28:00 Central Nervous System Agents

28:08.04 NONSTEROIDAL ANTI-INFLAMMATORY AGENTS

ACETYLSALICYLIC ACID

Limited use benefit (prior approval is not required).

ASA 80 mg tablets are a benefit to clients age 21 years and under to allow access for use in pediatric conditions (e.g. Kawasaki syndrome).

Table: ACETYLSALICYLIC ACID
Drug strength and dosage form DIN Brand name Manufacturer code
150MG Suppository 00785547 ASA PMS
650MG Suppository 00582867 ASA PMS
ST80MG Tablet 02269139 ACETYLSALICYLIC ACID JMP
ST80MG Tablet 02295563 LOWPRIN EUR
ST80MG Tablet 02202360 RIVASA RIV
ST325MG Tablet 00472468 APO ASA APX
ST325MG Tablet 00530336 ASA VTH
ST325MG Tablet 02150328 ASPIRIN BAY
ST80MG Tablet (Chewable) 02009013 ASAPHEN PMS
ST80MG Tablet (Chewable) 02280167 ASATAB ODN
ST80MG Tablet (Chewable) 02250675 EURO-ASA EUR
ST80MG Tablet (Chewable) 02296004 LOWPRIN SDZ
ST80MG Tablet (Chewable) 02429950 M-ASA MAN
ST80MG Tablet (Chewable) 02311518 PRO-AAS PDL
ST80MG Tablet (Chewable) 02202352 RIVASA RIV
ST81MG Tablet (Chewable) 02394790 ASA DAILY LOW DOSE PMS
ST81MG Tablet (Chewable) 02243974 ENTROPHEN PED
ST80MG Tablet (Delayed Release) 02427176 ASA EC SAN
ST80MG Tablet (Delayed Release) 02238545 ASAPHEN PMS
ST80MG Tablet (Delayed Release) 02283905 JAMP-ASA JMP
ST80MG Tablet (Delayed Release) 02311496 PRO-AAS PDL
ST80MG Tablet (Delayed Release) 02485222 RIVASA EC RIV
ST81MG Tablet (Delayed Release) 02461471 APO-ASA LD APX
ST81MG Tablet (Delayed Release) 02244993 ASA PMS
ST81MG Tablet (Delayed Release) 02372177 ASA VTH
ST81MG Tablet (Delayed Release) 02433044 ASA PMS
ST81MG Tablet (Delayed Release) 02449277 ASA TLI
ST81MG Tablet (Delayed Release) 02377683 ASA DAILY LOW DOSE APX
ST81MG Tablet (Delayed Release) 02426811 ASA EC SAN
ST81MG Tablet (Delayed Release) 02242281 ENTROPHEN PED
ST81MG Tablet (Delayed Release) 02283700 PRAXIS ASA DAILY LOW DOSE PMS
ST81MG Tablet (Delayed Release) 02420279 RIVASA EC RIV
ST162MG Tablet (Delayed Release) 02247550 ASAPHEN EC PMS
ST325MG Tablet (Delayed Release) 02010526 ASA VTH
ST325MG Tablet (Delayed Release) 02352427 ASATAB EC ODN
ST325MG Tablet (Delayed Release) 02150417 ASPIRIN BAY
ST325MG Tablet (Delayed Release) 00010332 ENTROPHEN PED
ST325MG Tablet (Delayed Release) 02050161 ENTROPHEN PED
ST325MG Tablet (Delayed Release) 00216666 NOVASEN TEV
ST650MG Tablet (Delayed Release) 00794244 ASA VTH
ST650MG Tablet (Delayed Release) 02352435 ASATAB EC ODN
ST650MG Tablet (Delayed Release) 00229296 NOVASEN TEV
ST650MG Tablet (Delayed Release) 02284537 PMS-ASA EC PMS
ST81MG Tablet (Enteric Coated) 02243896 ASA DAILY LOW DOSE PMS
ST81MG Tablet (Enteric Coated) 02237726 ASPIRIN BAY
ST81MG Tablet (Enteric Coated) 02243801 EQUATE DAILY LOW-DOSE PMS
ST81MG Tablet (Enteric Coated) 02427206 JAMP-ASA EC VTH
ST325MG Tablet (Enteric Coated) 00510696 ASA APX
ST325MG Tablet (Enteric Coated) 02285371 PMS-ASA EC PMS
ST650MG Tablet (Enteric Coated) 00472476 ASA APX
ST650MG Tablet (Enteric Coated) 00010340 ENTROPHEN PED
ST650MG Tablet (Enteric Coated) 01905392 ENTROPHEN PED

CELECOXIB

Table: CELECOXIB
Drug strength and dosage form DIN Brand name Manufacturer code
ST100MG Capsule 02420155 ACT CELECOXIB TEV
ST100MG Capsule 02437570 AG-CELECOXIB ANG
ST100MG Capsule 02418932 APO-CELECOXIB APX
ST100MG Capsule 02445670 AURO-CELECOXIB AUR
ST100MG Capsule 02426382 BIO-CELECOXIB BMI
ST100MG Capsule 02239941 CELEBREX UNK
ST100MG Capsule 02424371 CELECOXIB PDL
ST100MG Capsule 02429675 CELECOXIB SIV
ST100MG Capsule 02436299 CELECOXIB SAN
ST100MG Capsule 02424533 JAMP-CELECOXIB JMP
ST100MG Capsule 02420058 MAR-CELECOXIB MAR
ST100MG Capsule 02412497 MINT-CELECOXIB MIN
100MG Capsule 02479737 NRA-CELECOXIB UNK
ST100MG Capsule 02355442 PMS-CELECOXIB PMS
ST100MG Capsule 02426366 PRIVA-CELECOXIB PHA
ST100MG Capsule 02412373 RAN-CELECOXIB RBY
ST100MG Capsule 02425386 RIVA-CELECOX RIV
100MG Capsule 02442639 SDZ CELECOXIB SDZ
ST200MG Capsule 02420163 ACT CELECOXIB TEV
ST200MG Capsule 02437589 AG-CELECOXIB ANG
ST200MG Capsule 02418940 APO-CELECOXIB APX
ST200MG Capsule 02445689 AURO-CELECOXIB AUR
ST200MG Capsule 02426390 BIO-CELECOXIB BMI
ST200MG Capsule 02239942 CELEBREX UNK
ST200MG Capsule 02424398 CELECOXIB PDL
ST200MG Capsule 02429683 CELECOXIB SIV
ST200MG Capsule 02436302 CELECOXIB SAN
ST200MG Capsule 02424541 JAMP-CELECOXIB JMP
ST200MG Capsule 02420066 MAR-CELECOXIB MAR
ST200MG Capsule 02412500 MINT-CELECOXIB MIN
200MG Capsule 02479745 NRA-CELECOXIB UNK
ST200MG Capsule 02355450 PMS-CELECOXIB PMS
ST200MG Capsule 02426374 PRIVA-CELECOXIB PHA
ST200MG Capsule 02412381 RAN-CELECOXIB RBY
ST200MG Capsule 02425394 RIVA-CELECOX RIV
ST200MG Capsule 02442647 SDZ CELECOXIB SDZ

DICLOFENAC DIETHYLAMINE

Limited use benefit (prior approval not required).

Coverage is limited to 100 grams per month.

Table: DICLOFENAC DIETHYLAMINE
Drug strength and dosage form DIN Brand name Manufacturer code
1.16% Gel 02290375 VOLTAREN EMULGEL GSK
1.16% Gel 02338580 VOLTAREN EMULGEL JOINT PAIN REGULAR STRENGTH GSK
2.32% Gel 02393190 VOLTAREN EMULGEL EXTRA STRENGTH GSK

DICLOFENAC SODIUM

Table: DICLOFENAC SODIUM
Drug strength and dosage form DIN Brand name Manufacturer code
50MG Suppository 02231506 PMS-DICLOFENAC PMS
50MG Suppository 02261928 SANDOZ-DICLOFENAC SDZ
50MG Suppository 00632724 VOLTAREN NVR
100MG Suppository 02231508 PMS-DICLOFENAC PMS
100MG Suppository 02261936 SANDOZ-DICLOFENAC SDZ
100MG Suppository 00632732 VOLTAREN NVR
ST25MG Tablet (Delayed Release) 02231662 DOM-DICLOFENAC DPC
ST25MG Tablet (Delayed Release) 02302616 PMS-DICLOFENAC PMS
ST50MG Tablet (Delayed Release) 02231663 DOM-DICLOFENAC DPC
ST50MG Tablet (Delayed Release) 02302624 PMS-DICLOFENAC PMS
ST50MG Tablet (Delayed Release) 02261960 SANDOZ-DICLOFENAC SDZ
ST50MG Tablet (Delayed Release) 00514012 VOLTAREN NVR
ST25MG Tablet (Enteric Coated) 00839175 APO-DICLO APX
ST25MG Tablet (Enteric Coated) 00808539 TEVA-DICLOFENAC TEV
ST50MG Tablet (Enteric Coated) 00839183 APO-DICLO APX
ST50MG Tablet (Enteric Coated) 00870978 DICLOFENAC PDL
ST50MG Tablet (Enteric Coated) 02352397 DICLOFENAC EC SAN
ST50MG Tablet (Enteric Coated) 02231503 PMS-DICLOFENAC PMS
ST50MG Tablet (Enteric Coated) 00808547 TEVA-DICLOFENAC TEV
ST75MG Tablet (Extended Release) 02162814 APO-DICLO SR APX
ST75MG Tablet (Extended Release) 02224119 DICLOFENAC-SR PDL
ST75MG Tablet (Extended Release) 02231664 DOM-DICLOFENAC SR DPC
ST75MG Tablet (Extended Release) 02231504 PMS-DICLOFENAC PMS
ST75MG Tablet (Extended Release) 02261901 SANDOZ-DICLOFENAC SR SDZ
ST75MG Tablet (Extended Release) 02158582 TEVA-DICLOFENAC SR TEV
ST75MG Tablet (Extended Release) 00782459 VOLTAREN NVR
ST100MG Tablet (Extended Release) 02091194 APO-DICLO SR APX
ST100MG Tablet (Extended Release) 02224127 DICLOFENAC-SR PDL
ST100MG Tablet (Extended Release) 02231505 PMS-DICLOFENAC PMS
ST100MG Tablet (Extended Release) 02261944 SANDOZ-DICLOFENAC SR SDZ
ST100MG Tablet (Extended Release) 00590827 VOLTAREN SR NVR

DICLOFENAC SODIUM (TOPICAL)

Limited use benefit (prior approval required).

For the treatment of osteoarthritis when:

  • pain is inadequately controlled with acetaminophen and a non-steroidal anti-inflammatory (NSAID); or
  • there is contraindication to acetaminophen and NSAID; or
  • there is intolerance to acetaminophen and NSAID.
Table: DICLOFENAC SODIUM (TOPICAL)
Drug strength and dosage form DIN Brand name Manufacturer code
ST1.5% Solution 02354403 APO-DICLOFENAC APX
ST1.5% Solution 02476134 DICLOFENAC SODIUM TEL
ST1.5% Solution 02434571 DICLOFENAC TOPICAL RAX
ST1.5% Solution 02472309 JAMP DICLOFENAC TOPICAL JMP
ST1.5% Solution 02356783 PMS-DICLOFENAC PMS
ST1.5% Solution 02420988 TARO-DICLOFENAC TAR

DIFLUNISAL

Table: DIFLUNISAL
Drug strength and dosage form DIN Brand name Manufacturer code
ST250MG Tablet 02039486 DIFLUNISAL AAP
ST500MG Tablet 02039494 DIFLUNISAL AAP

FLURBIPROFEN

Table: FLURBIPROFEN
Drug strength and dosage form DIN Brand name Manufacturer code
ST50MG Tablet 01912046 APO-FLURBIPROFEN AAP
ST100MG Tablet 01912038 APO-FLURBIPROFEN AAP
ST100MG Tablet 02100517 TEVA-FLURBIPROFEN TEV

IBUPROFEN

Table: IBUPROFEN
Drug strength and dosage form DIN Brand name Manufacturer code
ST40MG Drop 02328445 ADVIL PEDIATRIC DROPS FEVER FROM COLDS OR FLU PFI
ST40MG/ML Drop 02242522 ADVIL PEDIATRIC DROPS PFI
ST40MG/ML Drop 02238626 CHILDREN'S MOTRIN MCL
ST20MG/ML Suspension 02232297 CHILDREN'S ADVIL PFI
ST20MG/ML Suspension 02354799 CHILDREN'S EUROPROFEN PED
ST20MG/ML Suspension 02242365 CHILDREN'S MOTRIN MCL
ST100MG Suspension 02328437 CHILDREN'S ADVIL FEVER FROM COLDS OR FLU PFI
ST100MG Suspension 02280175 CHILDREN'S IBUPROFEN PER
ST100MG Tablet 02246403 ADVIL PFI
ST200MG Tablet 01933558 ADVIL PFI
ST200MG Tablet 00441643 APO-IBUPROFEN APX
ST200MG Tablet 02257912 IBUPROFEN JMP
ST200MG Tablet 02314754 IBUPROFEN PMS
ST200MG Tablet 02314762 IBUPROFEN PMS
ST200MG Tablet 02368072 IBUPROFEN VTH
ST200MG Tablet 02368080 IBUPROFEN VTH
ST200MG Tablet 02439689 IBUPROFEN APX
ST200MG Tablet 02439727 IBUPROFEN APX
ST200MG Tablet 02186934 MOTRIN MCL
ST200MG Tablet 00629324 NOVO-PROFEN TEV
ST300MG Tablet 00441651 APO IBUPROFEN APX
ST300MG Tablet 00629332 NOVO-PROFEN TEV
ST400MG Tablet 02244577 ADVIL EXTRA STRENGTH PFI
ST400MG Tablet 00506052 APO IBUPROFEN APX
ST400MG Tablet 00636533 IBUPROFEN PDL
ST400MG Tablet 02314770 IBUPROFEN PMS
ST400MG Tablet 02317338 IBUPROFEN JMP
ST400MG Tablet 02439735 IBUPROFEN APX
ST400MG Tablet 02401290 JAMP-IBUPROFEN JMP
ST400MG Tablet 00629340 NOVO-PROFEN TEV
ST400MG Tablet 00836133 PMS-IBUPROFEN PMS
ST600MG Tablet 00585114 APO IBUPROFEN APX
ST600MG Tablet 00629359 TEVA-PROFEN TEV
600MG Tablet (Extended Release) 02443562 ADVIL 12 HOUR PFI

INDOMETHACIN

Table: INDOMETHACIN
Drug strength and dosage form DIN Brand name Manufacturer code
ST25MG Capsule 00611158 APO INDOMETHACIN APX
ST25MG Capsule 02461811 MINT-INDOMETHACIN MIN
ST25MG Capsule 00337420 TEVA-INDOMETHACIN TEV
ST50MG Capsule 00611166 APO INDOMETHACIN APX
ST50MG Capsule 02461536 MINT-INDOMETHACIN MIN
ST50MG Capsule 00337439 TEVA-INDOMETHACIN TEV
50MG Suppository 02231799 SANDOZ INDOMETHACIN SDZ
100MG Suppository 02231800 SANDOZ INDOMETHACIN SDZ

KETOPROFEN

Table: KETOPROFEN
Drug strength and dosage form DIN Brand name Manufacturer code
ST50MG Capsule 00790427 KETOPROFEN AAP
ST50MG Capsule 02150808 PMS-KETOPROFEN PMS
100MG Suppository 02015951 PMS-KETOPROFEN PMS
ST50MG Tablet (Enteric Coated) 00790435 KETOPROFEN-E AAP
ST50MG Tablet (Enteric Coated) 02150816 PMS-KETOPROFEN PMS
ST100MG Tablet (Enteric Coated) 00842664 KETOPROFEN-E AAP
100MG Tablet (Enteric Coated) 02150824 PMS-KETOPROFEN PMS
ST200MG Tablet (Extended Release) 02172577 KETOPROFEN SR AAP

MEFENAMIC ACID

Table: MEFENAMIC ACID
Drug strength and dosage form DIN Brand name Manufacturer code
ST250MG Capsule 02237826 DOM-MEFENAMIC ACID DPC
ST250MG Capsule 02229452 MEFENAMIC AAP
ST250MG Capsule 00155225 PONSTAN AAP

MELOXICAM

Table: MELOXICAM
Drug strength and dosage form DIN Brand name Manufacturer code
ST7.5MG Tablet 02250012 ACT MELOXICAM TEV
ST7.5MG Tablet 02248973 APO-MELOXICAM APX
ST7.5MG Tablet 02390884 AURO-MELOXICAM AUR
ST7.5MG Tablet 02248605 DOM-MELOXICAM DPC
ST7.5MG Tablet 02353148 MELOXICAM SAN
ST7.5MG Tablet 02248267 PMS-MELOXICAM PMS
ST7.5MG Tablet 02258315 TEVA-MELOXICAM TEV
ST15MG Tablet 02250020 ACT MELOXICAM TEV
ST15MG Tablet 02248974 APO-MELOXICAM APX
ST15MG Tablet 02390892 AURO-MELOXICAM AUR
ST15MG Tablet 02248606 DOM-MELOXICAM DPC
ST15MG Tablet 02324334 MELOXICAM PDL
ST15MG Tablet 02353156 MELOXICAM SAN
ST15MG Tablet 02248268 PMS-MELOXICAM PMS
ST15MG Tablet 02258323 TEVA-MELOXICAM TEV

MISOPROSTOL, DICLOFENAC SODIUM

Table: MISOPROSTOL, DICLOFENAC SODIUM
Drug strength and dosage form DIN Brand name Manufacturer code
ST200MCG & 50MG Tablet 02400596 SANDOZ DICLOFENAC MISOPROSTOL SDZ
ST200MCG & 75MG Tablet 02400618 SANDOZ DICLOFENAC MISOPROSTOL SDZ
ST200MCG & 50MG Tablet (Delayed Release) 01917056 ARTHROTEC PFI
ST200MCG & 50MG Tablet (Delayed Release) 02341689 GD-DICLOFENAC/MISOPROSTOL PFI
ST200MCG & 50MG Tablet (Delayed Release) 02413469 PMS-DICLOFENAC-MISOPROSTOL PMS
ST200MCG & 75MG Tablet (Delayed Release) 02229837 ARTHROTEC PFI
ST200MCG & 75MG Tablet (Delayed Release) 02341697 GD-DICLOFENAC/MISOPROSTOL PFI
ST200MCG & 75MG Tablet (Delayed Release) 02413477 PMS-DICLOFENAC-MISOPROSTOL PMS

NAPROXEN

Table: NAPROXEN
Drug strength and dosage form DIN Brand name Manufacturer code
500MG Suppository 02017237 PMS-NAPROXEN PMS
ST25MG/ML Suspension 02162431 NAPROXEN PEI
ST125MG Tablet 00522678 APO NAPROXEN APX
ST220MG Tablet 02362430 NAPROXEN PMS
ST220MG Tablet 02385007 NAPROXEN SODIUM APX
ST250MG Tablet 00522651 APO-NAPROXEN APX
ST250MG Tablet 00590762 NAPROXEN PDL
ST250MG Tablet 02350750 NAPROXEN SAN
ST250MG Tablet 00565350 TEVA-NAPROXEN TEV
ST275MG Tablet 02162725 ANAPROX APU
ST275MG Tablet 00784354 APO-NAPRO-NA APX
ST275MG Tablet 02351013 NAPROXEN SODIUM SAN
ST275MG Tablet 00887056 NAPROXEN-NA PDL
ST275MG Tablet 00778389 TEVA-NAPROXEN TEV
ST375MG Tablet 00600806 APO-NAPROXEN APX
ST375MG Tablet 00655686 NAPROXEN PDL
ST375MG Tablet 02350769 NAPROXEN SAN
ST375MG Tablet 00627097 TEVA-NAPROXEN TEV
ST500MG Tablet 00592277 APO-NAPROXEN APX
ST500MG Tablet 00618721 NAPROXEN PDL
ST500MG Tablet 02350777 NAPROXEN SAN
ST500MG Tablet 00589861 TEVA-NAPROXEN TEV
ST550MG Tablet 02162717 ANAPROX DS APU
ST550MG Tablet 01940309 APO-NAPRO-NA DS APX
ST550MG Tablet 02351021 NAPROXEN SODIUM DS SAN
ST550MG Tablet 02153386 NAPROXEN-NA DF PDL
ST550MG Tablet 02026600 TEVA-NAPROXEN DS TEV
ST250MG Tablet (Enteric Coated) 02246699 APO-NAPROXEN EC APX
ST250MG Tablet (Enteric Coated) 02350785 NAPROXEN EC SAN
ST250MG Tablet (Enteric Coated) 02243312 TEVA-NAPROXEN TEV
ST375MG Tablet (Enteric Coated) 02246700 APO-NAPROXEN EC APX
ST375MG Tablet (Enteric Coated) 02162415 NAPROSYN APU
ST375MG Tablet (Enteric Coated) 02350793 NAPROXEN EC SAN
ST375MG Tablet (Enteric Coated) 02294702 PMS-NAPROXEN EC PMS
ST375MG Tablet (Enteric Coated) 02310945 PRO-NAPROXEN PDL
ST375MG Tablet (Enteric Coated) 02243313 TEVA-NAPROXEN TEV
ST500MG Tablet (Enteric Coated) 02246701 APO-NAPROXEN EC APX
ST500MG Tablet (Enteric Coated) 02162423 NAPROSYN APU
ST500MG Tablet (Enteric Coated) 02350807 NAPROXEN EC SAN
ST500MG Tablet (Enteric Coated) 02294710 PMS-NAPROXEN EC PMS
ST500MG Tablet (Enteric Coated) 02310953 PRO-NAPROXEN PDL
ST500MG Tablet (Enteric Coated) 02243314 TEVA-NAPROXEN TEV
ST750MG Tablet (Extended Release) 02162466 NAPROSYN APU

PIROXICAM

Table: PIROXICAM
Drug strength and dosage form DIN Brand name Manufacturer code
ST10MG Capsule 00642886 APO PIROXICAM APX
ST10MG Capsule 00695718 TEVA-PIROXICAM TEV
ST20MG Capsule 00642894 APO PIROXICAM APX
ST20MG Capsule 00695696 TEVA-PIROXICAM TEV

SULINDAC

Table: SULINDAC
Drug strength and dosage form DIN Brand name Manufacturer code
ST150MG Tablet 00745588 TEVA-SULINDAC TEV
ST200MG Tablet 00745596 TEVA-SULINDAC TEV

TIAPROFENIC ACID

Table: TIAPROFENIC ACID
Drug strength and dosage form DIN Brand name Manufacturer code
ST200MG Tablet 02230827 PMS-TIAPROFENIC PMS
ST200MG Tablet 02179679 TEVA-TIAPROFENIC TEV
ST300MG Tablet 02231060 DOM-TIAPROFENIC DPC
ST300MG Tablet 02179687 TEVA-TIAPROFENIC TEV

28:08.08 OPIATE AGONISTS

ACETAMINOPHEN, CAFFEINE CITRATE, CODEINE PHOSPHATE

Limited use benefit (prior approval is not required).

For safety reasons NIHB has implemented a dose limit on acetaminophen. The limit accumulates against the amount of acetaminophen claimed to the program from plain acetaminophen and/or acetaminophen in combination with opioids such as codeine (i.e. Tylenol(r) #3) or oxycodone (i.e. Percocet(r)). A total of 360 grams of acetaminophen is permitted in a 100-day period, for a total daily dose of 3600mg/day.

Table: ACETAMINOPHEN, CAFFEINE CITRATE, CODEINE PHOSPHATE
Drug strength and dosage form DIN Brand name Manufacturer code
300MG & 15MG & 15MG Tablet 00653241 RATIO-LENOLTEC NO 2 TEV
300MG & 15MG & 15MG Tablet 02163934 TYLENOL WITH CODEINE NO.2 JSO
300MG & 15MG & 30MG Tablet 00653276 RATIO-LENOLTEC NO 3 TEV
300MG & 15MG & 30MG Tablet 02163926 TYLENOL WITH CODEINE NO.3 JSO

ACETAMINOPHEN, CODEINE PHOSPHATE

Limited use benefit (prior approval is not required).

For safety reasons NIHB has implemented a dose limit on acetaminophen. The limit accumulates against the amount of acetaminophen claimed to the program from plain acetaminophen and/or acetaminophen in combination with opioids such as codeine (i.e. Tylenol(r) #3) or oxycodone (i.e. Percocet(r)). A total of 360 grams of acetaminophen is permitted in a 100-day period, for a total daily dose of 3600mg/day.

Table: ACETAMINOPHEN, CODEINE PHOSPHATE
Drug strength and dosage form DIN Brand name Manufacturer code
32MG & 1.6MG/ML Elixir 00816027 PMS-ACETAMINOPHEN PMS
300MG & 30MG Tablet 00608882 TEVA-EMTEC-30 TEV
300MG & 30MG Tablet 00789828 TRIATEC-30 RIV

ACETAMINOPHEN, OXYCODONE HYDROCHLORIDE

Limited use benefit (prior approval is not required).

For safety reasons NIHB has implemented a dose limit on acetaminophen. The limit accumulates against the amount of acetaminophen claimed to the program from plain acetaminophen and/or acetaminophen in combination with opioids such as codeine (i.e. Tylenol(r) #3) or oxycodone (i.e. Percocet(r)). A total of 360 grams of acetaminophen is permitted in a 100-day period, for a total daily dose of 3600mg/day.

Table: ACETAMINOPHEN, OXYCODONE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
325MG & 5MG Tablet 02324628 APO-OXYCODONE/ACET APX
325MG & 5MG Tablet 02361361 OXYCODONE/ACET SAN
325MG & 5MG Tablet 02242468 RIVACOCET RIV
325MG & 5MG Tablet 02307898 SANDOZ OXYCODONE/ACETAMINOPHEN SDZ
325MG & 5MG Tablet 00608165 TEVA-OXYCOCET TEV

ACETYLSALICYLIC ACID, OXYCODONE HYDROCHLORIDE

Limited use benefit (prior approval is not required).

To promote safe, therapeutically effective and efficient use of drug therapy, NIHB has implemented an opioid dose limit of 200 mg morphine equivalents per day for chronic non-cancer pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 30-day period (i.e. 6000 morphine equivalents over 30 days).

Table: ACETYLSALICYLIC ACID, OXYCODONE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
325MG & 5MG Tablet 00608157 TEVA-OXYCODAN TEV

BUPRENORPHINE (SUBLOCADE)

Limited use benefit (prior approval required).

For the management of moderate to severe opioid use disorder in adult patients who have been inducted and clinically stabilized on a transmucosal buprenorphine-containing product; and

Patient must be induced and stabilized on an equivalent of 8 mg to 24 mg per day of transmucosal buprenorphine for a minimum of 7 days.

Note:

  • the prescriber has experience in the diagnosis and management of opioid use disorder and certified under Sublocade Certification Program.
  • Sublocade must be administered subcutaneously in the abdominal region by a healthcare provider.
  • Sublocade should be used as part of a complete treatment plan that includes counselling and psychosocial support.
  • client will be added to the Client Safety Program (CSP).
Table: BUPRENORPHINE (SUBLOCADE)
Drug strength and dosage form DIN Brand name Manufacturer code
300MG Solution (Extended Release) 02483092 SUBLOCADE IND

CODEINE MONOHYDRATE, CODEINE SULFATE TRIHYDRATE

Limited use benefit (prior approval required).

For treatment of:

  • chronic pain and patients that requires end of life care as an alternative to products containing codeine in combination with acetaminophen or ASA with or without caffeine; or
  • chronic pain and patients that requires end of life care as an alternative to regular release codeine tablets when large doses are required.

To promote safe, therapeutically effective and efficient use of drug therapy, NIHB has implemented an opioid dose limit of 200 mg morphine equivalents per day for chronic non-cancer pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 30-day period (i.e. 6000 morphine equivalents over 30 days).

Table: CODEINE MONOHYDRATE, CODEINE SULFATE TRIHYDRATE
Drug strength and dosage form DIN Brand name Manufacturer code
50MG Tablet (Extended Release) 02230302 CODEINE CONTIN CR PFR
100MG Tablet (Extended Release) 02163748 CODEINE CONTIN CR PFR
150MG Tablet (Extended Release) 02163780 CODEINE CONTIN CR PFR
200MG Tablet (Extended Release) 02163799 CODEINE CONTIN CR PFR

CODEINE PHOSPHATE

Limited use benefit (prior approval is not required).

To promote safe, therapeutically effective and efficient use of drug therapy, NIHB has implemented an opioid dose limit of 200 mg morphine equivalents per day for chronic non-cancer pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 30-day period (i.e. 6000 morphine equivalents over 30 days).

Table: CODEINE PHOSPHATE
Drug strength and dosage form DIN Brand name Manufacturer code
5MG/ML Liquid 00050024 CODEINE PHOSPHATE ATL
2MG/ML Solution 00380571 LINCTUS CODEINE ATL
15MG Tablet 02009889 CODEINE RIV
15MG Tablet 00593435 TEVA-CODEINE TEV
30MG Tablet 02009757 CODEINE RIV
30MG Tablet 00593451 TEVA-CODEINE TEV

FENTANYL

Limited use benefit (prior approval required).

For the management of chronic pain in patients who are unresponsive or intolerant to at least one long-acting oral sustained released product, such as morphine, hydromorphone and oxycodone, despite appropriate dose titration and adjunctive therapy including laxatives and antiemetics.

To promote safe, therapeutically effective and efficient use of drug therapy, NIHB has implemented an opioid dose limit of 200 mg morphine equivalents per day for chronic non-cancer pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 30-day period (i.e. 6000 morphine equivalents over 30 days).

Table: FENTANYL
Drug strength and dosage form DIN Brand name Manufacturer code
12MCG/HR Patch 02341379 PMS-FENTANYL MTX PMS
12MCG/HR Patch 02327112 SANDOZ FENTANYL SDZ
12MCG/HR Patch 02311925 TEVA-FENTANYL TEV
25MCG/HR Patch 02341387 PMS-FENTANYL MTX PMS
25MCG/HR Patch 02327120 SANDOZ FENTANYL SDZ
25MCG/HR Patch 02282941 TEVA-FENTANYL TEV
50MCG/HR Patch 02341395 PMS-FENTANYL MTX PMS
50MCG/HR Patch 02327147 SANDOZ FENTANYL SDZ
50MCG/HR Patch 02282968 TEVA-FENTANYL TEV
75MCG/HR Patch 02341409 PMS-FENTANYL MTX PMS
75MCG/HR Patch 02327155 SANDOZ FENTANYL SDZ
75MCG/HR Patch 02282976 TEVA-FENTANYL TEV
100MCG/HR Patch 02341417 PMS-FENTANYL MTX PMS
100MCG/HR Patch 02327163 SANDOZ FENTANYL SDZ
100MCG/HR Patch 02282984 TEVA-FENTANYL TEV

HYDROMORPHONE HYDROCHLORIDE

Limited use benefit.

Prior approval required for controlled release capsules only. Regular release dosage forms are full benefits and do not require prior approval.

For treatment of moderate to severe chronic pain when other opioids such as morphine have been ineffective in controlling pain or in patients experiencing intolerable side effects.

To promote safe, therapeutically effective and efficient use of drug therapy, NIHB has implemented an opioid dose limit of 200 mg morphine equivalents per day for chronic non-cancer pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 30-day period (i.e. 6000 morphine equivalents over 30 days).

Table: HYDROMORPHONE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
3MG Capsule (Extended Release) 02476614 APO-HYDROMORPHONE APX
4.5MG Capsule (Extended Release) 02476622 APO-HYDROMORPHONE APX
6MG Capsule (Extended Release) 02476630 APO-HYDROMORPHONE APX
9MG Capsule (Extended Release) 02476649 APO-HYDROMORPHONE APX
12MG Capsule (Extended Release) 02476657 APO-HYDROMORPHONE APX
18MG Capsule (Extended Release) 02476665 APO-HYDROMORPHONE APX
24MG Capsule (Extended Release) 02476673 APO-HYDROMORPHONE APX
30MG Capsule (Extended Release) 02476681 APO-HYDROMORPHONE APX
3MG Capsule (Sustained Release) 02125323 HYDROMORPH CONTIN PFR
4.5MG Capsule (Sustained Release) 02359502 HYDROMORPH CONTIN PFR
6MG Capsule (Sustained Release) 02125331 HYDROMORPH CONTIN PFR
9MG Capsule (Sustained Release) 02359510 HYDROMORPH CONTIN PFR
12MG Capsule (Sustained Release) 02125366 HYDROMORPH CONTIN PFR
18MG Capsule (Sustained Release) 02243562 HYDROMORPH CONTIN PFR
24MG Capsule (Sustained Release) 02125382 HYDROMORPH CONTIN PFR
30MG Capsule (Sustained Release) 02125390 HYDROMORPH CONTIN PFR
1MG/ML Liquid 01916386 PMS HYDROMORPHONE PMS
50MG Solution 02469413 HYDROMORPHONE HYDROCHLORIDE HP 50 RAX
3MG Suppository 01916394 PMS HYDROMORPHONE PMS
1MG Tablet 02364115 APO-HYDROMORPHONE APX
1MG Tablet 00705438 DILAUDID PFR
1MG Tablet 00885444 PMS-HYDROMORPHONE PMS
1MG Tablet 02319403 TEVA-HYDROMORPHONE TEV
2MG Tablet 02364123 APO-HYDROMORPHONE APX
2MG Tablet 00125083 DILAUDID PFR
2MG Tablet 00885436 PMS-HYDROMORPHONE PMS
2MG Tablet 02319411 TEVA-HYDROMORPHONE TEV
4MG Tablet 02364131 APO-HYDROMORPHONE APX
4MG Tablet 00125121 DILAUDID PFR
4MG Tablet 00885401 PMS-HYDROMORPHONE PMS
4MG Tablet 02319438 TEVA-HYDROMORPHONE TEV
8MG Tablet 02364158 APO-HYDROMORPHONE APX
8MG Tablet 00786543 DILAUDID PFR
8MG Tablet 00885428 PMS-HYDROMORPHONE PMS
8MG Tablet 02319446 TEVA-HYDROMORPHONE TEV

METHADONE HYDROCHLORIDE

Table: METHADONE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
Powder 00908835 METHADONE POWDER (OAT) MDS
10MG Solution 02481979 SANDOZ METHADONE UNK
10MG/ML Solution 02244290 METADOL-D PAL
10MG/ML Solution 02394596 METHADOSE MAT
10MG/ML Solution 02394618 METHADOSE MAT

METHADONE HYDROCHLORIDE (BC ONLY)

Table: METHADONE HYDROCHLORIDE (BC ONLY)
Drug strength and dosage form DIN Brand name Manufacturer code
10MG/ML Oral Liquid 66999999 METHADOSE DEL. W DIRECT INTER (OAT) UNK
10MG/ML Oral Liquid 67000000 METHADOSE DEL. W/OUT DIR INTER (OAT) UNK
10MG/ML Oral Liquid 66999997 METHADOSE W DIRECT INTERACTION (OAT) UNK
10MG/ML Oral Liquid 66999998 METHADOSE W/OUT DIRECT INTER (OAT) UNK

METHADONE HYDROCHLORIDE (METADOL)

Limited use benefit (prior approval required) with the following criteria:

For the management of moderate to severe cancer pain or chronic non-cancer pain, as an alternative to other opioids; or

For the management of pain for patients that requires end of life care. Pharmacists may only dispense a maximum supply of 30 days at one time.

Table: METHADONE HYDROCHLORIDE (METADOL)
Drug strength and dosage form DIN Brand name Manufacturer code
1MG/ML Solution 02247694 METADOL PAL
10MG/ML Solution 02241377 METADOL PAL
1MG Tablet 02247698 METADOL PAL
5MG Tablet 02247699 METADOL PAL
10MG Tablet 02247700 METADOL PAL
25MG Tablet 02247701 METADOL PAL

MORPHINE HYDROCHLORIDE

Limited use benefit (prior approval is not required).

To promote safe, therapeutically effective and efficient use of drug therapy, NIHB has implemented an opioid dose limit of 200 mg morphine equivalents per day for chronic non-cancer pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 30-day period (i.e. 6000 morphine equivalents over 30 days).

Table: MORPHINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
1MG/ML Syrup 00614491 DOLORAL 1 ATL
5MG/ML Syrup 00614505 DOLORAL 5 ATL

MORPHINE SULFATE

Limited use benefit (prior approval is not required).

To promote safe, therapeutically effective and efficient use of drug therapy, NIHB has implemented an opioid dose limit of 200 mg morphine equivalents per day for chronic non-cancer pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 30-day period (i.e. 6000 morphine equivalents over 30 days).

Table: MORPHINE SULFATE
Drug strength and dosage form DIN Brand name Manufacturer code
10MG Capsule (Extended Release) 02019930 M-ESLON ETH
15MG Capsule (Extended Release) 02177749 M-ESLON ETH
30MG Capsule (Extended Release) 02019949 M-ESLON ETH
60MG Capsule (Extended Release) 02019957 M-ESLON ETH
100MG Capsule (Extended Release) 02019965 M-ESLON ETH
200MG Capsule (Extended Release) 02177757 M-ESLON ETH
5MG Suppository 00632228 STATEX PAL
10MG Suppository 00632201 STATEX PAL
20MG Suppository 00596965 STATEX PAL
5MG Tablet 00594652 STATEX PAL
10MG Tablet 00594644 STATEX PAL
25MG Tablet 00594636 STATEX PAL
50MG Tablet 00675962 STATEX PAL
15MG Tablet (Extended Release) 02350815 MORPHINE SR SAN
15MG Tablet (Extended Release) 02015439 MS CONTIN SR PFR
15MG Tablet (Extended Release) 02244790 SANDOZ MORPHINE SR SDZ
15MG Tablet (Extended Release) 02302764 TEVA-MORPHINE SR TEV
30MG Tablet (Extended Release) 02350890 MORPHINE SR SAN
30MG Tablet (Extended Release) 02014297 MS CONTIN SR PFR
30MG Tablet (Extended Release) 02244791 SANDOZ MORPHINE SR SDZ
30MG Tablet (Extended Release) 02302772 TEVA-MORPHINE SR TEV
60MG Tablet (Extended Release) 02350912 MORPHINE SR SAN
60MG Tablet (Extended Release) 02014300 MS CONTIN SR PFR
60MG Tablet (Extended Release) 02244792 SANDOZ MORPHINE SR SDZ
60MG Tablet (Extended Release) 02302780 TEVA-MORPHINE SR TEV
100MG Tablet (Extended Release) 02014319 MS CONTIN SR PFR
100MG Tablet (Extended Release) 02478889 SANDOZ MORPHINE SR SDZ
100MG Tablet (Extended Release) 02302799 TEVA-MORPHINE SR TEV
200MG Tablet (Extended Release) 02014327 MS CONTIN SR PFR
200MG Tablet (Extended Release) 02478897 SANDOZ MORPHINE SR SDZ
200MG Tablet (Extended Release) 02302802 TEVA-MORPHINE SR TEV
5MG Tablet (Immediate Release) 02014203 MS IR PFR
10MG Tablet (Immediate Release) 02014211 MS IR PFR
20MG Tablet (Immediate Release) 02014238 MS IR PFR
30MG Tablet (Immediate Release) 02014254 MS IR PFR

MORPHINE SULFATE (KADIAN)

Limited use benefit (prior approval required).

For the treatment of opioid dependence where methadone and Suboxone are not available or not appropriate; or

For the treatment of chronic pain.

To promote safe, therapeutically effective and efficient use of drug therapy, NIHB has implemented an opioid dose limit of 200 mg morphine equivalents per day for chronic non-cancer pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 30-day period (i.e. 6000 morphine equivalents over 30 days).

Table: MORPHINE SULFATE (KADIAN)
Drug strength and dosage form DIN Brand name Manufacturer code
10MG Capsule (Sustained Release) 02242163 KADIAN BGP
10MG Capsule (Sustained Release) 09991310 KADIAN MAY
20MG Capsule (Sustained Release) 02184435 KADIAN BGP
20MG Capsule (Sustained Release) 09991311 KADIAN MAY
50MG Capsule (Sustained Release) 02184443 KADIAN BGP
50MG Capsule (Sustained Release) 09991312 KADIAN MAY
100MG Capsule (Sustained Release) 02184451 KADIAN BGP
100MG Capsule (Sustained Release) 09991313 KADIAN MAY

OXYCODONE HYDROCHLORIDE

Limited use benefit (prior approval is not required).

To promote safe, therapeutically effective and efficient use of drug therapy, NIHB has implemented an opioid dose limit of 200 mg morphine equivalents per day for chronic non-cancer pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 30-day period (i.e. 6000 morphine equivalents over 30 days).

Table: OXYCODONE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
10MG Suppository 00392480 SUPEUDOL SDZ
20MG Suppository 00392472 SUPEUDOL SDZ
5MG Tablet 02231934 OXY-IR PFR
5MG Tablet 02319977 PMS-OXYCODONE PMS
5MG Tablet 00789739 SUPEUDOL SDZ
10MG Tablet 02240131 OXY-IR PFR
10MG Tablet 02319985 PMS-OXYCODONE PMS
10MG Tablet 00443948 SUPEUDOL SDZ
20MG Tablet 02319993 PMS-OXYCODONE PMS
20MG Tablet 02262983 SUPEUDOL SDZ
20MG Tablet (Immediate Release) 02240132 OXY-IR PFR

28:08.12 OPIATE PARTIAL AGONISTS

BUPRENORPHINE (BUTRANS)

Limited use benefit (prior approval required).

For the following medical conditions:

  • pain due to cancer
  • chronic non-cancer pain-causing limitations in activities of daily living.
  • prevention of precipitated withdrawal during buprenorphine/naloxone induction (max 3 x 20 mcg patches are covered)
  • patient requires end of life care (diagnosed with a terminal illness or disease which is expected to be the primary cause of death within six months or less)

*Guidelines indicate little evidence for opioid use for fibromyalgia, headache or back or neck pain without a neuropathic component.

Table: BUPRENORPHINE (BUTRANS)
Drug strength and dosage form DIN Brand name Manufacturer code
5MCG Patch 02341174 BUTRANS 5 PFR
10MCG Patch 02341212 BUTRANS 10 PFR
15MCG Patch 02450771 BUTRANS 15 PFR
20MCG Patch 02341220 BUTRANS 20 PFR

BUPRENORPHINE (SUBLOCADE)

Limited use benefit (prior approval required).

For the management of moderate to severe opioid use disorder in adult patients who have been inducted and clinically stabilized on a transmucosal buprenorphine-containing product; and

Patient must be induced and stabilized on an equivalent of 8 mg to 24 mg per day of transmucosal buprenorphine for a minimum of 7 days.

Note:

  • the prescriber has experience in the diagnosis and management of opioid use disorder and certified under Sublocade Certification Program.
  • Sublocade must be administered subcutaneously in the abdominal region by a healthcare provider.
  • Sublocade should be used as part of a complete treatment plan that includes counselling and psychosocial support.
  • client will be added to the Client Safety Program (CSP).
Table: BUPRENORPHINE (SUBLOCADE)
Drug strength and dosage form DIN Brand name Manufacturer code
100MG Solution (Extended Release) 02483084 SUBLOCADE IND

BUPRENORPHINE HYDROCHLORIDE

Limited use benefit (prior approval required).

For the management of patients with opioid use disorder, in combination with psychosocial support:

  • patient is stabilized on a dose of no more than 8 mg per day of sublingual buprenorphine/naloxone for the preceding 90 days; and
  • patient is under the care of a health care provider with experience in the diagnosis and management of opioid use disorder; and
  • the prescriber has been trained to implant the buprenorphine subdermal implant.

Approval is for a maximum of four lifetime doses. One package of 4 implants is approved at every 6 months (e.g. four times X package of 4 implants)

Table: BUPRENORPHINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
80MG Implant 02474921 PROBUPHINE UNK

BUPRENORPHINE HYDROCHLORIDE, NALOXONE HYDROCHLORIDE

Limited use benefit (prior approval required).

For the treatment of opioid dependence when:

  • the client must be 16 years or older.
  • in cases where the client lives in a remote or isolated location, confirmation is required that the community has the ability to support buprenorphine/naloxone administration. These supports include the safe daily witnessing, storage and handling of the buprenorphine/naloxone doses. After this confirmation, NIHB will approve the buprenorphine/naloxone for the client.
Table: BUPRENORPHINE HYDROCHLORIDE, NALOXONE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
2MG & 0.5MG Tablet 02453908 ACT BUPRENORPHINE/NALOXONE TEV
2MG & 0.5MG Tablet 02424851 PMS-BUPRENORPHINE-NALOXONE PMS
2MG & 0.5MG Tablet 02295695 SUBOXONE IND
8MG & 2MG Tablet 02453916 ACT BUPRENORPHINE/NALOXONE TEV
8MG & 2MG Tablet 02424878 PMS-BUPRENORPHINE-NALOXONE PMS
8MG & 2MG Tablet 02295709 SUBOXONE IND
12MG & 3MG Tablet 02468085 SUBOXONE IND
16MG & 4MG Tablet 02468093 SUBOXONE IND

28:08.92 MISCELLANEOUS ANALGESICS AND ANTIPYRETICS

ACETAMINOPHEN

Limited use benefit (prior approval is not required).

For safety reasons NIHB has implemented a dose limit on acetaminophen. The limit accumulates against the amount of acetaminophen claimed to the program from plain acetaminophen and/or acetaminophen in combination with opioids such as codeine (i.e. Tylenol(r) #3) or oxycodone (i.e. Percocet(r)). A total of 360 grams of acetaminophen is permitted in a 100-day period, for a total daily dose of 3600mg/day.

Table: ACETAMINOPHEN
Drug strength and dosage form DIN Brand name Manufacturer code
ST80MG/ML Drop 01904140 ACETAMINOPHEN TAN
ST80MG/ML Drop 01905864 ACETAMINOPHEN TLI
ST80MG/ML Drop 02263793 PEDIAPHEN EUR
ST80MG/ML Drop 02027801 PEDIATRIX TEV
ST80MG/ML Drop 00875988 TEMPRA INFANT PAL
80MG/ML Drop 02046059 TYLENOL MCL
ST16MG/ML Liquid 01905848 ACETAMINOPHEN TLI
ST16MG/ML Liquid 00792713 PDP-ACETAMINOPHEN PED
ST16MG/ML Liquid 02263807 PEDIAPHEN EUR
ST16MG/ML Liquid 00884553 TEMPRA CHILDREN'S PAL
ST32MG/ML Liquid 01901389 ACETAMINOPHEN JMP
ST32MG/ML Liquid 01958836 ACETAMINOPHEN TLI
ST32MG/ML Liquid 00792691 PDP-ACETAMINOPHEN PED
ST32MG/ML Liquid 02263831 PEDIAPHEN EUR
32MG/ML Liquid 02027798 PEDIATRIX TEV
ST32MG/ML Liquid 00875996 TEMPRA CHILDREN'S DOUBLE STRENGTH PAL
32MG/ML Liquid 02046040 TYLENOL MCL
120MG Suppository 00553328 ABENOL GSK
120MG Suppository 02230434 ACET 120 PED
120MG Suppository 02046660 PMS-ACETAMINOPHEN PMS
160MG Suppository 02230435 ACET PED
325MG Suppository 01919393 ABENOL PED
325MG Suppository 02230436 ACET 325 PED
325MG Suppository 02046687 PMS-ACETAMINOPHEN PMS
650MG Suppository 02230437 ACET 650 PED
650MG Suppository 02046695 PMS-ACETAMINOPHEN PMS
ST80MG Tablet 02015676 ACETAMINOPHEN TAN
ST80MG Tablet 02263815 PEDIAPHEN EUR
ST160MG Tablet 02230934 ACETAMINOPHEN TAN
ST325MG Tablet 00605751 ACETAMINOPHEN VTH
ST325MG Tablet 00743542 ACETAMINOPHEN PMT
ST325MG Tablet 00789801 ACETAMINOPHEN TLI
ST325MG Tablet 01938088 ACETAMINOPHEN JMP
ST325MG Tablet 01977415 ACETAMINOPHEN TLI
ST325MG Tablet 02022214 ACÉTAMINOPHÈNE RIV
ST325MG Tablet 02362198 ACÉTAMINOPHÈNE RIV
ST325MG Tablet 00544981 APO ACETAMINOPHEN APX
ST325MG Tablet 02229873 APO-ACETAMINOPHEN APX
ST325MG Tablet 00389218 NOVO-GESIC TEV
ST325MG Tablet 00559393 TYLENOL MCL
ST325MG Tablet 00723894 TYLENOL MCL
ST500MG Tablet 00549703 ACETAMINOPHEN PMT
ST500MG Tablet 00605778 ACETAMINOPHEN VTH
ST500MG Tablet 00789798 ACETAMINOPHEN TLI
ST500MG Tablet 01939122 ACETAMINOPHEN JMP
ST500MG Tablet 01962353 ACETAMINOPHEN TAN
ST500MG Tablet 02252813 ACETAMINOPHEN PMT
ST500MG Tablet 02255251 ACETAMINOPHEN PMT
ST500MG Tablet 02362368 ACETAMINOPHEN APX
ST500MG Tablet 02022222 ACÉTAMINOPHÈNE RIV
ST500MG Tablet 02362228 ACÉTAMINOPHÈNE RIV
ST500MG Tablet 02362201 ACÉTAMINOPHÈNE BLASON SHIELD RIV
ST500MG Tablet 00545007 APO ACETAMINOPHEN APX
ST500MG Tablet 02229977 APO-ACETAMINOPHEN APX
ST500MG Tablet 02285797 EXTRA STRENGTH ACETAMINOPHEN VTH
ST500MG Tablet 02355299 JAMP ACETAMINOPHEN BLAZON JMP
ST500MG Tablet 00482323 NOVO-GESIC FORTE TEV
ST500MG Tablet 00892505 PMS-ACETAMINOPHEN PMS
ST500MG Tablet 00723908 TYLENOL MCL
ST500MG Tablet 00559407 TYLENOL EXTRA STRENGTH MCL
ST80MG Tablet (Chewable) 01905856 ACETAMINOPHEN TLI
ST80MG Tablet (Chewable) 02017458 ACETAMINOPHEN RIV
ST80MG Tablet (Chewable) 02129957 ACETAMINOPHEN VTH
ST160MG Tablet (Chewable) 02017431 ACETAMINOPHEN RIV
ST160MG Tablet (Chewable) 02142805 ACETAMINOPHEN VTH
ST160MG Tablet (Chewable) 02237562 ACETAMINOPHEN TLI
ST160MG Tablet (Chewable) 02263823 PEDIAPHEN EUR
ST160MG Tablet (Chewable) 02347792 TYLENOL JR STRENGTH FASTMELTS MCL
ST160MG Tablet (Chewable) 02241361 TYLENOL JUNIOR STRENGTH MCL

FLOCTAFENINE

Table: FLOCTAFENINE
Drug strength and dosage form DIN Brand name Manufacturer code
ST200MG Tablet 02244680 FLOCTAFENINE AAP
ST400MG Tablet 02244681 FLOCTAFENINE AAP

28:10.00 OPIATE ANTAGONISTS

NALOXONE HYDROCHLORIDE

Table: NALOXONE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
Injection 09991488 NALOXONE KIT UNK
0.4MG/ML Injection 09991460 NALOXONE KIT UNK
0.4MG Solution 02453258 S.O.S NALOXONE HYDROCHLORIDE SDZ
0.4MG/ML Solution 02148706 NALOXONE SDZ
0.4MG/ML Solution 02382482 NALOXONE TEL
0.4MG/ML Solution 02393034 NALOXONE OMG
1MG/ML Solution 02148714 NALOXONE SDZ
1MG/ML Solution 02393042 NALOXONE OMG
4MG Spray 02458187 NARCAN UNK

NALTREXONE HYDROCHLORIDE

Table: NALTREXONE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
50MG Tablet 02444275 APO-NALTREXONE APX
50MG Tablet 02451883 NALTREXONE HYDROCHLORIDE UNK
50MG Tablet 02213826 REVIA TEV

28:12.04 ANTICONVULSANTS - BARBITURATES

PHENOBARBITAL

Table: PHENOBARBITAL
Drug strength and dosage form DIN Brand name Manufacturer code
5MG/ML Elixir 00645575 PHENOBARB PED
100MG Tablet 00178829 PHENOBARB PED

PRIMIDONE

Table: PRIMIDONE
Drug strength and dosage form DIN Brand name Manufacturer code
ST125MG Tablet 00399310 PRIMIDONE AAP
ST250MG Tablet 00396761 PRIMIDONE AAP

28:12.08 ANTICONVULSANTS - BENZODIAZEPINES

CLOBAZAM

Table: CLOBAZAM
Drug strength and dosage form DIN Brand name Manufacturer code
ST10MG Tablet 02244638 APO-CLOBAZAM APX
ST10MG Tablet 02244474 PMS-CLOBAZAM PMS
ST10MG Tablet 02238334 TEVA-CLOBAZAM TEV

CLONAZEPAM

Limited use benefit (prior approval is not required).

To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 30 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e. 3 000 diazepam equivalents over 100 days). According to the product monograph for diazepam, the recommended usual adult dosage is up to 30 mg per day.

Table: CLONAZEPAM
Drug strength and dosage form DIN Brand name Manufacturer code
ST0.25MG Tablet 02179660 PMS-CLONAZEPAM PMS
ST0.5MG Tablet 02177889 APO-CLONAZEPAM APX
ST0.5MG Tablet 02230366 CLONAPAM VAE
ST0.5MG Tablet 02048701 PMS-CLONAZEPAM PMS
ST0.5MG Tablet 02207818 PMS-CLONAZEPAM-R PMS
ST0.5MG Tablet 02311593 PRO-CLONAZEPAM PDL
ST0.5MG Tablet 02242077 RIVA-CLONAZEPAM RIV
ST0.5MG Tablet 00382825 RIVOTRIL HLR
ST0.5MG Tablet 02239024 TEVA-CLONAZEPAM TEV
ST1MG Tablet 02230368 CLONAPAM VAE
ST1MG Tablet 02048728 PMS-CLONAZEPAM PMS
ST1MG Tablet 02311607 PRO-CLONAZEPAM PDL
ST2MG Tablet 02177897 APO-CLONAZEPAM APX
ST2MG Tablet 02230369 CLONAPAM VAE
ST2MG Tablet 02048736 PMS-CLONAZEPAM PMS
ST2MG Tablet 02311615 PRO-CLONAZEPAM PDL
ST2MG Tablet 02242078 RIVA-CLONAZEPAM RIV
ST2MG Tablet 00382841 RIVOTRIL HLR
ST2MG Tablet 02239025 TEVA-CLONAZEPAM TEV
ST pDIN For Extemporaneous Mixture 99503020 BENZODIAZEPINE ORAL LIQUID UNK

28:12.12 ANTICONVULSANTS - HYDANTOINS

PHENYTOIN

Table: PHENYTOIN
Drug strength and dosage form DIN Brand name Manufacturer code
ST30MG Capsule 00022772 DILANTIN UNK
ST100MG Capsule 02460912 APO-PHENYTOIN SODIUM APX
ST100MG Capsule 00022780 DILANTIN UNK
ST6MG/ML Suspension 00023442 DILANTIN UNK
ST25MG/ML Suspension 00023450 DILANTIN UNK
ST25MG/ML Suspension 02250896 TARO-PHENYTOIN TAR
ST50MG Tablet 00023698 DILANTIN INFATABS UNK

28:12.20 ANTICONVULSANTS- SUCCINIMIDES

ETHOSUXIMIDE

Table: ETHOSUXIMIDE
Drug strength and dosage form DIN Brand name Manufacturer code
ST250MG Capsule 00022799 ZARONTIN ERF
ST50MG/ML Syrup 00023485 ZARONTIN ERF

28:12.92 MISCELLANEOUS ANTICONVULSANTS

BRIVARACETAM

Limited use benefit (prior approval required).

For adjunctive therapy in adult patients with refractory partial-onset seizures who meet all of the following criteria:

  • are under the care of a physician experienced in the treatment of epilepsy; and
  • are currently receiving two or more antiepileptic medications; and
  • have failed or demonstrated intolerance to at least two other antiepileptic medications; and
  • are not receiving concurrent therapy with levetiracetam.
Table: BRIVARACETAM
Drug strength and dosage form DIN Brand name Manufacturer code
10MG Tablet 02452936 BRIVLERA UCB
25MG Tablet 02452944 BRIVLERA UCB
50MG Tablet 02452952 BRIVLERA UCB
75MG Tablet 02452960 BRIVLERA UCB
100MG Tablet 02452979 BRIVLERA UCB

CARBAMAZEPINE

Table: CARBAMAZEPINE
Drug strength and dosage form DIN Brand name Manufacturer code
ST20MG/ML Suspension 02367394 TARO-CARBAMAZEPINE TAR
ST20MG/ML Suspension 02194333 TEGRETOL NVR
ST200MG Tablet 00402699 APO CARBAMAZEPINE APX
ST200MG Tablet 00504742 MAZEPINE BMI
ST200MG Tablet 02407515 TARO-CARBAMAZEPINE TAR
ST200MG Tablet 00010405 TEGRETOL NVR
ST200MG Tablet 00782718 TEVA-CARBAMAZEPINE TEV
ST100MG Tablet (Chewable) 02244403 TARO-CARBAMAZEPINE TAR
ST200MG Tablet (Chewable) 02244404 TARO-CARBAMAZEPINE TAR
ST200MG Tablet (Extended Release) 02238222 DOM-CARBAMAZEPINE DPC
ST200MG Tablet (Extended Release) 02231543 PMS-CARBAMAZEPINE PMS
ST200MG Tablet (Extended Release) 02261839 SANDOZ-CARBAMAZEPINE SDZ
ST200MG Tablet (Extended Release) 02237907 TARO-CARBAMAZEPINE TAR
ST200MG Tablet (Extended Release) 00773611 TEGRETOL NVR
ST400MG Tablet (Extended Release) 02238223 DOM-CARBAMAZEPINE DPC
ST400MG Tablet (Extended Release) 02231544 PMS-CARBAMAZEPINE PMS
ST400MG Tablet (Extended Release) 02261847 SANDOZ-CARBAMAZEPINE SDZ
ST400MG Tablet (Extended Release) 02237908 TARO-CARBAMAZEPINE TAR
ST400MG Tablet (Extended Release) 00755583 TEGRETOL NVR

ESLICARBAZEPINE ACETATE

Limited use benefit (prior approval required).

For adjunctive therapy in adult patients with refractory partial-onset seizures who meet all of the following criteria:

  • are under the care of a physician experienced in the treatment of epilepsy; and
  • are currently receiving two or more antiepileptic medications; and
  • have failed or demonstrated intolerance to at least two other antiepileptic medications.
Table: ESLICARBAZEPINE ACETATE
Drug strength and dosage form DIN Brand name Manufacturer code
ST200MG Tablet 02426862 APTIOM SPC
ST400MG Tablet 02426870 APTIOM SPC
ST600MG Tablet 02426889 APTIOM SPC
ST800MG Tablet 02426897 APTIOM SPC

GABAPENTIN

Limited use benefit (prior approval is not required).

For safety reasons NIHB has implemented a dose limit on gabapentin. The limit accumulates against the amount of gabapentin claimed to the program. A total of 400 grams of gabapentin is permitted in a 30-day period, for a total daily dose of 4000 mg/day.

The gabapentin dose limit will be further reduced to 3600 mg per day. The new limit will be implemented region-by-region.

Table: GABAPENTIN
Drug strength and dosage form DIN Brand name Manufacturer code
100MG Capsule 02477912 AG-GABAPENTIN ANG
ST100MG Capsule 02244304 APO-GABAPENTIN APX
ST100MG Capsule 02321203 AURO-GABAPENTIN AUR
100MG Capsule 02450143 BIO-GABAPENTIN BMI
ST100MG Capsule 02243743 DOM-GABAPENTIN DPC
ST100MG Capsule 02246314 GABAPENTIN SIV
ST100MG Capsule 02353245 GABAPENTIN SAN
ST100MG Capsule 02416840 GABAPENTIN ACC
ST100MG Capsule 02285819 GD-GABAPENTIN PFI
ST100MG Capsule 02361469 JAMP-GABAPENTIN JMP
ST100MG Capsule 02391473 MAR-GABAPENTIN MAR
ST100MG Capsule 02084260 NEURONTIN UNK
ST100MG Capsule 02243446 PMS-GABAPENTIN PMS
100MG Capsule 02450097 PRIVA-GABAPENTIN PHA
ST100MG Capsule 02310449 PRO-GABAPENTIN PDL
ST100MG Capsule 02319055 RAN-GABAPENTIN RBY
ST100MG Capsule 02251167 RIVA-GABAPENTIN RIV
ST100MG Capsule 02244513 TEVA-GABAPENTIN TEV
300MG Capsule 02477920 AG-GABAPENTIN ANG
ST300MG Capsule 02244305 APO-GABAPENTIN APX
ST300MG Capsule 02321211 AURO-GABAPENTIN AUR
300MG Capsule 02450151 BIO-GABAPENTIN BMI
ST300MG Capsule 02243744 DOM-GABAPENTIN DPC
ST300MG Capsule 02246315 GABAPENTIN SIV
ST300MG Capsule 02353253 GABAPENTIN SAN
ST300MG Capsule 02416859 GABAPENTIN ACC
ST300MG Capsule 02361485 JAMP-GABAPENTIN JMP
ST300MG Capsule 02391481 MAR-GABAPENTIN MAR
ST300MG Capsule 02084279 NEURONTIN UNK
ST300MG Capsule 02243447 PMS-GABAPENTIN PMS
300MG Capsule 02450100 PRIVA-GABAPENTIN PHA
ST300MG Capsule 02310457 PRO-GABAPENTIN PDL
ST300MG Capsule 02319063 RAN-GABAPENTIN RBY
ST300MG Capsule 02251175 RIVA-GABAPENTIN RIV
ST300MG Capsule 02244514 TEVA-GABAPENTIN TEV
400MG Capsule 02477939 AG-GABAPENTIN ANG
ST400MG Capsule 02244306 APO-GABAPENTIN APX
ST400MG Capsule 02321238 AURO-GABAPENTIN AUR
400MG Capsule 02450178 BIO-GABAPENTIN BMI
ST400MG Capsule 02243745 DOM-GABAPENTIN DPC
ST400MG Capsule 02246316 GABAPENTIN SIV
ST400MG Capsule 02353261 GABAPENTIN SAN
ST400MG Capsule 02416867 GABAPENTIN ACC
ST400MG Capsule 02361493 JAMP-GABAPENTIN JMP
ST400MG Capsule 02391503 MAR-GABAPENTIN MAR
ST400MG Capsule 02084287 NEURONTIN UNK
ST400MG Capsule 02243448 PMS-GABAPENTIN PMS
400MG Capsule 02450119 PRIVA-GABAPENTIN PHA
ST400MG Capsule 02310465 PRO-GABAPENTIN PDL
ST400MG Capsule 02319071 RAN-GABAPENTIN RBY
ST400MG Capsule 02251183 RIVA-GABAPENTIN RIV
ST400MG Capsule 02244515 TEVA-GABAPENTIN TEV
ST600MG Tablet 02293358 APO-GABAPENTIN APX
600MG Tablet 02428334 AURO-GABAPENTIN AUR
600MG Tablet 02450186 BIO-GABAPENTIN BMI
ST600MG Tablet 02388200 GABAPENTIN SIV
ST600MG Tablet 02392526 GABAPENTIN ACC
ST600MG Tablet 02431289 GABAPENTIN SAN
ST600MG Tablet 02285843 GD-GABAPENTIN PFI
ST600MG Tablet 02402289 JAMP-GABAPENTIN JMP
ST600MG Tablet 02239717 NEURONTIN UNK
ST600MG Tablet 02255898 PMS-GABAPENTIN PMS
ST600MG Tablet 02310473 PRO-GABAPENTIN PDL
ST600MG Tablet 02259796 RIVA-GABAPENTIN RIV
ST600MG Tablet 02248457 TEVA-GABAPENTIN TEV
ST800MG Tablet 02293366 APO-GABAPENTIN APX
800MG Tablet 02428342 AURO-GABAPENTIN AUR
800MG Tablet 02450194 BIO-GABAPENTIN BMI
ST800MG Tablet 02388219 GABAPENTIN SIV
ST800MG Tablet 02392534 GABAPENTIN ACC
ST800MG Tablet 02431297 GABAPENTIN SAN
ST800MG Tablet 02402297 JAMP-GABAPENTIN JMP
ST800MG Tablet 02239718 NEURONTIN UNK
ST800MG Tablet 02255901 PMS-GABAPENTIN PMS
ST800MG Tablet 02310481 PRO-GABAPENTIN PDL
ST800MG Tablet 02259818 RIVA-GABAPENTIN RIV
ST800MG Tablet 02247346 TEVA-GABAPENTIN TEV
ST600MG Tablet (Immediate Release) 02410990 GLN-GABAPENTIN GLK
ST800MG Tablet (Immediate Release) 02411008 GLN-GABAPENTIN GLK

LACOSAMIDE

Limited use benefit (prior approval required).

For adjunctive therapy in adult patients with refractory partial-onset seizures who meet all of the following criteria:

  • are under the care of a physician experienced in the treatment of epilepsy; and
  • are currently receiving two or more antiepileptic medications; and
  • have failed or demonstrated intolerance to at least two other antiepileptic medications.
Table: LACOSAMIDE
Drug strength and dosage form DIN Brand name Manufacturer code
ST50MG Tablet 02475332 AURO-LACOSAMIDE AUR
ST50MG Tablet 02487802 MAR-LACOSAMIDE MAR
ST50MG Tablet 02490544 MINT-LACOSAMIDE MIN
ST50MG Tablet 02478196 PHARMA-LACOSAMIDE PMS
ST50MG Tablet 02474670 SANDOZ LACOSAMIDE SDZ
ST50MG Tablet 02472902 TEVA-LACOSAMIDE TEV
ST50MG Tablet 02357615 VIMPAT UCB
ST100MG Tablet 02475340 AURO-LACOSAMIDE AUR
ST100MG Tablet 02487810 MAR-LACOSAMIDE MAR
ST100MG Tablet 02490552 MINT-LACOSAMIDE MIN
ST100MG Tablet 02478218 PHARMA-LACOSAMIDE PMS
ST100MG Tablet 02474689 SANDOZ LACOSAMIDE SDZ
100MG Tablet 02472910 TEVA-LACOSAMIDE TEV
ST100MG Tablet 02357623 VIMPAT UCB
ST150MG Tablet 02475359 AURO-LACOSAMIDE AUR
ST150MG Tablet 02487829 MAR-LACOSAMIDE MAR
ST150MG Tablet 02490560 MINT-LACOSAMIDE MIN
ST150MG Tablet 02478226 PHARMA-LACOSAMIDE PMS
ST150MG Tablet 02474697 SANDOZ LACOSAMIDE SDZ
150MG Tablet 02472929 TEVA-LACOSAMIDE TEV
ST150MG Tablet 02357631 VIMPAT UCB
ST200MG Tablet 02475367 AURO-LACOSAMIDE AUR
ST200MG Tablet 02487837 MAR-LACOSAMIDE MAR
ST200MG Tablet 02490579 MINT-LACOSAMIDE MIN
ST200MG Tablet 02478234 PHARMA-LACOSAMIDE PMS
ST200MG Tablet 02474700 SANDOZ LACOSAMIDE SDZ
200MG Tablet 02472937 TEVA-LACOSAMIDE TEV
ST200MG Tablet 02357658 VIMPAT UCB

LAMOTRIGINE

Table: LAMOTRIGINE
Drug strength and dosage form DIN Brand name Manufacturer code
ST2MG Tablet 02243803 LAMICTAL GSK
ST5MG Tablet 02240115 LAMICTAL GSK
ST25MG Tablet 02245208 APO-LAMOTRIGINE APX
ST25MG Tablet 02381354 AURO-LAMOTRIGINE AUR
ST25MG Tablet 02142082 LAMICTAL GSK
ST25MG Tablet 02302969 LAMOTRIGINE PDL
ST25MG Tablet 02343010 LAMOTRIGINE SAN
ST25MG Tablet 02428202 LAMOTRIGINE SIV
ST25MG Tablet 02265494 MYLAN-LAMOTRIGINE MYL
ST25MG Tablet 02246897 PMS-LAMOTRIGINE PMS
ST25MG Tablet 02248232 TEVA-LAMOTRIGINE TEV
ST100MG Tablet 02245209 APO-LAMOTRIGINE APX
ST100MG Tablet 02381362 AURO-LAMOTRIGINE AUR
ST100MG Tablet 02142104 LAMICTAL GSK
ST100MG Tablet 02302985 LAMOTRIGINE PDL
ST100MG Tablet 02343029 LAMOTRIGINE SAN
ST100MG Tablet 02428210 LAMOTRIGINE SIV
ST100MG Tablet 02265508 MYLAN-LAMOTRIGINE MYL
ST100MG Tablet 02246898 PMS-LAMOTRIGINE PMS
ST100MG Tablet 02248233 TEVA-LAMOTRIGINE TEV
ST150MG Tablet 02245210 APO-LAMOTRIGINE APX
ST150MG Tablet 02381370 AURO-LAMOTRIGINE AUR
ST150MG Tablet 02142112 LAMICTAL GSK
ST150MG Tablet 02302993 LAMOTRIGINE PDL
ST150MG Tablet 02343037 LAMOTRIGINE SAN
ST150MG Tablet 02428229 LAMOTRIGINE SIV
ST150MG Tablet 02265516 MYLAN-LAMOTRIGINE MYL
ST150MG Tablet 02246899 PMS-LAMOTRIGINE PMS
ST150MG Tablet 02248234 TEVA-LAMOTRIGINE TEV

LEVETIRACETAM

Table: LEVETIRACETAM
Drug strength and dosage form DIN Brand name Manufacturer code
ST250MG Tablet 02274183 ACT LEVETIRACETAM TEV
ST250MG Tablet 02285924 APO-LEVETIRACETAM APX
ST250MG Tablet 02375249 AURO-LEVETIRACETAM AUR
250MG Tablet 02450348 BIO-LEVETIRACETAM BMI
ST250MG Tablet 02403005 JAMP-LEVETIRACETAM JMP
ST250MG Tablet 02247027 KEPPRA UCB
ST250MG Tablet 02353342 LEVETIRACETAM SAN
ST250MG Tablet 02399776 LEVETIRACETAM ACC
ST250MG Tablet 02442531 LEVETIRACETAM SIV
ST250MG Tablet 02454653 LEVETIRACETAM PMS
ST250MG Tablet 02440202 NAT-LEVETIRACETAM NPH
ST250MG Tablet 02296101 PMS-LEVETIRACETAM PMS
250MG Tablet 02311372 PRO-LEVETIRACETAM 250 PDL
ST250MG Tablet 02396106 RAN-LEVETIRACETAM RBY
250MG Tablet 02482274 RIVA-LEVETIRACETAM RIV
ST250MG Tablet 02461986 SANDOZ LEVETIRACETAM SDZ
ST500MG Tablet 02274191 ACT LEVETIRACETAM TEV
ST500MG Tablet 02285932 APO-LEVETIRACETAM APX
ST500MG Tablet 02375257 AURO-LEVETIRACETAM AUR
500MG Tablet 02450356 BIO-LEVETIRACETAM BMI
ST500MG Tablet 02297418 DOM-LEVETIRACETAM DPC
ST500MG Tablet 02403021 JAMP-LEVETIRACETAM JMP
ST500MG Tablet 02247028 KEPPRA UCB
ST500MG Tablet 02353350 LEVETIRACETAM SAN
ST500MG Tablet 02399784 LEVETIRACETAM ACC
ST500MG Tablet 02442558 LEVETIRACETAM SIV
ST500MG Tablet 02454661 LEVETIRACETAM PMS
ST500MG Tablet 02440210 NAT-LEVETIRACETAM NPH
ST500MG Tablet 02296128 PMS-LEVETIRACETAM PMS
ST500MG Tablet 02311380 PRO-LEVETIRACETAM PDL
ST500MG Tablet 02396114 RAN-LEVETIRACETAM RBY
500MG Tablet 02482282 RIVA-LEVETIRACETAM RIV
ST500MG Tablet 02461994 SANDOZ LEVETIRACETAM SDZ
ST750MG Tablet 02274205 ACT LEVETIRACETAM TEV
ST750MG Tablet 02285940 APO-LEVETIRACETAM APX
ST750MG Tablet 02375265 AURO-LEVETIRACETAM AUR
750MG Tablet 02450364 BIO-LEVETIRACETAM BMI
ST750MG Tablet 02403048 JAMP-LEVETIRACETAM JMP
ST750MG Tablet 02247029 KEPPRA UCB
ST750MG Tablet 02353369 LEVETIRACETAM SAN
ST750MG Tablet 02399792 LEVETIRACETAM ACC
ST750MG Tablet 02442566 LEVETIRACETAM SIV
ST750MG Tablet 02454688 LEVETIRACETAM PMS
ST750MG Tablet 02440229 NAT-LEVETIRACETAM NPH
ST750MG Tablet 02296136 PMS-LEVETIRACETAM PMS
ST750MG Tablet 02311399 PRO-LEVETIRACETAM PDL
ST750MG Tablet 02396122 RAN-LEVETIRACETAM RBY
750MG Tablet 02482290 RIVA-LEVETIRACETAM RIV
ST750MG Tablet 02462001 SANDOZ LEVETIRACETAM SDZ
pDIN For Extemporaneous Mixture 99503026 LEVETIRACETAM ORAL LIQUID UNK

OXCARBAZEPINE

Table: OXCARBAZEPINE
Drug strength and dosage form DIN Brand name Manufacturer code
150MG Tablet 02284294 APO-OXCARBAZEPINE APX
150MG Tablet 02348381 APX-OXCARBAZEPINE APX
150MG Tablet 02440717 JAMP-OXCARBAZEPINE JMP
300MG Tablet 02284308 APO-OXCARBAZEPINE APX
300MG Tablet 02348403 APX-OXCARBAZEPINE APX
300MG Tablet 02440725 JAMP-OXCARBAZEPINE JMP
300MG Tablet 02242068 TRILEPTAL NVR
600MG Tablet 02284316 APO-OXCARBAZEPINE APX
600MG Tablet 02348411 APX-OXCARBAZEPINE APX
600MG Tablet 02440733 JAMP-OXCARBAZEPINE JMP
600MG Tablet 02242069 TRILEPTAL NVR

OXCARBAZEPINE (SUSPENSION)

Limited use benefit (prior approval is not required).

For patients 19 years of age or over who are unable to swallow the tablet formulation due to:

  • tube feeding; or
  • severe dysphagia

Note: Trileptal (oxcarbazepine) suspension is an open benefit for patients 18 years of age and under and does not require prior approval for these patients.

  • Oxcarbazepine tablets are an open benefit for patients of all ages and do not require prior approval.
Table: OXCARBAZEPINE (SUSPENSION)
Drug strength and dosage form DIN Brand name Manufacturer code
60MG Suspension 02244673 TRILEPTAL NVR

PERAMPANEL

Limited use benefit (prior approval required).

For adjunctive therapy in patients with refractory partial-onset seizures or primary generalized tonic-clonic (PGTC) seizures who meet all of the following criteria:

  • are under the care of a physician experienced in the treatment of epilepsy; and
  • are currently receiving two or more antiepileptic medications; and
  • have failed or demonstrated intolerance to at least two other antiepileptic medications.
Table: PERAMPANEL
Drug strength and dosage form DIN Brand name Manufacturer code
ST2MG Tablet 02404516 FYCOMPA EIS
ST4MG Tablet 02404524 FYCOMPA EIS
ST6MG Tablet 02404532 FYCOMPA EIS
ST8MG Tablet 02404540 FYCOMPA EIS
ST10MG Tablet 02404559 FYCOMPA EIS
ST12MG Tablet 02404567 FYCOMPA EIS

PREGABALIN

Limited use benefit (prior approval required).

For the treatment of neuropathic pain in patients who have failed to effectively treat their pain with a tricyclic antidepressant (TCA); or

For the treatment of neuropathic pain in patients who have a contraindication or intolerance to a tricyclic antidepressant (TCA).

Coverage is limited to a maximum of 600mg per day.

Table: PREGABALIN
Drug strength and dosage form DIN Brand name Manufacturer code
25MG Capsule 02480727 AG-PREGABALIN ANG
ST25MG Capsule 02394235 APO-PREGABALIN APX
ST25MG Capsule 02433869 AURO-PREGABALIN AUR
ST25MG Capsule 02402556 DOM-PREGABALIN DPC
ST25MG Capsule 02435977 JAMP-PREGABALIN JMP
ST25MG Capsule 02268418 LYRICA UNK
ST25MG Capsule 02417529 MAR-PREGABALIN MAR
ST25MG Capsule 02423804 MINT-PREGABALIN MIN
25MG Capsule 02467291 M-PREGABALIN MAN
25MG Capsule 02479117 NRA-PREGABALIN UNK
ST25MG Capsule 02359596 PMS-PREGABALIN PMS
25MG Capsule 02396483 PREGABALIN PDL
ST25MG Capsule 02403692 PREGABALIN SIV
ST25MG Capsule 02405539 PREGABALIN SAN
25MG Capsule 02476304 PREGABALIN RIV
ST25MG Capsule 02377039 RIVA-PREGABALIN RIV
ST25MG Capsule 02390817 SANDOZ PREGABALIN SDZ
ST25MG Capsule 02392801 TARO-PREGABALIN SUN
ST25MG Capsule 02361159 TEVA-PREGABALIN TEV
50MG Capsule 02480735 AG-PREGABALIN ANG
ST50MG Capsule 02394243 APO-PREGABALIN APX
ST50MG Capsule 02433877 AURO-PREGABALIN AUR
ST50MG Capsule 02402564 DOM-PREGABALIN DPC
ST50MG Capsule 02435985 JAMP-PREGABALIN JMP
ST50MG Capsule 02268426 LYRICA UNK
ST50MG Capsule 02417537 MAR-PREGABALIN MAR
ST50MG Capsule 02423812 MINT-PREGABALIN MIN
50MG Capsule 02467305 M-PREGABALIN MAN
50MG Capsule 02479125 NRA-PREGABALIN UNK
ST50MG Capsule 02359618 PMS-PREGABALIN PMS
50MG Capsule 02396505 PREGABALIN PDL
ST50MG Capsule 02403706 PREGABALIN SIV
ST50MG Capsule 02405547 PREGABALIN SAN
50MG Capsule 02476312 PREGABALIN RIV
ST50MG Capsule 02377047 RIVA-PREGABALIN RIV
ST50MG Capsule 02390825 SANDOZ PREGABALIN SDZ
ST50MG Capsule 02392828 TARO-PREGABALIN SUN
ST50MG Capsule 02361175 TEVA-PREGABALIN TEV
75MG Capsule 02480743 AG-PREGABALIN ANG
ST75MG Capsule 02394251 APO-PREGABALIN APX
ST75MG Capsule 02433885 AURO-PREGABALIN AUR
ST75MG Capsule 02402572 DOM-PREGABALIN DPC
ST75MG Capsule 02435993 JAMP-PREGABALIN JMP
ST75MG Capsule 02268434 LYRICA UNK
ST75MG Capsule 02417545 MAR-PREGABALIN MAR
ST75MG Capsule 02424185 MINT-PREGABALIN MIN
75MG Capsule 02467313 M-PREGABALIN MAN
75MG Capsule 02479133 NRA-PREGABALIN UNK
ST75MG Capsule 02359626 PMS-PREGABALIN PMS
75MG Capsule 02396513 PREGABALIN PDL
ST75MG Capsule 02403714 PREGABALIN SIV
ST75MG Capsule 02405555 PREGABALIN SAN
75MG Capsule 02476320 PREGABALIN RIV
ST75MG Capsule 02377055 RIVA-PREGABALIN RIV
ST75MG Capsule 02390833 SANDOZ PREGABALIN SDZ
ST75MG Capsule 02392836 TARO-PREGABALIN SUN
ST75MG Capsule 02361183 TEVA-PREGABALIN TEV
150MG Capsule 02480751 AG-PREGABALIN ANG
ST150MG Capsule 02394278 APO-PREGABALIN APX
ST150MG Capsule 02433907 AURO-PREGABALIN AUR
ST150MG Capsule 02402580 DOM-PREGABALIN DPC
ST150MG Capsule 02436000 JAMP-PREGABALIN JMP
ST150MG Capsule 02268450 LYRICA UNK
ST150MG Capsule 02417561 MAR-PREGABALIN MAR
ST150MG Capsule 02424207 MINT-PREGABALIN MIN
150MG Capsule 02467321 M-PREGABALIN MAN
150MG Capsule 02479168 NRA-PREGABALIN UNK
ST150MG Capsule 02359634 PMS-PREGABALIN PMS
150MG Capsule 02396521 PREGABALIN PDL
ST150MG Capsule 02403722 PREGABALIN SIV
ST150MG Capsule 02405563 PREGABALIN SAN
150MG Capsule 02476347 PREGABALIN RIV
ST150MG Capsule 02377063 RIVA-PREGABALIN RIV
ST150MG Capsule 02390841 SANDOZ PREGABALIN SDZ
ST150MG Capsule 02392844 TARO-PREGABALIN SUN
ST150MG Capsule 02361205 TEVA-PREGABALIN TEV
ST300MG Capsule 02394294 APO-PREGABALIN APX
ST300MG Capsule 02436019 JAMP-PREGABALIN JMP
ST300MG Capsule 02268485 LYRICA UNK
ST300MG Capsule 02359642 PMS-PREGABALIN PMS
300MG Capsule 02396548 PREGABALIN PDL
ST300MG Capsule 02403730 PREGABALIN SIV
ST300MG Capsule 02405598 PREGABALIN SAN
300MG Capsule 02476371 PREGABALIN RIV
ST300MG Capsule 02377071 RIVA-PREGABALIN RIV
ST300MG Capsule 02390868 SANDOZ PREGABALIN SDZ
ST300MG Capsule 02392860 TARO-PREGABALIN SUN
ST300MG Capsule 02361248 TEVA-PREGABALIN TEV

RUFINAMIDE

Limited use benefit (prior approval required).

For the adjunctive treatment of seizures associated with Lennox-Gastaux syndrome in adults and children 4 years and older when prescribed by a neurologist or experienced specialist. Patient has failed or is intolerant to or has contraindications to at least two adjunctive antiepileptic drugs.

Table: RUFINAMIDE
Drug strength and dosage form DIN Brand name Manufacturer code
ST100MG Tablet 02369613 BANZEL EIS
ST200MG Tablet 02369621 BANZEL EIS
ST400MG Tablet 02369648 BANZEL EIS

TOPIRAMATE

Table: TOPIRAMATE
Drug strength and dosage form DIN Brand name Manufacturer code
ST15MG Capsule 02239907 TOPAMAX JSO
ST25MG Capsule 02239908 TOPAMAX JSO
ST25MG Tablet 02351307 ACCEL-TOPIRAMATE ACP
ST25MG Tablet 02395738 ACH-TOPIRAMATE ACC
25MG Tablet 02475936 AG-TOPIRAMATE ANG
ST25MG Tablet 02279614 APO-TOPIRAMATE APX
ST25MG Tablet 02345803 AURO-TOPIRAMATE AUR
ST25MG Tablet 02271141 DOM-TOPIRAMATE DPC
ST25MG Tablet 02287765 GLN-TOPIRAMATE GLK
ST25MG Tablet 02435608 JAMP-TOPIRAMATE JMP
25MG Tablet 02432099 MAR-TOPIRAMATE MAR
ST25MG Tablet 02315645 MINT-TOPIRAMATE MIN
ST25MG Tablet 02263351 MYLAN-TOPIRAMATE MYL
ST25MG Tablet 02262991 PMS-TOPIRAMATE PMS
ST25MG Tablet 02313650 PRO-TOPIRAMATE PDL
ST25MG Tablet 02396076 RAN-TOPIRAMATE RBY
ST25MG Tablet 02431807 SANDOZ TOPIRAMATE SDZ
ST25MG Tablet 02248860 TEVA-TOPIRAMATE TEV
ST25MG Tablet 02230893 TOPAMAX JSO
ST25MG Tablet 02356856 TOPIRAMATE SAN
ST25MG Tablet 02389460 TOPIRAMATE SIV
ST50MG Tablet 02312085 PMS-TOPIRAMATE PMS
ST100MG Tablet 02351315 ACCEL-TOPIRAMATE ACP
ST100MG Tablet 02395746 ACH-TOPIRAMATE ACC
100MG Tablet 02475944 AG-TOPIRAMATE ANG
ST100MG Tablet 02279630 APO-TOPIRAMATE APX
ST100MG Tablet 02345838 AURO-TOPIRAMATE AUR
ST100MG Tablet 02271168 DOM-TOPIRAMATE DPC
ST100MG Tablet 02287773 GLN-TOPIRAMATE GLK
ST100MG Tablet 02435616 JAMP-TOPIRAMATE JMP
100MG Tablet 02432102 MAR-TOPIRAMATE MAR
ST100MG Tablet 02315653 MINT-TOPIRAMATE MIN
ST100MG Tablet 02263378 MYLAN-TOPIRAMATE MYL
ST100MG Tablet 02263009 PMS-TOPIRAMATE PMS
ST100MG Tablet 02313669 PRO-TOPIRAMATE PDL
ST100MG Tablet 02396084 RAN-TOPIRAMATE RBY
ST100MG Tablet 02431815 SANDOZ TOPIRAMATE SDZ
ST100MG Tablet 02248861 TEVA-TOPIRAMATE TEV
ST100MG Tablet 02230894 TOPAMAX JSO
ST100MG Tablet 02356864 TOPIRAMATE SAN
ST100MG Tablet 02389487 TOPIRAMATE SIV
ST200MG Tablet 02351323 ACCEL-TOPIRAMATE ACP
ST200MG Tablet 02395754 ACH-TOPIRAMATE ACC
ST200MG Tablet 02279649 APO-TOPIRAMATE APX
ST200MG Tablet 02345846 AURO-TOPIRAMATE AUR
ST200MG Tablet 02271176 DOM-TOPIRAMATE DPC
ST200MG Tablet 02287781 GLN-TOPIRAMATE GLK
ST200MG Tablet 02435624 JAMP-TOPIRAMATE JMP
200MG Tablet 02432110 MAR-TOPIRAMATE MAR
ST200MG Tablet 02315661 MINT-TOPIRAMATE MIN
ST200MG Tablet 02263386 MYLAN-TOPIRAMATE MYL
ST200MG Tablet 02263017 PMS-TOPIRAMATE PMS
ST200MG Tablet 02313677 PRO-TOPIRAMATE PDL
ST200MG Tablet 02396092 RAN-TOPIRAMATE RBY
ST200MG Tablet 02431823 SANDOZ TOPIRAMATE SDZ
ST200MG Tablet 02248862 TEVA-TOPIRAMATE TEV
ST200MG Tablet 02230896 TOPAMAX JSO
ST200MG Tablet 02356872 TOPIRAMATE SAN
pDIN For Extemporaneous Mixture 99503027 TOPIRAMATE ORAL LIQUID UNK

VALPROIC ACID (DIVALPROEX SODIUM)

Table: VALPROIC ACID (DIVALPROEX SODIUM)
Drug strength and dosage form DIN Brand name Manufacturer code
ST125MG Tablet (Enteric Coated) 02239698 APO-DIVALPROEX APX
ST125MG Tablet (Enteric Coated) 02400499 DIVALPROEX SAN
ST125MG Tablet (Enteric Coated) 00596418 EPIVAL BGP
ST125MG Tablet (Enteric Coated) 02458926 MYLAN-DIVALPROEX MYL
ST125MG Tablet (Enteric Coated) 02244138 PMS-DIVALPROEX PMS
ST250MG Tablet (Enteric Coated) 02239699 APO-DIVALPROEX APX
ST250MG Tablet (Enteric Coated) 02400502 DIVALPROEX SAN
ST250MG Tablet (Enteric Coated) 00596426 EPIVAL BGP
ST250MG Tablet (Enteric Coated) 02458934 MYLAN-DIVALPROEX MYL
ST250MG Tablet (Enteric Coated) 02244139 PMS-DIVALPROEX PMS
ST500MG Tablet (Enteric Coated) 02239700 APO-DIVALPROEX APX
ST500MG Tablet (Enteric Coated) 02400510 DIVALPROEX SAN
ST500MG Tablet (Enteric Coated) 00596434 EPIVAL BGP
ST500MG Tablet (Enteric Coated) 02459019 MYLAN-DIVALPROEX MYL
ST500MG Tablet (Enteric Coated) 02244140 PMS-DIVALPROEX PMS

VALPROIC ACID (SODIUM VALPROATE)

Table: VALPROIC ACID (SODIUM VALPROATE)
Drug strength and dosage form DIN Brand name Manufacturer code
ST250MG Capsule 02238048 APO-VALPROIC APX
ST250MG Capsule 02231030 DOM-VALPROIC ACID DPC
ST250MG Capsule 02230768 PMS-VALPROIC ACID PMS
ST500MG Capsule (Enteric Coated) 02231031 DOM-VALPROIC ACID DPC
ST500MG Capsule (Enteric Coated) 02229628 PMS-VALPROIC ACID PMS
ST50MG/ML Solution 02238817 DOM-VALPROIC ACID DPC
ST50MG/ML Solution 02236807 PMS-VALPROIC ACID PMS
ST50MG/ML Syrup 02238370 APO-VALPROIC APX
ST50MG/ML Syrup 00443832 DEPAKENE BGP

VIGABATRIN

Table: VIGABATRIN
Drug strength and dosage form DIN Brand name Manufacturer code
ST500MG Powder For Solution 02068036 SABRIL LUK
ST500MG Tablet 02065819 SABRIL LUK

28:16.04 ANTIDEPRESSANTS

AMITRIPTYLINE HYDROCHLORIDE

Table: AMITRIPTYLINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
10MG Tablet 02477963 AG-AMITRIPTYLINE ANG
ST10MG Tablet 00370991 AMITRIPTYLINE PDL
ST10MG Tablet 02403137 APO-AMITRIPTYLINE APX
ST10MG Tablet 00335053 ELAVIL AAP
ST10MG Tablet 02435527 JAMP-AMITRIPTYLINE JMP
ST10MG Tablet 00293911 LEVATE BMI
ST10MG Tablet 02429861 MAR-AMITRIPTYLINE MAR
ST10MG Tablet 00654523 PMS-AMITRIPTYLINE PMS
10MG Tablet 02490110 PRIVA-AMITRIPTYLINE PHA
ST10MG Tablet 02326043 TEVA-AMITRIPTYLINE TEV
25MG Tablet 02477971 AG-AMITRIPTYLINE ANG
ST25MG Tablet 00371009 AMITRIPTYLINE PDL
ST25MG Tablet 02403145 APO-AMITRIPTYLINE APX
ST25MG Tablet 00335061 ELAVIL AAP
ST25MG Tablet 02435535 JAMP-AMITRIPTYLINE JMP
ST25MG Tablet 02429888 MAR-AMITRIPTYLINE MAR
ST25MG Tablet 00654515 PMS-AMITRIPTYLINE PMS
25MG Tablet 02490129 PRIVA-AMITRIPTYLINE PHA
ST25MG Tablet 02326051 TEVA-AMITRIPTYLINE TEV
50MG Tablet 02477998 AG-AMITRIPTYLINE ANG
ST50MG Tablet 00456349 AMITRIPTYLINE PDL
ST50MG Tablet 02403153 APO-AMITRIPTYLINE APX
ST50MG Tablet 00335088 ELAVIL AAP
ST50MG Tablet 02435543 JAMP-AMITRIPTYLINE JMP
ST50MG Tablet 00271152 LEVATE BMI
ST50MG Tablet 02429896 MAR-AMITRIPTYLINE MAR
ST50MG Tablet 00654507 PMS-AMITRIPTYLINE PMS
50MG Tablet 02490137 PRIVA-AMITRIPTYLINE PHA
ST50MG Tablet 02326078 TEVA-AMITRIPTYLINE TEV
ST75MG Tablet 02403161 APO-AMITRIPTYLINE APX
ST75MG Tablet 00754129 ELAVIL AAP
ST75MG Tablet 02435551 JAMP-AMITRIPTYLINE JMP
ST75MG Tablet 00405612 LEVATE BMI
ST75MG Tablet 02429918 MAR-AMITRIPTYLINE MAR

BUPROPION HYDROCHLORIDE (WELLBUTRIN)

Table: BUPROPION HYDROCHLORIDE (WELLBUTRIN)
Drug strength and dosage form DIN Brand name Manufacturer code
ST100MG Tablet (Extended Release) 02331616 BUPROPION SR PDL
ST100MG Tablet (Extended Release) 02391562 BUPROPION SR SAN
ST100MG Tablet (Extended Release) 02325373 PMS-BUPROPION SR PMS
ST100MG Tablet (Extended Release) 02275074 SANDOZ BUPROPION SR SDZ
ST150MG Tablet (Extended Release) 02325357 BUPROPION SR PDL
ST150MG Tablet (Extended Release) 02391570 BUPROPION SR SAN
ST150MG Tablet (Extended Release) 02382075 MYLAN-BUPROPION XL MYL
ST150MG Tablet (Extended Release) 02313421 PMS-BUPROPION SR PMS
ST150MG Tablet (Extended Release) 02275082 SANDOZ BUPROPION SR SDZ
ST150MG Tablet (Extended Release) 02475804 TARO-BUPROPION XL SUN
ST150MG Tablet (Extended Release) 02439654 TEVA-BUPROPION XL TEV
ST150MG Tablet (Extended Release) 02237825 WELLBUTRIN SR VAE
ST150MG Tablet (Extended Release) 02275090 WELLBUTRIN XL VAE
ST300MG Tablet (Extended Release) 02382083 MYLAN-BUPROPION XL MYL
ST300MG Tablet (Extended Release) 02475812 TARO-BUPROPION XL SUN
ST300MG Tablet (Extended Release) 02439662 TEVA-BUPROPION XL TEV
ST300MG Tablet (Extended Release) 02275104 WELLBUTRIN XL VAE

BUPROPION HYDROCHLORIDE (ZYBAN)

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

For smoking cessation:

Coverage is limited to 180 tablets during a one-year period. The year starts on the date the first prescription is filled. Once this quantity has been reached the client is eligible again for coverage for bupropion hydrochloride when one year has elapsed from the day the initial prescription was filled.

Table: BUPROPION HYDROCHLORIDE (ZYBAN)
Drug strength and dosage form DIN Brand name Manufacturer code
ST150MG Tablet (Extended Release) 02238441 ZYBAN VAE

CITALOPRAM HYDROBROMIDE

Table: CITALOPRAM HYDROBROMIDE
Drug strength and dosage form DIN Brand name Manufacturer code
10MG Tablet 02374617 AG-CITALOPRAM ANG
10MG Tablet 02448475 BIO-CITALOPRAM BMI
ST10MG Tablet 02325047 CITALOPRAM PDL
ST10MG Tablet 02387948 CITALOPRAM SIV
ST10MG Tablet 02430517 CITALOPRAM JMP
ST10MG Tablet 02445719 CITALOPRAM SAN
ST10MG Tablet 02273055 DOM-CITALOPRAM DPC
ST10MG Tablet 02370085 JAMP-CITALOPRAM JMP
ST10MG Tablet 02371871 MAR-CITALOPRAM MAR
ST10MG Tablet 02429691 MINT-CITALOPRAM MIN
ST10MG Tablet 02409003 NAT-CITALOPRAM NPH
10MG Tablet 02477637 NRA-CITALOPRAM UNK
ST10MG Tablet 02270609 PMS-CITALOPRAM PMS
ST10MG Tablet 02303256 RIVA-CITALOPRAM RIV
ST10MG Tablet 02431629 SEPTA-CITALOPRAM SPT
ST10MG Tablet 02312336 TEVA-CITALOPRAM TEV
ST20MG Tablet 02248050 ACT CITALOPRAM SPC
20MG Tablet 02339390 AG-CITALOPRAM ANG
ST20MG Tablet 02246056 APO-CITALOPRAM APX
ST20MG Tablet 02275562 AURO-CITALOPRAM AUR
20MG Tablet 02448491 BIO-CITALOPRAM BMI
ST20MG Tablet 02239607 CELEXA LUD
ST20MG Tablet 02257513 CITALOPRAM PDL
ST20MG Tablet 02353660 CITALOPRAM SAN
ST20MG Tablet 02387956 CITALOPRAM SIV
ST20MG Tablet 02430541 CITALOPRAM JMP
ST20MG Tablet 02248942 DOM-CITALOPRAM DPC
ST20MG Tablet 02313405 JAMP-CITALOPRAM JMP
ST20MG Tablet 02371898 MAR-CITALOPRAM MAR
ST20MG Tablet 02429705 MINT-CITALOPRAM MIN
ST20MG Tablet 02409011 NAT-CITALOPRAM NPH
20MG Tablet 02477645 NRA-CITALOPRAM UNK
ST20MG Tablet 02248010 PMS-CITALOPRAM PMS
ST20MG Tablet 02285622 RAN-CITALO RBY
ST20MG Tablet 02303264 RIVA-CITALOPRAM RIV
ST20MG Tablet 02248170 SANDOZ CITALOPRAM SDZ
ST20MG Tablet 02355272 SEPTA-CITALOPRAM SPT
ST20MG Tablet 02293218 TEVA-CITALOPRAM TEV
ST30MG Tablet 02296152 CTP 30 SPC
ST40MG Tablet 02248051 ACT CITALOPRAM SPC
40MG Tablet 02339404 AG-CITALOPRAM ANG
ST40MG Tablet 02246057 APO-CITALOPRAM APX
ST40MG Tablet 02275570 AURO-CITALOPRAM AUR
40MG Tablet 02448513 BIO-CITALOPRAM BMI
ST40MG Tablet 02239608 CELEXA LUD
ST40MG Tablet 02257521 CITALOPRAM PDL
ST40MG Tablet 02353679 CITALOPRAM SAN
ST40MG Tablet 02387964 CITALOPRAM SIV
ST40MG Tablet 02430568 CITALOPRAM JMP
ST40MG Tablet 02248943 DOM-CITALOPRAM DPC
ST40MG Tablet 02313413 JAMP-CITALOPRAM JMP
ST40MG Tablet 02371901 MAR-CITALOPRAM MAR
ST40MG Tablet 02429713 MINT-CITALOPRAM MIN
ST40MG Tablet 02409038 NAT-CITALOPRAM NPH
40MG Tablet 02477653 NRA-CITALOPRAM UNK
ST40MG Tablet 02248011 PMS-CITALOPRAM PMS
ST40MG Tablet 02285630 RAN-CITALO RBY
ST40MG Tablet 02303272 RIVA-CITALOPRAM RIV
ST40MG Tablet 02248171 SANDOZ CITALOPRAM SDZ
ST40MG Tablet 02355280 SEPTA-CITALOPRAM SPT
ST40MG Tablet 02293226 TEVA-CITALOPRAM TEV

CLOMIPRAMINE HYDROCHLORIDE

Table: CLOMIPRAMINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
ST10MG Tablet 00330566 ANAFRANIL AAP
ST25MG Tablet 00324019 ANAFRANIL AAP
ST50MG Tablet 00402591 ANAFRANIL AAP

DESIPRAMINE HYDROCHLORIDE

Table: DESIPRAMINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
ST10MG Tablet 02216248 DESIPRAMINE AAP
ST25MG Tablet 02216256 DESIPRAMINE AAP
ST50MG Tablet 02216264 DESIPRAMINE AAP
ST50MG Tablet 01946277 PMS DESIPRAMINE PMS
ST75MG Tablet 02216272 DESIPRAMINE AAP
ST75MG Tablet 01946242 PMS DESIPRAMINE PMS
ST100MG Tablet 02216280 DESIPRAMINE AAP

DOXEPIN HYDROCHLORIDE

Table: DOXEPIN HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
ST10MG Capsule 02049996 DOXEPIN APX
ST10MG Capsule 00024325 SINEQUAN AAP
ST25MG Capsule 02050005 DOXEPIN APX
ST25MG Capsule 00024333 SINEQUAN AAP
ST50MG Capsule 02050013 DOXEPIN APX
ST50MG Capsule 00024341 SINEQUAN AAP
ST75MG Capsule 00400750 SINEQUAN AAP
ST100MG Capsule 00326925 SINEQUAN AAP
ST150MG Capsule 02050056 DOXEPIN APX

DULOXETINE HYDROCHLORIDE

Table: DULOXETINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
30MG Capsule (Delayed Release) 02475308 AG-DULOXETINE ANG
ST30MG Capsule (Delayed Release) 02440423 APO-DULOXETINE APX
ST30MG Capsule (Delayed Release) 02436647 AURO-DULOXETINE AUR
ST30MG Capsule (Delayed Release) 02301482 CYMBALTA LIL
30MG Capsule (Delayed Release) 02452650 DULOXETINE PDL
ST30MG Capsule (Delayed Release) 02453630 DULOXETINE SIV
ST30MG Capsule (Delayed Release) 02490889 DULOXETINE SAN
ST30MG Capsule (Delayed Release) 02437082 DULOXETINE DR TEV
ST30MG Capsule (Delayed Release) 02451913 JAMP-DULOXETINE JMP
ST30MG Capsule (Delayed Release) 02446081 MAR-DULOXETINE MAR
30MG Capsule (Delayed Release) 02473208 M-DULOXETINE MAN
ST30MG Capsule (Delayed Release) 02438984 MINT-DULOXETINE MIN
30MG Capsule (Delayed Release) 02482126 NRA-DULOXETINE UNK
ST30MG Capsule (Delayed Release) 02429446 PMS-DULOXETINE PMS
ST30MG Capsule (Delayed Release) 02438259 RAN-DULOXETINE RBY
30MG Capsule (Delayed Release) 02451077 RIVA-DULOXETINE RIV
ST30MG Capsule (Delayed Release) 02439948 SANDOZ DULOXETINE SDZ
60MG Capsule (Delayed Release) 02475316 AG-DULOXETINE ANG
ST60MG Capsule (Delayed Release) 02440431 APO-DULOXETINE APX
ST60MG Capsule (Delayed Release) 02436655 AURO-DULOXETINE AUR
ST60MG Capsule (Delayed Release) 02301490 CYMBALTA LIL
60MG Capsule (Delayed Release) 02452669 DULOXETINE PDL
ST60MG Capsule (Delayed Release) 02453649 DULOXETINE SIV
ST60MG Capsule (Delayed Release) 02490897 DULOXETINE SAN
ST60MG Capsule (Delayed Release) 02437090 DULOXETINE DR TEV
ST60MG Capsule (Delayed Release) 02451921 JAMP-DULOXETINE JMP
ST60MG Capsule (Delayed Release) 02446103 MAR-DULOXETINE MAR
60MG Capsule (Delayed Release) 02473216 M-DULOXETINE MAN
ST60MG Capsule (Delayed Release) 02438992 MINT-DULOXETINE MIN
60MG Capsule (Delayed Release) 02482134 NRA-DULOXETINE UNK
ST60MG Capsule (Delayed Release) 02429454 PMS-DULOXETINE PMS
ST60MG Capsule (Delayed Release) 02438267 RAN-DULOXETINE RBY
60MG Capsule (Delayed Release) 02451085 RIVA-DULOXETINE RIV
ST60MG Capsule (Delayed Release) 02439956 SANDOZ DULOXETINE SDZ

ESCITALOPRAM OXALATE

Table: ESCITALOPRAM OXALATE
Drug strength and dosage form DIN Brand name Manufacturer code
ST10MG Tablet 02434652 ACH-ESCITALOPRAM ACC
10MG Tablet 02477742 AG-ESCITALOPRAM ANG
ST10MG Tablet 02295016 APO-ESCITALOPRAM APX
ST10MG Tablet 02397358 AURO-ESCITALOPRAM AUR
10MG Tablet 02481154 BIO-ESCITALOPRAM BMI
ST10MG Tablet 02263238 CIPRALEX LUD
ST10MG Tablet 02303949 ESCITALOPRAM PMS
ST10MG Tablet 02424401 ESCITALOPRAM PDL
ST10MG Tablet 02429039 ESCITALOPRAM SIV
ST10MG Tablet 02430118 ESCITALOPRAM SAN
ST10MG Tablet 02429780 JAMP-ESCITALOPRAM JMP
ST10MG Tablet 02423480 MAR-ESCITALOPRAM MAR
10MG Tablet 02471418 M-ESCITALOPRAM MAN
ST10MG Tablet 02407418 MINT-ESCITALOPRAM MIN
ST10MG Tablet 02309467 MYLAN-ESCITALOPRAM MYL
ST10MG Tablet 02440296 NAT-ESCITALOPRAM NPH
10MG Tablet 02476851 NRA-ESCITALOPRAM UNK
ST10MG Tablet 02469243 PHARMA-ESCITALOPRAM PMS
ST10MG Tablet 02426331 PRIVA-ESCITALOPRAM PHA
ST10MG Tablet 02385481 RAN-ESCITALOPRAM RBY
ST10MG Tablet 02428830 RIVA-ESCITALOPRAM RIV
ST10MG Tablet 02364077 SANDOZ ESCITALOPRAM SDZ
ST10MG Tablet 02318180 TEVA-ESCITALOPRAM TEV
ST20MG Tablet 02434660 ACH-ESCITALOPRAM ACC
20MG Tablet 02477769 AG-ESCITALOPRAM ANG
ST20MG Tablet 02295024 APO-ESCITALOPRAM APX
ST20MG Tablet 02397374 AURO-ESCITALOPRAM AUR
20MG Tablet 02481170 BIO-ESCITALOPRAM BMI
ST20MG Tablet 02263254 CIPRALEX LUD
ST20MG Tablet 02303965 ESCITALOPRAM PMS
ST20MG Tablet 02424428 ESCITALOPRAM PDL
ST20MG Tablet 02429047 ESCITALOPRAM SIV
ST20MG Tablet 02430126 ESCITALOPRAM SAN
ST20MG Tablet 02429799 JAMP-ESCITALOPRAM JMP
ST20MG Tablet 02423502 MAR-ESCITALOPRAM MAR
ST20MG Tablet 02407434 MINT-ESCITALOPRAM MIN
ST20MG Tablet 02309475 MYLAN-ESCITALOPRAM MYL
ST20MG Tablet 02440318 NAT-ESCITALOPRAM NPH
20MG Tablet 02476878 NRA-ESCITALOPRAM UNK
ST20MG Tablet 02469251 PHARMA-ESCITALOPRAM PMS
ST20MG Tablet 02426358 PRIVA-ESCITALOPRAM PHA
ST20MG Tablet 02385503 RAN-ESCITALOPRAM RBY
ST20MG Tablet 02428857 RIVA-ESCITALOPRAM RIV
ST20MG Tablet 02364085 SANDOZ ESCITALOPRAM SDZ
ST20MG Tablet 02318202 TEVA-ESCITALOPRAM TEV
ST10MG Tablet (Orally Disintegrating) 02454297 ACT ESCITALOPRAM ODT TEV
ST20MG Tablet (Orally Disintegrating) 02454300 ACT ESCITALOPRAM ODT TEV

FLUOXETINE HYDROCHLORIDE

Table: FLUOXETINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
ST10MG Capsule 02393441 ACH-FLUOXETINE ACC
ST10MG Capsule 02242177 ACT FLUOXETINE REC
ST10MG Capsule 02216353 APO-FLUOXETINE APX
ST10MG Capsule 02385627 AURO-FLUOXETINE AUR
10MG Capsule 02448424 BIO-FLUOXETINE BMI
ST10MG Capsule 02177617 DOM-FLUOXETINE DPC
ST10MG Capsule 02286068 FLUOXETINE SAN
ST10MG Capsule 02374447 FLUOXETINE SIV
ST10MG Capsule 02401894 JAMP-FLUOXETINE JMP
ST10MG Capsule 02380560 MINT-FLUOXETINE MIN
ST10MG Capsule 02177579 PMS-FLUOXETINE PMS
10MG Capsule 02448416 PRIVA-FLUOXETINE PHA
ST10MG Capsule 02314991 PRO-FLUOXETINE PDL
ST10MG Capsule 02018985 PROZAC LIL
ST10MG Capsule 02405695 RAN-FLUOXETINE RBY
ST10MG Capsule 02479486 SANDOZ FLUOXETINE SDZ
ST10MG Capsule 02216582 TEVA-FLUOXETINE TEV
ST20MG Capsule 02383241 ACH-FLUOXETINE ACC
ST20MG Capsule 02242178 ACT FLUOXETINE REC
ST20MG Capsule 02216361 APO-FLUOXETINE APX
ST20MG Capsule 02385635 AURO-FLUOXETINE AUR
20MG Capsule 02448432 BIO-FLUOXETINE BMI
ST20MG Capsule 02177625 DOM-FLUOXETINE DPC
ST20MG Capsule 02286076 FLUOXETINE SAN
ST20MG Capsule 02374455 FLUOXETINE SIV
ST20MG Capsule 02386402 JAMP-FLUOXETINE JMP
ST20MG Capsule 02380579 MINT-FLUOXETINE MIN
ST20MG Capsule 02177587 PMS-FLUOXETINE PMS
20MG Capsule 02448408 PRIVA-FLUOXETINE PHA
ST20MG Capsule 02315009 PRO-FLUOXETINE PDL
ST20MG Capsule 00636622 PROZAC LIL
ST20MG Capsule 02405709 RAN-FLUOXETINE RBY
20MG Capsule 02305488 RIVA-FLUOXETINE RIV
ST20MG Capsule 02479494 SANDOZ FLUOXETINE SDZ
ST20MG Capsule 02216590 TEVA-FLUOXETINE TEV
ST40MG Capsule 02464640 PMS-FLUOXETINE PMS
ST60MG Capsule 02464659 PMS-FLUOXETINE PMS
ST4MG/ML Solution 02231328 APO-FLUOXETINE APX
20MG Solution 02459361 ODAN-FLUOXETINE ODN

FLUVOXAMINE MALEATE

Table: FLUVOXAMINE MALEATE
Drug strength and dosage form DIN Brand name Manufacturer code
ST50MG Tablet 02255529 ACT FLUVOXAMINE ACG
ST50MG Tablet 02231329 APO-FLUVOXAMINE APX
ST50MG Tablet 02236753 FLUVOXAMINE PDL
ST50MG Tablet 01919342 LUVOX BGP
ST50MG Tablet 02303345 RIVA-FLUVOX RIV
ST100MG Tablet 02255537 ACT FLUVOXAMINE ACG
ST100MG Tablet 02231330 APO-FLUVOXAMINE APX
ST100MG Tablet 02236754 FLUVOXAMINE PDL
ST100MG Tablet 01919369 LUVOX BGP
ST100MG Tablet 02303361 RIVA-FLUVOX RIV

IMIPRAMINE HYDROCHLORIDE

Table: IMIPRAMINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
ST10MG Tablet 00360201 IMIPRAMINE AAP
ST25MG Tablet 00312797 IMIPRAMINE AAP
ST50MG Tablet 00326852 IMIPRAMINE AAP
ST75MG Tablet 00644579 IMIPRAMINE AAP

MIRTAZAPINE

Table: MIRTAZAPINE
Drug strength and dosage form DIN Brand name Manufacturer code
ST15MG Tablet 02286610 APO-MIRTAZAPINE APX
ST15MG Tablet 02411695 AURO-MIRTAZAPINE AUR
ST15MG Tablet 02256096 MYLAN-MIRTAZAPINE MYL
ST15MG Tablet 02273942 PMS-MIRTAZAPINE PMS
ST15MG Tablet 02312778 PRO-MIRTAZAPINE PDL
ST15MG Tablet 02250594 SANDOZ MIRTAZAPINE SDZ
ST30MG Tablet 02286629 APO-MIRTAZAPINE APX
ST30MG Tablet 02411709 AURO-MIRTAZAPINE AUR
ST30MG Tablet 02252287 DOM-MIRTAZAPINE DPC
ST30MG Tablet 02370689 MIRTAZAPINE SAN
ST30MG Tablet 02256118 MYLAN-MIRTAZAPINE MYL
ST30MG Tablet 02248762 PMS-MIRTAZAPINE PMS
ST30MG Tablet 02312786 PRO-MIRTAZAPINE PDL
ST30MG Tablet 02243910 REMERON FRS
ST30MG Tablet 02250608 SANDOZ MIRTAZAPINE SDZ
ST30MG Tablet 02259354 TEVA-MIRTAZAPINE TEV
ST45MG Tablet 02286637 APO-MIRTAZAPINE APX
ST45MG Tablet 02411717 AURO-MIRTAZAPINE AUR
ST45MG Tablet 02256126 MYLAN-MIRTAZAPINE MYL
ST15MG Tablet (Orally Disintegrating) 02299801 AURO-MIRTAZAPINE OD AUR
ST15MG Tablet (Orally Disintegrating) 02248542 REMERON RD FRS
ST30MG Tablet (Orally Disintegrating) 02299828 AURO-MIRTAZAPINE OD AUR
ST30MG Tablet (Orally Disintegrating) 02248543 REMERON RD FRS
ST45MG Tablet (Orally Disintegrating) 02299836 AURO-MIRTAZAPINE OD AUR
ST45MG Tablet (Orally Disintegrating) 02248544 REMERON RD FRS

MOCLOBEMIDE

Table: MOCLOBEMIDE
Drug strength and dosage form DIN Brand name Manufacturer code
ST100MG Tablet 02232148 MOCLOBEMIDE AAP
ST150MG Tablet 00899356 MANERIX VAE
ST150MG Tablet 02232150 MOCLOBEMIDE AAP
ST150MG Tablet 02243218 PMS-MOCLOBEMIDE PMS
ST300MG Tablet 02166747 MANERIX VAE
ST300MG Tablet 02240456 MOCLOBEMIDE AAP
ST300MG Tablet 02243219 PMS-MOCLOBEMIDE PMS

NORTRIPTYLINE HYDROCHLORIDE

Table: NORTRIPTYLINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
ST10MG Capsule 00015229 AVENTYL AAP
ST25MG Capsule 00015237 AVENTYL AAP

PAROXETINE HYDROCHLORIDE

Table: PAROXETINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
ST10MG Tablet 02262746 ACT PAROXETINE ACG
10MG Tablet 02475537 AG-PAROXETINE ANG
ST10MG Tablet 02240907 APO-PAROXETINE APX
ST10MG Tablet 02383276 AURO-PAROXETINE AUR
10MG Tablet 02444909 BIO-PAROXETINE BMI
ST10MG Tablet 02248447 DOM-PAROXETINE DPC
ST10MG Tablet 02368862 JAMP-PAROXETINE JMP
ST10MG Tablet 02411946 MAR-PAROXETINE MAR
ST10MG Tablet 02421372 MINT-PAROXETINE MIN
10MG Tablet 02467402 M-PAROXETINE MAN
10MG Tablet 02479753 NRA-PAROXETINE UNK
ST10MG Tablet 02248913 PAROXETINE PDL
ST10MG Tablet 02282844 PAROXETINE SAN
ST10MG Tablet 02388227 PAROXETINE SIV
ST10MG Tablet 02027887 PAXIL GSK
ST10MG Tablet 02247750 PMS-PAROXETINE PMS
10MG Tablet 02444313 PRIVA-PAROXETINE PHA
ST10MG Tablet 02248559 RIVA-PAROXETINE RIV
ST10MG Tablet 02248556 TEVA-PAROXETINE TEV
ST20MG Tablet 02262754 ACT PAROXETINE ACG
20MG Tablet 02475545 AG-PAROXETINE ANG
ST20MG Tablet 02240908 APO-PAROXETINE APX
ST20MG Tablet 02383284 AURO-PAROXETINE AUR
20MG Tablet 02444917 BIO-PAROXETINE BMI
ST20MG Tablet 02248448 DOM-PAROXETINE DPC
ST20MG Tablet 02368870 JAMP-PAROXETINE JMP
ST20MG Tablet 02411954 MAR-PAROXETINE MAR
ST20MG Tablet 02421380 MINT-PAROXETINE MIN
20MG Tablet 02467410 M-PAROXETINE MAN
20MG Tablet 02479761 NRA-PAROXETINE UNK
ST20MG Tablet 02248914 PAROXETINE PDL
ST20MG Tablet 02282852 PAROXETINE SAN
ST20MG Tablet 02388235 PAROXETINE SIV
ST20MG Tablet 01940481 PAXIL GSK
ST20MG Tablet 02247751 PMS-PAROXETINE PMS
20MG Tablet 02444321 PRIVA-PAROXETINE PHA
ST20MG Tablet 02248560 RIVA-PAROXETINE RIV
ST20MG Tablet 02248557 TEVA-PAROXETINE TEV
ST30MG Tablet 02262762 ACT PAROXETINE ACG
30MG Tablet 02475553 AG-PAROXETINE ANG
ST30MG Tablet 02240909 APO-PAROXETINE APX
ST30MG Tablet 02383292 AURO-PAROXETINE AUR
30MG Tablet 02444925 BIO-PAROXETINE BMI
ST30MG Tablet 02248449 DOM-PAROXETINE DPC
ST30MG Tablet 02368889 JAMP-PAROXETINE JMP
ST30MG Tablet 02411962 MAR-PAROXETINE MAR
ST30MG Tablet 02421399 MINT-PAROXETINE MIN
30MG Tablet 02467429 M-PAROXETINE MAN
30MG Tablet 02479788 NRA-PAROXETINE UNK
ST30MG Tablet 02248915 PAROXETINE PDL
ST30MG Tablet 02282860 PAROXETINE SAN
ST30MG Tablet 02388243 PAROXETINE SIV
ST30MG Tablet 01940473 PAXIL GSK
ST30MG Tablet 02247752 PMS-PAROXETINE PMS
30MG Tablet 02444348 PRIVA-PAROXETINE PHA
ST30MG Tablet 02248561 RIVA-PAROXETINE RIV
ST30MG Tablet 02248558 TEVA-PAROXETINE TEV
ST40MG Tablet 02293749 PMS-PAROXETINE PMS

PHENELZINE SULFATE

Table: PHENELZINE SULFATE
Drug strength and dosage form DIN Brand name Manufacturer code
ST15MG Tablet 00476552 NARDIL ERF

SERTRALINE HYDROCHLORIDE

Table: SERTRALINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
25MG Capsule 02477882 AG-SERTRALINE ANG
ST25MG Capsule 02238280 APO-SERTRALINE APX
ST25MG Capsule 02390906 AURO-SERTRALINE AUR
25MG Capsule 02445042 BIO-SERTRALINE BMI
ST25MG Capsule 02245748 DOM-SERTRALINE DPC
ST25MG Capsule 02357143 JAMP-SERTRALINE JMP
ST25MG Capsule 02399415 MAR-SERTRALINE MAR
ST25MG Capsule 02402378 MINT-SERTRALINE MIN
25MG Capsule 02488434 NRA-SERTRALINE UNK
ST25MG Capsule 02244838 PMS-SERTRALINE PMS
25MG Capsule 02445352 PRIVA-SERTRALINE PHA
ST25MG Capsule 02374552 RAN-SERTRALINE RBY
ST25MG Capsule 02248496 RIVA-SERTRALINE RIV
ST25MG Capsule 02245159 SANDOZ SERTRALINE SDZ
ST25MG Capsule 02353520 SERTRALINE SAN
ST25MG Capsule 02386070 SERTRALINE SIV
ST25MG Capsule 02469626 SERTRALINE JMP
ST25MG Capsule 02241302 SERTRALINE-25 PDL
ST25MG Capsule 02240485 TEVA-SERTRALINE TEV
ST25MG Capsule 02132702 ZOLOFT UNK
50MG Capsule 02477890 AG-SERTRALINE ANG
ST50MG Capsule 02238281 APO-SERTRALINE APX
ST50MG Capsule 02390914 AURO-SERTRALINE AUR
50MG Capsule 02445050 BIO-SERTRALINE BMI
ST50MG Capsule 02245749 DOM-SERTRALINE DPC
ST50MG Capsule 02357151 JAMP-SERTRALINE JMP
ST50MG Capsule 02399423 MAR-SERTRALINE MAR
ST50MG Capsule 02402394 MINT-SERTRALINE MIN
50MG Capsule 02488442 NRA-SERTRALINE UNK
ST50MG Capsule 02244839 PMS-SERTRALINE PMS
50MG Capsule 02445360 PRIVA-SERTRALINE PHA
ST50MG Capsule 02374560 RAN-SERTRALINE RBY
ST50MG Capsule 02248497 RIVA-SERTRALINE RIV
ST50MG Capsule 02245160 SANDOZ SERTRALINE SDZ
ST50MG Capsule 02353539 SERTRALINE SAN
ST50MG Capsule 02386089 SERTRALINE SIV
ST50MG Capsule 02469634 SERTRALINE JMP
ST50MG Capsule 02241303 SERTRALINE-50 PDL
ST50MG Capsule 02240484 TEVA-SERTRALINE TEV
ST50MG Capsule 01962817 ZOLOFT UNK
100MG Capsule 02477904 AG-SERTRALINE ANG
ST100MG Capsule 02238282 APO-SERTRALINE APX
ST100MG Capsule 02390922 AURO-SERTRALINE AUR
100MG Capsule 02445069 BIO-SERTRALINE BMI
ST100MG Capsule 02245750 DOM-SERTRALINE DPC
ST100MG Capsule 02357178 JAMP-SERTRALINE JMP
ST100MG Capsule 02399431 MAR-SERTRALINE MAR
ST100MG Capsule 02402408 MINT-SERTRALINE MIN
100MG Capsule 02488450 NRA-SERTRALINE UNK
ST100MG Capsule 02244840 PMS-SERTRALINE PMS
100MG Capsule 02445387 PRIVA-SERTRALINE PHA
ST100MG Capsule 02374579 RAN-SERTRALINE RBY
ST100MG Capsule 02248498 RIVA-SERTRALINE RIV
ST100MG Capsule 02245161 SANDOZ SERTRALINE SDZ
ST100MG Capsule 02353547 SERTRALINE SAN
ST100MG Capsule 02386097 SERTRALINE SIV
ST100MG Capsule 02469642 SERTRALINE JMP
ST100MG Capsule 02241304 SERTRALINE-100 PDL
ST100MG Capsule 02240481 TEVA-SERTRALINE TEV
ST100MG Capsule 01962779 ZOLOFT UNK

TRANYLCYPROMINE SULFATE

Table: TRANYLCYPROMINE SULFATE
Drug strength and dosage form DIN Brand name Manufacturer code
ST10MG Tablet 01919598 PARNATE GSK

TRAZODONE HYDROCHLORIDE

Table: TRAZODONE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
ST50MG Tablet 02147637 APO-TRAZODONE APX
ST50MG Tablet 02128950 DOM-TRAZODONE DPC
ST50MG Tablet 01937227 PMS TRAZODONE PMS
ST50MG Tablet 02144263 TEVA-TRAZODONE TEV
ST50MG Tablet 02164353 TRAZODONE PDL
ST50MG Tablet 02348772 TRAZODONE SAN
ST75MG Tablet 02237339 PMS-TRAZODONE PMS
ST100MG Tablet 02147645 APO-TRAZODONE APX
ST100MG Tablet 02128969 DOM-TRAZODONE DPC
ST100MG Tablet 01937235 PMS TRAZODONE PMS
ST100MG Tablet 02144271 TEVA-TRAZODONE TEV
ST100MG Tablet 02164361 TRAZODONE PDL
ST100MG Tablet 02348780 TRAZODONE SAN
ST150MG Tablet 02147653 APO-TRAZODONE D APX
ST150MG Tablet 02144298 TEVA-TRAZODONE TEV
ST150MG Tablet 02164388 TRAZODONE PDL
ST150MG Tablet 02348799 TRAZODONE SAN

TRIMIPRAMINE MALEATE

Table: TRIMIPRAMINE MALEATE
Drug strength and dosage form DIN Brand name Manufacturer code
ST75MG Capsule 02070987 TRIMIPRAMINE AAP
ST12.5MG Tablet 00740799 TRIMIPRAMINE AAP
ST25MG Tablet 00740802 TRIMIPRAMINE AAP
ST50MG Tablet 00740810 TRIMIPRAMINE AAP
ST100MG Tablet 00740829 TRIMIPRAMINE AAP

VENLAFAXINE HYDROCHLORIDE

Table: VENLAFAXINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
ST37.5MG Capsule (Extended Release) 02304317 ACT VENLAFAXINE XR TEV
ST37.5MG Capsule (Extended Release) 02331683 APO-VENLAFAXINE XR APX
ST37.5MG Capsule (Extended Release) 02452839 AURO-VENLAFAXINE XR AUR
ST37.5MG Capsule (Extended Release) 02299291 DOM-VENLAFAXINE XR DPC
ST37.5MG Capsule (Extended Release) 02237279 EFFEXOR XR UNK
37.5MG Capsule (Extended Release) 02471280 M-VENLAFAXINE XR MAN
ST37.5MG Capsule (Extended Release) 02278545 PMS-VENLAFAXINE XR PMS
ST37.5MG Capsule (Extended Release) 02307774 RIVA-VENLAFAXINE XR RIV
ST37.5MG Capsule (Extended Release) 02310317 SANDOZ VENLAFAXINE XR SDZ
ST37.5MG Capsule (Extended Release) 02380072 TARO-VENLAFAXINE XR SUN
ST37.5MG Capsule (Extended Release) 02275023 TEVA-VENLAFAXINE XR TEV
ST37.5MG Capsule (Extended Release) 02339242 VENLAFAXINE XR PDL
ST37.5MG Capsule (Extended Release) 02354713 VENLAFAXINE XR SAN
ST37.5MG Capsule (Extended Release) 02385929 VENLAFAXINE XR SIV
37.5MG Capsule (Extended Release) 02489678 VENLAFAXINE XR RIV
ST75MG Capsule (Extended Release) 02304325 ACT VENLAFAXINE XR TEV
ST75MG Capsule (Extended Release) 02331691 APO-VENLAFAXINE XR APX
ST75MG Capsule (Extended Release) 02452847 AURO-VENLAFAXINE XR AUR
ST75MG Capsule (Extended Release) 02299305 DOM-VENLAFAXINE XR DPC
ST75MG Capsule (Extended Release) 02237280 EFFEXOR XR UNK
75MG Capsule (Extended Release) 02471299 M-VENLAFAXINE XR MAN
ST75MG Capsule (Extended Release) 02278553 PMS-VENLAFAXINE XR PMS
ST75MG Capsule (Extended Release) 02307782 RIVA-VENLAFAXINE XR RIV
ST75MG Capsule (Extended Release) 02310325 SANDOZ VENLAFAXINE XR SDZ
ST75MG Capsule (Extended Release) 02380080 TARO-VENLAFAXINE XR SUN
ST75MG Capsule (Extended Release) 02275031 TEVA-VENLAFAXINE XR TEV
ST75MG Capsule (Extended Release) 02339250 VENLAFAXINE XR PDL
ST75MG Capsule (Extended Release) 02354721 VENLAFAXINE XR SAN
ST75MG Capsule (Extended Release) 02385937 VENLAFAXINE XR SIV
75MG Capsule (Extended Release) 02489686 VENLAFAXINE XR RIV
ST150MG Capsule (Extended Release) 02304333 ACT VENLAFAXINE XR TEV
ST150MG Capsule (Extended Release) 02331705 APO-VENLAFAXINE XR APX
ST150MG Capsule (Extended Release) 02452855 AURO-VENLAFAXINE XR AUR
ST150MG Capsule (Extended Release) 02299313 DOM-VENLAFAXINE XR DPC
ST150MG Capsule (Extended Release) 02237282 EFFEXOR XR UNK
150MG Capsule (Extended Release) 02471302 M-VENLAFAXINE XR MAN
ST150MG Capsule (Extended Release) 02278561 PMS-VENLAFAXINE XR PMS
ST150MG Capsule (Extended Release) 02307790 RIVA-VENLAFAXINE XR RIV
ST150MG Capsule (Extended Release) 02310333 SANDOZ VENLAFAXINE XR SDZ
ST150MG Capsule (Extended Release) 02380099 TARO-VENLAFAXINE XR SUN
ST150MG Capsule (Extended Release) 02275058 TEVA-VENLAFAXINE XR TEV
ST150MG Capsule (Extended Release) 02339269 VENLAFAXINE XR PDL
ST150MG Capsule (Extended Release) 02354748 VENLAFAXINE XR SAN
ST150MG Capsule (Extended Release) 02385945 VENLAFAXINE XR SIV
150MG Capsule (Extended Release) 02489694 VENLAFAXINE XR RIV

28:16.08 ANTIPSYCHOTIC AGENTS

ARIPIPRAZOLE

Table: ARIPIPRAZOLE
Drug strength and dosage form DIN Brand name Manufacturer code
ST2MG Tablet 02322374 ABILIFY OTS
ST2MG Tablet 02471086 APO-ARIPIPRAZOLE APX
2MG Tablet 02488000 ARIPIPRAZOLE PDL
ST2MG Tablet 02460025 AURO-ARIPIPRAZOLE PMS
ST2MG Tablet 02466635 PMS-ARIPIPRAZOLE PMS
2MG Tablet 02479346 RIVA-ARIPIPRAZOLE RIV
ST2MG Tablet 02473658 SANDOZ ARIPIPRAZOLE SDZ
ST2MG Tablet 02464144 TEVA-ARIPIPRAZOLE TEV
ST5MG Tablet 02322382 ABILIFY OTS
ST5MG Tablet 02471094 APO-ARIPIPRAZOLE APX
5MG Tablet 02488019 ARIPIPRAZOLE PDL
ST5MG Tablet 02460033 AURO-ARIPIPRAZOLE PMS
ST5MG Tablet 02466643 PMS-ARIPIPRAZOLE PMS
5MG Tablet 02479354 RIVA-ARIPIPRAZOLE RIV
ST5MG Tablet 02473666 SANDOZ ARIPIPRAZOLE SDZ
ST5MG Tablet 02464152 TEVA-ARIPIPRAZOLE TEV
ST10MG Tablet 02322390 ABILIFY OTS
ST10MG Tablet 02471108 APO-ARIPIPRAZOLE APX
10MG Tablet 02488027 ARIPIPRAZOLE PDL
ST10MG Tablet 02460041 AURO-ARIPIPRAZOLE PMS
ST10MG Tablet 02466651 PMS-ARIPIPRAZOLE PMS
10MG Tablet 02479362 RIVA-ARIPIPRAZOLE RIV
ST10MG Tablet 02473674 SANDOZ ARIPIPRAZOLE SDZ
ST10MG Tablet 02464160 TEVA-ARIPIPRAZOLE TEV
ST15MG Tablet 02322404 ABILIFY OTS
ST15MG Tablet 02471116 APO-ARIPIPRAZOLE APX
15MG Tablet 02488035 ARIPIPRAZOLE PDL
ST15MG Tablet 02460068 AURO-ARIPIPRAZOLE PMS
ST15MG Tablet 02466678 PMS-ARIPIPRAZOLE PMS
15MG Tablet 02479370 RIVA-ARIPIPRAZOLE RIV
ST15MG Tablet 02473682 SANDOZ ARIPIPRAZOLE SDZ
ST15MG Tablet 02464179 TEVA-ARIPIPRAZOLE TEV
ST20MG Tablet 02322412 ABILIFY OTS
ST20MG Tablet 02471124 APO-ARIPIPRAZOLE APX
20MG Tablet 02488043 ARIPIPRAZOLE PDL
ST20MG Tablet 02460076 AURO-ARIPIPRAZOLE PMS
ST20MG Tablet 02466686 PMS-ARIPIPRAZOLE PMS
20MG Tablet 02479389 RIVA-ARIPIPRAZOLE RIV
ST20MG Tablet 02473690 SANDOZ ARIPIPRAZOLE SDZ
ST20MG Tablet 02464187 TEVA-ARIPIPRAZOLE TEV
ST30MG Tablet 02322455 ABILIFY OTS
ST30MG Tablet 02471132 APO-ARIPIPRAZOLE APX
30MG Tablet 02488051 ARIPIPRAZOLE PDL
ST30MG Tablet 02460084 AURO-ARIPIPRAZOLE PMS
ST30MG Tablet 02466694 PMS-ARIPIPRAZOLE PMS
30MG Tablet 02479397 RIVA-ARIPIPRAZOLE RIV
ST30MG Tablet 02473704 SANDOZ ARIPIPRAZOLE SDZ
ST30MG Tablet 02464195 TEVA-ARIPIPRAZOLE TEV

ARIPIPRAZOLE (MAINTENA)

Table: ARIPIPRAZOLE (MAINTENA)
Drug strength and dosage form DIN Brand name Manufacturer code
300MG Injection 02420864 ABILIFY MAINTENA OTS
400MG Injection 02420872 ABILIFY MAINTENA OTS

ASENAPINE MALEATE

Limited use benefit (prior approval required).

For the acute treatment of manic or mixed episodes associated with bipolar I disorder as either:

  • monotherapy, after a trial of lithium or divalproex sodium has failed or is contraindicated, and trials of two atypical antipsychotic agents have failed due to intolerance or lack of response; or
  • co-therapy with lithium or divalproex sodium, after trials of two atypical antipsychotic agents have failed due to intolerance or lack of response.
Table: ASENAPINE MALEATE
Drug strength and dosage form DIN Brand name Manufacturer code
ST5MG Tablet 02374803 SAPHRIS FRS
ST10MG Tablet 02374811 SAPHRIS FRS

BREXPIPRAZOLE

Table: BREXPIPRAZOLE
Drug strength and dosage form DIN Brand name Manufacturer code
0.25MG Tablet 02461749 REXULTI OTS
0.5MG Tablet 02461757 REXULTI OTS
1MG Tablet 02461765 REXULTI OTS
2MG Tablet 02461773 REXULTI OTS
3MG Tablet 02461781 REXULTI OTS
4MG Tablet 02461803 REXULTI OTS

CHLORPROMAZINE HYDROCHLORIDE

Table: CHLORPROMAZINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
ST25MG Tablet 00232823 TEVA-CHLORPROMAZINE TEV
ST50MG Tablet 00232807 TEVA-CHLORPROMAZINE TEV
ST100MG Tablet 00232831 TEVA-CHLORPROMAZINE TEV

CLOZAPINE

Table: CLOZAPINE
Drug strength and dosage form DIN Brand name Manufacturer code
ST25MG Tablet 02248034 AA-CLOZAPINE AAP
ST25MG Tablet 00894737 CLOZARIL HLS
ST25MG Tablet 02247243 GEN-CLOZAPINE MYL
ST50MG Tablet 02458748 AA-CLOZAPINE AAP
ST50MG Tablet 02305003 GEN-CLOZAPINE MYL
ST100MG Tablet 02248035 AA-CLOZAPINE AAP
ST100MG Tablet 00894745 CLOZARIL HLS
ST100MG Tablet 02247244 GEN-CLOZAPINE MYL
ST200MG Tablet 02458756 AA-CLOZAPINE AAP
ST200MG Tablet 02305011 GEN-CLOZAPINE MYL

FLUPENTHIXOL DIHYDROCHLORIDE

Table: FLUPENTHIXOL DIHYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
ST0.5MG Tablet 02156008 FLUANXOL LUD
ST3MG Tablet 02156016 FLUANXOL LUD

FLUPENTIXOL DECANOATE

Table: FLUPENTIXOL DECANOATE
Drug strength and dosage form DIN Brand name Manufacturer code
20MG/ML Solution 02156032 FLUANXOL DEPOT LUD
100MG/ML Solution 02156040 FLUANXOL DEPOT LUD

FLUPHENAZINE DECANOATE

Table: FLUPHENAZINE DECANOATE
Drug strength and dosage form DIN Brand name Manufacturer code
25MG/ML Liquid 02091275 PMS-FLUPHENAZINE PMS
100MG/ML Liquid 02241928 PMS-FLUPHENAZINE PMS

FLUPHENAZINE HYDROCHLORIDE

Table: FLUPHENAZINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
ST1MG Tablet 00405345 FLUPHENAZINE AAP
ST2MG Tablet 00410632 FLUPHENAZINE AAP
ST5MG Tablet 00405361 FLUPHENAZINE AAP
ST5MG Tablet 00726354 PMS FLUPHENAZINE PMS

HALOPERIDOL

Table: HALOPERIDOL
Drug strength and dosage form DIN Brand name Manufacturer code
ST2MG/ML Solution 00759503 PMS-HALOPERIDOL PMS
5MG/ML Solution 00808652 HALOPERIDOL SDZ
5MG/ML Solution 02366010 HALOPERIDOL OMG
ST0.5MG Tablet 00396796 APO HALOPERIDOL APX
ST0.5MG Tablet 00363685 TEVA-HALOPERIDOL TEV
ST1MG Tablet 00396818 APO HALOPERIDOL APX
ST1MG Tablet 00363677 TEVA-HALOPERIDOL TEV
ST2MG Tablet 00363669 TEVA-HALOPERIDOL TEV
ST5MG Tablet 00363650 TEVA-HALOPERIDOL TEV
ST10MG Tablet 00463698 APO-HALOPERIDOL APX
ST10MG Tablet 00713449 TEVA-HALOPERIDOL TEV
ST20MG Tablet 00768820 TEVA-HALOPERIDOL TEV

HALOPERIDOL DECANOATE

Table: HALOPERIDOL DECANOATE
Drug strength and dosage form DIN Brand name Manufacturer code
50MG/ML Liquid 02130297 HALOPERIDOL LA SDZ
50MG/ML Liquid 02230707 PMS-HALOPERIDOL PMS
100MG/ML Liquid 02130300 HALOPERIDOL LA SDZ
100MG/ML Liquid 02239640 HALOPERIDOL LA OMG
100MG/ML Liquid 02230708 PMS-HALOPERIDOL PMS

LOXAPINE HYDROCHLORIDE

Table: LOXAPINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
ST25MG/ML Solution 02239101 XYLAC PED

LOXAPINE SUCCINATE

Table: LOXAPINE SUCCINATE
Drug strength and dosage form DIN Brand name Manufacturer code
ST2.5MG Tablet 02242868 XYLAC PED
ST5MG Tablet 02239918 DOM-LOXAPINE DPC
ST5MG Tablet 02230837 XYLAC PED
ST10MG Tablet 02239919 DOM-LOXAPINE DPC
ST10MG Tablet 02230838 XYLAC PED
ST25MG Tablet 02239920 DOM-LOXAPINE DPC
ST25MG Tablet 02230839 XYLAC PED
ST50MG Tablet 02239921 DOM-LOXAPINE DPC
ST50MG Tablet 02230840 XYLAC PED

LURASIDONE HYDROCHLORIDE

Limited use benefit (prior approval required).

For the treatment of schizophrenia and schizoaffective disorders in patients:

  • who have intolerance or lack of response to an adequate trial of another antipsychotic agent; or
  • a contraindication to another antipsychotic agent.
Table: LURASIDONE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
ST20MG Tablet 02422050 LATUDA SPC
ST40MG Tablet 02387751 LATUDA SPC
ST60MG Tablet 02413361 LATUDA SPC
ST80MG Tablet 02387778 LATUDA SPC
ST120MG Tablet 02387786 LATUDA SPC

METHOTRIMEPRAZINE MALEATE

Table: METHOTRIMEPRAZINE MALEATE
Drug strength and dosage form DIN Brand name Manufacturer code
ST2MG Tablet 02238403 METHOPRAZINE AAP
ST5MG Tablet 02238404 METHOPRAZINE AAP
ST25MG Tablet 02238405 METHOPRAZINE AAP
ST50MG Tablet 02238406 METHOPRAZINE AAP

OLANZAPINE

Table: OLANZAPINE
Drug strength and dosage form DIN Brand name Manufacturer code
ST2.5MG Tablet 02281791 APO-OLANZAPINE APX
ST2.5MG Tablet 02417243 JAMP-OLANZAPINE JMP
ST2.5MG Tablet 02410141 MINT-OLANZAPINE MIN
ST2.5MG Tablet 02311968 OLANZAPINE PDL
ST2.5MG Tablet 02372819 OLANZAPINE SAN
ST2.5MG Tablet 02385864 OLANZAPINE SIV
ST2.5MG Tablet 02303116 PMS-OLANZAPINE PMS
ST2.5MG Tablet 02403064 RAN-OLANZAPINE RBY
ST2.5MG Tablet 02337126 RIVA-OLANZAPINE RIV
ST2.5MG Tablet 02310341 SANDOZ OLANZAPINE SDZ
ST2.5MG Tablet 02276712 TEVA-OLANZAPINE TEV
ST2.5MG Tablet 02229250 ZYPREXA LIL
ST5MG Tablet 02281805 APO-OLANZAPINE APX
ST5MG Tablet 02417251 JAMP-OLANZAPINE JMP
ST5MG Tablet 02410168 MINT-OLANZAPINE MIN
ST5MG Tablet 02311976 OLANZAPINE PDL
ST5MG Tablet 02372827 OLANZAPINE SAN
ST5MG Tablet 02385872 OLANZAPINE SIV
ST5MG Tablet 02303159 PMS-OLANZAPINE PMS
ST5MG Tablet 02403072 RAN-OLANZAPINE RBY
ST5MG Tablet 02337134 RIVA-OLANZAPINE RIV
ST5MG Tablet 02310368 SANDOZ OLANZAPINE SDZ
ST5MG Tablet 02276720 TEVA-OLANZAPINE TEV
ST5MG Tablet 02229269 ZYPREXA LIL
ST7.5MG Tablet 02281813 APO-OLANZAPINE APX
ST7.5MG Tablet 02417278 JAMP-OLANZAPINE JMP
ST7.5MG Tablet 02410176 MINT-OLANZAPINE MIN
ST7.5MG Tablet 02311984 OLANZAPINE PDL
ST7.5MG Tablet 02372835 OLANZAPINE SAN
7.5MG Tablet 02385880 OLANZAPINE SIV
ST7.5MG Tablet 02303167 PMS-OLANZAPINE PMS
ST7.5MG Tablet 02403080 RAN-OLANZAPINE RBY
ST7.5MG Tablet 02337142 RIVA-OLANZAPINE RIV
ST7.5MG Tablet 02310376 SANDOZ OLANZAPINE SDZ
ST7.5MG Tablet 02276739 TEVA-OLANZAPINE TEV
ST7.5MG Tablet 02229277 ZYPREXA LIL
ST10MG Tablet 02281821 APO-OLANZAPINE APX
ST10MG Tablet 02417286 JAMP-OLANZAPINE JMP
ST10MG Tablet 02410184 MINT-OLANZAPINE MIN
ST10MG Tablet 02311992 OLANZAPINE PDL
ST10MG Tablet 02372843 OLANZAPINE SAN
ST10MG Tablet 02385899 OLANZAPINE SIV
ST10MG Tablet 02303175 PMS-OLANZAPINE PMS
ST10MG Tablet 02403099 RAN-OLANZAPINE RBY
ST10MG Tablet 02337150 RIVA-OLANZAPINE RIV
ST10MG Tablet 02310384 SANDOZ OLANZAPINE SDZ
ST10MG Tablet 02276747 TEVA-OLANZAPINE TEV
ST10MG Tablet 02229285 ZYPREXA LIL
ST15MG Tablet 02281848 APO-OLANZAPINE APX
ST15MG Tablet 02417294 JAMP-OLANZAPINE JMP
ST15MG Tablet 02410192 MINT-OLANZAPINE MIN
ST15MG Tablet 02312018 OLANZAPINE PDL
ST15MG Tablet 02372851 OLANZAPINE SAN
ST15MG Tablet 02385902 OLANZAPINE SIV
ST15MG Tablet 02303183 PMS-OLANZAPINE PMS
ST15MG Tablet 02403102 RAN-OLANZAPINE RBY
ST15MG Tablet 02337169 RIVA-OLANZAPINE RIV
ST15MG Tablet 02310392 SANDOZ OLANZAPINE SDZ
ST15MG Tablet 02276755 TEVA-OLANZAPINE TEV
ST15MG Tablet 02238850 ZYPREXA LIL
ST20MG Tablet 02417308 JAMP-OLANZAPINE JMP
ST5MG Tablet (Orally Disintegrating) 02327562 ACT OLANZAPINE ODT TEV
ST5MG Tablet (Orally Disintegrating) 02360616 APO-OLANZAPINE ODT APX
5MG Tablet (Orally Disintegrating) 02448726 AURO-OLANZAPINE ODT AUR
ST5MG Tablet (Orally Disintegrating) 02406624 JAMP OLANZAPINE ODT JMP
ST5MG Tablet (Orally Disintegrating) 02389088 MAR-OLANZAPINE ODT MAR
ST5MG Tablet (Orally Disintegrating) 02436965 MINT-OLANZAPINE ODT MIN
ST5MG Tablet (Orally Disintegrating) 02338645 OLANZAPINE ODT PDL
ST5MG Tablet (Orally Disintegrating) 02343665 OLANZAPINE ODT SIV
ST5MG Tablet (Orally Disintegrating) 02352974 OLANZAPINE ODT SAN
ST5MG Tablet (Orally Disintegrating) 02303191 PMS-OLANZAPINE ODT PMS
ST5MG Tablet (Orally Disintegrating) 02414090 RAN-OLANZAPINE ODT RBY
ST5MG Tablet (Orally Disintegrating) 02327775 SANDOZ OLANZAPINE ODT SDZ
ST5MG Tablet (Orally Disintegrating) 02243086 ZYPREXA ZYDIS LIL
ST10MG Tablet (Orally Disintegrating) 02327570 ACT OLANZAPINE ODT TEV
ST10MG Tablet (Orally Disintegrating) 02360624 APO-OLANZAPINE ODT APX
10MG Tablet (Orally Disintegrating) 02448734 AURO-OLANZAPINE ODT AUR
ST10MG Tablet (Orally Disintegrating) 02406632 JAMP OLANZAPINE ODT JMP
ST10MG Tablet (Orally Disintegrating) 02389096 MAR-OLANZAPINE ODT MAR
ST10MG Tablet (Orally Disintegrating) 02436973 MINT-OLANZAPINE ODT MIN
ST10MG Tablet (Orally Disintegrating) 02338653 OLANZAPINE ODT PDL
ST10MG Tablet (Orally Disintegrating) 02343673 OLANZAPINE ODT SIV
ST10MG Tablet (Orally Disintegrating) 02352982 OLANZAPINE ODT SAN
ST10MG Tablet (Orally Disintegrating) 02303205 PMS-OLANZAPINE ODT PMS
ST10MG Tablet (Orally Disintegrating) 02414104 RAN-OLANZAPINE ODT RBY
ST10MG Tablet (Orally Disintegrating) 02327783 SANDOZ OLANZAPINE ODT SDZ
ST10MG Tablet (Orally Disintegrating) 02243087 ZYPREXA ZYDIS LIL
ST15MG Tablet (Orally Disintegrating) 02327589 ACT OLANZAPINE ODT TEV
ST15MG Tablet (Orally Disintegrating) 02360632 APO-OLANZAPINE ODT APX
15MG Tablet (Orally Disintegrating) 02448742 AURO-OLANZAPINE ODT AUR
ST15MG Tablet (Orally Disintegrating) 02406640 JAMP OLANZAPINE ODT JMP
ST15MG Tablet (Orally Disintegrating) 02389118 MAR-OLANZAPINE ODT MAR
ST15MG Tablet (Orally Disintegrating) 02436981 MINT-OLANZAPINE ODT MIN
ST15MG Tablet (Orally Disintegrating) 02338661 OLANZAPINE ODT PDL
ST15MG Tablet (Orally Disintegrating) 02343681 OLANZAPINE ODT SIV
ST15MG Tablet (Orally Disintegrating) 02352990 OLANZAPINE ODT SAN
ST15MG Tablet (Orally Disintegrating) 02303213 PMS-OLANZAPINE ODT PMS
ST15MG Tablet (Orally Disintegrating) 02414112 RAN-OLANZAPINE ODT RBY
ST15MG Tablet (Orally Disintegrating) 02327791 SANDOZ OLANZAPINE ODT SDZ
ST15MG Tablet (Orally Disintegrating) 02243088 ZYPREXA ZYDIS LIL

PALIPERIDONE PALMITATE

Table: PALIPERIDONE PALMITATE
Drug strength and dosage form DIN Brand name Manufacturer code
50MG/0.5ML Suspension (Extended Release) 02354217 INVEGA SUSTENNA JSO
75MG/0.75ML Suspension (Extended Release) 02354225 INVEGA SUSTENNA JSO
100MG/ML Suspension (Extended Release) 02354233 INVEGA SUSTENNA JSO
150MG/1.5ML Suspension (Extended Release) 02354241 INVEGA SUSTENNA JSO
175MG Suspension (Extended Release) 02455943 INVEGA TRINZA JSO
263MG Suspension (Extended Release) 02455986 INVEGA TRINZA JSO
350MG Suspension (Extended Release) 02455994 INVEGA TRINZA JSO
525MG Suspension (Extended Release) 02456001 INVEGA TRINZA JSO

PERICYAZINE

Table: PERICYAZINE
Drug strength and dosage form DIN Brand name Manufacturer code
ST5MG Capsule 01926780 NEULEPTIL ERF
ST10MG Capsule 01926772 NEULEPTIL ERF
ST20MG Capsule 01926764 NEULEPTIL ERF
ST10MG/ML Drop 01926756 NEULEPTIL ERF

PERPHENAZINE

Table: PERPHENAZINE
Drug strength and dosage form DIN Brand name Manufacturer code
ST3.2MG/ML Liquid 00751898 PMS PERPHENAZINE PMS
ST2MG Tablet 00335134 PERPHENAZINE AAP
ST4MG Tablet 00335126 PERPHENAZINE AAP
ST8MG Tablet 00335118 PERPHENAZINE AAP
ST16MG Tablet 00335096 PERPHENAZINE AAP
ST16MG Tablet 00726206 PMS PERPHENAZINE PMS

PIMOZIDE

Table: PIMOZIDE
Drug strength and dosage form DIN Brand name Manufacturer code
ST2MG Tablet 02245432 PIMOZIDE AAP
ST4MG Tablet 02245433 PIMOZIDE AAP

PIPOTIAZINE PALMITATE

Table: PIPOTIAZINE PALMITATE
Drug strength and dosage form DIN Brand name Manufacturer code
50MG/ML Injection 00894672 PIPORTIL L4 SAC

PROCHLORPERAZINE

Table: PROCHLORPERAZINE
Drug strength and dosage form DIN Brand name Manufacturer code
10MG Suppository 00753688 PMS-PROCHLORPERAZINE PMS
10MG Suppository 00789720 SANDOZ PROCHLORPERAZINE SDZ

PROCHLORPERAZINE MALEATE

Table: PROCHLORPERAZINE MALEATE
Drug strength and dosage form DIN Brand name Manufacturer code
ST5MG Tablet 00753661 PMS-PROCHLORPERAZINE PMS
ST5MG Tablet 00886440 PROCHLORAZINE AAP
ST10MG Tablet 00753637 PMS-PROCHLORPERAZINE PMS
ST10MG Tablet 00886432 PROCHLORAZINE AAP

PROCHLORPERAZINE MESYLATE

Table: PROCHLORPERAZINE MESYLATE
Drug strength and dosage form DIN Brand name Manufacturer code
5MG/ML Solution 00753645 PMS PROCHLORPERAZINE PMS

QUETIAPINE FUMARATE

Table: QUETIAPINE FUMARATE
Drug strength and dosage form DIN Brand name Manufacturer code
ST25MG Tablet 02316080 ACT QUETIAPINE TEV
ST25MG Tablet 02313901 APO-QUETIAPINE APX
ST25MG Tablet 02390205 AURO-QUETIAPINE AUR
25MG Tablet 02447193 BIO-QUETIAPINE BMI
ST25MG Tablet 02298996 DOM-QUETIAPINE DPC
ST25MG Tablet 02330415 JAMP-QUETIAPINE JMP
ST25MG Tablet 02399822 MAR-QUETIAPINE MAR
ST25MG Tablet 02438003 MINT-QUETIAPINE MIN
ST25MG Tablet 02439158 NAT-QUETIAPINE NPH
ST25MG Tablet 02296551 PMS-QUETIAPINE PMS
25MG Tablet 02447088 PRIVA-QUETIAPINE PHA
ST25MG Tablet 02317346 PRO-QUETIAPINE PDL
ST25MG Tablet 02317893 QUETIAPINE SIV
ST25MG Tablet 02353164 QUETIAPINE SAN
ST25MG Tablet 02387794 QUETIAPINE ACC
ST25MG Tablet 02397099 RAN-QUETIAPINE RBY
ST25MG Tablet 02316692 RIVA-QUETIAPINE RIV
ST25MG Tablet 02313995 SANDOZ QUETIAPINE SDZ
ST25MG Tablet 02236951 SEROQUEL AZC
ST25MG Tablet 02284235 TEVA-QUETIAPINE TEV
ST50MG Tablet 02361892 PMS-QUETIAPINE PMS
ST100MG Tablet 02316099 ACT QUETIAPINE TEV
ST100MG Tablet 02313928 APO-QUETIAPINE APX
ST100MG Tablet 02390213 AURO-QUETIAPINE AUR
100MG Tablet 02447207 BIO-QUETIAPINE BMI
ST100MG Tablet 02299003 DOM-QUETIAPINE DPC
ST100MG Tablet 02330423 JAMP-QUETIAPINE JMP
ST100MG Tablet 02399830 MAR-QUETIAPINE MAR
ST100MG Tablet 02438011 MINT-QUETIAPINE MIN
ST100MG Tablet 02439166 NAT-QUETIAPINE NPH
ST100MG Tablet 02296578 PMS-QUETIAPINE PMS
ST100MG Tablet 02317354 PRO-QUETIAPINE PDL
ST100MG Tablet 02317907 QUETIAPINE SIV
ST100MG Tablet 02353172 QUETIAPINE SAN
ST100MG Tablet 02387808 QUETIAPINE ACC
ST100MG Tablet 02397102 RAN-QUETIAPINE RBY
ST100MG Tablet 02316706 RIVA-QUETIAPINE RIV
ST100MG Tablet 02314002 SANDOZ QUETIAPINE SDZ
ST100MG Tablet 02236952 SEROQUEL AZC
ST100MG Tablet 02284243 TEVA-QUETIAPINE TEV
ST200MG Tablet 02316110 ACT QUETIAPINE TEV
ST200MG Tablet 02313936 APO-QUETIAPINE APX
ST200MG Tablet 02390248 AURO-QUETIAPINE AUR
200MG Tablet 02447223 BIO-QUETIAPINE BMI
ST200MG Tablet 02299038 DOM-QUETIAPINE DPC
ST200MG Tablet 02330458 JAMP-QUETIAPINE JMP
ST200MG Tablet 02399849 MAR-QUETIAPINE MAR
ST200MG Tablet 02438046 MINT-QUETIAPINE MIN
ST200MG Tablet 02439182 NAT-QUETIAPINE NPH
ST200MG Tablet 02296594 PMS-QUETIAPINE PMS
ST200MG Tablet 02317362 PRO-QUETIAPINE PDL
ST200MG Tablet 02317923 QUETIAPINE SIV
ST200MG Tablet 02353199 QUETIAPINE SAN
ST200MG Tablet 02387824 QUETIAPINE ACC
ST200MG Tablet 02397110 RAN-QUETIAPINE RBY
ST200MG Tablet 02316722 RIVA-QUETIAPINE RIV
ST200MG Tablet 02314010 SANDOZ QUETIAPINE SDZ
ST200MG Tablet 02236953 SEROQUEL AZC
ST200MG Tablet 02284278 TEVA-QUETIAPINE TEV
ST300MG Tablet 02316129 ACT QUETIAPINE TEV
ST300MG Tablet 02313944 APO-QUETIAPINE APX
ST300MG Tablet 02390256 AURO-QUETIAPINE AUR
300MG Tablet 02447258 BIO-QUETIAPINE BMI
ST300MG Tablet 02299046 DOM-QUETIAPINE DPC
ST300MG Tablet 02330466 JAMP-QUETIAPINE JMP
ST300MG Tablet 02399857 MAR-QUETIAPINE MAR
ST300MG Tablet 02438054 MINT-QUETIAPINE MIN
ST300MG Tablet 02439190 NAT-QUETIAPINE NPH
ST300MG Tablet 02296608 PMS-QUETIAPINE PMS
ST300MG Tablet 02317370 PRO-QUETIAPINE PDL
ST300MG Tablet 02317931 QUETIAPINE SIV
ST300MG Tablet 02353202 QUETIAPINE SAN
ST300MG Tablet 02387832 QUETIAPINE ACC
ST300MG Tablet 02397129 RAN-QUETIAPINE RBY
ST300MG Tablet 02316730 RIVA-QUETIAPINE RIV
ST300MG Tablet 02314029 SANDOZ QUETIAPINE SDZ
ST300MG Tablet 02244107 SEROQUEL AZC
ST300MG Tablet 02284286 TEVA-QUETIAPINE TEV
50MG Tablet (Extended Release) 02457229 APO-QUETIAPINE XR APX
ST50MG Tablet (Extended Release) 02417359 QUETIAPINE XR SIV
ST50MG Tablet (Extended Release) 02417782 QUETIAPINE XR PDL
ST50MG Tablet (Extended Release) 02407671 SANDOZ QUETIAPINE XRT SDZ
ST50MG Tablet (Extended Release) 02300184 SEROQUEL XR AZC
ST50MG Tablet (Extended Release) 02395444 TEVA-QUETIAPINE XR TEV
ST150MG Tablet (Extended Release) 02457237 APO-QUETIAPINE XR APX
ST150MG Tablet (Extended Release) 02417367 QUETIAPINE XR SIV
ST150MG Tablet (Extended Release) 02417790 QUETIAPINE XR PDL
ST150MG Tablet (Extended Release) 02407698 SANDOZ QUETIAPINE XRT SDZ
ST150MG Tablet (Extended Release) 02321513 SEROQUEL XR AZC
ST150MG Tablet (Extended Release) 02395452 TEVA-QUETIAPINE XR TEV
ST200MG Tablet (Extended Release) 02457245 APO-QUETIAPINE XR APX
ST200MG Tablet (Extended Release) 02417375 QUETIAPINE XR SIV
ST200MG Tablet (Extended Release) 02417804 QUETIAPINE XR PDL
ST200MG Tablet (Extended Release) 02407701 SANDOZ QUETIAPINE XRT SDZ
ST200MG Tablet (Extended Release) 02300192 SEROQUEL XR AZC
ST200MG Tablet (Extended Release) 02395460 TEVA-QUETIAPINE XR TEV
300MG Tablet (Extended Release) 02457253 APO-QUETIAPINE XR APX
ST300MG Tablet (Extended Release) 02417383 QUETIAPINE XR SIV
ST300MG Tablet (Extended Release) 02417812 QUETIAPINE XR PDL
ST300MG Tablet (Extended Release) 02407728 SANDOZ QUETIAPINE XRT SDZ
ST300MG Tablet (Extended Release) 02300206 SEROQUEL XR AZC
ST300MG Tablet (Extended Release) 02395479 TEVA-QUETIAPINE XR TEV
400MG Tablet (Extended Release) 02457261 APO-QUETIAPINE XR APX
ST400MG Tablet (Extended Release) 02417391 QUETIAPINE XR SIV
ST400MG Tablet (Extended Release) 02417820 QUETIAPINE XR PDL
ST400MG Tablet (Extended Release) 02407736 SANDOZ QUETIAPINE XRT SDZ
ST400MG Tablet (Extended Release) 02300214 SEROQUEL XR AZC
ST400MG Tablet (Extended Release) 02395487 TEVA-QUETIAPINE XR TEV
25MG Tablet (Immediate Release) 02475979 AG-QUETIAPINE ANG

RISPERIDONE

Table: RISPERIDONE
Drug strength and dosage form DIN Brand name Manufacturer code
ST1MG Solution 02454319 JAMP-RISPERIDONE JMP
ST1MG/ML Solution 02280396 APO-RISPERIDONE APX
ST1MG/ML Solution 02279266 PMS-RISPERIDONE PMS
ST1MG/ML Solution 02236950 RISPERDAL JSO
0.25MG Tablet 02369079 AG-RISPERIDONE ANG
ST0.25MG Tablet 02282119 APO-RISPERIDONE APX
ST0.25MG Tablet 02359529 JAMP-RISPERIDONE JMP
ST0.25MG Tablet 02371766 MAR-RISPERIDONE MAR
ST0.25MG Tablet 02359790 MINT-RISPERIDON MIN
ST0.25MG Tablet 02252007 PMS-RISPERIDONE PMS
ST0.25MG Tablet 02312700 PRO-RISPERIDONE PDL
ST0.25MG Tablet 02328305 RAN-RISPERIDONE RBY
ST0.25MG Tablet 02356880 RISPERIDONE SAN
ST0.25MG Tablet 02283565 RIVA-RISPERIDONE RIV
ST0.25MG Tablet 02303655 SANDOZ RISPERIDONE SDZ
ST0.25MG Tablet 02282690 TEVA-RISPERIDONE TEV
0.5MG Tablet 02369087 AG-RISPERIDONE ANG
ST0.5MG Tablet 02282127 APO-RISPERIDONE APX
ST0.5MG Tablet 02359537 JAMP-RISPERIDONE JMP
ST0.5MG Tablet 02371774 MAR-RISPERIDONE MAR
ST0.5MG Tablet 02359804 MINT-RISPERIDON MIN
ST0.5MG Tablet 02252015 PMS-RISPERIDONE PMS
ST0.5MG Tablet 02312719 PRO-RISPERIDONE PDL
ST0.5MG Tablet 02328313 RAN-RISPERIDONE RBY
ST0.5MG Tablet 02356899 RISPERIDONE SAN
ST0.5MG Tablet 02283573 RIVA-RISPERIDONE RIV
ST0.5MG Tablet 02303663 SANDOZ RISPERIDONE SDZ
ST0.5MG Tablet 02264188 TEVA-RISPERIDONE TEV
1MG Tablet 02369095 AG-RISPERIDONE ANG
ST1MG Tablet 02282135 APO-RISPERIDONE APX
ST1MG Tablet 02359545 JAMP-RISPERIDONE JMP
ST1MG Tablet 02371782 MAR-RISPERIDONE MAR
ST1MG Tablet 02359812 MINT-RISPERIDON MIN
ST1MG Tablet 02252023 PMS-RISPERIDONE PMS
ST1MG Tablet 02312727 PRO-RISPERIDONE PDL
ST1MG Tablet 02328321 RAN-RISPERIDONE RBY
ST1MG Tablet 02356902 RISPERIDONE SAN
ST1MG Tablet 02283581 RIVA-RISPERIDONE RIV
ST1MG Tablet 02279800 SANDOZ RISPERIDONE SDZ
ST1MG Tablet 02264196 TEVA-RISPERIDONE TEV
2MG Tablet 02369117 AG-RISPERIDONE ANG
ST2MG Tablet 02282143 APO-RISPERIDONE APX
ST2MG Tablet 02359553 JAMP-RISPERIDONE JMP
ST2MG Tablet 02371790 MAR-RISPERIDONE MAR
ST2MG Tablet 02359820 MINT-RISPERIDON MIN
ST2MG Tablet 02252031 PMS-RISPERIDONE PMS
ST2MG Tablet 02312735 PRO-RISPERIDONE PDL
ST2MG Tablet 02328348 RAN-RISPERIDONE RBY
ST2MG Tablet 02356910 RISPERIDONE SAN
ST2MG Tablet 02283603 RIVA-RISPERIDONE RIV
ST2MG Tablet 02279819 SANDOZ RISPERIDONE SDZ
ST2MG Tablet 02264218 TEVA-RISPERIDONE TEV
3MG Tablet 02369125 AG-RISPERIDONE ANG
ST3MG Tablet 02282151 APO-RISPERIDONE APX
ST3MG Tablet 02359561 JAMP-RISPERIDONE JMP
ST3MG Tablet 02371804 MAR-RISPERIDONE MAR
ST3MG Tablet 02359839 MINT-RISPERIDON MIN
ST3MG Tablet 02252058 PMS-RISPERIDONE PMS
ST3MG Tablet 02312743 PRO-RISPERIDONE PDL
ST3MG Tablet 02328364 RAN-RISPERIDONE RBY
ST3MG Tablet 02356929 RISPERIDONE SAN
ST3MG Tablet 02283611 RIVA-RISPERIDONE RIV
ST3MG Tablet 02279827 SANDOZ RISPERIDONE SDZ
ST3MG Tablet 02264226 TEVA-RISPERIDONE TEV
4MG Tablet 02369133 AG-RISPERIDONE ANG
ST4MG Tablet 02282178 APO-RISPERIDONE APX
ST4MG Tablet 02359588 JAMP-RISPERIDONE JMP
ST4MG Tablet 02371812 MAR-RISPERIDONE MAR
ST4MG Tablet 02359847 MINT-RISPERIDON MIN
ST4MG Tablet 02252066 PMS-RISPERIDONE PMS
ST4MG Tablet 02312751 PRO-RISPERIDONE PDL
ST4MG Tablet 02328372 RAN-RISPERIDONE RBY
ST4MG Tablet 02356937 RISPERIDONE SAN
ST4MG Tablet 02283638 RIVA-RISPERIDONE RIV
ST4MG Tablet 02279835 SANDOZ RISPERIDONE SDZ
ST4MG Tablet 02264234 TEVA-RISPERIDONE TEV
ST0.5MG Tablet (Orally Disintegrating) 02413485 MYLAN-RISPERIDONE ODT MYL
ST1MG Tablet (Orally Disintegrating) 02413493 MYLAN-RISPERIDONE ODT MYL
ST2MG Tablet (Orally Disintegrating) 02413507 MYLAN-RISPERIDONE ODT MYL
ST3MG Tablet (Orally Disintegrating) 02413515 MYLAN-RISPERIDONE ODT MYL
ST4MG Tablet (Orally Disintegrating) 02413523 MYLAN-RISPERIDONE ODT MYL

RISPERIDONE (CONSTA)

Table: RISPERIDONE (CONSTA)
Drug strength and dosage form DIN Brand name Manufacturer code
12.5MG Injection 02298465 RISPERDAL CONSTA JSO
25MG Injection 02255707 RISPERDAL CONSTA JSO
ST37.5MG Injection 02255723 RISPERDAL CONSTA JSO
ST50MG Injection 02255758 RISPERDAL CONSTA JSO

THIOPROPERAZINE MESYLATE

Table: THIOPROPERAZINE MESYLATE
Drug strength and dosage form DIN Brand name Manufacturer code
ST10MG Tablet 01927639 MAJEPTIL ERF

THIOTHIXENE

Table: THIOTHIXENE
Drug strength and dosage form DIN Brand name Manufacturer code
ST5MG Capsule 00024449 NAVANE ERF

TRIFLUOPERAZINE HYDROCHLORIDE

Table: TRIFLUOPERAZINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
ST1MG Tablet 00345539 TRIFLUOPERAZINE AAP
ST2MG Tablet 00312754 TRIFLUOPERAZINE AAP
ST5MG Tablet 00312746 TRIFLUOPERAZINE AAP
ST10MG Tablet 00326836 TRIFLUOPERAZINE AAP
ST20MG Tablet 00595942 TRIFLUOPERAZINE AAP

ZIPRASIDONE HYDROCHLORIDE MONOHYDRATE

Table: ZIPRASIDONE HYDROCHLORIDE MONOHYDRATE
Drug strength and dosage form DIN Brand name Manufacturer code
ST20MG Capsule 02449544 AURO-ZIPRASIDONE AUR
ST20MG Capsule 02298597 ZELDOX UNK
ST40MG Capsule 02449552 AURO-ZIPRASIDONE AUR
ST40MG Capsule 02298600 ZELDOX UNK
ST60MG Capsule 02449560 AURO-ZIPRASIDONE AUR
ST60MG Capsule 02298619 ZELDOX UNK
ST80MG Capsule 02449579 AURO-ZIPRASIDONE AUR
ST80MG Capsule 02298627 ZELDOX UNK

ZUCLOPENTHIXOL ACETATE

Table: ZUCLOPENTHIXOL ACETATE
Drug strength and dosage form DIN Brand name Manufacturer code
50MG/ML Solution 02230405 CLOPIXOL-ACUPHASE LUD

ZUCLOPENTHIXOL DIHYDROCHLORIDE

Table: ZUCLOPENTHIXOL DIHYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
200MG/ML Solution 02230406 CLOPIXOL DEPOT LUD
ST10MG Tablet 02230402 CLOPIXOL LUD
ST25MG Tablet 02230403 CLOPIXOL LUD

28:20.04 AMPHETAMINES

AMPHETAMINE, DEXTROAMPHETAMINE

Limited use benefit (prior approval is not required).

The NIHB Program introduced a dose coverage limit for stimulants on February 25, 2015 as part of a strategy to deal with the potential misuse and abuse of these medications. The stimulant dose coverage limit is set at 100 mg of methylphenidate equivalents* per day for adults and children. This limit is calculated based on the total dose of all stimulants that patients are receiving from NIHB. The Program will continue to monitor the utilization of stimulants and adjust the eligible dose limit as required.

* To convert to methylphenidate equivalents, 1 mg of methylphenidate, or lisdexamfetamine is equal to 0.5 mg dextroamphetamine

Table: AMPHETAMINE, DEXTROAMPHETAMINE
Drug strength and dosage form DIN Brand name Manufacturer code
ST5MG Capsule (Extended Release) 02439239 ACT AMPHETAMINE XR TEV
5MG Capsule (Extended Release) 02248808 ADDERALL XR UNK
ST5MG Capsule (Extended Release) 02445492 APO-AMPHETAMINE XR APX
ST5MG Capsule (Extended Release) 02440369 PMS-AMPHETAMINES XR PMS
ST5MG Capsule (Extended Release) 02457288 SANDOZ AMPHETAMINE XR SDZ
ST10MG Capsule (Extended Release) 02439247 ACT AMPHETAMINE XR TEV
10MG Capsule (Extended Release) 02248809 ADDERALL XR UNK
ST10MG Capsule (Extended Release) 02445506 APO-AMPHETAMINE XR APX
ST10MG Capsule (Extended Release) 02440377 PMS-AMPHETAMINES XR PMS
ST10MG Capsule (Extended Release) 02457296 SANDOZ AMPHETAMINE XR SDZ
ST15MG Capsule (Extended Release) 02439255 ACT AMPHETAMINE XR TEV
15MG Capsule (Extended Release) 02248810 ADDERALL XR UNK
ST15MG Capsule (Extended Release) 02445514 APO-AMPHETAMINE XR APX
ST15MG Capsule (Extended Release) 02440385 PMS-AMPHETAMINES XR PMS
ST15MG Capsule (Extended Release) 02457318 SANDOZ AMPHETAMINE XR SDZ
ST20MG Capsule (Extended Release) 02439263 ACT AMPHETAMINE XR TEV
20MG Capsule (Extended Release) 02248811 ADDERALL XR UNK
ST20MG Capsule (Extended Release) 02445522 APO-AMPHETAMINE XR APX
ST20MG Capsule (Extended Release) 02440393 PMS-AMPHETAMINES XR PMS
ST20MG Capsule (Extended Release) 02457326 SANDOZ AMPHETAMINE XR SDZ
ST25MG Capsule (Extended Release) 02439271 ACT AMPHETAMINE XR TEV
25MG Capsule (Extended Release) 02248812 ADDERALL XR UNK
ST25MG Capsule (Extended Release) 02445530 APO-AMPHETAMINE XR APX
ST25MG Capsule (Extended Release) 02440407 PMS-AMPHETAMINES XR PMS
ST25MG Capsule (Extended Release) 02457334 SANDOZ AMPHETAMINE XR SDZ
ST30MG Capsule (Extended Release) 02439298 ACT AMPHETAMINE XR TEV
30MG Capsule (Extended Release) 02248813 ADDERALL XR UNK
ST30MG Capsule (Extended Release) 02445549 APO-AMPHETAMINE XR APX
ST30MG Capsule (Extended Release) 02440415 PMS-AMPHETAMINES XR PMS
ST30MG Capsule (Extended Release) 02457342 SANDOZ AMPHETAMINE XR SDZ

DEXTROAMPHETAMINE SULFATE

Limited use benefit (prior approval is not required).

The NIHB Program introduced a dose coverage limit for stimulants on February 25, 2015 as part of a strategy to deal with the potential misuse and abuse of these medications. The stimulant dose coverage limit is set at 100 mg of methylphenidate equivalents* per day for adults and children. This limit is calculated based on the total dose of all stimulants that patients are receiving from NIHB. The Program will continue to monitor the utilization of stimulants and adjust the eligible dose limit as required.

* To convert to methylphenidate equivalents, 1 mg of methylphenidate, or lisdexamfetamine is equal to 0.5 mg dextroamphetamine

Table: DEXTROAMPHETAMINE SULFATE
Drug strength and dosage form DIN Brand name Manufacturer code
ST10MG Capsule (Sustained Release) 02448319 ACT DEXTROAMPHETAMINE SR TEV
ST10MG Capsule (Sustained Release) 01924559 DEXEDRINE SPANSULE PAL
ST15MG Capsule (Sustained Release) 02448327 ACT DEXTROAMPHETAMINE SR TEV
ST15MG Capsule (Sustained Release) 01924567 DEXEDRINE SPANSULE PAL
ST5MG Tablet 01924516 DEXEDRINE PAL
ST5MG Tablet 02443236 DEXTROAMPHETAMINE AAP

LISDEXAMFETAMINE DIMESYLATE

Limited use benefit (prior approval is not required).

The NIHB Program introduced a dose coverage limit for stimulants on February 25, 2015 as part of a strategy to deal with the potential misuse and abuse of these medications. The stimulant dose coverage limit is set at 100 mg of methylphenidate equivalents* per day for adults and children. This limit is calculated based on the total dose of all stimulants that patients are receiving from NIHB. The Program will continue to monitor the utilization of stimulants and adjust the eligible dose limit as required.

* To convert to methylphenidate equivalents, 1 mg of methylphenidate, or lisdexamfetamine is equal to 0.5 mg dextroamphetamine

Table: LISDEXAMFETAMINE DIMESYLATE
Drug strength and dosage form DIN Brand name Manufacturer code
ST10MG Capsule 02439603 VYVANSE SHI
ST20MG Capsule 02347156 VYVANSE SHI
ST30MG Capsule 02322951 VYVANSE SHI
ST40MG Capsule 02347164 VYVANSE SHI
ST50MG Capsule 02322978 VYVANSE SHI
ST60MG Capsule 02347172 VYVANSE SHI

28:20.32 CNS STIMULANTS

METHYLPHENIDATE HYDROCHLORIDE

Limited use benefit (prior approval is not required).

The NIHB Program introduced a dose coverage limit for stimulants on February 25, 2015 as part of a strategy to deal with the potential misuse and abuse of these medications. The stimulant dose coverage limit is set at 100 mg of methylphenidate equivalents* per day for adults and children. This limit is calculated based on the total dose of all stimulants that patients are receiving from NIHB. The Program will continue to monitor the utilization of stimulants and adjust the eligible dose limit as required.

* To convert to methylphenidate equivalents, 1 mg of methylphenidate, or lisdexamfetamine is equal to 0.5 mg dextroamphetamine

Table: METHYLPHENIDATE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
ST5MG Tablet 02273950 APO-METHYLPHENIDATE APX
ST5MG Tablet 02234749 PMS-METHYLPHENIDATE PMS
ST10MG Tablet 02249324 APO-METHYLPHENIDATE APX
ST10MG Tablet 00584991 PMS-METHYLPHENIDATE PMS
ST20MG Tablet 02249332 APO-METHYLPHENIDATE APX
ST20MG Tablet 00585009 PMS-METHYLPHENIDATE PMS
ST18MG Tablet (Extended Release) 02441934 ACT METHYLPHENIDATE ER TEV
ST18MG Tablet (Extended Release) 02452731 APO-METHYLPHENIDATE ER APX
ST18MG Tablet (Extended Release) 02247732 CONCERTA JSO
ST18MG Tablet (Extended Release) 02315068 TEVA-METHYLPHENIDATE TEV
ST20MG Tablet (Extended Release) 02266687 APO-METHYLPHENIDATE SR APX
ST20MG Tablet (Extended Release) 02320312 SANDOZ METHYLPHENIDATE SR SDZ
ST27MG Tablet (Extended Release) 02441942 ACT METHYLPHENIDATE ER TEV
ST27MG Tablet (Extended Release) 02452758 APO-METHYLPHENIDATE ER APX
ST27MG Tablet (Extended Release) 02250241 CONCERTA JSO
ST27MG Tablet (Extended Release) 02315076 TEVA-METHYLPHENIDATE TEV
ST36MG Tablet (Extended Release) 02441950 ACT METHYLPHENIDATE ER TEV
ST36MG Tablet (Extended Release) 02452766 APO-METHYLPHENIDATE ER APX
ST36MG Tablet (Extended Release) 02247733 CONCERTA JSO
ST36MG Tablet (Extended Release) 02315084 TEVA-METHYLPHENIDATE TEV
ST54MG Tablet (Extended Release) 02441969 ACT METHYLPHENIDATE ER TEV
ST54MG Tablet (Extended Release) 02330377 APO-METHYLPHENIDATE ER APX
ST54MG Tablet (Extended Release) 02247734 CONCERTA JSO
ST54MG Tablet (Extended Release) 02315092 TEVA-METHYLPHENIDATE TEV

28:20.80 WAKEFULNESS-PROMOTING AGENTS

MODAFINIL

Table: MODAFINIL
Drug strength and dosage form DIN Brand name Manufacturer code
ST100MG Tablet 02239665 ALERTEC TEV
ST100MG Tablet 02285398 APO-MODAFINIL APX
ST100MG Tablet 02430487 AURO-MODAFINIL AUR
ST100MG Tablet 02442078 BIO-MODAFINIL BMI
ST100MG Tablet 02432560 MAR-MODAFINIL MAR
ST100MG Tablet 02420260 TEVA-MODAFINIL TEV

28:20.92 MISC ANOREXIGENIC AGENTS & RESPIRATORY & CEREBRAL STIMULANT

CAFFEINE CITRATE

Limited use benefit (prior approval not required).

For children up to 1 year of age

Table: CAFFEINE CITRATE
Drug strength and dosage form DIN Brand name Manufacturer code
Powder 00972037 CAFFEINE CITRATE MDS

28:24.04 ANXIOLYTICS, SEDATIVES AND HYPNOTICS - BARBITURATES

PHENOBARBITAL

Table: PHENOBARBITAL
Drug strength and dosage form DIN Brand name Manufacturer code
15MG Tablet 00178799 PHENOBARB PED
30MG Tablet 00178802 PHENOBARB PED
60MG Tablet 00178810 PHENOBARB PED

28:24.08 ANXIOLYTICS, SEDATIVES AND HYPNOTICS - BENZODIAZEPINES

ALPRAZOLAM

Limited use benefit (prior approval is not required).

To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 30 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e. 3 000 diazepam equivalents over 100 days). According to the product monograph for diazepam, the recommended usual adult dosage is up to 30 mg per day.

Table: ALPRAZOLAM
Drug strength and dosage form DIN Brand name Manufacturer code
ST0.25MG Tablet 01908189 ALPRAZOLAM PDL
ST0.25MG Tablet 02349191 ALPRAZOLAM SAN
ST0.25MG Tablet 00865397 APO-ALPRAZ APX
ST0.25MG Tablet 01913484 TEVA-ALPRAZOLAM TEV
ST0.25MG Tablet 00548359 XANAX UNK
ST0.5MG Tablet 01908170 ALPRAZOLAM PDL
ST0.5MG Tablet 02349205 ALPRAZOLAM SAN
ST0.5MG Tablet 00865400 APO-ALPRAZ APX
ST0.5MG Tablet 01913492 TEVA-ALPRAZOLAM TEV
ST0.5MG Tablet 00548367 XANAX UNK
ST1MG Tablet 02248706 ALPRAZOLAM PDL
ST1MG Tablet 02243611 APO-ALPRAZ APX
ST1MG Tablet 00723770 XANAX UNK
ST2MG Tablet 02243612 APO-ALPRAZ APX
ST2MG Tablet 00813958 XANAX TS UNK

BROMAZEPAM

Limited use benefit (prior approval is not required).

To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 30 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e. 3 000 diazepam equivalents over 100 days). According to the product monograph for diazepam, the recommended usual adult dosage is up to 30 mg per day.

Table: BROMAZEPAM
Drug strength and dosage form DIN Brand name Manufacturer code
ST1.5MG Tablet 02177153 APO-BROMAZEPAM APX
ST3MG Tablet 02177161 APO-BROMAZEPAM APX
ST3MG Tablet 02230584 TEVA-BROMAZEPAM TEV
ST6MG Tablet 02177188 APO-BROMAZEPAM APX
ST6MG Tablet 02230585 TEVA-BROMAZEPAM TEV

DIAZEPAM

Limited use benefit (prior approval is not required).

To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 30 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e. 3 000 diazepam equivalents over 100 days). According to the product monograph for diazepam, the recommended usual adult dosage is up to 30 mg per day.

Table: DIAZEPAM
Drug strength and dosage form DIN Brand name Manufacturer code
ST1MG/ML Solution 00891797 PMS-DIAZEPAM PMS
ST2MG Tablet 00405329 DIAZEPAM AAP
ST5MG Tablet 00313580 DIAZEPAM PDL
ST5MG Tablet 00362158 DIAZEPAM AAP
ST5MG Tablet 02247491 PMS-DIAZEPAM PMS
ST5MG Tablet 00013285 VALIUM HLR
ST10MG Tablet 00405337 DIAZEPAM AAP
ST10MG Tablet 02247492 PMS-DIAZEPAM PMS

DIAZEPAM (DIASTAT)

Limited use benefit (prior approval not required).

For children 12 years of age or under.

To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 30 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e. 3,000 diazepam equivalents over 100 days). According to the product monograph for diazepam, the recommended usual adult dosage is up to 30 mg per day.

Table: DIAZEPAM (DIASTAT)
Drug strength and dosage form DIN Brand name Manufacturer code
ST5MG/ML Gel 02238162 DIASTAT VAE
ST5MG/ML Gel 09853340 DIASTAT 2X10MG RECTAL PACK ELN
ST5MG/ML Gel 09853430 DIASTAT 2X15MG RECTAL PACK ELN

LORAZEPAM

Limited use benefit (prior approval is not required).

To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 30 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e. 3 000 diazepam equivalents over 100 days). According to the product monograph for diazepam, the recommended usual adult dosage is up to 30 mg per day.

Table: LORAZEPAM
Drug strength and dosage form DIN Brand name Manufacturer code
ST0.5MG Tablet 00655740 APO-LORAZEPAM APX
ST0.5MG Tablet 02041413 ATIVAN PFI
ST0.5MG Tablet 02041456 ATIVAN SUBLINGUAL PFI
ST0.5MG Tablet 02351072 LORAZEPAM SAN
ST0.5MG Tablet 02410745 LORAZEPAM SUBLINGUAL AAP
ST0.5MG Tablet 00728187 PMS-LORAZEPAM PMS
ST0.5MG Tablet 00655643 PRO-LORAZEPAM PDL
ST0.5MG Tablet 00711101 TEVA-LORAZEPAM TEV
ST1MG Tablet 00655759 APO-LORAZEPAM APX
ST1MG Tablet 02041421 ATIVAN PFI
ST1MG Tablet 02041464 ATIVAN SUBLINGUAL PFI
ST1MG Tablet 02351080 LORAZEPAM SAN
ST1MG Tablet 02410753 LORAZEPAM SUBLINGUAL AAP
ST1MG Tablet 00728195 PMS-LORAZEPAM PMS
ST1MG Tablet 00655651 PRO-LORAZEPAM PDL
ST1MG Tablet 00637742 TEVA-LORAZEPAM TEV
ST2MG Tablet 00655767 APO-LORAZEPAM APX
ST2MG Tablet 02041448 ATIVAN PFI
ST2MG Tablet 02041472 ATIVAN SUBLINGUAL PFI
ST2MG Tablet 02351099 LORAZEPAM SAN
ST2MG Tablet 02410761 LORAZEPAM SUBLINGUAL AAP
ST2MG Tablet 00728209 PMS-LORAZEPAM PMS
ST2MG Tablet 00655678 PRO-LORAZEPAM PDL
ST2MG Tablet 00637750 TEVA-LORAZEPAM TEV

NITRAZEPAM

Limited use benefit (prior approval is not required).

To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 30 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e. 3 000 diazepam equivalents over 100 days). According to the product monograph for diazepam, the recommended usual adult dosage is up to 30 mg per day.

Table: NITRAZEPAM
Drug strength and dosage form DIN Brand name Manufacturer code
ST5MG Tablet 00511528 MOGADON AAP
ST10MG Tablet 00511536 MOGADON AAP

OXAZEPAM

Limited use benefit (prior approval is not required).

To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 30 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e. 3 000 diazepam equivalents over 100 days). According to the product monograph for diazepam, the recommended usual adult dosage is up to 30 mg per day.

Table: OXAZEPAM
Drug strength and dosage form DIN Brand name Manufacturer code
ST10MG Tablet 00402680 APO OXAZEPAM APX
ST10MG Tablet 00497754 OXAZEPAM PDL
ST10MG Tablet 00414247 OXPAM BMI
ST10MG Tablet 00568392 RIVA OXAZEPAM RIV
ST15MG Tablet 00402745 APO OXAZEPAM APX
ST15MG Tablet 00497762 OXAZEPAM PDL
ST15MG Tablet 00568406 RIVA OXAZEPAM RIV
ST30MG Tablet 00402737 APO OXAZEPAM APX
ST30MG Tablet 00497770 OXAZEPAM PDL
ST30MG Tablet 00414263 OXPAM BMI
ST30MG Tablet 00568414 RIVA OXAZEPAM RIV

TEMAZEPAM

Limited use benefit (prior approval is not required).

To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 30 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e. 3 000 diazepam equivalents over 100 days). According to the product monograph for diazepam, the recommended usual adult dosage is up to 30 mg per day.

Table: TEMAZEPAM
Drug strength and dosage form DIN Brand name Manufacturer code
ST15MG Capsule 00604453 RESTORIL AAP
ST15MG Capsule 02225964 TEMAZEPAM APX
ST15MG Capsule 02229760 TEMAZEPAM PDL
ST15MG Capsule 02230095 TEVA-TEMAZEPAM TEV
ST30MG Capsule 00604461 RESTORIL AAP
ST30MG Capsule 02225972 TEMAZEPAM APX
ST30MG Capsule 02229761 TEMAZEPAM PDL
ST30MG Capsule 02230102 TEVA-TEMAZEPAM TEV

TRIAZOLAM

Limited use benefit (prior approval is not required).

To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 30 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e. 3 000 diazepam equivalents over 100 days). According to the product monograph for diazepam, the recommended usual adult dosage is up to 30 mg per day.

Table: TRIAZOLAM
Drug strength and dosage form DIN Brand name Manufacturer code
ST0.25MG Tablet 00808571 TRIAZOLAM AAP

28:24.92 MISCELLANEOUS ANXIOLYTICS, SEDATIVES, AND HYPNOTICS

BUSPIRONE HYDROCHLORIDE

Table: BUSPIRONE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
ST10MG Tablet 02211076 APO-BUSPIRONE APX
10MG Tablet 02223163 BUSPIRONE PDL
10MG Tablet 02447851 BUSPIRONE SAN
ST10MG Tablet 02230942 PMS-BUSPIRONE PMS
ST10MG Tablet 02231492 TEVA-BUSPIRONE TEV

HYDROXYZINE HYDROCHLORIDE

Table: HYDROXYZINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
ST10MG Capsule 00646059 HYDROXYZINE APX
ST10MG Capsule 00738824 NOVO-HYDROXYZIN TEV
ST25MG Capsule 00646024 HYDROXYZINE APX
ST25MG Capsule 00738832 NOVO-HYDROXYZIN TEV
ST50MG Capsule 00646016 HYDROXYZINE APX
ST50MG Capsule 00738840 NOVO-HYDROXYZIN TEV
ST2MG/ML Syrup 00024694 ATARAX ERF
ST2MG/ML Syrup 00741817 PMS HYDROXYZINE PMS

28:28.00 ANTIMANIC AGENTS

LITHIUM CARBONATE

Table: LITHIUM CARBONATE
Drug strength and dosage form DIN Brand name Manufacturer code
ST150MG Capsule 02242837 APO-LITHIUM CARBONATE APX
ST150MG Capsule 09857532 APO-LITHIUM CARBONATE APX
ST150MG Capsule 00461733 CARBOLITH BSH
ST150MG Capsule 02013231 LITHANE ERF
ST150MG Capsule 02216132 PMS-LITHIUM CARBONATE PMS
ST300MG Capsule 02242838 APO-LITHIUM CARBONATE APX
ST300MG Capsule 09857540 APO-LITHIUM CARBONATE APX
ST300MG Capsule 00236683 CARBOLITH BSH
ST300MG Capsule 00406775 LITHANE ERF
ST300MG Capsule 02216140 PMS-LITHIUM CARBONATE PMS
ST600MG Capsule 02011239 CARBOLITH BSH
ST600MG Capsule 02216159 PMS-LITHIUM CARBONATE PMS
ST300MG Tablet (Extended Release) 02266695 LITHMAX AAP

LITHIUM CITRATE

Table: LITHIUM CITRATE
Drug strength and dosage form DIN Brand name Manufacturer code
ST60MG/ML Syrup 02074834 PMS-LITHIUM CITRATE PMS

28:32.28 SELECTIVE SEROTONIN AGONISTS

ALMOTRIPTAN MALATE

Limited use benefit (prior approval is not required).

A total of 12 tablets are permitted in a 30-day period.

Table: ALMOTRIPTAN MALATE
Drug strength and dosage form DIN Brand name Manufacturer code
6.25MG Tablet 02405792 APO-ALMOTRIPTAN APX
6.25MG Tablet 02248128 AXERT MCL
6.25MG Tablet 02398435 MYLAN-ALMOTRIPTAN MYL
12.5MG Tablet 02424029 ALMOTRIPTAN PDL
12.5MG Tablet 02466821 ALMOTRIPTAN SAN
12.5MG Tablet 02405806 APO-ALMOTRIPTAN APX
12.5MG Tablet 02248129 AXERT MCL
12.5MG Tablet 02398443 MYLAN-ALMOTRIPTAN MYL
12.5MG Tablet 02405334 SANDOZ ALMOTRIPTAN SDZ
12.5MG Tablet 02434849 TEVA-ALMOTRIPTAN TEV

NARATRIPTAN HYDROCHLORIDE

Limited use benefit (prior approval is not required).

A total of 12 tablets are permitted in a 30-day period.

Table: NARATRIPTAN HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
1MG Tablet 02237820 AMERGE GSK
1MG Tablet 02314290 TEVA-NARATRIPTAN TEV
2.5MG Tablet 02237821 AMERGE GSK
2.5MG Tablet 02322323 SANDOZ NARATRIPTAN SDZ
2.5MG Tablet 02314304 TEVA-NARATRIPTAN TEV

RIZATRIPTAN BENZOATE

Limited use benefit (prior approval is not required).

A total of 12 tablets are permitted in a 30-day period.

Table: RIZATRIPTAN BENZOATE
Drug strength and dosage form DIN Brand name Manufacturer code
5MG Tablet 02393468 APO-RIZATRIPTAN APX
5MG Tablet 02380455 JAMP-RIZATRIPTAN JMP
5MG Tablet 02429233 JAMP-RIZATRIPTAN IR JMP
5MG Tablet 02379651 MAR-RIZATRIPTAN MAR
10MG Tablet 02381702 ACT RIZATRIPTAN TEV
10MG Tablet 02393476 APO-RIZATRIPTAN APX
10MG Tablet 02441144 AURO-RIZATRIPTAN AUR
10MG Tablet 02380463 JAMP-RIZATRIPTAN JMP
10MG Tablet 02429241 JAMP-RIZATRIPTAN IR JMP
10MG Tablet 02379678 MAR-RIZATRIPTAN MAR
10MG Tablet 02240521 MAXALT FRS
5MG Tablet (Orally Disintegrating) 02483270 ACCEL-RIZATRIPTAN ODT ACP
5MG Tablet (Orally Disintegrating) 02393484 APO-RIZATRIPTAN RPD APX
ST5MG Tablet (Orally Disintegrating) 02465086 JAMP-RIZATRIPTAN ODT JMP
5MG Tablet (Orally Disintegrating) 02462788 MAR-RIZATRIPTAN ODT MAR
5MG Tablet (Orally Disintegrating) 02240518 MAXALT RPD FRS
5MG Tablet (Orally Disintegrating) 02379198 MYLAN-RIZATRIPTAN ODT MYL
5MG Tablet (Orally Disintegrating) 02436604 NAT-RIZATRIPTAN ODT NPH
5MG Tablet (Orally Disintegrating) 02393360 PMS-RIZATRIPTAN RDT PMS
5MG Tablet (Orally Disintegrating) 02442906 RIZATRIPTAN ODT SAN
5MG Tablet (Orally Disintegrating) 02446111 RIZATRIPTAN ODT SIV
5MG Tablet (Orally Disintegrating) 02415798 RIZATRIPTAN RDT PDL
5MG Tablet (Orally Disintegrating) 02351870 SANDOZ RIZATRIPTAN ODT SDZ
5MG Tablet (Orally Disintegrating) 02396661 TEVA-RIZATRIPTAN ODT TEV
10MG Tablet (Orally Disintegrating) 02483289 ACCEL-RIZATRIPTAN ODT ACP
10MG Tablet (Orally Disintegrating) 02393492 APO-RIZATRIPTAN RPD APX
10MG Tablet (Orally Disintegrating) 02396203 DOM-RIZATRIPTAN RDT DPC
10MG Tablet (Orally Disintegrating) 02465094 JAMP-RIZATRIPTAN ODT JMP
10MG Tablet (Orally Disintegrating) 02462796 MAR-RIZATRIPTAN ODT MAR
10MG Tablet (Orally Disintegrating) 02240519 MAXALT RPD FRS
10MG Tablet (Orally Disintegrating) 02379201 MYLAN-RIZATRIPTAN ODT MYL
10MG Tablet (Orally Disintegrating) 02436612 NAT-RIZATRIPTAN ODT NPH
10MG Tablet (Orally Disintegrating) 02489384 NRA-RIZATRIPTAN ODT UNK
10MG Tablet (Orally Disintegrating) 02393379 PMS-RIZATRIPTAN RDT PMS
10MG Tablet (Orally Disintegrating) 02442914 RIZATRIPTAN ODT SAN
10MG Tablet (Orally Disintegrating) 02446138 RIZATRIPTAN ODT SIV
10MG Tablet (Orally Disintegrating) 02415801 RIZATRIPTAN RDT PDL
10MG Tablet (Orally Disintegrating) 02351889 SANDOZ RIZATRIPTAN ODT SDZ
10MG Tablet (Orally Disintegrating) 02396688 TEVA-RIZATRIPTAN ODT TEV

SUMATRIPTAN HEMISULFATE

Table: SUMATRIPTAN HEMISULFATE
Drug strength and dosage form DIN Brand name Manufacturer code
5MG Spray 02230418 IMITREX GSK
20MG Spray 02230420 IMITREX GSK

SUMATRIPTAN SUCCINATE

Limited use benefit (prior approval is not required).

A total of 12 tablets (or injections) are permitted in a 30-day period.

Table: SUMATRIPTAN SUCCINATE
Drug strength and dosage form DIN Brand name Manufacturer code
6MG/0.5ML Injection 99000598 IMITREX STAT DOSE KIT GSK
12MG/ML Solution 02212188 IMITREX GSK
12MG/ML Solution 02361698 TARO-SUMATRIPTAN TAR
25MG Tablet 02270749 DOM-SUMATRIPTAN DPC
25MG Tablet 02268906 MYLAN-SUMATRIPTAN MYL
25MG Tablet 02256428 PMS-SUMATRIPTAN PMS
25MG Tablet 02286815 TEVA-SUMATRIPTAN DF TEV
50MG Tablet 02268388 APO-SUMATRIPTAN APX
50MG Tablet 02270757 DOM-SUMATRIPTAN DPC
50MG Tablet 02212153 IMITREX DF GSK
50MG Tablet 02268914 MYLAN-SUMATRIPTAN MYL
50MG Tablet 02256436 PMS-SUMATRIPTAN PMS
50MG Tablet 02263025 SANDOZ SUMATRIPTAN SDZ
50MG Tablet 02286521 SUMATRIPTAN SAN
50MG Tablet 02324652 SUMATRIPTAN PDL
ST50MG Tablet 02385570 SUMATRIPTAN DF SIV
50MG Tablet 02286823 TEVA-SUMATRIPTAN DF TEV
100MG Tablet 02257904 ACT SUMATRIPTAN TEV
100MG Tablet 02268396 APO-SUMATRIPTAN APX
100MG Tablet 02270765 DOM-SUMATRIPTAN DPC
100MG Tablet 02212161 IMITREX DF GSK
100MG Tablet 02268922 MYLAN-SUMATRIPTAN MYL
100MG Tablet 02256444 PMS-SUMATRIPTAN PMS
100MG Tablet 02263033 SANDOZ SUMATRIPTAN SDZ
100MG Tablet 02286548 SUMATRIPTAN SAN
100MG Tablet 02324660 SUMATRIPTAN PDL
100MG Tablet 02385589 SUMATRIPTAN DF SIV
100MG Tablet 02239367 TEVA-SUMATRIPTAN TEV
100MG Tablet 02286831 TEVA-SUMATRIPTAN DF TEV

ZOLMITRIPTAN

Limited use benefit (prior approval is not required).

A total of 12 tablets are permitted in a 30-day period.

Table: ZOLMITRIPTAN
Drug strength and dosage form DIN Brand name Manufacturer code
2.5MG Spray 02248992 ZOMIG AZC
5MG Spray 02248993 ZOMIG AZC
2.5MG Tablet 02389525 DOM-ZOLMITRIPTAN DPC
2.5MG Tablet 02477106 JAMP ZOLMITRIPTAN JMP
2.5MG Tablet 02421623 JAMP-ZOLMITRIPTAN JMP
2.5MG Tablet 02399458 MAR-ZOLMITRIPTAN MAR
2.5MG Tablet 02419521 MINT-ZOLMITRIPTAN MIN
2.5MG Tablet 02421534 NAT-ZOLMITRIPTAN NPH
2.5MG Tablet 02324229 PMS-ZOLMITRIPTAN PMS
2.5MG Tablet 02362988 SANDOZ ZOLMITRIPTAN SDZ
2.5MG Tablet 02313960 TEVA-ZOLMITRIPTAN TEV
2.5MG Tablet 02379929 ZOLMITRIPTAN PDL
2.5MG Tablet 02238660 ZOMIG AZC
2.5MG Tablet (Orally Disintegrating) 02438453 AG-ZOLMITRIPTAN ODT ANG
2.5MG Tablet (Orally Disintegrating) 02381575 APO-ZOLMITRIPTAN RAPID APX
2.5MG Tablet (Orally Disintegrating) 02428237 JAMP-ZOLMITRIPTAN ODT JMP
2.5MG Tablet (Orally Disintegrating) 02324768 PMS-ZOLMITRIPTAN ODT PMS
2.5MG Tablet (Orally Disintegrating) 02362996 SANDOZ ZOLMITRIPTAN ODT SDZ
2.5MG Tablet (Orally Disintegrating) 02428474 SEPTA-ZOLMITRIPTAN-ODT SPT
2.5MG Tablet (Orally Disintegrating) 02342545 TEVA-ZOLMITRIPTAN OD TEV
2.5MG Tablet (Orally Disintegrating) 02379988 ZOLMITRIPTAN ODT PDL
2.5MG Tablet (Orally Disintegrating) 02442671 ZOLMITRIPTAN ODT SAN
2.5MG Tablet (Orally Disintegrating) 02243045 ZOMIG RAPIMELT AZC

28:32.92 MISCELLANEOUS ANTIMIGRANE AGENTS

FLUNARIZINE HYDROCHLORIDE

Table: FLUNARIZINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
ST5MG Capsule 02246082 FLUNARIZINE AAP

PIZOTIFEN MALATE

Table: PIZOTIFEN MALATE
Drug strength and dosage form DIN Brand name Manufacturer code
0.5MG Tablet 00329320 SANDOMIGRAN PAL
1MG Tablet 00511552 SANDOMIGRAN DS PAL

28:36.08 ANTIPARKINSONIAN AGENTS - ANTICHOLINERGIC AGENTS

BENZTROPINE MESYLATE

Table: BENZTROPINE MESYLATE
Drug strength and dosage form DIN Brand name Manufacturer code
1MG/ML Liquid 02238903 BENZTROPINE OMEGA OMG
ST1MG Tablet 00706531 PDP-BENZTROPINE PED
ST2MG Tablet 00426857 PDP-BENZTROPINE PED
ST2MG Tablet 00587265 PMS-BENZTROPINE PMS

ETHOPROPAZINE HYDROCHLORIDE

Table: ETHOPROPAZINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
50MG Tablet 01927744 PARSITAN ERF

PROCYCLIDINE HYDROCHLORIDE

Table: PROCYCLIDINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
0.5MG/ML Elixir 00587362 PDP-PROCYCLIDINE PED
2.5MG Tablet 00649392 PDP-PROCYCLIDINE PED
5MG Tablet 00587354 PDP-PROCYCLIDINE PED

TRIHEXYPHENIDYL HYDROCHLORIDE

Table: TRIHEXYPHENIDYL HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
0.4MG/ML Elixir 00885398 PMS-TRIHEXYPHENIDYL PMS
2MG Tablet 00545058 TRIHEXYPHENIDYL AAP
5MG Tablet 00545074 TRIHEXYPHENIDYL AAP

28:36.12 ANTIPARKINSONIAN AGENTS - CATECHOL-O-METHYLTRANSFERASE (COMT) INHIBITORS

ENTACAPONE

Table: ENTACAPONE
Drug strength and dosage form DIN Brand name Manufacturer code
ST200MG Tablet 02243763 COMTAN NVR
ST200MG Tablet 02380005 SANDOZ ENTACAPONE SDZ
200MG Tablet 02375559 TEVA-ENTACAPONE TEV

28:36.16 ANTIPARKINSONIAN AGENTS - DOPAMINE PRECURSORS

LEVODOPA, BENSERAZIDE HYDROCHLORIDE

Table: LEVODOPA, BENSERAZIDE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
ST50MG & 12.5MG Capsule 00522597 PROLOPA HLR
ST100MG & 25MG Capsule 00386464 PROLOPA HLR
ST200MG & 50MG Capsule 00386472 PROLOPA HLR

LEVODOPA, CARBIDOPA

Table: LEVODOPA, CARBIDOPA
Drug strength and dosage form DIN Brand name Manufacturer code
ST100MG & 10MG Tablet 02195933 APO-LEVOCARB APX
ST100MG & 10MG Tablet 02457954 MINT-LEVOCARB MIN
ST100MG & 10MG Tablet 02244494 TEVA-LEVOCARBIDOPA TEV
ST100MG & 25MG Tablet 02195941 APO-LEVOCARB APX
ST100MG & 25MG Tablet 02457962 MINT-LEVOCARB MIN
ST100MG & 25MG Tablet 02421488 PMS-LEVOCARB PMS
ST100MG & 25MG Tablet 02311178 PRO-LEVOCARB PDL
ST100MG & 25MG Tablet 00513997 SINEMET FRS
ST100MG & 25MG Tablet 02244495 TEVA-LEVOCARBIDOPA TEV
ST250MG & 25MG Tablet 02195968 APO-LEVOCARB APX
ST250MG & 25MG Tablet 02457970 MINT-LEVOCARB MIN
ST250MG & 25MG Tablet 00328219 SINEMET FRS
ST250MG & 25MG Tablet 02244496 TEVA-LEVOCARBIDOPA TEV
ST100MG & 25MG Tablet (Extended Release) 02272873 AA-LEVOCARB APX
ST200MG & 50MG Tablet (Extended Release) 02245211 AA-LEVOCARB APX
ST200MG & 50MG Tablet (Extended Release) 02421496 PMS-LEVOCARB PMS

LEVODOPA, CARBIDOPA (CARBIDOPA MONOHYDRATE)

Limited use benefit (prior approval required).

Initial coverage criteria (12 months):

For the treatment of patients with advanced levodopa-responsive Parkinson's disease; and

  • patient has severe disability associated with at least 25% of the waking day in the off state*;and/or
  • patient has ongoing, bothersome levodopa-induced dyskinesias, despite having tried frequent dosing of levodopa (at least five doses per day); and
  • patient has failed an adequate trial of adjunctive medications if not contraindicated or contrary to judgement of prescriber; and
  • patient is able to administer the medication and care for the administration port and infusion pump. Or alternatively, trained personnel or a care partner must be available to perform these tasks reliably; and
  • patient does not have a contraindication to the insertion of a percutaneous endoscopic gastrostomy-jejunostomy (PEG-J tube); and
  • patient does not have severe psychosis or dementia.

* Time in the off state, frequency of motor fluctuations, and severity of associated disability should be assessed by a movement disorder subspecialist and be based on an adequate and reliable account from longitudinal specialist care, clinical interview of a patient and/or care partner, or motor symptom diary.

Criteria for renewal or for initial NIHB coverage in patients currently maintained on Duodopa (12 months):

  • patient continues to demonstrate a significant reduction in the time spent in the off state; and/or
  • patient has had a decrease in bothersome levodopa-induced dyskinesias.
Table: LEVODOPA, CARBIDOPA (CARBIDOPA MONOHYDRATE)
Drug strength and dosage form DIN Brand name Manufacturer code
20MG & 5MG Gel 02292165 DUODOPA ABV

LEVODOPA, CARBIDOPA, ENTACAPONE

Table: LEVODOPA, CARBIDOPA, ENTACAPONE
Drug strength and dosage form DIN Brand name Manufacturer code
ST50MG & 12.5MG & 200MG Tablet 02305933 STALEVO NVR
ST75MG & 18.75MG & 200MG Tablet 02337827 STALEVO NVR
ST100MG & 25MG & 200MG Tablet 02305941 STALEVO NVR
ST125MG & 31.25MG & 200MG Tablet 02337835 STALEVO NVR
ST150MG & 37.5MG & 200MG Tablet 02305968 STALEVO NVR

28:36.20 ANTIPARKINSONIAN AGENTS - DOPAMINE RECEPTOR AGONISTS

APOMORPHINE HYDROCHLORIDE

Limited use benefit (prior approval required).

For the acute, intermittent treatment of hypomobility "off " episodes ("end-of-dose wearing off " and unpredictable "on/off " episodes) in patients with advanced Parkinson's disease (PD);

and

Patient is under the care of a physician with experience in the diagnosis and management of PD;

and

Apomorphine (Movapo) is being used as adjunctive therapy in patients who are receiving optimized PD therapy (levodopa and derivatives and dopaminergic agonists) and still experiencing "off " episodes.

Table: APOMORPHINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
10MG Solution 02459132 MOVAPO PAL

BROMOCRIPTINE MESYLATE

Table: BROMOCRIPTINE MESYLATE
Drug strength and dosage form DIN Brand name Manufacturer code
ST5MG Capsule 02230454 BROMOCRIPTINE AAP
ST5MG Capsule 02238637 DOM-BROMOCRIPTINE DPC
ST5MG Capsule 02236949 PMS-BROMOCRIPTINE PMS
ST2.5MG Tablet 02087324 BROMOCRIPTINE AAP
ST2.5MG Tablet 02238636 DOM-BROMOCRIPTINE DPC
ST2.5MG Tablet 02231702 PMS-BROMOCRIPTINE PMS

CABERGOLINE

Limited use benefit (prior approval required).

For treatment of hyperprolactinemia in patients who have failed therapy with or are intolerant to bromocriptine.

Table: CABERGOLINE
Drug strength and dosage form DIN Brand name Manufacturer code
0.5MG Tablet 02455897 APO-CABERGOLINE APX
0.5MG Tablet 02242471 DOSTINEX PFI

PRAMIPEXOLE DIHYDROCHLORIDE

Table: PRAMIPEXOLE DIHYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
ST0.25MG Tablet 02297302 ACT PRAMIPEXOLE TEV
ST0.25MG Tablet 02292378 APO-PRAMIPEXOLE APX
ST0.25MG Tablet 02424061 AURO-PRAMIPEXOLE AUR
ST0.25MG Tablet 02237145 MIRAPEX BOE
ST0.25MG Tablet 09857268 MIRAPEX (ON) BOE
ST0.25MG Tablet 02309122 PRAMIPEXOLE SIV
ST0.25MG Tablet 02325802 PRAMIPEXOLE PDL
ST0.25MG Tablet 02315262 SANDOZ PRAMIPEXOLE SDZ
ST0.5MG Tablet 02297310 ACT PRAMIPEXOLE TEV
ST0.5MG Tablet 02292386 APO-PRAMIPEXOLE APX
ST0.5MG Tablet 02424088 AURO-PRAMIPEXOLE AUR
ST0.5MG Tablet 02309130 PRAMIPEXOLE SIV
ST0.5MG Tablet 02325810 PRAMIPEXOLE PDL
ST0.5MG Tablet 02315270 SANDOZ PRAMIPEXOLE SDZ
ST1MG Tablet 02297329 ACT PRAMIPEXOLE TEV
ST1MG Tablet 02292394 APO-PRAMIPEXOLE APX
1MG Tablet 02424096 AURO-PRAMIPEXOLE AUR
ST1MG Tablet 02309149 PRAMIPEXOLE SIV
ST1MG Tablet 02325829 PRAMIPEXOLE PDL
ST1MG Tablet 02315289 SANDOZ PRAMIPEXOLE SDZ
ST1.5MG Tablet 02297337 ACT PRAMIPEXOLE TEV
ST1.5MG Tablet 02292408 APO-PRAMIPEXOLE APX
ST1.5MG Tablet 02424118 AURO-PRAMIPEXOLE AUR
ST1.5MG Tablet 02309157 PRAMIPEXOLE SIV
ST1.5MG Tablet 02325837 PRAMIPEXOLE PDL
ST1.5MG Tablet 02315297 SANDOZ PRAMIPEXOLE SDZ

ROPINIROLE HYDROCHLORIDE

Table: ROPINIROLE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
ST0.25MG Tablet 02337746 APO-ROPINIROLE APX
ST0.25MG Tablet 02352338 JAMP-ROPINIROLE JMP
ST0.25MG Tablet 02326590 PMS-ROPINIROLE PMS
ST0.25MG Tablet 02314037 RAN-ROPINIROLE RBY
ST0.25MG Tablet 02353040 ROPINIROLE SAN
ST0.25MG Tablet 02316846 TEVA-ROPINIROLE TEV
ST1MG Tablet 02337762 APO-ROPINIROLE APX
ST1MG Tablet 02352346 JAMP-ROPINIROLE JMP
ST1MG Tablet 02326612 PMS-ROPINIROLE PMS
ST1MG Tablet 02314053 RAN-ROPINIROLE RBY
ST1MG Tablet 02353059 ROPINIROLE SAN
ST1MG Tablet 02316854 TEVA-ROPINIROLE TEV
ST2MG Tablet 02337770 APO-ROPINIROLE APX
ST2MG Tablet 02352354 JAMP-ROPINIROLE JMP
ST2MG Tablet 02326620 PMS-ROPINIROLE PMS
ST2MG Tablet 02314061 RAN-ROPINIROLE RBY
ST2MG Tablet 02316862 TEVA-ROPINIROLE TEV
ST5MG Tablet 02337800 APO-ROPINIROLE APX
ST5MG Tablet 02352362 JAMP-ROPINIROLE JMP
ST5MG Tablet 02326639 PMS-ROPINIROLE PMS
ST5MG Tablet 02314088 RAN-ROPINIROLE RBY
ST5MG Tablet 02316870 TEVA-ROPINIROLE TEV

ROTIGOTINE

Limited use benefit (prior approval required).

As an adjunct to levodopa for the treatment of patients with advanced stage Parkinson's disease; and

Patient is currently receiving treatment with levodopa.

Table: ROTIGOTINE
Drug strength and dosage form DIN Brand name Manufacturer code
2MG Patch 02403900 NEUPRO UCB
4MG Patch 02403927 NEUPRO UCB
6MG Patch 02403935 NEUPRO UCB
8MG Patch 02403943 NEUPRO UCB

28:36.32 ANTIPARKINSONIAN AGENTS - MONOAMINE OXIDASE B INHIBITORS

SELEGILINE HYDROCHLORIDE

Table: SELEGILINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
ST5MG Tablet 02230641 APO-SELEGILINE APX
ST5MG Tablet 02068087 TEVA-SELEGILINE TEV

28:92.00 MISCELLANEOUS CENTRAL NERVOUS SYSTEM AGENTS

ACAMPROSATE CALCIUM

Limited use benefit (prior approval required).

For patients who have been abstinent from alcohol for at least four days and where available, are currently enrolled in an alcohol addiction treatment program.

Table: ACAMPROSATE CALCIUM
Drug strength and dosage form DIN Brand name Manufacturer code
333MG Tablet (Delayed Release) 02293269 CAMPRAL MYL

ATOMOXETINE HYDROCHLORIDE

Limited use benefit (prior approval required).

For the treatment of patients with Attention Deficit Hyperactivity Disorder (ADHD) who meet one of the following criteria:

  • failure or intolerance to methylphenidate or amphetamine; or
  • contraindication to stimulant medication; or
  • potential risk of stimulant misuse or diversion; or
  • prescribed or recommended by a pediatrician or a psychiatrist.
Table: ATOMOXETINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
10MG Capsule 02318024 APO-ATOMOXETINE APX
10MG Capsule 02358190 ATOMOXETINE AAP
10MG Capsule 02396904 ATOMOXETINE PDL
10MG Capsule 02445883 ATOMOXETINE SIV
10MG Capsule 02467747 ATOMOXETINE SAN
10MG Capsule 02471485 AURO-ATOMOXETINE AUR
10MG Capsule 02390469 DOM-ATOMOXETINE DPC
10MG Capsule 02381028 PMS-ATOMOXETINE PMS
10MG Capsule 02405962 RIVA-ATOMOXETINE RIV
10MG Capsule 02386410 SANDOZ ATOMOXETINE SDZ
10MG Capsule 02262800 STRATTERA LIL
10MG Capsule 02314541 TEVA-ATOMOXETINE TEV
18MG Capsule 02318032 APO-ATOMOXETINE APX
18MG Capsule 02358204 ATOMOXETINE AAP
18MG Capsule 02396912 ATOMOXETINE PDL
18MG Capsule 02445905 ATOMOXETINE SIV
18MG Capsule 02467755 ATOMOXETINE SAN
18MG Capsule 02471493 AURO-ATOMOXETINE AUR
18MG Capsule 02390477 DOM-ATOMOXETINE DPC
18MG Capsule 02381036 PMS-ATOMOXETINE PMS
18MG Capsule 02405970 RIVA-ATOMOXETINE RIV
18MG Capsule 02386429 SANDOZ ATOMOXETINE SDZ
18MG Capsule 02262819 STRATTERA LIL
18MG Capsule 02314568 TEVA-ATOMOXETINE TEV
25MG Capsule 02318040 APO-ATOMOXETINE APX
25MG Capsule 02358212 ATOMOXETINE AAP
25MG Capsule 02396920 ATOMOXETINE PDL
25MG Capsule 02445913 ATOMOXETINE SIV
25MG Capsule 02467763 ATOMOXETINE SAN
25MG Capsule 02471507 AURO-ATOMOXETINE AUR
25MG Capsule 02390485 DOM-ATOMOXETINE DPC
25MG Capsule 02381044 PMS-ATOMOXETINE PMS
25MG Capsule 02405989 RIVA-ATOMOXETINE RIV
25MG Capsule 02386437 SANDOZ ATOMOXETINE SDZ
25MG Capsule 02262827 STRATTERA LIL
25MG Capsule 02314576 TEVA-ATOMOXETINE TEV
40MG Capsule 02318059 APO-ATOMOXETINE APX
40MG Capsule 02358220 ATOMOXETINE AAP
40MG Capsule 02396939 ATOMOXETINE PDL
40MG Capsule 02445948 ATOMOXETINE SIV
40MG Capsule 02467771 ATOMOXETINE SAN
40MG Capsule 02471515 AURO-ATOMOXETINE AUR
40MG Capsule 02390493 DOM-ATOMOXETINE DPC
40MG Capsule 02381052 PMS-ATOMOXETINE PMS
40MG Capsule 02405997 RIVA-ATOMOXETINE RIV
40MG Capsule 02386445 SANDOZ ATOMOXETINE SDZ
40MG Capsule 02262835 STRATTERA LIL
40MG Capsule 02314584 TEVA-ATOMOXETINE TEV
60MG Capsule 02318067 APO-ATOMOXETINE APX
60MG Capsule 02358239 ATOMOXETINE AAP
60MG Capsule 02396947 ATOMOXETINE PDL
60MG Capsule 02445956 ATOMOXETINE SIV
60MG Capsule 02467798 ATOMOXETINE SAN
60MG Capsule 02471523 AURO-ATOMOXETINE AUR
60MG Capsule 02390515 DOM-ATOMOXETINE DPC
60MG Capsule 02381060 PMS-ATOMOXETINE PMS
60MG Capsule 02406004 RIVA-ATOMOXETINE RIV
60MG Capsule 02386453 SANDOZ ATOMOXETINE SDZ
60MG Capsule 02262843 STRATTERA LIL
60MG Capsule 02314592 TEVA-ATOMOXETINE TEV
80MG Capsule 02318075 APO-ATOMOXETINE APX
80MG Capsule 02358247 ATOMOXETINE AAP
80MG Capsule 02467801 ATOMOXETINE SAN
80MG Capsule 02471531 AURO-ATOMOXETINE AUR
80MG Capsule 02404664 PMS-ATOMOXETINE PMS
80MG Capsule 02422824 RIVA-ATOMOXETINE RIV
80MG Capsule 02386461 SANDOZ ATOMOXETINE SDZ
80MG Capsule 02279347 STRATTERA LIL
80MG Capsule 02362511 TEVA-ATOMOXETINE TEV
100MG Capsule 02318083 APO-ATOMOXETINE APX
100MG Capsule 02358255 ATOMOXETINE AAP
100MG Capsule 02467828 ATOMOXETINE SAN
100MG Capsule 02404672 PMS-ATOMOXETINE PMS
100MG Capsule 02422832 RIVA-ATOMOXETINE RIV
100MG Capsule 02386488 SANDOZ ATOMOXETINE SDZ
100MG Capsule 02279355 STRATTERA LIL
100MG Capsule 02362538 TEVA-ATOMOXETINE TEV

BETAHISTINE HYDROCHLORIDE

Table: BETAHISTINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
8MG Tablet 02449145 AURO-BETAHISTINE AUR
8MG Tablet 02280183 TEVA-BETAHISTINE TEV
16MG Tablet 02449153 AURO-BETAHISTINE AUR
16MG Tablet 02466449 BETAHISTINE SAN
16MG Tablet 02330210 PMS-BETAHISTINE PMS
16MG Tablet 02243878 SERC BGP
16MG Tablet 02280191 TEVA-BETAHISTINE TEV
24MG Tablet 02449161 AURO-BETAHISTINE AUR
24MG Tablet 02466457 BETAHISTINE SAN
24MG Tablet 02330237 PMS-BETAHISTINE PMS
24MG Tablet 02247998 SERC BGP
24MG Tablet 02280205 TEVA-BETAHISTINE TEV

DIMETHYL FUMARATE

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: DIMETHYL FUMARATE
Drug strength and dosage form DIN Brand name Manufacturer code
120MG Capsule (Delayed Release) 02404508 TECFIDERA UNK
240MG Capsule (Delayed Release) 02420201 TECFIDERA UNK

TETRABENAZINE

Table: TETRABENAZINE
Drug strength and dosage form DIN Brand name Manufacturer code
25MG Tablet 02407590 APO-TETRABENAZINE APX
25MG Tablet 02199270 NITOMAN VAE
25MG Tablet 02402424 PMS-TETRABENAZINE PMS
25MG Tablet 02410338 TETRABENAZINE RAX
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