Drug Benefit List

86:00 SMOOTH MUSCLE RELAXANTS

86:12.00 GENITOURINARY SMOOTH MUSCLE RELAXANTS

FLAVOXATE HCL

200MG Tablet

02244842     APO-FLAVOXATE     APX

02245480     PMS-FLAVOXATE     PMS

00728179     URISPAS     PAL

OXYBUTYNIN CHLORIDE

1MG/ML Syrup

02231089     APO-OXYBUTYNIN     APX

02223376     PMS-OXYBUTYNIN     PMS

2.5MG Tablet

02240549     PMS-OXYBUTYNIN     PMS

5MG Tablet

02163543     APO-OXYBUTYNIN     APX

02241285     DOM-OXYBUTYNIN     DPC

02230800     GEN-OXYBUTYNIN     GEN

02230394     NOVO-OXYBUTYNIN     NOP

02158590     NU-OXYBUTYN     NXP

02220059     OXYBUTYNIN     VAE

02220636     OXYBUTYNINE     PDL

02239073     PENTA-OXYBUTYNIN     PEN

02240550     PMS-OXYBUTYNIN     PMS

TOLTERODINE

Limited use benefit (prior approval required).

For the symptomatic relief of patients with an overactive bladder with symptoms of urinary frequency, urgency or urge incontinence or any combination of these in patients who have failed on or are intolerant of therapy with oxybutynin.

2MG Extended Release Capsule

02244612     DETROL LA     PFI

4MG Extended Release Capsule

02244613     DETROL LA     PFI

1MG Tablet

02239064     DETROL     PFI

2MG Tablet

02239065     DETROL     PFI

86:16.00 RESPIRATORY SMOOTH MUSCLE RELAXANTS

AMINOPHYLLINE

225MG Sustained Release Tablet

02014270     PHYLLOCONTIN     PFR

350MG Sustained Release Tablet

02014289     PHYLLOCONTIN     PFR

OXTRIPHYLLINE

20MG/ML Elixir

00476366     CHOLEDYL     PFI

00792942     PMS-OXTRIPHYLLINE     PMS

100MG Tablet

00441724     APO-OXTRIPHYLLINE     APX

200MG Tablet

00441732     APO-OXTRIPHYLLINE     APX

300MG Tablet

00511692     APO-OXTRIPHYLLINE     APX

THEOPHYLLINE

5.33MG/ML Elixir

00575151     PMS-THEOPHYLLINE     PMS

00466409     PULMOPHYLLIN     RIV

00627410     THEOPHYLLINE     ATL

5.33MG/ML Solution

01966219     THEOLAIR     MMH

100MG Sustained Release Tablet

00692689     APO-THEO     APX

02230085     NOVO-THEOPHYL SR     NOP

200MG Sustained Release Tablet

00692697     APO-THEO LA     APX

02230086     NOVO-THEOPHYL SR     NOP

300MG Sustained Release Tablet

00692700     APO-THEO LA     APX

02230087     NOVO-THEOPHYL SR     NOP

400MG Sustained Release Tablet

02014165     UNIPHYL     PFR

600MG Sustained Release Tablet

02014181     UNIPHYL     PFR