56:00 Gastrointestinal Drugs

56:04.00 ANTACIDS AND ADSORBENTS

BISMUTH SUBSALICYLATE

Limited use benefit (prior approval not required).

Coverage will be limited to 8 tablets a day every 14 days, followed by a 28 day lockout; or

Coverage will be limited to 120mL a day every 14 days, followed by a 28 day lockout.

Table: BISMUTH SUBSALICYLATE
Drug strength and dosage form DIN Brand name Manufacturer code
262MG Caplet 00245730 BISMUTH JMP
17.6MG/ML Suspension 02097079 PEPTO-BISMOL PGI
262MG Tablet 02326582 BISMUTH SUBSALICYLATE UNK
262MG Tablet 02177994 PEPTO BISMOL PGI

MAGNESIUM OXIDE

Table: MAGNESIUM OXIDE
Drug strength and dosage form DIN Brand name Manufacturer code
420MG Tablet 00299448 MAGNESIUM OXIDE VAE
420MG Tablet 80082915 MAGNESIUM OXIDE JMP
835MG Tablet 00689785 HI POTENCY MAGNESIUM OXIDE SWS
835MG Tablet 80082435 MAGNESIUM OXIDE JMP

SODIUM BICARBONATE

Table: SODIUM BICARBONATE
Drug strength and dosage form DIN Brand name Manufacturer code
325MG Tablet 80072247 SODIUM BICARBONATE MDS

56:08.00 ANTIDIARRHEA AGENTS

LOPERAMIDE HYDROCHLORIDE

Table: LOPERAMIDE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
0.2MG/ML Solution 02016095 PMS-LOPERAMIDE PMS
ST2MG/15ML Solution 02291800 IMODIUM CALMING MCL
ST2MG Tablet 02212005 APO-LOPERAMIDE APX
ST2MG Tablet 02248994 DIARRHEA RELIEF PMS
ST2MG Tablet 02256452 DIARRHEA RELIEF VTH
ST2MG Tablet 02225182 LOPERAMIDE PDL
ST2MG Tablet 02228351 PMS-LOPERAMIDE PMS
ST2MG Tablet 02238211 RIVA-LOPERAMIDE RIV
ST2MG Tablet 02132591 TEVA-LOPERAMIDE TEV

56:12.00 CATHARTICS AND LAXATIVES

BISACODYL

Table: BISACODYL
Drug strength and dosage form DIN Brand name Manufacturer code
5MG Suppository 02410893 BISACODYL JMP
5MG Suppository 02458845 BISACODYL UNK
10MG Suppository 02361450 BISACODYL JMP
10MG Suppository 00003875 DULCOLAX BOE
10MG Suppository 00582883 PMS-BISACODYL PMS
10MG Suppository 02241091 THE MAGIC BULLET DCM
ST5MG Tablet 00254142 DULCOLAX BOE
ST5MG Tablet 02246039 JAMP-BISACODYL JMP
ST5MG Tablet 00587273 PMS-BISACODYL PMS
ST5MG Tablet (Delayed Release) 00545023 APO-BISACODYL APX
ST5MG Tablet (Delayed Release) 02273411 BISACODYL-ODAN ODN

CITRIC ACID, MAGNESIUM OXIDE, SODIUM PICOSULFATE

Table: CITRIC ACID, MAGNESIUM OXIDE, SODIUM PICOSULFATE
Drug strength and dosage form DIN Brand name Manufacturer code
ST12G & 3.5G & 10MG Powder For Solution 02254794 PICO-SALAX FEI
ST12G & 3.5G & 10MG Powder For Solution 02317966 PURG-ODAN ODN

GLYCERINE

Table: GLYCERINE
Drug strength and dosage form DIN Brand name Manufacturer code
ADULT Suppository 00873462 GLYCERIN TEV
ADULT Suppository 01926039 GLYCERIN WPC
ADULT Suppository 02020394 GLYCERIN TEV
ADULT Suppository 80029765 JAMP GLYCERIN JMP
PEDIATRIC Suppository 02020815 GLYCERIN TEV
PEDIATRIC Suppository 01926047 GLYCERIN FOR INFANTS CHILDREN WPC

MACROGOL, POTASSIUM CHLORIDE, SODIUM BICARBONATE, SODIUM CHLORIDE, SODIUM SULFATE

Table: MACROGOL, POTASSIUM CHLORIDE, SODIUM BICARBONATE, SODIUM CHLORIDE, SODIUM SULFATE
Drug strength and dosage form DIN Brand name Manufacturer code
ST60G & 750MG & 1.68G & 1.46G & 5.68G/L Solution 00652512 GOLYTELY BTU
ST60G & 750MG & 1.68G & 1.46G & 5.68G/L Solution 00777838 PEGLYTE PED

MAGNESIUM CITRATE

Table: MAGNESIUM CITRATE
Drug strength and dosage form DIN Brand name Manufacturer code
ST5.40% Solution 00262609 CITRO MAG TEV
ST50MG/ML Solution 80001809 CITRODAN ODN

MAGNESIUM HYDROXIDE

Table: MAGNESIUM HYDROXIDE
Drug strength and dosage form DIN Brand name Manufacturer code
ST80MG/ML Liquid 02245289 MILK OF MAGNESIA PMS
ST80MG/ML Liquid 02150646 PHILLIPS MILK OF MAGNESIA BAY
ST311MG Tablet (Chewable) 02150638 PHILIPS MAGNESIA BAY

MINERAL OIL

Table: MINERAL OIL
Drug strength and dosage form DIN Brand name Manufacturer code
ST78% Gel 00608734 LANSOYL AUP
ST78% Gel 02186926 LANSOYL SUGAR FREE AUP
ST100% Liquid 01935348 MINERAL OIL (HEAVY) RBW

POLYETHYLENE GLYCOL 3350

Table: POLYETHYLENE GLYCOL 3350
Drug strength and dosage form DIN Brand name Manufacturer code
Powder 09991007 POLYETHYLENE GLYCOL MDS
Powder 09991054 POLYETHYLENE GLYCOL 3350 MDS
ST100% Powder For Solution 02324989 CLEARLAX PER
100% Powder For Solution 02460297 COMFILAX UNK
100% Powder For Solution 02374137 EMOLAX JMP
ST100% Powder For Solution 02450070 M-PEG 3350 MAN
ST1G Powder For Solution 02317680 LAX-A-DAY PED
1G Powder For Solution 02453193 LAX-A-DAY PHARMA PMS
ST1G Powder For Solution 02358034 PEG 3350 MDS
ST1G Powder For Solution 02346672 RELAXA RLI
ST1G Powder For Solution 02318164 RESTORALAX BAY

POLYETHYLENE GLYCOL 3350, SODIUM SULFATE, SODIUM BICARBONATE, SODIUM CHLORIDE, POTASSIUM CHLORIDE

Table: POLYETHYLENE GLYCOL 3350, SODIUM SULFATE, SODIUM BICARBONATE, SODIUM CHLORIDE, POTASSIUM CHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
ST60G & 750MG & 1.68G & 1.46G & 5.68G/L Powder 00677442 COLYTE PED

POLYETHYLENE GLYCOL 3350, SODIUM SULFATE, SODIUM BICARBONATE, SODIUM CHLORIDE, POTASSIUM CHLORIDE, BISACODYL

Table: POLYETHYLENE GLYCOL 3350, SODIUM SULFATE, SODIUM BICARBONATE, SODIUM CHLORIDE, POTASSIUM CHLORIDE, BISACODYL
Drug strength and dosage form DIN Brand name Manufacturer code
ST59.55G & 5.74G & 1.69G & 1.46G & 0.76G & 5MG Liquid 02326302 BI-PEGLYTE PED

PSYLLIUM MUCILLOID

Table: PSYLLIUM MUCILLOID
Drug strength and dosage form DIN Brand name Manufacturer code
ST50% Powder 00599875 MUCILLIUM PMS
ST680MG/G Powder 02174812 METAMUCIL FIBRE THERAPY ORIGINAL TEXTURE UNFLAVOURED PGI
ST680MG/G Powder 02174790 METAMUCIL FIBRE THERAPY SMOOTH TEXTURE ORANGE FLAVOUR PGI
ST680MG/G Powder 02174782 METAMUCIL FIBRE THERAPY SMOOTH TEXTURE ORANGE FLAVOUR (SUGAR-FREE) PGI
ST680MG/G Powder 02174804 METAMUCIL FIBRE THERAPY SMOOTH TEXTURE UNFLAVOURED PGI

SENNOSIDES

Table: SENNOSIDES
Drug strength and dosage form DIN Brand name Manufacturer code
ST1.7MG/ML Liquid 80024394 JAMP SENNAQUIL JMP
ST1.7MG/ML Liquid 02144379 SENNALAX PMS
ST1.7MG/ML Liquid 02084651 SENNAPREP PMS
ST1.7MG/ML Liquid 00367729 SENOKOT PFR
ST8.6MG Tablet 80043280 M SENNOSIDES MAN
8.6MG Tablet 80047592 OPUS SENNOSIDES OPU
ST8.6MG Tablet 01949292 RIVA SENNA RIV
ST9MG Tablet 80019511 BIOSENNOSIDES BMI
ST9MG Tablet 02247389 EURO SENNA EUR
ST9MG Tablet 80054498 M SENNOSIDES MAN
ST9MG Tablet 00896411 PMS-SENNOSIDES PMS
ST9MG Tablet 80009595 SENNA JMP
ST9MG Tablet 02237105 SENNA LAXATIVE VTH
ST9MG Tablet 02068109 SENNA SENNOSIDES PMS
ST9MG Tablet 80009182 SENNOSIDES JMP
ST9MG Tablet 00026158 SENOKOT PFR
ST12MG Tablet 80055641 M-SENNOSIDES MAN
ST12MG Tablet 00896403 PMS-SENNOSIDES PMS
ST12MG Tablet 80009183 SENNOSIDES JMP
ST15MG Tablet 02226030 EXLAX CHOCOLATED NVC
43MG Tablet 80061813 SENNACE VAN
8.6MG Tablet (Film Coated) 80064362 SENNA SENNOSIDES NATURALS UNK
15MG Tablet (Film Coated) 80054167 SENNOSIDES UNK

SODIUM PHOSPHATE

Table: SODIUM PHOSPHATE
Drug strength and dosage form DIN Brand name Manufacturer code
ST0.9G Oral Solution 80000689 PHOSLAX ODN
ST60MG & 160MG/ML Rectal Liquid 02096900 ENEMOL SODIUM PHOSPHATE DPC
ST60MG & 160MG/ML Rectal Liquid 00009911 FLEET ENEMA KIM
ST60MG & 160MG/ML Rectal Liquid 00108065 FLEET ENEMA PEDIATRIC KIM
ST180MG & 480MG/ML Solution 02230399 PHOSPHATES PMS
ST2.4G Solution 80034416 JAMP-SODIUM PHOSPHATE JMP
ST7G Solution 02231170 ENEMA HJS
123MG Tablet (Effervescent) 80047562 JAMP-SODIUM PHOSPHATE JMP

SORBITOL, SODIUM CITRATE, SODIUM LAURYL SULFOACETATE

Table: SORBITOL, SODIUM CITRATE, SODIUM LAURYL SULFOACETATE
Drug strength and dosage form DIN Brand name Manufacturer code
ST90MG & 9MG & 625MG Enema 02063905 MICROLAX MCL

56:14.00 CHOLELITHOLYTIC AGENTS

URSODIOL

Table: URSODIOL
Drug strength and dosage form DIN Brand name Manufacturer code
ST250MG Tablet 02472392 JAMP-URSODIOL JMP
ST250MG Tablet 02273497 PMS-URSODIOL PMS
ST250MG Tablet 02238984 URSO APC
ST250MG Tablet 02426900 URSODIOL GLK
ST500MG Tablet 02472406 JAMP-URSODIOL JMP
ST500MG Tablet 02273500 PMS-URSODIOL PMS
ST500MG Tablet 02245894 URSO DS APC
ST500MG Tablet 02426919 URSODIOL GLK
ST pDIN For Extemporaneous Mixture 99503024 UROSODIOL ORAL LIQUID UNK

56:16.00 DIGESTANTS

LACTASE

Table: LACTASE
Drug strength and dosage form DIN Brand name Manufacturer code
ST3,000U Caplet 02239139 DAIRY DIGESTIVE VTH
ST4,500U Caplet 02239140 DAIRY DIGESTIVE VTH
ST Oral Liquid 99100157 LACTEEZE DROPS AUP
ST300MG Tablet 80070358 JAMPLACTASE ENZYME JMP
ST3,000U Tablet 01951637 DAIRYAID TAN
ST3,000U Tablet 02230653 LACTAID KIM
ST3,000U Tablet 02017512 LACTOMAX STE
ST4,500U Tablet 02230654 LACTAID EXTRA STRENGTH KIM
ST4,500U Tablet 02224909 LACTOMAX EXTRA STE
ST9,000U Tablet 02231507 LACTAID ULTRA KIM

LIPASE, AMYLASE, PROTEASE

Table: LIPASE, AMYLASE, PROTEASE
Drug strength and dosage form DIN Brand name Manufacturer code
ST8,000U & 30,000U & 30,000U Capsule 00263818 COTAZYM FRS
ST8,000U & 30,000U & 30,000U Capsule 00502790 COTAZYM ECS 8 FRS
ST20,000U & 55,000U & 55,000U Capsule 00821373 COTAZYM ECS 20 FRS
ST10000U & 11200U & 730U Capsule (Delayed Release) 02200104 CREON MINIMICROSPHERES 10 ABB
ST25000U & 25500U & 1600U Capsule (Delayed Release) 01985205 CREON MINIMICROSPHERES 25 ABB
ST5000U & 5100U & 320U Granules For Suspension (Delayed Release) 02445158 CREON MINIMICROSPHERES MICRO BGP

56:20.00 EMETICS

IPECAC

Table: IPECAC
Drug strength and dosage form DIN Brand name Manufacturer code
14MG/ML Liquid 00378801 XENEX IPECAC XEN

56:22.00 ANTIEMETICS

NETUPITANT, PALONOSETRON (PALONOSETRON HYDROCHLORIDE)

Limited use benefit (prior approval required).

When used in combination with dexamethasone for the prevention of acute and delayed nausea and vomiting due to highly emetogenic cancer chemotherapy (eg. cisplatin > 70mg/m2).

Table: NETUPITANT, PALONOSETRON (PALONOSETRON HYDROCHLORIDE)
Drug strength and dosage form DIN Brand name Manufacturer code
ST300MG & 0.5MG Capsule 02468735 AKYNZEO PFR

56:22.08 ANTIHISTAMINES

DIMENHYDRINATE

Limited use benefit (prior approval not required).

The NIHB Program implemented a dose coverage limit for dimenhydrinate in June 2017 as part of a strategy to address safety concerns and potential misuse.

The dimenhydrinate dose limit is currently 400 mg per day for a total of 12,000 mg of dimenhydrinate in a 30-day period.

This limit applies only to the 15 mg and 50 mg tablets. Dimenhydrinate in liquid, suppository and injectable forms are not included in this limit.

Table: DIMENHYDRINATE
Drug strength and dosage form DIN Brand name Manufacturer code
50MG/ML Injection 00392537 DIMENHYDRINATE SDZ
50MG/ML Injection 00013579 GRAVOL CHU
10MG Liquid 00392731 DIMENHYDRINATE SDZ
25MG Suppository 00783595 GRAVOL CHU
50MG Suppository 00392553 SANDOZ DIMENHYDRINATE SDZ
100MG Suppository 00013609 GRAVOL CHU
ST3MG/ML Syrup 00230197 GRAVOL CHU
50MG Tablet 02241532 ANTI-NAUSEANT VTH
ST50MG Tablet 00363766 APO DIMENHYDRINATE APX
ST50MG Tablet 00013803 GRAVOL CHU
ST50MG Tablet 02245416 JAMP-DIMENHYDRINATE JMP
ST50MG Tablet 02377179 MOTION SICKNESS APX
ST50MG Tablet 00586331 PMS-DIMENHYDRINATE PMS
ST50MG Tablet 00021423 TEVA-DIMENATE TEV
ST50MG Tablet 00605786 TRAVEL VTH

DOXYLAMINE SUCCINATE, PYRIDOXINE HYDROCHLORIDE

Table: DOXYLAMINE SUCCINATE, PYRIDOXINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
ST10MG & 10MG Tablet (Delayed Release) 00609129 DICLECTIN DUI

56:22.20 5-HT3 RECEPTOR ANTAGONISTS

GRANISETRON HYDROCHLORIDE

Table: GRANISETRON HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
ST1MG Tablet 02308894 APO-GRANISETRON APX
ST1MG Tablet 02452359 NAT-GRANISETRON NPH

ONDANSETRON HYDROCHLORIDE

Table: ONDANSETRON HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
ST4MG Film 02389983 ONDISSOLVE ODF TAK
ST8MG Film 02389991 ONDISSOLVE ODF TAK
ST0.8MG/ML Solution 02291967 ONDANSETRON AAP
ST0.8MG/ML Solution 02229639 ZOFRAN NVR
4MG Solution 02490617 JAMP ONDANSETRON JMP
ST4MG Tablet 02478927 ACCEL-ONDANSETRON ACP
ST4MG Tablet 02296349 ACT ONDANSETRON TEV
ST4MG Tablet 02288184 APO-ONDANSETRON APX
ST4MG Tablet 02313685 JAMP-ONDANSETRON JMP
ST4MG Tablet 02371731 MAR-ONDANSETRON MAR
ST4MG Tablet 02305259 MINT-ONDANSETRON MIN
ST4MG Tablet 02297868 MYLAN-ONDANSETRON MYL
ST4MG Tablet 02417839 NAT-ONDANSETRON NPH
ST4MG Tablet 02421402 ONDANSETRON SAN
ST4MG Tablet 02258188 PMS-ONDANSETRON PMS
ST4MG Tablet 02312247 RAN-ONDANSETRON RBY
ST4MG Tablet 02274310 SANDOZ ONDANSETRON SDZ
ST4MG Tablet 02376091 SEPTA-ONDANSETRON SPT
ST4MG Tablet 02213567 ZOFRAN NVR
ST8MG Tablet 02478935 ACCEL-ONDANSETRON ACP
ST8MG Tablet 02296357 ACT ONDANSETRON TEV
ST8MG Tablet 02288192 APO-ONDANSETRON APX
ST8MG Tablet 02313693 JAMP-ONDANSETRON JMP
ST8MG Tablet 02371758 MAR-ONDANSETRON MAR
ST8MG Tablet 02305267 MINT-ONDANSETRON MIN
ST8MG Tablet 02297876 MYLAN-ONDANSETRON MYL
ST8MG Tablet 02417847 NAT-ONDANSETRON NPH
ST8MG Tablet 02325160 ONDANSETRON PDL
ST8MG Tablet 02421410 ONDANSETRON SAN
ST8MG Tablet 02258196 PMS-ONDANSETRON PMS
ST8MG Tablet 02312255 RAN-ONDANSETRON RBY
ST8MG Tablet 02274329 SANDOZ ONDANSETRON SDZ
ST8MG Tablet 02376105 SEPTA-ONDANSETRON SPT
ST8MG Tablet 02213575 ZOFRAN NVR
ST4MG Tablet (Orally Disintegrating) 02487330 MINT-ONDANSETRON ODT MIN
ST4MG Tablet (Orally Disintegrating) 02481723 ONDANSETRON ODT SDZ
ST4MG Tablet (Orally Disintegrating) 02444674 VPI-ONDANSETRON ODT UNK
ST4MG Tablet (Orally Disintegrating) 02239372 ZOFRAN ODT NVR
ST8MG Tablet (Orally Disintegrating) 02481731 ONDANSETRON ODT SDZ
ST8MG Tablet (Orally Disintegrating) 02444682 VPI-ONDANSETRON ODT UNK
ST8MG Tablet (Orally Disintegrating) 02239373 ZOFRAN ODT NVR

56:22.32 MISCELLANEOUS ANTIEMETICS

APREPITANT

Limited use benefit (prior approval required).

When used in combination with a 5-HT3 antagonist and dexamethasone for the prevention of acute and delayed nausea and vomiting due to highly emetogenic cancer chemotherapy (e.g. Cisplatin > 70mg/m2).

Table: APREPITANT
Drug strength and dosage form DIN Brand name Manufacturer code
ST80MG Capsule 02298791 EMEND FRS
ST125MG & 80MG Capsule 02298813 EMEND TRI-PACK FRS
ST125MG Capsule 02298805 EMEND FRS

56:22.92 MISCELLANEOUS ANTIEMETICS

DOXYLAMINE SUCCINATE, PYRIDOXINE HYDROCHLORIDE

Table: DOXYLAMINE SUCCINATE, PYRIDOXINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
ST10MG & 10MG Tablet (Delayed Release) 02413248 APO-DOXYLAMINE/B6 APX
ST10MG & 10MG Tablet (Delayed Release) 02406187 PMS-DOXYLAMINE-PYRIDOXINE PMS

NABILONE

Table: NABILONE
Drug strength and dosage form DIN Brand name Manufacturer code
0.25MG Capsule 02312263 CESAMET UNK
0.25MG Capsule 02358077 RAN-NABILONE RBY
0.25MG Capsule 02392925 TEVA-NABILONE TEV
0.5MG Capsule 02393581 ACT NABILONE TEV
0.5MG Capsule 02256193 CESAMET UNK
0.5MG Capsule 02380900 PMS-NABILONE PMS
0.5MG Capsule 02358085 RAN-NABILONE RBY
0.5MG Capsule 02384884 TEVA-NABILONE TEV
1MG Capsule 02393603 ACT NABILONE TEV
1MG Capsule 00548375 CESAMET UNK
1MG Capsule 02380919 PMS-NABILONE PMS
1MG Capsule 02358093 RAN-NABILONE RBY
1MG Capsule 02384892 TEVA-NABILONE TEV

56:28.12 HISTAMINE H2-ANTAGONISTS

CIMETIDINE

Table: CIMETIDINE
Drug strength and dosage form DIN Brand name Manufacturer code
ST200MG Tablet 00584215 CIMETIDINE AAP
ST300MG Tablet 00487872 CIMETIDINE AAP
ST300MG Tablet 02227444 MYLAN-CIMETIDINE MYL
ST400MG Tablet 00600059 CIMETIDINE AAP
ST600MG Tablet 00600067 CIMETIDINE AAP
ST800MG Tablet 00749494 CIMETIDINE AAP

FAMOTIDINE

Table: FAMOTIDINE
Drug strength and dosage form DIN Brand name Manufacturer code
10MG Capsule 99113721 FAMOTIDINE (QC) UNK
20MG Capsule 99113722 FAMOTIDINE (QC) UNK
ST20MG Tablet 01953842 APO-FAMOTIDINE APX
ST20MG Tablet 02351102 FAMOTIDINE SAN
ST20MG Tablet 02273357 MAXIMUM STRENGTH PEPCID AC MCL
ST20MG Tablet 02022133 TEVA-FAMOTIDINE TEV
ST40MG Tablet 01953834 APO-FAMOTIDINE APX
ST40MG Tablet 02351110 FAMOTIDINE SAN
ST40MG Tablet 02022141 TEVA-FAMOTIDINE TEV

NIZATIDINE

Table: NIZATIDINE
Drug strength and dosage form DIN Brand name Manufacturer code
ST150MG Capsule 00778338 AXID PED
ST150MG Capsule 02177714 PMS-NIZATIDINE PMS
ST300MG Capsule 00778346 AXID PED
ST300MG Capsule 02177722 PMS-NIZATIDINE PMS

RANITIDINE HCL

Table: RANITIDINE HCL
Drug strength and dosage form DIN Brand name Manufacturer code
150MG Capsule 99113708 RANITIDINE (QC) UNK

RANITIDINE HYDROCHLORIDE

Table: RANITIDINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
ST15MG/ML Solution 02280833 APO-RANITIDINE APX
ST150MG Tablet 02248570 ACT RANITIDINE TEV
ST150MG Tablet 00733059 APO-RANITIDINE APX
ST150MG Tablet 02463717 JAMP-RANITIDINE JMP
ST150MG Tablet 02443708 MAR-RANITIDINE MAR
ST150MG Tablet 02293471 MAXIMUM STRENGTH ACID REDUCER PMS
150MG Tablet 02473534 M-RANITIDINE MAN
ST150MG Tablet 02242453 PMS-RANITIDINE PMS
ST150MG Tablet 00740748 RANITIDINE PDL
ST150MG Tablet 02353016 RANITIDINE SAN
ST150MG Tablet 02385953 RANITIDINE SIV
ST150MG Tablet 02336480 RAN-RANITIDINE RBY
ST150MG Tablet 02247814 RIVA-RANITIDINE RIV
ST150MG Tablet 02243229 SANDOZ RANITIDINE SDZ
ST300MG Tablet 02248571 ACT RANITIDINE TEV
ST300MG Tablet 00733067 APO-RANITIDINE APX
ST300MG Tablet 02463725 JAMP-RANITIDINE JMP
ST300MG Tablet 02443716 MAR-RANITIDINE MAR
300MG Tablet 02473542 M-RANITIDINE MAN
ST300MG Tablet 02242454 PMS-RANITIDINE PMS
ST300MG Tablet 00740756 RANITIDINE PDL
ST300MG Tablet 02353024 RANITIDINE SAN
ST300MG Tablet 02385961 RANITIDINE SIV
ST300MG Tablet 02336502 RAN-RANITIDINE RBY
ST300MG Tablet 02247815 RIVA-RANITIDINE RIV
ST300MG Tablet 02243230 SANDOZ RANITIDINE SDZ

56:28.28 PROSTAGLANDINS

MISOPROSTOL

Table: MISOPROSTOL
Drug strength and dosage form DIN Brand name Manufacturer code
ST100MCG Tablet 02244022 MISOPROSTOL AAP
ST200MCG Tablet 02244023 MISOPROSTOL AAP

56:28.32 PROTECTANTS

SUCRALFATE

Table: SUCRALFATE
Drug strength and dosage form DIN Brand name Manufacturer code
ST200MG/ML Suspension 02103567 SULCRATE PLUS APC
ST1G Tablet 02125250 APO-SUCRALFATE APX
ST1G Tablet 02100622 SULCRATE APC
ST1G Tablet 02045702 TEVA-SUCRALFATE TEV

56:28.36 PROTON-PUMP INHIBITORS

AMOXICILLIN, CLARITHROMYCIN, LANSOPRAZOLE

Table: AMOXICILLIN, CLARITHROMYCIN, LANSOPRAZOLE
Drug strength and dosage form DIN Brand name Manufacturer code
ST500MG & 500MG & 30MG Kit 02470780 APO-LANSOPRAZOLE-AMOXICILLIN-CLARITHROMYCIN APX
ST500MG & 500MG & 30MG Kit 02238525 HP-PAC TAK

LANSOPRAZOLE

Limited use benefit (prior approval not required).

Coverage will be limited to 400 tablets/capsules every 180 days.

(Please refer to Appendix A).

Table: LANSOPRAZOLE
Drug strength and dosage form DIN Brand name Manufacturer code
ST15MG Capsule (Delayed Release) 02293811 APO-LANSOPRAZOLE APX
ST15MG Capsule (Delayed Release) 02357682 LANSOPRAZOLE SAN
ST15MG Capsule (Delayed Release) 02385767 LANSOPRAZOLE SIV
ST15MG Capsule (Delayed Release) 02433001 LANSOPRAZOLE PMS
ST15MG Capsule (Delayed Release) 02353830 MYLAN-LANSOPRAZOLE MYL
ST15MG Capsule (Delayed Release) 02395258 PMS-LANSOPRAZOLE PMS
ST15MG Capsule (Delayed Release) 02165503 PREVACID TAK
ST15MG Capsule (Delayed Release) 02422808 RIVA-LANSOPRAZOLE RIV
ST15MG Capsule (Delayed Release) 02385643 SANDOZ LANSOPRAZOLE SDZ
ST15MG Capsule (Delayed Release) 02402610 TARO-LANSOPRAZOLE SUN
ST15MG Capsule (Delayed Release) 02280515 TEVA-LANSOPRAZOLE TEV
ST30MG Capsule (Delayed Release) 02293838 APO-LANSOPRAZOLE APX
ST30MG Capsule (Delayed Release) 02414775 DOM-LANSOPRAZOLE DPC
ST30MG Capsule (Delayed Release) 02357690 LANSOPRAZOLE SAN
ST30MG Capsule (Delayed Release) 02366282 LANSOPRAZOLE PDL
ST30MG Capsule (Delayed Release) 02410389 LANSOPRAZOLE SIV
ST30MG Capsule (Delayed Release) 02433028 LANSOPRAZOLE PMS
ST30MG Capsule (Delayed Release) 02353849 MYLAN-LANSOPRAZOLE MYL
ST30MG Capsule (Delayed Release) 02395266 PMS-LANSOPRAZOLE PMS
ST30MG Capsule (Delayed Release) 02165511 PREVACID TAK
ST30MG Capsule (Delayed Release) 02422816 RIVA-LANSOPRAZOLE RIV
ST30MG Capsule (Delayed Release) 02402629 TARO-LANSOPRAZOLE SUN
ST30MG Capsule (Delayed Release) 02280523 TEVA-LANSOPRAZOLE TEV
ST30MG Tablet (Delayed Release) 02385651 SANDOZ LANSOPRAZOLE SDZ
pDIN For Extemporaneous Mixture 99503010 LANSOPRAZOLE ORAL LIQUID UNK

LANSOPRAZOLE ODT

Limited use benefit (prior approval not required).

Coverage will be limited to 400 tablets/capsules every 180 days.

For children 12 years of age or under who are unable to swallow the capsule formulation; or

For patients with dysphagia or a feeding tube when the use of the capsule formulation is not possible.

(Please refer to Appendix A).

Table: LANSOPRAZOLE ODT
Drug strength and dosage form DIN Brand name Manufacturer code
ST15MG Tablet (Delayed Release) 02249464 PREVACID FASTAB TAK
ST30MG Tablet (Delayed Release) 02249472 PREVACID FASTAB TAK

OMEPRAZOLE MAGNESIUM

Limited use benefit (prior approval not required).

Coverage will be limited to 400 tablets/capsules every 180 days.

(Please refer to Appendix A).

Table: OMEPRAZOLE MAGNESIUM
Drug strength and dosage form DIN Brand name Manufacturer code
ST20MG Capsule (Delayed Release) 02245058 APO-OMEPRAZOLE APX
ST20MG Capsule (Delayed Release) 00846503 LOSEC AZC
ST20MG Capsule (Delayed Release) 02339927 OMEPRAZOLE PDL
ST20MG Capsule (Delayed Release) 02348691 OMEPRAZOLE SAN
ST20MG Capsule (Delayed Release) 02411857 OMEPRAZOLE-20 SIV
ST20MG Capsule (Delayed Release) 02320851 PMS-OMEPRAZOLE PMS
ST20MG Capsule (Delayed Release) 02403617 RAN-OMEPRAZOLE RBY
ST20MG Capsule (Delayed Release) 02296446 SANDOZ OMEPRAZOLE SDZ
20MG Tablet (Delayed Release) 02449927 BIO-OMEPRAZOLE BMI
ST20MG Tablet (Delayed Release) 02420198 JAMP-OMEPRAZOLE DR JMP
ST20MG Tablet (Delayed Release) 02190915 LOSEC AZC
ST20MG Tablet (Delayed Release) 02439549 NAT-OMEPRAZOLE DR NPH
ST20MG Tablet (Delayed Release) 02416549 OMEPRAZOLE ACC
ST20MG Tablet (Delayed Release) 02374870 RAN-OMEPRAZOLE RBY
ST20MG Tablet (Delayed Release) 02402416 RIVA-OMEPRAZOLE DR RIV
ST20MG Tablet (Delayed Release) 02295415 TEVA-OMEPRAZOLE TEV
pDIN For Extemporaneous Mixture 99503002 OMEPRAZOLE ORAL LIQUID UNK

PANTOPRAZOLE MAGNESIUM

Limited use benefit (prior approval not required).

Coverage will be limited to 400 tablets/capsules every 180 days.

(Please refer to Appendix A).

Table: PANTOPRAZOLE MAGNESIUM
Drug strength and dosage form DIN Brand name Manufacturer code
ST40MG Tablet (Delayed Release) 02466147 PANTOPRAZOLE T SAN
ST40MG Tablet (Enteric Coated) 02408570 MYLAN-PANTOPRAZOLE T MYL
ST40MG Tablet (Enteric Coated) 02441853 PANTOPRAZOLE MAGNESIUM UNK
ST40MG Tablet (Enteric Coated) 02267233 TECTA TAK
ST40MG Tablet (Enteric Coated) 02440628 TEVA-PANTOPRAZOLE MAGNESIUM TEV

PANTOPRAZOLE SODIUM

Limited use benefit (prior approval not required).

Coverage will be limited to 400 tablets/capsules every 180 days.

(Please refer to Appendix A).

Table: PANTOPRAZOLE SODIUM
Drug strength and dosage form DIN Brand name Manufacturer code
40MG Tablet (Delayed Release) 02478781 AG-PANTOPRAZOLE ANG
40MG Tablet (Delayed Release) 02481588 AG-PANTOPRAZOLE SODIUM ANG
ST40MG Tablet (Delayed Release) 02292920 APO-PANTOPRAZOLE APX
ST40MG Tablet (Delayed Release) 02415208 AURO-PANTOPRAZOLE AUR
40MG Tablet (Delayed Release) 02445867 BIO-PANTOPRAZOLE BMI
ST40MG Tablet (Delayed Release) 02357054 JAMP-PANTOPRAZOLE JMP
ST40MG Tablet (Delayed Release) 02416565 MAR-PANTOPRAZOLE MAR
ST40MG Tablet (Delayed Release) 02417448 MINT-PANTOPRAZOLE MIN
40MG Tablet (Delayed Release) 02467372 M-PANTOPRAZOLE MAN
40MG Tablet (Delayed Release) 02471825 NRA-PANTOPRAZOLE UNK
ST40MG Tablet (Delayed Release) 02229453 PANTOLOC TAK
ST40MG Tablet (Delayed Release) 02318695 PANTOPRAZOLE PDL
ST40MG Tablet (Delayed Release) 02370808 PANTOPRAZOLE SAN
ST40MG Tablet (Delayed Release) 02431327 PANTOPRAZOLE RIV
ST40MG Tablet (Delayed Release) 02437945 PANTOPRAZOLE PMS
ST40MG Tablet (Delayed Release) 02439107 PANTOPRAZOLE DPC
ST40MG Tablet (Delayed Release) 02428180 PANTOPRAZOLE-40 SIV
ST40MG Tablet (Delayed Release) 02307871 PMS-PANTOPRAZOLE PMS
ST40MG Tablet (Delayed Release) 02425378 PRIVA-PANTOPRAZOLE PHA
ST40MG Tablet (Delayed Release) 02305046 RAN-PANTOPRAZOLE RBY
ST40MG Tablet (Delayed Release) 02316463 RIVA-PANTOPRAZOLE RIV
ST40MG Tablet (Delayed Release) 02301083 SANDOZ PANTOPRAZOLE SDZ
ST40MG Tablet (Delayed Release) 02285487 TEVA-PANTOPRAZOLE TEV

RABEPRAZOLE SODIUM

Limited use benefit (prior approval not required).

Coverage will be limited to 400 tablets/capsules every 180 days.

(Please refer to Appendix A).

Table: RABEPRAZOLE SODIUM
Drug strength and dosage form DIN Brand name Manufacturer code
ST10MG Tablet (Enteric Coated) 02345579 APO-RABEPRAZOLE APX
ST10MG Tablet (Enteric Coated) 02243796 PARIET JSO
ST10MG Tablet (Enteric Coated) 02310805 PMS-RABEPRAZOLE PMS
ST10MG Tablet (Enteric Coated) 02315181 PRO-RABEPRAZOLE PDL
ST10MG Tablet (Enteric Coated) 02385449 RABEPRAZOLE SIV
ST10MG Tablet (Enteric Coated) 02356511 RABEPRAZOLE EC SAN
ST10MG Tablet (Enteric Coated) 02298074 RAN-RABEPRAZOLE RBY
ST10MG Tablet (Enteric Coated) 02314177 SANDOZ RABEPRAZOLE SDZ
ST10MG Tablet (Enteric Coated) 02296632 TEVA-RABEPRAZOLE TEV
ST20MG Tablet (Enteric Coated) 02320460 DOM-RABEPRAZOLE EC DPC
ST20MG Tablet (Enteric Coated) 02243797 PARIET JSO
ST20MG Tablet (Enteric Coated) 02310813 PMS-RABEPRAZOLE PMS
ST20MG Tablet (Enteric Coated) 02315203 PRO-RABEPRAZOLE PDL
ST20MG Tablet (Enteric Coated) 02385457 RABEPRAZOLE SIV
ST20MG Tablet (Enteric Coated) 02356538 RABEPRAZOLE EC SAN
ST20MG Tablet (Enteric Coated) 02298082 RAN-RABEPRAZOLE RBY
ST20MG Tablet (Enteric Coated) 02314185 SANDOZ RABEPRAZOLE SDZ
ST20MG Tablet (Enteric Coated) 02296640 TEVA-RABEPRAZOLE TEV

56:32.00 PROKINETIC AGENTS

DOMPERIDONE MALEATE

Table: DOMPERIDONE MALEATE
Drug strength and dosage form DIN Brand name Manufacturer code
ST10MG Tablet 02103613 APO-DOMPERIDONE APX
10MG Tablet 02445034 BIO-DOMPERIDONE BMI
ST10MG Tablet 02238315 DOM-DOMPERIDONE DPC
ST10MG Tablet 02236857 DOMPERIDONE PDL
ST10MG Tablet 02238341 DOMPERIDONE SIV
ST10MG Tablet 02350440 DOMPERIDONE SAN
ST10MG Tablet 02369206 JAMP-DOMPERIDONE JMP
ST10MG Tablet 02403870 MAR-DOMPERIDONE MAR
ST10MG Tablet 02236466 PMS-DOMPERIDONE PMS
10MG Tablet 02445328 PRIVA-DOMPERIDONE PHA
ST10MG Tablet 02268078 RAN-DOMPERIDONE RBY
ST10MG Tablet 01912070 TEVA-DOMPERIDONE TEV
pDIN For Extemporaneous Mixture 99503005 DOMPERIDONE ORAL LIQUID UNK

METOCLOPRAMIDE HYDROCHLORIDE

Table: METOCLOPRAMIDE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
ST1MG/ML Solution 02230433 METONIA PED
ST5MG Tablet 00842826 APO-METOCLOP APX
ST5MG Tablet 02230431 METONIA PED
ST10MG Tablet 00842834 APO-METOCLOP APX
ST10MG Tablet 02230432 METONIA PED

56:36.00 ANTI-INFLAMMATORY AGENTS

BETAMETHASONE SODIUM PHOSPHATE

Table: BETAMETHASONE SODIUM PHOSPHATE
Drug strength and dosage form DIN Brand name Manufacturer code
0.05MG/ML Enema 02060884 BETNESOL PAL

HYDROCORTISONE ACETATE

Table: HYDROCORTISONE ACETATE
Drug strength and dosage form DIN Brand name Manufacturer code
100MG/60ML Enema 02112736 CORTENEMA APC

MESALAZINE

Table: MESALAZINE
Drug strength and dosage form DIN Brand name Manufacturer code
500MG Suppository 02112760 SALOFALK APC
1G Suppository 02474018 MEZERA UNK
1G Suppository 02153564 PENTASA FEI
1G Suppository 02242146 SALOFALK APC
1G/100ML Suspension 02153521 PENTASA FEI
2G/60G Suspension 02112795 SALOFALK APC
4G/100ML Suspension 02153556 PENTASA FEI
4G/60G Suspension 02112809 SALOFALK APC
ST500MG Tablet (Delayed Release) 02112787 SALOFALK APC
ST800MG Tablet (Delayed Release) 02267217 ASACOL ALL
ST400MG Tablet (Enteric Coated) 01997580 ASACOL ALL
ST400MG Tablet (Enteric Coated) 02171929 TEVA-5 ASA TEV
ST500MG Tablet (Extended Release) 02099683 PENTASA FEI
ST1G Tablet (Extended Release) 02399466 PENTASA FEI
ST1.2G Tablet (Extended Release) 02297558 MEZAVANT SHI

OLSALAZINE SODIUM

Table: OLSALAZINE SODIUM
Drug strength and dosage form DIN Brand name Manufacturer code
ST250MG Capsule 02063808 DIPENTUM APU

56:92.00 MISCELLANEOUS GI DRUGS

OBETICHOLIC ACID

Limited use benefit (prior approval required).

Criteria for initial 12-month coverage:

The patient has a confirmed diagnosis of primary biliary cholangitis (PBC), defined as:

  • positive antimitochondrial antibodies (AMA); or
  • liver biopsy results consistent with PBC.
  • and

The patient is under the care of a gastroenterologist, hepatologist or internal medicine specialist with experience in the treatment of PBC.

and

The patient has received ursodeoxycholic acid (UDCA) for a minimum of 12 months and has experienced an inadequate response to UDCA and can benefit from the addition of obeticholic acid. An inadequate response is defined as:

  • alkaline phosphatase (ALP) ≥ 1.67 x upper limit of normal (ULN); and/or
  • bilirubin > ULN and < 2 x ULN; and/or
  • evidence of compensated cirrhosis by fibroscan or biopsy.
  • or

The patient has experienced documented and unmanageable intolerance to UDCA.

Criteria for renewal every 12 months:

The patient continues to benefit from treatment with obeticholic acid as evidenced by:

  • a reduction in the ALP level to less than 1.67 x ULN; or
  • a 15% reduction in the ALP level compared with values before beginning treatment with obeticholic acid.
Table: OBETICHOLIC ACID
Drug strength and dosage form DIN Brand name Manufacturer code
5MG Tablet 02463121 OCALIVA UNK
10MG Tablet 02463148 OCALIVA UNK

PINAVERIUM BROMIDE

Limited use benefit (prior approval required).

For the treatment and relief of symptoms associated with functional bowel disorders including Irritable Bowel Syndrome (IBS), spastic colon, spastic colitis and mucous colitis; or

In postoperative paralytic ileus in order to accelerate the resumption of the intestinal transit following abdominal surgery.

Table: PINAVERIUM BROMIDE
Drug strength and dosage form DIN Brand name Manufacturer code
50MG Capsule 00465240 DICETEL SPH
50MG Tablet 02469677 APO-PINAVERIUM APX
50MG Tablet 01950592 DICETEL BGP
100MG Tablet 02469685 APO-PINAVERIUM APX
100MG Tablet 02230684 DICETEL BGP

VEDOLIZUMAB

Limited use benefit (prior approval required).

For the treatment of:

  • Crohn's disease according to established criteria.
  • ulcerative colitis according to established criteria.

(Please refer to Appendix A).

Table: VEDOLIZUMAB
Drug strength and dosage form DIN Brand name Manufacturer code
300MG Powder For Solution 02436841 ENTYVIO TAK
Date modified: