08:00 Anti-Infective Agents

08:08.00 ANTHELMINTICS

IVERMECTIN

Table: IVERMECTIN
Drug strength and dosage form DIN Brand name Manufacturer code
3MG Tablet 02480557 STROMECTOL FRS

MEBENDAZOLE

Table: MEBENDAZOLE
Drug strength and dosage form DIN Brand name Manufacturer code
100MG Tablet 00556734 VERMOX JSO

PYRANTEL PAMOATE

Table: PYRANTEL PAMOATE
Drug strength and dosage form DIN Brand name Manufacturer code
50MG Suspension 02412470 JAMP-PYRANTEL PAMOATE JMP
125MG Tablet 01944363 COMBANTRIN MCL

08:12.02 AMINOGLYCOSIDES

AMIKACIN SULFATE

Limited use benefit (prior approval required).

Table: AMIKACIN SULFATE
Drug strength and dosage form DIN Brand name Manufacturer code
250MG Liquid 02242971 AMIKACIN SULFATE SDZ

GENTAMICIN SULFATE

Table: GENTAMICIN SULFATE
Drug strength and dosage form DIN Brand name Manufacturer code
1MG/ML Solution 02082136 GENTAMICIN IV BAX
1.6MG/ML Solution 02082152 GENTAMICIN IV BAX
10MG/ML Solution 02268531 GENTAMICIN SDZ
40MG/ML Solution 02225131 CIDOMYCIN UNK
40MG/ML Solution 02242652 GENTAMICIN SDZ
pDIN For Extemporaneous Mixture 99506004 GENTAMYCIN STERILE INFUSION UNK

TOBRAMYCIN

Table: TOBRAMYCIN
Drug strength and dosage form DIN Brand name Manufacturer code
28MG Capsule 02365154 TOBI PODHALER BGP
1.2G Powder For Solution 00533688 TOBRAMYCIN FKD
1.2G Powder For Solution 02285150 TOBRAMYCIN RAX
10MG/ML Solution 02230639 TOBRAMYCIN FKD
10MG/ML Solution 02241209 TOBRAMYCIN SDZ
40MG/ML Solution 02420287 JAMP-TOBRAMYCIN JMP
40MG/ML Solution 02230640 TOBRAMYCIN FKD
40MG/ML Solution 02241210 TOBRAMYCIN SDZ
40MG/ML Solution 02382814 TOBRAMYCIN MYL
40MG/ML Solution 99005069 TOBRAMYCINE UNK
60MG Solution 02389622 TEVA-TOBRAMYCIN TEV
300MG Solution 02443368 TOBRAMYCIN INHALATION SDZ

08:12.06 CEPHALOSPORINS

CEFADROXIL

Table: CEFADROXIL
Drug strength and dosage form DIN Brand name Manufacturer code
500MG Capsule 02240774 APO-CEFADROXIL APX
500MG Capsule 02311062 PRO-CEFADROXIL PDL
500MG Capsule 02235134 TEVA-CEFADROXIL TEV

CEFAZOLIN SODIUM

Table: CEFAZOLIN SODIUM
Drug strength and dosage form DIN Brand name Manufacturer code
500MG Powder For Solution 02108119 CEFAZOLIN TEV
500MG Powder For Solution 02237137 CEFAZOLIN FKD
500MG Powder For Solution 02308932 CEFAZOLIN SDZ
1G Powder For Solution 02108127 CEFAZOLIN TEV
1G Powder For Solution 02237138 CEFAZOLIN FKD
1G Powder For Solution 02308959 CEFAZOLIN SDZ
1G Powder For Solution 02437112 CEFAZOLIN RAX
10G Powder For Solution 02108135 CEFAZOLIN TEV
10G Powder For Solution 02237140 CEFAZOLIN FKD
10G Powder For Solution 02308967 CEFAZOLIN SDZ
10G Powder For Solution 02437120 CEFAZOLIN RAX
pDIN For Extemporaneous Mixture 99506000 CEFAZOLIN STERILE INFUSION UNK

CEFIXIME

Table: CEFIXIME
Drug strength and dosage form DIN Brand name Manufacturer code
20MG/ML Powder For Suspension 00868965 SUPRAX ODN
100MG Powder For Suspension 02468689 AURO-CEFIXIME AUR
400MG Tablet 02432773 AURO-CEFIXIME AUR
400MG Tablet 00868981 SUPRAX ODN

CEFPROZIL

Table: CEFPROZIL
Drug strength and dosage form DIN Brand name Manufacturer code
25MG/ML Powder For Suspension 02329204 TARO-CEFPROZIL SUN
50MG/ML Powder For Suspension 02293579 TARO-CEFPROZIL SUN
250MG Tablet 02292998 APO-CEFPROZIL APX
250MG Tablet 02347245 AURO-CEFPROZIL AUR
250MG Tablet 02302179 SANDOZ CEFPROZIL SDZ
250MG Tablet 02293528 TARO-CEFPROZIL SUN
500MG Tablet 02293005 APO-CEFPROZIL APX
500MG Tablet 02347253 AURO-CEFPROZIL AUR
500MG Tablet 02302187 SANDOZ CEFPROZIL SDZ
500MG Tablet 02293536 TARO-CEFPROZIL SUN

CEFTAZIDIME

Limited use benefit (prior approval required).

Table: CEFTAZIDIME
Drug strength and dosage form DIN Brand name Manufacturer code
1G Powder For Solution 00886971 CEFTAZIDIME FKD
1G Powder For Solution 02437848 CEFTAZIDIME RAX
1G Powder For Solution 02212218 FORTAZ 1G GSK
2G Powder For Solution 00886955 CEFTAZIDIME FKD
2G Powder For Solution 02437856 CEFTAZIDIME RAX
2G Powder For Solution 02212226 FORTAZ 2G GSK
3G Powder For Solution 02439522 CEFTAZIDIME RAX
6G Powder For Solution 00886963 CEFTAZIDIME FKD
6G Powder For Solution 02437864 CEFTAZIDIME RAX
6G Powder For Solution 02212234 FORTAZ 6G GSK

CEFTRIAXONE SODIUM

Table: CEFTRIAXONE SODIUM
Drug strength and dosage form DIN Brand name Manufacturer code
250MG Powder For Solution 02250276 CEFTRIAXONE PFI
250MG Powder For Solution 02289679 CEFTRIAXONE FKD
250MG Powder For Solution 02292262 CEFTRIAXONE SDZ
250MG Powder For Solution 02325594 CEFTRIAXONE RAX
1G Powder For Solution 02250292 CEFTRIAXONE PFI
1G Powder For Solution 02287633 CEFTRIAXONE TEV
1G Powder For Solution 02292270 CEFTRIAXONE SDZ
1G Powder For Solution 02325616 CEFTRIAXONE RAX
2G Powder For Solution 02250306 CEFTRIAXONE PFI
2G Powder For Solution 02292289 CEFTRIAXONE SDZ
2G Powder For Solution 02325624 CEFTRIAXONE RAX
10G Powder For Solution 02325632 CEFTRIAXONE SODIUM FOR BP RAX
pDIN For Extemporaneous Mixture 99506001 CEFTRIAXONE STERILE INFUSION UNK

CEFUROXIME AXETIL

Table: CEFUROXIME AXETIL
Drug strength and dosage form DIN Brand name Manufacturer code
25MG/ML Granules For Suspension 02212307 CEFTIN GSK
250MG Tablet 02244393 APO-CEFUROXIME APX
250MG Tablet 02344823 AURO-CEFUROXIME APL
250MG Tablet 02212277 CEFTIN GSK
500MG Tablet 02244394 APO-CEFUROXIME APX
500MG Tablet 02344831 AURO-CEFUROXIME APL
500MG Tablet 02212285 CEFTIN GSK
500MG Tablet 02311453 PRO-CEFUROXIM PDL

CEPHALEXIN

Table: CEPHALEXIN
Drug strength and dosage form DIN Brand name Manufacturer code
250MG Capsule 00342084 TEVA-CEPHALEXIN TEV
500MG Capsule 00342114 TEVA-CEPHALEXIN TEV
25MG/ML Powder For Suspension 00015547 KEFLEX PED
25MG/ML Powder For Suspension 00342106 TEVA-CEPHALEXIN TEV
50MG/ML Powder For Suspension 00035645 KEFLEX PED
50MG/ML Powder For Suspension 00342092 TEVA-CEPHALEXIN TEV
125MG Powder For Suspension 02469170 LUPIN-CEPHALEXIN LUP
250MG Powder For Suspension 02469189 LUPIN-CEPHALEXIN LUP
250MG Tablet 00768723 APO-CEPHALEX APX
250MG Tablet 02470578 AURO-CEPHALEXIN AUR
250MG Tablet 02177781 PMS-CEPHALEXIN PMS
250MG Tablet 00583413 TEVA-CEPHALEXIN TEV
500MG Tablet 00768715 APO-CEPHALEX APX
500MG Tablet 02470586 AURO-CEPHALEXIN AUR
500MG Tablet 00828866 CEPHALEXIN-500 PDL
500MG Tablet 02177803 PMS-CEPHALEXIN PMS
500MG Tablet 00583421 TEVA-CEPHALEXIN TEV

08:12.07 MISCELLANEOUS B-LACTAM ANTIBIOTICS

AZTREONAM

Limited use benefit (prior approval required).

For the management of cystic fibrosis (CF) in patients if the following criteria are met:

  • patient has CF with chronic pulmonary Pseudomonas aeruginosa infections; and
  • prescribed by a clinician with experience in the diagnosis and treatment of CF.
Table: AZTREONAM
Drug strength and dosage form DIN Brand name Manufacturer code
75MG Powder For Solution 02329840 CAYSTON GIL

ERTAPENEM

Limited use benefit (prior approval required).

Table: ERTAPENEM
Drug strength and dosage form DIN Brand name Manufacturer code
1G Powder For Solution 02247437 INVANZ FRS

MEROPENEM

Limited use benefit (prior approval required).

Table: MEROPENEM
Drug strength and dosage form DIN Brand name Manufacturer code
500MG Powder For Solution 02378787 MEROPENEM SDZ
1G Powder For Solution 02378795 MEROPENEM SDZ
1G Powder For Solution 02436507 MEROPENEM RAX

08:12.12 MACROLIDES

AZITHROMYCIN

Table: AZITHROMYCIN
Drug strength and dosage form DIN Brand name Manufacturer code
20MG/ML Powder For Suspension 02418452 PMS-AZITHROMYCIN PMS
20MG/ML Powder For Suspension 02332388 SANDOZ AZITHROMYCIN SDZ
20MG/ML Powder For Suspension 02223716 ZITHROMAX PFI
40MG/ML Powder For Suspension 02418460 PMS-AZITHROMYCIN PMS
40MG/ML Powder For Suspension 02332396 SANDOZ AZITHROMYCIN SDZ
40MG/ML Powder For Suspension 02223724 ZITHROMAX PFI
100MG Powder For Suspension 02482363 AURO-AZITHROMYCIN AUR
200MG Powder For Suspension 02482371 AURO-AZITHROMYCIN AUR
250MG Tablet 02480700 AG-AZITHROMYCIN ANG
250MG Tablet 02415542 APO-AZITHROMYCIN APX
250MG Tablet 02330881 AZITHROMYCIN SAN
250MG Tablet 02442434 AZITHROMYCIN SIV
250MG Tablet 02278499 DOM-AZITHROMYCIN DPC
250MG Tablet 02452308 JAMP-AZITHROMYCIN JMP
250MG Tablet 02452324 MAR-AZITHROMYCIN MAR
250MG Tablet 02479680 NRA-AZITHROMYCIN UNK
250MG Tablet 02261634 PMS-AZITHROMYCIN PMS
250MG Tablet 02310600 PRO-AZITHROMYCINE PDL
250MG Tablet 02275309 RIVA-AZITHROMYCIN RIV
250MG Tablet 02265826 SANDOZ AZITHROMYCIN SDZ
250MG Tablet 02267845 TEVA-AZITHROMYCIN TEV
250MG Tablet 02212021 ZITHROMAX PFI
600MG Tablet 02261642 PMS-AZITHROMYCIN PMS
600MG Tablet 02231143 ZITHROMAX PFI

CLARITHROMYCIN

Table: CLARITHROMYCIN
Drug strength and dosage form DIN Brand name Manufacturer code
25MG/ML Granules For Suspension 02146908 BIAXIN BGP
25MG/ML Granules For Suspension 02408988 CLARITHROMYCIN SAN
25MG/ML Granules For Suspension 02390442 TARO-CLARITHROMYCIN TAR
50MG/ML Granules For Suspension 02244641 BIAXIN BGP
50MG/ML Granules For Suspension 02408996 CLARITHROMYCIN SAN
50MG/ML Granules For Suspension 02390450 TARO-CLARITHROMYCIN TAR
250MG Tablet 02274744 APO-CLARITHROMYCIN APX
250MG Tablet 01984853 BIAXIN BGP
250MG Tablet 02324482 CLARITHROMYCIN PDL
250MG Tablet 02442469 CLARITHROMYCIN SIV
250MG Tablet 02466120 CLARITHROMYCIN SAN
250MG Tablet 02471388 M-CLARITHROMYCIN MAN
250MG Tablet 02247573 PMS-CLARITHROMYCIN PMS
250MG Tablet 02361426 RAN-CLARITHROMYCIN RBY
250MG Tablet 02266539 SANDOZ CLARITHROMYCIN SDZ
250MG Tablet 02248804 TEVA-CLARITHROMYCIN TEV
500MG Tablet 02274752 APO-CLARITHROMYCIN APX
500MG Tablet 02126710 BIAXIN BGP
500MG Tablet 02324490 CLARITHROMYCIN PDL
500MG Tablet 02442485 CLARITHROMYCIN SIV
500MG Tablet 02351005 DOM-CLARITHROMYCIN DPC
500MG Tablet 02471396 M-CLARITHROMYCIN MAN
500MG Tablet 02247574 PMS-CLARITHROMYCIN PMS
500MG Tablet 02361434 RAN-CLARITHROMYCIN RBY
500MG Tablet 02346532 RIVA-CLARITHROMYCIN RIV
500MG Tablet 02266547 SANDOZ CLARITHROMYCIN SDZ
500MG Tablet 02248805 TEVA-CLARITHROMYCIN TEV
500MG Tablet (Extended Release) 02403196 ACT CLARITHROMYCIN XL TEV
500MG Tablet (Extended Release) 02413345 APO-CLARITHROMYCIN XL APX
500MG Tablet (Extended Release) 02244756 BIAXIN XL BGP

ERYTHROMYCIN

Table: ERYTHROMYCIN
Drug strength and dosage form DIN Brand name Manufacturer code
333MG Capsule (Enteric Coated) 00873454 ERYC PFI
250MG Tablet 00682020 ERYTHRO BASE AAP

ERYTHROMYCIN STEARATE

Table: ERYTHROMYCIN STEARATE
Drug strength and dosage form DIN Brand name Manufacturer code
250MG Tablet 00545678 ERYTHRO-S AAP

FIDAXOMICIN

Limited use benefit (prior approval required).

For the treatment of confirmed severe* Clostridium Difficile infection (CDI); and

  • fidaxomicin has been prescribed or recommended by an infectious disease specialist or gastroenterologist; and
  • there is a documented allergy (immune-mediated reaction) or severe intolerance to oral vancomycin resulting in discontinuation of vancomycin.
  • or
  • after an unsuccessful but adequate** trial of oral vancomycin; and
  • retreatment with vancomycin is not an option***; and
  • the patient is at a high risk of hospitalization due to severe complications; and
  • fidaxomicin is being used as monotherapy.

Notes:

*. Severe infection is defined as having any of the following symptoms: white blood cell count > 15,000 mm3 and fever; acute kidney injury with rising serum creatinine ≥ 1.5 times premorbid level or ≥ 175 micromoles/L; pseudomembranous colitis, hypotension, shock or megacolon.

**. An adequate trial of oral vancomycin is considered to be at least 10 days of therapy with a dose of at least 125mg four times daily.

***. Retreatment with fidaxomicin in recurrent CDI will be considered in symptomatic patients who require treatment of a previously resolved CDI episode. This is defined as a subsequent CDI episode occurring within 2 to 8 weeks of a previous episode from the date of diagnosis.

Table: FIDAXOMICIN
Drug strength and dosage form DIN Brand name Manufacturer code
200MG Tablet 02387174 DIFICID FRS

08:12.16 PENICILLINS

AMOXICILLIN

Table: AMOXICILLIN
Drug strength and dosage form DIN Brand name Manufacturer code
250MG Capsule 02352710 AMOXICILLIN SAN
250MG Capsule 00628115 APO-AMOXI APX
250MG Capsule 02388073 AURO-AMOXICILLIN AUR
250MG Capsule 02433060 JAMP-AMOXICILLIN JMP
250MG Capsule 00406724 NOVAMOXIN TEV
250MG Capsule 02230243 PMS-AMOXICILLIN PMS
500MG Capsule 02477726 AG-AMOXICILLIN ANG
500MG Capsule 02352729 AMOXICILLIN SAN
500MG Capsule 02401509 AMOXICILLIN SIV
500MG Capsule 00628123 APO-AMOXI APX
500MG Capsule 02388081 AURO-AMOXICILLIN AUR
500MG Capsule 02433079 JAMP-AMOXICILLIN JMP
500MG Capsule 00406716 NOVAMOXIN TEV
500MG Capsule 02230244 PMS-AMOXICILLIN PMS
500MG Capsule 00644315 PRO AMOX PDL
25MG/ML Granules For Suspension 00452149 NOVAMOXIN TEV
25MG/ML Granules For Suspension 01934171 NOVAMOXIN TEV
50MG/ML Granules For Suspension 02352753 AMOXICILLIN SAN
50MG/ML Granules For Suspension 02401541 AMOXICILLIN SIV
50MG/ML Granules For Suspension 02352788 AMOXICILLIN (SUGAR REDUCED) SAN
50MG/ML Granules For Suspension 00452130 NOVAMOXIN TEV
50MG/ML Granules For Suspension 01934163 NOVAMOXIN TEV
25MG/ML Powder For Suspension 00628131 APO-AMOXI APX
25MG/ML Powder For Suspension 02230245 PMS-AMOXICILLIN PMS
50MG/ML Powder For Suspension 00628158 APO-AMOXI APX
50MG/ML Powder For Suspension 02230880 APO-AMOXI SUGAR FREE APX
50MG/ML Powder For Suspension 02230246 PMS-AMOXICILLIN PMS
50MG/ML Powder For Suspension 00644331 PRO-AMOX PDL
125MG Tablet (Chewable) 02036347 NOVAMOXIN TEV
250MG Tablet (Chewable) 02036355 NOVAMOXIN TEV

AMOXICILLIN, CLAVULANIC ACID

Table: AMOXICILLIN, CLAVULANIC ACID
Drug strength and dosage form DIN Brand name Manufacturer code
25MG & 6.25MG/ML Powder For Suspension 01916882 CLAVULIN 125 F GSK
40MG & 5.7MG/ML Powder For Suspension 02288559 APO-AMOXI CLAV APX
40MG & 5.7MG/ML Powder For Suspension 02238831 CLAVULIN 200 GSK
50MG & 12.5MG/ML Powder For Suspension 01916874 CLAVULIN 250 F GSK
80MG & 11.4MG/ML Powder For Suspension 02238830 CLAVULIN 400 GSK
250MG & 125MG Tablet 02243350 APO-AMOXI CLAV APX
500MG & 125MG Tablet 02243351 APO-AMOXI CLAV APX
500MG & 125MG Tablet 01916858 CLAVULIN 500 F GSK
500MG & 125MG Tablet 02482576 SANDOZ AMOXI-CLAV SDZ
875MG & 125MG Tablet 02245623 APO-AMOXI CLAV APX
875MG & 125MG Tablet 02238829 CLAVULIN 875 GSK
875MG & 125MG Tablet 02482584 SANDOZ AMOXI-CLAV SDZ

AMPICILLIN

Table: AMPICILLIN
Drug strength and dosage form DIN Brand name Manufacturer code
250MG Capsule 00020877 TEVA-AMPICILLIN TEV
500MG Capsule 00020885 TEVA-AMPICILLIN TEV
1G Powder For Solution 01933345 AMPICILLIN SODIUM TEV
2G Powder For Solution 02226995 AMPICILLIN FKD
2G Powder For Solution 01933353 AMPICILLIN SODIUM TEV
2G Powder For Solution 02462346 AMPICILLIN SODIUM FOR BP AUR
pDIN For Extemporaneous Mixture 99506005 AMPICILLIN STERILE INFUSION UNK

CLOXACILLIN SODIUM

Table: CLOXACILLIN SODIUM
Drug strength and dosage form DIN Brand name Manufacturer code
250MG Capsule 00337765 TEVA-CLOXACILLIN TEV
500MG Capsule 00337773 TEVA-CLOXACILLIN TEV
25MG/ML Granules For Solution 00337757 TEVA-CLOXACILLIN TEV

PENICILLIN G BENZATHINE

Table: PENICILLIN G BENZATHINE
Drug strength and dosage form DIN Brand name Manufacturer code
600,000U/ML Suspension 02291924 BICILLIN PFI

PENICILLIN G POTASSIUM

Table: PENICILLIN G POTASSIUM
Drug strength and dosage form DIN Brand name Manufacturer code
1MU Injection 00773727 NOVO-PENICILLIN G POTASSIUM NOP

PENICILLIN G SODIUM

Table: PENICILLIN G SODIUM
Drug strength and dosage form DIN Brand name Manufacturer code
10MU Powder For Solution 02220296 PENICILLIN G FKD
1000000U Powder For Solution 02220261 PENICILLIN G SODIUM FKD
5000000U Powder For Solution 02220288 PENICILLIN G SODIUM FKD
pDIN For Extemporaneous Mixture 99506003 PENICILLIN G STERILE INFUSION UNK

PENICILLIN V POTASSIUM

Table: PENICILLIN V POTASSIUM
Drug strength and dosage form DIN Brand name Manufacturer code
25MG/ML Powder For Solution 00642223 APO PEN VK APX
60MG/ML Powder For Solution 00642231 APO PEN VK APX
300MG Tablet 00642215 PEN-VK AAP

PIPERACILLIN, TAZOBACTAM

Limited use benefit (prior approval required).

Table: PIPERACILLIN, TAZOBACTAM
Drug strength and dosage form DIN Brand name Manufacturer code
2G & 0.25G Powder For Solution 02401312 PIPERACILLIN AND TAZOBACTAM ALV
2G & 0.25G Powder For Solution 02299623 PIPERACILLIN SODIUM/TAZOBACTAM SODIUM SDZ
2G & 0.25G Powder For Solution 02370158 PIPERACILLIN SODIUM/TAZOBACTAM SODIUM TEV
3G & 0.375G Powder For Solution 02401320 PIPERACILLIN AND TAZOBACTAM ALV
3G & 0.375G Powder For Solution 02299631 PIPERACILLIN SODIUM/TAZOBACTAM SODIUM SDZ
3G & 0.375G Powder For Solution 02308452 PIPERACILLIN SODIUM/TAZOBACTAM SODIUM APX
3G & 0.375G Powder For Solution 02362627 PIPERACILLIN SODIUM/TAZOBACTAM SODIUM RAX
3G & 0.375G Powder For Solution 02370166 PIPERACILLIN SODIUM/TAZOBACTAM SODIUM TEV
4G & 0.5G Powder For Solution 02401339 PIPERACILLIN AND TAZOBACTAM ALV
4G & 0.5G Powder For Solution 02299658 PIPERACILLIN SODIUM/TAZOBACTAM SODIUM SDZ
4G & 0.5G Powder For Solution 02308460 PIPERACILLIN SODIUM/TAZOBACTAM SODIUM APX
4G & 0.5G Powder For Solution 02362635 PIPERACILLIN SODIUM/TAZOBACTAM SODIUM RAX
4G & 0.5G Powder For Solution 02370174 PIPERACILLIN SODIUM/TAZOBACTAM SODIUM TEV
12G & 1.5G Powder For Solution 02330547 PIPERACILLIN SODIUM/TAZOBACTAM SODIUM SDZ
12G & 1.5G Powder For Solution 02377748 PIPERACILLIN SODIUM/TAZOBACTAM SODIUM RAX
36G & 4.5G Powder For Solution 02439131 PIPERACILLIN SODIUM/TAZOBACTAM SODIUM RAX

08:12.18 QUINOLONES

CIPROFLOXACIN HYDROCHLORIDE

Table: CIPROFLOXACIN HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
100MG/ML Suspension 02237514 CIPRO BAY
250MG Tablet 02247339 ACT CIPROFLOXACIN TEV
250MG Tablet 02229521 APO-CIPROFLOX APX
250MG Tablet 02381907 AURO-CIPROFLOXACIN AUR
250MG Tablet 02353318 CIPROFLOXACIN SAN
250MG Tablet 02386119 CIPROFLOXACIN SIV
250MG Tablet 02380358 JAMP-CIPROFLOXACIN JMP
250MG Tablet 02379686 MAR-CIPROFLOXACIN MAR
250MG Tablet 02423553 MINT-CIPROFLOX MIN
250MG Tablet 02248437 PMS-CIPROFLOXACIN PMS
250MG Tablet 02317796 PRO-CIPROFLOXACIN PDL
250MG Tablet 02251221 RIVA-CIPROFLOXACIN RIV
250MG Tablet 02248756 SANDOZ CIPROFLOXACIN SDZ
250MG Tablet 02379627 SEPTA-CIPROFLOXACIN SPT
250MG Tablet 02303728 TARO-CIPROFLOX SUN
250MG Tablet 02266962 TARO-CIPROFLOXACIN TAR
500MG Tablet 02247340 ACT CIPROFLOXACIN TEV
500MG Tablet 02229522 APO-CIPROFLOX APX
500MG Tablet 02381923 AURO-CIPROFLOXACIN AUR
500MG Tablet 02444887 BIO-CIPROFLOXACIN BMI
500MG Tablet 02353326 CIPROFLOXACIN SAN
500MG Tablet 02386127 CIPROFLOXACIN SIV
500MG Tablet 02251280 DOM-CIPROFLOXACIN DPC
500MG Tablet 02380366 JAMP-CIPROFLOXACIN JMP
500MG Tablet 02379694 MAR-CIPROFLOXACIN MAR
500MG Tablet 02423561 MINT-CIPROFLOX MIN
500MG Tablet 02248438 PMS-CIPROFLOXACIN PMS
500MG Tablet 02445344 PRIVA-CIPROFLOXACIN PHA
500MG Tablet 02317818 PRO-CIPROFLOXACIN PDL
500MG Tablet 02251248 RIVA-CIPROFLOXACIN RIV
500MG Tablet 02248757 SANDOZ CIPROFLOXACIN SDZ
500MG Tablet 02379635 SEPTA-CIPROFLOXACIN SPT
500MG Tablet 02303736 TARO-CIPROFLOX SUN
500MG Tablet 02266970 TARO-CIPROFLOXACIN TAR
750MG Tablet 02247341 ACT CIPROFLOXACIN TEV
750MG Tablet 02229523 APO-CIPROFLOX APX
750MG Tablet 02380374 JAMP-CIPROFLOXACIN JMP
750MG Tablet 02379708 MAR-CIPROFLOXACIN MAR
750MG Tablet 02423588 MINT-CIPROFLOX MIN
750MG Tablet 02248439 PMS-CIPROFLOXACIN PMS
750MG Tablet 02251256 RIVA-CIPROFLOXACIN RIV
750MG Tablet 02248758 SANDOZ CIPROFLOXACIN SDZ
750MG Tablet 02379643 SEPTA-CIPROFLOXACIN SPT
750MG Tablet 02303744 TARO-CIPROFLOX SUN

LEVOFLOXACIN HEMIHYDRATE

Limited use benefit (prior approval not required).

Coverage will be limited to 14 tablets every 14 days, followed by a 14 day lockout.

Table: LEVOFLOXACIN HEMIHYDRATE
Drug strength and dosage form DIN Brand name Manufacturer code
250MG Tablet 02315424 ACT LEVOFLOXACIN TEV
250MG Tablet 02284707 APO-LEVOFLOXACIN APX
250MG Tablet 02284677 PMS-LEVOFLOXACIN PMS
250MG Tablet 02298635 SANDOZ LEVOFLOXACIN SDZ
500MG Tablet 02315432 ACT LEVOFLOXACIN TEV
500MG Tablet 02284715 APO-LEVOFLOXACIN APX
500MG Tablet 02415879 LEVOFLOXACIN PDL
500MG Tablet 02284685 PMS-LEVOFLOXACIN PMS
500MG Tablet 02298643 SANDOZ LEVOFLOXACIN SDZ
750MG Tablet 02315440 ACT LEVOFLOXACIN TEV
750MG Tablet 02325942 APO-LEVOFLOXACIN APX
750MG Tablet 02305585 PMS-LEVOFLOXACIN PMS
750MG Tablet 02298651 SANDOZ LEVOFLOXACIN SDZ

LEVOFLOXACIN HEMIHYDRATE (QUINSAIR)

Limited use benefit (prior approval required).

For the management of cystic fibrosis (CF) in patients 18 years or older if the following criteria are met:

  • patient has CF with chronic pulmonary Pseudomonas aeruginosa infections; and
  • prescribed by a clinician with experience in the diagnosis and treatment of CF; and
  • patient has had a previous trial of tobramycin by inhalation that has been ineffective or not tolerated or tobramycin is contraindicated; and
  • patient is not using another inhaled antibiotic(s) to treat pulmonary P. aeruginosa infections, either concurrently or for antibiotic cycling during off-treatment periods.

Note: NIHB coverage is limited to 240 mg twice daily in cycles of 28 days on followed by 28 days off.

Table: LEVOFLOXACIN HEMIHYDRATE (QUINSAIR)
Drug strength and dosage form DIN Brand name Manufacturer code
240MG Solution 02442302 QUINSAIR UNK

MOXIFLOXACIN HYDROCHLORIDE

Limited use benefit (prior approval not required).

Coverage will be limited to 14 tablets every 14 days, followed by a 14 day lockout.

Table: MOXIFLOXACIN HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
400MG Tablet 02478137 AG-MOXIFLOXACIN ANG
400MG Tablet 02404923 APO-MOXIFLOXACIN APX
400MG Tablet 02432242 AURO-MOXIFLOXACIN AUR
400MG Tablet 02447266 BIO-MOXIFLOXACIN BMI
400MG Tablet 02443929 JAMP-MOXIFLOXACIN JMP
400MG Tablet 02447061 JAMP-MOXIFLOXACIN JMP
400MG Tablet 02447053 MAR-MOXIFLOXACIN MAR
400MG Tablet 02457814 MED-MOXIFLOXACIN GMP
400MG Tablet 02472791 M-MOXIFLOXACIN MAN
400MG Tablet 02462974 MOXIFLOXACIN PDL
400MG Tablet 02450976 RIVA-MOXIFLOXACIN RIV
400MG Tablet 02383381 SANDOZ MOXIFLOXACIN SDZ
400MG Tablet 02375702 TEVA-MOXIFLOXACIN TEV

NORFLOXACIN

Table: NORFLOXACIN
Drug strength and dosage form DIN Brand name Manufacturer code
400MG Tablet 02229524 NORFLOXACIN AAP

08:12.20 SULFONAMIDES

SULFAMETHOXAZOLE, TRIMETHOPRIM

Table: SULFAMETHOXAZOLE, TRIMETHOPRIM
Drug strength and dosage form DIN Brand name Manufacturer code
40MG & 8MG/ML Suspension 00726540 TEVA-TRIMEL TEV
100MG & 20MG Tablet 00445266 SULFATRIM PEDIATRIC APX
400MG & 80MG Tablet 00445274 SULFATRIM APX
400MG & 80MG Tablet 00510637 TEVA-TRIMEL TEV
800MG & 160MG Tablet 00512524 PROTRIN DF PDL
800MG & 160MG Tablet 00445282 SULFATRIM DS APX
800MG & 160MG Tablet 00510645 TEVA-TRIMEL DS TEV

SULFASALAZINE

Table: SULFASALAZINE
Drug strength and dosage form DIN Brand name Manufacturer code
500MG Tablet 00598461 PMS-SULFASALAZINE PMS
500MG Tablet 02064480 SALAZOPYRIN PFI
500MG Tablet (Enteric Coated) 00598488 PMS-SULFASALAZINE PMS
500MG Tablet (Enteric Coated) 02064472 SALAZOPYRIN EN PFI

08:12.24 TETRACYCLINES

DOXYCYCLINE HYCLATE

Table: DOXYCYCLINE HYCLATE
Drug strength and dosage form DIN Brand name Manufacturer code
100MG Capsule 00740713 APO-DOXY APX
100MG Capsule 00817120 DOXYCIN RIV
100MG Capsule 02351234 DOXYCYCLINE SAN
100MG Capsule 00725250 TEVA-DOXYCYCLINE TEV
100MG Tablet 00874256 APO-DOXY APX
100MG Tablet 00860751 DOXYCIN RIV
100MG Tablet 02351242 DOXYCYCLINE SAN
100MG Tablet 00887064 DOXYTAB PDL
100MG Tablet 02158574 TEVA-DOXYCYCLINE TEV

MINOCYCLINE HYDROCHLORIDE

Table: MINOCYCLINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
50MG Capsule 02084090 MINOCYCLINE AAP
50MG Capsule 02108143 TEVA-MINOCYCLINE TEV
100MG Capsule 02084104 MINOCYCLINE AAP
100MG Capsule 02108151 TEVA-MINOCYCLINE TEV

TETRACYCLINE HYDROCHLORIDE

Table: TETRACYCLINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
250MG Capsule 00580929 TETRACYCLINE AAP

08:12.28 MISCELLANEOUS ANTIBIOTICS

CLINDAMYCIN HYDROCHLORIDE

Table: CLINDAMYCIN HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
150MG Capsule 02245232 APO-CLINDAMYCIN APX
150MG Capsule 02436906 AURO-CLINDAMYCIN AUR
150MG Capsule 00030570 DALACIN C PFI
150MG Capsule 02483734 JAMP CLINDAMYCIN JMP
150MG Capsule 02479923 M-CLINDAMYCIN MAN
150MG Capsule 02468476 RIVA-CLINDAMYCIN RIV
150MG Capsule 02241709 TEVA-CLINDAMYCIN TEV
300MG Capsule 02245233 APO-CLINDAMYCIN APX
300MG Capsule 02436914 AURO-CLINDAMYCIN AUR
300MG Capsule 02182866 DALACIN C PFI
300MG Capsule 02483742 JAMP CLINDAMYCIN JMP
300MG Capsule 02479931 M-CLINDAMYCIN MAN
300MG Capsule 02241710 TEVA-CLINDAMYCIN TEV
pDIN For Extemporaneous Mixture 99506008 CLINDAMYCIN STERILE INFUSION UNK

CLINDAMYCIN PALMITATE HYDROCHLORIDE

Table: CLINDAMYCIN PALMITATE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
15MG/ML Powder For Solution 00225851 DALACIN C PFI

CLINDAMYCIN PHOSPHATE

Table: CLINDAMYCIN PHOSPHATE
Drug strength and dosage form DIN Brand name Manufacturer code
150MG/ML Injection 02139286 CLINDAMYCIN FKD
150MG/ML Injection 02230535 CLINDAMYCIN SDZ
150MG/ML Injection 02230540 CLINDAMYCIN SDZ
150MG/ML Injection 00260436 DALACIN C PHOSPHATE PFI
150MG/ML Injection 02215683 NOVO-CLINDAMYCIN NOP
12MG Solution 02408511 CLINDAMYCIN IV INFUSION SDZ
18MG Solution 02408538 CLINDAMYCIN IV INFUSION SDZ

COLISTIN

Limited use benefit (prior approval required).

For the management of cystic fibrosis (CF) in patients if the following criteria are met:

  • patient has CF with chronic pulmonary Pseudomonas aeruginosa infections; and
  • prescribed by a clinician with experience in the diagnosis and treatment of CF.
Table: COLISTIN
Drug strength and dosage form DIN Brand name Manufacturer code
150MG Powder For Solution 02244849 COLISTIMETHATE FOR U.S.P RAX
150MG Powder For Solution 00476420 COLY-MYCIN M PARENTERAL ERF

LINEZOLID

Limited use benefit (prior approval required).

Tablets:

  • for treatment of proven vancomycin-resistant enterococci (VRE) infections; or
  • for the treatment of proven methicillin-resistant staphylococcus aureus (MRSA) infections in patients who cannot tolerate vancomycin.

I.V. solution:

  • when linezolid cannot be administered orally in the above mentioned situations.

Oral liquid:

  • when linezolid cannot be administered orally in the above mentioned situations;
  • plus at least one of the following:
  • for treatment of proven vancomycin-resistant enterococci (VRE) infections
  • for the treatment of proven methicillin-resistant staphylococcus aureus (MRSA) infections in patients who cannot tolerate vancomycin.
Table: LINEZOLID
Drug strength and dosage form DIN Brand name Manufacturer code
100MG Powder For Suspension 02243686 ZYVOXAM PFI
2MG Solution 02481278 LINEZOLID JMP
2MG/ML Solution 02243685 ZYVOXAM PFI
600MG Tablet 02426552 APO-LINEZOLID APX
600MG Tablet 02422689 SANDOZ LINEZOLID SDZ
600MG Tablet 02243684 ZYVOXAM PFI

RIFAXIMIN

Limited use benefit (prior approval required).

For reducing the risk of overt hepatic encephalopathy (HE) recurrence in patients:

  • who are unable to achieve adequate control of HE recurrence with a maximal tolerated dose of lactulose alone; and
  • when used in combination with a maximal tolerated dose of lactulose.
Table: RIFAXIMIN
Drug strength and dosage form DIN Brand name Manufacturer code
ST550MG Tablet 02410702 ZAXINE SLX

VANCOMYCIN HYDROCHLORIDE

Limited use benefit (prior approval required).

Used for the treatment of patients diagnosed with symptomatic Clostridium difficile infection.

Note: Oral vancomycin is not appropriate for systemic infections due to poor absorption from the GI tract.

Table: VANCOMYCIN HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
125MG Capsule 02407744 JAMP-VANCOMYCIN JMP
125MG Capsule 02430185 PMS-VANCOMYCIN PMS
125MG Capsule 00800430 VANCOCIN SEA
125MG Capsule 02377470 VANCOMYCIN FKD
125MG Capsule 02380544 VANCOMYCIN UNK
250MG Capsule 02407752 JAMP-VANCOMYCIN JMP
250MG Capsule 00788716 VANCOCIN SEA
250MG Capsule 02377489 VANCOMYCIN FKD
250MG Capsule 02380552 VANCOMYCIN UNK

VANCOMYCIN HYDROCHLORIDE (INJECTION)

Table: VANCOMYCIN HYDROCHLORIDE (INJECTION)
Drug strength and dosage form DIN Brand name Manufacturer code
500MG Powder For Solution 02139375 VANCOMYCIN FKD
500MG Powder For Solution 02230191 VANCOMYCIN PFI
500MG Powder For Solution 02394626 VANCOMYCIN SDZ
500MG Powder For Solution 02342855 VANCOMYCIN HYDROCHLORIDE RAX
1,000MG Powder For Solution 02230192 VANCOMYCIN PFI
1,000MG Powder For Solution 02396386 VANCOMYCIN RAX
1G Powder For Solution 02139383 VANCOMYCIN FKD
1G Powder For Solution 02394634 VANCOMYCIN SDZ
1G Powder For Solution 02342863 VANCOMYCIN HYDROCHLORIDE RAX
5G Powder For Solution 02139243 VANCOMYCIN FKD
5G Powder For Solution 02378337 VANCOMYCIN PFI
5G Powder For Solution 02394642 VANCOMYCIN SDZ
10G Powder For Solution 02241807 VANCOMYCIN FKD
10G Powder For Solution 02378345 VANCOMYCIN PFI
10G Powder For Solution 02394650 VANCOMYCIN SDZ
10G Powder For Solution 02405830 VANCOMYCIN HYDROCHLORIDE RAX

08:14.04 ALLYLAMINES

TERBINAFINE HYDROCHLORIDE

Table: TERBINAFINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
250MG Tablet 02254727 ACT TERBINAFINE TEV
250MG Tablet 02239893 APO-TERBINAFINE APX
250MG Tablet 02320134 AURO-TERBINAFINE AUR
250MG Tablet 02299275 DOM-TERBINAFINE DPC
250MG Tablet 02357070 JAMP-TERBINAFINE JMP
250MG Tablet 02031116 LAMISIL NVR
250MG Tablet 02294273 PMS-TERBINAFINE PMS
250MG Tablet 02262924 RIVA-TERBINAFINE RIV
250MG Tablet 02242735 TERBINAFINE PDL
250MG Tablet 02353121 TERBINAFINE SAN
250MG Tablet 02385279 TERBINAFINE SIV

08:14.08 AZOLES

FLUCONAZOLE

Table: FLUCONAZOLE
Drug strength and dosage form DIN Brand name Manufacturer code
150MG Capsule 02241895 APO-FLUCONAZOLE APX
150MG Capsule 02462168 BIO-FLUCONAZOLE BMI
150MG Capsule 02311690 CANESORAL BAY
150MG Capsule 02141442 DIFLUCAN PFI
150MG Capsule 02432471 JAMP-FLUCONAZOLE JMP
150MG Capsule 02428792 MAR-FLUCONAZOLE MAR
150MG Capsule 02243645 NOVO-FLUCONAZOLE NOP
150MG Capsule 02246620 PMS-FLUCONAZOLE PMS
150MG Capsule 02433702 PRIVA-FLUCONAZOLE PHA
150MG Capsule 02255510 RIVA-FLUCONAZOLE RIV
10MG/ML Powder For Solution 02024152 DIFLUCAN PFI
50MG Tablet 02281260 ACT FLUCONAZOLE TEV
50MG Tablet 02237370 APO-FLUCONAZOLE APX
50MG Tablet 02245292 MYLAN-FLUCONAZOLE MYL
50MG Tablet 02245643 PMS-FLUCONAZOLE PMS
50MG Tablet 02249294 TARO-FLUCONAZOLE TAR
50MG Tablet 02236978 TEVA-FLUCONAZOLE TEV
100MG Tablet 02281279 ACT FLUCONAZOLE TEV
100MG Tablet 02237371 APO-FLUCONAZOLE APX
100MG Tablet 02246109 DOM-FLUCONAZOLE DPC
100MG Tablet 02245293 MYLAN-FLUCONAZOLE MYL
100MG Tablet 02245644 PMS-FLUCONAZOLE PMS
100MG Tablet 02310686 PRO-FLUCONAZOLE PDL
100MG Tablet 02249308 TARO-FLUCONAZOLE TAR
100MG Tablet 02236979 TEVA-FLUCONAZOLE TEV

ISAVUCONAZOLE (ISAVUCONAZONIUM SULFATE)

Limited use benefit (prior approval required).

For the treatment of invasive mucormycosis (IM) in adults; or

For the treatment of invasive aspergillosis (IA) in adults when treatment with oral voriconazole has failed; or

Documented intolerance or contraindication to voriconazole.

Cresemba is to be prescribed by or in consultation with an Infectious Disease specialist.

Table: ISAVUCONAZOLE (ISAVUCONAZONIUM SULFATE)
Drug strength and dosage form DIN Brand name Manufacturer code
100MG Capsule 02483971 CRESEMBA UNK
200MG Powder For Solution 02483998 CRESEMBA UNK

ITRACONAZOLE

Table: ITRACONAZOLE
Drug strength and dosage form DIN Brand name Manufacturer code
100MG Capsule 02462559 MINT-ITRACONAZOLE MIN
100MG Capsule 02047454 SPORANOX JSO
Powder 09991094 ITRACONAZOLE PDR MDS
10MG Solution 02484315 JAMP ITRACONAZOLE JMP
10MG/ML Solution 02231347 SPORANOX JSO

KETOCONAZOLE

Table: KETOCONAZOLE
Drug strength and dosage form DIN Brand name Manufacturer code
200MG Tablet 02237235 APO-KETOCONAZOLE APX
200MG Tablet 02231061 TEVA-KETOCONAZOLE TEV

VORICONAZOLE

Limited use benefit (prior approval required).

For the treatment of patients with invasive aspergillosis; or

For the treatment of culture proven invasive candidiasis with documented resistance to fluconazole.

Table: VORICONAZOLE
Drug strength and dosage form DIN Brand name Manufacturer code
50MG Tablet 02409674 APO-VORICONAZOLE APX
50MG Tablet 02399245 SANDOZ VORICONAZOLE SDZ
50MG Tablet 02396866 TEVA-VORICONAZOLE TEV
50MG Tablet 02256460 VFEND PFI
200MG Tablet 02409682 APO-VORICONAZOLE APX
200MG Tablet 02399253 SANDOZ VORICONAZOLE SDZ
200MG Tablet 02396874 TEVA-VORICONAZOLE TEV
200MG Tablet 02256479 VFEND PFI

08:14.28 POLYENES

NYSTATIN

Table: NYSTATIN
Drug strength and dosage form DIN Brand name Manufacturer code
100000U/ML Oral Liquid 99113755 NYSTATIN 100,000U SUSP (QC) UNK
100,000U/ML Suspension 02125145 DOM-NYSTATIN DPC
100,000U/ML Suspension 02433443 JAMP-NYSTATIN JMP
100,000U/ML Suspension 00792667 PMS-NYSTATIN PMS
100,000U/ML Suspension 02194201 TEVA-NYSTATIN TEV

08:16.04 ANTITUBERCULOSIS AGENTS

ETHAMBUTOL HYDROCHLORIDE

Table: ETHAMBUTOL HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
100MG Tablet 00247960 ETIBI BSH
400MG Tablet 00247979 ETIBI BSH

ISONIAZID

Table: ISONIAZID
Drug strength and dosage form DIN Brand name Manufacturer code
10MG/ML Solution 00265500 ISOTAMINE VAE
10MG/ML Solution 00577812 PDP-ISONIAZID PED
100MG Tablet 00261270 ISOTAMINE VAE
100MG Tablet 00577790 PDP-ISONIAZID PED
300MG Tablet 00272655 ISOTAMINE VAE
300MG Tablet 00577804 PDP-ISONIAZID PED
pDIN For Extemporaneous Mixture 99503031 ISONIAZID ORAL LIQUID UNK

PYRAZINAMIDE

Table: PYRAZINAMIDE
Drug strength and dosage form DIN Brand name Manufacturer code
500MG Tablet 00618810 PDP-PYRAZINAMIDE PED
500MG Tablet 00283991 TEBRAZID VAE

RIFABUTIN

Table: RIFABUTIN
Drug strength and dosage form DIN Brand name Manufacturer code
150MG Capsule 02063786 MYCOBUTIN PFI

RIFAMPIN

Table: RIFAMPIN
Drug strength and dosage form DIN Brand name Manufacturer code
150MG Capsule 02091887 RIFADIN SAC
150MG Capsule 00393444 ROFACT UNK
300MG Capsule 02092808 RIFADIN SAC
300MG Capsule 00343617 ROFACT UNK
pDIN For Extemporaneous Mixture 99503022 RIFAMPIN ORAL LIQUID UNK

08:16.92 MISCELLANEOUS ANTIMYCOBACTERIALS

DAPSONE

Table: DAPSONE
Drug strength and dosage form DIN Brand name Manufacturer code
100MG Tablet 02041510 DAPSONE JAC
100MG Tablet 02481227 MAR-DAPSONE MAR
100MG Tablet 02489058 RIVA-DAPSONE RIV

08:18.04 ADAMANTANES

AMANTADINE HYDROCHLORIDE

Table: AMANTADINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
100MG Capsule 01990403 PMS-AMANTADINE PED
10MG/ML Syrup 02022826 PMS-AMANTADINE PED

08:18.08 ANTIRETROVIRALS

ABACAVIR SUFLATE, LAMIVUDINE

Table: ABACAVIR SUFLATE, LAMIVUDINE
Drug strength and dosage form DIN Brand name Manufacturer code
600MG & 300MG Tablet 02458381 PMS-ABACAVIR/LAMIVUDINE PMS

ABACAVIR SULFATE

Table: ABACAVIR SULFATE
Drug strength and dosage form DIN Brand name Manufacturer code
20MG/ML Solution 02240358 ZIAGEN VII
300MG Tablet 02396769 APO-ABACAVIR APX
300MG Tablet 02480956 MINT-ABACAVIR MIN
300MG Tablet 02240357 ZIAGEN VII

ABACAVIR SULFATE, LAMIVUDINE

Table: ABACAVIR SULFATE, LAMIVUDINE
Drug strength and dosage form DIN Brand name Manufacturer code
600MG & 300MG Tablet 02399539 APO-ABACAVIR-LAMIVUDINE APX
600MG & 300MG Tablet 02454513 AURO-ABACAVIR/LAMIVUDINE AUR
600MG & 300MG Tablet 02269341 KIVEXA VII
600MG & 300MG Tablet 02450682 MYLAN-ABACAVIR/LAMIVUDINE MYL
600MG & 300MG Tablet 02416662 TEVA-ABACAVIR/LAMIVUDINE TEV

ABACAVIR SULFATE, LAMIVUDINE, DOLUTEGRAVIR SODIUM

Table: ABACAVIR SULFATE, LAMIVUDINE, DOLUTEGRAVIR SODIUM
Drug strength and dosage form DIN Brand name Manufacturer code
600MG & 300MG & 50MG Tablet 02430932 TRIUMEQ VII

ABACAVIR SULFATE, LAMIVUDINE, ZIDOVUDINE

Table: ABACAVIR SULFATE, LAMIVUDINE, ZIDOVUDINE
Drug strength and dosage form DIN Brand name Manufacturer code
300MG & 150MG & 300MG Tablet 02416255 APO-ABACAVIR-LAMIVUDINE-ZIDOVUDINE APX

ATAZANAVIR SULFATE

Table: ATAZANAVIR SULFATE
Drug strength and dosage form DIN Brand name Manufacturer code
150MG Capsule 02456877 MYLAN-ATAZANAVIR MYL
150MG Capsule 02248610 REYATAZ BMS
150MG Capsule 02443791 TEVA-ATAZANAVIR TEV
200MG Capsule 02456885 MYLAN-ATAZANAVIR MYL
200MG Capsule 02248611 REYATAZ BMS
200MG Capsule 02443813 TEVA-ATAZANAVIR TEV
300MG Capsule 02456893 MYLAN-ATAZANAVIR MYL
300MG Capsule 02294176 REYATAZ BMS
300MG Capsule 02443821 TEVA-ATAZANAVIR TEV

DARUNAVIR

Table: DARUNAVIR
Drug strength and dosage form DIN Brand name Manufacturer code
600MG Tablet 02487241 APO-DARUNAVIR APX
800MG Tablet 02487268 APO-DARUNAVIR APX

DARUNAVIR (DARUNAVIR PROPYLENE GLYCOLATE)

Table: DARUNAVIR (DARUNAVIR PROPYLENE GLYCOLATE)
Drug strength and dosage form DIN Brand name Manufacturer code
600MG Tablet 02486121 AURO-DARUNAVIR AUR

DARUNAVIR ETHANOLATE

Table: DARUNAVIR ETHANOLATE
Drug strength and dosage form DIN Brand name Manufacturer code
75MG Tablet 02338432 PREZISTA JSO
150MG Tablet 02369753 PREZISTA JSO
400MG Tablet 02324016 PREZISTA JSO
600MG Tablet 02324024 PREZISTA JSO
800MG Tablet 02393050 PREZISTA JSO

DARUNAVIR ETHANOLATE, COBICISTAT

Table: DARUNAVIR ETHANOLATE, COBICISTAT
Drug strength and dosage form DIN Brand name Manufacturer code
150MG & 800MG Tablet 02426501 PREZCOBIX JSO

DOLUTEGRAVIR SODIUM

Table: DOLUTEGRAVIR SODIUM
Drug strength and dosage form DIN Brand name Manufacturer code
50MG Tablet 02414945 TIVICAY VII

DOLUTEGRAVIR SODIUM, RILPIVIRINE HYDROCHLORIDE

Table: DOLUTEGRAVIR SODIUM, RILPIVIRINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
50MG & 25MG Tablet 02475774 JULUCA VII

DORAVIRINE

Table: DORAVIRINE
Drug strength and dosage form DIN Brand name Manufacturer code
100MG Tablet 02481545 PIFELTRO FRS

EFAVIRENZ

Table: EFAVIRENZ
Drug strength and dosage form DIN Brand name Manufacturer code
50MG Capsule 02239886 SUSTIVA BMS
200MG Capsule 02239888 SUSTIVA BMS
600MG Tablet 02418428 AURO-EFAVIRENZ AUR
600MG Tablet 02458233 JAMP-EFAVIRENZ JMP
600MG Tablet 02381524 MYLAN-EFAVIRENZ MYL
600MG Tablet 02246045 SUSTIVA BMS
600MG Tablet 02389762 TEVA-EFAVIRENZ TEV

EFAVIRENZ, EMTRICITABINE, TENOFOVIR DISOPROXIL FUMARATE

Table: EFAVIRENZ, EMTRICITABINE, TENOFOVIR DISOPROXIL FUMARATE
Drug strength and dosage form DIN Brand name Manufacturer code
600MG & 200MG & 300MG Tablet 02468247 APO-EFAVIRENZ-EMTRICITABINE-TENOFOVIR APX
600MG & 200MG & 300MG Tablet 02300699 ATRIPLA GIL
600MG & 200MG & 300MG Tablet 02461412 MYLAN-EFAVIRENZ/EMTRICITABINE/TENOFOVIR DISOPROXIL FUMARATE MYL
600MG & 200MG & 300MG Tablet 02487284 PMS-EFAVIRENZ-EMTRICITABINE-TENOFOVIR PMS
600MG & 200MG & 300MG Tablet 02484676 SANDOZ EFAVIRENZ/EMTRICITABINE/TENOFOVIR SDZ
600MG & 200MG & 300MG Tablet 02393549 TEVA-EFAVIRENZ/EMTRICITABINE/TENOFOVIR TEV

EMTRICITABINE, BICTEGRAVIR (BICTEGRAVIR SODIUM), TENOFOVIR ALAFENAMIDE

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

EMTRICITABINE, COBICISTAT, ELVITEGRAVIR, TENOFOVIR ALAFENAMIDE

Table: EMTRICITABINE, COBICISTAT, ELVITEGRAVIR, TENOFOVIR ALAFENAMIDE
Drug strength and dosage form DIN Brand name Manufacturer code
200MG & 150MG & 150MG & 10MG Tablet 02449498 GENVOYA GIL

EMTRICITABINE, RILPIVIRINE HYDROCHLORIDE, TENOFOVIR ALAFENAMIDE

Table: EMTRICITABINE, RILPIVIRINE HYDROCHLORIDE, TENOFOVIR ALAFENAMIDE
Drug strength and dosage form DIN Brand name Manufacturer code
200MG & 25MG & 25MG Tablet 02461463 ODEFSEY GIL

ETRAVIRINE

Table: ETRAVIRINE
Drug strength and dosage form DIN Brand name Manufacturer code
100MG Tablet 02306778 INTELENCE JSO
200MG Tablet 02375931 INTELENCE JSO

FOSAMPRENAVIR CALCIUM

Table: FOSAMPRENAVIR CALCIUM
Drug strength and dosage form DIN Brand name Manufacturer code
50MG/ML Suspension 02261553 TELZIR VII
700MG Tablet 02261545 TELZIR VII

LAMIVUDINE

Table: LAMIVUDINE
Drug strength and dosage form DIN Brand name Manufacturer code
5MG Solution 02239194 HEPTOVIR GSK
10MG/ML Solution 02192691 3TC VII
100MG Tablet 02393239 APO-LAMIVUDINE HBV APX
100MG Tablet 02239193 HEPTOVIR GSK
150MG Tablet 02192683 3TC VII
150MG Tablet 02369052 APO-LAMIVUDINE APX
300MG Tablet 02247825 3TC VII
300MG Tablet 02369060 APO-LAMIVUDINE APX

LAMIVUDINE, DOLUTEGRAVIR SODIUM

Table: LAMIVUDINE, DOLUTEGRAVIR SODIUM
Drug strength and dosage form DIN Brand name Manufacturer code
300MG & 50MG Tablet 02491753 DOVATO VII

LAMIVUDINE, TENOFOVIR DISOPROXIL FUMARATE, DORAVIRINE

Table: LAMIVUDINE, TENOFOVIR DISOPROXIL FUMARATE, DORAVIRINE
Drug strength and dosage form DIN Brand name Manufacturer code
300MG & 300MG & 100MG Tablet 02482592 DELSTRIGO FRS

LAMIVUDINE, ZIDOVUDINE

Table: LAMIVUDINE, ZIDOVUDINE
Drug strength and dosage form DIN Brand name Manufacturer code
150MG & 300MG Tablet 02375540 APO-LAMIVUDINE-ZIDOVUDINE APX
150MG & 300MG Tablet 02414414 AURO-LAMIVUDINE/ZIDOVUDINE AUR
150MG & 300MG Tablet 02239213 COMBIVIR VII
150MG & 300MG Tablet 02387247 TEVA-LAMIVUDINE/ZIDOVUDINE TEV

LOPINAVIR, RITONAVIR

Table: LOPINAVIR, RITONAVIR
Drug strength and dosage form DIN Brand name Manufacturer code
80MG & 20MG/ML Solution 02243644 KALETRA ABV
100MG & 25MG Tablet 02312301 KALETRA ABV
200MG & 50MG Tablet 02285533 KALETRA ABV

MARAVIROC

Table: MARAVIROC
Drug strength and dosage form DIN Brand name Manufacturer code
150MG Tablet 02299844 CELSENTRI VII
300MG Tablet 02299852 CELSENTRI VII

NELFINAVIR MESYLATE

Table: NELFINAVIR MESYLATE
Drug strength and dosage form DIN Brand name Manufacturer code
50MG/G Powder 02238618 VIRACEPT PFI
250MG Tablet 02238617 VIRACEPT PFI
625MG Tablet 02248761 VIRACEPT PFI

NEVIRAPINE

Table: NEVIRAPINE
Drug strength and dosage form DIN Brand name Manufacturer code
200MG Tablet 02318601 AURO-NEVIRAPINE APL
200MG Tablet 02405776 JAMP NEVIRAPINE JMP
200MG Tablet 02387727 MYLAN-NEVIRAPINE MYL
400MG Tablet (Extended Release) 02427931 APO-NEVIRAPINE XR APX

RALTEGRAVIR POTASSIUM

Table: RALTEGRAVIR POTASSIUM
Drug strength and dosage form DIN Brand name Manufacturer code
400MG Tablet 02301881 ISENTRESS FRS

RILPIVIRINE HYDROCHLORIDE

Table: RILPIVIRINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
25MG Tablet 02370603 EDURANT JSO

RITONAVIR

Table: RITONAVIR
Drug strength and dosage form DIN Brand name Manufacturer code
100MG Tablet 02357593 NORVIR ABV

SAQUINAVIR MESYLATE

Table: SAQUINAVIR MESYLATE
Drug strength and dosage form DIN Brand name Manufacturer code
500MG Tablet 02279320 INVIRASE HLR

TENOFOVIR DISOPROXIL FUMARATE

Limited use benefit (prior approval required).

For the treatment of patients with HIV-1 infection who have failed or have experienced adverse events to an alternative agent; or

For the treatment of patients with chronic hepatitis B infection who have cirrhosis documented on radiologic or histologic grounds and a HBV concentration above 2,000 IU/mL.

Table: TENOFOVIR DISOPROXIL FUMARATE
Drug strength and dosage form DIN Brand name Manufacturer code
245MG Tablet 02247128 VIREAD GIL
300MG Tablet 02451980 APO-TENOFOVIR APX
300MG Tablet 02460173 AURO-TENOFOVIR AUR
300MG Tablet 02479087 JAMP-TENOFOVIR JMP
300MG Tablet 02452634 MYLAN-TENOFOVIR DISOPROXIL MYL
300MG Tablet 02472511 NAT-TENOFOVIR NPH
300MG Tablet 02453940 PMS-TENOFOVIR PMS
300MG Tablet 02403889 TEVA-TENOFOVIR TEV

TENOFOVIR DISOPROXIL FUMARATE, EMTRICITABINE

Table: TENOFOVIR DISOPROXIL FUMARATE, EMTRICITABINE
Drug strength and dosage form DIN Brand name Manufacturer code
200MG & 300MG Tablet 02274906 TRUVADA GIL
300MG & 200MG Tablet 02452006 APO-EMTRICITABINE-TENOFOVIR APX
300MG & 200MG Tablet 02487012 JAMP EMTRICITABINE/TENOFOVIR DISOPROXIL FUMARATE JMP
300MG & 200MG Tablet 02443902 MYLAN-EMTRICITABINE/TENOFOVIR DISOPROXIL MYL
300MG & 200MG Tablet 02461110 PMS-EMTRICITABINE-TENOFOVIR PMS
300MG & 200MG Tablet 02399059 TEVA-EMTRICITABINE/TENOFOVIR TEV

TENOFOVIR DISOPROXIL FUMARATE, EMTRICITABINE, COBICISTAT, ELVITEGRAVIR

Table: TENOFOVIR DISOPROXIL FUMARATE, EMTRICITABINE, COBICISTAT, ELVITEGRAVIR
Drug strength and dosage form DIN Brand name Manufacturer code
150MG & 200MG & 150MG & 300MG Tablet 02397137 STRIBILD GIL

TENOFOVIR DISOPROXIL FUMARATE, EMTRICITABINE, RILPIVIRINE HYDROCHLORIDE

Table: TENOFOVIR DISOPROXIL FUMARATE, EMTRICITABINE, RILPIVIRINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
200MG & 25MG & 300MG Tablet 02374129 COMPLERA GIL

TIPRANAVIR

Table: TIPRANAVIR
Drug strength and dosage form DIN Brand name Manufacturer code
250MG Capsule 02273322 APTIVUS BOE

ZIDOVUDINE

Table: ZIDOVUDINE
Drug strength and dosage form DIN Brand name Manufacturer code
100MG Capsule 01946323 APO-ZIDOVUDINE APX
100MG Capsule 01902660 RETROVIR VII
10MG/ML Syrup 01902652 RETROVIR VII

08:18.20 INTERFERONS

INTERFERON ALFA-2B

Table: INTERFERON ALFA-2B
Drug strength and dosage form DIN Brand name Manufacturer code
6,000,000IU/ML Solution 02238674 INTRON A FRS
10,000,000IU/ML Solution 02238675 INTRON A FRS
10,000,000IU/VIAL Solution 02223406 INTRON A FRS

PEGINTERFERON ALFA-2A

Limited use benefit (prior approval required).

For the treatment of patients with chronic hepatitis B infection who have a HBV DNA concentration above 2,000 IU/mL without decompensated cirrhosis, upon the written request of a hepatologist or other specialist in this area.

Table: PEGINTERFERON ALFA-2A
Drug strength and dosage form DIN Brand name Manufacturer code
180MCG/0.5ML Solution 02248077 PEGASYS HLR

PEGINTERFERON ALFA-2B, RIBAVIRIN

Limited use benefit (prior approval required).

For the treatment of chronic hepatitis C in patients who are treatment naïve, upon the written request of a hepatologist or other specialist in this area.

  • for genotypes 1, 4, 5 and 6, an initial 24 week supply will be approved. A further 24 week supply may be approved if patient has a viral reduction of at least 2 logs or HCV is undetectable at 12 weeks (48 weeks total); or
  • for genotypes 2 or 3, initial coverage for a maximum of 24 weeks will be approved. Renewals will not be covered.
Table: PEGINTERFERON ALFA-2B, RIBAVIRIN
Drug strength and dosage form DIN Brand name Manufacturer code
50MCG/0.5ML & 200MG Kit 02254573 PEGETRON KIT FRS

PEGINTERFERON BETA-1A

Limited use benefit (prior approval required).

As a first-line therapy for the treatment of relapsing remitting multiple sclerosis (RRMS) diagnosed according to the 2017 McDonald clinical criteria and magnetic resonance imaging (MRI) evidence, when prescribed by a neurologist experienced in the management of RRMS.

And for patients who meet all of the following criteria:

  • patient has had a clinical relapse and/or new MRI activity in the last two years; and
  • patient is fully ambulatory for 100 meters without aids; and
  • patient is 18 years of age or older.
Table: PEGINTERFERON BETA-1A
Drug strength and dosage form DIN Brand name Manufacturer code
94MCG Injection 02444402 PLEGRIDY UNK
125MCG Liquid 02444399 PLEGRIDY UNK

08:18.28 NEURAMINIDASE INHIBITORS

OSELTAMIVIR

Table: OSELTAMIVIR
Drug strength and dosage form DIN Brand name Manufacturer code
30MG Capsule 02472635 NAT-OSELTAMIVIR NPH
30MG Capsule 02304848 TAMIFLU HLR
45MG Capsule 02472643 NAT-OSELTAMIVIR NPH
45MG Capsule 02304856 TAMIFLU HLR
75MG Capsule 02241472 TAMIFLU HLR
6MG Powder For Suspension 02381842 TAMIFLU HLR

08:18.32 NUCLEOSIDES AND NUCLEOTIDES

ACYCLOVIR

Table: ACYCLOVIR
Drug strength and dosage form DIN Brand name Manufacturer code
40MG/ML Suspension 00886157 ZOVIRAX GSK
200MG Tablet 02207621 APO-ACYCLOVIR APX
200MG Tablet 02242784 MYLAN-ACYCLOVIR MYL
200MG Tablet 02285959 TEVA-ACYCLOVIR TEV
400MG Tablet 02207648 APO-ACYCLOVIR APX
400MG Tablet 02242463 MYLAN-ACYCLOVIR MYL
400MG Tablet 02285967 TEVA-ACYCLOVIR TEV
800MG Tablet 02207656 APO-ACYCLOVIR APX
800MG Tablet 02242464 MYLAN-ACYCLOVIR MYL
800MG Tablet 02285975 TEVA-ACYCLOVIR TEV

ADEFOVIR DIPIVOXIL

Limited use benefit (prior approval required).

For the treatment of chronic hepatitis B infection when used in combination with lamivudine in patients who have developed failure to lamivudine, as defined by an increase in HBV DNA of ≥ 1 log10 IU/mL above the nadir, measured on two separate occasions within an interval of at least one month, after the first three months of lamivudine therapy, and when failure to lamivudine is not due to poor adherence to therapy.

Table: ADEFOVIR DIPIVOXIL
Drug strength and dosage form DIN Brand name Manufacturer code
10MG Tablet 02420333 APO-ADEFOVIR APX
10MG Tablet 02247823 HEPSERA GIL

ENTECAVIR MONOHYDRATE

Limited use benefit (prior approval required).

For the treatment of chronic hepatitis B infection in patients with cirrhosis documented on radiologic or histologic grounds and a HBV DNA concentration above 2000IU/mL.

Table: ENTECAVIR MONOHYDRATE
Drug strength and dosage form DIN Brand name Manufacturer code
0.5MG Tablet 02396955 APO-ENTECAVIR APX
0.5MG Tablet 02448777 AURO-ENTECAVIR AUR
0.5MG Tablet 02282224 BARACLUDE BMS
0.5MG Tablet 02467232 JAMP ENTECAVIR JMP
0.5MG Tablet 02430576 PMS-ENTECAVIR PMS

FAMCICLOVIR

Table: FAMCICLOVIR
Drug strength and dosage form DIN Brand name Manufacturer code
125MG Tablet 02305682 ACT FAMCICLOVIR ACG
125MG Tablet 02292025 APO-FAMCICLOVIR APX
125MG Tablet 02229110 FAMVIR APU
125MG Tablet 02278081 PMS-FAMCICLOVIR PMS
125MG Tablet 02278634 SANDOZ FAMCICLOVIR SDZ
250MG Tablet 02305690 ACT FAMCICLOVIR ACG
250MG Tablet 02292041 APO-FAMCICLOVIR APX
250MG Tablet 02229129 FAMVIR APU
250MG Tablet 02278103 PMS-FAMCICLOVIR PMS
250MG Tablet 02278642 SANDOZ FAMCICLOVIR SDZ
500MG Tablet 02305704 ACT FAMCICLOVIR ACG
500MG Tablet 02292068 APO-FAMCICLOVIR APX
500MG Tablet 02177102 FAMVIR APU
500MG Tablet 02278111 PMS-FAMCICLOVIR PMS
500MG Tablet 02278650 SANDOZ FAMCICLOVIR SDZ

GANCICLOVIR SODIUM

Table: GANCICLOVIR SODIUM
Drug strength and dosage form DIN Brand name Manufacturer code
500MG Powder For Solution 02162695 CYTOVENE CHE

VALACYCLOVIR HYDROCHLORIDE

Table: VALACYCLOVIR HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
500MG Tablet 02295822 APO-VALACYCLOVIR APX
500MG Tablet 02405040 AURO-VALACYCLOVIR AUR
500MG Tablet 02307936 DOM-VALACYCLOVIR DPC
500MG Tablet 02441454 JAMP-VALACYCLOVIR JMP
500MG Tablet 02351579 MYLAN-VALACYCLOVIR MYL
500MG Tablet 02298457 PMS-VALACYCLOVIR PMS
500MG Tablet 02441861 PRIVA-VALACYCLOVIR PHA
500MG Tablet 02315173 PRO-VALACYCLOVIR PDL
500MG Tablet 02316447 RIVA-VALACYCLOVIR RIV
500MG Tablet 02347091 SANDOZ VALACYCLOVIR SDZ
500MG Tablet 02357534 TEVA-VALACYCLOVIR TEV
500MG Tablet 02442000 VALACYCLOVIR SIV
500MG Tablet 02454645 VALACYCLOVIR SAN
500MG Tablet 02219492 VALTREX GSK

VALGANCICLOVIR HYDROCHLORIDE

Table: VALGANCICLOVIR HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
50MG Powder For Solution 02306085 VALCYTE HLR
450MG Tablet 02435179 AURO-VALGANCICLOVIR AUR
450MG Tablet 02413825 TEVA-VALGANCICLOVIR TEV
450MG Tablet 02245777 VALCYTE HLR

08:18.40 HCV ANTIVIRALS

ELBASVIR, GRAZOPREVIR

Limited use benefit (prior approval required).

For adult patients with chronic hepatitis C infection at any fibrosis stage (F0-F4) who meet all of the following criteria:

  • treatment is prescribed by a hepatologist, gastroenterologist, or infectious disease specialist (or other prescriber experienced in treating patients with chronic hepatitis C); and
  • laboratory confirmed quantitative HCV RNA level taken in the last 12 months;

Retreatment for failure or re-infection in patients who have received an adequate prior course of direct-acting antivirals will be considered on a case-by-case basis.

Table: ELBASVIR, GRAZOPREVIR
Drug strength and dosage form DIN Brand name Manufacturer code
50MG & 100MG Tablet 02451131 ZEPATIER FRS

GLECAPREVIR, PIBRENTASVIR

Limited use benefit (prior approval required).

For treatment-naïve or treatment-experienced adult patients with genotypes 1, 2, 3, 4, 5, 6 with; or

For the treatment of direct acting antivirals (DAA)-experienced2 adult patients with genotype 1 with:

  • chronic hepatitis C at any fibrosis stage (F0-F4); and
  • detectable levels of HCV RNA in the last 12 months;

For genotypes 1, 2, 3, 4, 5 or 6, treatment-experienced is defined as a patient who has been previously treated with interferon, peginterferon (P), ribavirin (R) and/or sofosbuvir (SOF) (PR, SOF + PR, SOF + RBV), but no prior treatment experience with an NS3/4A protease inhibitor or NS5A inhibitor.

  • For genotype 1, DAA treatment-experienced is defined as a patient who has been previously treated with DAA regimens containing NS5A inhibitor [daclatasvir (DCV) + SOF or DCV + PR or ledipasvir/sofosbuvir, but no prior treatment experience with NS3/4A protease inhibitors] or containing NS3/4A protease inhibitors [simeprevir+SOF or simeprevir+PR or boceprevir+PR or telaprevir+PR, but no prior treatment experience with an NS5Ainhibitor].
Table: GLECAPREVIR, PIBRENTASVIR
Drug strength and dosage form DIN Brand name Manufacturer code
100MG & 40MG Tablet 02467550 MAVIRET ABV

RIBAVIRIN

Limited use benefit (prior approval required).

For adult patients with chronic hepatitis C infection at any fibrosis stage (F0-F4) who meet all of the following criteria:

  • treatment is prescribed by a hepatologist, gastroenterologist, or infectious disease specialist (or other prescriber experienced in treating patients with chronic hepatitis C); and
  • laboratory confirmed quantitative HCV RNA level taken in the last 12 months;

Retreatment for failure or re-infection in patients who have received an adequate prior course of direct-acting antivirals will be considered on a case-by-case basis.

Table: RIBAVIRIN
Drug strength and dosage form DIN Brand name Manufacturer code
200MG Tablet 02439212 IBAVYR PED
400MG Tablet 02425890 IBAVYR PED
600MG Tablet 02425904 IBAVYR PED

SOFOSBUVIR

Limited use benefit (prior approval required).

For adult patients with chronic hepatitis C infection at any fibrosis stage (F0-F4) who meet all of the following criteria:

  • treatment is prescribed by a hepatologist, gastroenterologist, or infectious disease specialist (or other prescriber experienced in treating patients with chronic hepatitis C); and
  • laboratory confirmed quantitative HCV RNA level taken in the last 12 months;

Retreatment for failure or re-infection in patients who have received an adequate prior course of direct-acting antivirals will be considered on a case-by-case basis.

Table: SOFOSBUVIR
Drug strength and dosage form DIN Brand name Manufacturer code
400MG Tablet 02418355 SOVALDI GIL

SOFOSBUVIR, LEDIPASVIR

Limited use benefit (prior approval required).

For adult patients with chronic hepatitis C infection at any fibrosis stage (F0-F4) who meet all of the following criteria:

  • treatment is prescribed by a hepatologist, gastroenterologist, or infectious disease specialist (or other prescriber experienced in treating patients with chronic hepatitis C); and
  • laboratory confirmed quantitative HCV RNA level taken in the last 12 months;

Retreatment for failure or re-infection in patients who have received an adequate prior course of direct-acting antivirals will be considered on a case-by-case basis.

Table: SOFOSBUVIR, LEDIPASVIR
Drug strength and dosage form DIN Brand name Manufacturer code
400MG & 90MG Tablet 02432226 HARVONI GIL

SOFOSBUVIR, VELPATASVIR

Limited use benefit (prior approval required).

For adult patients with chronic hepatitis C infection at any fibrosis stage (F0-F4) who meet all of the following criteria:

  • treatment is prescribed by a hepatologist, gastroenterologist, or infectious disease specialist (or other prescriber experienced in treating patients with chronic hepatitis C); and
  • laboratory confirmed quantitative HCV RNA level taken in the last 12 months;

Retreatment for failure or re-infection in patients who have received an adequate prior course of direct-acting antivirals will be considered on a case-by-case basis.

Table: SOFOSBUVIR, VELPATASVIR
Drug strength and dosage form DIN Brand name Manufacturer code
400MG & 100MG Tablet 02456370 EPCLUSA GIL

SOFOSBUVIR, VELPATASVIR, VOXILAPREVIR

Limited use benefit (prior approval required).

For treatment-experienced adult patients with:

  • chronic hepatitis C at any fibrosis stage (F0-F4); and
  • detectable levels of HCV RNA in the last 12 months;
  • and
  • treatment-experienced having failed a prior therapy with an HCV regimen containing:
  • NS5A inhibitor: daclatasvir (Daklinza), elbasvir (part of Zepatier), ledipasvir (part of Harvoni), ombitasvir (part of Holkira Pak ), velpatasvir (part of Epclusa ) for genotype 1, 2, 3, 4, 5 or 6; or
  • sofosbuvir (Sovaldi) without an NS5A inhibitor for genotype 1, 2, 3 or 4.
Table: SOFOSBUVIR, VELPATASVIR, VOXILAPREVIR
Drug strength and dosage form DIN Brand name Manufacturer code
400MG & 100MG & 100MG Tablet 02467542 VOSEVI GIL

08:30.04 AMEBICIDES

PAROMOMYCIN SULFATE

Table: PAROMOMYCIN SULFATE
Drug strength and dosage form DIN Brand name Manufacturer code
250MG Capsule 02078759 HUMATIN ERF

08:30.08 ANTIMALARIALS

CHLOROQUINE PHOSPHATE

Table: CHLOROQUINE PHOSPHATE
Drug strength and dosage form DIN Brand name Manufacturer code
250MG Tablet 99105293 CHLOROQUINE (PHOS.) (PQ) UNK
250MG Tablet 00021261 TEVA-CHLOROQUINE TEV

HYDROXYCHLOROQUINE SULFATE

Table: HYDROXYCHLOROQUINE SULFATE
Drug strength and dosage form DIN Brand name Manufacturer code
200MG Tablet 02246691 APO-HYDROXYQUINE APX
200MG Tablet 02491427 JAMP HYDROXYCHLOROQUINE SULFATE JMP
200MG Tablet 02424991 MINT-HYDROXYCHLOROQUINE MIN
200MG Tablet 02017709 PLAQUENIL SAC

PRIMAQUINE PHOSPHATE

Table: PRIMAQUINE PHOSPHATE
Drug strength and dosage form DIN Brand name Manufacturer code
26.3MG Tablet 02017776 PRIMAQUINE SAC

08:30.92 MISCELLANEOUS ANTIPROTOZOALS

ATOVAQUONE

Table: ATOVAQUONE
Drug strength and dosage form DIN Brand name Manufacturer code
150MG/ML Suspension 02217422 MEPRON GSK

METRONIDAZOLE

Table: METRONIDAZOLE
Drug strength and dosage form DIN Brand name Manufacturer code
500MG Capsule 02248562 APO-METRONIDAZOLE APX
500MG Capsule 02470284 AURO-METRONIDAZOLE AUR
500MG Capsule 01926853 FLAGYL ODN
250MG Tablet 00545066 METRONIDAZOLE AAP
pDIN For Extemporaneous Mixture 99503012 METRONIDAZOLE ORAL LIQUID UNK

08:36.00 URINARY ANTI-INFECTIVES

FOSFOMYCIN TROMETHAMINE

Table: FOSFOMYCIN TROMETHAMINE
Drug strength and dosage form DIN Brand name Manufacturer code
3G/PK Powder For Solution 02240335 MONUROL PAL
3G Powder For Solution 02473801 JAMP-FOSFOMYCIN JMP

NITROFURANTOIN

Table: NITROFURANTOIN
Drug strength and dosage form DIN Brand name Manufacturer code
100MG Capsule 02063662 MACROBID ALL
100MG Capsule 02455676 PMS-NITROFURANTOIN PMS
50MG Capsule (Delayed Release) 02231015 TEVA-NITROFURANTOIN TEV
100MG Capsule (Delayed Release) 02231016 TEVA-NITROFURANTOIN TEV
50MG Tablet 00319511 NITROFURANTOIN AAP
100MG Tablet 00312738 NITROFURANTOIN AAP
pDIN For Extemporaneous Mixture 99503004 NITRO-FURANTOIN ORAL LIQUID UNK

TRIMETHOPRIM

Table: TRIMETHOPRIM
Drug strength and dosage form DIN Brand name Manufacturer code
100MG Tablet 02243116 TRIMETHOPRIM AAP
200MG Tablet 02243117 TRIMETHOPRIM AAP
pDIN For Extemporaneous Mixture 99503017 TRIMETHOPRIM ORAL LIQUID UNK
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