68:00 Hormones and synthetic substitutes

68:04.00 ADRENALS

BECLOMETHASONE DIPROPIONATE

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

BUDESONIDE

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

CICLESONIDE

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

CORTISONE ACETATE

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

DEXAMETHASONE

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

DEXAMETHASONE PHOSPHATE

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

FLUDROCORTISONE ACETATE

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

FLUTICASONE FUROATE, UMECLIDINIUM BROMIDE, VILANTEROL TRIFENATATE

Limited use benefit (prior approval required).

For the maintenance treatment of chronic obstructive pulmonary disease (COPD) including chronic bronchitis and/or emphysema who meet the following criteria:

patients are not started on triple inhaled therapy as initial therapy for COPD; and
patients have had an inadequate response to optimal dual-inhaled therapy* for COPD.

*Dual-inhaled therapy refers to any combination of a long-acting muscarinic antagonist (LAMA), long-acting beta-2 agonist (LABA) or an inhaled corticosteroid (ICS).

Table: FLUTICASONE FUROATE, UMECLIDINIUM BROMIDE, VILANTEROL TRIFENATATE
Drug strength and dosage form	DIN	Brand name	Manufacturer code
100MCG & 62.5MCG & 25MCG Powder	02474522	TRELEGY ELLIPTA	GSK

FLUTICASONE PROPIONATE

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

HYDROCORTISONE (HYDROCORTISONE SODIUM SUCCINATE)

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

HYDROCORTISONE ACETATE

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

METHYLPREDNISOLONE

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

METHYLPREDNISOLONE (METHYLPREDNISOLONE SODIUM SUCCINATE)

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

METHYLPREDNISOLONE ACETATE

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

METHYLPREDNISOLONE ACETATE, LIDOCAINE HYDROCHLORIDE

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

MOMETASONE FUROATE

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

PREDNISOLONE SODIUM PHOSPHATE

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

PREDNISONE

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

TRIAMCINOLONE ACETONIDE

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

TRIAMCINOLONE DIACETATE

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

TRIAMCINOLONE HEXACETONIDE

Table: TRIAMCINOLONE HEXACETONIDE
Drug strength and dosage form	DIN	Brand name	Manufacturer code
20MG Suspension	02470632	TRIAMCINOLONE HEXACETONIDE INJECTABLE	UNK

68:08.00 ANDROGENS

DANAZOL

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

TESTOSTERONE (TOPICAL)

Limited use benefit (prior approval required).

The NIHB Program covers topical testosterone for the treatment of the following:

orchiectomy, undescended testes, Klinefelter's; or
pituitary tumour or post-pituitary surgery with low testosterone; or
AIDS-wasting syndrome with low testosterone; or
gender affirming hormone therapy.

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

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

TESTOSTERONE CYPIONATE

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

TESTOSTERONE ENANTHATE

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

TESTOSTERONE UNDECANOATE

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

68:12.00 CONTRACEPTIVES

DESOGESTREL, ETHINYL ESTRADIOL

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

ETHINYL ESTRADIOL, DESOGESTREL

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

ETHINYL ESTRADIOL, DROSPIRENONE

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

ETHINYL ESTRADIOL, ETONOGESTREL

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

ETHINYL ESTRADIOL, LEVONORGESTREL

Table: ETHINYL ESTRADIOL, LEVONORGESTREL
Drug strength and dosage form	DIN	Brand name	Manufacturer code
^ST0.03MG & 0.15MG Tablet	02398869	INDAYO	MYL
^ST0.15MG & 0.03MG Tablet	02296659	SEASONALE	TEV
^ST20MCG & 100MCG Tablet	02236974	ALESSE 21	PFI
^ST20MCG & 100MCG Tablet	02236975	ALESSE 28	PFI
^ST20MCG & 100MCG Tablet	02387875	ALYSENA 21	APX
^ST20MCG & 100MCG Tablet	02387883	ALYSENA 28	APX
^ST20MCG & 100MCG Tablet	02298538	AVIANE 21	TEV
^ST20MCG & 100MCG Tablet	02298546	AVIANE 28	TEV
^ST30MCG & 0.05MG, 40MCG & 0.075MG, 30MCG & 0.125MG Tablet	00707600	TRIQUILAR 21	BAY
^ST30MCG & 0.05MG, 40MCG & 0.075MG, 30MCG & 0.125MG Tablet	00707503	TRIQUILAR 28	BAY
^ST30MCG & 150MCG Tablet	02042320	MIN-OVRAL 21	PFI
^ST30MCG & 150MCG Tablet	02042339	MIN-OVRAL 28	PFI
^ST30MCG & 150MCG Tablet	02387085	OVIMA 21	APX
^ST30MCG & 150MCG Tablet	02387093	OVIMA 28	APX
^ST30MCG & 150MCG Tablet	02295946	PORTIA 21	TEV
^ST30MCG & 150MCG Tablet	02295954	PORTIA 28	TEV

ETHINYL ESTRADIOL, NORELGESTROMIN

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

ETHINYL ESTRADIOL, NORETHINDRONE

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

ETHINYL ESTRADIOL, NORETHINDRONE ACETATE

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

ETHINYL ESTRADIOL, NORGESTIMATE

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

LEVONORGESTREL

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

LEVONORGESTREL INTRAUTERINE INSERT

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

Coverage is granted for 1 device every 2 years.

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

LEVONORGESTREL, ETHINYL ESTRADIOL

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

NORETHINDRONE

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

NORETHINDRONE, ETHINYL ESTRADIOL

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

NORGESTIMATE, ETHINYL ESTRADIOL

Table: NORGESTIMATE, ETHINYL ESTRADIOL
Drug strength and dosage form	DIN	Brand name	Manufacturer code
^ST0.25MG & 0.035MG Tablet	02486318	TRI-JORDYNA 28	GLK
^ST25MCG & 0.180MG, 25MCG & 0.215MG, 25MCG & 0.25MG Tablet	02401967	TRICIRA LO 21	APX
^ST25MCG & 0.180MG, 25MCG & 0.215MG, 25MCG & 0.25MG Tablet	02401975	TRICIRA LO 28	APX
^ST25MCG & 0.180MG, 25MCG & 0.215MG, 25MCG & 0.25MG Tablet	02258560	TRI-CYCLEN LO (21 DAY)	JSO
^ST25MCG & 0.180MG, 25MCG & 0.215MG, 25MCG & 0.25MG Tablet	02258587	TRI-CYCLEN LO (28 DAY)	JSO
^ST35MCG & 0.180MG, 35MCG & 0.215MG, 35MCG & 0.25MG Tablet	02028700	TRI-CYCLEN 21-DAY	JSO
^ST35MCG & 0.180MG, 35MCG & 0.215MG, 35MCG & 0.25MG Tablet	02029421	TRI-CYCLEN 28-DAY	JSO

ULIPRISTAL ACETATE

Limited use benefit (prior approval not required).

For the preoperative treatment of moderate-to-severe signs and symptoms of uterine fibroids in adult clients of reproductive age; and for the intermittent treatment of moderate-to-severe signs and symptoms of uterine fibroids in adult clients of reproductive age who are not eligible for surgery, with the duration of each treatment course being three months, if the following conditions are met:

the patient is under the care of an obstetrician/gynecologist.
patients receiving ulipristal acetate should have their liver function tests monitored before, during, and after treatment.

Coverage will be limited to a maximum of four courses of therapy for clients aged 18 to 60 years.

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

68:16.04 ESTROGENS

CONJUGATED ESTROGENS

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

ESTRADIOL

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

ESTRADIOL HEMIHYDRATE

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

ESTRADIOL, NORETHINDRONE ACETATE

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

ESTRONE

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

68:16.12 ESTROGEN AGONISTS-ANTAGONISTS

RALOXIFENE HYDROCHLORIDE

Limited use benefit (prior approval required).

For secondary prevention of osteoporosis in clients who experience failure on bisphosphonates; or

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

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

68:18.00 GONADOTROPINS

GOSERELIN ACETATE

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

NAFARELIN ACETATE

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

68:18.04

DEGARELIX ACETATE

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

68:18.08

LEUPROLIDE ACETATE

Table: LEUPROLIDE ACETATE
Drug strength and dosage form	DIN	Brand name	Manufacturer code
3.75MG/VIAL Powder For Suspension	00884502	LUPRON DEPOT	ABV
7.5MG/VIAL Powder For Suspension	00836273	LUPRON DEPOT	ABV
11.25MG/VIAL Powder For Suspension	02239834	LUPRON DEPOT	ABV
22.5MG/VIAL Powder For Suspension	02230248	LUPRON DEPOT	ABV
30MG/VIAL Powder For Suspension	02239833	LUPRON DEPOT	ABV

68:20.02 ALPHA-GLUCOSIDASE INHIBITORS

ACARBOSE

Table: ACARBOSE
Drug strength and dosage form	DIN	Brand name	Manufacturer code
^ST50MG Tablet	02190885	GLUCOBAY	BAY
^ST50MG Tablet	02494078	MAR-ACARBOSE	MAR
^ST100MG Tablet	02190893	GLUCOBAY	BAY
^ST100MG Tablet	02494086	MAR-ACARBOSE	MAR

68:20.04 BIGUANIDES

METFORMIN HYDROCHLORIDE

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

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

LINAGLIPTIN

Open benefit.

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

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

LINAGLIPTIN, METFORMIN HYDROCHLORIDE

Open benefit.

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

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

SAXAGLIPTIN HYDROCHLORIDE

Open benefit.

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

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

SAXAGLIPTIN HYDROCHLORIDE, METFORMIN HYDROCHLORIDE

Open benefit.

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

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

SITAGLIPTIN PHOSPHATE MONOHYDRATE

Limited use benefit (prior approval required).

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

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

SITAGLIPTIN PHOSPHATE MONOHYDRATE, METFORMIN HYDROCHLORIDE

Limited use benefit (prior approval required).

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

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

68:20.06 INCRETIN MIMETICS

LIXISENATIDE

Table: LIXISENATIDE
Drug strength and dosage form	DIN	Brand name	Manufacturer code
10MCG Solution	02464276	ADLYXINE	SAC
20MCG Solution	02464284	ADLYXINE	SAC

SEMAGLUTIDE

Open benefit.

For the treatment of type 2 diabetes in combination with metformin alone, when diet and exercise plus maximal tolerated dose of metformin do not achieve adequate glycemic control.

Table: SEMAGLUTIDE
Drug strength and dosage form	DIN	Brand name	Manufacturer code
1MG Solution	02471469	OZEMPIC	NOO
1.34MG Solution	02471477	OZEMPIC	NOO

68:20.08 INSULINS

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

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

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

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

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

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

INSULIN (ISOPHANE) HUMAN BIOSYNTHETIC

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

INSULIN (ZINC CRYSTALLINE) HUMAN BIOSYNTHETIC (RDNA ORIGIN)

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

INSULIN ASPART

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

INSULIN BIOSYNTHETIC HUMAN BR

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

INSULIN DEGLUDEC

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

INSULIN DETEMIR

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

INSULIN GLARGINE

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

INSULIN GLULISINE

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

INSULIN HUMAN BIOSYNTHETIC

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

INSULIN LISPRO

Table: INSULIN LISPRO
Drug strength and dosage form	DIN	Brand name	Manufacturer code
100U/ML Injection	02229704	HUMALOG	LIL
100U/ML Injection	02229705	HUMALOG (CARTRIDGE)	LIL
100U/ML Injection	02403412	HUMALOG (KWIKPEN)	LIL
100U/ML Injection	09853715	HUMALOG 100U/ML CARTRIDGE	LIL
200U/ML Injection	02439611	HUMALOG 200U/ML KWIKPEN	LIL
100U Solution	02470152	HUMALOG	LIL

INSULIN LISPRO, INSULIN LISPRO PROTAMINE

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

LIXISENATIDE, INSULIN GLARGINE

Table: LIXISENATIDE, INSULIN GLARGINE
Drug strength and dosage form	DIN	Brand name	Manufacturer code
33MCG & 100U Solution	02478293	SOLIQUA	SAC

68:20.16 MEGLITINIDES

REPAGLINIDE

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

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

CANAGLIFLOZIN

Limited use benefit (prior approval required).

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

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

DAPAGLIFLOZIN PROPANEDIOL MONOHYDRATE

Open benefit.

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

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

EMPAGLIFLOZIN

Open benefit.

For the treatment of type 2 diabetes mellitus:

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

Established cardiovascular disease is defined as one of the following:

history of myocardial infarction
multi-vessel coronary artery disease in two or more major coronary arteries (irrespective of revascularization status)
single-vessel coronary artery disease with significant stenosis and either a positive non-invasive stress test or discharged from hospital with a documented diagnosis of unstable angina
unstable angina with confirmed evidence of coronary multi-vessel or single-vessel disease
history of ischemic or hemorrhagic stroke
occlusive peripheral artery disease.

Table: EMPAGLIFLOZIN
Drug strength and dosage form	DIN	Brand name	Manufacturer code
^ST10MG Tablet	02443937	JARDIANCE	BOE
^ST25MG Tablet	02443945	JARDIANCE	BOE

METFORMIN HYDROCHLORIDE, DAPAGLIFLOZIN

Open benefit.

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

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

METFORMIN HYDROCHLORIDE, EMPAGLIFLOZIN

Open benefit.

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

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

68:20.20 ANTIDIABETIC AGENTS - SULFONYLUREAS

GLICLAZIDE

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

GLYBURIDE

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

68:20.28 THIAZOLIDINEDIONES

PIOGLITAZONE HYDROCHLORIDE

Table: PIOGLITAZONE HYDROCHLORIDE
Drug strength and dosage form	DIN	Brand name	Manufacturer code
^ST15MG Tablet	02391600	ACH-PIOGLITAZONE	ACC
^ST15MG Tablet	02302861	ACT PIOGLITAZONE	TEV
^ST15MG Tablet	02302942	APO-PIOGLITAZONE	APX
^ST15MG Tablet	02397307	JAMP-PIOGLITAZONE	JMP
^ST15MG Tablet	02326477	MINT-PIOGLITAZONE	MIN
^ST15MG Tablet	02303124	PMS-PIOGLITAZONE	PMS
^ST15MG Tablet	02312050	PRO-PIOGLITAZONE	PDL
^ST15MG Tablet	02375850	RAN-PIOGLITAZONE	RBY
^ST15MG Tablet	02297906	SANDOZ PIOGLITAZONE	SDZ
^ST30MG Tablet	02339587	ACH-PIOGLITAZONE	ACC
^ST30MG Tablet	02302888	ACT PIOGLITAZONE	TEV
^ST30MG Tablet	02302950	APO-PIOGLITAZONE	APX
^ST30MG Tablet	02365529	JAMP-PIOGLITAZONE	JMP
^ST30MG Tablet	02326485	MINT-PIOGLITAZONE	MIN
^ST30MG Tablet	02303132	PMS-PIOGLITAZONE	PMS
^ST30MG Tablet	02312069	PRO-PIOGLITAZONE	PDL
^ST30MG Tablet	02375869	RAN-PIOGLITAZONE	RBY
^ST30MG Tablet	02297914	SANDOZ PIOGLITAZONE	SDZ
^ST45MG Tablet	02339595	ACH-PIOGLITAZONE	ACC
^ST45MG Tablet	02302896	ACT PIOGLITAZONE	TEV
^ST45MG Tablet	02302977	APO-PIOGLITAZONE	APX
^ST45MG Tablet	02365537	JAMP-PIOGLITAZONE	JMP
^ST45MG Tablet	02326493	MINT-PIOGLITAZONE	MIN
^ST45MG Tablet	02303140	PMS-PIOGLITAZONE	PMS
^ST45MG Tablet	02312077	PRO-PIOGLITAZONE	PDL
^ST45MG Tablet	02375877	RAN-PIOGLITAZONE	RBY
^ST45MG Tablet	02297922	SANDOZ PIOGLITAZONE	SDZ

68:22.12 GLYCOGENOLYTIC AGENTS

GLUCAGON RECOMBINANT DNA ORGIN

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

68:24.00 PARATHYROID

CALCITONIN SALMON (SYNTHETIC)

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

68:28.00 PITUITARY

DESMOPRESSIN ACETATE

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

68:32.00 PROGESTINS

DIENOGEST

Limited use benefit (prior approval required).

For the management of pelvic pain associated with endometriosis.

Table: DIENOGEST
Drug strength and dosage form	DIN	Brand name	Manufacturer code
^ST2MG Tablet	02493055	ASPEN-DIENOGEST	UNK
^ST2MG Tablet	02374900	VISANNE	BAY

MEDROXYPROGESTERONE ACETATE

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

PROGESTERONE

Limited use benefit (prior approval required).

For the treatment of clients:

with postmenopausal symptoms who are intolerant to medroxyprogesterone acetate (MPA); or
who are at risk of preterm birth; or
who are using the medication to prevent miscarriage.

In adults:

for use as Gender Affirming Hormone Therapy.

Table: PROGESTERONE
Drug strength and dosage form	DIN	Brand name	Manufacturer code
100MG Capsule	02476576	PMS-PROGESTERONE	PMS
^ST100MG Capsule	02166704	PROMETRIUM	FRS
^ST100MG Capsule	02463113	REDDY-PROGESTERONE	REC
^ST100MG Capsule	02439913	TEVA-PROGESTERONE	TEV

68:36.04 THYROID AGENTS

LEVOTHYROXINE SODIUM

Table: LEVOTHYROXINE SODIUM
Drug strength and dosage form	DIN	Brand name	Manufacturer code
^ST0.025MG Tablet	02172062	SYNTHROID	BGP
^ST0.05MG Tablet	02213192	ELTROXIN	ASP
^ST0.05MG Tablet	02172070	SYNTHROID	BGP
^ST0.075MG Tablet	02172089	SYNTHROID	BGP
^ST0.088MG Tablet	02172097	SYNTHROID	BGP
^ST0.1MG Tablet	02213206	ELTROXIN	ASP
^ST0.1MG Tablet	02172100	SYNTHROID	BGP
^ST0.112MG Tablet	02171228	SYNTHROID	BGP
^ST0.125MG Tablet	02172119	SYNTHROID	BGP
^ST0.137MG Tablet	02233852	SYNTHROID	BGP
^ST0.15MG Tablet	02213214	ELTROXIN	ASP
^ST0.15MG Tablet	02172127	SYNTHROID	BGP
^ST0.175MG Tablet	02172135	SYNTHROID	BGP
^ST0.2MG Tablet	02213222	ELTROXIN	ASP
^ST0.2MG Tablet	02172143	SYNTHROID	BGP
^ST0.3MG Tablet	02172151	SYNTHROID	BGP

LIOTHYRONINE SODIUM

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

THYROID

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

68:36.08 ANTITHYROID AGENTS

METHIMAZOLE

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

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Date modified:: 2020-10-15