Drug Benefit List

68:00 HORMONES AND SYNTHETIC SUBSTITUTES

68:04.00 ADRENALS

BECLOMETHASONE DIPROPIONATE

50MCG Inhaler CFC-Free

02242029     QVAR     MMH

100MCG Inhaler CFC-Free

02242030     QVAR     MMH

BUDESONIDE

0.125MG/ML Inhalation Solution

02229099     PULMICORT NEBUAMP     AZC

0.25MG/ML Inhalation Solution

01978918     PULMICORT NEBUAMP     AZC

0.5MG/ML Inhalation Solution

01978926     PULMICORT NEBUAMP     AZC

100MCG Powder for Inhalation

00852074     PULMICORT TURBUHALER     AZC

200MCG Powder for Inhalation

00851752     PULMICORT TURBUHALER     AZC

400MCG Powder for Inhalation

00851760     PULMICORT TURBUHALER     AZC

CORTISONE ACETATE

25MG Tablet

00280437     CORTISONE     VAE

DEXAMETHASONE

0.1MG/ML Elixir

01946897     PMS-DEXAMETHASONE     PMS

0.5MG Tablet

02261081     APO-DEXAMETHASONE     APX

00295094     DEXASONE     VAE

02237044     PHL-DEXAMETHASONE     PHH

01964976     PMS-DEXAMETHASONE     PMS

02240684     RATIO-DEXAMETHASONE     RPH

0.75MG Tablet

00285471     DEXASONE     VAE

01964968     PMS-DEXAMETHASONE     PMS

02240685     RATIO-DEXAMETHASONE     RPH

4MG Tablet

02250055     APO-DEXAMETHASONE     APX

00489158     DEXASONE     VAE

02237046     PHL-DEXAMETHASONE     PHH

01964070     PMS-DEXAMETHASONE     PMS

02240687     RATIO-DEXAMETHASONE     RPH

DEXAMETHASONE PHOSPHATE

4MG/ML Injection

00664227     DEXAMETHASONE     SDZ

01977547     DEXAMETHASONE     CYX

02204266     DEXAMETHASONE-OMEGA     OMG

10MG/ML Injection

00874582     DEXAMETHASONE     SDZ

00783900     PMS-DEXAMETHASONE     PMS

FLUDROCORTISONE ACETATE

0.1MG Tablet

02086026     FLORINEF     SHI

FLUTICASONE PROPIONATE

25MCG/INHALATION Inhaler

02213583     FLOVENT     GSK

50MCG/INHALATION Inhaler HFA

02244291     FLOVENT HFA 50     GSK

125MCG/INHALATION Inhaler HFA

02244292     FLOVENT HFA 125     GSK

250MCG/INHALATION Inhaler HFA

02244293     FLOVENT HFA 250     GSK

50MCG/DOSE Powder Diskus

02237244     FLOVENT DISKUS     GSK

100MCG/DOSE Powder Diskus

02237245     FLOVENT DISKUS     GSK

250MCG/DOSE Powder Diskus

02237246     FLOVENT DISKUS     GSK

500MCG/DOSE Powder Diskus

02237247     FLOVENT DISKUS     GSK

HYDROCORTISONE

10MG Tablet

00030910     CORTEF     PFI

20MG Tablet

00030929     CORTEF     PFI

METHYLPREDNISOLONE

4MG Tablet

00030988     MEDROL     PFI

16MG Tablet

00036129     MEDROL     PFI

METHYLPREDNISOLONE ACETATE

40MG/ML Suspension for Injection

00030759     DEPO-MEDROL     PMJ

02245400     METHYLPREDNISOLONE ACETATE     SDZ

02245407     METHYLPREDNISOLONE ACETATE     SDZ

80MG/ML Suspension for Injection

00030767     DEPO-MEDROL     PMJ

02245406     METHYLPREDNISOLONE ACETATE     SDZ

02245408     METHYLPREDNISOLONE ACETATE     SDZ

20MG/ML Suspension for Injection (Multi-Dose)

01934325     DEPO-MEDROL     PMJ

40MG/ML Suspension for Injection (Multi-Dose)

01934333     DEPO-MEDROL     PMJ

80MG/ML Suspension for Injection (Multi-Dose)

01934341     DEPO-MEDROL     PMJ

PREDNISOLONE SODIUM PHOSPHATE

1MG/ML Oral Liquid

02230619     PEDIAPRED     AVT

02245532     PMS-PREDNISOLONE     PMS

PREDNISONE

1MG Tablet

00598194     APO-PREDNISONE     APX

00271373     WINPRED     VAE

5MG Tablet

00312770     APO-PREDNISONE     APX

00156876     PREDNISONE     PRO

50MG Tablet

00550957     APO-PREDNISONE     APX

00232378     NOVO-PREDNISONE     NOP

00607517     PREDNISONE     PRO

TRIAMCINOLONE ACETONIDE

10MG/ML Suspension for Injection

01999761     KENALOG-10     WSB

02229540     TRIAMCINOLONE     SDZ

40MG/ML Suspension for Injection

01999869     KENALOG-40     WSB

02229550     TRIAMCINOLONE     SDZ

09857128     TRIAMCINOLONE ACETONIDE (5ML)     SIL

TRIAMCINOLONE DIACETATE

40MG/ML Suspension for Injection

01977555     STERILE TRIAMCINOLONE     CYX

TRIAMCINOLONE HEXACETONIDE

20MG/ML Suspension for Injection

02194155     ARISTOSPAN     VAO

68:08.00 ANDROGENS

DANAZOL

50MG Capsule

02018144     CYCLOMEN     SAC

100MG Capsule

02018152     CYCLOMEN     SAC

200MG Capsule

02018160     CYCLOMEN     SAC

TESTOSTERONE CYPIONATE

100MG/ML Injection

00030783     DEPO-TESTOSTERONE     PFI

02246063     TESTOSTERONE CYPIONATE     SDZ

TESTOSTERONE ENANTHATE

200MG/ML Injection

00029246     DELATESTRYL     BMS

00739944     PMS-TESTOSTERONE     PMS

TESTOSTERONE UNDECANOATE

40MG Capsule

00782327     ANDRIOL     ORG

68:12.00 CONTRACEPTIVES

ETHINYL ESTRADIOL, DESOGESTREL

30MCG & 150MCG (21) Tablet

02042487     MARVELON (21)     ORG

02042541     ORTHO CEPT (21)     JNO

30MCG & 150MCG (28) Tablet

02042479     MARVELON (28)     ORG

02042533     ORTHO CEPT (28)     JNO

ETHINYL ESTRADIOL, D-NORGESTREL

50MCG & 250MCG (21) Tablet

02043033     OVRAL (21)     WAY

50MCG & 250MCG (28) Tablet

02043041     OVRAL (28)     WAY

ETHINYL ESTRADIOL, DROSPIRENONE

30MCG & 3MG (21) Tablet

02261723     YASMIN     BEX

30MCG & 3MG (28) Tablet

02261731     YASMIN     BEX

ETHINYL ESTRADIOL, ETHYNODIOL DIACETATE

30MCG & 2MG (21) Tablet

00469327     DEMULEN 30 (21)     PFI

30MCG & 2MG (28) Tablet

00471526     DEMULEN 30 (28)     PFI

ETHINYL ESTRADIOL, LEVONORGESTREL

20MCG & 100MCG (21) Tablet

02236974     ALESSE (21)     WAY

20MCG & 100MCG (28) Tablet

02236975     ALESSE (28)     WAY

30MCG & 0.05MG (6), 40MCG & 0.075MG (5), 30MCG & 0.125MG (10) (21) Tablet

02043726     TRIPHASIL (21)     WAY

00707600     TRIQUILAR (21)     BEX

30MCG & 0.05MG (6), 40MCG & 0.075MG (5), 30MCG & 0.125MG (10), (28) Tablet

02043734     TRIPHASIL (28)     WAY

00707503     TRIQUILAR (28)     BEX

30MCG & 150MCG (21) Tablet

02042320     MIN OVRAL (21)     WAY

30MCG & 150MCG (28) Tablet

02042339     MIN OVRAL (28)     WAY

ETHINYL ESTRADIOL, NORELGESTROMIN

Limited use benefit (prior approval required).

For the treatment of patients who are intolerant to or unable to take oral contraceptives.

0.6MG & 6MG Transdermal System

02248297     EVRA     JNO

ETHINYL ESTRADIOL, NORETHINDRONE

35MCG & 0.5MG (21) Tablet

02187086     BREVICON 0.5/35 (21)     PFI

00317047     ORTHO 0.5/35 (21)     JNO

35MCG & 0.5MG (28) Tablet

02187094     BREVICON 0.5/35 (28)     PFI

00340731     ORTHO 0.5/35 (28)     JNO

35MCG & 0.5MG (7), 35MCG & 1MG (9), 35MCG & 0.5MG (5) (21) Tablet

02187108     SYNPHASIC (21)     PFI

35MCG & 0.5MG (7), 35MCG & 1MG (9), 35MCG & 0.5MG (5) (28) Tablet

02187116     SYNPHASIC (28)     PFI

35MCG & 1MG (21) Tablet

02189054     BREVICON 1/35 (21)     PFI

00372846     ORTHO 1/35 (21)     JNO

02197502     SELECT 1/35 (21)     DSP

35MCG & 1MG (28) Tablet

02189062     BREVICON 1/35 (28)     PFI

00372838     ORTHO 1/35 (28)     JNO

02199297     SELECT 1/35 (28)     DSP

35MCG & 500MCG (7), 35MCG & 750MCG (7), 35MCG & 1MG (7) (21) Tablet

00602957     ORTHO 7/7/7 (21)     JNO

35MCG & 500MCG (7), 35MCG & 750MCG (7), 35MCG & 1MG (7), (28) Tablet

00602965     ORTHO 7/7/7 (28)     JNO

ETHINYL ESTRADIOL, NORETHINDRONE ACETATE

20MCG & 1MG (21) Tablet

00315966     MINESTRIN 1/20 (21)     GCL

20MCG & 1MG (28) Tablet

00343838     MINESTRIN 1/20 (28)     GCL

30MCG & 1.5MG (21) Tablet

00297143     LOESTRIN 1.5/30 (21)     GCL

30MCG & 1.5MG (28) Tablet

00353027     LOESTRIN 1.5/30 (28)     GCL

ETHINYL ESTRADIOL, NORGESTIMATE

25MCG & 0.180MG (7), 25MCG & 0.215MG (7), 25MCG & 0.25MG (7) (21) Tablet

02258560     TRI-CYCLEN LO     JNO

25MCG & 0.180MG (7), 25MCG & 0.215MG (7), 25MCG & 0.25MG (7), (28) Tablet

02258587     TRI-CYCLEN LO     JNO

35MCG & 0.180MG (7), 35MCG & 0.215MG (7), 35MCG & 0.25MG (7) (21) Tablet

02028700     TRI-CYCLEN (21)     JNO

35MCG & 0.180MG (7), 35MCG & 0.215MG (7), 35MCG & 0.25MG (7), (28) Tablet

02029421     TRI-CYCLEN (28)     JNO

35MCG & 0.25MG (21) Tablet

01968440     CYCLEN (21)     JNO

35MCG & 0.25MG (28) Tablet

01992872     CYCLEN (28)     JNO

LEVONORGESTREL

52MG Intrauterine Insert

02243005     MIRENA     BEX

0.75MG Tablet

02241674     PLAN B     BAR

NORETHINDRONE

0.35MG (28) Tablet

00037605     MICRONOR (28)     JNO

68:16.04 ESTROGENS

CONJUGATED ESTROGENS

0.3MG Tablet

02239654     PMS-CONJUGATED ESTROGENS     PMS

02043394     PREMARIN     WAY

0.625MG Tablet

00265470     C.E.S.     VAE

00830232     CONGEST     TRI     *

00587281     PMS-CONJUGATED ESTROGENS     PMS

02043408     PREMARIN     WAY

0.9MG Tablet

00830224     CONGEST     TRI     *

02239655     PMS-CONJUGATED ESTROGENS     PMS

02043416     PREMARIN     WAY

1.25MG Tablet

00265489     C.E.S.     VAE

00830216     CONGEST     TRI     *

00587303     CONJUGATED ESTROGENS     PMS

02043424     PREMARIN     WAY

0.625MG/G Vaginal Cream

02043440     PREMARIN     WAY

CONJUGATED ESTROGENS, MEDROXYPROGESTERONE ACETATE

0.625MG & 2.5MG Kit

02242878     PREMPLUS     WAY

0.625MG & 5MG Kit

02242879     PREMPLUS     WAY

ESTRADIOL

0.06% Gel

02238704     ESTROGEL     SCH

0.39MG Patch

02245676     ESTRADOT 25     NVR

0.585MG Patch

02243999     ESTRADOT 37.5     NVR

0.78MG Patch

02244000     ESTRADOT 50     NVR

1.17MG Patch

02244001     ESTRADOT 75     NVR

1.56MG Patch

02244002     ESTRADOT 100     NVR

5MG Patch

02243722     OESCLIM     PAL

10MG Patch

02243724     OESCLIM     PAL

25MCG Patch

00756849     ESTRADERM     NVR

50MCG Patch

00756857     ESTRADERM     NVR

02246967     RHOXAL-ESTRADIOL DERM     RHO

75MCG Patch

02246968     RHOXAL-ESTRADIOL DERM     RHO

100MCG Patch

00756792     ESTRADERM     NVR

02246969     RHOXAL-ESTRADIOL DERM     RHO

0.5MG Tablet

02225190     ESTRACE     SHI

1MG Tablet

02148587     ESTRACE     SHI

2MG Tablet

02148595     ESTRACE     SHI

2MG Vaginal Ring

02168898     ESTRING     PMJ

25MCG Vaginal Tablet

02241332     VAGIFEM     NOO

ESTRADIOL (ESTRADIOL HEMIHYDRATE)

25MCG Patch

02247499     CLIMARA 25     BEX

50MCG Patch

02231509     CLIMARA 50     BEX

75MCG Patch

02247500     CLIMARA 75     BEX

100MCG Patch

02231510     CLIMARA 100     BEX

ESTRADIOL VALERATE

10MG/ML Injection

00029238     DELESTROGEN     BMS

ESTRADIOL, ESTRADIOL, NORETHINDRONE ACETATE

4.33MG & 0.51MG & 4.8MG Patch

02243530     ESTALIS-SEQUI 250/50     NVR

4.33MG & 0.62MG & 2.7MG Patch

02243529     ESTALIS-SEQUI 140/50     NVR

50MCG / 250MCG & 50MCG Patch

02108186     ESTRACOMB     NVR

ESTRADIOL, NORETHINDRONE ACETATE

0.51MG & 4.8MG Patch

02241837     ESTALIS 250/50     NVR

0.62MG & 2.7MG Patch

02241835     ESTALIS 140/50     NVR

ESTRONE

1MG/G Vaginal Cream

00727369     NEO-ESTRONE     NEO

ESTROPIPATE

0.625MG Tablet

02089793     OGEN     PFI

1.25MG Tablet

02089769     OGEN     PFI

2.5MG Tablet

02089777     OGEN     PFI

ETHINYL ESTRADIOL, NORETHINDRONE ACETATE

1MG/5MCG Tablet

02242531     FEMHRT     WCI

68:16.12 ESTROGEN AGONISTS-ANTAGONISTS

RALOXIFENE HCL

Limited use benefit (prior approval required).

For:
a.- secondary prevention of osteoporosis in women who experience failure on bisphosphonates.
b. - secondary prevention of osteoporosis in women who have a personal history or a first degree relative with a history of breast cancer.

60MG Tablet

02239028     EVISTA     LIL

68:20.02 ALPHA-GLUCOSIDASE INHIBITORS

ACARBOSE

50MG Tablet

02190885     GLUCOBAY     BAY

100MG Tablet

02190893     GLUCOBAY     BAY

68:20.04 BIGUANIDES

METFORMIN HCL

500MG Tablet

02167786     APO-METFORMIN     APX

02265575     BCI-METFORMIN     BCI

02257726     CO-METFORMIN     COB

02229994     DOM-METFORMIN     DPC

02148765     GEN-METFORMIN     GEN

02099233     GLUCOPHAGE     SAC

02229516     GLYCON     VAE

02230670     MED-METFORMIN     MEC

02220628     METFORMIN     PDL

02242794     METFORMIN     ZYM

02045710     NOVO-METFORMIN     NOP

02162822     NU-METFORMIN     NXP

02223562     PMS-METFORMIN     PMS

02269031     RAN-METFORMIN     RBY

02242974     RATIO-METFORMIN     RPH

02233999     RHOXAL-METFORMIN     RHO

02246820     RHOXAL-METFORMIN FC     SDZ

02239081     RIVA-METFORMIN     RIV

850MG Tablet

02229785     APO-METFORMIN     APX

02265583     BCI-METFORMIN     BCI

02257734     CO-METFORMIN     COB

02242726     DOM-METFORMIN     DPC

02229656     GEN-METFORMIN     GEN

02162849     GLUCOPHAGE     SAC

02239214     GLYCON     VAE     *

02231058     METFORMIN     PDL

02242793     METFORMIN     ZYM

02230475     NOVO-METFORMIN     NOP

02229517     NU-METFORMIN     NXP

02242589     PMS-METFORMIN     PMS

02269058     RAN-METFORMIN     RBY

02242931     RATIO-METFORMIN     RPH

02246821     RHOXAL-METFORMIN     RHO

02242783     RIVA-METFORMIN     RIV

68:20.08 INSULINS

INSULIN (10% NEUTRAL & 90% ISOPHANE) HUMAN BIOSYNTHETIC

100U/ML (3ML) Injection

02024292     NOVOLIN GE 10/90 PENFILL     NOO

INSULIN (20% NEUTRAL & 80% ISOPHANE) HUMAN BIOSYNTHETIC

100U/ML (3ML) Injection

02024306     NOVOLIN GE 20/80 PENFILL     NOO

INSULIN (30% NEUTRAL & 70% ISOPHANE) HUMAN BIOSYNTHETIC

100U/ML (3ML) Injection

00908134     NOVOLIN GE 30/70 PENFILL     NOO     *

00920681     NOVOLIN GE 30/70 PENFILL     NOO     *

09853812     NOVOLIN GE 30/70 PENFILL     NOO

100U/ML Injection

02024217     NOVOLIN GE 30/70 10ML     NOO

INSULIN (40% NEUTRAL & 60% ISOPHANE) HUMAN BIOSYNTHETIC

100U/ML (3ML) Injection

02024314     NOVOLIN GE 40/60 PENFILL     NOO

INSULIN (50% NEUTRAL & 50% ISOPHANE) HUMAN BIOSYNTHETIC

100U/ML (3ML) Injection

02024322     NOVOLIN GE 50/50 PENFILL     NOO

INSULIN (ISOPHANE) HUMAN BIOSYNTHETIC

100U/ML (1.5ML) Injection

01959239     HUMULIN N CARTRIDGE     LIL

99000342     NOVOLIN GE NPH PENFILL     NOO     *

100U/ML (3ML) Injection

00908991     HUMULIN N CARTRIDGE     LIL

09853804     HUMULIN N CARTRIDGE     LIL

99001586     HUMULIN N CARTRIDGE     LIL     *

09853782     NOVOLIN GE NPH PENFILL     NOO

99000334     NOVOLIN GE NPH PENFILL     NOO     *

100U/ML Injection

00587737     HUMULIN N 10ML     LIL

02024225     NOVOLIN GE NPH 10ML     NOO

100U/ML Injection (Pre-filled Pen)

02241310     HUMULIN N     LIL

INSULIN (ZINC CRYSTALLINE) HUMAN BIOSYNTHETIC (RDNA ORIGIN)

100U/ML (1.5ML) Injection

01959220     HUMULIN R CARTRIDGE     LIL

100U/ML (3ML) Injection

09853766     HUMULIN R CARTRIDGE     LIL

99001594     HUMULIN R CARTRIDGE     LIL     *

100U/ML Injection

00586714     HUMULIN R 10ML     LIL

INSULIN ASPART

100U/ML (3ML) Injection

02244353     NOVORAPID     NOO

100U/ML Injection

02245397     NOVORAPID     NOO

INSULIN HUMAN BIOSYNTHETIC

100U/ML (3ML) Injection

00908746     NOVOLIN GE TORONTO PENFILL     NOO     *

00921130     NOVOLIN GE TORONTO PENFILL     NOO     *

09853774     NOVOLIN GE TORONTO PENFILL     NOO

100U/ML Injection

02024233     NOVOLIN GE TORONTO     NOO

INSULIN HUMAN BIOSYNTHETIC 20% & ISOPHANE 80%

100U/ML (1.5ML) Injection

01962655     HUMULIN 20/80 CARTRIDGE     LIL

100U/ML (3ML) Injection

09853847     HUMULIN 20/80 CARTRIDGE     LIL

99001616     HUMULIN 20/80 CARTRIDGE     LIL     *

INSULIN HUMAN BIOSYNTHETIC 30% & ISOPHANE 70%

100U/ML (1.5ML) Injection

01959212     HUMULIN 30/70 CARTRIDGE     LIL

00909009     HUMULIN 30/70 CARTRIDGE     LIL

100U/ML (3ML) Injection

09853855     HUMULIN 30/70 CARTRIDGE     LIL

99001632     HUMULIN 30/70 CARTRIDGE     LIL     *

100U/ML Injection

00795879     HUMULIN 30/70     LIL

INSULIN LISPRO

100IU/ML Injection

02229704     HUMALOG 10ML     LIL

100U/ML (1.5ML) Injection

02229705     HUMALOG CARTRIDGE     LIL

100U/ML (3ML) Injection

02233562     HUMALOG CARTRIDGE     LIL     *

09853715     HUMALOG CARTRIDGE     LIL     *

99002817     HUMALOG CARTRIDGE     LIL     *

100IU/ML Injection (Pre-filled Pen)

02241283     HUMALOG     LIL

INSULIN LISPRO (25%), INSULIN LISPRO PROTAMINE SUSPENSION (75%)

100U/ML (3ML) Injection

02240294     HUMALOG MIX 25     LIL

100U/ML (3ML) Injection (Pre-filled Pen)

02240295     HUMALOG MIX 25     LIL

INSULIN ZINC SUSPENSION MEDIUM HUMAN BIOSYNTHETIC (RDNA ORIGIN)

100U/ML Injection

00646148     HUMULIN L 10ML     LIL

68:20.16 MEGLITINIDES

NATEGLINIDE

60MG Tablet

02245438     STARLIX     NVR

120MG Tablet

02245439     STARLIX     NVR

180MG Tablet

02245440     STARLIX     NVR

REPAGLINIDE

0.5MG Tablet

02239924     GLUCONORM     NOO

1MG Tablet

02239925     GLUCONORM     NOO

2MG Tablet

02239926     GLUCONORM     NOO

68:20.20 ANTIDIABETIC AGENTS - SULFONYLUREAS

CHLORPROPAMIDE

100MG Tablet

00399302     APO-CHLORPROPAMIDE     APX

250MG Tablet

00312711     APO-CHLORPROPAMIDE     APX

00156728     CHLORPROPAMIDE     PRO

00021350     NOVO-PROPAMIDE     NOP

GLICLAZIDE

30MG Tablet

02242987     DIAMICRON MR     SEV

80MG Tablet

02245247     APO-GLICLAZIDE     APX

00765996     DIAMICRON     SEV

02229519     GEN-GLICLAZIDE     GEN

02248453     GLICLAZIDE     PDL

02238103     NOVO-GLICLAZIDE     NOP

02155850     PROVAL-GLICLAZIDE     PRO

02254719     RHOXAL-GLICLAZIDE     RHO

GLYBURIDE

2.5MG Tablet

01913654     APO-GLYBURIDE     APX

02224550     DIABETA     SAC

02234513     DOM-GLYBURIDE     DPC

00720933     EUGLUCON     PMS

00808733     GEN-GLYBE     GEN

01959352     GLYBURIDE     PDL

02084341     MED-GLYBE     MEC

01913670     NOVO-GLYBURIDE     NOP

02020734     NU-GLYBURIDE     NXP

02229595     PENTA-GLYBURIDE     PEN

02236733     PMS-GLYBURIDE     PMS

01900927     RATIO-GLYBURIDE     RPH

02248008     RHOXAL-GLYBURIDE     RHO

02236543     RIVA-GLYBURIDE     RIV

5MG Tablet

01913662     APO-GLYBURIDE     APX

02224569     DIABETA     SAC

02234514     DOM-GLYBURIDE     DPC

00720941     EUGLUCON     PMS

00808741     GEN-GLYBE     GEN

01959360     GLYBURIDE     PDL

02085887     MED-GLYBE     MEC

01913689     NOVO-GLYBURIDE     NOP

02020742     NU-GLYBURIDE     NXP

02229596     PENTA-GLYBURIDE     PEN

02236734     PMS-GLYBURIDE     PMS

01900935     RATIO-GLYBURIDE     RPH

02248009     RHOXAL-GLYBURIDE     RHO

02236548     RIVA-GLYBURIDE     PHH

TOLBUTAMIDE

500MG Tablet

00312762     APO-TOLBUTAMIDE     APX

00156663     TOLBUTAMIDE     PRO

68:20.28 THIAZOLIDINEDIONES

PIOGLITAZONE HCL

Limited use benefit (prior approval required).

For treatment of type 2 diabetic patients who are not adequately controlled by or are intolerant to metformin and sulfonylureas or for whom these products are contraindicated.

15MG Tablet

02242572     ACTOS     LIL

30MG Tablet

02242573     ACTOS     LIL

45MG Tablet

02242574     ACTOS     LIL

ROSIGLITAZONE MALEATE

Limited use benefit (prior approval required).

For treatment of type 2 diabetic patients who are not adequately controlled by or are intolerant to metformin and sulfonylureas or for whom these products are contraindicated.

2MG Tablet

02241112     AVANDIA     GSK

4MG Tablet

02241113     AVANDIA     GSK

8MG Tablet

02241114     AVANDIA     GSK

68:22.12 GLYCOGENOLYTIC AGENTS

GLUCAGON RECOMBINANT DNA ORGIN

1MG/ML Injection

02243297     GLUCAGON     LIL

68:24.00 PARATHYROID

CALCITONIN SALMON (MIACALCIN)

Limited use benefit (prior approval required).

For treatment of patients with postmenopausal osteoporosis who have failed therapy, are intolerant to, or who have contraindications to both bisphosphonates and raloxifene.

200IU/dose Nasal Spray

02247585     APO-CALCITONIN     APX

02240775     MIACALCIN     NVR

CALCITONIN SALMON (SYNTHETIC)

200IU/ML Injection

01926691     CALCIMAR     SAC

200IU/ML Nasal Spray

02261766     SANDOZ-CALCITONIN     SDZ

68:28.00 PITUITARY

DESMOPRESSIN ACETATE

4MCG/ML Injection

00873993     DDAVP     FEI

0.1MG/ML Nasal Solution

00402516     DDAVP     FEI

0.1MG/ML Nasal Spray

02242465     APO-DESMOPRESSIN     APX

00836362     DDAVP     FEI

0.1MG Tablet

00824305     DDAVP     FEI

0.2MG Tablet

00824143     DDAVP     FEI

68:32.00 PROGESTINS

MEDROXYPROGESTERONE ACETATE

50MG/ML Injection

00030848     DEPO-PROVERA     PFI

150MG/ML Injection

00585092     DEPO-PROVERA     PFI

2.5MG Tablet

02244726     APO-MEDROXY     APX

02247581     DOM-MEDROXYPROGESTERONE     DPC

02229838     GEN-MEDROXY     GEN

02221284     NOVO-MEDRONE     NOP

02252740     NU-MEDROXY     NXP

02253550     PDL-MEDROXY     PDL

02231768     PENTA-MEDROXY     PEN

02246627     PMS-MEDROXYPROGESTERONE     PMS

00708917     PROVERA     PFI

02148552     RATIO-MPA     RPH

5MG Tablet

02244727     APO-MEDROXY     APX

02247582     DOM-MEDROXYPROGESTERONE     DPC

02229839     GEN-MEDROXY     GEN

02221292     NOVO-MEDRONE     NOP

02252759     NU-MEDROXY     NXP

02253577     PDL-MEDROXY     PDL

02231769     PENTA-MEDROXY     PEN

02246628     PMS-MEDROXYPROGESTERONE     PMS

00030937     PROVERA     PFI

02010739     PROVERA PAK     PFI

02148560     RATIO-MPA     RPH

10MG Tablet

02247583     DOM-MEDROXYPROGESTERONE     DPC

02229840     GEN-MEDROXY     GEN

02221306     NOVO-MEDRONE     NOP

02231770     PENTA-MEDROXY     PEN

02246629     PMS-MEDROXYPROGESTERONE     PMS

00729973     PROVERA     PFI

02010933     PROVERA     PFI

02148579     RATIO-MPA     RPH

100MG Tablet

02267640     APO-MEDROXY     APX

00030945     PROVERA     PFI

68:36.04 THYROID AGENTS

LEVOTHYROXINE SODIUM

0.025MG Tablet

02264323     EUTHYROX     GEN

02187574     LEVO-T     PMS

02172062     SYNTHROID     ABB

0.05MG Tablet

02213192     ELTROXIN     GSK

02264331     EUTHYROX     GEN

02187582     LEVO-T     PMS

02172070     SYNTHROID     ABB

0.075MG Tablet

02264358     EUTHYROX     GEN

02187590     LEVO-T     PMS

02172089     SYNTHROID     ABB

0.088MG Tablet

02264366     EUTHYROX     GEN

02172097     SYNTHROID     ABB

0.1MG Tablet

02213206     ELTROXIN     GSK

02264374     EUTHYROX     GEN

02187604     LEVO-T     PMS

02172100     SYNTHROID     ABB

0.112MG Tablet

02264390     EUTHYROX     GEN

02171228     SYNTHROID     ABB

0.125MG Tablet

02264404     EUTHYROX     GEN

02187612     LEVO-T     PMS

02172119     SYNTHROID     ABB

0.137MG Tablet

02264412     EUTHYROX     GEN

02233852     SYNTHROID     ABB

0.15MG Tablet

02213214     ELTROXIN     GSK

02264420     EUTHYROX     GEN

02187620     LEVO-T     PMS

02172127     SYNTHROID     ABB

0.175MG Tablet

02264439     EUTHYROX     GEN

02172135     SYNTHROID     ABB

0.2MG Tablet

02213222     ELTROXIN     GSK

02264447     EUTHYROX     GEN

02187639     LEVO-T     PMS

02172143     SYNTHROID     ABB

0.3MG Tablet

02213230     ELTROXIN     GSK

02264455     EUTHYROX     GEN

02187647     LEVO-T     PMS

02172151     SYNTHROID     ABB

THYROID

30MG Tablet

00023949     THYROID     ERF

60MG Tablet

00023957     THYROID     ERF

125MG Tablet

00023965     THYROID     ERF

68:36.08 ANTITHYROID AGENTS

PROPYLTHIOURACIL

50MG Tablet

00010200     PROPYL THYRACIL     PAL

100MG Tablet

00010219     PROPYL THYRACIL     PAL

THIAMAZOLE

5MG Tablet

00015741     TAPAZOLE     PAL