Appendix H - New Listings

The following items have been added to the NIHB Drug Benefit List since it was last published. Some of these items may have specific criteria for use. Please consult Appendix A for criteria.

24:00 CARDIOVASCULAR DRUGS

24:32.08 ANGIOTENSIN II RECEPTOR ANTAGONISTS

OLMESARTAN MEDOXOMIL, HYDROCHLOROTHIAZIDE

Table: OLMESARTAN MEDOXOMIL, HYDROCHLOROTHIAZIDE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
ST40MG & 12.5MG Tablet 02468956 ACH-OLMESARTAN HCTZ ACC 2019-07-30
ST20MG & 12.5MG Tablet 02468948 ACH-OLMESARTAN HCTZ ACC 2019-08-01

28:00 CENTRAL NERVOUS SYSTEM AGENTS

28:08.04 NONSTEROIDAL ANTI-INFLAMMATORY AGENTS

IBUPROFEN

Table: IBUPROFEN
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
600MG Tablet (Extended Release) 02443562 ADVIL 12 HOUR PFI 2019-06-25
ST400MG Tablet 02244577 ADVIL EXTRA STRENGTH PFI 2019-09-01

28:16.04 ANTIDEPRESSANTS

AMITRIPTYLINE HYDROCHLORIDE

Table: AMITRIPTYLINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
50MG Tablet 02477998 AG-AMITRIPTYLINE ANG 2019-07-26
10MG Tablet 02477963 AG-AMITRIPTYLINE ANG 2019-07-26
25MG Tablet 02477971 AG-AMITRIPTYLINE ANG 2019-07-26

08:00 ANTI-INFECTIVE AGENTS

08:12.16 PENICILLINS

AMOXICILLIN

Table: AMOXICILLIN
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
500MG Capsule 02477726 AG-AMOXICILLIN ANG 2019-07-26

24:00 CARDIOVASCULAR DRUGS

24:24.00 BETA ADRENERGIC BLOCKING AGENTS

ATENOLOL

Table: ATENOLOL
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
100MG Tablet 02369192 AG-ATENOLOL ANG 2019-07-12
50MG Tablet 02369184 AG-ATENOLOL ANG 2019-07-12
25MG Tablet 02369176 AG-ATENOLOL ANG 2019-07-12

24:06.08 HMG-COA REDUCTASE INHIBITORS

ATORVASTATIN CALCIUM

Table: ATORVASTATIN CALCIUM
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
10MG Tablet 02478145 AG-ATORVASTATIN ANG 2019-07-26
20MG Tablet 02478153 AG-ATORVASTATIN ANG 2019-07-26
40MG Tablet 02478161 AG-ATORVASTATIN ANG 2019-07-26
80MG Tablet 02478188 AG-ATORVASTATIN ANG 2019-07-26

08:00 ANTI-INFECTIVE AGENTS

08:12.12 MACROLIDES

AZITHROMYCIN

Table: AZITHROMYCIN
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
250MG Tablet 02480700 AG-AZITHROMYCIN ANG 2019-07-26

28:00 CENTRAL NERVOUS SYSTEM AGENTS

28:16.04 ANTIDEPRESSANTS

ESCITALOPRAM OXALATE

Table: ESCITALOPRAM OXALATE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
10MG Tablet 02477742 AG-ESCITALOPRAM ANG 2019-07-26
20MG Tablet 02477769 AG-ESCITALOPRAM ANG 2019-07-26

28:12.92 MISCELLANEOUS ANTICONVULSANTS

GABAPENTIN

Table: GABAPENTIN
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
400MG Capsule 02477939 AG-GABAPENTIN ANG 2019-06-18
300MG Capsule 02477920 AG-GABAPENTIN ANG 2019-06-18
100MG Capsule 02477912 AG-GABAPENTIN ANG 2019-06-18

08:00 ANTI-INFECTIVE AGENTS

08:12.18 QUINOLONES

MOXIFLOXACIN HYDROCHLORIDE

Table: MOXIFLOXACIN HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
400MG Tablet 02478137 AG-MOXIFLOXACIN ANG 2019-07-12

24:00 CARDIOVASCULAR DRUGS

24:32.08 ANGIOTENSIN II RECEPTOR ANTAGONISTS

OLMESARTAN MEDOXOMIL

Table: OLMESARTAN MEDOXOMIL
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
20MG Tablet 02475731 AG-OLMESARTAN ANG 2019-06-18
40MG Tablet 02475758 AG-OLMESARTAN ANG 2019-06-18

56:00 GASTROINTESTINAL DRUGS

56:28.36 PROTON-PUMP INHIBITORS

PANTOPRAZOLE SODIUM

Table: PANTOPRAZOLE SODIUM
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
40MG Tablet (Delayed Release) 02478781 AG-PANTOPRAZOLE ANG 2019-07-12
40MG Tablet (Delayed Release) 02481588 AG-PANTOPRAZOLE SODIUM ANG 2019-06-18

28:00 CENTRAL NERVOUS SYSTEM AGENTS

28:12.92 MISCELLANEOUS ANTICONVULSANTS

PREGABALIN

Table: PREGABALIN
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
50MG Capsule 02480735 AG-PREGABALIN ANG 2019-06-18
25MG Capsule 02480727 AG-PREGABALIN ANG 2019-06-18
75MG Capsule 02480743 AG-PREGABALIN ANG 2019-06-18
150MG Capsule 02480751 AG-PREGABALIN ANG 2019-06-18

28:16.08 ANTIPSYCHOTIC AGENTS

QUETIAPINE FUMARATE

Table: QUETIAPINE FUMARATE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
25MG Tablet (Immediate Release) 02475979 AG-QUETIAPINE ANG 2019-06-18

24:00 CARDIOVASCULAR DRUGS

24:32.04 ANGIOTENSIN-CONVERTING ENZYME INHIBITORS

RAMIPRIL

Table: RAMIPRIL
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
2.5MG Capsule 02477572 AG-RAMIPRIL ANG 2019-06-18
10MG Capsule 02477599 AG-RAMIPRIL ANG 2019-06-18
5MG Capsule 02477580 AG-RAMIPRIL ANG 2019-06-18

28:00 CENTRAL NERVOUS SYSTEM AGENTS

28:16.08 ANTIPSYCHOTIC AGENTS

RISPERIDONE

Table: RISPERIDONE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
2MG Tablet 02369117 AG-RISPERIDONE ANG 2019-06-18
0.25MG Tablet 02369079 AG-RISPERIDONE ANG 2019-06-18
3MG Tablet 02369125 AG-RISPERIDONE ANG 2019-06-18
0.5MG Tablet 02369087 AG-RISPERIDONE ANG 2019-06-18
4MG Tablet 02369133 AG-RISPERIDONE ANG 2019-06-18
1MG Tablet 02369095 AG-RISPERIDONE ANG 2019-06-18

24:00 CARDIOVASCULAR DRUGS

24:06.08 HMG-COA REDUCTASE INHIBITORS

ROSUVASTATIN CALCIUM

Table: ROSUVASTATIN CALCIUM
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
10MG Tablet 02477041 AG-ROSUVASTATIN ANG 2019-07-26
20MG Tablet 02477068 AG-ROSUVASTATIN ANG 2019-07-26
40MG Tablet 02477076 AG-ROSUVASTATIN ANG 2019-07-26
5MG Tablet 02477033 AG-ROSUVASTATIN ANG 2019-07-26

28:00 CENTRAL NERVOUS SYSTEM AGENTS

28:16.04 ANTIDEPRESSANTS

SERTRALINE HYDROCHLORIDE

Table: SERTRALINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
25MG Capsule 02477882 AG-SERTRALINE ANG 2019-06-18
50MG Capsule 02477890 AG-SERTRALINE ANG 2019-06-18
100MG Capsule 02477904 AG-SERTRALINE ANG 2019-06-18

24:00 CARDIOVASCULAR DRUGS

24:06.08 HMG-COA REDUCTASE INHIBITORS

SIMVASTATIN

Table: SIMVASTATIN
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
10MG Tablet 02480069 AG-SIMVASTATIN ANG 2019-06-18
5MG Tablet 02480050 AG-SIMVASTATIN ANG 2019-06-18
20MG Tablet 02480077 AG-SIMVASTATIN ANG 2019-06-18
40MG Tablet 02480085 AG-SIMVASTATIN ANG 2019-06-18
80MG Tablet 02480093 AG-SIMVASTATIN ANG 2019-06-18

28:00 CENTRAL NERVOUS SYSTEM AGENTS

28:12.92 MISCELLANEOUS ANTICONVULSANTS

TOPIRAMATE

Table: TOPIRAMATE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
25MG Tablet 02475936 AG-TOPIRAMATE ANG 2019-07-12
100MG Tablet 02475944 AG-TOPIRAMATE ANG 2019-07-12

56:00 GASTROINTESTINAL DRUGS

56:22.00 ANTIEMETICS

NETUPITANT, PALONOSETRON (PALONOSETRON HYDROCHLORIDE)

Table: NETUPITANT, PALONOSETRON (PALONOSETRON HYDROCHLORIDE)
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
ST300MG & 0.5MG Capsule 02468735 AKYNZEO PFR 2019-07-09

28:00 CENTRAL NERVOUS SYSTEM AGENTS

28:20.04 AMPHETAMINES

AMPHETAMINE, DEXTROAMPHETAMINE

Table: AMPHETAMINE, DEXTROAMPHETAMINE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
ST30MG Capsule (Extended Release) 02445549 APO-AMPHETAMINE XR APX 2019-06-18
ST15MG Capsule (Extended Release) 02445514 APO-AMPHETAMINE XR APX 2019-06-18
ST10MG Capsule (Extended Release) 02445506 APO-AMPHETAMINE XR APX 2019-06-18
ST20MG Capsule (Extended Release) 02445522 APO-AMPHETAMINE XR APX 2019-06-18
ST25MG Capsule (Extended Release) 02445530 APO-AMPHETAMINE XR APX 2019-06-18
ST5MG Capsule (Extended Release) 02445492 APO-AMPHETAMINE XR APX 2019-06-18

20:00 BLOOD FORMATION COAGULATION AND THROMBOSIS

20:12.04 ANTICOAGULANTS

DABIGATRAN ETEXILATE MESILATE

Table: DABIGATRAN ETEXILATE MESILATE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
110MG Capsule 02468905 APO-DABIGATRAN APX 2019-08-21
150MG Capsule 02468913 APO-DABIGATRAN APX 2019-08-21

28:00 CENTRAL NERVOUS SYSTEM AGENTS

28:92.00 MISCELLANEOUS CENTRAL NERVOUS SYSTEM AGENTS

ATOMOXETINE HYDROCHLORIDE

Table: ATOMOXETINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
80MG Capsule 02471531 AURO-ATOMOXETINE AUR 2019-07-26
10MG Capsule 02471485 AURO-ATOMOXETINE AUR 2019-07-26
60MG Capsule 02471523 AURO-ATOMOXETINE AUR 2019-07-26
40MG Capsule 02471515 AURO-ATOMOXETINE AUR 2019-07-26
25MG Capsule 02471507 AURO-ATOMOXETINE AUR 2019-07-26
18MG Capsule 02471493 AURO-ATOMOXETINE AUR 2019-07-26

08:00 ANTI-INFECTIVE AGENTS

08:18.08 ANTIRETROVIRALS

EMTRICITABINE, BICTEGRAVIR (BICTEGRAVIR SODIUM), TENOFOVIR ALAFENAMIDE

Table: EMTRICITABINE, BICTEGRAVIR (BICTEGRAVIR SODIUM), TENOFOVIR ALAFENAMIDE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
200MG & 50MG & 25MG Tablet 02478579 BIKTARVY GIL 2019-06-26

84:00 SKIN AND MUCOUS MEMBRANE AGENTS (SMMA)

84:92.00 MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS

ADAPALENE

Table: ADAPALENE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
0.3% Gel 02274000 DIFFERIN XP GAC 2019-07-08

28:00 CENTRAL NERVOUS SYSTEM AGENTS

28:36.16 ANTIPARKINSONIAN AGENTS - DOPAMINE PRECURSORS

LEVODOPA, CARBIDOPA (CARBIDOPA MONOHYDRATE)

Table: LEVODOPA, CARBIDOPA (CARBIDOPA MONOHYDRATE)
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
20MG & 5MG Gel 02292165 DUODOPA ABV 2019-07-02

52:00 EYE, EAR, NOSE AND THROAT (EENT) PREPARATIONS

52:40.28 EENT - PROSTAGLANDIN AGENTS

TRAVOPROST-TIMOLOL

Table: TRAVOPROST-TIMOLOL
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
0.0040.5/% Ophthalmic Solution 09857513 DUOTRAV PQ OP ALC 2019-07-01

96:00 PHARMACEUTICAL AIDS

96:00.00 PHARMACEUTICAL AIDS

BASES-EMULSIONS

Table: BASES-EMULSIONS
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
ST Cream 99000385 EMOLLIENT FOR CHILDREN WPC 2019-06-24

56:00 GASTROINTESTINAL DRUGS

56:12.00 CATHARTICS AND LAXATIVES

SODIUM PHOSPHATE

Table: SODIUM PHOSPHATE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
ST7G Solution 02231170 ENEMA HJS 2019-07-25

96:00 PHARMACEUTICAL AIDS

96:00.00 PHARMACEUTICAL AIDS

INFANT FORMULATION

Table: INFANT FORMULATION
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
Powder 95900155 ENFAMIL LOW IRON FORMULA 900GM MJO 2019-08-01
Oral Liquid 95900012 ENFAMIL LOWER IRON RTF MJO 2019-08-01

40:00 ELECTROLYTIC, CALORIC, AND WATER BALANCE

40:10.20 

BENRALIZUMAB

Table: BENRALIZUMAB
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
30MG Solution 02473232 FASENRA AZC 2019-07-22

28:00 CENTRAL NERVOUS SYSTEM AGENTS

28:08.04 NONSTEROIDAL ANTI-INFLAMMATORY AGENTS

IBUPROFEN

Table: IBUPROFEN
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
ST200MG Tablet 02439689 IBUPROFEN APX 2019-08-01

52:00 EYE, EAR, NOSE AND THROAT (EENT) PREPARATIONS

52:40.28 EENT - PROSTAGLANDIN AGENTS

TRAVOPROST

Table: TRAVOPROST
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
0.003% Solution 02457997 IZBA NVR 2019-06-27

24:00 CARDIOVASCULAR DRUGS

24:32.08 ANGIOTENSIN II RECEPTOR ANTAGONISTS

CANDESARTAN CILEXETIL, HYDROCHLOROTHIAZIDE

Table: CANDESARTAN CILEXETIL, HYDROCHLOROTHIAZIDE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
ST32MG & 25MG Tablet 02473267 JAMP CANDESARTAN-HCT JMP 2019-08-22

24:06.04 BILE ACID SEQUESTRANTS

CHOLESTYRAMINE RESIN

Table: CHOLESTYRAMINE RESIN
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
4G Powder For Suspension 02478595 JAMP-CHOLESTYRAMINE JMP 2019-07-25

52:00 EYE, EAR, NOSE AND THROAT (EENT) PREPARATIONS

52:02.00 EENT - ANTIALLERGIC AGENTS

KETOTIFEN FUMARATE

Table: KETOTIFEN FUMARATE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
0.25MG Solution 02489651 JAMP-KETOTIFEN JMP 2019-03-28

52:04.04 EENT - ANTIBACTERIALS

MOXIFLOXACIN HYDROCHLORIDE

Table: MOXIFLOXACIN HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
0.5% Solution 02472120 JAMP-MOXIFLOXACIN JMP 2019-07-03

84:00 SKIN AND MUCOUS MEMBRANE AGENTS (SMMA)

84:08.00 SMMA - ANTIPRURITICS AND LOCAL ANESTHETICS

LIDOCAINE

Table: LIDOCAINE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
5% Ointment 02386836 JAMPOCAINE JMP 2019-07-18

92:00 UNCLASSIFIED THERAPEUTIC AGENTS

92:36.00 DISEASE-MODIFYING ANTIRHEUMATIC AGENTS

SARILUMAB

Table: SARILUMAB
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
200MG Solution 02460548 KEVZARA SAC 2019-08-01
150MG Solution 02460521 KEVZARA SAC 2019-08-01
150MG Solution 02472961 KEVZARA SAC 2019-08-01
200MG Solution 02472988 KEVZARA SAC 2019-08-01

10:00 ANTINEOPLASTIC AGENTS

10:00.00 ANTINEOPLASTIC AGENTS

RIBOCICLIB (RIBOCICLIB SUCCINATE)

Table: RIBOCICLIB (RIBOCICLIB SUCCINATE)
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
200MG Tablet 02473569 KISQALI NVR 2019-06-14

84:00 SKIN AND MUCOUS MEMBRANE AGENTS (SMMA)

84:08.00 SMMA - ANTIPRURITICS AND LOCAL ANESTHETICS

LIDOCAINE

Table: LIDOCAINE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
5% Ointment 02083795 LIDODAN ODN 2019-06-18
5% Ointment 01963988 LIDODAN ODN 2019-07-17

56:00 GASTROINTESTINAL DRUGS

56:04.00 ANTACIDS AND ADSORBENTS

MAGNESIUM OXIDE

Table: MAGNESIUM OXIDE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
835MG Tablet 80082435 MAGNESIUM OXIDE JMP 2019-06-17
420MG Tablet 80082915 MAGNESIUM OXIDE JMP 2019-06-17

92:00 UNCLASSIFIED THERAPEUTIC AGENTS

92:16.00 ANTIGOUT AGENTS

FEBUXOSTAT

Table: FEBUXOSTAT
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
ST80MG Tablet 02473607 MAR-FEBUXOSTAT MAR 2019-06-17

24:00 CARDIOVASCULAR DRUGS

24:32.04 ANGIOTENSIN-CONVERTING ENZYME INHIBITORS

PERINDOPRIL ERBUMINE

Table: PERINDOPRIL ERBUMINE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
ST2MG Tablet 02474824 MAR-PERINDOPRIL MAR 2019-06-17
ST4MG Tablet 02474832 MAR-PERINDOPRIL MAR 2019-06-17
ST8MG Tablet 02474840 MAR-PERINDOPRIL MAR 2019-06-17

24:06.08 HMG-COA REDUCTASE INHIBITORS

PRAVASTATIN SODIUM

Table: PRAVASTATIN SODIUM
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
ST40MG Tablet 02432064 MAR-PRAVASTATIN MAR 2019-06-17
ST20MG Tablet 02432056 MAR-PRAVASTATIN MAR 2019-06-17
ST10MG Tablet 02432048 MAR-PRAVASTATIN MAR 2019-06-17

86:00 SMOOTH MUSCLE RELAXANTS

86:12.04 ANTIMUSCARINICS

TROSPIUM CHLORIDE

Table: TROSPIUM CHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
ST20MG Tablet 02488353 MAR-TROSPIUM MAR 2019-08-30

28:00 CENTRAL NERVOUS SYSTEM AGENTS

28:16.04 ANTIDEPRESSANTS

ESCITALOPRAM OXALATE

Table: ESCITALOPRAM OXALATE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
10MG Tablet 02471418 M-ESCITALOPRAM MAN 2019-07-01

28:36.20 ANTIPARKINSONIAN AGENTS - DOPAMINE RECEPTOR AGONISTS

APOMORPHINE HYDROCHLORIDE

Table: APOMORPHINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
10MG Solution 02459132 MOVAPO PAL 2019-07-25

92:00 UNCLASSIFIED THERAPEUTIC AGENTS

92:00.00 UNCLASSIFIED THERAPEUTIC AGENTS

QUINAGOLIDE (QUINAGOLIDE HYDROCHLORIDE)

Table: QUINAGOLIDE (QUINAGOLIDE HYDROCHLORIDE)
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
0.075MG Tablet 02223767 NORPROLAC FEI 2019-07-18

24:00 CARDIOVASCULAR DRUGS

24:06.08 HMG-COA REDUCTASE INHIBITORS

ATORVASTATIN CALCIUM

Table: ATORVASTATIN CALCIUM
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
80MG Tablet 02476541 NRA-ATORVASTATIN UNK 2019-07-25
10MG Tablet 02476517 NRA-ATORVASTATIN UNK 2019-07-25
40MG Tablet 02476533 NRA-ATORVASTATIN UNK 2019-07-25
20MG Tablet 02476525 NRA-ATORVASTATIN UNK 2019-07-25

08:00 ANTI-INFECTIVE AGENTS

08:12.12 MACROLIDES

AZITHROMYCIN

Table: AZITHROMYCIN
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
250MG Tablet 02479680 NRA-AZITHROMYCIN UNK 2019-09-05

28:00 CENTRAL NERVOUS SYSTEM AGENTS

28:08.04 NONSTEROIDAL ANTI-INFLAMMATORY AGENTS

CELECOXIB

Table: CELECOXIB
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
100MG Capsule 02479737 NRA-CELECOXIB UNK 2019-09-05
200MG Capsule 02479745 NRA-CELECOXIB UNK 2019-09-05

28:16.04 ANTIDEPRESSANTS

DULOXETINE HYDROCHLORIDE

Table: DULOXETINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
60MG Capsule (Delayed Release) 02482134 NRA-DULOXETINE UNK 2019-07-25
30MG Capsule (Delayed Release) 02482126 NRA-DULOXETINE UNK 2019-07-25

24:00 CARDIOVASCULAR DRUGS

24:06.08 HMG-COA REDUCTASE INHIBITORS

ROSUVASTATIN CALCIUM

Table: ROSUVASTATIN CALCIUM
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
10MG Tablet 02477491 NRA-ROSUVASTATIN UNK 2019-06-28
5MG Tablet 02477483 NRA-ROSUVASTATIN UNK 2019-06-28
20MG Tablet 02477505 NRA-ROSUVASTATIN UNK 2019-06-28
40MG Tablet 02477513 NRA-ROSUVASTATIN UNK 2019-06-28

40:00 ELECTROLYTIC, CALORIC, AND WATER BALANCE

40:18.18 POTASSIUM - REMOVING AGENTS

SODIUM POLYSTYRENE SULFONATE

Table: SODIUM POLYSTYRENE SULFONATE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
1G Powder For Suspension 02473941 ODAN-SODIUM POLYSTYRENE SULFONATE ODN 2019-05-31
250MG Suspension 02473968 ODAN-SODIUM POLYSTYRENE SULFONATE ODN 2019-07-01

56:00 GASTROINTESTINAL DRUGS

56:22.20 5-HT3 RECEPTOR ANTAGONISTS

ONDANSETRON HYDROCHLORIDE

Table: ONDANSETRON HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
ST8MG Tablet (Orally Disintegrating) 02481731 ONDANSETRON ODT SDZ 2019-08-01
ST4MG Tablet (Orally Disintegrating) 02481723 ONDANSETRON ODT SDZ 2019-07-01

94:00 DEVICES

94:01.00 DEVICES (DIABETIC)

LANCET

Table: LANCET
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
Lancet 97799139 ONETOUCH DELICAPLUS 33G LANCET UNK 2019-08-08

88:00 VITAMINS

88:28.00 MULTIVITAMIN PREPARATIONS

THIAMINE HYDROCHLORIDE

Table: THIAMINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
50MG Tablet 80049777 OPUS VITAMINE B1 OPU 2019-08-01
100MG Tablet 80049780 OPUS VITAMINE B1 OPU 2019-08-01

68:00 HORMONES AND SYNTHETIC SUBSTITUTES

68:20.06 INCRETIN MIMETICS

SEMAGLUTIDE

Table: SEMAGLUTIDE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
1.34MG Solution 02471477 OZEMPIC NOO 2019-09-11
1MG Solution 02471469 OZEMPIC NOO 2019-09-11

24:00 CARDIOVASCULAR DRUGS

24:32.04 ANGIOTENSIN-CONVERTING ENZYME INHIBITORS

PERINDOPRIL ERBUMINE

Table: PERINDOPRIL ERBUMINE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
ST2MG Tablet 02481634 PERINDOPRIL ERBUMINE SAN 2019-06-17
ST4MG Tablet 02481642 PERINDOPRIL ERBUMINE SAN 2019-06-17
ST8MG Tablet 02481650 PERINDOPRIL ERBUMINE SAN 2019-06-17

28:00 CENTRAL NERVOUS SYSTEM AGENTS

28:16.04 ANTIDEPRESSANTS

FLUOXETINE HYDROCHLORIDE

Table: FLUOXETINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
ST60MG Capsule 02464659 PMS-FLUOXETINE PMS 2019-07-16
ST40MG Capsule 02464640 PMS-FLUOXETINE PMS 2019-07-16

28:08.12 OPIATE PARTIAL AGONISTS

BUPRENORPHINE HYDROCHLORIDE

Table: BUPRENORPHINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
80MG Implant 02474921 PROBUPHINE UNK 2019-06-13

28:16.04 ANTIDEPRESSANTS

BUPROPION HYDROCHLORIDE (WELLBUTRIN)

Table: BUPROPION HYDROCHLORIDE (WELLBUTRIN)
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
ST300MG Tablet (Extended Release) 02475812 RAN-BUPROPION XL RBY 2019-08-06
ST150MG Tablet (Extended Release) 02475804 RAN-BUPROPION XL RBY 2019-08-06

28:12.92 MISCELLANEOUS ANTICONVULSANTS

LEVETIRACETAM

Table: LEVETIRACETAM
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
750MG Tablet 02482290 RIVA-LEVETIRACETAM RIV 2019-07-26
500MG Tablet 02482282 RIVA-LEVETIRACETAM RIV 2019-07-26
250MG Tablet 02482274 RIVA-LEVETIRACETAM RIV 2019-07-26

28:08.04 NONSTEROIDAL ANTI-INFLAMMATORY AGENTS

ACETYLSALICYLIC ACID

Table: ACETYLSALICYLIC ACID
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
ST80MG Tablet (Delayed Release) 02485222 RIVASA EC RIV 2019-06-17

08:00 ANTI-INFECTIVE AGENTS

08:12.16 PENICILLINS

AMOXICILLIN, CLAVULANIC ACID

Table: AMOXICILLIN, CLAVULANIC ACID
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
875MG & 125MG Tablet 02482584 SANDOZ AMOXI-CLAV SDZ 2019-07-03

84:00 SKIN AND MUCOUS MEMBRANE AGENTS (SMMA)

84:06.00 SMMA - ANTI-INFLAMMATORY AGENTS

HYDROCORTISONE ACETATE

Table: HYDROCORTISONE ACETATE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
2.5% Cream 02469421 SANDOZ HYDROCORTISONE SDZ 2019-06-28

96:00 PHARMACEUTICAL AIDS

96:00.00 PHARMACEUTICAL AIDS

INFANT FORMULATION

Table: INFANT FORMULATION
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
Powder 95900044 SIMILAC PM 60/40 450G PDR UNK 2019-08-01

28:00 CENTRAL NERVOUS SYSTEM AGENTS

28:08.12 OPIATE PARTIAL AGONISTS

BUPRENORPHINE HYDROCHLORIDE, NALOXONE HYDROCHLORIDE

Table: BUPRENORPHINE HYDROCHLORIDE, NALOXONE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
16MG & 4MG Tablet 02468093 SUBOXONE IND 2019-08-06
12MG & 3MG Tablet 02468085 SUBOXONE IND 2019-08-06

88:00 VITAMINS

88:16.00 VITAMIN D

CALCITRIOL

Table: CALCITRIOL
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
ST0.25MCG Capsule 02485710 TARO-CALCITRIOL TAR 2019-07-25
ST0.5MCG Capsule 02485729 TARO-CALCITRIOL TAR 2019-07-25

12:00 AUTONOMIC DRUGS

12:92.00 MISCELLANEOUS AUTONOMIC DRUGS

VARENICLINE TARTRATE

Table: VARENICLINE TARTRATE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
0.5MG Tablet 02426226 TEVA-VARENICLINE TEV 2019-07-22
1MG Tablet 02426781 TEVA-VARENICLINE TEV 2019-07-26
1MG Tablet 02426234 TEVA-VARENICLINE TEV 2019-07-26

94:00 DEVICES

94:01.00 DEVICES (DIABETIC)

PEN NEEDLE

Table: PEN NEEDLE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
ST315GXMM Needle 97799149 ULTICARE 31GX5MM PEN NEEDLE UNK 2019-07-12
ST318GXMM Needle 97799148 ULTICARE 31GX8MM PEN NEEDLE UNK 2019-07-12
ST324GXMM Needle 97799147 ULTICARE 32GX4MM PEN NEEDLE UNK 2019-07-12
ST326GXMM Needle 97799150 ULTICARE 32GX6MM PEN NEEDLE UMI 2019-07-12

92:00 UNCLASSIFIED THERAPEUTIC AGENTS

92:36.00 DISEASE-MODIFYING ANTIRHEUMATIC AGENTS

TOFACITINIB CITRATE

Table: TOFACITINIB CITRATE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
11MG Tablet (Extended Release) 02470608 XELJANZ XR PFI 2019-08-15

84:00 SKIN AND MUCOUS MEMBRANE AGENTS (SMMA)

84:08.00 SMMA - ANTIPRURITICS AND LOCAL ANESTHETICS

LIDOCAINE

Table: LIDOCAINE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
5% Ointment 00001961 XYLOCAINE UNK 2019-07-17

LIDOCAINE HCL

Table: LIDOCAINE HCL
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
5% Ointment 00811475 XYLOCAINE UNK 2019-07-23
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