sensura Mio Midi
Stoma Cap
10461
3184
COL
HOL
95099186
Stoma Cap
3186
HOL
POUCHES (OPEN-CLOSED) (2 PIECE)
PIN
95099059
PRODUCT DESCRIPTION
Assura Easiclose Drainable
PRODUCT #
13966
MFR
COL
95098475
95098478
Assura Easiclose Drainable
Assura Easiclose Drainable
14495
14494
COL
COL
95098996
95099065
Assura Easiclose Drainable
Assura Easiclose Drainable
13870
13924
COL
COL
95099063
95099061
Assura Easiclose Drainable
Assura Easiclose Drainable
13925
13964
COL
COL
95099060
95098514
Assura Easiclose Drainable
Assura Easiclose Drainable
13965
14498
COL
COL
95099058
95099057
Assura Easiclose Drainable
Assura Easiclose Drainable
13974
13975
COL
COL
95099056
95099055
Assura Easiclose Drainable
Assura Easiclose Drainable
13976
13984
COL
COL
95099054
95099053
Assura Easiclose Drainable
Assura Easiclose Drainable
13985
13986
COL
COL
95098886
95098887
Assura Pediatric Drainable
Assura Pediatric Drainable
14681
14691
COL
COL
95098840
95099027
Assura Pediatric Urostomy
Assura Two-Piece Closed
1789
12385
COL
COL
95099026
95099028
Assura Two-Piece Closed
Assura Two-Piece Closed
12386
12384
COL
COL
95099031
95099030
Assura Two-Piece Closed
Assura Two-Piece Closed
12344
12345
COL
COL
95099029
95099034
Assura Two-Piece Closed
Assura Two-Piece Closed
12346
12354
COL
COL
February 2016
253
Ostomy Supplies Benefit List
POUCHES (OPEN-CLOSED) (2 PIECE)
PIN
95099033
95099032
PRODUCT DESCRIPTION
Assura Two-Piece Closed
Assura Two-Piece Closed
PRODUCT #
12355
12356
MFR
COL
COL
95099025
95099024
Assura Two-Piece Closed
Assura Two-Piece Closed
12374
12375
COL
COL
95099023
95099045
Assura Two-Piece Closed
Assura Two-Piece Drainable
12376
2792
COL
COL
95099050
95099044
Assura Two-Piece Drainable
Assura Two-Piece Drainable
2743
2793
COL
COL
95098415
95098420
Assura Urostomy
Assura Urostomy
14229
14224
COL
COL
95098418
95098419
Assura Urostomy
Assura Urostomy
14226
14225
COL
COL
95098417
95098416
Assura Urostomy
Assura Urostomy
14227
14228
COL
COL
95099035
95099447
Assura Urostomy Night Bag
CenterPointLock Closed
21365
3347
COL
HOL
95099445
95099446
CenterPointLock Closed
CenterPointLock Closed
3343
3342
HOL
HOL
95099444
95099475
CenterPointLock Closed
CenterPointLock Drainable
3344
3803
HOL
HOL
95099474
95099473
CenterPointLock Drainable
CenterPointLock Drainable
3804
3806
HOL
HOL
95099477
95099471
CenterPointLock Drainable
CenterPointLock Drainable
3807
3812
HOL
HOL
95099461
95099469
CenterPointLock Drainable
CenterPointLock Drainable
3894
3814
HOL
HOL
95099472
95099459
CenterPointLock Drainable
CenterPointLock Drainable
3817
3832
HOL
HOL
95099458
95099457
CenterPointLock Drainable
CenterPointLock Drainable
3833
3834
HOL
HOL
95099460
95099480
CenterPointLock Drainable
CenterPointLock Drainable
3837
3842
HOL
HOL
95099479
95099478
CenterPointLock Drainable
CenterPointLock Drainable
3843
3844
HOL
HOL
95099481
95099467
CenterPointLock Drainable
CenterPointLock Drainable
3847
3872
HOL
HOL
95099465
95099463
CenterPointLock Drainable
CenterPointLock Drainable
3874
3892
HOL
HOL
95099476
95099464
CenterPointLock Drainable
CenterPointLock Drainable
3802
3897
HOL
HOL
95099462
95099466
CenterPointLock Drainable
CenterPointLock Drainable
3893
3873
HOL
HOL
95099470
95099448
CenterPointLock Drainable
CenterPointLock Premier
3813
8816
HOL
HOL
95099455
95099453
CenterPointLock Premier
CenterPointLock Premier
8842
8844
HOL
HOL
95099430
95099429
CenterPointLock Premier
CenterPointLock Premier
8902
8903
HOL
HOL
February 2016
254
Ostomy Supplies Benefit List
POUCHES (OPEN-CLOSED) (2 PIECE)
PIN
95099431
95099441
PRODUCT DESCRIPTION
CenterPointLock Premier
CenterPointLock Premier
PRODUCT #
8907
8343
MFR
HOL
HOL
95099443
95099449
CenterPointLock Premier
CenterPointLock Premier
8347
8814
HOL
HOL
95099452
95099454
CenterPointLock Premier
CenterPointLock Premier
8817
8843
HOL
HOL
95099456
95099428
CenterPointLock Premier
CenterPointLock Premier
8847
8904
HOL
HOL
95099442
95099440
CenterPointLock Premier
CenterPointLock Premier
8342
8344
HOL
HOL
95099451
95099450
CenterPointLock Premier
CenterPointLock Premier
8812
8813
HOL
HOL
95099437
95099436
CenterPointLock Stoma Cap
CenterPointLock Stoma Cap
3403
3404
HOL
HOL
95099438
95099439
CenterPointLock Stoma Cap
CenterPointLock Stoma Cap
3402
3407
HOL
HOL
95099433
95099432
CenterPointLock Urostomy
CenterPointLock Urostomy
3903
3904
HOL
HOL
95099434
95099435
CenterPointLock Urostomy
CenterPointLock Urostomy
3902
3907
HOL
HOL
95098818
95098810
Easiflex Closed
Easiflex Closed
14316
14319
COL
COL
95098811
95098812
Easiflex Closed
Easiflex Closed
14327
14332
COL
COL
95098809
95098814
Easiflex Closed
Easiflex Closed
14314
14331
COL
COL
95098807
95098813
Easiflex Closed
Easiflex Closed
14329
14326
COL
COL
95098816
95098808
Easiflex Closed
Easiflex Closed
14317
14334
COL
COL
95098832
95098829
Easiflex Drainable w Easiclose
Easiflex Drainable w Easiclose
14346
14342
COL
COL
95098824
95098462
Easiflex Drainable w Easiclose
Easiflex Drainable w Easiclose
14357
14528
COL
COL
95098542
95098488
Easiflex Drainable w Easiclose
Easiflex Drainable w Easiclose
14527
14525
COL
COL
95098465
95098463
Easiflex Drainable w Easiclose
Easiflex Drainable w Easiclose
14524
14521
COL
COL
95098464
95098822
Easiflex Drainable w Easiclose
Easiflex Drainable w Easiclose
14520
14364
COL
COL
95098827
95098828
Easiflex Drainable w Easiclose
Easiflex Drainable w Easiclose
14362
14361
COL
COL
95098821
95098825
Easiflex Drainable w Easiclose
Easiflex Drainable w Easiclose
14359
14356
COL
COL
95098826
95098831
Easiflex Drainable w Easiclose
Easiflex Drainable w Easiclose
14349
14347
COL
COL
95098823
95099931
Easiflex Drainable w Easiclose
Esteem Synergy Closed
14344
405431
COL
CON
February 2016
255
Ostomy Supplies Benefit List
POUCHES (OPEN-CLOSED) (2 PIECE)
PIN
95099925
95099928
PRODUCT DESCRIPTION
Esteem Synergy Closed
Esteem Synergy Closed
PRODUCT #
405442
405437
MFR
CON
CON
95099926
95099932
Esteem Synergy Closed
Esteem Synergy Closed
405441
405430
CON
CON
95099927
95099929
Esteem Synergy Closed
Esteem Synergy Closed
403946
405436
CON
CON
95099895
95099938
Esteem Synergy Drainable
Esteem Synergy Drainable
410808
405401
CON
CON
95099894
95099936
Esteem Synergy Drainable
Esteem Synergy Drainable
410809
405403
CON
CON
95099934
95098652
Esteem Synergy Drainable
Esteem Synergy Drainable
405405
403997
CON
CON
95098653
95099939
Esteem Synergy Drainable
Esteem Synergy Drainable
403995
405400
CON
CON
95099935
95099933
Esteem Synergy Drainable
Esteem Synergy Drainable
405404
405406
CON
CON
95099933
95099896
Esteem Synergy Drainable
Esteem Synergy Drainable
410805
410807
CON
CON
95099899
95099937
Esteem Synergy Drainable
Esteem Synergy Drainable
410803
405402
CON
CON
95099897
95099898
Esteem Synergy Drainable
Esteem Synergy Drainable
410806
410804
CON
CON
95098737
95098735
Esteem Synergy Invisiclose
Esteem Synergy Invisiclose
410812
410814
CON
CON
95098733
95098734
Esteem Synergy Invisiclose
Esteem Synergy Invisiclose
413353
410815
CON
CON
95098736
95098738
Esteem Synergy Invisiclose
Esteem Synergy Invisiclose
410813
410811
CON
CON
95098739
95098732
Esteem Synergy Invisiclose
Esteem Synergy Invisiclose
410810
413354
CON
CON
95098642
95098646
Esteem Synergy Urostomy
Esteem Synergy Urostomy
405450
405452
CON
CON
95098649
95098651
Esteem Synergy Urostomy
Esteem Synergy Urostomy
405454
405446
CON
CON
95098643
95098647
Esteem Synergy Urostomy
Esteem Synergy Urostomy
405449
405451
CON
CON
95098645
95098650
Esteem Synergy Urostomy
Esteem Synergy Urostomy
405453
405447
CON
CON
95098644
95098077
Esteem Synergy Urostomy
Natura + Drainable Pouch
405448
416415
CON
CON
95098076
95098053
Natura + Drainable Pouch
Natura + Drainable Pouch
416416
416413
CON
CON
95098054
95098055
Natura + Drainable Pouch
Natura + Drainable Pouch
416412
416411
CON
CON
95098056
95098057
Natura + Drainable Pouch
Natura + Drainable Pouch
416410
416409
CON
CON
95098058
95098059
Natura + Drainable Pouch
Natura + Drainable Pouch
416408
416407
CON
CON
February 2016
256
Ostomy Supplies Benefit List
POUCHES (OPEN-CLOSED) (2 PIECE)
PIN
95098060
95098061
PRODUCT DESCRIPTION
Natura + Drainable Pouch
Natura + Drainable Pouch
PRODUCT #
416406
416405
MFR
CON
CON
95098062
95098063
Natura + Drainable Pouch
Natura + Drainable Pouch
416404
416403
CON
CON
95098075
95098074
Natura + Drainable Pouch
Natura + Drainable Pouch
416417
416420
CON
CON
95098073
95098072
Natura + Drainable Pouch
Natura + Drainable Pouch
416423
416418
CON
CON
95098071
95098070
Natura + Drainable Pouch
Natura + Drainable Pouch
416421
416424
CON
CON
95098069
95098068
Natura + Drainable Pouch
Natura + Drainable Pouch
416472
416419
CON
CON
95098067
95098066
Natura + Drainable Pouch
Natura + Drainable Pouch
416422
416400
CON
CON
95098065
95098064
Natura + Drainable Pouch
Natura + Drainable Pouch
416401
416402
CON
CON
95098529
95098530
New Image Closed
New Image Closed
18333
18332
HOL
HOL
95098627
95098622
New Image Closed
New Image Closed
18362
18374
HOL
HOL
95098624
95098626
New Image Closed
New Image Closed
18372
18363
HOL
HOL
95098528
95098623
New Image Closed
New Image Closed
18334
18373
HOL
HOL
95098625
95098526
New Image Closed
New Image Closed Mini
18364
18353
HOL
HOL
95098525
95098527
New Image Closed Mini
New Image Closed Mini
18354
18352
HOL
HOL
95098636
95098634
New Image Dr Lock'n Roll
New Image Dr Lock'n Roll
18282
18284
HOL
HOL
95098637
95098639
New Image Dr Lock'n Roll
New Image Dr Lock'n Roll
18294
18292
HOL
HOL
95098638
95098635
New Image Dr Lock'n Roll
New Image Dr Lock'n Roll
18293
18283
HOL
HOL
95098047
95099564
New Image Drainable
New Image Drainable
18013
18204
HOL
HOL
95099562
95099565
New Image Drainable
New Image Drainable
18143
18203
HOL
HOL
95098048
95099566
New Image Drainable
New Image Drainable
18014
18202
HOL
HOL
95099561
95099563
New Image Drainable
New Image Drainable
18144
18142
HOL
HOL
95099570
95099571
New Image Drainable
New Image Drainable
18124
18123
HOL
HOL
95099572
95099567
New Image Drainable
New Image Drainable
18122
18104
HOL
HOL
95099568
95099569
New Image Drainable
New Image Drainable
18103
18102
HOL
HOL
February 2016
257
Ostomy Supplies Benefit List
POUCHES (OPEN-CLOSED) (2 PIECE)
PIN
95099547
95099548
PRODUCT DESCRIPTION
New Image Irrigator Drain
New Image Irrigator Drain
PRODUCT #
18153
18152
MFR
HOL
HOL
95099546
95099580
New Image Irrigator Drain
New Image Lock'n Roll
18154
18133
HOL
HOL
95098632
95099584
New Image Lock'n Roll
New Image Lock'n Roll
18004
18112
HOL
HOL
95099583
95099581
New Image Lock'n Roll
New Image Lock'n Roll
18113
18132
HOL
HOL
95099579
95098629
New Image Lock'n Roll
New Image Lock'n Roll
18134
18174
HOL
HOL
95099577
95099576
New Image Lock'n Roll
New Image Lock'n Roll
18183
18184
HOL
HOL
95099574
95098633
New Image Lock'n Roll
New Image Lock'n Roll
18193
18003
HOL
HOL
95098630
95099578
New Image Lock'n Roll
New Image Lock'n Roll
18173
18182
HOL
HOL
95099582
95099575
New Image Lock'n Roll
New Image Lock'n Roll
18114
18192
HOL
HOL
95098631
95099573
New Image Lock'n Roll
New Image Lock'n Roll
18006
18194
HOL
HOL
95098617
95098616
New Image Mini
New Image Mini
18393
18394
HOL
HOL
95098618
95099559
New Image Mini
New Image Urostomy
18392
18413
HOL
HOL
95099555
95099556
New Image Urostomy
New Image Urostomy
18404
18403
HOL
HOL
95098614
95099558
New Image Urostomy
New Image Urostomy
18423
18414
HOL
HOL
95099560
95099557
New Image Urostomy
New Image Urostomy
18412
18402
HOL
HOL
95098615
95098555
New Image Urostomy
Overnight Drainage Bag
18422
9839
HOL
HOL
95098319
95098384
Sensura Closed
Sensura Closed
10905
10155
COL
COL
95098383
95098382
Sensura Closed
Sensura Closed
10156
10164
COL
COL
95098380
95098385
Sensura Closed
Sensura Closed
10166
10154
COL
COL
95098381
95098320
Sensura Closed
Sensura Closed
10165
10904
COL
COL
95098317
95098376
Sensura Closed
Sensura Closed
10915
10918
COL
COL
95098318
95098392
Sensura Closed
Sensura Easiclose
10914
11135
COL
COL
95098398
95098397
Sensura Easiclose
Sensura Easiclose
11114
11115
COL
COL
95098395
95098391
Sensura Easiclose
Sensura Easiclose
11124
11136
COL
COL
February 2016
258
Ostomy Supplies Benefit List
POUCHES (OPEN-CLOSED) (2 PIECE)
PIN
95098394
95098386
PRODUCT DESCRIPTION
Sensura Easiclose
Sensura Easiclose
PRODUCT #
11125
11186
MFR
COL
COL
95098390
95098389
Sensura Easiclose
Sensura Easiclose
11194
11195
COL
COL
95098388
95098393
Sensura Easiclose
Sensura Easiclose
11196
11126
COL
COL
95098387
95098356
Sensura Easiclose
Sensura Flex Dr Pouch
11185
11615
COL
COL
95098358
95098361
Sensura Flex Dr Pouch
Sensura Flex Dr Pouch
11518
11505
COL
COL
95098360
95098359
Sensura Flex Dr Pouch
Sensura Flex Dr Pouch
11514
11515
COL
COL
95097990
95097989
Sensura Mio Click Maxi
Sensura Mio Click Maxi
11474
11482
COL
COL
95097988
95097991
Sensura Mio Click Maxi
Sensura Mio Click Maxi
11483
11473
COL
COL
95097949
95097992
Sensura Mio Click Maxi
Sensura Mio Click Maxi
11484
11472
COL
COL
95097995
95097994
Sensura Mio Click Maxi
Sensura Mio Click Maxi
11462
11463
COL
COL
95097993
95097996
Sensura Mio Click Midi
Sensura Mio Click Midi
11471
11461
COL
COL
95097998
95097997
Sensura Mio Closed
Sensura Mio Closed
12222
12213
COL
COL
95098000
95098001
Sensura Mio Closed
Sensura Mio Closed
12202
12201
COL
COL
95098003
95097999
Sensura Mio Closed
Sensura Mio Closed
11422
12212
COL
COL
95097948
95098004
Sensura Mio Closed
Sensura Mio Closed
11421
11413
COL
COL
95098005
95098006
Sensura Mio Closed
Sensura Mio Closed
11412
11402
COL
COL
95098007
95097979
Sensura Mio Closed
Sensura Mio Flex Maxi
11401
12274
COL
COL
95097978
95097977
Sensura Mio Flex Maxi
Sensura Mio Flex Maxi
12282
12284
COL
COL
95097983
95097981
Sensura Mio Flex Maxi
Sensura Mio Flex Midi
12262
12271
COL
COL
95098308
95098310
Sensura Urostomy Pouch
Sensura Urostomy Pouch
11825
11822
COL
COL
95098311
95098309
Sensura Urostomy Pouch
Sensura Urostomy Pouch
11821
11824
COL
COL
95098307
95098306
Sensura Urostomy Pouch
Sensura Urostomy Pouch
11827
11828
COL
COL
95099800
95099802
Sur-Fit AutoLock Accuseal
Sur-Fit AutoLock Accuseal
401465
401463
CON
CON
95099804
95099801
Sur-Fit AutoLock Accuseal
Sur-Fit AutoLock Accuseal
401461
401464
CON
CON
February 2016
259
Ostomy Supplies Benefit List
POUCHES (OPEN-CLOSED) (2 PIECE)
PIN
95099807
95099805
PRODUCT DESCRIPTION
Sur-Fit AutoLock Accuseal
Sur-Fit AutoLock Accuseal
PRODUCT #
401452
401460
MFR
CON
CON
95099803
95099806
Sur-Fit AutoLock Accuseal
Sur-Fit AutoLock Accuseal
401462
401453
CON
CON
95099788
95099789
Sur-Fit AutoLock Closed
Sur-Fit AutoLock Closed
401680
401679
CON
CON
95099791
95099790
Sur-Fit AutoLock Closed
Sur-Fit AutoLock Closed
401677
401678
CON
CON
95099815
95099813
Sur-Fit AutoLock Drainable
Sur-Fit AutoLock Drainable
401435
401437
CON
CON
95099811
95099810
Sur-Fit AutoLock Drainable
Sur-Fit AutoLock Drainable
401440
401441
CON
CON
95099808
95099816
Sur-Fit AutoLock Drainable
Sur-Fit AutoLock Drainable
401443
401434
CON
CON
95099814
95099812
Sur-Fit AutoLock Drainable
Sur-Fit AutoLock Drainable
401436
401439
CON
CON
95099809
95099716
Sur-Fit AutoLock Drainable
Sur-Fit Natura Accuseal
401442
401549
CON
CON
95099714
95099710
Sur-Fit Natura Accuseal
Sur-Fit Natura Accuseal
401551
401555
CON
CON
95099711
95099719
Sur-Fit Natura Accuseal
Sur-Fit Natura Accuseal
401554
401546
CON
CON
95099721
95099723
Sur-Fit Natura Accuseal
Sur-Fit Natura Accuseal
401544
401542
CON
CON
95099713
95099715
Sur-Fit Natura Accuseal
Sur-Fit Natura Accuseal
401552
401550
CON
CON
95099717
95099718
Sur-Fit Natura Accuseal
Sur-Fit Natura Accuseal
401548
401547
CON
CON
95099720
95099722
Sur-Fit Natura Accuseal
Sur-Fit Natura Accuseal
401545
401543
CON
CON
95099712
95099724
Sur-Fit Natura Accuseal
Sur-Fit Natura Bendable
401553
401541
CON
CON
95099729
95099732
Sur-Fit Natura Bendable
Sur-Fit Natura Bendable
401536
401533
CON
CON
95099730
95099728
Sur-Fit Natura Bendable
Sur-Fit Natura Bendable
401535
401537
CON
CON
95099727
95099726
Sur-Fit Natura Bendable
Sur-Fit Natura Bendable
401538
401539
CON
CON
95099725
95099731
Sur-Fit Natura Bendable
Sur-Fit Natura Bendable
401540
401534
CON
CON
95099744
95099743
Sur-Fit Natura Closed
Sur-Fit Natura Closed
401521
401522
CON
CON
95099742
95099741
Sur-Fit Natura Closed
Sur-Fit Natura Closed
401523
401524
CON
CON
95099737
95099738
Sur-Fit Natura Closed
Sur-Fit Natura Closed
401528
401527
CON
CON
95099739
95099740
Sur-Fit Natura Closed
Sur-Fit Natura Closed
401526
401525
CON
CON
February 2016
260
Ostomy Supplies Benefit List
POUCHES (OPEN-CLOSED) (2 PIECE)
PIN
95098689
95098687
PRODUCT DESCRIPTION
Sur-Fit Natura Drainable
Sur-Fit Natura Drainable
PRODUCT #
411491
411493
MFR
CON
CON
95099759
95099757
Sur-Fit Natura Drainable
Sur-Fit Natura Drainable
401501
401503
CON
CON
95099755
95099752
Sur-Fit Natura Drainable
Sur-Fit Natura Drainable
401505
401508
CON
CON
95099750
95099748
Sur-Fit Natura Drainable
Sur-Fit Natura Drainable
401510
401512
CON
CON
95099746
95099688
Sur-Fit Natura Drainable
Sur-Fit Natura Drainable
401514
404015
CON
CON
95099686
95098759
Sur-Fit Natura Drainable
Sur-Fit Natura Drainable
404017
404025
CON
CON
95098757
95098754
Sur-Fit Natura Drainable
Sur-Fit Natura Drainable
404027
404030
CON
CON
95098752
95098750
Sur-Fit Natura Drainable
Sur-Fit Natura Drainable
404032
404034
CON
CON
95098694
95098692
Sur-Fit Natura Drainable
Sur-Fit Natura Drainable
411265
411267
CON
CON
95098685
95098683
Sur-Fit Natura Drainable
Sur-Fit Natura Drainable
411289
411291
CON
CON
95098690
95098688
Sur-Fit Natura Drainable
Sur-Fit Natura Drainable
411490
411492
CON
CON
95099760
95099758
Sur-Fit Natura Drainable
Sur-Fit Natura Drainable
401500
401502
CON
CON
95099756
95099754
Sur-Fit Natura Drainable
Sur-Fit Natura Drainable
401504
401506
CON
CON
95099753
95099751
Sur-Fit Natura Drainable
Sur-Fit Natura Drainable
401507
401509
CON
CON
95099749
95099747
Sur-Fit Natura Drainable
Sur-Fit Natura Drainable
401511
401513
CON
CON
95099745
95099689
Sur-Fit Natura Drainable
Sur-Fit Natura Drainable
401515
404014
CON
CON
95099687
95099685
Sur-Fit Natura Drainable
Sur-Fit Natura Drainable
404016
404018
CON
CON
95098758
95098756
Sur-Fit Natura Drainable
Sur-Fit Natura Drainable
404026
404028
CON
CON
95098755
95098753
Sur-Fit Natura Drainable
Sur-Fit Natura Drainable
404029
404031
CON
CON
95098751
95098696
Sur-Fit Natura Drainable
Sur-Fit Natura Drainable
404033
411263
CON
CON
95098695
95098693
Sur-Fit Natura Drainable
Sur-Fit Natura Drainable
411264
411266
CON
CON
95098686
95098684
Sur-Fit Natura Drainable
Sur-Fit Natura Drainable
411288
411290
CON
CON
95098682
95098691
Sur-Fit Natura Drainable
Sur-Fit Natura Drainable
411292
411489
CON
CON
95099698
95099696
Sur-Fit Natura Flange Cap
Sur-Fit Natura Flange Cap
401908
401910
CON
CON
February 2016
261
Ostomy Supplies Benefit List
POUCHES (OPEN-CLOSED) (2 PIECE)
PIN
95099697
95098742
PRODUCT DESCRIPTION
Sur-Fit Natura Flange Cap
Sur-Fit Natura Invisiclose
PRODUCT #
401909
413312
MFR
CON
CON
95098741
95098740
Sur-Fit Natura Invisiclose
Sur-Fit Natura Invisiclose
413313
413314
CON
CON
95098749
95098539
Sur-Fit Natura Invisiclose
Sur-Fit Natura Invisiclose
413332
411309
CON
CON
95098537
95098534
Sur-Fit Natura Invisiclose
Sur-Fit Natura Invisiclose
411311
411361
CON
CON
95098743
95098748
Sur-Fit Natura Invisiclose
Sur-Fit Natura Invisiclose
413311
413333
CON
CON
95098747
95098746
Sur-Fit Natura Invisiclose
Sur-Fit Natura Invisiclose
413334
413335
CON
CON
95098745
95098533
Sur-Fit Natura Invisiclose
Sur-Fit Natura Invisiclose
413336
411362
CON
CON
95098535
95098538
Sur-Fit Natura Invisiclose
Sur-Fit Natura Invisiclose
411360
411310
CON
CON
95098536
95099851
Sur-Fit Natura Invisiclose
Sur-Fit Natura Little Ones
411312
401930
CON
CON
95099853
95099854
Sur-Fit Natura Little Ones
Sur-Fit Natura Little Ones
401928
401927
CON
CON
95099852
95099736
Sur-Fit Natura Little Ones
Sur-Fit Natura Mini
401929
401529
CON
CON
95099735
95099734
Sur-Fit Natura Mini
Sur-Fit Natura Mini
401530
401531
CON
CON
95099733
Sur-Fit Natura Mini
401532
CON
SKIN BARRIER / ADHESIVES
PIN
95099150
PRODUCT DESCRIPTION
Adapt Barrier Strips
PRODUCT #
79400
MFR
HOL
95099147
95099148
Adapt Convex Barrier Rings
Adapt Convex Barrier Rings
79540
79530
HOL
HOL
95099149
95098049
Adapt Convex Barrier Rings
Adapt Convex Barrier Rings
79520
79601
HOL
HOL
95098051
95098050
Adapt Convex Barrier Rings
Adapt Convex Barrier Rings
79602
79603
HOL
HOL
95098052
95099151
Adapt Paste
Adapt Paste
79301
79300
HOL
HOL
95099145
95099146
Adapt Skin Barrier Rings
Adapt Skin Barrier Rings
7806
7805
HOL
HOL
95097894
95099871
Adapt Slim Barrier Ring
Allkare Protective Barrier Wipe
7815
37444
HOL
CON
95099870
95097910
Allkare Protective Barrier Wipe
CeraPlus Skin Barrier
37439
11404
CON
HOL
95097911
95097912
CeraPlus Skin Barrier
CeraPlus Skin Barrier
11503
11504
HOL
HOL
95097914
95097913
CeraPlus Skin Barrier
CeraPlus Skin Barrier
11506
11505
HOL
HOL
95097906
95097907
CeraPlus Skin Barrier
CeraPlus Skin Barrier
11203
11204
HOL
HOL
February 2016
262
Ostomy Supplies Benefit List
SKIN BARRIER / ADHESIVES
PIN
95097908
95097909
PRODUCT DESCRIPTION
CeraPlus Skin Barrier
CeraPlus Skin Barrier
PRODUCT #
11402
11403
MFR
HOL
HOL
95097905
95098876
CeraPlus Skin Barrier
Coloplast Ostomy Paste
11202
2650
HOL
COL
95098875
95098866
Coloplast Ostomy Strip Paste
Coloplast Prep Barrier
2655
925
COL
COL
95098867
95098879
Coloplast Prep Barrier Wipe
Coloplast Skin Barrier
2041
3210
COL
COL
95098878
95098877
Coloplast Skin Barrier
Coloplast Skin Barrier
3215
3220
COL
COL
95098870
95098868
Coloplast Skin Barrier Rings
Coloplast Skin Barrier Rings
2330
2350
COL
COL
95098869
95098871
Coloplast Skin Barrier Rings
Coloplast Skin Barrier Rings
2340
2325
COL
COL
95098872
95099861
Coloplast Skin Barrier Rings
Eakin Cohesive Seals
2320
839001
COL
CON
95099860
95098352
Eakin Cohesive Seals
Eakin Cohesive Seals - Slim
839002
839005
CON
CON
95099859
95099858
Eakin Cohesive Skin Barrier
Eakin Cohesive Skin Barrier
839003
839004
CON
CON
95099157
95099156
Flextend Ext Wear Skin Barrier
Flextend Ext Wear Skin Barrier
8800
8801
HOL
HOL
95098267
95098268
FormaFlex Shape-to-Fit Skin Barrier
FormaFlex Shape-to-Fit Skin Barrier
14103
14102
HOL
HOL
95098266
95099152
FormaFlex Shape-to-Fit Skin Barrier
Hollihesive Skin Barrier
14104
7701
HOL
HOL
95099153
95099132
Hollihesive Skin Barrier
Medical Adhesive
7700
7730
HOL
HOL
95098252
95098251
Mouldable Rings (3.0mm)
Mouldable Rings (4.2mm)
12030
12042
COL
COL
95098041
95098040
Night Drainage Bag
Night Drainage Bag Adapter
ZL0400
NDA6
ARG
ARG
95099142
95099154
Premium Powder
Premium Skin Barrier
7906
7801
HOL
HOL
95099155
95098037
Premium Skin Barrier
Protective Wipes
7800
PW1515
HOL
ARG
95098036
95098233
Protective Wipes
SecuPlast Hydro Stips Aloe
PW1010
SPHA2
ARG
ARG
95098234
95098237
SecuPlast Hydro Strips
SecuPlast Mouldable Seals
SPH1
SMSL
ARG
ARG
95098236
95098235
SecuPlast Mouldable Seals
SecuPlast Mouldable Seals
SMSS
SMST
ARG
ARG
95097939
95099134
Sensi-Care Protective Barrier Wipe
Skin Gel Protective Wipes
413501
7917
CON
HOL
93299586
93299587
Skin-Prep Protective Barrier
Skin-Prep Protective Barrier
420425
420279
SNE
SNE
95098127
95099864
Stoma Paste
Stomahesive Paste Tube
SP60
183910
ARG
CON
February 2016
263
Ostomy Supplies Benefit List
SKIN BARRIER / ADHESIVES
PIN
95099880
95099879
PRODUCT DESCRIPTION
Stomahesive Protective Pdr
Stomahesive Skin Barrier
PRODUCT #
25510
21712
MFR
CON
CON
95099878
95099868
Stomahesive Skin Barrier
Urihesive Strips
21715
173929
CON
CON
SKIN BARRIERS OR WAFERS W FLANGE (2 PIECE)
PIN
95099118
95098552
PRODUCT DESCRIPTION
Assura E-E Wear
Assura E-E Wear
PRODUCT #
2831
14283
MFR
COL
COL
95099105
95099103
Assura E-E Wear
Assura E-E Wear
14232
14234
COL
COL
95099101
95099099
Assura E-E Wear
Assura E-E Wear
14236
14238
COL
COL
95099098
95099114
Assura E-E Wear
Assura E-E Wear
14239
14246
COL
COL
95099111
95099109
Assura E-E Wear
Assura E-E Wear
14251
14254
COL
COL
95099107
95099106
Assura E-E Wear
Assura E-E Wear
14257
14258
COL
COL
95098553
95098551
Assura E-E Wear
Assura E-E Wear
14282
14291
COL
COL
95098550
95098549
Assura E-E Wear
Assura E-E Wear
14292
14293
COL
COL
95098548
95098547
Assura E-E Wear
Assura E-E Wear
14294
14295
COL
COL
95098546
95098545
Assura E-E Wear
Assura E-E Wear
14296
14297
COL
COL
95098544
95099117
Assura E-E Wear
Assura E-E Wear
14298
2832
COL
COL
95099116
95099104
Assura E-E Wear
Assura E-E Wear
2833
14233
COL
COL
95099102
95099100
Assura E-E Wear
Assura E-E Wear
14235
14237
COL
COL
95099115
95099113
Assura E-E Wear
Assura E-E Wear
14243
14249
COL
COL
95099110
95099108
Assura E-E Wear
Assura E-E Wear
14252
14255
COL
COL
95098554
95098888
Assura E-E Wear
Assura Pediatric
14281
2181
COL
COL
95099075
95099094
Assura Std Wear
Assura Std Wear
12708
12716
COL
COL
95099088
95099086
Assura Std Wear
Assura Std Wear
12841
12844
COL
COL
95099084
95099083
Assura Std Wear
Assura Std Wear
12847
12848
COL
COL
95099091
95099073
Assura Std Wear
Assura Std Wear
14262
14271
COL
COL
95099097
95099096
Assura Std Wear
Assura Std Wear
2881
2882
COL
COL
February 2016
264
Ostomy Supplies Benefit List
SKIN BARRIERS OR WAFERS W FLANGE (2 PIECE)
PIN
95099095
95099082
PRODUCT DESCRIPTION
Assura Std Wear
Assura Std Wear
PRODUCT #
2883
12701
MFR
COL
COL
95099080
95099078
Assura Std Wear
Assura Std Wear
12703
12705
COL
COL
95099076
95099070
Assura Std Wear
Assura Std Wear
12707
14274
COL
COL
95099067
95099071
Assura Std Wear
Assura Std Wear
14277
14273
COL
COL
95099069
95099068
Assura Std Wear
Assura Std Wear
14275
14276
COL
COL
95099066
95099081
Assura Std Wear
Assura Std Wear
14278
12702
COL
COL
95099079
95099077
Assura Std Wear
Assura Std Wear
12704
12706
COL
COL
95099074
95099093
Assura Std Wear
Assura Std Wear
12709
12719
COL
COL
95099087
95099085
Assura Std Wear
Assura Std Wear
12842
12845
COL
COL
95099092
95099090
Assura Std Wear
Assura Std Wear
14261
14263
COL
COL
95099072
95099544
Assura Std Wear
CenterPointLock Floating
14272
3762
COL
HOL
95099515
95099545
CenterPointLock Floating
CenterPointLock Floating
37310
3767
HOL
HOL
95099541
95099542
CenterPointLock Floating
CenterPointLock Floating
3766
3764
HOL
HOL
95099543
95099526
CenterPointLock Floating
CenterPointLock Floating
3763
3749
HOL
HOL
95099530
95099527
CenterPointLock Floating
CenterPointLock Floating
3747
3743
HOL
HOL
95099516
95099518
CenterPointLock Floating
CenterPointLock Floating
3739
3737
HOL
HOL
95099520
95099522
CenterPointLock Floating
CenterPointLock Floating
3735
3733
HOL
HOL
95099523
95099525
CenterPointLock Floating
CenterPointLock Floating
3732
3730
HOL
HOL
95099536
95099538
CenterPointLock Floating
CenterPointLock Floating
3726
3723
HOL
HOL
95099535
95099531
CenterPointLock Floating
CenterPointLock Floating
3707
3706
HOL
HOL
95099533
95099514
CenterPointLock Floating
CenterPointLock Floating
3703
37311
HOL
HOL
95099528
95099529
CenterPointLock Floating
CenterPointLock Floating
3748
3742
HOL
HOL
95099517
95099534
CenterPointLock Floating
CenterPointLock Floating
3738
3702
HOL
HOL
95099532
95099539
CenterPointLock Floating
CenterPointLock Floating
3704
3722
HOL
HOL
February 2016
265
Ostomy Supplies Benefit List
SKIN BARRIERS OR WAFERS W FLANGE (2 PIECE)
PIN
95099537
95099540
PRODUCT DESCRIPTION
CenterPointLock Floating
CenterPointLock Floating
PRODUCT #
3724
3727
MFR
HOL
HOL
95099524
95099521
CenterPointLock Floating
CenterPointLock Floating
3731
3734
HOL
HOL
95099519
95099509
CenterPointLock Floating
CenterPointLock Premier Flex
3736
8743
HOL
HOL
95099512
95099485
CenterPointLock Premier Flex
CenterPointLock Premier Flex
8722
8735
HOL
HOL
95099488
95099490
CenterPointLock Premier Flex
CenterPointLock Premier Flex
8732
87711
HOL
HOL
95099501
95099504
CenterPointLock Premier Flex
CenterPointLock Premier Flex
8753
8748
HOL
HOL
95099506
95099491
CenterPointLock Premier Flex
CenterPointLock Premier Flex
8746
8778
HOL
HOL
95099492
95099500
CenterPointLock Premier Flex
CenterPointLock Premier Flex
8774
8754
HOL
HOL
95099502
95099505
CenterPointLock Premier Flex
CenterPointLock Premier Flex
8752
8747
HOL
HOL
95099507
95099508
CenterPointLock Premier Flex
CenterPointLock Premier Flex
8745
8744
HOL
HOL
95099482
95099484
CenterPointLock Premier Flex
CenterPointLock Premier Flex
8738
8736
HOL
HOL
95099486
95099487
CenterPointLock Premier Flex
CenterPointLock Premier Flex
8734
8733
HOL
HOL
95099489
95099513
CenterPointLock Premier Flex
CenterPointLock Premier Flex
8731
8727
HOL
HOL
95099510
95099511
CenterPointLock Premier Flex
CenterPointLock Premier Flex
8724
8723
HOL
HOL
95099483
95098837
CenterPointLock Premier Flex
Easiflex E-E Wear
8737
14301
HOL
COL
95098839
95098836
Easiflex E-E Wear
Easiflex E-E Wear
14305
14302
COL
COL
95098977
95098838
Easiflex E-E Wear
Easiflex E-E Wear
14304
14306
COL
COL
95098835
95098477
Easiflex E-E Wear
Easiflex Std Wear
14303
14402
COL
COL
95098466
95098543
Easiflex Std Wear
Easiflex Std Wear
14406
14309
COL
COL
95098468
95098467
Easiflex Std Wear
Easiflex Std Wear
14401
14403
COL
COL
95099905
95099906
Esteem Synergy Dura Mold
Esteem Synergy Dura Mold
409269
409268
CON
CON
95099904
95099914
Esteem Synergy Dura Mold
Esteem Synergy Stomahesive
409270
405475
CON
CON
95099911
95099909
Esteem Synergy Stomahesive
Esteem Synergy Stomahesive
405478
405480
CON
CON
95099916
95099920
Esteem Synergy Stomahesive
Esteem Synergy Stomahesive
405473
405468
CON
CON
February 2016
266
Ostomy Supplies Benefit List
SKIN BARRIERS OR WAFERS W FLANGE (2 PIECE)
PIN
95099922
95099919
PRODUCT DESCRIPTION
Esteem Synergy Stomahesive
Esteem Synergy Stomahesive
PRODUCT #
405458
403948
MFR
CON
CON
95099918
95099908
Esteem Synergy Stomahesive
Esteem Synergy Stomahesive
405483
405481
CON
CON
95099907
95099912
Esteem Synergy Stomahesive
Esteem Synergy Stomahesive
405482
405477
CON
CON
95099913
95099915
Esteem Synergy Stomahesive
Esteem Synergy Stomahesive
405476
405474
CON
CON
95099917
95099921
Esteem Synergy Stomahesive
Esteem Synergy Stomahesive
405472
405467
CON
CON
95099923
95099924
Esteem Synergy Stomahesive
Esteem Synergy Stomahesive
405457
405456
CON
CON
95099910
95098269
Esteem Synergy Stomahesive
First Choice Drainable
405479
8131
CON
HOL
95098130
95098129
Harmony Duo
Harmony Duo
HD1332
HD1350
ARG
ARG
95098128
95098131
Harmony Duo
Harmony Duo Flexible
HD1370
HDF1370
ARG
ARG
95098132
95098133
Harmony Duo Flexible
Harmony Duo Flexible
HDF1350
HDF1332
ARG
ARG
95098162
95098165
Harmony Duo Flexible w Aloe
Harmony Duo Flexible w Aloe
FHDF32
FHDF21
ARG
ARG
95098160
95098161
Harmony Duo Flexible w Aloe
Harmony Duo Flexible w Aloe
FHDF38
FHDF35
ARG
ARG
95098163
95098164
Harmony Duo Flexible w Aloe
Harmony Duo Flexible w Aloe
FHDF28
FHDF25
ARG
ARG
95098166
95098167
Harmony Duo Flexible w Aloe
Harmony Duo Flexible w Aloe
FHDF1370
FHDF1350
ARG
ARG
95098168
95098134
Harmony Duo Flexible w Aloe
Harmony Duo Pouch
FHDF1332
HDD1370
ARG
ARG
95098144
95098135
Harmony Duo Pouch
Harmony Duo Pouch
HDDL1332
HDD1350
ARG
ARG
95098136
95098148
Harmony Duo Pouch
Harmony Duo Pouch
HDD1332
HDCL1370
ARG
ARG
95098149
95098150
Harmony Duo Pouch
Harmony Duo Pouch
HDCL1350
HDCL1332
ARG
ARG
95098145
95098146
Harmony Duo Pouch
Harmony Duo Pouch
HDC1370
HDC1350
ARG
ARG
95098147
95098143
Harmony Duo Pouch
Harmony Duo Pouch
HDC1332
HDDL1350
ARG
ARG
95098142
95098141
Harmony Duo Pouch
Harmony Duo Pouch
HDDL1370
HDDLT1350
ARG
ARG
95098137
95098140
Harmony Duo Pouch
Harmony Duo Pouch
HDDS1370
HDDLT1370
ARG
ARG
95098139
95098138
Harmony Duo Pouch
Harmony Duo Pouch
HDDLT1332
HDDS1350
ARG
ARG
95098159
95098155
Harmony Duo w Aloe
Harmony Duo w Aloe
FHD1332
FHD25
ARG
ARG
February 2016
267
Ostomy Supplies Benefit List
SKIN BARRIERS OR WAFERS W FLANGE (2 PIECE)
PIN
95098154
95098153
PRODUCT DESCRIPTION
Harmony Duo w Aloe
Harmony Duo w Aloe
PRODUCT #
FHD28
FHD32
MFR
ARG
ARG
95098156
95098151
Harmony Duo w Aloe
Harmony Duo w Aloe
FHD21
FHD38
ARG
ARG
95098157
95098158
Harmony Duo w Aloe
Harmony Duo w Aloe
FHD1370
FHD1350
ARG
ARG
95098152
95098522
Harmony Duo w Aloe
New Image Floating
FHD35
14901
ARG
HOL
95098520
95098518
New Image Floating
New Image Floating
14907
14909
HOL
HOL
95098516
95098521
New Image Floating
New Image Floating
14911
14902
HOL
HOL
95098519
95098517
New Image Floating
New Image Floating
14908
14910
HOL
HOL
95098731
95098729
New Image Flat w Tape
New Image Flat w Tape
14301
14303
HOL
HOL
95098718
95098531
New Image Flat w Tape
New Image Flat w Tape
14706
14709
HOL
HOL
95098724
95098532
New Image Flat w Tape
New Image Flat w Tape
14308
14309
HOL
HOL
95098723
95098722
New Image Flat w Tape
New Image Flat w Tape
14701
14702
HOL
HOL
95098721
95098720
New Image Flat w Tape
New Image Flat w Tape
14703
14704
HOL
HOL
95098719
95098717
New Image Flat w Tape
New Image Flat w Tape
14705
14707
HOL
HOL
95098716
95098730
New Image Flat w Tape
New Image Flat w Tape
14708
14302
HOL
HOL
95098728
95098727
New Image Flat w Tape
New Image Flat w Tape
14304
14305
HOL
HOL
95098726
95098725
New Image Flat w Tape
New Image Flat w Tape
14306
14307
HOL
HOL
95098704
95098701
New Image Flat w/o Tape
New Image Flat w/o Tape
16104
16107
HOL
HOL
95098709
95098710
New Image Flat w/o Tape
New Image Flat w/o Tape
16407
16406
HOL
HOL
95098712
95098714
New Image Flat w/o Tape
New Image Flat w/o Tape
16404
16402
HOL
HOL
95098700
95098702
New Image Flat w/o Tape
New Image Flat w/o Tape
16108
16106
HOL
HOL
95098703
95098705
New Image Flat w/o Tape
New Image Flat w/o Tape
16105
16103
HOL
HOL
95098707
95098706
New Image Flat w/o Tape
New Image Flat w/o Tape
16101
16102
HOL
HOL
95098708
95098711
New Image Flat w/o Tape
New Image Flat w/o Tape
16408
16405
HOL
HOL
95098713
95098715
New Image Flat w/o Tape
New Image Flat w/o Tape
16403
16401
HOL
HOL
February 2016
268
Ostomy Supplies Benefit List
SKIN BARRIERS OR WAFERS W FLANGE (2 PIECE)
PIN
95099598
95099585
PRODUCT DESCRIPTION
New Image Floating
New Image Floating
PRODUCT #
15402
15906
MFR
HOL
HOL
95099593
95099592
New Image Floating
New Image Floating
15505
15506
HOL
HOL
95099637
95099636
New Image Floating
New Image Floating
15602
15603
HOL
HOL
95099635
95099591
New Image Floating
New Image Floating
15604
15802
HOL
HOL
95099590
95099589
New Image Floating
New Image Floating
15803
15804
HOL
HOL
95099588
95099587
New Image Floating
New Image Floating
15903
15904
HOL
HOL
95099586
95099646
New Image Floating
New Image Floating
15905
14202
HOL
HOL
95099644
95099611
New Image Floating
New Image Floating
14204
14403
HOL
HOL
95099609
95099608
New Image Floating
New Image Floating
14503
14504
HOL
HOL
95099606
95099642
New Image Floating
New Image Floating
14506
14603
HOL
HOL
95099605
95099603
New Image Floating
New Image Floating
14802
14804
HOL
HOL
95099602
95099600
New Image Floating
New Image Floating
14903
14905
HOL
HOL
95099640
95099639
New Image Floating
New Image Floating
15202
15203
HOL
HOL
95099599
95099601
New Image Floating
New Image Floating
14906
14904
HOL
HOL
95099604
95099641
New Image Floating
New Image Floating
14803
14604
HOL
HOL
95099643
95099607
New Image Floating
New Image Floating
14602
14505
HOL
HOL
95099610
95099612
New Image Floating
New Image Floating
14404
14402
HOL
HOL
95099645
95099594
New Image Floating
New Image Floating
14203
15504
HOL
HOL
95099596
95099597
New Image Floating
New Image Floating
15404
15403
HOL
HOL
95099638
95099595
New Image Floating
New Image Floating
15204
15503
HOL
HOL
95098283
95098333
Sensura Flex Skin
Sensura Flex Skin
11301
10101
COL
COL
95098277
95098274
Sensura Flex Skin
Sensura Flex Skin
11307
11313
COL
COL
95098272
95098363
Sensura Flex Skin
Sensura Flex Skin
11315
11316
COL
COL
95098273
95098275
Sensura Flex Skin
Sensura Flex Skin
11314
11312
COL
COL
February 2016
269
Ostomy Supplies Benefit List
SKIN BARRIERS OR WAFERS W FLANGE (2 PIECE)
PIN
95098281
95098322
PRODUCT DESCRIPTION
Sensura Flex Skin
Sensura Flex Skin
PRODUCT #
11303
10117
MFR
COL
COL
95098324
95098326
Sensura Flex Skin
Sensura Flex Skin
10114
10111
COL
COL
95098377
95098323
Sensura Flex Skin
Sensura Flex Skin
10103
10116
COL
COL
95098325
95098327
Sensura Flex Skin
Sensura Flex Skin
10113
10108
COL
COL
95098332
95098282
Sensura Flex Skin
Sensura Flex Skin
10102
11302
COL
COL
95097971
95097974
Sensura Mio Click
Sensura Mio Click
10515
10504
COL
COL
95097975
95097976
Sensura Mio Click
Sensura Mio Click
10503
10502
COL
COL
95097969
95097970
Sensura Mio Click
Sensura Mio Click
10531
10522
COL
COL
95097972
95097973
Sensura Mio Click
Sensura Mio Click
10513
10512
COL
COL
95097964
95097965
Sensura Mio Flex
Sensura Mio Flex
10563
10562
COL
COL
95097967
95097962
Sensura Mio Flex
Sensura Mio Flex
10561
10571
COL
COL
95097963
95097968
Sensura Mio Flex
Sensura Mio Flex
10564
10551
COL
COL
95098402
95098406
Sensura Std Wear
Sensura Std Wear
11022
11011
COL
COL
95098409
95098412
Sensura Std Wear
Sensura Std Wear
10022
10031
COL
COL
95098404
95098410
Sensura Std Wear
Sensura Std Wear
11031
10013
COL
COL
95098414
95098411
Sensura Std Wear
Sensura Std Wear
10011
10012
COL
COL
95098413
95098408
Sensura Std Wear
Sensura Std Wear
10021
10023
COL
COL
95098407
95098403
Sensura Std Wear
Sensura Std Wear
10032
11012
COL
COL
95098400
95098399
Sensura Std Wear
Sensura Std Wear
11024
11032
COL
COL
95098401
95098405
Sensura Std Wear
Sensura Std Wear
11023
11021
COL
COL
95099818
95099817
Sur-Fit AutoLock Dura Flex
Sur-Fit AutoLock Dura Flex
401431
401432
CON
CON
95099820
95099822
Sur-Fit AutoLock Dura Flex
Sur-Fit AutoLock Dura Flex
401429
401307
CON
CON
95099821
95099824
Sur-Fit AutoLock Dura Flex
Sur-Fit AutoLock Dura Flex
401308
401305
CON
CON
95099825
95099819
Sur-Fit AutoLock Dura Flex
Sur-Fit AutoLock Dura Flex
401304
401430
CON
CON
February 2016
270
Ostomy Supplies Benefit List
SKIN BARRIERS OR WAFERS W FLANGE (2 PIECE)
PIN
95099823
95099701
PRODUCT DESCRIPTION
Sur-Fit AutoLock Dura Flex
Sur-Fit Natura Dura Flex
PRODUCT #
401306
401905
MFR
CON
CON
95099673
95099672
Sur-Fit Natura Dura Flex
Sur-Fit Natura Dura Flex
413153
413154
CON
CON
95099671
95099670
Sur-Fit Natura Dura Flex
Sur-Fit Natura Dura Flex
413155
413156
CON
CON
95099669
95099668
Sur-Fit Natura Dura Flex
Sur-Fit Natura Dura Flex
413157
413159
CON
CON
95099666
95099665
Sur-Fit Natura Dura Flex
Sur-Fit Natura Dura Flex
413161
413162
CON
CON
95099663
95099661
Sur-Fit Natura Dura Flex
Sur-Fit Natura Dura Flex
413164
413166
CON
CON
95099659
95099667
Sur-Fit Natura Dura Flex
Sur-Fit Natura Dura Flex
413168
413160
CON
CON
95099664
95099662
Sur-Fit Natura Dura Flex
Sur-Fit Natura Dura Flex
413163
413165
CON
CON
95099660
95099655
Sur-Fit Natura Dura Flex
Sur-Fit Natura Dura Low Prof
413167
413180
CON
CON
95099657
95099658
Sur-Fit Natura Dura Low Prof
Sur-Fit Natura Dura Low Prof
413178
413177
CON
CON
95099647
95099649
Sur-Fit Natura Dura Low Prof
Sur-Fit Natura Dura Low Prof
413188
413186
CON
CON
95099648
95099654
Sur-Fit Natura Dura Low Prof
Sur-Fit Natura Dura Low Prof
413187
413181
CON
CON
95099651
95099656
Sur-Fit Natura Dura Low Prof
Sur-Fit Natura Dura Low Prof
413184
413179
CON
CON
95099653
95099652
Sur-Fit Natura Dura Low Prof
Sur-Fit Natura Dura Low Prof
413182
413183
CON
CON
95099650
95097929
Sur-Fit Natura Dura Low Prof
Sur-Fit Natura Dura Mold
413185
413420
CON
CON
95097928
95097927
Sur-Fit Natura Dura Mold
Sur-Fit Natura Dura Mold
413419
413418
CON
CON
95097926
95098480
Sur-Fit Natura Dura Mold
Sur-Fit Natura Dura Mold
413417
411806
CON
CON
95098482
95098486
Sur-Fit Natura Dura Mold
Sur-Fit Natura Dura Mold
411804
411800
CON
CON
95099675
95099674
Sur-Fit Natura Dura Mold
Sur-Fit Natura Dura Mold
404593
404594
CON
CON
95098484
95099676
Sur-Fit Natura Dura Mold
Sur-Fit Natura Dura Mold
411802
404592
CON
CON
95097936
95097931
Sur-Fit Natura Dura Mold Acc
Sur-Fit Natura Dura Mold Acc
421039
421040
CON
CON
95097932
95099855
Sur-Fit Natura Dura Mold Acc
Sur-Fit Natura Little Ones
421041
401925
CON
CON
95099773
95099775
Sur-Fit Natura Stoma Flex
Sur-Fit Natura Stoma Flex
125271
125269
CON
CON
95099768
95099770
Sur-Fit Natura Stoma Flex
Sur-Fit Natura Stoma Flex
125276
125274
CON
CON
February 2016
271
Ostomy Supplies Benefit List
SKIN BARRIERS OR WAFERS W FLANGE (2 PIECE)
PIN
95099777
95099779
PRODUCT DESCRIPTION
Sur-Fit Natura Stoma Flex
Sur-Fit Natura Stoma Flex
PRODUCT #
125267
125265
MFR
CON
CON
95099782
95099784
Sur-Fit Natura Stoma Flex
Sur-Fit Natura Stoma Flex
125262
125260
CON
CON
95099786
95099767
Sur-Fit Natura Stoma Flex
Sur-Fit Natura Stoma Flex
125258
125277
CON
CON
95099769
95099771
Sur-Fit Natura Stoma Flex
Sur-Fit Natura Stoma Flex
125275
125273
CON
CON
95099772
95099774
Sur-Fit Natura Stoma Flex
Sur-Fit Natura Stoma Flex
125272
125270
CON
CON
95099776
95099778
Sur-Fit Natura Stoma Flex
Sur-Fit Natura Stoma Flex
125268
125266
CON
CON
95099780
95099781
Sur-Fit Natura Stoma Flex
Sur-Fit Natura Stoma Flex
125264
125263
CON
CON
95099783
95099785
Sur-Fit Natura Stoma Flex
Sur-Fit Natura Stoma Flex
125261
125259
CON
CON
95099787
95098481
Sur-Fit Natura Stoma Flex
Sur-Fit Natura Stoma Mold
125257
411805
CON
CON
95098485
95097925
Sur-Fit Natura Stoma Mold
Sur-Fit Natura Stoma Mold
411801
413424
CON
CON
95097924
95097923
Sur-Fit Natura Stoma Mold
Sur-Fit Natura Stoma Mold
413423
413422
CON
CON
95097922
95098483
Sur-Fit Natura Stoma Mold
Sur-Fit Natura Stoma Mold
413421
411803
CON
CON
95098479
95097934
Sur-Fit Natura Stoma Mold
Sur-Fit Natura Stoma Mold Acc
411807
421034
CON
CON
95097935
95097933
Sur-Fit Natura Stoma Mold Acc
Sur-Fit Natura Stoma Mold Acc
421035
421033
CON
CON
95099706
95099705
Sur-Fit Natura Stomahesive
Sur-Fit Natura Stomahesive
401573
401574
CON
CON
95099703
95099702
Sur-Fit Natura Stomahesive
Sur-Fit Natura Stomahesive
401576
401577
CON
CON
95099700
95099704
Sur-Fit Natura Stomahesive
Sur-Fit Natura Stomahesive
401906
401575
CON
CON
February 2016
272
Compounds
*For compound formulations please see the Nova Scotia Pharmacists' Guide
All Beneficiaries
PRODUCT DESCRIPTION
Anthralin 0.4% Oint
Anthralin Soft 0.05% Paste
DIN
00901113
00902063
PROVTYPE
DNP
DNP
BENSTAT
SF
SF
Anthralin Soft 0.1% Paste
Anthralin Soft 0.2% Paste
00900907
00900915
DNP
DNP
SF
SF
Anthralin Weak 0.2% Oint
Disulfiram 250mg Cap
00901105
00903079
DNP
DNP
SF
SF
Hydrocortisone Pdr 1-2.5% in Clotrimazole Cr
00999474
DNP
SF
LCD (coal tar) Preparations
00358494
DNP
SF
LCD(20%) Preparations
Magic Mouthwash O/L
00358495
00999022
DNP
DNPM
SF
SFC
Methadone Pdr (o/l compound)
Placebo
00999734
00999008
DN
DNP
E
SFC
Probenecid 250mg Cap (Compound)
Probenecid 500mg Cap (Compound)
00903771
00903772
DNP
DNP
SF
SF
Salicylic Acid Oint
Tar Pomade
00900788
00901121
DNP
DNP
SF
SF
PRODUCT DESCRIPTION
Acetazolamide Oral Suspension
DIN
00903403
PROVTYPE
DNP
BENSTAT
F
Allopurinol Oral Suspension
Amiodarone Oral Suspension
00903171
00903325
DNP
DNP
FC
F
Amlodipine Oral Suspension
Atenolol Oral Syrup
00903749
00903346
DNP
DNP
F
F
Azathioprine Oral Suspension
Baclofen Oral Suspension
00903187
00903511
DNP
DNP
FC
F
Carvedilol Oral Suspension
Clonazepam Oral Suspension
00903641
00903559
DNP
DN
F
F
Clonidine Oral Suspension
Clotrimazole Oral Suspension
00999330
00903061
DNP
DNP
F
FC
Dexamethasone Oral Suspension
Domperidone Oral Suspension
00903062
00903085
DNP
DNPM
FC
FC
Enalapril Oral Suspension
Hydralazine Oral Suspension
00903554
00903591
DNP
DNP
F
F
Hydrochlorothiazide Oral Suspension
Hydrocortisone Oral Suspension
00999106
00903296
DNP
DNP
F
FC
Indomethacin Oral Suspension
Labetalol Oral Suspension
00903250
00903077
DNPM
DNP
FC
F
Lamotrigine Oral Suspension
Lansoprazole Oral Suspension
00903381
00903192
DNP
DNP
F
FC
Lisinopril Oral Suspension
Methimazole Oral Suspension
00903266
00903779
DNP
DNP
F
F
Metolazone Oral Suspension
Metoprolol Oral Suspension
00903780
00999104
DNP
DNP
F
F
Metronidazole Oral Suspension
Nadolol Oral Syrup
00903238
00903406
DNPM
DNP
FC
F
Naproxen Oral Suspension
00999135
DNPM
FC
Children 12 Years and Under
February 2016
273
Compounds
*For compound formulations please see the Nova Scotia Pharmacists' Guide
Children 12 Years and Under
PRODUCT DESCRIPTION
Nitrazepam Oral Suspension
Nitrofurantoin Oral Suspension
DIN
00903215
00903209
PROVTYPE
DN
DNPM
BENSTAT
F
FC
Propranolol Oral Suspension
Pyrazinamide Oral Suspension
00999155
00903781
DNP
DNP
F
FC
Sotalol Oral Suspension
Spironolactone Oral Suspension
00903782
00999107
DNP
DNP
F
F
Sulfasalazine Oral Suspension
00903449
DNP
F
February 2016
274
Appendix I – Abbreviations
Aer
Aerosol
MR
Modified Release
Amp
Ampoule
Nas
Nasal
Cap
Capsule
Neb
Nebules
CFU
Colony Forming Units
OD
Orally Disintegrating
Chewtab
Chewable Tablet
O/L
Oral Liquid
Cr
Cream
Oint
Ointment
CD
Controlled Distribution
Oph
Ophthalmic
CR
Controlled Release
Otic
Ear
DR
Delayed Release
Pck
Package
Drp
Drops
Pdr
Powder
EC
Enteric Coated
PF
Preservative Free
Eff
Effervescent
pkt
Packet
Elx
Elixir
Pl. Ampule
Plastic Ampule
ER
Extended Release
POS
Powder for Oral Solution
FC
Film Coated
Resp
Respirator
g
Gram
RD
Rapid Dissolving
Gran
Granules
RPD
Rapid Disintegrating
IM
Intramuscular
SL
Sublingual
Inh
Inhaler
Sod Chl
Sodium Chloride
Inj
Injection
Sol
Solution
Ins
Insulin
Sp
Spray
IR
Immediate Release
SR
Slow Release
Irr
Irrigation
Supp
Suppository
iu
International Unit
Susp
Suspension
IV
Intravenous
Syr
Syrup
LA
Long Acting
Tab
Tablet
Liq
Liquid
TCT
Tincture
Lot
Lotion
UDV
Unit Dose Vial
mcg
Microgram
USP
United States Pharmacopeia
mcl
Microliter
Vag
Vaginal
mEq
Milli-equivalent
w/w
By Weight
mg
Milligram
XL
Extended Release
mL
Milliliter
February 2016
Appendix I
Appendix II – Abbreviations of Manufacturers’ Names
AAP
ABB
ABV
ACC
ACO
ACT
AGA
AHI
AKN
ALC
ALL
ALM
APX
ARG
ARO
ASL
ATL
ATV
AUR
AUT
AVD
AVP
AXC
AXS
AZE
BAX
BAY
BBM
BCH
BDD
BGP
BHC
BIG
BMP
BNM
BOE
BOM
BRI
BSH
BTD
BTX
BVL
BVT
CDX
CEL
CHU
CIP
CMP
COB
COL
CON
CPD
CYI
DPT
DRX
DUI
EHS
EIS
EMD
AA Pharma Inc.
Abbott Laboratories Ltd.
AbbVie Corporation
Accel Pharma Inc.
Magnum Pharmaceutics
Actelion Pharmaceuticals Canada Inc.
Amgen Canada Inc.
Accord Healthcare Inc.
Dioptic Laboratories
Alcon Canada Inc.
Allergan Inc.
Almirall Canada Ltd.
Apotex Inc.
Argyle Medical Distributors Inc
Auro Pharma Inc
Astellas Pharma Canada Inc.
Laboratoire Atlas Inc.
Actavis Pharma Company
Aurium Pharma Inc.
Auto Control Medical Inc.
Alveda Pharma
Sanofi Pasteur Limited
Aptalis Pharma Canada Inc.
Axxess Pharma Inc.
AstraZeneca Canada Inc.
Baxter Corporation
Bayer Inc.
Best Buy Medical
Bioniche Inc.
Bayer HealthCare, Diabetes Care Division
BGP Pharma Inc
Bellco Healthcare Inc.
Biogen Idec Canada Inc.
Boca Medical Products
Bionime USA Corp
Boehringer Ingelheim (Canada) Ltd.
Roche Diagnostics, Div.of Hoffmann-LaRoche
Bristol-Myers Squibb Canada Inc.
Bausch & Lomb Canada Inc.
Becton Dickinson Canada
BTNX Inc
Biovail Pharmaceuticals Canada
Biovitrum
Canderm Pharmaca Inc.
Celgene
Church and Dwight Canada Corp.
Cipher Pharmaceuticals Inc.
Canadian Medical Partners
Cobalt Pharmaceuticals Company
Coloplast Canada
ConvaTec Canada Ltd
manually compounded
Cytex Pharmaceuticals Inc.
Dermtek Pharmaceuticals Ltd.
Domrex Pharma Inc.
Duchesnay Inc.
Entra Health Systems Inc
Eisai Limited
EMD Serono Canada Inc.
February 2016
ERF
FEI
FKB
FLC
FRS
GAC
GCH
GIL
GLE
GMD
GMP
GSK
GZM
HLR
HLZ
HOL
HOM
HOS
HPT
ICL
IMD
IRO
ITM
JAN
JCB
JNJ
JPC
KNG
LBK
LEO
LFS
LIL
MAR
MCK
MDS
MED
MEL
MGI
MID
MJO
MMT
MNT
MOL
MPD
MRS
MSC
MTD
MYL
MVL
NAT
NBM
NEO
NGP
NNC
NNO
NVO
NVR
NYC
ODN
ERFA Canada Inc.
Ferring Inc.
Fresenius Kabi Canada
Forest Laboratories Canada Inc.
Merck Canada Ltd.
Galderma Canada Inc.
GlaxoSmithKline Consumer Healthcare Inc.
Gilead Sciences Inc.
Glenwood Laboratories Canada Ltd.
GenMed, A Division of Pfizer Canada Inc.
Generic Medical Partners Inc.
GlaxoSmithKline Inc.
Genzyme Canada Inc.
Hoffmann-LaRoche Limited
Hill Dermaceuticals, Inc.
Hollister Limited
Home Diagnostics Inc.
Hospira Healthcare Corporation
Healthpoint Canada ULC
Indivior Canada Limited
I-Med Pharma Inc.
Iroko International LP
Intermune Canada
Janssen-Ortho Inc.
Jacobus Pharmaceutical Company Inc.
Johnson & Johnson Inc.
Jamp Pharma Corporation
King Pharma Canada Ltd.
Lundbeck Inc.
Leo Pharma Inc.
Lifescan Canada Ltd.
Eli Lilly Canada Inc.
Marcan Pharmaceuticals Inc
Zinda Pharma Ltd.
Medicis Canada Ltd.
Medican Technologies Inc.
Mediapharm Inc.
MGI Pharma Inc.
Abbott Diabetes Care / Medisense
Mead Johnson (Canada) Inc
MM Therapeutics Inc.
Mint Pharmaceuticals Inc.
Molnlycke Health Care Inc.
Medical Plastic Devices Inc.
Merus Labs Inc.
Medisca Pharmaceutique Inc.
Montmed Inc.
Mylan Pharmaceuticals ULC.
Meda Valeant Pharma Canada
Natco Pharma (Canada) Inc.
Nova Biomedical
Neolab Inc.
Next Generation Pharma Inc.
Novartis Consumer Health Canada Inc.
Novo Nordisk Canada Inc.
Novartis Ophthalmics
Novartis Pharmaceuticals Canada Inc.
Nycomed Canada Inc.
Odan Laboratories Ltd.
Appendix II
Appendix II – Abbreviations of Manufacturers’ Names
OMG
ORB
ORG
ORP
OTS
PAL
PDP
PER
PFI
PFR
PHL
PMS
PPB
PPC
PPH
QGT
RAN
RBH
RCH
RIV
ROG
SAS
SAV
SCH
SDZ
SEP
SEV
SHI
SIV
SKM
SNE
SNV
SPT
STA
STI
Omega Laboratories Ltd.
Orbus Pharma Inc.
Organon Canada Ltd.
Orphan Medical Inc.
Otsuka Canada Pharmaceuticals
Paladin Labs Inc.
PendoPharm, Division of Pharmascience Inc.
Perrigo International
Pfizer Canada Inc.
Purdue Pharma
Pharmel Inc.
Pharmascience Inc.
Proval Pharma Division of Servier Canada Inc.
Pharmaceutical Partners of Canada Inc.
Patriot Pharmaceuticals LLC.
Sigma-Tau Pharmaceuticals Inc.
Ranbaxy Pharmaceuticals Canada Inc.
Reckitt Benckiser Healthcare Ltd.
Dr. Reddy's Laboratories Inc.
Riva Laboratoire Inc.
Rougier Pharma, Division of ratiopharm Inc.
Sanis Health Inc
Sanofi-Aventis Canada Inc.
Schering-Plough (Canada) Inc.
Sandoz Canada Incorporated
Sunovion Pharmaceuticals Canada Inc.
Servier Canada Inc.
Shire Canada Inc.
Sivem Pharmaceuticals
SkyMed Medical Products
Smith & Nephew Inc.
Sunovion Pharmaceuticals Canada Inc.
Septa Pharmaceuticals Inc.
Stallergene Canada Inc.
Stiefel Canada Inc.
February 2016
STR
SWS
TAK
TAR
TER
TEV
THI
THR
TMI
TML
TMP
TPH
TRB
TRI
TYC
UCB
UTC
VAL
VAR
VCO
VIV
VLH
VLN
VTX
WAM
WCH
WNC
WLS
WSQ
WTS
XPI
YNO
ZIA
ZYM
SteriMax Inc.
Swiss Herbal Remedies Ltd.
Takeda Canada Inc.
Taro Pharmaceuticals Inc.
Tercica Inc.
Teva Canada Ltd.
Tremblay Harrison Inc.
Theramed Corporation
Trudell Medical International
Trimel Pharmaceutical Corporation
Teva Neuroscience Canada
TaroPharma, Div. of Taro Pharmaceuticals Inc.
Tribute Pharma Canada Inc
Triton Pharma Inc.
Tyco Healthcare
UCB Pharma Canada Inc.
United Therapeutics Corporation
Valeo Pharma Inc.
various manufacturers
Virco Pharmaceuticals (Canada) Inc.
ViiV Health Care Inc.
Lundbeck Canada Inc.
Valeant Canada Limited
Vertex Pharmaceuticals
Wampole Brands Inc.
Wyeth Consumer HealthCare Inc.
Warner Chilcott Canada Co
Wellspring Pharmaceutical Canada Corp.
Westwood Squibb, Div.of Bristol-Myers Squibb
Watson Pharma Company
Xediton Pharmaceuticals Inc.
Bayer Inc., Consumer Care Division
Zila Pharmaceuticals Inc.
Zymcan Pharmaceuticals Inc.
Appendix II
Appendix III – Criteria for Coverage of Exception Status Drugs
Coverage of exception status drugs will be approved according to the following criteria upon review of a prescriber's
written request. Included with the Nova Scotia Formulary are forms for Exception Status Drug requests, which may be
used to facilitate the approval process.
As an alternative to sending a written request to the Pharmacare office, certain exception status drugs have been
assigned criteria codes. To allow for on-line payment of these drugs, the criteria code may be provided by the prescriber
on the prescription or confirmed by the pharmacist. The use of these codes offers the prescriber and the pharmacist
access to immediate coverage for patients who clearly meet the exception status criteria. The criteria codes are indicated
within the following exception criteria.
ABATACEPT (Orencia 250mg/vial Injection)
- for patients with a diagnosis of active rheumatoid arthritis (RA) who:
1
· have not responded or who have had intolerable toxicity to an adequate trial of combination therapy of at least two
2
traditional DMARDs or
1
2
· if combination therapy is not an option, an adequate trial of at least three traditional DMARDs in sequence as
monotherapy and
1
· patients must have had an adequate trial of leflunomide. Exceptions can be considered in cases where leflunomide
is contraindicated or not tolerated
- therapy must include methotrexate alone or in combination unless contraindicated or not tolerated
- written request of a rheumatologist or prescriber with a specialty in rheumatology
- coverage will be approved initially for 16 weeks. Can be reassessed for yearly coverage dependent on patient achieving
an improvement in symptoms of at least 20%
1
2
An adequate trial is 5 months for IM gold, 6 months for penicillamine, 4 months for hydroxychloroquine and 3 months for all other traditional DMARDs
as well as leflunomide, infliximab and etanercept.
Traditional agents include methotrexate, IM gold, sulfasalazine, hydroxychloroquine, azathioprine, chloroquine, penicillamine and cyclosporine.
*ABIRATERONE ACETATE (Zytiga 250mg Tablet)
Asymptomatic or Mildly Symptomatic Patients:
­ in combination with prednisone for asymptomatic or mildly symptomatic metastatic CRPC patients after failure of
androgen deprivation therapy (including an LHRH agonist/antagonist or orchiectomy) who have not received prior
chemotherapy for metastatic CRPC and have ECOG PS 0 or 1.
­ abiraterone would be an alternative to enzalutamide and not sequential therapy in this asymptomatic or mildly
symptomatic patient population.
Symptomatic (post-docetaxel chemotherapy) Patients:
­ in combination with prednisone for metastatic CRPC patients with ECOG PS of 0-2 and progression after previous
treatment with docetaxel.
­ abiraterone would be an alternative to enzalutamide and not sequential therapy in this symptomatic post docetaxel
chemotherapy setting.
Retreatment:
­ Use of abiraterone in the post-docetaxel setting is not permitted if previously used in the pre-chemotherapy setting.
ACAMPROSATE (Campral 333mg Tablet)
- for treatment in patients who have been abstinent from alcohol for at least four days and who have contraindications to
naltrexone (i.e., acute hepatitis, liver failure or currently receiving opioids)
ACLIDINIUM BROMIDE (Tudorza Genuair 400mcg powder for inhalation)
­ for the treatment of moderate to severe chronic obstructive pulmonary disease (COPD) as defined by spirometry.
OR
­ for the treatment of COPD in patients with an inadequate response to short acting bronchodilators.
­ combination therapy with a long- acting beta-2 agonist /inhaled corticosteroid (LABA/ICS) and a long acting
anticholinergic (LAAC) inhaler will be considered in patients with: moderate to severe COPD, as defined by spirometry,
a history of COPD exacerbation(s) and an inadequate response to LABA/ICS or LAAC.
Note: Coverage for LABA and LAAC as two separate inhalers will not be considered.
NOTE: Exception status drugs for Drug Assistance for Cancer Patients are indicated by an asterisk (*).
February 2016
Appendix III
Clinical Notes:
1. Moderate to severe COPD is defined by spirometry as a post bronchodilator FEV1 < 60% predicted and FEV1/FVC
ratio of < 0.70. Spirometry reports from any point in time will be accepted.
If spirometry cannot be obtained, reasons must be clearly explained and other evidence of COPD severity provided,
i.e., Medical Research Council (MRC) Dyspnea Scale Score of at least Grade 3.
MRC Grade 3 is described as: walks slower than people of same age on the level because of shortness of breath
from COPD or has to stop for breath when walking at own pace on the level.
2. Inadequate response to short acting bronchodilators is defined as persistent symptoms, i.e., MRC of at least Grade 3,
after at least 2 months of short acting bronchodilator at the following doses*:
• 8 puffs per day of short acting beta-2 agonist or
• 12 puffs per day of ipratropium or
• 6 puffs per day of ipratropium plus salbutamol combination inhaler
* Inadequate response to LABA/ICS or LAAC is defined as persistent symptoms after at least 2 months of therapy.
3. COPD exacerbation is defined as an increase in symptoms requiring treatment with antibiotics and/or systemic (oral or
intravenous) corticosteroids.
Note: Inhalers which combine a LABA/LAAC are also available as ESD benefits. These products have their own criteria
which are listed in the NS Formulary.
ADALIMUMAB (Humira 40mg/vial Injection)
- See Anti-Tumor Necrosis Factor (TNF) Agents
ADEFOVIR DIPIVOXIL (Hepsera 10mg Tablet)
- in combination with lamivudine in patients who:
· have developed failure to lamivudine (increase in HBV DNA of ≥1 log10iu/mL over the nadir measured on two separate
occasions within an interval of at least one month, after the first 3 months of lamivudine therapy) AND
· when failure to lamivudine is not due to poor adherence to therapy
- coverage approved for 1 year
*AFATINIB DIMALEATE (Giotrif 20mg, 30mg, 40mg Tablet)
- for first line treatment of patients with EGFR mutation positive advanced or metastatic adenocarcinoma of the lung and
with an ECOG performance status 0 or 1
ALENDRONATE (Fosamax 40mg Tablet and generic brands)
- for the treatment of Paget’s disease of bone (6 month limit)
- other requests reviewed on a case by case basis
ALGLUCOSIDASE ALFA (Myozyme 50mg Powder for Injection)
- for the treatment of infantile onset Pompe disease in patients who have had the onset of symptoms and confirmed
cardiomyopathy before the age of 12 months AND
- participation in the long-term evaluation of the efficacy of treatment by periodic medical assessment as outlined in the
monitoring of therapy guidelines
- initial approval is for 6 months. Continued coverage will be based on evaluation of the efficacy of treatment by regular
medical assessment as outlined in the monitoring and discontinuation of therapy guidelines (available from the
Pharmacare Office upon request).
ALLERGEN IMMUNOTHERAPY (Allergy Serum, Pollinex-R Injection)
- for immunotherapy with specific, standardized allergenic material, administered in high-dose schedules for carefully
selected patients with a diagnosis of:
· IgE mediated anaphylactic reactions to insect stings or
· severe, seasonal (lasting two or more years) or perennial IgE dependent allergic rhinoconjunctivitis when optimal drug
therapy and allergen avoidance have not been sufficiently effective in controlling symptoms or
· IgE mediated allergic asthma, specifically where there is a clear temporal association between exposure and signs
and symptoms of asthma and when optimal drug therapy and avoidance measures have not been sufficiently effective
in controlling symptoms
Note: The allergy serum must be dispensed from a pharmacy on prescription from a prescriber. Initial authorization is for
two years, and can be continued for up to five years if improvement is noted.
NOTE: Exception status drugs for Drug Assistance for Cancer Patients are indicated by an asterisk (*).
February 2016
Appendix III
ALMOTRIPTAN (Axert 6.25mg, 12.5mg Tablet)
- See Selective 5HT1 - Receptor Agonists
*ALTRETAMINE (Hexalen 50mg Capsule)
- written request from an oncologist or prescriber with a specialty in oncology
- for the treatment of ovarian carcinoma
AMBRISENTAN (Volibris 5mg, 10mg Tablet)
- for the treatment of patients with at least Class III pulmonary arterial hypertension (PAH), either idiopathic or associated
with connective tissue disease who have failed therapy with sildenafil or who have contraindications to sildenafil.
- diagnosis must be confirmed by right heart catheterization
- request must be from a PAH specialist
ANAGRELIDE (Agrylin 0.5mg Capsule and generic brands)
Nova Scotia Seniors' Pharmacare Program:
- for the treatment of essential thrombocythemia (ET) in patients who have:
· failed hydroxyurea therapy (does not provide sufficient platelet reduction) or
· intolerable side effects from hydroxyurea therapy
Community Services Pharmacare Programs:
- for the treatment of essential thrombocythemia (ET) as an alternative to hydroxyurea
ANTI-TUMOR NECROSIS FACTOR (TNF) AGENTS (Adalimumab, Certolizumab Pegol, Etanercept,
Golimumab, Infliximab)
Ankylosing Spondylitis (Adalimumab, Etanercept, Golimumab, Infliximab)
- for the treatment of patients with moderate to severe ankylosing spondylitis (e.g., Bath AS Disease Activity Index
(BASDAI) score ≥4 on 10 point scale) who:
· have axial symptoms** and who have failed to respond to the sequential use of at least 2 NSAIDs at the optimum
dose for a minimum period of 3 months observation, or in whom NSAIDs are contraindicated OR
· have peripheral symptoms and who have failed to respond to, or have contraindications to, the sequential use of at
least 2 NSAIDs at the optimum dose for a minimum period of 3 months observation and have had an inadequate
response to an optimal dose or maximal tolerated dose of a DMARD
- must be prescribed by a rheumatologist or prescriber with a specialty in rheumatology
- requests for renewal must include information showing the beneficial effects of the treatment, specifically:
· a decrease of at least 2 points on the BASDAI scale, compared with the pre-treatment score; OR
· patient and expert opinion of an adequate clinical response as indicated by a significant functional improvement
(measured by outcomes such as HAQ or "ability to return to work")
**Patients with recurrent uveitis (2 or more episodes within 12 months) as a complication of axial disease, do not require a
trial of 2 NSAIDs.
Initial Coverage Duration and Maximum Dosage approved:
Adalimumab - initial period 6 months, maximum dose of 40mg every two weeks and not in combination with other
anti-TNF agents
Etanercept
- initial period 6 months, maximum dose of 50mg per week and not in combination with other anti-TNF
agents
Golimumab
- initial period 16 weeks, maximum dose 50mg per month and not in combination with other anti-TNF
agents
Infliximab
- initial coverage period 6 months, maximum dose 5mg/kg at 0, 2, and 6 weeks then every 6-8 weeks
thereafter and not in combination with other anti-TNF agents
Ankylosing Spondylitis (certolizumab pegol)
­ for the treatment of adult patients with moderate to severe ankylosing spondylitis (e.g., Bath AS Disease Activity Index
(BASDAI) score ≥4 on 10 point scale) who:
⋅ have axial symptoms** and who have failed to respond to the sequential use of at least 2 NSAIDs at the optimum
dose for a minimum period of 3 months observation, or in whom NSAIDs are contraindicated; OR
⋅ have peripheral symptoms and who have failed to respond to, or have contraindications to, the sequential use of at
NOTE: Exception status drugs for Drug Assistance for Cancer Patients are indicated by an asterisk (*).
February 2016
Appendix III
least 2 NSAIDs at the optimum dose for a minimum period of 3 months observation and have had an inadequate
response to an optimal dose or maximal tolerated dose of a DMARD.
­ must be prescribed by a rheumatologist or prescriber with a specialty in rheumatology.
­ requests for renewal must include information showing the beneficial effects of the treatment, specifically:
⋅ a decrease of at least 2 points on the BASDAI scale, compared with the pre-treatment score; OR
⋅ patient and expert opinion of an adequate clinical response as indicated by a significant functional improvement
(measured by outcomes such as HAQ or "ability to return to work").
**Patients with recurrent uveitis (2 or more episodes within 12 months) as a complication of axial disease do not require a
trial of 2 NSAIDs.
Initial Coverage Duration and Maximum Dosage approved:
­ initial coverage period 6 months. Loading dose of 400mg at Weeks 0, 2 and 4.
­ maximum maintenance dose of 200mg every 2 weeks or alternatively, 400mg every 4 weeks, and not in combination
with other anti-TNF agents.
Crohn's Disease (Adalimumab)
- for patients with moderate to severely active Crohn’s disease and are:
· refractory or have contraindications to an adequate course of 5-aminosalicylic acid and corticosteroids and other
immunosuppressive therapy
· initial reimbursement is restricted to an induction dose of 160mg followed by 80mg
· clinical response to be assessed twelve weeks after the first induction dose and maintenance therapy approved in
responders only at a dose not exceeding 40mg every two weeks
Crohn's Disease (Infliximab)
- for treatment of Crohn’s disease in adults, when prescribed by a gastroenterologist or physician with a specialty in
gastroenterology:
· in patients with moderate to severe active disease refractory to 5-ASA products AND glucocorticoids (e.g.,
prednisone) AND immunosuppressive therapy (azathioprine or 6-mercaptopurine or methotrexate)**. Initial approval
of infliximab will be for a single infusion of 5mg/kg/dose. A second infusion may be warranted in patients not
responding to the first infusion or in patients responding initially but then worsening before maintenance therapy is
effective. Request for approval beyond induction therapy will be considered on a case by case basis
· in patients with fistulizing disease who have actively draining perianal or enterocutaneous fistula(e) that have
recurred or persisted despite a course of appropriate antibiotic therapy (e.g., metronidazole +/-ciprofloxacin for a
minimum of 3 weeks) AND immunosuppressive therapy (azathioprine or 6-mercaptopurine or methotrexate)**. Initial
approval is for three infusions of infliximab of 5mg/kg/dose at 0, 2 and 6 week intervals
** Patients who are very ill and not candidates for surgery may qualify for infliximab therapy without a trial of AZA, 6-MP or
MTX, as they may require a more rapid onset of response.
Juvenile Rheumatoid Arthritis (Etanercept)
- for the treatment of moderate to severely active, polyarticular juvenile rheumatoid arthritis in children (age 4-17) who
have not responded to adequate treatment with one or more DMARDs for at least 3 months or have intolerance to
DMARDs, and do not have a contraindication to etanercept
Polyarticular Juvenile Idiopathic Arthritis (Adalimumab)
­ for the treatment of polyarticular juvenile idiopathic arthritis (pJIA)with the following criteria:
⋅ for patients aged 4-17 years with moderately or severe pJIA who have had a inadequate response to one or more
disease-modifying anti-rheumatic drugs (DMARDs); and
­ treatment must be initiated by a rheumatologist who is familiar with the use of DMARDs and/or biologic DMARDs in
children.
Psoriasis (Adalimumab, Etanercept, Infliximab)
- for patients with severe, debilitating chronic plaque psoriasis (PsO) who meet all of the following criteria:
· Body Surface Area (BSA) involvement of >10% and/or significant involvement of the face, hands, feet or genital region
· failure to respond to, contraindications to or intolerant of methotrexate and cyclosporine
· failure to respond to, intolerant of or unable to access phototherapy
- written request of a dermatologist or prescriber with a specialty in dermatology
NOTE: Exception status drugs for Drug Assistance for Cancer Patients are indicated by an asterisk (*).
February 2016
Appendix III
- continued coverage is dependent on evidence of improvement, specifically:
· ≥ 75% reduction in the Psoriasis Area and Severity Index (PASI) score, or
· ≥ 50% reduction in PASI with a ≥ 5 point improvement in DLQI (Dermatology Life Quality Index), or
· significant reduction in BSA involved, with consideration of important regions such as the face, hands, feet or genitals
- concurrent use of biologics not approved
Initial duration and maximum dosage approved:
Adalimumab - initial approval for a maximum of 16 weeks
- maximum dosage for ongoing coverage is 40mg every two weeks
Etanercept
- initial approval for a maximum of 12 weeks
- maximum dosage approved: 50mg biweekly for the initial 12 weeks then 50mg weekly thereafter
Infliximab
- initial approval for a maximum of 12 weeks
- dosage restricted to infliximab 5mg/kg 0, 2 and 6 weeks then every 8 weeks
Psoriatic Arthritis (Adalimumab, Golimumab)
- for patients with active psoriatic arthritis who meet all of the following:
· have at least three active and tender joints
· have not responded to an adequate trial with two DMARDs or have an intolerance or contraindication to DMARDs
· not used in combination with other TNF antagonists
- written request of a rheumatologist or prescriber with a specialty in rheumatology
- after initial coverage period, can be reassessed for yearly coverage dependent on patient achieving an improvement in
symptoms of at least 20%
Initial Coverage Duration and Maximum Dosage approved:
Adalimumab - initial period 3 months, maximum dose of 40mg every two weeks
Golimumab
- initial period 3 months, maximum dose 50mg per month
Psoriatic Arthritis (certolizumab pegol)
­ for the treatment of adult patients with active psoriatic arthritis who meet all of the following:
⋅ have at least three active and tender joints;
⋅ have not responded to an adequate trial with two DMARDs or have an intolerance or contraindication to DMARDs.
­ must be prescribed by a rheumatologist or prescriber with a specialty in rheumatology.
­ after initial coverage period, can be reassessed for yearly coverage dependent on patient achieving an improvement in
symptoms of at least 20%
Initial Coverage Duration and Maximum Dosage approved:
­ initial coverage period 3 months. Loading dose of 400mg at Weeks 0, 2 and 4.
­ maximum maintenance dose of 200mg every 2 weeks or alternatively, 400mg every 4 weeks, and not in combination
with other anti-TNF agents.
Psoriatic Arthritis (Etanercept)
- for the treatment of active psoriatic arthritis in patients who have not responded to an adequate trial with two DMARDs
or who have an intolerance or contraindication to DMARDs
- written request of a rheumatologist or prescriber with a specialty in rheumatology
- coverage will be approved initially for 3 months. Can be reassessed for yearly coverage dependent on patient achieving
an improvement in symptoms of at least 20%
Initial Coverage Duration and Maximum Dosage approved:
Etanercept - initial period 3 months, maximum dose of 50mg per week
NOTE: Exception status drugs for Drug Assistance for Cancer Patients are indicated by an asterisk (*).
February 2016
Appendix III
Rheumatoid Arthritis (Adalimumab, Certolizumab Pegol, Etanercept, Golimumab, Infliximab)
- for patients with a diagnosis of active rheumatoid arthritis (RA) who:
1
· have not responded or who have had intolerable toxicity to an adequate trial of combination therapy of at least two
2
traditional DMARDs or
1
2
· if combination therapy is not an option, an adequate trial of at least three traditional DMARDs in sequence as
monotherapy and
1
· patients must have had an adequate trial of leflunomide. Exceptions can be considered in cases where leflunomide
is contraindicated or not tolerated
- therapy must include methotrexate alone or in combination unless contraindicated or not tolerated
- written request of a rheumatologist or prescriber with a specialty in rheumatology
- after initial coverage period, can be reassessed for yearly coverage dependent on patient achieving an improvement in
symptoms of at least 20%
Initial Coverage Duration and Maximum Dosage approved:
Adalimumab - initial coverage period 6 months, maximum dose of 40mg every two weeks
Certolizumab Pegol - initial coverage period 12 weeks, maximum dose 400mg at weeks 0, 2 and 4, then 200mg every 2
weeks (or 400mg every 4 weeks)
Etanercept
- initial coverage period 6 months
Golimumab
- initial coverage period 16 weeks, maximum dose 50mg per month
Infliximab
- initial coverage period 6 months
1
2
An adequate trial is 5 months for IM gold, 6 months for penicillamine, 4 months for hydroxychloroquine and 3 months for all other traditional DMARDs
as well as leflunomide, infliximab and etanercept.
Traditional agents include methotrexate, IM gold, sulfasalazine, hydroxychloroquine, azathioprine, chloroquine, penicillamine and cyclosporine.
*Please note that the concurrent use of anti-TNF agents will not be approved.
APIXABAN (Eliquis, 2.5mg, 5mg Tablet)
Total Knee/Hip Replacement (Eliquis 2.5mg Tablet):
­ for the prophylaxis of venous thromboembolism following total knee replacement surgery for up to 14 days, as an
alternative to low molecular weight heparins. [Criteria Code 14]
­ for the prophylaxis of venous thromboembolism following total hip replacement surgery for up to 35 days, as an
alternative to low molecular weight heparins. [Criteria Code 35]
Notes:
­ The total duration of therapy includes the period during which doses are administered post-operatively in an acute care
(hospital) setting, and the approval period is for the balance of the total duration after discharge.
­ The first dose is typically administered 12 to 24 hours after surgery, assuming adequate hemostasis has been achieved.
­ The ADVANCE clinical trial program did not evaluate the efficacy or safety of sequential use of molecular weight
heparin followed by apixaban for the prophylaxis of VTE. Due to the current lack of evidence for sequential use,
coverage is not intended for this practice.
­ Clinical judgment is warranted to assess the increased risk for VTE and/or adverse effects in patients with a history of
previous VTE, myocardial infarction, transient ischemic attack or ischemic stroke; a history of intraocular or intracerebral
bleeding; a history of gastrointestinal disease with gastrointestinal bleeding; moderate or severe renal insufficiency
(estimated creatinine clearance <30 mL/min); severe liver disease; concurrent use of other anticoagulants; or age
greater than 75 years.
­ Apixaban has not been studied in clinical trials in patients undergoing hip fracture surgery, and is not recommended in
these patients.
Non-Valvular Atrial Fibrillation (AF) (Eliquis 2.5mg, 5mg Tablet):
­ Inclusion Criteria:
At-risk patients with non-valvular atrial fibrillation (AF) who require apixaban for the prevention of stroke and systemic
embolism AND in whom:
· anticoagulation is inadequate following at least a 2-month trial on warfarin; OR
· anticoagulation with warfarin is contraindicated or not possible due to inability to regularly monitor via International
Normalized Ratio (INR) testing (i.e. no access to INR testing services at a laboratory, clinic, pharmacy, and at home)
NOTE: Exception status drugs for Drug Assistance for Cancer Patients are indicated by an asterisk (*).
February 2016
Appendix III
­ Exclusion Criteria:
Patients with impaired renal function (creatinine clearance or estimated glomerular filtration rate < 25 mL/min) OR > 75
years of age and without documented stable renal function OR hemodynamically significant rheumatic valvular heart
disease, especially mitral stenosis; OR prosthetic heart valves
Notes:
­ At risk patients with non valvular atrial fibrillation are defined as those with a CHADS2 score of ≥ 1. Prescribers may
consider an antiplatelet regimen or oral anticoagulation for patients with CHADS2 score of ≥ 1.
­ Inadequate anticoagulation is defined as INR testing results that are outside the desired INR range for at least 35% of
the tests during the monitoring period (i.e. adequate anticoagulation is defined as INR test results that are within the
desired INR range for at least 65% of the tests during the monitoring period).
­ Documented stable renal function is defined as creatinine or estimated glomerular filtration rate maintained for at least 3
months.
­ Dosing: the usual recommended dose is 5mg twice daily; a reduced dose of apixaban 2.5mg twice daily is
recommended for patients with at least two [2] of the following: age > 80 years, body weight < 60kg, or serum creatinine
>133 micromole/litre.
­ Since renal impairment can increase bleeding risk, renal function should be regularly monitored. Other factors that
increase bleeding risk should also be assessed and monitored (see apixaban Product Monograph).
­ Patients starting apixaban should have ready access to appropriate medical services to manage a major bleeding
event.
­ There is currently no data to support that apixaban provides adequate anticoagulation in patients with rheumatic
valvular disease or those with prosthetic heart valves. As a result, apixaban is not recommended for these patient
populations.
*APREPITANT (Emend 80mg, 125mg Capsule and Tri-Pack Capsule)
- in combination with a 5-HT3 antagonist and dexamethasone in adult cancer patients treated with chemotherapy that
2
includes cisplatin as a single day therapy greater than or equal to (≥) 70mg/m to prevent acute and delayed nausea
and vomiting.
2
· aprepitant will only be used with single day cisplatin-based therapy ≥ 70mg/m (and not multiple day cisplatin
chemotherapy)
· aprepitant will not be used in patients receiving moderately emetogenic cancer chemotherapy or radiotherapy
· the 5-HT3 antagonist should only be used on the first day of cisplatin therapy with aprepitant continuing on Day 2 and
Day 3
ARIPIPRAZOLE (Abilify 2mg, 5mg, 10mg, 15mg, 20mg and 30mg Tablet)
- for the treatment of schizophrenia and schizoaffective disorders in patients who have a contraindication to quetiapine
and risperidone, or have failed a trial of quetiapine and risperidone due to intolerance or lack of response
ARIPIPRAZOLE (Abilify Maintena 300mg and 400mg Prolonged Release Injectable Suspension)
­ for the maintenance treatment of schizophrenia in adult patients who are stabilized on oral aripiprazole, and who have:
· problems with compliance with oral treatments or
· inadequate control or significant side-effects (e.g. EPS or TD) from one or more conventional depot antipsychotic
agents
ARTIFICIAL TEARS, PRESERVATIVE FREE (Celluvisc, Refresh, Refresh Plus, Refresh Tears, Tears
Naturale Free)
- for patients with a diagnosis of dry eye requiring frequent daily doses of artificial tears, to prevent sensitivity to
preservatives or in patients in whom preservative sensitivity is suspected
- written request from an ophthalmologist or optometrist confirming the diagnosis will be required to initiate coverage
ASENAPINE (Saphris 5mg and 10mg SL Tab)
- for the acute treatment of manic or mixed episodes associated with bipolar I disorder as either:
· monotherapy, after a trial of lithium or divalproex sodium has failed, and trials of less expensive atypical antipsychotic
agents have failed due to intolerance or lack of response
· co-therapy with lithium or divalproex sodium, after trials of less expensive atypical antipsychotic agents have failed
due to intolerance or lack of response
NOTE: Exception status drugs for Drug Assistance for Cancer Patients are indicated by an asterisk (*).
February 2016
Appendix III
*AXITINIB (Inlyta 1mg and 5mg Tablet)
- as a single second line agent for the treatment of patients (ECOG PS 0 or 1) with advanced or metastatic clear cell renal
cell carcinoma (RCC) who are unable to tolerate ongoing use of an effective dose of everolimus or who have a
contraindication to everolimus
- sequential use of axitinib and everolimus is not permitted except in the case of intolerability or contraindication
*AZITHROMYCIN (Zithromax POS 100mg/5mL, 200mg/5mL and 250mg, 600mg Tablet and generic brands)
­ the treatment of infections requiring a macrolide antibiotic when the patient has a documented intolerance to
clarithromycin [Criteria Code 02]
­ the treatment of chlamydia trachomatis as a single dose of 1g [Criteria Code 05]
­ the treatment and prevention of mycobacterium avium complex (MAC) [Criteria Code 06]
­ the treatment of infections requiring a macrolide antibiotic when the patient is taking medications that would significantly
interact with erythromycin/clarithromycin [Criteria Code 07]
*BENZYDAMINE HCL (Pharixia 15mg/mL Oral Rinse)
- for oncology patients only
BETAHISTINE (Serc 16mg, 24mg Tablet and generic brands)
- for the symptomatic treatment of recurrent episodes of vertigo associated with Meniere's disease
BETAMETHASONE, CALCIPOTRIOL (Dovobet 0.5mg/g/50mcg/g Gel)
- for the treatment of body and scalp psoriasis after failure of a topical steroid and a vitamin D analogue as single agents
BOCEPREVIR (Victrelis 200mg Capsule)
BOCEPREVIR/RIBAVIRIN PEGINTERFERON ALFA-2B (Victrelis Triple Injection/Capsule)
- for the treatment of chronic hepatitis C genotype 1 infection in combination with peginterferon alpha/ribavirin
(PegIFNα/RBV), if the following criteria are met:
· detectable levels of hepatitis C virus (HCV) RNA prior to treatment
· fibrosis stage of F2, F3, or F4 as determined by a biopsy/fibroscan where available
OR
recommendation of a hepatologist or a prescriber with a specialty in hepatitis
· one course of treatment only (up to 44 weeks duration)
BOSENTAN (Tracleer 62.5mg, 125mg Tablet and generic brands)
- written initial request from a pulmonary arterial hypertension (PAH) specialist only
- diagnosis of PAH should be confirmed by right heart catheterization
- IPAH (functional class III and IV)
· for the treatment of patients with World Health Organization (WHO) functional class III and IV idiopathic pulmonary
arterial hypertension (IPAH) who do not demonstrate vasoreactivity on testing or who do demonstrate vasoreactivity
on testing but fail a trial of calcium channel blockers (CCB) or are intolerant to CCB
- PAH secondary to scleroderma, congenital heart disease or HIV (functional class III and IV)
· for the treatment of patients with World Health Organization (WHO) functional class III and IV pulmonary arterial
hypertension (PAH) associated with scleroderma, congenital heart disease or HIV who do not respond to conventional
therapy
*BUDESONIDE (Pulmicort Nebuamps 0.125mg/mL, 0.25mg/mL, 0.5mg/mL Suspension)
- See Wet Nebulization Solutions
BUPRENORPHINE AND NALOXONE (Suboxone 2mg/0.5mg, 8mg/2mg Sublingual Tablet)
­ for the treatment of opioid dependence for patients in whom methadone is contraindicated (e.g., patients at high risk of,
or with, QT prolongation, or hypersensitivity to methadone)
­ for the treatment of opioid dependence for appropriate patients ages 18-24 years
­ must be prescribed by a physician licensed to prescribe methadone for opioid dependence or by a physician registered
to prescribe buprenorphine/naloxone for opioid dependence with the College of Physicians and Surgeons of Nova
Scotia (CPSNS).
NOTE: Exception status drugs for Drug Assistance for Cancer Patients are indicated by an asterisk (*).
February 2016
Appendix III
BUTORPHANOL (10mg/mL Nasal Spray)
- for the treatment of migraine, upon the request of a neurologist, prescriber with a specialty in neurology or a specialist in
pain management, when conventional forms of therapy are ineffective or inappropriate
CABERGOLINE (Dostinex 0.5mg Tablet and generic brands)
- for the treatment of micro- or macro-adenoma of the pituitary after failure of bromocriptine (as determined by prolactin
levels) or if bromocriptine is not tolerated
CALCIPOTRIOL (Dovonex 50mcg/g Ointment, Cream and 50mcg/mL Scalp Solution)
- for the treatment of psoriasis when conventional therapies have been ineffective or inappropriate
CANAGLIFLOZIN (Invokana 100mg and 300mg Tablet)
- for the treatment of Type II diabetes for patients with:
· inadequate glycemic control on metformin and a sulfonylurea; and
· for whom insulin is not an option
Note: 200mg is not a recognized dose; as such a dose of two 100mg tablets will not be funded.
*CAPECITABINE (Xeloda 150mg and 500mg Tablet and generic brands)
- requests must be from an oncologist or a prescriber with a specialty in oncology
Neo-Adjuvant and Adjuvant – Colon and Rectal Cancer
- neo-adjuvant treatment of stage II or stage III rectal cancer as a single agent prior to radiotherapy and/or concurrent
with radiotherapy
- adjuvant treatment of stage II or stage III rectal cancer as a single agent and/or concurrent with radiotherapy
- adjuvant treatment of stage III colon cancer as a single agent
- adjuvant treatment of stage III colon or rectal cancer as part of the XELOX (CAPOX) regimen as an alternative to
infusional 5-FU in the FOLFOX regimen
- coverage approved for 6 months, to be renewed as required
Metastatic Colorectal Cancer
- first line single agent as an alternative to combination chemotherapy
- alternative to the infusional 5-FU in the FOLFOX regimen as part of the XELOX (CAPOX) regimen
- coverage approved for 3 months, to be renewed as required
Advanced or Metastatic Breast Cancer (MBC)
- as a single agent or in combination with HER2 directed therapy (e.g. lapatinib or trastuzumab) as one line of therapy in
patients with advanced or metastatic breast cancer (MBC) who have an ECOG performance status of 0-2. For any one
patient, a capecitabine-based regimen may only be used as one line of therapy for the treatment of MBC
- coverage approved for 3 months, to be renewed as required
CARVEDILOL (Coreg 3.125mg, 6.25mg, 12.5mg, 25mg Tablet and generic brands)
- for the treatment of stable symptomatic heart failure with systolic dysfunction (i.e., left ventricular ejection fraction
(LVEF) less than or equal to 40%)
CERTOLIZUMAB PEGOL (Cimzia 200mg/mL SC Injection)
­ See Anti-Tumor Necrosis Factor (TNF) Agents
CETIRIZINE (Reactine 5mg, 10mg Tablet and generic brands)
- for chronic urticaria, defined as the presence of hives or lesions for longer than six weeks, which has responded to
treatment with cetirizine
NOTE: Exception status drugs for Drug Assistance for Cancer Patients are indicated by an asterisk (*).
February 2016
Appendix III
CHOLINESTERASE INHIBITORS (ChEI) (Donepezil, Galantamine, Rivastigmine)
- for the treatment of mild to moderate probable Alzheimer’s disease or possible Alzheimer’s disease with vascular
component, with Lewy bodies who meet the following criteria:
· a Mini-Mental State Examination (MMSE) score of 10 to 30 AND
· a Functional Assessment Staging Test (FAST) score of 4 to 5
- initial requests for reimbursement will be considered for a maximum 4 month approval; subsequent requests may be
considered for a maximum 12 month approval. Requests to switch from one agent in the class to another will not be
considered beyond the initial 4 month approval
CINACALCET (Sensipar 30mg, 60mg and 90mg Tablets)
- for the treatment of patients with chronic kidney disease on dialysis with severe secondary hyperparathyroidism who:
⋅ are not responding to optimal doses of Vitamin D analogues or phosphate binders (calcium or non-calcium based)
AND are either not a surgical candidate due to surgical or anesthetic risk OR awaiting kidney transplant
⋅ in addition laboratory findings must confirm serum phosphate >1.8mmol/L, serum calcium ≥2.2mmol/L and iPTH
>88pmol/L on more than one occasion at least 6 weeks apart
⋅ ongoing laboratory investigations must include serum calcium, albumin, phosphorous weekly for three weeks and
iPTH every 6 weeks
­ coverage for cinacalcet will be renewed if there is a greater than 30% decrease in iPTH after at least 3 months with
escalating dose, indicating the patient is responding
- approval period 12 months, provided there has been a greater than 30% decrease in iPTH as stated above
CIPROFLOXACIN, OPHTHALMIC (Ciloxan 0.3% Ophthalmic Solution and generic brands and Ointment)
- See Fluoroquinolones, Ophthalmic
*CIPROFLOXACIN, ORAL (Cipro 100mg/mL Oral Liquid and 250mg, 500mg, 750mg Tablet and generic
brands)
- See Fluoroquinolones, Oral
*CIPROFLOXACIN XL, ORAL (Cipro XL 1000mg Tablet)
- for the oral treatment of gram-negative infections in complicated urinary tract infections, for which other oral agents are
not effective or available [Criteria Code 10]
- for the oral treatment of acute uncomplicated pyelonephritis [Criteria Code 11]
CIPROFLOXACIN & DEXAMETHASONE, OTIC (Ciprodex Otic Suspension)
- for the treatment of patients with acute otitis media with otorrhea through tympanostomy tubes [Criteria Code 01]
- for the treatment of patients with acute otitis externa in the presence of a tympanostomy tube or known perforation of
the tympanic membrane [Criteria Code 02]
CLOPIDOGREL (Plavix 75mg Tablet and generic brands)
- for the secondary prevention of the following vascular ischemic events in patients with a history of symptomatic
atherosclerotic disease, including:
· ischemic stroke/ transient ischemic attack (TIA) in patients with a documented severe allergy to ASA or who
experience a recurrent thrombotic event (stroke, symptoms of TIA) while taking ASA or a GI hemorrhage while on
ASA,
· myocardial infarction (MI) in patients with a documented severe allergy to ASA or who experience a GI hemorrhage
while on ASA,
· peripheral vascular disease (PVD) in patients with a documented severe allergy to ASA or who experience a GI
hemorrhage while on ASA,
· unstable angina in patients with a documented severe allergy to ASA or who experience a GI hemorrhage while on
ASA
- in patients with intravascular stent implantation, the coverage period following insertion is:
Bare Metal Stent(s) (BMS) - 30 days
Drug Eluting Stent(s) (DES) - 12 months
Note: The [Criteria Code 30] may be used for the initial 30 days coverage period for all types of intravascular stent
implantation. For coverage beyond the initial 30 day online approval a written request from the prescriber is required.
NOTE: Exception status drugs for Drug Assistance for Cancer Patients are indicated by an asterisk (*).
February 2016
Appendix III
- for patients with non-ST-segment elevation acute coronary syndrome (ACS) (i.e., unstable angina or non-ST-segment
elevation myocardial infarction), in combination with ASA, for a coverage period of 3 months coverage. Coverage for 12
months is available for high risk patients:
· with a second ACS within 12 months, or
· with complex or extensive coronary artery disease (CAD) e.g., diffuse 3 vessel CAD not amenable to
revascularization, or
· who have had a previous stroke, TIA or have symptomatic PVD
- other requests on a case by case basis
*CODEINE, SUSTAINED RELEASE (Codeine Contin 50mg, 100mg, 150mg and 200mg Tablet)
- for the treatment of mild to moderate chronic pain syndrome, if pain has been controlled by doses less than 200mg q12h
- patients may be considered candidates if they are achieving good pain control from immediate-release plain codeine
preparations but prefer the convenience of a long-acting preparation, or if they are achieving good pain control from
acetaminophen or ASA plus codeine preparations but are limited by the acetaminophen content to no greater than 12
tablets per day
- not insured for the treatment of acute pain (e.g., post-operative pain)
CROMOGLYCATE SODIUM (pms-Sodium Cromoglycate1% Nebulizer Solution)
- See Wet Nebulization Solutions
*CYANOCOBALAMIN, INJECTION (Cyanocobalamin, Vitamin B12 100mcg/mL and 1000mcg/mL Injection)
- for the treatment of documented cyanocobalamin deficiency, when the oral route is inappropriate or contraindicated
(criteria applies to all Programs)
*CYANOCOBALAMIN, ORAL (Vitamin B12 500mcg and 1,000mcg Tablet)
- for the treatment of documented cyanocobalamin deficiency in recipients of the Community Services Pharmacare
Program, Family Pharmacare Program and Drug Assistance for Cancer Patients; oral cyanocobalamin is fully insured
for Seniors' Pharmacare Program
*CYANOCOBALAMIN, ORAL IN COMBINATION (Vitamin B12 1000mcg SL Tablet with Folic Acid)
- for the treatment of documented cyanocobalamin deficiency in recipients of the Community Services Pharmacare
Program, Family Pharmacare Program and Drug Assistance for Cancer Patients; oral cyanocobalamin is fully insured
for Seniors' Pharmacare Program
CYCLOSPORINE (Neoral 10mg, 25mg, 50mg, 100mg Capsule and 100mg/mL Oral Liquid and generic
brands)
- for the treatment of severe psoriasis
- for the treatment of severe rheumatoid arthritis
DABIGATRAN (Pradaxa 110mg and 150mg Capsule)
- Inclusion Criteria:
1
At-risk patients with non-valvular atrial fibrillation (AF) who require dabigatran for the prevention of stroke and systemic
embolism AND in whom:
2
3
· anticoagulation is inadequate following a reasonable trial on warfarin;
OR
· anticoagulation with warfarin is contraindicated or not possible due to inability to regularly monitor via
International Normalized Ratio (INR) testing (i.e. no access to INR testing services at a laboratory, clinic,
pharmacy, and at home)
At risk patients with non valvular atrial fibrillation are defined as those with a CHADS2 score of ≥ 1.
Inadequate anticoagulation is defined as INR testing results that are outside the desired INR range for at least 35% of the tests during the monitoring
period (i.e. adequate anticoagulation is defined as INR test results that are within the desired INR range for at least 65% of the tests during the
monitoring period).
3
A reasonable trial on warfarin is defined as at least two months of therapy.
1
2
NOTE: Exception status drugs for Drug Assistance for Cancer Patients are indicated by an asterisk (*).
February 2016
Appendix III
- Exclusion Criteria:
4
Patients with impaired renal function (creatinine clearance or estimated glomerular filtration rate < 30mL/min) OR ≥ 75
5
years of age and without documented stable renal function OR hemodynamically significant rheumatic valvular heart
6
disease , especially mitral stenosis; OR prosthetic heart valves.
* Please Note: Patients starting dabigatran should have ready access to appropriate medical services to manage a major
bleeding event.
4
Since renal impairment can increase bleeding risk, renal function should be regularly monitored. Other factors that increase bleeding risk should also
be assessed and monitored (see Pradaxa® (dabigatran) Product Monograph).
Documented stable renal function is defined as creatinine clearance or estimated glomerular filtration rate that is maintained for at least three months
(i.e. 30-49mL/min for 110mg twice daily dosing or ≥ 50 mL/min for 150 mg twice daily dosing).
6
There is currently no data to support that dabigatran provides adequate anticoagulation in patients with rheumatic valvular disease or those with
prosthetic heart valves, so dabigatran is not recommended in these populations.
5
*DARBEPOETIN (Aranesp Syringe Injection)
- for the treatment of transfusion dependent patients with hematologic malignancies who have a baseline anemia of ≤
90g/L and whose transfusion requirements are ≥ 2 units of packed red blood cells per month over 3 months
- initial approval for 12 weeks with the documentation of dose, hemoglobin and therapeutic outcome (number of
transfusions)
- approval of further 12 week cycles are dependent on evidence of satisfactory clinical response or reduced treatment
requirement to less than 2 units of PRBC monthly
Note: Specialized request forms are used to request coverage for darbepoetin.
DARIFENACIN (Enablex 7.5mg, 15mg Tablet)
- for the treatment of over-active bladder (not stress incontinence) for patients who cannot tolerate or have insufficient
response to an adequate trial of immediate relase oxybutynin (e.g. 3 months)
- a three month trial will be approved initially with assessment of the effectiveness of this therapy required if further
coverage is considered
*DASATINIB (Sprycel 20mg, 50mg, 70mg Tablet)
- as a single agent for the treatment of adults with chronic, accelerated or blast phase chronic myelogenous leukemia
(CML) and Philadelphia chromosome acute lymphoblastic leukemia (Ph⊕ ALL) with resistance or intolerance to prior
therapy including imatinib
- coverage approved for 6 months
DEFERASIROX (Exjade 125mg, 250mg, 500mg Tablet for Suspension)
- for the treatment of patients who require iron chelation and deferoxamine is contraindicated
*DENOSUMAB (Prolia 60mg/mL Pre-filled syringe)
- for women with postmenopausal osteoporosis for whom bisphosphonates are contraindicated due to hypersensitivity or
abnormalities of the esophagus (e.g., esophageal stricture or achalasia) and have at least two of the following:
· age >75 years
· a prior fragility fracture
· a bone mineral density (BMD) T-score ≤ -2.5
*DENOSUMAB (Xgeva 120mg/1.7mL Solution)
- as a single agent for the prevention of skeletal related events (SREs) for metastatic castrate resistant prostate cancer
(CRPC) patients with one or more documented bone metastases and ECOG performance status (PS) 0-2
DIENOGEST (Visanne 2mg Tablet)
- for the management of pelvic pain associated with endometriosis in patients for whom one or more less costly hormonal
options are either ineffective or cannot be used
NOTE: Exception status drugs for Drug Assistance for Cancer Patients are indicated by an asterisk (*).
February 2016
Appendix III
DIMETHYL FUMARATE (Tecfidera 120mg and 240mg DR Capsule)
- for the treatment of patients with relapsing remitting multiple sclerosis (RRMS) who meet all of the following criteria:
⋅ requested and followed by a neurologist experienced in the management of RRMS, and
⋅ recent expanded disability status scale (EDSS) score of 5.5 or less (i.e. patients must be able to ambulate at least 100
metres without assistance.)
Exclusion:
- not funded in combination with other disease modifying therapies
- not funded in patients with an EDSS > 5.5
- not funded in patients < 18 years of age
Renewals:
­ EDSS score < 5.5 (i.e. patients must be able to ambulate at least 100 metres without assistance). Date and details of
the most recent neurological examination and EDSS score must be provided (exam must have occurred within the last
90 days), and
- patients must be stable or have experienced no more than 1 disabling attack/relapse in the past year
DIPYRIDAMOLE & ASA (Aggrenox 200/25mg Capsule)
- for the secondary prevention of ischemic stroke/transient ischemic attack (TIA) in patients who have experienced a
recurrent thrombotic event (stroke, symptoms of TIA) while taking ASA
DONEPEZIL (Aricept 5mg, 10mg Tablet and generic brands)
- See Cholinesterase Inhibitors (ChEI)
DULOXETINE (Cymbalta 30mg, 60mg Capsule)
- for the treatment of neuropathic pain in diabetic patients who are unresponsive to adequate courses of two alternative
agents, such as tricyclic antidepressants and anticonvulsants
- dose limited to a maximum of 60mg per day
ENTACAPONE (Comtan 200mg Tablet and generic brands)
- for the treatment of Parkinson's disease as adjunctive therapy in patients who are not well controlled and are
experiencing significant "wearing off" symptoms despite optimal therapy with a levodopa and a decarboxylase inhibitor
ENTECAVIR (Baraclude 0.5mg Tablet and generic brands)
- for the treatment of chronic hepatitis B infection in patients with:
· documented cirrhosis on radiologic or histologic grounds AND
· a HBV DNA concentration above 2000iu/mL
ENZALUTAMIDE (Xtandi 40mg Capsule)
Asymptomatic or Mildly Symptomatic Patients:
­ as a single agent treatment for asymptomatic or mildly symptomatic metastatic CRPC patients after failure of
androgen deprivation therapy (including an LHRH agonist/antagonist or orchiectomy) who have not received prior
chemotherapy for metastatic CRPC, ECOG PS 0-1 and no risk for seizures.
­ enzalutamide would be an alternative to abiraterone and not sequential therapy in this asymptomatic or mildly
symptomatic patient population.
Symptomatic (post-docetaxel chemotherapy) Patients:
­ as a single agent treatment for metastatic CRPC patients with ECOG PS 0-2, no risk for seizures and progression
after previous treatment with docetaxel.
­ enzalutamide would be an alternative to abiraterone and not sequential therapy in this symptomatic post docetaxel
chemotherapy setting.
Retreatment:
­ use of enzalutamide in the post docetaxel setting is not permitted if previously used in the pre-chemotherapy setting.
NOTE: Exception status drugs for Drug Assistance for Cancer Patients are indicated by an asterisk (*).
February 2016
Appendix III
EPINEPHRINE (Epipen 1:1000, Epipen Jr. 1:2000 Injection and Twinject 0.15mg, 0.3mg Auto-Injector)
- for the emergency treatment of anaphylactic reactions, when out of reach of immediate medical attention
Note: Regular benefit, but with a quantity limit of two injections per fiscal year. Additional units require an exception status
request.
EPLERENONE (Inspra 25mg and 50mg Tablet)
- for patients >55 years with mild to moderate HF on standard HF treatments with EF≤ 30% (or ≤35% if QRS
duration >130ms) and recent (6 months) hospitalization for CV disease or with elevated BNP or NT-proBNP
levels.
Notes:
- Requests will be considered from practitioners with a specialty in cardiology.
- Patients must be on optimal therapy with an angiotensin-converting–enzyme (ACE) inhibitor, an angiotensin-receptor
blocker (ARB), or both and a beta-blocker (unless contraindicated) at the recommended dose or maximal tolerated
dose.
*ERLOTINIB (Tarceva 100mg, 150mg Tablet)
- as monotherapy for the treatment of patients with locally advanced or metastatic Non-Small Cell Lung Cancer (NSCLC)
after failure of at least one prior chemotherapy regimen and whose EGFR expression status is positive or unknown
- coverage approved for 6 months
*ERYTHROPOIETIN (Eprex Multidose Vial and Syringe Injection)
- for the treatment of transfusion dependent patients with hematologic malignancies who have a baseline anemia of ≤
90g/L and whose transfusion requirements are ≥ 2 units of packed red blood cells per month over 3 months
- initial approval for 12 weeks with the documentation of dose, hemoglobin and therapeutic outcome (number of
transfusions)
- approval of further 12 week cycles are dependent on evidence of satisfactory clinical response or reduced treatment
requirement to less than 2 units of PRBC monthly
- if transfusion requirements increase to ≥ 2 units/ month (over a 3 month period), one dose increase may be attempted
(maximum dose 60,000iu per week)
Note: Specialized request forms are used to request coverage for erythropoietin.
*ESTRADIOL (Climara, Estraderm, Estradot Transdermal Patch, Estrogel Topical Gel and generic brands)
*ESTRADIOL/NORETHINDRONE ACETATE (Estalis Transdermal Patch)
- for the treatment of menopausal symptoms in women who cannot tolerate the oral forms of hormone replacement
therapy
ETANERCEPT (Enbrel 25mg Powder For Injection and 50mg/Ml Injection)
- See Anti-Tumor Necrosis Factor (TNF) Agents
*ETIDRONATE (200mg Tablet, generic brands)
*ETIDRONATE AND CALCIUM (Didrocal Kit and generic brands)
- for the treatment of osteoporosis associated with documented fragility fracture when alendronate, risedronate and
raloxifene are not tolerated or are contraindicated
- for the treatment of osteoporosis without documented fragility fracture when the patient is at a high 10 year fracture risk
(>20% major osteoporotic fracture over 10 years) as indicated by the radiologist on a BMD report, and alendronate,
risedronate and raloxifene are not tolerated or are contraindicated
- other requests reviewed on a case by case basis
*EVEROLIMUS (Afinitor 2.5mg, 5mg, and 10mg Tablet)
- as a single agent for metastatic renal cell carcinoma (RCC) patients with documented clear cell histology who have a
Karnofsky performance status 70% or higher after progression or intolerance to the VEGF multi-targeted tyrosine kinase
inhibitors (TKIs), (e.g., sunitinib, pazopanib and/or sorafenib)
NOTE: Exception status drugs for Drug Assistance for Cancer Patients are indicated by an asterisk (*).
February 2016
Appendix III
- in combination with exemestane for postmenopausal patients (ECOG PS ≤2) with documented hormone receptor
positive, HER2 negative-advanced breast cancer after recurrence or progression following a non-steroidal aromatase
inhibitor (NSAI)
Note: It may be clinically reasonable to use the combination in patients with treated and stable brain metastasis.
­ for the treatment of patients with progressive, unresectable, well or moderately differentiated, locally advanced or
metastatic pancreatic neuroendocrine tumors (pNET) with good performance status (ECOG 0-2), until disease
progression
Note: Patients whose disease progresses on sunitinib are not eligible for funded treatment with everolimus for pNET
EZETIMIBE (Ezetrol 10mg Tablet and generic brands)
- for the treatment of hypercholesterolemia, as adjunctive therapy with statins, in patients who have not reached
treatment goals on maximum tolerated statin therapy alone
- for the treatment of hypercholesterolemia, as monotherapy, in patients who are intolerant to statins and, when
appropriate, fibrates
FEBUXOSTAT (Uloric 80mg Tablet)
- for the treatment of symptomatic gout in patients who have documented hypersensitivity to allopurinol
*FENTANYL (Fentanyl 12mcg/hr, 25mcg/hr, 50mcg/hr, 75mcg/hr, 100mcg/hr Transdermal System and generic
brands)
- for the treatment of malignant or chronic non-malignant pain in adult patients who were previously receiving continuous
opioid administration (i.e., not opioid naive), or who are unable to take oral therapy
FERUMOXYTOL (Feraheme 30mg/mL Injection)
- for the treatment of iron deficiency anemia in home hemodialysis, peritoneal dialysis and predialysis chronic kidney
disease patients.
⋅ coverage must be requested by a practitioner with a specialty in nephrology.
⋅ coverage will only be considered if the dose required is ferumoxytol 510mg to avoid wastage and unnecessary costs.
Notes:
- Given the safety concerns with IV iron, patients should be closely monitored for signs and symptoms of hypersensitivity
reactions including monitoring of blood pressure and pulse during and for at least 30 minutes following each infusion of
Feraheme®. IV iron product monographs recommend IV irons should only be administered when personnel and
therapies are immediately available for the treatment of anaphylaxis and other hypersensitivity reactions.
- Ferumoxytol is contraindicated in some patients, including those with hypersensitivities to this product, any allergies to
other parenteral iron products, and in individuals with any known drug allergy.
- Ferumoxytol may affect the diagnostic ability of MRI for up to 3 months.
FESOTERODINE FUMARATE (Toviaz 4mg and 8mg Tablets)
- for the treatment of over-active bladder (not stress incontinence) for patients who cannot tolerate immediate release
oxybutynin after an adequate trial (e.g. 3 months)
- a three month trial will be approved initially with assessment of the effectiveness of this therapy required if further
coverage is considered
FINGOLIMOD (Gilenya 0.5mg Capsule)
For the treatment of patients with relapsing remitting multiple sclerosis (RRMS) who meet all of the following criteria:
- have failed to respond to a full and adequate course of at least one disease modifying therapy (DMT) publicly insured in
Nova Scotia as an initial therapy, or has contraindications/intolerance to at least two initial therapies.
- one or more clinically disabling relapses in the previous year.
- significant increase in T2 lesion load compared with that from a previous MRI scan (i.e. 3 or more new lesions) or at
least one gadolinium-enhancing lesion.
- requested and followed by a neurologist experienced in the management of RRMS
NOTE: Exception status drugs for Drug Assistance for Cancer Patients are indicated by an asterisk (*).
February 2016
Appendix III
- recent expanded disability status scale (EDSS) score of 5.5 or less (i.e. patients must be able to ambulate at least 100
meters without assistance).
Dosage: 0.5mg daily
Approval period: 1 year
Exclusions:
- not funded in combination with other disease modifying therapies
- not funded in patients with an EDSS>5.5
- not funded in patients who have had a heart attack or stroke in the last six months of funding request, patients with a
history of sick sinus syndrome, atrioventricular block, significant QT prolongations, bradycardia, ischemic heart disease,
or congestive heart failure
- not funded in patients <18 years of age
- not funded due to needle phobia or preference for oral therapy over injection in patients without clinical contraindications
to interferon or glatiramer therapy
- Note: skin reactions at the site of injection do not qualify as contraindications to interferon or glatiramer therapy
Renewal:
- EDSS score ≤ 5.5 (i.e. patients must be able to ambulate at least 100 meters without assistance). Date and details of
the most recent neurological examination and EDSS scores must be provided (exam must have occurred within that last
90 days) AND
- Patients must be stable or have experienced no more than 1 disabling attack/relapse in the past year
Of Note:
*Failure to respond to full and adequate courses: defined as a trial of at least 6 months of interferon or glatiramer therapy
AND experienced at least one disabling relapse (attack) while on interferon or glatiramer therapy
**Intolerance is defined as: documented serious adverse effects or contraindications that are incompatible with further use
of that class of drug
*FLUCONAZOLE (Diflucan POS 10mg/mL)
- for the treatment of oropharyngeal candidiasis when nystatin has failed, or for systemic infections when oral tablets are
not an option
*FLUDARABINE (Fludara 10mg Tablet)
- for the treatment of chronic lymphocytic leukemia (CLL), in patients with an ECOG performance status of 0-2, when:
· the patient has failed to respond or relapsed during or after previous therapy with an alkylating agent, and
· intravenous administration is not desirable
FLUOROQUINOLONES, OPHTHALMIC (Ciprofloxacin, Ofloxacin)
- for the treatment of eye infections upon the order of an ophthalmologist, ophthalmology resident, prescribing optometrist
or other prescriber who has a specialty in ophthalmology [Criteria Code 01]
*FLUOROQUINOLONES, ORAL (Ciprofloxacin, Norfloxacin, Ofloxacin)
- for the treatment of patients intolerant or allergic (hypersensitivity reaction) to all other effective oral agents [Criteria
Code 01]
- for the treatment of aerobic, gram-negative infections which are resistant to other suitable oral agents [Criteria Code
02]
- for the oral treatment of multi-resistant, aerobic, gram-negative infections traditionally requiring parenteral therapy (e.g.,
osteomyelitis, complicated urinary tract infections, bacterial pneumonia in cystic fibrosis, prostatitis) for which other oral
agents are not effective or available [Criteria Code 03]
- for infections due to Pseudomonas aeruginosa (ciprofloxacin is the preferred agent) [Criteria Code 04]
- for the treatment of necrotizing (malignant) otitis externa [Criteria Code 05]
- for the prevention of endophthalmitis in patients who have had cataract surgery involving an unplanned vitrectomy
(ciprofloxacin) [Criteria Code 06]
NOTE: Exception status drugs for Drug Assistance for Cancer Patients are indicated by an asterisk (*).
February 2016
Appendix III
*FLUOROQUINOLONES, RESPIRATORY (Levofloxacin, Moxifloxacin)
- for the completion of therapy instituted in the hospital setting for the treatment of nosocomial pneumonia, community
acquired pneumonia (CAP) or acute exacerbation of chronic bronchitis (AECB) [Criteria Code 01]
- for the treatment of severe pneumonia in nursing home patients [Criteria Code 02]
1
2
- for the treatment of CAP in patients with comorbidity upon radiographic confirmation of pneumonia, or who have failed
first line therapies (macrolide, doxycycline, amoxicillin-clavulanate) [Criteria Code 03]
1
3
- for the treatment of AECB in complicated patients who have failed treatment with one of the following: amoxicillin,
doxycycline, TMP-SMX, cefuroxime, macrolide, ketolide or amoxicillin-clavulanate [Criteria Code 04]
1
2
3
If treated with an antibiotic within the past 3 months choose an antibiotic from a different class.
Comorbidity includes chronic lung disease, malignancy, diabetes, liver failure, renal failure, congestive heart failure, use of antibiotics or steroids in the
past 3 months, suspected macroaspiration, hospitalization within last 3 months, HIV/AIDS, smoking, malnutrition or acute weight loss.
Complicated AECB defined as increased cough and sputum, sputum purulence and increased dyspnea and FEV1 < 50% predicted or FEV1 50% 65% and one of the following: ≥4 exacerbations per year, ischemic heart disease, chronic oral steroid use or antibiotic use in past 3 months
FLUTICASONE FUROATE AND VILANTEROL (AS TRIFENATATE) (Breo Ellipta 100mcg/25mg dry powder
for inhalation)
­ for the treatment of moderate to severe chronic obstructive pulmonary disease (COPD) as defined by spirometry.
OR
­ for the treatment of COPD in patients with an inadequate response to short acting bronchodilators.
­ combination therapy with a long- acting beta-2 agonist /inhaled corticosteroid (LABA/ICS) and a long acting
anticholinergic (LAAC) inhaler will be considered in patients with: moderate to severe COPD, as defined by spirometry,
a history of COPD exacerbation(s) and an inadequate response to LABA/ICS or LAAC.
Note: Coverage for LABA and LAAC as two separate inhalers will not be considered.
Clinical Notes:
1. Moderate to severe COPD is defined by spirometry as a post bronchodilator FEV1 < 60% predicted and FEV1/FVC
ratio of < 0.70. Spirometry reports from any point in time will be accepted.
If spirometry cannot be obtained, reasons must be clearly explained and other evidence of COPD severity provided,
i.e., Medical Research Council (MRC) Dyspnea Scale Score of at least Grade 3.
MRC Grade 3 is described as: walks slower than people of same age on the level because of shortness of breath
from COPD or has to stop for breath when walking at own pace on the level.
2. Inadequate response to short acting bronchodilators is defined as persistent symptoms, i.e., MRC of at least Grade 3,
after at least 2 months of short acting bronchodilator at the following doses*:
• 8 puffs per day of short acting beta-2 agonist or
• 12 puffs per day of ipratropium or
• 6 puffs per day of ipratropium plus salbutamol combination inhaler
* Inadequate response to LABA/ICS or LAAC is defined as persistent symptoms after at least 2 months of therapy.
3. COPD exacerbation is defined as an increase in symptoms requiring treatment with antibiotics and/or systemic (oral or
intravenous) corticosteroids.
Note: Inhalers which combine a LABA/LAAC are also available as ESD benefits. These products have their own criteria
which are listed in the NS Formulary.
FORMOTEROL (Foradil 12ug Capsule For Inhalation, Oxeze 6mcg/Dose, 12mcg/Dose Turbuhaler, Zenhale
50/5mcg, 100/5mcg, 200/5mcg Inh)
- See Long-Acting Beta2-Agonists
FORMOTEROL, IN COMBINATION (Symbicort 100/6mcg, 200/6mcg Turbuhaler)
- See Long-Acting Beta2-Agonists/Inhaled Corticosteroids
FOSFOMYCIN TROMETHAMINE (Monurol 3g/sachet)
­ for the treatment of uncomplicated urinary tract infections in adult female patients where:
⋅ the infecting organism is resistant to other oral agents [Criteria Code 01] OR
⋅ other less costly treatments are not tolerated [Criteria Code 02]
NOTE: Exception status drugs for Drug Assistance for Cancer Patients are indicated by an asterisk (*).
February 2016
Appendix III
*GABAPENTIN (Neurontin 100mg, 300mg, 400mg, 600mg and 800mg Capsule and Tablet and generic
brands)
- for the treatment of neuropathic pain (e.g. diabetic neuropathy, postherpetic neuropathy) in patients who have failed a
trial of a tricylic antidepressant (e.g. amitriptyline, desipramine, imipramine, nortriptyline).
GALANTAMINE (Reminyl ER 8mg, 16mg, 24mg Capsule and generic brands)
- See Cholinesterase Inhibitors (ChEI)
GLYCOPYRRONIUM BROMIDE (Seebri 50mcg Capsule for Inhalation)
­ for the treatment of moderate to severe chronic obstructive pulmonary disease (COPD) as defined by spirometry.
OR
­ for the treatment of COPD in patients with an inadequate response to short acting bronchodilators.
­ combination therapy with a long- acting beta-2 agonist /inhaled corticosteroid (LABA/ICS) and a long acting
anticholinergic (LAAC) inhaler will be considered in patients with: moderate to severe COPD, as defined by spirometry,
a history of COPD exacerbation(s) and an inadequate response to LABA/ICS or LAAC.
Note: Coverage for LABA and LAAC as two separate inhalers will not be considered.
Clinical Notes:
1. Moderate to severe COPD is defined by spirometry as a post bronchodilator FEV1 < 60% predicted and FEV1/FVC
ratio of < 0.70. Spirometry reports from any point in time will be accepted.
If spirometry cannot be obtained, reasons must be clearly explained and other evidence of COPD severity provided,
i.e., Medical Research Council (MRC) Dyspnea Scale Score of at least Grade 3.
MRC Grade 3 is described as: walks slower than people of same age on the level because of shortness of breath
from COPD or has to stop for breath when walking at own pace on the level.
2. Inadequate response to short acting bronchodilators is defined as persistent symptoms, i.e., MRC of at least Grade 3,
after at least 2 months of short acting bronchodilator at the following doses*:
• 8 puffs per day of short acting beta-2 agonist or
• 12 puffs per day of ipratropium or
• 6 puffs per day of ipratropium plus salbutamol combination inhaler
* Inadequate response to LABA/ICS or LAAC is defined as persistent symptoms after at least 2 months of therapy.
3. COPD exacerbation is defined as an increase in symptoms requiring treatment with antibiotics and/or systemic (oral or
intravenous) corticosteroids.
Note: Inhalers which combine a LABA/LAAC are also available as ESD benefits. These products have their own criteria
which are listed in the NS Formulary.
GOLIMUMAB (Simponi 50mg/0.5ml Autoinjector and Pre-filled Syringe)
­ See Anti-Tumor Necrosis Factor (TNF) Agents
*GRANISETRON (Kytril 1mg Tablet and generic brands)
- See Serotonin (5-HT3) Antagonists
Note: Recommended dose is 2mg orally 1 hour pre-chemotherapy or 1mg 1 hour pre-chemotherapy and 1mg 12 hours
post-chemotherapy.
GRASS POLLEN ALLERGEN EXTRACT (Oralair 100 and 300 Unit IR S/L Tablet)
-
For the seasonal treatment of grass pollen allergic rhinitis in patients that have not adequately responded to, or
tolerated, conventional pharmacotherapy.
Notes:
- Treatment with 5-GPAE must be prescribed and initiated by physicians with adequate training and experience in the
treatment of respiratory allergic diseases.
- Treatment should be initiated four (4) months before onset of pollen season and should only be continued until the
end of the season.
- Treatment should not be taken for more than three (3) consecutive years.
NOTE: Exception status drugs for Drug Assistance for Cancer Patients are indicated by an asterisk (*).
February 2016
Appendix III
HYDROXYZINE (10mg, 25mg, 50mg Capsule, generic brands and Atarax Syrup)
- for chronic urticaria, defined as the presence of hives or lesions for longer than six weeks, which has responded
to treatment with hydroxyzine
*IBRUTINIB (Imbruvica 140mg Capsule)
As a treatment option for patients with relapsed and/or refractory chronic lymphocytic leukemia (CLL) or small lymphocytic
leukemia (SLL) who have received at least one prior therapy and are considered inappropriate for treatment or
retreatment with a fludarabine-based regimen, including :
- Patients who received prior fludarabine-based treatment and had a progression free interval of less than three years
- Patients who received prior fludarabine-based treatment and had a progression free interval of greater than three years,
but are now considered unfit for fludarabine-based retreatment due to age ≥ 70, or age ≥ 65 and the presence of
comorbidities (Cumulative Illness Rating Scale [CIRS] ≥ 6 or creatinine clearance <70ml/min)
- Patients who did not receive prior fludarabine-based treatment because they were considered unfit, and who relapsed
after at least two cycles of alkylator-based therapy, regardless of the progression free interval after that therapy
*IMATINIB (Gleevec 100mg, 400mg Tablet and generic brands)
- as a single agent for adult patients with a histological diagnosis of localized primary Gastrointestinal Stromal Tumors
(GIST) (KIT (CD-117)-positive) following surgical complete resection and at a high risk of recurrence
· risk of recurrence is dependent on location, size and mitotic rate. Specific parameters for considering adjuvant
therapy after resection of GIST along the gastrointestinal tract may include but are not limited to:
• gastric: any tumor >3cm where the mitotic rate is >5/50 high powered fields (HPFs). Adjuvant treatment
could be considered where the mitotic rate is <5HPFs and tumor >10cm
• duodenal, small bowel, peritoneal, colorectal: any tumor where the mitotic rate is >5HPFs; any tumor
>5cm in size
• coverage duration: 36 months
- for the treatment of chronic myelogenous leukemia (CML), as a single agent, in patients who have documented
evidence of Philadelphia chromosome positive CML, with an ECOG performance status of 0-2 and who:
· are in blast crisis, accelerated phase, or chronic phase OR
· as a secondary treatment in patients who demonstrate a hematologic relapse or cytogenetic progression after
interferon-alpha (INF-a) therapy
· coverage duration: 1 year
- requests for other indications will be reviewed on a case by case basis
- written request of an oncologist required
*IMIQUIMOD (Aldara 5% Cream and generic brands)
- for the treatment of external genital and perianal warts and condyloma acuminata in adults
- for the treatment of actinic keratosis on the head and neck in patients who have failed treatment with 5FU and
cryotherapy
­ for the treatment of biopsy-confirmed primary superficial basal cell carcinoma:
· with a tumor diameter of ≤ 2cm AND
· located on the trunk, neck or extremities (excluding hands and feet) AND
· where surgery or eradication therapy is not medically indicated
• recurrent lesions in previously irradiated area OR
• multiple lesions, too numerous to irradiate or remove surgically
· approval period: 6 weeks
Note: Surgical management should be considered first-line for superficial basal cell carcinoma in most patients, especially
for isolated lesions
INCOBOTULINUMTOXIN A (Xeomin 50u/vial and 100iu/vial)
- for the treatment of blepharospasm or cervical dystonia (spasmodic torticollis)
INDACATEROL (Onbrez 75mcg Micronized powder for inhalation)
See Long-Acting Beta2-Agonists
NOTE: Exception status drugs for Drug Assistance for Cancer Patients are indicated by an asterisk (*).
February 2016
Appendix III
INDACATEROL AND GLYCOPYRRONIUM (Ultibro Breezhaler 110mcg/50mcg Capsule)
- for the treatment of moderate to severe chronic obstructive pulmonary disease (COPD), as defined by spirometry, in
patients with an inadequate response to a long-acting beta-2 agonist (LABA) or long-acting anticholinergic (LAAC)
Note:
- Moderate to severe COPD is defined by spirometry (post-bronchodilator) FEV1 < 60% predicted and FEV1/FVC ratio of
< 0.70. Spirometry reports from any point in time will be accepted.
If spirometry cannot be obtained, reasons must be clearly explained and other evidence regarding COPD severity must
be provided for consideration (i.e. Medical Research Council (MRC) Dyspnea Scale score of at least Grade 3). MRC
Grade 3 is described as: walks slower than people of same age on the level because of shortness of breath (SOB) from
COPD or has to stop for breath when walking at own pace on the level.
- Inadequate response is defined as persistent symptoms after at least 2 months of long-acting beta-agonist (LABA) or
long-acting anticholinergic therapy (LAAC).
INFLIXIMAB (Remicade 100mg Powder For Injection)
- See Anti-Tumor Necrosis Factor (TNF) Agents
INSULIN ASPART (Novorapid 100iu/Ml Penfill and Vial)
INSULIN GLULISINE (Apidra 3ml Pre-filled Pen, 10ml Vial And Cartridges)
INSULIN LISPRO (Humalog Insulin, Cartridges and Kwikpen)
- regular benefit for children 18 years and younger, under Community Services, Family Pharmacare and Diabetes
Assistance Programs
- for the management of Type I and Type II diabetes mellitus in patients 19 years of age and older, who are:
· undergoing intensive therapy, i.e., administering three or more injections of insulin per day including basal insulin, and
· testing blood glucose levels 4-6 times per day
INSULIN DETEMIR (Levemir 100iu/mL Penfill and FlexTouch Pre-filled Pen)
INSULIN GLARGINE (Lantus 100iu/mL vial, cartridge, and Solostar Pre-filled pen)
- for the treatment of patients who have been diagnosed with Type 1 or Type 2 diabetes requiring insulin and have
previously taken NPH and/or premix insulin daily at optimal dosing
AND
· have experienced unexplained nocturnal hypoglycemia at least once a month despite optimal management
OR
· have documented severe or continuing systemic or local allergic reaction to existing insulin(s)
*INTERFERON ALPHA-2B (Intron-A Injection and Multidose Pen)
-
written request of an oncologist only
for hairy cell leukemia
for AIDS-related Kaposi's sarcoma
for chronic hepatitis B or C
for chronic myelogenous leukemia (CML)
for thrombocytosis associated with CML
for malignant melanoma
for basal cell carcinoma
*IPRATROPIUM BROMIDE (Atrovent 125mcg/mL and 250mcg/mL Inhaled Solutions and generic brands)
- See Wet Nebulization Solutions
*IPRATROPIUM BROMIDE, IN COMBINATION (Combivent Inhaled Solution and generic brands)
- See Wet Nebulization Solutions
*IRON DEXTRAN (DexIron 50mg/ml Injection)
- for the treatment of iron deficiency anemia in patients intolerant to oral iron replacement products OR
- for patients who have not responded to adequate therapy with oral iron.
NOTE: Exception status drugs for Drug Assistance for Cancer Patients are indicated by an asterisk (*).
February 2016
Appendix III
Notes:
- Given the safety concerns associated with IV iron, it is expected that the patients will be carefully screened and will
have tried various oral iron options before being eligible for IV iron.
- Details regarding oral iron tried, length of therapy, and outcome must be provided.
*ITRACONAZOLE (Sporanox 100mg Capsule)
- for the treatment of severe systemic fungal infections
- for the treatment of severe or resistant fungal infections in immunocompromised patients
- for the treatment of severe onychomycosis caused by dermatophyte fungi as diagnosed by a dermatologist, attending
physician or prescriber with a specialty in dermatology
IVACAFTOR (Kalydeco 150mg Tablet)
For the treatment of cystic fibrosis in patients who meet the following criteria:
- age 6 years and older; AND
- patient has documented G551D mutation in the Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) gene.
1
Initial renewal criteria :
Renewals will be considered in patients with documented response to treatment (after at least 6 months of therapy), as
evidenced by the following:
In cases where the patient’s sweat chloride levels prior to commencing therapy were above 60 mmol/litre:
- the patient’s sweat chloride level fell below 60 mmol/litre; OR
- the patient’s sweat chloride level is 30% lower than the level reported in a previous test;
1
It should be noted that, while baseline sweat chloride levels and FEV1 are not required to meet initial approval criteria for ivacaftor, these parameters
may be used to evaluate the effect of ivacaftor upon renewal of the request. It is important that the physician measures baseline sweat chloride levels
and FEV1 and provides this information upon renewal to avoid delays in the assessment of the renewal funding decision as these measurements
may be required to evaluate renewal requests.
In cases where the patient’s sweat chloride levels prior to commencing therapy were below 60 mmol/litre:
- the patient’s sweat chloride level is 30% lower than the level reported in a previous test; OR
- the patient demonstrates a sustained absolute improvement in FEV1 of at least 5% when compared to the FEV1 test
conducted prior to the commencement of therapy.
Subsequent renewal criteria after the patient has met the initial renewal criteria:
The patient is continuing to benefit from therapy with Kalydeco.
LACOSAMIDE (Vimpat 50mg, 100mg, 150mg, 200mg Tablet)
- as adjunctive treatment for patients with refractory partial-onset seizures who meet all of the following criteria:
· are under the care of a physician experienced in the treatment of epilepsy, and
· are currently receiving two or more antiepileptic drugs, and
· in whom all other antiepileptic drugs are ineffective or not appropriate
*LACTULOSE (667mg/mL Oral Liquid, generic brands)
- for portal systemic encephalopathy
- for pneumatosis cystoides intestinalis
LAMIVUDINE (Heptovir 100mg Tablet and generic brands)
- for the treatment of hepatitis B, upon written request of a specialist
- therapy is approved for one year, with reassessment required at that time
*LANSOPRAZOLE (Prevacid FasTab 15mg, 30mg Tablet)
- for patients who require the use of a proton pump inhibitor and require administration through a feeding tube.
*LANSOPRAZOLE (Prevacid 15mg, 30mg Capsule and generic brands)
- See Proton Pump Inhibitors
NOTE: Exception status drugs for Drug Assistance for Cancer Patients are indicated by an asterisk (*).
February 2016
Appendix III
LANTHANUM CARBONATE (Fosrenol 250mg, 500mg, 750mg, 1000mg Tablet)
- upon the written request of a nephrologist or other prescriber within the Provincial Dialysis Program
- for the treatment of hyperphosphatemia (>1.8mmol/L) and calciphylaxis (calcific arteriolopathy) or hypercalcemia after
failure on a calcium-based binder
Note: The initial coverage will be for a three-month period. Renewals will be at six month intervals when there has been a
significant reduction in phosphate levels (a decrease of more than 0.7mmol of phosphate).
*LAPATINIB (Tykerb 250mg Tablet)
- in combination with capecitabine as a treatment option in patients with human epidermal growth factor receptor 2
(HER2) positive advanced or Metastic Breast Cancer (MBC) with trastuzumab refractory disease (previously treated
with trastuzumab alone or in combination with chemotherapy such as taxane and/or vinorelbine) who have an ECOG
performance status of 0 to 2 and choose to receive systemic chemotherapy. Patients with previous exposure to
capecitabine are not considered eligible
LEDIPASVIR AND SOFOSBUVIR (Harvoni 90mg/400mg Tab)
- For treatment-naïve and treatment-experienced adult patients with chronic hepatitis C genotype 1 infection, with
1
compensated liver disease, (including compensated cirrhosis) according to the following criteria:
⋅ Prescribed by a hepatologist or other specialist with expertise in the treatment of hepatitis C
⋅ Lab-confirmed hepatitis C genotype 1
⋅ Patient has a quantitative HCV RNA value within the last 6 months
⋅ Fibrosis stage F2 or greater (Metavir scale or equivalent)
Duration of therapy reimbursed:
Genotype 1 Patient Population
Treatment naïve, non-cirrhotic, viral load < 6 M IU/mL
Treatment naïve, non-cirrhotic, viral load ≥ 6 M IU/mL OR
Treatment naïve, cirrhotic OR
2
Treatment-experienced , non-cirrhotic
2
Treatment-experienced , cirrhotic
Duration of therapy
8* weeks
12 weeks
24 weeks
Exclusion criteria:
­ Patients currently being treated with another HCV antiviral agent
­ Patients who have received a previous trial of ledipasvir/sofosbuvir (Re-treatment requests will not be considered)
Notes:
1. Compensated cirrhosis is defined as cirrhosis with a Child Pugh Score =A (5-6).
2. Treatment experienced is defined as those who failed prior therapy with an interferon-based regimen, including
regimens containing an HCV protease inhibitor.
3. HIV-HCV co-infected patients with Genotype 1 may be considered as per criteria listed above.
4. Treatment of decompensated HCV may be considered for coverage on an exceptional case by case basis.
* For this population cohort, evidence has shown that the SVR rates with the 8-week and 12-week treatment regimens are similar.
Treatment regimens of up to 12 weeks are recognized as a Health Canada approved treatment option. Patients may be considered for
12 weeks of coverage if they have borderline or severe fibrosis (F3-4) or if they are co-infected with HIV.
*LENALIDOMIDE (Revlimid 5mg, 10mg, 15mg, 25mg Capsule)
- in combination with dexamethasone in adult patients with progressive myeloma (MM) after at least one previous
treatment, not resistant to dexamethasone, documented measurable disease and ECOG performance status of 0-2
- as a single agent in adult myelodysplastic syndrome (MDS) patients with transfusion dependent anemia due to low or
intermediate-1 risk MDS associated with a deletion 5q cytogenetic abnormality with or without additional cytogenic
abnormalities
NOTE: Exception status drugs for Drug Assistance for Cancer Patients are indicated by an asterisk (*).
February 2016
Appendix III
Newly Diagnosed Multiple Myeloma Post-Autologous Stem Cell Transplant (NDMM post-ASCT)
For the maintenance treatment of patients with newly diagnosed multiple myeloma, following autologous stem-cell
transplantation (ASCT):
- in patients with stable disease or better, with no evidence of disease progression;
- treat until progression or development of unacceptable toxicity requiring discontinuation of lenalidomide;
- initial dose 10 mg lenalidomide PO daily, AND
- dose adjustments (5-15 mg) may be necessary based on individual patient characteristics/responses
Note:
­ Celgene will ensure that the Product will be prescribed and dispensed only by physicians and pharmacists, respectively,
who are registered with and agree in writing to adhere to the guidelines of the Company’s RevAid® Program, details of
which Program are available at https://revaid.ca/revaid.
LEUKOTRIENE RECEPTOR ANTAGONISTS (Montelukast, Zafirlukast)
- for the treatment of moderate to severe asthma in adults and children who:
· despite compliance are not adequately controlled with a moderate or high dose inhaled corticosteroid and require
additional symptom control (e.g., cough, awakening at night, missing activities such as school, work or social activities
because of asthma symptoms) and
· require increasing amounts of short-acting beta2-agonists, indicative of poor control
LEVETIRACETAM (Keppra 250mg, 500mg, 750mg Tablet and generic brands)
- as adjunctive therapy in the management of patients with epilepsy who are not satisfactorily controlled by conventional
therapy
LEVOCARNITINE (Carnitor 1g/5mL Injection, 100mg/mL Oral Liquid and 300mg Tablet)
- for the treatment of primary systemic carnitine deficiency
LEVODOPA AND CARBIDOPA AND ENTACAPONE (Stalevo 50mg, 75mg, 100mg, 125mg, 150mg Tablet)
- for the treatment of Parkinson’s disease as adjunctive therapy in patients who:
· are not well controlled and are experiencing significant “wearing off” symptoms despite optimal therapy with
levodopa/carbidopa
· were not well controlled and experienced significant “wearing off” symptoms despite optimal therapy with
levodopa/carbidopa and are currently using levodopa/carbidopa and entacapone separately
*LEVOFLOXACIN (Levaquin 250mg, 500mg Tablet and generic brands)
- See Fluoroquinolones, Respiratory
LINEZOLID (Zyvoxam 600mg Tablet)
- written request from an infectious disease specialist or prescriber with a specialty in infectious diseases
- for the treatment of proven vancomycin-resistant enterococci (VRE) infections
- for the treatment of proven methicillin-resistant staphylococcus aureus or epidermidis (MRSA/MRSE) infections in those
patients who are unresponsive to, or intolerant of vancomycin
LINAGLIPTIN (Trajenta 5mg Tab)
- for the treatment of Type II diabetes for patients with:
· inadequate glycemic control on metformin and a sulfonylurea; and
· for whom insulin is not an option
LISDEXAMFETAMINE DIMESYLATE (Vyvanse 10mg, 20mg, 30mg, 40mg, 50mg, and 60mg Capsule)
- for the treatment of Attention Deficit Hyperactivity Disorder (ADHD) in patients age 6 to 25 years who:
⋅ demonstrate significant and problematic disruptive behaviour or who have problems with inattention that interfere with
learning; and
⋅ have been tried on methylphenidate (immediate release or long-acting formulation) or dexamphetamine with
unsatisfactory results.
NOTE: Exception status drugs for Drug Assistance for Cancer Patients are indicated by an asterisk (*).
February 2016
Appendix III
Notes:
- Requests will be considered from specialists in pediatric psychiatry, pediatricians or general practitioners with expertise
in ADHD.
- The maximum dose reimbursed is 60mg daily.
LONG-ACTING BETA2-AGONISTS (Formoterol, Indacaterol, Salmeterol)
LONG-ACTING BETA2-AGONISTS/INHALED CORTICOSTEROIDS (Formoterol, In Combination; Salmeterol,
In Combination)
Asthma
- for the treatment of moderate to severe asthma in patients who:
· are compliant with inhaled corticosteroids at optimal doses; and
· require additional symptom control, (e.g., cough, awakening at night, missing activities such as school, work or social
activities because of asthma symptoms); and
· require increasing amounts of short-acting beta2-agonists, indicative of poor control
Chronic Obstructive Pulmonary Disease
­ for the treatment of moderate to severe chronic obstructive pulmonary disease (COPD) as defined by spirometry.
OR
­ for the treatment of COPD in patients with an inadequate response to short acting bronchodilators.
­ combination therapy with a long- acting beta-2 agonist /inhaled corticosteroid (LABA/ICS) and a long acting
anticholinergic (LAAC) inhaler will be considered in patients with: moderate to severe COPD, as defined by spirometry,
a history of COPD exacerbation(s) and an inadequate response to LABA/ICS or LAAC.
Note: Coverage for LABA and LAAC as two separate inhalers will not be considered.
Clinical Notes:
1. Moderate to severe COPD is defined by spirometry as a post bronchodilator FEV1 < 60% predicted and FEV1/FVC
ratio of < 0.70. Spirometry reports from any point in time will be accepted.
If spirometry cannot be obtained, reasons must be clearly explained and other evidence of COPD severity provided,
i.e., Medical Research Council (MRC) Dyspnea Scale Score of at least Grade 3.
MRC Grade 3 is described as: walks slower than people of same age on the level because of shortness of breath
from COPD or has to stop for breath when walking at own pace on the level.
2. Inadequate response to short acting bronchodilators is defined as persistent symptoms, i.e., MRC of at least Grade 3,
after at least 2 months of short acting bronchodilator at the following doses*:
• 8 puffs per day of short acting beta-2 agonist or
• 12 puffs per day of ipratropium or
• 6 puffs per day of ipratropium plus salbutamol combination inhaler
* Inadequate response to LABA/ICS or LAAC is defined as persistent symptoms after at least 2 months of therapy.
3. COPD exacerbation is defined as an increase in symptoms requiring treatment with antibiotics and/or systemic (oral or
intravenous) corticosteroids.
Note: Inhalers which combine a LABA/LAAC are also available as ESD benefits. These products have their own criteria
which are listed in the NS Formulary.
LORATADINE (Claritin 10mg Tablet and generic brands)
- for chronic urticaria, defined as the presence of hives or lesions for longer than six weeks, which has responded to
treatment with loratadine
LURASIDONE (Latuda 20mg, 40mg, 60mg, 80mg, 120mg Tablet)
- for the treatment of schizophrenia or schizoaffective disorder in patients who have a contraindication to quetiapine and
risperidone, or have failed a trial of quetiapine and risperidone due to intolerance or lack of response.
MAGNESIUM GLUCOHEPTONATE (5mg/mL Solution and generic brands)
- for the treatment of hypomagnesemia
NOTE: Exception status drugs for Drug Assistance for Cancer Patients are indicated by an asterisk (*).
February 2016
Appendix III
*METHADONE (Metadol 1mg, 5mg, 10mg, 25mg Tablet)
- for the management of severe chronic or malignant pain as an alternative to other opiates
- written request of a physician authorized to prescribe methadone
*METHADONE, ORAL LIQUID (Methadone o/l Compound)
- for the management of severe chronic or malignant pain as an alternative to other opiates
- for the management of patients undergoing therapy for drug dependence
- written request of a physician authorized to prescribe methadone
METHYLPHENIDATE (Biphentin 10mg, 15mg, 20mg 30mg, 40mg, 50mg, 60mg and 80mg Capsule)
METHYLPHENIDATE ER (Concerta 18mg, 27mg, 36mg, and 54mg Tablets and generic brands)
- for patients 6-25 years of age diagnosed with attention deficit hyperactivity disorder (ADHD) who require 12-hour
continuous coverage due to academic and/or psychosocial needs, and who meet the following:
· patients who demonstrate significant and problematic disruptive behaviour or who have problems with inattention that
interfere with learning AND
· prescribed by or in consultation with a specialist in pediatric psychiatry, pediatrics, general practitioners or other
prescribers with expertise in ADHD AND
· have been tried on immediate release or slow release methylphenidate with unsatisfactory results
*MIDAZOLAM (1mg/mL, 5mg/mL Injection and generic brands)
- for adjunctive therapy of pain management in palliative care patients outside the hospital setting [Criteria Code 01]
MIRABEGRON (Myrbetriq 25mg ER and 50mg ER Tablet)
- for the treatment of overactive bladder (OAB) with symptoms of urgency, urgency incontinence, and urinary frequency if
the patient has had an intolerance or inadequate response to an adequate trial of an anticholinergic therapy
- not to be used in combination with other pharmacological treatments of OAB
- a three month trial will be approved initially with assessment of the effectiveness of this therapy required if further
coverage is considered
MODAFINIL (Alertec 100mg Tablet and generic brands)
- for the treatment of narcolepsy confirmed by sleep study
MONTELUKAST (Singulair 4mg, 5mg Chewtabs, 4mg/pkt Granules and 10mg Tablets and generic brands)
- See Leukotriene Receptor Antagonists
*MOXIFLOXACIN (Avelox 400mg Tablet and generic brands)
- See Fluoroquinolones, Respiratory
*NABILONE (Cesamet 0.25mg, 0.5mg and 1mg Capsule and generic brands)
- for the management of severe nausea and vomiting associated with cancer chemotherapy
NALTREXONE (Revia 50mg Tablet)
- for the treatment of alcohol dependence, as an adjunct to a comprehensive psychotherapeutic or psychological
alcoholism counseling program to support abstinence, and reduce the risk of relapse
- eligibility is initially restricted to a three month period with reassessment at that time for further coverage
NARATRIPTAN (Amerge 1mg, 2.5mg Tablet and generic brands)
- See Selective 5HT1 - Receptor Agonists
NATALIZUMAB (Tysabri 300mg/15mL Vial)
Initial Request:
For the treatment of Relapsing-Remitting Multiple Sclerosis (RRMS) who meet all the following criteria:
- the patient’s physician is a neurologist experienced in the management of relapsing-remitting multiple sclerosis (RRMS);
AND
- the patient;
⋅ has a current EDSS less than or equal to 5.0; AND
NOTE: Exception status drugs for Drug Assistance for Cancer Patients are indicated by an asterisk (*).
February 2016
Appendix III
⋅ has failed to respond to a full and adequate course* (at least six months) of at least ONE disease modifying therapy
OR has contraindications/intolerance to at least TWO disease modifying therapies; AND
⋅ has had ONE of the following types of relapses in the past year:
• the occurrence of one relapse with partial recovery during the past year AND has at least ONE gadoliniumenhancing lesion on brain MRI, OR significant increase in T2 lesion load compared to a previous MRI; OR
• the occurrence of two or more relapses with partial recovery during the past year; OR
• the occurrence of two or more relapses with complete recovery during the past year AND has at least ONE
gadolinium-enhancing lesion on brain MRI, OR significant increase in T2 lesion load compared to a previous MRI.
- approval period: 1 year
Requirements for Initial Requests:
- the patient’s physician provides documentation setting out the details of the patient’s most recent neurological
examination within ninety (90) days of the submitted request. This must include a description of any recent attacks, the
dates, and the neurological findings.
- MRI reports do NOT need to be submitted with the initial request
Renewal:
- date and details of the most recent neurological examination and EDSS scores must be provided (exam must have
occurred within the last 90 days) AND
- patients must be stable or have experienced no more than 1 disabling attack/relapse in the past year; AND
- recent Expanded Disability Status Scale (EDSS) score less than or equal to 5.0.
* Failure to respond to a full and adequate course is defined as a trial of at least one approved first line therapy for a minimum of 6
months AND experienced at least one disabling relapse (attack) while on this therapy.
*NILOTINIB (Tasigna 150mg & 200mg Capsule)
First Line:
- as a single first line agent for the treatment of adults with chronic phase CML
Second Line:
- as a single second line agent for the treatment of adults with chronic or accelerated phase CML with resistance or
intolerance to prior therapy
These second line criteria include:
· Patients with CML in chronic phase who are intolerant to oral tyrosine kinase inhibitors (TKIs) (i.e. imatinib or
dasatinib or both)
· Patients with CML in chronic phase who are resistant to imatinib
· Patients with CML that have progressed to accelerated phase while on imatinib therapy
- In any one patient, only two of the TKIs will be funded within these criteria during their lifetime
- If a patient develops grade 3 or 4 toxicity to one of the TKIs used within 3 months of initiating therapy, access to a third
agent will be funded
- Sequential use of nilotinib and dasatinib is not permitted except in the circumstance described above (i.e. grade 3 or 4
toxicity)
*NORFLOXACIN (400mg Tablet and generic brands)
- See Fluoroquinolones, Oral
OCRIPLASMIN (Jetrea 2.5mg/mL Injection)
For the treatment of symptomatic vitreomacular adhesion (VMA) if the following clinical criteria and conditions are met:
- diagnosis of VMA should be confirmed through optical coherence tomography
- patient does not have any of the following: large diameter macular holes (> 400 micrometre), high myopia (> 8 dioptre
spherical correction or axial length > 28 millimetre), aphakia, history of retinal detachment, lens zonule instability,
recent ocular surgery or intraocular injection (including laser therapy), proliferative diabetic retinopathy, ischemic
retinopathies, retinal vein occlusions, exudative age-related macular degeneration, or vitreous hemorrhage
NOTE: Exception status drugs for Drug Assistance for Cancer Patients are indicated by an asterisk (*).
February 2016
Appendix III
Conditions:
- Ocriplasmin should be administered by a retinal specialist or by a qualified ophthalmologist experienced in intravitreal
injections
- Treatment with ocriplasmin should be limited to a single injection per eye (i.e., retreatments are not covered)
OFLOXACIN, OPHTHALMIC (Ocuflox 0.3% Ophthalmic Solution and generic brands)
- See Fluoroquinolones, Ophthalmic
*OFLOXACIN, ORAL (300mg and 400mg Tablet and generic brands)
- See Fluoroquinolones, Oral
OLANZAPINE (Zyprexa 2.5mg, 5mg, 7.5mg, 10mg, 15mg Tablet and generic brands)
OLANZAPINE, ORAL DISINTEGRATING (Zyprexa Zydis 5mg, 10mg, 15mg, 20mg Tablet and generic
brands)
- for the treatment of schizophrenia and related psychotic disorders upon the written request of a psychiatrist, either first
line or upon failure of other antipsychotic agents
- for the acute treatment of manic or mixed episodes in bipolar I disorder in patients with intolerance or a history of failure
to one other atypical antipsychotic
- for maintenance therapy in patients with bipolar disease who are currently stabilized on olanzapine
OMBITASVIR/PARITAPREVIR/RITONAVIR AND DASABUVIR (Holkira Pak 12.5/75/50mg and 250mg
Tablet)
- for treatment-naïve and treatment-experienced adult patients with chronic hepatitis C genotype 1 infection, with
1
compensated liver disease, (including compensated cirrhosis) according to the following criteria:
· prescribed by a hepatologist or other specialist with expertise in the treatment of hepatitis C;
· lab-confirmed hepatitis C genotype 1, sub-type 1a and 1b required;
· patient has a quantitative HCV RNA value within the last 6 months;
· fibrosis stage F2 or greater (Metavir scale or equivalent);
Duration of therapy reimbursed:
Genotype 1 Patient Population
Duration of Therapy
Treatment naïve and experienced
12 Weeks
Genotype 1b, non-cirrhotic**
Treatment naïve and experienced
12 Weeks in combination
Genotype 1a, non-cirrhotic
with ribavirin (Moderiba)
Treatment naïve and experienced
12 Weeks in combination
Genotype 1b, cirrhotic
with ribavirin (Moderiba)
Treatment naïve and experienced (prior
12 Weeks in combination
relapsers and prior partial responders)
with ribavirin (Moderiba)
Genotype 1a, cirrhotic
Treatment experienced genotype 1a, with 24 Weeks in combination
cirrhosis AND who have had a previous
with ribavirin (Moderiba)
null response to PegIFN and RBV
**Holkira Pak with ribavirin is recommended in patients with an unknown genotype 1 subtype or with mixed genotype 1
infection.
Exclusion criteria:
­ patients currently being treated with another HCV antiviral agent
­ patients who have received a previous trial of Holkira Pak (Re-treatment requests will NOT be considered)
­ decompensated patients
­ no funding for other genotypes except as noted in the above funding criteria for genotype 1
­ patients who have received previous NS3/4A protease inhibitor-based regimens (boceprevir, telaprevir, and simeprevirbased regimens)
­ patients who have received previous sofosbuvir-based regimens (including ledispavir/sofosbuvir)
Notes:
1. Compensated cirrhosis is defined as cirrhosis with a Child Pugh Score =A (5-6)
2. Treatment experienced patients are defined as those who have previously been treated with PegIFN/RBV and did
NOTE: Exception status drugs for Drug Assistance for Cancer Patients are indicated by an asterisk (*).
February 2016
Appendix III
NOT receive adequate response.
3. HIV-HCV co-infected patients with genotype 1 may be considered as per criteria listed above
*OMEPRAZOLE (Losec 10mg, 20mg Capsule/Tablet and generic brands)
- See Proton Pump Inhibitors
Note: Omeprazole is available as a full benefit if the dose does not exceed the standard dose of 20mg per day (maximum
of 425 tablets/capsules per year). If the dosage is greater than 20mg per day then the criteria for coverage must be met.
ONABOTULINUMTOXIN-A (Botox 50iu/vial and 100iu/vial Injection)
- for the treatment of the following Health Canada approved indications:
· focal spasticity following stroke in adults
· equinus foot deformity in cerebral palsy patients 2 years of age and older
· cervical dystonia
· blepharospasm, hemifacial spasm (VII nerve disorder) or strabismus in patients 12 years of age and older
ONABOTULINUMTOXIN-A (Botox 200iu/vial Injection)
- for the treatment of urinary incontinence due to neurogenic detrusor overactivity resulting from neurogenic bladder
associated with multiple sclerosis (MS) or subcervical spinal cord injury (SCI) in patients who have failed to respond to
behavioural modification and anticholinergics and/or are intolerant to anticholinergics
· subsequent treatments are provided at intervals no less than every 36 weeks
*ONDANSETRON (Zofran 4mg, 8mg Tablet, 4mg/5mL Oral Liquid, ODT Tablet and generic brands)
- See Serotonin (5-HT3) Antagonists
Note: Only requests for the oral dosage forms are eligible for consideration. Although the dose may vary, usually a single
oral 8mg dose pre-chemotherapy is sufficient to control symptoms. As well, some patients may require additional therapy
up to 48 hours after the last dose of chemotherapy or last radiation treatment. Benefit beyond 48 hours has not been
established and is therefore, not insured.
*OSELTAMIVIR (Tamiflu 30mg, 45mg, 75mg Capsule, 12mg/mL Oral Suspension)
- for the treatment of long-term care residents with clinically suspected or lab confirmed influenza A or B. A clinically
suspected case is one in which the patient meets the criteria of influenza-like illness and there is confirmation of
influenza A or B circulating within the facility or surrounding community
- for the prophylaxis of influenza A or B in long-term care residents where the facility has an outbreak
- a protocol has been developed by Public Health for the treatment of patients in long-term care facilities. The facility must
contact the Medical Officer of Health or local Public Health Office, who will notify the Pharmacare office (or dispensing
pharmacy after office hours) if coverage is required
OXCARBAZEPINE (Trileptal 60mg/mL Oral Liquid and 150mg, 300mg, 600mg Tablet and generic brands)
- for the treatment of epileptic seizures in patients who have had an inadequate response to or are intolerant of at least
three other formulary agents (prior or current use) including carbamazepine
OXYBUTYNIN XL (Ditropan XL 5mg and 10mg Tablet)
- for the treatment of over-active bladder (not stress incontinence) for patients who cannot tolerate immediate relase
oxybutinin after an adequate trial (e.g. 3 months)
- a three month trial will be approved initially with assessment of the effectiveness of this therapy required if further
coverage is considered
PALIPERIDONE (Invega Sustenna 50mg/0.5mL, 75mg/0.75mL, 100mg/mL, 150mg/1.5mL Injection Kit)
- for patients having problems with compliance on an oral antipsychotic or
- for patients who are currently receiving a conventional depot antipsychotic and are experiencing significant side effects
(EPS or TD) or lack of efficacy
*PANTOPRAZOLE MAGNESIUM (Tecta 40mg Tablet and generic brands)
- See Proton Pump Inhibitors
NOTE: Exception status drugs for Drug Assistance for Cancer Patients are indicated by an asterisk (*).
February 2016
Appendix III
*PANTOPRAZOLE SODIUM (Pantoloc 20mg, 40mg EC Tablet and generic brands)
- See Proton Pump Inhibitors
*PAZOPANIB (Votrient 200mg Tablet)
­ as a single agent first-line treatment option for patients with documented evidence of histologically confirmed advanced
or metastatic clear cell renal cell carcinoma (RCC) who have an ECOG PS of 0 or 1. In any one patient, all the following
conditions must be met:
⋅ pazopanib may be a first line option.
⋅ pazopanib may not be used after another VEGF tyrosine kinase inhibitor as sequential therapy.
⋅ In the event of significant toxicity, a switch to another VEGF tyrosine kinase inhibitor may be allowed.
PEGINTERFERON ALFA-2A (Pegasys 180mcg Injection)
- for the treatment of hepatitis C in patients who are treatment naive, upon the written request of a hepatologist or
prescriber with a specialty in hepatitis
- a 24 week period will be initially approved at which time a further request will be required documenting the patient’s
response. If a positive response occurs, coverage can be continued for an additional 24 weeks (48 weeks total)
- for the treatment of HBeAg negative Chronic Hepatitis B (CHB) patients with compensated liver disease, liver
inflammation and evidence of viral replication with demonstrated intolerance to or failure of lamivudine therapy, upon
written request of a hepatologist or prescriber with a specialty in hepatitis. Maximum duration of coverage is 48 weeks
PEGINTERFERON ALFA-2A AND RIBAVIRIN (Pegasys RBV Injection/Tablet)
PEGINTERFERON ALFA-2B AND RIBAVIRIN (Pegetron and Pegetron Redipen Injection/Capsule)
- for the treatment of hepatitis C in patients who are treatment naive, upon the written request of a hepatologist or
prescriber with a specialty in hepatitis
- a 24 week period will initially be approved at which time a further request will be required documenting the patient’s
response. If a positive response occurs, coverage can be continued for an additional 24 weeks (48 weeks total)
- as combination therapy with new protease inhibitors (i.e., boceprevir or telaprevir); futility rules being enforced. Patients
should stop all therapy (both protease inhibitor and PegIFNα/RBV) if hepatitis C virus levels are:
· with boceprevir, ≥ 100 IU/mL at 12 weeks or detectable at 24 weeks
· with telaprevir, ≥ 1,000 IU/mL at 4 weeks or 12 weeks, or detectable at 24 weeks
PENTOXIFYLLINE (Trental 400mg Tablet and generic brands)
- for the treatment of patients with ulcers due to ischemia of critical limbs
PERAMPANEL (Fycompa 2mg, 4mg, 6mg, 8mg, 10mg and 12mg Tablet)
­ as an adjunctive therapy in the management of partial-onset seizures, in adult patients with epilepsy who are not
satisfactorily controlled with conventional therapy who meet all of the following criteria:
⋅ are under the care of a physician experienced in the treatment of epilepsy;
⋅ are currently receiving two or more antiepileptic drugs; and
⋅ in whom all other antiepileptic drugs are ineffective or not appropriate.
*PILOCARPINE, ORAL (Salagen 5mg Tablet)
- for oncology patients only
- for the treatment of the symptoms of xerostomia due to salivary gland hypofunction caused by radiotherapy for cancer of
the head and neck
PIOGLITAZONE (Actos 15mg, 30mg, 45mg Tablet and generic brands)
- for treatment of Type II diabetes in patients who have:
⋅ inadequate glycemic control on optimal doses of sulfonylurea and metformin; or
⋅ demonstrated intolerance or contraindication to metformin and are on optimal doses of sulfonylurea; or
⋅ demonstrated intolerance or contraindication to sulfonylurea and are on optimal does of metformin
- patients must have a recent A1C of < 10% unless insulin therapy is inappropriate for the patient. Duration of intial
approval will be 6 months; further coverage will require demonstrated evidence of efficacy (a reduction of A1C of 0.7
observed to continue coverage)
NOTE: Exception status drugs for Drug Assistance for Cancer Patients are indicated by an asterisk (*).
February 2016
Appendix III
PIRFENIDONE (Esbriet 267mg Capsule)
Initial approval criteria:
1
- adult patients who have a diagnosis of mild to moderate idiopathic pulmonary fibrosis (IPF) confirmed by a respirologist
and a high-resolution CT scan within the previous 24 months.
- initial approval period: 7 months (allow 4 weeks for repeat pulmonary function tests)
Initial renewal criteria:
- patients must NOT demonstrate progression of disease defined as an absolute decline in percent predicted FVC of
≥10% from initiation of therapy until renewal (initial 6 month treatment period). If a patient has experienced progression
as defined above, then the results should be validated with a confirmatory pulmonary function test conducted 4 weeks
later.
- approval period: 6 months
Second renewal criteria (12 months after initiation of therapy):
- patients must NOT demonstrate progression of disease defined as an absolute decline in percent predicted FVC of
≥10% since initiation of therapy (baseline). If a patient has experienced progression as defined above, then the results
should be validated with a confirmatory pulmonary function test conducted 4 weeks later
- approval period: 12 months
1
Mild-moderate IPF is defined as: a FVC between 50-80% predicted, and a Percent Carbon Monoxide Diffusing Capacity (%DLCO) between 30-90% predicted.
PLERIXAFOR (Mozobil 24mg/1.2mL (20mg/mL) Single Use Vial)
- for use in combination with filgrastim to mobilize hematopoietic stem cells for subsequent autologous transplantation in
patients with Non-Hodgkin’s lymphoma (NHL) or multiple myeloma (MM) if one of the following criteria are met:
⋅ a PBCD34+ count of < 10cells/uL after 4 days of filgrastim; OR
⋅ less than 50% of the target CD34 yield is achieved on the 1st day of apheresis (after being mobilized with filgrastim
alone or following chemotherapy); OR
⋅ if a patient has failed a previous stem cell mobilization with filgrastim alone or following chemotherapy.
Note: Reimbursement is limited to a maximum of 4 doses (0.24mg/kg given daily) for a single mobilization attempt and to
prescriptions written by an oncologist or hematologist.
*POMALIDOMIDE (Pomalyst 1mg, 2mg, 3mg, and 4mg Capsule)
- for patients with relapsed and/or refractory multiple myeloma who have previously failed at least two treatments,
including both bortezomib and lenalidomide and demonstrated disease progression on the last treatment.
- Pomalidomide may be an option in rare instances where bortezomib is not tolerated or contraindicated but in all cases,
patients should have failed lenalidomide.
Note: Pomalidomide must be prescribed and dispensed only by physicians and pharmacists who are registered with and
®
agree in writing to adhere to the guidelines of the Company’s RevAid Program. Details are available at
https://revaid.ca/revaid.
PRASUGREL HYDROCHLORIDE (Effient 10mg Tablet)
- in combination with ASA for patients with:
⋅ ST-elevated myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) who have
not received antiplatelet therapy prior to arrival in the catheterization lab.
⋅ treatment must be initiated in hospital.
⋅ approval period 12 months (up to 3 months for patients with bare metal stents).
Notes:
­ Criteria Code 30 may be used for the initial 30 day coverage period, however a written request submitted to the
Pharmacare office is required to allow coverage for the remaining duration of treatment.
­ As per the product monograph, prasugrel is contraindicated in patients with a known history of transient ischemic attack
or stroke; those with active pathological bleeding such as gastrointestinal bleeding or intracranial hemorrhage; and
those with severe hepatic impairment (Child-Pugh Class C).
NOTE: Exception status drugs for Drug Assistance for Cancer Patients are indicated by an asterisk (*).
February 2016
Appendix III
­ As per the product monograph, prasugrel is not recommended in patients ≥ 75 years of age because of the increase
risk of fatal and intracranial bleeding; or those with body weight < 60kg because of increased risk of major bleeding due
to an increase in exposure to the active metabolite of prasugrel.
*PREGABALIN (Lyrica 25mg, 50mg, 75mg, 150mg, 225mg, 300mg Capsule and generic brands)
- for the treatment of neuropathic pain (e.g. diabetic neuropathy, postherpetic neuropathy) in patients who have failed a
trial of a tricylic antidepressant (e.g. amitriptyline, desipramine, imipramine, nortriptyline)
*PROTON PUMP INHIBITORS (PPIs)
Omeprazole
­ Standard dose: full benefit at usual daily dose (e.g. 20mg per day). Maximum 425 tabs/caps per year.
­ Double dose: requires special authorization and must have failed standard daily doses of all full benefit PPI’s
omeprazole, rabeprazole and pantoprazole sodium. Coverage duration: 8 week trial, followed by up to one year of
coverage. Use beyond the 8 week trial will be considered if step down to standard dose is not successful.
Pantoprazole Sodium
­ Standard dose: full benefit at usual daily dose (e.g. 40mg per day). Maximum 425 tabs/caps per year.
­ Double dose: requires special authorization and must have failed standard daily doses of all full benefit PPI’s
omeprazole, rabeprazole and pantoprazole sodium. Coverage duration: 8 week trial, followed by up to one year of
coverage. Use beyond the 8 week trial will be considered if step down to standard dose is not successful
Pantoprazole Magnesium and Lansoprazole
­ Standard dose: failure of a trial of all open benefit PPIs (omeprazole, rabeprazole and pantoprazole sodium). Maximum
425 tabs/caps per year.
­ Double dose: failure of standard dose of requested agent and double doses of rabeprazole. Coverage duration: 8 week
trial, followed by up to one year of coverage. Use beyond an 8 week trial will be considered if step down to standard
dose is not successful.
*QUINAGOLIDE (Norprolac 0.025mg, 0.05mg, 0.075mg, 0.15mg Tablet)
- for the treatment of hyperprolactinemia (idiopathic or originating from a prolactin secreting micro or macro-adenoma of
the pituitary) after failure of bromocriptine (as determined by prolactin levels) or if bromocriptine is not tolerated
RALOXIFENE (Evista 60mg Tablet and generic brands)
- for the treatment of postmenopausal osteoporosis associated with documented fragility fracture when bisphosphonates
are not tolerated or are contraindicated
- for the treatment of postmenopausal osteoporosis without documented fractures when patient is at high 10 year fracture
risk (using fracture risk tables) and bisphosphonates are not tolerated or are contraindicated
- other requests reviewed on a case by case basis
*REGORAFENIB (Stivarga 40mg tablet)
- for patients with metastatic and/or unresectable gastrointestinal stromal tumors (GIST) who have had disease
progression on, or intolerance to, imatinib and sunitinib; AND has ECOG ≤ 1
RIBAVIRIN (Ibavyr 400mg and 600mg tablet)
­ for use within a combination therapy regimen for the treatment of chronic hepatitis C, in accordance with the specific
eligibility criteria for approved agents.
RIBAVIRIN (Moderiba 200mg, 400mg and 600mg Tablet)
­ for use in chronic hepatitis C patients, genotype 1, who have been approved for coverage of Holkira Pak
RILUZOLE (Rilutek 50mg Tablet and generic brands)
- for the treatment of amyotrophic lateral sclerosis (ALS) or Lou Gehrig’s Disease, when initiated by a neurologist with
expertise in the management of ALS, when the patient has:
· probable or definite diagnosis of ALS
· ALS symptoms for less than five years
· FVC >60% predicted upon initiation of therapy
· no tracheostomy for invasive ventilation
NOTE: Exception status drugs for Drug Assistance for Cancer Patients are indicated by an asterisk (*).
February 2016
Appendix III
- coverage to be reviewed every six months
- coverage cannot be renewed once the patient has a tracheostomy for the purpose of invasive ventilation or mechanical
ventilation
RIOCIGUAT (Adempas 0.5mg, 1.0mg, 1.5mg, 2.0mg, 2.5mg Tablet)
- for the treatment of inoperable chronic thromboembolic pulmonary hypertension (CTEPH, World Health Organization
[WHO] Group 4) or persistent or recurrent CTEPH after surgical treatment in adult patients (≥18 years of age) with
WHO Functional Class (FC) II or III pulmonary hypertension (PH).
- Adempas® should be prescribed by a clinician with experience in the diagnosis and treatment of CTEPH.
RISEDRONATE (Actonel 30mg Tablet and generic brands)
- Paget’s disease of bone (2 month limit, one re-treatment course may be considered)
- other requests reviewed on a case by case basis
RISPERIDONE (Risperdal Consta 12.5mg/2mL 25mg/2mL, 37.5mg/2mL, 50mg/2mL Injection)
- for patients having problems with compliance on an oral antipsychotic or
- for patients who are currently receiving a conventional depot antipsychotic and are experiencing significant side effects
(EPS or TD) or lack of efficacy
RITUXIMAB (Rituxan 10mg/mL Injection)
- for the treatment of adult patients with severe active rheumatoid arthritis who have failed to respond to an adequate trial
with an anti-TNF agent
- cannot be used concomitantly with anti-TNF agents
- written request from a rheumatologist or prescriber with a specialty in rheumatology
- approval for re-treatment with rituximab will only be considered for patients who have achieved a response, followed by
a subsequent loss of effect and, after an interval of no less than six months from the previous dose
- for the induction of remission in patients with severely active granulomatosis with polyangitis (GPA) or microscopic
polyangitis (MPA) who have severe intolerance or other contraindication to cyclophosphamide, or who have failed an
adequate trial of cyclophosphamide
RIVAROXABAN (Xarelto 10mg Tablet)
- for the prophylaxis of venous thromboembolism following total knee replacement surgery for up to 14 days, as an
alternative to low molecular weight heparins [Criteria Code 14]
- for the prophylaxis of venous thromboembolism following total hip replacement surgery for up to 35 days, as an
alternative to low molecular weight heparins [Criteria Code 35]
RIVAROXABAN (Xarelto 15mg and 20mg Tablet)
Deep Vein Thrombosis/Pulmonary Embolism:
- Inclusion Criteria:
⋅ For the treatment of deep vein thrombosis (DVT) or pulmonary embolism (PE)
⋅ Approval Period: Up to six (6) months
⋅ Criteria Code 42 will be used to allow the 15mg strength to pay (max 42 tablets), which will allow patients to start
therapy while awaiting ESD approval for the six months of therapy
Notes:
­ The recommended dose of rivaroxaban for patients initiating DVT or PE treatment is 15mg twice daily for 3 weeks,
followed by 20mg once daily.
­ Drug plan coverage for rivaroxaban is an alternative to heparin/warfarin for up to six months. When used for greater
than 6 months, rivaroxaban is more costly than heparin/warfarin. As such, patients with an intended duration of therapy
greater than 6 months should be considered for initiation on heparain/warfarin.
­ Since renal impairment can increase bleeding risk, it is important to monitor renal function regularly. Other factors that
increase bleeding risks should also be assessed and monitored (see rivaroxaban product monograph)
NOTE: Exception status drugs for Drug Assistance for Cancer Patients are indicated by an asterisk (*).
February 2016
Appendix III
Non-Valvular Atrial Fibrillation:
- Inclusion Criteria:
1
­ At-risk patients with non-valvular atrial fibrillation (AF) who require rivaroxaban for the prevention of stroke and
systemic embolism AND in whom:
2
3
· Anticoagulation is inadequate following a reasonable trial on warfarin; OR
· Anticoagulation with warfarin is contraindicated or not possible due to inability to regularly monitor via International
Normalized Ratio (INR) testing (i.e. no access to INR testing services at a laboratory, clinic, pharmacy, and at home)
Exclusion Criteria:
4
- Patients with impaired renal function (creatinine clearance or estimated glomerular filtration rate < 30 mL/min) OR ≥ 75
5
years of age and without documented stable renal function OR hemodynamically significant rheumatic valvular heart
6
disease , especially mitral stenosis; OR prosthetic heart valves
* Please Note: Patients starting rivaroxaban should have ready access to appropriate medical services to manage a
major bleeding event.
At-risk patients with non-valvular atrial fibrillation are defined as those with a CHADS2 score of ≥ 1. Although the ROCKET-AF trial included patients with higher
CHADS2 scores (≥ 2), other landmark studies with the other newer oral anticoagulants demonstrated a therapeutic benefit in patients with a CHADS2 score of 1.
Prescribers may consider an antiplatelet regimen or oral anticoagulation for patients with a CHADS2 score of 1.
2
Inadequate anticoagulation is defined as INR testing results that are outside the desired INR range for at least 35% of the tests during the monitoring period (i.e.
adequate anticoagulation is defined as INR test results that are within the desired INR range for at least 65% of the tests during the monitoring period).
3
A reasonable trial on warfarin is defined as at least two months of therapy.
4
Since renal impairment can increase bleeding risk, renal function should be regularly monitored. Other factors that increase bleeding risk should also be
assessed and monitored (see Xarelto® (rivaroxaban) Product Monograph).
5
Documented stable renal function is defined as creatinine clearance or estimated glomerular filtration rate of 30-49 mL/min for 15mg once daily dosing or ≥ 50
mL/min for 20mg once daily dosing that is maintained for at least 3 months.
6
There is currently no data to support that rivaroxaban provides adequate anticoagulation in patients with rheumatic valvular disease or those with prosthetic heart
valves, so rivaroxaban is not recommended in these populations.
1
RIVASTIGMINE (Exelon 2mg/mL Oral Liquid and 1.5mg, 3mg, 4.5mg, 6mg Capsule and generic brands)
- See Cholinesterase Inhibitors (ChEI)
RUFINAMIDE (Banzel 100mg, 200mg and 400mg Tablet)
- for the adjunctive treatment of seizures associated with Lennox-Gastaut syndrome for patients who meet all of the
following criteria:
· are under the care of a physician experienced in treating Lennox-Gastaut syndrome-associated seizures, AND
· are currently receiving two or more antiepileptic drugs, AND
· in whom less costly antiepileptic drugs are ineffective or not appropriate
*RUXOLITINIB (Jakavi 5mg, 15mg and 20mg Tablet)
- as a single agent in patients with intermediate or high risk symptomatic myelofibrosis (using the Dynamic International
Prognostic Scoring System (DIPSS) Plus or symptomatic splenomegaly) with an ECOG performance status (PS) ≤ 3 as
first line therapy or refractory to other treatments. Ongoing monitoring and follow up of therapy will be required.
*SACCHARATED IRON OXIDE (Venofer 20mg/mL Injection)
- for the treatment of iron deficiency anemia in patients intolerant to oral iron replacement products OR
- for patients who have not responded to adequate therapy with oral iron.
Notes:
- Given the safety concerns associated with IV iron, it is expected that the patients will be carefully screened and will
have tried various oral iron options before being eligible for IV iron.
- Details regarding oral iron tried, length of therapy, and outcome must be provided.
*SALBUTAMOL (0.5mg/mL, 1mg/mL, 2mg/mL Unit Dose Inhaled Solution and 5mg/mL Inhaled Solution)
- See Wet Nebulization Solutions
*SALBUTAMOL, IN COMBINATION (Combivent Inhaled Solution and generic brands)
- See Wet Nebulization Solutions
NOTE: Exception status drugs for Drug Assistance for Cancer Patients are indicated by an asterisk (*).
February 2016
Appendix III
SALMETEROL (Serevent 50mcg/dose Diskhaler and 50mcg/dose Diskus)
- See Long-Acting Beta2-Agonists
SALMETEROL IN COMBINATION (Advair 50/100mcg, 50/250mcg, 50/500mcg Diskus and HFA 25/125
mcg/dose, HFA 25/250 mcg/dose Inhaler)
- See Long-Acting Beta2-Agonists/Inhaled Corticosteroids
SAXAGLIPTIN (Onglyza 2.5mg and 5mg Tablet)
­ for the treatment of Type II diabetes for patients with:
⋅ inadequate glycemic control on metformin and a sulfonylurea; and
⋅ for whom insulin is not an option.
SAXAGLIPTIN AND METFORMIN (Komboglyze 2.5mg/500mg, 2.5mg/850mg, 2.5mg/1000mg Tab)
­ for the treatment of Type II diabetes for patients:
⋅ who are already stabilized on therapy with metformin, a sulfonylurea and saxagliptin to replace the individual
components of saxagliptin and metformin; and
⋅ for whom insulin is not an option.
SELECTIVE 5HT1 - RECEPTOR AGONISTS (Almotriptan Tablet, Naratriptan Tablet, Sumatriptan Nasal
Spray)
Sumatriptan 50mg & 100mg Tablet, Naratriptan Tablet
1
- for the treatment of migraine headache when:
2
· migraines are moderate in severity and other therapies (e.g. NSAIDs, acetaminophen, DHE spray) are not effective,
or
2
2
· migraine attacks are severe or ultra severe
1
As diagnosed based on current Canadian guidelines.
Definitions: Moderate – pain is distracting causing need to slow down and limit activities;
Severe – pain affects ability to concentrate and very difficult to continue with daily activities;
Ultra severe – unable to speak or think clearly; not able to function; likely lying down or sleeping.
2
Almotriptan Tablet, Sumatriptan Nasal Spray
1
2
- for the treatment of migraine headache of moderate intensity when:
· other therapies (e.g. NSAIDs, acetaminophen, DHE spray) are not effective AND patients have not responded to oral
sumatriptan, zolmitriptan, rizatriptan and naratriptan.
1
2
· for the treatment of migraine headache of severe or ultra severe2 intensity when patients have not responded to oral
sumatriptan, zolmitriptan, rizatriptan, and/or naratriptan.
Sumatriptan 6mg/Syringe Injection
1
2
- for the treatment of migraine headache of moderate intensity when:
· other therapies (e.g. NSAIDs, acetaminophen, DHE spray) are not effective AND oral and nasal triptans are not
appropriate.
1
2
2
· for the treatment of migraine headache of severe or ultra severe intensity when oral and nasal triptans are not
appropriate.
1
Note: Coverage limited to 18 doses/3 months
• patients with >3 migraines/month on average despite prophylactic therapy may be considered for up to a
maximum of 12 doses/30 day
1
Reimbursement will be available for a maximum quantity of 18 triptan doses per quarter (e.g., Jan to Mar) regardless of the agent(s) used within the 90
day period.
*SEROTONIN (5-HT3) ANTAGONISTS (Granisetron, Ondansetron)
- for the treatment of emesis in patients who are:
· receiving moderately or severely emetogenic chemotherapy [Criteria Code 01] or
· receiving intravenous chemotherapy or radiotherapy and who have not experienced adequate control with other
available antiemetics [Criteria Code 02] or
· receiving intravenous chemotherapy or radiotherapy and who are experiencing intolerable side effects to other
antiemetics, including steroids and anti-dopaminergic agents [Criteria Code 03]
NOTE: Exception status drugs for Drug Assistance for Cancer Patients are indicated by an asterisk (*).
February 2016
Appendix III
Note:
­ Use of criteria codes is limited to appropriate doses pre and post chemotherapy or radiation. Criteria codes must not be
used for claims related to other causes of nausea and vomiting or for long term, daily management of nausea and
vomiting.
SEVELAMER (Renagel 800mg Tablet)
- upon the written request of a nephrologist or other prescriber within the Provincial Dialysis Program
- for the treatment of hyperphosphatemia (>1.8 mmol/L) and calciphylaxis (calcific arteriolopathy) or hypercalcemia after
failure on a calcium-based binder
Note: The initial coverage will be for a three-month period. Renewals will be at six month intervals when there has been a
significant reduction in phosphate levels (a decrease of more than 0.7mmol of phosphate).
SILDENAFIL (Revatio 20mg Tablet and generic brands)
- written request from a pulmonary arterial hypertension (PAH) specialist only
- diagnosis of PAH should be confirmed by right heart catheterization
- dose of sildenafil will be limited to 20mg tid
- IPAH (functional class III)
· for the treatment of patients with World Health Organization (WHO) functional class III idiopathic pulmonary arterial
hypertension (IPAH) who do not demonstrate vasoreactivity on testing, or who do demonstrate vasoreactivity on
testing but fail a trial of calcium channel blockers (CCB), or are intolerant to CCB
- PAH secondary to connective tissue disease (functional class III)
· for the treatment of patients with World Health Organization (WHO) functional class III pulmonary hypertension
associated with connective tissue disease who do not respond to conventional therapy
SIMEPREVIR (Galexos 150mg Capsule)
In combination with peginterferon alfa and ribavirin, for the treatment of chronic hepatitis C genotype 1 infection in adults
with compensated liver disease if the following clinical criteria and conditions are met:
­ detectable levels of hepatitis C virus (HCV) RNA in the last six months; AND
­ a fibrosis stage of F2, F3, or F4
Conditions:
­ patients should have their HCV strain tested for NS3 Q80K polymorphism
Dosage: 150 mg once daily for 12 weeks in combination with peginterferon alfa and ribavirin.
Response-guided therapy (RGT) for treatment naïve patients or treatment experienced patients as per Product
Monograph
Treatment Futility Rule as per Product Monograph
Renewals are not considered.
Exclusion Criteria:
- patients with the NS3 Q80K polymorphism
- patients who have received a prior treatment with boceprevir or telaprevir in combination with pegIFN/RBV and did
NOT receive an adequate response
- patients not genotype 1
- fibrosis stage less than F2 (Metavir scale or equivalent)
- decompensated liver disease
- patients less than 18 years old
- simeprevir monotherapy
- simeprevir in combination with sofosbuvir
SITAGLIPTIN (Januvia 25mg, 50mg, 100mg Tablet)
- For the treatment of Type II diabetes for patients with:
· inadequate glycemic control on metformin and a sulfonylurea; and
· for whom insulin is not an option
NOTE: Exception status drugs for Drug Assistance for Cancer Patients are indicated by an asterisk (*).
February 2016
Appendix III
SITAGLIPTIN AND METFORMIN (Janumet 50/500mg, 50/850mg, 50/1000mg and 50/1000 XR Tablet)
­ For the treatment of Type II diabetes for patients:
· who are already stabilized on therapy with metformin, a sulfonylurea and sitagliptin to replace the individual
components of sitagliptin and metformin; and
· for whom insulin is not an option.
SODIUM FERRIC GLUCONATE (Ferrlecit 12.5mg/ml Injection)
- for the treatment of iron deficiency anemia in patients intolerant to oral iron replacement products OR
- for patients who have not responded to adequate therapy with oral iron.
Notes:
- Given the safety concerns associated with IV iron, it is expected that the patients will be carefully screened and will
have tried various oral iron options before being eligible for IV iron.
- Details regarding oral iron tried, length of therapy, and outcome must be provided.
SOFOSBUVIR (Sovaldi 400mg tablet)
­ For the treatment of adult patients with chronic hepatitis C infection with compensated liver disease, (including
1
compensated cirrhosis) as follows:
Genotype 1 [for 12 weeks in combination with Pegylated interferon (PegIFN)/Ribavirin (RBV)]:
­ Treatment-naive patients
OR Genotype 2 (for 12 weeks in combination with RBV):
2
­ Treatment-naïve patients in whom interferon (IFN) is medically contraindicated
OR
3
­ PegIFN/RBV treatment-experienced patients
OR Genotype 3 (for 24 weeks in combination with RBV):
2
­ Treatment-naïve patients in whom interferon (IFN) is medically contraindicated
OR
3
­ PegIFN/RBV treatment-experienced patients
AND Who meet ALL of the following:
­ Prescribed by a hepatologist or other specialist with expertise in the treatment of hepatitis C.
­ Lab-confirmed hepatitis C genotype 1, 2, or, 3
­ Patient has a quantitative HCV RNA value within the last 6 months
­ Fibrosis stage F2 or greater (Metavir scale or equivalent)
Exclusion criteria:
Patients currently being treated with another HCV antiviral agent;
Patients who have previously received a treatment course of sofosbuvir
(Re-treatment requests will not be considered).
­
­
Notes:
1. Compensated cirrhosis is defined as cirrhosis with a Child Pugh Score = A (5-6)
2. Medical contraindication to IFN is defined as hypersensitivity to peginterferon or interferon alfa-2a or 2b, polyethylene
glycol or any component of the formulation resulting in discontinuation of therapy; OR presence of significant clinical
comorbidities which are deemed to have a high risk of worsening with IFN treatment. Details are required regarding
patient’s contraindications and/or risk of worsening significant comorbidities.
3. Treatment-experienced patients (with Genotype 2 or 3) are defined as patients who have previously been treated with
PegIFN/RBV and did NOT receive adequate response.
4. HIV-HCV co-infected patients may be considered as per criteria listed above.
5. Treatment of decompensated HCV may be considered for coverage on an exceptional case by case basis.
NOTE: Exception status drugs for Drug Assistance for Cancer Patients are indicated by an asterisk (*).
February 2016
Appendix III
SOLIFENACIN (Vesicare 5mg, 10mg Tablet and generic brands)
- for the treatment of over-active bladder (not stress incontinence) for patients who cannot tolerate or have insufficient
response to an adequate trial of immediate release oxybutynin (e.g. 3 months)
- a three month trial will be approved initially with assessment of the effectiveness of this therapy required if further
coverage is considered
SOMATROPIN (Humatrope, Genotropin GoQuick and MiniQuick, Nutropin, Nutropin Aq, Saizen Injection and
Cartridge)
- for treatment of growth hormone deficiency in patients with Turner Syndrome, upon the request of an endocrinologist or
prescriber with a specialty in endocrinology
Note: The larger 8.8mg/vial format can be approved when suitable for dosing requirements, if it does not result in drug
wastage.
*SORAFENIB (Nexavar 200mg Tablet)
- as a single agent first line systemic therapy option in adult patients with a diagnosis of hepatocellular carcinoma (HCC)
with Child-Pugh Class A liver dysfunction (mild hepatic impairment) with ECOG performance status 0-1; and who have
either progression of disease, or who are not candidates for curative intent treatments (transplantation, hepatic
resection), or other well established palliative interventions (ablation, transcatheter arterial chemo-embolization (TACE),
internal radiation)
- as a single agent for second line treatment of patients with documented evidence of histologically confirmed advanced
or metastatic clear cell renal cell carcinoma, considered to be intermediate or low risk (according to Memorial SloanKettering (MSKCC) prognostic score), have an ECOG performance status of 0 or 1 and progressed after prior cytokine
therapy (or intolerance) within the previous 8 months. In any one patient all of the following conditions must be met:
· sorafenib may be a second line option only after cytokine therapy
· sorafenib may not be used after another tyrosine kinase inhibitor (i.e., sunitinib) as sequential therapy
· In the event of severe toxicity within the first 8 weeks of therapy, a switch to another tyrosine kinase inhibitor (i.e.,
sunitinib) may be allowed
- coverage approved for 5 months with reassessment
SUMATRIPTAN (Imitrex 50mg, 100mg Tablet and generic brands)
- See Selective 5HT1 - Receptor Agonists
SUMATRIPTAN (Imitrex 6mg/Syringe Injection and generic brands)
- See Selective 5HT1 - Receptor Agonists
*SUNITINIB (Sutent 12.5mg, 25mg, 50mg Capsule)
- as a single agent first line treatment in patients with documented evidence of histologically confirmed advanced or
metastatic clear cell renal cell carcinoma who have an ECOG performance status of 0 or 1. In any one patient all of the
following conditions must be met:
· sunitinib may be a first line option
· sunitinib may not be used after another tyrosine kinase inhibitor (i.e., sorafenib, or pazopanib) as sequential therapy
· in the event of significant toxicity, a switch to another tyrosine kinase inhibitor (i.e., sorafenib or pazopanib) may be
allowed
- as a single agent for the treatment of advanced gastrointestinal stromal tumor (GIST) patients after failure of imatinib
due to intolerance or resistance
- coverage approved for 9 months with reassessment
- for the treatment of patients with progressive, unresectable, well or moderately differentiated, locally advanced or
metastatic pancreatic neuroendocrine tumors (pNET) with good performance status (ECOG 0-2), until disease
progression
TACROLIMUS (Protopic 0.03%, 0.1% Ointment)
- for children greater than 2 years of age with refractory atopic dermatitis. Coverage will be renewed yearly
- for the intermittent use for moderate to severe atopic dermatitis in adults who have:
· failed or are intolerant to a site appropriate strength of corticosteroid therapy (i.e., low potency on face versus
intermediate to high potency for trunk and extremities)
NOTE: Exception status drugs for Drug Assistance for Cancer Patients are indicated by an asterisk (*).
February 2016
Appendix III
TAZAROTENE (Tazorac 0.05%, 0.1% Gel)
- for use in psoriasis therapy when conventional therapies have been ineffective or inappropriate
*TEMOZOLOMIDE (Temodal 5mg, 20mg, 100mg, 200mg Capsule and generic brands)
- in combination with radiotherapy (concomitant therapy) and as adjuvant therapy (post radiation for 6 cycles) for newly
diagnosed high grade glioma patients with a good performance status (PS) (Karnofsky ≥ 60) and who choose to receive
first line systemic chemotherapy
- use as a single agent may be considered for patients with recurrent high grade glioma and a good PS (Karnofsky ≥ 60)
who have not previously been treated with first line combination (temozolomide and radiation) therapy
- use as a single agent may be considered for patients with high grade glioma who have recurrent disease occurring
during their initial adjuvant therapy. Other systemic treatment options such as etoposide, nitrosourea based therapy or
a clinical trial should be considered for patients who recur immediately following temozolomide therapy. Rechallenge
with temozolomide could be considered for patients with a temozolomide free interval of six months
TENOFOVIR DISOPROXIL (Viread 300mg Tablet)
- for the treatment of chronic hepatitis B infection in patients with:
· documented cirrhosis on radiologic or histologic grounds AND
· a HBV DNA concentration above 2000iu/mL
TERBINAFINE (Lamisil 250mg Tablet and generic brands)
- for the treatment of severe onychomycosis caused by dermatophyte fungi. (Suggested treatment periods: 6 weeks for
fingernails and 12 weeks for toenails. Longer periods of time will be considered on a case by case basis)
- for the treatment of dermatophyte infection unresponsive to other treatments or unlikely to respond to other treatments
due to the site or severity of the infection
TERIFLUNOMIDE (Aubagio 14mg Tablet)
For the treatment of patients with relapsing remitting multiple sclerosis (RRMS) who meet all of the following criteria:
­ requested and followed by a neurologist experienced in the management of RRMS, and
­ recent expanded disability status scale (EDSS) score of 5.5 or less (i.e. patients must be able to ambulate at least 100
metres without assistance)
Exclusions:
- not funded in combination with other disease modifying therapies
- not funded in patients with an EDSS > 5.5
- not funded in patients < 18 years of age
Renewals:
- EDSS score < 5.5 (i.e. patients must be able to ambulate at least 100 metres without assistance). Date and details of
the most recent neurological examination and EDSS score must be provided (exam must have occurred within the last
90 days), and
- Patients must be stable or have experienced no more than 1 disabling attack/relapse in the past year
*TESTOSTERONE, TOPICAL (Androderm Patch, Androgel Gel Packet & Testim Gel)
- for the treatment of congenital and acquired primary or secondary hypogonadism in males with a specific
diagnosis of:
· Primary: cryptorchidism, Klinefelter's, orchidectomy, and other established causes
· Secondary: pituitary-hypothalamic injury due to tumors, trauma, radiation
· deficiency should be clearly demonstrated by clinical features and confirmed by two separate biochemical tests
before initiating any therapy
Note: Maximum dose approved is 5g per day or a 5mg patch per day.
This will be adjudicated by limiting the quantity payable each quarter (e.g. Jan-Mar) to:
· 120 Androderm Patches (2.5mg or 5mg Patch);
· 300g of Androgel 2.5g gel (packet);
· 600g of Androgel 5g gel (packet); or
· 600g of Testim Gel
NOTE: Exception status drugs for Drug Assistance for Cancer Patients are indicated by an asterisk (*).
February 2016
Appendix III
Please be reminded that topical gels are to be billed per gram (not per packet)
*THYROTROPIN (Thyrogen 0.9mg/mL Injection)
- to monitor for recurrence and metastatic disease, in patients who have documented evidence of thyroid cancer and who
have undergone appropriate surgical and/or medical management. This includes:
· primary use in patients with inability to raise an endogenous TSH level (≥25 mu/L) with thyroid hormone withdrawal
· primary use in cases of documented morbidity in patients for whom severe hypothyroidism could be life-threatening
· secondary use in patients with previous thyroid hormone withdrawal resulting in a documented life-threatening event
- as a single agent for the preparation of radioiodine remnant ablation in patients with papillary or follicular thyroid cancer
who have undergone thyroidectomy as treatment for thyroid cancer
· thyrotropin is a reasonable alternate to thyroid hormone withdrawal in patients who are unable to tolerate the
prolonged hypothyroid state or who cannot achieve satisfactory elevation of endogenous TSH
· thyrotropin may be used in new patients or patients with previously incomplete remnant ablation or who have a
recurrence of thyroid cancer and require therapeutic remnant ablation
TICLOPIDINE (Ticlid 250mg Tablet and generic brands)
- for the secondary prevention of ischemic stroke or transient ischemic attack (TIA) in patients with a documented severe
allergy to ASA or who experience a recurrent thrombotic event (stroke, symptoms of TIA) while taking ASA [Criteria
Code 01]
- for the prevention of thrombosis in patients post intracoronary stent implantation for a period of up to 30 days following
insertion [Criteria Code 02]
- other requests on a case by case basis
TICAGRELOR (Brilinta 90mg Tablet)
-
1
to be taken in combination with ASA 75 mg -150mg daily for patients with acute coronary syndrome (i.e. ST elevation
myocardial infarction (STEMI), non-ST elevation myocardial infarction (NSTEMI), or unstable angina (UA), as follows:
2,3
STEMI
· STEMI patients undergoing primary percutaneous coronary intervention (PCI)
2,3
NSTEMI or UA
· presence of high risk features irrespective of intent to perform revascularization:
• high GRACE risk score (>140)
• high TIMI risk score (5-7)
• second ACS within 12 months
• complex or extensive coronary artery disease e.g. diffuse three vessel disease
• definite documented cerebrovascular or peripheral vascular disease
• previous CABG
OR
4
· undergoing PCI + high risk angiographic anatomy
-
coverage duration 12 months
Note: Criteria Code 30 may be used for the initial 30 day coverage period, however a written request submitted to the
Pharmacare office is required to allow coverage for the remaining duration of treatment.
1
Co-administration of ticagrelor with high maintenance dose ASA (>150 mg daily) is not recommended.
In the PLATO study more patients on ticagrelor experienced non CABG related major bleeding than patients on clopidogrel, however, there was no
difference between the rate of overall major bleeding, between patients treated with ticagrelor and those treated with clopidogrel. As with all other
antiplatelet treatments the benefit/risk ratio of antithrombotic effect vs. bleeding complications should be evaluated.
3
Ticagrelor is contraindicated in patients with active pathological bleeding, in those with a history of intracranial hemorrhage and moderate to severe
hepatic impairment.
4
High risk angiographic anatomy is defined as any of the following: left main stenting, high risk bifurcation stenting (i.e., two-stent techniques), long
stents ≥ 38 mm or overlapping stents, small stents ≤ 2.5 mm in patients with diabetes.
2
NOTE: Exception status drugs for Drug Assistance for Cancer Patients are indicated by an asterisk (*).
February 2016
Appendix III
TIOTROPIUM BROMIDE (Spiriva 18mcg Cap for Inhalation)
­ for the treatment of moderate to severe chronic obstructive pulmonary disease (COPD) as defined by spirometry.
OR
­ for the treatment of COPD in patients with an inadequate response to short acting bronchodilators.
­ combination therapy with a long- acting beta-2 agonist /inhaled corticosteroid (LABA/ICS) and a long acting
anticholinergic (LAAC) inhaler will be considered in patients with: moderate to severe COPD, as defined by spirometry,
a history of COPD exacerbation(s) and an inadequate response to LABA/ICS or LAAC.
Note: Coverage for LABA and LAAC as two separate inhalers will not be considered.
Clinical Notes:
1. Moderate to severe COPD is defined by spirometry as a post bronchodilator FEV1 < 60% predicted and FEV1/FVC
ratio of < 0.70. Spirometry reports from any point in time will be accepted.
If spirometry cannot be obtained, reasons must be clearly explained and other evidence of COPD severity provided,
i.e., Medical Research Council (MRC) Dyspnea Scale Score of at least Grade 3.
MRC Grade 3 is described as: walks slower than people of same age on the level because of shortness of breath
from COPD or has to stop for breath when walking at own pace on the level.
2. Inadequate response to short acting bronchodilators is defined as persistent symptoms, i.e., MRC of at least Grade 3,
after at least 2 months of short acting bronchodilator at the following doses*:
• 8 puffs per day of short acting beta-2 agonist or
• 12 puffs per day of ipratropium or
• 6 puffs per day of ipratropium plus salbutamol combination inhaler
* Inadequate response to LABA/ICS or LAAC is defined as persistent symptoms after at least 2 months of therapy.
3. COPD exacerbation is defined as an increase in symptoms requiring treatment with antibiotics and/or systemic (oral or
intravenous) corticosteroids.
Note: Inhalers which combine a LABA/LAAC are also available as ESD benefits. These products have their own criteria
which are listed in the NS Formulary.
TIZANIDINE (Zanaflex 4mg Tablet and generic brands)
- for the treatment of spasticity resulting from traumatic brain injury, multiple sclerosis (MS), spinal cord injury (SCI) or
cerebral vascular accident (CVA) in patients for whom baclofen is not indicated, ineffective or not tolerated
TOCILIZUMAB (Actemra 80mg/4mL, 200mg/10mL, 400mg/20mL Injection)
Rheumatoid Arthritis (RA)
­ for patients with a diagnosis of active rheumatoid arthritis (RA) who:
· have not responded or who have had intolerable toxicity to an adequate trial1 of combination therapy of at least two
traditional DMARDs2 or
· if combination therapy is not an option, an adequate trial1 of at least three traditional DMARDs2 in sequence as
monotherapy and
· patients must have had an adequate trial1 of leflunomide. Exceptions can be considered in cases where leflunomide
is contraindicated or not tolerated
- therapy must include methotrexate alone or in combination unless contraindicated or not tolerated
- written request of a rheumatologist or prescriber with a specialty in rheumatology
- after initial coverage period, can be reassessed for yearly coverage dependent on patient achieving an improvement in
symptoms of at least 20%
Initial Coverage Duration and Maximum Dosage approved:
Tocilizumab IV
­ initial coverage for 16 weeks at dose of 4mg/kg every 4 weeks, yearly coverage dependent on patient achieving an
improvement in symptoms of at least 20%
­ maximum dose: 800 mg every 4 weeks
1 An adequate trial is 5 months for IM gold, 6 months for penicillamine, 4 months for hydroxychloroquine and 3 months for all other traditional DMARDs
as well as leflunomide, infliximab and etanercept.
2 Traditional agents include methotrexate, IM gold, sulfasalazine, hydroxychloroquine, azathioprine, chloroquine, penicillamine and cyclosporine.
NOTE: Exception status drugs for Drug Assistance for Cancer Patients are indicated by an asterisk (*).
February 2016
Appendix III
*Please note that the concurrent use of anti-TNF agents will not be approved.
Systemic Juvenile Idiopathic Arthritis (sJIA)
- for the treatment of active systemic juvenile idiopathic arthritis (sJIA) in patients two years of age and older who have
responded inadequately to non-steroidal anti-inflammatory drugs (NSAIDs) and systemic corticosteroids (with or without
methotrexate), due to intolerance or lack of efficacy
- written request of a pediatric rheumatologist
- initial coverage for 16 weeks at dose of 12 mg/kg for those < 30kg or 8 mg/kg for those ≥ 30 kg to a maximum of
800mg, administered by IV every 2 weeks
- continued coverage beyond 16 weeks dependent on a positive patient response as determined by a pediatric
rheumatology specialist
- yearly coverage dependent on a continued positive patient response as determined by a pediatric rheumatology
specialist
TOLTERODINE (Detrol 1mg, 2mg Tablet and Detrol LA 2mg, 4mg Capsule and generic brands)
- for the treatment of over-active bladder (not stress incontinence) for patients who cannot tolerate immediate release
oxybutynin after an adequate trial (e.g. 3 months)
- a three month trial will be approved initially with assessment of the effectiveness of this therapy required if further
coverage is considered
TOPIRAMATE (25mg Sprinkle Capsule)
- For patients who require topiramate, cannot take the tablet form, and require sprinkle capsules for proper administration.
TRETINOIN (Vitamin A Acid Topical Preparations)
- regular benefit for beneficiaries 30 years and under
- for treatment of actinic keratosis in beneficiaries over the age of 30
TROSPIUM (Trosec 20mg Tablet)
- for the treatment of over-active bladder (not stress incontinence) for patients who cannot tolerate immediate release
oxybutynin after an adequate trial (e.g. 3 months)
- a three month trial will be approved initially with assessment of the effectiveness of this therapy required if further
coverage is considered
TRYPTOPHAN (Tryptan 500mg Capsule and 500mg, 750mg, 1g Tablet and generic brands)
- as an adjunct for the treatment of depression in the management of patients suffering from bipolar affective disorders
UMECLIDINIUM (AS BROMIDE) AND VILANTEROL (AS TRIFENATATE) (Anoro Ellipta 62.5mcg/25mcg dry
powder for oral inhalation)
- for the treatment of moderate to severe chronic obstructive pulmonary disease (COPD), as defined by spirometry, in
patients with an inadequate response to a long-acting beta-2 agonist (LABA) or long-acting anticholinergic (LAAC).
Notes:
- Moderate to severe COPD is defined by spirometry (post-bronchodilator) FEV1
< 60% predicted and FEV1/FVC ratio of < 0.70. Spirometry reports from any point in time will be accepted.
If spirometry cannot be obtained, reasons must be clearly explained and other evidence regarding COPD severity must
be provided for consideration (i.e. Medical Research Council (MRC) Dyspnea Scale score of at least Grade 3). MRC
Grade 3 is described as: walks slower than people of same age on the level because of shortness of breath (SOB) from
COPD or has to stop for breath when walking at own pace on the level.
- Inadequate response is defined as persistent symptoms after at least 2 months of long-acting beta agonist (LABA) or
long-acting anticholinergic therapy (LAAC).
NOTE: Exception status drugs for Drug Assistance for Cancer Patients are indicated by an asterisk (*).
February 2016
Appendix III
URSODIOL (Urso 250mg, DS 500mg Tablet and generic brands)
- for dissolution of radiolucent, noncalcified gallstones of less than 20mm size for patients who cannot undergo a
cholecystectomy
- for management of cholestatic liver disease such as primary biliary cirrhosis
USTEKINUMAB (Stelara 45mg/0.5mL Injection)
- for patients with severe, debilitating chronic plaque psoriasis (PsO) who meet all of the following criteria:
· Body Surface Area (BSA) involvement of >10% and/or significant involvement of the face, hands, feet or
genitals
· failure to respond to, contraindication to or intolerant of methotrexate and cyclosporine
· failure to respond to, intolerant of or unable to access phototherapy
- written request of a dermatologist or prescriber with a specialty in dermatology
- continued coverage is dependent on evidence of improvement, specifically:
· ≥ 75% reduction in the Psoriasis Area and Severity Index (PASI) score, or
· ≥ 50% reduction in PASI with a ≥ 5 point improvement in DLQI (Dermatology Life Quality Index), or
· significant reduction in BSA involved, with consideration of important regions such as the face, hands, feet or
genitals
- concurrent use of biologics not approved
- initial approval for a maximum of 16 weeks
- dosage restricted to 45mg at 0, 4 and 16 weeks, response must be assessed prior to fourth dose
- maintenance dosing every 12 weeks
VALGANCICLOVIR (Valcyte 450mg Tablet and generic brands)
­ for the treatment of cytomegalovirus (CMV) retinitis in HIV-positive patients, upon the request of an infectious disease
specialist or prescriber with a specialty in infectious disease
­ for the prevention of CMV disease post solid organ transplantation in patients at high-risk (D+ / R-) (i.e., donor
positive/recipient negative). Coverage will be for a maximum of 90 days
­ for the treatment of patients with CMV infection who have received a solid organ transplant.
*VANCOMYCIN (Vancocin 125mg, 250mg Capsule and generic brands)
- for the treatment of pseudomembranous colitis (PMC) when patients have not responded to initial therapy with
metronidazole, or for initial treatment of severe PMC, or when drug interactions or intolerance, prevent the use of
metronidazole [Criteria Code 01]
VEMURAFENIB (Zelboraf 240mg Tablet)
- as a first line, single agent for the treatment of BRAF V600 mutation positive unresectable or metastatic melanoma in
patients with an ECOG performance status (PS) of ≤ 1
- for BRAF V600 mutation positive patients who have progressed after first line treatment prior to vemurafenib availability,
funding of vemurafenib as a second line agent may be considered
VERTEPORFIN (Visudyne 15mg/vial Injection)
- for the treatment of wet age-related macular degeneration (AMD) as prescribed by an authorized ophthalmologist
[Criteria Code 01]
VIGABATRIN (Sabril 0.5g Sachet and 500mg Tablet)
- for adjunctive management of epilepsy not satisfactorily controlled by conventional therapy
*VISMODEGIB (Erivedge 150mg Capsule)
- as a single agent for the treatment of measurable metastatic BCC, OR
- for the treatment of locally advanced BCC (including basal cell nevus syndrome i.e. Gorlin syndrome who are 18 years
of age and older) in patients who are inappropriate for surgery and radiotherapy based on a discussion/evaluation with
other members of the multi-disciplinary team.
- patient has ECOG ≤ 2
*VITAMIN B12, INJECTION
- See Cyanocobalamin, Injection
NOTE: Exception status drugs for Drug Assistance for Cancer Patients are indicated by an asterisk (*).
February 2016
Appendix III
*VITAMIN B12, ORAL
- See Cyanocobalamin, Oral
VORICONAZOLE (Vfend 50mg, 200mg Tablet)
- for the treatment of patients with invasive aspergillosis
- for the treatment of invasive candidiasis (proven on culture) with documented resistance to fluconazole
*WET NEBULIZATION SOLUTIONS (Budesonide, Cromoglycate Sodium, Fenoterol, Ipratropium Bromide,
Salbutamol)
- for adult patients with a vital capacity of 900mL or less
- for adult patients with a respiratory rate greater than 25 breaths/minute
- for patients who have demonstrated they cannot follow instructions, cannot hold the spacer device or cannot hold the
device long enough to actuate it
- other requests reviewed on a case by case basis
*XALKORI (Crizotinib 200mg, 250mg Capsule)
- As a second-line therapy for patients with ALK-positive advanced non-small cell lung cancer with ECOG performance
status ≤ 2.
ZAFIRLUKAST (Accolate 20mg Tablet)
- See Leukotriene Receptor Antagonists
*ZANAMIVIR (Relenza 5mg Powder For Inhalation)
- for the treatment of long-term care residents with clinically suspected or lab confirmed influenza A or B, when there is
documented resistance to oseltamivir or when oseltamivir is contraindicated. A clinically suspected case is one in which
the patient meets the criteria of influenza-like illness and there is confirmation of influenza A or B circulating within the
facility or surrounding community
- for the prophylaxis of influenza A or B in long term care residents where the facility has an outbreak, when there is
documented resistance to oseltamivir or when oseltamivir is contraindicated.
- a protocol has been developed by Public Health for the treatment of patients in long-term care facilities. The facility
must contact the Medical Officer of Health or local Public Health Office, who will notify the Pharmacare office (or
dispensing pharmacy after office hours) if coverage is required
ZIPRASIDONE (Zeldox 20mg, 40mg, 60mg, 80mg Capsule)
- for the treatment of schizophrenia and schizoaffective disorder
*ZOLEDRONIC ACID (Aclasta 5mg/100ml Injection)
- for the treatment of Paget’s disease
- for women with postmenopausal osteoporosis for whom oral bisphosphonates are contraindicated due to abnormalities
of the esophagus (e.g. esophageal stricture or achalasia) and have at least two of the following:
· age > 75 years
· a prior fragility fracture
· a bone mineral density (BMD) T-score ≤-2.5
NOTE: Exception status drugs for Drug Assistance for Cancer Patients are indicated by an asterisk (*).
February 2016
Appendix III
Product Index
5-AMINOSALICYLIC ACID (MESALAMINE)
14
ABATACEPT
141
ABIRATERONE
138
ACAMPROSATE
213
ACARBOSE
19
ACEBUTOLOL
46
ACENOCOUMAROL
25
ACETAMINOPHEN (PARACETAMOL)
163
ACETAMINOPHEN, COMB. EXCL. PSYCHOLEPTICS
164
ACETAZOLAMIDE
229
ACETYLCYSTEINE
224
ACETYLSALICYLIC ACID
163
ACETYLSALICYLIC ACID (ASA) COMBINATIONS EXCL. PSYCHOLEPTICS
163
ACETYLSALICYLIC ACID (ASA) COMBINATIONS WITH PSYCHOLEPTICS
163
ACITRETIN
80
ACLIDINIUM BROMIDE
222
ACYCLOVIR
81
ADALIMUMAB
141
ADEFOVIR DIPIVOXIL
127
AFATINIB
134
ALENDRONIC ACID (ALENDRONATE)
153
ALENDRONIC ACID AND CHOLECALCIFEROL
155
ALFACALCIDOL
22
ALFENTANIL
156
ALFUZOSIN
99
ALGLUCOSIDASE ALFA
23
ALISKIREN
68
ALITRETINOIN
87
ALLOPURINOL
152
ALMOTRIPTAN
166
ALOGLIPTIN
20
ALPRAZOLAM
194
ALUMINIUM HYDROXIDE
1
AMANTADINE
178
AMBRISENTAN
38
AMCINONIDE
83
Product Index
AMIKACIN
117
AMILORIDE
40
AMINOBENZOATE POTASSIUM, SYSTEMIC
87
AMIODARONE
33
AMITRIPTYLINE
198
AMLODIPINE
48
AMOXICILLIN
109
AMOXICILLIN AND ENZYME INHIBITOR
110
AMPHETAMINES
207
AMPHOTERICIN
121
AMPICILLIN
109
ANAGRELIDE
135
ANAKINRA
141
ANASTROZOLE
137
ANTACIDS, ORDINARY SALT COMBINATIONS
1
ANTACIDS, ORDINARY SALT COMBINATIONS AND ANTIFLATULENTS
1
ANTIBIOTICS (OPHTHALMIC), COMBINATIONS
227
ANTIBIOTICS, COMBINATIONS
80
ANTIINFECTIVES, COMBINATIONS
30
ANTISPASMODICS, COMBINATIONS
8
APIXABAN
27
APRACLONIDINE
229
APREPITANT
10
ARIPIPRAZOLE
191
ARTIFICIAL TEARS AND OTHER INDIFFERENT PREPARATIONS
233
ASENAPINE
188
ASILSARTAN MEDOXOMIL
64
ASILSARTAN MEDOXOMIL AND CHLORTHALIDONE
68
ATAZANAVIR
125
ATENOLOL
45
ATENOLOL AND OTHER DIURETICS
48
ATOMOXETINE
209
ATORVASTATIN
71
ATORVASTATIN AND AMLODIPINE
76
ATOVAQUONE
216
ATROPINE
7
Product Index
AURANOFIN
150
AXITINIB
134
AZATHIOPRINE
143
AZELAIC ACID
86
AZITHROMYCIN
116
AZTREONAM
114
BACITRACIN
80
BACLOFEN
151
BCG VACCINE
139
BECLOMETHASONE
218
BELIMUMAB
141
BENAZEPRIL
56
BENZETHONIUM CHLORIDE, COMBINATIONS
85
BENZOYL PEROXIDE
86
BENZTROPINE
177
BENZYDAMINE
1
BETAHISTINE
214
BETAINE
23
BETAMETHASONE
13
BETAMETHASONE AND ANTIBIOTICS
85
BETAXOLOL
230
BETHANECHOL
213
BEZAFIBRATE
74
BICALUTAMIDE
137
BIMATOPROST
231
BISACODYL
11
BISMUTH SUBSALICYLATE
13
BISOPROLOL
46
BOCEPREVIR
126
BOSENTAN
37
BRETYLIUM TOSYLATE
33
BRIMONIDINE
229
BRINZOLAMIDE
229
BRINZOLAMIDE, COMBINATIONS
230
BROMAZEPAM
193
BROMOCRIPTINE
90
Product Index
BUDESONIDE
13
BUMETANIDE
40
BUPIVACAINE
156
BUPRENORPHINE
162
BUPRENORPHINE, COMBINATIONS
213
BUPROPION
206
BUSERELIN
135
BUSPIRONE
195
BUSULFAN
130
BUTORPHANOL
162
CABERGOLINE
90
CALCIPOTRIOL
80
CALCIPOTRIOL, COMBINATIONS
80
CALCITONIN (SALMON SYNTHETIC)
107
CALCITRIOL
22
CALCIUM ACETATE
236
CALCIUM FOLINATE
236
CANAGLIFLOZIN
21
CANAKINUMAB
142
CANDERSARTAN AND DIURETICS
67
CANDESARTAN
62
CANNABINOID DERIVATIVES, COMBINATIONS
164
CAPECITABINE
131
CAPTOPRIL
52
CARBAMAZEPINE
169
CARBOHYDRATES
30
CARVEDILOL
47
CEFACLOR
112
CEFADROXIL
112
CEFAZOLIN
112
CEFEPIME (HYDROCHLORIDE)
114
CEFIXIME
114
CEFOTAXIME
113
CEFPROZIL
112
CEFTAZIDIME
113
CEFTRIAXONE
113
Product Index
CEFUROXIME
112
CELECOXIB
149
CEPHALEXIN
111
CERTOLIZUMAB PEGOL
141
CETIRIZINE
225
CHLORAL HYDRATE
195
CHLORAMBUCIL
130
CHLORAMPHENICOL
109
CHLORDIAZEPOXIDE
192
CHLORHEXIDINE
1
CHLOROQUINE
216
CHLORPROMAZINE
180
CHLORPROPAMIDE
18
CHLORTHALIDONE
39
CHOLESTYRAMINE
75
CICLESONIDE
221
CICLOPIROX
78
CICLOSPORIN
233
CILAZAPRIL
57
CILAZAPRIL AND DIURETICS
59
CIMETIDINE
1
CINACALET
107
CIPROFLOXACIN
118
CISPLATIN
132
CITALOPRAM
200
CLARITHROMYCIN
115
CLIDINIUM AND PSYCHOLEPTICS
7
CLINDAMYCIN
86
CLINDAMYCIN, COMBINATIONS
86
CLOBAZAM
193
CLOBETASOL
84
CLOBETASONE
81
CLODRONIC ACID (CLODRONATE)
153
CLOMIFENE
95
CLOMIPRAMINE
197
CLONAZEPAM
168
Product Index
CLONIDINE
36
CLOPIDOGREL
26
CLORAZEPATE DIPOTASSIUM
192
CLOTRIMAZOLE
78
CLOXACILLIN
110
CLOZAPINE
183
CODEINE
225
CODEINE, COMBINATIONS EXCL. PSYCHOLEPTICS
160
COLCHICINE
153
COLESEVELAM
75
COLESTIPOL
75
COLLAGENASE (CLOSTRIDIOPEPITIDASE)
79
CONJUGATED ESTROGENS
94
CORTISONE
105
CRIZOTINIB
134
CROMOGLYCATE SODIUM
13
CYANOCOBALAMIN
29
CYANOCOBALAMIN, COMBINATIONS
29
CYCLOBENZAPRINE
152
CYCLOPENTOLATE
231
CYCLOPHOSPHAMIDE
130
CYCLOSPORINE
142
CYPROTERONE
95
CYPROTERONE AND ESTROGEN
95
DABIGATRAN ETEXILATE
27
DALTEPARIN
25
DANAZOL
96
DANTROLENE
152
DAPSONE
123
DAPTOMYCIN
121
DARBEPOETIN
30
DARIFENACIN
97
DARUNAVIR
126
DASABUVIR, OMBITASVIR, PARITAPREVIR AND RITONAVIR
129
DASATINIB
133
DEFERASIROX
235
Product Index
DEFEROXAMINE
235
DEGARELIX
138
DEHYDROCHOLIC ACID
11
DENOSUMAB
155
DESIPRAMINE
197
DESLORATADINE
226
DESMOPRESSIN
102
DESOGESTREL AND ESTROGEN
91
DESONIDE
82
DESOXIMETASONE
83
DESVENLAFAXINE
207
DEXAMETHASONE
103
DEXAMETHASONE AND ANTIINFECTIVES
229
DEXAMPHETAMINE
207
DEXTRIFERRON (IRON DEXTRAN)
28
DEXTROPROPOXYPHENE
162
DIABETIC LANCETS
237
DIAZEPAM
192
DIAZOXIDE
236
DICLOFENAC
144
DICLOFENAC, COMBINATIONS
145
DICYCLOVERINE (DICYCLOMINE)
7
DIENOGEST
95
DIFLUCORTOLONE
83
DIFLUNISAL
163
DIGOXIN
32
DIHYDROERGOTAMINE
164
DILTIAZEM
51
DIMENHYDRINATE
10
DIMETHYL FUMARATE
214
DIMETHYL SULFOXIDE
98
DINOPROSTONE
89
DIPHENHYDRAMINE
225
DIPHENOXYLATE
13
DIPYRIDAMOLE
26
DISOPYRAMIDE
32
Product Index
DOBUTAMINE
34
DOCETAXEL
132
DOCUSATE SODIUM
11
DOLUTEGRAVIR
128
DOMPERIDONE
8
DONEPEZIL
210
DORZOLAMIDE
229
DOXAZOSIN
37
DOXEPIN
199
DOXYCYCLINE
1
DOXYLAMINE
225
DRONEDARONE
33
DROPERIDOL
182
DROSPIRENONE AND ESTROGEN
92
DULOTEGRAVIR, ABACAVIR, LAMIVUDINE
128
DULOXETINE
207
DUTASTERIDE
100
EFAVIRENZ
127
ELETRIPTAN
167
ELTROMBOPAG
28
EMTRICITABINE, TENOFOVIR DISOPROXIL AND EFAVIRENZ
128
EMTRICITABINE, TENOFOVIR DISOPROXIL AND RILPIVIRINE
128
EMTRICITABINE, TENOFOVIR DISOPROXIL, ELVITEGRAVIR AND COBICISTAT
128
ENALAPRIL
53
ENALAPRIL AND DIURETICS
58
ENFUVIRTIDE
128
ENOXAPARIN
25
ENTACAPONE
180
ENTECAVIR
127
ENZALUTAMIDE
137
EPINEPHRINE
34
EPIRUBICIN
132
EPLERENONE
40
EPROSARTAN
60
EPROSARTAN AND DIURETICS
65
ERGOCALCIFEROL
22
Product Index
ERGOLOID MESYLATES
41
ERLOTINIB
133
ERYTHROMYCIN
115
ERYTHROMYCIN, COMBINATIONS
86
ERYTHROPOIETIN
29
ESCITALOPRAM
203
ESOMEPRAZOLE
6
ESTRADIOL
93
ESTRAMUSTINE
135
ESTRONE
94
ETANERCEPT
141
ETHACRYNIC ACID
40
ETHAMBUTOL
123
ETHINYL ESTRADIOL AND ETONOGESTREL
90
ETHOPROPAZINE (PROFENAMINE)
177
ETHOSUXIMIDE
168
ETHYNODIOL AND ESTROGEN
90
ETIDRONIC ACID (ETIDRONATE)
153
ETIDRONIC ACID AND CALCIUM, SEQUENTIAL
155
ETODOLAC
145
ETOPOSIDE
132
ETRAVIRINE
127
EVEROLIMUS
140
EXEMESTANE
138
EXENATIDE
21
EZETIMIBE
75
FAMCICLOVIR
124
FAMOTIDINE
3
FAMPRIDINE
214
FEBUXOSTAT
152
FELODIPINE
49
FENOFIBRATE
74
FENOTEROL AND OTHER DRUGS FOR OBSTRUCTIVE AIRWAY DISEASES
220
FENTANYL
156
FERRIC SODIUM GLUCONATE COMPLEX
29
FERROUS FUMARATE
28
Product Index
FERROUS GLUCONATE
28
FERROUS SULFATE
28
FERUMOXYTOL
29
FESOTERODINE
97
FEXOFENADINE
226
FILGRASTIM
138
FINASTERIDE
87
FINGOLIMOD
141
FLECAINIDE
33
FLOCTAFENINE
164
FLUCONAZOLE
122
FLUDARABINE
131
FLUDROCORTISONE
103
FLUMAZENIL
235
FLUMETASONE AND ANTIBIOTICS
85
FLUMETASONE AND ANTIINFECTIVES
233
FLUNARIZINE
214
FLUNISOLIDE
218
FLUOCINOLONE ACETONIDE
83
FLUOCINONIDE
83
FLUOROMETHOLONE
228
FLUOROURACIL
131
FLUOXETINE
199
FLUPENTHIXOL
183
FLUPHENAZINE
180
FLURAZEPAM
195
FLURBIPROFEN
148
FLUTAMIDE
136
FLUTICASONE
218
FLUVASTATIN
71
FLUVOXAMINE
203
FOLIC ACID
29
FONDAPARINUX
27
FORMOTEROL
220
FORMOTEROL AND OTHER DRUGS FOR OBSTRUCTIVE AIRWAY DISEASES
220
FOSAMPRENAVIR
125
Product Index
FOSFOMYCIN
121
FOSINOPRIL
57
FRAMYCETIN
85
FROVATRIPTAN
167
FUROSEMIDE
39
FUSIDIC ACID
80
GABAPENTIN
172
GALANTAMINE
212
GANCICLOVIR
124
GATIFLOXACIN
227
GEFITINIB
133
GEMCITABINE
131
GEMFIBROZIL
74
GENTAMICIN
117
GLATIRAMER ACETATE
139
GLICLAZIDE
18
GLIMEPIRIDE
18
GLUCAGON
106
GLUCOSE
236
GLYBURIDE (GLIBENCLAMIDE)
17
GLYCOPYRROLATE (GLYCOPYRRONIUM)
7
GLYCOPYRRONIUM BROMIDE
222
GOLIMUMAB
141
GOSERELIN
136
GRANISETRON
9
GRASS POLLEN
235
GUAIFENESIN
224
HALOPERIDOL
182
HEPARIN
25
HEXACHLOROPHENE
85
HISTRELIN
102
HOMATROPINE
231
HYDRALAZINE
37
HYDROCHLOROTHIAZIDE
38
HYDROCHLOROTHIAZIDE AND POTASSIUM-SPARING AGENTS
40
HYDROCORTISONE
13
Product Index
HYDROCORTISONE AND ANTIBIOTICS
84
HYDROMORPHONE
158
HYDROXYCHLOROQUINE
216
HYDROXYUREA (HYDROXYCARBAMIDE)
135
HYDROXYZINE
194
HYOSCYAMINE
7
IBRUTINIB
135
IBUPROFEN
146
IDURSULFASE
23
IMATINIB
133
IMIDAZOLE DERIVATIVES, COMBINATIONS
78
IMIPENEM AND ENZYME INHIBITOR
114
IMIPRAMINE
197
IMIQUIMOD
81
INCOBOTULINUMTOXIN-A
150
INDACATEROL
220
INDACATEROL AND GLYCOPYRRONIUM BROMIDE
220
INDAPAMIDE
39
INDINAVIR
125
INDOMETHACIN
144
INFLIXIMAB
141
INSULIN (HUMAN)
15
INSULIN ASPART
15
INSULIN DETEMIR
16
INSULIN GLARGINE
16
INSULIN GLULISINE
15
INSULIN LISPRO
15
INSULIN PEN NEEDLES
237
INSULIN SYRINGES
237
INTERFERON ALPHA-2B
138
INTERFERON BETA-1A
138
INTERFERON BETA-1B
139
IPRATROPIUM BROMIDE
219
IRBESARTAN
61
IRBESARTAN AND DIURETICS
66
IRON, MULTIVITAMINS AND FOLIC ACID
29
Product Index
IRON, MULTIVITAMINS AND MINERALS
29
ISONIAZID
123
ISOPROPYL MYRISTATE
217
ISOSORBIDE DINITRATE
35
ISOSORBIDE MONONITRATE
35
ISOTRETINOIN
87
ITRACONAZOLE
122
IVACAFTOR
226
KETAMINE
156
KETOCONAZOLE
78
KETOPROFEN
148
KETOROLAC
145
KETOTIFEN
225
LABETALOL
47
LACOSAMIDE
176
LACTIC ACID PRODUCING ORGANISMS
14
LACTULOSE
12
LAMIVUDINE
126
LAMIVUDINE AND ABACAVIR
128
LAMOTRIGINE
170
LANREOTIDE
103
LANSOPRAZOLE
5
LANSOPRAZOLE, CLARITHROMYCIN AND AMOXICILLIN
6
LANTHANUM CARBONATE
236
LAPATINIB
134
LARONIDASE
23
LATANOPROST
231
LEDIPASVIR AND SOFOSBUVIR
129
LEFLUNOMIDE
140
LENALIDOMIDE
143
LETROZOLE
137
LEUPROLIDE (LEUPRORELIN)
136
LEVETIRACETAM
173
LEVOBUNOLOL
230
LEVOCABASTINE
218
LEVOCARNITINE
23
Product Index
LEVODOPA AND DECARBOXYLASE INHIBITOR
177
LEVODOPA, DECARBOXYLASE INHIBITOR AND COMT INHIBITOR
177
LEVOFLOXACIN
119
LEVONORGESTREL
93
LEVONORGESTREL AND ESTROGEN
91
LEVOTHYROXINE SODIUM
105
LIDOCAINE
79
LIDOCAINE, COMBINATIONS
156
LINAGLIPTIN
21
LINCOMYCIN
117
LINEZOLID
121
LIOTHYRONINE SODIUM
106
LIRAGLUTIDE
21
LISDEXAMFETAMINE
210
LISINOPRIL
54
LISINOPRIL AND DIURETICS
58
LITHIUM
188
LOMUSTINE
130
LOPERAMIDE
13
LORATADINE
225
LORAZEPAM
193
LOSARTAN
59
LOSARTAN AND DIURETICS
64
LOTEPREDNOL
228
LOVASTATIN
70
LOXAPINE
183
LURASIDONE
182
MACROGOL
12
MAGNESIUM CITRATE
12
MAGNESIUM GLUCOHEPTONATE
22
MAGNESIUM HYDROXIDE
98
MAPROTILINE
199
MARAVIROC
128
MEBENDAZOLE
217
MEDROXYPROGESTERONE
93
MEFENAMIC ACID
149
Product Index
MEFLOQUINE
216
MEGESTROL
135
MELOXICAM
146
MELPHALAN
130
MEMANTINE
212
MERCAPTOPURINE
131
METFORMIN
16
METFORMIN AND ALOGLIPTIN
19
METFORMIN AND ROSIGLITAZONE
19
METFORMIN AND SAXAGLIPTIN
19
METFORMIN AND SITAGLIPTIN
19
METHADONE
213
METHAZOLAMIDE
230
METHENAMINE
121
METHIMAZOLE (THIAMAZOLE)
106
METHOCARBAMOL
151
METHOCARBAMOL, COMBINATIONS EXCLUDING PSYCHOLEPTICS
151
METHOTREXATE
131
METHOTRIMEPRAZINE (LEVOMEPROMAZINE)
180
METHOXSALEN
79
METHSUXIMIDE (MESUXIMIDE)
168
METHYLDOPA (RACEMIC)
36
METHYLNALTREXONE BROMIDE
12
METHYLPHENIDATE
208
METHYLPREDNISOLONE
86
METHYLPREDNISOLONE, COMBINATIONS
105
METOCLOPRAMIDE
8
METOLAZONE
39
METOPROLOL
44
METRONIDAZOLE
81
MEXILETINE
32
MICONAZOLE
78
MIDAZOLAM
196
MIDODRINE
34
MIGLUSTAT
23
MINERAL SALTS IN COMBINATION
12
Product Index
MINOCYCLINE
108
MINOXIDIL
37
MIRABEGRON
96
MIRTAZAPINE
205
MISCELLANEOUS DEVICES
236
MISOPROSTOL
3
MOCLOBEMIDE
204
MODAFINIL
208
MOMETASONE
84
MONTELUKAST
223
MORPHINE
157
MOXIFLOXACIN
120
MULTIENZYMES (LIPASE, PROTEASE, ETC)
14
MUPIROCIN
80
MYCOPHENOLIC ACID
140
NABILONE (CANNABINOID (THC) DERIVATIVES)
10
NABUMETONE
149
NADOLOL
44
NAFARELIN
102
NALOXONE
235
NALTREXONE
213
NAPROXEN
147
NARATRIPTAN
165
NATALIZUMAB
141
NATEGLINIDE
21
NEBIVOLOL
47
NELFINAVIR
125
NEOMYCIN
80
NEOSTIGMINE
212
NEVIRAPINE
127
NICOTINIC ACID
75
NIFEDIPINE
50
NILOTINIB
134
NILUTAMIDE
136
NIMODIPINE
50
NITRAZEPAM
195
Product Index
NITROFURANTOIN
121
NITROGLYCERIN (GLYCERYL TRINITRATE)
34
NIZATIDINE
3
NORELGESTROMIN AND ESTROGEN
92
NOREPINEPHRINE
34
NORETHINDRONE
92
NORETHINDRONE AND ESTROGEN
90
NORFLOXACIN
119
NORGESTIMATE AND ESTROGEN
92
NORTRIPTYLINE
199
NYSTATIN
12
NYSTATIN, COMBINATIONS
89
OCRIPLASMIN
233
OCTREOTIDE
102
OFLOXACIN
118
OLANZAPINE
184
OLMESARTAN MEDOXOMIL
64
OLMESARTAN MEDOXOMIL AND DIURETICS
68
OLOPATADINE
232
OLSALAZINE (5-ASA)
14
OMALIZUMAB
224
OMEPRAZOLE
3
ONABOTULINUMTOXIN-A
150
ONDANSETRON
8
OPIUM
13
ORCIPRENALINE
222
ORLISTAT
14
ORPHENADRINE (CITRATE)
151
OSELTAMIVIR
127
OTHER RESPIRATORY SYSTEM PRODUCTS
226
OXAPROZIN
148
OXAZEPAM
192
OXCARBAZEPINE
169
OXTRIPHYLLINE (CHOLINE THEOPHYLLINATE)
222
OXYBUTYNIN
96
OXYCODONE
159
Product Index
PACLITAXEL
132
PALIPERIDONE
191
PALONOSETRON
9
PAMIDRONIC ACID (PAMIDRONATE)
153
PANTOPRAZOLE
4
PAPAVERINE
7
PAROMOMYCIN
13
PAROXETINE
201
PAZOPANIB
134
PEGAPTANIB
232
PEGFILGRASTIM
138
PEGINTERFERON ALFA-2A
139
PEGINTERFERON ALFA-2A, COMBINATIONS
139
PEGINTERFERON ALFA-2B, COMBINATIONS
139
PEGVISOMANT
101
PENICILLAMINE
150
PENTOSAN POLYSULFATE SODIUM
42
PENTOXIFYLLINE
41
PEPSIN
15
PERAMPANEL
176
PERICYAZINE (PROPERICYAZINE)
181
PERINDOPRIL
55
PERINDOPRIL AND DIURETICS
58
PERPHENAZINE
181
PETHIDINE (MEPERIDINE)
160
PHENELZINE
204
PHENOBARBITAL
167
PHENOXYMETHYLPENICILLIN (PENICILLIN V)
110
PHENTOLAMINE
41
PHENYLEPHRINE
34
PHENYTOIN
168
PHYTONADIONE
28
PILOCARPINE
213
PIMECROLIMUS
87
PIMOZIDE
183
PINAVERIUM
7
Product Index
PINDOLOL
42
PINDOLOL AND OTHER DIURETICS
48
PIOGLITAZONE
19
PIPERACILLIN AND ENZYME INHIBITOR
111
PIRFENIDONE
143
PIROXICAM
146
PIZOTIFEN
167
PLACEBO
237
PLASTIC IUD WITH PROGESTOGEN
90
PLATELET AGGREGATION INHIBITORS, COMBINATIONS
27
PLERIXAFOR
139
PODOPHYLLOTOXIN
81
POLYSTYRENE SULFONATE
235
POMALIDOMIDE
143
POSACONAZOLE
123
POTASSIUM CHLORIDE
22
POTASSIUM CITRATE
22
PRAMIPEXOLE
178
PRASUGREL
27
PRAVASTATIN
70
PRAZOSIN
36
PREDNISOLONE
104
PREDNISOLONE AND ANTIINFECTIVES
229
PREDNISONE
104
PREGABALIN
174
PRIMAQUINE
216
PRIMIDONE
167
PROCAINAMIDE
32
PROCARBAZINE
133
PROCHLORPERAZINE
181
PROCYCLIDINE
176
PROGESTERONE
95
PROGUANIL, COMBINATIONS
216
PROPAFENONE
33
PROPRANOLOL
43
PROPYLTHIOURACIL
106
Product Index
PROTEASE INHIBITORS, COMBINATIONS
126
PROXYMETACAINE
232
PRUCALOPRIDE
12
PYRIDOSTIGMINE
213
QUETIAPINE
186
QUINAGOLIDE
90
QUINAPRIL
56
QUINAPRIL AND DIURETICS
59
QUININE
216
RABEPRAZOLE
5
RALOXIFENE
96
RALTEGRAVIR
128
RAMIPRIL
55
RAMIPRIL AND DIURETICS
58
RANITIDINE
2
RASAGILINE
179
REGORAFENIB
134
REPAGLINIDE
21
RIBAVIRIN
128
RIFABUTIN
123
RIFAMPIN (RIFAMPICIN)
123
RIFAMPIN AND ISONIAZID
123
RILPIVIRINE
127
RILUZOLE
214
RIOCIGUAT
38
RISEDRONIC ACID (RISEDRONATE)
154
RISPERIDONE
189
RITONAVIR
125
RITUXIMAB
133
RIVAROXABAN
27
RIVASTIGMINE
211
RIZATRIPTAN
166
ROFLUMILAST
224
ROMIPLOSTIM
28
ROPINIROLE
178
ROSIGLITAZONE
19
Product Index
ROSUVASTATIN
73
RUFINAMIDE
170
RUXOLITINIB
134
SACCHARATED IRON OXIDE
28
SALBUTAMOL
219
SALBUTAMOL AND IPATROPRIUM BROMIDE
220
SALBUTAMOL AND OTHER DRUGS FOR OBSTRUCTIVE AIRWAY DISEASES
220
SALMETEROL
219
SALMETEROL AND OTHER DRUGS FOR OBSTRUCTIVE AIRWAY DISEASES
220
SAQUINAVIR
125
SAXAGLIPTIN
20
SCOPOLAMINE
9
SELEGILINE
179
SELENIUM SULFIDE
78
SENNA GLYCOSIDES
11
SENNA GLYCOSIDES, COMBINATIONS
12
SERTRALINE
202
SEVELAMER
235
SILDENAFIL
38
SILDOSIN
99
SILICONES
7
SILVER SULFADIAZINE
81
SIMEPREVIR
126
SIMVASTATIN
68
SITAGLIPTIN
20
SODIUM AUROTHIOMALATE
150
SODIUM CHLORIDE
31
SODIUM CHLORIDE, HYPERTONIC
233
SODIUM PHOSPHATE
23
SOFOSBUVIR
128
SOLIFENACIN
97
SOMATROPIN
101
SORAFENIB
133
SOTALOL
43
SPIRAMYCIN
115
SPIRONOLACTONE
40
Product Index
STAVUDINE
126
STERILE WATER
236
STOMI EQUIPMENT
236
SUCRALFATE
6
SUFENTANIL
156
SULFACETAMIDE
227
SULFAMETHOXAZOLE AND TRIMETHOPRIM
114
SULFASALAZINE
14
SULFINPYRAZONE
153
SULINDAC
144
SULPHUR
86
SUMATRIPTAN
164
SUNITINIB
133
TACROLIMUS
87
TADALAFIL
34
TAMOXIFEN
136
TAMSULOSIN
99
TAZAROTENE
80
TELAPREVIR
126
TELBIVUDINE
127
TELMISARTAN
63
TELMISARTAN AND AMLODIPINE
68
TELMISARTAN AND DIURETICS
67
TEMAZEPAM
195
TEMOZOLOMIDE
130
TENOFOVIR DISOPROXIL
126
TENOFOVIR DISOPROXIL AND EMTRICITABINE
128
TENOXICAM
146
TERAZOSIN
99
TERBINAFINE
78
TERBUTALINE
219
TERIFLUNOMIDE
141
TESTOSTERONE
93
TETRABENAZINE
214
TETRACYCLINE
108
THEOPHYLLINE
223
Product Index
THEOPHYLLINE, COMBINATIONS EXCLUDING PSYCHOLEPTICS
223
THIAMINE (VIT B1)
22
THIOGUANINE
131
THIOPROPERAZINE
181
THIOTHIXENE
183
THYROID GLAND PREPARATIONS
106
THYROTROPIN
236
TIAPROFENIC ACID
148
TICAGRELOR
27
TICLOPIDINE
26
TIGECYCLINE
108
TIMOLOL
43
TIMOLOL, COMBINATIONS
230
TINZAPARIN
25
TIOTROPIUM BROMIDE
222
TIPRANAVIR
125
TIZANIDINE
151
TOBRAMYCIN
117
TOCILIZUMAB
142
TOLBUTAMIDE
18
TOLNAFTATE
78
TOLTERODINE
96
TOLVAPTAN
41
TOPIRAMATE
171
TOPOTECAN
135
TRAMADOL
162
TRAMADOL, COMBINATIONS
162
TRANDOLAPRIL
57
TRANDOLAPRIL AND VERAPAMIL
59
TRANEXAMIC ACID
27
TRANYLCYPROMINE
204
TRAVOPROST
231
TRAZODONE
205
TREPROSTINIL
26
TRETINOIN
86
TRIAMCINOLONE
1
Product Index
TRIAMCINOLONE AND ANTIBIOTICS
84
TRIAZOLAM
195
TRIFLUOPERAZINE
181
TRIFLURIDINE
227
TRIHEXYPHENIDYL
176
TRIMEBUTINE
6
TRIMETHOPRIM
114
TRIMIPRAMINE
198
TRIPTORELIN
136
TROPICAMIDE
231
TROSPIUM
97
TRYPTOPHAN
204
URSODIOL (URSODEOXYCHOLIC ACID)
11
USTEKINUMAB
142
VALACYCLOVIR
124
VALGANCICLOVIR
125
VALPROIC ACID (DIVALPROEX SODIUM)
170
VALSARTAN
60
VALSARTAN AND DIURETICS
65
VANCOMYCIN
120
VARIOUS
235
VARIOUS NASAL PREPARATIONS
219
VASOPRESSIN
101
VEMURAFENIB
134
VENLAFAXINE
206
VERAPAMIL
50
VERTEPORFIN
232
VIGABATRIN
170
VILANTEROL AND FLUTICASONE FUROATE
220
VILANTEROL AND UMECLIDINIUM BROMIDE
220
VISMODEGIB
135
VORICONAZOLE
122
WARFARIN
24
ZAFIRLUKAST
223
ZANAMIVIR
127
ZIDOVUDINE
126
Product Index
ZIDOVUDINE AND LAMIVUDINE
128
ZIPRASIDONE
182
ZOLEDRONIC ACID
155
ZOLMITRIPTAN
165
ZOLPIDEM
197
ZOPICLONE
196
ZUCLOPENTHIXOL
183