Drug Benefit List

56:00 GASTROINTESTINAL DRUGS

56:04.00 ANTACIDS AND ADSORBENTS

BISMUTH SUBSALICYLATE

17.6MG/ML Liquid

02097079     PEPTO BISMOL     PGI

262MG Tablet

02177994     PEPTO BISMOL     PGI

56:08.00 ANTIDIARRHEA AGENTS

LOPERAMIDE HCL

0.2MG/ML Liquid

02192667     DIARR-EZE     PMS

02016095     PMS-LOPERAMIDE     PMS

2MG Tablet

02170272     ANTI-DIARRHEAL     SDR

02212005     APO-LOPERAMIDE     APX

02229552     DIARR-EZE     PMS

02164450     DIARRHEA RELIEF     SDR

02239535     DOM-LOPERAMIDE     DPC

02183862     IMODIUM     MCL

02225182     LOPERAMIDE     PDL

02132591     NOVO-LOPERAMIDE     NOP

02228351     PMS-LOPERAMIDE     PMS

02233998     RHOXAL-LOPERAMIDE     RHO

02257564     RHOXAL-LOPERAMIDE     RHO

02238211     RIVA-LOPERAMIDE     RIV

56:12.00 CATHARTICS AND LAXATIVES

BISACODYL

5MG Enteric Coated Tablet

00545023     APO-BISACODYL     APX

00420433     BISACODYL     PRO

00714488     BISACOLAX     ICN

00254142     DULCOLAX     BOE

00587273     PMS-BISACODYL     PMS

5MG Suppository

00003867     DULCOLAX     BOE

10MG Suppository

00754595     APO-BISACODYL     APX

00261327     BISACOLAX     ICN

00003875     DULCOLAX     BOE

00582883     PMS-BISACODYL     PMS

00404802     RATIO-BISACODYL     RPH

02229743     SOFLAX EX     PMS

BISACODYL (POLYETHYLENE GLYCOL BASE)

Limited use benefit (prior approval required).

For treatment of constipation in patients with spinal cord injury.

10MG Suppository

02241091     MAGIC BULLET     DCM

DIOCTYL CALCIUM SULFOSUCCINATE

240MG Capsule

02245080     APO-DOCUSATE CALCIUM     APX

00830275     DOCUSATE CALCIUM     TAR

00842044     NOVO-DOCUSATE CALCIUM     NOP

00664553     PMS-DOCUSATE CALCIUM     PMS

00809055     RATIO-DOCUSATE CALCIUM     RPH

DIOCTYL SODIUM SULFOSUCCINATE

100MG Capsule

02245079     APO-DOCUSATE SODIUM     APX

02106256     COLACE     WPC

00716731     DOCUSATE SODIUM     TAR

00794406     DOCUSATE SODIUM     SDR

00830267     DOCUSATE SODIUM     TRI

02246036     DOCUSATE SODIUM     RPH

02239658     DOM-DOCUSATE SODIUM     DPC

02020084     NOVO-DOCUSATE     NOP

00703494     PMS-DOCUSATE SODIUM     PMS

00870196     RATIO-DOCUSATE SODIUM     RPH

00514888     SELAX     ODN

01994344     SOFLAX     PMS

200MG Capsule

02029529     SOFLAX     PMS

250MG Capsule

02006596     SELAX     ODN

10MG/ML Drop

02090163     COLACE     WPC

00870218     DOCUSATE SODIUM     RPH

00880140     PMS-SODIUM DOCUSATE     PMS

02006723     SOFLAX     PMS

4MG/ML Syrup

02086018     COLACE     WPC

00703508     PMS-DOCUSATE SODIUM     PMS

00870226     RATIO-DOCUSATE SODIUM     RPH

02006758     SOFLAX SYRUP     PMS

50MG/ML Syrup

00848417     PMS-DOCUSATE SODIUM     PMS

DIOCTYL SODIUM SULFOSUCCINATE, SENNA

50MG & 187MG Tablet

00026123     SENOKOT S     PFR

FIBER

469MG Tablet

00595829     NOVO-FIBRE     NOP

GLYCERINE

Adult Suppository

00873462     GLYCERIN     RPH     *

01926039     GLYCERIN     WLA

00812153     GLYCERINE     WLA     *

00812250     GLYCERINE     WLA     *

00884022     GLYCERINE     RPH     *

Pediatric Suppository

02020815     GLYCERIN INFANT     RPH

01926047     GLYCERIN INFANT & CHILD     PFI

00891053     GLYCERINE     RPH

LACTULOSE

667MG/ML Oral Liquid

02242814     APO-LACTULOSE     APX

02247383     EURO-LAC     EUR

667MG/ML Syrup

00703486     PMS-LACTULOSE     PMS

00854409     RATIO-LACTULOSE     RPH

00690686     RATIO-LACTULOSE     RPH

MACROGOL, POTASSIUM CHLORIDE, SODIUM BICARBONATE, SODIUM CHLORIDE, SODIUM SULFATE

60G & 750MG & 1.68G & 1.46G & 5.68G/L Powder

00677442     COLYTE     ZYM

00652512     GOLYTELY     BAX

00777838     PEGLYTE     PMS

MAGNESIUM HYDROXIDE

80MG/ML Liquid

02150646     MILK OF MAGNESIA PLAIN/SUGARFREE     BCD

311MG Tablet

02150638     MILK OF MAGNESIA     BCD

MINERAL OIL

78% Jelly

00608734     LANSOYL GEL     AXC

02186926     LANSOYL GEL SUGARFREE     AXC

100% Liquid

01951718     NUJOL     SCH

PLANTAGO SEED

50% Powder

00599875     MUCILLIUM     PMS

POLYETHYLENE GLYCOL, POTASSIUM CHLORIDE, SODIUM BICARBONATE, SODIUM CHLORIDE, SODIUM SULFATE

Oral Liquid

02147793     KLEAN-PREP     RVX

POTASSIUM CHLORIDE, SODIUM BICARBONATE, SODIUM CHLORIDE, SODIUM SULFATE

2.97G & 6.74G & 5.86G & 22.74G Powder

02239569     LYTEPREP     TPX

PSYLLIUM HYDROPHILIC MUCILLOID

680MG/G Powder

02174812     METAMUCIL ORIGINAL TEXTURE     PGI

02174790     METAMUCIL SM TEXT ORANGE     PGI

02174782     METAMUCIL SM TEXT ORANGE S/F     PGI

02174804     METAMUCIL SM TEXT UNFLAV     PGI

SENNOSIDES

1.7MG/ML Liquid

02144379     SENNALAX     PMS

02084651     SENNAPREP     PMS

00367729     SENOKOT     PFR

00367737     X-PREP     PFR

5MG/G Powder

00026042     SENOKOT     PFR

8.6MG Tablet

02247389     EURO-SENNA     EUR

00896411     PMS-SENNOSIDES     PMS

01949292     RIVA-SENNA     RIV

02089653     SANDOZ-SENNOSIDES     SDZ

02237105     SENNA LAXATIVE     SDR

02068109     SENNATAB     PMS

00026158     SENOKOT     PFR

12MG Tablet

00896403     PMS-SENNOSIDES     PMS

02089645     SANDOZ-SENNOSIDES     SDZ

SODIUM CITRATE, SODIUM LAURYL SULFOACETATE, SORBITOL

90MG & 9MG & 625MG Enema

02063905     MICROLAX     PMS

SODIUM PHOSPHATE DIBASIC, SODIUM PHOSPHATE MONOBASIC

180MG & 480MG/ML Oral Liquid

02206218     PHOSPHO SODA FLEET LAXATIVE     JAJ

02230399     PMS-PHOSPHATES SOLUTION     PMS

60MG & 160MG/ML PED Rectal Liquid

00108065     FLEET ENEMA PEDIATRIC     JAJ

60MG & 160MG/ML Rectal Liquid

02096900     ENEMOL     DPC

00009911     FLEET ENEMA     FRS

56:14.00 CHOLELITHOLYTIC AGENTS

URSODIOL

250MG Tablet

02238984     URSO     AXC

500MG Tablet

02245894     URSO DS     AXC

56:16.00 DIGESTANTS

LACTASE

3,550U Capsule

02016478     LACTRASE     RIV

Oral Liquid

00903981     LACTAID     MCL

50000U Oral Liquid

99003325     DAIRY-FREE     KIN

3,000U Tablet

02200384     DAIRY DIGESTIVE     PER

02239139     DAIRY DIGESTIVE     SDR

02017512     DAIRY FREE     KIN

01951637     DAIRYAID     TAN

02230653     LACTAID     JNO

4,500U Tablet

02239140     DAIRY DIGESTIVE EXTRA STRENGTH     SDR

02224909     DAIRY FREE EXTRA STRENGTH     KIN

02230113     DAIRYAID EXTRA STRENGTH     TAN

02230654     LACTAID EXTRA STRENGTH     JNO

LIPASE, AMYLASE, PROTEASE

5,000U & 16,600U & 18,750U Capsule

02239007     CREON 5 MINIMICROSPHERES     SPH

8,000U & 30,000U & 30,000U Capsule

00263818     COTAZYM     ORG

20,000U & 66,400U & 75,000U Capsule

02239008     CREON 20 MINIMICROSPHERES     SPH

4,000U & 11,000U & 11,000U Capsule (Enteric Coated Particles)

02181215     COTAZYM ECS4     ORG

4,000U & 12,000U & 12,000U Capsule (Enteric Coated Particles)

00789445     PANCREASE MT 4     JNO

4,500U & 20,000U & 25,000U Capsule (Enteric Coated Particles)

02203324     ULTRASE MS 4     AXC

8,000U & 30,000U & 30,000U Capsule (Enteric Coated Particles)

00502790     COTAZYM ECS 8     ORG

10,000U & 30,000U & 30,000U Capsule (Enteric Coated Particles)

00789437     PANCREASE MT 10     JNO

10,000U & 33,200U & 37,500U Capsule (Enteric Coated Particles)

02200104     CREON 10 MINIMICROSPHERES     SPH

12,000U & 39,000U & 39,000U Capsule (Enteric Coated Particles)

02045834     ULTRASE MT 12     AXC

16,000U & 48,000U & 48,000U Capsule (Enteric Coated Particles)

00789429     PANCREASE MT 16     JNO

20,000U & 55,000U & 55,000U Capsule (Enteric Coated Particles)

00821373     COTAZYM ECS 20     ORG

20,000U & 65,000 & 65,000U Capsule (Enteric Coated Particles)

02045869     ULTRASE MT 20     AXC

25,000U & 74,000U & 62,500U Capsule (Enteric Coated Particles)

01985205     CREON 25 MINIMICROSPHERES     SPH

4,500U & 20,000U & 25,000U Long Acting Capsule

02242374     PANCREASE LA     JNO

24,000U & 100,000U & 100,000U/G Powder

02230020     VIOKASE     AXC

8,000U & 30,000U & 30,000U Tablet

02230019     VIOKASE     AXC

16,000U & 60,000U & 60,000U Tablet

02241933     VIOKASE     AXC

56:20.00 EMETICS

IPECAC

Syrup

00378801     IPECAC     XEN

00721328     PMS-IPECAC     PMS

56:22.08 ANTIHISTAMINES

DIMENHYDRINATE

50MG/ML Injection

00392537     DIMENHYDRINATE     SDZ

00013579     GRAVOL     HOR

3MG/ML Liquid

00230197     GRAVOL     HOR

00757705     PMS-DIMENHYDRINATE     PMS

25MG Suppository

00783595     GRAVOL     HOR

50MG Suppository

00392553     DIMENHYDRINATE     SIL

00013595     GRAVOL     HOR

15MG Tablet

00511196     GRAVOL     HOR

50MG Tablet

00363766     APO-DIMENHYDRINATE     APX

00156655     DIMENHYDRINATE     PRO

00013803     GRAVOL     HOR

00399779     NAUSEATOL     SIL

00586331     PMS-DIMENHYDRINATE     PMS

00605786     TRAVEL AID     VTH

DOXYLAMINE SUCCINATE, PYRIDOXINE HCL

10MG & 10MG Tablet

00609129     DICLECTIN     DUI

MECLIZINE HCL

25MG Chewable Tablet

00220442     BONAMINE     PFI

56:22.20 5-HT3 RECEPTOR ANTAGONISTS

DOLASETRON MESYLATE

20MG/ML Injection

02231380     ANZEMET     SAC

50MG Tablet

02231378     ANZEMET     SAC

100MG Tablet

02231379     ANZEMET     SAC

GRANISETRON

1MG Tablet

02185881     KYTRIL     HLR

ONDANSETRON HCL DIHYDRATE

0.8MG/ML Liquid

02229639     ZOFRAN     GSK

4MG Tablet

02264056     NOVO-ONDANSETRON     NOP

02258188     PMS-ONDANSETRON     PMS

02278529     RATIO-ONDANSETRON     RPH

02274310     SANDOZ-ONDANSETRON     SDZ

02213567     ZOFRAN     GSK

02239372     ZOFRAN ODT     GSK

8MG Tablet

02264064     NOVO-ONDANSETRON     NOP

02258196     PMS-ONDANSETRON     PMS

02278537     RATIO-ONDANSETRON     RPH

02274329     SANDOZ-ONDANSETRON     SDZ

02213575     ZOFRAN     GSK

02239373     ZOFRAN ODT     GSK

56:22.92 MISCELLANEOUS ANTIEMETICS

DOMPERIDONE MALEATE

10MG Tablet

02103613     APO-DOMPERIDONE     APX

02238315     DOM-DOMPERIDONE     DPC

02236857     DOMPERIDONE     PDL

02278669     GEN-DOMPERIDONE     GEN

02157195     NOVO-DOMPERIDONE     NOP

02231477     NU-DOMPERIDONE     NXP

02236466     PMS-DOMPERIDONE     PMS

02268078     RAN-DOMPERIDONE     RBY

01912070     RATIO-DOMPERIDONE     RPH

500MG Tablet

02238444     FTP-DOMPERIDONE     FTP

NABILONE

0.5MG Capsule

02256193     CESAMET     VAE

1MG Capsule

00548375     CESAMET     VAE

56:28.12 HISTAMINE H2-ANTAGONISTS

CIMETIDINE

200MG Tablet

00584215     APO-CIMETIDINE     APX

02227436     GEN-CIMETIDINE     GEN

00582409     NOVO-CIMETINE     NOP

00865796     NU-CIMET     NXP

02229717     PMS-CIMETIDINE     PMS

300MG Tablet

00487872     APO-CIMETIDINE     APX

00596477     CIMETIDINE     PDL

02231287     DOM-CIMETIDINE     DPC

02227444     GEN-CIMETIDINE     GEN

00582417     NOVO-CIMETINE     NOP

00865818     NU-CIMET     NXP

02229718     PMS-CIMETIDINE     PMS

400MG Tablet

00600059     APO-CIMETIDINE     APX

00618691     CIMETIDINE     PDL

02231288     DOM-CIMETIDINE     DPC

02227452     GEN-CIMETIDINE     GEN

00603678     NOVO-CIMETINE     NOP

00865826     NU-CIMET     NXP

02229719     PMS-CIMETIDINE     PMS

600MG Tablet

00600067     APO-CIMETIDINE     APX

00618705     CIMETIDINE     PDL

02231290     DOM-CIMETIDINE     DPC

02227460     GEN-CIMETIDINE     GEN

00603686     NOVO-CIMETINE     NOP

00865834     NU-CIMET     NXP

02229720     PMS-CIMETIDINE     PMS

800MG Tablet

00749494     APO-CIMETIDINE     APX

02227479     GEN-CIMETIDINE     GEN

00663727     NOVO-CIMETINE     NOP

02229721     PMS-CIMETIDINE     PMS

FAMOTIDINE

20MG Tablet

01953842     APO-FAMOTIDINE     APX

02241372     FAMOTIDINE     PDL

02196018     GEN-FAMOTIDINE     GEN

02022133     NOVO-FAMOTIDINE     NOP

02024195     NU-FAMOTIDINE     NXP

02238342     PENTA-FAMOTIDINE     PEN

00710121     PEPCID     FRS

02242327     RATIO-FAMOTIDINE     RPH

02237148     ULCIDINE     VAE

40MG Tablet

01953834     APO-FAMOTIDINE     APX

02241373     FAMOTIDINE     PDL

02196026     GEN-FAMOTIDINE     GEN

02022141     NOVO-FAMOTIDINE     NOP

02024209     NU-FAMOTIDINE     NXP

02238343     PENTA-FAMOTIDINE     PEN

00710113     PEPCID     FRS

02242328     RATIO-FAMOTIDINE     RPH

02237149     ULCIDINE     VAE

NIZATIDINE

150MG Capsule

02220156     APO-NIZATIDINE     APX

00778338     AXID     PHH

02185814     DOM-NIZATIDINE     DPC

02246046     GEN-NIZATIDINE     GEN

02239558     NIZATIDINE     PDL

02240457     NOVO-NIZATIDINE     NOP

02177714     PMS-NIZATIDINE     PMS

300MG Capsule

02220164     APO-NIZATIDINE     APX

00778346     AXID     PHH

02246047     GEN-NIZATIDINE     GEN

02238195     NIZATIDINE     PHH

02239559     NIZATIDINE     PDL

02240458     NOVO-NIZATIDINE     NOP

02177722     PMS-NIZATIDINE     PMS

RANITIDINE HCL

15MG/ML Oral Solution

02242940     NOVO-RANITIDINE     NOP

02212374     ZANTAC     GSK

150MG Tablet

00733059     APO-RANITIDINE     APX

02265591     BCI-RANITIDINE     BCI

02248570     CO-RANITIDINE     COB

02207761     GEN-RANITIDINE     GEN

02219077     MED-RANITIDINE     MEC

00828564     NOVO-RANIDINE     NOP

00865737     NU-RANIT     NXP

02242453     PMS-RANITIDINE     PMS

00740748     RANITIDINE     PDL

00828823     RATIO-RANITIDINE     RPH

02243229     RHOXAL-RANITIDINE     SDZ

02245782     RIVA-RANITIDINE     PHH

02247814     RIVA-RANTIDINE     RIV

02212331     ZANTAC     GSK

300MG Tablet

00733067     APO-RANITIDINE     APX

02265605     BCI-RANITIDINE     BCI

02248571     CO-RANITIDINE     COB

02207788     GEN-RANITIDINE     GEN

02219085     MED-RANITIDINE     MEC

00828556     NOVO-RANIDINE     NOP

00865745     NU-RANIT     NXP

02242454     PMS-RANITIDINE     PMS

00740756     RANITIDINE     PDL

00828688     RATIO-RANITIDINE     RPH

02243230     RHOXAL-RANITIDINE     RHO

02247815     RIVA-RANITIDINE     RIV

02245783     RIVA-RANITIDINE     PHH

02212358     ZANTAC     GSK

56:28.28 PROSTAGLANDINS

MISOPROSTOL

100MCG Tablet

02244022     APO-MISOPROSTOL     APX

02240754     NOVO-MISOPROSTOL     NOP

200MCG Tablet

02244023     APO-MISOPROSTOL     APX

02248846     MISOPROSTOL     PDL

02240755     NOVO-MISOPROSTOL     NOP

02244125     PMS-MISOPROSTOL     PMS

56:28.32 PROTECTANTS

SUCRALFATE

200MG/ML Suspension

02103567     SULCRATE PLUS     AXC

1G Tablet

02125250     APO-SUCRALFATE     APX

02045702     NOVO-SUCRALATE     NOP

02134829     NU-SUCRALFATE     NXP

02238209     PMS-SUCRALFATE     PMS

02130939     SUCRALFATE-1     PDL

02100622     SULCRATE     AXC

56:28.36 PROTON-PUMP INHIBITORS

AMOXICILLIN, CLARITHROMYCIN, LANSOPRAZOLE

500MG & 500MG & 30MG Kit

02238525     HP-PAC     ABB

LANSOPRAZOLE

Limited use drug status (prior approval required)
Coverage will be provided:
- as part of multi-drug therapy (maximum 7-14 day coverage) for eradication of Helicobacter pylori in individuals with peptic ulcer disease (diagnosed by urea breath test, serology or endoscopically).
Coverage will also be provided if the following prerequisites are met:
- patient has tried at least 60 days of Apo-Omeprazole® (Generic) and
- patient has tried at least 60 days of Rabeprazole sodium (Pariet®). Total trial of 120 days will be confirmed against medication history:
- for treatment of confirmed gastric and duodenal ulcers. Or
- for mild to moderate gastroesophageal reflux disease (GERD) in patients who have failed on or not tolerated and 4-week trial of histamine-2 receptor antagonists. Or
- for severe gastroesophageal reflux disease (GERD) and complications as first-line therapy for a maximum period of 3 months. Patients should be reassessed endoscopically or with step-down therapy using a histamine-2 receptor antagonist. Or
- for treatment of nonsteroidal anti-inflammatory drug (NSAID)-induced ulcers where the NSAID must be continued. Or
- for prevention of NSAID-induced ulcers in patients who have a history of ulcer complications, are over the age of 65 years, have comorbid disease such as cardiovascular disease or coagulopathies or are on concomitant medications which increase risk of ulcers or bleeding. Or
- Zollinger-Ellison Syndrome*. Or
- Barrett's Esophagus*. Or
- esophagitis associated with connective tissue disease. Or
- other exceptional circumstances, evaluated on an individual basis.
* Diagnosis must be confirmed by a specialist qualified to diagnose and treat condition

15MG Sustained Release Capsule

02165503     PREVACID     ABB

30MG Sustained Release Capsule

02165511     PREVACID     ABB

OMEPRAZOLE

Limited use drug status (prior approval required)
Coverage will be provided:
- as part of multi-drug therapy (maximum 7-14 day coverage) for eradication of Helicobacter pylori in individuals with peptic ulcer disease (diagnosed by urea breath test, serology or endoscopically).
Coverage will also be provided if the following prerequisites are met:
- patient has tried at least 60 days of Apo-Omeprazole® (Generic) and
- patient has tried at least 60 days of Rabeprazole sodium (Pariet®). Total trial of 120 days will be confirmed against medication history:
- for treatment of confirmed gastric and duodenal ulcers. Or
- for mild to moderate gastroesophageal reflux disease (GERD) in patients who have failed on or not tolerated and 4-week trial of histamine-2 receptor antagonists. Or
- for severe gastroesophageal reflux disease (GERD) and complications as first-line therapy for a maximum period of 3 months. Patients should be reassessed endoscopically or with step-down therapy using a histamine-2 receptor antagonist. Or
- for treatment of nonsteroidal anti-inflammatory drug (NSAID)-induced ulcers where the NSAID must be continued. Or
- for prevention of NSAID-induced ulcers in patients who have a history of ulcer complications, are over the age of 65 years, have comorbid disease such as cardiovascular disease or coagulopathies or are on concomitant medications which increase risk of ulcers or bleeding. Or
- Zollinger-Ellison Syndrome*. Or
- Barrett's Esophagus*. Or
- esophagitis associated with connective tissue disease. Or
- other exceptional circumstances, evaluated on an individual basis.
* Diagnosis must be confirmed by a specialist qualified to diagnose and treat condition

10MG Capsule

02119579     LOSEC     AZC

20MG Capsule

00846503     LOSEC     AZC

OMEPRAZOLE (GENERIC)

20MG Capsule

02245058     APO-OMEPRAZOLE     APX

OMEPRAZOLE MAGNESIUM

Limited use drug status (prior approval required)
Coverage will be provided:
- as part of multi-drug therapy (maximum 7-14 day coverage) for eradication of Helicobacter pylori in individuals with peptic ulcer disease (diagnosed by urea breath test, serology or endoscopically).
Coverage will also be provided if the following prerequisites are met:
- patient has tried at least 60 days of Apo-Omeprazole® (Generic) and
- patient has tried at least 60 days of Rabeprazole sodium (Pariet®). Total trial of 120 days will be confirmed against medication history:
- for treatment of confirmed gastric and duodenal ulcers. Or
- for mild to moderate gastroesophageal reflux disease (GERD) in patients who have failed on or not tolerated and 4-week trial of histamine-2 receptor antagonists. Or
- for severe gastroesophageal reflux disease (GERD) and complications as first-line therapy for a maximum period of 3 months. Patients should be reassessed endoscopically or with step-down therapy using a histamine-2 receptor antagonist. Or
- for treatment of nonsteroidal anti-inflammatory drug (NSAID)-induced ulcers where the NSAID must be continued. Or
- for prevention of NSAID-induced ulcers in patients who have a history of ulcer complications, are over the age of 65 years, have comorbid disease such as cardiovascular disease or coagulopathies or are on concomitant medications which increase risk of ulcers or bleeding. Or
- Zollinger-Ellison Syndrome*. Or
- Barrett's Esophagus*. Or
- esophagitis associated with connective tissue disease. Or
- other exceptional circumstances, evaluated on an individual basis.
* Diagnosis must be confirmed by a specialist qualified to diagnose and treat condition

10MG Delayed Release Tablet

02230737     LOSEC     AZC

20MG Delayed Release Tablet

02190915     LOSEC     AZC

PANTOPRAZOLE

Limited use drug status (prior approval required)
Coverage will be provided:
- as part of multi-drug therapy (maximum 7-14 day coverage) for eradication of Helicobacter pylori in individuals with peptic ulcer disease (diagnosed by urea breath test, serology or endoscopically).
Coverage will also be provided if the following prerequisites are met:
- patient has tried at least 60 days of Apo-Omeprazole® (Generic) and
- patient has tried at least 60 days of Rabeprazole sodium (Pariet®). Total trial of 120 days will be confirmed against medication history:
- for treatment of confirmed gastric and duodenal ulcers. Or
- for mild to moderate gastroesophageal reflux disease (GERD) in patients who have failed on or not tolerated and 4-week trial of histamine-2 receptor antagonists. Or
- for severe gastroesophageal reflux disease (GERD) and complications as first-line therapy for a maximum period of 3 months. Patients should be reassessed endoscopically or with step-down therapy using a histamine-2 receptor antagonist. Or
- for treatment of nonsteroidal anti-inflammatory drug (NSAID)-induced ulcers where the NSAID must be continued. Or
- for prevention of NSAID-induced ulcers in patients who have a history of ulcer complications, are over the age of 65 years, have comorbid disease such as cardiovascular disease or coagulopathies or are on concomitant medications which increase risk of ulcers or bleeding. Or
- Zollinger-Ellison Syndrome*. Or
- Barrett's Esophagus*. Or
- esophagitis associated with connective tissue disease. Or
- other exceptional circumstances, evaluated on an individual basis.
* Diagnosis must be confirmed by a specialist qualified to diagnose and treat condition

40MG Enteric Coated Tablet

02229453     PANTOLOC     SPH

RABEPRAZOLE SODIUM

10MG Enteric Coated Tablet

02243796     PARIET EC     JNO

56:32.00 PROKINETIC AGENTS

METOCLOPRAMIDE HCL

1MG/ML Oral Liquid

02230433     PMS-METOCLOPRAMIDE     PMS

5MG Tablet

00842826     APO-METOCLOP     APX

00871001     METOCLOPRAMIDE     PDL

02143275     NU-METOCLOPRAMIDE     NXP

02230431     PMS-METOCLOPRAMIDE     PMS

10MG Tablet

00842834     APO-METOCLOP     APX

00870994     METOCLOPRAMIDE     PDL

02143283     NU-METOCLOPRAMIDE     NXP

02230432     PMS-METOCLOPRAMIDE     PMS

56:36.00 ANTI-INFLAMMATORY AGENTS

5-AMINOSALICYLIC ACID

500MG Delayed Release Tablet

02099683     PENTASA     FEI

2G/60G Enema

02112795     SALOFALK     AXC

4G/60G Enema

02112809     SALOFALK     AXC

400MG Enteric Coated Tablet

01997580     ASACOL     PGP

500MG Enteric Coated Tablet

02112787     SALOFALK     AXC

250MG Suppository

02112752     SALOFALK     AXC

500MG Suppository

02112760     SALOFALK     AXC

MESALAZINE

1G/100ML Enema

02153521     PENTASA     FEI

4G/100ML Enema

02153556     PENTASA     FEI

400MG Enteric Coated Tablet

02171929     NOVO 5-ASA     NOP

500MG Enteric Coated Tablet

01914030     MESASAL     GSK

1G Suppository

02153564     PENTASA     FEI

1000MG Suppository

02242146     SALOFALK     AXC

OLSALAZINE SODIUM

250MG Capsule

02063808     DIPENTUM     LUD