Drug Benefit List

08:00 ANTI-INFECTIVE AGENTS

08:08.00 ANTHELMINTICS

MEBENDAZOLE

100MG Tablet

00556734     VERMOX     JNO

PYRANTEL PAMOATE

50MG/ML Suspension

01944355     COMBANTRIN     PFI

125MG Tablet

01944363     COMBANTRIN     PFI

PYRVINIUM PAMOATE

10MG/ML Suspension

02019809     VANQUIN     WLA

08:12.06 CEPHALOSPORINS

CEFACLOR

250MG Capsule

02230263     APO-CEFACLOR     APX

00465186     CECLOR     PHH

02237729     CEFACLOR     IVX

02177633     DOM-CEFACLOR     DPC

02231691     NOVO-CEFACLOR     NOP

02231432     NU-CEFACLOR     NXP

02238200     PDL-CEFACLOR     PDL

500MG Capsule

02230264     APO-CEFACLOR     APX

00465194     CECLOR     PHH

02177641     DOM-CEFACLOR     DPC

02231693     NOVO-CEFACLOR     NOP

02231433     NU-CEFACLOR     NXP

02238201     PDL-CEFACLOR     PDL

02237730     SCHEIN-CEFACLOR     SCN

25MG/ML Suspension

02237500     APO-CEFACLOR     APX

00465208     CECLOR     PHH

02177668     DOM-CEFACLOR     DPC

02238202     PDL-CEFACLOR     PDL

50MG/ML Suspension

02237501     APO-CEFACLOR     APX

00465216     CECLOR     PHH

02177676     DOM-CEFACLOR     DPC

02238203     PDL-CEFACLOR     PDL

75MG/ML Suspension

02237502     APO-CEFACLOR     APX

00832804     CECLOR BID     PHH

02177684     DOM-CEFACLOR     DPC

02238204     PDL-CEFACLOR     PDL

CEFADROXIL

500MG Capsule

02240774     APO-CEFADROXIL     APX

00507245     DURICEF     BMS

02235134     NOVO-CEFADROXIL     NOP

CEFIXIME

20MG/ML Suspension

00868965     SUPRAX     SAC

400MG Tablet

00868981     SUPRAX     SAC

CEFPROZIL

25MG/ML Suspension

02163675     CEFZIL     BMS

50MG/ML Suspension

02163683     CEFZIL     BMS

250MG Tablet

02163659     CEFZIL     BMS

500MG Tablet

02163667     CEFZIL     BMS

CEFUROXIME AXETIL

25MG/ML Suspension

02212307     CEFTIN     GSK

250MG Tablet

02244393     APO-CEFUROXIME     APX

02212277     CEFTIN     GSK

02242656     RATIO-CEFUROXIME     RPH

500MG Tablet

02244394     APO-CEFUROXIME     APX

02212285     CEFTIN     GSK

02242657     RATIO-CEFUROXIME     RPH

CEPHALEXIN

250MG Capsule

00342084     NOVO-LEXIN     NOP

500MG Capsule

00342114     NOVO-LEXIN     NOP

25MG/ML Suspension

02177862     DOM-CEPHALEXIN     DPC

00342106     NOVO-LEXIN     NOP

50MG/ML Suspension

02177870     DOM-CEPHALEXIN     DPC

00342092     NOVO-LEXIN     NOP

250MG Tablet

00768723     APO-CEPHALEX     APX

02177846     DOM-CEPHALEXIN     DPC

00583413     NOVO-LEXIN     NOP

00865877     NU-CEPHALEX     NXP

00828858     PDL-CEPHALEXIN     PDL

02229587     PENTA-CEPHALEXIN     PEN

02177781     PMS-CEPHALEXIN     PMS

500MG Tablet

00768715     APO-CEPHALEX     APX

02177854     DOM-CEPHALEXIN     DPC

00583421     NOVO-LEXIN     NOP

00865885     NU-CEPHALEX     NXP

00828866     PDL-CEPHALEXIN     PDL

02229588     PENTA-CEPHALEXIN     PEN

02177803     PMS-CEPHALEXIN     PMS

08:12.12 MACROLIDES

AZITHROMYCIN

20MG/ML Suspension

02223716     ZITHROMAX     PFI

40MG/ML Suspension

02223724     ZITHROMAX     PFI

250MG Tablet

02247423     APO-AZITHROMYCIN     APX

02255340     CO-AZITHROMYCIN     COB

02278359     GEN-AZITHROMYCIN     GEN

02267845     NOVO-AZITHROMYCIN     NOP

02261634     PMS-AZITHROMYCIN     PMS

02275287     RATIO-AZITHROMYCIN     RPH

02265826     SANDOZ-AZITHROMYCIN     SDZ

02212021     ZITHROMAX     PFI

600MG Tablet

02256088     CO-AZITHROMYCIN     COB

02261642     PMS-AZITHROMYCIN     PMS

02231143     ZITHROMAX     PFI

CLARITHROMYCIN

500MG Extended Release Tablet

02244756     BIAXIN XL     ABB

250MG Film Coated Tablet

01984853     BIAXIN     ABB

500MG Film Coated Tablet

02126710     BIAXIN     ABB

25MG/ML Suspension

02146908     BIAXIN     ABB

50MG/ML Suspension

02244641     BIAXIN     ABB

ERYTHROMYCIN

250MG Enteric Coated Capsule

00726672     APO-ERYTHRO     APX

00607142     ERYC     PFI

333MG Enteric Coated Capsule

01925938     APO-ERYTHRO     APX

333MG Enteric Coated Tablet

00873454     ERYC     PFI

00769991     P.C.E.     ABB

250MG Tablet

00682020     APO-ERYTHRO BASE     APX

ERYTHROMYCIN ESTOLATE

25MG/ML Suspension

00021172     NOVO-RYTHRO ESTOLATE     NOP

50MG/ML Suspension

00262595     NOVO-RYTHRO ESTOLATE     NOP

ERYTHROMYCIN ETHYLSUCCINATE

40MG/ML Suspension

00605859     NOVO-RYTHRO ETHYLSUCCINATE     NOP

80MG/ML Suspension

00652318     NOVO-RYTHRO ETHYLSUCCINATE     NOP

600MG Tablet

00637416     APO-ERYTHRO-S     APX

00583782     EES-600     ABB

00704377     ERYTHRO-ES     PDL

ERYTHROMYCIN ETHYLSUCCINATE & SULFISOXAZOLE ACETYL

40MG & 120MG/ML Suspension

00583405     PEDIAZOLE     ABB

ERYTHROMYCIN STEARATE

250MG Tablet

00545678     APO-ERYTHRO-S     APX

00563854     ERYTHROMYCIN     PDL

02051850     NU-ERYTHROMYCIN S     NXP

500MG Tablet

00688568     APO-ERYTHRO S     APX

00704393     ERYTHRO     PDL

08:12.16 PENICILLINS

AMOXICILLIN

250MG Capsule

00628115     APO-AMOXI     APX

02238171     GEN-AMOXICILLIN     GEN

02181487     LIN-AMOX     LIN

02239761     MED-AMOXICILLIN     MEC

00406724     NOVAMOXIN     NOP

00865567     NU-AMOXI     NXP

02229584     PENTA-AMOXICILLIN     PEN

02230243     PMS-AMOXICILLIN     PMS

00644307     PRO-AMOX     PDL

02241826     SCHEIN-AMOXICILLIN     SCN

500MG Capsule

00628123     APO-AMOXI     APX

02238172     GEN-AMOXICILLIN     GEN

02181495     LIN-AMOX     LIN

02239762     MED-AMOXICILLIN     MEC

00406716     NOVAMOXIN     NOP

00865575     NU-AMOXI     NXP

02233017     PENTA-AMOXICILLIN     PEN

02230244     PMS-AMOXICILLIN     PMS

00644315     PRO-AMOX     PDL

02241827     SCHEIN-AMOXICILLIN     SCN

125MG Chewable Tablet

02036347     NOVAMOXIN     NOP

250MG Chewable Tablet

02036355     NOVAMOXIN     NOP

25MG/ML Suspension

00628131     APO-AMOXI     APX

00452149     NOVAMOXIN     NOP

01934171     NOVAMOXIN SUGAR REDUCED     NOP

00865540     NU-AMOXI     NXP

02229582     PENTA-AMOXICILLIN     PEN

02230245     PMS-AMOXICILLIN     PMS

00644323     PRO-AMOX     PDL

02240829     RIVA-AMOXICILLIN     RIV

50MG/ML Suspension

00628158     APO-AMOXI     APX

02181517     LIN-AMOX     LIN

00452130     NOVAMOXIN     NOP

01934163     NOVAMOXIN SUGAR REDUCED     NOP

00865559     NU-AMOXI     NXP

02229583     PENTA-AMOXICILLIN     PEN

02230246     PMS-AMOXICILLIN     PMS

00644331     PRO-AMOX     PDL

02240830     RIVA-AMOXICILLIN     RIV

AMOXICILLIN, CLAVULANIC ACID

25MG & 6.25MG/ML Suspension

02243986     APO-AMOXI CLAV     APX

01916882     CLAVULIN-F 125     GSK

02244646     RATIO-ACLAVULANATE-125F     RPH

40MG & 5.7MG/ML Suspension

02238831     CLAVULIN 200     GSK

50MG & 12.5MG/ML Suspension

02243987     APO-AMOXI CLAV     APX

01916874     CLAVULIN-F 250     GSK

02244647     RATIO-ACLAVULANATE-250F     RPH

80MG & 11.4MG/ML Suspension

02238830     CLAVULIN 400     GSK

250MG & 125MG Tablet

02243350     APO-AMOXI CLAV     APX

01916866     CLAVULIN     GSK

02243770     RATIO-ACLAVULANATE     RPH

500MG & 125MG Tablet

02243351     APO-AMOXI CLAV     APX

01916858     CLAVULIN-F     GSK

02243771     RATIO-ACLAVULANATE     RPH

875MG & 125MG Tablet

02245623     APO-AMOXI CLAV     APX

02238829     CLAVULIN     GSK

02248138     NOVO-CLAVAMOXIN     NOP

02247021     RATIO-ACLAVULANATE     RPH

AMPICILLIN

250MG Capsule

00020877     NOVO-AMPICILLIN     NOP

00717657     NU-AMPI     NXP

500MG Capsule

00020885     NOVO-AMPICILLIN     NOP

00717673     NU-AMPI     NXP

25MG/ML Suspension

00603260     APO-AMPICILLIN     APX

00717495     NU-AMPI     NXP

50MG/ML Suspension

00603287     APO-AMPICILLIN     APX

00717649     NU-AMPI     NXP

02043203     PENBRITIN     WAY

CLOXACILLIN

250MG Capsule

00618292     APO-CLOXI     APX

02069660     CLOXACILLINE     PRO

00337765     NOVO-CLOXIN     NOP

00717584     NU-CLOXI     NXP

500MG Capsule

00618284     APO-CLOXI     APX

02069679     CLOXACILLINE     PRO

00337773     NOVO-CLOXIN     NOP

00717592     NU-CLOXI     NXP

25MG/ML Suspension

00644633     APO-CLOXI     APX

00337757     NOVO-CLOXIN     NOP

00717630     NU-CLOXI     NXP

PENICILLIN V BENZATHINE

36MG/ML Suspension

02229618     PEN VEE     PED

60MG/ML Suspension

02229617     PEN VEE     PED

PENICILLIN V POTASSIUM

25MG/ML Suspension

00642223     APO-PEN VK     APX

60MG/ML Suspension

00642231     APO-PEN VK     APX

00391603     NOVO-PEN VK     NOP

300mg Tablet

02229619     PEN VEE     PED

300MG Tablet

00642215     APO-PEN VK     APX

00021202     NOVO-PEN VK     NOP

00717568     NU-PEN VK     NXP

00468029     PENICILLINE V     PDL

02232391     PVF-K     PED

PIVAMPICILLIN

35MG/ML Suspension

00582239     PONDOCILLIN     LEO

500MG Tablet

00582247     PONDOCILLIN     LEO

PIVMECILLINAM HCL

200MG Tablet

00657212     SELEXID     LEO

08:12.18 QUINOLONES

CIPROFLOXACIN HCL

250MG Tablet

02229521     APO-CIPROFLOX     APX

02155958     CIPRO     BAY

02251752     CIPROFLOXCIN     PDL

02247339     CO-CIPROFLOXACIN     COB

02251272     DOM-CIPROFLOXACIN     DPC

02245647     GEN-CIPROFLOXACIN     GEN

02161737     NOVO-CIPROFLOXACIN     NOP

02249634     NU-CIPROFLOXACIN     NXP

02251310     PHL-CIPROFLOXACIN     PHH

02248437     PMS-CIPROFLOXACIN     PMS

02249960     PREM-CIPROFLOXACIN     PRE

02267934     RAN-CIPROFLOXACIN     RBY

02246825     RATIO-CIPROFLOXACIN     RPH

02248756     RHOXAL-CIPROFLOXACIN     RHO

02251221     RIVA-CIPROFLOXACIN     RIV

02266962     TARO-CIPROFLOXACIN     TAR

500MG Tablet

02229522     APO-CIPROFLOX     APX

02155966     CIPRO     BAY

02251760     CIPROFLOXACIN     PDL

02247340     CO-CIPROFLOXACIN     COB

02251280     DOM-CIPROFLOXACIN     DPC

02245648     GEN-CIPROFLOXACIN     GEN

02161745     NOVO-CIPROFLOXACIN     NOP

02249642     NU-CIPROFLOXACIN     NXP

02251329     PHL-CIPROFLOXACIN     PHH

02248438     PMS-CIPROFLOXACIN     PMS

02249979     PREM-CIPROFLOXACIN     PRE

02267942     RAN-CIPROFLOXACIN     RBY

02246826     RATIO-CIPROFLOXACIN     RPH

02248757     RHOXAL-CIPROFLOXACIN     RHO

02251248     RIVA-CIPROFLOXACIN     RIV

02266970     TARO-CIPROFLOXACIN     TAR

750MG Tablet

02229523     APO-CIPROFLOX     APX

02155974     CIPRO     BAY

02251779     CIPROFLOXACIN     PDL

02247341     CO-CIPROFLOXACIN     COB

02251299     DOM-CIPROFLOXACIN     DPC

02245649     GEN-CIPROFLOXACIN     GEN

02161753     NOVO-CIPROFLOXACIN     NOP

02249650     NU-CIPROFLOXACIN     NXP

02251337     PHL-CIPROFLOXACIN     PHH

02248439     PMS-CIPROFLOXACIN     PMS

02249987     PREM-CIPROFLOXACIN     PRE

02267950     RAN-CIPROFLOXACIN     RBY

02246827     RATIO-CIPROFLOXACIN     RPH

02248758     RHOXAL-CIPROFLOXACIN     RHO

02251256     RIVA-CIPROFLOXACIN     RIV

NALIDIXIC ACID

500MG Tablet

02017687     NEGGRAM     SAC

NORFLOXACIN

400MG Tablet

02229524     APO-NORFLOX     APX

02237682     NOVO-NORFLOXACIN     NOP

02239670     PDL-NORFLOXACINE     PDL

02246596     PMS-NORFLOXACIN     PMS

02241483     RIVA-NORFLOXACIN     RIV

OFLOXACIN

200MG Tablet

02231529     APO-OFLOX     APX

02243474     NOVO-OFLOXACIN     NOP

300MG Tablet

02231531     APO-OFLOX     APX

02243475     NOVO-OFLOXACIN     NOP

400MG Tablet

02231532     APO-OFLOX     APX

02243476     NOVO-OFLOXACIN     NOP

08:12.20 SULFONAMIDES

SULFAMETHOXAZOLE

500MG Tablet

00421480     APO-SULFAMETHOXAZOLE     APX

SULFAMETHOXAZOLE, TRIMETHOPRIM

40MG & 8MG/ML Suspension

00846465     APO-SULFATRIM     APX

00726540     NOVO-TRIMEL     NOP

00865753     NU-COTRIMOX     NXP

100MG & 20MG Tablet

00445266     APO-SULFATRIM PED     APX

400MG & 80MG Tablet

00445274     APO-SULFATRIM     APX

00510637     NOVO-TRIMEL     NOP

00865710     NU-COTRIMOX     NXP

00512516     PROTRIN     PDL

800MG & 160MG Tablet

00445282     APO-SULFATRIM DS     APX

00510645     NOVO-TRIMEL DS     NOP

00865729     NU-COTRIMOX DS     NXP

00512524     PROTRIN DF     PRO

02241527     RIVA-SEP DS     RIV

SULFASALAZINE

500MG Enteric Coated Tablet

00598488     PMS-SULFASALAZINE     PMS

02064472     SALAZOPYRIN     PFI

500MG Tablet

00598461     PMS-SULFASALAZINE     PMS

02064480     SALAZOPYRIN     PFI

08:12.24 TETRACYCLINES

DOXYCYCLINE

100MG Capsule

00740713     APO-DOXY     APX

00817120     DOXYCIN     RIV

00742562     DOXYCYCLINE     PDL

00725250     NOVO-DOXYLIN     NOP

02044668     NU-DOXYCYCLINE     NXP

02093103     RATIO-DOXYCYCLINE     RPH

100MG Tablet

00874256     APO-DOXY     APX

00860751     DOXYCIN     RIV

00887064     DOXYTAB     PDL

02158574     NOVO-DOXYLIN     NOP

02044676     NU-DOXYCYCLINE     NXP

02091232     RATIO-DOXYCYCLINE     RPH

00578452     VIBRA-TABS     PFI

MINOCYCLINE HCL

Limited use benefit (prior approval required).

For:
a. - patients who cannot tolerate other tetracyclines.
b. - patients with severe widespread acne who have failed on tetracycline.

50MG Capsule

02084090     APO-MINOCYCLINE     APX

02239667     DOM-MINOCYCLINE     DPC

02237875     MED-MINOCYCLINE     MEC

02173514     MINOCIN     STI

02108143     NOVO-MINOCYCLINE     NOP

02153394     PDL-MINOCYCLINE     PDL

02239238     PMS-MINOCYCLINE     PMS

01914138     RATIO-MINOCYCLINE     RPH

02237313     RHOXAL-MINOCYCLINE     SDZ

02242080     RIVA-MINOCYCLINE     RIV

100MG Capsule

02084104     APO-MINOCYCLINE     APX

02239668     DOM-MINOCYCLINE     DPC

02237876     MED-MINOCYCLINE     MEC

02173506     MINOCIN     STI

02239982     MINOCYCLINE     IVX

02108151     NOVO-MINOCYCLINE     NOP

02154366     PDL-MINOCYCLINE     PDL

02239239     PMS-MONOCYCLINE     PMS

01914146     RATIO-MINOCYCLINE     RPH

02237314     RHOXAL-MINOCYCLINE     SDZ

02242081     RIVA-MINOCYCLINE     RIV

TETRACYCLINE HCL

250MG Capsule

00580929     APO-TETRA     APX

00156744     TETRACYCLINE     PRO

250MG Tablet

00717606     NU-TETRA     NXP

08:12.28 MISCELLANEOUS ANTIBIOTICS

CLINDAMYCIN HCL

150MG Capsule

02245232     APO-CLINDAMYCIN     APX

02248525     CLINDAMYCINE     PDL

00030570     DALACIN C     PFI

02258331     GEN-CLINDAMYCIN     GEN

02241709     NOVO-CLINDAMYCIN     NOP

02130033     RATIO-CLINDAMYCIN     RPH

02242409     RIVA-CLINDAMYCIN     RIV

300MG Capsule

02245233     APO-CLINDAMYCIN     APX

02248526     CLINDAMYCINE     PDL

02182866     DALACIN C     PFI

02258358     GEN-CLINDAMYCIN     GEN

02241710     NOVO-CLINDAMYCIN     NOP

02192659     RATIO-CLINDAMYCIN     RPH

02242410     RIVA-CLINDAMYCIN     RIV

CLINDAMYCIN PALMITATE HCL

15MG/ML Solution

00225851     DALACIN C     PFI

FUSIDATE SODIUM

250MG Tablet

01934252     FUCIDIN FC     LEO

LINEZOLID

Limited use benefit (prior approval required).

Tablets:

For treatment of proven vancomycin-resistant enterococci (VRE) infections when other antibiotics are not available, and for the treatment of proven Methicillin-Resistant Staphylococcus aureus (MRSA) infections in patients who cannot tolerate or who had an idiosyncratic reaction with Vancomycin.

I.V. solution:

When linezolid cannot be administered orally in the above mentioned situations.

2MG/ML Injection

02243685     ZYVOXAM     PFI

600MG Tablet

02243684     ZYVOXAM     PFI

08:14.04 ALLYLAMINES

TERBINAFINE HCL

250MG Tablet

02239893     APO-TERBINAFINE     APX

02254727     CO-TERBINAFINE     COB

02242503     GEN-TERBINAFINE     GEN

02031116     LAMISIL     NVR

02240346     NOVO-TERBINAFINE     NOP

02248845     NU-TERBINAFINE     NXP

02240807     PMS-TERBINAFINE     PMS

02262177     SANDOZ-TERBINAFINE     SDZ

02247530     TERBINAFINE     PRE

08:14.08 AZOLES

FLUCONAZOLE

150MG Capsule

02241895     APO-FLUCONAZOLE     APX

02141442     DIFLUCAN     PFI

02245697     GEN-FLUCONAZOLE     GEN

02243645     NOVO-FLUCONAZOLE     NOP

02246620     PMS-FLUCONAZOLE     PMS

02255510     RIVA-FLUCONAZOLE     RIV

10MG/ML Suspension

02024152     DIFLUCAN     PFI

50MG Tablet

02237370     APO-FLUCONAZOLE     APX

00891800     DIFLUCAN     PFI

02245292     GEN-FLUCONAZOLE     GEN

02236978     NOVO-FLUCONAZOLE     NOP

02245643     PMS-FLUCONAZOLE     PMS

02249294     TARO-FLUCONAZOLE     TAR

100MG Tablet

02237371     APO-FLUCONAZOLE     APX

00891819     DIFLUCAN     PFI

02245293     GEN-FLUCONAZOLE     GEN

02236979     NOVO-FLUCONAZOLE     NOP

02245644     PMS-FLUCONAZOLE     PMS

02249308     TAR0-FLUCONAZOLE     TAR

ITRACONAZOLE

100MG Capsule

02047454     SPORANOX     JNO

10MG/ML Solution

02231347     SPORANOX     JNO

KETOCONAZOLE

200MG Tablet

02237235     APO-KETOCONAZOLE     APX

02231061     NOVO-KETOCONAZOLE     NOP

02122197     NU-KETOCON     NXP

08:14.28 POLYENES

NYSTATIN

100,000U/ML Suspension

02125145     DOM-NYSTATIN     DPC

00792667     PMS-NYSTATIN     PMS

02194201     RATIO-NYSTATIN     RPH

500,000U Tablet

02194198     RATIO-NYSTATIN     RPH

08:16.04 ANTITUBERCULOSIS AGENTS

ETHAMBUTOL HCL

100MG Tablet

00247960     ETIBI     VAE

400MG Tablet

00247979     ETIBI     VAE

ISONIAZID

10MG/ML Syrup

00265500     ISOTAMINE     VAE

00577812     PMS-ISONIAZID     PMS

50MG Tablet

00577782     PMS-ISONIAZID     PMS

300MG Tablet

00272655     ISOTAMINE     VAE

00577804     PMS-ISONIAZID     PMS

PYRAZINAMIDE

500MG Tablet

00618810     PMS-PYRAZINAMIDE     PMS

00283991     TEBRAZID     VAE

RIFABUTIN

150MG Capsule

02063786     MYCOBUTIN     PFI

RIFAMPIN

150MG Capsule

02091887     RIFADIN     SAC

00393444     ROFACT     VAE

300MG Capsule

02092808     RIFADIN     SAC

00210463     RIMACTANE     NVR

00343617     ROFACT     VAE

08:18.04 ADAMANTANES

AMANTADINE HCL

100MG Capsule

02130963     DOM-AMANTADINE     DPC

02034468     ENDANTADINE     LIN

02139200     GEN-AMANTADINE     GEN

02199289     MED-AMANTADINE     MEC

01990403     PMS-AMANTADINE     PMS

01914006     SYMMETREL     BMS

10MG/ML Syrup

02130971     DOM-AMANTADINE     DPC

02022826     PMS-AMANTADINE     PMS

01913999     SYMMETREL     BMS

08:18.08 ANTIRETROVIRALS

ABACAVIR

20MG/ML Oral Liquid

02240358     ZIAGEN     GSK

300MG Tablet

02240357     ZIAGEN     GSK

ABACAVIR, LAMIVUDINE

600MG & 300MG Tablet

02269341     KIVEXA     GSK

ABACAVIR, LAMIVUDINE, ZIDOVUDINE

300MG & 150MG & 300MG Tablet

02244757     TRIZIVIR     GSK

AMPRENAVIR

Limited use benefit (prior approval required).

For the management of HIV disease in patients who have failed other protease inhibitor combinations, or for patients who experienced a lack of tolerability to other protease inhibitors.

50MG Capsule

02243541     AGENERASE     GSK

150MG Capsule

02243542     AGENERASE     GSK

15MG/ML Oral Liquid

02243543     AGENERASE     GSK

ATAZANAVIR SULFATE

Limited use benefit (prior approval required).

For the management of HIV in patients who failed other protease inhibitor combinations, or for patients who experienced a lack of tolerability to other protease inhibitors

150MG Capsule

02248610     REYATAZ     BMS

200MG Capsule

02248611     REYATAZ     BMS

DIDANOSINE

125MG Capsule

02244596     VIDEX EC     BMS

200mg Capsule

02244597     VIDEX EC     BMS

250MG Capsule

02244598     VIDEX EC     BMS

400MG Capsule

02244599     VIDEX EC     BMS

4G/BOTTLE Oral Liquid

01940635     VIDEX PED     BMS

EFAVIRENZ

50MG Capsule

02239886     SUSTIVA     BMS

100MG Capsule

02239887     SUSTIVA     BMS

200MG Capsule

02239888     SUSTIVA     BMS

600MG Tablet

02246045     SUSTIVA     BMS

FOSAMPRENAVIR CALCIUM

50MG/ML Oral Suspension

02261553     TELZIR     GSK

700MG Tablet

02261545     TELZIR     GSK

INDINAVIR SULFATE

200MG Capsule

02229161     CRIXIVAN     FRS

400MG Capsule

02229196     CRIXIVAN     FRS

LAMIVUDINE

10MG/ML Solution

02192691     3TC     GSK

100MG Tablet

02239193     HEPTOVIR     GSK

150MG Tablet

02192683     3TC     GSK

300MG Tablet

02247825     3TC     GSK

LAMIVUDINE, ZIDOVUDINE

150MG & 300MG Tablet

02239213     COMBIVIR     GSK

LOPINAVIR, RITONAVIR

133.3MG & 33.3MG Capsule

02243643     KALETRA     ABB

80MG & 20MG/ML Oral Solution

02243644     KALETRA     ABB

NELFINAVIR MESYLATE

50MG/G Powder for Suspension

02238618     VIRACEPT     PFI

250MG Tablet

02238617     VIRACEPT     PFI

625MG Tablet

02248761     VIRACEPT     PFI

NEVIRAPINE

200MG Tablet

02238748     VIRAMUNE     BOE

RITONAVIR

100MG Capsule

02241480     NORVIR SEC     ABB

80MG/ML Liquid

02229145     NORVIR     ABB

SAQUINAVIR MESYLATE

200MG Capsule

02239083     FORTOVASE     HLR

02216965     INVIRASE     HLR

500MG Tablet

02279320     INVIRASE     HLR

STAVUDINE

15MG Capsule

02216086     ZERIT     BMS

20MG Capsule

02216094     ZERIT     BMS

30MG Capsule

02216108     ZERIT     BMS

40MG Capsule

02216116     ZERIT     BMS

ZALCITABINE

0.375MG Tablet

01990918     HIVID     HLR

0.75MG Tablet

01990896     HIVID     HLR

ZIDOVUDINE

100MG Capsule

01946323     APO-ZIDOVUDINE     APX

01902660     RETROVIR     GSK

10MG/ML Syrup

01902652     RETROVIR     GSK

08:18.20 INTERFERONS

PEGINTERFERON ALFA-2A

Limited use benefit (prior approval required).

For the treatment of chronic hepatitis C in patients who are treatment naïve, upon the written request of a hepatologist or other specialist in this area.

a. - For genotypes 1, 4, 5 and 6, an initial 24 week supply will be approved. A further 24 week supply may be approved if patient has a viral reduction of at least 2 logs or HCV is undetectable at 12 weeks (48 weeks total).

b. - For genotypes 2 or 3, initial coverage for a maximum of 24 weeks will be approved. Renewals will not be covered

180MCG/0.5ML Injection

02248077     PEGASYS     HLR

180MCG/1ML Injection

02248078     PEGASYS     HLR

PEGINTERFERON ALFA-2A, RIBAVIRIN

Limited use benefit (prior approval required).

For the treatment of chronic hepatitis C in patients who are treatment naïve, upon the written request of a hepatologist or other specialist in this area.

a. - For genotypes 1, 4, 5 and 6, an initial 24 week supply will be approved. A further 24 week supply may be approved if patient has a viral reduction of at least 2 logs or HCV is undetectable at 12 weeks (48 weeks total).

b. - For genotypes 2 or 3, initial coverage for a maximum of 24 weeks will be approved. Renewals will not be covered

180MCG/0.5ML & 200MG Injection & Tablet

02253429     PEGASYS RBV     HLR

180MCG/1ML & 200MG Injection & Tablet

02253410     PEGASYS RBV     HLR

PEGINTERFERON ALFA-2B

Limited use benefit (prior approval required).

For the treatment of chronic hepatitis C in patients who are treatment naïve, upon the written request of a hepatologist or other specialist in this area.

a. - For genotypes 1, 4, 5 and 6, an initial 24 week supply will be approved. A further 24 week supply may be approved if patient has a viral reduction of at least 2 logs or HCV is undetectable at 12 weeks (48 weeks total).

b. - For genotypes 2 or 3, initial coverage for a maximum of 24 weeks will be approved. Renewals will not be covered

74MCG/VIAL Injection

02242966     UNITRON PEG     SCH

118.4MCG/VIAL Injection

02242967     UNITRON PEG     SCH

177.6MCG/VIAL Injection

02242968     UNITRON PEG     SCH

222MCG/VIAL Injection

02242969     UNITRON PEG     SCH

PEGINTERFERON ALFA-2B, RIBAVIRIN

Limited use benefit (prior approval required).

For the treatment of chronic hepatitis C in patients who are treatment naïve, upon the written request of a hepatologist or other specialist in this area.

a. - For genotypes 1, 4, 5 and 6, an initial 24 week supply will be approved. A further 24 week supply may be approved if patient has a viral reduction of at least 2 logs or HCV is undetectable at 12 weeks (48 weeks total).

b. - For genotypes 2 or 3, initial coverage for a maximum of 24 weeks will be approved. Renewals will not be covered

50MCG/0.5ML & 200MG Injection & Capsule

02246026     PEGETRON     SCH

02254573     PEGETRON REDIPEN     SCH

80MCG/0.5ML & 200MG Injection & Capsule

02246027     PEGETRON     SCH

02254581     PEGETRON REDIPEN     SCH

100MCG/0.5ML & 200MG Injection & Capsule

02246028     PEGETRON     SCH

02254603     PEGETRON REDIPEN     SCH

120MCG/0.5ML & 200MG Injection & Capsule

02246029     PEGETRON     SCH

02254638     PEGETRON REDIPEN     SCH

150MCG/0.5ML & 200MG Injection & Capsule

02246030     PEGETRON     SCH

02254646     PEGETRON REDIPEN     SCH

08:18.32 NUCLEOSIDES AND NUCLEOTIDES

ACYCLOVIR

40MG/ML Suspension

00886157     ZOVIRAX     GSK

200MG Tablet

02207621     APO-ACYCLOVIR     APX

02242784     GEN-ACYCLOVIR     GEN

02197405     NU-ACYCLOVIR     NXP

02237541     PDL-ACYCLOVIR     PDL

02078627     RATIO-ACYCLOVIR     RPH

00634506     ZOVIRAX     GSK

400MG Tablet

02207648     APO-ACYCLOVIR     APX

02242463     GEN-ACYCLOVIR     GEN

02197413     NU-ACYCLOVIR     NXP

02237542     PDL-ACYCLOVIR     PDL

02078635     RATIO-ACYCLOVIR     RPH

01911627     ZOVIRAX     GSK

800MG Tablet

02207656     APO-ACYCLOVIR     APX

02242464     GEN-ACYCLOVIR     GEN

02197421     NU-ACYCLOVIR     NXP

02237543     PDL-ACYCLOVIR     PDL

02078651     RATIO-ACYCLOVIR     RPH

01911635     ZOVIRAX     GSK

FAMCICLOVIR

125MG Tablet

02229110     FAMVIR     NVR

250MG Tablet

02229129     FAMVIR     NVR

500MG Tablet

02177102     FAMVIR     NVR

GANCICLOVIR SODIUM

500MG Injection

02162695     CYTOVENE     HLR

VALACYCLOVIR HCL

500MG Tablet

02219492     VALTREX     GSK

VALGANCICLOVIR HCL

450MG Tablet

02245777     VALCYTE     HLR

08:30.04 AMEBICIDES

DIIODOHYDROXYQUIN

210MG Tablet

01997769     DIODOQUIN     GLE

650MG Tablet

01997750     DIODOQUIN     GLE

PAROMOMYCIN SULFATE

250MG Capsule

02078759     HUMATIN     ERF

08:30.08 ANTIMALARIALS

CHLOROQUINE PHOSPHATE

250MG Tablet

00021261     NOVO-CHLOROQUINE     NOP

HYDROXYCHLOROQUINE SULFATE

200MG Tablet

02246691     APO-HYDROXYQUINE     APX

02252600     GEN-HYDROXYCHLOROQUINE     GEN

02017709     PLAQUENIL     SAC

PRIMAQUINE PHOSPHATE

26.3MG Tablet

02017776     PRIMAQUINE     SAC

PYRIMETHAMINE

25MG Tablet

00004774     DARAPRIM     GSK

08:30.92 MISCELLANEOUS ANTIPROTOZOALS

ATOVAQUONE

150MG/ML Suspension

02217422     MEPRON     GSK

METRONIDAZOLE

500MG Capsule

02248562     APO-METRONIDAZOLE     APX

00783137     TRIKACIDE     PMS

250MG Tablet

00545066     APO-METRONIDAZOLE     APX

00420409     METRONIDAZOLE     PDL

PENTAMIDINE ISETHIONATE

300MG/VIAL Injection

02183080     PENTAMIDINE     MAY

TRIMETREXATE GLUCURONATE

25MG/VIAL Injection

02065770     NEUTREXIN     MIO

08:36.00 URINARY ANTI-INFECTIVES

NITROFURANTOIN

50MG Capsule

01997637     MACRODANTIN     PGP

02231015     NOVO-FURANTOIN     NOP

100MG Capsule

02063662     MACROBID     PGP

02231016     NOVO-FURANTOIN     NOP

50MG Tablet

00319511     APO-NITROFURANTOIN     APX

100MG Tablet

00312738     APO-NITROFURANTOIN     APX

TRIMETHOPRIM

100MG Tablet

02243116     APO-TRIMETHOPRIM     APX

200MG Tablet

02243117     APO-TRIMETHOPRIM     APX