Drug Benefit List

92:00 UNCLASSIFIED THERAPEUTIC AGENTS

92:00.00 UNCLASSIFIED THERAPEUTIC AGENTS

ADALIMUMAB

Limited use benefit (prior approval required).

For the treatment of:
- Rheumatoid Arthritis according to established criteria.
(Please refer to Appendix A).

40MG/Vial Injection

02258595     HUMIRA     ABB

ALENDRONATE SODIUM

Limited use benefit (prior approval required).

For treatment of:
a. - osteoporosis in patients who have documented hip, vertebral or other fractures
b. - osteoporosis in patients with intolerance or lack of response to etidronate or etidronate/calcium
c. - Paget's Disease

5MG Tablet

02248727     APO-ALENDRONATE     APX

02233055     FOSAMAX     FRS

02270110     GEN-ALENDRONATE     GEN

02248251     NOVO-ALENDRONATE     NOP

10MG Tablet

02248728     APO-ALENDRONATE     APX

02201011     FOSAMAX     FRS

02270129     GEN-ALENDRONATE     GEN

02247373     NOVO-ALENDRONATE     NOP

40MG Tablet

02258102     CO-ALENDRONATE     COB

02201038     FOSAMAX     FRS

70MG Tablet

02248730     APO-ALENDRONATE     APX

02258110     CO-ALENDRONATE     COB

02245329     FOSAMAX     FRS

02261715     NOVO-ALENDRONATE     NOP

02273179     PMS-ALENDRONATE     PMS

02275279     RATIO-ALENDRONATE     RPH

ALFUZOSIN HYDROCHLORIDE

Limited use benefit (prior approval required).

For treatment of Benign Prostatic Hyperplasia (BPH) in patients who do not tolerate or have not responded to other alpha- adrenergic blockers.

10MG Sustained Release Tablet

02245565     XATRAL     SAC

ALLOPURINOL

100MG Tablet

00555681     ALLOPURINOL     PDL

00402818     APO-ALLOPURINOL     APX

00364282     NOVO-PUROL     NOP

00004588     ZYLOPRIM     GSK

200MG Tablet

02130157     ALLOPURINOL     PDL

00479799     APO-ALLOPURINOL     APX

00565342     NOVO-PUROL     NOP

00506370     ZYLOPRIM     GSK

300MG Tablet

00555703     ALLOPURINOL     PDL

00402796     APO-ALLOPURINOL     APX

00363693     NOVO-PUROL     NOP

00294322     ZYLOPRIM     GSK

AZATHIOPRINE

50MG Tablet

02242907     APO-AZATHIOPRINE     APX

00004596     IMURAN     GSK

02248843     NU-AZATHIOPRINE     NXP

BETAHISTINE HCL

16MG Tablet

02243878     SERC     SPH

24MG Tablet

02247998     SERC     SPH

BOTULINUM TOXIN TYPE A

Limited use benefit (prior approval required).

For the treatment of focal dystonias and hyperhydrosis.

100IU Injection

01981501     BOTOX     ALL

BROMOCRIPTINE MESYLATE

5MG Capsule

02230454     APO-BROMOCRIPTINE     APX

02230719     BROMOCRIPTINE     PRO

02238637     DOM-BROMOCRIPTINE     DPC

02236949     PMS-BROMOCRIPTINE     PMS

2.5MG Tablet

02087324     APO-BROMOCRIPTINE     APX

02153378     BROMOCRIPTINE     PRO

02238636     DOM-BROMOCRIPTINE     DPC

00371033     PARLODEL     NVR

02231702     PMS-BROMOCRIPTINE     PMS

CABERGOLINE

Limited use benefit (prior approval required).

For treatment of hyperprolactinemia in patients who have failed therapy with or are intolerant to bromocriptine.

0.5MG Tablet

02242471     DOSTINEX     PFI

CLOPIDOGREL BISULFATE

75MG Tablet

02238682     PLAVIX     SAC

COLCHICINE

0.6MG Tablet

00572349     COLCHICINE     ODN

1MG Tablet

00621374     COLCHICINE     ODN

CYCLOSPORINE

Limited use benefit (prior approval required).

For transplant therapy.

10MG Capsule

02237671     NEORAL     NVR

25MG Capsule

02150689     NEORAL     NVR

02247073     RHOXAL-CYCLOSPORINE     RHO

50MG Capsule

02150662     NEORAL     NVR

100MG Capsule

02150670     NEORAL     NVR

02242821     RHOXAL-CYCLOSPORINE     SDZ

100MG/ML Solution

02150697     NEORAL     NVR

CYPROTERONE ACETATE, ETHINYL ESTRADIOL

2MG & 35MCG Tablet

02233542     DIANE-35     BEX

DUTASTERIDE

Limited use benefit (prior approval required).

a. - For treatment of Benign Prostatic Hyperplasia (BPH) in patients who do not tolerate or have not responded to an adrenergic blocker.
or
b. - For use in combination therapy when monotherapy with an alpha-blocker is not sufficient.

0.5MG Capsule

02247813     AVODART     GSK

ETANERCEPT

Limited use benefit (prior approval required).

For the treatment of:
- Rheumatoid Arthritis according to established criteria.
(Please refer to Appendix A).

25MG/VIAL Injection

02242903     ENBREL     IMX

50MG/ML Injection

02274728     ENBREL     IMX

ETIDRONATE DISODIUM

200MG Tablet

02248686     CO-ETIDRONATE     COB

01997629     DIDRONEL     PGP

02245330     GEN-ETIDRONATE     GEN

ETIDRONATE DISODIUM, CALCIUM CARBONATE

400MG & 500MG Tablet

02176017     DIDROCAL     PGP

EXTEMPORANEOUS MIXTURE

Miscellaneous

00990019     EXTEMPORANEOUS MIXTURE          *

00999994     EXTEMPORANEOUS MIXTURE          *

00999997     EXTEMPORANEOUS MIXTURE          *

00999999     EXTEMPORANEOUS MIXTURE          *

FINASTERIDE

5MG Tablet

02010909     PROSCAR     FRS

FLUNARIZINE HCL

5MG Capsule

02246082     APO-FLUNARIZINE     APX

00846341     SIBELIUM     PMS

INFLIXIMAB

Limited use benefit (prior approval required).

For treatment of:
-Fistulizing Crohn's disease according to established criteria.
-For adult patients with moderately to severely active Crohn's Disease who have had an inadequate response to conventional therapy.
or
-Rheumatoid Arthritis according to established criteria
(Please refer to Appendix A).

100MG/VIAL Injection

02244016     REMICADE     CER

LEFLUNOMIDE

Limited use benefit (prior approval required).

For treatment of patients with rheumatoid arthritis who:
a. - have failed treatment with methotrexate.
b. - cannot tolerate or have contraindications to methotrexate.

10MG Tablet

02256495     APO-LEFLUNOMIDE     APX

02241888     ARAVA     SAC

02261251     NOVO-LEFLUNOMIDE     NOP

20MG Tablet

02256509     APO-LEFLUNOMIDE     APX

02241889     ARAVA     SAC

02261278     NOVO-LEFLUNOMIDE     NOP

LEUCOVORIN CALCIUM

5MG Tablet

02170493     LEUCOVORIN CALCIUM     WAY

MYCOPHENOLATE MOFETIL

Limited use benefit (prior approval required).

For transplant therapy.

250MG Capsule

02192748     CELLCEPT     HLR

500MG Tablet

02237484     CELLCEPT     HLR

MYCOPHENOLATE SODIUM

Limited use benefit (prior approval required).

For transplant therapy.

180MG Enteric Coated Tablet

02264560     MYFORTIC     NVR

360MG Enteric Coated Tablet

02264579     MYFORTIC     NVR

NAFARELIN ACETATE

2MG/ML Nasal Solution

02188783     SYNAREL     PFI

NEDOCROMIL SODIUM

2% Ophth Solution

02241407     ALOCRIL     ALL

OCTREOTIDE

10MG/VIAL Injection

02239323     SANDOSTATIN LAR     NVR

20MG/VIAL Injection

02239324     SANDOSTATIN LAR     NVR

30MG/VIAL Injection

02239325     SANDOSTATIN LAR     NVR

50MCG/ML Injection

02248639     OCTREOTIDE ACETATE OMEGA     OMG

00839191     SANDOSTATIN     NVR

100MCG/ML Injection

02248640     OCTREOTIDE ACETATE OMEGA     OMG

00839205     SANDOSTATIN     NVR

200MCG/ML Injection

02248642     OCTREOTIDE ACETATE OMEGA     OMG

500MCG/ML Injection

02248641     OCTREOTIDE ACETATE OMEGA     OMG

00839213     SANDOSTATIN     NVR

PAMIDRONATE DISODIUM

30MG Injection

02059762     AREDIA IV     NVR

02244550     PAMIDRONATE DISODIUM     MAY

02245998     PMS-PAMIDRONATE     PMS

02264951     RHOXAL-PAMIDRONATE     RHO

60MG Injection

02244551     PAMIDRONATE DISODIUM     MAY

02264978     RHOXAL-PAMIDRONATE     SDZ

90MG Injection

02059789     AREDIA IV     NVR

02244552     PAMIDRONATE DISODIUM     MAY

02245999     PMS-PAMIDRONATE     PMS

02264986     RHOXAL-PAMIDRONATE     SDZ

PENTOSAN POLYSULFATE SODIUM

100MG Capsule

02029448     ELMIRON     JNO

PERGOLIDE MESYLATE

0.05MG Tablet

02123320     PERMAX     DPY

0.25MG Tablet

02123339     PERMAX     DPY

1MG Tablet

02123347     PERMAX     DPY

RISEDRONATE SODIUM

Limited use benefit (prior approval required).

For treatment of:
a. - osteoporosis in patients who have documented hip, vertebral or other fractures.
b. - osteoporosis in patients who are intolerant of or do not respond to etidronate or etidronate/calcium.
c. - Paget's disease.

5MG Tablet

02242518     ACTONEL     PGP

30MG Tablet

02239146     ACTONEL     PGP

35MG Tablet

02246896     ACTONEL     PGP

SIROLIMUS

Limited use benefit (prior approval required).

Coverage will be provided as a second line therapy for patients failing mycophenolate mofetil.

1MG/ML Oral Liquid

02243237     RAPAMUNE     WAY

1MG Tablet

02247111     RAPAMUNE     WAY

SODIUM FLUORIDE

20MG Enteric Coated Tablet

02099225     FLUOTIC     AVT

TACROLIMUS

Limited use benefit (prior approval required).

For transplant therapy.

0.5MG Capsule

02243144     PROGRAF     AST

1MG Capsule

02175991     PROGRAF     AST

5MG Capsule

02175983     PROGRAF     AST

5MG/ML Injection

02176009     PROGRAF     AST

TAMSULOSIN HCL

Limited use benefit (prior approval required).

For treatment of Benign Prostatic Hyperplasia (BPH) in patients who do not tolerate or have not responded to other alpha- adrenergic blockers.

0.4MG Long Acting Tablet

02270102     FLOMAX CR     BOE

0.4MG Sustained Release Capsule

02238123     FLOMAX SR     BOE

TETRABENAZINE

25MG Tablet

02199270     NITOMAN     LHL

WATER

100% Injection

99002264     STERILE WATER     AUT     *

00905178     WATER FOR INJECTION     UNK     *

00905194     WATER FOR INJECTION          *

00905224     WATER FOR INJECTION     UNK     *

00038202     WATER STERILE     ABB     *

00624721     WATER STERILE     AZC