68:00 HORMONES AND SYNTHETIC SUBSTITUTES

68:04.00 ADRENALS

BECLOMETHASONE DIPROPIONATE

Table: BECLOMETHASONE DIPROPIONATE
Drug strength and dosage form DIN Brand name Manufacturer code
50MCG Aerosol 02242029 QVAR VAE
100MCG Aerosol 02242030 QVAR VAE

BUDESONIDE

Table: BUDESONIDE
Drug strength and dosage form DIN Brand name Manufacturer code
3MG Capsule (Sustained Release) 02229293 ENTOCORT TIL
100MCG Powder 00852074 PULMICORT TURBUHALER AZC
200MCG Powder 00851752 PULMICORT TURBUHALER AZC
400MCG Powder 00851760 PULMICORT TURBUHALER AZC
0.125MG Suspension 02465949 TEVA-BUDESONIDE TEV
0.125MG/ML Suspension 02229099 PULMICORT NEBUAMP AZC
0.25MG/ML Suspension 01978918 PULMICORT NEBUAMP AZC
0.5MG Suspension 02465957 TEVA-BUDESONIDE TEV
0.5MG/ML Suspension 01978926 PULMICORT NEBUAMP AZC

CICLESONIDE

Table: CICLESONIDE
Drug strength and dosage form DIN Brand name Manufacturer code
100MG/INHALATION Aerosol 02285606 ALVESCO AZC
200MG/INHALATION Aerosol 02285614 ALVESCO AZC

CORTISONE ACETATE

Table: CORTISONE ACETATE
Drug strength and dosage form DIN Brand name Manufacturer code
25MG Tablet 00280437 CORTISONE VAE

DEXAMETHASONE

Table: DEXAMETHASONE
Drug strength and dosage form DIN Brand name Manufacturer code
0.1MG/ML Liquid 01946897 PMS DEXAMETHASONE PMS
0.5MG Tablet 02261081 APO-DEXAMETHASONE APX
0.5MG Tablet 01964976 PMS DEXAMETHASONE PMS
0.75MG Tablet 01964968 PMS DEXAMETHASONE PMS
2MG Tablet 02279363 PMS-DEXAMETHASONE PMS
4MG Tablet 02250055 APO-DEXAMETHASONE APX
4MG Tablet 01964070 PMS DEXAMETHASONE PMS
4MG Tablet 02311267 PRO-DEXAMETHASONE PDL
pDIN For Extemporaneous Mixture 99503007 DEXAMETHASONE ORAL LIQUID UNK

DEXAMETHASONE PHOSPHATE

Table: DEXAMETHASONE PHOSPHATE
Drug strength and dosage form DIN Brand name Manufacturer code
4MG/ML Liquid 00664227 DEXAMETHASONE SDZ
4MG/ML Liquid 01977547 DEXAMETHASONE RAX
4MG/ML Liquid 02204266 DEXAMETHASONE-OMEGA OMG
10MG/ML Liquid 00874582 DEXAMETHASONE SDZ
10MG/ML Liquid 02204274 DEXAMETHASONE-OMEGA OMG
10MG/ML Liquid 00783900 PMS-DEXAMETHASONE PMS

FLUDROCORTISONE ACETATE

Table: FLUDROCORTISONE ACETATE
Drug strength and dosage form DIN Brand name Manufacturer code
0.1MG Tablet 02086026 FLORINEF PAL

FLUTICASONE PROPIONATE

Table: FLUTICASONE PROPIONATE
Drug strength and dosage form DIN Brand name Manufacturer code
50MCG/INHALATION Aerosol 02244291 FLOVENT HFA GSK
125MCG/INHALATION Aerosol 02244292 FLOVENT HFA GSK
250MCG/INHALATION Aerosol 02244293 FLOVENT HFA GSK
100MCG/DOSE Powder 02237245 FLOVENT DISKUS GSK
250MCG/DOSE Powder 02237246 FLOVENT DISKUS GSK
500MCG/DOSE Powder 02237247 FLOVENT DISKUS GSK

HYDROCORTISONE (HYDROCORTISONE SODIUM SUCCINATE)

Table: HYDROCORTISONE (HYDROCORTISONE SODIUM SUCCINATE)
Drug strength and dosage form DIN Brand name Manufacturer code
100MG Powder For Solution 00030600 SOLU-CORTEF ACT-O-VIAL PFI
250MG Powder For Solution 00030619 SOLU-CORTEF ACT-O-VIAL PFI
1G Powder For Solution 00030635 SOLU-CORTEF ACT-O-VIAL PFI

HYDROCORTISONE ACETATE

Table: HYDROCORTISONE ACETATE
Drug strength and dosage form DIN Brand name Manufacturer code
10MG Tablet 00030910 CORTEF PFI
20MG Tablet 00030929 CORTEF PFI

METHYLPREDNISOLONE

Table: METHYLPREDNISOLONE
Drug strength and dosage form DIN Brand name Manufacturer code
4MG Tablet 00030988 MEDROL PFI
16MG Tablet 00036129 MEDROL PFI

METHYLPREDNISOLONE (METHYLPREDNISOLONE SODIUM SUCCINATE)

Table: METHYLPREDNISOLONE (METHYLPREDNISOLONE SODIUM SUCCINATE)
Drug strength and dosage form DIN Brand name Manufacturer code
40MG Injection 02367947 SOLU-MEDROL PFI
125MG Injection 02367955 SOLU-MEDROL PFI
500MG Injection 00030678 SOLU-MEDROL PFI
1G Injection 00036137 SOLU-MEDROL PFI
1G Injection 02367971 SOLU-MEDROL PFI
500MG Powder For Solution 02231895 METHYLPREDNISOLONE SODIUM SUCCINATE TEV
1G Powder For Solution 02241229 METHYLPREDNISOLONE SODIUM SUCCINATE TEV

METHYLPREDNISOLONE ACETATE

Table: METHYLPREDNISOLONE ACETATE
Drug strength and dosage form DIN Brand name Manufacturer code
20MG/ML Suspension 01934325 DEPO-MEDROL PFI
40MG/ML Suspension 00030759 DEPO-MEDROL PFI
40MG/ML Suspension 01934333 DEPO-MEDROL PFI
40MG/ML Suspension 02245400 METHYLPREDNISOLONE SDZ
40MG/ML Suspension 02245407 METHYLPREDNISOLONE SDZ
80MG/ML Suspension 00030767 DEPO-MEDROL PFI
80MG/ML Suspension 01934341 DEPO-MEDROL PFI
80MG/ML Suspension 02245406 METHYLPREDNISOLONE SDZ
80MG/ML Suspension 02245408 METHYLPREDNISOLONE SDZ

METHYLPREDNISOLONE ACETATE, LIDOCAINE HYDROCHLORIDE

Table: METHYLPREDNISOLONE ACETATE, LIDOCAINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
40MG & 10MG Suspension 00260428 DEPO-MEDROL WITH LIDOCAINE PFI

MOMETASONE FUROATE

Table: MOMETASONE FUROATE
Drug strength and dosage form DIN Brand name Manufacturer code
200MCG Powder 02243595 ASMANEX TWISTHALER FRS
400MCG Powder 02243596 ASMANEX TWISTHALER FRS

PREDNISOLONE SODIUM PHOSPHATE

Table: PREDNISOLONE SODIUM PHOSPHATE
Drug strength and dosage form DIN Brand name Manufacturer code
1MG/ML Solution 02230619 PEDIAPRED SAC
1MG/ML Solution 02245532 PMS-PREDNISOLONE PMS

PREDNISONE

Table: PREDNISONE
Drug strength and dosage form DIN Brand name Manufacturer code
1MG Tablet 00598194 APO PREDNISONE APX
1MG Tablet 00271373 WINPRED AAP
5MG Tablet 00312770 APO PREDNISONE APX
5MG Tablet 00156876 PREDNISONE PDL
5MG Tablet 00021695 TEVA-PREDNISONE TEV
50MG Tablet 00550957 APO PREDNISONE APX
50MG Tablet 00232378 TEVA-PREDNISONE TEV
pDIN For Extemporaneous Mixture 99503008 PREDNISONE ORAL LIQUID UNK

TRIAMCINOLONE ACETONIDE

Table: TRIAMCINOLONE ACETONIDE
Drug strength and dosage form DIN Brand name Manufacturer code
40MG/ML Injection 00990876 KENALOG-40 BMS
10MG/ML Suspension 01999761 KENALOG-10 BMS
10MG/ML Suspension 02229540 TRIAMCINOLONE SDZ
40MG/ML Suspension 01999869 KENALOG-40 BMS
40MG/ML Suspension 01977563 TRIAMCINOLONE RAX
40MG/ML Suspension 02229550 TRIAMCINOLONE SDZ
40MG/ML Suspension 09857128 TRIAMCINOLONE UNK

TRIAMCINOLONE DIACETATE

Table: TRIAMCINOLONE DIACETATE
Drug strength and dosage form DIN Brand name Manufacturer code
40MG/ML Suspension 01977555 TRIAMCINOLONE RAX

68:08.00 ANDROGENS

DANAZOL

Table: DANAZOL
Drug strength and dosage form DIN Brand name Manufacturer code
50MG Capsule 02018144 CYCLOMEN SAC
100MG Capsule 02018152 CYCLOMEN SAC
200MG Capsule 02018160 CYCLOMEN SAC

TESTOSTERONE (TOPICAL)

Limited use benefit (prior approval required).

The NIHB Program covers topical testosterone for the treatment of the following in adult males above 18 years old.

  • Orchiectomy, undescended testes, Klinefelter's; OR
  • Pituitary tumour or post-pituitary surgery with low testosterone; OR
  • AIDS-wasting syndrome with low testosterone; OR
  • Gender affirming hormone therapy.

Note: Older males with non-specific symptoms such as, but not limited to, fatigue, malaise, or depression who have a low random testosterone level do not meet coverage criteria.

Table: TESTOSTERONE (TOPICAL)
Drug strength and dosage form DIN Brand name Manufacturer code
1% Gel 02245345 ANDROGEL BGP
1% Gel 02245346 ANDROGEL BGP
1% Gel 02463792 TARO-TESTOSTERONE TAR
1% Gel 02463806 TARO-TESTOSTERONE TAR
1% Gel 02280248 TESTIM PAL
12.5MG Gel 02249499 ANDROGEL BGP
2.5MG Patch 02239653 ANDRODERM ALL
5MG Patch 02245972 ANDRODERM ALL

TESTOSTERONE CYPIONATE

Table: TESTOSTERONE CYPIONATE
Drug strength and dosage form DIN Brand name Manufacturer code
100MG/ML Solution 00030783 DEPO-TESTOSTERONE PFI
100MG/ML Solution 02246063 TESTOSTERONE CYPIONATE SDZ

TESTOSTERONE ENANTHATE

Table: TESTOSTERONE ENANTHATE
Drug strength and dosage form DIN Brand name Manufacturer code
200MG/ML Solution 00029246 DELATESTRYL VAE

TESTOSTERONE UNDECANOATE

Table: TESTOSTERONE UNDECANOATE
Drug strength and dosage form DIN Brand name Manufacturer code
40MG Capsule 02322498 PMS-TESTOSTERONE PMS
40MG Capsule 02421186 TARO-TESTOSTERONE TAR

68:12.00 CONTRACEPTIVES

DESOGESTREL, ETHINYL ESTRADIOL

Table: DESOGESTREL, ETHINYL ESTRADIOL
Drug strength and dosage form DIN Brand name Manufacturer code
ST25MCG & 150MCG, 125MCG, 100MCG Tablet 02272903 LINESSA 21 ASP
ST25MCG & 150MCG, 125MCG, 100MCG Tablet 02257238 LINESSA 28 ASP

ETHINYL ESTRADIOL, DESOGESTREL

Table: ETHINYL ESTRADIOL, DESOGESTREL
Drug strength and dosage form DIN Brand name Manufacturer code
ST30MCG & 150MCG Tablet 02317192 APRI 21 TEV
ST30MCG & 150MCG Tablet 02317206 APRI 28 TEV
ST30MCG & 150MCG Tablet 02396491 FREYA 21 MYL
ST30MCG & 150MCG Tablet 02396610 FREYA 28 MYL
ST30MCG & 150MCG Tablet 02042487 MARVELON 21 FRS
ST30MCG & 150MCG Tablet 02042479 MARVELON 28 FRS
ST30MCG & 150MCG Tablet 02410249 MIRVALA 21 APX
ST30MCG & 150MCG Tablet 02410257 MIRVALA 28 APX

ETHINYL ESTRADIOL, DROSPIRENONE

Table: ETHINYL ESTRADIOL, DROSPIRENONE
Drug strength and dosage form DIN Brand name Manufacturer code
ST0.02MG & 3MG Tablet 02415380 MYA APX
ST0.02MG & 3MG Tablet 02321157 YAZ BAY
ST0.03MG & 3MG Tablet 02261723 YASMIN 21 BAY
ST0.03MG & 3MG Tablet 02261731 YASMIN 28 BAY
ST0.03MG & 3MG Tablet 02410788 ZAMINE 21 APX
ST0.03MG & 3MG Tablet 02410796 ZAMINE 28 APX

ETHINYL ESTRADIOL, ETHYNODIOL DIACETATE

Table: ETHINYL ESTRADIOL, ETHYNODIOL DIACETATE
Drug strength and dosage form DIN Brand name Manufacturer code
ST30MCG & 2MG Tablet 00469327 DEMULEN 30 (21 DAY PACK) PFI
ST30MCG & 2MG Tablet 00471526 DEMULEN 30 (28 DAY PACK) PFI

ETHINYL ESTRADIOL, ETONOGESTREL

Table: ETHINYL ESTRADIOL, ETONOGESTREL
Drug strength and dosage form DIN Brand name Manufacturer code
ST2.6MG & 11.4MG Ring (Slow-Release) 02253186 NUVARING FRS

ETHINYL ESTRADIOL, LEVONORGESTREL

Table: ETHINYL ESTRADIOL, LEVONORGESTREL
Drug strength and dosage form DIN Brand name Manufacturer code
0.03MG & 0.15MG Tablet 02398869 INDAYO MYL
ST0.15MG & 0.03MG Tablet 02296659 SEASONALE TEV
ST20MCG & 100MCG Tablet 02236974 ALESSE 21 PFI
ST20MCG & 100MCG Tablet 02236975 ALESSE 28 PFI
ST20MCG & 100MCG Tablet 02387875 ALYSENA 21 APX
ST20MCG & 100MCG Tablet 02387883 ALYSENA 28 APX
ST20MCG & 100MCG Tablet 02298538 AVIANE 21 TEV
ST20MCG & 100MCG Tablet 02298546 AVIANE 28 TEV
ST30MCG & 0.05MG, 40MCG & 0.075MG, 30MCG & 0.125MG Tablet 00707600 TRIQUILAR 21 BAY
ST30MCG & 0.05MG, 40MCG & 0.075MG, 30MCG & 0.125MG Tablet 00707503 TRIQUILAR 28 BAY
ST30MCG & 150MCG Tablet 02042320 MIN-OVRAL 21 PFI
ST30MCG & 150MCG Tablet 02042339 MIN-OVRAL 28 PFI
ST30MCG & 150MCG Tablet 02387085 OVIMA 21 APX
ST30MCG & 150MCG Tablet 02387093 OVIMA 28 APX
ST30MCG & 150MCG Tablet 02295946 PORTIA 21 TEV
ST30MCG & 150MCG Tablet 02295954 PORTIA 28 TEV

ETHINYL ESTRADIOL, NORELGESTROMIN

Table: ETHINYL ESTRADIOL, NORELGESTROMIN
Drug strength and dosage form DIN Brand name Manufacturer code
ST6MG & 0.6MG Patch (Extended Release) 02248297 EVRA JSO

ETHINYL ESTRADIOL, NORETHINDRONE

Table: ETHINYL ESTRADIOL, NORETHINDRONE
Drug strength and dosage form DIN Brand name Manufacturer code
35MCG & 0.5MG Tablet 02187086 BREVICON 0.5/35 (21-DAY PACK) PFI
ST35MCG & 0.5MG Tablet 02187094 BREVICON 0.5/35 (28-DAY PACK) PFI
ST35MCG & 1MG Tablet 02189054 BREVICON 1/35 (21-DAY PACK) PFI
ST35MCG & 1MG Tablet 02189062 BREVICON 1/35 (28-DAY PACK) PFI
ST35MCG & 1MG Tablet 02197502 SELECT 1/35 (21-DAY) PFI
ST35MCG & 1MG Tablet 02199297 SELECT 1/35 (28-DAY) PFI

ETHINYL ESTRADIOL, NORETHINDRONE ACETATE

Table: ETHINYL ESTRADIOL, NORETHINDRONE ACETATE
Drug strength and dosage form DIN Brand name Manufacturer code
ST10MCG & 1MG Tablet 02417456 LOLO ALL
ST20MCG & 1MG Tablet 00315966 MINESTRIN 1/20 (21-DAY) WAC
ST20MCG & 1MG Tablet 00343838 MINESTRIN 1/20 (28-DAY) WAC
ST30MCG & 1.5MG Tablet 00297143 LOESTRIN WAC
ST30MCG & 1.5MG Tablet 00353027 LOESTRIN WAC

ETHINYL ESTRADIOL, NORGESTIMATE

Table: ETHINYL ESTRADIOL, NORGESTIMATE
Drug strength and dosage form DIN Brand name Manufacturer code
ST35MCG & 0.25MG Tablet 01968440 CYCLEN (21 DAY) JSO
ST35MCG & 0.25MG Tablet 01992872 CYCLEN (28 DAY) JSO

LEVONORGESTREL

Table: LEVONORGESTREL
Drug strength and dosage form DIN Brand name Manufacturer code
19.5MG Insert (Extended-Release) 02459523 KYLEENA BAY
0.75MG Tablet 02371189 OPTION 2 PER
1.5MG Tablet 02433532 BACKUP PLAN ONESTEP APX
1.5MG Tablet 02425009 CONTINGENCY ONE MYL
1.5MG Tablet 02293854 PLAN B UNK

LEVONORGESTREL INTRAUTERINE INSERT

Limited use benefit with quantity and frequency limits (prior approval is not required).

Coverage is granted for 1 device every 2 years.

Table: LEVONORGESTREL INTRAUTERINE INSERT
Drug strength and dosage form DIN Brand name Manufacturer code
13.5MG Insert (Extended-Release) 02408295 JAYDESS BAY
52MG Insert (Extended-Release) 02243005 MIRENA BAY

LEVONORGESTREL, ETHINYL ESTRADIOL

Table: LEVONORGESTREL, ETHINYL ESTRADIOL
Drug strength and dosage form DIN Brand name Manufacturer code
ST0.15MG & 0.03MG & 0.01MG Tablet 02346176 SEASONIQUE TEV

NORETHINDRONE

Table: NORETHINDRONE
Drug strength and dosage form DIN Brand name Manufacturer code
ST0.35MG Tablet 02441306 JENCYCLA LUP
ST0.35MG Tablet 00037605 MICRONOR 28-DAY JSO
ST0.35MG Tablet 02410303 MOVISSE MYL

NORETHINDRONE, ETHINYL ESTRADIOL

Table: NORETHINDRONE, ETHINYL ESTRADIOL
Drug strength and dosage form DIN Brand name Manufacturer code
35MCG & 0.5MG, 35MCG & 1MG Tablet 02187108 SYNPHASIC 21 PFI
ST35MCG & 0.5MG, 35MCG & 1MG Tablet 02187116 SYNPHASIC 28 PFI

NORGESTIMATE, ETHINYL ESTRADIOL

Table: NORGESTIMATE, ETHINYL ESTRADIOL
Drug strength and dosage form DIN Brand name Manufacturer code
ST25MCG & 0.180MG, 25MCG & 0.215MG, 25MCG & 0.25MG Tablet 02401967 TRICIRA LO 21 APX
ST25MCG & 0.180MG, 25MCG & 0.215MG, 25MCG & 0.25MG Tablet 02401975 TRICIRA LO 28 APX
ST25MCG & 0.180MG, 25MCG & 0.215MG, 25MCG & 0.25MG Tablet 02258560 TRI-CYCLEN LO (21 DAY) JSO
ST25MCG & 0.180MG, 25MCG & 0.215MG, 25MCG & 0.25MG Tablet 02258587 TRI-CYCLEN LO (28 DAY) JSO
ST35MCG & 0.180MG, 35MCG & 0.215MG, 35MCG & 0.25MG Tablet 02028700 TRI-CYCLEN 21-DAY JSO
ST35MCG & 0.180MG, 35MCG & 0.215MG, 35MCG & 0.25MG Tablet 02029421 TRI-CYCLEN 28-DAY JSO

ULIPRISTAL ACETATE

Limited use benefit (prior approval not required).

Coverage will be limited to 90 tablets, benefits only for women age 18 to 60 years.

Table: ULIPRISTAL ACETATE
Drug strength and dosage form DIN Brand name Manufacturer code
ST5MG Tablet 02408163 FIBRISTAL ALL

68:16.04 ESTROGENS

CONJUGATED ESTROGENS

Table: CONJUGATED ESTROGENS
Drug strength and dosage form DIN Brand name Manufacturer code
ST0.625MG/G Cream 02043440 PREMARIN PFI
ST0.3MG Tablet (Extended Release) 02414678 PREMARIN PFI
ST0.625MG Tablet (Extended Release) 02414686 PREMARIN PFI
ST1.25MG Tablet (Extended Release) 02414694 PREMARIN PFI

CONJUGATED ESTROGENS, MEDROXYPROGESTERONE ACETATE

Table: CONJUGATED ESTROGENS, MEDROXYPROGESTERONE ACETATE
Drug strength and dosage form DIN Brand name Manufacturer code
ST0.625MG & 2.5MG Tablet 02242878 PREMPLUS PFI
ST0.625MG & 5MG Tablet 02242879 PREMPLUS PFI

ESTRADIOL

Table: ESTRADIOL
Drug strength and dosage form DIN Brand name Manufacturer code
ST0.25MG Gel 02424924 DIVIGEL SEA
ST0.5MG Gel 02424835 DIVIGEL SEA
ST1MG Gel 02424843 DIVIGEL SEA
ST25MCG Patch 02245676 ESTRADOT 25 NVR
ST25MCG Patch 02243722 OESCLIM SEA
ST37.5MCG Patch 02243999 ESTRADOT 37.5 NVR
ST50MCG Patch 02244000 ESTRADOT 50 NVR
ST50MCG Patch 02243724 OESCLIM SEA
ST75MCG Patch 02244001 ESTRADOT 75 NVR
ST100MCG Patch 02244002 ESTRADOT 100 NVR
ST2MG Ring (Slow-Release) 02168898 ESTRING PFI
ST0.5MG Tablet 02225190 ESTRACE TRM
ST1MG Tablet 02148587 ESTRACE TRM
ST2MG Tablet 02148595 ESTRACE TRM

ESTRADIOL HEMIHYDRATE

Table: ESTRADIOL HEMIHYDRATE
Drug strength and dosage form DIN Brand name Manufacturer code
ST0.06% Gel 02238704 ESTROGEL FRS
ST25MCG Patch 02247499 CLIMARA 25 BAY
ST50MCG Patch 02231509 CLIMARA 50 BAY
ST50MCG Patch 02246967 SANDOZ ESTRADIOL DERM SDZ
ST75MCG Patch 02247500 CLIMARA 75 BAY
ST75MCG Patch 02246968 SANDOZ ESTRADIOL DERM SDZ
ST100MCG Patch 02246969 SANDOZ ESTRADIOL DERM SDZ
ST0.5MG Tablet 02449048 LUPIN-ESTRADIOL LUP
ST1MG Tablet 02449056 LUPIN-ESTRADIOL LUP
ST2MG Tablet 02449064 LUPIN-ESTRADIOL LUP
ST10MCG Vaginal Tablet 02325462 VAGIFEM 10 NOO

ESTRADIOL, NORETHINDRONE ACETATE

Table: ESTRADIOL, NORETHINDRONE ACETATE
Drug strength and dosage form DIN Brand name Manufacturer code
ST50MCG & 140MCG Patch 02241835 ESTALIS NVR
ST50MCG & 250MCG Patch 02241837 ESTALIS NVR

ESTRONE

Table: ESTRONE
Drug strength and dosage form DIN Brand name Manufacturer code
ST1MG/G Cream 00727369 ESTRAGYN SEA

68:16.12 ESTROGEN AGONISTS-ANTAGONISTS

RALOXIFENE HYDROCHLORIDE

Limited use benefit (prior approval required).

For secondary prevention of osteoporosis in women who experience failure on bisphosphonates.

For secondary prevention of osteoporosis in women who have a personal history or a first degree relative with a history of breast cancer.

Table: RALOXIFENE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
60MG Tablet 02358840 ACT RALOXIFENE ACG
60MG Tablet 02279215 APO-RALOXIFENE APX
60MG Tablet 02239028 EVISTA LIL
60MG Tablet 02358921 PMS-RALOXIFENE PMS

68:18.00 GONADOTROPINS

GOSERELIN ACETATE

Table: GOSERELIN ACETATE
Drug strength and dosage form DIN Brand name Manufacturer code
3.6MG/DEPOT Implant 02049325 ZOLADEX UNK

NAFARELIN ACETATE

Table: NAFARELIN ACETATE
Drug strength and dosage form DIN Brand name Manufacturer code
2MG/ML Aerosol 02188783 SYNAREL PFI

68:18.04

DEGARELIX ACETATE

Table: DEGARELIX ACETATE
Drug strength and dosage form DIN Brand name Manufacturer code
80MG Powder For Solution 02337029 FIRMAGON FEI
120MG Powder For Solution 02337037 FIRMAGON FEI

68:20.02 ALPHA-GLUCOSIDASE INHIBITORS

ACARBOSE

Table: ACARBOSE
Drug strength and dosage form DIN Brand name Manufacturer code
ST50MG Tablet 02190885 GLUCOBAY BAY
ST100MG Tablet 02190893 GLUCOBAY BAY

68:20.04 BIGUANIDES

METFORMIN HYDROCHLORIDE

Table: METFORMIN HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
ST500MG Tablet 02257726 ACT METFORMIN ACG
ST500MG Tablet 02167786 APO-METFORMIN APX
ST500MG Tablet 02438275 AURO-METFORMIN AUR
ST500MG Tablet 02229994 DOM-METFORMIN DPC
ST500MG Tablet 02099233 GLUCOPHAGE SAC
ST500MG Tablet 02229516 GLYCON VAE
ST500MG Tablet 02380196 JAMP-METFORMIN JMP
ST500MG Tablet 02380722 JAMP-METFORMIN BLACKBERRY JMP
ST500MG Tablet 02353377 METFORMIN SAN
ST500MG Tablet 02378841 METFORMIN MAR
ST500MG Tablet 02385341 METFORMIN FC SIV
ST500MG Tablet 02388766 MINT-METFORMIN MIN
ST500MG Tablet 02223562 PMS-METFORMIN PMS
ST500MG Tablet 02314908 PRO-METFORMIN PDL
ST500MG Tablet 02269031 RAN-METFORMIN RBY
ST500MG Tablet 02242974 RATIO-METFORMIN TEV
ST500MG Tablet 02239081 RIVA-METFORMIN RIV
ST500MG Tablet 02246820 SANDOZ METFORMIN FC SDZ
ST500MG Tablet 02379767 SEPTA-METFORMIN SPT
ST850MG Tablet 02257734 ACT METFORMIN ACG
ST850MG Tablet 02229785 APO-METFORMIN APX
ST850MG Tablet 02438283 AURO-METFORMIN AUR
ST850MG Tablet 02242726 DOM-METFORMIN DPC
ST850MG Tablet 02162849 GLUCOPHAGE SAC
ST850MG Tablet 02239214 GLYCON VAE
ST850MG Tablet 02380218 JAMP-METFORMIN JMP
ST850MG Tablet 02380730 JAMP-METFORMIN BLACKBERRY JMP
ST850MG Tablet 02353385 METFORMIN SAN
ST850MG Tablet 02378868 METFORMIN MAR
ST850MG Tablet 02385368 METFORMIN FC SIV
ST850MG Tablet 02388774 MINT-METFORMIN MIN
ST850MG Tablet 02242589 PMS-METFORMIN PMS
ST850MG Tablet 02314894 PRO-METFORMIN PDL
ST850MG Tablet 02269058 RAN-METFORMIN RBY
ST850MG Tablet 02242931 RATIO-METFORMIN TEV
ST850MG Tablet 02242783 RIVA-METFORMIN RIV
ST850MG Tablet 02246821 SANDOZ METFORMIN SDZ
ST850MG Tablet 02379775 SEPTA-METFORMIN SPT

68:20.05 DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS

LINAGLIPTIN

Limited use benefit (prior approval required).

For the treatment of patients with type 2 diabetes mellitus who did not achieve glycemic control or who demonstrated intolerance to an adequate trial of metformin AND a sulfonylurea.

Table: LINAGLIPTIN
Drug strength and dosage form DIN Brand name Manufacturer code
ST5MG Tablet 02370921 TRAJENTA BOE

LINAGLIPTIN, METFORMIN HYDROCHLORIDE

Limited use benefit (prior approval required).

For the treatment of patients with type 2 diabetes mellitus who did not achieve glycemic control or who demonstrated intolerance to an adequate trial of metformin AND a sulfonylurea.

Table: LINAGLIPTIN, METFORMIN HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
ST2.5MG & 1000MG Tablet 02403277 JENTADUETO BOE
ST2.5MG & 500MG Tablet 02403250 JENTADUETO BOE
ST2.5MG & 850MG Tablet 02403269 JENTADUETO BOE

SAXAGLIPTIN HYDROCHLORIDE

Limited use benefit (prior approval required).

For the treatment of patients with type 2 diabetes mellitus who: did not achieve glycemic control or who demonstrated intolerance to an adequate trial of metformin AND a sulfonylurea.

Table: SAXAGLIPTIN HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
ST2.5MG Tablet 02375842 ONGLYZA AZC
ST5MG Tablet 02333554 ONGLYZA AZC

SAXAGLIPTIN HYDROCHLORIDE, METFORMIN HYDROCHLORIDE

Limited use benefit (prior approval required).

For the treatment of patients with type 2 diabetes mellitus who did not achieve glycemic control or who demonstrated intolerance to an adequate trial of metformin AND a sulfonylurea.

Table: SAXAGLIPTIN HYDROCHLORIDE, METFORMIN HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
ST2.5MG & 1000MG Tablet 02389185 KOMBOGLYZE AZC
ST2.5MG & 500MG Tablet 02389169 KOMBOGLYZE AZC
ST2.5MG & 850MG Tablet 02389177 KOMBOGLYZE AZC

SITAGLIPTIN PHOSPHATE MONOHYDRATE

Limited use benefit (prior approval required).

For the treatment of patients with type 2 diabetes mellitus who did not achieve glycemic control or who demonstrated intolerance to an adequate trial of metformin AND a sulfonylurea.

Table: SITAGLIPTIN PHOSPHATE MONOHYDRATE
Drug strength and dosage form DIN Brand name Manufacturer code
ST25MG Tablet 02388839 JANUVIA FRS
ST50MG Tablet 02388847 JANUVIA FRS
ST100MG Tablet 02303922 JANUVIA FRS

SITAGLIPTIN PHOSPHATE MONOHYDRATE, METFORMIN HYDROCHLORIDE

Limited use benefit (prior approval required).

For the treatment of patients with type 2 diabetes mellitus who did not achieve glycemic control or who demonstrated intolerance to an adequate trial of metformin AND a sulfonylurea.

Table: SITAGLIPTIN PHOSPHATE MONOHYDRATE, METFORMIN HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
ST50MG & 1000MG Tablet 02333872 JANUMET FRS
ST50MG & 500MG Tablet 02333856 JANUMET FRS
ST50MG & 850MG Tablet 02333864 JANUMET FRS
ST50MG & 1000MG Tablet (Extended Release) 02416794 JANUMET XR FRS
ST50MG & 500MG Tablet (Extended Release) 02416786 JANUMET XR FRS
ST100MG & 1000MG Tablet (Extended Release) 02416808 JANUMET XR FRS

68:20.08 INSULINS

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

Table: INSULIN (30% NEUTRAL & 70% ISOPHANE) HUMAN BIOSYNTHETIC
Drug strength and dosage form DIN Brand name Manufacturer code
100U/ML Injection 00795879 HUMULIN 30/70 LIL
100U/ML Injection 01959212 HUMULIN 30/70 CARTRIDGE LIL
100U/ML Injection 09853855 HUMULIN 30/70 CARTRIDGE LIL
100U/ML Injection 02024217 NOVOLIN GE 30/70 NOO
100U/ML Injection 02025248 NOVOLIN GE 30/70 PENFILL NOO
100U/ML Injection 09853812 NOVOLIN GE 30/70 PENFILL NOO

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

Table: INSULIN (40% NEUTRAL & 60% ISOPHANE) HUMAN BIOSYNTHETIC
Drug strength and dosage form DIN Brand name Manufacturer code
100U/ML Injection 02024314 NOVOLIN GE 40/60 PENFILL NOO

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

Table: INSULIN (50% NEUTRAL & 50% ISOPHANE) HUMAN BIOSYNTHETIC
Drug strength and dosage form DIN Brand name Manufacturer code
100U/ML Injection 02024322 NOVOLIN GE 50/50 PENFILL NOO

INSULIN (ISOPHANE) HUMAN BIOSYNTHETIC

Table: INSULIN (ISOPHANE) HUMAN BIOSYNTHETIC
Drug strength and dosage form DIN Brand name Manufacturer code
100U/ML Injection 00587737 HUMULIN N LIL
100U/ML Injection 01959239 HUMULIN N (CARTRIDGE) LIL
100U/ML Injection 02403447 HUMULIN N (KWIKPEN) LIL
100U/ML Injection 09853804 HUMULIN N 100U/ML (CARTRIDGE) LIL
100U/ML Injection 02024225 NOVOLIN GE NPH NOO
100U/ML Injection 09853782 NOVOLIN GE NPH 100U/ML PENFILL NOO
100U/ML Injection 02024268 NOVOLIN GE NPH PENFILL NOO

INSULIN (ZINC CRYSTALLINE) HUMAN BIOSYNTHETIC (RDNA ORIGIN)

Table: INSULIN (ZINC CRYSTALLINE) HUMAN BIOSYNTHETIC (RDNA ORIGIN)
Drug strength and dosage form DIN Brand name Manufacturer code
100U/ML Injection 00586714 HUMULIN R LIL
100U/ML Injection 09853766 HUMULIN R 100U/ML (CARTRIDGE) LIL
100U/ML Injection 01959220 HUMULIN R CARTRIDGE LIL

INSULIN ASPART

Table: INSULIN ASPART
Drug strength and dosage form DIN Brand name Manufacturer code
100U/ML Injection 02244353 NOVORAPID NOO
100U/ML Injection 02245397 NOVORAPID NOO
100U/ML Injection 02377209 NOVORAPID NOO

INSULIN BIOSYNTHETIC HUMAN BR

Table: INSULIN BIOSYNTHETIC HUMAN BR
Drug strength and dosage form DIN Brand name Manufacturer code
100U Solution 02415089 HUMULIN R (KWIKPEN) LIL

INSULIN DEGLUDEC

Table: INSULIN DEGLUDEC
Drug strength and dosage form DIN Brand name Manufacturer code
100U Solution 02467879 TRESIBA NOO
200U Solution 02467887 TRESIBA NOO

INSULIN DETEMIR

Table: INSULIN DETEMIR
Drug strength and dosage form DIN Brand name Manufacturer code
100U/ML Injection 02412829 LEVEMIR FLEXTOUCH NOO
100U/ML Injection 02271842 LEVEMIR PENFILL NOO

INSULIN GLARGINE

Table: INSULIN GLARGINE
Drug strength and dosage form DIN Brand name Manufacturer code
100U/ML Injection 02245689 LANTUS SAC
100U/ML Injection 02251930 LANTUS SAC
100U/ML Injection 02294338 LANTUS SOLOSTAR SAC
100U Solution 02444844 BASAGLAR LIL
100U Solution 02444852 BASAGLAR LIL
100U Solution 02461528 BASAGLAR LIL
300U Solution 02441829 TOUJEO SOLOSTAR SAC

INSULIN GLULISINE

Table: INSULIN GLULISINE
Drug strength and dosage form DIN Brand name Manufacturer code
100U/ML Injection 02279479 APIDRA CARTRIDGE SAC
100U/ML Injection 02294346 APIDRA SOLOSTAR SAC
100U/ML Injection 02279460 APIDRA VIAL SAC

INSULIN HUMAN BIOSYNTHETIC

Table: INSULIN HUMAN BIOSYNTHETIC
Drug strength and dosage form DIN Brand name Manufacturer code
100U/ML Injection 02024233 NOVOLIN GE TORONTO NOO
100U/ML Injection 02024284 NOVOLIN GE TORONTO PENFILL NOO
100U/ML Injection 09853774 NOVOLIN GE TORONTO PENFILL NOO

INSULIN LISPRO

Table: INSULIN LISPRO
Drug strength and dosage form DIN Brand name Manufacturer code
100U/ML Injection 02229704 HUMALOG LIL
100U/ML Injection 02229705 HUMALOG (CARTRIDGE) LIL
100U/ML Injection 02403412 HUMALOG (KWIKPEN) LIL
100U/ML Injection 09853715 HUMALOG 100U/ML CARTRIDGE LIL
200U/ML Injection 02439611 HUMALOG 200U/ML KWIKPEN LIL

INSULIN LISPRO, INSULIN LISPRO PROTAMINE

Table: INSULIN LISPRO, INSULIN LISPRO PROTAMINE
Drug strength and dosage form DIN Brand name Manufacturer code
100U/ML Injection 02240294 HUMALOG MIX 25 (CARTRIDGE) LIL
100U/ML Injection 02403420 HUMALOG MIX 25 (KWIKPEN) LIL
100U/ML Injection 02240297 HUMALOG MIX 50 (CARTRIDGE) LIL
100U/ML Injection 02403439 HUMALOG MIX 50 (KWIKPEN) LIL

68:20.16 MEGLITINIDES

REPAGLINIDE

Table: REPAGLINIDE
Drug strength and dosage form DIN Brand name Manufacturer code
ST0.5MG Tablet 02321475 ACT REPAGLINIDE ACG
ST0.5MG Tablet 02355663 APO-REPAGLINIDE APX
ST0.5MG Tablet 02424258 AURO-REPAGLINIDE AUR
ST0.5MG Tablet 02239924 GLUCONORM NOO
ST0.5MG Tablet 02354926 JAMP REPAGLINIDE JMP
ST0.5MG Tablet 02415968 REPAGLINIDE PDL
ST0.5MG Tablet 02357453 SANDOZ REPAGLINIDE SDZ
ST1MG Tablet 02321483 ACT REPAGLINIDE ACG
ST1MG Tablet 02355671 APO-REPAGLINIDE APX
ST1MG Tablet 02424266 AURO-REPAGLINIDE AUR
ST1MG Tablet 02239925 GLUCONORM NOO
ST1MG Tablet 02354934 JAMP REPAGLINIDE JMP
ST1MG Tablet 02415976 REPAGLINIDE PDL
ST1MG Tablet 02357461 SANDOZ REPAGLINIDE SDZ
ST2MG Tablet 02321491 ACT REPAGLINIDE ACG
ST2MG Tablet 02355698 APO-REPAGLINIDE APX
ST2MG Tablet 02424274 AURO-REPAGLINIDE AUR
ST2MG Tablet 02239926 GLUCONORM NOO
ST2MG Tablet 02354942 JAMP REPAGLINIDE JMP
ST2MG Tablet 02415984 REPAGLINIDE PDL
ST2MG Tablet 02357488 SANDOZ REPAGLINIDE SDZ

68:20.18 SODIUM-GLUCOSE CONTRANSPORTER 2 (SGLT2) INHIBITORS

CANAGLIFLOZIN

Limited use benefit (prior approval required).

For the treatment of patients with type 2 diabetes mellitus who did not achieve glycemic control or who demonstrated intolerance to an adequate trial of metformin AND a sulfonylurea.

Table: CANAGLIFLOZIN
Drug strength and dosage form DIN Brand name Manufacturer code
ST100MG Tablet 02425483 INVOKANA JSO
ST300MG Tablet 02425491 INVOKANA JSO

DAPAGLIFLOZIN PROPANEDIOL MONOHYDRATE

Limited use benefit (prior approval required).

For the treatment of patients with type 2 diabetes mellitus who did not achieve glycemic control or who demonstrated intolerance to an adequate trial of metformin AND a sulfonylurea.

Table: DAPAGLIFLOZIN PROPANEDIOL MONOHYDRATE
Drug strength and dosage form DIN Brand name Manufacturer code
ST5MG Tablet 02435462 FORXIGA AZC
ST10MG Tablet 02435470 FORXIGA AZC

EMPAGLIFLOZIN

Open benefit with therapeutic notes (prior approval is not required).

For the treatment of type 2 diabetes mellitus:

  • in patients who did not achieve glycemic control with an adequate trial of metformin AND a sulfonylurea

OR

  • to reduce the incidence of cardiovascular death in patients with established cardiovascular disease who did not achieve adequate glycemic control despite an appropriate trial of metformin

Established cardiovascular disease is defined as one of the following:

  • history of myocardial infarction
  • multi-vessel coronary artery disease in two or more major coronary arteries (irrespective of revascularization status)
  • single-vessel coronary artery disease with significant stenosis and either a positive non-invasive stress test or discharged from hospital with a documented diagnosis of unstable angina
  • unstable angina with confirmed evidence of coronary multi-vessel or single-vessel disease
  • history of ischemic or hemorrhagic stroke
  • occlusive peripheral artery disease.
Table: EMPAGLIFLOZIN
Drug strength and dosage form DIN Brand name Manufacturer code
ST10MG Tablet 02443937 JARDIANCE BOE
ST25MG Tablet 02443945 JARDIANCE BOE

METFORMIN HYDROCHLORIDE, DAPAGLIFLOZIN

Limited use benefit (prior approval required).

For the treatment of patients with type 2 diabetes mellitus who did not achieve glycemic control or who demonstrated intolerance to an adequate trial of metformin AND a sulfonylurea.

Table: METFORMIN HYDROCHLORIDE, DAPAGLIFLOZIN
Drug strength and dosage form DIN Brand name Manufacturer code
ST850MG & 5MG Tablet 02449935 XIGDUO AZC
ST1000MG & 5MG Tablet 02449943 XIGDUO AZC

METFORMIN HYDROCHLORIDE, EMPAGLIFLOZIN

Open benefit with therapeutic notes (prior approval is not required).

For the treatment of patients with type 2 diabetes mellitus in patients who are eligible to receive metformin and empagliflozin, to replace the individual components.

Table: METFORMIN HYDROCHLORIDE, EMPAGLIFLOZIN
Drug strength and dosage form DIN Brand name Manufacturer code
500MG & 12.5MG Tablet 02456605 SYNJARDY BOE
500MG & 5MG Tablet 02456575 SYNJARDY BOE
850MG & 12.5MG Tablet 02456613 SYNJARDY BOE
850MG & 5MG Tablet 02456583 SYNJARDY BOE
1000MG & 12.5MG Tablet 02456621 SYNJARDY BOE
1000MG & 5MG Tablet 02456591 SYNJARDY BOE

68:20.20 ANTIDIABETIC AGENTS - SULFONYLUREAS

GLICLAZIDE

Table: GLICLAZIDE
Drug strength and dosage form DIN Brand name Manufacturer code
ST80MG Tablet 02245247 APO-GLICLAZIDE APX
ST80MG Tablet 00765996 DIAMICRON SEV
ST80MG Tablet 02248453 GLICLAZIDE PDL
ST80MG Tablet 02287072 GLICLAZIDE SAN
ST80MG Tablet 02238103 TEVA-GLICLAZIDE TEV
ST30MG Tablet (Extended Release) 02297795 APO-GLICLAZIDE MR APX
ST30MG Tablet (Extended Release) 02242987 DIAMICRON MR SEV
ST30MG Tablet (Extended Release) 02429764 JAMP GLICLAZIDE-MR JMP
ST30MG Tablet (Extended Release) 02423286 MINT-GLICLAZIDE MR MIN
ST30MG Tablet (Extended Release) 02438658 MYLAN-GLICLAZIDE MR MYL
ST30MG Tablet (Extended Release) 02463571 RAN-GLICLAZIDE MR RBY
ST30MG Tablet (Extended Release) 02461323 SANDOZ GLICLAZIDE MR SDZ
ST60MG Tablet (Extended Release) 02407124 APO-GLICLAZIDE MR APX
ST60MG Tablet (Extended Release) 02356422 DIAMICRON MR SEV
ST60MG Tablet (Extended Release) 02423294 MINT-GLICLAZIDE MR MIN
60MG Tablet (Extended Release) 02439328 RAN-GLICLAZIDE RBY
ST60MG Tablet (Extended Release) 02461331 SANDOZ GLICLAZIDE MR SDZ

GLYBURIDE

Table: GLYBURIDE
Drug strength and dosage form DIN Brand name Manufacturer code
ST2.5MG Tablet 01913654 APO GLYBURIDE APX
ST2.5MG Tablet 02224550 DIABETA SAC
ST2.5MG Tablet 01959352 GLYBURIDE PDL
ST2.5MG Tablet 02350459 GLYBURIDE SAN
ST2.5MG Tablet 01913670 TEVA-GLYBURIDE TEV
ST5MG Tablet 01913662 APO GLYBURIDE APX
ST5MG Tablet 02224569 DIABETA SAC
ST5MG Tablet 02234514 DOM-GLYBURIDE DPC
ST5MG Tablet 00720941 EUGLUCON PMS
ST5MG Tablet 02350467 GLYBURIDE SAN
ST5MG Tablet 02236734 PMS-GLYBURIDE PMS
ST5MG Tablet 01913689 TEVA-GLYBURIDE TEV

TOLBUTAMIDE

Table: TOLBUTAMIDE
Drug strength and dosage form DIN Brand name Manufacturer code
ST500MG Tablet 00312762 TOLBUTAMIDE AAP

68:20.28 THIAZOLIDINEDIONES

PIOGLITAZONE HYDROCHLORIDE

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.

Table: PIOGLITAZONE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
ST15MG Tablet 02303442 ACCEL PIOGLITAZONE ACP
ST15MG Tablet 02391600 ACH-PIOGLITAZONE ACC
ST15MG Tablet 02302861 ACT PIOGLITAZONE ACG
ST15MG Tablet 02302942 APO-PIOGLITAZONE APX
ST15MG Tablet 02307634 DOM-PIOGLITAZONE DPC
ST15MG Tablet 02397307 JAMP-PIOGLITAZONE JMP
ST15MG Tablet 02326477 MINT-PIOGLITAZONE MIN
ST15MG Tablet 02303124 PMS-PIOGLITAZONE PMS
ST15MG Tablet 02312050 PRO-PIOGLITAZONE PDL
ST15MG Tablet 02375850 RAN-PIOGLITAZONE RBY
ST15MG Tablet 02297906 SANDOZ PIOGLITAZONE SDZ
ST15MG Tablet 02274914 TEVA-PIOGLITAZONE TEV
ST15MG Tablet 02434121 VAN-PIOGLITAZONE VAN
ST30MG Tablet 02303450 ACCEL PIOGLITAZONE ACP
ST30MG Tablet 02339587 ACH-PIOGLITAZONE ACC
ST30MG Tablet 02302888 ACT PIOGLITAZONE ACG
ST30MG Tablet 02302950 APO-PIOGLITAZONE APX
ST30MG Tablet 02307642 DOM-PIOGLITAZONE DPC
ST30MG Tablet 02365529 JAMP-PIOGLITAZONE JMP
ST30MG Tablet 02326485 MINT-PIOGLITAZONE MIN
ST30MG Tablet 02303132 PMS-PIOGLITAZONE PMS
ST30MG Tablet 02312069 PRO-PIOGLITAZONE PDL
ST30MG Tablet 02375869 RAN-PIOGLITAZONE RBY
ST30MG Tablet 02297914 SANDOZ PIOGLITAZONE SDZ
ST30MG Tablet 02274922 TEVA-PIOGLITAZONE TEV
ST30MG Tablet 02434148 VAN-PIOGLITAZONE VAN
ST45MG Tablet 02303469 ACCEL PIOGLITAZONE ACP
ST45MG Tablet 02339595 ACH-PIOGLITAZONE ACC
ST45MG Tablet 02302896 ACT PIOGLITAZONE ACG
ST45MG Tablet 02302977 APO-PIOGLITAZONE APX
ST45MG Tablet 02307650 DOM-PIOGLITAZONE DPC
ST45MG Tablet 02365537 JAMP-PIOGLITAZONE JMP
ST45MG Tablet 02326493 MINT-PIOGLITAZONE MIN
ST45MG Tablet 02303140 PMS-PIOGLITAZONE PMS
ST45MG Tablet 02312077 PRO-PIOGLITAZONE PDL
ST45MG Tablet 02375877 RAN-PIOGLITAZONE RBY
ST45MG Tablet 02297922 SANDOZ PIOGLITAZONE SDZ
ST45MG Tablet 02274930 TEVA-PIOGLITAZONE TEV
ST45MG Tablet 02434156 VAN-PIOGLITAZONE VAN

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.

Table: ROSIGLITAZONE MALEATE
Drug strength and dosage form DIN Brand name Manufacturer code
ST2MG Tablet 02403366 APO-ROSIGLITAZONE APX
ST2MG Tablet 02241112 AVANDIA GSK
ST4MG Tablet 02403374 APO-ROSIGLITAZONE APX
ST4MG Tablet 02241113 AVANDIA GSK
ST8MG Tablet 02403382 APO-ROSIGLITAZONE APX
ST8MG Tablet 02241114 AVANDIA GSK

68:22.12 GLYCOGENOLYTIC AGENTS

GLUCAGON RECOMBINANT DNA ORGIN

Table: GLUCAGON RECOMBINANT DNA ORGIN
Drug strength and dosage form DIN Brand name Manufacturer code
1MG/ML Injection 02333619 GLUCAGEN NOO
1MG/ML Injection 02333627 GLUCAGEN HYPOKIT NOO
1MG/ML Injection 02243297 GLUCAGON LIL

68:24.00 PARATHYROID

CALCITONIN SALMON (SYNTHETIC)

Table: CALCITONIN SALMON (SYNTHETIC)
Drug strength and dosage form DIN Brand name Manufacturer code
200IU/ML Solution 01926691 CALCIMAR SAC

68:28.00 PITUITARY

DESMOPRESSIN ACETATE

Table: DESMOPRESSIN ACETATE
Drug strength and dosage form DIN Brand name Manufacturer code
4MCG/ML Liquid 00873993 DDAVP FEI
0.1MG/ML Nasal Spray 00402516 DDAVP FEI
0.1MG/ML Nasal Spray 00836362 DDAVP FEI
0.1MG/ML Nasal Spray 02242465 DESMOPRESSIN AAP
ST0.1MG Tablet 00824305 DDAVP FEI
ST0.1MG Tablet 02284030 DESMOPRESSIN APX
ST0.1MG Tablet 02304368 PMS-DESMOPRESSIN PMS
ST0.1MG Tablet 02287730 TEVA-DESMOPRESSIN TEV
ST0.2MG Tablet 00824143 DDAVP FEI
ST0.2MG Tablet 02284049 DESMOPRESSIN APX
ST0.2MG Tablet 02304376 PMS-DESMOPRESSIN PMS
ST60MCG Tablet (Orally Disintegrating) 02284995 DDAVP MELT FEI
ST120MCG Tablet (Orally Disintegrating) 02285002 DDAVP MELT FEI
ST240MCG Tablet (Orally Disintegrating) 02285010 DDAVP MELT FEI

68:32.00 PROGESTINS

DIENOGEST

Limited use benefit (prior approval required).

For the management of pelvic pain associated with endometriosis.

Table: DIENOGEST
Drug strength and dosage form DIN Brand name Manufacturer code
ST2MG Tablet 02374900 VISANNE BAY

MEDROXYPROGESTERONE ACETATE

Table: MEDROXYPROGESTERONE ACETATE
Drug strength and dosage form DIN Brand name Manufacturer code
50MG/ML Suspension 00030848 DEPO-PROVERA PFI
150MG/ML Suspension 00585092 DEPO-PROVERA PFI
150MG/ML Suspension 02322250 MEDROXYPROGESTERONE SDZ
ST2.5MG Tablet 02244726 APO-MEDROXY APX
ST2.5MG Tablet 02253550 MEDROXY PDL
ST2.5MG Tablet 00708917 PROVERA PFI
ST2.5MG Tablet 02221284 TEVA-MEDROXYPROGESTERONE TEV
ST5MG Tablet 02244727 APO-MEDROXY APX
ST5MG Tablet 02253577 MEDROXY PDL
ST5MG Tablet 00030937 PROVERA PFI
ST5MG Tablet 02221292 TEVA-MEDROXYPROGESTERONE TEV
ST10MG Tablet 02277298 APO-MEDROXY APX
ST10MG Tablet 00729973 PROVERA PFI
ST10MG Tablet 02221306 TEVA-MEDROXYPROGESTERONE TEV
ST100MG Tablet 02267640 APO-MEDROXY APX

PROGESTERONE

Limited use benefit (prior approval required).

For the treatment of women:

  • With postmenopausal symptoms who are intolerant to medroxyprogesterone acetate (MPA); OR
  • Who are at risk of preterm birth; OR
  • Who are using the medication to prevent miscarriage.

In adults:

  • For use as Gender Affirming Hormone Therapy.
Table: PROGESTERONE
Drug strength and dosage form DIN Brand name Manufacturer code
ST100MG Capsule 02166704 PROMETRIUM FRS
ST100MG Capsule 02463113 REDDY-PROGESTERONE REC
ST100MG Capsule 02439913 TEVA-PROGESTERONE TEV

68:36.04 THYROID AGENTS

LEVOTHYROXINE SODIUM

Table: LEVOTHYROXINE SODIUM
Drug strength and dosage form DIN Brand name Manufacturer code
ST0.025MG Tablet 02264323 EUTHYROX SRO
ST0.025MG Tablet 02172062 SYNTHROID BGP
ST0.05MG Tablet 02213192 ELTROXIN ASP
ST0.05MG Tablet 02264331 EUTHYROX SRO
ST0.05MG Tablet 02172070 SYNTHROID BGP
ST0.075MG Tablet 02264358 EUTHYROX SRO
ST0.075MG Tablet 02172089 SYNTHROID BGP
ST0.088MG Tablet 02172097 SYNTHROID BGP
ST0.1MG Tablet 02213206 ELTROXIN ASP
ST0.1MG Tablet 02264374 EUTHYROX SRO
ST0.1MG Tablet 02172100 SYNTHROID BGP
ST0.112MG Tablet 02264390 EUTHYROX SRO
ST0.112MG Tablet 02171228 SYNTHROID BGP
ST0.125MG Tablet 02264404 EUTHYROX SRO
ST0.125MG Tablet 02172119 SYNTHROID BGP
ST0.137MG Tablet 02264412 EUTHYROX SRO
ST0.137MG Tablet 02233852 SYNTHROID BGP
ST0.15MG Tablet 02213214 ELTROXIN ASP
ST0.15MG Tablet 02264420 EUTHYROX SRO
ST0.15MG Tablet 02172127 SYNTHROID BGP
ST0.175MG Tablet 02264439 EUTHYROX SRO
ST0.175MG Tablet 02172135 SYNTHROID BGP
ST0.2MG Tablet 02213222 ELTROXIN ASP
ST0.2MG Tablet 02264447 EUTHYROX SRO
ST0.2MG Tablet 02172143 SYNTHROID BGP
ST0.3MG Tablet 02264455 EUTHYROX SRO
ST0.3MG Tablet 02172151 SYNTHROID BGP

LIOTHYRONINE SODIUM

Table: LIOTHYRONINE SODIUM
Drug strength and dosage form DIN Brand name Manufacturer code
ST5MCG Tablet 01919458 CYTOMEL PFI
ST25MCG Tablet 01919466 CYTOMEL PFI

THYROID

Table: THYROID
Drug strength and dosage form DIN Brand name Manufacturer code
ST30MG Tablet 00023949 THYROID ERF
ST60MG Tablet 00023957 THYROID ERF
ST125MG Tablet 00023965 THYROID ERF

68:36.08 ANTITHYROID AGENTS

PROPYLTHIOURACIL

Table: PROPYLTHIOURACIL
Drug strength and dosage form DIN Brand name Manufacturer code
ST50MG Tablet 00010200 PROPYL-THYRACIL PAL
ST100MG Tablet 00010219 PROPYL-THYRACIL PAL

THIAMAZOLE

Table: THIAMAZOLE
Drug strength and dosage form DIN Brand name Manufacturer code
ST5MG Tablet 02480107 MAR-METHIMAZOLE MAR
ST5MG Tablet 00015741 TAPAZOLE PAL
ST10MG Tablet 02480115 MAR-METHIMAZOLE MAR
ST10MG Tablet 02296039 TAPAZOLE PAL
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